Notisia Semanal Ministériu Saúde RDTL: 09/01/2010

JUNE 2002

East Timor Ministry of Health
Health Policy Framework
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“…Let us not be tempted to build and
develop modern hospitals that are costly
and in which only half a dozen people
benefit from good treatment. Let us
concentrate above all on planning intensive
campaigns of sanitation, prevention, and the
treatment of epidemics and endemics for the
whole population. …”

Xanana Gusmao

Message for Opening of Melbourne
Strategic Development Planning for ET
Conference
5 April 1999
East Timor Ministry of Health
Health Policy Framework
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FOREWORD
On behalf of our Government, I am very pleased to present to the people of East Timor a
set of policy objectives and principles upon which the health system of East Timor will
be based.
East Timor health sector has set itself the task of developing a unified health system
capable of delivering quality health care to all our citizens efficiently, effectively and in a
caring environment.
This vision and its underlying values and health policy objectives are contained in this
document and are in accord with the objectives spelt out in the National Development
Plan, in relation to Poverty Reduction and Economic Growth.
In this Health Policy framework document we present a wide range of policies that will
be the blueprint to guide the development of our health care delivery system in the future.
The strategic approach guiding us is that of Comprehensive Primary Health Care.
Accordingly we intend to focus more attention on the basics through decentralized
management of health services.
Our main thrust is to increase access to services by making primary health care available
and affordable to the people of East Timor, particularly the vulnerable groups. We will
ensure the availability of safe, quality essential drugs in health facilities, and rationalize
the use of resources through health financing and health facilities configuration,
providing a sustainable health system focusing on priority health needs and strengthening
our ability to effectively deal with the burden of disease.
Considering the magnitude of the task ahead and the perceived benefits of a well
functioning health system, appeal to the key actors in the health sector to continue with
their understanding and support.
As part of the policy development process, I appointed the Health Policy Working Group
(HPWG) ensuring wide representation. They will continue to work with Ministry of
Health’s technical departments to further develop/review health policies. Thorough
consultation of stakeholders has been undertaken. Recommendations from this
consultative process have been further consolidated and are currently informing the
policy decision-making.
Detailed micro-policies will be developed in due course. This will further outline specific
operational policies, which will be published and will thus complement this policy
framework document.
The Health Policy Framework Paper (HPFP) is intended to introduce to stakeholders, in a
single document, updated policy guidance. This document is also designed to provide
information about the MoH vision and strategic perspective.
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On behalf of our Ministry of Health, I would like to acknowledge and thank all those who
have participated in the consultation process, for dedicating their time and energy to this
all-important task.
It is my sincere hope that this document will inspire all of us to work in unison towards
the improvement of the health of our nation and ensure a brighter future for our children.
We hope this effort will help all of us, rich or poor, urban or rural to take individual and
collective responsibility for our health.
Hon. Rui Maria de Araujo MD, MPH
Minister for Health
East Timor
June 2002
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Health Policy Framework
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LIST OF ABBREVIATIONS
ADB Asian Development Bank
AIDS Acquired Immunodeficiency Syndrome
CHW Community Health Worker
CNRT Conselho Nacional da Resistencia de Timor
CPI Consumer Price Index
DHMA District Health Management Adviser
DHMT District Health Management Team
DHP District health Plan
DOT Direct Observed Treatment
EDL Essential Drugs List
EPI Expanded Program of Immunization
ET East Timor
ETTA East Timor Transitional Administration
ETPA East Timor Public Administration
FHS Faculty of Health Sciences
FY Financial Year
GDP Gross Domestic Product
HIS Health Information Systems
HIV Human Immunodeficiency Virus
HPFP Health Policy Framework Paper
HPWG Health Policy Working Group
HSRDP Health Sector Rehabilitation and Development Program
IMF International Monetary Fund
MD Medical Doctor
MoF Ministry of Finance
MoH Ministry of Health
MPH Master in Sciences in Public Health
NCHET National Center for Health Education and Training
NDP National Drug Policy
NGO Non Government Organization
NTG National Treatment Guidelines
STI Sexually Transmitted Infections
TB Tuberculosis
TBA Traditional Birth Attendant
TFET Trust Fund for East Timor
UNDP United Nations Development Program
UNFPA United Nations Populations Fund
UNICEF United Nations Children Fund
USD United States Dollars
WB World Bank
WHO World Health Organization
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TABLE OF CONTENTS
FOREWORD ................................................................................................................................................ 3
LIST OF ABBREVIATIONS ........................................................................................................................ 5
TABLE OF CONTENTS.............................................................................................................................. 6
i. INTRODUCTION...................................................................................................................................... 9
i.1 Background .......................................................................................................................................... 9
i.2. Problems and constraints..................................................................................................................... 9
i.2.1. Main General problems ................................................................................................................. 9
i.2.2. Main Public Health problems...................................................................................................... 10
i.2.3.Problems related to the performance of the health system ........................................................... 12
i.3. Health policy development process.................................................................................................... 12
i.4. Health policy framework paper.......................................................................................................... 14
ii. SITUATION ANALYSIS....................................................................................................................... 15
ii.1. Social and economic profile.............................................................................................................. 15
ii.1.1. Macro socio-economic profile.................................................................................................... 15
ii.1.2. Demographic profile .................................................................................................................. 16
ii.2. Overview of health development in East Timor................................................................................ 17
ii.2.1. Overview ................................................................................................................................... 18
ii.2.2. Sectoral profile ........................................................................................................................... 20
ii.3. Health services infrastructure............................................................................................................ 20
ii.3.1. MoH infrastructure.................................................................................................................... 20
ii.3.2. Other health providers................................................................................................................ 21
ii.4. Epidemiological profile..................................................................................................................... 21
ii.5. Performance of the health system ..................................................................................................... 22
1. VISION, MISION, VALUES AND GOALS OF THE MINISTRY OF HEALTH ................................ 24
1.1. VISION ............................................................................................................................................ 24
1.2. VALUES .......................................................................................................................................... 24
1.3 MISSION STATEMENT................................................................................................................... 25
1.4. GOALS............................................................................................................................................. 25
1.4.1. OVERALL GOAL ..................................................................................................................... 25
1.4.2. OPERATIONAL GOAL............................................................................................................ 25
2. PRIORITY SETTING............................................................................................................................ 26
3. HUMAN RESOURCE DEVELOPMENT.............................................................................................. 27
3.1. Human resource constraints .............................................................................................................. 27
3.2. Human Resource Policies and Strategies. ......................................................................................... 28
3.3. Strategies .......................................................................................................................................... 28
3.4. Guiding principles: ............................................................................................................................ 29
4. HEALTH FINANCING........................................................................................................................ 30
4.1. Introduction. ..................................................................................................................................... 30
4.2. Current situation ............................................................................................................................... 30
4.3. Health financing in the next decade .................................................................................................. 31
4.4. Health financing policies and strategies ............................................................................................ 31
4.5. Policy objectives............................................................................................................................... 31
4.6. Strategies .......................................................................................................................................... 32
4.6.1. With regard to sustainability: ..................................................................................................... 32
4.6.2. With regard to efficiency............................................................................................................ 32
4.6.3. With regard to Equity. ................................................................................................................ 33
4.7. General government revenue (taxes)................................................................................................. 33
4.8. Remuneration of Health Professionals .............................................................................................. 33
5. ORGANIZATION AND MANAGEMENT........................................................................................... 34
5.1. SERVICE DELIVERY SYSTEM..................................................................................................... 34
5.1.1. Background ................................................................................................................................... 34
5.1.2. Policy objective .............................................................................................................................. 34
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5.1.3. Services configuration................................................................................................................... 35
5.2. BASIC PACKAGE OF SERVICES ..................................................................................................... 37
5.2.1. Introduction ................................................................................................................................... 37
5.2.2. Principles and Policies.................................................................................................................... 37
5.2.3. Conclusion..................................................................................................................................... 38
5.2.4. Basic packages ............................................................................................................................... 38
5.2.4.1. Preventive/promotive basic package ....................................................................................... 38
5.2.4.2. Curative basic package ............................................................................................................ 39
5.2.4.3. Rehabilitative basic package ................................................................................................... 39
5.3. DECENTRALIZATION...................................................................................................................... 40
5.3.1. Background. .................................................................................................................................. 40
5.3.2. Guiding principles .......................................................................................................................... 40
Equity .................................................................................................................................................. 41
Community participation..................................................................................................................... 41
Efficiency ............................................................................................................................................ 41
Capacity of local level .......................................................................................................................... 41
5.3.3. Policies .......................................................................................................................................... 41
5.3.4. Functions to be decentralized ......................................................................................................... 42
5.3.4.1. Human Resource functions...................................................................................................... 42
5.3.4.2. Administration and Management functions............................................................................. 43
5.3.4.3. Financing functions: ................................................................................................................ 44
5.3.5. Conclusion..................................................................................................................................... 44
5.4. MANAGEMENT STRUCTURES........................................................................................................ 45
5.4.1. Ministry of Health .......................................................................................................................... 45
5.4.2. National Bodies .............................................................................................................................. 45
National Council of Health................................................................................................................... 45
National Laboratory ............................................................................................................................. 45
National Center for Health Education and Training............................................................................. 45
Institute of Health Sciences .................................................................................................................. 45
Food and Drug safety Agency.............................................................................................................. 46
Blood Transfusion service.................................................................................................................... 46
National Research Center ..................................................................................................................... 46
5.4.3. Management structures at District Level........................................................................................ 46
District Health Management Teams ..................................................................................................... 46
Hospital Management boards ............................................................................................................... 47
District Health Councils ....................................................................................................................... 47
5.5. MONITORING AND EVALUATION................................................................................................. 48
5.5.1. Background ................................................................................................................................... 48
5.5.2. Policy objective .............................................................................................................................. 48
5.5.3. Policy content ................................................................................................................................ 48
5.6. PUBLIC/PRIVATE MIX...................................................................................................................... 50
5.6.1. Background. .................................................................................................................................. 50
5.6.2. Policy objective. ............................................................................................................................. 50
5.6.3. Policy contents ............................................................................................................................... 50
5.7. CONTRACTING OUT ......................................................................................................................... 52
5.7.1. Background ................................................................................................................................... 52
5.7.2. Policies .......................................................................................................................................... 52
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6.1. Background ...................................................................................................................................... 53
6.2. Policy objective ................................................................................................................................ 53
6.3. Policy contents ................................................................................................................................. 54
6.4. AUTONOMOUS INSTITUTIONS ...................................................................................................... 55
6.4.1. Background ................................................................................................................................... 55
6.4.2. Policies .......................................................................................................................................... 56
7. EXTERNAL ASSISTANCE.................................................................................................................... 58
7. DRUG POLICY...................................................................................................................................... 53
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7.1. Background ...................................................................................................................................... 58
7.2. Current situation ............................................................................................................................... 58
7.3. Policies. ............................................................................................................................................ 60
7.4. Sector-wide Approach (SWAP) ........................................................................................................ 62
7.5. Focus of external assistance in the medium term. ............................................................................. 62
7.6. Linkages with civil societies involved in health................................................................................ 62
LIST OF ANNEXES:.................................................................................................................................. 63
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i. INTRODUCTION
i.1 Background
“ …the overriding goals for the development of East Timor are to reduce poverty…
…and to promote rapid, equitable and sustainable economic growth…”
(East Timor National Development Plan, May 2002)
Without good health, individuals, families, communities and nations cannot hope to
achieve their social and economic goals. To ensure health goals are achieved, there is
need to develop sound health policies to guide health development in East Timor.
Following the 1999 popular referendum and the upheavals that beset the country, East
Timor witnessed almost a total collapse of the health system. Prior to 1999, East Timor
was one of the poorest provinces of Indonesia and the health indices were and probably
still are the worst in the region.
The post referendum period saw the efforts of the Transitional Administration, donors
and humanitarian efforts to rehabilitate the heath system. While these interventions made
over the last three years resulted in some tangible progress, there remains much to be
accomplished in the development of the health system. Accessibility to basic health
services, measured as population living within a walking distance of two hours of a
health facility (4-8 kilometers), is estimated to be 78% countrywide and within 70
minutes walking distance (67’ during dry season) with wide variations between rural and
urban areas and between different districts. The country still faces a myriad of health
challenges including high maternal and infant mortality, illness and death from
preventable diseases, high prevalence of malnutrition, poor reproductive health and poor
access to safe water and sanitation.
i.2. Problems and constraints
i.2.1. Main General problems
There are a series of critical problems that can hinder the ability of the Ministry of Health
in the regulation and the delivery of quality health services in East Timor.
•
General collapse
Despite the big efforts undertaken during the first two years of reconstruction, most
sectors are still facing major challenges to run their programs effectively. Problems with
basic necessities like water, sanitation, nutrition, housing and, in general, poverty, have
great repercussion in health. Post Independence East Timor faces these problems with
optimism but with great difficulties.
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•
Poverty and illiteracy
East Timor is currently one of the poorest countries of the world. More than 50% of the
population lives below the poverty line - 0.55 USD per day. The economic growth
prospects are based on the expected revenue from the oil production in the Timor Sea for
which an agreement was signed with the Australian government on 20th May 2002,
immediately after proclamation of the Independence. Until then, East Timor will remain
highly dependant on external funding.
Illiteracy is a main problem with more than 60% of the population not being able to read
or write. It is demonstrated that literacy is correlated to educational attainments as well as
with individual’s health and nutritional status, life expectancy and fertility.
•
Capacity of the workforce
Under the Indonesian health system, East Timorese were relegated to positions of
minimum responsibility. Capacity for management was concentrated on Indonesian staff
leaving Timorese mostly playing mere administrative roles. Areas of major importance
for the development of the health system, like management, policy or finances are now
being supported with international input that is also building the capacity needed to run
the system independently in the future. Despite the efforts made in this area, there will be
need of external technical support for the coming years.
•
Deficient Infrastructure
The destruction of structures left the country with almost no health facility in minimum
usage conditions. There are plans to rehabilitate and reconstruct a number of health
centers but many will remain in too poor condition for the delivery of quality health
services.
•
Low governance and accountability
The low general managerial capacity in the government, low ability to control and
enforce policies and the general low engagement of the civil society in the public life
give as a result low governance. In the Ministry of Health this is reflected in weak
organizational structure with specific areas of underdevelopment leading the system to
low performance (e.g. low financial follow up capacity, low policy analysis skills or
weak managerial capacity of the different divisions). As a result of it there is low
accountability and high risk of corruption.
i.2.2. Main Public Health problems
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•
East Timor has one of the highest maternal mortality rates in the region with estimated
rates of up to 860 mothers dying every 100,000 live births of problems related to
pregnancy, delivery or early post-delivery. One of the main reasons for such high level of
maternal problems is the low utilization of skilled assistance for antenatal care, delivery
(less than 50%), and postnatal care services. Infant mortality is high mainly due to
problems related to the delivery, low birth weight and infections.
High rates of maternal and infant mortality.
•
malaria, diarrhoeal diseases, respiratory tract infections, tuberculosis or dengue.
There is also an increase in non-communicable diseases adding burden of disease to
East Timor.
A high proportion of illness and death due to preventable communicable diseases like
•
This problem is not directly increasing mortality but malnourished children are more
likely to get sick and die than those with appropriate growth and development.
The high prevalence of malnutrition, iodine and vitamin A deficiency.
•
population.
People drinking unsafe water are more likely to get sick and to get more severe sickness
than those drinking clean and safe water. The mix of lack of sanitary facilities together
with lack of safe water represent one of the biggest hazards for health, specially for the
health of children under five year old whose immune system is still developing.
The lack of access to safe drinking water and sanitary facilities for a majority of the
•
Poor reproductive health.
There is a very low acceptance/utilization of reproductive health services (specially
family planning) due to a complex interaction of social, cultural, physical accessibility
and historical factors. Having too short time between deliveries is proven to be one of the
factors increasing maternal, fetal mortality and low birth weight (which increases
likelihood of death in new born).
•
Low education in prevention of oral health problems and low levels of oral hygiene in
general have developed some generations of Timorese with great dental problems and
will continue passing to new generations if health promotion, prevention and curative
interventions are not soon effectively implemented.
Precarious oral health.
•
problems
The high prevalence throughout the country of post-conflict related mental healthwith very low coverage and quality of mental health services.
•
the pandemic in East Timor. Temporary immigration during the post conflict
intervention highly increases the social risk of spread of the disease.
Poor knowledge of HIV/AIDS among the population can facilitate the development of
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•
health problems.
i.2.3.Problems related to the performance of the health system
Degradation of the environment has brought environmental as well as occupational
•
Poor and inequitable access to health services.
People living in far-flung areas have difficult access to health services. Scattered
population makes difficult for health planners to achieve an equitable yet rational
distribution of scarce resources for health. Additional problems are the very bad
condition of the road network and the low availability of affordable public transport.
•
Inadequate management support system.
Legislation and regulation in East Timor is still incipient and is not covering major areas
affecting the health of the population like environment, food, pollution, etc. A flourishing
but unregulated private sector in health can be highly hazardous with severe
consequences for the population (e.g. illegal and uncontrolled retailing of drugs,
unregulated professional exercise or the use of harmful traditional techniques).
•
sickness episodes resulting often in death or disability.
An inadequate referral system with its subsequent delay in treatment of severe acute
i.3. Health policy development process
To respond to the current challenges facing the health sector and to guide the future
development of the health system, the Ministry of Health has identified health policy
development as a priority. The process has gone through several stages of modification.
The policy development has been guided by the need to make the process all-inclusive
and as participatory and Timorese driven as possible.
A health policy working group (HPWG) was established in February 2001. With the
technical support of a policy adviser a process for policy formulation was started. The
methodology was based on a list of substantive and organizational issues that was already
provided to the group for them to build consensus about the alternatives that were most
appropriate for the reality of East Timor. The different issues were discussed among the
participants and consensus building about the appropriate alternative sought for each
policy issue.
This initial method was found to be complex and not owned by the HPWG leading to low
attendance of the discussion sessions and low participation in the process.
Some modifications to the methodology proposed in February 2001 were introduced in
March 2001. The workload was distributed among smaller groups, gathering information
about the issue and discussing about the best option for East Timor. Consensus was
gathered through presentation of the different areas to the whole group and selection of
the most appropriate alternatives. A number of policy decisions were taken during this
process.
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Another modification in the process was introduced in which all the previously identified
policy issues were grouped into six macro-policy areas:
•
Priority setting in health
•
Health Financing
•
Human resources development
•
Organization and management
o
Health service configuration
o
Decentralization
o
Management structures
o
Autonomous structures
o
Monitoring and Evaluation
o
Basic package of services
o
Public/private mix
•
Drug policy
•
The different issues to be discussed were presented, discussed and agreed by the group
during the sessions. The different alternatives to the issues agreed for the six areas were
to be presented for discussion in the stakeholder consultation workshops. This process
stalled in August 2001 due mainly to diversion of attention to important historical events
like the first elections for legislative assembly and nomination of a second transitional
government. Major changes in the structure of the former Division of Health Services
(Ministry of Health since then) also contributed to lose of momentum in the process of
policy formulation.
In November 2001 and after a joint donor mission review it was decided to re-start the
process for policy formulation. The Ministry of Health was committed in the Grant
Agreement with the World Bank to produce a draft policy framework by the end of 2001
(later extended to June 2002).
The six policy areas selected in the previous process were respected and followed in this
new attempt. Vision of the health sector, guiding principles, mission and goals of the
Ministry of Health were defined and decided with consensus of stakeholders (it is
important to ensure that all subsequent decisions were consistent with these values).
External assistance
Consensus building
international facilitators (their role being mainly to inform, guide and facilitate the
process) and then through consultation with stakeholders. Decisions taken/proposed were
presented in the form of a policy paper for discussion and distributed to the different
stakeholders prior to consultation.
was reached initially through group discussions with input from two
The stakeholder consultation
May 2002) where presentation of the different proposals for health policy was introduced
was organized in the form of two workshops (February and
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to the stakeholders and the alternatives discussed, amendments proposed and finally
approved and stated in this policy framework paper.
i.4. Health policy framework paper
This policy framework paper presents a first comprehensive vision of the strategic policy
direction of the Ministry of Health.
The interactive process between the HPWG and external actors and the search for
consensus has provided the framework document with different perspectives of the policy
issues. It is hoped that this process will increase the responsiveness of the policies
formulated to the specific health needs in different sectors of the social network.
The document is set up in two parts: the first part includes background, introduction,
presentation of the policy development process and a situational analysis; the second part
provides the substantive policy areas including the relevant policy recommendations.
Each policy paper includes an introduction to the issue, the rational for policy
development in each area, the guiding principles for the policy formulation and the policy
recommendations.
------//------
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ii. SITUATION ANALYSIS
ii.1. Social and economic profile
ii.1.1. Macro socio-economic profile
Population figures in East Timor differ depending of the sources. Last census run in 1990
placed the population at 747,557 (including 47,000 non East Timorese)
from 849,699
registered during the civil registration exercise done in March/June 2001. Other figure
was provided by the Suco survey run in 2001 with about 790,000 without including the
approximately 120,000 who left East Timor during the violence of 1999 and have been
living in refugee camps since then
Population growth is estimated at 3.93% per year with a sex ratio male: female of 1.07:1
1. Figures range2 registered during the a census done in March/May 2000 to 737,8113.4
Life expectancy at birth is 57
with a very wide base (54% under the age of 20) gradually narrowing towards its top.
While in the year 2000, the UN Statistic Division estimated that only 8% of the
population was living in urban areas the reality is that a great exodus from rural to urban
settlements has been ongoing for the last two years and is expected to continue if the
situation in rural areas does not improve.
Infant mortality rate is among the highest in the world with 121 children dying before
reaching the age of one year. Fertility rate is 4.6 and maternal mortality (deaths related to
pregnancy, delivery and post-partum) is considered to be one of the greatest problems in
the country with estimates of more than 860 women dying of every 100,000 live births in
one year
Illiteracy rate is high and primary education quality indicators low (53 [19 - 85] children
average per teacher and 48 [21 - 85] per classroom). In Liquiça District, around 67% of
the population had no education at all (71% for women) and around 47% of the same
population get less than 5 US$ per month as total income
5 with a population pyramid typical of a developing country6.7
East Timor, during the Indonesia invasion, was receiving 85% of its current and
investment expenses from the capital, not being able to generate more than 15% of the
1
East Timor National Development Plan, May 2002
2
UNHCR figures of returnees up to December 2000
UNTAET Census and Statistics Unit, Population Census by CNRT in March/May 2000 with added
3
Suco Survey of Poverty Assessment,. ETTA, WB, ADB, UNDP March 2001
4
http://www.un.org/Depts/unsd/social/index.htm
5
Human Development Report, UNDP May 2001
6
http://www.unfpa.org/news/pressroom/1999/etimor.htm
7
V. 2001
A Survey on Accessibility of Health Services and Health Seeking Behavior in Liquiçaça District, Walden,East Timor Ministry of Health
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government expenditure for the province (116 million US dollars). The financial plan
was entirely done in Jakarta with no capacity development for budgeting at local level.
Most imports took place at subsidized prices, especially for key products like petroleum
products or rice. The 75% of the recurrent budget was spent on salaries and wages for
workers of the overstaffed civil service.
After the crisis of September 1999 the GDP fell to about 40% and the prices rose by
about 200%. Donor community responded on emergency basis having provided 135
millions of USD by June 2000, through humanitarian assistance to priority sectors (food,
shelter and health).
The international intervention has generated a dual economy that, during the first two
years, has not left much benefit to the Timorese community in terms of direct profits
from economic activities. Most of the companies and firms that got benefit were
international organizations working in a vacuum of fiscal regulations yielding very little
for East Timor’s incipient government.
Despite all these negative indicators, there is a recovery of the private sector mostly in
services in Dili and agriculture in rural areas. There are projections of growth of about
15% in the FY 2001/02. The increase in prices has been deadened (CPI >11.5% Apr
2001 to <2.5% Sep 2001), and the inflation rate level is located in 3% now. The growth is
expected to slow down in 2002/2003 due mainly to the downsizing of the peacekeeping
operation and. withdrawal of international staff.
ii.1.2. Demographic profile
The population of ET is young with over 48.1% under 17 years, 17% under 5 years and
an average life expectancy of 57 years. The majority of the population lives in the
northern coastal region, spanning 6 districts and accounting for about 60% of the
population. There are two main towns about 2.5 hours apart, Dili and Baucau, and these
2 districts comprise about 25% of the population.
About 70% of the population lives in rural communities characterized by small, dispersed
villages in mountainous areas existing on subsistence agriculture with the main crops
being rice and coffee. Public transport is not readily available, and the most common
modes of transportation are buses between the main towns, walking and the use of small
ponies in the agricultural areas.
In each District, there are communities that can be cut off during the rainy season
because of landslides or broken bridges. The District of Oecussi, with about 48,000
people, is uniquely characterized by its location inside of West Timor making it only
accessible by air or barge to Dili as its referral point.
Table 1.1 below shows the population estimates. This was based on the results of a
census run by the CNRT (Conselho Nacional da Resistencia Timoresa) in March/June
2000 updated with UNHCR returnee figures as per December 2000. The estimated
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population comes to a total of around 850,000. These figures might be distorted
(overestimated) for the bias introduced by the interviewees (traditional leaders) expecting
aid to be related to population figures.
There are development intentions regarding the expansion of agriculture in the south and
south eastern parts of the country; tourism development in the north and north east; off
shore petroleum exploration off the south west and port development in the north and
north west. However, none of the sectors feel that this will result in major shifts of
population.
Essentially, these projected economic developments will mean employment and income
generation for those areas, but it is not predicted that people will move out of their
Districts. In fact, the expressed opinion is that Timorese tend to be very loyal to their
home District. The recent recruitment drive in MOH is illustrative of this difficulties in
filling vacancies in some Districts that are in part due to the reluctance of people to seek
work outside of their home District and even sub District.
Table 1.1 District populations
District Area Population %
Aileu 729 34,718 4.2
Ainaro 799 42,575 5
Baucau 1,494 107,527 12.6
Bobonaro 1,368 71,717 8.44
Covalima 1,226 48,952 5.76
Dili 372 147,975 17.4
Ermera 746 97,326 11.4
Lautem 1,702 49,213 5.8
Liquiça 548 49,988 5.9
Manatuto 1,705 37,541 4.41
Manufahi 1,325 40,884 4.9
Oecussi 815 51,268 6
Viqueque 1,781 62,552 7.36
Total 14,610 849,699
ii.2. Overview of health development in East Timor
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ii.2.1. Overview
Performance of the Health System during Indonesia occupation was unsatisfactory with
many factors contributing to it. Only 2% of the development national budget was
allocated to health (under financed), other sectors influencing health status of the
population were also performing at very low profile and a complex administration and
high levels of corruption made the health sector very inefficient.
Health indicators during the Indonesian occupation were remarkably lower in East Timor
than they were in other provinces of Indonesia or other countries with similar socioeconomic
profile. Life expectancy was 49/51 years (all Indonesia 65.8, Cambodia 54,
Yemen 56 or Bangladesh 59), infant mortality rates around 85/1000 (all Indonesia 35,
Gabon 86, Ivory Coast 88 or Benin 87) and under-five mortality of 124/1000 (all
Indonesia 52, Iraq 125 or Zimbabwe 125)
As part of the program of rehabilitation and reconstruction for East Timor, supported by
the Trust Fund for East Timor (TFET) that is sponsored by different donors (Japan,
Portugal, European Commission, Australia, etc.) and managed by the World Bank, a
program was developed for the health sector. The overall goal of the program was to
rehabilitate and develop its health system to be responsive to the immediate basic health
needs of the population within a well integrated and sustainable policy framework
appropriate for an Independent East Timor.
The three main components of the project are:
8.
•
for service provision in the continuum emergency-development. The strategy was to
be implemented rapidly to ensure delivery of basic services to the maximum of the
population. Capacity building of East Timorese health staff was to be tackled and also
to maximize efficient use of resources available. Actions was not to interfere with the
development of the future health system and to take into account the principles
developed by the East Timorese Health Professionals Working Group, including
sensitivity to culture, religion and traditions of the East Timorese people. The interim
Health Authority created, together with the health service providers, the ground for
what lately were the district health plans (DHP) whose implementation was ensured
through signature of Memorandum of Understanding with all the NGOs.
The main priorities within this first component were:
Restore access to basic health services: basically consisted in a transitional strategy
o
Immunization, micronutrient supplementation and health promotion,
Acceleration of selected high priority activities like TB control,
o
Development of essential; drugs list and standard treatment guidelines
o
Rehabilitation and equipping of health centers
o
Rationalization of hospital services
8
http://www.worldbank.org/html/extdr/offrep/eap/etimor/donorsmtg99/dtcjamhealthed.pdf
East Timor Ministry of Health
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o
levels with strengthening of capacity in this area
Re-establishment of an administrative infrastructure at central and district
•
Health Policy and Health System development with focus on three main priorities:
o
Policy development with concentration on:
􀂃
Sector objectives and context
􀂃
The role of government in health
􀂃
community participation, etc.)
Basic health services (access, financing, targets, private sector,
o
and the supporting systems (logistics, information, monitoring and evaluation)
Design of a health system including the design of the administrative structure
o
area as determined by the health policy and system design. Some priorities in
this area were tackled like the need for supporting medical students in
continuing their studies and get new medical resources in the medium to long
run.
Human resource strategy taking into account existing and future needs in this
•
management unit was included within the Interim Health Authority structure
providing support and building capacity of the Timorese counterpart.
The first program was extended up to June 2003.
At the end of 2001, NGOs were requested to withdraw from their role of health service
provider in government health facilities and to transfer this responsibility to the newly
recruited District Health Management Teams. By that time the health care provision was
done through a network of one national hospital in Dili (initially managed by an
international organization but assumed by the ET civil servants in June 2001), one
regional hospital in Baucau, 10 community health centers with inpatient department, 53
community health centers with no inpatients facilities, 86 health posts and 135 mobile
clinics visiting remote location on twice-per-week basis. The Ministry of Health defines
access as the distance covered by walking two hours or 4 to 8 Kms.
Following recommendations made by a joint donor evaluation mission in May 2001, a
second HSRDP was granted through the second phase of TFET (TFET II). This second
project aims to consolidate achievements of the first one by:
Project Management: in order to ensure a proper implementation of the program, a
o
Supporting ongoing health services delivery,
o
Improve the range and quality of health services,
o
Develop and implement a health support system, and
o
Since the withdrawal of the Indonesians in October 1999, East Timor has a unique
opportunity to develop a new health system based on sound policies aiming to achieve
the overall goal of improving the health status of the people of East Timor.
Develop and implement a sector health policy and management system.
East Timor Ministry of Health
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Health professionals in East Timor had the initiative to organize themselves even during
the occupation period and came with a proposed strategy for rehabilitation of the health
system based on sound values and priorities.
ii.2.2. Sectoral profile
ii.2.2.1. Financing /expenditure situation
The recurrent budget of the health system is currently (fiscal year 2002/2003) around 7
Million USD per year that provides an average of 8 USD per capita (for a population of
850,000). This allocation is on the same range to other countries with similar income
(Guinea Conakry 7, Azerbaijan 6 or Armenia 11) and much higher than other countries in
the area (India 2, Vietnam 1 or Cambodia 1).
Around 45% of the recurrent budget is spent on salaries and wages with the other 55%
going to goods and services (drugs being 24%).
Major sources of funding are the Trust Fund for East Timor (TFET) and bilateral
contributions (see above).
Financial and technical assistance from foreign countries in the rehabilitation of the
health system should be considered, as a main driving force to the reconstruction but only
commitment from East Timorese will finally produce a system able to generate health
outcomes for the society.
ii.2.2.2. Human Resources/staffing situation
The current situation regarding staffing levels within the Ministry of Health is a
workforce recruited as civil servants of 830 with still more than 500 under stipends of the
MOH (temporary workers to be replaced by civil servants). The total size of the civil
service for health is currently 1452 employees.
There are major problems in the area of human resources in the health system of East
Timor. Some of them are: imbalance in the production, low skills and wrong skill mix
among the staff, deficiencies in the development of a national strategy for human
resources development and inefficient use of existing human resources. There are also
potential problems like the retention of the staff in their positions or the coverage of
remote areas with appropriate health staff. Low morale together with a weak management
give as a result low performance of the workforce.
ii.3. Health services infrastructure
ii.3.1. MoH infrastructure
East Timor Ministry of Health
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Currently the system is producing health care through a network of facilities across the
country. A network of health facilities including two hospitals with surgical capacity,
some rural clinics (one in every district), health centers (one in every sub-district) and
basic health posts and mobile clinics are currently providing the front line curative
services to the community. Minimum promotive and preventive activity is being
implemented so far and almost no rehabilitative care has been yet introduced.
ii.3.2. Other health providers
Multiple actors play different roles in the health arena, the Catholic Church being one of
the most important. The presence of foreign armed forces playing peace keeping roles
also has implication in the health sector as they implement health interventions, generally
concentrated in the military contingent but sporadically offering health services to the
community.
Traditional medicine has been an alternative to the sometimes difficult to access
Indonesian health services. These last 25 years have developed among the Timorese
society a culture of traditional medicine adopting traditional practices (e.g. eating habits,
post-partum beliefs or waning practices) and accepting the traditional alternative as the
best option for health care seeking.
Private sector has not been a significative source of health care during the first year after
September 1999. Currently it is assuming a more important role with services being
offered both in the clinical and in the pharmaceutical areas. There are different private
non-for-profit initiatives like cooperatives offering health maintenance services to their
beneficiaries, non-government organizations (actually in a small number) but others are
purely for-profit. Both play a very important role that once regulated can increase equity
and benefit the most vulnerable sectors of society.
ii.4. Epidemiological profile
East Timor has an epidemiological profile typical of a tropical underdeveloped country in
an early epidemiological transition.
Communicable diseases account for the majority of deaths (approximately 60%,
particularly in children) followed by the non-communicable diseases, chronic diseases,
road traffic accidents and other conditions.
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 with its subsequent nutritional deficiencies.
Cross sectional nutritional surveys run in the year 2000 suggest that 3-4% of children
aged 6 months to five years are acutely severely malnourished (wasting), while more than
two in five are chronically malnourished (stunting).
East Timor Ministry of Health
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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
capital, are high transmission areas and chloroquine resistant strains have been reported.
East Timor is endemic for leprosy; prior to September 1999, the registered leprosy case
prevalence rate is 1.8 per 10 000
and P vivax malaria are equally represented. Four districts, including the- Indonesian MOH data
East Timor is highly endemic for lymphatic filariasis and patients with clinical
manifestations of chronic lymphatic obstruction have been well documented.
Tuberculosis is a major public health problem, with an estimated 8000 active TB cases
nationally (over 1% of the total population).
Sexually transmitted infections (STI) are common in sexually active age groups.
Routine childhood immunization recommenced in early March 2000 and is now (May
2002) covering 39% of the children under one year of age.
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.
ii.5. Performance of the health system
Accessible services are defined as those within the distance of two hours walk from the
house of the user (approximately 4 to 8 Km). Access is currently poorly assessed. The
access data reported varies from 53% of the population with access to health services in
Aileu to 91% in Manatuto with an average of 78% Some studies are planned
(Demographic and Health) that will provide the MOH with more accurate data regarding
access and coverage.
The utilization of the health services is still very low with less than 2 visits per capita per
year (being 3 the average in similar development environments). Hospitals are used just
by less than 5% of the population (9% average in low income countries) and the coverage
of institutional delivery services is less than 50%. Preventive activities like
immunization are currently covering less than 50% of the target (children under one year
of age).
The rehabilitation of the health system is still in its very early stages and is not expected
to produce sound health outcomes in the near future (specially having other factors, out
of the health sector, reinforcing the low health status of the community). The quality of
the services provided currently is not good mainly due to factors presented above.
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This policy framework is expected to provide a solid base for decision making that will,
at the end, result in an improvement of the quality and efficiency of the services and
therefore on the likelihood of these services producing a positive impact in the health of
the Timorese population consistent with the current professional knowledge.
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1. VISION, MISION, VALUES AND GOALS OF THE MINISTRY OF HEALTH
1.1. VISION
Health problems are not exclusively originated in health-related sources. In fact if we
study the factors that influence the health status of a population we will see that health
care contributes in a small scale to the whole health status. Education, income, housing,
food, water and sanitation are among the most important determinants of health. The
Ministry of Health of East Timor is aware of this variety of determinants of the health
status and assume from its inception a vision that implies a broad definition of health.
“Healthy East Timorese people in a healthy East Timor”
With this vision statement, the Ministry of health envisages a Timorese community
enjoying a level of health that will allow them to develop all their potentialities in a
healthy environment. The fact that the vision implies a healthy East Timor means that
sectors other than health should contribute to reach the point that this vision foresees
(multisectoral approach to health).
The vision also reflects an aim to poverty reduction where the level of production and
income allows all Timorese individuals to enjoy a healthy life and to have the minimum
means to cover basic needs. Only a healthy community will be able to achieve poverty
alleviation.
1.2. VALUES
From the perspective of the Ministry of Health, the values underlying this vision involve
a great commitment to
equity and cultural sensitivity through behaviors based on
ethics, solidarity
Equity is understood as distribution of health resources according to need. To ensure
equity in health it is necessary to relate access or utilization of health care to needs.
Equity is also related to equality. There is evidence of differences in disease burden
among different geographic areas (within or between countries), ethnic groups,
occupation, employment status, different income groups or different sexes. It is
recognized that excess inequality is not just unfair but is in addition health damaging.
Cultural sensitivity is referred as being aware that cultural differences and similarities
exist and have an effect on values, learning processes and behaviors. Being responsive
the local history, culture or the environment where health service is being delivered
increase community reliance in the health system. Some times in health such values are
harmful and is only through a respectful approach that a strategy for solution can
succeed. In East Timor, cultural diversity is high and so are the different perceptions of
health and disease and the different health care seeking behaviors. In order to find
and friendliness.
East Timor Ministry of Health
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appropriate approaches to these problems, cultural sensitivity is to be ensured in all
decisions made.
As stated in the East Timor Constitution, health and medical care is a right of every
Timorese and the (?) obligation to protect and promote it. The system is universal,
general and depending of the possibilities of the State, free of charge. The management
of the system will be decentralized and participatory.
1.3 MISSION STATEMENT
Consistent with the vision statement, the Mission of the Ministry of Health is to strive to
ensure the availability, accessibility and affordability of health services to all East
Timorese people, to regulate the health sector and to promote community and
stakeholders participation (including other sectors)
1.4. GOALS
1.4.1. OVERALL GOAL
From these three components of the mission (ensuring availability, regulating and
promoting participation) the Ministry of Health expects to contribute to the overall goal
of improving the health status of East Timorese.
1.4.2. OPERATIONAL GOAL
The Ministry of Health aims to provide quality health care to East Timorese by
establishing and developing a cost-effective and needs-based health system which will
specially address the health issues and problems of women, children and other vulnerable
groups, particularly the poor, in a participatory way.
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2. PRIORITY SETTING
The Ministry of Health (MoH) of East Timor, in search of protection for its citizens
against sickness and all its consequences, and given the scarcity of resources to pay high
quality health care for all, needs to set priorities. In order to promote equity within the
health sector it is necessary to establish criteria for allocation of resources.
Objective health needs was defined as the main criteria for priority setting. If equity is to
be achieved and objective health needs used as a criteria for resource allocation, the
distribution of resources according to objective health needs will be common practice
within the MoH.
The MoH is committed not only to ensure appropriate care according to health needs
detected through its own information sources but also to satisfy as much as possible the
consumers demands. To include the perspective of the user is paramount if
responsiveness of the health system is to be achieved.
Other approaches to priority setting like the preference of the supply side (doctors,
nurses, midwives, etc.), although will be taken into account, they will not exert major
influence in the decision making process.
The entire health sector cannot be seen in isolation from a whole environment in which
politics, economics or cultural issues are modeling many of the movements of the new
government in East Timor. The fact that political influence will shape decisions in the
MoH cannot be ignored and although is not seen as a major priority setting criteria it
should be taken into consideration.
In previous policy forums within the Ministry of Health, decision was made about the
grouping of health services by type (promotive, preventive, curative, rehabilitative and
palliative) and by level of care (primary, secondary and tertiary).
Following criteria of cost-effectiveness, the MoH will give higher priority to preventive
and promotive interventions than to curative. The great impact of changes in coverage of
curative services in the budget, allows the government to invest in interventions that will
produce in the long run greater health outcomes. Despite this, increasing technical
efficiency should be aimed in order to ensure the whole range of services to cover health
needs.
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3. HUMAN RESOURCE DEVELOPMENT
3.1. Human resource constraints
One of the biggest challenges in ensuring health for all in East Timor is development and
proper management of health human resources. The major problems confronting human
resource development in East Timor have been identified as:
o
- Production -number and type of health workers resulting in:
- Undersupply/oversupply in certain types of health personnel
- Sufficient number produced but not recruited
- Staff/Skill Mix-Level of training and skills available in relation to skills
needed.
- Health policy and human resource development policies
- Utilization of existing personnel
Imbalances in the following areas:
o
Low morale of the health workers
o
Health.
Human resource development problems have their roots in the Indonesian health system
and the events that followed the September 1999 referendum. These include:
Inadequate human resource management and planning capacity within the Ministry of
o
referendum of September 1999 resulted in a large number of health workers of
Indonesian origin to leave East Timor, the majority of who occupied senior
professional and managerial posts in the health services. This loss has serious
implications for the local capacity to deliver health services.
Mass departure of health workers from East Timor. The violence that followed the
o
health workers who were trained under the Indonesian health system.
Inability of the Ministry of Health to absorb a large number of mid and lower level
o
related to future reduced possibilities for government employment following the
recruitment process aimed at rationalizing civil service.
Low morale of health workers in the civil service due to the current uncertainties
o
Unregulated private practice given the large number of unemployed health workers.
o
workers many often performing single tasks as a result health workers are unwilling
to take new roles or are ill-prepared for multi-skilled tasks.
Inadequate skill mix. The Indonesian health system employed a vast number of health
East Timor Ministry of Health
Health Policy Framework
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o
produced only basic level workers. High-level training of health workers was
undertaken in Indonesia.
Low capacity of local training institutions. Local training was fragmented and
3.2. Human Resource: Policies and Strategies.
To perform effectively, health services in East Timor need professionally trained and
strongly motivated personnel. These conditions are crucial if the quantity and quality of
health services needed are not to be compromised. Availability of human resources for
health ultimately, determines the effectiveness of the other strategies adopted to meet the
goals of East Timor Health system. To sustainable development of the health system, the
government is committed to investing in its human capital. To reflect the priorities of the
MoH, and to achieve greater self-sufficiency, the MoH will seek to allocate funds within
its budget to ensure implementation of in-country and overseas training program as part
of an overall Human Resource Development Plan of East Timor.
The objective of Human Resource Development Policies (HRDP) is to ensure that
sufficient health personnel are available and capable of delivering quality health services.
HRD policy will be to recruit, train and manage sufficient number of health personnel,
based on identified health service delivery needs and within sustainable resources. The
policy will seek to achieve equitable distribution as well as skill mix that is appropriate
for the health delivery system adopted by East Timor. In optimizing on available human
resources, a key element of HRD policy will be productivity improvement. To this end,
appropriate incentives will be developed to motivate and retain qualified personnel in the
health services.
Within this broad policy guideline, specific HRD policies and strategies will be
elaborated. This will relate to recruitment, training, performance, regulation etc
3.3. Strategies
The main strategies to achieve the HRD policy objective and consistent with human
resource broad policy guideline will be:
o
community health centers
Recruit available workforce according to needs giving priority to health posts and
o
- Strengthening training institutions and build capacity of teaching clinical
institutions
- Developing and implementing problem-based and competence-based
curricula and preparation for multi-skilled tasks
Develop and implement education and training systems
East Timor Ministry of Health
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- Investing among all health professionals in short term upgrading of staff to
take up new roles to deliver services at the appropriate levels
- Investing in professional education and new skills required providing
leadership in the health sector.
- Implementation of in-country and overseas training program by allocating
funds for scholarships within the government annual budget towards
meeting the needs of the country.
o
- Establish staffing norms for numbers and skill mix at each level and
facility type. The staffing norms based on type and workload will form the
basis for recruitment and distribution.
- Develop and maintain a human resource information system to support,
planning, development and distribution of health personnel
- Increasing the capacity in human resource planning by training senior staff
in management skills.
Improve human resource planning
o
- Performance appraisal (PA). Set up efficient and responsive PA that will
monitor efficiency and be closely related to reward and promotion, linking
incentives to workload, performance and output.
- Incentives (economic, access to academic upgrade, etc.) to favor
redistribution of health personnel to underserved areas and to reward
productivity
Improve human resources management
o
control of medical practitioners
Develop and implement mechanisms for registration, regulation and quality
3.4. Guiding principles:
o
and staffing
Underserved areas and primary health services will be given priority in training
o
mix at each level through an integrated approach.
Health services will be delivered by multi-skilled personnel with appropriate skill
o
should be delivered in the most cost-effective way.
All training programs will be based on identified needs of the health services and
East Timor Ministry of Health
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4. HEALTH FINANCING
4.1. Introduction.
To date most of the health services are financed through external funding and exchequer
drawings. Projections into the future indicate that the most likely scenario will be a fall in
real per capita government expenditure on health in the coming decade.
Currently insurance do not provide any revenue to the public health sector, furthermore,
community and other insurance schemes are not yet developed in East Timor.
Through the health financing policies, innovative financing mechanisms will be
developed. These will include:
o
secondary and tertiary health facilities,
Gradual and phased introduction of user fees (cost-sharing) in government
o
The establishment and gradual expansion of a mandatory “Health Insurance”.
o
social/community financing schemes.
The net result of these efforts will be increased financial flows into the sector. Additional
funding coupled with efficiency strategies (such as shift from curative to
preventive/promotive) will go a long way towards achieving the public health policy
goals.
Further, the Ministry of Health will facilitate the development of
4.2. Current situation
The major health financing problems that are likely to be faced by East Timor health
system can be listed as:
o
Insufficient funding,
o
Inefficient use of available resources,
o
Inadequate allocation of health resources to cost effective health services,
o
Lack of incentives for health workers to provide quality care,
o
Inadequate regulation of private provision of health care,
o
poor and well-off populations, and
Inequitable distribution of resources between urban and rural and between
o
system.
At the same time, there is over-reliance on unsustainable sources of health care funding
such as external donor funding.
High-household expenditures in health care even in the midst of a “free care”East Timor Ministry of Health
Health Policy Framework
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4.3. Health financing in the next decade
To adequately finance increasing demand for health services in the next decade, health
sector will have to rely more on diversified sources of financing. The prospects for
increasing the share of health expenditure from general government revenue are poor due
to low tax base.
Experiences elsewhere seems to suggest that regardless of how much the governments
are spending on health, traditional reliance on government funding (general revenue)
have not produced the quality or quantity of health services the people desire.
4.4. Health financing policies and strategies
Health financing policies involve arrangements for raising funds, allocating, organizing,
and managing health resources including alternative financing mechanisms.
The broad strategic policy options for financing health services are:
. Mobilizing additional resources within the health sector (new sources and
reallocation of resources within the health sector)
. Mobilizing additional funds from outside the health sector (reallocating resources
between the health sector and other sectors)
.
Increasing efficiency by making better use of scarce resources (improving
efficiency)
. Altering the organizational composition of the health sector, and shifting
responsibility for the provision of some of the services to the private sector (non
governmental sector).
In the context of East Timor, the following policy will guide the financing of the health
sector:
The Ministry of Health will seek to secure adequate funding for provision of basic
package of services and, to allocate and manage financial resources available to the
health sector, in a way that will promote sustainability, efficiency and equity.
4.5. Policy objectives
Specific health financing strategies to be developed should support the overall goal of the
health sector. The policy objectives of these strategies will be the promotion of financial
sustainability, public health goals of equity, access, efficiency and quality. Public health
expenditure will deliberately be channeled towards areas of greatest need and impact.
Special attention will be given to equitable distribution of health resources, increasing
East Timor Ministry of Health
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32
access to rural communities, targeting the poor, and applying cost-effective interventions
in resource allocation.
4.6. Strategies
In pursuing the above broad policy the Ministry of Health will develop the following
specific strategies:
4.6.1. With regard to sustainability:
o
secure additional resources to finance health services. These will include:
The Ministry of Health will implement alternative financing mechanisms to
o
and tertiary health facilities. Prior implementation of this strategy the
Ministry of Health will provide the community with good information
about reasons, methods, etc. Exemption of fees to the poor will be applied
through appropriate mechanisms based in the community.
Phased introduction of cost sharing (user fees) in government secondary
o
Security and Assistance) establishment of social health insurance
mechanism managed and organized initially by the government and
compulsory for employees in the formal sector. In future the mandatory
insurance, not necessarily controlled by the government will be required.
In the long run, the insurance scheme should be expanded to cover people
outside the formal sector.
Consistent with the Constitution of East Timor article number 56 (Social
o
insurance schemes.
The Ministry will also encourage employer-based and cooperative-based
o
at the community level.
4.6.2. With regard to efficiency:
The Ministry will explore the potential for informal prepayment schemes
o
of cost-effective preventive and curative package of services
Cost effective interventions: Public spending on health care will target financing
o
secondary curative services. To ensure increased coverage of priority health
interventions are met, the ministry will target health expenditures to areas of
greatest need and impact on health status improvement
Increasing public funding for preventive and promotive health services relative to
o
Improving allocation and management of existing health resources
East Timor Ministry of Health
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33
o
contracting out services to health providers
Collaborating with Non-governmental sector in health service provision, through
o
management systems, contracting out supportive services etc
4.6.3. With regard to Equity:
Containing costs of providing curative services through strengthening
o
To protect the poor from financial cost of health care, the Ministry will:
o
services and for high-risk population groups to ensure financial access by
those unable to pay.
Develop a system of fee exemptions and waivers for selected health
4.7. General government revenue (taxes)
This is likely to be the major source of funding for the public health services in East
Timor in the foreseeable future. However, this should not be the only source of funding
public health services.
In seeking to mobilize adequate funding for health services, the Ministry will continue to
lobby the government for an appropriate share of the total government revenue. At the
same time, cost recovery methods including user fees in selected government health
facilities and various forms of social insurance and community financing will be
explored.
4.8. Remuneration of Health Professionals
Methods of remunerating health professionals will have an impact on the financing and
delivery of health services. The remuneration system should take into account the supply
of and prevailing market conditions for health professionals.
Public service should aim at retaining adequate number of qualified health personnel by
providing appropriate incentives.
The Ministry of Health will adopt a system of remuneration that will be financially
sustainable, and which will motivate health provider but at the same time avoid perverse
incentives, such as doctor-induced demand, that some of the payment methods may
entail.
For the immediate future, remuneration of the health professionals in the government
health services will be based on a salary plus additional reward for extra work, while
keeping the other options open for future review taking into account development of the
health system. In particular, the Ministry of Health recommends piloting of the capitation
system in some districts in East Timor as a longer-term option in primary care services.
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5. ORGANIZATION AND MANAGEMENT
5.1. SERVICE DELIVERY SYSTEM
5.1.1. Background
The previous health care delivery system was very centralized. The facilities or services
provided in East Timor were based on a standard that was not relevant to local population
needs, situation and/or capacity to maintain. There was more physical capacity than
necessary, yet the province was provided with too little of human and financial resources
needed to deliver services or to maintain the system.
The present system is based on a rationalization of the previous configuration, adapting
the supply to the expected demand after the first pre-independence transitional
government got in power.
Currently there is one National hospital offering surgical and medical services (including
four basic specialties) and one regional hospital offering also surgical and medical care.
There are nine district community health centers offering inpatient services and serving
as medical referral for the district population. At sub-district level, there is one
community health center without inpatient’s beds with additional health posts and mobile
clinics that increase coverage to remote areas.
After two years of rehabilitation of the health system, the information regarding demand
and the economic projections give us a ground to define a more adapted health service
configuration.
The current level of health service utilization is rapidly improving. Improvement in
transport services and roads will have an impact on the demand; therefore the supply has
to be ready to cope with it.
Maternal mortality, although not yet confirmed (no health information system yet in
place), might be a major cause of death. In order to offer essential care to obstetric
problems there is need for a minimum network of health facilities linked through a
referral system that ensures rapid and effective life-saving interventions which will
contribute to reduce this problem.
5.1.2. Policy objective
With this new policy the government tries to increase coverage and quality of health
services to a standard that ensures the delivery of a minimum package of cost-effective
curative and promotive/preventive interventions.
Equitable distribution of resources is translated here into an improvement of services in
remote areas, emphasizing on reinforcement of the referral system and hospital services
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with surgical capacity within a distance of two driving hours from every sub-district
facility.
In order to achieve efficiency, cost containment of third level services (hospital care) is
contained below 35-40% of total recurrent budget with this new configuration and
deploying more resources to lower levels of care (sub-district and district levels).
The limited availability of resources is also taken into account when the new system is
defined, trying to keep supply at the lowest profile able to deliver the expected minimum
package of services.
5.1.3. Services configuration
The proposed configuration is based on a definition of access by which a service is
considered accessible when is located within a distance of 4-8 Km from the household
(more or less two hours walking distance).
For planning purposes, a model for emergency obstetric care was used to define
minimum standards of accessibility to the different layers of the health system. This
model, takes into account the high burden that maternity related problems put in East
Timor.
The nearest services to the community will be delivered through a network of 85 Health
Posts staffed with a team of one nurse and one midwife able to deliver minimum package
of curative and preventive/promotive care. To complete coverage 116 mobile clinics will
deliver services on a twice-per-week basis in far-flung areas with difficult access by
normal transport (motor-bike clinic). MOH, according to its possibilities, will try to shift
from mobile to fix services (health posts) if there is a demand that justify such change
and the means are available. These facilities are coordinated through a sub-district
community health center with no inpatient services.
At this first level of care, the role of certain community traditional health workers like the
“ducun”
This sub-district network constitutes the entry point to the system for most of the
community. Services provided at this level ensures basic package of curative and
preventive/promotive interventions. Community based rehabilitative programs will be
implemented through an integrated approach.
At district level, one community health center, normally located in the district capital,
will offer more comprehensive but yet essential services to the community. Medical care
will be provided either ambulatory or by admission. Depending on the vicinity of larger
hospital facilities admission of patients will be done through an observation unit with two
to four beds for pre-referral stabilization of severe cases, observation and application of
treatments for less than 24 hours (Aileu and Liquiça) or through a ward of 10 to 20 beds
(TBA) or the “kader” (CHW) will be revised and supported from the MOH.
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with a set of diagnostic support equipment including laboratory with capacity for
essential tests (Lautem, Viqueque, Manatuto, Manufahi and Ermera).
In order to ensure surgical services able to provide comprehensive emergency obstetric
care (including cesarean section), four of the current district community health centers
will be upgraded and equipped with staff and material to the level of Referral Hospitals
(Pante Makasar in Oecusse, Maliana in Bobonaro, Suai in Covalima and Maubisse in
Ainaro). An inpatient ward of 24 beds will be maintained to cope with the referrals from
the region. In these facilities essential diagnostic equipment will also be available.
Baucau with 114 beds will serve as surgical and medical referral for the three Western
districts (Viqueque, Lautem, and Baucau) offering surgical and basic specialists services
(also some visiting specialists).
In Dili, the National Hospital will provide medical, surgical and specialized services
(including visiting specialists for specific medical and surgical needs). A complete set of
diagnostic equipment will be available.
This entire network will be appropriately linked through a referral system based in two
pillars: radio-communication system and ambulance services. One ambulance will serve
each district that will be activated through any of the radio stations installed in all sub
district facilities.
Staffing of health facilities will be a matter of micro policy development.
The system here proposed will be flexible enough to adapt itself to changes in the
demand, economic situation or other factors influencing the need of health services and
the capacity to supply them.
Annex 3: Service Delivery System Matrix
Annex 4: Driving Time from district capitals to nearest referral hospital
Annex 5: Location of Health facilities in East Timor
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5.2. BASIC PACKAGE OF SERVICES
5.2.1. Introduction
The government is faced with the challenge of reducing the burden of disease that afflict
the majority of the people of East Timor and by so doing, it will have contributed to the
improvement of the health status of the people. Recognizing that the government has
limited resources to provide comprehensive/complete services that may be demanded at
all levels, it is imperative that the Ministry of Health defines a package of services that it
can deliver ensure greater coverage and impact to the majority of the people.
Basic package of health services consists of essential health services and cost effective
interventions to prevent and control or treat problems causing the highest burden of
disease in a country. The burden of disease in East Timor consists mainly of common
endemic communicable and preventable diseases. A big proportion of these diseases can
be effectively dealt with at health post and health center level.
Basic package based on disease burden assumes epidemiological information is available.
The Ministry of Health takes a dynamic view of basic package and recognizes that a
Health Information System (HIS) has yet to be developed that will better define the
burden of disease and inform decision-making.
5.2.2. Principles and Policies
The guiding principle for the definition of the basic package and therefore the choice of
the services to be provided is underpinned by cost-effective principle and the ability of
the MoH to finance and deliver health services. The choice of services is influenced by
the incidence or prevalence of the disease or condition, the probability of suffering severe
disability or dying from it, and its potential as an emerging problem of socio-economic
importance. The available intervention, its effectiveness, cost and compatibility with
other interventions as a package- that is, an integrated approach to delivering the service
will be used. The proposed package of services takes these factors into account and
adopts services to local circumstances.
It is envisaged that the basic package as is defined will be incremental as services
provided will be possible to be extended depending on the country’s capacity and
changing epidemiological profile.
The package of services will be a combination of clinical, public health and rehabilitative
services. Public health services will provide immunization and mass treatment for the
diseases for which this is an effective intervention. Routine monitoring and surveillance
mechanism will be used to detect and deal with outbreak of diseases.
Clinical services will provide effective treatment for common disease problems as well as
emergency care. Maternity services are a mixture of public health and clinical services
that are very important in the context of East Timor given the unacceptably high maternal
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mortality rate and the need for sustained and focused effort to reduce this mortality rate.
Rehabilitative services within the basic package will be limited to basic interventions
within the skills and facilities available at district level.
5.2.3. Conclusion
In the context of East Timor, these health services and interventions constitute the basic
package of services that will be delivered by MoH within the district health system (first
level contact with modern health care), i.e. Mobile Clinics, Health Posts and Community
Health Centers in order to meet 80-90% of the curative and public health needs of the
people at a cost the government can afford. Basic package will form the basis of rationing
the services to be provided at this level. At each level of health services delivery the
ministry will further define the minimum standards of services, facilities and staffing
required and the referral system for the cases that will need specialized care at secondary
and tertiary levels where private sector health providers will also be involved.
A basic package of services defined for clinical and for public health services in East
Timor is illustrated in the following tables.
5.2.4. Basic packages
5.2.4.1. Preventive/promotive basic package
Health Problem/Services Interventions
Immunization EPI
ANC/PNC/ND care Safe-Motherhood
Health Education School health, public campaigns
Nutrition services Periodic de-worming, micronutrient
supplementation (Vit A, Iodine, iron
etc), promotion of breastfeeding,
growth monitoring, promotion of
locally produced food.
Environmental Health Personal hygiene, water quality
control, sanitation and waste
management
Mental Health Mental health education of high-risk
groups.
Family planning Provision of voluntary family
planning services
Oral health IEC, fluoridation, routine oral check
up, removal of plaque
Communicable diseases/Malaria prevention Surveillance, prevention of
transmission, early detection,
promotion of bed-nets use
Occupational health Hazard prevention at work place and
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protective measures
STI/HIV/AIDS prevention
IEC, safe blood supply, disposable
syringes, condom promotion for STI
prevention
5.2.4.2. Curative basic package
Health Problem/Services Interventions
Malaria Case management according to
guidelines
Tuberculosis (TB) Directly Observed Treatment
(DOTS)/ case management
Upper Respiratory Track Infections (URTI) Symptomatic treatment
Sexually transmitted Diseases (STI) Case management using syndromic
management of STIs/referral
Anemia Case management
Parasitic infections Case management
Skin Diseases Case management
Eye infections Case management
Diarrhoeal Oral rehabilitation/case management
Dengue fever Symptomatic therapy
Common Trauma Early treatment of burns,
wounds/referral
Urinary Tack Infection (UTI) Case management/referral
Musculoskeletal disorders Case management/ referral
Mental Disorders Case management, counseling and
referral
Cardiovascular diseases Case management/ referral
Abnormal delivery care Case management/ referral
Malnutrition Case management/ referral
Leprosy Detection/referral/treatment
5.2.4.3. Rehabilitative basic package
Health Problem/Services Interventions
Musculoskeletal disorders due to post trauma,
degenerative disease or other diseases
affecting physical abilities
Community-Based rehabilitation
Mental disorders sequel or post-trauma
syndrome
Post-trauma counseling
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5.3. DECENTRALIZATION
5.3.1. Background.
In many countries health system decentralization is being promoted on the basis of its
potential benefits. Some of the reasons for decentralization are: to bring health services
and their management closer to communities; greater ability to meet local needs; greater
possibility for community participation and involvement in health issues and greater
accountability. It is also presumed that decentralization will result in greater effectiveness
and efficiency in service delivery.
During the Indonesian rule, the health system was based on a multi-level management
and service delivery system (central, regional and district levels). The development of
programs and projects, planning, resource allocation and decisions on human resources
management were functions of the national and regional levels. In spite of attempts to
decentralize service delivery, the process of decentralizing the planning, management and
financing of health care from the central government to the provincial and “kabupaten”
governments was slowly evolving.
Health delivery system was based on vertical programs and projects designed at central
and provincial levels. The role of the peripheral levels was mainly implementation with
limited decision-making. Excessive bureaucracy characterized the system.
In the current health system most of the management systems including decision-making
and planning systems are still centralized. Districts have played a limited role in
planning. Although policy and planning should be centrally coordinated, there is need to
balance the central and periphery.
Promotion of a more participatory process for health system will require a change in the
center-periphery relationships.
Certain constraints stand in the way of effective decentralization. The capacity of the
peripheral levels has been recognized as a problem for the effective operation of health
services in East Timor. Vertical program management and specific technical support are
still powerful factors in maintaining a centrally controlled system; fostering specific
programs loyalties rather than horizontal integration at district level.
5.3.2. Guiding principles
The policy objective of decentralization is to improve service delivery and management
of resources and to make services more responsive to the needs of the people through
participation of local-level health workers and communities in the development and
implementation of health programs.
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Equity
There is need to ensure that decentralization will not result in greater inequities and
therefore fiscal equalization measures may have to be implemented
Community participation
Unless there is true representation of community interest, decentralization may be
captured by local interests that may not necessarily represent the interests of the
community.
Efficiency
Decentralization should aim at improving efficiency. Services should be rendered at the
most cost-effective level (allocative efficiency) but at the same time economies of scale
are maximized where possible.
Capacity of local level
There is need to ensure that the local level has the capacity to perform effectively the
responsibilities that may be decentralized.
5.3.3. Policies
The Ministry of Health, has taken preliminary steps to decentralize its health services. It
has initiated a process of strengthening district-level health management and is in the
process of defining the responsibilities of these various levels at the district and
institutional levels to clearly delineate roles and responsibilities.
Consistent with the aspiration of the East Timorese government and the constitution,
MoH decentralization policy will aim at gradually decentralize/ de-concentrating the
planning, management and service delivery by transferring authority and responsibility to
lower levels within the government health system and to national and autonomous health
bodies.
In the longer-term, the form of decentralization of MoH activities will be aligned with the
government’s decisions on political and public administration decentralization structures.
This may entail a role for local authorities in health in which case the necessary legal
mechanisms will be required to enable the decentralized institutions to carry out their
functions.
District health services
health services to the lowest level. The districts will therefore become the focus of health
development as being the most viable unit for management.
will be promoted as the vehicle for decentralization of primary
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Effective decentralization will require
develop and implement specific management systems (e.g., accounting, logistics), which
form one cornerstone for decentralized management. Once these are in place, more and
more functions can be decentralized to the lower levels.
support systems. The MoH will continue to
Bottom-up planning
participatory process, such as District Health Plans, for reviewing policy options and
local-level planning. This will give peripheral offices of the Ministry of Health control
over local data and locally based solutions within the national policy guidelines.
and capacity building will be emphasized through more structured
Developing community-level involvement
strategic decentralization strategy. These will centre on establishing inter-sectoral
collaboration and working through local communities to search for new ways to plan and
implement health programs in coordination with the Ministry of Health. More and more,
the provision of health care services will involve the other sectors as well as the
community.
The MoH will have the responsibility to safeguard
districts with a weak income base, poor infrastructure and a smaller share of trained
manpower by allocating funds from the central level.
The Ministry of Health policy is to
progressively assume responsibilities.
Decentralization of the health system will adapt to the future government decentralization
of political and public administration structure, such as local authorities, and to be in line
with decentralization in other sectors of the central government, in which case the
necessary legal framework will be developed. Suitable legal mechanisms will be required
to enable the decentralized institutions to carry out their functions.
in health program management is part of theequity by cross-subsidizing poorerstrengthening the District Management structures to
5.3.4. Functions to be decentralized
In the short-to-medium term the following functional areas will be prioritized for deconcentration
of responsibilities and authority to the periphery fall under human
resources, administration/management and financing.
5.3.4.1. Human Resource functions
Recruitment
The central level will retain the responsibility recruitment as part of national human
resource plan. It will also coordinate with CISPE in recruitment exercise regarding health
staff in levels 3 and above. The District will be delegated responsibility and authority for
recruitment of health staff in level 1 and 2.
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Supervision
The central level has responsibility of overall supervision of the health system. All levels
will have responsibility for supervision of the personnel working under them.
Appropriate authority will be delegated to the district to ensure proper supervision of
health service delivery.
Discipline enforcement
Disciplinary actions will be taken at the central level for senior staff. District managers
will report disciplinary matters to the central level and recommend actions to be taken.
The district will have responsibility for taking disciplinary actions for health workers in
level 1 and 2 only.
Deployment of staff
The central level will recommend deployment of staff according to national priorities.
However, at the district level, District Health Management Team will be responsible for
deployment of health staff posted to the district.
Incentives
The central level will develop an appropriate national incentive system, such as
performance-based system for overall district performance. Clear guidelines for
implementation will be produced. The district will have authority and responsibility for
developing and implementing appropriate district incentives for the personnel.
Production
For the medium term, the central level will have responsibility for production, education
and training programs of the MoH while the districts will have responsibility for
recommending training programs following identification of training needs at local level.
5.3.4.2. Administration and Management functions
Planning
The central level will have responsibility for oversight while district will identify
priorities /needs. The district will have responsibility for budget input.
Monitoring and Evaluation
The central level will have responsibility for compilation of National figures while
districts will be involved in data collection, analysis and interpretation
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Supervision as a monitoring tool will be performed at all levels of the system. The MoH
will have responsibility for developing performance benchmarks for institutions.
5.3.4.3. Financing functions:
Resource Mobilization
The central level will have responsibility for ensuring equity. MoH proposes a strategy of
cross subsidy of districts by establishment of an equalization fund. The districts will
allow initiative to mobilize local funds in coordination with Central level; the proposed
timeframe for this is five years for districts.
Fees Retention
The central level will at the beginning retain 25% and the district 75% of locally
generated revenue from fees (user fees). The tendency will be to reach 100% of retention
from districts depending of the administrative capacity developed in the periphery. The
Central and district level will have authority corresponding with the responsibilities. The
proposed timeframe will be within the next five years.
Expenditure
The central level will have responsibility of determining expenditure ceilings and issuing
block grants. It will retain the responsibility for capital expenditure. The districts will
budget and effect expenditure for recurrent budget items e.g. consumables. The district
will in the long run have authority to manage district block grants and authority to
reallocate within block funds according to guidelines/regulations laid down. A system of
expenditure planning will be put in place to ensure that funds are spent on most costeffective
areas.
5.3.5. Conclusion
While the MoH is committed to gradual decentralization of health system, however, it
recognizes that decentralization depends on the management ability of those responsible
for the administration of resources and on a commitment by the central level to transfer
functions to the local level. In the short run, a strong central unit will be crucial for
successful decentralization.
The Ministry of Health will continue to explore decentralization options as health system
develops, but at the same time it is committed to ensure that the first steps in the
decentralization process are taken.
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5.4. MANAGEMENT STRUCTURES
5.4.1. Ministry of Health
The MoH central level will have the role of overseeing the performance of the health
system in the country. The main functions of the central level will be the development of
policies and regulations, establishing of standards for health services, setting priorities,
national planning and budgeting, donor coordination, management of national programs,
monitoring and evaluation of the health system including supervision of the lower levels.
The MoH will also have the crucial role of safeguarding equity through resource
allocation mechanisms such as cross subsidy.
5.4.2. National Bodies
National Council of Health
National Council of Health (NCH) will be established at the Ministry of Health level.
The role of the NCH will be to provide stewardship of health sector along the national
health goals. NCH will advice the MoH on policy matters and issues touching on public
health interest. The NCH will be established by an Act of Parliament or by a Presidential
decree. Law will define the organization, functioning and composition of the NCH.
National Laboratory
The function of the national laboratory will be to provide referral laboratory services for
the country. It will set standards for laboratory services and be responsible for quality
control, it will also provide on job training for laboratory technicians.
National Center for Health Education and Training
This center will have the role of ensuring continuous education of the health staff.
NCHET plan, develop, implement and evaluate continuing education and in-service
training programs of the MoH. It will be responsible for developing and reviewing
curriculum for health workers training.
Institute of Health Sciences
The MoH will establish an Institute of Health Sciences. This institute will be affiliated to
the University of East Timor under a faculty of Health sciences. The role of this institute
will be to develop appropriate academic programs and to train graduate-level health
professionals such as nurses and paramedical health workers according to projected
needs of health human resources in East Timor.
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Food and Drug safety Agency
The Food and Drug safety Agency will be established under the umbrella of the National
Board for Licensing and Registration of Drugs. The Agency will be charged with the
responsibility of inspecting regulation enforcement on food and drug safety and
implementing appropriate measures. The MoH will develop the necessary legal
framework that will be required for the agency to carry out its functions.
Blood Transfusion service
This will be a nationally coordinated program whose main role will be to promote safe
blood donation. Its function will be to manage the national blood bank and carry out the
relevant training.
National Research Center
In the medium to long term, the MoH will establish a National Research Center (NRC).
The NRC will be charged with the responsibility of promoting and supporting essential
health research initiatives and developing a national health research agenda in East
Timor. It will issue clearance for research, co-ordinate research activities, conduct
research training and disseminate research findings.
5.4.3. Management structures at District Level
The objectives of the management structures are to improve efficiency and quality of
services as well as to ensure responsiveness of the health services to the needs of the
people they serve.
Within the context of district heath system a number of management structures will be
created.
District Health Management Teams
District Health Management Teams have been established in all districts and their terms
of reference elaborated. The role of the (DHMT) will be to plan, supervise, coordinate,
monitor, report, and evaluate all health activities at the district level. The DHMT is
expected to ensure effective and efficient health service delivery in the whole district. In
addition to service delivery responsibilities, the team will carry out administrative,
financial, and logistical functions that fall under their jurisdiction. In carrying out its
responsibilities, DHMT will link with and develop working relationships with the
district’s health-related stakeholders.
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Hospital Management boards
Gradually, Hospital management boards will be created. Initially Hospital Management
boards will be advisory. Their function will be to represent the interests of the users and
the community regarding hospital services to ensure that standards are maintained, and
resources are efficiently used. The boards will also initiate activities such as fund raising
for improvement of the hospital facilities/services. The MoH will develop guidelines on
the functions, authority, legal mandate and the relationship with the hospital managers.
District Health Councils
In line with decentralization policy, is clear that more local involvement is required.
District Health Councils will be established in all Districts to provide local oversight of
the district health services and to provide linkages with the community. The function of
the District Health Council will be to advice the DHMT but at the same time act as a
watchdog of public in the district. In general the council will be empowered to
superintend the management of health services and support public health care programs,
being as well a good forum for feedback of/to the community. The body will have
representation from the Ministry of Health, the District Administration, Local NGOs and
Religious Organizations and the local community. District Health Management Teams
(DHMTs) and District Health Council will work closely together in prioritizing needs. In
the long run, the Ministry intends that eventually, these Councils assume more
responsibility in overseeing the use of locally generated health funds.
At the community level, the MoH will support health facility and community initiatives,
such as health center facility committees or village health committees that support
improvement of health services to the community.
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5.5. MONITORING AND EVALUATION
5.5.1. Background
With the withdrawal of the Indonesian system, East Timor was left practically with no
mechanism to monitor the efficiency of the almost destroyed health system.
During the first year after Indonesia left East Timor, the health system was concentrated
in providing health services mainly through the intervention of international nongovernment
organizations. Monitoring and evaluation was done basically through the
individual NGO mechanisms and very often not coordinated by the Interim Health
Authority (at the beginning WHO played an important role in monitoring and report of
activities through the Epidemiological Surveillance System).
The Division of Health Services (DHS) adopted a monitoring tool early in 2001 being
able since then to scrutinize and follow up all main processes related to health service
delivery. The Monitoring Quarterly Report provides the Ministry of Health with
information on the level of utilization of the main health services like outpatient,
inpatient, maternity and immunization. It also provides information about the quality of
the drug supply as well as the referral system. Access is also monitored through this tool
though not much accuracy is involved in this reported area.
Currently, the same tool is being improved and is already providing a good view of the
patterns of utilization of the different areas of the system.
With regard to evaluation, NGOs ran some evaluation of their own projects and many
didn’t report to the MOH, as it was internal to their organizations. Some surveys have
been done in some districts providing very scattered evidence not very representative of
the whole country.
5.5.2. Policy objective
Monitoring and Evaluation are, for the MOH, key elements to the health system allowing
it to react to deviations in the planned intervention as well as to measure the impact and
the process.
5.5.3. Policy content
The Ministry of health will ensure that impact, processes, outcomes and responsiveness
of the health system is monitored and evaluated in order to know whether the strategies
adopted are producing the expected results.
All programs and interventions should provide indicators and benchmarks that allow the
MOH to monitor and evaluate their performance.
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The Health Information System will be also an important tool for monitoring the effect of
the health interventions in terms of changes in morbidity, mortality and other aspects of
the process itself.
At each level of the system a set of indicators will be analyzed and contrasted on periodic
basis. Reporting to higher levels is just informative but much of the emphasis has to be
put in the local analysis of data and feedback to relevant levels. Monitoring and
evaluation tools will be necessary for decentralization purposes.
Decision-making will be based on the information provided by the different levels of the
system and good decisions will only be possible if accurate information is available about
the inputs and outputs that the system is processing and producing.
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5.6. PUBLIC/PRIVATE MIX
5.6.1. Background.
Indonesian system was pluralistic in nature with private and public participation in health
sector, provision and financing. However the system was characterized by inefficiency,
unregulated private practice, corruption and inequity in service delivery.
In post Indonesian rule, the private health sector has continued to exist. While there is no
reliable information on the current level of private health sector, what is officially known
is probably under-estimated.
The private sector consists of for-profit as well as not-for profit providers. These include:
medical practitioners clinics, nurses and midwives, private laboratories, private
pharmacies and traditional medical practitioners. The private sector is still highly
unregulated with no legal regulatory mechanism yet in place.
A number of policy options exist in configuring the overall health system with regard to
public/private mix. Based on two variables of nature of service provision and nature of
financing, therefore a health system can be publicly financed and publicly provided
(Public -Public), publicly financed and privately provided (Public-Private), privately
financed and publicly provided (Private-public), or privately financed and privately
provided (Private-Private)
The government does not consider controlling the entire health sector nor does it favour
private-private system. The challenge will be to determine the most appropriate
public/private mix in service provision and financing.
5.6.2. Policy objective
The policy objective is to increase coverage, efficiency, quality, equity and consumer
choice through the regulated participation of the private health sector.
5.6.3. Policy contents
•
of public and private provision and financing of health services.
Ministry of Health will promote a pluralistic health system based on a mixture
•
of public health services in the medium term while the private sector will
complement and supplement the provision and financing of health services
particularly in underserved areas.
The MoH will by necessity continue to be the dominant provider and financier
•
sector, delivery and financing of essential package of public health services
The strategic vision of the MoH is that its role will be to regulate the health
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while gradually shifting the delivery of other health services to the private
sector.
•
in health through:
The MoH will create an enabling environment for private sector participation
o
the Ministry of Health and other health providers.
Creating forums and avenues for dialogue and collaboration between
o
discretionary health services by the private sector and NGOs in
underserved areas
Explore incentives to encourage the provision of essential and
o
registration and licensing of private and NGO health providers and
institutions.
Effecting relevant legislation to facilitate and streamline the
Regulation of health sector
private sector participation in health can bring but also is aware of the pitfalls of
unregulated private health sector. The MoH will therefore seek to balance the control and
incentives mechanisms in order to influence positively and maximize benefits of the
private sector participation. To begin with, the MoH has developed guidelines for NGOs
wishing to operate in the health sector. It will be necessary also to ensure that the quality
of care and standards of medical practice and professional ethics are met. Minimum
quality standards for private health facilities will be developed and issued in the form of
regulation. In order for the MoH to effectively regulate the private sector, it will develop
suitable regulatory and inspectorate mechanisms.
. While the government recognizes the advantage that the
The role of the government in service delivery
services
outside these core services will be privately provided and financed. In making policy
decisions regarding services to be allocated between public and private sectors, the MoH
will take into account which services the private sector is relatively efficient at providing
and which services have a relatively better performance when provided by government.
The MoH will in future consider contracting private providers services in areas where the
Ministry of Health is not able to cater for the population specifically.
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. The MoH will define a set of corethat will be financed and delivered by the government. Health care services
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5.7. CONTRACTING OUT
5.7.1. Background
The role of contracts or service agreements in health care is an important part of
public/private mix. It is important to define the nature of these public/private
relationships, as they can be complex.
In the health sector, there are several types/objectives of contracting out services. These
include: contract for a service such as primary health care, where the public sector has
little implementation capacity e.g. contracting private doctors in rural districts,
contracting out of emergency ambulance services, contracting out support services.
There are broad issues of principle and process that need to be highlighted. These include
the importance of the transparency of the process of contracting and the negotiation skills
and as well as ability to manage contracts of a wide scale. Furthermore, there is need to
examine the legislation or public service regulations that will govern such contracts, and
formulation of any other laws and regulations that may needed.
5.7.2. Policies
The Ministry will consider contractual agreements for services where there is a clear that
such an agreement will be improving quality of services and is the most cost effective
way of delivering the specific services. This will be done where the MoH has the ability
to supervise and manage contracts. The MoH will initially, contract out support services
in hospitals and in the longer run explore contracting PHC services with NGOs
Development of contracting arrangements will be guided by experiences of other
countries. It is important that there exists a well-developed, competitive and efficient and
transparent private sector. At the same time, there should be capacity within the
government to manage contracts in order to ensure value for money. Finally, necessary
guidelines and legal advice must be available. The MoH will further define the nature of
these relationships and the type of contract most likely to be appropriate.
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East Timor Ministry of Health
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53
6
6.1. Background
. DRUG POLICY
During Indonesia occupation the implementation in East Timor of apparently good
National Drug Policies had major gaps, leading to frequent problems of supply at the
delivery point and inappropriate use (polypharmacy, overuse of antibiotics, overuse of
injections and low compliance).
After the withdrawal of Indonesia and during the transitional period to Independence,
East Timor has relied initially on the contribution of NGOs and UN agencies through
donations. The management of the drug supply was decentralized, each district having
the responsibility of ordering, picking up at the central store in Dili and distributing the
pharmaceuticals to the health facilities.
Later, with the withdrawal of the NGOs and the introduction in September 2001 of a
program for development of an Autonomous Medical Supply System the supply of drugs
was again centralized in Dili. An Essential Drugs List was drafted and importation was
done by the firm managing the AMSS on international competitive basis.
Stock outs of essential drugs are being reported from some districts every quarter
(Quarterly Monitoring Report), inappropriate use of drugs is common, irregular
importation of drugs (smuggling) by uncontrolled elements leading to marketing of
pharmaceuticals of unreliable quality is detected and non protection of the population
against too high prices are common problems faced currently by the health sector.
Private pharmacies are currently operating in East Timor without any standard or
supervision from the government leading to high risk of public and individual health
hazards.
6.2. Policy objective
This policy will contribute to ensure that a sufficient range of safe and effective drugs of
good quality is accessible and affordable for the entire population and that they are
properly used.
The principles guiding this policy are based on the values that the Ministry of health
adheres.
Efficient management of drugs and other medical consumables will allow the
government to promote equity by ensuring adequate quality and affordable drugs supply
to all the people in east Timor, including the most vulnerable groups. Equity will also be
protected by adapting the cost of drugs to the real economic situation of the country.
Allowing a regulated development of the private sector will improve access to products
and services with a public health benefit and will limit harmful practices.
East Timor Ministry of Health
Health Policy Framework
54
6.3. Policy contents
•
and regulations derived from this policy framework that will make it enforceable.
Drug registration and licensing, quality assurance (legal frame) and regulation of
prescription and distribution will be promulgated in order to support the
implementation of this drug policy.
Legislative and regulatory framework: the ministry of health will develop legislations
•
carefully selected in order to ensure proper quality and best prices.
Selection and registration of drugs: the drugs to be used by government will be
o
Drug List (NEDL) containing all drugs that should be available in public
institutions or part of a Non Scheduled Drugs List (NSDL) with drugs not
included in the NEDL but allowed to be imported and delivered at specific
levels of service delivery with special justification. A list of medical
consumables and equipment will also be done ensuring minimum quality
standards of production, sterilization, handling and delivery.
All drugs to be used in East Timor will be part of either the National Essential
o
be done by the National Board for Licensing and Registration of Drugs
(NBLRD) and supervised by the Food and Drug Inspectorate within the
Ministry of Health. The NBLRD will be legally constituted.
Only registered drugs will be allowed in east Timor. Registration of drugs will
•
business in the area of pharmaceuticals is to ensure availability of drugs to the general
public, protect consumers of harmful or hazardous substances and to ensure proper
quality and control prices of pharmaceutical products. Private pharmacies will be able
to retail drugs out of the NEDL only if they are included in the NSDL and are
registered in the NBLRD. They have also to be registered as a business in the relevant
authority (Trade and Commerce Department of the Ministry of Economic Affairs).
Decisions on licensing will be done by this National board following
recommendations of the Ministry of Health (board of directors). The composition of
the NBLRD will be defined in further micro policy formulation.
Licensing of private pharmaceutical services: the objective of licensing private
•
production of drugs. Only drugs produced following Good Manufacturing Practices
(GMP) standards will be authorized for importation. GMP is a system for ensuring
that pharmaceuticals are consistently produced and controlled according to
internationally accepted quality standards
Production and Quality Assurance: East Timor will not have in the short run local
•
in this area in other developing countries, East Timor has decided to establish an
Autonomous Medical Supply System (AMSS). This is a legally established public
organization, independent from direct ministerial control with full financial and
Procurement and distribution: in order to avoid inefficiencies frequently experienced
East Timor Ministry of Health
Health Policy Framework
55
managerial autonomy enshrined in the law establishing it. The AMSS is answerable
to a Board of Trustees (BoT) appointed by the President with MoH and other
stakeholder representation. It operates under its own in-house regulations (approved
by BoT). The workforce is answerable to the AMSS management and is not part of
the civil service. Financially is self-sustaining and is run on a non-profit, but
commercial basis. The system doesn’t allow credit sales and only works on cash and
carry basis. All essential drugs imported by the AMSS will be exempted of custom
duties or other taxes. A single price is offered for all parts of the country. Only a few
other entities will be authorized to import drugs, mainly cooperatives of nongovernmental
health services or private pharmaceutical business.
Distribution of drugs will be done from the central warehouse (AMSS) to the facility
level. Storage and supply of vaccines and other special drugs and consumables for
specific programs (family planning, TB, etc.) will be the responsibility of the AMSS
as well for what the health system will pay a management fee to the AMSS.
The Ministry of health will develop micro policies for drug donations that will protect
the government of costive disposal of non-acceptable or expired drugs and other
wastages that could arise due to the donations. Some programs are often funded by in
kind items like drugs. The MoH will ensure that drugs donated for these programs are
following the same quality, storage and distribution standards than the rest of drugs
purchased for general health services use.
•
per year. Assuming the population of East Timor to be around 800,000 that represent
$1.6 M USD or the 16% of the total recurrent budget for health. The current levels of
poverty in East Timor and the pessimistic short-term projections in terms of domestic
economy put very difficult the implementation of any cost sharing scheme in the
short run but could be a possibility when economic situation improves.
Drug Financing: East Timor drug expenditure is currently about 2 USD per person
•
Guidelines (NTGs) relevant to the existing morbidity patterns. The National Essential
Drugs List and the National Formulary (reference manual with drug information) will
be based on these NTGs. All prescribers, dispensers and other health workers will be
appropriately trained and compliance closely followed to ensure rational use of
available drugs.
Rational use of drugs: the Ministry of Health, will issue National Treatment
•
practices with legal restrictions to those harmful or proven to be ineffective. Research
in this area will be promoted.
Traditional medicine: the Ministry of health will tend not to disapprove these
------//------
6.4. AUTONOMOUS INSTITUTIONS
6.4.1. Background
East Timor Ministry of Health
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56
The policy options for managing health institutions include running the institutions
within the government existing ministerial functions, granting semi-autonomous status or
creation of statutory bodies regulated by law.
Autonomous status presents an enormous challenge to the organization, its management,
and staff of the institution concerned. The longer-term effects of semi-autonomy on the
country's health services means that working relationships have to be renegotiated,
organizational systems redesigned, new knowledge and skills learnt and practiced at
once. Often, the autonomous status calls for appropriate legal framework to be put in
place.
The rationale for autonomous functioning of the national health institutions is
improvement of efficiency and effectiveness by exempting it from central government
bureaucracy. The policy formulation of autonomy of health institutions will be guided by:
the need to ensure that the institutions do not become a drain on government resources,
transparency and accountability, the capacity of the institution to implement
management practices
on a structured and informed process of policy analysis, and experience in other places.
bestin the services it is to provide, that autonomy decisions are based
6.4.2. Policies
Given the challenges establishing and managing autonomous institutions
expected benefits, the Ministry of Health will carefully review the need for autonomous
status of various health institutions based on policy objectives and guiding principles of
improving performance of health institutions and will make appropriate
recommendations to the government.
In the immediate term, the MoH proposes that the Central Medical Store to granted an
autonomous status to be known as Autonomous Medical Supplies System (AMSS).
Experience elsewhere has shown that this system can be of great benefit in improving
efficiency and transparency and have the potential in the long run to save the government
millions of dollars through Good Management Practices implied in this medical supply
system.
The main role of the Autonomous Medical Supplies system will be to ensure efficient
provision of medical supplies including drugs and medical materials as well as support
monitoring of medical supplies management at district level. As an Autonomous Medical
Supplies institution, the AMSS will be a not-for-profit institution but will nevertheless be
required to run on commercial principles. The operations will be self-financing by
recovering costs. Any surplus revenue realized will be injected back to improve its
operations. The Government will provide the initial capital required to start the
operations. Legislation will be required to establish AMSS as legal entity. The legislation
will further define the status, authority, composition of the institution and the relationship
with the MoH.
“vis a vis” the
East Timor Ministry of Health
Health Policy Framework
57
With regard to other health institutions, in the long-run the MoH will consider granting
semi-autonomous status to licensing and regulatory national bodies, and tertiary hospitals
especially where it is accompanied by the introduction of user charges and where
Hospital Management Boards have developed the capacity to manage the institutions.
The longer-term effects of semi-autonomy on the country's health services may be even
more marked, in terms of the change in the hospital's role in the health system, changed
staff attitudes and patient perceptions, and most important, the renegotiated relationship
with the Ministry of Health or with Government. It is important that the policy
formulation of hospital semi-autonomy be based on a structured and informed process of
policy analysis, and that it be enabled to draw on documented experience in other places.
------//------
East Timor Ministry of Health
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58
7. EXTERNAL ASSISTANCE
7.1. Background
External assistance to the health sector has taken several forms such as multilateral,
bilateral, charitable organizations/NGOs and can be delivered in form of Technical
Assistance (consultants, studies, research), capacity building (training) or
scholarships/fellowships. External assistance has also been provided in the form of
equipment and commodities. It was estimated that in year 2000 external assistance was
covering approximately ¾ of the health spending requirements of East Timor.
External assistance started during the emergency phase in the aftermath of the 1999
violence that almost completely destroyed the health infrastructure. During the initial and
much of the transitional phase, NGOs and international agencies provided the muchneeded
managerial and technical (doctors) capacity.
In March 2000 a trust fund for East Timor (TFET) was established under the World
Bank. Two projects are being implemented. The first phase (TFET1) focused on
addressing the immediate basic health needs and health system through the restoration of
access to basic package of services and the second (TFET2) has the objective of assisting
in rehabilitating and developing a cost-effective and financially sustainable health system
and with a well integrated and sustainable health policy framework to prepare the health
system to meet its future needs.
7.2. Current situation
In addition to humanitarian aid/ NGOs and TFET arrangement, bilateral and multilateral
UN external agencies offer assistance to the health sector in East Timor. Most agencies
focus on increasing access to specific areas of their expertise and training activities.
Technical Assistance (TA) has concentrated on such problem as the curricula for training
health workers or rehabilitation/reconstruction of health facilities.
In spite of the extensive technical assistance offered by donors, efforts to strengthen
management systems, planning and capacity building have been modest.
It is critical that the coordinated international support program, which has contributed so
much to the successes achieved to date in East Timor, continues to support the nascent
state over its transition and in the difficult years following independence. Much work
remains to be done in the coming years. East Timor will seek the support of its donor
partners in finalizing its national development strategy and medium-term expenditure
framework and in providing technical assistance to areas of government where capacity
is still developing. This continued international partnership would be crucial to ensure
that the gains made in social and economic recovery in the last two years are maintained
and strengthened after independence.
East Timor Ministry of Health
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59
Although financing gaps will continue to exist external assistance in the coming years is
likely to decline or remain constant in real terms. Official documents foresee in the
medium term, donor contributions and bilateral assistance will be substantially reduced.
According to these assumptions, in the medium term for each dollar spent by public
sector 0.5 or more will come from the country fiscal tax revenue and the rest from
external assistance.
However, a number of governments and UN agencies have indicated interests in
providing support to the Ministry of Health in specific areas in the future. The estimated
bilateral assistance to 2005/06 financial year with current donor commitment amounts to
USD 6.63 million. UNICEF, WHO and UNFPA have expressed their interest in continue
to support health projects in East Timor. Estimated amounts in the next 4 years are USD
723,000. In some cases, however, the extent and basis of bilateral donor contributions has
not yet been determined.
It is worth to note that a number of factors have in the past
of external assistance
health sector had several drawbacks like the lack of control and accountability, and delay
in disbursement of funds, resulting in inequity and different standards of health services
between districts. Other problems related to donor projects included the overload of local
capacity to coordinate donors particularly during program development and
implementation, lack of sustainability and institutional development and inefficient use
of resources.
On the part of the MoH, the absence of a health sector strategic policy framework that
would present coherent goals, objectives and targets which would guide the level of
investment required for achieving the policy objectives to be agreed upon by the
Government of East Timor and development partners, has limited the effective leadership
role of the MoH in dialogue with the donors.
External assistance to the health sector will be guided by the need to develop a health
system that is equitable, efficient and sustainable. Donor contributions will be targeted to
identified priorities of the health sector. Longer-term donor commitment will be preferred
where it is critical to the realization of the objectives of the health programs.
Some key external policy issues will require further dialogue with donors. These include:
approaches in funding health programs considering the likely divergence of different
donor’s external assistance policies, such as preference for project funding or Sector
Wide Approach, as well as the MoH capacity to manage those funds in order to make the
constrained the effectivenessin East Timor. Assistance through NGOs in the initial phase of
best use of the external assistance.
Another issue, which is related to approach of funding is how such assistance should be
channeled either
directly Non-Governmental health providers.
through the government, earmarked for specific health areas or to
East Timor Ministry of Health
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7.3. Policies.
The MoH will therefore pursue the following policies related to external assistance.
The MoH policy towards external assistance will be to pursue strategies that will
maximize benefits to the health sector mobilizing external assistance towards addressing
identified priority areas and in accordance with the plan of the government in order to
achieve sustainable health development under the government leadership. The MoH
policy will be to engage all development partners in continuous dialogue for the interest
of country.
To maximize donor inputs the attention will need to be given to the following
implementation issues:
•
Donor supported program funding should take into account the ability of the Ministry to
use available funds during a given time period and the capacity to manage/implement the
identified program activities. If necessary it should build into their programs
mechanisms to ensure that institutional capacity is augmented to allow for effective
program implementation.
Limited absorption capacity of the Ministry of Health.
•
The work-plans of donor program activities should be supportive of those of the MOH.
As part of the donor contribution, participation in the elaboration of the work-plans of the
MOH will be sought.
Work-Plans
•
All technical assistance consultants will work with identified counterparts to ensure
capacity building within the MoH and civil society in coordination within the MOH. In
addition, consultants will be required to provide technical reports as well as the
methodologies used in their studies.
Capacity building
•
Technical assistance needs will be jointly identified by MoH and concerned donors. The
MoH and the donors will also draw up the Terms of Reference (TOR) for proposed
consultants.
To ensure relevance and value for money
•
The Ministry of Health will be responsible and accountable for external assistance
provided. Division of Health Policy and Planning will do donor coordination. External
Management and Coordination of external assistance
East Timor Ministry of Health
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61
assistance will be monitored through forums such as Donor Co-ordination meetings and
joint donor missions.
•
All NGOs dealing with health should submit their proposals to the MOH for technical
review and once approved, work consistently with the MOH’s policies and procedures.
Guidelines for NGO interventions have been produced as well as a set of principles that
the projects proposed should follow.
NGOs
•
All programs of cooperation with the UN agencies, bilateral and multilateral
organizations will be based upon formal agreement with the MOH and the
country/organization/agency. Coordination and negotiation between organizations will be
the responsibility of the government. MOH will also be responsible for providing
clearance to any foreign technical input of support to the health sector.
UN Agencies, Bilateral and Multilateral organizations
•
All training activities by donor agencies involving health workers will follow MoH
training guidelines already issued.
Training activities
•
To ensure that equipment provided through external assistance are appropriate to the
level of health care services in East Timor, the MoH will develop guidelines and
standards regarding such equipment. These guidelines will ensure standardization of
equipment and that no obsolete equipment is donated. Furthermore, the equipments will
be those that the MoH is able to maintain. Donors will ensure that proper training is
provided for any equipment that is supplied.
Equipment
•
MoH will develop guidelines concerning donations of drugs and other consumables.
These guidelines will form the basis for acceptance or rejection of such donations.
Commodities
•
The Ministry of Health will prefer longer-term support through program aid rather than
short- term projects (stand alone projects). Longer-term support is likely to have impact
of external assistance in improving health status of the people
Timeframe
East Timor Ministry of Health
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62
•
In the short run, bilateral and multilateral assistance may be required for budget support
to ensure that projects can be effectively implemented e.g. in EPI.
Budget support
7.4. Sector-wide Approach (SWAp)
The MoH supports the objectives of SWAp to ensure that external assistance is not
donor-driven but according to priorities agreed between MoH and the donors. In
principle the MoH recognizes the potential advantages and mutual benefit sector-wide
approach. To the donors, it ensures supportive policy environment for aid to produce
sustained benefits, have influence on policy across the whole sector, aid benefits are
broader, more sustainable and help build solid systems. To the government, all resources
support Government strategy, rules of the game reduce costs of dealing with multiple
donors, builds capacity, does not duplicate, possibly increased donor commitments on
longer term in a less earmarked form,
7.5. Focus of external assistance in the medium term
External aid policies of donors are shifting from emergency rehabilitation to development
of
priorities as health system evolves.
Emphasis on donor contributions will be given to
expanding coverage particularly to under-served areas and to ensuring provision of basic
package. Priority areas will also be technical assistance in developing the health system
and institutional and health workers capacity building. Strengthening policy and
management systems, planning and capacity building will enable the MoH to take a
leadership and stewardship role in the health sector.
sustainable activities. These activities are expected to correspond to national ofimproving access to health services by
7.6. Linkages with civil societies involved in health.
The MoH will develop clear strategies on how civil society involvement in health care
will be promoted/assisted with the objective of harnessing their contribution to health
improvement and particularly in strengthening community linkages. To this end, MoH
will discuss with the donors on how funds could be channeled to civil societies.
------//------
East Timor Ministry of Health
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LIST OF ANNEXES:
1.- Participants of the Policy Formulation Process
2.- Participants of the Stakeholder Consultation Workshop 29/05/02
3.- Service Delivery System in East Timor (matrix)
4.- Driving Time From District CHC L3/L4 to Nearest Surgical referral Facility
5.- Distribution of Health Facilities in East Timor
East Timor Ministry of Health
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Annex 1
MEMBERS OF THE CORE HEALTH POLICY WORKING GROUP
Dr Rui Araujo (Minister of Health)
Dr Joao Martins (former Vice-Minister of health)
Dr Rui Paulo de Jesus (former Director General health)
Dr Virna Martins (Director Division of Health Policy and Planning MoH)
Sr Basilio Martins (Head of sub-division of Legislation and Regulation)
Sr Augusto Tolan (Chief administrator Central Laboratory)
Sra Enriqueta da Silva (Association of Laboratory Technicians)
Dr Antonio Gusmao (Clinica Café Timor)
Dr Artur Corte Real (ET Medical Association)
Sr Delfin da Costa (Pharmacist Association)
INTERNATIONAL FACILITATORS
Mr Alvaro Alonso, Senior Adviser Health Policy and Management
Mr Moses Njau, Adviser on Health Policy Development
Ms Iris Hamelbergh, Adviser Administration
PARTICIPANTS FOR SPECIFIC POLICY AREAS
Sr Diamantino de Jesus, Head of Sub-Division Human Resources MOH
Prof. Huq, World Health Organization specialist in Human Resources
Mr James Herm PhD, Senior Lecturer University of New York, New York*
Mr Paolo Belli, Harvard School of Public Health, Harvard University*
Sr Valente da Silva, Head Sub-Division Monitoring and Evaluation MOH
Dr Alex Andjapardize, Representative World Health Organization East Timor
Dr Stembergh Vasconcelos, Health Coordinator UNICEF East Timor
Mr Daniel Baker Head of UNFPA East Timor
Sra Lidia Gomes, Head Sub-Division Basic Package MOH
Sra Ana Isabel de Fatima, Head Sub-Division of Health Promotion MOH
* Concept papers by these authors used as base for policy discussions
East Timor Ministry of Health
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Annex 2
STAKEHOLDER CONSULTATION MEETING FOR HEALTH POLICY
FORMULATION 29th May 2002
Facilitators
Dr Rui Araujo Health Policy Working Group (HPWG)
Dr Joao Martins (HPWG)
Dr Virna Martins (HPWG)
Sr Augusto Tolan (HPWG)
Sra Enriqueta da Silva (HPWG)
Dr Artur Corte Real (HPWG)
Sr Delfin (HPWG)
Sra Nidia Oliveira (volunteers)
Sr Luis dos Reis (volunteer)
Sr Valente Da Silva (volunteer)
Sr Joao Martires (volunteers)
Sr Justino Babo (secretary)
Sr Raimundo Lobato (secretary)
Sr Fredy Martins (secretary)
Sr Silvino Memo (secretary)
Sr Francisco Sarmento (secretary)
Attendance
Ministry of Health
Sr Luis Lobato, Vice-Minister of Health
Sr Carlos Tilman, Director Health Service Delivery
Sr Francisco Dos Santos, Director of Division Finances, Administration, Procurement
and Logistics
Sra Ana Isabel De Fatima, Head Sub-Division of Health Promotion
Sra Lidia Gomes, Head of Sub-Division of Basic Package
Sr Basilio M. Pinto, Sub-Division of Regulation and Legislation
Sr Felisciano Pinto, Head of Sub-Division Specialized Services
Sr Estanislau da Cruz, Head of Sub-Division Laboratory and Blood Transfusion
Sra Sonia Valladares Sub-Division of Health Information
Sr Mario Ribeiro, Head of Sub-Division Drugs and Medical Supply
Dr Pedro Sam, Director National Hospital Dili
Sr Pedro Canisio, Sub-Division of Health Promotion
Sr Marcelo Amaral Sub-Division Human Resources
Sr Chico Salgueiro, Director National Center for Health Education and Training
Sr Diamantino de Jesus, Head of Sub-Division Human Resources
Sr Domingos Da cruz, Head of Sub-Division of Finances
East Timor Ministry of Health
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66
Sra Isabel Gomez, District Liaison Officer
Sr Jose dos Reis Magno, Head of District Health Services Aileu
Sr Diogo de Araujo Amaral, Head of District Health Services Ainaro
Sr Antonio Bonito, Head of District Health Services Baucau
Dr Bourdaleu F. Moniz, Head of District Health Services Bobonaro
Sr Jose Amaral, Head of District Health Services Covalima
Sr Macario Faria da Silva, acting Head of District Health Services Dili
Sr Agustino Maria Pereira, acting Head of District Health Services Ermera
Dr Romualdo Bosco, Head of District Health Services Lautem
Sr Filomeno de Oliveira, Head of District Health Services Liquiça
Dr Jose Maria Ugarte District Health Management Adviser
Sra Sarah Moon District Health Management Adviser
Dra Edelmira Go, District Health Management Adviser
Dr Luis Eduardo Fonseca District Health Management Adviser
Sr Agapito da Silva Soares, Head of District Health Services Manatuto
Sr Alberto Martins, Head of District Health Services Manufahi
Sr Manuel Acunha, Head of District Health Services Oecussi
Sr Marcos Seo, Administrator Hospital Oecussi
Dr Mendes Pinto, Head of District Health Services Viqueque
Other Ministries
Sr Cristino Gusmao Ministry of Finances
Sr David Ximenes Ministry of Internal Administration
Sr Manuel Noronsa State Secretariat for Labor and Solidarity
Sr Carlitos Cabral State Secretariat for Labor and Solidarity
Sr Amandio Amaral freitas State Secretariat for Labor and Solidarity
District Administration
Sra Maria Paixao District Administrator Aileu
Traditional Leaders
Sr Elidio Mau-Felo District Aileu
Sr Balbino de Araujo District Ainaro
Sr Domingo Mardy District Bobonaro
Sr Adriano Joao District Bobonaro
Sr Armindo Ferreira District Covalima
Sr Anselmo da Concepcao District Dili
Sr Felix Gusmao District Dili
Sr Anibal Pereira District Dili
Sr Silvino Memo District Oecussi
Sr Armindo Viana District Viqueque
East Timor Ministry of Health
Health Policy Framework
67
Professional Associations
Sr Luis Lobato Nurses association of East Timor
Sra Lidia Gomes Midwives association of east Timor
Sra Ivone de Jesus Midwives association of east Timor
Sra Dirce Maria Soares Nutritionist Association
Sr Andres Soares Health Teachers Association
Sra Enriqueta da Silva Laboratory Technicians Association
Sr delfin da Costa Pharmacists Association
Sr Alberto Moniz Radiologist Association
Sr Aniceto Cardoso Health Professional Association (KLIPSTIL)
Non-Governmental Organizations
Sra Nina de Fatima Oxfam
Mr Robert Thulen Oxfam
Pastoral da Crianza
Dr Jaime Sarmiento Caritas East Timor
Sr Manuel Mausiry PRADET East Timor
Sr Luis Freitas East Timor Red Cross
Non-Government Health service Providers
Dr Ross Brandon Café Timor Clinic
Dr Sr Duarte Ximenes Café Timor Clinic
Dr Antonio Gusmao Café Timor Clinic
Dr Don Murphy Clinica Bairo Pite
Motael Clinic (Carmelitas)
Irma Paola Dellaciana Irmas Salesianas de Venilale
Irma Joana Canesianas Dili
Sr Vinsanciua Juarez PRR Kuluhun and Eimutin
Pharmaceuticals
Sr Cosme Bonavides Autonomous Medical Supply System
Sr Boris Zemtov Autonomous Medical Supply System
Sr Isaac Autonomous Medical Supply System
Lastari Pharma
Traditional Medicine
Sra Maria C. de Jesus Traditional Birth Attendant (Dukun)
Sr Baltasar Traditional healer
Sr Patricio da Costa Traditional healer
Sr Alexandrino da Costa Traditional healer
L Sr Ricarda CIJ Religious Herbalists
Youth Groups
East Timor Ministry of Health
Health Policy Framework
68
Sra Isabel Exposito HIV working group
Sra Santina A.F. HIV working group
Sra Rosa de Sousa HIV working group
Sr Nuno HIV working group
Sra Cecilia de Jesus
Representative Scoutairos (boys and girls)
Women Groups
Sra Rosa de Sousa FOKUPERS
Sra Santina Fernandes FOKUPERS
Sra Laura Soares Abrantes FOKUPERS
Sra Maria Angelina Pereira ET Wave
Sra Dulce Vital REDE Feto
Embassies and cooperation office’s representatives
Mr Shao Guanfu China Embassy in East Timor
Representative AusAID
Mr Guglielmo Colombo European Commission
Mass media (as stakeholders)
Representative TVTL
Sr Jose Gabriel Timor Post
Sr Victor Maia RTK
Suara Timor Lorosae
UN and International Agencies
Dr Alex Andjapardize WHO
Dr Stemberrg Vasconcelos UNICEF
Dr Aniceto Cardoso UNFPA
Mr Daniel baker UNFPA
Others
Sr Samuel Belo Protestant community
Mr Joe Thomas, HIV project manager
Apolinario dos Reis
Sr Francisco Assis
TOTAL 115

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Monday, September 27, 2010

Mai ita hamutuk lembra timor Leste ba Nafatin

Thursday, September 23, 2010

EAST TIMOR’S HEALTH POLICY

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