23 July 2020
Swift action prevents community transmission of COVID-19 in Timor-Leste
THE LONG READ
In a small village in the west of Timor-Leste, a village chief is awakened at 4am. A community member urgently passes on the news that a person has arrived from the border.
He immediately contacts the newly-formed government surveillance team that visits, interviews and refers migrants to a government quarantine facility for assessment and testing for COVID-19.
“This is a job I take very seriously. I know that if I let my guard down for just one moment, lives will be at stake,” said Sr Eurico da Costa de Jesus, who served as village chief for 15 years in Comoro, Dili.
In April, Timor-Leste had 24 confirmed cases, but its closest neighbour, Indonesia with whom it shares a land border has regularly been reporting a rapid rise in numbers. Community vigilance along the borders, while respecting migrants’ human rights, is just one part of a vital and complex surveillance system for COVID-19, involving hospital, health facility, sentinel and national data collection. It is led by the Ministry of Health and supported by WHO along with the UHC Partnership and other multi- and bi-lateral partners and is part of the intensified effort to protect the population from COVID-19.
Eurico da Costa de Jesus, Village Chief, Comoro, Dili
Transforming a fragile health system
For any country, COVID-19 presents a daunting challenge. For a new country like Timor-Leste, which has a fragile health system with a limited health budget, a shortage of health workers, and an underfunded medical supply system, COVID-19 could spell disaster. However, the Ministry of Health has acted swiftly, enabling the country to effectively contain the outbreak so far. The Ministry’s leadership has worked closely with WHO and has received a high level of technical support from the UHC Partnership.
Until now, almost all cases have been linked to clusters contained within government identified quarantine centres. There has, so far, been no community transmission.
This could change at any time but as a result of early positive steps, the country is in a stronger position to respond to new outbreaks.
Until the first confirmed case on 21 March 2020, Timor-Leste had no identified isolation and quarantine facilities, limited surveillance capacity and had just initiated in-country testing for COVID-19.
In five to six weeks, it transformed to have in-country testing, functional COVID-19 facilities, staff rapidly trained on COVID-19 management, a gradual increase in stocks of Personal Protective Equipment (PPE), capacity for an expanded testing strategy and active surveillance capabilities.
So how did this transformation come about?
A lab technician working at the National Health Laboratory on the PCR workstation donated by WHO.
National action and international cooperation
Since 2011, WHO has been supporting Timor-Leste to strengthen its health system. Through the UHC Partnership, it provides extensive technical assistance in areas such as health financing, primary health care and human resources for health, thanks to the funding provided by the European Union (EU), the Grand Duchy of Luxembourg, Irish Aid, the Government of Japan, the French Ministry for Europe and Foreign Affairs, the UK Department for International Development and Belgium.
As soon as WHO warned the world of the threat of COVID-19 and subsequently declared a Public Health Emergency of International Concern on 30 January, the WHO country office led by Dr Rajesh Pandav, WHO Representative, took immediate action. The long-standing relationship between WHO and the Government proved crucial at this stage.
Dr Pandav met with President Francisco Guterres, Prime Minister Taur Matan Ruak, the Parliament and senior government officials to continually raise the alarm for urgent preparedness.
Political leaders and the government responded to this call. The Prime Minister set up a crisis management centre and multisector task force, which then developed a national COVID-19 Preparedness Action Plan with support from WHO and other partners.
WHO Representative to Timor-Leste, Dr Rajesh Pandav, along with the UN Resident Coordinator, Mr Roy Trivedy, the Minister of Health and selected officials in an initial meeting with the Prime Minister long before the first confirmed COVID-19 case in Timor-Leste.
Photo courtesy of the Prime Minister’s Office, Timor-Leste
WHO’s previous work with Timor-Leste also paved the way for an effective response. In 2019, WHO supported the development of the country’s Pandemic Influenza Preparedness Plan and integrated it with the National Action Plan for Health Security. This helped place Timor-Leste in a strong position to prepare for all health security situations in the medium- to long-term, map multisectoral health security resources and take action around COVID-19 for sustainable preparedness.
“WHO’s role in supporting the Ministry of Health in responding to the COVID-19 pandemic has been both crucial and exceptional,” said Sr Narciso Fernandes, National Director, Policy, Planning and Cooperation, Timor-Leste.
“We are achieving very important gains in Timor-Leste through our partnership with WHO. We are committed to supporting the country to ensure that its citizens are safe from COVID-19 and future pandemics. The world will not be safe until everyone is safe,” said Andrew Jacobs, EU Ambassador to Timor-Leste.
Sr Narciso Fernandes, National Director, Policy, Planning and Cooperation, Timor-Leste
© WHO / Shobhan
Andrew Jacobs, EU Ambassador to Timor-Leste
© WHO / Shobhan
Technical assistance and flexible funding
WHO was on the ground straight away when the first suspected case of COVID-19 was reported. The initial patient interview and support with testing was provided by WHO staff supported through the UHC Partnership.
The UHC Partnership’s funding and technical support is programmed to be flexible in order to quickly respond to priorities identified by the government. This agility and bottom-up approach has made all the difference.
WHO then guided the nationwide response by providing technical assistance to establish quarantine and isolation centres, testing facilities, training health workers and emergency responders in case management, infection prevention and surveillance, and building capacity for data collection. It also provided the country with its first set of test kits and Personal Protective Equipment (PPE) for health workers.
Timor-Leste’s statement at the 73rd World Health Assembly in May 2020 acknowledged this WHO support:
“I would like to express my deep gratitude for the support we have received from the World Health Organization in strengthening our COVID-19 response. The technical and logistical support from the country office and the regional office, including the supply of our first batch of PPE and test kits, have been crucial for a rapid and comprehensive response. The Ministry of Health appreciates the continued support from Dr Rajesh Pandav, WHO Representative, Timor-Leste and Dr Poonam Khetrapal Singh, Regional Director, WHO South East Asia Region,” said Dr Odete da Silva Viegas, Director General of Health Services, Ministry of Health, Timor-Leste.
Timorese health workers undergoing training on how to use PPE facilitated by WHO and other health development partners.
“The support from WHO has been immensely valuable right from the outset. This includes the National Action Plan for COVID-19 preparedness and response, numerous technical guidelines adapted to the Timor-Leste context, laboratory support, training of health workers and surveillance capacity building,” said Bonifácio Maucoli dos Reis, Vice Minister for Strategic Health Development and Acting Minister of Health.
Dr da Silva Viegas added: “COVID-19 has emphasized the criticality of a strong and resilient health system focused on primary health care as the best response to this and future pandemics. Timor-Leste is firmly committed to providing universal health coverage to all its people.”
Dr Odete da Silva Viegas, Director General of Health Services, Ministry of Health, Timor-Leste
© WHO / Shobhan
Bonifácio Maucoli dos Reis, Vice Minister for Strategic Health Development and Acting Minister of Health, Timor-Leste
© WHO / Shobhan
Collaboration through partners
WHO and the EU, through the UHC Partnership, are co-chairs of the Timor-Leste Development Partners Forum. WHO and the EU have emphasized that, now more than ever, all bilateral partners need to work in solidarity and coordinate their efforts. During the COVID-19 outbreak, partners sought WHO’s advice and relied on the country office as a point of coordination to support Timor-Leste’s national emergency response.
WHO also initiated strong multisectoral dialogue. With this solid foundation, all country health partners helped meet the government’s needs, including providing additional funding. Taking advantage of WHO’s convening power, agencies including the United States Agency for International Development (USAID) and the Australian Government’s Department of Foreign Affairs and Trade (DFAT) provide collective support not only for the national response to COVID-19 but also for other health services including a recent outbreak of dengue and a flooding emergency.
Moving forward: ears on the ground
Timor-Leste’s ‘state of emergency’ includes travel restrictions, managed migration and other social interventions such as physical distancing and wearing of masks in communal areas, temporary suspension of schools and religious congregations, restrictions on public transport and cash transfer for poor households. But when these restrictions are lifted, community transmission is likely to follow. It is therefore crucial to establish an early warning system to identify ‘hotspots‘ where the disease is spreading, introduce localized restrictions and reinforce public health and social measures.
Stronger surveillance and expanded testing are currently providing ‘ears on the ground’ to pick up early signals of cases. All referral hospitals and municipalities now act as sentinels and collect samples on a regular basis. When cases are detected, the surveillance team responds immediately with contact tracing. Communities also need to continue looking out for any possible threat and alert the authorities.
“We are looking out for each other as a community. We are looking out for our country. This is the only way we can be safe,” said Virginia dos Santos, a student and professional fashion model from Timor-Leste.
WHO has also developed and supported a surveillance database, which the Ministry of Health now uses to track all COVID-19 tests and confirmed cases, and numbers in quarantine and isolation. All the information from the Ministry of Health and the government crisis management centre comes from this surveillance database. This system will soon be integrated into the country’s general health information system.
Dr Rajesh Pandav, WHO Representative to Timor-Leste
© WHO / Shobhan
Virginia dos Santos, student and professional fashion model
© WHO / N. Fernandes
“The COVID-19 preparedness and response journey in Timor-Leste is far from over, but it is immensely gratifying to witness this solidarity and commitment at the national and global level as we work alongside the Government of Timor-Leste and the EU delegation, and to have the push and persistence from WHO both at the Regional Office and the Headquarters in Geneva. If we stand together, we can control COVID-19 before it takes more lives,” said Dr Rajesh Pandav, WHO Representative to Timor-Leste.
There have been no confirmed cases in Timor-Leste for the last two months, but with cases still rising in neighboring Indonesia, the spectre of COVID-19 importation looms large. Timor-Leste’s health system has now incorporated a proper emergency response mechanism and is doing all that it can to detect cases and prevent them from spreading. The UHC Partnership stands ready and willing to provide whatever support the Government might need in the future.