Photo: East Timor Human Rights Centre

1. 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

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