Ministry of Health State of Palestine Public Health Policy for Palestinian Children Palestinian Child Health Priorities Based on the Child s Rights to Health December 2012
Ministry of Health State of Palestine Public Health Policy for Palestinian Children Palestinian Child Health Priorities Based on the Child s Rights to Health Education Health Child Participation Disability Protection December 2012
Note: Data included in this report is primarily based on statistics available in 2011 when this work was initiated
Participants in the Preparation of the Policy: From the MOH: Committee Coordinator: Dr. Waleed Al-Khateeb Ms. Ilham Shamasnah Ms. Taghreed Hijaz Dr. Jawad Al-Bitar Dr. Bassem Naji Dr. Mamdouh Njoom Dr. Ghada Khoury Eng. Ala Abu Rub Ms. Lubna Sader Ms. Lina Bahar Dr. Abdullah Zahran Ms. Taghreed Yaseen Ms. Jameeleh Dababneh Ms. Majida Saeedi Ms. Amal Al-Haj From Save the Children Ms. Lubna Iskander Final Editing and General Supervision: Dr. Asaad Ramlawi Dr. Waleed Al-Khateeb This document was produced with the technical and financial support of Save the Children International All rights are preserved In case of quotation please refer to the document as: MOH-Palestinian Child Public Health Policy- Palestinian Child Health Priorities Based on the Child s Rights to Health Palestine 2012
Acknowledgment This policy is the result of national consultations based on the report by the Palestinian National Authority (PNA) on the implementation of the Convention on the Rights of the Child (CRC), seeking to make the rights and health of Palestinian children a fundamental pillar of our national plans for a healthy society. We would like to express our deep appreciation to all those who contributed to the development of this document, from inside and outside the Ministry, and to the efforts of the Palestinian civil society organizations, and all departments and directorates of the Palestinian Ministry of Health (MOH). Special thanks are due to Dr. Walid Al-Khatib coordinator of MOH internal committee on the rights of the child, Dr. Jawad Bitar, Dr. Bassem Naji, Mr. Alaa Abul-Rub, Ms. Ilham Shamasneh, Ms. Lubna As-Sadr, Ms. Lina Bahr, Dr. Abdulla Zahran,, Dr. Mamdouh Nujoum, Ms. Taghrid Hijaz, Ms. Jameeleh Dababneh, Ms. Taghreed Yaseen, Ms. Majida Saeedi, and to Ms. Hanan Abed and Mr. Ihab Shukri from the Ministry of Education. (MOE) We would like to thank UNICEF and Save the Children for their technical and financial support in the production of this document, and to the Palestinian Central Bureau of Statistics (PCBS). Dr. Asaad Ramlawi Director General of Primary Health Care, MOH
Table of Contents Introduction...7 Executive Summary...8 Problem Statement...11 Situation Analysis...13 Major Health Indicators in Palestine...14 Child Mortality Social Practices Nutrition and Physical Activity Non-Communicable Diseases (Chronic Diseases) NCDs Mental Health School Counselling Health Education and Adolescents Health Availability of Services and Infrastructure Early Detection and Disability Policy Framework...22 Vision Mission Policy s Ultimate Goal Intervention Levels Policy Rationale Policy priorities according to Consultations with the Partners Partners Marginalized Groups/ Marginalized Children Strategies of the Palestinian Public Health Policy...27 Obstacles...49 Risks...49 Strengths...50 Weaknesses...50 Needed Supportive Studies and Protocols...51 Child Rights to Health Indicators...52
Annexes: Annex 1: Palestinian Health Strategies Prevention and Healthy Life Styles... 58 Annex 2: Suggested Roles and Needs for Early Detection and Referral... 62 Annex 3: Influence of the Political Situation on the Socio-Economic Life of the Palestinian People...64 Annex 4: The Health Situation in Palestine... 68 Health Legal and Legislative Framework Policy and Strategic Framework Partnership with UNRWA Health Centres and Personnel Annex 5: Summary of Some Health Indicators... 69 Nutrition Health Education and Adolescent s Health Inappropriate Preventable Social Practices that can Affect Child s Health Early Marriage and Consanguinity Smoking and Substance/Drug Abuse Non-Communicable Diseases (NCDs) Mental Health Affordability Annex 6: Best Practices...83 Combating Smoking and Pollution Accident Prevention School Health Prevention of Nutrition Related Problems Health Education and Awareness Raising Systems, Services and Monitoring Partnership, Coordination and Role Distribution Protecting Mother and Child s Health Annex 7: General National Health Rights Based Indicators... 88
Introduction Through our continuous and diligent efforts to develop and improve qualitative, affordable and accessible health services in Palestine to match the level of sacrifices of our people under these difficult circumstances, this policy will add to our national achievements to build our Palestinian State on a sound footing. It represents a good example of partnership and cooperation within the different departments of the ministry itself, and with partners from other governmental and non-governmental organizations. We worked together to ensure the best interests of the Palestinian children, without discrimination, and to ensure their survival and development, and to create an enabling environment for them. We, at the Ministry of Health have prioritized Palestinian children since our inception. Furthermore, we are one of the leading countries in the field of primary health care and maternal and child care in the region. However, this achievement is a first steps towards the institutionalization of children s rights within our priorities and programs. It puts us among the few countries that have a national policy based on the rights of the child. What is special about this document is that it was built not only on the basis of well-being and needs of the child, but was based on their rights. It puts the Palestinian child in the center of attention, commensurate with his/her status as the foundation and future of the Palestinian society. They are half of the present and all of the future. This policy paper focused on the child s individual rights and not only the right of the family. Children deserve special attention and positive discrimination. It puts the best interest of the child above all other considerations. Children are the most vulnerable group and are at risk of marginalization due to the economic, political and social factors. Considering the current circumstances, and the fact that Palestinian children have not yet reached the stage where they are represented within society. Moreover, this policy targets the children from marginalized groups and marginalized areas and gives them more attention to reduce the socioeconomic gap as much as possible, and to achieve justice, equity and equality in access to services. This may not be a perfect policy from the point of view of some, but it reflects the reality and what we can realistically accomplish in the coming years. It also sets an example and model for future formulation of health policies and plans. This document is house grown and is a national Palestinian effort, and is in harmony with the Palestinian Child Law and amendments, and in accordance with international standards of human and child rights; to plan according to our national priorities and our local capacity and identify the way for the realization of the rights of Palestinian children, and make human and child rights the pillars and building blocks of the Palestinian society. And, as they say It is better to light a candle rather than to curse the darkness. Dr. Hani Abdeen Minister of Health Public Health Policy for Palestinian Children/Right to Health Priorities 7
Executive Summary The occupied Palestinian territory (OPT) is a unique situation of fragility because of the Israeli occupation. There is no single expression to describe the conditions in the OPT starting from the establishment of the Palestinian National Authority (PNA), until now. During this period, the early years of development were followed by a terrible humanitarian situation which has endangered, and in some cases reversed, much of what has been achieved during the years before; (de-development). Achievements made by the MOH and partners are clear and proven at the level of policies, plans, programs and services, particularly in primary health care programs, which have surpassed those in some neighbouring countries. This includes, but not limited to the protection of Palestinian children from communicable diseases, screening and surveillance programs in nutrition and school health, as well as health education programs. All of this has been accomplished under challenging conditions; imposing difficult choices on the MOH. Nevertheless, there have been obvious negative effects resulting from the geographic division (lack of contiguity) of the Palestinian territories due to military checkpoints and Israeli security zones on the one hand, and the internal Palestinian division on the other hand, which together undermine the State s control over a large part of its territory, preventing it from implementing its policies and development plans in most cases, and even imposing unstable humanitarian situations, leading to a discrepancy in access to services. As a result, the social and economic conditions are unstable, impeding the achievement of the expected significant progress following this period of hard work. To the contrary, in certain sectors the situation became comparable to what had been prevalent prior to Al-Aqsa Intifada in 2000. The above situation has had negative effects on the health status of children, especially in marginalized areas and marginalized groups. This situation has also led to a health system with multiple service providers, who are not sufficiently coordinating and sharing information among themselves. Effective participation in the process of national planning, policy development and decision-making is also inadequate. Instead, competition for limited resources sometimes led to the duplication of some services in some areas at the expense of other services and areas. Please see Annex 3 for more information on the impact of the political situation on the social and economic life in the OPT. Taking into account the PNA expenditure on the treatment of non-communicable diseases (NCDs) (reaching about 48% of its health budget), and the inability to estimate the expenditure on persons with disabilities and children in general, and given the large number of interventions in the field of nutrition over the past years, the continued suffering by Palestinian children from nutrition-related problems to date, and the fact that many health programs and interventions have not been evaluated, it becomes necessary to take decisive and proactive steps to evaluate the previous interventions. This should help identify reasons for achieved successes in 8
order to expand and scale them up, as well as draw lessons learned and end the ineffective programs, or at least change their course. In addition, focus should be made on prevention programs targeting children and their lifestyles in parallel with the curative interventions; to ensure a healthy and productive generation and society. Furthermore, early and proper detection /diagnosis and intervention will help alleviate the suffering of many children and their families in the future, and will constitute a cost-effective strategy for the government in economic and social terms. Children constitute around half of Palestinian society and the child mortality rate is relatively low (compared to regional and other developing countries). Nevertheless, given the importance of Palestinian children s lives and health, and since some of the mortality, disability and morbidity cases were due to preventable causes, and also because of the wide range of marginalization in the OPT, policy focus on children in general, with affirmative action for marginalized groups, would help protect their future and that of future generations. Given the prevalence of some negative social norms and phenomena, whether due to the Israeli military occupation or due to ignorance, and the negative effects of some external habits to the Palestinian society, considering the overall vulnerability and susceptibility of children, it is necessary to promote prevention through education and counselling, and allow a chance for children and especially adolescents to obtain reliable and safe information in relation to their physical and mental health. It is equally important to respond to their specific needs and ensure their development as effective and proactive members of society. It is not enough to deliver information using traditional methods. Rather, interactive education and learning methods should be used in conveying messages in accordance with modern directions in health education and promotion. This requires enhancing the natural and social environment of children and their families, and equipping them with life skills that they will need to make the right decisions, and adopt healthy lifestyles and behaviours in order to enhance their health and the health of their families and society; as active members, rather than being passive recipients of information only. Hence it is necessary to develop comprehensive preventive programs at all levels, and with the involvement of all stakeholders, as well as to strengthen the positive existing programs, build on previous successes, and prevent duplication while closing the gaps in programs and ensuring sustainability. It should be noted that change does not occur spontaneously but needs time, concerted effort and the necessary capacities, since: Public Health Policy for Palestinian Children/Right to Health Priorities 9
Focus on addressing the problem when it occurs is usually less cost effective in economic terms in the long run, will need a lenghty period of time to yield results, and will require larger financial and human resources. Focus on prevention may be costly in economic terms at the beginning, but the long-term results will be productive, and cost less in comparison to dealing with a problem once it has occurred. Schools and kindergartens (KGs) are a suitable place to target a large segment of children, parents and the community, and to start changing some negative habits and practices. Based on the vision of MOH of creating a comprehensive and integrated health system that contributes to sustainable improvement and enhancement in the health status of the Palestinian population; through its mission of working together with all partners to improve performance and upgrade the health sector, to ensure professionally sound management of the health sector, and create an empowered leadership with the capacity to set policies, regulate the work and ensure quality services in the public and private sectors, and be based on MOH recognition of the right to health and to access equitable quality services, with a special focus on marginalized groups, and seeking to achieve the MOH s strategic goal of promoting healthy lifestyles and implementing public health programs, the Ministry decided to develop a national policy focusing on children as the future of a healthy and productive society, and as a special group with specific rights and needs, and promoting affirmative action in favour of children in marginalized areas. As part of its commitment to implementing the UN Covention on the Rights of the Child (CRC), the PNA issued in December 2010 its report on the implementation of the CRC in the OPT. This policy has been created based on the recommendations and findings presented in that report through a participatory process involving government institutions, civil society organizations, international organizations and UN agencies. 10
Problem Statement Numerous health education, screening and surveillance programs exist. However, due to limited financial and human resources, and due to an often unpredictable context, these programs are not usually scaled up or extended to the adequate level, and sometimes they are not mainstreamed or provided with the required human resources. The Palestinian health system is often forced to provide an immediate response to certain emergency situations (reaction), the expenditure on these interventions tends to exceed the costs of a preventative approach. This is primarily due to the prevailing political, economic and social conditions. Some child mortality, disability and morbidity are caused by preventable factors. Statistics indicate an increase in the prevalence of chronic diseases in Palestinian society and among young groups. These diseases can be reduced and their complications mitigated by early detection, proper intervention and adoption of healthy lifestyles. Comparison is difficult when it comes to disability, but it is expected that the last wars on Gaza Strip, military incursions, complications of some chronic diseases and traffic accidents contribute to increasing disability rates. Palestinian society is known to have cohesive families, and the child is seen as a member of a family. Despite this positive attitude towards child protection, family s priorities and interests may dominate and prevail over those of the child, who is not seen as a member with specific personality and character, capable of protecting his/her own health and making responsible choices. Furthermore, systems specifically dealing with and targeting the child are lacking. A specific strategy for children is lacking, and they are not seen as partners in the planning process. Hence this policy seeks to promote the principle of health responsibility of Palestinian children and those around them, by equipping them with the necessary skills and knowledge on the one hand, and creating an enabling environment on the other. Many families lack adequate awareness on health issues and rights in general, the importance of early detection, service delivery points, the concept of primary mental health, among others. The PNA report on the implementation of the CRC stated that there is still fairly low pre and post-natal follow up by mothers, even though services are available and free of charge. Health awareness on issues of early marriage, maternal age, and consanguinity as risk factors for congenital malformation and risks the child and mother s well being are available, yet many mothers still support negative behaviours. Furthermore, families are subjected to pressures from society and the extended family. Therefore, focus on children without taking their surrounding environment into consideration will only put them in a swirl of dilemmas between school, home, community and family. Public Health Policy for Palestinian Children/Right to Health Priorities 11
Correlation is noticed between health indicators and a mother s educational level and family income. Hence focus on education, incorporation of health messages and awareness at the school age, reduction of school dropout and improved access to information would improve numerous health indicators while also contributing to improving family income in the future. Change takes time. Hence focus on children in various age groups and according to each group s needs, and the use of school curricula, extracurricular activities and media channels to instil these messages from an early age would help create awareness on children s health rights, and will consequently ensure children s rights for future generations. Children in marginalized areas are more vulnerable to the deteriorated economic, political and social conditions than children in other areas. Overlooking this group may have consequences with the potential of negatively affecting other children and achievements in other areas. Moreover, this would be a violation of the rights of this group of children. Therefore, efforts should seek to include these areas and groups and reduce the gap. Children with a disability, poor nutritional status, NCDs and other forms of chronic illnesses tend to live in poverty. Families with children constitute around 80.1-82.8% of all Palestinian families, and the proportion of poor families among them may reach 59.3%. The Palestinian child statistics 2011 indicate that 27.2% of children live in poverty (with 13.9% living in abject poverty). The family poverty rate, according to consumption patterns, is 13.2% among families without children and 22.7% among families with children, proportionally increasing with the increase in the number of children. There are limited numbers of Palestinian studies that have examined the relationship between poverty and illness, but it is well known that the costs of dealing with long term health problems is a financial burden that depletes family resources. Furthermore, chronic illnesses, accidents and poverty may cause secondary disabilities, thus increasing the economic and social burden on the family and the State. This situation is exacerbated for families that live in remote and/or isolated communities or those affected directly or specifically by the Israeli occupation and its measures, as they have to pay high transportation costs and other indirect costs in addition to treatment costs. In 2009, MOSA was providing assistance for 6124 poor children with chronic diseases. There are children who are not currently receiving assistance and are unaware that social assistance is available to support them and their families. Based on the right of the child to enjoy a healthy life, and taking into consideration the fact that most these diseases are preventable through a comprehensive long-term approach at all levels, with specific roles and responsibilities, the government and its partners can save children and their families the suffering, or at least mitigate its adverse influences. 12
Situation Analysis Children in the age group 0-17 years constitute 49% of the population. In 2011, there were around 1,450,000 children enrolled in schools. Using the 2007 population figures as a reference point (4,016,416), the percentage of children enrolled in primary and secondary education is 36% of the total population. Since 40% of children aged 3-6 years are enrolled in KGs, and there are more children attending day care centres, especially children of working mothers, and also since many under fives have siblings in schools or KGs, the targeting of schools, KGs, day care centres and clinics would reach the larger proportion of society. As stated above, the separation of the different areas within the OPT by checkpoints, the apartheid Wall, closures and barriers is fragmenting the territory and creating discrepancy in access to services, especially affecting the population of rural and remote areas, as well as Bedouin communities, who have to bear additional indirect costs. Access remains a problem, whether in financial terms or in terms of infrastructure and transport. The marginalized groups are usually the most affected, enduring more severe negative effects. A 100% increase in the number of households experiencing catastrophic health care costs occurred between the years 1998-2007 (due to Intifada related injuries and continuing Israeli invasions and attacks on civilian populations). This also correlates with increasing numbers of families living in poverty and in need of receiving free national health insurance, which is directly increasing health spending costs for the MOH. In 2008, families had to spend 36.7% of their non-food expenditure on purchasing health care services. 1 Around 53% of the expenditure is allocated for food (a higher percentage in Gaza and for food-insecure families). Strategies to cope with poverty and food insecurity include families reduction of consumption of nutritional foods in terms of quantity and quality, and a reduction of expenditure on health and education. 2 Please, see Annexes 3 and 4 for more information on the health situation in Palestine. 1 Palestinian health accounts, PCBS, 2011. 2 Socio-economic and food security survey in the West Bank and Gaza Strip, occupied Palestinian territory. PCBS, WFP and FAO 2010. Public Health Policy for Palestinian Children/Right to Health Priorities 13
Major Health Indicators in Palestine Child mortality: The family survey (2010) results indicate a decline in infant mortality to 20.6 per 1000 live births. However the rate varies between the West Bank (18.8) and Gaza (23.0). Under five mortality was 25.1 per 1000 live births (22.1 in the West Bank and 29.2 in Gaza). These indicators suggest an improvement in child health conditions, but do not indicate the conditions that affect children s rights, and do not always reflect the unstable state of health conditions and violations of children s rights. The marginalized groups are the most vulnerable to threats and risks. 3 The following table summarizes the most common causes of mortality in the age group 0-19 in the West Bank in 2011 according to the annual health report: Most common causes Congenital malformations Infectious diseases (sepsis) Age group Age group Most common causes 0-4 5-19 0-4 5-19 175 6 Traffic accidents 21 24 161 5 Heart disease 1 13 Respiratory illnesses 43 18 Other accidents 17 18 Sudden death 46 - Malignancy 12 30 Malnutrition and metabolic disorders 21 2 Cerebral palsy 7 18 For children 0-4 years of age, the main causes of death are usually congenital malformation, respiratory disorders, low birth weight (LBW), sudden infant death (SID) and heart diseases. Higher rates of LBW are reported in rural areas and refugee camps, which are attributed to poverty, mother s age and educational level, rather than the type of locality. Other factors that may affect mother and child s health is poor nutrition during pregnancy, early marriage and active and passive smoking of cigarettes or water pipes. 4 For older ages (5-19) the main causes of death include traffic accidents and other accidents, respiratory disorders, malformations, cerebral palsy and malignant neoplasm. Child statistics (2011) indicate that respiratory diseases are the main cause of infant mortality in the West Bank. For children under five, antenatal-related diseases were the main cause of death. Therefore, it is necessary to focus on the surrounding environment and promote and monitor maternal health during pregnancy. 3 Palestinian National Authority Report on the Implementation of the Convention on the Rights of the Child (CRC) in the Occupied Palestinian Territory (Dec. 2010). PCBS (2011) 4 Women s Health Surveillance Report: A Multi-Dimensional View to Palestinian Women s Health, Juzoor for Health and Social Development, 20 May 2009. 14
Accidents are a main preventable killer of children During 2011, in the age group 5-19, the mortality rate due to traffic accidents was 12.1% - the second highest among all causes of death, after malignant neoplasm. In the age group 1-4, traffic accidents were recorded as the second cause of death in that year, following respiratory diseases. Other accidents were reported as the fourth cause of death in this age group, following congenital malformations. 5 During 2011, 106 deaths and 8132 injuries, including 74 disabilities (at least 20 of them among children), were reported as resulting from traffic accidents. The highest percentage of moderate and severe injuries was among children under one year of age. For children aged 1-4 years, accidents were the major cause of death for 27.7% of the total deaths in that age group with traffic accidents accounting for 11.7% of young children s death. For children 5 to 18 years of age, the main cause of death was also due to accidents which accounted for 46% of total deaths (5.5% of which were due to traffic accidents.) 6 Although studies are not available on the economic costs of traffic accidents, the cost is estimated to be in millions of dollars annually. Social practices: The deteriorating political and economic conditions, and the resulting social pressures and harassments at military checkpoints and barriers and by settlers have led to a state of general frustration, and the revival of some negative social practices that have been reduced for some time, such as early marriage, school dropout, violence, child labour, drug abuse, and smoking especially among children and girls. Therefore, raising awareness and equipping children with the tools and skills to resist the negative influences in the surrounding environment will help protect them from various adverse social and health practices that will have a negative impact on their health in the future. For further information, please see Annex 5. 5 6 Nutrition and physical exercise: Malnutrition is a serious problem affecting mental development and contributing to obesity and adult diseases in the future, especially when associated with little physical exercise. The OPT combines nutrition problems for both developed and developing countries, including stunting, wasting (hunger), anaemia, overweight and obesity. This situation poses a double burden on strategy development. It should also be noted that the deteriorating economic situation in Palestine has left around 40% of the population dependent on food assistance, and reduced the consumption of nutritious foods such as meat, vegetables and fruits (Please see Annex 5 for further information). 5 Annual Health Report. Ministry of Health. 2011 6 Palestinian National Authority report on the implementation of the Convention on the Rights of the Child (CRC) in the Occupied Palestinian Territory (Dec. 2010). PCBS (2011) Public Health Policy for Palestinian Children/Right to Health Priorities 15
Non-communicable (chronic) diseases: 7 According to MOH data, the prevalence of NCDs is increasing, with 48% of MOH budget spent on the treatment of these diseases 8. There is a need to adopt a comprehensive approach and early intervention in this regard. There is a gap in the health care services for children between the ages of 3-18 years. Admission and treatment costs are not free of charge for children above the age of three, and sometimes medications are not available. Some chronic/non-communicable diseases require using medical equipments which are not always available. Needy patients should receive assistance to purchase the necessary medical equipments. Moreover, patients with NCDs, especially children, females and teenagers suffer from resistance and denial, so they need special support and counselling from family, peers, community and school. Some might try to hide it. However, families with NCD children are usually under huge psychological and economic pressure. Some families cannot afford transportation to the hospitals and clinics and cost of stay. In cases where a special nutrition regime is required, it is usually problematic due to the poor economic situation. During the National NCD Conference, it was agreed that more efforts need to be exerted in combating smoking, encouraging physical exercise, reducing obesity and using healthy nutritional habits. For more information, please see Annex 5. Mental health: Currently, mental health units are integrated into primary health care (PHC) centres. Intervention is primarily focused on the provision of medicines rather than community PHC, that gives priority to prevention and detection of at risk children; to protect them from various life pressures and adverse impacts of changes in their environment. In addition, there is a shortage in terms of early detection of psychological and behavioural disorders within high risk groups, and in life skillsbased mental health awareness that is aimed at reducing the risk of psychological problems among children and ensuring the active participation of families. There is no legal mechanism to enforce guardians to bring their children for follow up sessions and treatment. Transportation and the need to be accompanied by an adult sometimes prevent guardians from bringing the children to the centre, especially the girls. This situation results in children not receiving timely and consistent treatment. According to the Annual Health Report of 2011, during 2010 new cases registered by MOH were 129 in the age group 0-9 years, increasing with age to reach 246 cases in the age group 10-19 years. Major causes of mental health problems mentioned are epilepsy, schizophrenia, neurosis and mental retardation. Epilepsy is still classified as a mental health illness rather than a chronic disease. In addition, indicators suggest that suicide attempts are increasing. All this indicates the importance of early detection, diagnosis and intervention. For more information, please see Annex 5. 7 Palestinian National Authority Report on the Implementation of the Convention on the Rights of the Child (CRC) in the Occupied Palestinian Territory (Dec. 2010). PCBS (2011) 8 Dr. Asaad Ramlawi. On the international day to combat smoking. MOH website, May 2011. 16
Early diagnosis and intervention have great importance in reducing the duration and severity of mental health diseases. Early screening is recommended to be conducted in health clinics and schools to detect at risk children, and provide them with the required assistance. Counselling and support networks should be offered to children living in families with one or more members with a mental disorder. Training courses were offered to counsellors and there is still a need to offer specialized training by qualified trainers in order to enhance the quality of programs targeting children. School counselling: The Ministry of Education (MOE) runs a school counselling program in 68% of public schools. The school counselling program works in synergy with the school health program in both MOH and MOE, dealing with students in need of professional counselling, and addressing anxiety, fears, problems related to stress, family support, and referrals. The program is specifically sensitive to targeting children at risk of school dropout and those with low attainment and performance at school, offering guidance to students on the advantages of staying in school and avoiding early marriage and dropout. The program also identifies those who may have been exposed to violence, abuse and/or exploitation. The program is part of the national child protection network; it refers children in need of more intensive treatment, or for certain treatments by more competent professionals at MOH or in the NGO sector. However, there is a need for more counsellors, especially in high risk areas; Jerusalem suburbs, East Jerusalem, Hebron, South Hebron, Jordan Valley, areas adjacent to the Wall, or areas close to settlements and military camps, among others. Health education and adolescents health: 9 There are many services, activities and policies addressing the issues of health education, school health, nutrition, adolescent health, counselling, environment and others. However, they are not institutionalized and thus not sustainable. They are rarely evaluated and lack the required material and financial resources to scale them up, either because they are not included in regular budgets or because they lack financial support and/or qualified human resources in the field. Expansion of these efforts is impeded by the absence of a comprehensive vision that sees the school as part of the family and community environment surrounding the child. The condensed school curriculum often hinders the implementation of activities and limits opportunities for follow up and discussion with parents, because teachers are overwhelmed with teaching tasks, and because there are limited initiatives for community-based activities during after school hours. MOH produces a large number of educational materials and carries out field work despite the inadequate number of health educators. In addition, there is a need to depart from traditional education styles towards interactive methods, and to invest in the pre-school level in health education as indicated by various research studies. For more information, please see Annex 5. 9 Palestinian National Authority Report on the Implementation of the Convention on the Rights of the Child (CRC) in the Occupied Palestinian Territory (Dec. 2010). PCBS (2011) Public Health Policy for Palestinian Children/Right to Health Priorities 17
Reaching out to parents and children while they are in PHC waiting areas offers a good opportunity to increase their awareness about health related topics; like early intervention, parenting skills, and basic best health practices, in addition to specific topics like nutrition, mental health, chronic illnesses, and other types of health issues relevant to children. These messages should be short, focused, and appeal to both mothers and fathers in a manner that can be easily understood and remembered. This can be achieved by expanding the production and dissemination of educational and learning materials via the use of television, and closed circuit TVs within the PHC waiting areas and for broadcasting on local TV stations. Availability of services and infrastructure: In 2011 there were 748 PHC centres in the OPT. There are 669 (81%) and 147 (19%) centres in the West Bank and Gaza, respectively. Governmental PHC centres constitute 458 (61.2%) of the total PHC centres (404 (60.4%) in the West Bank and 54 (36.7%) in Gaza). MOH uses mobile clinics to reach communities in remote areas. These centres would be more than sufficient to meet local needs in normal conditions. However, in view of the Israeli closure policy and procedures, MOH continues to expand services in clinics based on constant demands by the local communities for greater health service availability. Usually this expansion may affect the quality of services, reduce the availability of specialized care and professionals, and increase the cost. Wide variations exist between the different geographic areas. The situation is not encouraging for health practitioners to work in marginalized and hard to reach areas. In some instances, mothers have reported that they delay pregnancy testing and visits until they have access to a female doctor. 10 This has an impact on women s motivation and access to pre and post-natal services, and consequently may affect the right of the child to life even before it is born. Higher rates of postnatal care visits were mainly associated with increased income, caesarean delivery, and receiving health education on postnatal care during prenatal care. The most reported reasons for not receiving postnatal care were no presenting symptoms of a health problem, checkpoints, high cost and lack of money, the woman s reluctance to seek care alone, the lack of female staff to offer the services, difficult transportation, and distant service delivery point, and not knowing where to receive the service. However, there is improvement in this regard compared to previous years. Recently, some medical schools and physician training programs in some hospitals instituted a quota for equal enrolment between males and females. 11 For more information, please refer to Annex 5. 10 Only 13% of the general physicians and 6% of the specialized physicians are females. Among the specialists, only 44% are gynaecologists. Female nurses and midwives are also under the recommended level. 11 The PCBS Population, Housing and Establishment Census of 2007 and Women s Health Surveillance Report- Juzoor- May 2009. 18
Early detection and disability: 12 Based on the disability survey 2011, child statistics indicate that children with disability constitute 1.5% of children in the OPT. Congenital causes constitute 29.6% of the cases, followed by acquired illnesses in 24% of the cases. Other major causes of disability include accidents, heredity, problems during pregnancy and child birth, physical and psychological abuse, stress and Israeli measures. The acquired illnesses were the most common causes of visual and hearing impairments, remembering/memory and concentration, slow learning and mental disability. Congenital cases were more related to communication problems. However, the issue should be linked to the mother s educational level and age. MOH is committed by the Basic Law and the Public Health Law (article 2) to provide the necessary services related to early intervention and prevention of diseases as mentioned earlier. The Phenyl Ketone Urea (PKU) and the Thyroid Stimulating Hormone (TSH) tests are free and compulsory at PHC centres. Positive cases of PKU receive free special milk for children, and parents are informed on how to provide the child with a special diet. Physical checkups for babies are performed on a regular basis before vaccination. Early screening is done through the Integrated Management of Childhood Illnesses (IMCI) program and the well-baby clinics. Child development is monitored through the mother and child health handbook. Early screening for developmental disorders, illnesses and other medical conditions is provided at all PHC centres of MOH, UNRWA and NGOs. The Ministry also adopts the Integrated Management of Childhood Illnesses Initiative (IMCI) in association with UNICEF to reduce mortality, build capacity of health professionals and case management skills, but the IMCI includes the psycho-social aspect rather than Malaria component to adapt to the Palestinian context. An IMCI national plan was implemented covering the period 2006-2008, but difficulties are encountered due to lack of institutional capacity. 13 Premarital testing is obligatory for certifying the marriage certificate in court. During 2010, according to the Annual Health Report, 150 cases of disability (mostly visual and physical) and 1147 congenital diseases were detected in the age group 1-3 years in MCH centres. Yet there is a problem in referral, and procedures to assist the nursing and medical staff to decide on the follow up steps once the case is detected, and where to refer the child for follow up, and how to ensure appropriate and affordable treatment or rehabilitative interventions for the referred children. 12 Palestinian National Authority report on the implementation of the Convention on the Rights of the Child (CRC) in the Occupied Palestinian Territory (Dec. 2010). PCBS (2011) 13 UNICEF Situation Analysis Report Draft of February 2009 and MOH sources. Public Health Policy for Palestinian Children/Right to Health Priorities 19
School health services include programs conducted by MOH; as medical screening to students (physical exam, oral and dental screening and psychological tests), referral to relevant professional services and follow up, 14 provision of vaccination, first aid and emergency services, surveillance of communicable diseases, surveillance of death cases among students, water testing and treatment, monitoring environmental health in schools and KGs, and conducting physical and mental health education activities. This is in addition to programs conducted by MOE which include the provision of supporting devices, such as wheelchairs, glasses, hearing aids, etc, mental health through school counselling, awareness raising, screening for mental, emotional or psychological problems, referral and follow up, meetings with teachers and parents, dealing with special needs and school violence. However, this area is under-covered due to the lack of psychological specialists. Unfortunately, the majority of schools still lack a nurse s room. School health programs are not adequately institutionalized and there is a shortage in human resources. Updates: Summary of the results of the survey conducted by the PCBS in cooperation with the MOH and the UNFPA, on evaluating the youth needs ( 15-24 years old) of youth friendly health services in the West Bank (2011): The primary results of this survey were announced on 25 July 2012. Despite the fact that the targeted group in this survey is the youth in the age group 15-24, yet the results give an indication of the most important services and things to consider when developing the national policies and plans for the youth and children (tomorrow s youth). The results also support this policy paper. There is a gap between health knowledge and practices. The youth considered that the most prominent health problems/ issues are the ones due to unhealthy practices such as smoking, drug addiction, etc, followed by psychological problems and noncommunicable chronic diseases. Private clinics were used by youth more than governmental clinics to seek health services. One fifth of the youth who needed medical services did not seek it. Half of the surveyed youth thought that the available health services did not meet their needs, either due to lack of availability, lack of understanding and care about youth needs, negligence and medical errors, and in some cases the high cost. 14 In the first grade in terms of migrant testicles, throat, abdomen, thyroid, weight and height, heart exam, and dental and ophthalmic exams for grades 7 and 10, examination of girls in the sixth grade for back problems. For dental health there is a gargling project in pilot schools for one year, a fluoride sealant project, a fluoride gel project and 5 mobile dental clinics. 20
Most prefer to have the health center close to their residence, and to be integrated. Privacy was considered a major issue for them when seeking the health service. The health system in its current shape requires serious investment in medical staff to establish a new practical model of youth friendly health services, and attract them to get safe and correct information. Mental health, physical health and reproductive health constitute their main concern, in addition to prevention in terms of healthy life styles, availability of information, availability of means of prevention and reproductive health in its wider sense. The role of the local community, and raising awareness at all levels including youth, family and community were highlighted as a main focus of attention. The study showed that only one third of the surveyed youth practiced sport. That youth resort to other means than the health clinic; as the internet, TV among others to get information. Some of these means might not be monitored or safe. The curriculum sometimes does not provide the required information due to lengthy materials, shortness of time or lack of expertise. Lack of confidence between the students and counsellors or teachers increases the gap further. The youth have lots of free un-invested time, which leads to harmful health and social practices. The study recommended piloting youth friendly health centres in marginalized areas in the first phase, and later expand this experience based on the lessons learned. Public Health Policy for Palestinian Children/Right to Health Priorities 21
Policy Framework Vision: Promote the general health of children in the Palestinian society, through investing in children as a basis for a healthy society, by providing them with the necessary tools and an enabling environment to enhance a healthy and productive future society, reduce the health-related discrepancy among children, and address the rights and needs of children, especially the marginalized ones, according to the specific needs of the different age groups, thus reducing the health and financial burden associated with health problems that can be controlled in the long term, and mitigating their complications and negative effects, and ensuring that the available resources are geared towards other health priorities. Mission: Advance and promote a healthy society by controlling preventable diseases, accidents and mortality, reducing complications and mitigating their adverse effects whenever they occur. This is to be achieved through the provision of quality preventive health services to the community and children by qualified human resources; through prevention and healthy lifestyles; changing the culture regarding health, nutrition and environment; raising health awareness at all levels; controlling communicable and non-communicable diseases, especially those occurring at an early age; combating accidents; reducing complications of diseases and accidents; reducing infant and maternal mortality; and mitigating the impact of stress on children and families, in a way that ensures equitable access to all social segments and different geographic areas while focusing on marginalized groups. Policy s Ultimate Goal: Reduce the prevalence of non-communicable diseases and disabilities and their complications in children through prevention and early detection targeting all children, and through detecting and protecting at risk children, and providing remedies to vulnerable children and protecting them from complications at an early age. Children, according to their age, should have control and responsibility towards what they intake, and towards external factors around them. They should be responsible for their bodies and for their own protection and development. The government should provide the conducive enabling environment by giving consideration to the following: Performing screening tests on all children, while considering that some hereditary diseases occur at a later age. Adopting the principle of rights rather than needs, especially with regard to marginalized children. 15 15 Marginalization could be due to individual, social or geographic factors. 22
Drawing on and upgrading the existing institutions and initiatives. Considering children as essential partners and not just as recipients of services. Adopting long-term, sustainable, cost efficient and effective programs. Developing the existing capacity with regard to policy making, services, attitudes, knowledge and skills. Intervention levels: The child (the focus of the intervention), family, KG, school, care centres, community, institutions and the government, taking into consideration the varying degrees of effects the prevailing political, economic, social, cultural and environmental conditions may have on each of the above elements. 16 Remedy Vulnerable/ marginalized children Protection At risk children Prevention All children Policy rationale: Why do we need this policy? 1. Children are the basis for a healthy, sound and productive society. 2. Children comprise 50% of Palestinian society, but they do not possess the needed tools and skills that would encourage them to practice healthy lifestyles, and cope with the adverse life changes affecting their mental and physical health. 3. Children are a special group with special needs that are different from adults. They require more focus and allocation of financial and human resources. 16 For example, the prevailing culture and socio-economic conditions greatly affect the child and his/her immediate environment (family, school and community), whereas the political conditions have a higher impact on the indirect environment (institutions and the government), which will reflect on the direct environment of the child. Nevertheless, at a certain point, children will need to be equipped with the necessary tools to have a say in governmental policies and influence their peers and the surrounding environment. Public Health Policy for Palestinian Children/Right to Health Priorities 23