Currently, there is no in-country facility at the Timorese people can access first world tertiary care, and only a few wealthy Timorese who are able to access this level of health care in other countries. The majority of health care in the country is provided via primary care, local health posts and district health clinics with referrals to the few secondary care facilities for life-threatening conditions.
Despite an infant and maternal death rate that is among the highest in the world, half of the population of Timor-Leste is under 15 years of age. Curable and treatable diseases are among the leading causes of death, and the average life expectancy in Timor-Leste is 56 years, compared to 82 years in Australia. Other current health statistics underpinning the rationale for the proposed Hospital services include:
. There is only one doctor per 10,000 citizens in Timor-Leste, compared with one doctor per 400 citizens in Australia;
. There are currently around 500 hospital beds for 1.2 million people available in Timor-Leste, half of which are at the Dili National Hospital, compared to over 5000 beds per million people in Australia; in other words there is one hospital bed per 2,400 people in Timor-Leste, compared with one hospital bed per 200 people in Australia;
. One in three children is severely stunted as the result of malnutrition. Malnutrition is a major risk factor for susceptibility to infection and poor outcome of serious illness or surgery.
. There is no consistent sub-specialist care in Timor-Leste.
The Timor-Leste Ministry of Health is committed to providing quality health care to its citizens, and is working closely with international aid organisations to rebuild its health system. Other major funders (Cuba, WHO, USAID, World Vision, CARE, Red Cross etc) are focused on primary health care provision, leaving a very significant gap in Timor-Leste's health services.
The Dili National Hospital, the largest and best-resourced health facility in the country does offer limited tertiary care, but its capacity to do so across the full range of health issues is severely limited by difficulties in procuring, operating and servicing high-level medical equipment and by the availability of trained medical and nursing staff.
The creation of a quality, tertiary care and teaching hospital will therefore fill the major gaps in care that currently exist, and to assist in building the capacity of the East Timorese health system to develop into the future. HOH regularly consults with the Timor-Leste Ministry of Health and key organisations in the existing health system as it develops the HOH services.
At present an increasing number of Timorese patients are being transferred as emergencies to hospitals in Surabaya and Bali at a cost to the Timor government of many millions of dollars.
These transfers are always stressful and difficult with the patient's health deteriorating as hasty arrangements are put in place for the transfer. The patient and a relative are taken to a foreign country, having never been out of Timor-Leste before in most cases, where there is no family support.
By virtue of the fact that they are usually seriously ill these patients often die out of country leaving a very distressed and lonely relative who then has to arrange the transfer of a body back to Timor-Leste at great expense and with up to a months delay.
HOH should be able to treat the great majority of these patients meaning that much of this distress and trauma will be avoided. Because there will be no delay in treatment there should be far better outcomes for the patient.
Timor-Leste's population is predominantly young (43.2% of the population are under 15), so whilst the proportion of congenital heart defect is fairly constant between populations, there is a very significant burden of congenital cardiac disease in Timor-Leste.
Poverty exposes large proportions of the Timor-Leste population to scabies, and consequential infection with Group A streptococcal infection, which can result in rheumatic fever and rheumatic heart disease (RHD)(often labelled the disease of the poor). RHD frequently requires surgical intervention by means of heart valve surgery which a tertiary hospital, such as the one planned, will provide. Without intervention it is usually fatal. Cardiologists who have come as part of Associate Professor Cochrane's team estimate that up to 250 young patients in Timor-Leste require and are suitable for this heart surgery each year. This does not take into account the backlog of untreated cases already existing in Timor-Leste.
Estimates available from the World Health Organization suggest that the need for paediatric cardiac services in the developing world is one surgical centre per million people. *
Dr Dan Murphy of Bairo Pite Clinic has publicly stated his clinic alone has a waiting list of 300 patients requiring heart surgery. `I've got a book full and I just cross them out as they die. If they were in Australia, they would be operated on'.
Orthopaedic surgery is vastly under-resourced in both human and financial terms in Timor-Leste. Conditions which receive early surgical intervention in Australia result in permanent disability and life-threatening complications in Timor-Leste. Timely orthopaedic surgery has a very high rate of success in eliminating or significantly mitigating disability, when treatment is provided early. Plastic Surgery
There are a variety of problems which can be resolved by plastic surgery in Timor-Leste. These include congenital defects and deformities, burns and cleft palate defects. Cleft palate defects require early intervention to ensure the child has the opportunity to live life without physical deformity and to avoid the social, economic and cultural impacts of deformity. Dependence on fires, both indoor and outdoor, results in accidental burns and scalds particularly in children. Without treatment burns can lead to serious disability and chronic pain. There is an identified link between children suffering untreated / undiagnosed epilepsy in Timor-Leste and children who sustain burns in their homes.
Surgical missions to Timor-Leste including the East Timor Eye Group are significantly limited by resources in Timor-Leste. Their efforts concentrate on cataract removal and lens implants, but they are unable to address the wide range of other eye conditions that receive routine treatment in Australia. The ability to provide treatment would prevent permanent blindness and visual disability, as well as other life-threatening conditions.
While the primary care of infectious diseases is not a core focus of HOH's services, given the high incidence of malaria and tuberculosis in the Timorese population, many patients reviewed for specialist surgery will also suffer from infectious disease. HOH can commence treatment for these diseases which rely on adherence to a pharmaceutical regime over a period of months. There will be other patients who will be referred to HOH to treat the complications of tuberculosis or for primary care of severe malaria, TB or haemorrhagic dengue fever. Protocols for the isolation of patients with infectious disease will need to be implemented as a priority to ensure the safety of patients at all times.
Patients who are severely ill with tuberculosis, malaria and dengue will be admitted on a daily basis through referral from other hospitals, particularly if Dili National and other facilities are not able to admit the patient.
An essential and intrinsic part of the HOH vision is to train the citizens of Timor-Leste to progressively participate in, and eventually take over the provision of the clinical services of the Hospital, as well as the operation and administration of the Hospital. Flinders University Medical Faculty runs a campus in Darwin and has indicated strong support for the project. All medical, nursing and allied health staff will participate both in the delivery of care and also in the delivery of training to Timor-Leste undergraduate and post graduate allied health, nursing and medical staff.
* Editorial, 'Establishing Paediatric Cardiovascular Services in the Developing World - A Wake-Up Call', Circulation (American Heart Association), 2007; 116:1876-1878.
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