WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTHEAST ASIA NEW

To review and analyze the existing situation of food safety;
To identify resources and infrastructure requirements for a food safety programme;
To develop a draft national strategy for food safety and identify strategies and mechanisms to integrate food safety programme with the health care system;
To develop a draft food safety manual and assist in the development of a national food safety policy and planning for its implementation; and
To design a training curriculum and develop training materials using flexible educational technology.

The WHO Regional Office developed a 10-point Regional Strategy for Food Safety in the South East Asia Region in 1998. The present work has, to the extent practicable, used this framework as a ‘field application trial’ (Appendix 1)

A proposed Workplan for a prioritized and staged effort in food safety (2002-2007) has also been developed.

2. Existing Situation and the main problems faced

Environmentally related diseases are a major drain on the scarce East Timor health sector resources and unquestionably contribute to a significant loss of both urban and rural productivity¹. Food microbiological contaminant-related diarrhoeal diseases are a major cause of national childhood mortality and morbidity².

The incidence of foodborne diseases is a consequence of many interrelated factors including deficiencies in the food security system³ in food distribution and through food handlers without training in food hygiene. There are also factors arising from the particular health and sociodemographic circumstances including inadequate water and sanitary infrastructure⁴, under-nourishment, pre-existing high levels of both communicable and noncommunicable diseases, poverty and a lack of education. Finally, there are constraints within the health system. These include the lack of clear ministry responsibilities, no relevant health legislation and no food inspectorate to monitor contamination. There is inadequate surveillance capacities (trained staff, laboratory) for foodborne diseases.

At present, there is no identified Agency empowered to make rules and regulations under food laws. With the responsibilities and functions still somewhat undefined, there is no mechanism for coordination between Ministries for food control activities. Food control is not, for example, recognized within the organisational structure of the Ministry of Health at either the central or district levels⁵. While the primary legislation will be promulgated at the central level, it remains unclear if the implementation of the regulations will be at the central or district level. The situation with food hygiene education and awareness raising in the community is potentially less complex. At the district level, the district public health officers have environmental health and nutrition advocacy responsibilities⁶ that would readily interface with food hygiene.

While there are food control activities being pursued through other portfolios, these are sector specific (e.g. the Ministry of Agriculture and Fisheries is responsible for the control of abattoirs and slaughterhouses, aquaculture and seafood) and oriented towards animal health and welfare, quarantine and the farm production to slaughter for meat products. The present system for meat is to ‘field slaughter’ large animals in residential areas near the markets. This practice is uncontrolled and repeated use of the same area for wastewater and scraps disposal is contributing to the poor hygiene. There is no system for meat inspection or certification. Fish from the more isolated areas is smoked and at dried home prior to sale. Fresh fish is available both from local markets and through itinerant vendors. Near to the larger centres (Dili, Baucau), traders visit to purchase the catch. Fish from more isolated areas are often brought to the market on the public minibuses.

3. Food import -export

Food control in East Timor has international trade dimensions. At the present time, exports are largely restricted to coffee (2001: 60 000 tons; USD 4.1 million). Coffee is the largest single employment sector in East Timor and the largest single foreign exchange earner⁷. There has been a tradition of export of live Bali cattle to the Indonesian provinces and there is a significant potential for increased export of a variety of spices (vanilla, candlenut etc) and marine products.

Trade in food products with Indonesia is thriving with a very wide range of canned and processed foods available in the East Timor markets. The foods appear to have been registered for retail sale in Indonesia, and hence subject to the supervision of the Indonesian Drug and Food Agency. All of the products examined in a small survey⁸ were within their use-by-dates but that is to be expected in the present circumstances of recent and expanding importation. This will not necessarily continue to be the case. There are presently no mechanisms in place for the monitoring of food imports. Hence it is not possible to determine in any coordinated way if there are quality problems in the supply.

4. National food control

East Timor, as an interim measure, presently operates using the historical Indonesian legislation. There are however, as in many areas of health, no structures or capacities for implementation of food safety control food hygiene. Unless there is broad-scale adoption of the historical system, and there are very real advantages in doing so for some parts (e.g. the Indonesian Codex Alimentarius Decree), then any de novo approach will need both careful prioritization and an acceptance that this will take at least 5-7 years for implementation.

There is no overarching coordination mechanism through which to develop clear allocation of roles and responsibilities. Until there is a Cabinet level decision for the designation of procedures and Agency responsibilities, (a practice common in other jurisdictions), domestic control and that for import-export will remain divided. The system will also perpetuate food safety control for meat slaughterhouses and fisheries separate from the licensing of food establishments and food inspection procedures for processing plants, eating places and retail markets, and other food safety outlets. In East Timor’s circumstances, with few trained resources and supporting facilities, minimization of duplication in food control would have significant benefits.

The introduction of national food control legislation requires the introduction or adoption of National Food Standards. For the present at least, East Timor has neither an operational National Bureau of Standards or a process whereby those of the FAO/WHO co-sponsored Codex Alimentarius e.g. for food additives and food contaminants, could be taken into legislation.

There are no Guidelines, codes of practice or advisory standards for hygiene practice for the production, processing storage, and distribution of foods. These will be essential to support future implementation. While it may be anticipated that many middle-sized businesses will adopt their own in-house ‘standards’, this is very unlikely to be true for the majority of medium – small restaurants.

Development of food control legislation, particularly the preparation of rules and regulations would, under normal circumstances, be undertaken in consultation with trade interests and the consumers. For the present, there is no readily identifiable Associations (e.g. food and beverage manufacturers, processors, and suppliers, hotels, restaurant and catering bodies) who could be brought into the process. The lack of a private sector involvement also places constraints on the adoption of voluntary food initiatives, potentially a very cost-effective strategy for East Timor.

There is no effective mechanism in place for quarantine controls or a food inspectorate within the ministries (Health or Agriculture) either at the central level, within the districts, or at East Timor’s borders. Within the health sector, there has been no consideration of the role and responsibilities of an inspectorate. Issues of the levels of inspection, target risk groups, certification of food handlers’ and, food establishment licensing are still largely academic. Similarly, until there is a decision on how food control is to be conducted, consideration of staffing needs and training requirements etc are largely theoretical.

The future adoption of a food inspectorate, with responsibilities for implementation of regulations and codes of practice brings forward a series of requirements so that prosecutions for non-compliance can be instituted. There are presently no laboratory facilities for food monitoring. Staff trained in sampling, storage, transport and food analysis of samples to be used in evidence are not presently available.

While WHO continues to support the MoH in publishing a Weekly Epidemiological Bulletin for selected disease incidence, there is no requirement (or general ability and laboratory support at the district level) to support the mandatory notification of foodborne diseases. Simple diarrhoea, diarrhoea with blood and suspected cholera are reported, but these are not unique to food. There is no capacity from the data collected to compile statistics on foodborne diseases.

The Dili Central Laboratory currently has available services including basic parasitology, clinical chemistry, haematology, urine analysis and some bacteriology. The work of the laboratory is presently wholly dedicated to clinical support. Realistically, it will be some considerable time before the facilities are of a standard that could be used for food control.

There has not been a tradition of extension and advisory services to the food industry and trade by the government in East Timor. With the respective level of skills, training in non- regulatory aspects would be inappropriate in many cases. The training of street food vendors and small-scale restaurants has been conducted in the past, but with the high turnover rates in the semiformal and informal food sectors, this requires renewal.

There are no public education and participation programmes specifically directed towards food hygiene. Since 1999, a number of national and international NGOs have undertaken ad hoc, often district specific, hygiene awareness raising activities for water and sanitation projects.

5. Activities undertaken

5.1 National Food Safety Policy

A draft national policy and strategy for food safety had been prepared, which is targeted at providing protection for the whole food supply chain, from primary producer through to end consumer. The policy proposes:

Transfer of food safety responsibilities and regulatory control to one MoH directed food agency through the whole supply chain;
Mandatory introduction of food safety schemes across all primary industry sectors based on risk assessment with immediate priority given to meat, dairy products and seafood;
Formal consultative mechanisms between government, industry and consumers;
Integration of regulatory and enforcement roles including training, inspection and food auditing;
After five years of operation, a formal review to determine the effectiveness of the policies, programmes and implementation of the national food hygiene standards.

5.2 National Food Safety Strategy

Stage 1: Memorandum of Understanding between Agencies

To eliminate problems such as duplication of regulatory activity, the need for a large bureaucracy, and fragmentation and a lack of coordination, it is proposed to convene a Senior Officials Group from the ministries responsible for health, agriculture and economic affairs. The group would prepare a joint paper for Cabinet decision on: ‘Definition of the Sectoral Roles and Responsibilities for Food Control in East Timor’.

Following the decision by Cabinet, it is proposed that a Memorandum of Understanding be agreed. There would be no changes required to the existing operational frameworks. However, the MOU would formalize the current informal links between agencies.

The MOU would provide leadership in food safety through ensuring a whole of government response to food safety, providing improvements in response capabilities and, by raising the profile of food safety, send a clear message to industry and consumers of the priority given to food safety issues. It is proposed that the MoH would provide the consultative mechanism between government and industry on matters relating to application of all standards and be the sole regulatory authority for the safety of food products for the domestic market.

The Ministry of Agriculture and Fisheries would operate under delegated authority for quarantine issues, disease management of livestock and plant products, and management of chemical residues in agricultural produce. The Ministries representing Commerce, Trade and Industry would actively participate in the monitoring and review of food regulation and provide an important link between government and industry for issues of international trade.

Stage 2: Establish a National Food Control Advisory Committee

The establishment of a National Food Control Advisory Committee (NFCAC) best achieves the formulation of a National Food Safety Policy and Plan of Action. The Committee should have responsibility for policy development, promotion of harmonized food standards, general oversight of the implementation of domestic food regulation and standards, and promotion of a consistent approach to the compliance with, and enforcement of, food standards.

The Committee would have a broad remit, allowing it to make scientific assessments of any matter which may have a direct of indirect effect on the safety of the food supply including matters in relation to animal health, animal welfare and plant health. It would cover all stages of production and supply, from primary production, safety of animal feeds, right through to the supply of food to consumers.

The NFCAC is proposed to be made up of officials from government agencies having key responsibilities for food safety issues and experts coopted by the government. At least some members of the committee would need to have expertise in the food industry, public health, the interests of consumers or the enforcement of food legislation. The present model also proposes:

A Food Regulation Consultative Panel consisting of stakeholder representatives to provide advise the Committee on food regulation policy and food standards; a Food Surveillance Panel to keep under review the possibilities of microbiological or chemical contamination of the national food supply; a Food Monitoring Panel with representatives from the Department of Health (Chair), central laboratories, agriculture, and the district PHOs to provide an across-agency approach to food monitoring and a Panel on Education, Training and Communication to provide the mechanism to achieve consistency of auditing and training within government and consistency of enforcement between Districts.

Stage 3: Establishment of a Food Control Sub-Division within the Ministry of Health

The present proposal for FCS within the Ministry of Health eliminates the historical fragmentation of food safety control across agencies and, within the resource constraints available, introduces a mechanism for food safety responsibilities in compliance with international best practice. The FCS would provide the mechanisms to achieve consistency of interpretation of food law and standards of enforcement.

5.3 Education and Training Curricula and Manuals

WHO/ICD/SEAMEO Food Safety Training for Nutritionists and other Health Professionals

The training course comprises both written materials and a CD ROM. ICD SEAMEO, in cooperation with the Indonesian Ministry of Health will complete the Bahasa Indonesian version in June 2002.

Training on safe food handling for food inspectors

The training materials are for the technical aspects only. Until there are policies and implementation plans developed by the Ministry of Health, a legislative infrastructure including regulations for food safety control and a clear allocation of the roles and responsibilities between the central and district levels of Government, it is not possible to develop training directed at regulatory implementation.

Training of Food Handlers

A modular (4 part) course was prepared by adaptation from that of the Australian Institute of Environmental Health 1999. The original: Food safe – Food Handlers Training Programme – Guide for Proprietors and Food safe – Food Handlers Training Programme contain tests and other evaluation tools, templates for temperature records and cleaning guides, checklists and hygiene audit forms. There is also a training video ”Welcome To Food Safe – Food Handlers Training Programme”. The video is available in English, Cantonese, Bahasa Indonesian, Bahasa Melayu and Thai versions.

Food Safety Training Course for Street Food Vendors

There are already curricula and training programmes available in Bahasa Indonesian available from WR-Indonesia. The scope of these modules, which includes a number of pictograms for less educated vendors, includes:

The benefits of selling hygienic food – repeat customers, good reputation and greater income;
Bacteria and food - where they come from (water, raw and stale food, animals and vermin, poor cleanliness);
How bacteria breed very quickly if food is not fresh and cooked properly or kept for too long; and
How to prevent contamination of food through good (and inexpensive) practices.

6. Conclusions and recommendations:

6.1 National Policy, Strategy and Workplans

National Planning and National Health Sector Plans

An integrated Plan of Action, taking into account the draft Policy and Strategy for Food Safety, needs to be incorporated into the MoH National Health Plan with clear channels of reporting from the district to the central levels.

6.2 Food Control of Imports and Exported Products

It is essential that the trade in food imports and exports for East Timor be continued without impediment. The historical linkages to the Codex Alimentarius should be continued through present channels until there is an opportunity to introduce the CODEX Standards into legislation. The coffee export trade is presently operating with external quality assurance. In the absence of national standards, this should be continued for the foreseeable future. A National Bureau of Standards or Standards Association will be essential in the longer term for weights, and measures and the introduction of standards for construction, environment, water quality, laboratory standards etc.

6.3 National Food Control Mechanisms

The promulgation of general health legislation and specific regulations for the national food supply will take some years to develop. Policy decisions on the nature of the food control system for licensing and cost allocation are prerequisites to final strategy development. The resource and infrastructure requirements will also be contingent on the shape of the agreed strategy. Certainly, until there are standards available, laboratory facilities to ensure compliance, opportunities for regulation of the food industry are severely limited. Consideration of a food inspectorate with mandatory powers needs to be deferred until the support structures are in place.

6.4 Training for Food Control and Food Hygiene

Priority needs to be given to human resource development for food safety for each of the Government sectors (policy/planning managers, district public health officers), and, on a cost to the food industry based programme, public health inspectors.

The training of laboratory personnel and support to at least a basic food microbiology competency will be critical before any food inspection programme can be implemented. This should be started at the earliest date practicable.

Managers and owners of food service outlets and food handlers should have staff training and competency requirements imposed as a condition of their business licensing approvals.

Education programmes presents special challenges. WHO has supported the development of training-awareness raising materials for small food outlets and street food vendors in East Timor in the past and these should be reviewed to assess their ongoing applicability for implementation.

Draft curricula and training modules have been either identified or developed for each of the above groups as part of the present work. There is now a need for these to be tested through pilot training courses and the outcomes evaluated. Training for trainers at the professional level is also necessary.

There have been 25-30 international short-term consultants contributing to the food safety programme in neighbouring Bahasa Indonesian/Bahasa Melayu speaking countries. Between 40-50 training modules as well as audiovisual aids and teaching aids have been prepared and tested in national training courses. Malaysia in particular has had a very active programme in health promotion through WHO facilitated healthy schools, healthy villages and healthy markets activities. While it is accepted that in the longer term, there will be a move away from Bahasa Indonesia as the national language for East Timor, as an interim measure, the existing resources should be reviewed and used.

6.5 Community Health Promotion

In the short term, community education will be the most resource effective strategy for reducing food safety risks. Many of the needed interventions are low cost, simple and the benefits quickly achieved and hence sustainable. While the formal Ministry of Health structure is not robust at the sub-district and small community levels, there are health promotion opportunities through the health centre-based community nurses and midwives. Outside the formal health care provider system, there is a network of influential village leaders and community NGOs. A particular emphasis needs to be placed on a healthy schools and healthy markets style strategy for food hygiene.

The main environmentally linked diseases are closed interrelated as to the same source problem. The lack of food hygiene is just one contributor. A holistic approach is needed with other environmental health promotion in the areas of safe water supply and sanitation with further extension to household hygiene as the opportunity arises. The health-hygiene messages need to target the most vulnerable groups – under five and pregnant women.

6.6 Foodborne Disease Surveillance

There is presently no reporting system for foodborne diseases as part of the overall communicable and noncommunicable disease reporting system. While such a mechanism is needed to identify outbreaks and trends, reality dictates that until there is a viable food monitoring laboratory and system, the present weekly epidemiological reporting needs to be sustained and the development of a systematic and validated documentation of general mortality and morbidity introduced.

7. Acknowledgements

Particular appreciation is given to Dr Claudio Almeida, Director, INPPAZ who provided WHO and PAHO food safety publications in Portuguese. The ICD SEAMEO Regional Centre at the University of Indonesia, Jakarta was generous in its support with detailed training courses for nutritionists and professionals. The Australian Institute of Environmental Health’s Food Safe training course and multilingual video for food handlers provided the framework for the curricula for food handlers. Materials on food safety including current regulations, guidelines and pre-tested training courses (e.g. for street food vendors) in English and Bahasa Indonesian was obtained with the generosity of the Indonesian Ministry of Health’s Directorate Generals of Drug and Food and Communicable Diseases and Environmental Health.

References

¹Draff Profil Kesehatan – Propinsi Timor Timur (1998). Kanwil Departemen Kesehatan, Timor Timur

²Weekly Epidemiological Bulletins (2000-2001). Infectious Disease Surveillance and Epidemic Preparedness Unit, World Health Organization, Dili, East Timor

³The 2001 Survey of Sucos – Initial Analysis and Implications for Poverty reduction (2001) A partnership of the East Timor Transitional Administration, The Asian Development Bank, The World Bank and the United Nations Development Programme.

⁴Dr Sultana Khanum (2001). Report of a Visit to East Timor 23-27 April 2001. Summary Duty Travel Report, and The Food and Nutrition Situation in East Timor June 2000. A Report to the First Interim Health Authority, UNTAET and the World Bank

⁵Organizational Chart (2001) Ministry of Health Timor Lorosae

⁶District Health Services Organization in East Timor Health Sector Rehabilitation and Development Program – Joint Donor Review Mission November 7-21 2001

⁷Foodsafe – Food Handlers Training Programme – Guide for Proprietors and Workbook (2000), (including video English/Bahasa Indonesian) Australian Institute for Environmental Health, Perth, Australia.

⁸Guidelines on Developing, Conducting and Evaluating Training for Health Workers in East Timor: (2001) Division of Health Services, East Timor Transitional Administration (16 August 2001)

⁹10 - Point Regional Strategy for Food Safety in the South-East Asia Region (SEARFSS). SEARO, New Delhi (undated).

Annex 1

10-Point Regional Strategy for Food Safety
in the South-East Asia Region (RSFS)

The 10-point Regional Strategy has, where practicable, been adopted as the underlying framework for development of the East Timor FS Strategy. In the present environment clearly a staged approach is essential with only the most essential elements relating to disease reduction and maintenance of essential trade in food products recommended to be prioritised for application in first 2-3 year time frame. The opportunity to evaluate the RSFS in a ‘field test’ environment has the potential to assist other SEARO countries in their ‘food safety strategy’ improvement programmes.

Strategy 1: Food safety policy to be integrated with food security, food quality and nutrition and consistent with international requirements for participation in trade.

The linking of food security, food quality and nutrition-food hygiene is a very appropriate strategy on a number of levels. Thus all require quality community based health promotion activities which by and large will be mutually supportive. Food quality, food hygiene and nutrition will also greatly benefit from adoption of practices to significantly reduce food losses through spoilage during harvest and storage. Safe water supplies should also be brought into the equation.

There are, however, inherent difficulties in integrating the international and national elements of food safety programs for East Timor in the short term. The international food export imperative is towards a single commodity coffee (some 10% of total export commodity value) which must not be impeded.

Food imports ((excluding rice) are largely from Indonesia and fortuitously subject to strict control at the manufacturing stage. This reduces the urgency for action. The inspection of imported foods is unlikely to rest with the Ministry of Health due to resource limits.

Strategy 2: Adopt and periodically review legislative instruments for food control to ensure that there is protection of the communities health and facilitation of international trade.

Consultation with East Timor trade and consumer groups is presently not a practical option with no representative peak food sector bodies available for consultation. This also places significant constraints on the options for introduction of low cost-low input voluntary strategies.

In the short term, East Timor needs to establish a Consultative Forum with its main trading partners in food products to ensure that the are no impediments to cross-border food trade. In the intermediate term, when an appropriately skilled workforce has been established, the Government will need to give consideration to participation in relevant Codex meetings.

Strategy 3: Food inspection should be prioritised according to consumer risk, facilitated by training and guidelines and with appropriate resources.

The draft strategy proposes a Ministry of Health supervised Food Safety Inspectorate supported by Districts inspectors. The role of this unit would be to ensure compliance with National Food Hygiene regulations and Codes of Practice. The RSFS proposes a risk-based HACCP approach. This is not practicable until there is a more skilled workforce. Even then, experience suggests that junior staff, who may require long-term support for the HACCP system, will perform the food inspection activities.

Strategy 4: National analytical capacity should be strengthened by training, resources and establishment of quality assurance protocols and procedures.

There are very serious constraints on the availability of both laboratory facilities and trained personnel. Within the competing priorities, it is difficult to propose that the very limited facilities should be directed to food control other than where there exists serious concern for public health or the potential for constraints on East Timor’s economy. Food and beverage control might need to undertake some analysis on food adulteration (particularly alcoholic beverages) and there will be a need to address the microbiological contamination of local foods but other areas such as heavy metals, pesticides, food additives etc can only be seen as a very low priority for the present.

Strategy 5: Identify the need for, and optimum approach to foodborne disease surveillance

Without reliable statistics it will remain a difficult task to identify the priority that should be assigned to food borne disease control. Such a role is of vital importance in the event of serious outbreaks. In the short –medium term, there is neither the laboratory facilities nor epidemiological expertise for this task

Strategy 6: Provide assistance to food importers, producers, industry and trade to ensure the safety of food and require these sectors to participate in providing food safety and quality in all of their products

The government will, for the foreseeable future, be in no position to provide support to the private sector. Until there is a regulatory structure in place (3-5 years), voluntary compliance is the only practical option. The provision of an inspectorate will be facilitated if this is funded on a formal food sector cost recovery basis

Strategy 7: Assist the retail and food service sectors (particularly the street food vendors) trade to ensure the safety of food and require these sectors to participate in providing food safety and quality in all of their products

Assistance to awareness raising in the informal food-vending sector will be a government responsibility. For the medium-larger scale food service industry training could be introduced through a levy on licensing and registration.

Strategy 8: Assistance to consumers to become aware of the importance of access to safe and nutritious food

The Ministry of Health is already committed to health promotion as a key public health strategy.

Strategy 9: Recognition of the need for and facilitation of both short and long term education and training for all sectors of the community

The available short to medium term priorities will undoubtedly be for staff training and community education. Food hygiene is already considered within the schools program. It is unlikely that training directed to the private sector will be a practical option for some years.

Strategy 10: Support a co-ordinated approach to food safety research, prioritising generation of the necessary data to better manage food safety

Realistically, East Timor will not be in a position to undertake research into indigenous foods for which there is no Codex guidance for the foreseeable future. The human and laboratory resources required are both beyond those presently available. This should remain a low priority other than where the work for standardisation has already been undertaken by other SEA countries and direct adoption is a viable alternative. .

THIRD WORLD DODGEBALL WE DIVIDED OUR GROUP
WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE
WORLD INTELLECTUAL PROPERTY ORGANIZATION 34 CHEMIN DES COLOMBETTES

Tags: health organization, public health, regional, world, office, organization, southeast, health

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTHEAST ASIA NEW

Review and Evaluation of TB Programme in Maldives

CONTENTS

Page