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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Accessed 12 October, 2010.
World Health Organisation, Maternal and Newborn Health: Making Pregnancy Safer – Assessment Tool for the Quality of Hospital Care for Mothers and Newborn Babies, https://docs.google.com/viewer?url=http://www.euro.who.int/__data/assets/pdf_file/0008/98792/E93128.pdf
Accessed October 15th, 2010.
World Health Organisation, Timor-Leste: National Health System Profile http://searo.who.int/EN/Section313/Section1526.htm, Accessed October, 2010.
World Health Organisation, Making Pregnancy Safer, http://www.searo.who.int/en/Section13/section2364.htm
Accessed October 21st, 2010.
World Health Organisation, Global Health Observatory http://apps.who.int/ghodata/?vid=19600
Accessed October 20th, 2010.
World Health Organisation, Timor-Leste: National Expenditure On Health, (USD). https://docs.google.com/viewer?url=http://www.who.int/entity/nha/country/tls.pdf
World Health Organisation, http://www.who.int/topics/pregnancy/en/
Accessed October 15-31, 2010.
World Health Organisation, Making Pregnancy Safer, http://www.who.int/topics/pregnancy/en/ Accessed October 15-31, 2010.
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
“How gender inequalities impact on the achievement of MDG 4 and 5.” World Health Organisation
http://www.euro.who.int/en/what-we-do/health-topics/Life-stages/maternal-and-newborn-health/news/news3/2010/12/progress-regarding-mdgs-3,-4-and-5.-draft-conclusions-from-who-meeting-of-national-focal-points-for-family-and-community-health-in-durres,-albania.
Accessed 12.10.10
A Comprehensive Approach Required, http://www.australianvolunteers.com/volunteer/volunteer-stories/a-comprehensive-approach-required.aspx
Accessed 12 October, 2010.
Global Health Observatory, Indicator Statistics, http://apps.who.int/ghodata/?vid=19600#,
Accessed October, 2010.
List of countries by total health expenditure (PPP) per capita, World Health Organisation (2006, 2009) 10
https://docs.google.com/viewer?url=http://www.who.int/entity/nha/country/tls.pdf
Accessed 12 October, 2010.
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)
Official Government Portal of Timor-Leste, http://timor-leste.gov.tl/?lang=en
Accessed 1-31 October, 2010.
SEARO
http://www.searo.who.int/en/Section13/section2364.htm
Accessed October, 2010.
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)
Showing posts with label east timor. Show all posts
Showing posts with label east timor. Show all posts
Saturday, August 13, 2011
Thursday, July 21, 2011
The Role of Women in Making and Building Peace: Reflections on Timor-Leste
Last June in Suai, a small town in Timor-Leste, I held an open day with local women and men to mark the tenth anniversary of Security Council Resolution 1325 on women, peace, and security. This resolution recognizes the unique impact of conflict on women’s lives and highlights their often overlooked contributions to resolving and preventing conflict. It also calls on the international community to involve women fully in every aspect of our work for peace and security.
The discussion at the meeting was lively. Women presented their achievements and shared their ideas on how the international community could better help them reach their goals. Topics ranged from community policing to cross-border reconciliation with communities in Indonesia to domestic violence. I was struck by the energy and diversity of the more than one hundred people who came to voice their concerns. Police officers, local government officials, and community leaders joined scores of ordinary women—mothers, wives, breadwinners, and heads of household.
My lasting impression of the women of Suai was that they were not demoralized by their past. On the contrary, they radiated energy and resourcefulness. Their stories and work helped me understand that if the United Nations were to make a lasting contribution to peace and stability in Timor-Leste on my watch, it would be by building on the initiative and resilience of these women and helping them become fully involved in determining the country’s future.
Women’s involvement in decision making is particularly important in Timor-Leste, where men and women are building the economic and social foundations of a stable society and resilient institutions, following a twenty-four-year struggle for independence which claimed the lives of 183,000 Timorese.
One of the women taking on this challenge is Madalena Bi Dau Soares, a former, long-serving fighter in the Timorese guerilla army. I met Madalena in her home in the Liquiça district to which she had returned in 1999 to set up and run two kindergartens that she financed with her small veteran’s pension. When asked why she did it, she gave a simple answer: “I wanted to achieve something good, leave a mark in the community. After fighting for independence, men found other things to do. I wanted the same for me.”
Filomena dos Reis is another independence fighter turned grassroots peace activist. She trains Timorese women in mediation, negotiation, and conflict-resolution. In 2005, Filomena and her colleagues organized a cross-border dialogue between Timorese and Indonesians. The initiative was in response to conflicts between communities, due to cattle straying across parts of the border that were not clearly demarcated. To resolve these disputes, the two sides selected sixty people to participate in the dialogue, which was watched by five hundred observers. The talks, which took place over three days in September 2005, resulted in a set of recommendations that were submitted to the Timorese and Indonesian Governments. One of the recommendations was to conclude ongoing negotiations about passes allowing women to move freely between markets on either side of the border. This became a reality in 2010, when the two Governments issued the border passes.
Madalena’s and Filomena’s achievements are even more impressive in light of the Timorese women’s history over the past decades. In fact, women played a significant role in Timor-Leste’s struggle for independence. During the Indonesian occupation of Timor-Leste from 1975 to 1999, women were guerilla fighters and members of the clandestine front. In Timor-Leste and abroad, they advocated against the Indonesian occupation. They brought resistance fighters food, ammunition, and messages, and gave them shelter. Women’s organizations also contributed by training ¬women in survival and teaching vocational skills.
The women of Timor-Leste now have a huge stake in reconciliation and peacebuilding initiatives. They want their country to learn from its history in order to have a peaceful and stable future. Nevertheless, women were largely absent from high-level dialogue initiatives to end outbreaks of violence in 1999 and 2006. The situation may, however, be changing. Throughout Timor-Leste, women are leading grassroots reconciliation initiatives, and they are moving into the corridors of power. Indeed, female political participation in Timor-Leste, now comprising 30 per cent of parliament members, is the highest in Southeast Asia. Women also lead the ministries of finance, justice, and social solidarity. Across the country, women are carving out a space for themselves at the national, district, and village levels to address domestic violence, economic hardship, and other issues that affect women and the population at large.
Bearing in mind this history of strength, suffering, and survival, what can the United Nations do to help those women in Timor-Leste and other countries who fight for peace and security for themselves and their families? I think one of our most important roles is to provide positive role models for women’s involvement at all levels of decision making. My experience as one of three female Special Representatives of the Secretary-General leading peacekeeping missions is that the presence of a woman in high-level discussions can make a difference. The presence of a female leader can inspire other women in international, national, and local institutions to seek high offices. This was an important motivator for me when I worked in Afghanistan and Sudan, where cultural norms often kept women from holding decision-making positions.
We need female role models at every level of the institutions we support. That is why I encourage police-contributing countries to send a higher proportion of female police officers to Timor-Leste and other countries. The presence of women in uniform sends a clear signal to the population that women have a central role to play in maintaining public safety and security. Timor-Leste is leading the way for the United Nations in this regard—today, women make up almost 20 per cent of the country’s police service, while women represent only 6 per cent of the UN police in the country.
In other areas, however, Timor-Leste can make further strides. For example, only ten of the country’s 442 village chiefs are women. The United Nations should do all it can to help women reach such positions of responsibility traditionally reserved for men.
Women in decision-making positions can also ensure that women’s concerns and interests are taken into account when choices influencing peace and security are made. From my work in different conflict areas, I know that decision makers often fail to include women’s knowledge and interests when making policy. In Afghanistan, for example, the international community did not act as agriculture moved from traditional crops to narcotics. Women were not part of that decision-making process. Another example pertains to the methods used by disarmament programmes to identify combatants, which exclude women associated with or providing support to the armed forces. At the same time, reintegration programmes fail to take into account women’s specific needs for livelihoods. This happens even though we know that women’s abilities to make a living and provide for their families is a crucial factor in bringing a society back from conflict.
By failing to take advantage of women’s thinking and contributions in rural economies, and by underestimating the role women can play in averting the economic collapses that are often at the root of cycles of conflict, we miss important parts of the peace puzzle and risk investing in peace and security solutions that are likely to fail.
The international community has much to learn from Madalena Bi Dau Soares and Filomena dos Reis and their readiness to seek new ways to contribute to the security and well-being of their communities. If peace and stability are to be sustainable, women like them must be involved at every stage, from setting government strategy to carrying out projects, and from voting on laws to implementing them in the communities. As members of the United Nations, we must listen to women, recognize their transformative powers, and defend and promote their inclusion in every way that we can. If we are serious about peace—and we are—it is the only way forward.
The discussion at the meeting was lively. Women presented their achievements and shared their ideas on how the international community could better help them reach their goals. Topics ranged from community policing to cross-border reconciliation with communities in Indonesia to domestic violence. I was struck by the energy and diversity of the more than one hundred people who came to voice their concerns. Police officers, local government officials, and community leaders joined scores of ordinary women—mothers, wives, breadwinners, and heads of household.
My lasting impression of the women of Suai was that they were not demoralized by their past. On the contrary, they radiated energy and resourcefulness. Their stories and work helped me understand that if the United Nations were to make a lasting contribution to peace and stability in Timor-Leste on my watch, it would be by building on the initiative and resilience of these women and helping them become fully involved in determining the country’s future.
Women’s involvement in decision making is particularly important in Timor-Leste, where men and women are building the economic and social foundations of a stable society and resilient institutions, following a twenty-four-year struggle for independence which claimed the lives of 183,000 Timorese.
One of the women taking on this challenge is Madalena Bi Dau Soares, a former, long-serving fighter in the Timorese guerilla army. I met Madalena in her home in the Liquiça district to which she had returned in 1999 to set up and run two kindergartens that she financed with her small veteran’s pension. When asked why she did it, she gave a simple answer: “I wanted to achieve something good, leave a mark in the community. After fighting for independence, men found other things to do. I wanted the same for me.”
Filomena dos Reis is another independence fighter turned grassroots peace activist. She trains Timorese women in mediation, negotiation, and conflict-resolution. In 2005, Filomena and her colleagues organized a cross-border dialogue between Timorese and Indonesians. The initiative was in response to conflicts between communities, due to cattle straying across parts of the border that were not clearly demarcated. To resolve these disputes, the two sides selected sixty people to participate in the dialogue, which was watched by five hundred observers. The talks, which took place over three days in September 2005, resulted in a set of recommendations that were submitted to the Timorese and Indonesian Governments. One of the recommendations was to conclude ongoing negotiations about passes allowing women to move freely between markets on either side of the border. This became a reality in 2010, when the two Governments issued the border passes.
Madalena’s and Filomena’s achievements are even more impressive in light of the Timorese women’s history over the past decades. In fact, women played a significant role in Timor-Leste’s struggle for independence. During the Indonesian occupation of Timor-Leste from 1975 to 1999, women were guerilla fighters and members of the clandestine front. In Timor-Leste and abroad, they advocated against the Indonesian occupation. They brought resistance fighters food, ammunition, and messages, and gave them shelter. Women’s organizations also contributed by training ¬women in survival and teaching vocational skills.
The women of Timor-Leste now have a huge stake in reconciliation and peacebuilding initiatives. They want their country to learn from its history in order to have a peaceful and stable future. Nevertheless, women were largely absent from high-level dialogue initiatives to end outbreaks of violence in 1999 and 2006. The situation may, however, be changing. Throughout Timor-Leste, women are leading grassroots reconciliation initiatives, and they are moving into the corridors of power. Indeed, female political participation in Timor-Leste, now comprising 30 per cent of parliament members, is the highest in Southeast Asia. Women also lead the ministries of finance, justice, and social solidarity. Across the country, women are carving out a space for themselves at the national, district, and village levels to address domestic violence, economic hardship, and other issues that affect women and the population at large.
Bearing in mind this history of strength, suffering, and survival, what can the United Nations do to help those women in Timor-Leste and other countries who fight for peace and security for themselves and their families? I think one of our most important roles is to provide positive role models for women’s involvement at all levels of decision making. My experience as one of three female Special Representatives of the Secretary-General leading peacekeeping missions is that the presence of a woman in high-level discussions can make a difference. The presence of a female leader can inspire other women in international, national, and local institutions to seek high offices. This was an important motivator for me when I worked in Afghanistan and Sudan, where cultural norms often kept women from holding decision-making positions.
We need female role models at every level of the institutions we support. That is why I encourage police-contributing countries to send a higher proportion of female police officers to Timor-Leste and other countries. The presence of women in uniform sends a clear signal to the population that women have a central role to play in maintaining public safety and security. Timor-Leste is leading the way for the United Nations in this regard—today, women make up almost 20 per cent of the country’s police service, while women represent only 6 per cent of the UN police in the country.
In other areas, however, Timor-Leste can make further strides. For example, only ten of the country’s 442 village chiefs are women. The United Nations should do all it can to help women reach such positions of responsibility traditionally reserved for men.
Women in decision-making positions can also ensure that women’s concerns and interests are taken into account when choices influencing peace and security are made. From my work in different conflict areas, I know that decision makers often fail to include women’s knowledge and interests when making policy. In Afghanistan, for example, the international community did not act as agriculture moved from traditional crops to narcotics. Women were not part of that decision-making process. Another example pertains to the methods used by disarmament programmes to identify combatants, which exclude women associated with or providing support to the armed forces. At the same time, reintegration programmes fail to take into account women’s specific needs for livelihoods. This happens even though we know that women’s abilities to make a living and provide for their families is a crucial factor in bringing a society back from conflict.
By failing to take advantage of women’s thinking and contributions in rural economies, and by underestimating the role women can play in averting the economic collapses that are often at the root of cycles of conflict, we miss important parts of the peace puzzle and risk investing in peace and security solutions that are likely to fail.
The international community has much to learn from Madalena Bi Dau Soares and Filomena dos Reis and their readiness to seek new ways to contribute to the security and well-being of their communities. If peace and stability are to be sustainable, women like them must be involved at every stage, from setting government strategy to carrying out projects, and from voting on laws to implementing them in the communities. As members of the United Nations, we must listen to women, recognize their transformative powers, and defend and promote their inclusion in every way that we can. If we are serious about peace—and we are—it is the only way forward.
Tuesday, March 8, 2011
Essential Obstetric Care in Timor-Leste: The Shape of Safe Motherhood in a Developing Country.
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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[iii] Source Family Health International http://www.fhi.org/en/Topics/maternalmort.htm
[iv] Source Democratic Republic of Timor-Leste Health Profile, August 2002.
[v] Source Democratic Republic of Timor-Leste, Health Profile, August 2002.
[vi] Source CIA World Fact Book Website
[vii] 2009
[viii]5 Nepal Demographic and Health Surveys 2001 and 2006
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