|Subject: AusAID report of 'FactFinding' mission
Date: Sat, 27 Mar 1999 09:27:38 -0500
From: Rob Wesley-Smith <firstname.lastname@example.org>
MEDIA RELEASE THE HON KATHY SULLIVAN MP PARLAMENTARY SECRETARY TO THE MINISTER FOR FOREIGN AFFAIRS
23 March 1999
EAST TIMOR: HUMANITARIAN SITUATION AND ASSISTANCE
On 9 March I instructed AusAID officials to undertake a mission to East Timor and to report urgently to me on the food and medical situation.
The AusAID mission has spent the past week in East Timor and has met with a broad spectrum of organisations including representatives of church groups, government agencies, international humanitarian organisations, non-government agencies and the private sector.
I wish to stress that the AusAID assessment mission concluded that there is no immediate large scale humanitarian crisis in East Timor. At present, overall stocks of both food and medicines are considered adequate although there are localised shortages in some areas as a result of transport and distribution difficulties which are compounded by security concerns.
The recent events in East Timor have led to an increase in the number of internally displaced persons. It is estimated that there are approximately 5,000 internally displaced people in East Timor, many of whom are being cared for by church groups.
Australia will provide humanitarian assistance to ensure that the basic needs of these displaced persons are met. This assistance will include the provision of food, shelter and other basic necessities.
The assessment mission also found that a shortage of professional medical staff in East Timor is putting the health system under severe pressure. While Australia has indicated we are willing to help augment the existing health systems through the deployment of a surgical team, we have consulted the Government of Indonesia on this matter which has indicated that it is prepared to meet the demand for doctors.
We are prepared to provide food, medicines and medical personnel at short notice should they be required.
The Australian Government will monitor closely the need for additional humanitarian assistance in East Timor over the coming months.
A Copy of the Report prepared is attached.
Media Contacts: Innes Willox (Ministers Office) 02 62777500 or 0419 206 890, or Matt Francis (AusAID) 02 62064960 or 0417 683 126
[Poster's comment: In general it seems that the AusAid report can be interpreted according to your outlook. Australia prefers to say the present deprivation is basically normal, so there is no crisis. All interventions have to go through Indonesian government. (The continuing recognition of de jure Indonesian control of East Timor continues to hamper genuine policy options.) Much is limited by 'localised security concerns', which the Australian government simply will not address. Whilst they offer aid for 5,000 IDPs - 'internally displaced persons' - it is admitted that one agency is planning for 25,000 IDPs. The Australian government also ignores the fact that many East Timorese do not trust the Indonesian health system to the point that they die outside it. The idea of ABRI doctors 'filling the gap' is a joke. The offer of an Australian surgical team was refused by Indonesia, Alexander Downer said that was fine as it was better that Indonesia supplied the doctors. Whilst the report says there is no overall shortage of medicines, they admit that antibiotics are regularly in short supply in government health centres, essential drugs are often in short supply in remote areas, and many are 'expensive and invariably out of the reach of many East Timorese'. Situation normal, that's OK then! And so on. Enough to make one sick. The report follows.]
* REPORT OF AusAID FACT-FINDING MISSION TO EAST TIMOR
10 TO 20 MARCH 1999
· At present, supplies of food and medicines in East Timor are adequate. Some temporary delays have been experienced in recent weeks. Ongoing, localised shortages continue to occur as the result of transport difficulties caused by security concerns.
· The departure of a significant number of non-East Timorese doctors has left critical gaps in medical services and there are real prospects that the health system could come under intense pressure. A particular concern is the lack of a civilian surgeon - consequently even routine surgical procedures are unattainable for the vast majority of the population.
· Localised population displacements related to ongoing political tensions continue to occur. The needs of displaced persons are currently being met by church groups and local NGOs.
· There is no immediate requirement for a large-scale humanitarian response. Indonesian Government officials have said they are taking steps to prevent critical gaps in the food and health system occurring. There are, however, some areas in which the Australian Government can assist at this time.
· The Team recommends consideration of a package of assistance totalling approximately $2 million.
Ø This would include a surgical team and other medical personnel to fill critical gaps in the health system.
Ø The proposed package would also include temporary assistance to internally displaced persons through support to church groups and local NGOs for the provision of basic necessities.
· While this package would fill an immediate need, attention must also be given to working with the authorities to address more systemic issues and, in particular, the lack of skilled East Timorese.
· Further disruptions to imports of essential items and/or internal transport networks could result in acute shortages in the future.
A number of recent press reports and public statements have suggested East Timor was facing a shortage of essential supplies, possibly leading to widespread starvation and serious health implications (in some cases resulting in deaths from preventable diseases).
In response to these reports AusAID was tasked with assessing whether there are current and/or anticipated future shortages; and recommending options for Australian assistance if required.
The AusAID team met with various Indonesian Government agencies and humanitarian organisations in Jakarta from 10 to 12 March. The team travelled to Dili on 13 March where it met with a range of individuals representing a broad spectrum of organisations in East Timor. These included church, local non-government organisations, international humanitarian organisations, government agencies, and private sector organisations. The team also visited hospitals, health clinics, local markets in Dili and regional centres, the Dili Port, and warehouses for rice and medical supplies. The team also visited areas outside Dili.
2. Report context
A climate of uncertainty, security problems in some areas and rapid developments relating to an impending shift in the political architecture (autonomy or independence) have created an environment rife with rumours and placed considerable strain on the systems for distribution of essential supplies.
The departure of a significant number of non-East Timorese business people over the first few months of the year has left significant gaps in the distribution network. While the actual number of departees is unknown, Port Authority data shows 13,000 embarking passengers in the first 2.5 months of 1999 - equivalent to the total number of embarking passengers for 1998. In Becaro Market in Dili, approximately 70% of the non-East Timorese traders have left, whereas in Baucau Market, the departures have translated into a reduction in Javanese stallholders from sixteen to three and a similar reduction in Sulawesian stallholders from fifteen to two.
Retailers who remain in East Timor may also be minimising their risks by delaying or re-scheduling orders. Port Authority data show that the volume of non-rice goods discharged in Dili has dropped from a monthly average of 26,000 tonnes last year to just 3,700 tonnes in February.
We were advised that a looting incident on 3 March aboard a vessel discharging a shipment of rice destined for CARE Indonesia relief activities generated some reluctance on the part of shipping companies to carry cargo into Dili Port. It is clear, however, that vessels are now discharging cargo in Dili (see below).
Concerns about the security situation, departure of traders from the province and the looting of the CARE shipment have fuelled speculation that a humanitarian crisis was imminent.
3. Food situation
There was a temporary scarcity of affordable rice in late February / early March. During this period, retail prices for low grade rice from DOLOG (District Logistics Agency) warehouses rose from Rp3,000 per kg to Rp3,500 per kg in Dili and may have peaked at Rp4,000 per kg in some regional centres. In other markets, where supplies of the lower grade rice were exhausted, higher-grade American rice was sometimes available as an alternative during this period at Rp5,000 per kg.
Aggregate food supplies in East Timor now appear to be adequate to cover the immediate requirements. Reports suggest that the recent corn harvest has been adequate to meet the needs of the 60% of the population for whom corn is the principal staple crop. The prospects for the rice harvest in April/May also appear favourable. Under this scenario, East Timor will need to import 40,000 to 50,000 tonnes of rice through DOLOG and private channels over the next twelve months to meet anticipated demand. This is the normal situation.
Shipping services to Dili have returned to normal over the past week. Enhanced security awareness amongst port employees and reported assurances by the Dili Military Commander through the Ministry of Communications that future shipments will be secured by ABRI may help to reassure ship owners. During the course of the Team's visit a succession of cargo and passenger vessels were observed at the port. Importantly, 1,200 tonnes of DOLOG rice arrived on 11 March. This rice is gradually filtering on to the market thus alleviating some of the immediate concerns. DOLOG confirmed that a further 5,950 tonnes of rice is aboard a vessel that docked in Dili on 15 March. This vessel is in the process of discharging the rice (discharge capacity is approximately 800 tonnes per day). DOLOG also indicated that three vessels have departed from Surabaya, South Sulawesi and Banyuwangi respectively, carrying a further 8,200 tonnes of rice for East Timor. These vessels will all arrive in the week beginning 22 March.
On 18 March, approximately 1,750 tonnes of rice were stockpiled in the DOLOG warehouses in Dili. The market in Dili has responded to the recent rice shipments with the retail price of DOLOG rice reverting to Rp3,000 per kg. Similar prices were quoted in Baucau market.
Internal transport difficulties to some districts, related to insecurity and lack of trucks, continue to impede distribution. Assuming however that these are overcome, any prospects that may have existed for a humanitarian crisis (created by inadequate food supplies) will have dissipated. Nevertheless, future shipments to East Timor must be closely monitored to ensure that there is no repetition of the shortages of a couple of weeks ago.
Rice buffer stock levels in DOLOG warehouses throughout East Timor are below normal levels. Recent shipments will help ease this situation, but there is limited capacity to withstand any further disruptions to the distribution network. Some private traders have warehouses in Atambua, in West Timor, and have tended to retain a large proportion of their buffer stocks there even before the recent political uncertainties.
On the demand side, the team identified two critical areas. As with the rest of Indonesia, inflation, as a result of the economic crisis, has had a significant impact on the purchasing power of many Timorese. The urban poor have felt these problems particularly acutely. By comparison, rural communities in East Timor are to some extent insulated given that the vast majority are subsistence farmers. The exodus of non-East Timorese has further distorted the purchasing power of the urban poor by removing employment opportunities and reducing demand in the informal sector. For example, many Timorese stallholders in the Municipal and Comoro Markets in Dili reported a significant downturn in the number of customers and a corresponding decrease in turnover in recent months.
The needs of some urban poor are currently being met through the BULOG (National Logistics Agency) Special Marketing Operations, which supply 20kg of rice per family per month at the subsidised price of Rp20,000. These operations, which form part of the Indonesian Government Social Safety Net program, were originally implemented in the rural areas in response to the El Nino-related drought of 1997-98. The status of the BULOG Special Marketing Operations beyond the scheduled conclusion date at the end of March is unclear, at this stage. If the BULOG Special Marketing Operations are not continued, there may be significant needs in urban areas.
CARE Indonesia has also been implementing an emergency food-for-work program in drought-affected rural areas using USAID funding. Following the recent favourable maize harvest, the focus of the CARE program is expected to shift to the urban areas of East Timor for the remainder of the project duration (i.e. until August). However, this program would be insufficient to meet the needs that might arise if the BULOG Special Marketing Operations were terminated. In any case, it is likely that the numbers of urban poor in East Timor will continue to rise for the reasons outlined earlier. This situation should be closely monitored.
A second area of need exists with those displaced by conflict between pro-independence and pro-integration groups. Approximately 5,000 internally displaced persons (IDPs) are currently scattered around a number of locations in East Timor, often seeking refuge within church compounds. Many are entirely dependent on church groups and/or local NGOs for their basic needs. Many IDPs may be unable or unwilling to return to their homes and, should their numbers increase dramatically, church groups and local NGOs will find it difficult to provide and coordinate appropriate responses. The involvement of international humanitarian organisations may become appropriate at this stage assuming official approval is granted. Meanwhile, CARITAS International has already launched an appeal for emergency assistance to IDPs, based on projections of up to 25,000 IDPs.
4. Medical supplies and pharmaceuticals
In aggregate terms, there currently appears to be ample stocks of medicines in East Timor. Visits to hospitals, government warehouses responsible for the distribution of drugs to health centres, and private pharmacies indicate that there is no overall shortage of medical supplies or pharmaceuticals. However, health clinics in remote rural areas are often short of essential drugs. Items such as antibiotics are regularly in short supply in government health centres. This situation is not new or unique to East Timor. Some people often have to purchase pharmaceuticals from private chemists. These drugs are expensive and invariably out of the reach of many East Timorese.
Hospital medical and pharmaceutical supplies in Dili are adequate at this time (Currently, hospital bed utilisation is 30% of capacity). Dili Hospital places orders for supplies twice a year. The order is put out to tender and the successful bidder is required to fulfil the order within 90 days of entering into a contract. The contract was effective in January and to date 80% of the order has been filled and stocks are sufficient (based on current demand) until April. The hospital is awaiting the arrival of the balance of the order.
We understand that as a matter of practice, pharmaceuticals dispensed by hospitals are usually only sufficient to cover the initial part of a treatment regime and patients are required to supplement the balance by purchasing directly from private pharmacies.
Baucau Hospital has adequate medical supplies and pharmaceuticals given low rates of utilisation. Staff estimate that they hold sufficient supplies to last for another 9 months. Up to December last year, 80% of hospital beds were being used regularly. Usage is now down to 20-30%. The numbers of out patients are also at very low levels. As the team was not able to visit other regional hospitals, a conclusive assessment of availability of essential medical items is not possible, although it is reported that some regional hospitals may be down to 2 months supplies.
In aggregate terms, medical and pharmaceutical supplies allocated by the central government for health clinics in East Timor appear to be adequate. A shipment of supplies was sent in September/October 1998 and a second is scheduled for this month. The SOE responsible for stocking district government medical and pharmaceutical warehouses has said that the first shipment should cover requirements until June 1999. The two government warehouses visited by the Team also confirmed this estimate.
The second shipment, in addition to the government allocation, contains a supplementary allocation (financed by the World Bank) and a significant Japanese Aid component. The Directorate of Drug Control in Jakarta indicated that a large component of this second shipment is antibiotics. We were advised that this shipment has been ready in Surabaya for some time but departure has been delayed owing to concerns over security of the shipment on its arrival in Dili. Given that shipping patterns appear to be returning to normal, it seems likely that this shipment should now be able to proceed. When these supplies arrive, East Timor should have sufficient medical supplies in aggregate terms to last another 12 months.
Nonetheless, there appear to be shortages of certain items, particularly antibiotics. We were told that the shortage of antibiotics is particularly acute in the more remote rural health centres. Given that the majority of East Timorese are rural dwellers, this weakness represents a problem which needs to be addressed. However, to address this adequately, a longer-term intervention is required to strengthen management of the drug distribution network.
The health system operated by the church groups does suffer from a shortage of medical and pharmaceutical supplies, but this is mostly due to the lack of funding.
5. The Health System
While the aggregate medical and pharmaceutical supply situation appears adequate, the overriding concern at this time is that the health system is at risk of collapse if the exodus of doctors from East Timor is not stemmed and replacement doctors provided for those who have already departed. Toward the end of 1998, we understand that there were 109 doctors in the government system (in Hospitals and health clinics). Now there are 81 doctors remaining. There has been no public surgeon for nearly one year. Doctors we spoke to indicated that there was a general preference among non-East Timorese doctors to be transferred once their contract expires.
While we are still trying to obtain information about when current contracts are due to expire, it would be safe to surmise that without a strategy to replace departing doctors, the health system in East Timor could deteriorate significantly - there are only nineteen East Timorese doctors in the province currently. We understand that approximately six East Timorese medical students graduate each year in Indonesia. It is, however, not clear whether these doctors will choose to return to East Timor.
ABRI indicated that it would make the services of military doctors (and an ABRI surgeon) available to the general public.
The team followed up press reports that 50-100 people were dying every day from curable diseases. It was not possible to obtain firm data on this, but the departure of doctors adds to concerns about the health system's capacity to address medical needs.
A number of international NGOs are exploring the possibility of filling gaps in the medical system. We understand that one group in particular is attempting to provide a surgeon through the church health system. These proposed interventions are very positive within the context of the current situation. There is certainly a need for a number of surgeons and doctors given the current ratio of skilled medical staff to population. However, this by itself will not address the problems which exist in the referral system. Rural health centres are not well equipped in terms of physical and human resources to maximise referral capacity.
6. Conclusions and Recommendations for Australian assistance
The current situation regarding essential supplies in East Timor cannot be described as a humanitarian crisis. Many of the problems being experienced at present are systemic and can only be addressed through medium to longer-term interventions that strengthen institutional capacity, develop indigenous expertise and physical resources, and alleviate endemic poverty - areas which the forthcoming program planning mission should attempt to address. The Team did, however, identify areas requiring urgent assistance of a humanitarian nature and a possible option in the medium term to ensure adequate coordination for aid interventions.
In accordance with normal procedures, the Indonesian Government will be consulted on proposals for assistance. Indonesian Government views on all these proposals will be important to their implementation and it will be important to ensure the distribution of aid is impartial and goes to those in genuine need.
In view of the above findings, two broad areas are proposed for consideration for assistance. This package is estimated to total approximately $2 million.
· Provision of medical assistance
* It is recommended that options for the temporary placement of a surgeon to assist the shortage of surgical services be investigated. It is also recommended that the surgeon is accompanied by a surgical support team.
* It is recommended that support be provided to remote health clinics, including the provision of nurse practitioners.
· Assistance to Internally Displaced Persons (IDPs)
* It is recommended that funding is made available for local initiatives to provide relief assistance to IDPs.
In addition, in the medium term, consideration could be given to support for an experienced coordinator to help ensure effective coordination between international agencies and the relevant local authorities.
By the way, the NT Government in trying to reestablish its damaged or non-existent reputation as a caring provider, on 26 Mar issued a very defensive PR by minister Manzie supporting the capacity of 'ASEA Rehab' to supply medical services, as if we might deny that. We in Darwin have supported ASEA Rehab, it is the NT Government that has denied it adequate support, and in this PR still offers nothing.
A delegation of myself and Sonny met Darwin DFAT staff yesterday to press many points on aid and politics. I will post the letter we used as a basis for discussion. Rob Wesley-Smith affet