Immunization for Palestinians in Need

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Table of Contents

The Scope, Relevance, and Effectiveness of the ‘Road Map’
PNA’s Efforts to Enhance Maternal and Child Health
The Appropriateness of the Strategy’s Objectives and Outcomes
The Implementation Progress of the PHA Strategy
References

A quality mission statement communicates an organization’s unique purpose. It proclaims its goals, target population, and the foundations that underpin its actions. The mission of the PHA Strategy is to promote partnerships between Palestine’s Ministry of Health (MoH) and stakeholders in order to improve the effectiveness of medical care services. The mission also indicates what the strategy intends to achieve, which include the promotion of health governance, regulation, and policy formulation. In terms of scope, the PHA Strategy intends to improve the accessibility of quality health care services to people living in occupied Palestinian Territories (oPTs). Nevertheless, the mission statement does not indicate the fundamental premises or rationales for its strategic actions. It only indicates that it will promote accessibility, regulation, and governance within the health sector through partnerships, but does not indicate why that is necessary.

The strategy’s vision statement aptly describes the MoH’s future scope in terms of health care provision. It states that the ministry will create a care system that deals with health issues affecting Palestinians. It provides a clear roadmap that would guide the players in the health sector in developing ‘an integrated health system’ in Palestine. However, the strategic vision gives no clear rationale why the ministry should pursue this long-term direction. As grounds for implementing the strategy, the MoH should indicate whether the path would improve the health outcomes of Palestinians.

A statement of values guides an organization in pursuing its strategic vision. The MoH’s value statement describes pertinent principles and practices that would lead to improved health care delivery and accessibility in the oPTs. The four values address various aspects of Palestine’s public health that are compatible with the MoH’s vision statement. However, the statement of values is rather weak because it does not define the vulnerable groups, the nature of health care services, or the health promotion interventions needed in the oPTs. This will make it difficult to entrench these values into the ministry’s operating practices.

The Scope, Relevance, and Effectiveness of the ‘Road Map’

The roadmap for the development of the Palestinian 2011-2013 health strategy comprised of three phases: the current state (2009), the future (envisioned) position (2010), and the ways of achieving it. Phase 1 took place between March and July 2009 and it involved five action areas. These included a conference organized by the MoH, a review of Palestinian health articles published in the Lancet, an appraisal of relevant data, an assessment of MoH’s progress and achievements, and the creation of a database of all donors and stakeholders. Stakeholders from “NGOs, academia, the private sector, and unions” (PNA 2010, Para. 8) attended the MoH conference while the literature review involved academic articles reporting studies (WHO) conducted in Palestine and the UK.

On the other hand, the review of relevant medical data and donor enumeration involved local implementers and MoH internal staff under the auspices of the Health Policy and Planning General Directorate (HPPGD). In this phase, the roadmap addressed the issue of stakeholder participation and engagement to enhance the understanding of the target population’s health needs. The data gathered ensured that the PHS strategy is anchored on accurate empirical evidence. The views of the health professionals, academics, and union representatives who have hands-on experience on the Palestinian public health matters further corroborated the research evidence. It is evident that the engagement involved concerted efforts from both private and public agencies and thus, it was comprehensive in scope. In the oPT zones, donors and private providers play a crucial role in health care expansion in remote areas that may be underserved by the MoH. They identify the underlying weaknesses in the current health system and devise ways of improving accessibility. Therefore, their input was invaluable in the formulation of the PHA Strategy. Moreover, approaches and tools used in this roadmap enhanced inclusivity and could potentially lead to an evidence-based health system. However, public participation, which gives an accurate and authentic portrayal of the current state of health, was not used in formulating the strategy.

The second phase of the roadmap outlined the MoH’s envisioned position in 2010. The roadmap specified five key areas that needed to be addressed during this phase. During this phase, a National Health Strategy (2011-2013) was disseminated to the National Council for Health Policy and Planning (NCHPP), the MoH officials, and Thematic Group leaders between October and November 2010 (PNA 2010). Based on their feedback, the strategy was re-drafted in December the same year before being evaluated in roundtable meetings involving the MoH, NGOs, NCHPP, and private health providers. On January 2011, based on the suggestions of the meeting attendees, a draft of the document was submitted to the Ministry of Planning and Administration (MoPAD) followed by a final draft in March.

The second phase involved the formulation of the actual PHS strategy. The Monitoring and Evaluation Committee sought input and feedback from the Thematic Groups, the HPPGD, and the National Council for Health Policy and Strategic Planning during the second phase. The scope of the consultations was wide since they involved professionals from the health ministry, technical experts, policy planners, and leaders from “medical schools, local NGOs, medical syndicates, the Palestine Medical Council, and the private sector” (PNA 2010, Para. 8). The stakeholder roundtable meetings were crucial in identifying the ground rules and respective roles of each player in the sector. The consultations involving various public and private agencies helped identify the issues that needed to be addressed. After the consultative meetings, the stakeholders’ views and recommendations were incorporated in the draft document, which was then subjected to fine-tuning. It can be concluded that the final document incorporated the views of the relevant private and public actors in the health sector. Nevertheless, besides the health ministry budget, it is not clear how the funding will be addressed since the donor agencies were not consulted. This has a potential of not incentivizing donors to give more grants towards this program.

The third phase of the roadmap covered a period of one year (February 2009 to March 2010). It focused on policy and strategy formulation and harmonization of existing processes to develop a roadmap. This step involved continuing education done by the health ministry in the Palestinian areas of Nablus and Ramallah (Awad 2010). Subsequent interdepartmental discussions and cooperation with the Italian health ministry yielded the first draft of the MoH strategy. The MoH staff then edited the document to align it with the ministry’s value, vision, and mission statements. Subsequent meetings with the donors, the NCHPP, NGOs, MoH personnel, WHO, and Italian officials, among others yielded the final strategy document. Therefore, the strategy is comprehensive and all-inclusive, as it involved views and perspectives of multiple local and international health agencies, experts, and global donor organizations. The final process was more comprehensive and exhaustive in its coverage. The involvement of multiple agencies and partners ensured that all opportunities for action were identified and expert opinion incorporated in developing an effective strategy document.

PNA’s Efforts to Enhance Maternal and Child Health

The Palestinian National Authority employs a number of strategies to enhance the effectiveness of foreign aid directed towards improving child and maternal health (PNA 2011). In the oPT areas of West Bank and Gaza, infant mortality rate has remained relatively high since the 1990s. Rahim et al. (2009) attribute the high infant mortality rate to “health disparities and inadequate primary care” (p. 968). Moreover, the Israeli barriers have also hampered the accessibility of health care services to the oPT zones. As a result, maternal and child health care services are lacking in these areas. Although the penetration of maternal and child health services in oPTs is low, the country’s fertility rate is relatively high (4.6%) partly due to “early marriage and restricted work opportunities for women” (PNA 2012, Para. 6). The PNA has focused its efforts on programs that improve child and maternal health as well as on reducing the fertility and infant mortality rates.

MoPAD funds PNA’s programs with the assistance of donors from the international community. The PNA launched an action plan aimed at enhancing the effectiveness of donor funding in supporting key initiatives. The initial action plan (2008-2010) was revised to a new one for the 2011-2013 periods. Palestine is one of the countries that receive the highest foreign aid from donors (Palestinian Central Bureau of Statistics [PCBS] 2008). This presents problems to the health ministry with regard to equitable resource allocation to reduce disparities and increase accessibility of primary care services. Since the accessibility of health care services in oPT areas is low, monitoring the effectiveness of the financial aid received from the international community is crucial to ensure that the programs achieve the intended health outcomes.

As aforementioned, the PNA plays the oversight role to ensure aid effectiveness is achieved as laid down in the Paris Declaration. According to PCBS (2011), the effective expenditure by the MoH amounted to about 1,200 million shekels in 2010 with recurrent spending (salaries) taking up about 42%. Moreover, unpaid bills totaling “300 million shekels” were carried forward from 2010 to 2011 (PCBS 2011). This indicates that the PNA keeps track of the health care spending originating from both the ministry of health and the international community. One way in which PNA enhances the effectiveness of foreign aid is through integrated ownership of the health programs. Interventions and strategies, such as the PHA Health Strategy, often involve consultations during their development.

The MoH coordinates the consultative meetings and ensures that the stakeholders’ views and suggestions are incorporated in the final strategy. In this way, the donors identify with and support the policies since they are consulted during formulation. For instance, the Ministry of Health centers in Gaza and West Bank, which served an estimated 19,094 women in 2010, involved collaboration between the MoH and NGOs (Mataria et al. 2011). Therefore, MoH enhances the effectiveness of foreign aid directed towards maternal and child health interventions through coordination, consultation, and development of policies that promote ownership.

The MoH, through PNA, also harmonizes donor projects to avoid duplication of roles in oPT areas. The ministry supports collaboration amongst donors in the health sector to ensure that the projects are effective in promoting child and maternal care. The proliferation of donor-funded programs in oPT regions can lead to overlap of roles if they are not coordinated. Child and maternal health services in Palestine cover issues related to family planning, fertility rate, and infant mortality, which are all coordinated by the Ministry of Health (Clark et al. 2010). The PNA harmonizes all health care projects and interventions.

The Ministry of Health also advises donors to align their programs with the national health strategy. It oversees all programs within the health sector, including donor-funded initiatives. It requires donors, NGOs, and other international agencies to implement programs that are within the ministry’s strategic framework. The partners collaborate with the MoH in providing financial and technical support for the Palestinian health strategy. They are required to disburse funds in accordance with the government policies and dialogue with the ministry on matters of policy and project implementation. Monitoring and evaluation also involve joint efforts between the donors and the ministry of health. MoH also provides benchmarks for evaluating the results of an intervention. It allows donors to plan for measurable outputs within a specified period.

The Appropriateness of the Strategy’s Objectives and Outcomes

The MoH outlines eight specific objectives for the 2011-2013 health strategy. Its central aim is to promote equitable, effective, and quality health care services to Palestinians. The ministry intends to strengthen health governance to promote planning, evidence-based practice, accountability, and professional development. It is through effective health care administration and regulation that quality medical services can be made available to vulnerable groups. Stringent licensing requirements would enhance accountability and eliminate unhealthy practices that affect the health outcomes of the population. Moreover, professional development, as enshrined in MoH’s second objective, would enhance health care delivery and management.

The ministry also intends to increase public awareness in relation to chronic disease conditions. The ministry plans to achieve this through private-public partnerships. However, community involvement, which is lacking in the third objective, is also essential in chronic disease management and health promotion. Health care accessibility, which is often low in remote areas, will be reached through collaborations involving NGOs and the ministry staff. In its fifth objective, the ministry intends to develop elaborate health care financing options that involve an integrated budgeting system. However, this may not incentivize players in the health sector since the ministry will monitor their expenditures.

Aid effectiveness is another key objective proposed in the health strategy. The ministry proposes uniform procedures for financial disbursements and project appraisal. However, as already stated, the overregulation of the health sector can reduce the number of actors in the health sector, which will hamper health care delivery. The ministry also intends to promote partnerships between different players to enhance health care accessibility. However, coordinating these partnerships may be problematic considering the high number of health care products tailor-made for each demographic group. Its final objective is to enhance collaboration between the MoH and the other sectors of the economy in terms of strategy formulation and planning. This will ensure that health issues are addressed comprehensively through inter-ministerial policies.

Deriving from the objectives, the expected outcomes of the 2011-2013 strategy relate to enhanced accountability of the ministry of health with regard to quality service delivery and spending. The other outcomes include enhanced quality of life, decreased obesity and smoking rate, healthy dietary practices, enhanced coordination of care services, improved health care financing, and increased staffing levels, among others. These outcomes, though promising, are not pegged on specific benchmarks nor is there a criterion for measuring the progress of the ‘strategy’ within the three-year period.

The Implementation Progress of the PHA Strategy

The National Health Strategy underscores the government’s commitment to improving the health outcomes of Palestinians within the three-year period. The Ministry of Health coordinates the various activities and programs initiated by partners to achieve the set objectives and the MDGs. The PNA (2010) reported a significant progress with regard to the attainment of the Strategy’s objectives and the MDG goals despite the unfavorable restrictions by Israeli military in the oPT areas. According to Batniji et al. (2009), Palestine has increased the accessibility of primary health services (child and maternal care) through the several medical centers located in oPT areas.

Available data indicate that the post-PHA period has recorded a significant reduction in infant mortality rate. In 2010, infant mortality rate stood at 24 deaths per a thousand births compared to 33 deaths in the 1990s (Giacaman et al. 2011). Nevertheless, health care disparity is evident in oPT areas of Gaza and West Bank. For instance, in the Gaza strip, the infant mortality rate stood at 22.4 deaths for every a thousand births compared to West Bank’s 18.2 in 2012 (Mahmoud 2013). This gap indicates that Gaza Strip needs more health care resources to eradicate the causes of the high infant mortality rate and enhance equity.

Moreover, communicable diseases, congenital malformations, respiratory infections, and Hepatitis can be addressed through improved accessibility of health care services (Husseini et al. 2009). The MoH records show that the maternal death rate declined from 38 to 32 per a thousand women while HIV infection cases increased from 66 cases to 75 in 2011 (Mahmoud 2013). Thus, there has been some progress in addressing maternal and child health issues in Palestine. The MoH, through partnerships with NGOs and UNRWA, has significantly expanded primary health care services in the oPT regions. In 2005, there were 654 primary health centers (PHCs) providing services to a population of 3.7 million Palestinians (PCBS 2007). In general, the MoH is the leading provider of primary health services followed by NGOs and UNRWA.

Although the partnerships between MoH and private providers have improved the accessibility of health care services, a significant proportion of the population lacks essential medical services. In West Bank, 12% of the population lacks primary health care while 22% cannot get emergency services (PCBS 2011). In zone C, which is not the jurisdiction of the PNA, PHC centers are few and thus, the availability of basic services to the inhabitants is low. Moreover, restricted workforce movement in certain areas in West Bank means that many people rely on mobile medical clinics for health services. Similarly, in Gaza, health care services are lacking with about 50% of hospitals lacking medical equipment and drugs (Mahmoud 2013).

As aforementioned, non-communicable conditions such as diabetes, cardiovascular diseases, cancer, and respiratory illnesses are the main causes of mortality in oPT regions. This underscores the need to invest in initiatives that focus on lifestyle change to prevent these chronic conditions in adults. With regard to infant mortality, interventions should aim at creating awareness about the significance of antenatal and neonatal care.

References

Awad, M 2010, Health care and immunization for Palestinian mothers and children in need, Web.

Batniji, R et al. 2009, ‘Health as human security in the occupied Palestinian territory’, The Lancet, vol. 373, no.9, pp. 1133-1143.

Clark, C et al. 2010, ‘Association between exposure to political violence and intimate-partner violence in the occupied Palestinian territory: a cross-sectional study’, The Lancet, vol. 375, no. 9, pp. 310-316.

Giacaman, R et al. 2011, ‘Health status and health services in the Palestinian occupied territories’, The Lancet, vol. 373, no. 6, pp. 837-849.

Husseini, A et al. 2009, ‘Cardiovascular diseases, diabetes mellitus, and cancer in the occupied Palestinian territory’, The Lancet, vol. 372, no.9, pp. 109-204

Mataria, A et al. 2011, ‘The Health Care System: An Assessment and Reform Agenda’, The Lancet, vol. 373, no. 9, pp.1207–1217.

Mahmoud, A 2013, ‘Health Challenges in Palestine’, Science & Diplomacy, vol. 2, no. 1, pp. 91-98.

Ministry of Health [MoH] 2009, Health Status in Palestine, Annual report 2008, Web.

Palestinian Central Bureau of Statistics [PCBS] 2007,Palestinian Family Health Survey 2006: Preliminary Report, Web.

Palestinian Central Bureau of Statistics [PCBS] 2008, Palestine in Figures 2007, Web.

Palestinian Central Bureau of Statistics [PCBS] 2011, Palestinian Survey on Family Health 2010, Web.

Palestinian National Authority [PNA] 2010, Ministry of Health: Palestinian National Health Strategy 2011 – 2013, Web.

Palestinian National Authority [PNA] 2011, Ministry of Health: Health Conditions of the Arab Populations in the Occupied Arab Territories, Web.

The Palestinian National Authority [PNA] 2012.The National Strategy to Achieve the MDGs by 2015, Web.

Rahim, H et al. 2009, ‘Maternal and child health in the occupied Palestinian territories’, The Lancet, vol. 373, no. 7, pp. 967-977.

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