2006年-世界发展银行全球_Timor-Leste_Health_Sector_Review___Appendices_65页_652kb

Timor-Leste Health Sector Review Summary

Core Content Overview

The Timor-Leste Health Sector Review provides a comprehensive analysis of the country's major health challenges, current policies, and service delivery systems. It emphasizes the importance of addressing health inequalities, strengthening the health system, and aligning interventions with international best practices and Timor-Leste's developmental context.

Major Health Problems in Timor-Leste

• High infant and child morbidity and mortality: Mainly due to poor nutrition, infectious diseases, and complications during pregnancy and childbirth.
• High maternal mortality: Linked to poor nutrition, delivery complications, and frequent childbirths with short intervals.
• High infectious disease burden: Particularly tuberculosis (TB) and malaria, but also leprosy, filariasis, and intestinal parasites.

International Consensus on Interventions

Child Mortality

• Key interventions: Immunization, early treatment of diarrhea and respiratory infections, use of insecticide-treated bed nets, safe delivery, and nutrition interventions (complementary feeding, breastfeeding, Vitamin A distribution, zinc supplementation).
• Community-based approach: Effective for reducing neonatal mortality, with community health workers playing a central role.

Maternal Mortality

• Key interventions: Skilled attendants at delivery, emergency obstetric care, and a functional referral system.
• Family planning: A supportive intervention to reduce the number of pregnancies and thus lower the risk of fatal complications.
• Need for facility-based services: Unlike child health, maternal mortality reduction requires a well-functioning health system.

Malaria

• Integrated approach: Combines insecticide-treated bed nets, indoor residual spraying, early diagnosis, effective treatment, and health education.
• Environmental and behavioral components: Important for long-term control.

Tuberculosis

• Focus on diagnosis and treatment: Rapid identification and appropriate care at the primary health level.
• DOTS strategy: Essential for national TB control, requiring government and private sector collaboration.

Other Infectious Diseases

• Filariasis and Intestinal Parasites: Emphasis on mass treatment with specific drug combinations (e.g., albendazole + diethylcarbamazine or ivermectin) for 4-6 years to interrupt transmission.
• Water, sanitation, and hygiene (WASH): Critical for long-term prevention and control of these diseases.

Addressing Inequalities

• Key theme: Interventions must reach the poor, who face greater health challenges and limited access to services.
• Two approaches:
  1. Targeting the poor: Direct support through cash, goods, or services.
  2. Universal coverage: Ensuring access to health services for all, with specific measures to reach marginalized groups.

Health Sector Policies

Basic Policies

1. Health Policy Framework (June 2002):

   • Mission: Provide quality, cost-effective, needs-based health services, focusing on vulnerable groups.
   • Principles: Priority setting, decentralization, and service delivery system.
   • Structure: Three levels of service delivery: health posts (Level 1), Community Health Centers (Level 2), and Regional Referral Hospitals (Level 3).
   • Human resources: Multi-skilled personnel, integrated approach.
   • Health financing: No charges at primary level, phased charges at secondary and tertiary levels.
   • Drug policy: Registration, importation regulation, and distribution.

2. Basic Package of Health Services (BPS) Policy (March 2004):

   • Defines the minimum services expected from public health facilities.
   • Key service areas: Maternal health, child health, communicable diseases, non-communicable diseases, health promotion, and environmental health.
   • Service levels: Health posts, CHCs (Level 2, 3, 4), and Regional Referral Hospitals.
   • Implementation: District Health Management Teams develop evidence-based annual plans.

3. Private Sector Policy (December 2003):

   • Promotes a pluralistic health system with public and private participation.
   • MOH remains the dominant provider, with private sector complementing services, especially in underserved areas.
   • Encourages dialogue, incentives, and legislation for private and NGO engagement.

Micro-Policies

• Nine micro-policies have been developed, focusing on specific programs such as reproductive health, childhood illnesses, nutrition, immunization, and oral health.
• Examples:
  • Reproductive Health Strategy: Emphasizes rights, integrated services, and community-based approaches.
  • IMCI Policy: Aligns with international best practices but lacks integration with BPS.
  • National Nutrition Strategy: Provides broad directions but needs more detailed implementation guidance.
  • National Oral Health Strategy: Consistent with international practice, but implementation details and monitoring mechanisms are lacking.

Policy Development Process

• Guidelines: MOH has issued guidelines for policy development, involving stakeholders, being evidence-based, and complementary to other policies.
• Donor influence: Donor and UN agency support has shaped policy development and funding.
• Challenges:
  • Fragmentation: Risk of developing "vertical" programs with limited integration.
  • Implementation gaps: Most policies focus on goals and components, not on implementation capacity or resources.
  • Need for clarity: Distinguish between "core policies" and "guidelines" to improve coherence and review processes.
  • Executive summaries: Useful for better understanding and absorption of policy documents.

Health Service Delivery and Utilization

• Qualitative study (May 2005) highlights:
  • Low utilization: Many poor households do not use the nearest health facility.
  • Barriers: Financial, geographic, cultural, and informational.
  • Medical pluralism: Coexistence of traditional and biomedical practices.
  • Human resource challenges: Shortage of doctors, reliance on midwives and nurses, and need for better training and supervision.

Key Recommendations

• Strengthen the referral system for maternal and child health.
• Improve community health worker programs to enhance child health outcomes.
• Ensure universal access to essential health services, especially for the poor.
• Integrate community-based approaches with broader health strategies.
• Develop implementation guidelines and monitoring mechanisms for all policies.
• Address non-communicable diseases through dedicated micro-policies.
• Enhance human resources and capacity building for effective service delivery.