Globally, the number of tuberculosis (TB) cases continues to rise and to cause more
deaths, especially in resource poor countries. The World Health Organization (WHO)
strategy known as Directly Observed Treatment Short-course (DOTS) strategy has been
recommended to be adopted as the gold standard health system response to fight TB in
these settings, but it has faced huge constraints in its implementation because of the lack
of both financial and human resources. There remains a tendency for a one size fits all,
with little scope for adaptation to find local solutions to local problems.
The DOTS strategy was introduced to East Timor in 1995. The nature of the culture,
geography and political history of the country and its people combined with the very high
burden of TB (see Chapter 1) offers an interesting opportunity for a series of inter-linked
case studies examining TB control issues. These include the nature of TB control
programs during the conflict and post-conflict situations and the cultural and health
system barriers and enabling factors for treatment compliance in this setting. This
operational research study was conducted to explore these issues and to answer some of
the key research questions identified by the National TB Control Program. This thesis
was based on: i). An extensive review of the literature on the issues of TB, post-conflict
health service reconstruction and East Timor; ii). The findings from two qualitative
research studies; and iii). The findings from two quantitative studies. The aims of the
study and methodology used are discussed in greater detail in Chapter-2. vii
East Timor was as sovereign nation prior to the arrival of Europeans in the 16th Century.
The country was colonized by the Portuguese for more than 450 years and was under
Indonesian occupation for 24 years from 1975, finally gaining its full independence in
May 2002. Tuberculosis has been recognized as a problem and claimed many lives
during the time of colonial and foreign occupation. It was not until 1995, however, that
the local authorities and local leaders, and was called for more serious intervention. The
response was positive with the establishment of DOTS pilot in some government clinics
and the establishment church based TB control program. But, the programs were
destroyed following the September 1999 violence by pro-Jakarta militia. Soon after that,
a comprehensive national TB program was established. The history, politics, health
system and TB issues in East Timor are comprehensively discussed in Chapter-3.