Palestinian National Authority Ministry of Health Health Planning Unit National Strategic Health Plan Medium Term Development Plan (2008-2010) January 2008
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Table of Content I- Selected indicators... 4 II- Abbreviations... 6 III- Preface... 8 IV. Acknowledgments... 10 METHODOLOGY1. NSHP development methodology... 12 1. NSHP development methodology... 14 1.1 Introduction... 14 1.2 Key Steps to Develop the Third NSHP... 14 1.3 Timeframe (2007)... 17 2. Health Situation Analysis... 20 2.1 Introduction... 20 2.2 Provision of Health Services... 21 2.2.1 Primary Health Care and Public Health Services... 25 2.3 Health Finance... 35 2.4 Health Services Quality... 38 2.5 Human Resources... 40 2.6 Governance... 43 2.8 Strategic Health Planning... 45 2.9 Health Information System:... 49 2.10 The Obstacles and the Proposed Solutions... 51 2.11.1 Challenges... 52 2.11.2 Opportunities... 53 3. Health Strategy... 56 3.1 Health Sector Guiding Principles... 56 3.2 Strategic Objectives... 58 3.3 Sub-objectives... 58 4. Medium Term Development Action Plan... 64 Annex (1) Population Projections 2006 and 2020... 82 Annex (2) Distribution of Localities by Population ()... 83 Annex (3) Primary Health Care and Public health Programs... 84 Annex (4) Classification of Primary health care facilities... 86 Annex (5) Standard lab services at PHC clinics... 87 Annex (6) Human Resources needed in PHC clinics... 88 Annex (7) Population per PHC facility... 89 Annex (8) Number of Hospitals and beds in 2006... 90 Annex (9) Hospital beds increase during the period between 1994-2006... 94 Annex (10) Hospitals beds utilization... 95 Annex (11) Standards for opening new secondary / tertiary unit/service... 96 Annex (12) Ministry of Health staff for the year 2006... 97 Annex (13) Available Human Resources and future needs... 98 Annex (14) Health education programs in Palestine... 103 Annex (15) Summary of MoH Developmental projects 2008 2010*... 104 * 1 2
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I- Selected indicators No. Indicator ( West Bank Gaza Strip Palestine 1. Population (2006) 2,444,478 1,443,814 3,888,292 2. Percentage of Palestinians under 14 years 44.2 49.1 46.6 3. Poverty rate 54.7% 87.7% 65.8% 4. Life expectancy among males - - 71.7 5. Life expectancy among females - - 73.2 6. Crude death rate per 1000 pop - - 3.9 7. Crude birth rate per1000 pop 36.7 8. IMR per 1000 live births 23.2 29 25.6 9. Neonatal mortality rate per 1000 live births 16.3 20.7 18.1 10. Under-five mortality rate per 1,000 live births 26 32 28.4 11. Number of PHC clinics 521 130 651 12. Number of Hospital beds 2,961 2,053 5,014 13. Beds Per 1,000 capita 1.2 1.4 1.3 14. Health expenditure per capita (US$) 135 15. Incidence rate of Hepatitis B Carriers per 100,000 pop 43.6 34.2 39.9 16. Incidence rate of Hepatitis C Carriers per 100,000 pop 2.7 5.1 3.7 17. Incidence rate of Hepatitis A per 100,000 pop 81.23 91.52 86.38 18. Incidence rate of AIDS/ HIV per 100,000 pop 0.09 0.0 0.06 19. Incidence rate of Pulmonary TB per 100,000 pop 0.51 1.0 0.76 20. Incidence rate of Extra pulmonary TB per 100,000 pop 0.3 0.15.23 21. Incidence rate of Leishmaniasis per 100,000 pop 9.91 0.0 4.95 22. Incidence rate of Meningococcal disease per 100,000 pop 0.0 7.13 2.62 23. Incidence rate of Haemophilia. Infl.menin. per 100,000 pop 1.36 0.21 0.79 24. Incidence rate of Brucellosis per 100,000 pop 4.21 1.87 3.04 (1) The Maternal mortality rate is not included because of contradiction in the available data and estimations. 4
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II- Abbreviations CAUS Client Accessibility, Utilization and Satisfaction EMS Emergency Medical Services EMT Emergency Medical Teams GDP Gross Domestic Product GPC General Personnel Council GS Gaza Strip HER Health Expenditure Review HPPU Health Policy and Planning Unit HR Human Resources HSNRC Health Sector National Reform Committee HSR Health Sector Review HSDP Health System Development Project HWC Health Work Committees IC Italian Cooperation IMR Infant Mortality Rate MCH Mother and Child Health MMR Maternal Mortality Rate MoF Ministry of Finance MoH Ministry of Health MoP Ministry of Planning MTDP Medium Term Development Plan NGOs Non Governmental Organizations NHPSPC National Health Policy and Strategic Planning Council NMR Neonatal Mortality Rate NSHP National Strategic Health Plan PAST "Programma di Assistenza Sanitaria alla Palestina"; Italian Health Project PCBS Palestinian Central Bureau of Statistics PH Public Health PHC Primary Health Care PHIC Palestinian Health Information Centre PMRS Palestinian Medical Relief Society PMS Police Medical Services PNA Palestinian National Authority PRCS Palestine Red Crescent Society QID Quality Improvement Department SOPs Standard Operation Procedures UNRWA United National Relief and Works Agency USAID United States Agency for International Development WB West Bank WHO World Health Organization 6
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III- Preface Evaluation of health needs and prioritizing them are fundamental in driving the attention and funds in the correct direction positively affecting the health status of the Palestinian people. Accordingly it is also desirable to focus on the best use of limited available resources to magnify health results and promote equity. The prioritization process depends on many factors as the epidemiological indicators, diseases trends and diseases burden evaluation. It is also influenced by the political and social decisions and commitments. Due to lack of resources, and in order to magnify health benefits, a process of expenditure rationalization is taken. It was necessary for setting our medium term development plan to review all previous evaluation studies, with special focus on: significance of problems, mortality rates, morbidity rates, and the economic and social burden of diseases. Moreover, the percentage of population affected, as well as interventions costs and their out put. other conditions to be taken into consideration to provide the needed prevention, diagnostic and therapeutic requirements. A precondition to our work was to define two basic working mechanisms; the first was strengthening the technical planning unit at the MoH, supported by qualified and experienced personnel to accomplish the mission of preparing the plan and to market it and monitor its implementation and evaluation. The second mechanism was to formalize the activities of the national health policies and strategic planning council involving all stakeholders. The planning unit set out the principle mechanisms, methodologies and tools to define priorities. The depth analysis of the health sector with linkage to the present political, social and economical conditions, has played a major role in defining a clear set of priorities 8
and comprehensive activities to cope with available resources and population needs, mainly the marginalized and poor, as health is a cornerstone of the social and economic development of the nation, and its input is crucial to decrease the poverty aspects. As starting the plan, and in correlation with the government s intentions to propose the Medium Term Development Plan parallel to Palestinian Reform and Development Plan, coordination between the MoH and MoP teams was effective to produce both documents. The NHPSPC was encountered in several stages of preparing the plan as well as feedback was taken from international donors and institutions that enriched the plan. We are looking forward to the implementation of this plan as a true step toward the reform and development of the health system to achieve sustainable health care services and equity distribution and effectiveness of services with high quality, with modern and wise use of health policies and planning to be achievable and measurable improvement qualitatively and quantitatively. Dr. Fathi Abu Moghli Minister of Health 9
IV. Acknowledgments The National Strategic Health Plan (NSHP) is a document critical for the development of health sector. It was developed ensuring participation from all stakeholders. I would like to emphasize that the preparation of this plan is not a separate activity but it is a continuation of a long planning process and has many milestones such as NSHP 1994, NSHP 1999-2003, Human Resources development Plan 2001, Health Sector Review 2004, Ministry of Health Reform and Organization Plan 2005, MTDP 2006-2008 and NSHP preparatory workshop which was held in Jericho on 17 th - 18 th February 2006. I would also like to express my deep appreciation to the members of National Health Policy and Strategic Planning Council (NHPSPC) for their guidance, support and important role in revision and enrichment of this document. The active and consolidated support of all internationals, especially World Health Organization and the Italian Cooperation,to HPU is gratefully acknowleged. The Health Planning Unit (HPU) is looking forward for the implementation of this plan to achieve all its objectives to improve the health status of Palestinians. Head of HPU Deputy Assistant Dr. Fahed Essayed 10
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CHAPTER 1 METHODOLOGY 12
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1. NSHP development methodology 1.1 Introduction There was an unanimous agreement within the Palestinian health sector on the necessity to develop the National Strategic Health Plan (NSHP) that incorporates agreed upon national health policies, which will help draw-up strategic objectives and needed activities to achieve them, while defining the role and responsibilities of different partners. There were many factors that motivated the development of the NSHP: There is currently no overall strategic framework to guide the sector. The previous NSHP ran from 1999 to 2003. The availability of NSHP which clarifies the roles and responsibilities of the different health partners and accepted by all stakeholders will enhance the cooperation and integration in the health sector towards improved quality and efficiency of health services and to achieve equitable accessibility. The development of the NSHP is the continuation and completion of a series of planning activities such as: A- The Health Sector Review (HSR) B- The Health Expenditure Review (HER) C- Establishment of Health Sector National Reform Committee (HSNRC). D- Ministry of Health (MoH) Reform and Organization Plan (2005) E- Medium Term Development Plan (MTDP) 2006-2008. F- Client satisfaction, accessibility and utilization study done under HSDP 2004. G- Strengthening the Palestinian Health System, RAND Cooperation 2005. H- The preparatory workshop to Third National Strategic Health Plan held in Jericho on 17 th 18 th February 2006. 1.2 Key Steps to Develop the Third NSHP Strengthening the Health Policy and Planning Unit (HPPU) 1. Supporting the unit by qualified staff 2. Reviewing the plans prepared by MoH administrative units 3. Forming the National Health Policy and Strategic Planning Council (NHPSPC). 14
Forming MoH technical committees The tasks of these committees are: 1- Collected, reviewed and analysed the available documents and data. 2- Prepared plans, programs, and projects' action plans through which the strategic objectives can be achieved. 3- Prepared the strategic plan draft to be submitted to the NHPSPC Invited the NHPSPC to meet in order to: 1- Reviewed, and approved the general structure of NSHP. The proposed structure of NSHP was: Methodology. Situation Analysis. Health Strategy. Medium Term Development Action plan. 2- Assigned technical representatives from United Nations Relief and Works Agency (UNRWA), Non Governmental Organizations (NGO s), Police Medical Services (PMS) and private sector whom reviewed and enriched the draft prepared by MoH technical committees. Meetings with the responsibles of the different MoH departments have been held in order to clarify both process and content of the draft plan and templates of the action plan. Moreover, feed back has been provided and the draft was enriched by their suggestions and comments, indicators and targets defined. HPPU in coordination with different committees prepared the final draft of NSHP. Revision of the final draft: The NHSP final draft was submitted to the NHPSPC to review and finalize the NHSP. 15
Endorsement NSHP 1. The final draft reviewed and endorsed by NHPSPC 2. The final draft endorsed by the PNA cabinet of ministers. Distribution of the NSHP : MoH printed the NSHP in both Arabic and English and distributed it in a ceremony to which the national and international institutions were invited. The NSHP was presented to the representative of local authorities and to the responsibles at operational and peripheral level, jointly by responsibles from MoH and other stakeholders and providers. Follow up: The implementation of the plan will be followed up continuously, outcomes will be evaluated including customers satisfaction, and the document will be updated annually to cover the next coming three years that follow. 16
1.3 Timeframe (2007) The timeframe for the development of the NSHP 2008-2010 is as follows: Month Aug 07 Sep 07 Oct. 07 Nov. 07 Dec. 07 Jan. 08 Week 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 Strengthening HPPU Forming MoH technical committees Collect and review the studies, documents and data Prepare the programmes and projects to achieve the strategic objectives MoH technical committee in cooperation with HPPU prepare a draft of NSHP. Invite the NHPSPC to meet The Joint committees review and enrich the NSHP draft HPPU in cooperation with technical committees prepare the reviewed draft. NHSP draft was reviewed by the NHPSPC PNA cabinet endorse the NSHP Printing the NSHP in Arabic and English Distribution Ceremony 17
CHAPTER 2 Health Situation Analysis 18
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2. Health Situation Analysis 2.1 Introduction The territories of Palestinian National Authority are composed of two separated geographical areas; West Bank (WB) and Gaza Strip (GS). The total number of Palestinian population in these two areas is 3.9 million (1.4 million in GS and 2.5 million WB). The population density in GS is 10 times that in WB while the area of WB is 15 times bigger than GS. It is expected that the population in WB and GS will increase by 50% in 2020 in comparison with 2006 (Annex 1). There are 558 localities in WB and GS, in addition to 27 refugee camps (Annex 2). Since the year 2000, the Palestinian territories are suffering from siege and closure, and the GS crossings are closed most of the time. On the other hand, the Israeli roadblocks, checkpoints and the apartheid wall divided the WB and isolates Jerusalem hospitals which provide specialized health care services that are not available in WB and GS such as cancer radiotherapy. This increased the burden on MoH which should provide the health care services to all localities. Compared to other lower middle income countries, the health status in Palestine is relatively good. The crude birth and death and rates per 1000 are 36.7 and 3.9 respectively ( 2 ), the infant mortality rate (IMR) is 25.6 per 1000 live births, under five mortality rate is 28.4 per 1000 live births, and neonatal mortality rate is 18.1 per 1000 live births. Palestine is considered free of poliomyelitis according to WHO criteria. The communicable diseases of childhood such as mumps, whooping cough, tetanus, and measles have been largely controlled through the successful immunization program. There are no reported cases of diphtheria, rabies and neonatal tetanus. (2) PCBS, Demographic and Socioeconomic Status of the Palestinian People at the end of 2006, December 2006. 20
Palestine is at a transition phase from communicable to non-communicable diseases as the incidence and prevalence of cardiovascular diseases, diabetes and cancer have increased. This relatively good health status may not be sustainable due to the continuous deterioration of the economic situation. The GDP decreased by about one third in 2006 compared to 1999 and the poverty rate is more than 60% ( 3 ). The health sector in general and MoH in particular have been greatly affected by the recent PNA financial crisis due to complete termination of transfer of taxes revenues from Israel and the freeze of international financial support after forming the tenth Palestinian Government in March 2006. As other PNA employees, MoH staff did not receive their regular salaries during the period between March 2006 and July 2007 and they are not expected to receive their arrears before the end of 2007. MoH was not able to provide the essential operational budget of which more than 80% has been funded by international donors. In addition, most of the new programs and activities included in MTDP 2006-2008 were not initiated. Even the ongoing projects such as development of Alaqsa hospital, Alshifa surgical hospital, Naser surgical hospital, were freezed due to lack of raw materials as a result of the siege and closure on GS. 2.2 Provision of Health Services The Palestinian health care system is extraordinarily complex and fragmented. It has various layers like an old city that has been rebuilt era after era, sometimes incorporating and sometimes obliterating earlier structures ( 4 ). As a result, today it has at least five distinguishable components. The first component of the health care system is the governmental sector. MoH is operating 24 out of the 78 hospitals in the WB and GS with a total of 2,864 beds which represent 57% of the hospital beds in Palestine. In addition, MoH is operating 413 out of (3) World Bank Report, Two Years after London- Restarting Palestinian Economic Recovery, September 2007 (4) Marc Roberts, Health Sector Review, 2005 21
651 Primary Health Care (PHC) facilities ( 5 ). This represents a very rapid growth since the establishment of the MoH in 1994. About 1,012 new beds (around 66% in GS) and 170 new PHC facilities were opened (mostly in the West Bank) in less than 13 years. Some of these facilities were handed over from the NGOs to MoH, in other facilities services have been integrated and coordinated between MoH and Palestine Red Crescent Societies (PRCS) as well Palestinian Medical Relief Society (PMRS) as examples. Upon the agreement between MoH and PRCS, the Ministry is in process of organizing a central blood bank service inclusive of that previously run by PRCS. Recently, the share of the MoH in overall service delivery appears to have risen significantly. The extension of insurance coverage after the beginning of the Al-Aqsa Intifada has increased the numbers of those eligible to use MoH facilities. Economic difficulties have lowered incomes and hence made more and more Palestinians unwilling or unable to afford the fees charged by other health care providers. Mobility restrictions have hampered the access to the facilities of the other health care providers more than they have limited access to MoH facilities. One recent survey suggests that 50% of all visits to health care providers are done to the MoH facilities (6). Within the MoH, the delivery systems in WB and GS have operated quite independently. Given the influence of historical background, the WB generally followed Jordanian administration practices, while GS followed Egyptian administration practices. Information systems, management structures and even clinical decision-making can vary significantly and there are strong political forces that make effective standardization and systemic homogenization difficult to achieve. The main roles and responsibilities of MoH according to the Palestinian Public Health Law are: 1- Regulating and supervising the provision of health care in Palestine 2- Planning the health care services in coordination with different stakeholders 3- Enhance health promotion to improve the health status (5) Health Information Centre, 2006 Annual Statistics Report. (6) PCBS, Health Care Providers and Beneficiaries Survey, 2005. 22
4- Development of the human resources in health sector 5- Management and dissemination of health information 6- Ensure national health expenditure being allocated according to population needs. The second component of the health care system is the NGOs' sector. These vary widely from longstanding missionary hospitals, to facilities supported by international organizations, to community health centres organized by political factions, or supported by Islamic charities. The sectors PHC centres tend to be relatively small, and have been declining in number since 1994. NGOs are, however, the second largest hospital care provider; operating and controlling 1,582 beds in 28 hospitals. A substantial part of the working load is due to referred cases to outside MoH facilities that are covered through governmental health insurance. Some cases are referred by MoH medical committees, while others are referred by humanitarian aid committee in the ministers' cabinet. The number and the cost of referred cases to outside MoH facilities increased significantly since 2003. In particular the PRCS with total yearly budget of US$7 million is the national provider of pre-hospital emergency medical services (EMS) to the public. The provision of this service is accomplished through a national 101 emergency telephone number. The headquarters in Ramallah and 8 main stations and 23 substations in the West Bank; 6 main stations and 2 substation in Gaza Strip; and 120 vehicles and 350 EMTs and ambulance drivers are on-duty 24 hours a day. There is unanimous agreement on the need to facilitate the roles and responsibilities of NGOs through: 1. Establishing and developing a comprehensive health care system and assure accessibility and affordability of services based on integration to avoid overlapping. 2. Enhance community participation and encourage voluntary care. 3. Rationalize the use of resources and support primary health care as strategic choice. 23
4. Cooperate and work in partnership according to health sector objectives and priorities, in order to: Ensure consistency with national health policies and strategies. Contribute and feed data to the national health information system Upgrade the skills of human resources in health sector Assure quality standards of the health services provided. Consider client satisfaction and improve health services accordingly. The third component of the health care system is the private sector, as of 2006, the private sector operated nearly 433 beds, in 23 hospitals - many of which were specialized maternity beds- and some private diagnostic units. As these numbers indicate, many of these institutions are quite small. More and accurate data about the private practice is not available It is to be taken into consideration the unruled practice of alternative medicine as a widespread provision of services. The fourth component of the health care system is operated by UNRWA. This is mainly an outpatient system, which, in 2006, operated 53 facilities and one hospital of 63 beds capacity. UNRWA serves all those individuals, and their descendents, who were displayed in the war of 1948. There are 1.5 million refugees in WB and GS representing 41% of the total population, 65% of GS and 26.5% of WB population are refugees ( 7 ). The fifth component is the Police Medical Services (PMS), which provide medical care to the police forces and their families. PMS operates 2 hospitals of 72 beds capacity. (7) Palestinian Central Bureau of Statistics, Palestinian Population by Refugees Status, www.pcbs.gov.ps 24
2.2.1 Primary Health Care and Public Health Services Primary Health Care is considered the cornerstone of health services, and not only the major tool but also the promoting and improving mechanism to restore and sustain the well-being of the Palestinian people. Promotion and preventive strategies are high priority for reducing burden of diseases. In addition to maintaining and improving the communicable diseases programmes, paying special attention to the prevention of accidents and hazardous behaviours is necessary. The supervision on implementation of bylaws in the field of road accidents prevention, as well as risk management in occupational health, control of potentially hazardous behaviours and consumers protection, have to be strengthened. Primary Health Care and Public Health facilities provide services through multiple activities. In the area of public health, the MoH central public health laboratory have many programs including preventive medicine, non communicable diseases program, community health, mother and child health, environmental health, etc. (Annex 3). PHC is on the top of the health sector priorities. In this aspect, all stakeholders in the health sector aim to improve the access to PHC services especially for the marginalized groups and enhance the PHC services efficiency and effectiveness. MoH is considered the major provider of primary health care services as it operates 413 PHC facilities out of 651 representing 63.4% of total PHC facilities, where as local NGO s operates 28.4%, followed by UNRWA that operates 8.2% of the facilities. Moreover, it is worth to mention that the private sector contributes to some PHC and PH services despite the lack of information around its actual size (8). Primary Health Care and Public health facilities are classified into four levels according to type of services provided, (Annex 4). The classification is based on the following factors: (8) Health Information Centre, 2005 Annual Statistics Report 25
Population size benefiting of the PHC facility Distance to nearest PHC facility Availability and type of health services in nearest facility. Table (2): Classification of PHC and PH facilities in Palestine: Criteria Level I II III IV Population Up to 1000 2001-4000 6001-12000 Over 12000 Minimum area 120 180 240 420 Health education + + + + Mother and Child + + + + Health First Aid + + + + General practitioner Twice weekly 5 times per 5 times per 5 times per week week week Specialist - once Twice Twice weekly monthly monthly Laboratory (9) Peripheral I Peripheral II Peripheral III Peripheral IV Ultrasound - Once Twice Twice weekly monthly monthly Dental care - - - ± X ray - - - ± In addition to the above mentioned four level clinics there are mobile clinics which provide outreach service to small remote localities and to areas isolated by the Separation Wall. The need for these mobile clinics is increasing as the building of the Separation Wall continues and more Palestinians are isolated. Table (3): Distribution of MoH PHC facilities by level of services provided in 2006: Area Level 1 Level 2 Level 3 Level 4 Total West Bank 88 184 76 8 356 Gaza Strip 0 31 19 7 57 Total 88 215 95 15 413 As for human resources distribution in PHC facilities according to level, it ranges from one employee in level I to more than 20 employees in level IV (Annex 6). Despite the increase in the number of PHC and PH facilities from 595 in year 2000 to 651 in (9) Annex 5 shows the laboratory services according to PHC level. 26
2006, the average population per facility has risen to 5,752 capita per facility compared to 5,294 capita per facility in 2000 (Annex 7). Table (4): The Distribution of the PHC facilities by health care provider in 2000 and 2006: Year Area No. of Population MoH NGOs UNRWA Total Population per centre WB 2,011,930 316 145 34 495 4,065 GS 1,138,126 43 40 17 100 11,381 2000 Total 3,150,056 359 185 51 595 5,294 WB 2,444,478 356 130 35 521 4,692 GS 1,443,814 57 55 18 130 11,106 2006 Total 3,888,292 413 185 53 651 5,973 A community based plan on the re-organization of mental health services in Palestine was issued in February 2004 by the steering committee of mental health (composed of: MoH, WHO, French and Italian Cooperation, UNRWA, and NGOs); integration of mental health care services in PHC, reconfiguration of staff, provision of short term inpatient care to severe acute cases as close as possible to their place of residency. 27
2.2.2 Secondary and Tertiary Health Care Services By the end of 2006, there were 78 hospitals with total capacity of 5,014 hospital beds and the ratio of hospital beds per 1000 capita was 1.3 beds (1.2 in WB and 1.4 in GS). MoH is the main provider of the secondary health care services; MoH operates 57.1% of the hospital beds through its 24 hospitals distributed all over Palestine. The NGOs is the second provider where its beds represent 31.6% of the total hospital beds. Private hospitals, Police Medical Services and UNRWA operate 8.6%, 1.4% and 1.3% of the hospital beds respectively (Annex 8) (10). The size of the hospitals varies from a small hospital of 10 beds to a large hospital of more than 200 beds as shown in table (5) (11). Table (5): Distribution of the hospitals according to the number of beds in 2006 Number of beds Number of Hospitals 25 or less 28 26-50 19 51-100 16 101-150 7 151-200 4 More than 200 4 Total 78 The hospital beds increased by 57% between 1994 and 2006; from 3,199 to 5,014. About 56 % of this increase is due to increase in MoH hospital beds while 22%, 16%, 2% and 4% of this increase is due to expansion of NGOs, private, UNRWA and PMS hospital beds respectively. The majority of this increase was in GS where the hospital beds increased by 1087 beds compared to an increase of 728 beds in WB. In GS this expansion was mainly the responsibility of MoH as the increase in its beds represents 66% of beds increase, while 77% of beds increase in WB was a joint responsibility of MoH and Private sector (Annex9). (12) (10) Health Information Centre, 2006 Health Statistic in Palestine. (11) This does not include the psychiatric and rehabilitation hospitals. (12) Health Information Centre, Health Statistic in Palestine (1994-2006) 28
The expansion in the hospital sector was unplanned to achieve geographical equity; the ratio of bed per 1000 capita varies from one district to another as follows: 1.4 in GS and 1.2 in WB In Khanyuonis it is two folds more than Ramallah (2.3 versus 1.1) In Jericho it is two folds more than North GS (1.2 versus 0.6) In Bethlehem it is six folds more than Jenin (3.6 versus 0.6) In Gaza city it is four folds more than Rafah (2.1 versus 0.5) In addition to shortage in tertiary health care services, where the distribution of tertiary health care services was not based on a clear policy and did not take into consideration effectiveness and efficiency principles. So, some of the tertiary services are still purchased from the neighbouring countries. Most of the hospitals are located inside the cities and a lot of people face many difficulties to reach hospitals, especially those in Jerusalem due to apartheid wall, Israeli roadblocks and the Israeli closure policy of the Palestinian territories. The importance of Jerusalem hospitals is due to: 1- The implementation of a permanent network model of coordination of activities to provide integrated services and ensure quality standards of care. The estimated annual operating budget of this model reaches up to 40 million US$, and it includes: A total of six hospitals; Al Makased, Augusta Victoria, Saint John, Saint Joseph, PRCS hospital and Princess Basma Rehabilitation Centre. A total of 1170 employees (most of them are Palestinians of non Jerusalem ID holders). 20% of total beds in WB 2- Provision of tertiary health services for all Palestinians, mainly cardiac surgery, ophthalmology, radiotherapy and lithotripsy. 3- Provision of health care services to 30,000 admitted patients and 150,000 out patients per year. 13 (13) Arab Studies Society, East Jerusalem Multi Sector Review Strategy, 2003 29
The monthly services of the Palestinian hospitals are estimated by: 35,000 admitted persons, 23,000 (64.5%) out of them are admitted to MoH hospitals. 85,000 persons visit out patient clinics, 62,000 (73.5%) out of them go to out patient clinics at MoH hospitals. 11,000 surgical operations, 5,000 are done in MoH hospitals 9,000 deliveries, 5,000 are done in MoH hospitals. MoH hospitals provide around two haemodialysis sessions per week per patient for around 500 patients (14). It is worth mentioning that while MoH hospitals are generally over utilized and crowded, the non-governmental hospitals are underutilized. The average occupancy rate of MoH hospitals was estimated at 80% (85% in WB and 78% in GS), while the overall average of occupancy rate of all governmental and non- governmental hospitals is estimated at 65%. The average length of stay is estimated at 2.5 days for general hospitals, 19.5 for the rehabilitation hospitals and 59 days for psychiatric hospitals. The number of patients admitted to hospitals per year is estimated by 11% of the total population and this is a high percentage for a young population of which the percentage of the population over 65 years old is around 3%. The high rate of admissions and short length of stay may indicate either unnecessary admissions or early discharge. The actual need for hospital beds depends mainly on the prevailing epidemiology and applied medical technology; diagnostic or therapeutic applications which includes technical methods, skills, processes, techniques, tools and raw material to improve the management of health conditions. The projection of the future needs of hospital beds can be estimated either based on the ratio of beds per capita or based on the actual workload. (14) WHO, Addressing the Health Situation in the Occupied Palestinian Territories, June 2006. 30
There is no unified and agreed upon ratio for bed per capita at the international level so the estimation based on the workload and size of the population is considered more accurate because it is based on occupancy rate, average length of stay, percentage of population admitted to hospitals. The following points were taken into consideration to calculate the projected number of hospital beds based on the workload and size of population methodology: Hospital utilization is estimated according to officially published information by MoH during the period between 2000 and 2006 (Annex 10). The population until 2006 is estimated according to PCBS publications and after 2006 is based on 3% annual growth (Annex 1). The average length of stay is estimated at 3 days except for Jerusalem hospitals it is estimated at 4.4 days. The occupancy rate is estimated at 80%. While estimating the needs for hospital beds and their distribution both from geographical point of view and type (medicine, surgery, intensive care, maternity, and rehabilitation), it is mandatory to evaluate the appropriateness of admissions and utilization of beds, according to international agreed standards in term of daycare vs. ordinary admissions, or in term of length of stay, or in term of occupancy rate and turn over index. Therefore a master plan for hospital beds and facilities distribution and utilization is advisable to be prepared as soon, in the view of efficient utilization of available expertise and resources, in order to match quality standards ensuring equitable access to Palestinian population with particular attention to the most deprived. 31
Table (6): Estimated need of general hospital beds (15) Governorate Available # beds 2006 2008 2010 2015 Difference: ( 17) Estimated # of beds ( 16) (Available- - Estimated) Estimated # of beds Difference (Available - Estimated) Estimated # of beds Difference: (Available- Estimated) West Bank 2,562 2,857-295 3,018-456 3,500-938 Jerusalem 563 467 96 487 76 565-2 171 268-97 283-112 328-157 Jenin Tulkarem 169 187-18 197-28 228-59 Qalqilai 85 91-6 97-12 113-28 Salfeet 12 24-12 25-13 29-17 Nablus 485 501-16 527-42 611-126 Ramallah 293 379-86 404-111 468-175 Jericho 54 60-6 63-9 73-19 Bethlehem 296 242 54 256 40 297-1 Hebron 434 638-204 679-245 788-354 Gaza Strip 1,963 1,903 60 2,043-80 2,368-406 North Gaza 177 196-19 214-37 248-71 Gaza 971 970 1 1,039-68 1,204-233 Middle Gaza 94 185-91 198-104 230-136 Khanyonis 640 495 145 531 109 616 24 Rafah 81 57 24 61 20 70 11 Palestine 4,525 4,760-235 5,061-536 5,868-1,343 Table (7): Estimated need of psychiatric beds: Districts Available beds 2006 Estimated # of beds 2008 2010 2015 Difference (Available- Estimated) Estimated # of beds Difference (Available- Estimated) Estimated # of beds Difference (Available- Estimated) Bethlehem 280 206 74 217 63 252 28 Gaza City 39 34 5 36 3 42-3 Palestine 319 240 79 253 66 294 25 Table (7) shows that there is no need for new psychiatric beds until 2015. The current MoH health plan aims to develop the community-based mental health services on both primary and secondary health care levels. This plan is undergoing review to decide on reduction of psychiatric beds in Mohammad Saeed Kamal Hospital (Bethlehem) and allocate inpatient beds in some general hospitals to provide care for acute mental cases. (15) It is expected that another 100 bed will be added in 2008 (50 in Ramallah, 50 in Qalqilia) (16) Estimated number of beds based on workload and population size. (17) (-) is shortage and (+) is surplus.
Table (8): Estimated need of rehabilitation beds Area Available beds 2006 Estimated # of beds 2008 2010 2015 Difference (Available- Estimated) Estimated # of beds Difference (Available- Estimated) Estimated # of beds Difference (Available- Estimated) WB 118 154-36 163-45 188-70 GS 52 62-10 67-15 78-26 Palestine 170 216-46 230-60 266-96 Table (8) shows that there will be shortage of around 46 rehabilitation beds in 2008 and this shortage will increase to 96 in 2015. So the decision to add not less than 50 rehabilitation beds by 2010 is to be based on more in-depth analysis of rehabilitation patients' needs and the availability of such services. The expansion of hospital beds should take into consideration the following (Annex 11): 1- Achieve efficiency, effectiveness, sustainability, equity and affordability 2- Give special attention to actual needs for different types of beds (Annex 8). 3- The ability of expansion to meet future needs. New beds will be added if: 1. There is a shortage in the available number of beds according to workload methodology. 2. The service is unavailable in the service area (18). A priority will be given to referral hospitals and service areas with lowest ratio of beds per capita. The hospital sector faces a lot of challenges such as: 1- Inequity in the geographical distribution of hospital beds 2- Absence of a clear policy for establishing and distributing of tertiary health care services. (18) Service area: A circle with the hospital as the centre and a half diameter of 30 Km. 33
3- Low quality of services perceived by beneficiaries especially in the governmental hospitals ( 19 ). 4- Poor coordination and integration between different health care providers 5- Over utilization of MoH hospitals and underutilization of the non- governmental hospitals. 6- Centralized management of MoH hospitals with limited control over budgeting and staffing. 7- Hospital information system to be developed in order to promote procedures of coordination, evaluation and control. 8- The dual work of the governmental staff in public and non governmental sectors. 9- Lack of hospitals capabilities to provide some tertiary services. 10- Restricted access of patients to hospitals due to the apartheid wall and the closure policy and Israeli roadblocks. 11- Quantitative and qualitative shortages in different categories of hospital staff. The above mentioned challenges are the main drivers for collaboration between the health care stakeholders to establish Al-Watani teaching hospital in Nablus, to prepare a master plan for the medical compound in Ramallah, to construct the first phase of Internal medicine department at Alshifa hospital, to staff and run Prince Nayef Radiotherapy Centre in Gaza city. (19) Client Accessibility, Utilization and Satisfaction (CAUS) study, 2004 34
2.3 Health Finance The Palestinian economy has deteriorated in recent years, especially following the Al-Aqsa Intifada. Gross Domestic Product (GDP) per capita decreased from US$ 1,612 in 1999 to 1,129 in 2006. The poverty rate increased to more than 60% of the population (20). Palestine allocates a significant part of its resources to the health sector. The health expenditure is estimated by 8-9% of the GDP, and this is higher than in other developing countries. The health expenditure per capita is estimated by US$ 135 (21). The financial resources of the health sector are (22) : 1. Taxes 2. Health insurance premiums and co- payments. 3. Out -of pocket mainly of those patients not enrolled in health insurance. 4. Local community donations (financial and in kind) 5. UNRWA. 6. Contribution of the international community (loans and grants). The decision of the Late President Yasser Arafat after the Al-Aqsa Intifada to offer free health insurance to the unemployed persons and their families led to decrease in health insurance revenues. Currently the coverage of the governmental health insurance is estimated by 60% of the Palestinian families, more than half of them are freely insured (29.9% paid, 30.5% free charge). After 2000, a fluctuation in MoH revenues was noticed as shown in table (9). Table (9): MoH revenues for the years 2000-2006 in thousand US$ Item 2000 2001 2002 2003 2004 2005 2006 Health insurance Co-payment 29,500 9,200 19,000 8,000 21,888 6,948 26,067 8,214 30,543 8,772 29,957 5,332 30,493 4,768 Total 38,700 27,000 28,836 34,281 39,315 35,289 35,261 Comparative Weight 1 0.70 0.75 0.89 1.02 0.91 0.91 (20) World Bank Report, Two Years after London- Restarting Palestinian Economic Recovery, September 2007. (21) Oxford Policy Management, Health Public Expenditure 2005. (22) Oxford Policy Management, Health Public Expenditure 2005. 35
All MoH revenues including the health insurance revenues are transferred to the Ministry of Finance (MoF). As noticed in the table (10), salaries and drug items constitute the most of the MoH operating expenditure. In 2005, the total of the MoH operating expenditure was US$ 139.6 million. Table (10): MoH operating expenditure in 2005 Activities Amount thousand US$ Percentage 23 Salaries 73,197 52.4% Pharmaceuticals and medical supplies 31,501 22.6% Referrals to outside MoH facilities ( ) 21,926 15.7% Other operating costs 12,959 9.3% Total 139,583 100% Since 2000, MoH expenditure increased dramatically. In 2005, the amount of operating expenditure was US$ 139.6 million compared to US$100.3 million in 2000; this represents 39% increase in the operating expenditure. Table (11): MoH operating expenditure in thousand US$ Activities 2000 2001 2002 2003 Salaries 45,500 46,000 57,622 54,555 Pharmaceuticals and 24,616 14,129 24,785 17,572 medical supplies Referrals to outside 6,200 8,500 6,344 12,650 MoH facilities Other operating cost 24,020 12,500 10,786 13,643 Total 100,336 81,129 99,537 98,420 2004 70,986 23,500 18,888 13,100 126,474 2005 73,197 31,501 21,926 12,959 139,583 In 2006, health sector in general and MoH in particular faced an acute financial crisis after complete termination transfer of tax revenues by Israel to the PNA. In addition, there was a sharp decline in the foreign aid, which led to the interruption in salaries and the inability to ensure the operational expenses. (23) This does not include the cost of cases referred by Humanitarian Aid committee at Ministers' Cabinet. 36
In addition, there was a huge rise in expenditure on purchasing medical services out of MoH facilities. A total of 30,000 cases were referred out of MoH facilities in 2005, costing over US$ 60 million (24), out of which more than 40% of expenses were to health centres in neighbouring countries. Therefore, there is a need to develop the health financing system through: 1. Determining the basic level of care provided to all citizens and a package of health services for the insured citizens. 2. The restructuring and developing of the health insurance system. 3. Review and development of criteria and mechanisms of purchasing medical services from outside Palestinian facilities. 4. Rational use of drugs. 5. Improving the procurement and supply system. 6. Adding new services and technologies should be based on cost benefit analysis. 7. Enhanced cooperation among the various health service providers to prelude the expansion governmental insurance to cover the services provided by NGOs and private sector to make effective use of available resources. 8. Enhanced coordination between governmental health insurance and private health insurance. 9. Effective supervisory role and improved capacities of the MoH to control the quality, effectiveness and costs of services. 10. Preparation of health reform and development plan, annual action plan and budgets based on real cost of activities intended to be implemented. (24) US$ 21.96 million from MOH budget and the remaining are from budget of Humanitarian Aid Committee in Ministers' Cabinet. 37
2.4 Health Services Quality The first national effort toward quality improvement of health services in Palestine goes back to 1994 as the Palestinian Health Council established a central unit for quality improvement. The efforts were focused on understanding concept of quality in health care and its influence on the well being of the population. In 1996 and later to MoH foundation as part of PNA, the ministry started implementation of quality improvement projects through Health System Development Project (HSDP) funded by World Bank in order to build national capacities in quality improvement. The project was in two phases starting 1996 until 2005. In its first phase training of main team members on total quality management, improve Team Work, as well prioritize improvement processes in several primary and secondary health care facilities in both West Bank and Gaza Strip were achieved. In the second phase of the project, many initiatives and improvement priorities were tackled, which included the production of nine clinical diagnostic and management guidelines of chronic diseases, training health professionals on drug rationalization, diabetic protocols implementation, health projects and evaluation. Standard operational procedures (SOP) were drafted for primary health care work as well for laboratory work and clinical procedures. Additionally, the drug interaction directory for doctors and pharmacists was prepared. In 2005 and as part of the MoH efforts toward institutionalizing quality improvement processes, a ministerial decision was taken to found quality improvement department. In the last two years the quality improvement department (QID) took the initiative toward awaking late quality improvement processes and to disseminate lessons learned and exchange experiences and achieved the following in PHC and secondary health care sectors: Approve referral system among PHC and SHC in its first part. Develop out patients clinics operational protocols Develop surgical departments operational protocols 38
Develop clinical protocols from the guidelines and train health professionals in both primary and secondary health care. At present the major challenges are related to the largely perceived needs to introduce nationwide quality standards for licensing all health services in order to certificate health personnel of all cadres to operate in health sector, both public and private services as well as those dealing with alternative medicine. Such need is to be ruled through the endorsement of laws and bylaws that will enable the MoH to play its role of stewardship and supervision of health activities and warrant of quality level of care provided to all Palestinians. Moreover, challenges are linked to preparedness of technical personnel to lead improvement processes and to build capacities of health personnel in different managerial and technical levels to adopt quality improvement as a concept and approach of work through earning new knowledge and skills. 39
2.5 Human Resources There are around 40,000 persons working in the health sector, out of them 8,048 are physicians, 2,035 are dentists, 3,842 are pharmacists, 6,652 are nurses, 10,521 are para-medicals and 7,520 are administrative staff. Table (12): Health Human Resources. Ratio per 1000 capita Number Palestine Group WB GS Total WB GS Total Jordan Egypt Israel UK Iran Physicians 4401 3759 8160 1.77 2.57 2.07 2.03 0.54 3.8 2.3 0.87 Dentists 1355 680 2035 0.55 0.47 0.52 1.29 0.14 1.17 1.1 0.19 Pharmacist 2242 1600 3842 0.92 1.11 0.99 3.14 0.1 0.7 4.5 0.2 Nurses 2452 4200 6652 1 2.91 1.71 2.94 1.98 6.26 12.12 1.19 Midwifes 475 204 679 0 0 0.12 0.3 0.02 0.19 0.63 0.19 Para-medicals 7421 3100 10521 3.04 2.15 2.71 1.17 0.05 -- 2.78 1.71 Administrative 4263 3257 7520 1.74 2.26 1.93 3.15 0.07 -- 21.2 1.04 MoH as main health care provider is the main employer in the health sector. In 2006 MoH counted around 13,057 as employed health workers (39% administrative staff, 26% Nurses, 18% physicians and 17% other categories). 59% of MoH staff is in the hospitals, 27% in the primary health care and 14% in the other MoH directorates (Annex12). Human resources are the major element in the improvement of health services qualitatively and quantitatively. In this regard the development and improvement of human resources has been a strategic objective of the health care system. Human resources development is facing many challenges, mainly the inadequate implementation of human resources development plan prepared in 2001. Respectively unplanned growth continued among human resources yet the shortage continued in many specialties and surplus in others. Annex 13 shows the current available human resource (shortage and surplus) and estimated future needs. 40
Another challenge that faces human resources is the lack of continuous education programs. The existence of such programs is crucial due to the diversity of schools and countries that graduates health personnel requiring mechanisms to integrate the different graduates in the health system and to guarantee the minimum similarity of health care approaches. This requires developing and implementing the national clinical management protocols and standard operational procedures. The health sector suffers from the migration of the rare qualified and trained staff from the governmental sector to private sector and / or to outside Palestine. This is due to instability of economic and political situation in Palestine and low salaries particularly of those employed in the governmental sector. The current incentives system is insufficient to encourage the health human resources to build their capacity, which have a negative impact on the efficiency, effectiveness and performance of health system. In Palestine there are eight universities and 15 faculties provide the health education programs which offer 85 Health educational programs, 36 out of them grant university degree, 22 grant diploma,13 grant master degree and 11 grant higher Diploma (Annex 14) but these programs do not meet the needs of the health sector due to: 1. The need to strengthen the accreditation system of educational institutions and programs based on the international standards. 2. Shortage in some specialties, such as family medicine, psychiatry, and preventive medicine, while most of these programs are in nursing, medical laboratory and public health 3. Most public health programs are similar and there is a need for sub specialties such as epidemiology, nutrition, reproductive health, health economics, health management, health information systems, and scientific research. 4. Scarce financial and human resources needed for postgraduate studies. 41