Chris McCall – More than a decade on from gaining independence, East Timor has made gains in health but still faces an uphill battle to achieve universal health coverage and access. Chris McCall reports.

A small half-island on the equator came to independence in ruins with high-quality, free health care for all as a key goal. More than a decade on, East Timor is still working to leave behind centuries of oppression, but idealism is not dead in the capital Dili. The people developing East Timor's health system still want a future without the pitfalls of medicine in more prosperous countries.

When asked about his vision for East Timor's health system, Health Minister Sergio Lobo says it is about access. He compares East Timor with its richer neighbours, Malaysia, Singapore, and Australia. In those countries, he says, not everyone can always access their world-class health services. "In Malaysia, Singapore, Australia, any problem, they will fix it. The services are there, but not for everybody", Lobo told The Lancet.

Lobo is a surgeon who trained in Indonesia, the country that brutally occupied East Timor for 24 years until 1999. As punishment for East Timor's decision to vote for independence that year, Indonesia's military and its East Timorese militia allies went on a rampage of violence, trashing the country and leaving nearly every house in ruins.

After 2 years of UN-led administration, it achieved independence in 2002. Many buildings have still not been repaired today, but a lot has changed. East Timor now has oil wealth from mineral resources in the Timor Sea to the south. Dili has shopping complexes and advertising hoardings. At least a few people now are visibly wealthy, even if most are clearly not. Even a new round of internecine fighting in 2006 is receding into history.

Much of the government's new money has gone into building up the health system and results are starting to show. In September, WHO honoured East Timor for its rapid progress towards eradicating malaria, noting that only three deaths from malaria were recorded in 2013.

During the conversation, Lobo returns several times to his vision. He talks about having a socialist attitude to health, with a capitalist mentality. He talks about changing the mindset of the people from a hospital-based to a community-based approach. He talks a lot about public health and good use of money.

"We opted for free health care for everybody and sometimes this is not used properly. I am conducting some studies on health financing. For now the commitment of the state is to go for free health care for everybody", he said. "For us to have free health care for everybody, it has to be affordable."

Lobo has had some difficult decisions to make. Not long ago, he was criticised in parliament for buying motorbikes for his doctors instead of ambulances. His argument was that it was a better use of funds. For the price of 19 ambulances, he got 600 motorbikes. "They increase the mobility of the doctors. With one ambulance we spend a lot of money. Many times the patient dies during the trip – very bad roads", he said.

Making progress

East Timor now has a medical school, a nursing school, and a midwifery school. The first post-independence government was led by the left-leaning Fretilin party. Fretilin negotiated for Cuban doctors to come in and the medical school has adopted a Cuban model. Not everyone is convinced it is the perfect one for East Timor.

The current health minister is part of a centrist coalition led by former resistance leader and current Prime Minister Xanana Gusmao. There are advantages and disadvantages in the Cuban approach, Lobo says. It is strong on public health, but less strong on basic clinical skills like suturing. In Cuba, where there is a highly structured health system, this is less of an issue than in East Timor, where many clinics are isolated.

From Dili's harbour you can see an island called Atauro. By an accident of history it is part of East Timor. It has a dark history as a prison island for the Portuguese, the Japanese, and the Indonesians, who left thousands who opposed Indonesian rule there to survive or die.

Most of Atauro's 10,000 people live a subsistence lifestyle, growing crops or catching fish. They now have a health clinic again, although the emergency room is basic. The island has eight doctors and four nurses. It has an airfield and emergency flights by plane or helicopter are possible. Not long ago, cases requiring emergency surgery had to get to Dili by boat.

Nurse Januario Soares says very few cases of malaria are now being reported. A few years ago, if they tested for malaria it routinely came back positive. His colleague Isabel Afonso is aged just 25 years and qualified as a midwife 2 years ago. She is part of the new generation of East Timorese medical professionals. Both trained in Indonesia, at different times.

Weak infrastructure

Distance, time, and infrastructure are issues across the country. The centre is mountainous. The south coast is hard to reach by land transport.

Foreign health workers say it has also been held back by widespread superstitions – eg, a common belief that the first milk produced after childbirth, the yellowish colostrum, is bad for the baby. In some areas, it was routinely thrown out and replaced with sugar water, although such practices are becoming less common.

As an example of the infrastructure problems, the health minister cites the cost of sending a letter to Dili from one of the main regional towns, Viqueque. "If you want to send a letter from Viqueque to Dili you will spend around US$200. You have to send a car. We have no postal service. We are lacking the basic infrastructure", Lobo said. "Many of the health-related issues are outside the competence of the Minister of Health."

In the wet season, another problem is dengue fever, spread by mosquitoes like malaria. The country's drains are poor and badly in need of renovation.

East Timor has no MRI scanner. There is one CT scanner but it is old. The only radiologists are two Cuban doctors. Radiology is limited and the machines often break down because of overuse.

Most of the health budget goes on salaries and medicines. A doctor can earn from $500 to $1500 a month, not a princely sum but more than adequate for a country like East Timor. However, there are very few medical specialists. Its home-grown medical graduates can practise in East Timor, but the local medical degree is generally not recognised overseas.

Unfortunately, the only places where these young doctors can do specialist training to international standards are all outside East Timor. Lobo says he is seeking ways around this situation, which might involve foreign specialists coming to work in East Timor with local doctors assisting, who then go overseas simply as observers.

One of the most insidious problems, however, is malnutrition, which potentially affects the next generation's mental ability. East Timor's population is young and growing, with around 171 million people. Malnutrition rates in children have slowly been coming down but in 2013 still stood at 51%. Many people walking around Dili are visibly thin. "It affects people in the most productive years of life, children of school age, in the periods where the brain is being formed. It will affect their IQ", said Lobo.

In theory, doctors in rural areas are supposed to make two visits a month to children with malnutrition. But whether this is always possible is doubtful. Not far from the minister's office is that of another doctor, Dan Murphy, an American who came to East Timor at the time of the 1999 violence. At Bairo Pite clinic, ordinary East Timorese queue for hours to see "Dr Dan".

East Timor should not be sitting on its laurels just yet, he says. The demands being made on the young East Timorese doctors are intense. Often they are virtually on their own in remote clinics with little support.

Malaria might be coming under control but the country remains disorganised and much basic work has not been done. There is no real pathology service at all, he says, making it pointless to take a biopsy even if it is clinically indicated. "We don't even vaccinate newborns for hepatitis B", Murphy added.

One of his main concerns is tuberculosis, which he says is shockingly common. Dealing effectively with it and providing good directly observed therapy, during which patients are regularly observed taking specialised antibiotics over several months, is a challenge, he says. It might involve doing things in cheap, non-traditional but effective ways.

"What you need is a network that goes all the way out to the village. Not necessarily a nurse. It could be someone who is trained up. In fact these people might do it better", he said.

But when asked about what he would like to see in East Timor in the decades to come, Murphy's answer echoes that of the minister. He also talks about injustice in health care and about how East Timor has a chance to do things right that other countries have not. "What we would like to see here is breaking down some of those barriers. And getting quality health care in the whole country", Murphy said. "You have got to have good management. I am learning that the process takes a lot of time and you also have to have an ability to learn from your mistakes. Resources tend to accumulate at the top. Here we are starting to get some infrastructure. We can make a phone call to nearly every village now."

But he added: "We don't have development in enough areas to make health care really good and reasonable."

His main concern is also similar to the minister's. It is about how to maintain the uniqueness of this culturally rich half-island nation, where people flick between three or four languages as easily as picking up a piece of paper. "The trick is how do we develop East Timor and still maintain the beautiful quality of East Timorese people – being friendly, helping one another out", he said.

Source: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2961926-7/fulltext?rss=yes