Universal Health Coverage, Equality, Equity, and the Distance Between Bidau Tokobaru and the Aldeias of Vatuvou
Health services are free in Timor-Leste. But free means something profoundly different depending on where you were born. This essay examines what Universal Health Coverage truly requires — and why the distance between a policy declaration and a patient in a remote aldeia is measured not in kilometres, but in hours of travel, days of lost income, and lives of accumulated disadvantage.
This is Essay IV of the Health Policy Essay Series by Dr Sergio GC Lobo, SpB. Essays I–III examined healthcare market failure, the role of private investment, and pharmaceutical procurement. This essay focuses on Universal Health Coverage as lived experience — exploring the crucial distinction between equality and equity, the specific barriers Timor-Leste's geography and social structure impose on rural and remote populations, and the architecture of interventions needed to close the gap.
Section 57 of Timor-Leste's Constitution enshrines the right to health. Health Law No. 2/2004 affirms that all citizens are entitled to access health services without financial barriers. In principle, the nation has committed to something close to the ideal of Universal Health Coverage: every person, regardless of income or location, can walk through a government health facility's door without paying a single dollar.
But this formal commitment, however sincere, runs into a geographical and social reality that fundamentally distorts its meaning. Consider two Timorese citizens exercising the same right, at the same moment, on the same morning.
Maria lives in Bidau Tokobaru, Dili. She wakes with a fever. Within fifteen minutes, she has walked to a community health centre. Within the hour, she has been seen, diagnosed, given medication from the pharmacy, and is on her way home. Her right to free healthcare has been exercised completely, at a cost of fifteen minutes and a short walk.
João lives in an aldeia of Vatuvou, Maubara, in Liquiçá Municipality. He wakes with the same fever. To reach the nearest health post, he must walk or travel on poor roads for two to three hours each way. He must find transport — costing between two and ten dollars — or ask a family member to carry him. He must leave his farm, delegate his responsibilities, arrange for someone to watch his children. The medicines he needs may not be in stock when he arrives. His right to free healthcare exists on paper. Its exercise costs him most of a day, several days' income, and a journey that, in the wet season, may be impossible entirely.
This asymmetry is not a minor administrative gap. It is a structural injustice embedded in how the health system is geographically organized, how resources are allocated, and how the costs of access are distributed between those who happen to live near services and those who do not. Understanding and correcting it is not optional. It is the core task of genuine Universal Health Coverage.
Universal Health Coverage means that all people have access to the full range of quality health services they need, when and where they need them, without financial hardship.
— World Health Organization, UHC Definition, 2010 (and reaffirmed in the 2019 UN Political Declaration)
This definition contains five distinct requirements, each of which must be satisfied simultaneously for UHC to be real rather than rhetorical. The services must be available. They must be of adequate quality. They must be accessible when needed — not only during working hours or in good weather. They must be geographically accessible — where people are, not only where it is convenient to build facilities. And they must not impose financial hardship on those who use them. A health system that satisfies four of these five conditions has not achieved UHC. It has achieved something, which may be valuable, but which falls short of the promise.
The WHO further specifies that UHC requires equity at its core — that the goal is not merely to provide services, but to ensure that the most vulnerable and most disadvantaged populations are served as well as, or better than, the privileged and accessible. A system that delivers excellent services to urban populations while leaving rural and remote populations with nominal coverage has not achieved UHC. It has achieved unequal coverage — which is precisely the situation Timor-Leste faces today.
Population coverage — which groups and individuals are included. True UHC includes everyone: rural and urban, poor and wealthy, women and men, people with disabilities, indigenous communities, and the most geographically isolated.
Service coverage — the range and quality of health interventions available. From primary prevention to complex surgery; from maternal care to palliative care; from emergency response to long-term chronic disease management.
Financial protection — the degree to which out-of-pocket payments are eliminated or limited. This includes direct costs (fees) and indirect costs (transport, accommodation, lost wages) that can make "free" services effectively unaffordable.
Progress toward UHC is measured in all three dimensions simultaneously. Expanding services without expanding geographic access leaves the same populations uncovered. Eliminating fees without addressing transport costs shifts the burden rather than removing it. Including everyone on paper while concentrating services in capital cities is coverage without equity. True UHC requires movement in all three dimensions at once, with particular attention to the populations furthest from adequate coverage.
Timor-Leste's legal framework is, in important ways, exemplary. The Constitutional right to health, the 2004 Health Law, and repeated government health strategies have established the principle that health is a right, not a privilege, and that the state is obligated to deliver on that right. The country has one of the lowest out-of-pocket health expenditure rates among low- and middle-income countries — a genuine achievement that reflects the formal commitment to free-at-point-of-use services.
Yet research published in peer-reviewed journals tells a different story about who actually uses the health system. Despite healthcare being free at the point of delivery, wealthier patients access hospital care at nearly twice the rate of poorer patients. Rural households are systematically less likely to seek hospital services than urban households. The poorest quintile is significantly less likely to use more expensive services than other socioeconomic groups. As a landmark study summarized bluntly: the public resources for health care are subsidising the rich more than the poor.
This is not an accident. It is the predictable result of a system in which formal financial barriers have been removed — a real and important step — but substantive barriers of geography, transport, indirect cost, quality, and social access remain largely intact. Removing price at the door is necessary. It is not sufficient.
Perhaps no distinction is more important — and more frequently blurred — in health policy discourse than the difference between equality and equity. They sound similar. They are sometimes used interchangeably in political speech. They are not the same concept, and confusing them leads to policies that feel fair while perpetuating injustice.
Giving every person the same thing — the same services, the same resources, the same formal rights — regardless of their circumstances, needs, or starting position.
Equality without equity produces formally fair outcomes that are structurally unjust. It ignores the different distances between people and their rights.
Giving every person what they need to achieve the same outcomes — recognizing that different starting positions require different supports, different investments, and different intensities of service.
Equity recognizes that treating unequal situations equally is itself a form of inequality. Real fairness requires proportional response to proportional need.
The classic visual representation — three people of different heights standing on identical boxes to watch a game over a fence — captures this distinction immediately. Equality is giving everyone the same box. Equity is giving each person the height of support they need to actually see over the fence. The goal — being able to watch the game — is the same. The means must be different because the starting positions are different.
In health policy, the fence is adequate health outcomes. The people are Timorese citizens at different distances from services, with different economic capacities to absorb the indirect costs of access, living in different geographic and social circumstances. Equality gives them all the same formal right. Equity gives them all a real chance to exercise it.
Timor-Leste's geography makes the equality-equity distinction not philosophical but visceral. The country is small in area — approximately 14,874 square kilometres — but its terrain is among the most challenging in Southeast Asia. More than 70 percent of the population lives in rural areas, the majority in communities dispersed across mountainous terrain connected by roads that more than 90 percent of assessments rate as poor or very poor. Floods in the wet season routinely render road access impossible for days or weeks at a time.
The health system is structured in a hierarchy: the Hospital Nacional Guido Valadares (HNGV) in Dili at the apex, five referral hospitals at the municipal level, approximately 69 community health centres (CHCs), 42 maternity houses, and more than 313 health posts. This tiered structure is logical in design. In implementation, it means that the most sophisticated diagnostic and treatment capacity is concentrated in Dili — specifically in and around the Bidau Tokobaru area where HNGV is located — while the outermost population lives, in some cases, a day's journey from the nearest functional health facility.
Removing user fees at the point of service is a genuine and important achievement. Research across multiple countries confirms that user fee removal increases utilisation of health services, particularly among the poorest population groups. Timor-Leste's low out-of-pocket expenditure rate reflects this achievement. But the research also consistently shows that fee removal alone does not eliminate inequity in access. It removes one barrier while leaving others intact — and in some geographic contexts, the remaining barriers are more significant than the fees ever were.
A multi-site qualitative study of barriers to healthcare access in eight Timor-Leste districts found that lack of patient transport is the critical cross-cutting issue preventing access to hospital care. Without transport, communities resort to carrying patients by porters or on horseback, walking for hours, or paying for unaffordable private arrangements. Other significant out-of-pocket expenses include blood supplies from private suppliers, accommodation and food for patient and accompanying family members, and — in the worst cases — repatriation of the deceased. The paper's title captures the community's dilemma precisely: "I go I die, I stay I die, better to stay and die in my house."
The hidden costs that "free" health services impose on remote populations include: transport costs for the journey to and from the facility; food and accommodation for multi-day hospital stays far from home; costs of accompanying family members, which cultural norms often require; income lost during the days of travel and recovery; childcare and eldercare arrangements during absence; and, when services are unavailable on the first visit due to stockouts or absent staff, the full cost of the journey multiplied by the number of attempts. For a farming family operating at or near subsistence level, these costs are not minor inconveniences. They are determinants of whether care is sought at all.
Academic research using nationally representative data from Timor-Leste tells a consistent and troubling story. Rural households are less likely to seek hospital care than urban households (odds ratio 0.7 in one major study — meaning a rural household has only 70 percent of the probability of an urban household of accessing hospital services for the same health need). The poorest quintile is systematically less likely to use more expensive hospital services. Women face additional barriers, including the requirement in many rural communities for male permission or accompaniment before seeking care outside the home. Urban doctors perform better clinically than rural doctors — not primarily due to differences in individual competence, but due to better facilities, equipment, and professional support environments.
The conclusion that public health resources disproportionately benefit the better-off is uncomfortable but important. It means that Timor-Leste's health budget — funded by petroleum revenues that represent a shared national resource — is currently being redistributed upward: the urban middle class, by virtue of proximity to services, captures a disproportionate share of public health investment relative to the rural poor, who contributed equally to the national wealth but receive less from its distribution. This is not merely an inefficiency. It is an injustice built into the architecture of the system.
The barriers preventing rural and remote Timorese populations from exercising their formal right to health are multiple, interacting, and in some cases mutually reinforcing. They cannot be addressed by any single intervention. Understanding their taxonomy is the prerequisite for designing the layered response that equity demands.
These barriers do not act independently. They compound each other in ways that make the sum of their effects greater than any individual element would suggest. A family that could manage the transport cost might still not go if the breadwinner cannot be absent from the farm during harvest. A woman who has overcome social barriers to seek care may be deterred by the knowledge that the medicine she needs has been out of stock for weeks. A patient who reaches the hospital may not return for follow-up because the first visit depleted the family's savings. The barriers form a system of exclusion, and addressing any one of them without addressing the others produces limited results.
If all Timorese citizens hold an equal right to health, then populations facing greater barriers to exercising that right are entitled to proportionally greater investment to enable them to do so. A flat distribution of health resources — the same per-capita allocation regardless of geographic isolation, infrastructure deficit, or social disadvantage — is equality without equity. Real Universal Health Coverage requires investing more where the gap between right and reality is greatest.
This principle has direct budgetary and planning implications. It means that the Ministry of Health's budget allocation should not simply be proportional to population by municipality. It should be weighted for remoteness, road quality, supply chain difficulty, and the documented under-utilisation of services that reflects accumulated barriers. The populations hardest to serve should receive the most concentrated investment, not the least — because they are the furthest from the care that the Constitution promises them.
The WHO is unequivocal on this point: primary health care (PHC) is the most effective and cost-efficient pathway to UHC, particularly in low-income countries with geographically dispersed populations. PHC, properly understood, is not simply a clinic in a village. It is a philosophy of health delivery that brings services to communities — preventive care, maternal and child health, management of common conditions, health promotion, community health worker networks, and outreach programmes — and builds the community-level health infrastructure on which the entire referral pyramid depends.
Timor-Leste has made commitments to PHC through its integrated health network and through programmes like SISCa (Servisu Integrado da Saúde Comunitária). The principle — that regular community outreach by health teams reaches the populations who cannot or will not travel to facilities — is exactly right. The challenge is consistent implementation at adequate quality across all 2,225 aldeias of the country, with functional supply chains to support the medicines and equipment the outreach teams carry, and with sufficient trained personnel to staff both the outreach teams and the facilities they serve.
The SISCa programme — Timor-Leste's integrated community health service model — represents the country's primary mechanism for taking health services to remote populations. Under SISCa, multidisciplinary health teams conduct monthly outreach visits to community locations, providing maternal and child health services, immunization, nutrition screening, and basic primary care. This model directly addresses the geographic barrier: instead of requiring the patient to travel to the service, the service travels to the patient.
Community health workers and health promoters — local community members with basic health training — extend the reach of the formal health system into the aldeias between outreach visits. They serve as the first point of contact, the health literacy resource, the referral navigator, and the early warning system for community health problems. In Timor-Leste's specific context, where cultural and social barriers are as significant as geographic ones, the community health worker's role is irreplaceable: they speak the local language (which may not be Tetum), they understand local beliefs, and they are trusted by the community in ways that visiting clinical staff are not.
The limitation of these programmes is not in their design. It is in their consistent implementation, their resource support, and the quality of care they can deliver when essential medicines are chronically out of stock, when the health worker's motorbike has no fuel budget, when the cold chain for vaccines has failed, or when the district health team's capacity to support outreach visits has been compromised by staff vacancies. Every essay in this series ultimately returns to the same conclusion: the architecture is largely right. The execution is what requires urgent attention and sustained investment.
It might seem counterintuitive to invoke the private sector in an essay about equity. Private providers charge fees; they locate where paying customers are; they are motivated by profit, not by need. These are real tendencies, documented in the previous essays in this series, and they explain why unregulated private health markets fail to deliver equity. But the question for Timor-Leste is not whether to have private health providers. They exist, and their number will grow. The question is whether they can be harnessed — through regulation, contracting, obligation, and incentive — to contribute to the equity goals the public system cannot fully achieve alone.
The government's capacity to deliver health services to every aldeia of Vatuvou in Maubara, every remote suco of Manufahi or Aileu, every fishing community in coastal Atauro — while maintaining quality, supply chain integrity, and workforce coverage across the entire country — is structurally limited by fiscal resources, human capital, logistical capacity, and the sheer organizational complexity of reaching a dispersed population through mountainous terrain. Where the public system is genuinely absent or underperforming, a regulated private presence is better than an absence of care. The task is to ensure that regulated private presence serves equity rather than exploiting it.
Private pharmacies in municipal centres provide a buffer when public medicine stock runs out — if their prices are regulated and patients have subsidy access. They extend the effective reach of the medicine supply system without government warehouse investment.
Private laboratories in Dili can be contracted by the government to provide diagnostic services for public patients referred from remote areas — particularly for tests requiring equipment not available in district hospitals. Regulated price, full certification, public reimbursement.
Private vehicle owners and transport operators can be contracted or subsidized as part of a patient transport scheme — particularly for emergency and referral cases — in areas where government ambulance coverage is absent or unreliable.
Private telemedicine platforms can connect remote health workers and patients with specialists in Dili — reducing unnecessary referrals, enabling earlier diagnosis, and bringing specialist guidance to places where the specialist will never be physically present.
Private clinics licensed under social obligation frameworks — required to serve a defined proportion of patients at regulated or zero cost — expand total facility capacity in urban and peri-urban areas, freeing public resources for rural deployment.
Private health facilities accredited as training sites multiply the country's capacity to produce nurses, midwives, and community health workers — the workforce essential for extending primary health care to remote areas.
Perhaps the most transformative potential contribution of the private sector to equity in Timor-Leste's health system lies in digital health — specifically, telemedicine and e-consultation platforms that allow a health worker in a remote health post to access specialist guidance without either patient or specialist needing to travel.
The 2023 Maluk Timor Annual Report notes that despite poor internet coverage in Timor-Leste's rural areas, mobile phone use is high and interest in digital learning and e-health is significant. A community health worker with a smartphone and a telemedicine app can, in principle, show a dermatological lesion to a dermatologist in Dili, consult a cardiologist about an ECG reading, or transmit a patient's ultrasound image for remote interpretation. None of these consultations require the patient to travel. None require the specialist to leave Dili. The geographical barrier that makes the equity problem so intractable is, at least partially, bypassed by the communication network.
This is not utopian. WHO-supported telehealth pilots have demonstrated effectiveness in comparable small island and mountainous developing country contexts. The prerequisites — consistent mobile coverage across all administrative divisions, reliable solar or backup power at health posts, trained health workers who can use the platforms, and the legal and regulatory framework to govern teleconsultation — are achievable, and several are already partly in place. The private sector's role is in developing, investing in, and operating these platforms under government contracts that ensure equity of access: the telemedicine service must be available to the health worker in the aldeia of Vatuvou on the same terms as to the clinic in Bidau Tokobaru.
Not all public-private partnerships serve equity equally well. A PPP that builds a specialist clinic in Dili for middle-class and expatriate patients contributes to total health capacity but does not directly address the equity gap for rural populations. A PPP that is explicitly designed for equity — one that conditions private operating licenses on geographic deployment commitments, service to low-income populations, and participation in government referral and reimbursement systems — is a fundamentally different instrument.
Equity-oriented PPP designs that are relevant to Timor-Leste's context include: mobile diagnostic units operated by private providers under government contracts, deploying to rural areas on scheduled rotations; community pharmacy franchise models that extend regulated medicine supply to municipal and sub-district level; private ambulance service contracts for areas without government ambulance coverage; and specialist teleconsultation services contracted by the Ministry of Health for delivery to rural health posts.
The private sector's contribution to equity is not automatic. It requires a governance framework that explicitly shapes private behaviour toward equity goals. This means, at minimum: licensing conditions that include geographic deployment obligations or social tariff requirements; reimbursement mechanisms that pay private providers for serving public patients at regulated rates; regulatory oversight by AIFAESA and the Ministry of Health that verifies compliance with quality and equity obligations; and transparent reporting requirements that allow public accountability for the equity performance of licensed private providers.
Without these conditions, the private sector will concentrate where profitable, serve the already-served, and leave the equity gap intact. With them, the private sector becomes an additional instrument in the government's toolkit for closing the distance between the right to health and its real exercise by every Timorese citizen, wherever they live.
Commission a national health equity mapping exercise using geospatial data to identify, by aldeia and suco, the actual utilisation rates, travel times, transport costs, and supply chain reliability that characterize each community's effective access to health services. The equity gap cannot be closed if it is not first measured. Geospatial analysis, as used effectively in Laos for PHC planning, provides a powerful basis for resource allocation decisions.
Replace simple per-capita budget allocation across municipalities with an equity-weighted formula that directs proportionally greater resources to the most geographically isolated and under-served municipalities. This is not charity to the rural poor. It is the correction of an existing injustice that directs disproportionate public resources toward the urban well-off.
Establish a formalized patient transport support mechanism — through government ambulance expansion, contracted private transport, or a combination — that covers the journey from remote communities to referral hospitals for emergency and scheduled care. Transport costs are the single most documented barrier to hospital access in Timor-Leste. Addressing them directly would have an immediate and demonstrable equity impact.
The monthly community outreach model is the right architecture for reaching dispersed rural populations. It needs consistent fuel budgets, medicine supply, cold chain support, supervision, and community health worker recognition and incentives. An outreach team that runs out of fuel or arrives without medicines has failed twice — once for the community, and once for the trust relationship that makes community engagement possible.
Establish a government-commissioned telemedicine platform connecting all community health centres and health posts to specialist consultants in Dili. Mandate its use in the referral pathway: before a patient is sent on a four-hour journey to hospital, a teleconsultation with a specialist should confirm the necessity of the referral. This would reduce unnecessary referrals, improve triage, and save patients the most costly journeys while ensuring those who genuinely need hospital care are identified and supported to make the journey.
Reform the licensing framework to require every private health facility and pharmacy to meet defined equity conditions: minimum proportion of services at public tariff; participation in the government referral and reimbursement system; geographic deployment obligations proportional to facility size; and regular reporting on the income and geographic profile of patients served. Private investment in health is welcome — but it is licensed under the condition that it contributes to, rather than undermines, the government's equity goals.
Require the Ministry of Health to publish, annually, a publicly accessible equity audit showing utilisation rates, service availability, stockout rates, and wait times by municipality and, where data permits, by sub-district. Public accountability for equity progress — or the lack thereof — is itself a governance instrument. It creates the political visibility for equity failures that motivates corrective action.
Universal Health Coverage is one of the most important commitments a government can make to its citizens. It says: regardless of where you were born, what your parents owned, or how far you live from a city, your health matters equally, and the state will work to ensure you can access the care you need without it destroying your life or your finances. This commitment is morally serious. It is constitutionally grounded in Timor-Leste. It is internationally endorsed as a core development goal. And it is, in the current state of Timor-Leste's health system, substantially unfulfilled for the majority of the population who live beyond Dili's gravitational pull.
The distinction between equality and equity is not academic. It is the difference between a policy that declares universal access and a policy that actually delivers it. Timor-Leste has the equality — the formal declaration, the zero-fee policy, the constitutional right. What it urgently needs is the equity: the proportional investment in remote communities, the transport infrastructure, the community health worker networks, the telemedicine systems, the supply chain reliability, and the governance architecture that together close the gap between what the law promises and what a mother in an aldeia of Vatuvou can actually access when her child is sick.
The private sector, properly governed, is not an obstacle to this equity agenda. It is a resource that can be harnessed in its service — providing telemedicine, extending diagnostic reach, supplying medicines in areas of public shortage, and mobilizing capital for health infrastructure that the government budget cannot fund alone. The condition is governance: licensing that obligates equity contribution, regulation that prevents exploitation, and oversight that verifies compliance.
The distance from Bidau Tokobaru to an aldeia of Vatuvou is not very many kilometres. The distance between their health realities is enormous. Closing that distance is what Universal Health Coverage, genuinely implemented, means in Timor-Leste. It is the work of a generation, and it must begin now.
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