East Timor Health Sector Situation Report - World Health Organization

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    Background Paper for Donors’ Meeting on East Timor

    Canberra, 14-15 June 2001

    January 2000 May 2001

    World Health Organization

    Dili, East Timor

    June 2001


    S.No. Particulars Page

    OVERVIEW……………………………………………………………………….. 1. 1



    4 Pharmaceuticals and Drug Supply………………………………………..…… 4 Communicable Disease Surveillance………………………………………….. 5 Control of Outbreaks…………………….………..…………………………... 5 Health Laboratory Services…………………………..……………………….. 6 Roll Back Malaria……………………..………………………………………. 7 Tuberculosis…………………………………………..……………………….. 7 Expanded Programme of Immunization………………………………..…….. 8 Nutrition and Food Safety………………………………………..……………. 8 Integrated Management of Childhood Illness (IMCI)…………………..…… 9 Reproductive Health………………………………..…………………………. 10 HIV/AIDS and Sexually Transmitted Infections……………………………… 10 Mental Health…………………………………..……………………………...

    11 Environmental Health…………………………………………………………. 11 Other Areas of Need…………………………………………………………….


    12 WHO collaboration with UN Agencies and NGOs……..……….….………….

     WHO Profile and Visibility…………………………………………………….. 13

     WHO Technical Support to DHS and NGOs………………………………….. 13

    CONSTRAINTS……………………………………………………………..……... 6. 13


    CONCLUSION………………………………………………………………..……. 8. 15

    ACKNOWLEDGEMENT……………………………………………..…….…….. 9. 16


    At the early stage during September 1999-January 2000, WHO together with UNICEF acted as a "Temporary Ministry of Health" coordinating health sector activities in East Timor. ICRC and fifteen International NGOs, together with military medical teams from INTERFET provided curative services to the general population.

    WHO actively participated in and technically supported the review of health services of East Timor (conducted in December 1999 and January 2000) and the subsequent establishment in February 2000 of the Interim Health Authority - a precursor of the present Division of Health Services. WHO continues to work in partnership with both the Divisions of Health Services and Water & Sanitation under the charge of Cabinet Members for Social Affairs and Infrastructure.

    WHO collaborative activities has been aligned accordingly to be consistent with the latest developments in East Timor which is now ready to move from a state of emergency to a development phase.

    The visit of the WHO Director-General, Dr Gro Harlem Bruntland in October 2000 was instrumental in raising awareness and understanding in the East Timor Transitional Administration on the importance of the health sector, as a major part of social and economical development of East Timor. Consequent upon her visit, health was given priority in administrative as well as at all political levels.

    During 1999-2000, WHO adopted a flexible and responsive approach in providing technical support to the DHS by recruiting consultants in the areas where expertise was urgently needed such as Epidemiology, Human Resources Development, Essential drugs and Malaria. As the national recruitment process of DHS staff at the different levels moved towards completion in 2001, it became evident that Reproductive Health, Epidemiology, Public Health, Human Resources Development, Laboratory, Nursing, HIV/AIDS/STI, Nutrition and Food Safety are the priority areas in which DHS need long-term professional support from WHO. For this purpose, WHO has already recruited highly qualified professionals in most of the above-mentioned areas.

    This paper is intended to give an account of WHO’s contribution to East Timor since January 2000 up

    to May 2001. It is important to mention that in addition to its own resources the work of WHO in East Timor has been supported mostly through resources provided by AusAID, USA, Italy, UK, Spain, Sweden and Portugal.


     Pre-crisis estimates suggest an infant mortality rate (IMR) of between 70 and 90 per 1,000 live births; the

    most common causes being infections, prematurity and birth trauma.

     Only one in five births is attended by appropriately skilled personnel prior to the crisis.

     The maternal mortality ratio has been estimated to be as high as 890 per 100 000 live births, although this

    estimate is difficult to verify at the present time.

     The under 5 mortality rate (U5MR) was reportedly 125 per 1 000 live births (World Bank Joint Assessment

    Mission, 1999), but this may be an underestimate.

     The most common childhood illnesses are acute respiratory and diarrhoeal diseases, followed by malaria

    and dengue infection. An estimated 80% of children have intestinal parasitic infection.

     Cross sectional nutritional surveys conducted in selected districts suggest that 3-4% of children aged 6

    months to five years are acutely malnourished, while one in five are chronically malnourished.

     Malaria is highly endemic in all districts, with the highest morbidity and mortality rates reported in children.

    The peak transmission periods are July/August and December/January, although a longer transmission

    season exists in the east of the country (Lautem district), owing to the prolonged wet season. Based on

    historical and recent data, P falciparum and P vivax malaria are equally represented. Four districts,

    including the capital, are high transmission areas and chloroquine resistant strains have been reported.

     East Timor is endemic for leprosy; the registered leprosy case prevalence rate is 1.8 per 10,000.

     East Timor is also highly endemic for lymphatic filariasis; three species are present (Brugia timori, Bruga

    malayi and Wuchereria bancrofti), and patients with clinical manifestations of chronic lymphatic

    obstruction have been well documented.

    Background Paper for Canberra Donors’ Meeting, 14-15 June 2001 1

     Tuberculosis is a major public health problem, with an estimated 20,000 active TB cases nationally (over

    2.5% of the total population, representing a prevalence of approximately 2,500 per 100 000). In May 2001,

    in Dili, two multidrug resistant TB cases have been reported; these require further investigation.

     Sexually transmitted infections (STI) are common. The existing curative institutions report a total of about

    35 STI cases per week, mostly in Dili and Baucau districts. However, the actual situation is still to be


     Routine childhood immunization was recommended in early March 2000. To prevent an expected outbreak

    of measles, more than 45,000 children were immunized during a special campaign. National Immunization

    Days (NID) for polio eradication campaign in the entire territory were observed in November and

    December 2000 with a total coverage of over 84%. At the same time, the routine EPI coverage was noted to

    be very low, for e.g., DTP-3 coverage was less than 20%.

     The level of knowledge on health matters in the general population is poor, and health promotion has been

    identified as a key component of the basic package of health services to be introduced.

     Between 1 January 2000 and 31 May 2001, the curative institutions (international NGOs and the military

    medical team from INTERFET) provided 979,912 consultations and curative interventions to the


     Communicable diseases account for the majority of deaths, approximately 60%, particularly in children.

    These deaths are associated with respiratory infection, diarrhoea and malaria, followed by the non-

    communicable diseases, chronic diseases, road traffic accidents and other conditions.

    WHO played a catalytic role in East Timor in the formation of future direction of health development, its health authority and formulating health policy, planning and health regulations. During the emergency phase, WHO was instrumental in overall coordination amongst NGOs, national and international institutions, UN Agencies and Donors involved in the restoration process of the health sector in East Timor.

    In January 2000, a group composed of representatives from WHO, UNICEF, UNFPA, International NGOs and the East Timorese Health Professionals' working group undertook a review of health service provision throughout the territory and drafted a document defining minimum standards for health care service provision. At the second workshop, which took place in mid February 2000, a consensus was reached on the minimum standards document and the formation of the Interim Health Authority was formally announced. The Interim Health Authority was composed of 16 senior East Timorese health professionals supported by seven international UNTAET staff.

    Later, on 15 July 2000, as a result of reorganization and the establishment of an East Timor Transitional Authority (ETTA) the Interim Health Authority was renamed the Division of Health Services (DHS). Dr Rui Maria de Araujo has been appointed as the Head of Division of Health Services on 24 May 2001.

    Health sector redevelopment has been based on a sector-wide approach advocated by WHO and works both to restore access to basic services and to rebuild a sustainable health system. Health services in East Timor are currently provided by a large number of different entities. Coverage of the population is uneven both in terms of physical access and the services provided. This situation has arisen from the necessary involvement of international NGOs in health service provision during the emergency and early development phases. A strategy was developed in May 2000 to implement and guide the restoration of health sector, which intends to:

    ; Be rapidly implementable

    ; Ensure delivery of basic services to the maximum possible population

    ; Build capacity among East Timorese health staff

    ; Ensure more efficient use of resources

    ; Not interfere with the development of the future health system

    ; Take into account the principles developed by the East Timorese Professional Working Group

    (technically supported by WHO) including sensitivity to culture, religion and traditions of the East

    Timorese people.

    To ensure more equitable coverage, more efficient use of resources, and a clear division of responsibilities along with greater accountability, DHS has proposed one key entity be identified in each district to plan, organize and manage the provision of services. DHS requested proposals from lead NGOs for the Background Paper for Canberra Donors’ Meeting, 14-15 June 2001 2

    provision and management of health services for each district, in the form of a District Health Plan. Other health agencies working in the district need to collaborate and coordinate their activities with the lead agency

    To facilitate the development of District Health Plans, WHO organized a workshop, on 10 June 2000. In addition, during the preparation of a District Health Plan all NGOs involved in the health sector received technical support from WHO.

    Following DHS review of the NGOs' proposals and district health plan, a Memorandum of

    Understanding between the DHS and each of the district service providers was signed in September 2000.

    The District Health Plans (DHPs) include a total of 64 community health centers, 88 health posts and 117 mobile clinics. During the first year, emphasis has been put on the use of mobile clinics in some areas to allow for a more careful selection of sites for additional fixed facilities. Data collected in March 2001 indicates that 80% of population now have access to permanent health care facilities. However, monitoring of DHPs suggests that utilization of health services is low and highly variable with just below 40% of health facilities appropriately utilized. WHO has been providing technical backstopping in the implementation of the DHPs in the field of communicable diseases surveillance and control activities, outbreak investigations, health education as well as the training of nationals in priority areas required for provision of basic health services.

    As no medical literature was available in East Timor, WHO has been providing Emergency Health Library Kits and District Health Library Kits to major health providers in all the districts. WHO/East Timor is also in the process of establishing a medical reference library to cater to the needs of service providers all over the territory. This library currently stocks about 1000 medical reference publications.


    The Human Resources Development (HRD) database which was developed jointly by WHO and

    HealthNet International showed that there had been 2632 employees in the former East Timorese Health System. The East Timorese Health Professionals Working Group estimated that approximately 2000 of these were present in the country and ready for work. Most of the senior level health service managers and doctors were Indonesian and have left, leaving a serious gap at senior and middle management level.

    The total workforce establishment, which was originally fixed at 1087 by CNRT and NCC, is the basis for the numbers currently being recruited. It is anticipated that an additional 367 posts will be allocated in the coming fiscal year. The national recruitment of the health workforce has suffered from many delays but is now nearing completion. WHO supported the DHS in the development of all the national job descriptions and the recruitment process.

    WHO provided an intensive 5-week training in organizational management for staff newly appointed to senior management posts in the DHS to prepare them for their new posts. At the request of DHS, WHO will provide further training input to develop capacity of DHS in providing management training for staff at all levels.

    A special problem is faced in the medical workforce, where the current information shows that there are approximately 34 East Timorese doctors, of these 25 are in East Timor, 3 are currently studying in Australia on AUSAID scholarships, 6 are living overseas and it is unclear as to whether they will return. In addressing the shortfall in the medical profession, it is crucial to ensure that current medical students, who have achieved the required academic standards, continue their studies. WHO is currently providing scholarships for 10 medical students to continue their studies in Indonesia.

    The reduction in the workforce together with the shortage of doctors necessitates health workers of all categories taking on extended roles and functions in clinical areas. WHO in close collaboration with UNICEF and UNFPA have developed structured training plans and programmes in areas such as Reproductive Health, Integrated Management of Childhood Illness, Communicable Diseases and Advanced Patient Assessment and Clinical Decision Making. These training programmes, designed to strengthen clinical capacity at health centre level, will be implemented as staff are confirmed in their posts.

    The former “ad hoc” approach to training is now being replaced by implementation of standardized, structured, competency-based training courses which will be accredited. All future training will be coordinated Background Paper for Canberra Donors’ Meeting, 14-15 June 2001 3

    through the National Center for Health Education and Training (NCHET). WHO is providing support to the newly appointed Continuing Education Coordinator to undertake this complex role.

    WHO has provided ongoing support to DHS on all aspects of human resources development since March 2000 through provision of a technical adviser. WHO has given particular attention in providing technical support to the recently recruited staff of the Human Resources Section to strengthen its role and function within the DHS.

    WHO undertook a detailed analysis of the current nurse training curricula in relation to the newly defined nursing roles in East Timor. The current and planned national continuing education modules were examined and future training requirements were identified. It was noted that the current training for nurses and midwives is not adequate enough for advanced health assessment and clinical decision-making skills. WHO recommended that a new expanded role of existing nurses and midwives must take place in the field of PHC as community nurse practitioner to bridge the gaps of health care delivery problems. Based on this finding, the DHS requested WHO to provide the expertise for training nurses and develop suitable training modules. Keeping this in mind, WHO/Dili has proposed a budget for an eleven-month STP in the plan of action for 2001.


Pharmaceuticals and Drug Supply

     In order to facilitate future development of a National Essential Drugs Programme, WHO supported the

    development of a national Essential Drugs List for East Timor during June/July 2000. Since most of the

    health facilities will have to be staffed by nurses/auxiliary staff in the absence of qualified doctors, detailed

    instructions with the Essential Drugs List have also been prepared for use by such staff. WHO has also recommended a system for a comprehensive essential drugs programme for East Timor,

    including the framing of a national drug policy, the drafting of drug legislation and promoting the concept

    of rational use of drugs among the health services.

     The implementation of these systems could now materialize with resources as proposed in the World Bank

    project. The major thrust from WHO will be towards capacity building and training national staff in the

    development of pharmaceutical component of the health care facility.

Communicable Disease Surveillance

     In order to encourage the timely recognition of and response to epidemic diseases, WHO established a

    communicable disease surveillance system early in its presence in East Timor. The original system was

    subsequently modified in January 2000. Based on the data from the surveillance system, it has been

    possible to coordinate and provide guidance to the NGOs involved in providing clinical and public health

    services in East Timor.

     All laboratory services in East Timor were destroyed in the wake of the post-referendum violence. The

    surveillance system is therefore based on regular clinical reports submitted by NGO lead agencies providing

    primary health care in the field, using WHO case definitions. Diseases currently subject to surveillance

    include: simple and bloody diarrhoea, suspected cholera, suspected malaria, other (non-malaria) febrile

    illness, suspected measles, suspected meningitis/encephalitis upper and lower respiratory tract infection,

    acute jaundice syndrome, acute flaccid paralysis (suspected poliomyelitis) and neonatal tetanus. Weekly analysis of the surveillance database is summarized in a Weekly Epidemiological Bulletin. The

    WHO Bulletin is disseminated to all institutions involved in health in East Timor, and to many international

    collaborators. The Bulletin is published in both English and Tetum, and an electronic version of the Bulletin

    has been available via the Timor Today internet site since May 2001.

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

     more than 162,357 cases of malaria,

     over 62,500 cases of lower respiratory tract infection,

     41,397 and 7,131 cases of simple and bloody diarrhoea respectively,

     1,479 cases of suspected measles, and

    Background Paper for Canberra Donors’ Meeting, 14-15 June 2001 4

     over 456 cases of suspected meningitis.

     The communicable disease surveillance network also identified for the first time in East Timor, cases of

    Japanese encephalitis (JE). On the basis of this investigation and sero-epidemiological studies, JE infection

    has been identified as an important public health problem in East Timor. The immunization of children

    against JE should be considered an appropriate intervention, and an immunization schedule will be

    developed using the serological findings from this study. The intervention will require the allocation of

    adequate resources and an understanding by donor and other agencies of the importance of the elimination

    of JE as a public health problem in East Timor.

Control of Outbreaks

     Between January 2000 and May 2001, the following outbreaks or sporadic cases of communicable diseases

    of public health importance have been investigated:

     acute flaccid paralysis (suspected poliomyelitis) 5 clusters or sporadic cases; all cases have been

    confirmed negative to Polio viruses by the international reference laboratory in Melbourne, Australia

     dengue fever four outbreaks in urban Dili;

     Japanese encephalitis in Viqueqe District (May 2000) and Bobonaro district (April 2001)

     Simple (suspected amoebic) and bloody diarrhoea (suspected Shigella) outbreaks in Aileu district

    related to contaminated water supplies and suspected food contamination.

     Unknown diseases two reports requiring field investigation (one each in Liquisa and Manufahi


     WHO has worked with DHS and other Agencies in a community education campaign for the control of

    dengue fever, Japanese encephalitis and malaria, which was repeated before wet season.

Health Laboratory Services

    The capacity of laboratories in East Timor for both communicable and non-communicable diseases is very limited. The Central Laboratory at Dili is the main laboratory of the territory. It does not cover all the branches of laboratory medicine and has been conducting a limited range of tests. There is a very basic network of health laboratories at district and peripheral levels although only malaria and tuberculosis microscopy is carried out in most districts.

    DHS recognizing the importance of laboratory services, requested WHO to provide technical support in the restoration of laboratory services in East Timor. WHO provided technical services of a consultant who developed a plan for reconstruction of laboratory services in East Timor. Based on the expert’s assignment, it was recommended by WHO that Health Laboratory Services should be developed as an integrated part of National Health services and include both clinical medicine and public health. The consultant provided both short and long-term plans ranging from one to three years for establishing and strengthening full-fledged laboratory services at central and peripheral levels of East Timor.

    Following these recommendations, since February 2001 WHO has provided the services of a laboratory manager/advisor whose main task is the provision of support for the management of the Central Laboratory in all aspects, including support for the district laboratories and advice on the future structure of the overall laboratory system. The WHO staff plays a coordinating role between the Central Laboratory and DHS as previously there was no one assigned for this within DHS. This was of paramount importance as the laboratory had effectively become quite isolated within the system and did not have the reagents necessary to provide even a basic standard of service. As a result, a large amount of urgent reagents have been successfully ordered and delivered through DHS. Another serious problem the laboratory faced was a very unreliable electricity supply and an application from DHS to AusAid for funding for a generator has recently been accepted. Renovation of the Central Laboratory building is expected to be completed using TFET-2 funding which starts in July 2001.

    WHO staff is working closely with the management of the Central Laboratory and has prepared a programme for training of laboratory staff aimed at establishing a set of standard operating procedures. This programme also allows for training of Central Laboratory staff as trainers who could be responsible for organizing and conducting training of staff in the district laboratories. Unfortunately, the implementation of this Background Paper for Canberra Donors’ Meeting, 14-15 June 2001 5

    programme has been delayed until the completion of the recruitment round in the health service which is expected to be finished in July 2001.

    The WHO laboratory specialist is also involved in a WHO initiated survey specifically designed to answer two important medical questions in East Timor. The first aspect of the survey is to investigate the prevalence of glucose-6-phosphate-dehydrogenase (G6PD) deficiency in the population. This information is required for introduction of primaquine for radical treatment of P. vivax infection, as it is counter-indicated in those with this deficiency. The second part of this survey is to collect samples to test for the prevalence of lymphatic filariasis which is known to exist in East Timor but at an unknown level. It is important to have baseline data before initiating a programme of mass treatment which is cheap and available as part of the WHO programme for the eradication of this disease.

Roll Back Malaria

    Due to the breakdown of surveillance, vector control activities and treatment facilities, malaria showed a three-fold increase in East Timor following the crisis in 1999. Jointly with two international NGOs Merlin

    and IRC WHO has been actively collaborating for control of malaria by:

    ; establishing a Vector Borne Disease Control Working Group in consultation with the DHS to help

    coordinate the activities of and to provide technical back-up to the NGOs involved in vector

    control activities

    ; establishing malaria diagnostic facilities, including retraining of microscopists and equipping 13

    district laboratories in the country

    ; arranging anti-malarial drug supplies

    ; promoting and distributing bed nets, especially for protection of pregnant women and children

    under 5 years

    ; orientating clinicians through dissemination of WHO guidelines for management of dengue fever

    and dengue haemorrhagic fever/dengue shock syndrome.

    ; disseminating protocols for case definitions and treatments

    ; conducting social research into community knowledge, attitudes and practices related to malaria

    Based on the current situation, WHO has identified the following integral strategy for control of Malaria and other vector borne disease activities in East Timor in future:

    ; mapping of high risk areas

    ; setting up of entomology and vector control strategies

    ; distribution and re-treatment of bednets, and assessment of their efficacy

    ; redesigning of drainage systems with proper gradients

    ; timely diagnosis and treatment of patients

     Pending the establishment of a National Vector Borne Disease Control Programme as part of a

    coordinated Environmental Health initiative, DHS has requested WHO to coordinate vector control

    activities in East Timor. Since July 2000 up to April 2001, WHO conducted regular meetings, with the

    keen participation of NGOs involved in vector and vector borne disease control: Merlin, IRC and

    Oxfam, as well as the PKF Health Cell and other interested organizations. This group has been active

    in coordinating both VBD research activities and applied VBD control activities, and have been a vital

    resource in framing a national vector borne disease control strategy. In April 2001, after appointment of

    international staff in DHS in the field of vector control, the work of this group has been coordinated by

    DHS with technical support from WHO.

There is an urgent need to establish a national Entomology and Vector Control Laboratory to

    undertake micro-stratification in high risk and/or drug resistance areas to develop evidence-based

    vector control strategies to reduce vector breeding and interrupt transmission, as per RBM guidelines.

    The laboratory will also be responsible for development of integrated vector control strategies for

    control of other vector borne diseases.

    Background Paper for Canberra Donors’ Meeting, 14-15 June 2001 6

     For Dengue control, community-based promotion of the storage of water in mosquito proof

    containers/cisterns/mendis indoors is essential. In addition, there is an urgent need for the professional

    and routine management of solid waste disposal to support community efforts to reduce vector-

    breeding sites.

     Development projects, particularly related to water resources development and agriculture sectors, are

    known to be associated with potential high build up of vector borne diseases, especially malaria and

    Japanese Encephalitis (Irrigation) and Dengue Haemorrhagic fever (harvesting of rain water/domestic

    storage of water). It is therefore strongly recommended that all development projects should be

    subjected to an environmental health impact assessment to anticipate adverse health impacts and to

    recommend mitigating measures for incorporation at the design and planning stage, costed into the

    project. WHO can provide the necessary guidance.


     Significant progress has been made in the establishment of a national TB control programme in East

    Timor. The programme is based on the WHO DOTS strategy. Caritas Norway, together with Caritas

    East Timor, the Menzies School of Health Research in Darwin, Australia, and WHO have actively

    supported the establishment of this programme.

     The National TB Control Programme was officially launched on 21 January 2000 and has achieved

    much in its first year. The programme is active in al the 13 districts of East Timor. There are 20

    diagnostic centers working within the NTP structure and 11 satellite centers for treatment of TB

    patients are operating in Dili. During the year 2000, 4,054 patients were diagnosed and TB treatment

    within the NTP commenced.

     The majority of diagnosed TB cases in East Timor attend the three Dili TB clinics (Motael, Bairo Pite

    and Becora), with each clinic enrolling 25-30 new cases for treatment each week. On the request of WHO, the WFP has been able to provide to the TB patients supplementary food like

    rice and cooking oil during JanuarySeptember 2000.

     In May 2001, in Dili, two multidrug-resistant TB cases have been reported. The investigation of cases

    is in the process.

Expanded Programme of Immunization

     Routine immunization services in East Timor were re-established and supported by UNICEF, under the

    coordination of IHA and with WHO technical support, in early March 2000. The service is

    implemented by NGOs involved in health service provision in the field. After two months of

    implementation, issues to be resolved from both technical and managerial aspects included vaccine

    supply, differing needs between districts, and clarification of roles among all parties involved.

     On 16 June 2000, in order to facilitate clarity and consensus among all parties involved regarding the

    policies and implementation plans of the national immunization services, UNICEF and IHA (with

    WHO technical support) conducted a National Workshop on immunization services in East Timor.

    This workshop resulted in agreement by all participants in the use of a standard immunization schedule

    recommended by WHO and a plan of action for conducting National Immunization Days and the

    immunization of primary school children. All districts conducted two polio immunization days during

    November and December as part of the National Immunization Day programme. Preliminary reports

    suggest high (>84%) coverage rates in the target age-groups. At the same time, it was noted that the

    routine EPI coverage was as low as 20% for DTP-3.

    WHO and UNICEF supported a study of prevalence of Hepatitis B markers among pregnant women at the ICRC and Bairopite clinics, Dili. This study identified that 14 out of 219 (6.4%) pregnant women were found positive for HBsAg. This result indicates the importance of introduction of HB vaccination for newborns in East Timor within the framework of EPI. This will be only possible after improving the performance of routine EPI coverage in the territory.

Nutrition and Food Safety

    Background Paper for Canberra Donors’ Meeting, 14-15 June 2001 7

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

     An early anthropometric survey suggested that acute malnutrition was not very common among

    returnees. However as the conditions in the camps in West Timor worsened, more returnees (especially

    those returning spontaneously) were thin and in poorer general condition, and pockets of childhood

    malnutrition were identified (eg Atsabe, in Ermera district).

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


     the vicious cycle of illness, and

     lack of knowledge about appropriate weaning foods for babies and small children. The food distribution system has been adjusted, from regular general distributions to targeted

    distributions aimed at vulnerable groups. Special attention has been given to areas like Ermera district.

    WHO Regional Adviser on Nutrition and Health Development visited East Timor and suggested steps for development of national nutritional and food safety programmes for East Timor. WHO will provide technical assistance to assist DHS in developing realistic and achievable plans and implementing nutritional programmes and food safety policies.

Integrated Management of Childhood Illness (IMCI)

     An important objective of the still to be developed health plan for East Timor will be to reduce the

    Infant Mortality Rate (IMR) and Under-5 Mortality Rate (U5MR) from their present high levels. It is

    very likely that these rates have increased during the period of instability following the independence

    referendum. Data presented in the East Timor Province Health Profile (Ministry of Health, Indonesia,

    1998) show that, for children under 5 years of age, diarrhoea, malaria, and acute respiratory infection

    (ARI), including pneumonia, constitute the majority of reasons for paediatric consultation at health

    centres and hospitals. These same conditions, plus TB, are the principal causes of death in the same

    age group.

     Data from the first 12 months of infectious disease surveillance coordinated by WHO confirm that ARI,

    malaria and diarrhoea, in that order, continue to be the most common reason for consultation at

    mainstream health care centres, with malaria the most common reported cause of death. One of the strategies that may be used to achieve a reduction in IMR and U5MR is the development

    and implementation of a system of comprehensive care for sick children that visit health facilities, such

    as the one promoted by IMCI.

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

     improved quality of care in situations where a disease specific approach is not appropriate (eg

    when children present with more than one complaint, or for young infants with non-specific

    clinical signs);

     a methodical approach where medically trained staff are scarce;

     an emphasis on prevention of childhood illnesses, through immunization and, if necessary, vitamin

    A supplementation;

     promotion of improved infant feeding, including breast feeding;

     avoidance of duplication of efforts in the fields of training, monitoring, supervision and

    management; and

     less wastage of resources, because children are treated with the most cost-effective intervention for

    their condition.

     An IMCI approach would also immediately address three essential components of building up a new

    health system improving health worker skills, improving the health system and improving family and

    community practices.

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

    Background Paper for Canberra Donors’ Meeting, 14-15 June 2001 8

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