WORLD HEALTH ORGANIZATION FIFTY-SECOND WORLD HEALTH ASSEMBLY Provisional agenda item 17 A52/25 29 March 1999
Health conditions of, and assistance to, the Arab population in the occupied Arab territories, including Palestine Report by the Director-General
INTRODUCTION 1. The Fifty-first World Health Assembly, in resolution WHA51.27, requested the Director-General to take urgent steps in cooperation with Member States to support the Ministry of Health of the Palestinian Authority in its efforts to overcome current difficulties and in particular, to guarantee free circulation of patients, those responsible for health and emergency services, and the normal provision of medical goods. The resolution further requested the Director-General to continue to provide the necessary technical assistance to support health programmes and projects during the transitional period; to obtain funding from various sources; to activate the organizational unit at WHO headquarters concerned with the health of the Palestinian people, and to continue to provide health assistance so as to improve the health conditions of the Palestinian people; and to report on progress to the present Health Assembly. 2. To respond to the terms of this resolution, WHO has maintained its special technical assistance programme in the interim period of self-rule.
COORDINATION IN ACHIEVING PALESTINIAN HEALTH GOALS 3. The economic regression that started in 1996 in the Palestinian Self-Rule Areas continued in 1998. Permanent “closures” remained the norm, yet the number of work permits granted increased in 1998 (from an average of 38 000 to 44 400 per month), leading to a substantial decrease in unemployment (down by 20.25% in the first three quarters of 1998). This positive development has been offset, however, by the downturn in the global economy and rising inflation. The average monthly wage increased by 2.7% in the first three quarters of 1998. Nevertheless, according to the Palestinian Central Bureau of Statistics, household consumption decreased significantly (down by 8.5%), confirming assertions of marked increases in poverty levels in the Palestinian Self-Rule Areas. One area of household expenditure seriously affected was health care, which shrank by 21.96% between the fourth quarter of 1997 and the first quarter of 1998. 4. Public investments by the donor community decreased by 17% in the first three quarters of 1998 compared with the same period in 1997. Nevertheless, investments have averaged US$ 500 million per year since 13 September 1993, the date of the signing of the Oslo Accord. After the Wye River Memorandum, the international donor community met in Washington at the end of 1998 and pledged support of more than
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US$ 3.2 thousand million over the next five years for development of the Palestinian Self-Rule Areas. The consultative group meeting in Frankfurt earmarked US$ 770 million for 1999. 5. The Palestinian Authority further developed its revenue collection mechanism in 1998. Its proceeds are exceeding forecasts and the Authority’ s budget is balanced. The health sector allocation of expenditure in the Palestinian budget has been maintained at around US$ 100 million a year. More than 50% of the recurrent expenditure of the Palestinian Authority is spent on salaries and wages. This reflects a trend in the expansion of employment in the public sector. The Ministry of Health expenditure pattern does not differ from that of other ministries. 6. With the empowerment of the Palestinian Authority through increased responsibilities for planning and coordination, most of the sector working groups under the donors’ coordination mechanism, have decreased their activities. The Palestinian Ministry of Planning and International Cooperation has therefore started to play a more direct role along with the other ministries involved. The local aid coordination mechanism and consultations between donors and international agencies have increasingly replaced the sector working groups. To compensate for this, informal but effective coordination has been built up among international organizations in the Palestinian Self-Rule Areas: ILO, FAO, UNESCO, WHO, the World Bank, UNICEF, UNDP, WFP and the Commission of the European Communities. 7. Palestinian nongovernmental organizations, which played a prominent role in providing alternative health services during the years of the intifada, have intensified their internal efforts of coordination and cooperation, aiming to enhance the complementarity of their roles and services. The Ministry of Health and the nongovernmental organizations have undertaken limited but promising experiments of cooperation in the delivery of primary health care services. Despite decreased resources and constraints on people’ s movements, there is much better coordination. Harmonization of health policies is being developed between the West Bank and Gaza Strip. Several key sectors, such as pharmaceuticals, have developed common policies, strategies and working mechanisms, providing a basis for more effective national development planning. These positive developments result from the combined efforts of the international and Palestinian communities to meet the challenges facing the occupied territories. 8. Despite the Ministry of Health’ s best efforts there have been problems with some essential aspects of the health service delivery system, such as the supply of drugs. In the autumn of 1998, delivery of drugs to the health service stopped because of delay in payments to the suppliers. Hospitals and primary health care clinics consequently experienced serious drug shortages. 9. With the Ministry of Health’ s budget stable at around US$ 100 million, and the population still growing rapidly (3.7%), funds for the expansion of health services are simply not available. Partly because of these financial constraints, the opening of several new facilities has been delayed. The opening of the Gaza European Hospital, financed by the European Community, has been delayed several times. Services, however essential, can scarcely be expanded. With funding constraints expected to last for several years, the Ministry of Health continually reviews its development plans. A five-year national health plan is being thoroughly analysed to guarantee sustainability. 10. In view of the uncertain economic situation, the sustainability of social services in general and of the health sector in particular has become a serious concern to the international community. Projects and donations are carefully scrutinized for their cost implications to the sector and the budget of the Palestinian Authority. The combined development efforts by the Palestinian Authority and the international community have strained Ministry of Health resources. Staff in critical management positions have been under pressure to deal with both daily tasks and the development efforts supported by the donor community. The process
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of coordination among different international programmes has, however, substantially improved, with more tangible results and outputs for most technical assistance projects. 11. Despite the important constraints faced and an overall decrease in sector funding, international assistance to the health sector has improved. This is partly due to a better understanding, by both the Palestinian Authority and the donors, of the sector’ s development priorities and of the mechanisms to implement projects.
SPECIAL TECHNICAL ASSISTANCE PROGRAMME 12. To ensure effective coordination in the health sector, WHO has continued to share health data and information with interested donors and organizations. Planning of activities within the Palestinian Self-Rule Areas has been jointly carried out with the World Bank, UNICEF, UNDP, UNFPA, the Commission of the European Communities and with several nongovernmental organizations active in the area. 13. A study, jointly prepared by the Ministry of Health, the World Bank and WHO, on the development priorities of the Palestinian Self-Rule Areas, has been presented to the international and the Palestinian health communities.1 The document highlights the problems faced by the Palestinian Authority in developing an effective health system and suggests measures that could improve the system’ s efficiency and sustainability. It concludes that the Palestinian Self-Rule Areas are at a crossroads in the evolution of their health system. The prospects for improving the system depend largely on the ability of the Ministry of Health to mobilize sufficient support among the stakeholders (key policy-makers, providers such as the Ministry of Health, nongovernmental organizations, donor agencies and users) to implement the changes proposed in the study. The study suggests that the process of developing the new national health plan, once the interim period of selfrule is over, will provide an opportunity to foster a policy of dialogue and consensus-building. This will help to ensure that the necessary support materializes. Donors can help in two ways. They can support capacitybuilding in management, policy formulation and service delivery that would result in the development of sustainable local institutions, and they can provide financial assistance to those investments that are financially sustainable within the limits of the Palestinian Self-Rule Areas’resources in the medium and long term. Together, these measures will engender an effective and efficient delivery system. 14. As a result of the study, WHO has focused its efforts on alerting donors and international organizations to the need to rehabilitate primary health care in the West Bank and Gaza, and to strengthen and improve primary health care services. In line with this, a number of priority activities have been planned and undertaken. 15. An assessment of the general situation of the primary health care network is being carried out by WHO with the support of UNDP and the World Bank, and a proposal for a programme of rehabilitation and rationalization is being prepared. The goal is to guarantee that sustainable primary health care services will be provided in decent premises and distributed within an appropriate referral system. The Government of Japan has already made funds available for rehabilitating a large number of primary health care clinics in the West Bank. 16. A programme of complete rehabilitation of the Expanded Programme on Immunization cold chain in the Palestinian Self-Rule Areas has been finalized. This activity, developed by WHO and executed jointly
1 World Bank Country Study, West Bank and Gaza, Medium-Term Development Strategy for the Health Sector, Washington, D.C., 1998.
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with UNICEF, has been part of the effort to improve and sustain cost-effective public health activities that reach the majority of the population, benefiting mostly the disadvantaged and poor people in the area. It has been supported by a generous donation from the European Commission Humanitarian Office. 17. WHO is currently executing two UNFPA projects, aimed at the integration of reproductive health into primary health care services. The projects address some basic problems that hamper the delivery of structured and coherent reproductive health services in the Palestinian Self-Rule Areas. Guidelines appropriate to the local context are being drafted for the management of all aspects of reproductive health. This effort has brought together all the different health providers in the area. The projects also address practical aspects of the delivery of services by improving several key primary health care clinics in the West Bank and Gaza where comprehensive reproductive health services are provided. These projects are now approaching the end of their first year of implementation. 18. The Palestinian Essential Drug Programme has continued its activities to improve access to pharmaceuticals in the Palestinian Self-Rule Areas. The list of essential drugs for primary health care is almost complete and the essential drugs list for hospitals is under preparation. The primary health care list is already in use by the Ministry of Health as the basis for drug procurement. 19. A remarkably high level of consensus has been built among health professionals on the need to use the list to promote a public health approach to curative services, and to improve the rational use of drugs among health professionals in the Palestinian Self-Rule Areas. The Ministry of Health and many Palestinian health professionals agree on the urgent need to develop and use standard Palestinian diagnostic treatment and referral protocols. The awareness raised on this issue has started to take effect, and Ministry of Health expenditure on pharmaceuticals is declining. 20. The human component of the Brucellosis Control Programme, supported by the Government of Greece, is entering its second year of implementation. It is operated in conjunction with the animal component executed by UNDP, and supported by several donors. WHO provides backstopping and technical advice. Within the framework of the projects, training courses were held for key Ministry of Health staff on computer literacy and basic epidemiology. In Greece, two Ministry of Health laboratory staff are being trained in laboratory techniques for confirming the diagnosis of brucellosis, and three physicians are being trained in epidemiology applied to brucellosis at the National Institute of Health. Laboratory equipment was supplied to strengthen the network of laboratories responsible for the first-level diagnosis of the disease. New policies aimed at disease control were adopted by the Ministry of Health, such as compulsory notification of the disease by private practitioners and private laboratories, with free treatment for everyone diagnosed with brucellosis, even the uninsured. 21. A project proposal, within the framework of the International Initiative for the Prevention of Disabilities (IMPACT), has been prepared with UNICEF and UNDP and has been submitted to interested donors for funding. 22. A donation by the Government of Italy permitted the assignment of a teaching assistant to Birzeit University to support the development of a new diploma course in primary health care. With the support of WHO and others, the University has developed an innovative teaching programme that balances community needs with high quality academic standards. 23. In response to a request by the Ministry of Health to enhance capabilities in areas where local expertise is lacking, support was provided to a member of the Ministry to upgrade his knowledge of health economics, and to a member of a Palestinian nongovernmental organization to develop her managerial skills with particular attention to the problems of nutrition. 4
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24. Publications continue to be provided to the Ministry of Health, to nongovernmental organizations and to relevant health institutions in the Palestinian Self-Rule Areas. Support has been provided to other organizations of the United Nations system for the procurement and/or delivery of equipment to the Palestinian Authority for health-related projects.
CONCLUSIONS 25. “Empowerment” of the Ministry of Health to play a role in caring for the health of the Palestinians has progressed despite the difficulties encountered in the past year. The health reforms initiated by the Minister of Health, through joint work under the aegis of the Ministry of Health, WHO and the World Bank, are the first steps in ensuring good governance. In this way, Palestinian society is organizing and managing the affairs of the health sector, and providing support to those involved in achieving the health goals of the Palestinians.
ACTION BY THE HEALTH ASSEMBLY 26. The Health Assembly is invited to note the report.
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