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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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Presentation Transcript

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

health system after september 1999
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
early post conflict months
Early post-conflict months
  • International NGOs providing emergency services
  • Some UNOCHA coordination
  • ET Health Professionals WG, Joint Health WG
  • Essentially no “government” role
early post conflict months4
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)
achievements by end 2001
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
achievements by end 20016
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
selected non achievements
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
the un transitional administration
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
world bank strengths
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
world bank constraints
World Bank - constraints

“Procurement rules”

world bank constraints11
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

  • 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”
next time general
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
next time the interim health authority
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)
next time un transitional admin
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
next time world bank
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
next time donor community
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
next time ngos
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
next time un agencies
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
next time everyone
Next time - everyone
  • Know, understand and accept the different roles, strengths and weaknesses of different institutions
  • From that base collaborate to solve problems