East Timor Health Sector Situation Report Jan-Jun 2000

Source: World Health Organization (WHO)

Date: 18 Aug 2000

OVERVIEW
During the two weeks of violence that followed the 30 August 1999 population consultation in East Timor, more than 75% of the population was displaced. A large proportion of private and public buildings, including health centers, hospitals and other health facilities, were heavily damaged or destroyed.

In addition to the physical destruction of health facilities, there was a loss of senior health staff from the central, district and sub-district levels. Many doctors and other core health professionals were Indonesian nationals, and returned to Indonesia during the lead-up to the referendum. This loss of expertise further contributed to the total collapse of the East Timorese health system, and left only 35 East Timorese doctors in the country.

East Timor needed urgent assistance from the international community. Within a few days of the deployment of INTERFET (the International Force for East Timor), OCHA, UNHCR, ICRC and WHO's Department of Emergency and Humanitarian Action (EHA) had established a presence in East Timor. WHO/EHA role was to immediately coordinate the public health interventions and ensure timely and appropriate information sharing among all partners involved. ICRC and fifteen international NGOs, together with military medical teams from INTERFET, began to provide curative services to the general population. By 30 June 2000, almost half a million consultations have been provided - more than one half of the current population of East Timor.

WHO has participated in the review of health services of East Timor and technically supported the establishment, in February 2000, of the Interim Health Authority. WHO will continue to support the Interim Health Authority in the formulation of national health policy, and in strengthening of national capacity in public health and curative health services. Special emphasis will be given to the reconstruction and delivery of basic services, prevention and control of communicable diseases (especially malaria and tuberculosis), and child, adolescent and women's health. For this purpose, WHO has prepared a detailed Plan of Action.

WHO will also continue to play a technical coordination role in the field of health service and sustainable public health development and fully supports the Sector Wide Approach being adopted in East Timor. The support provided by WHO has been, from the early phase of the crisis, coordinated by the Department of Emergency and Humanitarian Action (EHA).

Currently, most curative health services to the general population are provided by international NGOs. From September 2000 until September 2001, each district will have a nominated lead NGO that will be responsible to the IHA for planning, coordination, implementation and delivery of clinical and basic public health services.

During this time, the national health capacity will be gradually established through timely and appropriate training programmes and the involvement of East Timorese partners in health work force and service delivery planning processes. WHO, in collaboration with HealthNet International, took the lead in supporting UNTAET and the Interim Health Authority in addressing this issue through provision of technical support to develop capacity in all aspects of human resources development, as part of health systems reconstruction. Activities include HRD policy development, short and long term workforce planning, national educational planning and human resources management. A computerized HRD database will be completed by July 2000. Specific target areas will be development of management skills, redefinition of the roles and functions of health workers and redesign of health worker training programmes.

In order to encourage the timely recognition of and response to epidemic diseases, WHO established a communicable disease surveillance system early in its presence in East Timor. The original system was subsequently modified in January 2000. The surveillance system is based on regular reports submitted by NGO lead agencies providing primary health care in the field, using WHO case definitions. Weekly analysis of the surveillance database is summarized in a Weekly Epidemiological Bulletin.

Based on the data from the surveillance system, it has been possible to coordinate and guide the work of the NGOs involved in providing clinical and public health services in East Timor. The work of WHO in the field of disease surveillance will subsequently form the foundation for a national disease surveillance system.

The communicable disease surveillance network also has the ability to detect other conditions of potential public health importance but not subject to formal surveillance. For example, the system identified, for the first time in East Timor, cases of Japanese Encephalitis and Cutaneous Leishmaniasis.

Despite the destruction of health facilities and limited accessibility to rural areas in East Timor, a timely and rapid laboratory and epidemiological investigation of Japanese Encephalitis was successfully undertaken by WHO and the Interim Health Authority, in close collaboration with, MSF (France), ICRC, IRC, Medical Relief International (Merlin) and the Institute of Clinical Pathology and Medical Research (ICPMR) Sydney, Australia. This joint action provides an excellent example of how international and national institutions can work together in the spirit of partnership advocated by the WHO Director-General, Dr Gro Harlem Brundtland.

Jointly with Merlin and the International Rescue Committee, WHO is implementing a Roll Back Malaria strategy in East Timor.

Significant progress has been made in the establishment of a National Tuberculosis Programme, based on the WHO DOTS strategy, in East Timor. Caritas Norway, together with Caritas East Timor, the Menzies School of Health Research in Darwin, Australia, and WHO have actively supported the establishment of the programme. More than 1 300 TB patients are currently receiving treatment through the programme, which is active in 9 clinics and three hospitals in six districts of East Timor. By the end of the year, it is anticipated that the programme will have progressively extended to cover the whole country.

With WHO participation, other key public health functions such as routine childhood immunization have been reestablished. However, areas such as water and food testing, have been delayed by slow progress in re-establishing appropriate legislation, while still others such as health information systems and improving laboratory services have been hampered by the complexities of donor support.

Although there are still emergency needs in health and other sectors, it is clear that East Timor generally is no longer in a state of emergency. The current phase could be classified as a transitional / developmental phase, in which international support will need to be adjusted and re-focused. As we move into this stage, it is imperative that support be provided for the establishment of a sustainable and independent health system in East Timor.

The World Bank has acknowledged this by allocating a grant of US$12.7 million from the Emergency Trust Fund for a Health Sector Rehabilitation and Development Project, reflecting the timely changes that are taking place in East Timor.

DEMOGRAPHICS AND HEALTH STATUS

Demographics

Provisional estimates by the UNTAET Bureau of Statistics, Research and Census (May 2000) put the population of East Timor at 780 000.

Over 280 000 individuals were displaced during the East Timor crisis of 1999; of those, 165 000 have now returned to their usual place of abode. Within East Timor, more than 80% of the remaining population was internally displaced due to destruction of their homes and ongoing violence. UNHCR estimates that about 105 000 East Timorese remain in West Timor, but most of these are eventually expected to return to East Timor. In addition, 12,000 to 16,000 East Timorese are currently resident in Australia; there is no indication of when they may return to East Timor.

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

The birth rate is high, but an accurate post-crisis estimation is difficult to make.

The true crude mortality rate during and after the crisis is difficult to estimate; few deaths have been reported through the WHO communicable diseases surveillance system or other avenues. A formal death surveillance system has not yet been established.

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

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

Unemployment among East Timorese nationals is estimated at 70%. Per capita income is now estimated around US$210 per year, approximately 50% below its 1996 level (Source: Project Appraisal Document on a Proposed Grant in the amount of US$12,7 Million Equivalent to East Timor for a Health Sector Rehabilitation and Development Project, May 24 2000; World Bank Document). Health status

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

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

The maternal mortality ratio (MMR) has been estimated at 450-500 per 1000 live births; however, due to the large proportion of births taking place without skilled birth attendants, the MMR may be as high as 850 per 100 000 live births. This is unacceptably high; for example, in Indonesia, the mortality ratio is estimated to be only 390 per 100 000 life births. The most common cause of maternal death is severe bleeding, generally occurring in postpartum period.

The under 5 mortality rate (U5MR) was reportedly 124 per 1 000 live births (UNICEF and Government of Indonesia estimates, 1997; World Bank Joint Assessment Mission, 1999), but this may be an underestimate.

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

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

Malaria is highly endemic in all districts, with the highest morbidity and mortality rates reported in children. The peak transmission periods are July/August and December/January, although a longer transmission season exists in the east of the country (Lautem district), owing to the prolonged wet season. Based on historical and recent data, P falciparum and P vivax malaria are equally represented. Four districts, including the capital, are high transmission areas and chloroquine resistant strains have been reported. Since 1 January 2000, almost 62 000 suspected malaria cases (with 40 deaths) have been reported to the national communicable diseases surveillance system. - Kalra NL: "REVIEW OF INTEGRATED EMERGENCY MALARIA CONTROL PROGRAMME IN EAST TIMOR"; data from WHO communicable diseases surveillance system

East Timor is endemic for leprosy; prior to the crisis, the registered leprosy case prevalence rate is 1.8 per 10 000 - Indonesian MOH data

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

Tuberculosis is a major public health problem, with an estimated 8000 active TB cases nationally (over 1% of the total population). More than 1 300 patients are currently under treatment; of these, 31% are under 15 years of age.

Sexually transmitted infections (STI) are common in sexually active age groups. The existing curative institutions reported a total of about 35 STI cases per week (not confirmed)

Routine childhood immunization recommenced in early March. To prevent an expected outbreak of measles, more then 45 000 children were immunized during a special campaign; this immunization programme has limited the number of cases of measles reported in East Timor (634 reported cases between 1 January and 30 June 2000, representing a crude attack rate of 13.6 cases per 100 000 per month). -data from WHO communicable diseases surveillance system

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

Between 20 September 1999 and 30 June 2000, the curative institutions (international NGOs and the military medical team from INTERFET) provided 480 000 consultations and curative interventions to the population. - data from WHO communicable diseases surveillance system

Communicable diseases account for the majority of deaths (approximately 60%, particularly in children) followed by the non-communicable diseases, chronic diseases, road traffic accidents and other conditions.

INTERIM HEALTH AUTHORITY, HEALTH POLICY AND PLANNING, AND HEALTH REGULATIONS

Interim Health Authority

The future direction of Health development in East Timor has been discussed in two workshops involving health workers, UN agencies and health service providers.

After the first workshop (held in mid-December 1999), a Joint Working Group on Health Services was formed. This group was composed of representatives from WHO, UNICEF, UNFPA, international NGOs and the East Timorese Health Professionals' Working Group. It undertook a review of health service provision throughout the country, and drafted a document defining minimum standards for health care service provision.

The second workshop, chaired by WHO, took place in mid-February 2000 and, once again, involved health workers, UN agencies and health service providers. At this workshop a consensus was reached on the minimum standards document, and the formation of the Interim Health Authority was formally announced.

The Interim Health Authority is composed of 16 senior East Timorese health professionals. It is supported by the UNTAET Office of Health, which contributes seven international UNTAET staff. A provisional organogram for the IHA has been agreed, and regulatory planning work is expected to begin in July 2000.

Although no formal head has been appointed, nor other specific positions assigned, IHA is seen as the embryonic "Ministry of Heath", with overall responsibility for defining health policy, and for the planning, implementation and coordination of health services for the country.

Health Policy and Health Regulations

The Interim Health Authority, together with WHO, is in process of formulating health policy guidelines for East Timor, and a draft for the reform of health services in the country is being prepared. The reform is based on an integrated approach to health care delivery.

Health services are proposed to be free at the point of delivery, but economic constraints, both now and in future, mean that the main policy makers are starting to consider options for contributory financing (including health insurance schemes and patient co-payments).

District Health Plans

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

• be rapidly implementable;
• ensure delivery of basic services to the greatest possible population;
• build capacity among East Timorese health staff;
• ensure efficient use of available resources;
• not interfere with the future development of the health system; and
• take into account the principles developed by the East Timorese Health Professionals' Working Group (technically supported by WHO), including sensitivity to culture, religion and traditions of the East Timorese people.

This IHA initiative will make for easier coordination, monitoring and evaluation of health sector.

The Interim Health Authority has requested proposals from lead NGOs for the provision and management of health services for each district, in the form of a District Health Plan.

To facilitate a development of the District Health Plans, WHO organised a workshop, held on 10 June 2000. The workshop provided the opportunity to WHO and IHA to give detailed information and recommendations to the NGOs regarding the important components of health planning at the district level, focusing specifically on the 12-18 month transitional period from NGO leadership to a national health authority.

All NGOs involved in health sector leadership are expected to submit their proposals to the IHA for review not later than 5 July 2000; these documents will form the basis of Memoranda of Understanding between the IHA and each of the district service providers.

HEALTH SERVICE DELIVERY

Health Services Coordination

At this stage, many NGOs, national and international institutions, UN agencies and donors wish to be involved in the process of restoration of health services in East Timor. To harmonize and coordinate these efforts, the Interim Health Authority has begun coordinating the work in public health and curative services.

Before the formation of the Interim Health Authority, WHO had responsibility for this overall coordination. At present, WHO provides mostly technical and some operational support to the Interim Health Authority, other UN agencies, and national and international NGOs involved in health.

On WHO's recommendation, the Interim Health Authority has elected to refrain from strongly vertical (ie single disease) programmes that may potentially damage or retard the integrated health care approach.

Primary Health Care

The review of health service provision undertaken by the Joint Working Group between the December and February workshops identified 15 international NGOs, 6 local NGOs, 23 church organisations, four military contingents, and two private or business agencies providing health care services.

These bodies are mostly running small clinics, many with rural extension services via mobile clinics. At least one clinic per district has simple facilities for in-patient care. The levels of coverage and access vary widely across the country, depending on the policies (and resources) of the different implementing agencies.

The Expanded Programme of Immunization has re-commenced this year, with the support of UNICEF, technical input from WHO and various NGOs. The standard antigens for childhood immunization (DTP, OPV and measles) are in use, and tetanus toxoid for pregnant women has also commenced.

Hospitals

There are currently two civilian hospitals in Dili offering at least some specialist surgical and medical services. The principal hospital, Toko Baru, is run by ICRC, while the Portuguese Government Mission has a small inpatient facility in the former Dr Antonio Carvalho Hospital. It is intended that these will, in future, both be administered as a single hospital, but divided into two campuses. No sub-specialty care is available in the country.

In Baucau, the former Indonesian hospital is running with the support of MSF Belgium. It provides a basic surgical service for the eastern districts. MDM Portugal is supporting the small hospital in Los Palos in the east of the country.

Human resources

The East Timorese Health Professionals Working Group identified approximately 2,000 health workers as present in the country and available for work. This is considerably lower than the estimated 3,500 health workers during the former system. Most of the senior level health service managers and doctors were Indonesian and they have now left the country. Only approximately 35 East Timorese doctors remain, one at specialist level. There is a serious lack of capacity at senior and middle management levels.

Projections for the future health workforce are much lower than previous staffing levels. UNTAET proposed 1,480 staff, however the NCC and CNRT, concerned at the problems of sustaining the civil service after the withdrawal of UNTAET, have proposed 1,087. There is concern as to the difficulties of sustaining a health service with such a small workforce.

Virtually all of the Timorese health workers were previously employed by international or national NGOs. Currently, a number are paid by UNTAET. It is intended that civil service recruitment will commence within the next two months, once district health plans are accepted and the final size of the health workforce is established.

The recovery of the personnel records of all former health staff provides valuable information to support the civil service recruitment process. WHO and HealthNet International have collaborated to transfer the records into a computerized database, which is linked with the civil service databases. This database is expected to be completed in mid July 2000 and will be a useful tool to support both long- and short-term workforce and training planning processes.

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

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

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

A HRD Task Group was formed within the IHA. A WHO/HealthNet specialist is working closely with the Group. The work of this taskforce was disrupted by the attendance of members at a 6-week intensive English course. The Task Group has now been reformed with new members and will recommence working at the beginning of July.

Pharmaceuticals and Drug Supply

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

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

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

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

• Since a large number of doctors have left the country, it will be mainly nurses and midwives who run the level 2 and level 3 clinics. This fact was kept in mind while developing the list of essential drugs.
• The draft list of essential drugs was discussed at a meeting of an expert group of East Timorese doctors, who provided advice and suggestions for the inclusion of various drugs at different levels of the health service.
• Vaccines used by UNICEF and contraceptives used in the programme were included.
• The National Tuberculosis Programme provided the list of anti-tuberculosis drugs.

1. National Drug Policy
2. Legislation, regulations and guidelines
3. Selection of drugs
4. Supply
5. Quality assurance
6. Rational drug use
7. Monitoring and evaluation
8. Human resources development
9. Technical cooperation among countries

PUBLIC HEALTH

Communicable disease surveillance

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

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

Weekly analysis of the surveillance database is summarized in a Weekly Epidemiological Bulletin. The WHO Bulletin is disseminated to all institutions involved in health in East Timor, and to many international collaborators. In addition to the English language version, it is proposed that the Bulletin will soon be produced in a second official language of East Timor. Starting in June 2000, an electronic version of the Bulletin is available via the Timor Today internet site.

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

• more than 61 000 cases of malaria,
• almost 23 000 cases of lower respiratory tract infection,
• 13 700 and 2 600 cases of simple and bloody diarrhoea respectively,
• 634 cases of suspected measles, and
• over 300 cases of suspected meningitis.

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

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

Control of Outbreaks

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

• acute flaccid paralysis (suspected poliomyelitis) - 3 clusters or sporadic cases, two of which have been confirmed negative by the international reference laboratory in Melbourne, Australia, while results from the third are still pending;
• dengue fever - two outbreaks in urban Dili;
• cutaneous leishmaniasis - one sporadic suspected case;
• Japanese encephalitis - two clinical cases, and associated field investigation; and
• Unknown diseases - two reports requiring field investigation (one each in Liquisa and Manufahi districts).

Malaria Control

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

• malaria showed a three-fold increase in incidence due to the break down of surveillance and treatment,
• there was poor access to effective drugs, and
• vector control activities had collapsed.

Merlin with the technical back-up from EHA and RBM was responsible for

• establishing malaria diagnostic facilities
• retraining of microscopists,
• equipping of all 13 district laboratories of the country
• disseminating RBM protocols for case definitions and treatments
• arranging all antimalarial drug supplies,
• undertaking cross sectional malaria prevalence surveys and drug resistance studies, to recommending efficacious insecticides for IRS, and
• promoting net usage.

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

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

It is important to note that two cases of quinine resistant malaria have been detected. Currently, MERLIN has made arrangement to conduct further drug resistance studies in East Timor.

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

IRC distributed a total of 115 000 pre treated mosquito nets in all 13 districts, including two nets per family where protection of pregnant mothers and children was necessary. Since they were distributed through different local NGOs, a list, indicating names of head of the family and complete addresses, is being completed to facilitate retreatment and to determine the net usage level. IRC has carried out a KAP study to develop IEC material for disease and prevention awareness.

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

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

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

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

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

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

The ITN programme needs further strengthening along the following lines.

• Net coverage in the second phase should be extended to the whole population, with priority given to vulnerable groups (eg people sleeping in field huts to protect their crops, etc.).
• Retreatment of nets should preferably be carried out through the primary health care system, with the total involvement of communities. Retreatment should be done at sub-health centers on predetermined dates, with prior information of the chiefs of the villages. Alternatively, retreatment of nets could be carried out in schools, with the involvement of children, teachers and communities with health staff as facilitators [this method has been employed with great success in Papua New Guinea (PNG)]. As at 26 May 2000, there are 752 functioning schools in East Timor, with 6 929 teachers and 173 259 children on their rolls. The primary health care route provides a proxy index (on the basis of retreatment of nets) on net usage level over "do it your self kit" route as being contemplated by IRC.
• IRC may undertake "Bed net affordability and willingness to buy" surveys to institutionalize partial subsidy and/or a social marketing system to ensure sustainability

For Dengue Heamoraghic Fever control, storage of water in mosquito proof containers/cisterns/mendis indoors and professional management of solid waste disposal are important components of any control strategy.

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

Pending the establishment of a National Vector Borne Disease Control Programme as part of a coordinated Environmental Health initiative, the Interim Health Authority has requested WHO to coordinate vector control activities in East Timor. WHO has begun conducting regular meetings, with the keen participation of NGOs involved in vector and vector borne disease control: Merlin, IRC and Oxfam.

Tuberculosis

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

The programme is active in 9 clinics and three hospitals in six districts of East Timor.

More than 1,300 TB patients are currently receiving treatment.

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

By the end of the year, the programme will have progressively extended to cover the whole country.

Expanded Programme of Immunization

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

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

On 16 June 2000, in order to facilitate clarity and consensus among all parties involved regarding the policies and implementation plans of the national immunization services, UNICEF and IHA (with WHO technical support) conducted a National Workshop on immunization services in East Timor.

This workshop resulted in agreement by all participants in the use of a standard immunization schedule (recommended by WHO) and a plan of action for conducting National Immunization Days (September - October, synchronized with sNIDs to be held in Indonesia), and the immunization of primary school children.

Child nutrition

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

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

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

• the vicious cycle of illness and poor appetite, and
• lack of knowledge about appropriate weaning foods for babies and small children.

Integrated Management of Childhood Illness

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

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

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

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

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

• improved quality of care in situations where a disease specific approach is not appropriate (eg when children present with more than one complaint, or for young infants with non-specific clinical signs);
• a methodical approach where medically trained staff are scarce;
• an emphasis on prevention of childhood illnesses, through immunization and, if necessary, vitamin A supplementation;
• promotion of improved infant feeding, including breast feeding;
• avoidance of duplication of efforts in the fields of training, monitoring, supervision and management; and
• less wastage of resources, because children are treated with the most cost-effective intervention for their condition.

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

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

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

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

• to create awareness and knowledge of IMCI among health authorities in East Timor, thereby facilitating informed decisions when a national child health policy is developed; and
• to make a provisional plan for the introduction of IMCI in East Timor.

A "classical" 11-day IMCI training course is proposed for September 2000, using the Indonesian IMCI guidelines and training materials. The course would have the following objectives:

• To explain the core of the IMCI approach to participants,
• To train future trainers and supervisors for IMCI
• To adapt the Indonesian IMCI materials for use in East Timor

The next steps would be:

• to develop a comprehensive plan to introduce and implement IMCI in East Timor in a phased manner, first focusing on those health workers who deal with sick children under 5 in outpatient settings (hospitals and clinics); and
• to develop a set of IMCI guidelines and related training materials for East Timor, again focusing on the needs of health workers who deal with sick children under 5 in outpatient settings in hospitals and clinics.

The UNICEF supported opening of schools in East Timor. During short time of observation, it was found that some proportion of the children and teachers have visual defects. WHO and UNICEF jointly organized screening of school children and teachers in Dili. From 10 schools, 590 children were screened, out of which 16.4% had visual defects and 5% required ophthalmological examination. Among teachers, 69% were found having visual defects and 5.7% require ophthalmological examination. All of them needed glasses, which will be provided free by the Laila Foundation & Territory Health Services, NT Australia and an ophthalmologist will be sent for persons identified who require additional ophthalmological examination. In addition, 105 East Timorese staff working in UN Agencies and CNRT were also examined.

Reproductive Health, HIV/AIDS and Sexually Transmissible Infections

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

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

HIV incidence is very low, but the virus was already circulating well before the crisis. So far attempts to introduce condom use for control of HIV and other STDs have only been attempted among the expatriate community, via UN Agencies House and "night spots".

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

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

Before clarification of the situation and conducting investigation, it is suggested that VDRL positive pregnant women should be treated for Syphilis. The drugs prescribed for treatment of syphilis in pregnant women are Parenteral Penicillin regimen. In case the patient is sensitive to Penicillin, Erythromycin regimen outlined should be prescribed. Also any person found positive for VDRL should be treated accordingly.

Mental Health

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

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

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

The WHO HQ technical Department of Mental Health is assisting the Interim Health Authority to establish a National Basic Mental Health System

Other Areas of Need

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

There is no leprosy control programme. Only intervention which took place when WHO distributed, through the NGOs providing health services, MDT drugs and provided WHO guidelines regarding clinical diagnosis and treatment of leprosy patients. It requires further action and involvement of leprosy technical units for planning and field operations for achieving global target of elimination of leprosy.

WHO ROLE, PLAN OF ACTION, AND COLLABORATION WITH OTHER AGENCIES

WHO Plan of Action for East Timor, 2000-01

In February 2000, the WHO office in East Timor developed a detailed Plan of Action (PoA), where the major thrust is national manpower and capacity development of the public health service in East Timor. EHA/HQ has provided the services of a Public Health expert to adapt the Plan of Action to the UN Cap Appeal

At present, the WHO PoA 2000-2001 for East Timor is under active scrutiny of both regional and HQ technical units. To continue WHO's presence, coordinating function and technical advisory role, Regular Budget needs to be identified while more external funds are sought for continuation of project activities.

The World Bank Health Sector Rehabilitation and Development Program

In light of this situation, in April 2000, World Bank Mission developed a project proposal. The overall goal of this proposal is

I. To address the immediate basic health needs of population of East Timor, and
II. Develop health policies and systems appropriate to the country.

• Restoring access to basic package of services, and
• Laying the foundation of health policy and system development.

Under the objective 'restoring access to basic package of services', WHO will be involved in accelerating implementation of selected high priority activities e.g.

1. Prevention and control of communicable diseases

2. Health Promotion

3. Further define and elaborate the basic package of health service development and adopt essential drugs list and standard guidelines for prevention and control of communicable/non-communicable diseases

4. Capacity strengthening which includes development of basic package and health administration and management.

1. development of an information system, and a monitoring and evaluation system; and

2. Human Resource Strategy Development for health and implementation of a Human Resource Development Programme, including fellowships.

WHO Profile and Visibility

Between 3 January and 30 June 2000, the Humanitarian Assistance and Emergency Rehabilitation Pillar of UNTAET produced 67 situation reports. In those reports, the activities of WHO have appeared on 42 occasions.

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

WHO has also participated in (and chaired meetings of) the Common Country Assessment in East Timor, through the Working Group on Access to Basic Services.

WHO Technical Support to the Interim Health Authority and NGOs

During the period 1 January to 30 June 200, WHO sponsored and presented the following training courses and seminars:

• Seminar on dengue vectors and their control
• Seminar on the clinical management of dengue fever and dengue haemorrhagic fever / dengue shock syndrome
• Seminar on the epidemiology, clinical features and control of Japanese encephalitis
• Seminar on the epidemiology, clinical recognition, management and control of outbreaks of meningitis
• Development of health education materials for the prevention of vector borne diseases
• Seminar on district health planning processes and resources available to NGOs to assist and guide their development

WHO and UNICEF collaborated to organize vision screening for school children and teachers in Dili.

WHO, UNICEF and the World Food Programme propose to conduct health assessment of the general population

WHO, Merlin, IRC and Oxfam propose a close collaboration to enhance the control of vector borne diseases.

It is important to mention that mostly all UN agencies already had established offices with regular budget and staff. For example, UNDP office has 10 regular professional staff, 3 consultants and UNICEF has 11 regular professional staff and 9 consultants with 6-11 months contracts.

The relationship of WHO with UNICEF, UNDP, WFP and other UN agencies is very cordial and cooperative, e.g. WFP provided containers, free of charge, for transportation of necessary equipments, such as computers, printers, photocopier machine etc., from Darwin to Dili.

CONCLUSION

Although there are still emergency needs in health and other sectors, it is clear that East Timor has now moved on from the emergency stage. The current phase could be classified as a transitional/development phase, which requires differently focused international support.

From the beginning of the crisis and moving towards a more developmental phase, it is imperative that support be continued to be provided for the establishment of a sustainable and independent health system in East Timor.

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

While the Interim Health Authority should become responsible for overall coordination with national and international agencies and institutions involved in the development of the health sector in East Timor, WHO will continue its current technical advisory and supportive role to the Interim Health Authority, UN Agencies, national and international NGOs and other institutions involved in health.