III. The Health Situation
Promotion of Health in Timor-Leste
Although the level of health in Timor-Leste remains distressingly poor, the country has in some ways come a long way since Independence. In 2002 the ravaged population of one million had only 11 doctors, and virtually no formal health system. The UN and International Red Cross came to the rescue. Also Cuba generously pitched in, as it has done for so many struggling nations. Cuba sent over 300 doctors to Timor and is now training 700 Timorese doctors to take over.
With over 70% of the population living in remote villages and aldeas (small settlements), the logistics of providing health services are daunting. With guidance from WHO and a number of foreign NGOs, the Timorese Health Ministry worked out a pyramidal plan of health provision. Key to delivery of services in remote areas are basic health posts called “SISCa” (Servisu Integradu do Saúde Comunitária): locations at the sub-district level where pregnant women and mothers are summonsed once a month for pre-natal screening, growth monitoring of infants, vaccination, and health education.
Key to the functioning of the SISCa initiative the extensive network of so-called Promotores Saúde Familiar or PSFs (family health promoters), local village volunteers who act as messengers and information dispatchers for the professional health staff (a doctor and/or a nurse and a two levels of trainers). It is the task of the PSFs to round up mothers and children in the outlying aldeas and make sure they come to the monthly SISCa assemblies.
At these SISCa events, PSFs help with growth monitoring (which entails both weighing and measuring arm-circumference of children under five) and filling in growth charts and various forms. PSFs also assist with group “health education,” using colorful flipcharts and sometimes flannel-graphs or role plays.
I had a chance to visit a SISCa event in the district of Ermera, deep in the central mountains. I was given a ceremonious welcome as the author of Where There Is No Doctor, which has been translated into the local language of Tetun (though the book isn’t provided to the PSFs).
The SISCa event was visibly impressive. 70 to 80 colorfully-dressed mothers were present, most with an infant at breast and others in tow. A number of elderly village patriarchs were also present—some to see an ophthalmological technician who had come to provide reading glasses and check for cataract. The health staff was very busy weighing and measuring babies, giving out worm medicines, applying vaccines, and filling out forms.
At the SISCa gathering a lot was certainly happening. Yet as I watched, a number of questions arose. I marveled at the cheerfulness and patience of the mothers. Many had walked for hours from their distant aldeas. At the event they stood for additional hours, outside in the sun, waiting for hours to be attended. There were no benches.
Despite all the effort to monitor the health and nutrition of children and mothers at the SISCa centers, child undernutrition and mortality remain distressingly high, and in the last couple of years have shown very little improvement.
One reason for the low impact of the SISCa program is the relatively low attendance, as shown on the adjacent chart. In part this is due to the long distance many mothers have to walk—some often over very difficult terrain. But the large large crowds at the SISCa events also an obstacle to individualized communication and care.
I was concerned by how many children were visibly underweight—certainly the majority. The younger infants, while still primarily breastfed, mostly looked well nourished. But from 4 to 5 month onward, once they’d begun weaning, most looked very thin. On viewing a batch of the growth charts, a disturbing pattern was apparent. A child would gain weight well for the first 4 or 5 months, then—after weaning began—would stop gaining weight for 2 or 3 months, and susequently lose weight due to a bout of diarrhea or other illness. The low weight often lasted for several years and the majority of children remained stunted.
What concerned me most was that I didn’t see much individual advice being given to the mothers of these children—even of those who were seriously undernourished. When I asked about this, a nurse explained that with so many babies needing to be weighed, measured, recorded and vaccinated in a single day, there simple wasn’t time enough to counsel each mother. The prescribed health education for the whole group of mothers, I was told, had already taken place earlier that morning, using flip charts to make the necessary points. As best I could tell, these were the orthodox health messages about hand washing and eating from the “4 food groups,” with little two-way communication to investigate the concerns and needs of individual mothers and children.
When we asked some of the mothers the significance of the growth chart and the meaning of little black dots that were marked on it each month, they had little idea.
This kind of communication shortfall with Growth Monitoring is not unique to Timor. More than 30 years ago, when UNICEF was avidly promoting Selective Primary Health Care through GOBI (Growth Monitoring, Oral Rehydration Therapy, Breast Feeding, and Immunization), evaluators were already distressed at the way Growth Monitoring had so often deteriorated into a pointless ritual. Babies were routinely weighed and the charts dutifully filled out with little if any useful advice, explanation or follow-up provided to mothers.
The SHARE team is aware of weaknesses in the SISCa program. Their biggest worry is that these monthly events have had minimal impact in lowering the high rates of child undernutrition and mortality. To improve the methods of health education, the SHARE staff has taken ideas from my book Helping Health Workers Learn. For example, they created a supersized flannel-graph Growth Chart, to help mothers understand how the charts work, and the significance of different patterns of the little dots. They were eager for new ideas.
In our workshops with the Family Health Promoters (PSFs) we explored a variety of hands-on, “discovery-based” learning methods. To further improve understanding of Growth Charts, I showed pictures from Mexico of how mothers, using a cardboard figure of a mother and a “gourd baby”, can actually weigh the gourd as it gains weight (due to the liquid that flows into it from a bottle that forms the “mother’s” breast). In this way mothers can see for themselves—and record their changing weight on the supersized Growth Chart—how a child grows well when breastfed, grows less when bottlefed or given inadequate weaning foods, and looses weight when diarrhea strikes. (To cause “diarrhea,” the plug in the gourd-baby’s backside is pulled out; as water runs out, weight is measurably lost. This method is illustrated on pages 22-16 and 22-17 of Helping Health Workers Learn.)
Both the SHARE team and the PSFs were excited by trying and adapting some of hands-on, problem-solving teaching methods developed in m Mexico and Latin America. They felt the need to work more closely with the mothers and families in trying to figure out more effective approaches to improve children’s nutrition and health.