Journal of Human Security | 2014 | Volume 10 | Issue 1 | Pages 14–31
DOI: 10.12924/johs2014.10010014
ISSN: 1835-3800
Research Article
Fragile States, Infectious Disease and Health Security: The
Case for Timor-Leste
John M. Quinn
1,
*, Nelson Martins
2,
**, Mateus Cunha
3
, Michiyo Higuchi
4
, Dan Murphy
5
and Vladimir Bencko
1
1
Prague Center for Global Health, Institute of Hygiene and Epidemiology, First Faculty of Medicine, Charles
University in Prague, Studnickova 7, 12800 Prague 2, Czech Republic; E-Mail: john.quinn@lf1.cuni.cz (JMQ),
vladimir.bencko@lf1.cuni.cz (VB)
2
Faculty of Medicine and Health Sciences, Universidade Nacional Timor-Leste, Dili, Timor-Leste; School of Public
Health and Community Medicine, Level 2, Samuels Building, The University of New South Wales, Sydney NSW
2052, Australia; E-mail: lalatak61@hotmail.com
** Former Minister of Health for the Democratic Republic of Timor-Leste 2007–2012
3
Ministry of Health, Dili, Democratic Republic of Timor-Leste; E-Mail: cunha2009ph@gmail.com
4
Department of Public Health and Health Systems, Nagoya University School of Medicine, 466–8550 Aichi,
Japan; E-mail: m.m.higuchi@med.nagoya-u.ac.jp
5
Medical Director, Bairo Pite Clinic, Dili, Timor-Leste; E-mail: drdanmurphy@yahoo.com
* Corresponding Author: E-Mail: john.quinn@lf1.cuni.cz; Tel.: +420 608246032; Tel.2: +1 6307479081
Submitted: 3 October 2013 | In revised form: 5 February 2014 | Accepted: 6 February 2014 |
Published: 21 April 2014
Abstract: Timor-Leste is a very young and developing nation state. Endemic infectious disease
and weakened health security coupled with its growing and inclusive public institutions keep
Timor-Leste fragile and in transition on the spectrum of state stability. The objective here is to
systematically review Timor-Leste's state and public health successes, showing how a fragile
state can consistently improve its status on the continuum of stability and improve health
security for the population. The case study follows a state case study approach, together with a
disease burden review and a basic description of the health portrait in relation to Timor-Leste's
fragile state status. Disease burden and health security are directly proportional to state
stability and indirectly proportional to state failure. Timor-Leste is a clear example of how public
health can feed into increased state stability. Our discussion attempts to describe how the weak
and fragile island nation of Timor-Leste can continue on its current path of transition to state
stability by increasing health security for its citizens. We surmise that this can be realized when
public policy focuses on primary healthcare access, inclusive state institutions, basic hygiene
and preventative vaccination programs. Based on our review, the core findings indicate that by
© 2014 by the authors; licensee Librello, Switzerland. This open access article was published
under a Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0/).
increasing health security, a positive feedback loop of state stability follows. The use of Timor-
Leste as a case study better describes the connection between public health and health security;
and state stability, development and inclusive state institutions that promote health security.
Keywords: development medicine; fragile and failed states; global public health; health
security; public health policy
1. Background: Fragile and Failed States in the
Global Public Health Context
The broad, and relatively new concepts found in
interdisciplinary literature on the global public health
debate, of health security, human security, economic
security, sustainable development and fragile and
failed states remain elusive. 'Sustainable' means to be
upheld and maintained at a certain level. A sustainable
model in healthcare is one that receives input, possibly
from the state and other stakeholders, provides a
service and standard of care and is ready and able to
continually provide that service in a cycle system with
inputs, outputs and health security offered to a certain
level for patients or end-users. There are no universally
agreed-upon definitions; these concepts are hotly de-
bated, inconsistent, disputed and pose difficulty in of-
fering accurate descriptions for discussion across disci-
plines. For the purposes of this paper and in order to
remain within the framework of the current global
public health debate, we define health security as the
access to essential health services and protection from
environmental and behavioral risks that diminish public
health [1,2]. This definition frames health security as
an aspect of human security, which includes core
features such as freedom from want, "and access to life
saving clinical and public health interventions" [3].
Plainly, health and human security converge in defi-
nitions as the adequate access to healthcare re-
sources. This is grounded in community-based primary
healthcare and basic hygiene access, and emphasizes
the protection of populations against external and
internal threats of conflict and the threat of structural
violence. Health and human security protect against
oppressive state regimes, failing state systems and
failing extractive state institutions; protect against in-
fectious disease and pandemics; and in general
provide the most basic in public health and collective
security. Structural violence is the set of systemic
sociopolitical, economic, legal, religious and cultural
norms that harm, disadvantage and limit individuals,
groups and societies from reaching their full potential
[4,5]. Structural violence is often embedded in long-
standing ubiquitous social structures, normalized by
exclusive state institutions [6].
The relationship between health security and state
stability is directionally proportional—as health security
increases across a population and state, the stability of
the state is bolstered, even if only temporarily, and this
feeds into a positive feedback loop to further strength-
en the state's institutional capacity and stability, which
must be embedded in inclusive state institutions for its
citizens. What we see when looking into the recent
past of Timor-Leste is an improvement in its health
security, even if only slightly, against other states in
the region, although it is still highly dependent upon
aid and external support. This is leading to state
stability in a positive feedback loop gaining traction to
further strengthen the state's stability and subsequent
health security. This relationship is represented pic-
torially in Table 1.
This paper concludes that the state is the final de
facto vassal to offer inclusive institutions that can
engender an environment of health security. Corrupt
states with corrupt and exclusive state institutions
reduce health and human security and may isolate
subgroups in the community and society. The private
and philanthropic sectors do not offer a sustainable
and equitable solution to provide basic healthcare
programming and infrastructure; however, a stable
state with inclusive democratic practices for its
population can offer health security.
Health security has evolved over time, so it
encompasses many entities that make up the present
nexus of health and security. The United Nations
(UN), World Health Organization (WHO), Asia-Pacific
Economic Cooperation (APEC), and the European
Union (EU) approach a health security definition
within specific areas: emerging diseases; global
infectious diseases; deliberate release of chemical and
biological materials; violence, conflict, and human-
itarian emergencies; natural disasters and environ-
mental change; and radioactive accidents [7‒9].
Environmental degradation may pose the largest threat
to health security at present and in the future and is a
cross-cutting theme throughout global human, food,
economic and health security.
Global infectious diseases are those that are
transmissible and communicable between people due
to the presence and growth of a pathogen; examples
being bacteria, fungi, parasites or a virus that causes
an infection [10]. Communicable diseases differ from
non-communicable diseases (NCD), which are not
transmissible from person-to-person via any vector or
pathogen; they are far more numerous and are re-
lated to the environment, social behavior and eco-
15
nomics. Due to poorly understood economic stressors
and other unidentified factors, NCDs are breaking out
in the least developed and developing nations, where
communicable disease incidence and prevalence pre-
viously dominated the risk profile. It is true that
infectious and communicable disease is truly global,
given the porous nature of state borders and the
increasing movement of people globally. Infectious
disease is no longer limited to the tropics and cardio-
vascular disease, once encountered only in the devel-
oped world, is no longer unseen in developing nation
states; it is its own epidemic.
Examples of non-communicable diseases (NCDs)
include hypertension, obesity, diabetes, and cancer
(although some cancer/malignancies are found to be
caused or otherwise contributed to by viral strains),
among many others. NCDs are not the focus of this
case study as the direct link with state fragility or
failure is not as clear. With this, it is understood that
the incidence of trauma and trauma-related injuries
and death, classified as non-communicable disease, is
indeed higher in regions and states characterized by
fragility and instability. Trauma-related morbidity and
mortality might be significant in fragile and failed
states, and may influence health security and sub-
sequent state stability over time. There are many
factors that may contribute to trauma morbidity such
as the age of the population, health and safety stan-
dards and practices, state infrastructure, violence,
access to munitions, gender-based intuitional violence,
and many other factors. However, this paper focuses
on infectious diseases, basic public health structure and
institutions, and the link between these factors and
state stability.
The present literature does not offer a clear causal
link between infectious disease and state fragility or
failure, and increased infectious disease does not
necessarily lead to violence or state collapse ([11] p.
208). Provision adequate health security by a state to
its population is the first line of defense against public
health emergencies and is a core component in pro-
viding human security at the most basic levels—this
holds true even though global policymakers and public
health professionals do not always agree on accepted
definitions.
Furthermore, food security and poverty in general
are also aspects of health and human security. Food
security encompasses adequate access to food, food
markets and sustainable agriculture, including environ-
mental sustainability. Poverty is loosely defined as
having limited or no financial capital, no access to
capital or equitable finance, and no access to adequate
and equitable work; the consequence of which is to
lose human, food and health security as a result of
these deficiencies [12]. Food security is obtained when
all people at all times have access to sufficient, safe,
nutritious food to maintain a healthy and active life, as
well as adequate water and sanitation [13]. Food
security is a complex sustainable development issue.
It is linked to health security through malnutrition,
human growth and development, the immune system
and disease susceptibility, but it is also linked to sus-
tainable economic development, environmental integ-
rity, equitable trade and finance.
Sustainable development is the equitable and dem-
ocratic progress that focuses on increasing living stan-
dards and positive growth, is consistent, is evenly
spread across communities and populations, and does
not rapidly diminish natural resources, human capital
or otherwise cause creative destruction on the short
or long term [14‒16]. Sustainable development is not
just a humanitarian concern; healthy populations are
an essential aspect of economic development and
global order and stability.
Economic security is the collective concern for the
economic well being between states and their popu-
lations; mankind has a common concern for the
economic well-being of states and the belief that
economic insecurity breeds state and individual insta-
bility, conflict and violence. Economic security in the
context of public policy and global health is the ability
of a nation state to follow its choice of policies in
order to develop the national economy and globally
compete as desired [17,18]. At a personal level,
economic security is understood as having access to
work, financial resources or enough income to support
a consistent standard of living, and includes financial
solvency, future access to work and cash-flow.
Labelling a state as 'fragile' or 'failed' risks excluding
it from the international community by suggesting it is
no longer able to appropriately receive or process
money, aid or goods from donors. Using this method,
states are not branded as 'failed' or 'stable', but rather
are placed on a continuum of stability. At the bottom of
the scale are fragile states in danger of failure, whereas
near the middle of the scale are those which are
developing towards stability. Towards the top of the
scale are the states which are the most stable—for now.
State fragility and potential failure must be put in
context on the spectrum of state fragility, taking into
account multiple matrices of data for comparison and
analysis, and understanding that each state has a
myriad of complex variables to overcome. State
fragility and failure must be put in context and as-
sessed using quantitative or semi-quantitative meas-
ures that permit comparison between countries. This
enables us to assess the vulnerabilities of each country.
Data indicators used to measure state fragility and
failure in the main instrument of this research paper
are summarized in Table 1.
16
Table 1. Indicators used to measure state fragility and state failure as listed in the US Fund for Peace,
Failed States Index 2012.
Social Economic Political and Military
Demographic pressure,
natural disasters and
environmental degradation
Disease and public health
Food scarcity, malnutrition
Mortality
Refugees and internally
displaced persons
Group grievances
Human flight and brain
drain
Uneven economic development
Slum population
Access to improved services
Poverty and economic decline
Government debt
Unemployment, youth
employment
Purchasing power, inflation
State legitimacy
Corruption
Government effectiveness
Political participation
Drug trade and illicit economy
Protests and demonstrations
Public services
Water, sanitation, basic infrastructure and
energy
Quality of healthcare
Human rights and rule of law
Civil liberties and political freedoms
Human trafficking
Incarceration, torture and executions
Security apparatus
Internal conflict, riots and protests
Rebel activity, military coups, bombings
Factionalized elites
External intervention
Foreign assistance, peacekeeper presence
Foreign military intervention
UN presence
Sanctions
State credit rating
Table 1 is not exhaustive and highlights only the
core components of the present research and analysis
ranking state fragility and failure; many indicators are
still contested and under debate throughout the
literature.
However, common features of fragile and failed
states are that they are wrought in crisis and may
exhibit geographical, physical and fundamental eco-
nomic constraints, internal strife, gross management
flaws, overgrown greed and despotism, handicapping
nepotism, debilitating external attack and lack of
health for their people [19,20]. When nation-states are
consumed by violence, they cease to deliver basic
human or health security, or any level of public health;
these governments lose credibility, and the state
becomes questionable and illegitimate in the hearts
and minds of its citizens [21,22]. Furthermore, fragile
states experience a slow disappearance of state insti-
tutions and a breakdown of rule of law, which leads to
a deteriorating health security situation [14,23,24].
Economic strife and human conflict threaten health
security and lead to an increase in infectious disease,
physical trauma, malnourishment and mental health
disorders [15,25‒28].
To sum up, the combination of deteriorating health,
human, food and economic security contribute to the
situation of fragile states [29]. This paper is a qual-
itative review of a country case study and the
strength of its state institutions and public health suc-
cesses, which demonstrate how a fragile state can
improve and stabilize in a post-conflict setting through
health security.
2. Objective
To describe infectious disease and health security in
17
Timor-Leste and juxtapose it to state stability status,
as ranked on the Failed States Index (FSI). Timor-
Leste has experienced significant institutional and
state successes. These successes have led to direct
public health successes in a positive feedback loop,
engendering more state stability. Institutional and pro-
gram successes in public health that have improved
state stability are described.
Regionally, as China and the United States vie for
power and influence throughout the Pacific Region,
smaller states such as Timor-Leste are greatly influ-
enced by private and public state and non-state actors
levying for control of violence and power, as well as
regional authority. When left untreated, state fragility
can threaten health security, collective growth, stability
and regional order. If public health policy is not further
addressed in Timor-Leste in order to continue growth
and strengthening of public institutions and public
health infrastructure, the many gains of stability may
be lost and fragility of the state may worsen or fail.
3. Methods
We will carry out a state case study and review and
qualitatively describe the disease burden and basic
health security portrait, and then place these elements
within the continuum of state stability, fragility or
failure. This will bedone by taking a systemic approach
and critically evaluating data from the Ministry of
Health in Timor-Leste, with a direct input from the
former Minster of Health, the Immunization Program
leadership in Timor-Leste, two qualitative regional
health assessments (which occurred in February and
May 2011), other Timorese health experts, a review of
the literature and data published by the UN, WHO,
UNICEF, and the Fund for Peace's.
Failed States Index (FSI), the main research instru-
ment used.
The literature review will include infectious diseases
endemic to Timor-Leste, new and present challenges
and state successes through institutions in post-conflict
countries after 1945. Finally, a basic review of recent
social, political and economic events will be made, in
order to place recent state success within their context
and to provide a framework of state stability and public
health infrastructure through primary healthcare access
programs. In turn, this will allow the proposal of a state
stability policy for future successes and improved
health security.
3.1. Failed State Index (FSI)
The Fund for Peace publishes the annual Failed States
Index (FSI). The Index assesses all countries in terms
of the pressures they experience and, ultimately, their
aggregate susceptibility to state failure. There are
multiple metrics that are based upon key social,
political and economic indicators that make up this
index (see Table 1). The FSI then ranks countries using
a Composite Score (CSxxx), where a higher score
indicates a state's greater inclination towards failure.
There are many indices that track fragility and state
failure, but the Fund for Peace's FSI offers a main-
stream, accepted and inclusive set of metrics based on
a sound methodology. Those states which experience
drastic food and other commodity price fluctuations,
economic distortion and disparity in social, health or
political areas, or food riots and public health crises top
the FSI list. The entire top third of the states listed on
the Failed States Index are either fragile or near failure
and are experiencing conflict, war, fragile post-conflict
status or, at the very least, political and socioeconomic
unrest and violence. The FSI does not predict state
failure but rather describes state fragility.
It must be noted that the FSI is controversial and
some opponents lament that describing state fragility
or failure is nothing but an academic exercise of
futility when dealing with state security and devel-
opment in complex situations and in a complex global
arena—even more so when dealing with public health.
The data used is indeed open source, some from
direct government sources and possibly not sound or
otherwise questionable in reporting, while others are
from NGOs and may be inconsistent in nature. How-
ever, the key indicators of external pressure and
capacity realities in governance found within the FSI
are directly related to health security for their citizens,
overall potential for state stability, and the potential
for an improving health security situation.
4. Results
4.1. Timor-Leste—The Recent Past
As public health programs and institutional stability
increases, state stability increases; as public health in-
stitutions weaken and, consequently, public health
indicators decrease, state stability decreases.
Timor-Leste is a relatively small tropical island state
just north of Australia and attached to Indonesia, with
a remote and detached Oecussa region bound by
Indonesia to the south and east, and the sea to the
west. The effects of Indonesian rule on Timor-Leste
were vast and multifaceted, and are still today being
debated in social science circles. While it is true, that
there were many failings across ethnic and religious
groups, and in terms of state institutions, this does
not fall within the scope of the present paper. How-
ever, the use of violence by the Indonesian state and
lack of access to state institutions, especially in the
public health sector, for Christian Timorese are not
quantifiable for the time of Indonesian rule and
systemic violence. Access to public health infra-
structure during Indonesian rule was near non-existent
throughout rural Timor and only available to the polit-
ically connected and wealthy in the regional capital,
Dili. In the post-2002 health system, confidence
remained rather low as access has been plagued by
18
violence and ongoing infrastructure impediments, with
aid and the humanitarian sector helping unevenly with
some institutional shortcomings. It is difficult to assess
and appraise public confidence in the healthcare system
and confidence across religious and ethnic minorities for
the transition period from 2002 to 2011. However, the
death rate reduction and access to primary prevention
schemes found in the data table below do provide
evidence of improved institutional capacity and overall
public health improvement for the population.
The Revolutionary Front for an Independent East
Timor (FRETILIN) was formed and tried to push out
an invading Indonesia in the 1970's. The US and
Soviet Union did little to abate the Indonesian take-
over and the Secretary of State at the time, Henry
Kissinger, discussed East Timor and did not protest
the Indonesian President Suharto in reference to the
strategic Indonesian invasion and takeover in 1974
[30]. In late 1975, the UN Security Council called on
Indonesia to withdraw its troops from East Timor and
to summarily stop all acts of war and killing.
There was a prolonged war on the island until a
UN-, Portuguese- and Indonesian-backed referendum
on independence was held in 1999. A majority of
Timorese voted for independence, which was answered
with violence and conflict, and forced over 300,000 into
West Timor as Internal Displaced Peoples (IDPs) and
refugees [31]. During the violence, the entire infra-
structure, roads, homes, agricultural irrigation, water
supply systems, schools, hospitals, markets and nearly
100% of the country's electrical grid were summarily
destroyed. The destruction of 70% of the country's
infrastructure in 1999 has severely undermined Timor-
Leste's economic growth and health security. In Autumn
1999, an Australian-led peacekeeping mission, the Inter-
national Force for East Timor (INTERFET), was deployed
in the country and brought the violence to an end.
Timor-Leste joined the United Nations in 2002,
became a member of the ASEAN Regional Forum (ARF)
in 2005 and is presently an applicant to the ASEAN
(Association of Southeast Asian Nations) itself. The
building of democratic institutions is growing and
development and stability are spreading organically.
There is a well-structured policy of reconciliation and
forgiveness for the atrocities committed (the Com-
mission for Reception, Truth and Reconciliation;
Comissão de Acolhimento, Verdade e Reconciliação,
CAVR). Significant progress has been made in re-
unifying the country after multiple acts of violence
threatened to destabilize it, although concerns remain
about overall accountability and gender discrimination
moving forward.
For example, in early 2006, approximately 700 mili-
tary personnel petitioned President Gusmao to ad-
dress complaints of discrimination, which flared into
more street violence. There were additional deaths,
widespread destruction of property, and the continued
displacement of thousands of Dili residents, as well as
a decrease in health security; almost 10% of the
country's population became IDPs. In most complex
emergencies, public health intervention focuses on the
immediate health needs, not underlying conditions
and systemic issues [32]. This is best illustrated by
the gender based violence and maternal and ante-
natal care, which was lacking during the crisis. At the
time, there was reduced coordination, and a lack of
public health dialogue and of advocacy around sen-
sitive reproductive health issues—the need to
strengthen neglected areas and the inclusion of all
components of sexual and reproductive health provides
a foundation to respond to crises [33,34]. At this
stage, health security was at significant risk and
health infrastructure was decaying substantially; the
fragile state of Timor-Leste was teetering on state
failure.
Before such failure occurred, the Government of
Timor-Leste asked the Governments of Australia,
Malaysia, New Zealand, and Portugal to send security
forces to stabilize the country. In late summer 2006,
the UN Security Council passed Resolution 1704,
creating the United Nations Integrated Mission in
Timor-Leste (UNMIT). Its mandate included assisting
with the restoration of stability, rebuilding the insti-
tutions comprising the security sector, supporting the
Government of Timor-Leste in conducting presidential
and parliamentary elections, and achieving account-
ability for the crimes against humanity and other
atrocities committed in 1999 [35,36].
This mandate included a major policing unit with
shared influence and successIn early spring 2011,
UNMIT completed its handover of executive policing
authority back to the Timorese, effectively declaring
Timor-Leste's security apparatus' stable and capable
of maintaining rule of law to an international stan-
dard. Despite significant global pessimism about UN-
backed institutions and bureaucracy, the case can
made here that the fragile, near failed state of Timor-
Leste is a fledgling still moving forward with inter-
nationally recognized and UN-backed institutions,
which have focused government support and have
produced stable outcomes. Resuscitating fragile and
failed states starts with the prevention of collapse and
restructuring or supporting weak-but-still-growing in-
stitutions. In Timor-Leste the efforts made by the
Timorese and supported by the UN and coalition
countries have worked, and have met or exceeded
expectations. Similar positive trends of development
in public health infrastructure and can enable further
quantified gains to feed into a positive feedback loop
and stabilize, and can lead to broader health security
and more firmly root state stability.
Timor-Leste is not presently in a lasting state of
social unrest or violent conflict. However, its post-
conflict status and elements of fragility, combined with
only a budding democratic infrastructure, are at risk of
being pushed towards failure if further investment is
not made to secure health security for its citizens.
Timor-Leste (FSI
2012
= 28; CS
92.7
) differs from its land
19
neighbor Indonesia (FSI
2012
= 63; CS
80.6
), nearby
Papua New Guinea (FSI
2012
= 54; CS
83.7
) or the
Philippines (FSI
2012
= 56; CS
83.2
) greatly. Globally,
Timor-Leste is ranked before Nepal (FSI
2012
= 27;
CS
93
) and after Bangladesh (FSI
2012
= 29; CS
92.2
) (see
Table 2 for regional comparisons). FSI methodologies
have evolved since its inception in 2005, yet the core
12 social, economic and political indicators (each split
into an average of 14 sub-indicators) have remained
the same and quantify these areas. The FSI does help
describe the public health situation on the ground in
Timor-Leste and does so quantitatively.
Table 2. Country Rankings and Composite scores for 2012 [22].
Country Failed States Index Rank
(the lower the value, the more
fragile the state)
Failed States Index Composite
Score (CSxxx) (higher values
denote increased state fragility)
Timor-Leste (East Timor) 28 92.7
Indonesia 63 80.6
Papua New Guinea 54 83.7
Solomon Islands 47 85.6
Philippines 56 83.2
China 76 78.3
Malaysia 110 68.5
Brunei 123 64.1
Singapore 157 35.6
Australia 165 29.2
New Zealand 171 25.6
With a population of roughly 1.2 million, half the
adult population illiterate, a third of the population
urbanized in the capital Dili, GDP per capita of less than
$1000 and a median age of 22 years, the recipe for
social and economic instability is clear and the neces-
sity of improvements in public health is policy evident.
Public health leadership, primary healthcare access,
vaccination and immunization program compliance
and overall inclusive institutional capacity building are
still in a state of fragile growth in Timor-Leste. Pre-
ventable disease through vaccination programs and
basic public health and hygiene measures such as clean
water, toilets, access to night-time mosquito nets or
repellents, health educational programs, electricity, and
affordable primary healthcare access can help ensure
health security and can stabilize fragile states. In the
case of Timor-Leste, these basic health measures and
indicators of health security have been improving since
cessation of its recent violent past. However, in order to
completely resuscitate this fledgling state and put on a
sustainable trajectory of permanency, continued sup-
port of inclusive state institutions and primary health-
care prevention programs must be pursued diligently,
both by the state and in aid programming schemes.
The health and social demographics in Timor-Leste
define its public health portrait. A majority of the
population identify as Roman Catholic, greatly influ-
encing maternal and child health in terms of contra-
ception practices and cultural acceptance. Language
choices for healthcare literature, education and public
health campaigns (promoting, for example, seatbelts,
water hygiene and medication compliance) are dif-
ficult as Portuguese, Bahasa Indonesia, English,
Tetum and other natives languages are all spoken
with varying fluency by different communities [26].
This linguistic diversity is a challenge to public health
teams that work throughout the country, including the
Ministry of Health, and makes it difficult for any formal
and unified health guidelines to be disseminated
throughout the districts.
The necessary conditions for a state to reverse its
course and achieve stability—the recognition and legit-
imacy of the transitional administration and executive
branch, social cohesion within the state, the small size
of the country, and coordination facilitated by a high
level of consensus among all actors, are all readily
observed in Timor-Leste [37]. The public health and
epidemiological profile of the country influences the
health security situation and is better described by
highlighting the gains made in state stability.
4.2. Timor-Leste's Public Health Infrastructure
While public health and health security deteriorated
and most of the population relied heavily on human-
itarian-based health services backed by the Australian
led peace force, scattered volunteer doctors, and a
community clinic, state stability faltered (Timor-Leste
FSI historical data: (FSI
2007
= 20; CS
94.9
)
i
(FSI
2008
= 25;
CS
93.8
), (FSI
2009
= 20; CS
97.2
), (FSI
2010
= 18; CS
98.2
),
20
(FSI
2011
= 23; CS
94.9
) [22]). There was a significant
climb of 10 ranking points (from 18 to 28, while
aggregate values slid from 98.2 to 92.7) between
2010 and 2012 (FSI
2010
= 18; CS
98.2
and FSI
2012
= 28;
CS
92.7
). This may be in part due to the 'State
Legitimacy' score improving as the first anti-corruption
minister took office, as well as a reduction in the
crime rate, which was reported to have dropped by
20% in 2011, and the third round of free and fair
elections, which were completed in summer 2012
without major violence.
The UN Transitional Administration in East Timor
(UNTAET) supported a transition from humanitarian-
based healthcare services towards an indigenous and
sustainable infrastructure, which had varying success.
In 2005, the Cuban Government offered to train 1000
medical doctors, open a faculty of medicine, and send
roughly 200 medical doctors (including specialists) to
work in rural- and sub-district community health
centers and hospitals. In 2010, the first returning
Timorese doctors educated in Cuba were armed with
medical knowledge but scant medical mentors, whose
role was also to offer sustainability, while the Cuban
doctors sent to rural districts sometimes found life and
medical practice for wages in the capital, outside the
government program, to be a more attractive option.
There are scattered foreign surgeons and other
medical specialists found scattered throughout Dili,
however, an inadequate number remain in the health
system regularly or consistently to help improve
health security to a sustainable level. There is no
reliable data on the number of doctors per capita, but
some estimates gauge that there is one physician for
every 10,000 people. The requirement for well-
trained, adequate and consistent medical staff, from
general and specialist surgeons to family practice phy-
sicians, to ensure human security is significant.
This major healthcare workforce deficiency has
partially been answered by the establishment of a
Faculty of Medicine in 2005; a Faculty of Public Health
in 2004; a School of Nursing and School of Midwifery
in 2008; and the recent establishment of a Cabinet of
Health Research and Development (CHRD), the first
health research institute in Timor-Leste [38]. The
CHRD seeks to further assist the use of public health
research data to inform decision makers and to
develop and enhance ethical, sustainable and con-
sistent public health policy. The Ministry of Health has
also provided more than 2,000 scholarships for
undergraduate and post-graduate students, including
20 medical specialists who are to complete their
medical training in Indonesia, Malaysia, Papua New
Guinea and Fiji. The opening of these ministerial-lead
and government-backed programs and educational
institutions are a great example of how fragile states
can develop and stabilize, moving away from failure
with the establishment of public health initiatives,
underscored by government institutions and private
partnerships, which help build capacity and create a
better environment for improved health security.
Clinics, both public and private and regardless of
specialization, constantly receive patients with a range
of problems; among others, newborns and infants
suffering from preventable and treatable Acute Res-
piratory Distress Syndrome (ARDS), Miliary Tuber-
culosis, Tuberculosis in the bone (Pott's Disease),
chronic anemic states in children and mothers, un-
known tumors and neoplasia, disfiguring physical
trauma, mental health and many other preventable or
otherwise treatable illnesses. The disease burden poses
a liability for the healthcare infrastructure. In post-
conflict states, mental health and psychosocial trauma
are omnipresent, yet Timor-Leste lacks capacity for
mental health services [39]. Timor-Leste lacks a
focused and all inclusive mental health campaign to
promote mental health, reduce the cultural taboos of
mental illness, and offer those who are suffering from
mental health illnesses adequate resources for effective
diagnosis and treatment.
4.3. Food Security and Malnourishment
Malnourishment is food insecurity to the point where
one cannot grow, function or develop normally. Mal-
nourishment can also take the form of overcon-
sumption of food, leading to the NCD of obesity and
many other health conditions. Prone to drought,
flooding, and natural disaster, the risk to Timor-Leste's
food security is exacerbated by poor infrastructure
and high rates of poverty [22]. Food security can
greatly affect child and maternal health as social and
cultural factors influence resource allocation among
children and consequently affect their health in
rural Timor-Leste [40]. Adequate access to vitamin A
and nutritious food that promotes growth and human
development is still a challenge for some, with 37% of
the population lacking adequate access.
However, in the FSI, Timor-Leste's Demographic
Pressures score dropped slightly as the opening of a
food plant in 2010 as part of in a joint venture with the
World Food Programme (WFP) increased local food
capacity; nevertheless, 43% of the population are
reported to be food insecure [22,41]. This is coupled
with a US$5.6 million grant provided by the Inter-
national Fund for Agricultural Development (IFAD)
providing to improve food security for poor maize
growing households; the project aims to improve food
security for communities which experience a 'hungry
season' of up to three months without sufficient food
stores [42].
Food security and health security are directly
proportional. Timor-Leste still relies on international
assistance for many sectors, including efforts to feed
its population, and is unlikely to become self-reliant in
the near future, as only roughly 10% of its area is
arable land and it has an inadequate agricultural
infrastructure. Food security will greatly affect health
security in urban and rural Timor-Leste, and state
21
stability will be influenced by food security or in-
security. The need for continued support for sustain-
able agriculture programs and development of the
agricultural sector will increase food security and state
stability [43]. Conflict engenders predictable health
indicator patterns and Timor-Leste is no exception.
Selected health indicators relating to basic hygiene
and food security characteristics are found in Table 3.
Table 3. Selected Health Indicators: Timor-Leste.
Indicator Prevalence Comment
Prevalence of Child Malnutrition
(Percentage of under-5 year olds
uderweight) (2005‒2011) [44]
43.7% The percentage of children under the age of five whose
weight for his/her age is more than two standard
deviations below the WHO Child Growth Standards
median
Population Undernourished
(Percentage of Total Population)
(2006‒2008) [45]
31% Undernourished Population: individuals whose food
intake is chronically insufficient to meet their minimum
energy requirements
Population With Sustainable
Access to Improved Sanitation
(2010) [44]
69% The percentage of the population with access to
adequate excreta disposal facilities, such as a connection
to a sewer or septic tank system, a pour-flush latrine, a
simple pit latrine or a ventilated improved pit latrine
(considered adequate if it is private or shared and not
public, and can effectively prevent human, animal and
insect contact with excreta. Improved sanitation includes
connection to public sewers, connection to septic
systems, pour-flush latrines, simple pit latrines, and
ventilated improved pit latrines. Not considered as
improved sanitation are service or bucket latrines (where
excreta is manually removed), public latrines, and open
latrines [46].
Population With Sustainable
Access to an Improved Water
Source (2010)
69% The percentage of the population with sustainable
access to an improved water source (household
connections, public standpipes, boreholes, protected dug
wells, protected springs and rainwater collection).
Unimproved water sources are unprotected wells,
unprotected springs, vendor-provided water, bottled
water (unless water for other uses is available from an
improved source), and tanker truck-provided water [46]
Vitamin A Supplementation
Coverage Rate (Full Coverage)
(2009) [47]
45% The percentage of children reached with two doses of
vitamin A supplementation.
Vitamin A is an essential nutrient for the proper
functioning of the immune system and the healthy
growth and development of children. Insufficient intake
of vitamin A in children can dramatically increase the risk
of death, blindness, and illness, especially from measles
and diarrhoea.
Infant Mortality Rate (IMR)
estimated [48]
36.78
deaths per
1,000 live
births
This is in contrast to an estimated (IMR) = 70–95 per
1000 live births in 2002 [49]
4.4. Emergency Medical Services: Risks and Barriers
to Health Security
Basic road infrastructure is significantly deficient
throughout the country. There is no rail transport, and
buses and ad hoc bus transportation is expensive and
dangerous. This negatively affects basic public health
logistics such as cold-chain management for vaccines
and medicines, mobile health teams and emergency
response in disasters. Few drivers adhere to safe
22
driving practices; a public health seat belt campaign
has not yet been securely embraced and many regions
and villages have a single unsafe road where children
play and village work may be performed connecting
them with the rest of the country. It is not yet ade-
quately quantified in the literature, but road traffic
accidents and trauma from a lack of implemention of
safety standards are anecdotally endemic.
Despite the presence of five major district hospitals
equipped with four core specialists, a nurse anes-
thetist, and despite having some 65 multifunction
ambulances based at community health centers in the
sub-districts, consistent and comprehensive emer-
gency medical services do not exist and multiple
trauma patients must often be transported by their
own means to Dili for treatment. Access to consistent
and adequate fuel and vehicle maintenance is a major
barrier for the ambulance service. Definitive medical
treatment and tertiary care for multisystem trauma
patients does not exist in Dili and petition must be
made for patients to be medically evacuated abroad
to receive definitive care. A community-based emer-
gency medical services system implementation with
tertiary care services offered in the capital would offer
emergency medical services in a sustainable fashion.
Poor transport, unsafe practices and access to ade-
quate emergency medical services are all barriers not
only to primary healthcare access but to health
security in general.
The Burden of Disease in Timor-Leste, a break-
down of infectious and communicable diseases.
Infectious and communicable disease is getting worse
for much of the resource poor and developing world.
This can be observed by looking at health indicators
and economic progress across states, taking into
special consideration the impact of the global financial
crisis. Developing nations may lack finance and
systems to effectively address the behavioral, environ-
mental and health systems factors related to health
security, which determine the burden of com-
municable diseases [50]. Timor-Leste faces a severe
threat and increased health risk from endemic
infectious disease, inadequate hygiene access, and,
consequently, decreasing health security and in-
creased state fragility. Its tropical location, isolated
population, and diverse ecosystems make it a haven
for tropical disease, climate change-related health
issues, and barriers to health security. Timor-Leste is
highly vulnerable to natural disasters such as earth-
quakes, tsunamis, floods, landslides and erosion,
resulting from the combination of heavy monsoon
rain, steep topography and widespread deforestation;
these factors also contribute to infectious disease risk.
Climate change and environmental degradation also
contribute to the disease burden.
Mycobacterium tuberculosis is a pathogen, which
causes tuberculosis and is a threat to health security
throughout Asia. Due to the resource-poor nature of
health services in Timor-Leste, the quantitative disease
burden of tuberculosis is impossible to determine on a
country-wide basis. Despite the post-conflict national
Tuberculosis Control Program [51], infection rates, a
lack of medicine, and poor treatment compliance mean
that the disease continues to devastate communities
[52]. Multidrug-resistant tuberculosis (MDR-TB) is
becoming more common and affects a large pro-
portion of the pediatric population, despite a vaccine
program; past estimates (diagnoses?) of MDR-TB are
a level of at 1.6% among the newly diagnosed and
14.5% among those previously treated [53]. Myco-
bacterium leprae, the pathogen that causes leprosy, a
neglected tropical disease afflicting humans since time
immemorial, was eliminated as a public health con-
cern in 2010; with a reported prevalence of the disease
of 0.83 per 10,000 inhabitants in comparison to 0.75
per 10,000 in the year 2000. If all actors and partners
do not stay committed, this threat could return. In
Timor-Leste, tuberculosis easily affects pediatric
patients under the age of five years and threatens
health security and quality of life, and causes death.
Approximately one third of the total population may
be infected with tuberculosis. Those that have tuber-
culosis and HIV/AIDS infection are at the highest risk
of disease complications and death. The disease
burden of tuberculosis together with HIV/AIDS cannot
yet be quantified for Timor-Leste, as disease pre-
valence is only available as an estimate. Present
estimates range from a 0.2% to 1.5% HIV infection
rate, compared with a rate of 0% in 2000; the first
diagnosis of a patient as HIV positive was reported in
2003. A massive increase in sexually transmitted
diseases, such as HIV/AIDS and human pappilomma
virus (HPV) may be rising amongst the younger
population, with social and demographic shift in the
population.
Endemic Malaria, resistant to conventional cholo-
quine treatment and prophylaxis, is also seen
throughout Timor-Leste. Malaria is a major global
health problem, often exacerbated by political in-
stability, conflict and forced migration. It thrives in
fragile and failed states [54]. The cost of prophylaxis is
prohibitive for the majority of the population, (foreign-
based workers and private sector workers excluded)
Use of bed nets at night (when the female mosquito is
most actively seeking a blood meal) is still well below
50% among at-risk groups. Endemic Japanese
Encephalitis is seen in many districts as the vaccine is
costly Poor access leaves many with central nervous
system morbidity for life once infected, should they
survive it.
Dengue fever and viral hemorrhagic fevers (VHFs)
are endemic. Dengue fever is a most pressing public
health issue for Timor-Leste. Almost all other neigh-
boring countries have experienced a fatal outbreak of
the disease, but Timor-Leste has experienced
recurrent outbreaks with devastating effects in 2005,
2010 and 2012. Dengue fever, carried by the Aedes
aegypti mosquito, has high mortality rates in the
23
pediatric and geriatric populations. It cannot be cured
and treatment is only directed at the symptoms.
Prevention of Dengue fever can only be carried out
through avoiding the mosquito bite and vector control
—there is no vaccine.
Schistosomiasis (Bilharzia) has a global prevalence
of roughly 200 million, with 600 million people who
swim or work in infected waters at risk. Its prevalence
in Timor-Leste has been poorly quantified. This blood
fluke infects through the skin and can cause symp-
toms tanging from a constant itch to multiple system
organ failure and death. With environmental degra-
dation and changes to water supply and rivers caused
by climate change, leptospirosis incidents of may be
rising in the area around Dili and other urban centers.
In the event of flash floods, landslides, earthquakes or
a tsunami, water borne illnesses increase.
Anemia caused by chronic disease, parasitic infect-
ions and malnutrition is possibly at epidemic levels.
Many parasitic infections lead to anemia, as do states
of malnutrition. Severe anemia can cause death, while
in chronic forms it can lead to impaired growth and
cognition for the developing brain, and in pregnant
women anemia can lead to low birth weight and
maternal death [25]. The combination of long-
standing anemia, inflammation, and target organ
damage causes growth retardation, under-nutrition,
and cognitive delays in children, adversely affecting
personal, economic and social growth [25].
Leptosporsis is a zoonosis from rats, dogs, livestock
and rodents that urinate into water supplies around
urban dwellings; it enters the body from infected
water supplies through cuts, abrasions, or the eyes or
mouth. Leptospiriss can be self-limiting, causing only
fever and flu-like illness, but it can also lead to
significant disability and multiple organ failure if not
diagnosed or treated properly, the best treatment
being prevention from exposure [55].
Soil-related Helminth infections (Acariasis, Trich-
uriasis and Hookworm infections) debilitate many
children and leave them socially ostracized and
chronically anemic through poor hygiene and lack of
prevention or educational resources [56]. Lymphatic
filariasis (elephantiasis) causes social ostracization and
dysmorphic effects from unnatural swelling of the
lymph nodes. This disease is not terribly common in
Timor-Leste but many residents are at risk for
contracting it through mosquito bites and treatment
remains expensive and out-of-reach for rural popu-
lations without adequate access to primary healthcare
services. If economic opportunity continues to decline
in the rural periphery and the Timorese continue to
ascend upon the capital Dili in search of work, urban
areas may exceed capacity and contribute to the
spread of disease. Also, in the event of further social
and political strife, incidences of the disease could
greatly increase.
Typhoid, treatable with a vaccine widely available in
the developed world, is prevalent in Timor-Leste,
although under-diagnosed and under-treated. Rabies,
from a variety of rabid animals (dogs, cats, bats, etc.)
living amongst rural populations is a severe risk to
health once patients become exposed through a bite
or scratch. Prophylaxis for rabies exists in the form of
pre- and post-exposure vaccines, but is very costly
and requires significant compliance with painful
inoculations and, in the case of post-exposure treat-
ment, prompt medical treatment is mandatory for
success. Upon exposure to rabies through saliva (ie.
an animal bite), prompt treatment before the virus
reaches the peripheral nerve can stop the disease
from spreading. However, with poor road infra-
structure, no remote medical clinics or the lack of
pharmaceutical cold chain management to maintain
safe and viable vaccines, this is not possible for much
of the at-risk population.
Amebic dysentery is also poorly diagnosed in many
medical laboratories, but is very prevalent in Timor.
Giardia lamblia, the parasite that causes bloating and
diarrhea, is also very common and debilitates many
people each year. The disease burden in post conflict
and fragile states is significant, and Timor-Leste is no
exception. Public health infrastructure and solid,
focused governmental policy can alleviate and prevent
many of these illnesses through renewed vaccination
and immunization efforts, basic health services, and
the promotion of hygiene practices.
4.5. Present Challenges for Health Policy in Timor-
Leste
The United Nations Children's Fund (UNICEF) esti-
mates that only 71% of children under five with
suspected pneumonia are taken to an appropriate
healthcare provider at; of this population it is
estimated that only 45% would receive antibiotic
treatment of any kind. Globally, pneumonia, and other
respiratory infections and diseases are a major con-
tributor to pediatric illness and fatality. UNICEF also
estimates that only 63% of children under five years
old with diarrhea received oral rehydration therapy
and continued feeding in 2010. Diarrhea and the
dehydration associated with it are the number one
causes of death in the developing world and can lead
to chronic malnourishment, growth and development
abnormalities, and an overall lack of health security
for children. In Timor-Leste, the risk of pediatric
diarrhea and complications such as acute dehydration
and death are significant.
In order to address of the growing disease burden,
and to increase the access to health services of
communities living in the rural and remote areas, the
Ministry of Health instituted the Servisu Integradu da
Saúde Communitária (Integrated Community Health
Services or SISCa) project. Dr. Nelson, Minister of
Health from 2007 to 2012, called upon District and
Sub-District Administrators, Suco Chiefs and Councils,
Aldeia Chiefs, Youth Organizations, Women's Net-
24
works and NGOs working within the country for
support. Collaboration within government-backed
public health programs offered by the SUSCa en-
genders partnership and disease prevention. However,
the gains made will be lost if continued inclusive
institutional investment in human and financial capital
with clear and sustainable targets and outcomes are
not further outlined.
4.6. Primary Prevention: Vaccination Catastrophe
The SISCa program provides disease prevention, early
treatment and, anecdotally, increases health security.
However, disease prevention through vaccination,
such as those available for polio and measles, is rarely
seen in Timor-Leste. Poor vaccine compliance and/or
access to viable vaccines contribute to this epidemic
of increasing incidence of preventable illness. These
barriers to care, which exacerbate risk factors, lead to
a vaccination catastrophe. Primary prevention in the
form of vaccination saves lives, reduces disease
burden and morbidity, and can eliminate disease when
carried out as a sustainable and consistent process.
The World Health Organization (WHO) Expanded
Program of Immunization (EPI), realised in collab-
oration with the UNICEF, the Ministry of Health, and
aid agencies in Timor-Leste, focuses on vaccination
coverage for children under the age of five against
measles, tetanus, diphtheria, polio, tuberculosis and
pertussis. Despite significant investment in cold chain
management, training, educational resources for
parents, and mechanisms to guarantee vaccination
compliance and coverage for children, data from
UNICEF suggest that only between 66 and 72% of
this population have currently received these basic
vaccinations. Less than 46% of reporting districts
have achieved more than 80% coverage of the third
effective dose of the diphtheria, pertussis and tetanus
vaccine [57].
When the herd immunity, the total immunity of a
population, drops below 90%, the risk of disease
outbreak increases logarithmically. Some patients in
the population are too sick, immune-compromised or
are allergic to be administered the vaccine but a herd
immunity of 90% can protect these otherwise ex-
posed members, as well as at-risk children. The risk of
infectious diseases which are totally preventable
through vaccine quickly leads to an outbreak when
herd immunity is consistently low and more children
are at risk of coming into contact with preventable
diseases which they are not immunized against.
Table 4 illustrates the risk of preventable infectious
disease in Timor-Leste for the vulnerable population
of under five year olds. The acute need for a re-focus
on primary healthcare and primary prevention through
vaccination and immunization against preventable
illnesses is highlighted here. Preventable illness and
infectious disease threaten state stability in Timor-
Leste by threatening health security.
Table 4. Immunization and Health data: Timor-Leste pediatric population [49,58‒60].
Immunization 2010, 1-year-old children immunized against: TB corresponding vaccines: BCG 71%
Immunization 2010, 1-year-old children immunized against: DPT corresponding vaccines: DPT1 75%
Immunization 2011, 1-year-old children immunized against: DPT corresponding vaccines: DPT3
(up to the third dose of vaccine booster)
67%
Immunization 2010, 1-year-old children immunized against: Polio corresponding vaccines: Polio3 72%
Immunization 2010, 1-year-old children immunized against: Measles corresponding vaccines:
Measles
66%
Immunization 2010, % newborns protected against tetanus 81%
With this, the comprehensive multi-year plan for
immunization, scheduled to be carried out from 2009
2013, aims to reach national immunization coverage
targets which have been established by the Millen-
nium Challenge Corporation (MCC). The MCC's Board
of Directors approved the Government of Timor-
Leste's threshold program proposal in May 2010 and
work started in 2011 in the form of the Millennium
Challenge Corporation Threshold Program for Immu-
nization (MCC-TPI). Timor-Leste's MCC-TPI, admin-
istered by United States Agency for International
Development (USAID), is assisting the Ministry of
Health in its efforts to increase nationally the coverage
of the third and final diphtheria, pertussis and tetanus
(DPT3) vaccine, as well as measles immunization rates
(these would increase herd immunity). This project's
goal is to achieve a combined national average of
81.5% coverage for DPT3 and total measles coverage
in children below one year of age by 2013. A
complementary goal for MCHIP is to strengthen the
Expanded Program on Immunization (EPI) to ensure
program sustainability.
5. Discussion
Timor-Leste has shifted from being a fragile state on
the verge of failure to one on a path of sustainable
stability. By improving its public health infrastructure,
25
programming and health security rooted in disease
prevention and primary healthcare access, both health
security and state stability will improve. Timor-Leste's
public health leadership has helped to establish a
programme which must receive continuous support
and development to succeed.
As external actors continue to depart from the UN
lead mission in 2012, local capacity at all levels must
continue to meet the daily challenges and be ever
more inclusive, sustainable and broad in scope. A fo-
cused developmental approach through public-private
partnership and transparency helps build capacity in
fragile state settings and engenders state building
[61‒63].
Humanitarian aid and development are in a state of
paradigm shift, with one force pushing for the growth
of new sources of aid and loans from middle income
countries, private capital and charitable organizations,
while the other focuses on the rights of individuals
and advocacy of at-risk populations and communities;
Timor-Leste can no longer rely on outside aid for
public health support and its future state stability pro-
spects. Humanitarianism may even be in a weak state
as the global financial crisis has challenged the
paradigm of donor financial support and subsequent
operations; sustainability is not integrated into this old
model of aid. There are aid organizations that focus
on little more than maintaining budgets, offering
antiquated solutions to complex issues, and keeping
projects in a steady state, but not actually fixing any
systemic problems [64]. By encouraging inclusive
institutional support at the public health level, general
capacity building and self-directed growth which
reduces the risk of failure, it is possible that a wholly
sustainable public health model can engender health
security and help solidify state stability by moving
away from external non-state and unilateral or-
ganization support.
Unilateral actors such as the United States (US)
and European Union (EU), as well as multilateral
actors like the UN, Asian Development Bank, and the
World Bank will be tested with one of the 21st
century's largest challenges: development within
fragile and failed states. US-based assistance focuses
on bolstering stability by strengthening the founda-
tions of good governance, accelerating economic
growth, improving the health of citizens, and sup-
porting the professionalization of security forces such
developmental support is a good method, but guid-
ance but must be temporary and sustainable.
5.1. Networks
"Goodbye conflict, hello development," may be the
introduction to the citizens guide to the 2012 budget
for Timor-Leste, but many regional challenges remain
for the country itself; this is outlined by the fledgling
economic and health security of its citizens. In 2010
the G7+ was formed by fragile and failed states in
order to create a collective voice and platform to
address their particular needs. The G7+ is a voluntary
association of countries that are or have been affected
by conflict and are now in transition to the next stage
of development, the main objective of which is to
share experiences and learn from one another, as well
as to advocate reforms to the way the international
community engages in conflict-affected states [65].
The G7+ promotes democracy, strong institutions
and good governance. This is a 'rock-bottom' help
network for countries that live with the threat of
failure. The Chair of this state support group is Timor-
Leste's Finance Minister, Emilia Pires, and the focus is
on clearly identifying the needs of the these fragile
nation-states in order to maintain and develop sus-
tainable policies and inclusive institutions that focus
on stability for their citizens.
The G7+ is a state-level support group which
draws upon public-private donors and actors and aims
to create focused policies which engender stability by
ending and preventing conflict. Aid effectiveness is a
main priority of the G7+, with peace and state
building as core components. The direct link between
Timor-Leste's leadership role in the G7+ and its public
health outcomes will not be seen for a decade or
more. However, the concept of building strong insti-
tutional capacities in state health infrastructure, and
the direct and indirect benefits of this capacity
growth, is seen in the public health advancements in
post-2002 Timor-Leste discussed throughout this
paper. The rising presence and leadership of Timor-
Leste in the G7+ is a clear example of how improve-
ments in public health have lead to sustainable state
stability.
5.2. Present State Challenges
The elections in mid-March, June and July 2012 were
defining moments in the stability of Timor-Leste and
for the idea of fragile states stabilizing with the
focused backing of inclusive institutions, rule of law,
governance and the democratic electoral process. This
socio-political transformation in Timor-Leste is seen in
safe and fair elections, and will be underscored by
political power and wealth being redistributed amongst
a variety of competing societal interests [66].
However, political will and democratic process are
not the only actors in the direction of state stability.
Timor-Leste has received oil and gas revenues from
major projects in the Joint Petroleum Development
Area that it shares with Australia. The Petroleum Fund
is a government-backed program aiming to ensure the
sustainable use of oil revenues over the long term.
Assets have grown from $6.9 billion in 2010, $8.3
billion in 2011 and reached over $10 billion in 2012
[67]. This steady financial growth has greatly
influenced the state's 'Poverty and Decline' level on
the FSI matrix and can help improve health security
when spent wisely on inclusive policy. It is up to the
26
democratically elected government of Timor-Leste to
allocate its financial resources in a way that will en-
gender human and health security for its citizens.
Economic development and growth in foreign direct
investment is significant and can offer sustainable and
inclusive state stability.
This paper does not set out to break down and
assess the budgetary strategy of Timor-Leste. How-
ever, year-on-year, and with the help of oil-resource
and foreign direct investment funds and aid, Timor-
Leste has been able to slowly build a budding
infrastructure and pay its healthcare staff to work and
become trained in this once war-ravaged country. The
Strategic Development Plan has helped pave the way
for an investment strategy that focuses strongly on
major infrastructure, skills, and structural gaps, which
may generate a sustainable private sector and reduce
poverty [68].
Despite this economic growth being relatively
consistent, this developing economy based on the US
dollar is still dependent on government spending and
assistance from international donors. Due to signif-
icant human capital shortages, not only in healthcare,
but also in engineering, legal and other sectors,
private sector development is slow to mature, public
health-related infrastructure (particularly in terms of
power and water) remains wanting, the judicial
system is incomplete, and an equal access market-
place or overall business environment remains to be
seen. The transition from state fragility to stability is
still tenuous and much remains to be done.
6. Conclusion
The FSI will not predict future human conflict or state
failure but it can better describe state fragility and
help focus attention on fragile and failing states for
immediate aid and intervention in an effort to prevent
state catastrophe. Fragile states have a diminished
ability to provide basic services and offer no
sustainable means of health security to their citizens.
The continued strengthening of government account-
ability and transparency, and re-focusing on the public
health sector are key components of public policy
promoting stability. An extremely young state, Timor-
Leste has struggled to maintain unity in government
while fighting greater structural weaknesses, including
corruption, political polarization, and dependence on
foreign aid. The G7+ offers a platform for fragile and
failed states to promote stability through organically
constructed institutions and public policy.
Increasing health security will continue to guide
Timor-Leste from fragile to stable statehood. A re-
inforced public health policy of primary healthcare
access, immunizations and increased overall vac-
cination coverage for the under five-year-old population
may increase health security significantly. Timor-Leste
clearly illustrates the link between public health
institutions and health security and state stability and
development. Lessons learned from Timor-Leste's still
complex transition from a post-conflict state to a
successful nation can provide international leadership
an example of which it should take note. Endemic
infectious disease, decreased health security and weak
but growing public institutions keep Timor-Leste fragile,
while new investment and economic prospects, when
handled properly and with efficient and appropriate
public health policy, may engender state stability and
may help to avoid state failure. Health Security is
directly linked to state security. Public health policy
must be implemented in order to prop up its fledgling
public health sector and still growing democratic
institutions. Increasing health security through public
health can push Timor-Leste out of fragility and
engender sustainable economic growth, development
and consequently true statehood.
Competing Interests
The authors declare that they have no competing
interests
Author Contributions
JQ and NM wrote the first draft of the manuscript. MC
offered data and data confirmation from the Ministry
of Health. VB, DM and MH supported data,
organization, methodology and contributed to revising
subsequent drafts. All authors approved the final
version.
Disclosures
John Quinn performed a two-phase heath assessment
of Timor-Leste in 2011 and presented his findings and
solutions to the Minister of Health in May 2011. There
are no commercial disclosures or statements to
release.
Nelson Martins served as Minister of Health for Timor-
Leste from 2007 to 2012, the comments and
contributions made within this paper are his own and
do not necessarily reflect government or ministerial
policy, past, present or future.
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Appendix 1. List of Abbreviations
CAVR Comissão de Acolhimento, Verdade e Re-
conciliação (Commission for Reception,
Truth and Reconciliation)
Csxxx composite score of the Failed States Index
EC European Commission
ESA Agricultural Development Economics Division
EU European Union
FSIxxxx Failed States Index
IMF International Monetary Fund
MDG Millennium Development Goals
OCHA Office for the Coordination of Humanitarian
Affairs, United Nations
USAID United States Aid and International
Development
WHO World Health Organization
WFP World Food Program
UN United Nations
31