Photo: East Timor Human Rights Centre

1
From emergency to development Initial steps in
the rebuilding of the health system in East Timo
r Global Health Council 29th Annual Conferen
ce May 2002
Photo East Timor Human Rights Centre
2
Health system after September 1999

• 35 of health facilities totally destroyed
• Only 23 without major damage
• Virtually all equipment/supplies looted or
  destroyed
  
• Most doctors/dentists/senior management staff
  gone
  
• No central administration infrastructure

3
Early post-conflict months

• International NGOs providing emergency services
• Some UNOCHA coordination
• ET Health Professionals WG, Joint Health WG
• Essentially no government role

4
Early post-conflict months

• International NGOs providing emergency services
• Some UNOCHA coordination
• ET Health Professionals WG, Joint Health WG
• Essentially no government role
• February 2000 Interim Health Authority formed
  29 East Timorese and 6 UN staff (one borrowed
  vehicle, a few tables and chairs)

5
Achievements by end 2001

• Good sector-wide approach/collaboration
• Fully East Timorese MoH in place
• 800 staff recruited with delays but no major
  unrest
  
• All health centres and most posts open
• Most essential drugs provided from approved list
  by MoH
  
• Development of Autonomous Medical Supply System
  contracted out
  
• Central medical warehouse almost constructed

6
Achievements by end 2001

• Health infrastructure surveyed and 22 new health
  centres under construction
  
• 4 and 2-wheel vehicle fleet mostly in place
• Radio network installation contracted
• Medical equipment needs assessed, major
  procurement underway
  
• Policy/regulation development started on
  pharmaceuticals and medical practice
  
• Activities initiated on TB, HIV/AIDS prevention,
  IMCI, reproductive, mental and dental health

7
Selected non-achievements

• No effective policy dialogue/consultation
• No human resource development plan
• No definitive hospital development plan
• Delayed civil works program
• Inadequate support to National Centre for Health
  Education and Training
  

8
The UN transitional administration

• Strengths
• Legitimacy
• Multinational nature
• Constraints
• Multinational nature
• The mission vs the Mission
• Peace-keeping vs development
• Centralization/control
• High turnover/short-term staff ?Lack of
  accountability
  
• Grossly deficient procurement

9
World Bank - strengths

• Consistent and informed support to the Interim
  Health Authority
  
• Mostly helpful, expert technical assistance
• Strong Sector-wide Approach advocates as trustees
  of pooled funding
  
• Defined (if complex) procedures
• Task and country team committed to results

10
World Bank - constraints

• Procurement rules

11
World Bank - constraints

• Procurement rules - Obsession with avoiding
  misprocurement
  
• Procurement procedures - Not adapted to the
  post-conflict situation
  
• Procurement games - To satisfy the procedures
• Procurement capacity - Insufficient for the broad
  range of goods and services
  

12
NGOs

• Strengths
• Rapid response/self-sufficiency
• Commitment/willingness to work in remote areas
  and tough conditions
  
• Ultimately good cooperation with government
• Constraints
• Lack of staff experienced in development
• High staff turnover
• Overstatement of capacity
• Expensive needs

13
Competing demands complicate transition
14
Money drives everything too much, too soon
15
Next time General

• No compromise on
• Sector-wide approach
• National control
• Focus on sustainability
• Compromise on
• Procedures (adapt to context)
• Speed
• Control (within the un system)
• Immediate improvements in quality

16
Next time The Interim Health Authority

• Ensure national control
• Assess and control the infrastructure early
  make a crude/conservative coverage plan and use
  it
  
• Develop a temporary (transition) policy
  addressing conflicting demands - explain choices
  
• Accept all competent partners but coordinate
  actively (use time-limited MoU)

17
Next time UN Transitional Admin.

• Secure key government functions with
  (uni-national?) expert teams (legal, civil
  service recruitment, procurement)
  
• Recruit senior national staff early in all
  sectors
  
• Better cross-sectoral collaboration
• Decentralize decision making and some spending
  control
  
• Dedicated problem-solving/lessons team

18
Next time World Bank

• Free up procedures agree on acceptable
  adaptations. Or accept greater bilateral role
  
• Provide more implementation support
• Ensure adequate procurement capacity, especially
  early, especially for civil works - as much as is
  needed.
  
• Transparent and frequent explanation of where the
  money is going
  
• Less focus on disbursement

19
Next time Donor community

• Re-examine emergency funding policies remember
  transition takes time
  
• Honest, self-critical evaluation of funded
  activities
  
• Respect a sector-wide approach
• Consider banking of funds until absorptive
  capacity expands

20
Next time NGOs

• Bring expertise and identify funding before
  coming - or reconsider
  
• Brief staff on need for transition from emergency
  to sustainable development
  
• Recognize challenges and constraints of
  transition government seek to help
  
• After the emergency, use longer term staff

21
Next time UN agencies

• Focus on (transition to) development
• Early and sustained support for human resource
  management, health system assessment and
  planning, supply and logistics systems, EPI,
  IMCI, EOC, HIV/AIDS
• Reassess priority of communicable disease
  reporting

22
Next time - everyone

• Know, understand and accept the different roles,
  strengths and weaknesses of different
  institutions
  
• From that base collaborate to solve problems