A mother’s last journey: what does a death in Timor-Leste tell us about health equity and climate injustice?

Family in Timor-Leste. Credit: WHO Timor-Leste

Dili, Timor-Leste — The path to Gleno Health Centre winds through the green folds of Ermera’s mountains, narrow and rugged. This district, just southwest of the capital Dili and famed for its coffee and cool air, becomes a trap when rains fall—its fragile roads dissolving into mud. It was down this path that Joanina, a 29-year-old mother from the remote village of Sagabesi-lima, took her final journey.

Joanina had done everything right. She attended antenatal check-ups regularly at Gleno Health Centre. She was healthy, hopeful, and ready to welcome her sixth child. But days before she went into labour in March 2024, torrential rains— part of the increasing climate extremes seen in Timor-Leste —triggered a landslide that wiped out the nearest road, cutting off her village. With weak foundations and poor drainage, many roads in the area collapse under heavy rainfall. No ambulance or public transport could reach her. As she began to bleed heavily, her family did what locals often do: they fashioned a stretcher from a plastic chair and tried to carry her down the muddy trail.

Joanina didn’t make it in time. By the time help arrived, she was gone—leaving behind five children and a grieving husband. “The loss of a mother’s life is a great loss for the whole family,” said her husband. “Now, I tell everyone—childbirth is a matter of two lives. You must prepare in time to give birth in a hospital,” he added.

But what happens when the hospital is too far? When climate extremes amplify the already uneven access to health?

Joanina’s story is not an exception, but a cruel reminder of how climate change deepens inequities, turning geography, poverty, and fragile health systems into deadly barriers.

In Timor-Leste, climate change is already posing major challenges for health system. It is disrupting already limited energy supplies and access to safe water—both critical to healthcare facilities. It is disturbing supply chains for essential medical equipment and pharmaceuticals, causing shortages and limiting critical care. Flooding, landslides, and extreme weather events routinely damage infrastructure, hindering services and endangering both patients and health workers. Post-disaster conditions raise the risk of disease outbreaks, further burdening already stretched facilities.

Longer, harsher heatwaves are putting the elderly and children at risk. Hospitals are tackling more climate-sensitive health outcomes, including strokes, respiratory issues, and water- and vector-borne diseases. Malnutrition, mental health conditions, and health emergencies continue to strain the system. These pressures erode the health system’s ability to respond, deliver care, and ensure equitable access to quality universal health coverage (UHC) in a warming world.

Residents of In Sagabesi-lima have long been demanding reliable transportation but change has been slow. Beneath Ermera’s beauty lies a terrain that turns deadly with rain. Landslides and floods routinely sever communities like Sagabesi-lima from essential services, turning even routine events like childbirth into life-threatening emergencies. “Even when health facilities are well-equipped, it means little if patients can’t get there. In places like Ermera, where footpaths are sometimes the only roads, families often choose home births because hospitals feel impossibly far. And that choice can come at a fatal cost,” said a health worker.

Joanina’s death is a stark reminder: in some places, even a single functioning road can mean the difference between life and loss. And too often, it’s the climate that turns trails into traps.

(Deceased’s name has been changed)

Context

Climate change undermines the right to health and to a healthy environment. As a Small Island Developing State, Timor-Leste faces significant health threats from the impacts of climate change. This year alone, the country has experienced multiple natural disasters and climate hazards, further exacerbating vulnerabilities and health risks within a fragile health system with limited capacity to respond and adapt.

Climate change also exacerbates health inequalities within the country, with the downstream effects weighing most heavily on marginalized communities and vulnerable populations such as women and children. The most common causes of mortality and morbidity in Timor-Leste are climate-sensitive health outcomes, such as stroke, respiratory, waterborne, foodborne- and vector-borne diseases, as well as ongoing challenges related to nutritional and mental health issues, and health emergencies.

These issues also impact the health system’s ability to cope, respond and provide high-quality and equitable universal health coverage. Health facilities, particularly in rural and remote areas, are often ill-equipped to withstand extreme weather events. For example, the 2021 cyclone Syroja affected 178,000 people, with nearly half of them being women and girls. Around 56% of health care facilities were damaged, disrupting maternal and reproductive health services as well as access to health services. In addition, climate-driven food insecurity, water contamination, and malnutrition heightened pregnancy-related risks and worsened maternal and child health, increasing the risk of maternal and newborn deaths and hindering access to essential care. Timor-Leste has one of the highest maternal mortality rates in the Southeast Asia, at 195 per 100,000 live births.

The impacts of climate change have proven to pose significant challenges to the country's health system, including:

Interruptions in already limited energy supplies and availability of safe water, both of which are crucial for healthcare facilities;
disruptions to supply chains for essential medical equipment and pharmaceuticals, leading to shortages and hinder the ability to provide critical care;
damage to healthcare infrastructure from flooding, landslides, and extreme weather events,which can impede service delivery and compromise the safety of both patients and healthcare workers;
a heightened risk of disease outbreaks in post-disaster situations, leading to increased demand for care

Health facilities face difficulties coping with these challenges, further straining an already resource-constrained healthcare system.

Implementation process

Implementation began with multi-sectoral coordination led by the Ministry of Health, in collaboration with local authorities, civil society, key stakeholders and partners

Some of the key steps included the following:

Assessment and mapping of vulnerabilities
The Ministry of Health (MoH) conducted assessments to identify the most climate-vulnerable regions and populations. Findings revealed that these included pregnant women, children, and the elderly in isolated rural areas. The MoH, in collaboration with the WHO, had conducted extensive Climate and Health Vulnerability and Adaptation assessments and Climate and Health risk profiles. Specific interviews were carried out with vulnerable groups during this process.
Policy and plan development
Based on the findings, the government integrated climate justice principles into national health adaptation planning. These included commitments to maternal health access, gender-sensitive care, and support for underserved communities. The MoH has endorsed the National Strategy on Reproductive, Maternal, Newborn, Child and Adolescent Health, the National Health Sector Strategic Plan, the Health National Adaptation Plan, the Climate Resilient and Environmentally Sustainable Health Care Facilities Policy and Strategy, the Climate Resilient Water Safety Plan, and the National Health Care Waste Management Policy
Community engagement, social participation and family planning services
Inclusive consultations were held with women, youth, persons with disabilities, and traditional leaders to shape interventions. Community-based monitoring groups and local health committees were mobilized. The Servisu Integradu Saúde Comunitária (SISCa) (“Integrated Community Health Services”) program and mobile clinics are expanding access to routine antenatal checkups, emergency obstetric care and postnatal care schedules. However, these services are often impacted due to landslides and flooding.
National family planning campaign
The campaign promotes birth spacing, specifically a three-year interval, to reduce maternal and infant mortality.
Strengthening the Health Information Management System (HMIS) and the Early Warning, Alert, and Response System (EWARS)
Efforts are being made to strengthen HMIS, DHIS2 and surveillance systems and to establish a climate-informed health surveillance and early warning system, using EWARS-csd.
Deployment of climate-resilient interventions and overall strengthening of the health system
Interventions included mobile maternal health teams, climate-informed referral systems, local early warning messaging, and infrastructure reinforcements such as improved health post access during rainy seasons. Solar PV systems and solar-powered climate resilient water treatment systems have been installed in selected municpalities. Multiple interventions are being put in place to improve WASH, nutritional services and girls’ education. Efforts are underway to enhance emergency stockpiles and referral mechanisms.
Health workforce capacity building
Health professionals have been trained in climate-sensitive service delivery, focusing on maternal and child health during emergencies and extreme weather events. Multiple trainings were conducted to strengthen emergency, obstetric and newborn care, and to promote antenatal care and skilled birth attendance and midwifery education.
Digital health
The Liga Inan mobile application helps improve communication between rural mothers and health care providers, promoting adherence to prenatal care schedules.
Financial incentives and user fee removal system
Initiatives like the Bolsa De Mae program and removal of user fees for maternal services are aimed at reducing financial barriers to accessing care.
Monitoring and feedback
Effort are ongoing to strengthen the Health Information Management System, surveillance system and overall data collection.

Lessons learned

Key policies need to be climate-integrated. Timor-Leste’s health sector has multiple policies, strategies and guidelines, but most are stand-alone and not integrated. The National Health Sector Strategic Plan does not address climate change. While there is a short section on environmental health, considering sanitation, food safety, vector-borne disease, waste management and air pollution, and outlining objectives to improve the environment, the interaction between environmental health and climate change is not being discussed in the plan.
Climate change directly impacts the health system and the health care delivery in the country. Climate change impacts are a daily reality in the country. Numerous injuries and deaths are directly attributable to climate hazards.
Climate and health advocacy, training, and capacity building for the local community, health workers and health professionals including clinicians and policy- and decision makers are critical to ensure the provision of quality, equitable care.
There is a strong need to strengthen the EWARS-csd system and to ensure that health programs are climate-informed.
Health infrastructure and health systems must be made more climate resilient. Access to quality services depend on the health system’s ability to prepare, respond to and address the impacts on climate change. This includes strengthening health infrastructure and health supply and equipment management systems.
Sustainability of key interventions are critical. Scaling up interventions mentioned above will contribute to overall improved reproductive, maternal, newborn, and child health (RMNCH) services in the country, reduce respective mortality rates, and contribute to the achievements of the Sustainable Development Goals.
There is a need to strengthen emergency and referral care services as well as existing disaster risk reduction strategies and risk communication efforts.
Climate-health finance is essential to provide high-quality and equitable primary health care services and to achieve UHC.
Integrating climate considerations within existing public health, preventive health programs and services are essential to ensure that no mother or child will suffer preventable deaths.

Challenges

High baseline maternal mortality rates
Persistent disparities between municpalities in health and education, with vulnerable populations being disproportionality affected
High baseline rates of child stunting, wasting, malnutrition and food insecurity
Geographical disparities, poor road conditions, lack of transport, poor WASH infrastructure and under-equipped rural health facilities make it difficult to deliver services during climate-related disruptions like floods or landslides
Limited overall capacity: As a post-conflict and one of the youngest countries in the world, Timor-Leste faces multifaceted human resource challenges that require extensive support, including in areas such as climate and health research.
Limited health system capacity
Weak intersectoral coordination between health, environment, transport, and disaster response sectors delayed implementation and reduced the effectiveness of emergency responses
Insufficient climate-health data integration and training hindered timely risk detection and appropriate care.
Inadequate funding and limited HR knowledge and capacity restrict investments in resilient infrastructure, emergency stockpiles, and clean energy solutions. Institutional knowledge and policymaking are yet to be translated into adequate climate-health investments
Language barriers and cultural beliefs

Success factors

Some progress in RMNCH. Child mortality and neonatal mortality has declined, but they continue to be higher than regional averages
Improved immunization services.
Mobile outreach and community-based health services. Deploying mobile clinics and empowering community health volunteers helped overcome access barriers in remote areas, ensuring continuity of maternal and emergency care during climate disruptions.
Cross-Sector coordination mechanisms. Establishing joint planning between the Ministries of Health, Transport, and Disaster Management improved communication and enabled faster emergency response during floods and landslides.
Capacity building. Targeted training programs equipped frontline health staff with skills in climate-sensitive care, early risk detection, and emergency preparedness, strengthening local response capacity. Climate and health awareness is slowly increasing.
Leveraging local knowledge. Involving traditional leaders and communities in planning and feedback loops increased trust, improved early warning message delivery, and helped tailor solutions to local realities.
Key policies are put in place. The National Health Sector Strategic Plan, Climate Resilient Environmentally Sustainable Health Care Facility Policy and Strategy has been in place. The H-NAP and and National Environmental Health Strategy have been developed yet implementation is hampered by limited funds.
Partnership and Collaboration. Support from WHO,other UN agencies, partners and NGOs can make a big difference.

Recommendations

Prioritize Vulnerable Populations in All Planning. Use equity-based approaches to identify and target communities most affected by climate change, ensuring services reach women, children, the elderly, people with disabilities, and rural populations.
Strengthen Local Health Systems with Climate Resilience in Mind. Invest in mobile outreach, climate-adapted infrastructure, renewable energy in health facilities, and stockpiles of essential supplies to maintain services during emergencies.
Integrate Climate Data into Health Decision-Making. Establish systems that connect meteorological data with health surveillance and emergency response, allowing timely, evidence-based action and early warning. It is also vital to integrate climate considerations in overall health sector planning and other public health programs and key interventions
Invest in DRR activities and risk communication, including strengthening of referral mechanisms and emergency care
Promote Cross-Sectoral Collaboration and Community Participation. Build governance structures that bring together health, environment, disaster, and civil society actors. Ensure communities are not just beneficiaries but active partners in designing solutions. It is also important to further strengthen partnerships with international agencies, institutions and leverage mechanisms and platforms such as ATACH.
Strengthen maternal and child health services by integrating climate change considerations into quality health care.
Invest in Climate-Resilient and Environmentally Sustainable infrastructure to minimize carbon emission and promote green, environmentally friendly practices
Facilitate access to climate and health financing

Key resources

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