East Timor Health Sector Situation Report



WORLD HEALTH ORGANIZATION

East Timor

East Timor Health Sector

Situation report

January – December 2000

OVERVIEW

Beginning at the time of the referendum on independence for East Timor on August 30, 1999, civil unrest during the early month of September lead to the displacement up to 75% of the 850 000 residents of East Timor. Many hundreds of people were killed and a large proportion of private and public buildings heavily destroyed. During this time, 77% of health facilities were damaged. In addition to the physical destruction of health facilities, the emigration from East Timor of doctors and core health professionals (many of them Indonesian nationals) caused the total collapse of the health systems in the territory.

East Timor needed urgent assistance from the international community. Within a few days of the deployment of INTERFET (the International Force for East Timor), OCHA, UNHCR, ICRC and WHO’s Department of Emergency and Humanitarian Action (EHA) had established a presence in East Timor. WHO/EHA role was to immediately coordinate the public health interventions and ensure timely and appropriate information sharing among all partners involved. WHO deployed staff members from HQ, Regional Office for South-East Asia and WHO Country Office in Indonesia as well as employed professionals on short-term assignments. ICRC and fifteen international NGOs, together with military medical teams from INTERFET, began to provide curative services to the general population. During the year 2000, a total of 694,745 consultations and curative interventions were undertaken almost half a million consultations have been provided – more than 80% of the current population of East Timor.

At the early stage in September 1999 to January 2000, WHO together with UNICEF acted as a "Temporary Ministry of Health" coordinating health sector activities in the Territory. ICRC and fifteen International NGOs, together with military medical teams from INTERFET provided curative services to the general population.

On 25 October 1999, by resolution 1272/1999, the Security Council established the United Nations Transitional Administration in East Timor (UNTAET) with overall responsibility for the administration of East Timor through exercise of all legislative and executive authority, including the administration of justice. UNTAET was mandated to consult and cooperate with the East Timorese people to develop national democratic institutions, and to transfer to these institutions its administrative and public service functions.

WHO, with technical back-up from the EHA Department, actively participated in and technically supported the review of health services of East Timor (conducted in December 1999 and January 2000) and the subsequent establishment in February 2000 of the Interim Health Authority - a precursor of the present Division of Health Services.

On 15 July 2000, a transitional Government of East Timor was established, headed by the Transitional Administrator, a Cabinet consisting of 8 Members - four East Timorese and four international staff from ETTA - and a National Council with 33 members. WHO will work in partnership with the Divisions of Health Services and Water & Sanitation under the charge of Cabinet Members for Social Affairs and Infrastructure.

Consistent with the latest developments when East Timor is now ready to move from a state of emergency to development stages, the direction of WHO collaborative activities will be aligned accordingly. In the current situation in East Timor, more than 80% of the population have inadequate income, poor health status, lack of access to adequate health care, safe water & sanitation, insufficient food and nutrition and are faced with poor housing, especially due to wide scale destruction of buildings. Consequently, health would be a major priority for the development of East Timor.

The visit of the WHO Director-General, Dr Gro Harlem Bruntland in October 2000 was instrumental in creating realization in East Timor Transitional Administration on the importance of the health sector, as a major part of social and economical development of East Timor. Consequent upon her visit, health was given priority in administrative as well as at all political levels. This report is intended to give an account of WHO activities during the year 2000.

DEMOGRAPHICS AND HEALTH STATUS

Demographics

• Provisional estimates by the UNTAET Bureau of Statistics, Research and Census (May 2000) put the population of East Timor at 841 000.

• Over 280 000 individuals were displaced during the East Timor crisis of 1999; of those, 165 000 have now returned to their usual place of abode. Within East Timor, more than 80% of the remaining population was internally displaced due to destruction of their homes and ongoing violence. UNHCR estimates that about 105 000 East Timorese remain in West Timor, but most of these are eventually expected to return to East Timor. In addition, 6,000 to 10,000 East Timorese are currently residing in Australia; there is no indication of when they may return to East Timor.

• Just over 50% of the population is under 20 years of age; children under 5 years of age make up 13.5% of the population.

• The birth rate is high (almost 60% in 1998), but an accurate post-crisis estimation is difficult to make.

• The true crude mortality rate during and after the crisis is difficult to estimate; few deaths have been reported through the WHO communicable diseases surveillance system or other avenues.

• It is thought that over 95% of the population is ethically East Timorese. Ethnic minority groups include a small Chinese community; there is also a small population of Indonesian Muslims who chose to remain in the country after the crisis.

• Approximately 9,000 foreign nationals are presently in East Timor, working on reconstruction, aid and development and security related activities.

• Unemployment among East Timorese nationals is estimated at 70%. Per capita income is now estimated around US$210 per year, approximately 50% below its 1996 level (Source: (a) Project Appraisal Document on a Proposed Grant in the amount of US$12,7 Million Equivalent to East Timor for a Health Sector Rehabilitation and Development Project, May 24 2000; World Bank Document. Source: (b) Building Blocks for a Nation, November 2000 – The Common Country Assessment (CCA) for East Timor prepared by the UN country team).

Health status

• Pre-crisis estimates suggest an infant mortality rate (IMR) of between 70 and 90 per 1 000 live births; the most common causes were infections, prematurity and birth trauma.

• Only one in five births is attended by appropriately skilled personnel; prior to the crisis, this figure was approximately 40%.

• The maternal mortality ratio has been estimated to be as high as 890 per 100 000 live births. This is unacceptably high; for example, in Indonesia, the mortality ratio is estimated to be half as high (390 per 100 000 life births). The most common cause of maternal death is severe bleeding, generally occurring in postpartum period.

• The under 5 mortality rate (U5MR) was reportedly 125 per 1 000 live births (World Bank Joint Assessment Mission, 1999), but this may be an underestimate.

• The most common childhood illnesses are acute respiratory and diarrhoeal diseases, followed by malaria and dengue infection. An estimated 80% of children have intestinal parasitic infection.

• Cross sectional nutritional surveys have been conducted in selected districts, and suggest that 3-4% of children aged 6 months to five years are acutely malnourished, while one in five are chronically malnourished. WHO, WFP and the IHA propose to conduct a national nutritional survey for the identification of nutritional problems for targeted intervention.

• Malaria is highly endemic in all districts, with the highest morbidity and mortality rates reported in children. The peak transmission periods are July/August and December/January, although a longer transmission season exists in the east of the country (Lautem district), owing to the prolonged wet season. Based on historical and recent data, P falciparum and P vivax malaria are equally represented. Four districts, including the capital, are high transmission areas and chloroquine resistant strains have been reported. Since 1 January 2000, over 128 000 suspected malaria cases (with 140 deaths) have been reported to the national communicable diseases surveillance system. (WHO Weekly Epidemiological Bulletin, East Timor.

• East Timor is endemic for leprosy; the registered leprosy case prevalence rate is 1.8 per 10 000.

• East Timor is highly endemic for lymphatic filariasis; three species are present (Brugia timori, Bruga malayi and Wuchereria bancrofti), and patients with clinical manifestations of chronic lymphatic obstruction have been well documented.

• Tuberculosis is a major public health problem, with an estimated 20 000 active TB cases nationally (over 2.5% of the total population, and representing a prevalence of approximately 2 500 per 100 000. During the year 2000, 4,054 patients were diagnosed and treatment for TB commenced.

• Sexually transmitted infections (STI) are common in sexually active age groups. The existing curative institutions reported a total of about 35 STI cases per week, mostly in Dili and Baukau districts. However, the actual situation is still to be ascertained.

• Routine childhood immunization recommenced in early March. To prevent an expected outbreak of measles, more then 45 000 children were immunized during a special campaign; this immunization programme has limited the number of cases of measles reported in East Timor (1,343 reported cases between 1 January and 31 December 2000, representing a crude attack rate of 14.5 cases per 100 000 per month). National Immunization Days (NID) for polio eradication campaign in the entire territory was observed in November and December 2000. Total coverage was over 84%. At the same time, the routine EPI coverage was noticed to be very low, for e.g., DTP-3 coverage was less than 20%.

• The level of knowledge on health matters in the general population is poor, and health promotion has been identified as a key component of the basic package of health services to be introduced.

• Between 1 January and 31 December 2000,the curative institutions (international NGOs and the military medical team from INTERFET) provided 694,745 consultations and curative interventions to the population.

• Communicable diseases account for the majority of deaths, approximately 60%, particularly in children associated with respiratory infection, diarrhoea and malaria, followed by the non-communicable diseases, chronic diseases, road traffic accidents and other conditions.

Health System

← WHO played a catalytic role in East Timor in the formation of future direction of health development, the formation of its health authority and in formulating health policy, planning and health regulations.

Starting from the emergency phase, many NGOs, national and international institutions, UN agencies and donors wished to be involved in the process of restoration of health services in East Timor. To harmonize and coordinate these efforts, WHO had the responsibility for the overall coordination. Later Interim Health Authority successfully took over this function.

A group composing of representatives from WHO, UNICEF, UNFPA, International NGOs and East Timorese Health Professionals' working group undertook in January 2000 a review of health service provision throughout the territory and drafted a document defining minimum standards for health care service provision. At the second workshop, which took place in mid February 2000, a consensus was reached on the minimum standards document and the formation of the Interim Health Authority was formally announced. The Interim Health Authority was composed of 16 senior East Timorese health professionals supported by seven international UNTAET staff.

Later on 15 July 2000 as a result of reorganization and establishment of an East Timor Transitional Authority (ETTA) the Interim Health Authority had been renamed as Division of Health Services (DHS). Dr Sergio Lobo has been appointed as the Head of Division of Health Services.

The Division of Health Services, with support of WHO is in the process of formulating health policy guidelines for East Timor, and draft for the reform of health services in the country is being prepared. The reform is based on an integrated approach to health care delivery. Health services are proposed to be free at the point of delivery, but now and future, mean that the main policy makers are considering options for contributory financing, including health insurance schemes and patient co-payments.

Health services in East Timor are currently provided by a large number of different entities. Coverage of the population is uneven both in terms of physical access and in terms of the services provided. This situation has arisen from the necessary involvement of NGOs in health service provision during the emergency and early development phases. A strategy is being developed and implemented to guide the transition from the current situation to the future health system. This strategy must:

□ Be rapidly implementable

□ Ensure delivery of basic services to the maximum possible population

□ Build capacity among East Timorese health staff

□ Ensure more efficient use of resources

□ Not interfere with the development of the future health system

□ Take into account the principles developed by the East Timorese Professional Working Group (technically supported by WHO) including sensitivity to culture, religion and traditions of the East Timorese people.

To ensure more equitable coverage, more efficient use of resources, and clear division of responsibilities along with greater accountability, DHS has proposed that one key entity be identified in each district to plan, organize and manage the provision of services. Other health agencies working in the district will need to collaborate and coordinate their activities with the lead agency. DHS has requested proposals from lead NG0s for the provision and management of health services for each district, in the form of a District Health Plan.

To facilitate a development of a District Health Plan, WHO had organized a workshop, on10 June 2000. This was a good opportunity for WHO and DHS to provide detailed information and recommendations to the NGOs regarding important components of district health and specificity of the task during the transitional period (12-18 month). In addition, during the preparation of a District Health Plan all NGOs involved in health sector had received technical support and help from WHO.

Health service providers (NGOs, church health services and others) have collaborated with the Division of Health Services and the District Administration to prepare District Health Plans (DHP) drawing on their knowledge of the districts. This was the most rapid way to plan and start to implement activities to improve the quality of care provided and to ensure more effective and equitable use of available resources.

In August 2000, the draft plans (for all districts except Dili District which is being handled differently) were reviewed by the DHS and modifications negotiated with the NGO health service providers.

The DHPs include a total of 63 community health centers, 85 health posts and 116 mobile clinics. During the first year emphasis has been put on the use of mobile clinics in some areas to allow for a more careful selection of sites for additional fixed facilities. Based on these plans a memorandum of understanding (MOU) has been signed in September 2000 between the DHS and each of the district service providers. The MOUs serve to express the mutual intent to implement the DHPs and define coverage targets, services to be provided and the roles of the different parties involved. A set of performance indicators will be used to monitor progress.

In support of the DHPs, the DHS will support the costs of East Timorese health staff (up to a fixed ceiling in each district), provide most medical supplies, provide transport and cover some operating costs. Expatriate staff and the costs associated with them will not be borne by the DHS. WHO will serve DHPs by providing technical backstopping in the field of communicable diseases surveillance and control activities, outbreak investigations, health education, training of nationals in priority areas requiring for provision of basic health services.

As no medical literature was available in East Timor, WHO has been providing Emergency Health Library Kits and District Health Library Kits to major health providers in all the districts. WHO, East Timor is in the process of establishing a medical library to cater to the needs of service providers all over the territory. This library currently has about 1000 medical reference publications.

Human resources

• The East Timorese Health Professionals Working Group identified approximately 2,000 health workers as present in the country and available for work. This is considerably lower than the estimated 3,500 health workers during the former system. Most of the senior level health service managers and doctors were Indonesian and they have now left the country. Only approximately 35 East Timorese doctors remain, one at specialist level. There is a serious lack of capacity at senior and middle management levels. The UNTAET/DHS initially suggested a workforce of approximately 1500; however CNRT, the National Resistance Council, and the National Consultative Council (NCC) were concerned that they would not be able to support a large civil service in the future proposed health workforce of not more than 1087. The more detailed workforce planning was integral to the overall development of district plans by DHS. Recruitment of this workforce has been much delayed and the recruitment will be completed only by end of March 2001.

• Virtually all of the Timorese health workers were previously employed by international or national NGOs. Currently, a number of them are paid by UNTAET. WHO and HealthNet International have collaborated to transfer the records into a computerized database, which is linked with the civil service databases.

• Due to the reduction in the workforce and the shortage of doctors, health workers of all categories will have to take on extra roles and responsibilities, in both clinical and administrative areas. It is crucial that these health workers are given appropriate training for their new functions. A short term national training plan will be developed and implemented for the future appointed health workers, this will be funded through the UNTAET and World Bank administered Trust Funds.

• Currently training of health workers is carried out by NGO’s on an ad hoc basis much is on the job training and only a very few training courses are competency based. Future training will be competency based and standardized to ensure accreditation processes. This will be based on the national job descriptions, which are currently being developed by the IHA prior to the civil service recruitment process.

• HRD is an important component of the District Health Plans. A HRD planning framework has been developed to assist districts in planning the human resources required to implement the planned health services.

• A HRD Task Group was formed within the Division of Health Services. A WHO specialist is working closely with the Group. The work of this taskforce was disrupted by the attendance of members at a 6-week intensive English course. The Task Group has now been reformed with new members commenced its work in the beginning of July 2000.

Pharmaceuticals and Drug Supply

• During the emergency phase immediately after the crisis, WHO took a leading role in the management of drug supplies, via the SUMA programme.

• To date, the major source of medications and other consumables for the health service has been the various NGOs, which have each provided for their own programmes. Smaller amounts of specific drugs have come through other programmes, such as the national TB programme (supported by Caritas and WHO), and the Merlin project on malaria.

The Irish NGO, Goal, also supported the original SUMA team which was set up by WHO/EHA. The WHO/Goal team has gone on to be the nucleus of the Central Pharmacy within the UNTAET/Interim Health Authority. The Central Pharmacy has also received substantial donations from JICA and from UNICEF, and has begun to support health services throughout the country. The official opening of the central pharmaceutical warehouse took place on 4 April 2000.

• To support the future development of a national drug policy, WHO has provided the services of a technical consultant. He has developed a list of essential drugs for East Timor, based on an assessment of the current health status of the general population, available data on morbidity, mortality and prevalence of communicable and non-communicable diseases, and the experience of available staff at various levels of the health service.

o Since a large number of doctors have left the country, it will be mainly nurses and midwives who run the level 2 and level 3 clinics. This fact was kept in mind while developing the list of essential drugs.

o The draft list of essential drugs was discussed at a meeting of an expert group of East Timorese doctors, who provided advice and suggestions for the inclusion of various drugs at different levels of the health service.

o Vaccines used by UNICEF and contraceptives used in the programme were included.

o The National Tuberculosis Programme provided the list of anti-tuberculosis drugs.

• For establishment of a comprehensive national essential drug programme for East Timor necessary steps and systems have been identified. The initial systems at the national level can be effective only when the national government is formed. Right now, at best, a plan and structure can be formulated that will have to be implemented in phases. The systems and related activities will have to be planned in a away that their operation starts in the interim period and continues after the national government comes into existence. The necessary steps to establish a comprehensive national essential drug programme for East Timor will be formulated under the following headings:

1. National Drug Policy

2. Legislation, regulations and guidelines

3. Selection of drugs

4. Supply

5. Quality assurance

6. Rational drug use

7. Monitoring and evaluation

8. Human resources development

9. Technical cooperation among countries

• The implementation of these systems could be materialized using resources proposed in the World Bank project. The timely provided WHO technical support was an important and crucial step for starting establishment of essential drug programme in East Timor. The major thrust from WHO will be towards capacity building and training national staff in the development of pharmaceutical component of the health care facility. WHO has prepared a plan of action that acts synergistic to the proposed DHS activities supported by the World Bank.

PUBLIC HEALTH

Communicable disease surveillance

• In order to encourage the timely recognition of and response to epidemic diseases, WHO/EHA established a communicable disease surveillance system early in its presence in East Timor. The original system was subsequently modified in January 2000. Based on the data from the surveillance system, it has been possible to coordinate and provide guidance to the NGOs involved in providing clinical and public health services in East Timor. The work done by the WHO in the field of disease surveillance will be a foundation for the subsequent establishment of a national disease surveillance system.

• All laboratory services in East Timor were destroyed in the wake of the post-referendum violence. The surveillance system is therefore based on regular clinical reports submitted by NGO lead agencies providing primary health care in the field, using WHO case definitions. Diseases currently subject to surveillance include: simple and bloody diarrhoea, suspected cholera, suspected malaria, other (non-malaria) febrile illness, suspected measles, suspected meningitis/encephalitis upper and lower respiratory tract infection, acute jaundice syndrome, acute flaccid paralysis (suspected poliomyelitis) and neonatal tetanus.

• Weekly analysis of the surveillance database is summarized in a Weekly Epidemiological Bulletin. The WHO Bulletin is disseminated to all institutions involved in health in East Timor, and to many international collaborators. The Bulletin is published in both English and Tetum, and an electronic version of the Bulletin has been available via the Timor Today internet site since June 2000.

• Major communicable disease problems recorded by the surveillance system since 1 January 2000 include:

o more than 127 000 cases of malaria,

o over 45 000 cases of lower respiratory tract infection,

o 28 000 and 4 800 cases of simple and bloody diarrhoea respectively,

o 1 336 cases of suspected measles, and

o over 383 cases of suspected meningitis.

• Currently the basic microbiological and some serological tests can be done at the central laboratory but work is needed to establish a reliable integrated laboratory system in the country providing services to Public health and curative institutions alike.

• Restoration of the integrated laboratory services is planned including equipment and training. As diagnostic facilities become re-established and diagnostic criteria agreed upon, a laboratory component to the surveillance system will begin to monitor incident cases of malaria by species, newly diagnosed cases of tuberculosis, and bacterial isolates from sterile sites.

• The communicable disease surveillance network also identified, for the first time in East Timor, cases of Japanese encephalitis (JE) . On the basis of this investigation and sero-epidemiological studies, JE infection has been identified as an important public health problem in East Timor. The immunization of children against JE should be considered an appropriate intervention, and an immunization schedule will be developed using the serological findings from this study. The intervention will require the allocation of adequate resources and an understanding by donor and other agencies of the importance of the elimination of JE as a public health problem in East Timor.

Control of Outbreaks

• Between January and December 2000, the following outbreaks or sporadic cases of communicable diseases of public health importance have been investigated:

o acute flaccid paralysis (suspected poliomyelitis) – 3 clusters or sporadic cases, two of which have been confirmed negative by the international reference laboratory in Melbourne, Australia, while results from the third are still pending;

o dengue fever – three outbreaks in urban Dili;

o cutaneous leishmaniasis – one sporadic suspected case;

o Japanese encephalitis – two clinical cases, and associated field investigation; and

o Simple (suspected amoebic) and bloody diarrhoea (suspected Shigella) outbreaks in Aileu district related to contaminated water supplies and suspected food contamination.

o Unknown diseases – two reports requiring field investigation (one each in Liquisa and Manufahi districts).

• WHO has worked with the Division of Health Services and other Agencies in a community education campaign for the control of dengue fever, Japanese encephalitis and malaria which it plans to repeat over the coming wet season.

Roll Back Malaria

• WHO Emergency and Humanitarian Action Department (EHA) made a quick assessment of the malaria situation early in October 1999. They noted that:

o malaria showed a three-fold increase in incidence due to the break down of surveillance and treatment,

o there was poor access to effective drugs, and

o vector control activities had collapsed.

• WHO/EHA identified two International NGOs, Merlin (Medical Emergency Relief International) and IRC (International Rescue Committee) to work in partnership for control of malaria in East Timor. DFID and WHO, in partnership, agreed to support these initiatives with insecticide treated bed nets (ITNs) (175,000) and essential medical supplies.

Merlin acted as lead International NGO for:

o establishing malaria diagnostic facilities,

o retraining of microscopists,

o equipping of all 13 district laboratories of the country

o disseminating RBM protocols for case definitions and treatments

o arranging all antimalarial drug supplies,

o undertaking cross sectional malaria prevalence surveys and drug resistance studies, to recommending efficacious insecticides for IRS, and

o promoting net usage.

• Merlin, under the supervision of WHO, has trained malaria microscopists for 13 districts, and arranged supply of equipment and reagents. Eight out of 13 district laboratories are now functional, while the rest are expected to become operational by the end of July.

• Workshops on the management of severe and complicated malaria were conducted in 7 districts using WHO protocol and guidelines. Adequate provision of essential drugs now exist, and clinicians are familiar with recommended drug regimens and emergency management of malaria.

• WHO guidelines for the management of dengue fever and dengue haemorrhagic fever / dengue shock syndrome have been used in the orientation of clinicians for the treatment of this disease.

• It is important to note that two cases of quinine resistant malaria have been detected.

• Merlin has conducted a study of the clinical and parasitological efficacy of chloroquine in the treatment of uncomplicated Plasmodium falciparum infection was conducted in Los Palos subdistrict, a hyperendemic area in eastern East Timor (May 10 2000 – August 11 2000) using modified WHO 1997 guidelines. Overall treatment failure was 67.7%. Treatment failures were treated with the current second-line drug sulphadoxine-pyrimethamine (SP) and 100% of those followed had adequate clinical and parasitological response. The results of this study led to the adoption of sulphadoxine-pyrimethamine as first line treatment for uncomplicated falciparum malaria.

• Merlin is now planning a similar study of the therapeutic efficacy of sulphadoxine-pyrimethamine as first line for uncomplicated falciparum malaria in the Bobonaro district following reports of suspected clinical treatment failures.

• For treatment of uncomplicated malaria in East Timor WHO had recommended Chloroquine and Sulfadoxine pyramethamine (Fansidar) combination. Combined use of these two drugs is an effective for prevention of cerebral malaria deaths and development of drug resistance of Plasmodium falciparum can be avoided as has been demonstrated in Papua New Guinea, Gambia and Philippines.

IRC was given responsibilities for protection of pregnant women and children under 5 years of age through an Insecticide Treated Bed Net (ITN) programme, health education and disease awareness.

• IRC has distributed over 115 000 pre treated mosquito nets in all 13 districts, including two nets per family where protection of pregnant mothers and children was necessary. Since they were distributed through different local NGOs, a list, indicating names of head of the family and complete addresses, is being completed to facilitate re-treatment and to determine the net usage level. IRC has carried out a KAP study to develop IEC material for disease and prevention awareness and is planning a follow-up Kap study to evaluate the effectiveness of the programme. Bed nets with reported longer duration of insecticide efficacy (“PermaNets”) were distributed in the Lautem district towards the end of the year and will be included in the evaluations planned for the year 2001.

• IRC are have also been re-treating bed nets for the coming wet season and have continued to promote community malaria prevention through community health educators.

In summary, the malaria control strategy formulated and initiated by HEA in close collaboration with RBM, has been implemented effectively by the two lead International NGOs, MERLIN and IRC, supported by several local NGOs; this has been achieved under the most difficult field conditions. These efforts have largely helped keep the morbidity and mortality at no higher than the previous year's level, despite extremely adverse conditions.

Based on the current situation, WHO has identified the following areas for consideration in future RBM and integrated vector control activities in East Timor:

• With the functioning of district health authority and establishment of district level malaria laboratories, the WHO surveillance Unit should initiate recording malaria morbidity data by species of parasite. These data will help in mapping high-risk areas and forecasting epidemics. Similar mapping is required for drug resistant areas of the country, and the preparation of district health maps.

• Emergency stocks of pyrethroid insecticides, as approved by WHO PES, along with dispensing equipments and material, should be kept in reserve as per RBM norms for control of malaria epidemics.

• In view of the observed endemicity of dengue in East Timor, these contingency plans should include outbreaks of dengue haemorrhagic fever / dengue shock syndrome.

• There is an urgent need to establish a national Entomology and Vector Control Laboratory to undertake micro-stratification in high risk and/or drug resistance areas to develop evidence-based vector control strategies to reduce vector breeding and interrupt transmission, as per RBM guidelines. In the absence of primaquine therapy for malaria cases, and the resultant build up of a reservoir of infection (particularly in foci P falciparum drug resistance), this activity will become crucial. The laboratory will also be responsible for development of integrated vector control strategies for control of other vector borne diseases.

• The ITN programme needs further strengthening along the following lines.

o Net coverage in the second phase should be extended to the whole population, with priority given to vulnerable groups (eg people sleeping in field huts to protect their crops, etc.).

o Re-treatment of nets should preferably be carried out through the primary health care system, with the total involvement of communities. Re-treatment should be done at sub-health centers on predetermined dates, with prior information of the chiefs of the villages. Alternatively, re-treatment of nets could be carried out in schools, with the involvement of children, teachers and communities with health staff as facilitators [this method has been employed with great success in Papua New Guinea (PNGIRC may undertake “Bed net affordability and willingness to buy” surveys to institutionalize partial subsidy and/or a social marketing system to ensure sustainability

• To render urban Dili free of mosquitoes, the drainage system in the watershed areas of the Comoro River (in the east) and the Santana (in the west) needs to be re-designed to take care of surplus irrigation water in rice fields, and storm and waste water from residential areas. Similarly, the practice of growing kang kung (a green, leafy vegetable crop) in city swamps and in specially prepared beds in major drainage canals needs to be stopped. The drainage system needs to be developed with a proper gradient. Major drains require a cunette in the bed to take care of periods of low water flow. The District Health Authority may hire the services of expert civil / public health engineers to prepare a blue print for this work in urban Dili.

• For Dengue control, community-based promotion of the storage of water in mosquito proof containers/cisterns/mendis indoors is essential. In addition, there is an urgent need for the professional and routine management of solid waste disposal to support community efforts to reduce vector-breeding sites.

• Development projects, particularly related to water resources development and agriculture sectors, are known to be associated with high build up of vector borne diseases, especially malaria and Japanese Encephalitis (Irrigation) and Dengue Haemorrhagic fever (harvesting of rain water/domestic storage of water). It is therefore strongly recommended that all development projects should be subjected to an environmental health impact assessment to anticipate adverse health impacts and to recommend mitigating measures for incorporation at the design and planning stage, costed into the project. WHO can provide the necessary guidance.

• There is a need for health authorities in East Timor to work more closely with their colleagues dealing with water and sanitation programmes as these are likely to have a more significant impact on reducing the morbidity and mortality of many infectious diseases than hospital or clinic-based activities, at least in the short-term.

• Pending the establishment of a National Vector Borne Disease Control Programme as part of a coordinated Environmental Health initiative, the Interim Health Authority has requested WHO to coordinate vector control activities in East Timor. WHO has begun conducting regular meetings, with the keen participation of NGOs involved in vector and vector borne disease control: Merlin, IRC and Oxfam, as well as the PKF Health Cell and other interested organizations. This group has been active in coordinating both VBD research activities and applied VBD control activities, and will be a vital resource in framing a national vector borne disease control strategy.

Tuberculosis

• Significant progress has been made in the establishment of a national TB control programme in East Timor. The programme was initiated by WHO/EHA and is based on the WHO DOTS strategy. Caritas Norway, together with Caritas East Timor, the Menzies School of Health Research in Darwin, Australia, and WHO have actively supported the establishment of this programme.

• The National TB Control Programme was officially launched on 21 January 2000 and has achieved much in its first year. The programme is active in al the 13 districts of East Timor. There are 20 diagnostic centers working within the NTP structure and 11 satellite centers for treatment of TB patients are operating in Dili. During the year 2000, 4,054 patients were diagnosed and TB treatment within the NTP commenced.

• The majority of diagnosed TB cases in East Timor attend the three Dili TB clinics (Motael, Bairo Pite and Becora), with each clinic enrolling 25-30 new cases for treatment each week.

• It is noteworthy that on the request of the WHO the WFP has been able to provide to the TB patients supplementary food like rice and cooking oil during January – September 2000.

Expanded Programme of Immunization

• Routine immunization services in East Timor were re-established and supported by UNICEF, under the coordination of IHA and with WHO technical support, in early March 2000. The service is implemented by NGOs involved in health service provision in the field. As a result of immunization of more than 45 000 children against measles, limited cases of this infection occurred. However, after two months of implementation, there were lessons learned and issues to be resolved from both technical and managerial aspects.

• The issues included vaccine supply, differing needs between districts, and clarification of roles among all parties involved. Efforts have been made to deal with these issues through the various meetings.

• On 16 June 2000, in order to facilitate clarity and consensus among all parties involved regarding the policies and implementation plans of the national immunization services, UNICEF and IHA (with WHO technical support) conducted a National Workshop on immunization services in East Timor. This workshop resulted in agreement by all participants in the use of a standard immunization schedule recommended by WHO and a plan of action for conducting National Immunization Days and the immunization of primary school children. All districts conducted two polio immunization days during November and December as part of the National Immunization Day programme. Preliminary reports suggest high (>84%) coverage rates in the target age-groups. At the same time, it was noted that the routine EPI coverage was as low as 20% for DTP-3.

WHO and UNICEF supported a study of prevalence of Hepatitis B markers among pregnant women at the ICRC and Bairopite clinics, Dili. This study identified that 14 out of 219 (6.4%) pregnant women were found positive for HBsAg. This result indicates the importance of introduction of HB vaccination for newborns in East Timor within the framework of EPI, which will be possible only after improving the performance of routine EPI coverage in the territory.

Child nutrition

• Child nutrition has been a concern since the early crisis days.

• An early anthropometric survey suggested that acute malnutrition was not very common among returnees. However as the conditions in the camps in West Timor worsened, more returnees (especially those returning spontaneously) were thin and in poorer general condition, and pockets of childhood malnutrition were identified (eg Atsabe, in Ermera district).

• Two main factors have been identified in the majority of those children around the country thin and stunted:

o the vicious cycle of illness and poor appetite, and

o lack of knowledge about appropriate weaning foods for babies and small children.

• The food distribution system has been adjusted, from regular general distributions to targeted distributions aimed at vulnerable groups. Special attention has been given to areas like Ermera district.

Integrated Management of Childhood Illness

• An important objective of the still to be developed health plan for East Timor will be to reduce the IMR and U5MR from their present high levels.

• It is very likely that these rates have increased during the period of instability following the independence referendum.

• Data presented in the East Timor Province Health Profile (Ministry of Health, Indonesia, 1998) show that, for children under 5 years of age, diarrhoea, malaria, and acute respiratory infection (ARI, including pneumonia) constitute the majority of reasons for paediatric consultation at health centres and hospitals. These same conditions, plus TB, are the principal causes of death in the same age group.

• Data from the first 12 months of infectious disease surveillance coordinated by WHO confirm that ARI, malaria and diarrhoea, in that order, continue to be the most common reason for consultation at mainstream health care centres, with malaria the most common reported cause of death.

• One of the strategies that may be used to achieve a reduction in IMR and U5MR is the development and implementation of a system of comprehensive care for sick children that visit health facilities, such as the one promoted by IMCI.

• The advantages of introducing an IMCI strategy in East Timor would include:

o improved quality of care in situations where a disease specific approach is not appropriate (eg when children present with more than one complaint, or for young infants with non-specific clinical signs);

o a methodical approach where medically trained staff are scarce;

o an emphasis on prevention of childhood illnesses, through immunization and, if necessary, vitamin A supplementation;

o promotion of improved infant feeding, including breast feeding;

o avoidance of duplication of efforts in the fields of training, monitoring, supervision and management; and

o less wastage of resources, because children are treated with the most cost-effective intervention for their condition.

An IMCI approach would also immediately address three essential components of building up a new health system – improving health worker skills, improving the health system and improving family and community practices.

When implemented correctly, IMCI should eventually lead to a lower U5MR.

• The generic WHO and UNICEF guidelines and training materials and for IMCI generally need to be adapted to reflect the epidemiological situation, language and national policies of the country in which they are being implemented. Under the former administration, East Timorese health workers were often trained in Bahasa Indonesia. Moreover, the disease pattern has not changed at the macro level since independence. It should therefore be relatively easy to develop a national IMCI approach for East Timor from the current IMCI materials from Indonesia.

• IMCI guidelines could then be used as a basis for national policies and guidelines for the management of ARI, CDD and paediatric malaria.

• The IMCI Medical Officer from WHO Indonesia visited Dili from 16–23 June 2000. The aims of his visit were:

o to create awareness and knowledge of IMCI among health authorities in East Timor, thereby facilitating informed decisions when a national child health policy is developed; and

o to make a provisional plan for the introduction of IMCI in East Timor.

He also conducted an orientation to IMCI for representatives of NGOs, UNICEF and WHO.

• A set of IMCI guidelines and related training materials adapted from the Indonesian programme for East Timor is nearing completion, again focusing on the needs of health workers who deal with sick children under 5 in outpatient settings in hospitals and clinics.

• The next step will be to develop a comprehensive plan to introduce and implement IMCI in East Timor in a phased manner, first focusing on those health workers who deal with sick children under 5 in outpatient settings (hospitals and clinics).

Screening of School Children in East Timor

• The UNICEF supported opening of schools in East Timor. During a short time of observation, it was found that some proportion of the children and teachers have visual defects. WHO and UNICEF jointly organized screening of school children and teachers in Dili. From 10 schools, 590 children were screened, out of which 16.4% had visual defects and 5% required ophthalmological examination. Among teachers, 69% were found having visual defects and 5.7% require ophthalmological examination. All of them needed glasses, which were provided free by the Laila Foundation & Territory Health Services, NT Australia. The group of ophthalmologists from Darwin visited Dili and more than 200 patients were operated on during the year 2000.

Health and Nutrition Survey

• WHO is currently planning a comprehensive health and nutrition survey in two districts for March/April 2001 (after the wet season) to complement a national, more general health survey planned by the Division of Health Services (DHS). The WHO survey will involve a detailed investigation of the recent health and mortality history, nutritional status, and vaccination coverage of a random sample of 200 households from each of the two districts, along with specimen collection from target groups within the sample to measure the prevalence of anemia, malaria, helminth infestation and a number of serological markers of infectious disease.

• It is hoped that this information will, when combined with the information collected during the national survey, provide a solid foundation for health service planning across East Timor.

Reproductive Health, HIV/AIDS and Sexually Transmissible Infections

• During the initial emergency phase each agency providing health services defined its own approach to reproductive and child health. Most provided only simple antenatal and obstetric services. Obstetric complications were among the commonest reasons for aeromedical evacuation from rural areas to Dili in the early phase. An active reproductive heath group formed by UNFPA and a number of NGOs and other agencies is supporting the Interim Health Authority to develop suitable programmes for the future Timorese national health service.

• Contraception has not had a good reputation in the past. It is closely associated in the public mind with a perceived policy of “Javanization” which included attempts to decrease the birth rate of ethnic Timorese. The Catholic Church, which is by far the most important religious group in the country, officially frowns upon it. Recently, Msgr. Carlos Filipe Ximenes Belo, the Titular Bishop of Lorium, Apostolic Administrator of the Diocese of Dili, in a letter dated 22 June 2000 to all health providers and UN agencies involved in family planning and HIV/STI prevention, informed that the promotion of "artificial family planning like distributing condoms and abortion (morning-after) pills etc to our people" was unacceptable to the church. To make future progress in the field family planning and HIV/STI prevention in East Timor will require very careful selection of technical information, educational materials and regular collaboration and close dialog with the church. As the Catholic Church of East Timor is very influential, and the strongest messenger and adviser of the healthy life style of the population, WHO is proposing regular meetings with the representatives of the church.

← In East-Timor before September 1999, there were no proper surveillance system and laboratory testing facilities for HIV testing. In the absence of these facilities, it is difficult to retrospectively conclude as to when the infection was introduced in East Timor. High incidence of sexually transmitted infections (STI) such as gonococcal infection and syphilis cases among East-Timor population were reported during 1996-1998 (East Timor Health Profiles published during 1996-1999 by the Indonesian health authorities). Prevalence of high rates of STI during the period would possibly enhance the risk for spread of HIV infection among East-Timor population. Trends could be similar to other parts of Indonesia. No official data is available about screening for HIV infection and AIDS cases in East Timor. However, pre-independence Indonesian data reported at least one suspected death in East Timor due to AIDS. With the establishment of an epidemiological surveillance system by WHO in East Timor, the reports received from different clinics from all the districts indicated STI are not uncommon among sexually active age groups.

Since September 1999, East-Timor receives properly screened blood supplies from Australia to meet its requirements. At the same time, to meet emergency requirements for blood supply, “replacement donors” are being used. Persons who donate under this scheme, prior to acceptance of blood donation, are screened for HIV and Hepatitis-B Virus (HBV) using rapid tests. Available data from Baucau and Dili Central Hospitals indicated that since February 2000, 531 blood donors were screened for HIV infection. Of those screened, five males and 2 females in the age group of 26-35 and 18-35 respectively, were found to be positive for HIV infection. High incidence of STI before crisis period and rumour about one suspected death in East Timor due to AIDS gives indirect evidence that HIV infection existed in East Timor before 1999 crisis.

In East Timor today factors are present, which can contribute to a developing epidemic. This includes, the disruption to society which occurred in 1999, a lack of information as to what constitutes risky sexual behaviour and on sexually transmitted infections, low level of HIV/AIDS/STI awareness, poverty and a large groups of young men and women who are unemployed/not in school or involved in other rehabilitation activities.

Presence of large number of young, predominantly male expatriates and their possible sexual interaction in the territory may also attribute to the increased risk for HIV transmission.

Realizing the urgent need for initiating timely steps to prevent the spread of infection in East Timor, the Division of Health Services, together with WHO, UNICEF, UNFPA, UNDP (core group of UNAIDS), has evolved prevention and control measures focussing on health education, dissemination of information, promotion of safe sexual behaviour among population, counselling HIV positive persons, establishment of facilities for early identification and treatment of STI and provision of safe blood transfusion services.

An Interagency HIV/AIDS/STI Mission to East Timor was undertaken during 12-24 November 2000. The Mission consisted of representatives from UNICEF, WHO, UNFPA, Family Health International, USAID and UNAIDS. The work programme of each UN Agency was clearly identified. Under the responsibility of WHO, strengthening of HIV surveillance, support establishment of safe blood transfusion services, laboratory diagnosis for HIV/STI and training for treatment and establishment of other curative services for STI have been identified.

The financial resources for implementation of these programmes are yet to be identified by WHO. WHO/East Timor has submitted through its Regional Office and HQ to the ECHO a proposal for funding.

• During the screening of Police recruits for VDRL Test, 10% positive cases were found. Similarly, during the screening of pregnant women, quite a high number of cases were found VDRL positive. In both the situations, no signs of lesions of primary or secondary Syphilis were detected. It is possible that patients having past experience of Yaws infection may be found positive for VDRL test. It is well known that in Non-treponemal serologic tests for syphilis (e.g. VDRL, RPR) become reactive during the initial stage, remain reactive during the early infection and may continue for many years. Treponemal serologic tests (e.g., FTA-ABS, MHA-TP) usually remain reactive for life.

• From data available in literature, cases of Yaws have been detected in some Indonesian Islands. The data for presence of Yaws in East Timor are not available and requires investigation. In case the presence is detected, programme for control and eradication of Yaws in East Timor has to be launched.

• Before clarification of the situation through a formal investigation, WHO has recommended that where VDRL testing is available, pregnant women should be tested routinely and VDRL positive pregnant women should be treated for Syphilis, along with their newborn babies. The drugs prescribed for treatment of syphilis in pregnant women and neonates are Parenteral Penicillin regimen. In case the patient is sensitive to Penicillin, Erythromycin regimen outlined should be prescribed. Also any person found positive for VDRL should be treated accordingly. WHO has provided draft Syphilis testing and treatment guidelines to the DHS which are currently under review.

Mental Health

• Many national and international organizations and institutions have poured into East Timor, offering to help with post conflict emotional and psychological trauma. Proposals to train from 15 to 50 doctors and 45 to 200 nurses in mental health and psychiatry have been received.

• While these generous offers and expressions of concern are much appreciated, they must be considered in relation to East Timor’s priority health needs and existing health workforce constraints. Work has already commenced on the analysis of training needs of the health workforce and, within this, priority is being given to the development of community based mental health programmes.

• Eleven health workers have undertaken training in mental health in Australia, with special reference to community support programmes.

• DHS had requested WHO to provide technical support in developing national mental health programme. A WHO consultant has been identified, who will visit East-Timor during March 2001.

Environmental Health

The water supply and sanitation system was not spared from destruction during the post-ballot violence. There was widespread looting, burning and damage to town and village water supplies and sanitation. Towns with public water supply systems had pumps, vehicles, motors, water treatment plants, offices including facilities for testing of water quality and pipelines were stolen or damaged.

The Asian Development Bank estimated the cost of a three year programme for reconstruction and recovery towards water supply systems and utilities to be about 25 million, and 8 million for drainage and sanitation.

The East Timor Transition Authority (ETTA) finds it difficult to find and attract qualified East Timorese for management positions in water and sanitation services. There are still 75 “sanitarians” of which half are currently working with the NGOs.

Sanitation coverage remains extremely low. Both solid and liquid waste disposal is inadequate and there is lack of public latrines. For example, concentrated on-site toilets in Dili pose a high risk of contaminating underground water and surface water drains. A preliminary master plan for drainage and sewerage for Dili has been currently prepared by AQUAPOR, an INGO from Portugal. This needs further working in details for system components design and costing.

There does not exist formal collection of garbage in the urban areas of East Timor. Currently there are a few local and international commercial waste collection services operating in Dili under a contact with UNTAET and other institutions. However, it is not sufficient to provide an adequate collection of garbage in the municipal area. Tibar, the waste disposal site for Dili is not operating as a sanitary landfill site. Field observations indicate that a significant proportion of garbage is being deposited on open land, road verges, dry riverbeds, and drains. Often they are burnt on the street or in open places in several locations in the city.

Drinking water supply, sanitation, solid waste management and drainage are four major areas for improvement requiring special attention to have better environmental quality in East Timor at present.

WHO had recruited a consultant to stress the importance of environmental health and improve coordination of the Division of Health Services. The consultant was involved in coordinating the efforts in this direction by having discussions with the Department of Water and Sanitation Services, Environmental Protection Unit of ETTA and other key partners like UNICEF, Asian Development Bank and other international NGOs involved in the process of rehabilitation and development of water and sanitation sector in East Timor.

WHO has been requested by the Department of Water and Sanitation to technically scrutinize the project proposal on Dili Water Supply Rehabilitation and improve the work plan prepared by Tokyo Engineering Consultants Co. Ltd. The project only dealt with the work of source abstraction and did not cover the future implementation of water distribution or wastewater disposal. WHO together with DHS recommended that the proposed water supply rehabilitation work including distribution system in Dili should be prepared with the simultaneous development of sewage reticulation system and improvement on existing drainage system.

WHO strongly recommends that any development project in East Timor should take into consideration the impact of the health on its population and clear the proposals with health authorities. WHO is willing to provide the required technical support to the Division of Health Services in this important task.

Health Laboratory Services

The capacity of Laboratories in East Timor for both communicable and non-communicable diseases is very limited. The central laboratory at Dili is the main laboratory of the territory. It does not cover all the branches of laboratory medicine and has been conducting limited range of tests. There is absence of health laboratory network at district and peripheral levels. Only basic malaria and tuberculosis microscopy has been carried out in some districts.

DHS recognizing the importance of laboratory services, requested the WHO to provide technical support in restoration of the laboratory services in East Timor. WHO provided technical services of a consultant who developed a plan for reconstruction of laboratory services in East Timor. Based on the expert’s assignment, it was recommended by WHO that Health Laboratory Services should be developed as an integrated part of National Health services and include both clinical medicine and public health. The consultant provided both short and long-term plans ranging from one to three years for establishing and strengthening full-fledged laboratory services at central and peripheral levels of East Timor.

Nurse Practitioner Training

WHO undertook a detailed analysis of the current nurse training curricula in relation to the newly defined nursing roles in East Timor. The current and planned national continuing education modules were examined and future training requirements were identified. It was noted that the current training for nurses and midwives is not adequate enough for advanced health assessment. WHO recommended that a new expanded role of existing nurses and midwives must take place in the field of PHC as community nurse practitioner for bridging the gaps of health care delivery problems. Based on this finding, the DHS requested WHO to provide the expertise for training nurses and develop suitable training modules. Keeping this in mind, WHO/Dili has proposed a budget for an eleven month STP in the plan of action for 2001.

Other Areas of Need

• No progress has been achieved in development of control programmes against intestinal parasitic infection, lymphatic filariasis, and iodine deficiency anemia in children and women, which also are common public health problems.

• Currently there is no leprosy control programme for East Timor. The only intervention that took place during year 2000 was that WHO distributed, through the NGOs providing health services, MDT drugs and WHO’s guidelines regarding clinical diagnosis and treatment of leprosy patients. It is proposed to establish a Leprosy Control Programme by involving a Singapore based Leprosy Mission for Southeast Asia, an NGO in identification of leprosy cases. WHO will provide the required technical support and MDT drugs for the leprosy patients.

WHO COLLABORATION WITH UN AGENCIES AND NGOS

WHO has been one of the ten UN Agencies (UNICEF, UNDP, UNFPA, UNHCR, ILO, WFP, FAO, IOM and UNOPS) working in close cooperation to support rebuilding and development activities in East Timor.

These agencies, both collectively and individually, are joining hands with other active development partners in bringing to East Timor their global networks, technical expertise and many years of accrued experiences and lessons learnt in developing countries across the globe.

A number of UN Agencies have embarked upon the task of preparing a Common Country Assessment (CCA) for East Timor, in cooperation with all relevant development partners in the country to establish a common database of development indicators as well as a common analysis of key development challenges. This document will serve as a major input into the debate about the development agenda for East Timor in the years to come.

WHO and other UN Agencies in East Timor, under the leadership of UN Development Coordinator had submitted a paper outlining specific areas of strategic support to be provided to the Transitional Government of East Timor in the immediate period ahead, and eventually, in support of the East Timorese Government as and when established.

WHO, through it's department of EHA, has and will continue to extend support and cooperation to other UN Agencies, donors, NGOs and different institutions in their respective efforts to raise the health delivery levels in East Timor. Notable activities and partnership of the WHO are:

← Jointly working with Merlin and International Rescue Committee (IRC) implementing a Roll Back Malaria

← Close collaboration with Merlin, IRC, Oxfam and Timor Aid to enhance the control of vector borne diseases.

← Close collaboration and involvement of all national and international NGOs in disease surveillance, outbreak investigations, organizing training activities and prevention and control of communicable diseases.

← Technical support of UNICEF, in EPI activities.

← Jointly with UNICEF, organized screening of vision for school children and teachers in Dili. The vision of more than 16% of the students and 60% of teachers was found to be deficient and arrangements have been made to provide them with spectacles free of cost in collaboration with Laila Foundation and Territory Health Services NT (Australia).

← Provide sectoral support to the World Bank Project with a grant of US$12.7 million for the Health Sector Rehabilitation and Development.

← Cooperation with Health Net International has enabled the transfer of personal records of all former health staff into a computerized database linked to the civil service database. This will be a useful tool to support both long- and short-term training and planning of the workforce.

← Jointly with Caritas Norway, Caritas East Timor and the Menzies School of Health Research in Darwin, Australia supported establishment of a National Tuberculosis Programme. A notable support to mention is that on the request made by WHO to the WFP, the TB patients were provided supplementary food.

← Jointly with UNICEF, World Food Programme, Health Net, IRC and other NGOs proposed to conduct health and nutrition assessment in East Timor.

WHO Profile and Visibility

• WHO and the Division of Health Services jointly issued statements on the issues of Environmental Health and HIV/AIDS situation in East Timor.

• WHO and UNICEF jointly organized the World AIDS Day on 1 December 2000.

• WHO and UNICEF jointly conducted a national workshop on EPI and participated in NID in November/December 2000.

• During year 2000, with the visit of the Director-General of WHO to East Timor, the importance of health as an essential element of the national development was realized among East Timorese leaders.

• Three radio interviews and one TV discussion were organized on health topics.

• Up to October 2000, the Humanitarian Assistance and Emergency Rehabilitation, Pillar of UNTAET produced more than 80 situation reports. More than half of these reports reported on WHO activities in East Timor.

• WHO contributed a substantial portion of the UN Secretary-General’s report to the General Assembly, Humanitarian Relief, Rehabilitation and Development for East Timor.

WHO Technical Support to the Interim Health Authority and NGOs

During the year 2000, WHO sponsored and presented the following training courses and seminars:

• Seminar on dengue vectors and their control

• Seminar on the clinical management of dengue fever and dengue haemorrhagic fever / dengue shock syndrome

• Seminar on the epidemiology, clinical features and control of Japanese encephalitis

• Seminar on the epidemiology, clinical recognition, management and control of outbreaks of meningitis

• Development of health education materials for the prevention of vector borne diseases

• Seminar on district health planning processes and resources available to NGOs to assist and guide their development

Two Seminars on HIV/AIDS/STI were held in October and November 2000 to disseminate information among Timorese health workers and among students.

Constraints

• The absence of national health professional staff, such as medical doctors and staff at managerial levels.

• Delay in civil service recruitment has slowed down the efforts of WHO for implementing activities in collaboration with DHS for health sector development.

• Inadequate communication facilities and difficulties of accessibility between districts, particularly during rainy seasons.

Staff and Consultant visits to East Timor Office:

A number of WHO staff, STCs/STPs/Temporary Advisers visited and worked in the Territory in difficult conditions to provide assistance in establishing and strengthening the health sector during emergency/developmental phase. The names of these persons are listed below:

On assignment:

|Name of STC/STP |From |To |

|Dr B.K. Verma |28 September 1999 |12 January 2000 |

|Dr E. Gambini |September 1999 |May 2000 |

|Dr Jim Black |September 1999 |May 2000 |

|Dr Rob Condon |May 2000 |November 2000 |

|Dr N.L. Kalra |8 May 2000 |7 June 2000 |

|Dr Prem K. Gupta |May 2000 |July 2000 |

|Prof D.S. Agarwal |October 2000 |November 2000 |

|Prof. Chaiyos Kunanusont |12 November 2000 |24 November 2000 |

|Dr Joyce Smith |15 June 2000 |13 September 2000 |

| |November 2000 |February 2001 |

|Dr Sandra Chaves |November 1999 |January 2000 |

|Dr Robert J Condon | May 2000 |18 November 2000 |

|S.K. Varma |June 2000 |October 2000 |

|Dr Ina Hernawati, Temporary Adviser |6 November 2000 |11 November 2000 |

|Mr Sharad Adhikary |December 2000 |February 2001 |

|Prof Penchan Suwansang Monaiyapong |14 December 2000 |16 January 2001 |

|Ms Helen Counihan |10 February 2001 |9 October 2001 |

Visitors:

|Mr Howard Stephenson, MSO, SEARO | 26 June 2000 |30 June 2000 |

|Dr Frits Reijsenbach de Hann, Medical |16June 2000 |23 June 2000 |

|Officer, Jakarta | | |

|Dr Georg Petersen, WR Indonesia |October 1999 | |

|Dr Buriot, WHO/HQ |October 1999 | |

|Dr M. Connolly, WHO/HQ |November 1999 | |

|Dr Lianne Kuppens, WHO/HQ |February 2000 | |

|Ms Karin Timmermans, STP (Drug & |April 2000 | |

|Traditional Medicine), Indonesia | | |

|J. Larusdottir, TO/EHA/SEARO |October 1999 | |

|H. Caussey, Scientist (Epid.), SEARO |October 1999 | |

|Dr E. Sorensen, EHA, SEARO |23 Sept2000 |1 October 2000 |

| |14 October 2000 |16 October 2000 |

|Dr Linaung, EHA,SEARO | | |

|Dr Gro Harlem Brundtland, DG |14-15 October 2000 | |

|Mrs Ann Kern, Executive Director |14-15 October 2000 | |

|Dr Daniel Tarantola, Senior Policy Adviser |14-18 October 2000 | |

|Mr Jon Liden |14-15 October 2000 | |

|Dr Duangvadee Sungkhobol |8 January 2001 |13 January 2001 |

| | | |

SEARO Staff deputed to work in Dili Office on travel status:

From To

Dr Alex Andjaparidze January 2000 31 December 2001

Mr S.K. Marwah May 2000 (1 month)

Ms Chandni Debnath June 2000 November 2000

Mr C.S. Sharma 6 October 2000 5 December 2000

Mr S. Ragupathi 6 October 2000 6 April 2001

Serving Local Staff

|Sl.No. |Name of serving local staff |Title |

|1 |Ms Domingas de Jesus Dos Reis |Secretary |

|2 |Mr Jose Barreto |Assistant |

|3 |Ms Sonia Goncalves |Secretary |

|4 |Mr Pedro Araujo |Driver |

|5 |Mr Francisco da Silva |Driver |

|6 |Mr Jose da Costa |Messenger |

CONCLUSION

WHO has a unique opportunity to utilize its high technical expertise and to work together with other UN agencies, national and international NGOs and donor institutions in the field of development of East Timor, where health been seen as a priority.

It is important that all levels of WHO should now recognize and give due consideration to the current dynamics in East Timor. A conscientious effort is needed to re-establish sustainable health services in the territory. While the International agencies have been strongly involved in provisions of health services during emergency period, Timorese will gradually take over the responsibility for the service delivery. The establishment of the East Timor Transitional Administration (ETTA) and the Division of Health Services, representing the national health authority, are moving in the right direction.

The main health problems facing the population now are those that existed even before the crisis: common childhood diseases, communicable diseases (especially malaria, TB, Japanese encephalitis and dengue fever) and reproductive health problems, including a high maternal mortality. WHO has been currently involved in providing technical assistance through assignment of consultants and professionals in these areas.

As a direct consequence of unemployment and losses suffered by the people, the nutritional levels of families, especially children, need to be assessed and remedial measures put in place. Assessments to-date suggest that where child malnutrition exists, it is mostly consequence of inadequate feeding practices rather than food availability as well as infections and other childhood diseases.

The reestablishing of health services at the district and sub-district level is vital for ensuring access to health care for the Timorese people. The district health plan, carried out in cooperation between DHS and International NGOs, will be carefully monitored. Basic services such as EPI, care during pregnancy and maternity as well as treatment of common childhood diseases, in particular diarrhoea and ARI, must be given highest priority.

The absence of national health professional staff, such as medical doctors and staff at managerial levels, is one of the constraints. Since a minimum of 6-7 year period is needed to educate and train a doctor, the problem cannot be solved in the near future. The roles of trained nurses and auxiliary staff have been redefined requiring them to provide basic diagnostic, curative and preventive advice to patients at village and sub-district levels. Substantial resources are therefore needed for training and human resource development.

The situation of laboratory and other diagnostic facilities is difficult, as can be gauged from the fact that there is only one trained X-ray technician in the country. This has serious implications for the diagnostic capability of the five referral hospitals in the country. Current capacity of laboratory services in these hospitals is limited to very basic blood and stool tests. There is an urgent need to strengthen capacity of Central Laboratory to fulfill its role as a reference laboratory through renovation, upgrading of facilities and training of staff. WHO has already engaged an eight-month laboratory consultant for this purpose.

The Division of Health Services has been quite actively functioning as a coordinator with national and international agencies and institutions involved in the development of the health sector in East Timor. WHO continues its technical advisory and supportive role to the DHS, other sister Agencies, national and international NGOs and other institutions involved in health.

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