Essential Obstetric Care in Timor-Leste:
The Shape of Safe Motherhood in a Developing Country.
The Shape of Safe Motherhood in a Developing Country.
Joanne Beilby
Introduction
The challenge of enabling safe motherhood in Timor-Leste is significant. In a developing country ravaged by war and the struggle for independence, Essential Obstetric Care (EOC), by western standards, is scantily provided. The magnitude of maternal mortality is very high, with one in thirty-five women having a lifetime risk of obstetric death. As with many developing countries, inequalities in maternal health is a function of social, cultural and contextual factors, extending past health services to policy making, education, economics and beyond. This paper will analyse the provision of Essential Obstetric Care in Timor-Leste, the barriers to supply, and make suggestions for improvement given current constraints.
Provision of Essential Obstetric Care in Timor-Leste
Timor-Leste comprises four islands and a population of approximately 1.1 million.[i] According to The Democratic Republic of Timor-Leste Health Profile, August 2002, the following distribution of health professionals provides services to the people of Timor-Leste: 47 physicians (12 national and 35 international), 624 nurses and 226 midwives. With only one tertiary level health facility and poor primary care, the lack of EOC and Emergency Obstetric Care (EmOC) has led to an extremely high Maternal Mortality Rate (MMR) estimated to be 660 deaths per every 100,000 births.[ii]
The prevailing causes of maternal mortality in Timor-Leste include haemorrhage, sepsis, unsafe abortion, obstructed labour and hypertensive diseases of pregnancy. Indirect causes include increasing incidence of teenage pregnancy and early marriage, geographic isolation, poor reproductive health, low maternal literacy/education rates, prevalence of acute infectious diseases such as malaria, and chronic disease states such as malnutrition and anaemia.[iii] All are exacerbated by the many social, economic, geographic and political factors underpinning and in some cases, obstructing change.
With the instigation of the Timorese Ministry of Health in 2001, and the subsequent adoption of the Millennium Development Goals, several key areas of deficit were identified that directly relate to the provision of EOC and maternal health outcomes.
The following objectives were defined:
Ø the reduction of maternal and infant mortality;
Ø the improvement of reproductive health;
Ø equity of access to health services;
Ø provision of a regulated minimum healthcare service;
Ø increased health literacy for women, (including access to information); and
Ø improvement in the nutritional status of mothers and children.[iv]
Reduce MMR by 75% between 1990 and 2015 | ||
INDICATORS | 2001 | MDG TARGET 2015 |
MMR per 100,000 live births | 240-800 | 252 |
Proportion of births attended by skilled personnel | 24%-38% | 60% |
EOC in Timor-Leste: Current Service Provision and Coverage
The physical infrastructure for health services delivery is extremely limited throughout Timor-Leste. The only tertiary level referral hospital, located in Baucau, provides 114 beds and has the capacity to provide surgery with general anaesthesia. Four regional hospitals of 24 beds serve the districts of Cavalima, Bobonaro, Oecusse and Ainaro. Basic inpatient services are provided. Surgery is not yet available. All other districts provide community centres with the capacity to offer basic health services and to deploy mobile clinics. These centres are termed ‘level one’ health facilities and cover a four to eight kilometre radius. They provide basic non-diagnostic curative consultation, antenatal and postnatal care, immunization, infant growth monitoring, and health promotion.
Community health centre facilities (level two) exist at the sub–district level for the provision of health promotion, prevention, and out-patient curative consultations. Services are supported by a simple laboratory. Level three healthcare facilities are located in the districts bordering Dili, Aielu and Liquica. This level of healthcare facility has the additional capacity of basic Emergency Obstetric Care (EmOC), with procedures such as forceps or vacuum assisted delivery, manual removal of placenta, and treatment of other obstetric complications.
Inpatient facilities for up to 20 beds are located in five districts, providing level 4 services such as minor surgery not requiring general anaesthesia. These facilities provide diagnostic medical consultation and referral where appropriate, medical pathology and other support diagnostics.[v]
EOC Coverage
According to the Timor-Leste Health Statistics Report, skilled health personnel attend only 27.2% of all births. Use of modern methods of contraception is very low at <7% of the married population of reproductive age, and the development of a nationwide family planning programme is still at policy development stage.
Rural isolation means inequitable and problematic access to antenatal care, skilled birth attendants, EOC and EmOC for many Timorese women. Accessibility is greatly reduced by geographic isolation with only 27% of Timorese living in urban areas and the remainder living in rural villages.[vi] The population resides primarily on one half of the major island, East Timor, however there are also residents on three other remote islands who receive little to no EOC services. Access issues are central to reducing the MMR and to providing better coverage and EOC service provision.
Barriers to coverage
The provision of EOC services across Timor-Leste is a challenge. Indonesian occupation since 1975 and subsequent recognition of self-determination by the United Nations in 2002 has left Timor-Leste struggling with post-crisis development. Tax revenue insufficiency linked to low GDP per capita means a meagre base from which to redistribute wealth. Public goods such as health care receive too few dollars to address needs. A policy re-prioritisation matched by adequate funding will make the difference in the short term. For increased capacity and long term change, economic growth, stewardship and outsourcing are required.
The ongoing problem of refugees in Timor-Leste persists. Itinerant populations provide particular problems in EOC service delivery. They are difficult to reach for educational and preventative care purposes and provide ongoing primary and antenatal care difficulties due to the nomadic behaviour of internally displaced persons (IDP). Issues of equitable distribution are poorly addressed and becoming more important as IDPs return to their pre-war homes. Their migration brings an increase in service demand in remote areas and staffing these areas is problematic with midwives reluctant to service communities without utilities and basic infrastructure such as communications.
Cultural perceptions affect penetration of available services in Timor-Leste further complicating EOC service provision. Many perceive the use of medical facilities for child birth as constituting failure on behalf of the mother. Consequently, Timorese women do not routinely seek EOC, and only seek EmOC when in a critical condition.
Fifty-two percent of Timorese are illiterate and health literacy is poor. Ignorance of modern methods affects utilization of available EOC services. A reduction in maternal morbidity and mortality will be greatly facilitated by a non-didactic, culturally sensitive, continuous, female friendly, educational campaign that directly targets women of reproductive age and puberty.
Pregnant Timorese married to economic migrants often feel isolated and vulnerable away from their maternal families. The tendency for women (particularly primigravidae) to attempt to return to their home village prior to delivery also sees many travelling long distances leaving areas of high service provision to arrive in areas of low service provision. The women often work as long as possible, travelling late in the third trimester, often unaided and without the care of a primary physician or midwife should difficulties arise.
Barriers to EOC Service Provision
By far, the greatest barrier to EOC service provision is lack of funds. Healthcare financing requires responsible and informed economic management by the government of Timor-Leste and recognition that as a public good, health care has associated externalities and failures that need to be addressed. This is a key role of government – to provide essential services where the allocative power of competitive markets fails. In collaboration with partner organisations, (NGOs and donor funding), the reliance on out of pocket funding as a dominant source of health financing can be minimised. This is especially important for Timor-Leste as the burden of out of pocket costs falls heaviest on the poor, and serves as a barrier and disincentive to consumption of health care services.
Given that healthcare the world over is predicated on the problem of infinite need and scarce resources, the use of evidence based investment is critical. Policy grounded in the criteria of efficiency, equity and effectiveness must be paramount if dollars and morals are not to be squandered. The current capacity of the government of Timor-Leste to respond to public health concerns is minimal and as a result, initiatives and development in public health, particularly broad primary health care measures such as EOC policy reform, are limited in their application and effectiveness. If Timor-Leste is to achieve the Millennium Development Goals then collaboration with external partners is essential.
Barriers to EOC Service Provision: The Economic Realities
Government health expenditure per capita is very low, ranking 141st lowest out of the 193 World Health Organisation (WHO) member nations.[vii] Purchasing Power Parity (PPP) for health expenditure as a function of Gross Domestic Product (GDP) illustrates per capita expenditure of US$109 per annum. Total health expenditure as a percentage of GDP is 17.7%. Such constrained expenditure despite high proportion of GDP directly correlates with low income per capita and low Gross Domestic Product (GDP).
Efficiency, Effectiveness and Equity
Health care in Timor-Leste lacks both technical and allocative efficiency. The ineffective provision of EOC is endemic. The number of trained health care professionals is insufficient for the population, and their distribution is highly concentrated to major urban centres leaving the majority of the population, rural dwelling Timorese, to fend for themselves. EOC services are out of date, fail to meet evidence based criteria, and consistently employ antiquated methods due to insufficient resources and capital; physical, human and monetary. Existing EOC is ineffectual in meeting the needs of the population.
Efficient EOC services depend on the availability of basic EOC drugs, serviceable equipment, consumables, staffing and infrastructure. Shortages of all are widespread in fixed healthcare facilities and mobile services. These inadequacies prevent the delivery of evidence based EOC and EmOC services.
Gender inequalities exist is the form of non-prioritised health services for women, women of remote areas, and women of low educational status. The disempowerment of women means women seek health care, food and entitlements last. Little to no political power or influence over policy direction consolidates this position at an individual, community and national level.
Currently, there are no indigenous obstetricians in Timor-Leste and the country depends on the services of expatriate specialists. It is questionable whether the development of ongoing effective EOC/EmOC services is possible given the current Timorese educational priorities. There is an inequitable education of females and educated males often seek better employment opportunities abroad. Women tend to have greater ties to their country and region of birth and if educated, could contribute substantially to the local labour market. A role for development partners may be to facilitate training in obstetrics/gynaecology for the provision of EOC at a primary health level and EmOC at hospitals, as well as counsellors for family planning.
Future Directions: What can be done to improve EOC in Timor-Leste?
Policy is central to achieving better health outcomes and efficient EOC services. Appropriate and equitable EOC interventions need to reach underserved and vulnerable women as a first priority to save lives. This requires political commitment and equitable representation for maternal health in federal budgets. Urgent action is imperative. Technology is not the constraint in the provision of health services such as EOC, demand and supply side policy is, and existing proven practices and tools must be up-scaled and implemented immediately. Disadvantaging women is a force multiplier for the rest of society and there is a well demonstrated relationship between maternal and child health outcomes. Ministers must learn to view health as an asset model, not a deficit model, whereby timely and proactive investment contributes to the social and economic prosperity of all.
There must be wider strengthening of the health care system and developmental stewardship with collaboration partners will help this to progress. Excellent economic management is essential and supply must be at the lowest possible cost. Gap analysis linked to targeted investment can align science with cost and predict outcomes for investment dollars. Marginal budgeting for bottlenecks will address gaps and barriers in the market. While government must ensure affordability, manage competition, provide cost containment and ensure equity, the tax revenue base must also be increased. Sin taxes and foreign owned companies can help relieve reliance on donor funding as will private/social health insurance once developed and promoted.
To meet the twin objectives of efficiency and equity, it is not enough to rely on the macro-economics; the sources of inequity must be identified and addressed through policy. These are the external factors affecting health care - culture, geography, gender, education, social capital, employment, socio-economic status and empowerment all affect the demand and provision of EOC services in Timor-Leste. In moderating the drivers of health care costs, the government needs to address the education of all in family planning and health care. No up-front fees and low out of pocket costs are vital to ensure the poor are able to access services, and use of EOC needs to be promoted to the vulnerable at the community level. Universal attendance by a skilled birth attendant must be a nationwide priority.
It is important for policy makers to realise that equity and efficiency can occur together. Health metrics such as the National Health Accounts (NHA) are vital tools to inform priorities through data. They are indispensable for quantification of health effects and the use of population modelling to determine cost effectiveness. It is essential that Timor-Leste facilitate the collection and release of such data so that health economic evaluation can be used in decision making. Accurate and up to date statistics on risk factors and diseases are required to formulate policy and measure change. In the absence of data, the burden of disease and response to policy changes cannot be effectively evaluated.
Nationally, work is progressing to improve EOC in Timor-Leste. Training of midwives has commenced at Timor-Leste’s first dedicated midwifery facility. While it is proving difficult to increase the proportion of births attended by skilled personnel, an incremental approach will assist. It is salutary to note the lessons of Nepal in 2001-2006. With a skilled birth attendant presence of only 18%, in a disrupted health system working at capacity, attention was instead directed towards improving women’s literacy, legalisation of abortion and empowerment of women. The result was a drop in the MMR by almost half (539 deaths per 100,000 live births in 2001 to 281 in 2006), fall in the total fertility rate, increase in women’s literacy and empowerment, and increased use of family planning services.[viii] All achieved without changing the number of births attended by skilled personnel and minimal funding.
The lessons of Nepal demonstrate that a successful approach does not necessarily mean costly investment in tertiary infrastructure. Increased women’s literacy and health promotion is essential to empowerment and progress. It is women who need to take charge of their reproductive life and become champions of the cause if the desired health outcomes are to be achieved. Promoting community involvement at planning, delivery and in ongoing monitoring enables women and ensures their interest and compliance in national priorities.
The Timor-Leste National Safe Motherhood Strategy needs more staff directed towards its completion. Where capital shortages are prohibitive, the government needs to recognise the many benefits partner organisations can offer and utilize them. Small countries frequently lack capacity to reap economies of scale and provide efficient and equitable public goods. Outsourcing workload and exploiting comparative advantage is imperative where domestic capacity lags.
Attention must also be directed beyond the current generation of women requiring EOC to future generations. It is well recognised that many difficulties in childbirth arise from poor nutrition during maternal growth phases and that a life cycle approach is an appropriate contributor to preventative health care and reduction is EmOC demand. Timor-Leste is not a food resource poor country. It has good annual rainfall and a bountiful supply from the sea. None-the-less, there is a high percentage of malnutrition, due in part to ignorance and also from poverty, that leads to general lack of food security and poor nutritional indicators. Ensuring good nutrition through education and supplements where required will enable proper growth and birthing ability for women of subsequent generations.
Conclusion
Health is a human right and essential obstetric care is a fundamental part of ensuring health for women and children. To remedy the poor outcomes in maternal health, Timor-Leste must address both the technical and allocative inefficiencies that have given rise to an inequitable provision of EOC services and increase provision and demand for services through targeted cost effective programmes. Macro-economic policy must focus on growth and development to support GDP and the provision of health care, and policy in all sectors must drive changes to prioritize maternal health particularly for the vulnerable and underserved.
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[vii] 2009
[viii]5 Nepal Demographic and Health Surveys 2001 and 2006
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