From emergency to development
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From emergency to development Initial steps in the rebuilding of the health system in East Timor Global Health Council 29 th Annual Conference May 2002. Photo: East Timor Human Rights Centre. Health system after September 1999. 35% of health facilities totally destroyed

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From emergency to development

Initial steps in the rebuilding

of the health system in East Timor

Global HealthCouncil

29th Annual Conference

May 2002

Photo: East Timor Human Rights Centre

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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

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Early post-conflict months

  • International NGOs providing emergency services

  • Some UNOCHA coordination

  • ET Health Professionals WG, Joint Health WG

  • Essentially no “government” role

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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)

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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

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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

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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

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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

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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

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World Bank - constraints

“Procurement rules”

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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

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  • 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”

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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

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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)

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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

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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

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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

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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

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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

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Next time - everyone

  • Know, understand and accept the different roles, strengths and weaknesses of different institutions

  • From that base collaborate to solve problems