Civic Engagement is Creating a More Equitable Health System in Timor-Leste
Civil society was a key force behind Timor-Leste’s independence in 2002 from Portuguese colonization and Indonesian occupation and continues to play a crucial role in the country’s development. After independence, civil society organizations (CSOs) helped rebuild the country by providing humanitarian assistance and serving Timorese families. Today, they are helping revitalize Timor-Leste’s health system.
The country’s vibrant CSO landscape includes as many as 250 municipal and national non-governmental organizations (NGOs) belonging to the Forum of Nongovernmental Organizations of Timor-Leste (FONGTIL). Fifty-two of these are engaged in health-related activities, and 43 are actively working in the four priority health areas of water, sanitation, and hygiene; maternal and child health; nutrition; and TB prevention and care. With their deep understanding of and close ties to communities, these CSOs are well positioned to identify health system problems and solutions, contribute ideas to the Ministry of Health’s (MOH) annual action plan, and participate in monitoring that holds the government accountable.
These contributions are sorely needed. A political economy analysis conducted by the USAID Health System Sustainability Activity (the Activity) in 2022 revealed that despite attempted reforms, social accountability remained weak within Timor-Leste’s MOH. Citizens and communities were not active participants in health system governance, demand from the public for quality health care was tepid, and national health leaders had limited understanding of community health priorities. As a result, the health system’s failures have had an outsized effect on underserved and vulnerable populations, including people with disabilities, young women, and those living in distant, rural villages.
The Activity recognized that CSOs can help remedy this. But first, mechanisms for participatory governance were needed to allow CSOs to engage meaningfully with the MOH and to build trust and shared accountability between the two sides. To create a bridge between the MOH and CSOs, the Activity coordinated the creation of a health network consisting of the 43 CSOs working in priority health areas. The resulting network, called the Timor-Leste Health Network (Rede Ba Saúde Timor-Leste, REBAS-TL) includes women’s groups, organizations of people living with disabilities, youth groups, media associations, and associations working for lesbian, gay, bisexual, transgender, queer, and other marginalized groups. It was launched amid joyful celebration in May 2022.
Following the establishment of REBAS-TL, the Activity focused on strengthening the network’s understanding of the health system’s functions and the importance of advocacy and civic engagement to improve health. The Activity created a positive, criticism-free space for the MOH and CSOs to discuss their priorities, roles, and concerns and figure out where they could collaborate. Empowered through the new REBAS-TL network, CSOs have begun bridging the gap between communities and the health system and advocating for policies and services that reduce health disparities and prioritize the needs of marginalized populations. And for the first time since Timor-Leste’s independence, the MOH has formally recognized CSOs as partners in shaping the health system rather than as just service providers, as documented in the MOH’s national partnership manual.
Celebrating the one-year anniversary of REBAS-TL’s launch this year, we could already see tangible change. With the Activity support, REBAS-TL contributed to the MOH’s development of the first-ever health worker job descriptions and recruitment manual, designed to help the MOH fill longstanding vacancies through a competency- and merit-based hiring process. REBAS-TL also shared its priorities around the country’s 2020–2030 health sector strategic plan, the national human resources for health strategy, and essential health service packages.
At the local level, Asosiasaun Feto ba Futuru, a REBAS-TL member, engaged with the municipal health director in Manatuto municipality to discuss malnutrition in the community and a lack of medical supplies at the health post — issues that health authorities are often unaware of. Similarly, Asosiasaun Rede Covalima engaged with the health director of Covalima municipality to raise awareness about malnutrition, infant mortality, and the absence of doctors at some of health posts. The organization will continue to monitor the actions that were agreed upon with the director. Elsewhere, two other CSOs in the REBAS-TL network advocated for inclusion in municipal health consultative meetings in accordance with the national partnership manual and now consistently receive invitations from health authorities to report on key health issues in the community and identify potential solutions.
In the coming year, the Activity will continue to support REBAS-TL in advocating for health policies and services that are evidence-based, patient-centered, and culturally appropriate. We will also facilitate engagement between the MOH and REBAS-TL to define mechanisms for the MOH to openly and regularly share health data with the CSOs.
By taking a whole-of society-approach and embracing health system complexity, the Activity identified a novel solution that brings CSOs together and uses their collective strength to help improve the health system. The REBAS-TL network represents an innovative and important step toward a locally led, accountable, transparent, and inclusive health system.