Initial Steps in Rebuilding the Health Sector in East Timor

OVERVIEW

In May 2002 Timor Leste (East Timor) emerged as a new nation after centuries of foreign rule and decades of struggle for independence. Its birth was a painful one; a United Nations-brokered Popular Consultation in August 1999, in which an overwhelming majority of the people opted for independence, was followed by several weeks of vengeful violence, looting, and destruction by pro-Indonesia militias. It left the territory and all of its essential services devastated. In this context, the United Nations Transitional Administration in East Timor (UNTAET), with the country's leaders and people and many other partners, set about restoring order and services, building a government structure, and preparing for independence.

This paper summarizes the rehabilitation and development of the health sector from early 2000 to the end of 2001. The health situation in East Timor at the beginning of that period was similar to that of many less developed countries, but it was compounded by several years of deterioration in health services and also by the destruction of late 1999. The situation was characterized by high child and maternal mortality rates and a high prevalence of communicable diseases, including malaria and tuberculosis. The health infrastructure was in total disarray, with more than a third of health facilities totally destroyed and much of the rest substantially damaged. Most equipment and supplies had been looted or damaged beyond



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Initial Steps in Rebuilding the Health Sector in East Timor Initial Steps in Rebuilding the Health Sector in East Timor OVERVIEW In May 2002 Timor Leste (East Timor) emerged as a new nation after centuries of foreign rule and decades of struggle for independence. Its birth was a painful one; a United Nations-brokered Popular Consultation in August 1999, in which an overwhelming majority of the people opted for independence, was followed by several weeks of vengeful violence, looting, and destruction by pro-Indonesia militias. It left the territory and all of its essential services devastated. In this context, the United Nations Transitional Administration in East Timor (UNTAET), with the country's leaders and people and many other partners, set about restoring order and services, building a government structure, and preparing for independence. This paper summarizes the rehabilitation and development of the health sector from early 2000 to the end of 2001. The health situation in East Timor at the beginning of that period was similar to that of many less developed countries, but it was compounded by several years of deterioration in health services and also by the destruction of late 1999. The situation was characterized by high child and maternal mortality rates and a high prevalence of communicable diseases, including malaria and tuberculosis. The health infrastructure was in total disarray, with more than a third of health facilities totally destroyed and much of the rest substantially damaged. Most equipment and supplies had been looted or damaged beyond

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Initial Steps in Rebuilding the Health Sector in East Timor use. More than 80 percent of medically qualified staff had returned to Indonesia, and the central health administration was defunct. Following the period of conflict, the East Timorese health staff did their best to reorganize and provide services, and the international community responded quickly to the need. In particular, international emergency relief nongovernmental organizations (NGOs) moved in to provide health services at many points across the country. Facilitated by the existence of an East Timorese Health Professionals Working Group, UNTAET established the Interim Health Authority (IHA) in February 2000. This body brought together remaining senior East Timorese health staff with the UNTAET health staff to coordinate rehabilitation and development of the sector. The IHA evolved into the Division of Health Services (DHS) in the first transitional government in July 2000 and into the Ministry of Health (MOH) in the second transitional government in September 2001. In April 2000 a joint donor mission led by the World Bank and the IHA designed the first phase of the Health Sector Rehabilitation and Development Program (HSRDP), which provided the framework for a sector wide approach to the planning and implementation of activities in the health sector. HSRDP I had two main components: restoring access to basic services for the entire population and development of the health policy and system for the future. A major feature of the program was the development, with NGO partners, of district health plans covering all districts. The second phase of the program was initiated in mid-2001. HSRDP II comprised three components: support to ongoing services, improvement in the scope and quality of services and support systems, and development of policy, regulations, and administrative systems. In both phases a substantial part of the funding came through the multidonor Trust Fund for East Timor (TFET), administered by the World Bank. Recurrent costs were covered through funds administered by UNTAET, and substantial additional support was provided through continued humanitarian assistance and from bilateral development assistance. Achievements by November 2001 included the establishment and staffing of the government health service across the whole country, including district health management teams in all districts. Drug supplies were reasonably well secured and based on an approved essential drug list. The civil works program was under way for the construction of health centers and a central medical store, and a consultancy was initiated to develop an autonomous medical supply system. Basic services had been restored to most facilities included in the district health plans with the active collabo-

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Initial Steps in Rebuilding the Health Sector in East Timor ration of designated NGO partners. Program activities had been initiated on immunization, tuberculosis, HIV/AIDS, malaria, integrated management of childhood illness, mental health, and dental health. The main referral hospital had been handed over to East Timorese management. To achieve this progress, many constraints had to be overcome, and progress was slow in a number of areas. Policy development proved difficult to get started, especially the adequate involvement of stakeholders, and a long-term plan for human resource development was still lacking at the end of 2001. Staff recruitment was extremely slow, a situation that had consequences for morale and for the credibility of the administration. Procurement of goods, supplies, and consultant services was also slower than expected, often bogged down by the procedural complexities and their interinstitutional differences, and the civil works program was well behind schedule. Among the challenges faced by those coordinating health sector development were competing objectives and expectations held by the political leaders, the administration, the donors, and other stakeholders. Trying to address incompatible demands and justify directions taken was a drain on limited staff capacity. Many stakeholders played a role in the reconstruction of the health sector, including the United Nations (UN) agencies, in particular the World Health Organization (WHO), UNICEF, and the United Nations Fund for Population Activities (UNFPA). This paper addresses the authors' perceptions of strengths and weaknesses of only three of the main actors: UNTAET, the World Bank, and the international NGOs. Each contributed very substantially, and each brought constraints, without which progress could perhaps have been much faster. Paradoxically, the availability of quite considerable financial resources in the first two years of reconstruction may not have been entirely positive. Funding in excess of absorptive capacity and pressure to spend can lead to approaches that will ultimately be unsustainable. The paper concludes with the authors' thoughts on what could be different in a similar situation in the future. It makes some general recommendations and specific suggestions directed at UN transitional administrations, the World Bank, international NGOs, and those who provide funding. Box 1 is a list of acronyms and abbreviations used in this paper.

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Initial Steps in Rebuilding the Health Sector in East Timor BOX 1 Acronyms and Abbreviations AFAP Australian Foundation for the Peoples of Asia ASP Associacao Saude em Portuguese AusAID Australian Agency for International Development CHA central health authority (IHA, DHS, or MOH) CHC community health center CIC Cooperaçao Intercambio e Cultura CNRM National Council of the Maubere Resistance CNRT National Council of Timorese Resistance DHP district health plan DHS Division of Health Services DOTS directly observed treatment strategy DPKO Department of Peace Keeping Operations ECHO European Commission Humanitarian Office EPI Expanded Programme of Immunization ETHPWG East Timor Health Professionals Working Group ETTA East Timor Transitional Administration FALINTIL National Liberation Army of East Timor FRETILIN Revolutionary Front of Independent East Timor HP health plan HSP health service provider HSRDP Health Sector Rehabilitation and Development Program INTRODUCTION On May 20, 2002 East Timor became independent, the first new country of the 21st century. For more than 400 years this territory had been under the domination of foreign rule, first as a Portuguese colony, then during 24 years of Indonesian occupation. After the Popular Consultation on the future status of East Timor, organized under the auspices of the United Nations in August 1999, in which autonomy within Indonesia was rejected by the East Timorese people in favor of independence, the territory suffered several weeks of terror and

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Initial Steps in Rebuilding the Health Sector in East Timor IMCI integrated management of childhood illness IHA Interim Health Authority INTERFET International Force in East Timor ICRC International Committee of the Red Cross IOs international organizations MBBS Bachelor of Medicine and Bachelor of Surgery MOH Ministry of Health MPH Master of Public Health NGO nongovernmental organization PMU program management unit RH reproductive health SWAP sector-wide approach TA technical assistance TFET Trust Fund for East Timor UDC Christian Democratic Union of Timor UNAMET United Nations Mission in East Timor UNFPA United Nations Fund for Population Activities UNICEF United Nations Childrens Fund UNTAET United Nations Transitional Administration in East Timor WHO World Health Organization 4WD four-wheel drive destruction at the hands of pro-Indonesian militia groups backed by uncontrolled elements of the Indonesian army. An apparent scorched earth policy was implemented with terrible efficiency in the few weeks between the referendum and the arrival of the multinational peacekeeping force known as INTERFET. The devastation of the territory, including its infrastructure and public systems, was almost total. At the start of 2000, government services of all types were in ruins; there was no public transportation, no banking system, and few commercial outlets for any type of product. The United Nations, in the form of the UNTAET, formally took on the

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Initial Steps in Rebuilding the Health Sector in East Timor administration of the territory, including the deployment of UN peace-keeping forces, and was establishing a civilian administration covering all sectors. It is in this context that efforts were started to reconstruct a health system for East Timor. In post-conflict situations, the rush of external assistance to alleviate suffering and or prevent further disaster almost inevitably leads to major challenges of coordinating and rationalizing the response. East Timor is one of the more recent cases. This report attempts to briefly describe the process of rehabilitation and development of the health system during 2000-2001, including some of the achievements, the constraints that were faced, and the roles of some of the main actors. It does not pretend to be an academic treatment of the topic of health in post-conflict situations and does not make reference to earlier work in this area. Many of the observations made here may have already been recorded in other settings. The report comments on the development of the health sector during 2000 and 2001 from the perspective of those trying to implement the rehabilitation and development program. Although significant advances were made in a short period of time, the process was at times frustrating and inefficient. The authors were well placed to observe the failings and deficiencies of the effort in East Timor from the inside.1 In our view, most of the numerous institutions and individuals involved acted in good faith and with commitment to the cause. Much of the inefficiency observed we judged to be due to the inflexibility of institutional systems. We do not view this as inevitable and hope that this paper can stimulate discussion of changes that could be made to respond more effectively to future post-conflict situations. If this paper is critical of the entities involved, the only intention is to provide a basis for reflection in case the international community is confronted with a similar task in the future. It aims to provide some insights for the various agencies involved into how the process came together at the implementation level and what might be improved in a future rebuilding program in similar circumstances. 1   The authors include the three most senior East Timorese officials of the central health authority during 2000 and 2001, the two most senior members of the UNTAET health sector team, one of whom also served as the director of the program management unit of the part of the HSRDP funded through the multidonor TFET administered by the World Bank, and the three World Bank, Washington, staff most directly involved in the HSRDP, including the two task managers who served in succession in that role.

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Initial Steps in Rebuilding the Health Sector in East Timor Appendix A contains a brief chronology of major events in the political development and establishment of government in East Timor as well as selected developments in the health sector. A useful summary of the situation in 2000 can be found in United Nations (2000). THE HEALTH CONTEXT The population of East Timor varied during 2000-2001 with the progressive return of those who had fled to West Timor during this time. The population was between 750,000 and 800,000, with approximately one-third in the capital, Dili, and the larger towns, and the remainder scattered in small rural villages and hamlets, many inaccessible by road. The rural population is mainly engaged in subsistence agriculture. During 2000- 2001 the difficulties of subsistence were increased by the aftermath of the destruction and looting, during the events of 1999, of entire hamlets, along with cereal and seed reserves and the slaughter of livestock. The main health problems of the population of East Timor are like those of many developing countries with similar climatic conditions and level of development. The main causes of death in 1997-1998 were reported as pneumonia and diarrhea in children; malaria is highly endemic, and the prevalence of tuberculosis extremely high. Reproductive health problems also contribute much to the ill health of the population. Although few reliable and current data were available, it was estimated, based on pre-1999 reports, the precarious living conditions, and the deterioration of health services, that the infant mortality rate in 2000 was around 125 deaths per 1,000 live births or higher and the mortality rate under age 5 was 200 or higher. Reported figures suggest that the maternal mortality rate was in the range of 550-900 deaths per 100,000. Whatever the exact figures, East Timor in 2000 had a health profile similar to some of the poorest developing countries despite the previous relatively large number of health facilities and staff. The Health System After September 1999 A survey conducted in January 2000 put some shocking numbers on the known extensive destruction of the health infrastructure. It found that 35 percent of all health facilities had been totally destroyed. Only 23 percent of buildings had escaped without major damage, including, fortuitously, the referral hospitals in Dili and the district of Baucau. Virtually all

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Initial Steps in Rebuilding the Health Sector in East Timor equipment and supplies had been looted or damaged beyond use. Most doctors and senior health management staff had left, returning to Indonesia. Only around 25 East Timorese doctors and one specialist remained. The central administration of the health system was completely destroyed. In the months immediately following the conflict, both national and international groups moved quickly to deliver health services. Many of the remaining senior East Timorese health professionals organized themselves to form the East Timor Health Professionals Working Group (ETHPWG). With some external input from the World Health Organization and others, by December ETHPWG had developed a rough plan for future health services. International NGOs had moved in quickly and were providing emergency services. Although some services were being provided across much of the territory, coverage was uneven. A Joint Health Working Group, consisting of members of the ETHPWG, the UN agencies concerned with health, and the NGOs, did its best to coordinate activities among its members and with UNTAET, but the focus, appropriately, was on emergency relief rather than on planning how to rebuild the system. Establishment of "Government" Coordination On February 16, 2000, UNTAET created the Interim Health Authority, consisting of 16 senior East Timorese health professionals at the central level (plus 1 in each of 13 districts) and the 6 UNTAET health staff who had by that time arrived in East Timor. One East Timorese health specialist and one UNTAET staff member coordinated the group. Its physical resources consisted of one vehicle and a few tables and chairs. The lack of vehicles was to become a major constraint. The authors believe that the health sector was consistently neglected in the distribution of UN vehicles despite the priority verbally given to the sector. Holding meetings of the newly formed IHA was always a challenge, as the "office" of the IHA was in a huge auditorium shared with many other sectors of the transitional administration. Chairs were in short supply, and the noise level at times so high that communication during meetings was close to impossible. Within a few days, the IHA had formed nine working groups to address what were perceived to be the most pressing issues. The IHA decided that the sooner a development perspective was adopted, the faster a sustainable system could be built. Despite this perspective, it proved difficult for the IHA to avoid spending much of its time and effort reacting to crises and to external offers of support or demands for action or information. The

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Initial Steps in Rebuilding the Health Sector in East Timor offers and demands, mostly very well intentioned, ranged from being well informed and potentially helpful to being naive and time wasting. At times the primary motivation appeared to be identifying a niche for a particular organization, often with minimal funding, that had sent someone on an exploratory mission. Even offers accompanied by assurances of long-term support were at times more of a distraction than a help. At one point, for example, in the early weeks of the IHA, three different groups were seeking its endorsement for their plans to rebuild the dental health services. None had the resources or, arguably, the expertise for this task. Similarly, relatively large amounts of the available public health expertise were diverted into dealing with asbestos in destroyed buildings at a time of much more urgent health issues, because of the strong advocacy efforts of one small group. Accusations of unethical neglect of what the group perceived to be a priority public health issue were persistently leveled with very little appreciation of its relative importance. One of the important early activities of the newly formed IHA was team visits to all of the districts to gather information to inform the upcoming first Joint Donor Health Mission. This was intended not only to provide a basis for analysis and planning, but also to demonstrate to the donors that the IHA was the authority with the best information and the institution "in charge" of the situation in the health sector. Despite the inevitable limitations of the information collected, this proved to be important in establishing the IHA's credibility. HEALTH SECTOR REHABILITATION AND DEVELOPMENT PROGRAM Phase I In March-April 2000, the first Joint Donor Mission for the planning of the rehabilitation of the health sector took place. It was led jointly by the World Bank and the IHA. Members of the mission included representatives of the governments of Australia and Portugal and of the European Commission. The team, encompassing a wide range of technical expertise, prepared a framework for action that became the HSRDP. It was considered from the outset that a sector-wide approach was critical to provide overall guidance to all activities in the health sector. This proved to be fundamental to the excellent cooperation among all major actors in the health sector over the ensuing two years. The HSRDP had two main com-

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Initial Steps in Rebuilding the Health Sector in East Timor ponents: restoring access to basic services for the entire population and development of the health policy and system for the future. The HSRDP was the basis for a World Bank grant to the health sector supported by $12.7 million (US) from the multidonor TFET over 15 months. The project supported by this grant was prepared, appraised, and negotiated within six weeks, demonstrating the commitment of the World Bank to streamline its usual procedures in light of the special situation in East Timor. However, it took UNTAET an additional 10 weeks to agree to and meet the conditions for effectiveness of the grant, a vital loss of time. This delay was due to a number of factors, including issues around central control versus delegated authority, the legal aspects of this and other arrangements, and the slow identification and approval of essential staff for the project's management unit. More generally, the delay was due to overload of the few competent staff empowered to make decisions, the inefficiency of a system making up procedures as it went along, and, in the authors' view, a legal and administrative approach that was unduly cautious given the urgency of the situation. In the implementation of the first component, a critical element of the transitional strategy was reaching agreement with NGOs to work with the IHA to prepare district health plans. Despite initial reluctance by some of the international NGOs to be coordinated by the "government," that is, UNTAET, the legitimate role of the IHA was eventually accepted and a close relationship with the NGOs ensued. This allowed rationalization of the distribution of the resources by requesting one or sometimes two NGOs to take the lead in each district based on an approved plan. Table 1 shows the distribution of the main international NGOs providing health services in the districts, outside of the Dili (capital) district, before and after the development of district health plans. The collaboration of the NGOs allowed for the simultaneous preparation of district health plans for each of the 12 districts outside Dili, a task beyond the capacity of the IHA alone. In the negotiation of agreements on the district health plans, the IHA did not have the capacity to review them in detail. It therefore placed its emphasis on reviewing, and intentionally limiting, the number of fixed facilities and the numbers of health staff, international and, especially, national. Achievement of good population access was sought through planning the initial use of mobile clinics (nurses with motorcycles) in some areas. These emphases were driven by a strong need to secure the sustainability of the future health system by ensuring that the previous system was not simply put back in place. The system under Indonesian rule

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Initial Steps in Rebuilding the Health Sector in East Timor TABLE 1 International NGOs Providing Basic Health Services in East Timor (Excluding Dili District) District   NGO   As of 19 March 2000 As of 30 April 2001, following District Health Plans Aileu · OIKOS · World Vision International · OIKOS · World Vision International Ainaro · Timor Aid · CIC/ASP · ICRC · Timor Aid/AFAP · CIC/ASP Baucau · Medecins Sans Frontieres, Belgium · German Doctors for Development · Medecins Sans Frontieres, Belgium Bobonaro · Medecins Sans Frontieres, Holland · World Vision International · Timor Aid · Jesuit Relief Services · Health Net International Ermera · Assistencia Medica International, Portugal · Services for the Health in Asian and African Regions · International Committee of the Red Cross · Assistencia Medica International, Portugal Lautem · Medecins du Monde, Portugal · Alliance of Friends for Medical Care in East Timor · Jesuit Relief Services · Medecins du Monde, Portugal Liquica · Medecins Sans Frontieres, Holland · Health Net International Manatuto · Asistencia Medica International Portugal · Medecins Sans Frontieres, France · Instituto Marques Valle de Flor Oecussi · International Medical Corps · International Medical Corps Same · OIKOS · OIKOS Suai · Medecins du Monde, France · Medecins du Monde, France Viqueque · Medecins du Monde, France · Comite de Action Medicale

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Initial Steps in Rebuilding the Health Sector in East Timor lack of accountability of short-term staff for the medium- and long-term consequences of their action (or inaction) allowed inefficiency and incompetence in some essential support services to go unchecked. One direct reaction to this situation was a centralization of control such that even senior experienced UN staff working at the sectoral level had negligible control over resources. The health sector, for example, had no petty cash or imprest account of UN funds from which to make small purchases of goods and services. Centralized control, coupled with failure of certain central support services, was a constraint to achieving quick progress. One function of the transitional administration that was, in our view, frequently very inefficient was procurement. Deficiencies were most apparent, and potentially most harmful, in the critical area of the procurement of pharmaceuticals, but they were also seen in areas as diverse as stationery and office equipment and recruitment of technical assistance. The authors believe that this is an area in which standards of performance must be defined and monitored. The multinational nature of UNTAET was observed by us to be both a strength and a liability. On one hand, it guarded against the emerging government being exposed to only a single particular national perspective on any issue. On the other hand, certain complex activities were made more so when members of the teams implementing them came from very diverse experiential backgrounds. The World Bank It is difficult to exaggerate the importance of the role of the World Bank in the reconstruction of the health services in East Timor. It took a leading role in the early joint assessment of needs and in the development of the Health Sector Rehabilitation and Development Project (HRSDP), including the provision of high-quality technical assistance, managed the Trust Fund for East Timor (TFET) funds, and was responsive to and supportive of the CHA's needs throughout 2000-2001. The level of technical expertise provided by World Bank consultants was, with few exceptions, excellent, reflecting an unconstrained access to global expertise not seen in some other institutions limited by regional structures or strict fee payment policies. The World Bank was a strong advocate of the sector-wide approach and as controller of the pooled TFET funding was in a good position to encourage adherence to such an approach. Another strength of the World Bank is that its procedures for procurement and financial manage-

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Initial Steps in Rebuilding the Health Sector in East Timor ment, if sometimes bewilderingly complex, are at least well established. Perhaps most important, the World Bank had a competent task team in Washington committed to results and problem resolution and a supportive, politically astute, and accessible country office. Working with the World Bank was nevertheless not without difficulties. As the custodian of the pooled TFET funds, the World Bank understandably felt pressure to show results to satisfy at least partially skeptical donors. This translated into what at times appeared to be a preoccupation with disbursement of funding potentially at the cost of other considerations. The pressure to spend could have led to hasty decisions on some important issues. The most important area of constraint in working with the World Bank is summarized in one word: procurement. The first aspect of this was a concern with procurement rules that at times, and in some World Bank staff members, appeared obsessive. While a strong desire to guard against corruption and collusion is understandable, preoccupation with the avoidance of any suggestion of misprocurement can lead to an excessively rigid application of the rules. Another dimension of the problem is that the procurement procedures have been developed for a context quite unlike the post-conflict rehabilitation and development situation, in which capacity in the interim government may be limited and urgency assumes a greater importance. The procedures may be well suited to the management of large loans over several years in an established system, but they are less well adapted to making available relatively small amounts of money needed quickly for action in a post-conflict context, in which managerial capacity of the client is, almost inevitably, limited. The consequence of these first two procurement concerns, coupled with the very real need to get on with the job, was a series of time-consuming maneuvers designed to satisfy the requirements of the procurement rules while working within the capacity constraints. A more flexible interpretation of the rules"”or better still, a set of adapted rules for post-conflict situations"”would appear to be a more efficient way of arriving at the same result. Given the need to work with existing World Bank procurement procedures and taking into account the wide range of goods and services that needed to be procured simultaneously, the specialist procurement capacity within the central health authority/program management unit (CHA/ PMU) was grossly inadequate. This led to constant frustration that the

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Initial Steps in Rebuilding the Health Sector in East Timor considerable funds available could not be accessed and used as rapidly as had been planned. Even with procedures adapted for a similar situation, should these become available in the future, sufficient expert procurement capacity would be critical to quick progress. NGOs In the East Timor context, the NGOs operating in the health sector were almost entirely international, in most cases those that are well established internationally. Only two local NGOs, both with limited experience in health, played a role, although a number of church-affiliated clinics also provided services. This section focuses on the role of the international NGOs, but we cannot here fully describe the crucial role they played nor fully critique their performance. An undoubted strength of the international NGOs is their ability to respond rapidly and their operational self-sufficiency. In East Timor, they moved in quickly, employed local health staff, and were the predominant source of health care, both at the primary and the hospital level for many months. Their contribution to saving lives and preventing suffering in East Timor was enormous. A second strength is the high level of commitment of most of their international staff and a willingness to work in remote areas and under tough conditions. A third very positive aspect of their presence in East Timor was their ultimately good cooperation with the CHA. This can probably be attributed to the very frequent contact between the NGOs and the CHA and the fact that they were recognized and treated as genuine partners in the development process. Without this close collaboration, the task of reestablishing a health system and transferring responsibility for it to East Timorese health professionals would have been very much more difficult. Among the factors constraining the performance of the NGOs was a relative lack of development experience among their personnel. Many of the volunteers in East Timor were on their first mission, and very few personnel, including paid staff, had experience that would allow them to contribute fully to the development of the health system. Although some NGOs sought staff with public health qualifications and experience, this was the exception rather than the rule. In emergency situations, the provision of services under severe conditions often means high per capita expenditures and little concern for national ownership or sustainability. This per-

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Initial Steps in Rebuilding the Health Sector in East Timor spective can be counterproductive in a context of development, in which the last two elements are of high priority. A very high turnover of NGO staff, possibly important in emergency situations to avoid burnout, was a problem in East Timor, where close collaboration in medium-term activities was sought. It is encouraging that some NGOs recognized their limited capacity in development and voluntarily withdrew after the emergency phase and that others are specifically adapting themselves to post-conflict development. The authors believe, however, that the post-conflict aspect of the work should not be exaggerated. This can be a convenient label for NGOs (or indeed other institutions, including academic departments) looking for a new niche or to expand their role beyond emergencies (without necessarily changing their expertise). Many, perhaps most, of the problems facing the health sector in East Timor were those facing developing countries in general, including those that have not seen conflict in many years. Addressing these problems requires expertise in reform and management of health systems in developing countries; the post-conflict context is only one dimension of a complex problem. Because some NGOs have conflict and emergency health experience in which conditions and logistics are usually difficult and security a major concern, one consequence is the relatively high cost of their operations. Under such circumstances, the norm for communication equipment and vehicles, for example, is higher than can be sustained in a longer term development effort. Similarly, in emergency situations, speed in procurement of drugs and supplies is of greater importance than such concerns as cost-effective purchasing (not to mention standardization and use of generic brands). In the East Timor context, the combined communication and logistics capacity of the NGOs working in the health sector dwarfed the capacity of the CHA. Funding for both NGOs and the CHA came ultimately from the same donors; cost-effectiveness and sustainability should have been one of their concerns. A microcosm exemplifying the conflict between humanitarian assistance and the arguably equally humanitarian issue of sustainable development was the Dili General Hospital. The International Committee of the Red Cross moved in quickly and effectively to take on all aspects of the running of the territory's main referral hospital. It did so in a professional way and during 21 months provided resources that few, if any, institutions would have been able to match. Clearly it must be commended for providing such a valuable service to the people of East Timor. However, it did this

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Initial Steps in Rebuilding the Health Sector in East Timor at an estimated cost of $300,000 (US) per month, including in-kind contributions, an expenditure equivalent to almost half of the government's average monthly recurrent cost budget for health for 2001. Clearly, this was not a sustainable level of input. To its credit, the ICRC gave UNTAET 15 months advance warning of its eventual withdrawal, and its staff showed a good understanding of the need to scale back its operations progressively and to transfer responsibility to national staff as the date of departure approached. Another difficult aspect of the NGO involvement in East Timor resulted from the enormous variability in capacity of the NGOs and the need of some to compete vigorously for funding. The need to compete and to be seen to be performing led to considerable overstatement of capacity in some cases. While some NGOs do have true professional experience in and resources for the rehabilitation of health facilities, for example, others claimed to have such expertise but, in fact, made shoddy repairs that did not last long after the photographs had been taken for the head office and the donors. It was difficult for the CHA to assess, a priori, the expertise of different NGOs, including some with excellent self-promotional skills. From the perspective of the CHA, the best NGOs were those with a clear institutional definition of their intended role in East Timor, that worked in collaboration with the CHA, that knew their true capacity and limitations, that ensured they had capable staff on the ground, and that had sufficient financial resources to achieve their objectives. In contrast, the most problematic NGOs were those that had a limited, often general management presence in the territory and were seeking a role and official endorsement for it that they would then use to seek funds. While claiming to be more responsive to the needs of the CHA, such NGOs usually wasted its time and achieved little. TOO MUCH MONEY TOO SOON? One of the inevitable conclusions of the experience in East Timor in 2000-2001 can be summarized, if oversimply, as "money drives everything." It is clear that without money in sufficient quantity, nothing could be achieved and that it is important to exploit politically driven interest in funding a particular effort while it lasts. It is also true that the awareness that funding will start to decline and the related need to spend available money quickly can have distorting effects. One of the reasons that relatively large amounts of money were avail-

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Initial Steps in Rebuilding the Health Sector in East Timor able early in East Timor was the consolidated appeal for funding in the emergency phase. Given the relative political attractiveness of emergencies and the undeniable health needs in such situations, a significant amount of money was quickly available to the health sector. The fact that, even by mid- to late 2000, much of the money had not been spent suggests that the emergency funds surpassed the absorptive capacity. This led to some of the funded entities, not wanting to be left with unspent funds, finding creative ways of using them within the stipulated guidelines but with little relevance to the true needs. A particular consequence of the availability of emergency funding to the health sector was the rehabilitation of some health facilities, including hospitals, by NGOs before any plan for health facility location and size had been completed. Rehabilitation is popular with donors to emergency situations (in part because it is visible and can absorb considerable resources) and certainly some rehabilitation is essential, but early unplanned or poorly executed rehabilitation can produce difficulties for the future government. Another cause for the relative overabundance of early funding is that "size matters." There are few incentives at any level for a manager of funds to opt for a smaller budget and activity portfolio. Prestige (and to some extent promotion) in international agencies and the development banks is undoubtedly linked, in part, to the size of the budgets handled by an individual. An NGO head of mission is likely to be viewed well by the head office if he or she is able to secure generous funding from donors on the ground even if it exceeds the real needs or the organization's capacity to spend effectively. There are few incentives for requesting or spending less money than is available. Another cause of the pressure to spend money early is the "use it or lose it" financing approach taken by most funding and financial management entities. One particularly problematic effect of the oversupply of funds is the distortion of local salary scales. In East Timor, international NGOs in the health sector by and large acted responsibly in this regard, adopting a shared voluntary salary scale. Nevertheless, payment of high salaries to local staff by some agencies, including those of the UN, was one of the main factors contributing to discontent with "government" salaries. A particular reason for the availability of very considerable resources in the East Timor context was the needs of the UN peacekeeping operation. One example that affected the health sector was the needs of the UN peacekeepers for continuously available medical air evacuation services. Given that the entity providing these was paid for a minimum number of flying

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Initial Steps in Rebuilding the Health Sector in East Timor hours and that military demand proved to be relatively low, these services were available to the civilian population. While meeting an obvious humanitarian need, this introduced a distortion to the health system and may have created expectations that clearly cannot be met in the future. The sudden availability in East Timor of large amounts of external funding created an artificial situation in which unrealistic expectations could arise and unsustainable services be put in place. This will make the task of the future leadership more difficult when financial and other resources decline to more realistic levels. More generally, the availability of high levels of resources may have led to the exposure of East Timorese counterparts to bad examples in terms of choices in the use of funds and in use of official resources, for example, transport. This occurred at a time whenthe international community, perhaps above all, should have been providing a model to the future leaders of the new East Timor. WHAT COULD BE DIFFERENT NEXT TIME? The complexity of post-conflict situations and the differences from one setting to another make it difficult to come up with succinct and generalizable recommendations. Based on our experience in East Timor in 2000-2001, we make the following suggestions. We hope that readers' analysis of the preceding text may also provide lessons that are not specifically mentioned here. Specific suggestions directed at UN transitional administrations, the World Bank, international NGOs, and those who provide funding are made below. We start here with some more general suggestions. The authors feel strongly that a sector-wide approach to planning and coordinating the rehabilitation and development of the health sector is essential from the outset. Whatever management challenges it may produce and whatever criticisms it may draw from donors and others with particular interests, it is the best option for ensuring the coherent development of the health sector. The alternative of a series of semi-independent projects, each with its own management and coordination burden, is likely to prove very difficult for the future Ministry of Health to control and integrate at a later time. National control of the rehabilitation and development process should not be compromised for the sake of more rapid decision making and progress. All actors in the health sector should accept from the outset the legitimacy of the interim government, especially its national members.

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Initial Steps in Rebuilding the Health Sector in East Timor Similarly, no compromise should be made concerning a deliberate focus on sustainability. Ignoring sustainability in order to make quick gains is likely to produce long-standing difficulties for the future government. Every effort should be made to move quickly from a humanitarian assistance approach to one of sustainable development. Prolongation of the emergency phase should be avoided. In this regard, it is important to ensure that arguments for high, short-term inputs based on humanitarian concerns do not automatically override long-term considerations. The fact that humanitarian relief assistance is currently much easier to obtain than development assistance is a concern, as the source of the funding can determine the nature of the inputs. As early as possible, a full and professional assessment of the physical health infrastructure should be conduct by an expert team. This is likely to prove more important than a rapid assessment of the health situation, especially in situations in which the latter is to a large extent predictable. Based on this assessment, a crude and conservative plan for future health facilities should be made and communicated to all concerned. This will inevitably be revised, as long-term funding realities become apparent and health policy is developed. It should be made clear that decisions concerning rehabilitation, construction, placement, size, and services available at health facilities are to be made by the interim government. Without jeopardizing the above areas, the authors feel that compromises should be made in procedures, in the time frame for producing results, in centralized control, and in application of unrealistically high standards of quality. In all of these areas it is important to recognize the constraints of the post-conflict situation and the inevitably limited capacity of the emerging government. Procedures"”for example, those for procurement, budgeting, and financial management"”should be adapted to this context while still ensuring an acceptable level of accountability. Significant benefit might be gained in the long term by removing some of the pressure to produce results quickly. More emphasis should be placed on the durability and sustainability of achievements than on rapid disbursement of funds and quick results. Nevertheless, more could be achieved early with some loosening of central control, particularly in the UN system. Sectoral experts from the system who have a track record of responsible management should be given greater managerial independence, including over financial resources. This should include the freedom to organize and fund training activities, recruit short-term staff, and make

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Initial Steps in Rebuilding the Health Sector in East Timor purchases of minor supplies, without passing through the central procurement process. While concern with the quality of service provision is important, setting unrealistic targets in this regard too soon can be a barrier to providing basic services to all quickly. Effort to put national systems in place to achieve long-term improvements in the quality of health care should not be given priority until basic services are widely available. This also provides time for standardizing guidelines and developing human resource development plans. One serious constraint to the health sector in East Timor was the very delayed recruitment of national health staff. In situations in which a health service has to be recreated, senior health staff should be recruited as soon as possible so that, from a secure position, they can participate fully in the development process, including the recruitment of staff at lower levels. It is critical that this happens simultaneously in all sectors, so that national staff can interact with their national counterparts in other sectors rather than foreign substitutes. This in turn should lead to better cross-sectoral collaboration, which was a weakness in East Timor. The transition period is a critical opportunity for rapid capacity development that can only be achieved if national staff are allowed to assume genuine responsibility and are provided support to meet it. From their interaction with other parts of the UNTAET, the authors have the following recommendations for future administrations. First is the importance of securing key central administrative functions in the interim government with teams that are truly expert in the field concerned. In such areas as legal systems, civil service recruitment, and government procurement, it may be useful to have expertise supplied by an entity from a particular UN member state rather than through multinational teams. The budget office of the transitional administration in East Timor was one very successful example of this approach. Trying to put together a key service with people from many different national systems may be extremely inefficient, as was demonstrated in certain areas in East Timor. Structuring a civil service and recruiting staff for it, for example, require real expertise. Delays in this can have a huge impact on staff morale and the progress of system development. Compromise on the UN principle of a multinational staff could greatly facilitate some largely administrative functions for which diversity of input may be of little benefit. Efficiency could be improved and a lot of frustration avoided by the establishment of a dedicated UN problem-solving and lesson accumulation

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Initial Steps in Rebuilding the Health Sector in East Timor team on the ground working across sectors. This would lead to addressing of systemic issues rather than ad hoc resolution of problems in one sector only to have them arise again in another. Much of the inefficiency in East Timor could be traced to minor issues, but no entity was charged with the responsibility and authority to identify and definitively resolve such issues. Regarding the World Bank, the authors would like to propose adaptation of procedures, particularly for procurement, to the post-conflict setting. The adapted procedures need not apply to all funds but should allow less-constrained spending on some elements of the rehabilitation and development program. Either agreement should be reached on acceptable adaptations to allow easier spending of some portion of the World Bank controlled funds, or a greater role for bilateral funding should be accepted and clearly defined, especially for areas in which more straightforward and rapid fund dispersement may be needed. Whether or not such changes are made, the World Bank should ensure more support to program implementation. In particular, it is critical to ensure that the PMU has adequate procurement capacity, especially early, especially for civil works. Transparent and frequent explanations of where the money is going is critical for maintaining good collaboration with and a good image of the World Bank. This could be coupled with less focus on disbursement and more focus on what is being achieved. In order for the World Bank to adopt such an approach, its donors should, in turn, do so. It is difficult to make a succinct set of recommendations concerning NGOs, in part because of the diversity of their nature and competence. Among the international NGOs that can be considered the leaders in the field, there does seem to be an active process of self-analysis and attempts at reform. We encourage this. NGOs should be clear about their particular strengths and stick to situations in which they are appropriate. NGOs with expertise in emergency situations may not contribute effectively to health system development. In any event, it would be useful for staff of NGOs working in post-conflict situations to be briefed on the essential aspects of sustainable development. With respect to the possible initial oversupply of resources, it may be important to examine the emergency appeal process. While it may be important to capitalize on initial interest, it is equally important that the funds raised be used to maximum effect. From the outset it is important to consider what will happen after the post-conflict crisis is over and a country is left to its own devices and perhaps struggling with its new independence.

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Initial Steps in Rebuilding the Health Sector in East Timor The donor community may be generous in the first few years following the conflict, but experience shows that it takes much longer to rebuild a country or even to implement an initial development program. Absorptive capacity may be low initially and take several years to grow. Proportionately more of the resources may be needed in the years following the immediate post-conflict response. A longer time horizon for countries emerging from conflict may be needed. This should not perpetuate the emergency phase or delay the imperatives of ownership and capacity building. It could be facilitated by allowing funds raised in the first flush of donor support to be put in reserve, for example in sector-specific trust funds, for use when capacity and development needs are increasing. Finally, it is important to put in place mechanisms for documenting and learning from experience in post-conflict situations. Those directly involved in the support of rebuilding efforts are usually too busy to spend time documenting the process and may not be objective. Nevertheless, their experience in confronting practical issues under difficult circumstances could be extremely valuable and should be captured. Although there will be many situation-specific factors, it is likely that there will be many more common issues. Unless experience is recorded and analyzed, changing the way various organizations do business, people will keep repeating the same mistakes and running into the same obstacles. We hope that some of the experiences of East Timor and the above suggestions that are drawn from them will be of use in reforming approaches to countries in post-conflict situations. REFERENCES United Nations Country Team 2000 Common Country Assessment for East Timor: Building Blocks for a Nation. East Timor: United Nations. Van der Heijden, T., and K. Thomas 2001 Review of WHO's Emergency Response in East Timor. (unpublished manuscript), Geneva, World Health Organization.