Timor Leste – A Briefing for Newly Arrived Health Practitioners
Introduction –
This guide is designed to inform the visiting health practitioner of the key issues in Timor Leste, to enable ethical and informed practice and to facilitate culturally sensitive health care for the East Timorese.
Background
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.
https://www.cia.gov/library/publications/the-world-factbook/maps/maptemplate_tt.html
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 and it is the largest public health concern in the country.[ii]
Timor-Leste was a Portuguese colony from the middle of the 16th century until 1975, when independence was gained from Portugal. However nine days later, Indonesian forces aggressively invaded and occupied Timor. In 1976, forced integration with Indonesia was met with hostility and between 100,000 - 250,000 people were killed in the two decades that followed. In 1999, a referendum sponsored by the United Nations returned an overwhelming vote for independence from Indonesia. However prior to the arrival of the U.N. peacekeeping force, anti-independence militia, organised and equipped by the Indonesian military, destroyed much of Timor-Leste in a vengeful act of retribution. 1400 Timorese were killed and 300,000 people were forcibly made refugees in Western Timor.[iii] From homes to schools, hospitals, water and electrical supply, the majority of Timor-Leste’s infrastructure was destroyed. Much respect is due the Timorese for their unceasing fight against subjugation and pacification at the hands of the Indonesians.
There is ongoing sensitivity regarding the role of the U.N and its failure to supply peacekeeping at the required time. Australia shares a 50 year development zone agreement with Timor-Leste in place of a maritime boundary and while Australia is regarded well for its twice utilized peacekeeping role, there remain some border areas that are unresolved and an undercurrent of tension and sometime instability for the fledgling nation.
As a developing country ravaged by war and the struggle for independence, health care by western standards, is scantily provided in Timor-Leste. The magnitude of maternal mortality is very high, with one in thirty-five women having a lifetime risk of obstetric death. Inequalities in health exist as a function of social, cultural and contextual factors, extending past health services to policy making, education, economics and beyond.
Key Issues In Timor-Leste
Key issues in Timor-Leste revolve around poverty and equity. They have been exacerbated by the war for independence and ongoing instability, and the difficulties of developing a new country in a challenging economic climate. Timor-Leste faces many health issues and barriers to be overcome.
Cultural Issues
The culture of Timor-Leste is a synergy of its many influences including colonizing country of Portugal and its accompanying religion of Roman Catholicism, Malaysian culture, and the indigenous cultures of Austronesia and Melanesia. Craftsmanship, weaving and poetry are highly valued and widespread throughout the country.[iv] Cultural perceptions affect penetration of available health services in Timor-Leste and further complicate service provision. Many perceive the use of medical facilities for child birth for example as constituting failure on behalf of the mother. Consequently, Timorese women do not routinely seek essential obstetric care and only seek emergency obstetric care when in a critical condition.
Ethnic and Religious Issues
There are three main ethnic groups in Timor-Leste: Austronesian (Malayo-Polynesian), Papuan, and a small Chinese minority. Of the religions practiced in Timor-Leste, Roman Catholicism is dominant with 98% of the population being Catholic. During Indonesian occupation, participation at churches grew supporting the development of a resistance movement. Minority religions include Muslim at 1%, Hindu at 0.5%, Buddhist at 0.1% and Protestant at 1% (2005).[v] Despite the dominance of Roman Catholicism, animist traditions exist within this demographic and continue to have an effect on the culture of Timor-Leste.
Consideration should be made of contraceptive and family planning advice with regard to the religions of Timor-Leste. For many years, contraception has been contrary to the teaching of the Catholic church and may still be regarded distastefully by the Catholic community. Muslim women who wear the hijab will not attend a male clinician and many will require the authorization and presence of their husbands or fathers when medical treatment is required. Furthermore, the persisting influence of the former Portuguese society still dominates and results in unempowered and marginalised women in Timor-Leste.
Gender Issues
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.
Maternal mortality is an issue of serious concern in Timor-Leste. Reduction in the maternal mortality rate has been identified as a key development goal and accordingly targeted by the government of Timor-Leste and the United Nations in the Millennium Development Goals set down for member nations.
The average life expectancy in Timor-Leste is sixty years for males and sixty-two years for females,[vi] however statistical data for Timor-Leste is rudimentary at best. With only one tertiary level health facility and poor primary health care, there is a critical lack of Essential Obstetric Care and Emergency Obstetric Care service. This has led to an extremely high Maternal Mortality Rate (MMR) estimated to be 660 deaths per every 100,000 births.[vii]
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.[viii] All are exacerbated by the many social, economic, geographic and political factors underpinning and in some cases, obstructing change.
The East Timorese Ministry of Health is addressing several key areas of deficit that directly relate to the provision of essential obstetric care and maternal health outcomes. They are the reduction of maternal and infant mortality, the improvement of reproductive health, equity of access to health services, provision of a regulated minimum healthcare service, increased health literacy for women, (including access to information), and improvement in the nutritional status of mothers and children.[ix]
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.
Rural isolation means inequitable and problematic access to antenatal care, skilled birth attendants, essential obstetric care and emergency obstetric care for many Timorese women. 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 health care services. Access and equity issues are central to reducing the MMR and to providing better coverage and service provision.
Health Equity Issues
Health literacy is poor throughout the community in Timor-Leste and attempts to improve health literacy have been overly didactic, poorly targeted and have failed. The existing disease surveillance programme has failed to identify and evaluate routine disease.
Much of the population of Timor-Leste continues to reside in areas unserviced by health-care facilities and diagnostic laboratories. Organised activities designed to change behaviour have been fragmented, erratic and ineffectual. Despite the creation of a new faculty for the training of Health Care Professionals, human health care resources remain limited. 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.
Health Services - Physical Infrastructure
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. [x]
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. [xi]
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.[xii]
Resource Allocation Issues
In Timor-Leste, the provision of primary health care has been problematic. Accessibility barriers exist due to prohibitive geographical isolation; 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, 2009.[xiii] The Purchasing Power Parity (PPP) 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).[xiv] 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 East Timorese who live in rural villages without access to health care.
The Government of Timor-Leste has extensive partnership arrangements with several donor organisations to increasingly fund selective primary health care programmes that meet with the Millennium Development Goals objectives. Donor organisations include AusAid, USAID, ACT Malaria, and the World Health Organisation, working in partnership with charitable NGOs such as Rotary International, Care International, and private philanthropic organisations such as The Bill and Melinda Gates Global Fund. In particular, large amounts of funding is targeted to reduce the burden of malaria by 30%, by 2015. (There is an estimated 150,000 clinical cases of malaria per annum in Timor-Leste).
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.
Health Economics In Timor-Leste
Existing healthcare financing does not meet the needs of the Timorese. Policy changes are warranted to provide responsible and informed economic management by the government of Timor-Leste that recognize 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 health policy reform, is limited in its application and effectiveness.
Internally Displaced Persons (IDP) Issues
The ongoing problem of refugees in Timor-Leste persists. Itinerant populations provide particular problems in health care 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 health care professionals reluctant to service communities without utilities and basic infrastructure such as communications. Approximately 100,000 IDPs remain as a legacy of the independence war.
Nutritional Resources
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 poor nutritional practices and also from poverty that leads to general lack of food security and poor nutritional outcomes.
Ethical Issues
Ethical issues for the visiting health care professional in Timor-Leste stem from ‘Western style’ paternalism and attitudes of superiority. It is important to remain cognizant of history and the resilience of the Timorese and to respect them as capable and intelligent people. Much respect is due the Timorese and their culture in and of its own right. It is not to be assumed that ‘Western’ practices are superior to local practices. All health care professionals should include the patient and local people as partners in their own health care development, provision and management. Informed consent in East-Timor is not the same as in Western cultures as issues of health involve all members of the family and community and are discussed as broadly.
It is recommended that the new health care professional observe closely for the usual practices of the community in which they are based and work within the boundaries of that community with sensitivity and respect for cultural differences. Culture shock is to be expected at first and quiet reflection time and sensitive discussion with colleagues can help to reduce the sense of dislocation for the visiting practitioner while improving cultural understanding and tolerance.
Conclusion
Successful practice in Timor-Leste relies on the recognition and management of many culturally sensitive key issues related to religion, history, culture, gender, equity and resource constraints. Fellow health care professionals can ensure ethical and informed practice by relying on the capacity of the clinician to respect, observe and learn the traditional Timorese ways, while also recognizing the importance of minimising unethical and paternalistic behaviour.
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Post Graduate Subject Reading Lists:
Maternal and Child Health in Developing Countries (2010)
Curtin University
Ethics In International Health (2011)
Curtin University – Centre for International Health
International Health and Primary Health Care (2010)
Curtin University
Economics of Health Financing (2011)
Curtin University
[i] Malaria Basic III, pg1.
[ii] The Global Fund, Funding Document Round 7 (2009), Passim.
[iii] CIA The World Fact Book https://www.cia.gov/library/publications/the-world-factbook/geos/tt.html
[iv] East Timor: a bibliography, a bibliographic reference, Jean A. Berlie, (2001)
[v] CIA The World Fact Book https://www.cia.gov/library/publications/the-world-factbook/geos/tt.html
[vi] Source United Nations – Timor-Leste Millennium Development Goals
[vii] Timor-Leste: Health Statistics Report, 2006.
[viii] Source Family Health International http://www.fhi.org/en/Topics/maternalmort.htm
[ix] Source Democratic Republic of Timor-Leste Health Profile, August 2002.
[x] Source Democratic Republic of Timor-Leste, Health Profile, August 2002.
[xi] Source Democratic Republic of Timor-Leste, Health Profile, August 2002.
[xii] Source Democratic Republic of Timor-Leste, Health Profile, August 2002.
[xiii] OECD (November 2009). "OECD Health Data 2009 - Frequently Requested Data". Organisation for Economic Co-operation and Development.
[xiv]WHO (May 2009). "World Health Statistics 2009". World Health Organization.
[xiv] List of countries by total health expenditure (PPP) per capita, World Health Organisation (2006, 2009)