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

*, Nelson Martins

**, Mateus Cunha

, Michiyo Higuchi

, Dan Murphy

and Vladimir Bencko

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.quin[email protected] (JMQ),

vladimir[email protected] (VB)

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: lalata[email protected]

** Former Minister of Health for the Democratic Republic of Timor-Leste 2007–2012

Ministry of Health, Dili, Democratic Republic of Timor-Leste; E-Mail: cunha2009ph@gmail.com

Department of Public Health and Health Systems, Nagoya University School of Medicine, 466–8550 Aichi,

Japan; E-mail: [email protected]

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

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-

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.

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

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

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

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;

) 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

)

(FSI

2008

= 25;

93.8

), (FSI

2009

= 20; CS

97.2

), (FSI

2010

= 18; CS

98.2

(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;

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

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

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

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-

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,

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

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.

References

[1] Ng N, Prah Ruger J. Global Health Governance at

a Crossroads. Global Health Governance.

2011;3(2):1‒35.

[2] Labonté R, Gagnon M. Framing health and foreign

policy: Lessons for global health diplomacy.

Globalization and Health. 2010;6(14):1–19.

[3] Kent G. Freedom from Want: The Human Right

to Adequate Food. Washington, DC, USA:

Georgetown University Press; 2005.

[4] Galtung J. Violence, peace and peace research.

Journal of Peace Research. 1969;6;167–191.

[5] Galtung J, Höivik T. Structural and Direct

Violence: A note on operationalization. Journal of

Peace Research. 1971;8(1)73–76.

[6] Gilligan J. Violence: Reflections on a national

epidemic. New York, NY, USA: Vintage Books;

1997.

[7] Aldis W. Health Security as a public health

concept: A critical analysis. Health Policy

Planning. 2008;23(6):369–375.

[8] Chiu YW, Weng YH, Su YY, Huang CY, Chang YC,

Kuo KN. The nature of international health

security. Asia Pacific Journal of Clinical Nutrition.

2009;18(4):679–83.

[9] Macrae J. Purity or Political Engagement?: Issues

in food and health security interventions in

complex political emergencies. Journal of

Humanitarian Assistance. 1998. Availaible from:

http://sites.tufts.edu/jha/archives/126.

[10] Kasper DL, Fauci AS. Harrison's Infectious

Diseases. New York, NY, USA: McGraw-Hill;

2010.

[11] Patrick S. Weak Links: Fragile States, Global

Threats and International Security. A Council on

Foreign Relations Book. New York, NY, USA:

Oxford University Press; 2011.

[12] Quinn JM, Bencko V. Food security, public health,

financial regimes and international law. Chapter

23. In: Westra L, Soskolne CL, Spady DW,

editors. Human Health and Ecological Integrity.

London, UK: Earthscan from Routledge; 2012.

[13] Inter-Parliamentary Union. Declaration adopted

at the Parliamentarians' Day on the occasion of

the World Food Summit. Italian Senate of the

Republic. Rome, Italy; 15 November 1996.

[14] Acemoglu D, Robinson JA. Why Nations Fail: The

origins of power, prosperity and poverty. London,

UK: Profile Books; 2012.

[15] Collier P. The Bottom Billion: Why the poorest

countries are failing and what can be done about

it. Oxford, UK: Oxford University Press; 2007.

[16] Stiglitz J. Making Globalization Work. New York,

NY, USA: Norton; 2006. p. 44.

[17] Akpeninor JO. Modern Concepts of Security.

London, UK: Author House; 2012.

[18] Nye JS. Collective Economic Security.

International Affairs (Royal Institute of

International Affairs) 1974;50(4)584–598.

[19] Gros JG. Towards a taxonomy of failed states in

the New World Order: Decaying Somalia, Liberia,

Rwanda and Haiti. Third World Quarterly.

1996;17(3):461.

[20] Rotberg RI. State Failure and State Weakness in

a time of Terror. World Peace Foundation.

Washington, DC, USA: Brookings Institution

Press; 2003.

[21] Rotberg RI. When States Fail: Causes and

Consequences. Princeton, NJ, USA: Princeton

University Press; 2004.

[22] The Fund for Peace. Failed States Index 2011

and Conflict Assessment Indicators: Country

analysis indicators and their measures.

Washington, DC, USA: The Fund for Peace

publication CR-11-14-FS (11-06Q); 2011.

[23] Naim M. Illicit: How Smugglers, Traffickers and

Copycats are Hijacking the Global Economy. 1st

Edition. New York, NY, USA: Doubleday Press;

2005.

[24] Zartman IW. Cowardly Lions: Missed

Opportunities to Prevent Deadly Conflict and

State Collapse. London, UK: Lynne Rienner

Publisher; 2005.

[25] Hotez PJ. Forgotten People, Forgotten Diseases:

The neglected tropical diseases and their impact

on global health and development. Washington,

DC, USA: George Washington University and

Sabin Vaccine Institute, ASM Press; 2008.

[26] Hotez PJ. Vaccines as Instruments of Foreign

Policy. European Microbiology Organization

(EMBO) Report. 2001;2(10):862–868.

[27] Catalano R. The health effects of economic

insecurity. American Public Health Association.

American Journal of Public Health.

1991;81(9):1148–1152.

[28] Paris R. Human Security: Paradigm Shift or Hot

Air? International Security. 2001;26(2):87–102.

[29] Schrecker T. Multiple crises and global health:

New and necessary frontiers of health politics.

Global Public Health: An International Journal for

Research, Policy and Practice. 2012;7(6):557–

573. Available from: http://dx.doi.org/10.1080/

17441692.2012.691524.

[30] Burr W, Evans LE, editors. East Timor Revisited:

Ford, Kissinger and the Indonesian Invasion,

1975‒1976, Ford and Kissinger Gave Green Light

to Indonesia's Invasion of East Timor, 1975: New

Documents Detail Conversations with Suharto.

Washington, DC, USA: National Security Archive,

Electronic Briefing Book No. 62; 6 December

2001.

[31] Human Rights Watch. East Timor: Forced

Expulsions to West Timor and the Refugee Crisis.

1 December 1999. Document No. C1107. Avail-

able from: http://www.refworld.org/docid/45cc

24ac2.html.

[32] Waldman RJ. Prioritizing health care in complex

emergencies. The Lancet. 2001;357(9266):

1427–1429.

[33] Wayte K, Zwi AB, Belton S, Martins J, Martins N,

Whelan A, Kelly PM. Conflict and development:

Challenges in responding to sexual and reprod-

uctive health needs in Timor-Leste. Reproductive

Health Matters. 2008;16(31):83–92.

[34] Wild K, Barclay L, Kelly P, Martins N. The tyranny

of distance: Maternity waiting homes and access

to birthing facilities in rural Timor-Leste. Bulletin

of the World Health Organization. 2012;90(2);

97–103.

[35] UN Security Council. Security Council resolution

1704 (on establishment of the UN Integrated

Mission in Timor-Leste (UNMIT)). 25 August

2006. Report No. S/RES/1704.

[36] United States Department of State. Bureau of

East Asian and Pacific Affairs: Background Note:

Timor-Leste. 11 October 2011. Available from:

http://www.state.gov/r/pa/ei/bgn/35878.htm.

[37] Alonso A, Brugha R. Rehabilitating the health

system after conflict in East Timor: A shift from

NGO to government leadership. Health Policy

and Planning. 2006;21(3):206–216.

[38] Martins N, Hawkins Z. Striving for better health

through health research in post-conflict Timor-

Leste. Health Research Policy and

Systems. 2012;10(13)1–4. Available from: http://

www.ncbi.nlm.nih.gov/pmc/articles/PMC3359172.

[39] Brooks R, Silove D, Steel Z, Rees S. Explosive

anger in postconflict Timor-Leste: Interaction of

scoio-economic disadvantage and past human

rights-related trauma. Journal of Affective

Disorder. 2011;131(1)268–276.

[40] Reghupathy N, Judge DS, Sanders KA, Amaral

PC, Schmitt H. Child size and household

characterization in rural Timor-Leste. American

Journal of Human Biology. 2012;24(1):35–41.

[41] da Costa M, Erkskine W, Nesbitt H, Spyckerelle L,

do Rosario Ferreira A, Zimenes A, Lopez M.

Household food insecurity in Timor-Leste. Food

Security. 2013;5(1):83–94.

[42] International Fund for agricultural Development

(IFAD). Improving food security in Timor-Leste

to end 'hungry season', US$5.6 million from

IFAD for agricultural development. Newsroom

Press Release: Press release No.: IFAD/37/2012.

Available from: http://www.ifad.org/media/

press/2012/37.htm.

[43] Kelly M. Working with farmers for better

agriculture in Timor-Leste. Proceedings of the

Transforming Timor-Leste Conference. 6–7 July

2009. Available from: http://hdl.handle.net/

10536/DRO/DU:30024764.

[44] World Health Organization (WHO). Global Health

Observatory (2012). Available from: http://

www.who.int/gho/database/en/.

[45] Food and Agricultural Organization of the United

Nations (FAO). Food Security Statistics, Pre-

valence of Undernourishment in Total Population

(online database), 2012. Available from:

http://www.fao.org/economic/ess/ess-fs/en/. In

PDF available from: http://www.fao.org/

docrep/018/i3107e/i3107e02.pdf.

[46] World Health Organization Statistics (WHO

2012). Available from: http://www.who.int/

gho/publications/world_health_statistics/2012/en/

index.html.

[47] United Nations Children's Fund (UNICEF). The

State of the World's Children 2011: Adolescence,

an age of opportunity. New York, NY, February

2011.

[48] Central Intelligence Agency (CIA). The World

Fact Book (2012). Timor-Leste. Washington, DC,

USA: Central Intelligence Agency; 2013. Avail-

able from: https://www.cia.gov/library/publi-

cations/the-world-factbook/geos/tt.html.

[49] Ministry of Health (MoH). Health profile. Dili,

Timor-Leste: Ministry of Health; 2002. Available

from: http://www.searo.who.int/timorleste/pub

lications/Health_Information_TLS_Health_profile_

RDTL.pdf.

[50] Gupta I, Pradeep G. Communicable diseases in

the South-East Asia region of the World Health

Organization: Towards a more effective re-

sponse. Bulletin of the World Health Organ-

ization. 2010;88(3)199–205.

[51] Martins N, Kelly PM, Grace JA, Zwi AB.

Reconstructing Tuberculosis Services after Major

Conflict: Experiences and Lessons Learned in

East Timor. Public Library of Science (PLoS)

Medicine. 2006;3(10):e383.

[52] Martins N, Kelly P. Food incentives to improve

completion of tuberculosis treatment: Ran-

domised controlled trial in Dili, Timor-Leste.

British Medical Journal. 2009;339:b4248. Avail-

able from: http://www.bmj.com/content/339/

bmj.b4248.

[53] World Health Organization (WHO). Regional

Office for South-East Asia. Country Profile:

Timor-Leste. Communicable Disease Depart-

ment, Tuberculosis. March 2009. Available from:

http://www.searo.who.int/en/Section10/Section2

097/Section2100_14804.htm.

[54] Martins JS, Zwi AB, Martins N, Kelly PM. Malaria

control in Timor-Leste during a period of

politicalinstability: What lessons can be learned?

Conflict and Health. 2009;3(11):1–10.

[55] Eddleston M, Davidson R, Brent A, Wilkinson R.

Oxford Handbook of Tropical Medicine. Third

Edition. Oxford, UK: Oxford University Press;

2010.

[56] Hotez PJ, Ehrenberg JP. Escalating the global

fight against neglected tropical disease through

interventions in the Asia Pacific region. Advances

in Parasitology. 2010;72:31–53.

[57] World Health Organization (WHO). World Health

Statistics 2011. Geneva, Switzerland. Joint Re-

porting Form. Available from: http://www.

who.int/whosis/whostat/2011/en/index.html

[58] United Nations Children's Fund (UNICEF). At a

Glance: Timor-Leste. Statistics. 2011. Available

from: http://www.unicef.org/infobycountry/Timor

leste_statistics.html

[59] United Nations (UN), Department of Economic

and Social Affairs, Population Division 2009.

World Population Prospects: The 2008 Revision,

Highlights. New York, NY, USA. Working Paper

No. ESA/P/WP.210.

[60] World Health Organization (WHO). WHO Vaccine

Preventable Diseases: Monitoring System 2012:

Global Summary. Available from: http://www.

who.int/vaccines/globalsummary/immunization/ti

meseries/tswucoveragedtp3.htm.

[61] Fritz V, Menocal AR. Developmental States in the

New Millennium: Concepts and Challenges for a

New Aid Agenda. Development Policy Review.

2007;25(5):531–552.

[62] Macrae J, Zwi A, Birungi H. A healthy peace?

Restructuring and reform of the health sector in

a post-conflict situation—the case of Uganda.

London School of Hygiene and Tropical Medicine,

and Makerere University, Uganda. In: Walt G.

Health policy: an introduction to process and

power. London, UK: Zed Books; 1993. pp. 84–85.

[63] Kruk ME, Freedman LP, Anglin GA, Waldman RJ.

Rebuilding health systems to improve health and

promote statebuilding in post-conflict countries:

A theoretical framework and research agenda.

Social Science and Medicine. 2010;70(1):89–97.

[64] Moyo D. Dead Aid: Why aid is not working and

how there is a better way for Africa. New York,

NY, USA: Farrar Straus & Giroux; 2011.

[65] Da Costa H. G7+ and the New Deal: Country-Led

and Country-Owned Initiatives: A perspective

from Timor-Leste. Journal of Peacebuilding and

Development, Special Issue: Hybridity in Peace-

building and Development. 2012;7(2)96–102.

[66] Sahin SB. Building the nation in Timor-Leste and

its implications for the country's democratic

development. Australian Journal of International

Affairs. 2011;65(2)220–242.

[67] Venancio AM, de Vasconselos A. Petroleum Fund

of Timor-Leste: Quarterly Report. Timor-Leste.

2012;8(XXII).

[68] World Bank. Democratic Republic of Timor-Leste

Joint Staff Advisory note on the Poverty

Reduction Strategy Paper. 29 April 2005. Report

No: 31924-TP, Volume 1.

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