The Timorese Ministry of Health (MoH) is a frontline health service
institution that has shown credible results in a fraught and fragile country
context. The ministry (formerly the Interim Health Authority or IHA)
faced acute and particular challenges to begin. Yet it made good on the
opportunities afforded to it to avert excess mortality, reduce high rates of
infant and maternal mortality, halve the incidence of malaria, and provide
basic health services at the village level. Through these and later achievements,
the ministry gained the trust of a previously disenfranchised population
and galvanized its durability and resilience.
In contributing to a volume examining positive institutional experiences,
this chapter examines how and why, in an otherwise low-capacity,
low-income country, the MoH has maintained and deepened its positive
development trajectory over time. As in the other cases, this chapter
describes how the core underpinnings of its success are found in the three
concentric circles that constitute its operating environment: the sociopolitical
context in which it emerged and continues to function, its interaction
with clients and external relationships, and its inner institutional workings
(World Bank 2011a). Unlike the Ministry of Social Solidarity (MSS), which
took root in its response to the 2006 Crisis, the MoH’s early success is a
product of steady and consistent development and an ability to stay the
course through periods of social dislocation, tension, and confl ict.
From its inception at independence, the ministry’s role and functions
were clear, but it had to make diffi cult choices to begin to address
its health sector priorities, and to decide the sequencing of activities
and resourcing. Among those decisions, health offi cials grappled with
questions of how to build the foundations for health sector recovery,
while at the same time responding to the humanitarian emergency and
chronic health conditions that were unfolding across the country. To a
large extent, it is the trade-offs and policy choices made by health administrators
during this period and up to independence that determined the
agency’s future success.1
From the early years of the MoH’s functioning
and through deliberate efforts to deepen and expand its institutional
performance, the ministry has maintained a steady path toward creating
an integrated, results-oriented institution that is led by and for Timorese
and responds to the unique and diffi cult conditions facing the country.
The MoH has long stood out as an institution that other Timorese
ministries have wanted to emulate, in large part due to its early accomplishments.
Yet there was no watershed for the MoH, and its future
success remains uncertain. It exhibited strong performance in planning
and management in the period from the referendum to 2006, and many
of its early efforts have yielded visible dividends. But its performance
has fl uctuated in recent years. Persistently high rates of malnutrition and
maternal mortality are worrying, and the ministry’s positive institutional
trajectory is setback by deteriorating planning and budget links, volatility
in procurement, human resource constraints, and political interference.
Under these conditions, the future test for the ministry will be its resilience
and durability in the context of increasingly politicized budgeting and
administrative uncertainty. Despite this uncertainty, looking back at the
sector’s initial recovery, several features stand out as having contributed to
the MoH’s early ability to deliver results and secure legitimacy where there
was previously popular mistrust. Many of these achievements are rooted
in the ministry’s policy priorities and in its social and human capital and
warrant deliberate attention, but before highlighting the MoH’s developmental
attributes, this chapter examines the ministry’s record and situates
its development in context.