Since its independence in 2002, the Government of the Democratic Republic of Timor-Leste
(RDTL) has shown a strong commitment to development and good governance that has resulted
in many improvements in health. Despite the progress and achievements related to some of the
Millennium Development Goals (MDGs), particularly MDG-4 (reduce the under-five mortality
rate by two-thirds between 1990 and 2015), the challenges posed by the socio-cultural dynamics
and the health system itself are evident and pose threats to the progress and achievements made
so far. These include a shortage of health workers, poor parental attitudes and knowledge, family
characteristics, inadequate communication, poor infrastructure, including access to water,
electricity and information, poor working environments and insufficient equipment.
Funded by the Millennium Challenge Cooperation (MCC), through USAID and the Maternal and
Child Health Integrated Program (MCHIP), Imunizasaun Proteje Labarik (IPL or Immunization
Protects Children) provides technical support to the Ministry of Health (MOH) of Timor-Leste.
The project aims to increase the national average of DPT-3 and measles immunization coverage
rates to 81.5%, mainly by providing comprehensive assistance to improve the effectiveness,
quality and accessibility of child immunizations in seven districts. The referred districts are
Ainaro, Baucau, Dili, Ermera, Liquica, Manufahi and Viqueque.
Dili district is the country?s most populous. Coverage rates are lower in Dili than in many other
districts despite most residents having good physical access to services, media and education.
For this reason, IPL, Dili District Health Services (DHS) and the MOH conducted mixedmethods,
cross-sectional study in March to April 2012 in the 26 most densely populated subdivisions
of Dili district. The study aimed to identify the socio-cultural and health system factors
that contribute to low immunization coverage in urban Dili, which would serve as the basis for
making recommendations on how to improve immunization services and their promotion. The
study involved 61 in-depth interviews (IDIs) with the health staff, caregivers, community
leaders; and 83 immunization encounters observed at 11 vaccination sites. The team also 3
conducted 11 FGDs (Focus Group Discussions) with 70 caregivers of eligible children of 6 to 23
months. The responses from the interviews and group discussions enabled the team to analyze
key respondents? knowledge and attitudes, experiences, perceptions and expressions about the
immunization services and their benefits to children.
The study identified a correlation between socio-cultural and health system factors that
contributed to the quality of care and immunization services in the district. These factors
included inadequate health services, health workers? attitudes, caregivers? knowledge and
attitudes, healthcare seeking behaviors and inadequate information. Most of the health facilities
have a shortage of health workers, and many existing staff must try to balance multiple
responsibilities: they not only provide care for children, but also care for pregnant women; must
complete administration work; and carry out outreach and sweeping activities. Also, some
facilities provide antigens only a few days in a week and see a limited numbers of patients per
day. Another factor is difficulty in accessing healthcare due to geography and weather conditions
that prevent the caregivers from seeking healthcare.
In addition, lack of outreach in urban Dili limits the health facilities? ability to immunize more
children. These highlighted factors point to the need for improvement of access to health care
services, provision of more health information for caregivers and better coordination between
Dili DHS, Community Health Centers (CHCs), community leaders and Promotor Saúde Familia
(PSF or Community Health Volunteers). Another finding related to health workers? attitudes was
inadequate communication and information to the caregivers regarding type of vaccines given to
the children and the next scheduled date for vaccination. On the other hand, health workers?
inappropriate attitudes and handling of caregivers hampered caregivers? desire to bring their
children to be immunized. Such attitudes were reflected in screaming, anger, being unfriendly
and using abusive words.
Knowledge and attitudes of caregivers are often influenced by the health services and
relationships with the health workers. An interesting finding was that caregivers of fully
immunized children were mostly well motivated, had good knowledge of benefits of 4
immunization and received support from the family members. Caregivers of partially and unimmunized
children either missed opportunities to take their children to be vaccinated, had
conflicting priorities, were afraid/shy, misunderstood the schedule, came late, had illnesses, lived
far from services, had previous bad experiences, lost their card/LISIO (Livrinho Saude Inan no
Oan or Mother and Child Health Book), had a home delivery, had false beliefs/perceptions
and/or were less motivated.
The research findings will be presented to Dili DHS and its different stakeholders to find
appropriate solutions to overcome the challenges in order to improve immunization coverage.
However, the following recommendations could guide to improve immunization services in the
Dili district (details are presented in the page #27):
1. Provide operational support from the MOH and Dili DHS: Utilize the findings from
IPL?s 2011 baseline assessment in Dili and the findings from this study for advocacy with
the MOH, Dili DHS and EPI (Expanded Program on Immunization) Working Group for
better EPI implementation.
2. Immunization services strengthening.
3. Strengthen multi-sectoral partnerships with key stakeholders.
4. Carry out addition research on child health and immunization to further clarify some of
this study?s findings.
The team expects that the implementation of its recommendations will improve immunization
services and programs in the Dili district.