WORLD HEALTH ORGANIZATION FIFTY-THIRD WORLD HEALTH ASSEMBLY Provisional agenda item 16 A53/25 27 March 2000
Health conditions of, and assistance to, the Arab population in the occupied Arab territories, including Palestine Report by the Director-General
INTRODUCTION 1. Resolution WHA52.5 requested the Director-General to maintain WHO’s support to the Ministry of Health of the Palestinian Authority. The resolution further requested the Director-General to continue to provide the necessary technical assistance to support health programmes and projects and to obtain funding from various sources to meet the health needs of the Palestinian people. 2. To respond to the terms of this resolution, WHO maintained its special technical assistance programme aimed at empowering the Palestinian Ministry of Health to play its role in caring for the health of the Palestinian people.
COORDINATION IN ACHIEVING PALESTINIAN HEALTH GOALS 3. Building on the trend started in 1998 the economic situation of the West Bank and Gaza improved in 1999, bringing much-needed relief to impoverished Palestinian families. Higher occupation levels (an additional 47 000 more jobs were available in the first half of 1999 as compared with 1998 and the unemployment rate dropped to 13.8%), together with a 2.9% increase in the real average daily wage, contributed in bringing needed resources to Palestinian households. Recruitment of Palestinian workers in Israel and Israeli settlements increased by 3.2% in the first half of 1999; the informal flow of labour to Israel also increased. Women’s participation in the labour force rose from 11.4% to 12.4%, although the number of unemployed women increased by 12.6%. 4. Donors’ commitments to the Palestinian Development Plan for the year 1999 totalled US$ 524.4 million. By October 1999, however, donors’ assistance actually received amounted to only 47.5% of the funds committed. This has raised concern that, should the trend of decreased disbursements which emerged in 1998 continue, public funds would not suffice to provide the level of support to development that the Palestinian economy will still need for some time. Nevertheless, the level of donors’ assistance (disbursements) to the Palestinians since 1993 reached US$ 2458 million, about 59.3% of total commitments. This is the equivalent to approximately US$ 200 per capita per year. 5. Due to the improving economic situation, the fiscal performance of the Palestinian Authority has further improved, bringing about a balanced budget which does not require donors’ support. The
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improvement of public finance has not translated, however, into a larger share of resources for the Ministry of Health. The year 2000 budget for the Ministry has been set at US$ 98 million, approximately at the same level, in real terms, as last year. However, in order to limit the disrupting consequences of cash flow problems experienced in 1998 (delayed payments to suppliers, etc., by the Ministry of Finance), the two ministries have formally agreed that the Ministry of Health is to retain and manage all the revenues generated by patients’ copayments (drugs, tests, referrals, etc.). This is a welcome development. 6. For 2000, the Public Development Programme of the Palestinian Authority, which is largely financed by donors, assigned 26% of the entire social sector’s investments to the health sector. 7. It has been observed that the level of public sector employment has reached the limits of sustainability, straining the budget of the Palestinian Authority used to finance development activities. Steps have been taken by the Palestinian Authority at the highest level to prevent further increase in the number of civil servants. 8. As reported last year, donors’ coordination mechanisms at local level showed signs of inadequacy. The Ministry of Planning and International Cooperation has made a substantial effort to revive the sector working groups that, under the co-chairmanship of the Ministry and the United Nations Special Coordinator in the Occupied Territories and with the involvement of donor country representatives, provide assistance to the Palestinian Authority. The aim is to adapt them to the realities of development and health and to the requirements of Palestinians and donors. The effort has started to yield results (see paragraph 15 below). 9. The increased efforts of the Palestinian Ministry of Health and nongovernmental health organizations in enhancing coordination and complementarity of their respective roles and services are bearing fruit. In several areas, primary health care services are currently harmoniously delivered by the Ministry of Health and the organizations within the same premises. The Ministry of Health, UNRWA and Palestinian nongovernmental organizations are jointly developing common standard guidelines for the delivery of reproductive health services within the primary health care services. The Palestinian essential drug list and the Palestinian drug formulary has been drawn up with the support of all interested parties. 10. Increased coordination among donors and international bodies has also proved fruitful. The joint efforts of WHO, UNDP, the World Bank, the Commission of the European Communities and the Government of Japan have secured the funding for the rehabilitation of the primary health care facilities of the Ministry of Health, and work is well under way. The overhaul of premises will be completed by mid-year; replacement of premises will take longer. The rehabilitation plan does not envisage either expansion of existing infrastructure or investments that would require further recruitment of staff. 11. Due to the cash flow problems reported above, the supply of drugs to the Ministry of Health has been irregular, although the severe shortages experienced the previous year did not reoccur. Partly because of the support provided by WHO, immunization services have continued uninterrupted. It is expected that the recent financial arrangements between the Ministry of Finance and the Ministry of Health, together with ongoing efforts to rationalize procedures, will continue to improve the drug supply to public institutions. 12. After thorough analysis and exhaustive consultation with all stakeholders, the Ministry of Health has finalized its second Five-Year National Health Plan, incorporated in the Palestinian Development Plan. The heavy capital investment required would have to be financed from donor 2
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contributions. Concerns over the sustainability of the health system have limited the expansion of health services. Donors closely scrutinize the long-term impact of their investments in the health sector. 13. Despite the considerable constraints experienced and an overall decrease in funding, international assistance to the health sector continues to progress as a result of better understanding of the sector’s development priorities and improved mechanisms for project evaluation and subsequent implementation. 14. Substantial efforts in terms of health prevention and promotion will be required soon to improve the health of Palestinians. Diabetes, hypertension and cardiovascular diseases – typical of developed societies – are on the increase, laying a heavy burden not only on the finances of the Palestinian Authority but also on the health of the people. Preventable accidents are still a leading cause of mortality and morbidity.
WHO SPECIAL TECHNICAL ASSISTANCE PROGRAMME 15. The WHO Special Technical Assistance Programme initiated in the late 1980s has continued working with the Palestinians towards empowering the Ministry of Health to undertake its role in caring for the health of the people. The restructuring of the sector working groups provided the opportunity to strengthen the information-sharing mechanisms between the Ministry of Health and the donor community. Informal meetings with donors and organizations of the United Nations system on selected topics of interest were recognized as important to activities and programmes within the health sector because they analysed more thoroughly the issues and problems faced by the Ministry of Health in playing its role. The activity has proved effective and will be further strengthened in the future. 16. The effort undertaken over the past two years by WHO has borne its fruits. Since the end of last year enough financial resources were committed from donors and international organizations to complete the rehabilitation of the primary health care facilities of the Ministry of Health (see paragraph 10 above). Other donors are concentrating their efforts on improving those of the nongovernmental organizations. Nevertheless, the actions described above are only the first, essential step in improving primary health care services to the Palestinian population. 17. WHO has also continued to support and monitor the Palestinian Expanded Programme on Immunization. It actively monitored the availability and supply of vaccines, and whenever need arose undertook to procure them for the Ministry of Health. Such steps were essential to prevent the disruption of immunization services in the Palestinian Self-Rule Areas, given the sometimes critical financial situation of the Palestinian Authority. Now that the Programme’s cold chain has been rehabilitated by WHO and UNICEF with the support of the European Community Humanitarian Office, the programme of immunization, a fundamental component of primary health care, has been strengthened, and activities for WHO’s global initiatives, such as the eradication of poliomyelitis, have progressed undisrupted. 18. With the funding and collaboration of UNFPA, WHO has implemented the first year of two projects aimed at the integration of reproductive health services into primary health care, which will be completed in the last quarter of 2000. These projects are also part of WHO’s strategy of strengthening and bringing closer to the Palestinians quality primary health care services. Guidelines on the delivery of locally appropriate reproductive health services have been drafted. This undertaking has brought together all the health providers in the Palestinian Self-Rule Areas.
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19. The Palestinian Essential Drug Programme, supported by WHO, continued its activities. The essential drug list has been completed and is being fine-tuned; a Palestinian essential drug formulary has been drafted. The Ministry of Health already uses the list as the basis for drugs procurement, even though the staff has not yet been trained or reoriented. Other programmed activities, such as the drafting of standard diagnostic, treatment and referral protocols, need to be completed and extensive training given. In general terms, however, the programme seems to have developed a large enough base of understanding of the essential drugs concept among Palestinian health professionals to influence positively the future development of the pharmaceutical sector. The relevance for the Palestinians of those activities in the pharmaceutical sector is demonstrated by the intervention of the Palestinian Legislative Council, which has completely reviewed the sector on the basis inter alia of the reports and analysis by the Programme. 20. The Brucellosis Control Programme has progressed substantially. Together, the human component, carried out by WHO, and the veterinary component, executed by UNDP, have put in place the main elements of an effective strategy for control of the most serious zoonosis in the area. The Ministry of Health, with WHO’s technical and material support, undertook extensive training and awareness-raising campaigns among all the health providers. As a result, a comprehensive and technically efficient network of laboratories and health providers has been established for the detection of human cases. In order to improve reporting, the Ministry of Health introduced compulsory notification of the disease by private practitioners and private laboratories, and has agreed to provide free diagnosis and treatment of all cases of brucellosis. In parallel to the human component activities, the Ministry of Agriculture undertook the first-ever census of the animal population in the Palestinian Self-Rule Areas, as well as highly successful mass vaccination against brucellosis. Results of those fundamental activities will become apparent after the second year of animal mass vaccination. The generous funding of the human component by the Government of Greece made it possible to deploy necessary laboratory equipment and provide all required training. 21. The severe drought experienced last year in the region prompted WHO to undertake a project aimed at improving the quality of water in the Palestinian Self-Rule Areas. With a generous grant from the European Community Humanitarian Office, activities aimed at the rehabilitation and protection of existing water sources (springs and wells) were undertaken. Chlorinators for water disinfection were provided and installed on springs and other water sources; water storage and collection systems in schools still not connected to water networks were rehabilitated; reverse osmosis units were provided and installed in health and educational institutions in Gaza Strip. The capacity of the Ministry of Health to monitor the quality of water, especially in the rural areas, was strengthened with the provision of equipment, vehicles and training. The project, which is still in the implementation phase, is expected to improve in a tangible way the quality of water in the Palestinian Self-Rule Areas. 22. Publications were provided to the Ministry of Health, nongovernmental organizations and relevant health institutions in the Palestinian Self-Rule Areas. Support has been extended to organizations of the United Nations system in the procurement and/or delivery to the Palestinian Authority of drugs and equipment for health-related projects. 23. A WHO mission to the Palestinian Self-Rule Areas, in consultation with the Health Sector Working Group, formulated a number of recommendations for strengthening the Special Technical Assistance Programme. Links with the activities of the Regional Office for the Eastern Mediterranean should be strengthened and financing should be examined. As a result of this report, the DirectorGeneral launched an appeal to Member States involved in the peace process to assist WHO financially in carrying out its mandate in accordance with resolution WHA52.5.
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CONCLUSIONS 24. The empowerment of the Palestinian Ministry of Health, which started with the first five-year health plan, has now progressed well despite the many difficulties encountered. Soon, the second fiveyear plan will become operational. The importance given to the social sector in this new planning cycle illustrates the priorities of the Palestinian Authority, among which health issues figure at the highest level.
ACTION BY THE HEALTH ASSEMBLY 25. The Health Assembly is invited to note the report.
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