Political Economy of Healthcare in Post-conflict Timor-Leste: Contestation and Ownership in Policy-Making

Abstract

This thesis examines the political economy of national ownership in situations of aid-dependent and oil-dependent, with particular reference to the case of the reconstruction of the healthcare system in Timor-Leste. The study demonstrates that, in a range of areas, the FRETILIN government (2002-2007) was able to exercise some autonomous decision-making even though it was heavily aid dependent. Conversely, under CNRT government (2007-2017), elites were empowered by oil resources and consequently they had greater control over development. The study identifies three main approaches used in development policy-making: patronage-based, populist and rationalist, and argues that, from 2002 onwards, the Timorese government generally used patronage-based strategies that benefitted elite political networks, increasing corruption. However, the creation of a ‘modern’ healthcare system that would benefit future Timorese generations was central to elites’ political ideology and consequently healthcare became subject to populist rather than patronage-based politics. Analysis of four key health programmes, funded separately by the World Bank, the Cuban government, WHO, and USAID, shows that ownership in the field of healthcare has become concentrated among powerful groups (donors, elites, MoH, and the Church). Meanwhile, health professionals, who advocate a liberal approach, lack a political voice. These case studies indicate that the Paris Declaration’s focus on country ownership to ensure better aid delivery was unrealistic because, in reality, ‘ownership’ becomes subject to contestation among powerful actors with different power resources. Findings on the analysis of the four programmes also suggest that Timorese elites did not worry much about healthcare, rather than it being ‘central’ to their ideology.