Context

The small island nation of East Timor (officially named Timor-Leste) won a long and costly battle for Independence from its former colonizer – Indonesia – in 2002. Amidst the challenges of building a strong nation and reducing poverty, a security crisis erupted in May 2006 which had widespread effects: the Prime Minister, Mari Alkatiri, resigned; Australian troops were deployed to patrol the streets of the capital, Dili; and some 68,000 people left or were forced from their homes ending up in make shift camps around the city. The events were broadcast in the Australian media and around the world. The UN has, once again, extended its mandate in East Timor.

Poverty, unemployment and homelessness continue to be daily realities for many Timorese, tens of thousands of whom are still living in Internally Displaced Persons camps as a result of the violence that has plagued the fledgling nation for two years. Gang violence occurs frequently, fuelled by political rivalries and unemployment, which leaves large numbers of young men vulnerable to boredom, frustration and alcohol use. A new government is now in place and it is hoped the situation will become more stable over time.

In May 2007, project manager, Rachel Reilly, travelled to Dili on behalf of IF to meet with potential project partners, learn more about current development needs and identify where IF was potentially able to assist. IF has always had a heart for supporting East Timor. However, the difficulties associated with the civil conflict have meant that identifying suitable project partners and discussing potential projects has taken some time.

IF support to the Alola Foundation

One of the results of Rachel’s trip was that IF gave some funding to the Alola Foundation to help with its breastfeeding support project and the publication of a war widow’s memory book.

The Alola Foundation is a not-for-profit organisation, founded by Kirsty Sword Gusmao in 2001. The Foundation was originally established to help raise awareness of, and campaign against, the sexual and gender-based violence experienced by women and young girls in Timor-Leste. However, in response to the needs identified by Timorese women, Alola Foundation has developed to provide services and programs in areas such as advocacy, employment, education, maternal and child health and humanitarian assistance. Through Alola’s ‘Women’s Resource Centre’ the organisation also supports leadership programs and greater participation of women in all aspects of government, civil society and the economy. They were one of the few women’s organisations able to continue their work during the violence.

For this reason, the IF Management Committee decided to make a one-off donation to Alola to help them continue their work during this difficult time. This contribution was used to support two smaller projects run by Alola:

• Breastfeeding counselling in hospitals

Many children fail to thrive because of poor breastfeeding practices and it has been identified as an area of training critically required in Timor Leste. Subsequently, volunteer members of ‘Mother Support Groups’ have been counselling mothers at two major hospitals, Dili National Hospital and Baucau Hospital, about breastfeeding and the use of the Maternity Packs that Alola distributes. This was a six month pilot project, and if successful, Alola would apply to donors for longer term funding and to other hospitals.

•  Reprinting of Memory Books

Women widowed as a result of the violence in 2006 have, with the assistance of Alola, produced a booklet outlining their memories of the past and their wishes for the future of Timor-Leste. The book is a record of the experiences of women on both sides of the conflict whose lives were deeply affected by the violence. The production of the book has facilitated healing by allowing the women to share their stories of grief, forgiveness and hope. It has also become a symbol of reconciliation.

Since the book’s launch on the first year anniversary of the massacre, demand for it has outstripped supply. Therefore, IF contributed to the production of a second print run of the book in the Tetum language (which has been completed). Alola is now investigating options to create an English version - with key stories translated - so it is more accessible for others to appreciate.

Tobacco control program

The major focus of IF’s support is a tobacco control program in partnership with the East Timorese Ministry of Health and another not-for-profit organisation - Caritas Dili.

Tobacco-related illness

Tobacco is one of the major preventable causes of mortality and morbidity in both the developing and developed world. Tobacco use is linked to lung cancer, cardiovascular disease, chronic airways disease, premature births and many other disorders. In particular, tobacco use increases the severity of, and spread of, tuberculosis and other respiratory conditions which are high amongst adults and children in Timor Leste.

Expenditure on tobacco represents a major financial burden for impoverished East Timorese. Most tobacco consumed is in the form of cigarettes imported from neighbouring countries including Indonesia and Australia. Cigarettes are readily available in small shops and from roadside vendors (USD $1 per pack in a country where the majority of the population live on less than $2 per day). Some tobacco is produced and sold locally, mainly for chewing. Tobacco, along with betel nut, is commonly used as a gift or to initiate social exchanges. It is also possible that due to the high rate of smoking amongst expatriates, smoking is seen as a sign of status and wealth.

While there is little data to draw upon, tobacco use amongst men in Timor Leste is estimated to be as high as 70-80%. It is less common for women to smoke; however high levels of environmental smoke have a detrimental effect on the health of both women and children. The prevalence of tuberculosis and other respiratory conditions is high in all age groups and other problems associated with poverty, such as malnutrition, are exacerbated by exposure to tobacco smoke.

Timor-Leste signed the WHO Framework Convention on Tobacco Control on 25^th May, 2004 and ratified the treaty on 22^nd December, 2004. Since that time, tobacco control efforts have been the responsibility of the head of the Department of Non-Communicable Disease and a technical assistant from the WHO. Over this time, they have conducted a Youth Survey of tobacco use, undergone training in tobacco control provided by the Bloomberg Foundation and begun work on an education program for schools.

Currently, there are few laws governing the production, sale or use of tobacco, meaning there is no restriction on supply to minors, smoking areas or regulation via the tax system. Tobacco advertising is banned on the national television station, TLTV, however such advertising appears frequently on imported Indonesian and Chinese television stations.

The health system in Timor Leste is ill equipped to cope with the demand placed on it by tobacco-related illness, and this is an area where effective change is possible for a relatively small cost.

How the tobacco control program got started

In November 2006, IF received a proposal for a tobacco-related health promotion project from Dr. Rowena Ivers, an IF supporter and Australian expert in tobacco control program design and evaluation (having undertaken a PhD about smoking and tobacco in Aboriginal communities). Subsequently, during Rachel’s visit to Timor Leste in June 2007, she had numerous discussions with a range of local and international health professionals and government officials about the potential to develop an IF supported anti tobacco program.

These talks were very positive resulting in the signing of a two year Commitment Agreement with project partners: Timor-Leste’s Ministry of Health (Non-communicable Disease Department) and Caritas (Dili). The objective of this tobacco control program is to assist in reducing the harm caused by tobacco throughout Timor Leste in accordance with the World Health Organisation’s (WHO) Framework Convention on Tobacco Control.

IF’s role in the program

Following a number of discussions between the various stakeholders involved, it was agreed that IF would support a Timorese professional to work on tobacco control within Caritas Dili (as an adjunct to their existing tuberculosis program). The primary focus of IF’s support will be capacity building, i.e. training the local worker in principles of tobacco control and networking with other tobacco workers in the region. Financial and technical support will also entail:

• Ongoing mentoring of the project worker by Rowena and Rachel, e.g. the provision of technical advice on matters such as: (i) research on and development of strategies, policies and materials for the program, (ii) appropriate training and work plans, and (iii) regular consultation with the steering committee regarding project activities;

• Facilitating contact with Australian Tobacco Control organisations or experts;

• Evaluating and providing feedback on the reports submitted by Caritas Dili; and

• Visits by IF project managers to assist with and monitor the project.

A systemic approach to change

This type of program focuses on changes that can be made at a policy level so as to achieve ongoing systemic change. There are six components to the program and IF will have primary responsibility for component 1.

Component 1: Training and employment of the local worker.

Component 2: Wherever possible and appropriate, the project worker will aim to build the capacity of other Caritas staff and other associated health workers on tobacco control through training and mentoring and organised workshops. The project worker will also assist in building capacity for future health workers by contributing to curriculum development for health students.

Component 3: Contribution to Policy development: researching policy options and presenting these to the Ministry.

Component 4: Education: to work in conjunction with the Ministry and WHO to develop and translate school and tertiary education curricula relating to tobacco and health.

Component 5: Community Awareness-Raising: sourcing of and adaptation and translation of low-cost health promotion resources, adaptation of anti-tobacco television and radio ads, advertising in local papers, production and distribution of ‘No Smoking’ stickers (need to work out how this will be funded).

Component 6: Smoking Cessation: progress with provision of smoking cessation advice to health professionals.

The project will be overseen by a steering committee comprising representatives of each of the organisations and possibly representatives from the community and/or health sectors. The steering committee will be responsible for ensuring project activities are coordinated and address community priorities relating to tobacco control.

Duration of IF support

IF’s funding for year two of the program will be subject to: (i) successful outcomes in year one, and (ii) IF receiving a suitable report and evaluation of the program’s first year. During the second year, other donor partners will be sought to take this work forward.

Summary

Such a broad public health initiative is a departure from the usual type of project that IF supports, which is both exciting and challenging for us. Given the expertise IF has to offer, with both the Project Manager, Rachel Reilly, and the Project Advisor, Rowena Ivers, having extensive anti tobacco experience, we are confident IF can provide the requested level of support and the likelihood of making an impact is excellent! We look forward to providing you with more information as the program develops.

A little more about IF’s project partners

Caritas Dili is member of Caritas Internationalis, a confederation of 163 Catholic relief, development and social service organisations. The guiding values of Caritas Internationalis include:

The dignity of the human being! The weak and oppressed are not objects of pity, but agents of change leading the struggle to eradicate dehumanizing poverty, unacceptable living and working conditions, and unjust social, political, economic and cultural structures.

Caritas has an ongoing presence in communities, before, during and after crisis situations. Important, too, is that being part of civil society and incorporating the perspective of the poor, Caritas can continuously adapt its strategies to an ever changing environment.

Caritas empowers people to participate fully in all matters affecting their lives, and it advocates on their behalf at national and international forums.

Caritas promotes partnership: local autonomy is paramount in ensuring effective teamwork for the good of all.  By pooling expertise and resources, Caritas is able to identify issues at the grassroots, analyse them at national and international levels, and then take action locally, regionally and globally.

The Non-Communicable Disease Dept of the Ministry of Health (“the Ministry”) is one of six divisions of health service delivery within the Ministry of Health. The Ministry overall is responsible for national planning and co-ordination of health programs throughout Timor-Leste. Underlying the ministry’s vision for a healthy Timor, where people can develop their full potential in a healthy environment, is a commitment to equity and cultural sensitivity through actions based on ethics, solidarity and friendliness.

The mission of the Ministry of Health is to strive to ensure the availability, accessibility and affordability of health services to all the people of Timor-Leste, to regulate the health sector and to promote community and stakeholders’ participation in the promotion of health. This includes sectors other than the health sector, in acknowledgement of a broad definition of health and its determinants.