INITIAL STEPS IN REBUILDING THE HEALTH SECTOR IN EAST TIMOR

Jim Tulloch,

Fadia Saadah,

Rui Maria de Araujo,

Rui Paulo de Jesus,

Sergio Lobo,

Isabel Hemming,

Jane Nassim, and

Ian Morris

Roundtable on the Demography of Forced Migration

Committee on Population

NATIONAL RESEARCH COUNCIL OF THE NATIONAL ACADEMIESand

Program on Forced Migration and Health at the Mailman School of Public Health Columbia University

THE NATIONAL ACADEMIES PRESS
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Initial Steps in Rebuilding the Health Sector in East Timor INITIAL STEPS IN REBUILDING THE HEALTH SECTOR IN EAST TIMOR Jim Tulloch, Fadia Saadah, Rui Maria de Araujo, Rui Paulo de Jesus, Sergio Lobo, Isabel Hemming, Jane Nassim, and Ian Morris Roundtable on the Demography of Forced Migration Committee on Population NATIONAL RESEARCH COUNCIL OF THE NATIONAL ACADEMIESand Program on Forced Migration and Health at the Mailman School of Public Health Columbia University THE NATIONAL ACADEMIES PRESS Washington, DCwww.nap.edu

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Initial Steps in Rebuilding the Health Sector in East Timor THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W.Washington, DC20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by a grant to the National Academy of Sciences and the Mailman School of Public Health of Columbia University by the Andrew W. Mellon Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number 0-309-08901-8 (Book) International Standard Book Number 0-309-50584-4 (PDF) Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu Copyright 2003 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Research Council. (2003). Initial Steps in Rebuilding the Health Sector in East Timor. Jim Tulloch, Fadia Saadah, Rui Maria de Araujo, Rui Paulo de Jesus, Sergio Lobo, Isabel Hemming, Jane Nassim, and Ian Morris. Roundtable on the Demography of Forced Migration. Committee on Population, Division of Behavioral and Social Sciences and Education and Program on Forced Migration and Health at the Mailman School of Public Health of Columbia University. Washington, DC: The National Academies Press.

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Initial Steps in Rebuilding the Health Sector in East Timor THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Initial Steps in Rebuilding the Health Sector in East Timor ROUNDTABLE ON THE DEMOGRAPHY OF FORCED MIGRATION 2003 CHARLES B. KEELY (Chair), Walsh School of Foreign Service, Georgetown University LINDA BARTLETT, Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta RICHARD BLACK, Center for Development and Environment, University of Sussex STEPHEN CASTLES, Refugee Studies Centre, University of Oxford WILLIAM GARVELINK, Bureau of Humanitarian Response, U.S. Agency for International Development, Washington, DC ANDRE GRIEKSPOOR, Emergency and Humanitarian Action Department, World Health Organization, Geneva JOHN HAMMOCK, Feinstein International Famine Center, Tufts University BELA HOVY, Program Coordination Section, United Nations High Commissioner for Refugees, Geneva JENNIFER LEANING, School of Public Health, Harvard University DOMINIQUE LEGROS, Epi Centre, Médecins Sans Frontières, Paris NANCY LINDBORG, Mercy Corps, Washington, DC CAROLYN MAKINSON, The Andrew W. Mellon Foundation, New York SUSAN F. MARTIN, Institute for the Study of International Migration, Georgetown University W. COURTLAND ROBINSON, Center for Refugee and Disaster Studies, Johns Hopkins University SHARON STANTON RUSSELL, Center for International Studies, Massachusetts Institute of Technology WILLIAM SELTZER, Department of Sociology and Anthropology, Fordham University PAUL SPIEGEL, International Emergency and Refugee Health Branch, Centers for Disease Control and Prevention, Atlanta RONALD WALDMAN, Mailman School of Public Health, Columbia University ANTHONY ZWI, School of Public Health and Community Medicine, University of New South Wales HOLLY REED, Program Officer

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Initial Steps in Rebuilding the Health Sector in East Timor COMMITTEE ON POPULATION 2003 KENNETH W. WACHTER (Chair), Department of Demography, University of California, Berkeley ELLEN BRENNAN-GALVIN, Yale University, New Haven, Connecticut JANET CURRIE, Department of Economics, University of California, Los Angeles JOHN N. HOBCRAFT, Population Investigation Committee, London School of Economics CHARLES B. KEELY, Walsh School of Foreign Service, Georgetown University DAVID I. KERTZER, Department of Anthropology, Brown University DAVID A. LAM, Population Studies Center, University of Michigan, Ann Arbor CYNTHIA LLOYD, The Population Council, New York DOUGLAS S. MASSEY, Department of Sociology, University of Pennsylvania RUBÉN G. RUMBAUT, Center for Research on Immigration, Population and Public Policy, Department of Sociology, University of California, Irvine JAMES W. VAUPEL, Max Planck Institute for Demographic Research, Rostock, Germany LINDA J. WAITE, Population Research Center, University of Chicago ROBERT J. WILLIS, Institute for Social Research, University of Michigan, Ann Arbor BARNEY COHEN, Director

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Initial Steps in Rebuilding the Health Sector in East Timor Preface In response to the need for more research on displaced persons, the Committee on Population developed the Roundtable on the Demography of Forced Migration in 1999. This activity, which is supported by the Andrew W. Mellon Foundation, provides a forum in which a diverse group of experts can discuss the state of knowledge about demographic structures and processes among people who are displaced by war and political violence, famine, natural disasters, or government projects or programs that destroy their homes and communities. The roundtable includes representatives from operational agencies, with long-standing field and administrative experience. It includes researchers and scientists with both applied and scholarly expertise in medicine, demography, and epidemiology. The group also includes representatives from government, international organizations, donors, universities, and nongovernmental organizations. The roundtable is organized to be as inclusive as possible of relevant expertise and to provide occasions for substantive sharing to increase knowledge for all participants, with a view toward developing cumulative facts to inform policy and programs in complex humanitarian emergencies. To this aim, the roundtable has held annual workshops on a variety of topics, including mortality patterns in complex emergencies, demographic assessment techniques in emergency settings, and research ethics among conflict affected and displaced populations. Another role for the roundtable is to serve as a promoter of the best research in the field. The field is rich in practitioners but is lacking a

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Initial Steps in Rebuilding the Health Sector in East Timor coherent body of research. In recent years a number of attempts to codify health policies and practices for the benefit of the humanitarian assistance community have been launched. The SPHERE Project"”a group of nongovernmental organizations"”has produced a set of guidelines for public health interventions in emergency settings. The nongovernmental organization Médecins Sans Frontières has published a manual entitled Refugee Health: An Approach to Emergency Situations (1997). In addition, a number of short-term training courses have been developed, including the Health Emergencies in Large Populations (HELP) course sanctioned by the International Committee of the Red Cross and the Public Health in Complex Emergencies course, which is partially funded by the U.S. Agency for International Development. All of these are intended to convey the state of the art to health care practitioners who serve refugees. Yet the scientific basis for these currently recommended best practices is rarely presented along with the guidelines. And many of the current recommendations are based on older, perhaps even outdated, analyses and summaries of the literature. Furthermore, even when data are available, they are frequently inconsistent, unreliable, and spotty. Few of the currently recommended practices are based on scientifically valid epidemio-logical or clinical studies conducted among the refugee populations they are intended to benefit. Recognition of the need for a more evidence-based body of knowledge to guide the public health work practiced by the relief community has led to a widespread call for more epidemiological research. This was acted on by the World Health Organization, which formed an Advisory Group for Research in Emergency Settings. In some sense the current wave of recommendations represents the end of a cycle of learning that began with the publication of a series of papers in the medical literature in the late 1980s. The data contained in those papers were originally generated during the period 1978-1986. But the world and the nature of forced migration have changed a great deal since then, and the relevance of those data can now be called into question. Therefore, the roundtable and the Program on Forced Migration and Health at the Mailman School of Public Health of Columbia University have commis-sioned a series of epidemiological reviews and case studies on priority public health problems for forced migrants that will update the state of knowledge. These occasional monographs are individually authored documents presented to the roundtable and any recommendations or conclusions are solely attributable to the authors. It is hoped these reports will result in the formulation of newer and more scientifically sound public health practices

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Initial Steps in Rebuilding the Health Sector in East Timor and policies and will identify areas in which new research is needed to guide the development of health care policy. Many of the monographs may represent newer areas of concern for which no summary information is available in the published literature. The present monograph"”on rebuilding the health sector in East Timor following the nation's struggle for independence"”is the second in this series. It provides an overview of the state of the health system before, during, and after reconstruction and discusses achievements and failures in the rebuilding process, using an informative case study to draw conclusions for potential improvements to the process in other post-conflict settings. Other topics under consideration in the series include reviews of current knowledge on psychosocial issues, reproductive health, malnutrition, and diarrheal diseases, as well as other case studies. This monograph has been reviewed by individuals chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council's Report Review Committee. The purpose of this independent review was to provide candid and critical comments that would assist the institution in making the published monograph as accurate and as sound as possible. The review comments and draft manuscript remain confidential. Charles B. Keely of Georgetown University served as review coordinator for this monograph. We wish to thank the following individuals for their participation in the review of this report: Dennis Dijkzeul, The Institute for International Law of Peace and Armed Conflict, Ruhr Universität Bochum, and Sharon Stanton Russell, Massachusetts Institute of Technology. Although the individuals listed above provided constructive comments and suggestions, it must be emphasized that responsibility for this monograph rests entirely with the authors. We would also like to acknowledge Egbert Sondorp, Health Policy Unit, London School of Hygiene and Tropical Medicine, and Anthony Zwi, School of Public Health and Community Medicine, University of New South Wales, who took the time to look over and suggest improvements to Appendix C. This series of monographs is being made possible by a special collaboration between the Roundtable on the Demography of Forced Migration of The National Academies and the Program on Forced Migration and Health at the Mailman School of Public Health of Columbia University. We thank the Andrew W. Mellon Foundation for its continued support of

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Initial Steps in Rebuilding the Health Sector in East Timor the work of the roundtable and the program at Columbia. A special thanks is due Carolyn Makinson of the Mellon Foundation for her enthusiasm and significant expertise in the field of forced migration, which she has shared with the roundtable, and for her help in facilitating partnerships such as this. Most of all, we are grateful to the authors of this report. We hope that this publication contributes to both better policy and better practice in the field. Charles B. Keely Chair, Roundtable on the Demography of Forced Migration Ronald J. Waldman Member, Roundtable on the Demography of Forced Migration Holly E. Reed Program Officer, Roundtable on the Demography of Forced Migration

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Initial Steps in Rebuilding the Health Sector in East Timor Contents   Overview   1   Introduction   4   The Health Context   7     The Health System After September 1999,   7     Establishment of "Government" Coordination,   8   Health Sector Rehabilitation and Development Program   9     Phase I,   9     Phase II,   13     Achievements as of November 2001,   16     Constraints and Failures,   18     Competing Objectives and Demands,   20   Strengths and Limitations of the Some of the Main Actors   22     UN Transitional Administration in East Timor,   22     The World Bank,   24     NGOs,   26   Too Much Money Too Soon?,   28   What Could Be Different Next Time?,   30   References,   34

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Initial Steps in Rebuilding the Health Sector in East Timor   Appendixes   A   Chronology of Selected Developments and Events in East Timor   35 B   Illustrative Memorandum of Understanding for Implementation of a District Health Plan   38 C   Bibliographic Materials   44 D   About the Authors   55