< Health Projects Overview

Health Projects Overview

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A World Bank mission visited East Timor in March and April 2000 to continue the preparation of the first health sector development and rehabilitation project the first year of which was to be a transitional stage from emergency relief work towards the building of a transitional health system.

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There were ultimately two health sector development and rehabilitation projects (HSDRP1 and HSDRP2) the first of which was funded mainly by the Trust Fund for East Timor and the second of which was funded mainly by the European Union.  There was then a smaller follow-on project, the Timor Leste Health Sector Support Programme funded by the European Union.

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The primary task of the first mission was to assess the priority rehabilitation and civil works that needed to be implemented in the first year of the project including:

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• Assessing the damage to the different facilities, especially health centres, district health offices and referral hospitals.

• Identifying key priority civil works. 

• Preparing terms of reference, specifications and other preparatory documents required for the implementation of the project.

• Preparing cost estimates and a detailed procurement plan for these activities.

• Identifying any additional steps needed for the assessment of the rehabilitation work in the health sector.

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Under Indonesian rule, the East Timor was greatly over-provided with health facilities.  There were 10 major hospitals including military and catholic hospitals, 30 community health centres with in-patient facilities, 99 community health centres without in-patient facilities, 289 satellite health centres, 14 mobile clinics and 18 catholic clinics all for a total population of about 800,000.

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A great many of the facilities were badly built and maintained and many facilities were built where it was convenient for the authorities to build them rather than being built in order to serve their client populations.  Many of the facilities were also damaged or destroyed during the events that ended Indonesian rule and the country therefore had the chance to rationalise and improve the provision of health facilities at all levels (both in number and size) and drastically reduce its operational budget.

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It was therefore proposed to re-organise the structure of the health system and provide a more rational distribution of facilities that would ensure equality of access for all the population.  Preliminary proposals were made for this re-organisation during the mission and these proposals were further refined during subsequent missions.

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It was initially proposed that health facilities would be provided at three levels:

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• Community health centres at sub-district level with no in-patient facilities

• Rural hospitals at district level with in-patient facilities

• Referral hospitals at regional and national levels

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Community Health Centres

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It was proposed that basic community health centres (CHCs) would be provided at the sub-district level and the numbers provided would depend upon the number and distribution of the population and during later missions, it was decided to construct some larger CHCs.  It was also initially proposed that smaller settlements would be served by mobile clinics operating from the CHCs but it was decided during later missions to construct some small, simple health posts in remote locations.  See Community Health Centres Project.

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Rural Hospitals

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Rural hospitals were to be provided at the district level and again the numbers were to depend upon the number and distribution of the population and on ease of access to the main referral hospitals.  I produced preliminary designs and budgets for the rural hospitals (which were more like large health centres than hospitals) which were to be provided with in-patient facilities for either 6 or 10 patients, a public health office, consultation and examination rooms, treatment and observation rooms, a laboratory, a dispensary, public and staff toilets and support services.  See attached preliminary designs for Rural Hospitals below.

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In the event, the World Bank projects did not construct any rural hospitals but concentrated on the construction of health centres and referral hospitals which were considered to be of more importance.

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Referral Hospitals

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It was proposed that there would be four referral hospitals situated at Dili, Bacau, Maliana and Oecussi.

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• Dili Hospital which had not been damaged but required major repairs and renovation particularly to services and serviced areas, was to remain the major Referral and Teaching Hospital in the country. 

• Bacau had two hospitals and it was proposed that these were reduced to one, 100-bed Referral Hospital which required major repairs and renovations and possibly extensions and additions.

• The referral hospital in Maliana was badly damaged during the troubles and had not been very well built in the first place.  It was also too large and it was proposed to repair and renovate it and reduce it in size to accommodate 32 beds.

• The Oecussi Enclave (which is surrounded by Indonesian West Timor) had a small population but, because of problems of access to Dili, required its own referral hospital.  The hospital was badly damaged and it was proposed to repair and renovate it and reduce it in size to accommodate 32 beds.

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It was also proposed to construct a new 32-bed referral hospital in Ainaro (where the existing hospital had been destroyed) to serve the population in the centre of the island.

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In the event, Dili Hospital had more major renovations and extensions constructed under the project than was initially envisaged.  The main hospital in Bacau, which was undamaged and still functioning, was not renovated as there were insufficient funds.  New 24-bed hospitals were constructed at Maliana and Oecusse and the new hospital planned for Ainaro was actually built at Maubisse where it could serve a larger population. This latter decision was a very brave one by the then Minister of Health as he was from Ainaro and he came in for a lot of criticism from his constituents for moving it.

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Towards the end of the second project, it was decided to construct another 24-bed referral hospital at Suia and to proceed with the construction of a new hospital on a new site at Bacau. See Referral Hospitals Project.

 

Autonomous Medical Store

Under the previous regime, there had been a central medical store in Dili and a store in every district.  A pharmaceutical consultant reviewing the pharmaceutical needs of the country proposed that only one central store located in Dili was required to supply all of the health facilities in the country.  An existing building in Dili had been renovated to provide temporary facilities for the storage of pharmaceuticals and other medical supplies but this building was too small, badly built and the roof was leaking.  It was proposed therefore to construct a new central medical store in Dili on a site next to the existing store.  This site was not ideal as it was liable to flooding during the rainy season but no alternative could be found and the new building therefore had to be designed to take account of the site conditions as well as the climate and the brief provided by the pharmaceutical consultant.  See Autonomous Medical Store Project.

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Project Achievements

The two HSDRP projects made a significant contribution to the reconstruction of the health system and the construction of health facilities in East Timor.  

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Twenty nine new, fully equipped community health centres were constructed mainly in remote rural areas of the country. Three new referral hospitals were constructed and equipped in three regional centres and the country’s main referral hospital in Dili was extensively renovated and extended.  A new central medical store was constructed together with a new central diagnostic laboratory.

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The construction of these facilities took a long time and they were fairly extensive but given the logistical difficulties due to the lack of experienced contractors, skilled artisans and the majority of building materials this is, I think, understandable and I am quite proud to be associated with these projects.