final health sector review

DFID Department for Int e rna ti on al Development

Review

Dr. Yehia Abed

Palestinian National AuthorityEuropean Commission World Bank

HealthSector

Note: This Report is supported by the HSR Steering Committee as part of the efforts to make available the nd-ings and results of the review to other health stakeholders and professionals. The Author , however, is the sole responsible for the Report content. The Report has been commissioned by the Italian Cooperation for this speci c assignment.

Joint Report on Health Sector Review (HSR), March 2007

Forward

Since its beginning 13 years ago the PNA Ministry of Health has put a priority on un-derstanding the heath situation in Palestine, recognizing that it is a crucial step before moving forward with a reform process to cement its service delivery system. In that spirit, it endeavored to revise the actual status of our Health Sector, and enlisted the donors technical and nancial support to this process.Very early on in 2002, an ambitious idea of a serious revision of the Palestinian Health Sector emerged and was presented to the Ministry of Health by the European Com-mission. But it was only towards the end of 2002 that the MOH approved the Project, as that year witnessed one of the most volatile phases in our political history, with the Israeli re-occupation of the West Bank and the ensuing threats to reoccupy Gaza Strip as well.

The Projects agreement was signed on 22 February 2003 by the Project partners and donors: the WHO, the IC, the EC, the Worlds Bank, and the DFID, in addition to the Ministry of Health. As the War in Iraq broke out in spring 2003, the Projects imple-mentation had to be delayed till it nally took off on 24 May 2003. The HSR project was designed to be an analytical exercise aimed to provide the MOH and the Health care providers with a clear overview and analysis of the Health sec-tor performance, to propose a set of priorities and recommendations to improve the Health status, and to suggest future mid term strategies. To that end the project in-vestigated major areas of the Health sector (Service delivery & Organization, Policy & Planning, Economics &Finance.) Although much has already been achieved in the last decade in improving health services, yet, there were still major gaps in understanding the extent of the Health problems and the kind of interventions that can be successful in eliminating them. Lack of information hampered work in this area and this is why the project focused on increasing knowledge and promoting technically sound policies and approaches to improve the Health Sector.The Project ran into three phases: Assessment, Workshops for strategy consensus, and a Conference. The development and production of this report have been an enormous assignment Five MOH task forces were formulated in the areas of System Delivery, Governance, Health Care Financing, Health Status and Outcome, Health System Per-formance. The task force members and leaders worked diligently to prepare docu-ments, assemble information, and collect database each within his task, supported by the relevant international consultants.

Two workshops were held in Cyprus in May 2004 and in September 2004 where the international consultants and Task Forces convened to discuss the progress of the proj-ect. The MOH Task forces prepared their nal technical reports, and presented their ndings during the Rome conference which was held from 14-16 December 2004, and chaired by HE. Dr. Jawad Tibi, the former Minister of Health. The Projects technical activities were concluded with the Luxor workshop in Egypt in summer 2005.

The resulting draft manuscript was prepared by Dr. Marc Roberts. It is a monumental effort reecting enormous, dedicated and unremitting labor over a long period of time. The document was then reviewed by the Steering committee members and sent to var-

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ious specialists and MOH staff who made a number of suggestions and comments.

The report supplies adequate context for those who really want an understanding of the health situation in Palestine and gives insight into our unique circumstances. The insight gained will hopefully aid in the solution of real problems, and in developing our fth national strategic health plan.

Indeed this report is particularly timing since it appears as the MOH is coming to de-pend more on large scale international donor projects and programmes, and we hope that the report will build towards a handful of ideas that are needed for development and for effective foreign aid.

In fact, the Health Sector Review exercise showed that in our common pursuit of sustainable health development, the MOH and the donor community are important partners. We are honored to have this joint study the rst of its kind and an encourag-ing testimony of our good and growing cooperation.

The Ministry of Health is grateful to Dr. Marc Roberts for his extensive contribution to the development of the initial and nal drafts of this report

Particular thanks go to Dr. Yehia Abed who has overseen editing and production de-tails of the second phase of the report.

We also acknowledge the valuable contribution of the international experts who de-voted time and energy to assist in the development of the report.

We are grateful to our own colleagues in the MOH for their substantial technical con-tributions. We were also fortunate to benet from the collaboration and contributions of representatives of other PNA ministries, local NGOs, and other health institutions

We are particularly grateful to Dr. Riyad Zanoun- the ex-Health Minister, for sharing with us his insightful views and constructive comments on the nal draft. His contri-bution lent impetus to the process.

Above all, an acknowledgement at this occasion would not be complete without sin-cere thanks to the project donors for their nancial support towards organizing and hosting of workshops and meetings, and nally funding the development and publica-tion of this report. The HSR could not have been successful without the help of the Steering Committee members: Dr. Anne Johansen, Dr. Juan Tello, Dr. Ambrogio Ma-nenti, Dr. Rino Pappagallo, Ms. Sawsan Aranki-Batato and Mr. Naseem Noor. .who had been deeply involved in every aspect of the overall project

Finally a publication like this can only be a beginning and much remains to be done. Strategies to conserve the achievements of the Health sector and at the same time to remedy the existing problems are needed at all levels and should form an integral part of all our future plans. And strategies have to be turned into action. It is our hope that this report will stimulate such activities for without urgent, informed and practical ac-tion, the marvelous efforts of this and other projects will not be conserved.

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We hope that the report will help turn this challenge into an opportunity for change in the lives of the Palestinian people. .

Dr. Maged Abu RamadanDirector-General of International Cooperation

Chairman of HSR Steering Committee

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IV

Acknowledgements

The Palestinian Ministry of Health wishes to express its sincerest thanks to the HSR partner donors represented by the Italian Cooperation, the European Commission, the World Health Organization, the World Bank, and the DFID for pooling resources to invest in the Project. Without their involvement, the Project could not have seen the light. Recognition is also due to the HSR Steering Committee members, who actively par-ticipated in the ne shaping of the Project, and played a crucial role in the overall man-agement and monitoring of the Projects activities over the course of implementation.

Special thanks are dedicated to the Ministry of Health technical task forces whose insightful input in the working sessions and their positive attitudes helped bring this project to completion, in cooperation with the international consultants whose contri-bution is highly acknowledged.

Final editing and assembly of the Projects report has been greatly enhanced through the efforts of Dr. Yehia Abed to whom we are greatly indebted.

We trust that the HSR report would serve as a reference tool for all those interested to learn more about the actual status of the Health service delivery system in Palestine, with all its strengths and all its weaknesses.

Finally, we take this special opportunity to congratulate the Palestinian people on this gratifying accomplishment, hoping that it would open the gate wide before the donor community to provide more aid to the Palestinian Health Sector.

Ahead of us lies the implementation stage of the recommendation reached, the realiza-tion of which calls for intense and concerted efforts by all.

Dr. Radwan El AkhrasMinister of Health


Table of content

Foreword..........................................................................................................................................I

Acknowledgments........................................................................................................................II

List of abbreviations and acronyms........................................................................................VI

Executive Summary.................................................................................................................VIII

Health Sector Review........................................,...........................................................................1

1. Introduction.....................................................................................................................1

2. Background.....................................................................................................................2

2.1. Historical overview........................................................................................................22.2. Demography, socioeconomic and political status...................................................32.3. Health system in West Bank and Gaza......................................................................5

3. General process and methods......................................................................................5

4. Task Force activities and ndings................................................................................7

4.1 Task Force I: health status and outcome and Task Force V: Health System Performance.........................................................................................74.2 Task Force II: The health sector nancing..............................................................104.2.1 Health expenditures.....................................................................................................104.2.2 Service costing...............................................................................................................164.3 Task Force III: Health care delivery system...........................................................184.4 Task Force IV: Governance........................................................................................21

5. Recommendations: .....................................................................................................235.1 Health care service planning and delivery.............................................................235.2 National health information system........................................................................255.3 Human Resource development.................................................................................265.4 Management issues......................................................................................................275.5 Health nancing...........................................................................................................295.6 Treatment/medical referral abroad..........................................................................30

6. Bibliography...................................................................................................................32

Annexes

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LIST OF ABBREVIATIONS AND ACRONYMSA&E Accident and EmergencyAAH Ahli Arab Hospital (GS)ALOS Average Length of StayALS Average Length of StayAOR Average Occupancy RateAQH Al Aqsa Hospital (GS)BBP Basic Benet PackageBOR BED Occupancy RateCIS CLINIC Information SystemCMS Central Medical StoresCVD Cardiac Vascular DiseaseDG Director General DGIC Directorate General International CooperationDGPHC Directorate General Primary Health CareDIS Disability Information SystemDM Diabetes MellitusEC European CommissionEJ East Jerusalem EMAP Emergency Medical Assistance Project FTE Full Time EquivalentG&AS General and Administrative ServicesGDC GAZA Diagnostic CenterGDP Gross Domestic ProductGHI Government Health InsuranceGP General PractitionerGS Gaza StripHDIP HEALTH Development Information and Policy Institute HER Health Expenditure ReviewHIS HEALTH Information SystemHMIS HEALTH Management Information System HRD HUMAN Resources Development HSR Health Sector ReviewHURP Hospital Utilization Review ProtocolIC Italian CooperationICD10 INTERNATIONAL Classication of Diseases 10th EditionICU Intensive Care UnitID IDENTIFICATIONIDB Islamic Development BankIPD Inpatient departmentIVF IN Vitro FertilityMARAM Palestinian Health NGO MCH MATERNAL and Child HealthMoF Ministry of FinanceMoH MINISTRY of Health MoP Ministry of Planning

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MOU MEMORANDUM Of Understanding MRA Medical Referral AbroadMRI MAGNETIC Resonance ImagingMTEF Medium Term Expenditure FrameworkNCD NON-communicable DiseasesNGO NON-Governmental Organisation NIS NEW Israel SheqalimO&G Obstetrics and GynaecologyOOP Out of pocketOPD Outpatient departmentOPHT OphthalmologyOPT Occupied Palestinian TerritoryOT Operating TheatrePA PALESTINIAN Authority PCBS Palestinian Central Bureau of StatisticsPHC Primary Health CarePHIC PALESTINIAN Health Information CentrePNA Palestinian National AuthorityQI QUALITY ImprovementQIP QUALITY Improvement ProjectRAH Ramallah General Hospital (WB)RIC Rimal Clinic (GS)SC Steering CommitteeSCBU Special Care Baby UnitSMC SUPERIOR Medical CommitteeSWAp Sector Wide ApproachT&SS Technical and support servicesTAO TREATMENT Abroad OfceTF Task ForceToR Terms of ReferenceUN United NationsUNDP UNITED Nations Development Programme UNFPA UNITED Nations Fund for Population UNICEF UNITED Nations Childrens Fund UNRWA United Nations Relief and Works AgencyUS UNITED States of AmericaUS$ US Dollar USAID United States Agency for International DevelopmentWB West BankWBGS West Bank and Gaza StripWHO World Health Organization

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Executive Summary1. The initial scope of the Health Sector Review was to provide donors and aid agencies with an updating of the public sectors (MOH ) health needs and priorities, essentially to guide and justify further funding objectives: by and large an initiative, promoted primarily to address donor investment decisions.

Very soon, however, other scopes emerged. The exercise would thereafter cover the whole health sector, with the same MOH more extensively involved. The results would be considered by the Palestinian National Authority, the MOH, and by its partners for strategic orientations and national health plans. The bases were laid for a review of the sector policy and plan development.

Despite voicing criticism on its limitations and gaps, the majority of health stakeholders in the Territories have been, since its inception, very keen in demanding the issuing of ndings and conclusions. It was common opinion that the HSR would represent a valid baseline for sector improvement. Indeed some feel that important lessons and inspiration still can be drawn from the HSR process and results.

2. In February 2003 a Memorandum of Understanding (MOU) was signed by the Minister of Health, European Union (EU), Italian Cooperation (IC), the UK Department for International Development (DFID) and the World Health Organization (WHO) on the implementation of the project. For that purpose the group established a Steering Committee (SC). The World Bank joined the exercise later, as a member of the Steering Committee. Each of the member was nancing specic activities within three main areas (pillars): policy and planning, service provision and nancing.

External consultants were brought in from the ISS (Istituto Superiore di Sanit Italy), HERA Consulting Firm (EC), World Bank, WHO and DFID. Such consultants were reviewing the situation with few MOH ofcials in small workshops or site visits (mostly at the MOH hospitals and PHC centers) All the available related documents and health reports were examined, few primary data collection were carried out. For logistic reasons, the eld visits and the interviews were undertaken in small teams. In some circumstances consultants coordination, in terms of timing, contents and methods, proved to be a problem.

3. In March 2004 HSR partners assessed the consultants outputs. Despite the valuable work and contributions gathered, there was a general consensus to further extend the survey activities, essentially to facilitate a larger and more guiding MOH involvement, something was felt missing from the exercise.

A Plan for Moving Forward was endorsed by the HRS-SC partners to reinforce the MOH ownership and commitment. The plan would also

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require a broader view into the sector.

Renewed research efforts were carried out under the arrangement in ve Task Forces, as follows : Task Force I: Health Status and Outcomes Task Force II: Health Care Financing Task Force III: Delivery System Task Force IV: Governance Task Force V: Health System Performance

In June 2004 a SC meeting, held in Cyprus, claried methodology and distribution of Tasks. Relevant cross-cutting issues such as equity, efciency and quality were identied. In September 2004 a nal workshop with a larger MOH participation assessed the results of the Task Forces activities.

4. As agreed in MOU, a Conference was held in Rome in December 2004 in order to broaden the discussion on the exercise ndings and formulate a number of recommendations based on that efforts. The gathering had to achieve a consensus on them and possibly identify strategies to improve the sector. A collectively agreed text was to be issued as recommendations to be adopted by the MOH. They were in fact included in the conference proceedings published few months later.

More remarkably, for the rst time in several years, a large and qualied representations from Palestinian ngos, agencies, donors, public institutions, private sector, universities, professional societies, Ministries, met together to express their view on the sector future.

5. Participants and stakeholders at Rome Conference conveyed their positive assessment of the HSR as a unique opportunity to understand sectors prob lems and needs as well as an occasion for coordination and dialogue. In the face of such enthusiastic feedback, the HSR-SC expressed the willingness to continue the technical coordination on policy/planning development and jointly explore ways and means for an implementation agenda of the recommendations.

A lively nation-wide debate took place in Territories about actions to improve the sector. It involved several donors, civil society organizations, agencies and government and non-government institutions. Though unconnected and uncoordinated, many meetings on the subject of the sector future were held throughout the 2005.

Ofcial inter-ministerial bodies were set up to consolidate the HSR works into an operational agenda. Such efforts were however halted/delayed by procedural issues and competencies issues. A later attempt to converge on such common agenda was made in Jericho.

The political turmoil, which followed the 2006 election, did not spare the

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sector and such undertakings. The agenda for changes and improvements had to wait better times.

6. In the Reports body and Annexes, the reader will nd more details on the HSR ndings. Here it sufce to summarize the main highlights as raised by the ve Task Forces, integrated by the rst phase consultants works.

6.1. Task Force I, Health Status and Outcost, reviewed the disease size and burden among the Palestinian population. The health determinants, in the context of so called epidemio logical transition , were scrutinized. Changes in peoples life behaviors were increasing the incidence and prevalence of non communicable diseases.

The risk of morbidity and premature death, particularly from CVDs and diabetes was said to be on the rise. Lack of coordination and collaboration between different providers meant duplication of services and poor control of such health problems.

The political situation, rising poverty and unemployment had also favored an increase of micro and macronutrient deciency.

The team also reported that about 35-50% of all Hospitals emergency admissions were related to accidents and that accidents in Palestine was the rst leading cause of death among children (1-4 Y). For all ages also it is the second most important cause of deaths (12.5%) after heart diseases, a gure usually unnoticed by health ofcials.

6.2. Task Force II, Health Care Financing, deemed the MOH nancial status to be seriously affected by the rising costs of services, increased demand, insufcient budget and donor-dependency. Revenues of the Government Health Insurance were utterly insufcient to cover the basic needs. Hospital service costs and expenditures were found to vary extensively showing different policies, approaches and sensibilities for overhead costs and capital investments.

Treatment abroad costs showed a serious escalation pattern, affecting all other MOH budget allocations. Expenditures on treatment abroad was found to move from US$ 6,344,190 million in 2002 to 32.5 million in 2003 and 52.3 million in 2004. Investment on national capacity, improvement of contracting policy and proper patients evaluation would reduce its burden.

Establishing an Integrated National Health Insurance would provide a long term solution to the nancial instability and poor sustainability of the Palestinian health system. Donors would help by converging on forms of sector-wide planning and budgeting.

More rational sector planning, associated to better MOH budget discipline and cost containment measures, would provide substantive relief and ensure

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proper use of the scarce resources.

Developmental and ordinary plans were issued with little coherence with nancial solvency and sustainability.

6.3. Findings by the Task Force III, Delivery Sistem, concerning service provision at primary and secondary level, suggested the following: A quantitative and qualitative unbalance between the services provided and the demand of a population undergoing an epidemiological transition. Poor coordination and cooperation between secondary and primary level of care, in a given physical area, on managing the health demand. Poor referral practice and scarce transfer of patients information between the different levels of the system Poor overall information system management

The main problem identied in government hospitals was a huge overloading due to unwarranted referral, self referrals, absence of admission protocol and triage. Alternatives to hospitalizations, such as day hospitals or one-day surgery practices, were largely missing.

The level of appropriateness of hospital utilization was found to be 92% in Alwatini and 72% in Radia Hospitals.

In contrast with public hospitals, non prot facilities in West Bank and Gaza were found to have a low bed occupancy. And yet those living in rural areas and remote villages, suffered from limited access to hospital services.

Investigations on the quality of health service were focused on client satisfaction. Responses indicated wide variation of satisfaction among health facilities and among different aspects. It was evident however that patients were expecting more from professionals and health institutions both in term of physical accessibility and quality of the assistance.

Other aspects of quality of care were also assessed such the presence and utilization of clinical practice guidelines especially at PHC level. The ndings described a patchy picture were some care were better standardized than others. Across services the quality of the clinical practice was found uneven.

6.4.Task Force IV, Governance, highlighted different aspects associated to the sector governance. The provision of care within the public sector was affected by lack of delegation of responsibilities on decisions on budget and human resources. (across the Ministries and within the Ministry of Health).

Facilities managers were unable to exercise their best options because they

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had not substantial power on inputs and resources. Likewise they were not closely scrutinized for accountability. At central level also governance was scarcely distributed.

6.5. Task Force V, Health System Performance, has been assessing health system performance from different angles. Findings showed that there was a wide variation in staff productivity and workload within facilities, specialties, and even across months and weeks. Some of the staff would be unduly penalized as for the workload. Much of such deciencies were associated to poor decisions and management skills and could be corrected with proper service organization changes.

Poor and inconsistent (between West Bank and Gaza) MOH recruitment methods of health ofcers as well as lack of proper licensing and accreditation of health care professionals across the system were part of the problems.

Managerial skills were particularly decient at facility levels (Hospitals and Health Centers) .

Efforts by the MOH and other providers to improve efciency could not be considered systematic. A case in point was the handling of the pharmaceutical sector. Over-prescribing and other provider-patients inappropriate behaviors were unjustiably increasing costs and budget requirements.

7.0 Cross-Cutting issues : The overall health sector information system was mentioned to be an important cross-cutting issue. Insufcient utilization of evidence-based planning was a reason for concern. In absence of strong assessment of facts, the plans were lacking credibility and prone to objections.. Moreover, the existing data systems were not integrated or coordinated. Also, essential pieces of information needed for planning, such as national health accounts, comprehensive chronic diseases data, and pharmaceutical prescribing were almost entirely missing.

8.0 Based on the above the HSR Task Forces presented a list of recommendations to be considered by the MOH in its dual capacity of sector regulator and service provider. Though in essence generic and not translated into any operational form, they were nevertheless considered to be important as reference from which priorities and actions could be developed. Indeed in Rome, the SC, the MOH and many national and international stakeholders pledged to adopt in short time an agenda for changes.

In short, it has stressed the Rome conference recommendations: Making, project management and organizational restructure. A permanent forum for all health care stakeholders in Palestine should be established in order to achieve broad-based consensus and cooperation in matters of mutual interests.

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Immediate action shall be taken to contain costs and setting the pace for a National Health Financing system. Services will have to be reorganized by integrating better the levels of care and the different providers. Quality of service shall be improved through proper licensing and accreditation of the health care facilities. Planning of human resource for health shall be developed in order to ensure the right mix of skills. Professional licensing and education were also to be stepped up. Donors and beneciaries partnership shall lead to forms of better coordination within a framework of sector-wide programs.

9.0 The HSR exercise has been criticized from many angles: donor-driven, fragmented in the approach, realization and analysis, lengthy and somehow costly, incorrect and incomplete, inconclusive and supercial, slow to deliver. Yet it was a courageous effort in a context of political uncertainty. It was also a committed, transparent and stimulating partnership. It was in fact the only joint undertaking by beneciary and providers at that level of technical complexity in recent years.

The HSR helped in maintaining a nation-wide dialogue on the sector and raising the general willingness to engage in sector improvement. While the supporting gures may be outdated, their relative and intrinsic value remain largely intact.

They shall be taken as reference baseline for future comparisons. The serious problems highlighted by the gures are still there, if anything worsened.

The HSR shall not be considered the only source of evidence and information available to decision makers. In recent times a number of important assessments have taken place in the sector.

DFID for instance has produced a Public Expenditure Review. The Italian Cooperation has nanced National Health Account surveys through the PCBS. The Bank, WHO and other agencies, NGOs, Palestinian institutions have done similarly.

It is therefore important that the HSR suggestions and ndings are complemented and integrated with the wider analytic efforts which have taken place ( or will take place ) over the years.

This Report will fulll its task if it is able to renew the interest in re-launching a nation-wide drive to modernize the sector: in short an agenda for changes. That is in everybodys interest: beneciary and donor alike. It would be a great achievement if the report would stimulate such renewed course.

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The health sector review

1. Introduction

The purpose of this report is to summarize the various descriptive and analytical in-vestigations completed by a group of International and local experts on the Health Sector Review (HSR), conducted in the years 2003-2005 in Gaza and West Bank. The review followed the agreement for a joint updating on the state of MOH and other providers services in the sector. The initial scope of work was to support donors decisions on aid assistance to the MOH , while at same time suggesting to the latter a number of measures to improve its organization and offset the rapid increase in public health expenditures.The MOH had been, since the Oslo Agreement, the major provider of free care in the Territories. It carried also the major responsibility towards promoting and pro-tecting the health and well being of the population. Despite the large aid assistance, the MOH and the entire sector was suffering from nancial crisis. The deepening of the political crisis and subsequent economic recession meant a decrease in real term of the MOH budget. It was increasingly difcult to satisfy the raising demand for free health care services. Raising expenditures were due to several factors: consumers expectations, increasing demand of sophisticated technology, escalation of health services cost, demographic changes, staff ination and also casualties and restrictions due to Israeli military at-tacks on populated Palestinian areas. As a result mechanisms of treating inefcient use of public resources and poor performance were becoming a sector priority also for donors.It was therefore agreed between few major donors and the MOH to undertake an evaluation of the status of the public sector in Palestine as comprehensive as possible, before new investment were to be made. It became soon evident, however, that the review should fulll broader purposes. For most of the stakeholders (donors, private sector, public sector, Ministries, international agencies, universities...), the exercise could spark a process of sector rationalization and reform. The exercise could offer the opportunity to address the many problems of a rather fragmented sector. Expectations grew fast among professionals and interested parties. In fact two main changes took place in the course of the HSR. The progressive MOH awareness of the sector problems and the emerging of nation-wide ticket for reform. This Report accounts for the ndings and works of the HSR during the period 2003/2005. Two phases can be there identied: the rst spanned from February 2003 to March 2004 and was marked by survey activities led by groups of donors consultants. The scope of work was divided among them. The largest survey team was provided by the EC through the HERA Consulting.

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The second phase was implemented under a new Plan for moving forward and lasted till the end of 2004. Additional works and ndings were collected by international and local consultants as well as MOH directive staff divided into ve Task Forces. Basically this second phase was meant to expand and improve the ndings of the rst one. This Report is in fact based on the ndings, as they were presented at the December 2004 Rome Conference by the different Task Forces. The following chapters cover also an overview of the HSR background and methodol-ogy before summarizing its suggestions and recommendations.

2. Background

2.1. Historical overview

Following the Oslo Peace Agreement between the Palestinian Liberation Organization and the Government of Israel in September 1994, the Palestinian National Authority (PNA) took over the responsibility for health services over WB and GS, occupied by Israel in 1967. The PNA was established in May 1994 and soon after the MOH. The Headquarters of the latter were based in Gaza.

High priority was then placed on the development of health care services. Donors sup-port permitted a rapid expansion of the public health system. The Five-Year National Health Plan, for the period 1999-2003, provided a vision and objectives for the health care system.

The Plan, prepared with the contribution of many experts inside and outside the MOH, was considered an important step towards the recognition of the MOH role as a sector regulator and coordinator. Its implementation, however, soon met with a context of permanent political uncertainty.

The second Intifada in year 2000 draw most of the attention to emergencies and nega-tively affected its realization. The economic and political crisis continued to plague the sector for years. The sudden deterioration of the relationship between donors and Palestinian institutions in 2006 brought the crisis to a low never experienced before.

However, for the four years preceding the HSR, many donors and local stakeholders had voiced their dissatisfaction with the efciency, effectiveness and sustainability of the sector, even more important under emergency and critical circumstances.

Questions were raised about the limited ability of the PNA to prioritize health services and interventions. The inadequate performance of health system in Palestine was also attributed to poor coordination between the international community and the PNA, the MOH and the Palestinian health organizations.

Despite the magnitude of donor investments, the external assistance appeared uneven in the absence of a clear framework for health sector development.

The health sector was largely fragmented between different providers. It was nanced

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by a number of different funding sources such as the Governmental Health Insur-ance, patient co-payment payments, taxes, donor contributions and social insurance revenues.

All these funding sources were unable to supply enough revenues to maintain a consis-tent and sufcient line of nancing of current and development needs.

In addition, the government health sector had scarce capabilities in term of budgeting and expenditure management.

The HSR was therefore launched as an attempt to restore a patter for sector improve-ment , beyond the prevailing crisis approach.

2.2. Features of demography, socioeconomic and political status in WB&GS

1. The Gaza Strip (GS) comprises 5 provinces and a population of 1,370,345 inhabitants: about 72% of them are refugee. The population is concentrated in 7 towns, 10 villages and 8 camps with a total area of 360 Km2. (1,2) Israel still control about 40% of the total area. It is a at and over-populated region in which density can be estimated at more than 5,000 people per one square kilometer. The Israeli army had divided, before its withdrawal, the Gaza Strip into 3 main isolated zones, largely un-connected and constantly besieged by military forces.

The West Bank (WB) is a more mountainous region comprising 9 provinces. As In Gaza, the Israelis Forces have frequently subjected the population to raids and incursions, and harshly restricted the movement of goods and people, including patients and professionals.

The WB population amounts to 2,367,550 inhabitants dispersed in 500 cities, villages and camps. About 400 villages are scattered in remote and rural places, with a combined area of around 6000 Km2. The refugee population represents about 29% of the WB total.

2. The socioeconomic status of the Territories has been classied at the low-middle-income level by the World Bank. Recently, however, it has moved towards the low developed countries (3) & (4).

Much of the economic deterioration in recent years is due to the military siege and isolation of the population. Since the start of the second Intifada, the income per capita has declined sharply and consistently by 12% in 2000, by 19% in 2001, 31% in 2002, and 40% in 2003 in comparison to 1996(5).

In 2003 the per capita income was said to be US$ 1,020(6). Gross National Income losses amounted to at least US$2.4 billion in real terms by the end of 2001. Average income per capita is now 30 percent lower than it was when the Gaza-Jericho Agreement was signed in 1993. (7) The average income per

3


capita was US$1710 in 1996. Gaza was half of that of the WB,.

Unemployment rate among the labor force has been increasing throughout the Intifada. Published data mention recent rates of 30.95% in WB and 47.6% in the GS (8) & (9).

Unemployment has in turn produced an increase in poverty level.

The number of families falling below the poverty line was estimated at 33% in 1998 and 65% by July 2001 according to the Palestinian Central Bureau of Statistics; (Poverty line is an income of US$ 360 a month for a typical household consisting of 2 adults and 4 children).

The state of political insecurity and socioeconomic instability has been also affecting the peoples health.

Table1 shows a list of selected signicant health and socioeconomic indicators as is-sued by the Palestinian Central Bureau of Statistics (PCBS) and the Annual Report on the Status of Health in Palestine 2004.

Table 1. Selected relevant health and socioeconomic indica-tors in WBGS

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Indic ator* Rate or No. Remarks

Tota l pop u la t ion (WBG S) 3,737,895 WB: 2,367,550 ; GS: 1,370,345

Number of bi rths 94,406 WB: 59,421 ; GS : 42,326 Children 0-14 yr.s 46% WB: 44. 9%; GS: 49. 9% Female popul ation 49.3% Male to Female 102.7 Pop u la t ion Growth Rate%* 3.7% GS: 4%, WB: 3.4% Refug ee Popu lation 1,5554,570 (44%) GS: 70. 8%, WB: 31.6% Life Exp ectanc y (LE) M: 73.8 y M: 72.3 , F: 70.7 y Household Members 6.4 Mem bers WB: 6.1; GS: 6.9, in 2000 Infant mo rtality rate 23.3 per 1000 As repor ted Materna l mor tality rate 13.8 per 100,000 GS: 42 Crude Birth rate 39.2 per 1000

Fer tility rate per wo man 3.85: WB : 3.3 G S: 4.8

Labour force of the total popu lation , 15 years & over

38.7% *PCBS, Statistical yearbook.

All: 72.3 70.7 Males 73.8 Females


2.3. Health system in WB & GS

1. The health care system comprises four main providers; the Ministry of Health, United Nations for Relief and Working Agency for Palestinian Refugees (UNRWA), non-governmental organizations (NGOs) and the private sector.

Health expenditure has been estimated at 8.6% of the total GDP in Palestine in 2002 ( World Bank source). More recent gures from the same source are higher, because of the GDP drop and the actual increase of private expen ditures.

The per-capita expenditure on health in Palestine was found to be in the year 2001 US$ 122 , compared to 1641$ in Israel, 46$ in Egypt and 163 $ in Jordan. (10).

2. Although there have been considerable increase of health services over the years, many patients are still referred to Egypt, Jordan or Israel for special treatment or further diagnostic procedures. The cost of transferring patients abroad, incurred by the MOH in 2002, was US$ 4,322,000. Transferred cases were mostly for cardiovascular and ophthalmic diseases, neuro-surgery, and advanced cancer management (11).

In spite of the nancial and operational constrains, the Palestinian health sector has shown resilience and achievements over the years, in particular as to the provision of a reasonable and generalized level of primary, secondary and tertiary health care.

Since the Israelis handover of the health facilities to the newly established MOH in May 1994, many developmental projects have been nanced by the MOH and the entire sector on human resources, technologies, beds, diagnostic facilities, services and capacity. The improvements came to an end with the second Intifada , when much of the donors and providers attention progressively shifted from development to crisis management.

The HSR came then as the rst attempt to reestablish the importance of development planning and strategic frameworks.

3.General process and methods

1. The agreement on the Health Sector Review (HSR) Memorandum of Understanding (MOU) took more than one year because of the increasing unrests in the Territories, the lengthy arguments on the aims and methodology of the enquiry and formalities.. In February 2003, the MOU was nally signed by the Minister of Health,

5


European Union (EU), Italian Cooperation (IC), the UK Department for International Development (DFID) and the World Health Organization (WHO) on the implementation of the review .

Representatives from these organizations formed a Steering Committee (SC) responsible for the overall supervision of the Review. Their rst meeting was held on the July 28, 2003 under the Minister of Health chairmanship. The rst team of experts arrived in May 2003. At that time, the World Bank joined the exercise and requested to enter as full member of the Steering Committee.

The works were thereafter distributed among different groups of consultants, the largest scope of work being assigned to HERA Consulting, nanced by the EC. More focused works were carried out by experts hired by the IC, DIFID and the Bank.

2. The overall review was in fact divided into three main pillars: policy and planning, service provision and nancing. Most of the survey was to be based on secondary sources of information: few data were to be eld-collected.

Under the MOU agreement, the different groups would have worked under the coordination of the HERAs team leader. Given the different lines of reporting and accountability, that proved to be quite difcult. Despite all the efforts to integrate better the different team works, reports were issued separately. Indeed consultations or joint eld work were far from ideal over this rst phase. Another emerging problem was the insufcient involvement of local professionals and MOH ofcials. 3. A considerable number of documents were reviewed, facilities, run by different types of operators, visited, subjects interviewed and data collected.

This rst phase ended in March 2004, when the participants and the MOH agreed to postpone the publication of the rst Report. Instead, it was felt necessary to go ahead with further works under improved arrangements.

The second phase of HSR was launched following the approval by the Steering Committee of a document in March 18, 2004 entitled Health Sector Review Proposed Plan for Moving Forward. The plan would give the MOH more prominent ownership of the exercise, in exchange for more extensive involvement of its professional staff.

The contract with the EC-Consulting Firm was terminated and consultants drawn from the same company were hired on individual basis.

The other partners provided additional consultants. WHO was charged of nding a top qualied international professional who could dene and drive the works as Technical Coordinator of the second phase.

6


Early in June 2004, the main stakeholders, including the MOH, met in Cyprus to discuss the further reviews, which would be covered by ve Task Forces. During a second workshop in Cyprus in September 6-10, 2004, the outputs were discussed in plenary with the participation of large number of MOH ofcials.

4. The second phase lasted till December 2004 when nal ndings and reports were released and were discussed at Rome Conference. The proceeding of the Conference contained large section of the HSR ndings and recommendations.

It was then decided to publish a nal report with the collection and integration of the ndings and a conclusive assessment of the exercise. That was deemed important as historical record, operational reference and lesson learning document.

Such publication was however delayed by several constrains. In particular, the search for a scientic writer and editor, able to collate and analyze the dif ferent documents, proved to be particularly difcult .

5. In spite of delays in publishing this nal report, the HSR works and recommendations were taken as background and justication for different initiatives and gatherings held in 2005 to establish an agenda for sector development/reform.

On the technical side, the World Bank promoted a workshop with the MOH on some of the most relevant HSR issues in Luxor (Egypt), while, on a more political ground, some Palestinian professionals and agencies set up a national health forum with the intent of contributing to a possible reform process.

The same PA established an ofcial Inter-ministerial and inter-sectoral Committee for the same purposes. In Jericho the latter made a strong attempt to launch an agreed upon agenda., in spite of controversies on the process ownership among the different players.These efforts came, however, to an abrupt end following the 2006 Palestinian election. Yet a number of important preconditions for the launching of a national strategic plan and health sector reform were already there.

4. Task Forces activities and ndings

4.1. Task Force I : Health Status and Outcomes, and Task Force V: Health System Performance.

7


1. Task Force I and V outlined a number of issues related to disease outcome and system performance. Their ndings compliment and integrate results from other TFs, particularly from TF II and III.

The content of the Task Force I and V reports was fairly comprehensive, detailed and contained a great number of observations on the existing health care system weaknesses and strengths.

2. Task Force I has been assessing population disease burden through available data: in particular the prevalence of non-communicable diseases, accidents and physical disabilities were measured.

Un-surprisingly, the MOH reporting system, used for the annual report, contained insufcient information on chronic diseases and disabilities. Most of the facilities did not report timely, complete and correct data on these specic health problems.

In general coverage and quality of the system would need further improvement. Reliable information on the reasons for contacts and services provided was not uniformly available. Hospital discharge summaries and clinics les were either poorly lled in or did not contain important details such diagnosis (at discharge), major biochemical tests, X-ray examinations, other relevant diagnostics and the treatments (e.g. what surgery).

Even when important and indispensable information on the diseases were available in the health facilities, that would not indicate the disease burden in the community at large. Epidemiological data from outside the health care services would be needed. Thus, the HIS should always be routinely supplemented by general population household surveys (e.g. every second or fourth year) to make possible an assessment of disease pattern. Vital statistics are also important elements in assessing such pattern. It was clear that the quality of the death and birth reporting should be improved.

3. Despite these shortcomings, the team review highlighted the increasing prevalence of micro and macronutrient deciency, associated with the rising poverty, unemployment, smoking, and continuous physical and psychosocial stress. The risk of morbidity and premature deaths, particularly from CVDs and diabetes was also shown to be on the increase.

About 35-50% of all Hospitals emergency admissions were related to accidents.

Accidents in Palestine were the rst leading cause of death among children (1-4 Y); it constituted 19.7% of total deaths. It also constituted 50.2% of total deaths among children (5-19Y) and 31.6% of total deaths among adults (20-59 Y). For all ages also accidents were the second most important cause of deaths (12.5%) after heart diseases, a gure usually neglected by health professionals.

8


Registration forms, for accident reporting at the emergency rooms and PHC clinics, were lacking sufcient details to identify causes and locations, types and severity, cost and resulted disabilities.

Prevalence of disability and mapping of rehabilitation services were also assessed. Since the Palestinian Authority had been established, several public hospitals in West Bank, including Radia, Ramallah, Jericho and Hebron had introduced rehabilitation services.

4. Task Force V searched for evidence on health services access, quality of care and technical efciency at the MOH health facilities.

Staff productivity and workload varied within MOH facilities, specialties, and even over time ( e.g. across days of the month). The workload of some specialists in certain facilities was seemingly very low, while in other facilities general practitioners have average patient-doctor visit time of less than two minutes. Lack of qualied nurses at the primary health and emergency care level as well as they reduced role in case management were affecting the quality of health care. Regular staff productivity and workload assessment were found to be inadequate. Such assessments would help managers and decision makers to address unbalances and redundancies.

In this sense, qualied health services managers, mastering planning, budgeting, accounting, procurement and data analysis, were found to be in great shortage. On the other side, nancial and procurement decisions were centrally controlled and left very little incentives for better facility management. 5. The same review team assessed the MOH budgeting and expending procedures.

The annual budget was historically determined. It was based on a combination of previous year expenditure, and routine percentage increase. Expected aid developmental projects for the following year were included in the budget.

Budget allocations were made with little reference to the size and type of priorities, inputs-outputs matching or inefciency concerns. Development planning and budget were largely unrelated. Sustainability and affordability were missing notes. Furthermore, actual expenditures had often little relation with the allocated budget.

The public sector in fact lacked the necessary tools of economic and nancial analysis that could improve the use of the scarce resources

6. Quality of health care services was assessed through client and staff

9


satisfaction.

Questionnaires were administered on an initially simple, limited and non-rep resentative number of staff and patients.

The questions focused on non-clinical aspects of MOH health care services and captured issues related to management of health facilities, staff motivation, and the ow of patients in the facility. The responses seemed to indicate variation in both client and staff satisfaction. On the whole there was plenty of recommendations to improve quality of government services which could meet staffs and clients requests.

Loopholes and shortcomings in facility and service accreditation and licensing were hampering quality improvements. Rules and regulations were enforced in an inconsistent pattern.

7. A general problem that had surfaced during the works of Task Force I and V was the limited coordination and collaboration between the facilities of the MOH in West Bank and Gaza, partly for historical reasons and partly because of the lack of mobility within and between these two areas. The limited coordination and collaboration manifests itself in the form of differences in the administration and implementation of rules and regulations between the two areas.

4.2. Task Force II: The Health Sector Financing Task Force

Task Force II assessed expenditures and nancing through (a) a rapid health expendi-ture review and (b) costing studies in a sample of health facilities in GS,

4.2.1. The Health Expenditure Review (HER)

The Health Expenditure Review (HER) addressed three basic questions: where do the resources come from, where do they go, and what kinds of services and goods do they purchase.

1. In terms of nancing the Task Force identied the size of national health expenditures as well as main primary sources of nancing. There was a general agreement on the limitations posed by the large donor dependency and the scarcity of public funds, though the sector as a whole consumed an important size of the GNP.

In that connection, different strategies for ensuring a reliable and sufcient ow of resources were explored, such as national insurance, co-payments mechanisms or donors convergence on budget support and sector wide nancing.

Inefciencies should be treated to improve availability of funds for health priorities. Better contracting policy, revised provider payment mechanisms

10


and pre-dened basic benet package are few examples of cost containment measures.

The future role of MOH as regulator, provider and fund generator/administrator was also debated. Changes in its role would require and introduce deep changes in the sector organization and nancing. 2. The primary sources of funding for the whole health sector were :

The Ministry of Finance: revenues from taxation, health insurance, co-payments and other governmental revenues International donor and agencies including UNRWA. Private for-prot investment Household expenditures (out of pocket payments)

In 2002 the WB& GS health sector was nanced by the PNA Ministry of Finance (15%), the households (38%) and donors (48%): the per capita health expenditure was 94 US$ . This was lower than the 1996 gure, when per capita expenditure was estimated at US$ 122.

Forty-seven percent of expenditures were made through the MOH (31% recurrent, 16% capital), while UNRWA was responsible for 10%, NGOs 25% and the private for prot sector 17% of total.

Excluding private-for-prot providers, it was estimated that 29% of health expenditure was directed towards primary care and 49% towards the hospital sector.

3. Total donors assistance to the health sector was described in details: size, ow to the providers (MoH, UNRWA and NGOs) and functional utilization by sub sector e.g. PHC and Hospitals. TF2 also collected information on actual consumption in the sub-sectors (drugs, medical supplies, laboratory reagents, food, stationary, etc.).

The nancial difculties of the PNA, as a result of the Intifada, have increased the dependence of the MOH on donor nancing. In 2001-2002 for instance donor assistance was the following:

US$ 370-570 million for PNA budget support (in 2002, donors contributed some 50% of all civil servants salary payments). US$ 300-375 million for other emergency needs; US$ 150-330 million to maintain institutional and infrastructure programs.

4. The Health Sector received about 20% of the total donors assistance to the OPT in 2003, that is around US$ 240 million out of US$ 1.2 billion (or US$ 65 per capita). (Figure 1) The MOH (recurrent and capital budget) received 61% (US$ 145 million) of the total fund allocated to the health sector

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Budget support 69.00 29%ESSP 28.45 12%

Budget support 281.00 Dvlp 47.34 20%Emerg.&Hum. 212.34 Total 144.79 61%Dvlp 315.78Total 809.12

MRA 18.12 8%

NGOs 54.00 23%Emerg.&Hum. 24.00Dvlp 63.00Total 87.00

Budget support 96.72 Budget support 20.38 9%Emerg.&Hum. 35.14 Emerg.&Hum. 1.88 1%Total 131.86 Total 22.26 9%

?? ?Budget supportEmerg.&Hum.Dvlp 53.43Total 155.19 Total 239.17 100%

Total Donor's Assistance Health Sector

MoH

UNRWA

Donors

101.76

1,183.17 MoF

NGOs

UNRWA

IDB

Figure 1. Total Donors Assistance 2003 and ows of funds to the health sector (US$ Million)

5. Analysis of the MOH budget highlighted the general inconsistency between nancial affordability and planning as well as budget request and expenditures.

More striking were the unbalances among the budget items. The growth of staff costs over the years of the Intifada were made at the expense of other basic operational items.

The annual budget of the MOH used to be around US$ 100 million over the last few years up to 2003. The proportional distribution of the MOH expen diture was 58% for salaries, 25% for drugs, medical supplies and vaccines, 10.8% for operating services, and 6.4% for referrals for treatments abroad. (Table 2 and 3)

The Emergency Services Support Program (ESSP) represented the source of funds for 29% of total expenditure, 62% of the operating costs, and 93% of drugs and medical supplies.

12

(Islamic Development Bank (IDB) not included). UNRWA and NGOS represent respectively 9% and 23%.

Despite the magnitude of donor aid, the external assistance appears fragmented in the absence of a clear framework for health sector development.


Table 2 . MOH (as a provider) Actual Consumption 2003 (US$ million)

Table 3. MOH (as a provider) Actual Consumption 2003 (%)

WB GS

Actua l consu mption 2003

HOSP PHC Ad m & Oth er

Total HOSP PHC Ad m & Oth er

Total

Salari es 51.8 12.9 8.5 5.3 26.8 13.8 5.9 5.3 25.0

Drugs and m ed. supp lies 27.2 9.5 6.1 0.1 15.7 8.3 3.1 0.1 11.5

Oth er operating costs 14.4 3.3 1.1 1.5 5.8 5.3 0.8 2.4 8.5

Total 93.4 25.7 15.7 6.9 48.3 27.4 9.9 7.8 45.1

The recurrent budget of the MOH grew by 54% between 1999 and 2003, from US$72 million to US$111 million.

Within this, expenditure on staff has increased from US$ 35 to US$ 58 million, an increase of 66%, reecting the signicant increase in the numbers employed rather than increased salary levels.

6. An analysis of health expenditure undertaken prior to Intifada by the MOH and the World Bank indicated that, as a result of the rapid expansion of government service, the health sector (and in particular the government sector) was already facing problems of sustainability and affordability.

During the Intifada the PNA has increased access to Government services by expanding membership of the Government Health Insurance (GHI) to people because of Intifada-related loss of jobs, damage to elds/crops or other infrastructure.

The GHI contributes directly to the Governments revenues and is not, as the name implies, a true insurance scheme. The GHI experienced a 20% reduction in income between 1999 and 2002 while membership more than doubled.

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WB GS

Actua l consu mption

HOSP PHC Ad m

& Oth er

Total HOSP PHC Ad m

& Oth er

Total

Salari es 100% 25% 17% 10% 52 % 27% 11% 10% 48 %

Drugs and m ed. supp lies 100% 35% 22% 0% 58 % 30% 12% 1% 42 %

Oth er operating costs 100% 23% 7% 10% 41 % 37% 6% 16% 59 %

Total 100 % 28 % 17 % 7% 52 % 29 % 11 % 8% 48 %


GH I 2003

Househ. 669 36,013 2,847 6,506 19,480 160,00 0 769 226,284 57%

% 0% 16% 1% 3% 9% 71% 0% 100%

Revenu es 160,00 0 6,432,000 748,000 1,920,444 2,115,778 0 102,44 4 11 ,478,667 44%WB

% 1% 56% 7% 17% 18% 0% 1% 100%

Househ. 2,100 30,605 8,853 6,723 25,823 93,820 698 168,622 43%

% 1% 18% 5% 4% 15% 56% 0% 100%

Revenu es 368,66 7 8,319,333 1,804,667 1,024,667 2,978,222 0 93,111 14,588,667 56%GS

% 3% 57% 12% 7% 20% 0% 1% 100%

Househ. 2,769 66,618 11,700 13,229 45,303 253,82 0 1,467 394,906

% 1% 17% 3% 3% 11% 64% 0% 100%

Revenu es 528,66 7 14,751,333 2,552,667 2,945,111 5,094,000 0 195,55 6 26,067,333 WB&GS

% 2% 57% 10% 11% 20% 0% 1% 100%

Table 4 GHI 2003: Households and revenues (US$) 2003 by territory and by category of enrollees.

The GHIs total revenues in 2003 were US$ 26 million or 27% of MOH actual expen-diture and 11% of total fund allocated to the health sector. (table 4)

The compulsory enrollment represented 17% of total membership and 57% of the premiums.

7. In the course of the review, it was highlighted a critical problem concerning the referral of a disproportionate number of patients to private non-prot health providers in WB& GS or to the neighboring countries health services.

The so-called treatment abroad (or medical referral abroad) meant any services purchased and provided outside the MOH facilities

The consultants gathered a considerable size of data on this issue from MOH les, containing all types of patient information, such as main medical procedure, diagnosis according to International Classication of Diseases (ICD10), number of cases (as inpatient or as outpatient), cost per case, source of referral, place of referral (where from and where to), waiting time, etc.

The treatments abroad are registered in two databases one in Gaza Strip and one in West Bank. The data on treatment abroad were structured the same way from January 1st to June 30th 2003. The data for the years 2000 to 2002 were also available for time analysis.

14


Data were cross-tabulated against places of referral in Gaza Strip, West Bank, East Jerusalem, Jordan, Egypt and Israel. All the data tables were merged into one Access database in order to facilitate the analysis.

The TA was consuming a great deal of the MOH current budget. Moreover the MOH expenses on it were only a portion of the total annual cost of such services. The other portion was handled by the President Ofce: in fact a parallel system to the MOH practice on referral.

The cost of TA/Medical Referral Abroad (MRA) (for patients referred by other authorities than the MoH) represents 8% of the funds allocated to the health sector (13% if the patients referred by MOH are included).

Table 5 Medical referral abroad 2003

2003 # Ref errals Total cost US$ Contribu tion of patient s US$

Net cos t US$ Mean cos t US$

We st Bank 11,249 21,798,214 941,026 20,857,188 1,938

MoH 6,367 7,496,234 826,396 6,669,838 1,177

Presi dent's Of fice 4,882 14,301,980 114,630 14,187,350 2,930

Gaza Strip 8,946 11,617,743 59,932 11,677,675 1,299

MoH 6,871 7,688, 199 59,932 7,748,131 1,119

Presi dent's Of fice 2,075 3,929,544 3,929,544 1,894

Tot al W B&GS 20,195 33,415,957 1,000,958 32,534,863 1,655

Tot al MoH 13,238 15,184,433 886,328 14,417,970 1,147

Tot al Pre siden t's Offi ce 6,957 18,231,524 114,630 18,116,894 2,621

Tot al 20,195 33,415,957 1,000,958 32,534,863 1,655

8. Based on the US$ 32.5 million in 2003 (Table 5), the extrapolated cost for 2004 would be US$ 52.3 million (for 30,000 referrals). This spectacular in crease in referrals is particularly obvious for WB.

In fact the MOH (and PNA in general) would increasingly operate as a purchaser of health services from the private sector (inside and outside WBGS): a change which should require full consideration for the future of the MOH and sector.

Despite the fact that the Palestinian MOH has developed advanced diagnosis and treatment facilities in West Bank and Gaza Strip, it has been always necessary to refer patients in need of special diagnosis and care to institutions outside the Palestinian MOH: NGO and private health providers in West Bank, Gaza Strip and East Jerusalem or providers in Israel, Jordan and Egypt. These patients were managed through the Special Treatment Department at MOH in WB and GS.

9. The analysis of 7,641 patients during the period January 1st to June 30th 2003 seems to show that Egypt is the referral option for Gaza Strip patients

15


(more than 56% of all Gaza Strip referrals), possibly because of the travel limitation to West Bank and East Jerusalem.

West Bank takes care of nearly 50% of all patients within the West Bank : the remaining patients are treated in either East Jerusalem or Jordan.

The Jordanian private providers choice would explain the higher cost of treatment abroad in the West Bank (NIS 10,164,252) than Gaza (NIS 3,566,491), though, despite the fact that the population is twice as big in West Bank as in Gaza Strip, the number of patients referred is higher in Gaza Strip.

10. The highest bill was associated with infertility care: 3.1 million NIS for 436 procedures.

Heart catheterization had 893 procedures and a cost of 0.9 million NIS. Ophthalmology had 594 procedures at a cost of 1.9 million NIS. Rehabilitation had 277 procedures and the cost of 1.6 million NIS. MRI scans were 269 and the cost of 0.27 million NIS.

4.2.2. Service costing surveys

1. Through standard costing studies, Task Force II found a large cost variation at selected health facilities, casting doubts on management capabilities.

While, for instance, admission and bed average costs would depend on case-mix ( e.g. disease prole, age of patients, case severity) as well as input costs and volume, ndings pointed out a lack of standard clinical approach, excessive variation in bed utilization, staff productivity and overhead costs.

2. The studies involved all type of facilities, with the exception of level II clinics. Surveys were carried out at Ramallah Hospital, Jenin Clinic, EGH, Al Aqsa Hospital (GS), NGO hospital: Ahli Arab Hospital (GS), Rimal Clinic (GS). Results for the Jenin Clinic were discarded due to results inconsistencies.

A second mission was held late August early September 2004 to complete the data collection, in view of the second workshop in Cyprus.

3. An Excel template for data collection and entry as well as a quick reference guide were adopted. The Excel le contained 11 data entry sheets to costs items for the year 2003: personnel, drugs, medical disposables, laboratory materials, X-Ray materials, medical gases, other operating costs, xed assets (investment cost). Direct allocation of cost to the different cost centers was attempted.

4. The main ndings and results of the studies are presented in the Table 6.

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The four analyzed hospitals were quite different in terms of capacity: 74 beds in Al Aqsa Hospital (AQH) against 231 at the European Gaza Hospital (EGH). Ahli Arab Hospital (AAH) had 87 staff against the 695 in EGH. Moreover, the depreciation cost was missing for AQH and Ramallah General Hospital (RAH), which would make unit cost higher at these facilities.

The full cost per bed varied from US$ 20,518 (AAH) to US$ 33,860 (EGH).

AAH had the highest full cost per admission (US$ 347) and per bed-day (US$ 108).

The full costs per outpatient attendance and per Accident & Emergency episode were similar at EGH and AAH (from US$ 18 to US$ 21), but rather lower in Ramallah.

Table 6 Hospitals costing study (Year 2003): summary table

GS WB

EGH Ahli Arab (AAH)

Al Aq sa (AQH)

Ramallah (RAH)

Beds 231 80 74 143

AOR 80% 42% 91% 96%

ALS 3.7 3.2 1.8 2.7

Personnel 695 87 271 340

Tot al cos t US$ 8,735,877 1,641,433 1,796,822 4,188,379

Ful l cost per bed US$ 33,860 20,518 24,281 29,289

Ful l cost per admission (IPD cost only) US$ 329 347 127 142

Ful l cost per bed -day (IP D cost only ) US$ 90 108 73 53

Ful l cost per Out patient (OP D cost only) US$ 20 Na 13

Ful l cost per admission A&E (A&E cost only ) US$ 18 21

Na 8

Dir ect cost drugs per admission (IPD) US$ 32.04 19.85 16 17.5

Dir ect cost medical disp . Per admission (IPD) US$ 7.6 4.7 3 12 5

Ful l cost per surg ical ope ration US$ 174 88.3 Na 107.5

Ful l cost per lab te st US$ 1.9 6.6 Na 0.5

Ful l cost per radi ology exam US$ 18.3 26.8 Na 3.8

Averag e Annua l Salary per FTE US$ 5,532 11,770 4,196 5,321

FTE per bed 2.7 1.1 3.7 2.4

Bed days per FTE per year 97 140 91.2 148

In terms of efciency, AAH had the lowest Full Time Equivalent (FTE) per bed (1.1) ratio, while Al Aqsa the highest. The reverse was for the salaries (US$ 11,770 against 4,196).

This does not mean that the salaries were higher in AAH, but that the ratio between medical and para-medical personnel was higher in private than in public hospitals.

5. The bed-days per FTE per year varied from 91 (AQH) to 148 (RAH). A FTE staff, supposed more qualied, at the AAH attended 140 bed days.

17


The Average Occupancy Rate (AOR) was quite higher in the public hospitals (from 80% -EGH- to 96% -RAH-) compared to AAH (42%). However the former, were ( see the next chapter) at the higher range of occupancy rates in the public sector ( respectively for Gaza and West Bank).

EGH drugs cost per inpatients was US$ 32 , compared to the average of US$ 17 for the three other hospitals.

These disparities, and other variations such as cost per laboratory test, radiology exam and surgical operation, would require additional investigations (and more sophisticated methods) to shed proper light on the main contributing factors. However, they all point out the rather different approaches, within sectors and between sectors, to expenditures, hospital admission policies, staff recruitment, overhead costs etc...

4.3. Task Force III: Health Care Delivery System:

1. Task Force III provided an overview of the health system delivery in the Territories. A team from ISS conducted studies focusing on the provision of health services and on the use of such services in WB and Gaza. During the rst phase the team mapped the services available and possible mismatch between demand and supply. In a second phase, the team expanded the previous investigations on Hebron, Ramallah and Gaza hospitals, assessed hospital utilization in other two selected hospitals in Nablus, conducted an assessment on the referral network of PHC centers and screened the inpatients time arrival at selected A&E .

2. As expected, health care services in WB & GS were provided by ve main health care providers: MOH, UNRWA, NGOs, private sector and medical services of the Security Forces. They covered, in different degrees, all the Palestinian market of primary health care (PHC), hospitals, pharmacies, diagnostic units and paramedical services. ( )

The MOH and UNRWA were the main providers of primary preventive and curative health care. The MOH was also the larger provider of the secondary health care (hospitals). On the whole, it is responsible for around half of all the Palestinian health facilities in WB and GS.

At the time of the study the situation was as for Table 7. NGOs and the private sector were notably more prevalent in WB than Gaza .

Table 7 indicates a wide regional variations of bed/population ratios. Generally speaking hospital access was found more difcult for those living in rural areas and remote villages, than for those living in urban and central areas.

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Table 7 Distribution of hospitals beds and PHC centres in WBGS according to health care providers in 2004

Hospita ls' be ds Pri mary hea lth ca re ce ntre s Provinces of Ga za Strip

Populati on

MoH UNRWA NGO's Pri vate Total Ratio of bed per 10,000 population

MoH UNRWA NGO's Total

Gaza North 254,093 58 0 62 0 120 4.7 10 8 3 21

Gaza Ci ty 470,605 788 0 231 39 1,058 22.5 14 19 4 37

Mid. Area 193,648 97 0 0 0 97 5.0 16 10 5 31

Kh an Y ounis 259,640 496 0 166 0 662 25.5 12 6 2 20

Rafah 159,250 52 0 0 52 3.3 4 8 4 16

Subtot al 1,337,236 1,491 0 459 39 1,989 14.87 56 51 18 125

Jerusalem 389,663 0 0 457 72 529 13.6 16 28 3 47

Jenin 246,685 113 0 8 36 157 6.4 51 29 6 86

Tu lkarem 162,936 101 0 45 0 146 9.0 25 8 2 35

Qa lqilia 90,960 10 63 0 10 83 9.1 16 12 2 30

Salfit 60,132 12 0 0 0 12 2.0 15 5 1 21

Nablus 317,331 259 0 109 100 468 14.7 41 37 4 82

Ram allah 270,678 155 0 78 78 311 11.5 48 35 5 88

Beth lehem 40,909 55 0 0 0 55 13.4 17 29 2 48

Jericho 169,190 373 0 223 32 628 37.1 16 5 3 24

Hebron 551,809 166 0 186 94 446 8.1 112 26 7 145

Subtot al 2300,293 1,244 63 1,106 422 2,835 12.32 357 214 35 606

Grand Tot al 3,637,529 2,735 63 1,565 461 4,824 13.26 413 265 53 731

Source : MoH -HMIS. The Statu s of Hea lth in Pal estine 2003 : Annual Repor t. Gaza, HMIS , 2004.

3. The surveyed government hospitals in West Bank (830 beds) had a bed occupancy rate of 83.1% and an average length of stay of 2.4 days. In Gaza (1,337 beds), the review showed a bed occupancy rate of 73.1% and an average length of stay of 3.1 days. MOH hospitals tended to be busier and more overloaded than non-MOH hospitals. For comparison, the NGOs bed occupancy rate in 2003 was 37.2.

4. In Ramallah and Hebron referrals notes indicated that admissions were requested by the Emergency Department, respectively for 50% & 51% of cases, and by the OPD in 20% & 8%; the remaining referrals were from different sources. In Nablus, admissions were coming from the Accident and Emergency Department in 52% of cases, from PHC and General Practitioner in 15% of each case and from other Government Hospitals in the 10% and the 8% of remaining admissions were from other sources. In Radia Hospital, referrals from the Accident and Emergency Department accounted for 38% of the admissions; the second category was from OPD

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NGOs UNRWA


(18%) and the remaining was distributed on other sources of referrals.

In Gaza, hospitalisation was mainly requested through the OPD (36%) and the Accident and Emergency Department (64%).

5. An Hospital Appropriate Utilization Protocol was applied in two Nablus hospitals: Alwatani and Rafedia.

The level of appropriateness of hospital utilization was found to be 92% and 72% respectively.

Most of the inappropriate hospitalizations were ascribed to one or a combination of the following factors: poorly decided referral, self referrals, lack of patient management, absence of admission protocol and triage, absence of alternative to the hospitalisation (day hospitals or day surgery ), inadequate discharge planning, inadequate ow of information, and unplanned decisions between the hospitals and PHC centers.

6. To better clarify the context in which the decisions for inappropriate admissions were taken by the patient or by his/her caretaker, nine satellite PHC centres in Nablus area were assessed for accessibility factors.

Table 8 and Table 9 report few of them which would contribute to self referral or unworthy hospitalisation decisions.

The main reasons for bypassing the PHC or hospital self-referring were lack of condence in the PHC services, diagnostic limitations, lack of drugs, absence of specialized staff or unavailability of PHC afternoon shifts.

Indeed the arrival time of inpatients, screened at the Accident and Emergency Department in Al Watani Hospital, showed that, while 61.6% of patients were admitted in the morning shift (08.00 -14.30), an important percentage (36%) were done between 14.31 24.00.

Table 8 The problems identied in the satellite PHC centres Findings Frequen cy Remarks Catchmen ts area per facili ty 1061 1 peo p le Hours of op era tio ns 6.30 ho urs The off ic ia l du ty work time per day Av erage N of v isi ts for day 66.6 Av erage N of patien ts seen per day/ GP

46.5 Each doctor is sched u led 3.9 days out o f 6

Presence of lab ora tory 3 o f 9 = 33% Sp ecial ized MD per PHC 1.6 Each doctor is sched u led 0.9 days

out o f 6 Presence of CP: PH C in v il lag es 1 o f 9 = 10 % Presence of CP: PH C to Hospita ls 6 o f 9 = 70 % Inv o lvemen t of the comm un ity in the PHC

0 o f 9 = 0%

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Table 9 Out of stock pharmaceutical supply in the satellite PHC centers.

Type of drug Shortage in PHC % of patie nts w ithout treatme nt

An a lgesics 3 of 9 = 33 % 0.9

Ant i- infl amm atory 3 of 9 = 33 % 1.4

Anti bi o ti cs 3 of 9 = 33 % 1.6

Chronic d iseases 7 of 9 = 80 % 8.4

4.4. Task Force IV: Governance

1. Task Force IV focused on the employment process, in particular the recruitment of medical staff in MOH, an issue for many reasons controversial. The reason for such specic attention was said to be the importance of achieving a standard of staff recruitment, selection and assignment in the public sector. In fact the selection process was felt to be marred by number of inefciencies.

2. Three selection systems were identied by the experts. Procedures in West Bank were different from those in Gaza and both at variance with procedures at the Gaza European Hospital.

Different procedures and authorities were meaning little homogeneity in the health staff mix and prole across the regions.

In Gaza the vacancy holders were excluded from the selection and appointment of the employee candidates. Much of the decision and the process was controlled by the GPC (General Personal Council), an institution independent from the MOH and for many years under the President Ofce.

At the EGH the recruitment was completely independent from the GPC and from the same MOH recruitment system.

In WB the employment process was directed by the MOH and would give more say to MOF and the individual employing unit .

3. Beside the recruitment and selection policies and practice, Task Force IV assessed the situation of the health care education system.

The number of schools for health professionals in the Territories were said to be substantial: one medical school, two dental schools, schools for nurses and other professionals and public health post graduate studies at Al-Quds,

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Beir Zeit and Najah Universities.

Not all activities in these institutions met international standards and they were often unbalanced in the supply of professionals. Lack of general planning of human resource need was highlighted.

Indeed some clinical and non-clinical qualications were found grossly in shortage.

Despite the training of health professionals abroad through the large number of scholarships, there was a lack of qualied staff in several places. Brain drain and high MOH attrition were also adding problems to the availability of qualied professionals in the sector, particularly in its public component .

Many health professionals had acquired their education and training outside the Territories and in different educational settings. The need for uniform criteria of licensing and recruitment were underlined.

Above all, it was stressed that the educational and employing sectors (private and private) should coordinate themselves to achieve a rational and planned outputs.

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5. Recommendations

As the name implies, the HSR had to review and measure the state and problems of the entire health sector. In practice much of the focus was on the MOH. This was justied in different manners: the MOH predominant role as provider, nancer and regulator, the donors large investment into the MOH services as well as into technical assistance and the simplicity of surveying in short time a large provider.

As a matter of facts the teams ended up providing ndings and recommendations relevant to the whole sector. Moreover, despite the HSR MOU agreement was rather vague about the adoption of recommendations (after all it was to be only a review), the SC and other stakeholders increasingly showed interest in identifying suggestions to move forward. Indeed they become part of the Rome Conference deliberations and embodied in its proceedings. The MOH, in fact, undersigned them and pledged to adopt a proactive role in implementation. While a list of broad based recommendations were reported in the above mentioned proceedings, the same are spelled out in more details hereunder. The following 6 main areas are made to summarize recomm

final health sector review

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