Initial Steps in Rebuilding the Health Sector in East Timor (2003)

Initial Steps in Rebuilding the Health Sector in East Timor

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

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-

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.

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

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

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.

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 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.

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

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.

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

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.

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-

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

had been characterized by a large number of often overstaffed facilities that were underfunded and underutilized.

An agreement with each NGO was covered by a negotiated memorandum of understanding (see Appendix B). The close collaboration with the NGOs was greatly facilitated by—indeed would not have been possible without—the full collaboration of the European Commission Humanitarian Office (ECHO), which was the major funding source of many of the important NGOs. ECHO agreed to use the district health plans as the basis for funding and also agreed with the IHA on ceilings for selected items, like directly hired staff, rehabilitation, and drugs (the latter by that time being provided in large part by the government). Without such ceilings it would have been difficult for the IHA to limit unwanted effects on the health system arising, for example, from rehabilitation of health facilities in inappropriate sites. The ceilings were, however, sufficiently high to allow basic repairs and initial rehabilitation to all facilities included in the district health plans.

Not surprisingly, the planned downsizing of the health system provoked some strong reaction from some NGOs and especially from the health workers, already justifiably insecure about their futures, all of them at that stage receiving stipends from UNTAET (or, in a minority of cases, from the NGOs) but not formally reemployed. The extent of the planned reduction in the number of facilities and staff is summarized in Table 2.

The first phase of the HSRDP also saw the implementation of the initial civil works program. It was decided to focus on community health centers to ensure one such facility in each of the territory's 65 subdistricts. It was planned that rehabilitation of health posts could be undertaken through community support at a later stage and that hospital reconstruction would also be delayed until a full assessment of need had been completed. A total of 23 sites were selected for construction and the design work tendered and completed. Construction of a new central pharmacy warehouse was also initiated, as was procurement of vehicles and equipment. The health policy development process was also started, but it stalled in mid-2001 for a variety of reasons.

With the formation in August 2000 of the First Transitional Government of East Timor, led by a cabinet that included East Timorese members, the IHA evolved into the DHS of the Government's Department of Social Affairs. The process of recruiting of East Timorese health civil servants was initiated in the last months of 2000 with the finalization of some 50 job descriptions for around 800 posts in 150 locations. This process, conducted

over the next six months, taxed to the limit the capacity of the DHS and the other relevant sections of UNTAET. A process had to be devised that was fair both to the older, long-serving nurses and auxiliaries and the younger, perhaps better qualified nurses and midwives. Long delays in the recruitment process, related in large part to the lack of sufficient professional expertise in the area of civil service development and recruitment in the transitional administration, added to the frustration of health workers, all of whom were anxious to know whether and where they would be employed. The delays affected the credibility of the DHS with some NGOs, which had to bear much of the discontent in the districts.

In the middle of 2001 the HSRDP entered a second phase, which was the result of two concurrent exercises. The first was the preparation of the second budget of the transitional administration. In contrast to the exercise of the previous fiscal year, the 2001-2002 combined sources budget was, as the name suggests, an attempt to quantify and plan the use of funding from

all sources. Preparation of this budget was a major and complex task. The combination of time constraints and the limited experience with such budgeting resulted in a limited role for the East Timorese members of the DHS in the process despite efforts to ensure full participation.

Nevertheless, the preparation of this budget was an important opportunity to reaffirm the principle of the sector-wide approach. The budget included remaining funds from the first TFET-funded project, an additional $12.6 million (US) planned for the second TFET-funded project, funds from the proposed transitional government's budget, and funds from bilateral donors and NGOs. Table 3 summarizes briefly and approximately the sources of funding and their agreed use during 2000-2001.

This combined sources budget and its associated work plans maintained the main elements of the HSRDP Phase I. It comprised three components for which 10 percent of funds could be reassigned without requiring new cabinet approval. The three components were: support to ongoing services, improvement in the scope and quality of services and support systems, and development of policy, regulations, and administrative systems.

During the period from April to September 2001, the DHS, using TFET funds, took over the financial support to NGOs in five districts. Although the funding levels were considerably reduced from those provided by other sources during the emergency phase, they were still very substantial. The DHS was providing an equivalent of $35,000 to $45,000 (US) per district per month for recurrent costs. An important question that faced the DHS was the manner in which technical support could be most efficiently provided to the district health services after September 2001, when the memorandum of understanding with the NGOs was to expire. For a number of reasons, including the cost and the inconsistent and variable quality of the support provided, it was considered undesirable simply to continue the existing system of support to one or two lead NGOs in each district.

At first, it was proposed that a competitive process be undertaken in which NGOs and other entities could bid to provide technical support to a group of two to four districts. After much discussion and a growing understanding, based on feedback from the field, of the support being provided at that time by the NGOs and its cost, the DHS decided against this option. By the third quarter of 2001, East Timorese district health management teams had been recruited in each of the districts, and it was not

considered appropriate to put in place what would effectively have been another, nongovernmental layer in the system. The DHS extended funding to some NGOs that agreed to continue to provide services, at lower levels, to the end of 2001, but a phase-out strategy was announced and vigorously defended by the newly recruited leaders of the DHS, which in September 2001 became the Ministry of Health. It was decided that the ministry should use part of its TFET resources to hire directly the foreign expertise needed. Advertisements were placed in international media and a recruitment process initiated.

Certainly the most important achievement by late 2001 was that in a little more than 18 months a fully East Timorese Ministry of Health had been put in place and over 800 health staff had been recruited and were working across the territory. This had been achieved with little unrest, despite the very significant downsizing of the health workforce and a certain tendency toward strikes and other employee protest in East Timor at the time. All community health centers were staffed and functioning, as were most of the health posts. However, the delays in civil service recruitment meant that staff at district level had been in place only for a short period by the time the phased withdrawal of NGO support was started. Rapid subsequent progress toward East Timorese district health teams' assuming district-level management can be considered another achievement. Only with time, however, will it be possible to judge whether the phasing out of international NGOs and their replacement with directly hired national expertise was well timed.

Since April 2000, most drugs had been provided to the health system by the central health authority (CHA),² from an agreed essential drug list, without major ruptures of stock. A new central pharmacy warehouse was entering the final stage of construction following international tendering of its design and construction. A consultant group had also been contracted to develop an autonomous medical supply system to ensure efficient procurement storage and distribution of pharmaceuticals and other medical supplies. A complete survey of health infrastructure and equipment had been completed, and 22 new health centers were under construction and major procurements of equipment completed or under way. Around 160 motorcycles and 35 four-wheel drive (4WD) vehicles had been procured for the health system, including appropriately equipped ambulances, and installation of a high-frequency radio network had been contracted after researching needs and experience elsewhere.

Policy and regulation development on pharmaceuticals and medical practice had been started through initial consultancy visits followed by a number of working sessions in which senior East Timorese health staff de-

veloped proposals for submission to the Cabinet (later, the Council of Ministers). Nevertheless, considerable work remained to be done to reach agreement on the details of these complex policy areas.

In relation to disease-specific activities, one important achievement was the reestablishment of the National Tuberculosis Program implemented in collaboration with Caritas East Timor. Caritas Norway provided financial support and technical assistance, with additional technical input from WHO and the Northern Territory (of Australia) Health Services. Activities were coordinated under a memorandum of understanding with the Interim Health Authority elaborated in mid-2000. Over 6,000 cases of tuberculosis were detected and placed on treatment according to the directly observed treatment strategy. This went some way toward catching up on the treatment of the backlog of patients accumulated in recent years. By the end of 2001, the program covered all districts and many subdistricts. By that time, integrated management of childhood illness (IMCI) had been introduced through the adaptation of a Bahasa Indonesian version of the IMCI materials and the training of trainers. Similarly, decisions had been made about the initial approach to improving reproductive health services, with a focus on introducing and monitoring midwifery standards and identifying and addressing deficiencies.

With financial and technical support from AusAID, and within the framework of a sector-wide approach, projects were also under way on mental and dental health and HIV/AIDS prevention. Mental health activities initially focused on post-trauma recovery but were quickly expanded to start to address broader mental health needs, particularly in the capital. The initial project was followed up by a three-year project to develop services oriented to community prevention and basic services throughout the territory. The dental health project was developed using a similar two-stage process. Initial training of dental nurses aimed to provide basic palliative care in all districts. Two consultancy visits by joint UN teams in 2000 and 2001 assessed HIV/AIDS susceptibility and made initial plans for prevention activities. These were, however, slow to be implemented, and a short-term project was therefore initiated by the DHS with AusAID support. This focused on establishing an East Timorese working group to start to develop an approach to HIV/AIDS prevention in the particularly challenging religious and cultural context of East Timor, as well as on immediate prevention activities for vulnerable groups.

One notable overall achievement was the collaboration among all major actors in the health sector, including multilateral, bilateral, and UN

technical agencies and NGOs to work within the framework of the sector wide approach. There was little duplication of effort and relatively little competition for visibility. There was at times debate as to whether the HSRDP in East Timor constituted a true sector-wide approach. In the view of the authors, it fulfilled the most important aims of such an approach. Although all funding was not pooled into a common fund, there was sufficient pooling of funds to ensure a core program, and clear definition of the uses of other sources of funding ensured nonduplication of effort. This is reflected in Table 2, which shows the main sources of funding and the areas of work supported by each. The main objective of the sector wide approach, to achieve one coherent program of development in the health sector, was very largely achieved.

Despite what we believe to be the considerable achievements in the development of the health sector, there were also a number of areas in which progress was frustratingly slow or inadequate. It proved difficult, for example, to establish an effective health policy development process involving a range of health and nonhealth stakeholders. Among health staff with no previous experience in or responsibility for health policy, many of the issues that needed to be discussed may have seemed irrelevant and their presentation unnecessarily complex. The bigger policy issues were not of immediate obvious relevance to their own demands for employment, adequate salaries, and good working conditions, which were understandably their main preoccupations.

A small group inside and outside the CHA did show an interest in these topics and in trying to move the policy dialogue forward, but attempts at broader consultation were not successful. The process to develop policy adopted by the CHA with external technical assistance may not have been ideal in the context; although technically elegant and comprehensive and emphasizing national capacity for and ownership of the decision making, the process was viewed by most of the participants as too academic. Simple approaches to policy development when capacity is limited remain a challenge. They should keep in mind the broader context but focus, initially on issues of most concern to the stakeholders and those most likely to have long-lasting detrimental effects if not addressed early.

Another area in which progress was inadequate was the development of a comprehensive human resource development plan to guide priorities

in medium- and long-term education and training. WHO provided strong technical support for meeting immediate needs, for example, in the preparation of more than 50 job descriptions and in defining a new cadre of nurse practitioners. Given the limited number of trained specialists and technicians, there was a pressing need to start training that could extend over several years. Dealing with the immediate needs for recruitment and capacity building left little time for developing the longer term plan. At the end of 2001, long-term planning for human resources remained an important need.

One area of delay that was particularly frustrating, because it should have been avoidable, was the civil works program, specifically the construction of community health centers. In this area the slower than planned progress was almost entirely due to inadequate capacity to handle procurement procedures and, in particular, the interaction between the World Bank procedures and those that were being developed and simultaneously applied by the UN transitional administration. Relative to the initial, admittedly extremely ambitious, civil works plan, initiation of construction was delayed by around one year. A central issue in the interagency differences in this area was the need to balance delegation of authority to the sectoral level (specifically to the senior staff that headed jointly the IHA and the program management unit of the TFET-funded project) with the need for centralized UN control and assumption of liability. Another aspect that complicated the process was the deriving of a tendering process, which gave emerging local companies the opportunity to compete while not excluding the potential economies of scale that might be offered by a large foreign contractor. Predictably this was a sensitive issue, with both foreign and local companies raising concerns. In one instance, there was a significant delay when a request for proposals was reissued because the first was deemed not to have resulted in effective competition.

As some of the rehabilitation carried out by NGOs restored health facilities to a level not compatible with the district health plans and because much of it was of a superficial nature, the IHA imposed limitations on rehabilitation activities. However, delays in the civil works program undermined the rationale for this approach. An early and detailed overview of the physical state of the infrastructure could have helped to guide rather than try to restrict NGO rehabilitation efforts.

As mentioned above, development of hospitals was intentionally postponed to the second phase of the HSRDP while concentrating on rehabilitating and reconstructing more peripheral services. In at least three dis-

tricts, international NGOs had partially rehabilitated and were supporting hospitals that would be likely candidates to be downsized or closed in a rational health plan. This was one of the factors that obliged the CHA to make the unpopular decision to suspend further development of hospitals until a full assessment of needs and capacity and a comprehensive plan were developed. This was not achieved by the end of 2001, despite the political pressure created by this situation. Proposals developed by a consulting group were considered to be likely to lead to hospitals' consuming too large a proportion of the health budget, and a reassessment was called for.

A considerable achievement, obtained through the skillful negotiation of several senior East Timorese health staff, was the establishment of the National Centre for Health Education and Training. This brought together what had been in Indonesian times a number of independent educational and training centers for health professionals, for example, the nursing school, the nursing academy, and training institutions for sanitarians and nutritionists. An international NGO fully supported the rehabilitation of a previous complex of buildings to house the centre. However, these achievements were not followed with adequate technical and managerial support to the complex task of fusing the different activities into a well-functioning entity. This remains part of the human resource agenda that needed to be addressed.

One of the major challenges to the CHA in East Timor was the need to try to meet objectives and demands that were not all compatible. These demands were made by the public, by the political leadership, and by the donors. Table 4 summarizes some of the conflicting demands. Although these are not necessarily in direct contradiction, it should be apparent from the table that effort and resources would be applied with different priority depending on the relative importance given to each of these demands.

One area in which there was a marked contrast between the needs of the external assistance agencies and the needs and capacity of the CHA was in budgeting and planning. Not unreasonably, the donor agencies required a detailed 1-year budget and work plan, 1- to 2-year procurement plans, and a strategic plan covering a period from 4 to 10 years. The detailed combined-sources budget had to be broken down into "program" and "project" elements, by a series of standard expenditure codes and according

to the source and security of funding. Even for experienced international staff, this was quite a demanding task.

The CHA, working with national staff with little or no previous experience or responsibility for budgeting and planning, had different priorities. It attempted to get each of the 14 units within the authority to set rather general 1-2 year objectives and then to make 3-month plans with a small number of well-defined achievable milestones that could be readily monitored. The planning of activities and achieving results were given far more importance than how to spend the money. The interest of the East Timorese unit heads in the financing was largely focused on the budgets for planned activities and on funds within their direct control. Few beyond the most senior staff were interested in the budgeting of funds over which they considered they had little influence.

Clearly, both the needs of the external assistance agencies and the internal needs of the CHA were legitimate. Almost inevitably, however, the former ended up being most time-consuming, particularly for the limited foreign expertise available.

Further demands were placed on the limited planning capacity of the CHA by the need to comment on and approve plans for collaboration from the three main UN agency partners prepared in different formats and covering different periods of time. These plans were designed to meet the agen-

cies' institutional needs rather than accommodating to the program structure and priorities of the government.

The development of the health sector in East Timor involved multiple partners. We focus here on just three: UNTAET, the World Bank, and the NGOs. The roles of bilateral development assistance agencies and those of the UN system are not addressed here. Of the latter, the WHO, UNICEF, and UNFPA were the most involved and made many valuable contributions. The role played by WHO was evaluated by an independent team as part of a global study and is documented elsewhere (see Van der Heijden and Thomas, 2001).

One other group not examined in detail here meriting particular mention is the ETHPWG, formed within days of the conflict by the remaining senior East Timorese. The fact that this group was formed so early was critical. It was the national group most concerned about development of the health system, rather than the interests of one particular professional group. Its existence largely explains the ease with which the Interim Health Authority could be created by UNTAET and immediately achieve credibility, in contrast to the developments in some other sectors.

It is impossible to fully summarize here the strengths and constraints of the UNTAET and its backup in New York from the DPKO. We have chosen several aspects that we believe to be important to the development of the sector. Arguably, the most important strength of the UNTAET was its legitimacy as the entity mandated to manage day-to-day matters and develop a government structure in East Timor. This conveyed full legitimacy, in turn, to the Interim Health Authority (and subsequently the DHS and later the first MOH), set up under UNTAET, to coordinate all matters related to health. Once it was recognized that the emergency phase was giving way to a development phase, this legitimacy was not challenged.

It is not obvious, however, that the role of UNTAET as the coordinator of development was best served by its institutional dependence on DPKO. The expertise of this entity did not appear to extend to a comprehensive understanding of the needs and priorities in the development of a

health sector. This was reflected, for example, in the recruitment of staff for the health sector. Recent experience in any (post-) conflict situation, for example Kosovo, may have appeared to DPKO staff in New York to be a useful selection criterion, whereas extensive experience in health systems in developing countries similar to East Timor was what was really needed. A greater role for WHO in the recruitment of staff in similar situations may be desirable.

This was just one dimension of the incompatibility of the logic and needs of "development" and "peacekeeping." Another is what the authors came to see as the mission versus The Mission. We saw UNTAET's mission in the health sector as having two parts: restoring health services to the people of East Timor as rapidly as possible and developing and initiating a sustainable health system for the future. At times it seemed as if staff working in other parts of UNTAET saw their role as simply maintaining the machinery of the UN Mission, which was viewed by them as primarily one of peacekeeping, albeit a unique one with unusual elements. It was imperative in their view that this be done according to usual practice and UN rules for such situations, and there was minimal interest in the development tasks that UNTAET was mandated to carry out. This led to the sometimes absurd and often frustrating conflict between the aims and needs of the UN staff working with the East Timor transitional administration and those of staff working with the UNTAET Mission's administration. One example of the consequences was a distribution of transport and communication facilities that did not reflect the priority of the development activities. While the UNTAET administrative staff were all equipped with 4WD vehicles, often used only in the capital, the health sector staff, required to assess, organize, and supervise health activities throughout the country were not aupplied with a vehicle for many months, despite frequent requests. A primary source of these disputes and inequities was different sources of funding, but they were also the result of different overall priorities.

In some cases, staff carrying out critical functions in other areas of the transitional administration appeared to have minimal experience in working in a development context and, in particular, had very limited understanding of the importance of the concept of sustainability.

Understandably, with a critical international community looking on, UNTAET was concerned both to produce results quickly and to maintain control, especially over the considerable resources being expended. The concern for control was heightened by the serious lack of individual accountability inherent in a situation in which staff turnover is extremely high. The

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.

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-

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

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.

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-

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

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.

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-

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

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.

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.

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

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

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.

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.

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.