Public Health Control In Timor Leste: A 2010 Review

Public Health Control of Malaria in Timor-Leste: A 2010 Review

By Joanne Beilby

Introduction

The Democratic Republic of Timor-Leste comprises four islands and a population of approximately 1.1 million. Indonesian occupation since 1975 and subsequent recognition of self-determination by the United Nations in 2002 has left this small yet determined nation struggling with post crisis development difficulties in the twin contractionary economic realities of the inflationary oil crisis and the global economic downturn.

The islands of Timor-Leste lie in the tropical maritime of South-East Asia making them susceptible to the blood disease, malaria. Globally, malaria causes more than 300 million acute illnesses and one million deaths annually.i In Timor-Leste, 100% of the population resides in areas endemic to malaria. The disease is responsible for >40% of deaths annually.ii This paper will analyse recent primary health care responses to the problem of malaria in Timor-Leste. Consideration will be given to both comprehensive and selective primary health care initiatives from government and non-governmental organisations, and the efficacy of these initiatives assessed.

What is Malaria?

Malaria is a vector borne infectious disease caused by a eukaryotic parasite of the genus Plasmodium. The parasite is borne by the Anopheles mosquito and is endemic to many tropical and sub-tropical regions throughout Asia, the Americas, and Africa. Five species of the Plasmodium parasite are infectious to humans. Two of these, P. falciparum and P. vivax, are endemic to Timor-Leste. The Anopheles species vectors in Timor-Leste consist of: A. maculates; A. barbirostris; A. annularis; A. minimus; A. subpictus; A. sundaicus; A. aconitus; and A. minimus. The most common species vectors in Timor-Leste are the A. aconitus and the A. minimus. The parasite is transmitted to humans through the proboscis of the female mosquito when she draws a blood meal with which to nourish her eggs. Over time, the parasite multiplies in the liver of the human host, within the erythrocytes. Symptomatically, the disease causes fever and headache and can lead to loss of consciousness and death.iii

Targeting Malaria

In Timor-Leste, the extent of malaria infection exceeds 191,000 per annum. While approximately 68 deaths are reported annually, insufficient data collection and reporting means this figure is likely to be highly inaccurate with the true number estimated to be 1,041 per annum.iv To a small country such as Timor-Leste, this figure represents > 40% of deaths per annum.

Total Population : 1.1 million Population in Malarious Areas : 1.1 million No. of Lab Confirmed Malaria Cases : 45,973 Pf Proportion : 73.3% No. of Probable Malaria Cases : 97,621 No. of Deaths Due to Malaria (Reported) : 31 (Reported) Cases Treated with ACTs : 34,406 No. of LLINs Distributed : 79,226 No. of Effective LLINs + ITNs (cumulative) Availability : 259,950 No. of Population Protected Population Protected with IRS : 0 Vectors: An. maculates, An. barbirostris, An annularis, An minimus, An.subpictus, An. sundaicus, An.aconitus, An.minimus, the former two species being the main vectors. Over All, the Malaria situation in Timor-Leste is deteriorating.

Reducing the incidence of malaria in Timor-Leste is a considerable challenge. It requires both a broadening and a deepening of Comprehensive and Selective Primary Health Care (PHC) initiatives and a broad base of support to realise the goal. In order to address the disease and its effects on the population and economy, PHC policy must address more than clinical cases that present at the doctor’s door; it must address the cause.

Malaria Situation in Timor Leste, 2008 : At a Glance

Source: World Health Organisation – Regional Office for South-East Asia, (2009).

Primary Health Care (PHC) embodies three defining principles: a philosophical approach to health and health care; a set of strategies; and a level of service provision.v PHC is defined by the World Health Organisation Alma-Ata declaration of 1978 as follows:

"Primary health care seeks to extend the first level of the health system from sick care to the development of health. It seeks to protect and promote the health of defined communities and to address individual problems and populates health at an early stage.”vi

Comprehensive Primary Health Care (CPHC) is a development of PHC that goes further than clinical case by case management of disease. CPHC incorporates broad based, community accessible programmes such as disease prevention, health promotion, and health literacy, and pairs it with holistic health principles of equity, accessibility and affordability for all. In a wealthy industrialised nation such as Australia, CPHC is demonstrable in programmes such as immunisation, disease surveillance and newborn screening tests.

“Comprehensive primary health care is a broad based approach to health care. It can include not only clinical care (doctors, nurses, health workers), but prevention programs, health promotion, rehabilitation, public health measures and advocacy on health related matters.”vii

In Timor-Leste, it has been difficult to provide PHC. Accessibility is problematic as geographical isolation is prohibitive; only 22 percent of Timorese live in urban areas with the remainder living in rural villages. Annually, government total health expenditure is significantly low per capita, ranking 141st lowest out of the 193 World Health Organisation member nations, in 2009.viii The Purchasing Power Parity (PPP) statistic for health expenditure as a function of GDP illustrates indicative per capita expenditure of US$109 per annum. Total health expenditure as a percentage of GDP is 17.7%. Such severely constrained expenditure despite high proportion of GDP allocation directly correlates with low income per capita and low Gross Domestic Product (GDP).ix The number of trained health care professionals (HCPs) is insufficient for the population, and the distribution is highly concentrated to urban centres leaving the majority of Timorese living in rural villages to fend for themselves.

Comprehensive Primary Health Care in Timor-Leste: Covering up from the Bite

With little government funding available for CPHC initiatives it is inevitable that current CPHC government policies and interventional programmes targeting malaria in Timor-Leste are increasingly funded by donor partners such as AusAid, USAID, ACT Malaria, and the World Health Organisation, working in partnership with charitable NGOs such as Rotary Australia via the Rotarians Against Malaria (RAM) programme, Care International, and private philanthropic organisations such as The Bill and Melinda Gates Global Fund. The government of Timor-Leste currently has an extensive partnership arrangement with The Global Fund for the design and implementation of several programmes, (by definition, such programmes cannot be termed CPHC, rather they can be called SPHC types), to reduce the burden of malaria by 30%, (estimated to represent 150,000 clinical cases of malaria), and increase the Comprehensive Primary Health Care capacity of Timor-Leste to control malaria.

Intervention

Policy/Strategy

Intervention

Policy/Strategy

+ Insecticide-treated nets (ITN)

Distribution of ITN/LLINs – Free

Intermittent preventive treatment (IPT)

+ ACT is free or highly subsidized in public sector

+ Targeting – All age groups

+ Targeting – Children under 5 years, pregnant women

+ Oral artemisinin monotherapies banned

Indoor residual spraying (IRS)

+ IRS is used for prevention and control of epidemics

+ Parasitological confirmation for all age groups

+ Free malaria diagnosis and first-line treatment of malaria

+ Prereferral treatment at health-facility level with quinine im or artesunate suppositories

+ RDTs in areas without microscopy

Data Source: World Health Organisation, International, (2009).

Comprehensive Primary Health Care: Interventions & Policies in Timor-Leste, (2008).

These grants will be delivered over two funding rounds amounting to $2,736,768.00 and $9,407,120.00 respectively. Specifically, the programmes include: insecticide-treated nets (ITNs) and long lasting insecticide treated nets (LL-INs) to 70% of the population; improved early access to Rapid Diagnostic Tests (RDT), particularly in areas without microscopy; treatment of 90% of cases within 48 hours; increased community involvement and behavioural change; development of multi-sectoral collaboration through training of HCP and non-HCP staff for enhanced disease surveillance programmes across ten districts; indoor residual spraying (IRS); and intermittent preventative treatments (IPTs) during epidemics.x

The WHO details the following CPHC malaria control strategies under development in Timor-Leste:

Malaria control activities at the community and peripheral levels will be integrated within the basic health services.

The proposed institutional framework for malaria control adopted by the newly formed Ministry of Health will consist of a Vector Borne Diseases Control (Malaria Unit) under the Division of Communicable Diseases.

Districts are directly responsible for implementation of malaria prevention and control measures.

All health care facilities will carry out passive surveillance. Microscopic screening of selective suspected malaria cases is carried out at the district hospitals. It is proposed to expand this facility to all health centres in the future.

Vector control: ITNs, environmental management with regards to water supply and sanitation, IEC.xi

Selective Primary Health Care in Timor-Leste: Interim Measures for Biting Times

CPHC is a demanding standard for health care and understandably considerably difficult for a small developing nation to achieve. Authors such as JA Walsh and KS Warren advocate for Selective Primary Health Care (SPHC) initiatives as a means of achieving short-term disease control in developing countries, while capacity is gained for the implementation of sustainable long term CPHC goals.xiiOstensibly, SPHC differs from CPHC in that it does not espouse the same philosophical determinants. The differences between CPHC and SPHC can be summarised as follows:

Management priorities for infectious disease in developing nations are based on disease prevalence, degree of morbidity and mortality, and efficacy of control measures. With such issues under consideration, Timor-Leste utilises the immediacy of selective focus for cost-effective medical interventions. Treatment for febrile malaria is a common SPHC medical intervention made available to clinical cases presenting to a medical facility. This is the embodiment of SPHC: the disease is addressed by medical personnel, in a medical facility, with medical interventions for disease eradication. Health care is delivered on a case by case basis in response to a disease state. There is a distinct overlap between CPHC initiatives and SPHC initiatives and a significant propensity to confuse both approaches to PHC. This is due to the similarity of service and practice in implementation; the distinguishing features being the philosophical paradigm and underlying values.

Other examples of SPHC interventions in Timor-Leste include treatment by regional need, and scientific research; an inexpensive and cost effective SPHC tool per capita. Timor-Leste together with USAID, distributed 80,500 long lasting insecticide treated nets (LL-IN) to malarious areas of hyper-endemnicity in 2005. Results in 2007 showed 90% of nets were being used effectively with an increase of 15% of children under five years sleeping under a bed net nationally.xiii Though bed nets are an important frontline measure in preventing malaria transmission, the LL-IN insecticide remains effective for only five years. ITN insecticide (non-long lasting) is effective for two years. At this point, the efficacy of the nets is compromised and they need to be replaced or re-impregnated. Comprehensive PHC Selective PHC View of health Positive Wellbeing Absence of disease Locus of control over health Communities and individuals Health professionals Major Focus Health through equity and community empowerment Medical solutions for disease eradication Health Care Providers Multi-disciplinary teams Medical doctors Strategies for health Multi-sectoral collaboration Medical interventions

Source: UNSW, (2010).

Differences Between Comprehensive and Selective Primary Health Care, (2010).

Though they can form part of a CPHC policy, Intermittent Primary Health Care Based Preventative Treatments (IPTs) are frequently part of SPHC solutions to malaria in Timor-Leste. Anti-malarial drug combination therapy, (artemisinin-based combination therapy), parasitological confirmation or Rapid Diagnostic Tests (RDTs) in areas without microscopy, medical directed treatment of malaria, and effective triage and intra-muscular chloroquine and oral sulfadoxine-pyrimethamine for malarious patients, all form effective SPHC frontline defences against malaria in Timor-Leste.

When Success is a Moving Target: Measuring Change During Change

A favourable climate makes perennial transmission a reality for Timor-Leste. Despite efforts from both CPHC and SPHC approaches, malaria continues to undermine public health. Due to recent CPHC efforts, 80% of cases are now reported from four of the 13 districts of Timor-Leste, taking the number from 15,212 in 2000 to 45,973 in 2008. This may indicate a rise in the incidence of malaria or just indicate increased reporting of the disease. A corresponding parasitological confirmation rate increase from 44% to 50% suggests both may be true, as does the percentage increase of clinical cases from 53% to 75% at the same time. Children under five years still account for approximately 35% of total cases, (approximately 60% of those covered under the ITN programme).xiv

Source: World Health Organisation – Regional Office for South-East Asia, (2010).

Trends of Confirmed Malaria Cases in Timor-Leste, 2002-2008.

Increasing resistance to chloroquinine has seen a failure rate of 67% contributing to the rise in malaria cases. There has been difficulty implementing programmes due to personnel shortages and failure in vector controls has been attributed to lack of community participation, personnel, funding and inter-sectoral collaboration. Parasitological confirmation is compromised by insufficient effectively trained microscopists and pathologists. Nets are under-utilised, poorly employed, remain undistributed and in some cases destroyed due to lack of education. Much of the population continues to reside in areas unserviced by health-care facilities and diagnostic laboratories.

Activities designed to change behaviour have been fragmented, erratic and consequently ineffectual. Despite the creation of a new faculty for the training of HCPs, human health care resources remain deleteriously limited. Health literacy is poor throughout the community. Attempts to improve health literacy have been overly didactic, poorly targeted and consequently have failed. The existing disease surveillance programme has failed to identify and evaluate routine malarious disease. The problem of malaria continues to deteriorate in Timor-Leste.xv

Conclusion

Addressing the problem of malaria in Timor-Leste is a considerable challenge. The difficulties of a developing nation warrant a systematic approach to disease mitigation from both the Comprehensive and Selective Primary Health Care paradigms. Sustained collaborative efforts can result in effective disease control for the population if more than the immediate clinical cases are kept in sight.

ENDNOTES

i Malaria Basic III, pg1.

ii The Global Fund, Funding Document Round 7 (2009), Passim.

iii Harrison's Principles of Internal Medicine, Passim.

iv The Global Fund, http://www.theglobalfund.org/programs/grant/?compid=1594&grantid=741&lang=en&CountryId=TMP

v Defining Primary Health Care, UNSW

vi Alma Ata, (1978).

vii Aboriginal Medical Services Alliance Northern Territory (AMSANT), http://www.amsant.com.au/amsant/what-is-primaryhealth-care.html

viii OECD (November 2009). "OECD Health Data 2009 - Frequently Requested Data". Organisation for Economic Co-operation and Development.

ix WHO (May 2009). "World Health Statistics 2009". World Health Organization.

ix List of countries by total health expenditure (PPP) per capita, World Health Organisation (2006, 2009)

x The Global Fund, Round 2 (2003) & Round 7 (2009), Passim.

xi WHO SEARS Website

xii JA Walsh, and KS Warren, Selective primary health care: an interim strategy for disease control in developing countries, New England Journal of Medicine (Volume 301:967-974)

xiii Malaria Basic III, pg 2.

xiv WHO SEARS Website, (2010).

xv WHO SEARS Website, (2010).

BIBLIOGRAPHY

Books:

Eugene Braunwald, Stephen L. Hauser, Anthony S. Fauci, Dennis L. Kasper, Dan L. Longo, and Larry Jameson [Eds], Harrison's Principles of Internal Medicine, 15th Ed, McGraw-Hill, 2001.

Government Papers/Websites:

Ministry of Health, National Malaria Strategy, 2003-2013 Division of Communicable Diseases, Democratic Republic of Timor-Leste (2003) http://www.burnet.edu.au/freestyler/gui/media/ETNatMalariaStrategy.pdf Accessed 15.3.10

Websites:

Aboriginal Medical Services Alliance Northern Territory (AMSANT), http://www.amsant.com.au/amsant/what-is-primaryhealth-care.html Accessed 22.3.10

UNSW Medicine, PHC Connect: Building the Capacity for Primary Health Care http://www.phcconnect.edu.au/defining_primary_health_care.htm

Malaria Situation In SEAR Countries: Timor-Leste, World Health Organisation Office for South-East Asia http://www.searo.who.int/EN/Section10/Section21/Section340_4028.htm Accessed 15.3.10

Epidemiological Profile: Democratic Republic of Timor-Leste, World Health Organisation Office for South-East Asia http://www.who.int/malaria/publications/country-profiles/mal2008-democraticrepublicoftimor-leste-en.pdf Accessed 21.3.10

OECD (November 2009), OECD Health Data 2009 - Frequently Requested Data, Organisation for Economic Co-operation and Development. http://www.oecd.org/document/16/0,3343,en_2649_34631_2085200_1_1_1_1,00.html Accessed 23.3.10

World Health Organisation (May 2009), World Health Statistics 2009, World Health Organization. http://www.who.int/whosis/whostat/2009/en/index.html Accessed 23.3.10

List of countries by total health expenditure (PPP) per capita, World Health Organisation (2006, 2009)

Distribution of Lab Confirmed Cases of Malaria, 2006, World Health Organisation Office for South-East Asia http://www.searo.who.int/LinkFiles/Malaria_in_the_SEAR_TLS_Malaria06.pdf Accessed 21.3.10

Reported Malaria Morbidity Rates (/1000) in Timor-Leste, (2002-2008), World Health Organisation Office for South-East Asia http://www.searo.who.int/LinkFiles/Malaria_in_the_SEAR_mr-tls.pdf Accessed 21.3.10

District-wise Annual Clinical Malaria Incidence (ACMI /1000) in Timor Leste, 2005, World Health Organisation Office for South-East Asia http://www.searo.who.int/LinkFiles/Malaria_in_the_SEAR_District-wiseCasesTLS04-05.pdf Accessed 21.3.10

Distribution of Malaria Cases (including clinical) in Timor – Leste, 2000-2005, World Health Organisation Office for South-East Asia http://www.searo.who.int/LinkFiles/Malaria_in_the_SEAR_DistcasesTLS00-05.pdf Accessed 21.3.10

Distribution of Malaria Cases by Months in Timor Leste, 2004 – 2005, World Health Organisation Office for South-East Asia http://www.searo.who.int/LinkFiles/Malaria_in_the_SEAR_Month-wisecasesTLS04-05.pdf

ITN Coverage in Timor Leste, 2004- 2005, World Health Organisation Office for South-East Asia http://www.searo.who.int/LinkFiles/Malaria_in_the_SEAR_ITN_TLS04-05.pdf Accessed 21.3.10

Distribution of Malaria Cases by Age groups in 2004 – 2005, World Health Organisation Office for South-East Asia http://www.searo.who.int/LinkFiles/Malaria_in_the_SEAR_Age-wiseTLS04-05.pdf Accessed 21.3.10

Micro-stratification of Areas at Sub-district level Based on Malaria Receptivity, World Health Organisation Office for South-East Asia http://www.searo.who.int/LinkFiles/Malaria_in_the_SEAR_Micro-stratification.pdf Accessed 21.3.10

Sub-districts with Predominant Land Pattern and Malaria Case Incidence in Timor Leste, 2003, World Health Organisation Office for South-East Asia http://www.searo.who.int/LinkFiles/Malaria_in_the_SEAR_sub-districts.pdf Accessed 21.3.10

Micro-stratification of malarious areas in terms of Annual Case (suspected) Incidence in East Timor (2000-2001), World Health Organisation Office for South-East Asia http://www.searo.who.int/LinkFiles/Malaria_in_the_SEAR_Micro-stratification-of-malarious.pdf

USAID, Malaria Basic III, http://www.basics.org/reports/FinalReport/Malaria-Final-Report_BASICS.pdf Accessed 20.3.10

Journal Articles:

JA Walsh, and KS Warren, Selective primary health care: an interim strategy for disease control in developing countries, New England Journal of Medicine (Volume 301:967-974) http://content.nejm.org/cgi/content/short/301/18/967

Joao S Martins, Anthony B Zwi, Nelson Martins and Paul M Kelly, Malaria Control in Timor-Leste during a period of Political Instability: what Lessons can be Learned? Conflict and Health, (2009). http://www.conflictandhealth.com/content/3/1/11 Accessed 16.3.10

World Health Organization: World Malaria Report 2008. Geneva: World Health Organization; 2008.

Ministry of Health: National Mosquito-Borne Disease Control Strategy. Ministry of Health, Democratic Republic of Timor-Leste; 2005.

The Global Fund: Program Grant Agreement between the Global Fund to fight AIDS, Tuberculosis and Malaria and the Ministry of Health of the Government of the Democratic Republic of Timor-Leste. Geneva: The Global Fund to fight AIDS, Tuberculosis and Malaria; 2003.

World Health Organization: Timor-Leste Crisis Epidemiological Updates 19 June 2006. Dili: The World Health Organization; 2006.

Ministry of Health: Malaria Treatment Protocol. 3rd edition. Ministry of Health, Democratic Republic of Timor-Leste; 2007.

Kolaczinski J, Webster J: Malaria control in complex emergencies: the example of East Timor, Tropical Medicine and International Health 2003, 8(1):48-55.

Alonso A, Brugha R: Rehabilitating the health system after conflict in East Timor: a shift from NGO to government leadership, Health Policy and Planning 2006., 21(3)