03 January 2013
The forming of the health system in East Timor: a retrospective view
ETLJB 03 January 2012 Guest Poster: Matthew Libbis BA (Hons), Anthropology - The East Timorese Transitional Administration (ETTA) asked the United Nations Transitional Administration in East Timor’s (UNTAET) children’s fund, (UNICEF) to report on what non government organisations (NGOs) were doing on health and nutrition amongst pregnant and lactating mothers and children under five years in the 13 districts of the soon to be independent Democratic Republic of East Timor (RDTL) in 2001.
The de facto government in waiting was astounded by the results; not by the horrific morbidity and mortality rates, which were ten times those in the developed world; rather, what was to become the Ministry of Health (MoH) knew that it could not afford to continue the health programs being run by these NGOs, in particular the education programs that taught people that their children do not have to die from preventable illness and disease, and giving birth need not be dangerous.
Each district was administered by a different NGO with their own charter, policies and programs; and consistent with the tenets of democracy, the MoH wanted government control over the sector. ETTA at this stage only had a policy development role, and was not yet in a position to run a health system. The Interim Health Authority (IHA), which became the Division of Health Services (DHS), set up under the World Bank’s Trust Fund for East Timor (TFET), knew that it could not meet such raised expectations, so it invited the NGOs to leave.
The elected Constituent Assembly which was comprised predominantly of members of the Fretilin party bypassed a further election and voted itself into office. It declared that the health system would not interfere with traditional health practices, but would embrace them. Indonesia had outlawed such practices, so it was a culturally sensitive approach to allow them; a more cynical view would be that by not spending on a health budget not only allows people to continue these practices, but forces them to do so.
Indonesia had run a social health system and it was one of the reasons it used to justify moving people into containment areas, along with access to markets, water and education. But the fact that it also used hospitals as places of murder, torture and forced abortions and sterilisation did not endear hospitals to local communities. Added to that, the widespread destruction wrought by marauding militia and departing Indonesia meant few health facilities remained after 1999.
The church and coffee cooperatives also run health clinics, but sometimes people have no choice but to use traditional medicine when they cannot get to a hospital, or if western medicine is either not available or too expensive. Other times, people choose traditional medicine for a variety of reasons.
When a minibus ran off the road and a dozen people were injured with cuts and bruises and broken limbs, a truck came and collected them to take them to the healer, some 20 kilometres away. They wanted to go there, over rugged terrain, rather than the hospital that was just five kilometres in the other direction.
A nurse’s feverish baby died of dehydration because local practice was to keep the baby swaddled without rehydration. The symptoms were well known to the nurse, but it did not fit customary practice to treat in a western way; knowledge and training do not permeate the home when they are outweighed by family pressures to conform to known ways. Children with diarrhoea are given bread rather than water in the belief that the bread will stop them up, whereas water will continue the runs. Dehydration is the biggest killer, especially amongst children.
Respiratory problems are the most common and serious illness, followed by fever and diarrhoea. Hepatitis and tuberculosis are also prevalent. Endemic chronic malnutrition exacerbates the overall poor state of health. Illnesses are treated by the liman badain, or traditional healer, rubbing, or the patient ingesting infusions made from leaves, herbs, oil and bark from certain trees.
People helping patients assume a responsibility, which it seems is the inverse of duty of care in the common law system: a UN police officer attending a road accident and administering first aid to a victim who died, and even a doctor giving CPR in a hospital to a patient who died, were blamed for those deaths. Whether the liman badain holds such culpability is uncertain.
Patients often present too late for treatment. A wife rang her husband’s workplace one morning to report that her husband would not be in because he had been bitten by a snake the night before; when asked whether he had had medical treatment, the answer was no.
People might only go to hospital as a last resort when traditional medicine fails, which may be too late for treatment. This applies particularly to sick children, who are brought in only as a last measure, when it is often too late to save them, which exacerbates the mistrust of the hospital, as it is perceived that if you take children to hospital, they will die.
There are signs in birth clinics to feed the baby from the breast within the first hour, and midwives will enforce that; however, a number of births still occur in homes, particularly in remote areas. In villages, birth takes place in the home, sometimes alone, or with a traditional midwife or a relative, neither of whom have medical training. Sometimes the infant is fed sugar dissolved in water, or a rice porridge, rather than breastmilk.
In one instance, a distraught husband in the hills asked on his police radio for help with his wife who was having a difficulty delivery. The UN police commander requested a helicopter to bring them to hospital, but this was denied because the woman was not a UN staff member. Both mother and child died.
After independence, the government realised that it could not suddenly start running a national health system, and invited back the health NGOs that it had earlier invited to leave. However, unlike, before when they were subsidised and ETTA had only to pay 10% of costs, now they had to pay the full amount, including medical salaries. When it could not afford to do so, doctors began leaving.
Cuba began sending in doctors, and training locals in medicine. Five years on from independence, child and maternal mortality rates had not changed. At 10 years of independence, the figures are beginning to improve. There have been developments in the health sector by NGOs and UNICEF working with the MoH; one recent example is a mobile phone service for mothers (http://www.healthallianceinternational.org/), which can now be utilised in remote areas which at independence had no telecommunications coverage.
*The information for this piece has come from personal research, observation, interviews and interaction; UNTAET situation reports, as well as many WHO and Lao Hamutuk bulletins. The author also conducted the referenced UNICEF consultancy.
See also A Comment on Witchcraft and Dispute Resolution in East Timor by Matthew Libbis
Matthew Libbis conducted anthropological fieldwork from 2000 to 2002 in East Timor, focusing on how the population was making the transition from occupation into independence. In addition to exploring socially sustaining institutions such as marriage, ritual and customs, his research was guided by prevailing issues that most concerned and affected the community, such as tensions between food production and participation in the formal economy, as well as more pressing issues of housing and reconciliation. He returned to East Timor from 2006 to 2008 following the Crisis that ripped the country apart to work in rebuilding the shattered civil society and governance structures. He has more recently been working in community resilience, social inclusion policy implementation, and humanitarian and disaster management, mitigation and recovery. He may be contacted at malibbis-at-gmail.com