Health

According to the World Health Organization, health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. Health is an essential element of national development. Considering this, the Government has given the highest priority to health in the National Development Plan.

Major Public Health Problems and Constraints

Poor and unequal access to health services, the absence of a regulatory framework, and an inadequate referral system are some of the problems affecting the performance of the health system in the country.

There is a shortage of doctors and technical expertise. The country, therefore, needs international technical support to develop and implement strategies for prevention and control of both communicable and noncommunicable diseases.

There is a need for further technical supervision in health sector development, e.g. development and refining of health sector strategies and policies, development of long-term budget requirements, capacity building of local staff, increase in public awareness and education on health issues. To achieve sustainable development, Timor-leste needs to improve the nutritional status of its population, improve environmental health, improve food safety practices and strengthen disaster preparedness/response.

The specific problems and constraints being faced by the health sector are:

• Lack of awareness of health problems, particularly among women and a general lack of understanding of health benefits;
• Poor access to health service for people living in far-flung areas;
• High prevalence of preventable communicable diseases such as malaria, tuberculosis, childhood respiratory infections, measles, typhoid, diarrhoeal diseases and a rising incidence of noncommunicable diseases;
• Poor knowledge of HIV/AIDS among the population, and absence of a systematic or reliable surveillance system;
• Early marriage and pregnancy and neglect of gender issues;
• High prevalence of malnutrition, iodine and vitamin A deficiency;
• Unequal distribution of food and health care in the family favouring boys;
• High Infant Mortality Rate (IMR) and Under-5 Mortality Rate (U5MR), caused by infectious diseases, with low utilization of skilled assistance for antenatal care, and poor reproductive health identified as the main causes;
• Inadequate system of comprehensive care for sick children who attend health facilities;
• Lack of drug legislation and policies, and in monitoring implementation of the national drug policy and training of pharmacists;
• The prevalence of mental health problems with very low coverage and quality of mental health services;
• Inadequate water supply and sanitation system for a majority of the population;
• An inadequate referral system;
• Lack of laboratory services;
• Low education in prevention of oral health problems and low levels of oral hygiene in general;
• Severe shortage of human resources, and
• Inadequate communication facilities and difficulties in accessibility between districts, particularly during the rainy season.

Current Health Problems

The main health problems in Timor-leste are:

(1) Estimates suggest an infant mortality rate (IMR) of between 70 and 95 per 1,000 live births; the most common causes being infections, prematurity and birth trauma¹. Prior to the crisis, appropriately skilled personnel attended only one in five births.

(2) The maternal mortality (deaths related to pregnancy, delivery, and post-partum) rate has been estimated to be as high as 800 per 100,000 live births considered to be one of the greatest problems in the country². Poor reproductive health is a major cause of maternal mortality, with increasing incidence of teenage pregnancies, and short periods between each pregnancy³. The under five mortality rate (U5MR) was reportedly 125 per 1000 live births⁴, but this may be an underestimate.

(3) The most common childhood illnesses are acute respiratory and diorrhoeal diseases, followed by malaria and dengue infection.

(4) Maternal and child malnutrition have long been common in the country. Yet, many communities have only a limited understanding of basic health and nutrition. An estimated 80% of children have intestinal parasitic infections with its subsequent nutritional deficiencies⁵. This is combined with high infant mortality rates of 78-149 per 1,000 live births, and under-five years' mortality rates of 124-201 per 1,000 live births⁶. There is an acute shortage of doctors, nurses, and midwives. According to WHO survey (January 2000- December 2001) states that a partial survey of children six months to five years of age in four districts in March 2000 showed 45% underweight, 41 % stunted (height for age below median -2SD) and 22% wasted (weight for height below median -2SD). The same survey showed the nutritional status of mothers to be poor -35% having a body mass index (BMI) below 18.5, which is a "critical situation" according to WHO criteria⁷.

(5) Malaria is highly endemic in all districts, with the highest morbidity and mortality rates reported in children⁸. Due to the breakdown of surveillance, vector control activities and treatment facilities, malaria had shown a three-fold increase in Timor-Leste following the crisis in 1999. Four epidemiological types of malaria have been identified, which include forest malaria, rice field malaria, coastal malaria, and swamp malaria. The peak transmission periods are July/August and December/January, although a longer transmission season exists in the east (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 trans-mission areas and chloroquine-resistant strains have been reported.

(6) Timor-Leste is endemic for leprosy. The results from the recent survey - conducted by the International Leprosy Mission in Oecussi district demonstrated an astonishingly high prevalence of leprosy. These findings indicate a prevalence of 115/10,000 amongst those examined, which is the highest prevalent rate of leprosy as compared to any other country or territory. This data, however, does not give the prevailing situation in the whole country, as prior to September 1999, the registered leprosy case prevalence rate was 1.8/10,000.
Currently, there is no leprosy control programme in the country⁸.

(7) Timor-Leste is also highly endemic for lymphatic filariasis; three species are present (Brugia timori, Brugia malayi and Wuchereria bancrofti), and patients with clinical manifestations of chronic lymphatic obstruction have been well documented⁸.

(8) Tuberculosis is a major public health problem, with an estimated 8,000 active TB cases nationally, i.e. over 2.5% of the total population⁸.

(9) HIV/AIDS has become the most de-vastating disease faced by humanity. Sexually transmitted infections (STI) are common in sexually active age groups. 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 ascertained. Indeed the danger may be greater in Timor-Leste, since the risk of HIV/AIDS is particularly high in countries that have been affected by conflict, population displacement, and widespread destruction. Other factors present in Timor-Leste today which can contribute to an epidemic development include the disruption of society which occurred in 1999, a lack of information as to what constitutes risky sexual behaviour and on sexually transmitted infections, low level of HIV/AIDS/STI awareness, poverty, and large groups of young men and women who are unemployed/not in school or involved in other rehabilitation activities.Therefore, this global problem has the potential of devastating effects on the people of Timor-Leste as they become exposed to the rest of the world ⁹.

(10) Routine childhood immunization was recommenced 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 (NIDs) for polio eradication 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 low. At least 50% of the children 5 years or younger have not received basic immunization. Study indicates that vaccination for population of 5 years old or more is as follows, BCG (urban-41 %, rural-27%), Polio (urban-36%, rural-33%), DPT (urban-36%, rural-22%) and Measles (urban-25%, rural-14%). (Poverty Assessment Project 2001 Workshop, February 2002). The next NIDs will be held in September and October 2002. Approximately 130,500 children are expected to be vaccinated in each of these tWo rounds.

(11) The level of knowledge on health matters in the general population is poor, and health promotion has been identified as a key component of health services.

(12) Another problem is yaws, which has been documented in Aileu, Bobonaro, Los Palos, and Viqueque. It is believed that there are more cases in other parts of the country. WHO is in the process of advising the Ministry of Health to formulate strategies to eliminate this disease.

(13) The capacity of laboratories is very limited. The Central Laboratory at Dili 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 with only malaria and tuberculosis microscopy carried out in most districts¹⁰.

(14) A majority of the population does not have access to safe drinking water and sanitary facilities. A study has indicated that at least 415,000 people of Timore-Leste rely on unsafe sources for drinking Water. (Poverty Assessment Project 2001 Workshop, February 2002). They depend on contaminated or unprotected sources of water. Existing systems for solid and liquid waste disposal are inadequate ¹¹.

(15) Communicable diseases account for approximately 60% of deaths, particularly in children. These deaths are associated with respiratory infection, diarrhoea, and malaria, followed by rising incidence of noncommunicable diseases, chronic diseases, road traffic accidents and other conditions^l2. Japanese encephalitis (JE) infection has been identified as an important public health problem in the country. An increasing percentage of the male population are smokers, which may lead to a rise in cardiovascular as well as neoplastic diseases.