Final Health Sector Review

DFID
Department for
Int e rna ti onal
Development
Review
Dr. Yehia Abed
Palestinian National Authority European Commission World Bank
Health
Sector

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 specic
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-
I
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.

II
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 Ramadan
Director-General of International Cooperation
Chairman of HSR Steering Committee
III
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 Akhras
Minister 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........................................................................................................2
2.2. Demography, socioeconomic and political status...................................................3
2.3. 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.........................................................................................7
4.2 Task Force II: The health sector nancing..............................................................10
4.2.1 Health expenditures.....................................................................................................10
4.2.2 Service costing...............................................................................................................16
4.3 Task Force III: Health care delivery system...........................................................18
4.4 Task Force IV: Governance........................................................................................21
5. Recommendations: .....................................................................................................23
5.1 Health care service planning and delivery.............................................................23
5.2 National health information system........................................................................25
5.3 Human Resource development.................................................................................26
5.4 Management issues......................................................................................................27
5.5 Health nancing...........................................................................................................29
5.6 Treatment/medical referral abroad..........................................................................30
6. Bibliography...................................................................................................................32
Annexes
V
LIST OF ABBREVIATIONS AND
ACRONYMS
A&E Accident and Emergency
AAH Ahli Arab Hospital (GS)
ALOS Average Length of Stay
ALS Average Length of Stay
AOR Average Occupancy Rate
AQH Al Aqsa Hospital (GS)
BBP Basic Benet Package
BOR BED Occupancy Rate
CIS CLINIC Information System
CMS Central Medical Stores
CVD Cardiac Vascular Disease
DG Director General
DGIC Directorate General International Cooperation
DGPHC Directorate General Primary Health Care
DIS Disability Information System
DM Diabetes Mellitus
EC European Commission
EJ East Jerusalem
EMAP Emergency Medical Assistance Project
FTE Full Time Equivalent
G&AS General and Administrative Services
GDC GAZA Diagnostic Center
GDP Gross Domestic Product
GHI Government Health Insurance
GP General Practitioner
GS Gaza Strip
HDIP HEALTH Development Information and Policy Institute
HER Health Expenditure Review
HIS HEALTH Information System
HMIS HEALTH Management Information System
HRD HUMAN Resources Development
HSR Health Sector Review
HURP Hospital Utilization Review Protocol
IC Italian Cooperation
ICD10 INTERNATIONAL Classication of Diseases 10th Edition
ICU Intensive Care Unit
ID IDENTIFICATION
IDB Islamic Development Bank
IPD Inpatient department
IVF IN Vitro Fertility
MARAM Palestinian Health NGO
MCH MATERNAL and Child Health
MoF Ministry of Finance
MoH MINISTRY of Health
MoP Ministry of Planning
VI
MOU MEMORANDUM Of Understanding
MRA Medical Referral Abroad
MRI MAGNETIC Resonance Imaging
MTEF Medium Term Expenditure Framework
NCD NON-communicable Diseases
NGO NON-Governmental Organisation
NIS NEW Israel Sheqalim
O&G Obstetrics and Gynaecology
OOP Out of pocket
OPD Outpatient department
OPHT Ophthalmology
OPT Occupied Palestinian Territory
OT Operating Theatre
PA PALESTINIAN Authority
PCBS Palestinian Central Bureau of Statistics
PHC Primary Health Care
PHIC PALESTINIAN Health Information Centre
PNA Palestinian National Authority
QI QUALITY Improvement
QIP QUALITY Improvement Project
RAH Ramallah General Hospital (WB)
RIC Rimal Clinic (GS)
SC Steering Committee
SCBU Special Care Baby Unit
SMC SUPERIOR Medical Committee
SWAp Sector Wide Approach
T&SS Technical and support services
TAO TREATMENT Abroad Ofce
TF Task Force
ToR Terms of Reference
UN United Nations
UNDP UNITED Nations Development Programme
UNFPA UNITED Nations Fund for Population
UNICEF UNITED Nations Childrens Fund
UNRWA United Nations Relief and Works Agency
US UNITED States of America
US$ US Dollar
USAID United States Agency for International Development
WB West Bank
WBGS West Bank and Gaza Strip
WHO World Health Organization
VII
Executive Summary
1. 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
VIII
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
IX
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
X
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
XI
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.
XII
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.
XIII
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.
1
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
2
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
4
Indic ator* Rate or No. Remarks
Tot al pop ulat 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 ulat ion Growth Rat e%* 3.7% GS: 4%, WB: 3.4%
Refug ee Popu lation 1,5554,570 (44%) GS: 70. 8%, WB: 31.6%
Lif e Exp ectancy (LE) M: 73.8 y M: 72.3 , F: 70.7 y
Household Members 6.4 Members 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 woman
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
11
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 315.78
Total 809.12
MRA 18.12 8%
NGOs 54.00 23%
Emerg.&Hum. 24.00
Dvlp 63.00
Total 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 support
Emerg.&Hum.
Dvlp 53.43
Total 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
Adm &
Oth er
Total HOSP PHC
Adm &
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 med. 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.
13
WB GS

Actua l
consu mption
HOSP PHC
Adm
&
Oth er
Total HOSP PHC
Adm
&
Oth er
Total
Salari es 100% 25% 17% 10% 52% 27% 11% 10% 48%
Drugs and med. 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%

GHI 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 WB&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.

16
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 4.73 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.
18
Table 7 Distribution of hospitals beds and PHC centres in
WBGS according to health care providers in 2004
Hospita ls' beds 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 Younis 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
Qalqilia 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
Ramallah 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
19
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
Findi ngs Frequen cy Remar ks
Cat chmen ts area per faci l i ty 1061 1 peo pl e
Hours of op erations 6.30 ho urs The off i c i al du ty work ti me per day
Av erage N of visi ts for day 66.6
Av erage N of patien ts seen per
day/ GP
46.5 Each doct or is sched uled 3.9 days
out of 6
Presence of lab ora tory 3 of 9 = 33%
Sp eci al ized MD per PHC 1.6 Each doct or is sched uled 0.9 days
out of 6
Presence of CP: PHC in vi l lag es 1 of 9 = 10 %
Presence of CP: PHC to Hospitals 6 of 9 = 70 %
Inv olvemen t of the comm uni ty in
the PHC
0 of 9 = 0%

20
Table 9 Out of stock pharmaceutical supply in the satellite
PHC centers.
Type of drug Shortage in PHC % of patients without treatme nt
An algesi cs 3 of 9 = 33 % 0.9
Ant i-infl amm at ory 3 of 9 = 33 % 1.4
Anti bi oti cs 3 of 9 = 33 % 1.6
Chroni c diseases 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,
21
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.
22
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 recommendations based on ndings across the
different task forces: A certain degree of freedom of interpretation was needed.
Health Care Services Planning and Delivery
Health Information System (HIS)
Human Resource Development (HRD)
Management issues
Health nance
Treatment Abroad
In the Annexes the reader can nd more specic recommendations reported by each
of the Task Force.
5.1 Health Care Services Planning and Delivery
1. Coordination between the primary, secondary and tertiary levels needed to
be strengthened.
A variety of ways were suggested: clear denition of roles (levels of care
and scope of services), an enforced referral system (e.g. a Health ID Card),
the elaboration of a Health Service Master Plan.
The analysis shows lack of exibility in readjusting service prole according
to the health needs and epidemiological transition and inappropriate planned
technology and human resources deployment. Another problem area
explored is that no diversication in answering the health needs of the
Palestinian people.
A Master Plan was useful in order to avoid duplication and fragmentation
by dening service needs or a certicate of need , against demographic,
23
epidemiological, equity and uniformity considerations.
The Plan would dene what services each type of provider would deliver,
the role of other provider services in relation to the government services
(e.g. expansion or complement); how should be paid/ nanced/supported
and what technology would be allowed or not. In fact the distribution and
introduction of any medical technology in the system should reect the best
available knowledge on its cost-benet.

A Master Plan would probably indicate a basic benet package across the
system, that is a minimum number of core services to the entire population,
which are both essential and realistic within available nancial resources.
2. It was evident that a clear vision was needed for the future public - private
mix of health care services.
Despite the expansion of the capacity of the MOH services, the situation was
generally characterized by a very high utilization of its facilities, especially at
secondary health care facilities.
At the same time many non-MoH hospitals had much lower utilization rates
and were experiencing nancial hardship (partly due to the populations
inability to pay for services) , which forced few of them out of business.
MOH and NGO/private hospitals should, whenever possible, enter in a
contractual agreement to cover publicly funded services non available, or
services which need investment of large capitals.
3. The MOH should develop measures for more effective regulation of all
partners involved in the health sector (private providers for prot and
not-for-prot, pharmacists, professional bodies, training institutions, private
health insurance companies, etc.).
A review and update of the Health Care Facilities accreditation and licensing
system in Palestine need to be undertaken.
4. There was also indications of weakly enforced referral system at the MOH
secondary health care level. Cases which could be treated at lower level were
handled, instead, at the higher tier, with negative impact on efciency and
quality of care.
5. As part of a quality improvement measures, the MOH should look to the
clinical skills of its staff doctors, nurses, paramedical staff and others.
The ndings from the survey and interviews should be used to identify areas
where administrative and management practices may need to be revised and
improved. Quality improvement would require professional standards,
efcient use of resources, patient safety measures, coherence in clinical
practice.
6. The rather long and articulated list of suggestions included the following :
24
Reorganize the mechanisms and procedures for coordination
between the three levels of care and across providers.
Enforcement of a more rigorous referral system and adoption
of a gate keeping protocol.
Setting and rooting the quality improvement principles such as accessibility,
equity and efciency.
Developing policies for contractual relationships with the non-MoH sector.
A review and update the accreditation and licensing system to Health Care
Facilities in Palestine should be undertaken.
Equitable reallocation of hospital beds and technologies.
Revising the stafng prole in each type of health facility.
Redistribution of the health personnel in the health network.
Moreover, at the (public) hospitals, the following should be considered :
Strengthening the collaboration between diagnostic services
and hospital wards.
Adoption of clinical and diagnostic protocols
Improving the quality of laboratory procedures.
Improving internal management and responsibilities.
Adoption of clinical audit.
Establishment of day care units and one-day surgery activities
in the emergency department and OPD.
Establishment of Hospitals Friends Associations.
PHC would have to:
Improving internal management and responsibilities.
Deploy human resource according to the workload and needs
Adopt incentive policies for doctors and nurses.
Develop more effective forms of patients management and referral.
Experiment afternoon working hours for selected PHC centers.
Re-qualify nurses to facilitate their involvement in pts management.
5.2 A National Health Information System (HIS)
1. A crucial prerequisite for planning, implementation and maintenance of
the health care system was felt to be the availability of reliable information.
A National Health Information System (HIS) covering all providers in
WB and GS (public, international NGOs, and private) was strongly in need.
The existing data collection could not be fully utilized due to lack of
uniform registration systems and other factors. One of the positive model
was the computerized HIS at the European Gaza Hospital. The available
data dictionary was also an important element for creating a standardized
HIS.
25
2. Population data should supplement the HIS through studies outside the
health care services, say every second or fourth year. Vital statistics were
considered important elements in assessing the health status of the
Palestinian population. Reliable reporting of deaths and causes of deaths as
well births were to be improved.
Recommendations were therefore the following:
Development of an overall policy and strategy on HIS.
A National Committee to ensure integration of all stakeholders
data should be established.
The existing health facility information system should be reviewed,
updated and enabled to play an important role in analysis of efciency
in using resources (inputs and outputs).
The MOH should cooperate with national and international
institutions and universities on regular health surveys, vital statistics
and health indicators to create the necessary skills
for evidence based planning.
Improving data collection on non-communicable diseases, accidents
and rehabilitation.

5.3 Human Resource Development (HRD)
1. Human resources education, from the achievement of basic qualications
through staff upgrading by continuing education and on-the-job training
programs, should be ranked as a high priority.
2. Health services are based on the work of many different professionals.
Providers must be sure that all positions are staffed with people with the
best possible qualications.
Availability of professionals with standard capacities and skills are also
responsibility of the educational institutions, professional organizations,
and the same MOH as regulator.
Not all the health training and educational institutes in Palestine meet
international standards nor they are able to cover all the needs in the
country. Efforts should be exerted to diversify the output and achieve
independent accreditation.
3. Health professionals were recruited both from inside and outside the
Territories, but still there was lack of qualied staff in several places and in
specialized services. Providers other than the MOH have a different staff
policy and often pay better salaries. Public health service retention and/or
hiring of higher qualications should be based on appropriate incentive
policies
26
4. By no mean health professional needs were to be conned to clinical
qualications. The HSR stressed the shortage of paramedical, technical
and administrative skills .
Health managers were for instance in great demand. Such personnel should
be able to deal with human resource management, budgeting and
accounting practices, procurement, contracting, follow-up and monitoring,
QA procedures.
5. Legislation and rules for licensing health professionals needed to be
enforced. The committee responsible for such activity should be given
sufcient resources and authority. This national body must be empowered to
ensure uniform health professionals licensing and accreditation. This was felt
even more important as many of them were graduated or trained in different
countries and health systems around the world.
Final recommendations were :
Development of a national short term and long term human
health resources plans in collaboration with Palestinian educational
institutions and employers.
MOH current staff patterns and size shall be reviewed on the basis
of present and future priority and nancial affordability.
Redeployment plans have to be prepared based on the same principles.
The MOH should develop its own incentive policies for staff retention
and recruitment of professionals in dear need.
Continuous education and training programs of relevant staff on
general management, nancial management and accounting,
procurement, contractual skills, and other related issues.
Supporting and strengthening to the HR licensing and accreditation system
The MOH should readdress the recruitment and selection procedures
in order to achieve uniformity of approach, fairness,
professionalism and transparency.
5.4 Management issues
1. The rst step in improving the provider capacity of the MOH needs to
be a thorough review of its organizational structure, an extensive program
of managerial professionalism and more focus on facility management.
2. The MOH had limited authority on personnel and budget. Personnel
employment process is controlled by the GPC and MOF. Budget is strongly
inuenced and controlled by the MOF decisions.
The role of the Government Personnel Council (GPC) needed to be
signicantly diminished. Hiring should be based on service needs, not
on employment targets.
27
The MOH needed also to have better control over its own budget, and hence
decide on the best use of resources, including staff recruitment and
deployment.
The removal of such limitations and empowering of the MOH, should be
equally coupled with larger management responsibility and authority
to district and facility levels.
3. There were indications of a wide variation in staff productivity and
workload across MOH health facilities, services as well as working periods
( e.g. during days of the month). The workload of some specialists in certain
facilities was seemingly quite low, while in other facilities general
practitioners had an average of patient-doctor visit time of less than
two minutes.
4. Staff workload needed to be reviewed on a continuous basis and used to
make adjustments on the facilities services, staff deployment and
opening hours.
Redistribution of tasks should be based on the assessment of the
different staff practice (general practitioners, specialists, nurses etc.)
in order to assign them to the least expensive and yet competent staff.
Indicators of productivity and workload should be built in the health facility
information systems.
5. There was compelling evidence of lack of qualied nurses at the
primary health and emergency care level in particular
(given the multiple tasks they have to perform). Such shortage will become
even more acute if qualied nurses would play a more extensive role in
service provision and management.
6. A management issue which was raised by different task forces as pivotal
to cost containment in the public sector was that of asset management
practices.
Physical asset management guidelines should be established, where links
between investment cost and recurrent cost are clearly made to ensure that
the long-term consequences of investments (whether from MOH own
resources or donations) is duly taken into account, before nal decisions
are made.
For medical equipment this could be done using the Life Cycle Cost Analysis
(LCCA), which assesses the total cost of equipment (or facility) ownership.
The life cycle cost analysis would include staff cost, consumables,
maintenance, repair costs, overhead cost and revenues (if relevant).

Such asset management guidelines should include guidance on the
advantages and disadvantages of purchasing or leasing equipment,
28
or contracting medical services all together. Choices between in-house
maintenance vs. maintenance contracts should also be considered.
7. While it is clear that the lack of mobility, within and between West Bank
and Gaza, hampers coordination and overall improvement of the health
sector, the status of one Government and two separated Territories makes all
more compelling the extensive use of all available means and technologies at
all levels for management purposes.
Based on the above the following suggestions were made:
The MOH should take form and, in turn, devolve more budget
and HR authority to middle and facility managers.
MOH HR recruitment, employment, promotion, incentives and
sanctions should be based on fair and transparent policies.
Indicators of productivity and workload in the health facility should
be adopted and used for service management purposes.
Staff workload in the MOH should be reviewed on periodic basis;
accordingly, redistribution of tasks and readjustment of staff allocation
should be made.
Qualied nurses should be given more authority and responsibilities
at clinical and service management levels.
Physical asset management guidelines should be established and
implemented.
Provision and improving all possible alternatives for efcient and effective
communication means between MOH staff in WB and Gaza.

5.5 Health nancing
1. The different departments in MoH, MoF and MoP in charge of planning,
budgeting, accounting and nancial management of the health sector need
to join efforts to audit the sector allocative efciency and introduce
adjustment measures.
Allocative efciency auditing would cover the type of service and care, level
of care, type of provider and geographic, demographic, economic and
epidemiological distribution of resources. Financial allocations are better
assessed through a national health account.
2. Budgeting and planning consistency, cost control measures, better
allocative efciency might have the additional benet of encouraging the
donor community to move from project aid to budget support, SWAP or
indeed any other sector nancing mechanisms. Donors would remain an
important nancer (and hence partner) over many years yet.
3. Key departments and staff should be identied, inside and outside MoH,
and trained in health facilities costing studies. The disparity of unit costs
29
among health facilities requires major decisions on overhead costs,
organization and operation.
4. Based on the analysis of the Medical Referral Abroad (MRA) 2003 and 2004
database and the analysis of the trends, the MOH should prioritize high cost
interventions requiring referral according to known cost-effectiveness
criteria.
The choice of establishing new treatment capacities within the public sector
should be economically assessed against using or establishing services in the
private sector (for prot and not-for prot) or outsourcing outside the
Territories.
The MOH should review, assess and improve its contracting policy for an
efcient public/private mix approach.
5. The MOH should explore new nancing and expending mechanisms
(initially on a pilot basis) in order to draw experience and knowledge on
possible changes and reforms.
Matters like health sector nancing strategies, provider payment
mechanisms, benet package, health service strategic purchasing need to be
considered and experimented.
6. The role of the MOH as provider in a changing nancial and health
provisions environment shall be reconsidered. If the trend as purchaser of
high cost care abroad continues, it may be necessary to assess of cost and
benets of in house provisions against outsourcing.
Recommendations:
Establish a national health account on which to base the
regular auditing of the sector allocative efciency.
Increase consistency between MOH planning and budgeting process.
Develop consistent sector-wide plans and expenditure frameworks.
Develop and experiment new nance and expenditure mechanisms
Financial staff should be trained to set up and conduct cost analysis studies.
The MOH should identify and prioritize high cost services
for treatment abroad, while developing costing models to choose
between provider alternatives.
The MOH should raise awareness and knowledge of key
departments and staff on matters like health expenditures
and other related issues.
The MOH should review, assess and improve its contracting
policy and its regulatory framework.

30
5.6 Treatment /medical referral abroad
1. A major expenditure item in the Government budget was the TA/MRA.
Such opportunity was made available to those patients which will not nd
appropriate level of care and diagnostics in the government health care
system.
The procedure was found largely abused by all parties, patients included, and
had been characterized by numerous loopholes.
The HSR calls for substantial improvements of the transfer practice, from
request approval to the selection of the external provider and, above all, the
method of payment.
Un-warranted transfers to different external facilities (whether for
terminal or trivial cases) were identied. The purchaser had scarce attention
to the outcome and providers quality assessment (based for instance on
case-volume capacity or mortality-complications rates). Fees negotiation was
poorly done (if at all). Standard process approval needed to be enforced to
avoid excessive unaccountable decisions.
2. The choice of providers, based on volume of clinical procedures and the
availability of a number of complementary and supportive services
( function-bearing facility), was essential in order to purchase quality care
and maximize resources.
The rational for purchasing from a leading provider should be the following:
The diagnosis and treatment require huge resources in terms of
special medical equipment and trained manpower.
The procedure is relatively or frankly rare and adequate
experience is only available in a few places.
The diagnostic or treatment are complex and can only be carried
out if a number of crosscutting functions are present within
the same providers facility.
The relationship between quality and patients volume is well documented
for special high-risk procedures and high medical technology conditions, e.g.
radiation treatment linear accelerator, cardiac by-pass, transplants etc.
3. Long term contract frameworks with few providers would include items such
as minimum guaranteed number of annual cases, basis case costs, indications
of what and how volume discounts can be practiced, how complicated cases
are dened, handled and compensated for.
4. At present there is not a uniform procedure in place for referral of patient
abroad from the GS or WB. In fact there are two systems (one for GS and
one for WB).
31
5. A detailed database recording the reasons for patient referral abroad, all
examination results, procedures, nal diagnosis, outcome and costs should
be duly maintained
Recommendations:
Develop uniform regulations for referral abroad.
Develop an inventory of all MOH/ NGO/private sector services in
Territories capable to cover the potential transfers.
Develop bidding documents for procurement of diagnostic and treatment
services, including pre-qualication and evaluation criteria
Develop contracting tools
Develop auditing mechanisms
Adopt more efcient payment forms (per capita, per bed, per day,
per pathology...)
Qualify and supporting TAO capacities in terms of decision
making process, clinical and nancial auditing and information system.

32
33
6. Bibliography
This list is used by one or more of the consultants during
1. Health Development Information Project: Infrastructure and Health
Services in the West Bank: Guidelines for Health Care Planning, the West
bank Rural PHC Survey, Mustafa Barghouthi, MD and Ibrahim Daibes,
MPH, in Cooperation with the World Health Organization, 1993
2. Health Development Information Project: Infrastructure and Health
Servies in the Gaza Strip, the Gaza Strip Primary Health Care Survey,
Ibrahim Daibes, MPH and Mustafa Barghouthi, MD, in Cooperation with
the World Health Organization, 1996
3. Health Sector reform in the Occupied Palestinian Territories (OPT):
Targeting the Forest or the Trees? Rita Giacaman, Hanan F. Abdul-Rahim
and Laura Wick, Institute of Community and Public Health, Birzeit
University, West Bank, OPT, Health Policy and Planning; 18 (1), Oxford
University Press 2003
4. HERA: Draft Report, Health Sector Review in West Bank and Gaza
Strip, European Commission, September 2003, HERA
5. HERA: West Bank and Gaza Strip, Health Sector Review, Memorandum
( June 2003), Marc Reveillon, Health Research for Action (HERA)
6. IDRC: Health Insurance and Health Service Utilization in the West Bank
and Gaza Strip, Principal Investigator Jean Lennock, Research Assistant Atef
Shubita, the Health, Development, Information and Policy Institute in
Cooperation with International Development and Research Center (IDRC),
Ottawa, Canada, and the Ford Foundation, Cairo Egypt, February 1998
7. ISS: 1st Draft, Health Services in Palestine: Needs, Provision and
Performance A mapping analysis, Rome, October 2003, Istituto Superiore
di Santa
8. IUED: Palestinian Public Perceptions on Their Living Conditions, The Role
of International and Local Aid during the second Intifada, Report V,
December 2002, IUED Graduate Institute of Development Studies,
University of Geneva, A study funded by SDC Swiss Agency for
Development and Cooperation, UNDP, UNICEF, UNWRA and the UN
World Food Program
9. Ministry of Health: Palestinian Development Plan 1999 2003,
Palestinian Authority, January 1999
10. Ministry of Health: Health Status in Palestine, Power Point Presentation,
Palestinian National Authority, Ministry of Health, May 28, 2003
11. Ministry of Health: National Strategic Health Plan, Palestine (1999 2003),
Palestinian National Authority,
12. Ministry of Health: Palestinian Drug Formulary, 2002, First Edition,
Palestinian National Authorities, Ministry of Health, General Directorate of
Pharmacy
13. Ministry of Health: Palestinian Health Data Dictionary, September 2002
14. Ministry of Health: The Status of Health in Palestine Annual Report
Palestine 2002 HMIS, July 2003, State of Palestine
15. Ministry of Health: The Status of Health in Palestine, 2001 Palestine Annual
Report and Health Indicators, HMIS, July 2002, State of Palestine
16. Ministry of Health: West Bank and Gaza Strip, Health Sector Review,
Memorandum ( June 2003), Philippe Vinard, Health Research for Action
(HERA) Final Report Analysis of Patient Treatment Abroad, Palestinian
17. Ministry of Planning and International Cooperation: National Plan of
Action for Palestinian Children, Agenda for Social Renewal, Revised and
Updated 1999 2001, Secretariat for the National Plan of Action for
Palestinian Children the work of the task force groups:June 1999
18. Project Appraisal Report on a Proposed Credit in the Amount of US$ 7.9
Million to West Bank and Gaza for a Health System Development Project,
November 8, 1999
19. RAND DRAFT - Strengthening the Palestinian Health System, August 8,
2003
20. Tamara Barnea and Raq Husseini, Separate and Cooperate, Cooperate and
Separate, The Disengagement of the Palestine Health Care System from
Israel and its Emergence as an Independent System, 2002 Praeger Publishers
21. Technical Agreement for the Health Sector Review in Pales tine, between
the Palestinian Ministry of Health and EC, IC, WHO and DFID, January
2003
22. Technical Memo to the Steering Committee of the Health Sector
Review (HSR), First Step of the HSR, Complementary Information on
Methodology and Organization, June 2 2003
23. World Bank, Twenty-Seven Months Intifada, Closures and Palestinian
Economic Crisis, An Assessment, May 2003
34
Annex 1
Part1:
Executive Summary Task Force 1
Report Health Status and Outcomes
Part2:
Executive Summary Task Force 5
Report Health Sector Performance
Part1. Executive Summary Task Force 1 Report Health Status and
Outcomes
The success of future health system development efforts will require signicant strengthening of the exist-
ing system, the introduction of new data capabilities, and more systematic use of data in informing health
system policies.
This report describes the potential strategies for strengthening the Palestinian health system. Focus in this
report is on four major topics:
1. Basic Health indicators,
2. Non- Communicable Diseases,
3. Accidents, and
4. Physical disabilities.
Methodology followed in the preparation consists of a comprehensive review of available documents and
studies in addition to interviews with many key informants in the MOH. The availability of data, as well
as data quality, strengths, weaknesses, and the extent of data use by decision makers is fully described.
Further, an Accidents Registration form was piloted at several PHC facilities and hospitals, both in GS
and WB. The overall objective is to illustrate an example of information to be formulated in a database
which will serve decision makers in meaningful policy making in cure and prevention. Summary of each
subgroup is followed by Recommendations
1. Basic Health Indicators
Measures that reect or indicate the state of health of people in a dened population can be used to de-
scribe a situation and to measure change or trends over a period of time.
Most health indicators are quantitative in nature but some are more qualitative.
The MOH needs to use health indicators to analyze its commitment to form policies for socio-economic
and health development, to monitor progress in implementing health programmers, and to evaluate their
impact on the health status of the population. Health indicators are necessary in order to:
Analyze the present situation
Make comparisons
Measure change over time
Perhaps most importantly, existing data systems have not been integrated or coordinated. Many types of
data that are essential for effective health system planning and operation are not consistently available,
including national health accounts that cover all health sectors, comprehensive chronic diseases registries,
and data on pharmaceutical prescribing and use.
Vital statistics data, which are relatively well developed, have important limitations, such as underreporting
in infant and maternal mortality and absence of birth/delivery related abnormalities.
Many types of data are collected in some parts of the health system but not in others and/or collected in
differentand incompatibleformats in different locations. Also, many types of data are recorded on
paper rather than electronically. The existing system for data collection does not meet the needs of the
health authorities.
The availability is limited, especially from other providers than MOH, with poor or no existing access to
data is. This makes the publishing of data incomplete and difcult to use in the planning and management
of health services. Not only is a uniform registration form needed, but also a database system for this
form is crucial to ensure an effective and prompt reaction to obtained knowledge and point out changes
in trends.
There are many persistent and increasing health problems, including chronic diseases, disabilities, and
accidents. As ndings indicate, many of the mentioned health problems can be prevented Effective pre-
vention means more cost-effective healthcare. A core base to build upon consists of the available HMIS
system and the establishment of PHIC.
Recommendations
A planning group under the HMIS should be formed as soon as possible with the task of
producing a plan for developing a reporting system (a national health information system) for
all health care providers, based on computer technology and a national database, with access
for relevant authorities and researchers. Existing experience (e.g. CIS, HIS, TAO, EHG a.o.)
and relevant preparations (e.g. the data dictionary) should be utilized in this process.
Public health laws and practices must be emphasized and, if necessary, amended, and every
practitioner must be following clear national reporting protocol.
A working group involving all types of health care providers should create a list of indicators
and describe the data needed for this.
Integrity of information and information technology should be sustained within PHIC.
Support PHIC as core for information in MOH and stop any fragmentation or duplication
in this eld
Improve cooperation and coordination with other information systems in MOH like cancer
registry, DIS and NCDs, these systems should work in cooperation with PHIC.

2. Non-communicable Diseases
The so-called epidemiological transition is taking place partly because of the rapid aging of the Palestine
population, the political situation, and the socio-economic transformation. Besides, changes in nutritional
patterns, i.e. diet changing to include a smaller proportion of complex carbohydrates, vitamins, and pro-
teins and a larger portion of unhealthy food (less expensive). The result is increasing prevalence of micro
and macronutrient deciency, associated with the rising poverty, unemployment, smoking, in addition to
the continuous living under physical and psychosocial stress and pressure. These unhealthy practices
have called for chronic diseases prevalence increase, the risk of morbidity and premature death, particu-
larly from CVDs and Diabetes.
Diabetes mellitus (DM), especially type 2 diabetes, is a serious disease and a cause for growing public
health concern in both developed and developing countries. In many countries, it is now a leading cause
of death, disability and a high health care cost. These facts have been highlighted in World Health Report
1997 which warns that diabetes is one of the most daunting challenges posed today by virtue of its fre-
quency and the cost and suffering imposed by its complications. In addition, diabetes is no longer a disease
of the afuent; it is now a third world problem and the developing countries will bear the brunt of the
diabetes epidemic in the 21st century.
In MOH report 2003, the reported incidence rate (new registered cases) of DM in the West Bank was 161
per 100,000. Data from the Gaza strip are not available.
Distribution of incidence rate of DM by age group shows that, the peak onset of the disease is the age
group of 25-34 years at the rate of 43.1 per 100,000, reaching 1,310.2 per 100,000 in the age group 55-64
and 1,225.0 per 100,000 at the age 65 years and above which is mainly the more susceptible age for the dis-
ease. Distribution of incidence rate by sex shows 128.0 per 100,000 males and 195.5 per 100,000 females.
However, no or weak national data are available on the overall incidence and prevalence of CVD, hyper-
tension diseases, Diabetes Mellitus in Palestine. In general MOH depends on mortality data to estimate the
impacts of these diseases. The current system
Counts mainly the visits of the patients to PHC, which does not reect the real prevalence or incidence.
Besides, there is no classication by age or gender, mainly due to lack of computerized systems. Neither is
there any information on disabilities resulting from any of the chronic diseases. This lack of information
leads to inability to estimate the direct and indirect cost; resources required, e.g. drugs, and policy and
decision-making regarding prevention and treatment.
Also lack of coordination and collaboration between different providers is an issue indicating difculty in
obtaining true gures on the major indices of mortality and morbidity and an open door for duplication
of services and, therefore, misuse of resources, especially medications. Moreover, the absence of unied
denition and diagnostic methods and tools for DM makes obtaining reliable data doubtful. DM cases
diagnosed from the hospital or the private sector are also missed throughout the current data collection
system.
Despite of decient statistical data and the prevailing political situations which are affecting negatively all
aspects of lives in the OPT, real efforts are being done on the national level to organize and implement a
unied strategy for the prevention and control of diabetes in Palestine.
Further, the rst Clinical Information System was established at Remal Primary Health Clinic-Gaza City
in 2002 under the component Management Information System (MIS) Health System Development
Project (HSDP), funded by World Bank. The system has proved to be efcient in facilitating the monitor-
ing of the diabetes registration. It helped obtaining satisfactory reliable statistics on the type of diabetes,
type of medication, and many important indicators of diabetes e.g. Body Mass Index and obesity.
The registration system was also enriched to include a case management component, and it was further
deployed to include Jabalia-Gaza, Ramallah, and Nablus (West Bank) PHC Clinics as a start point to a
decentralized system of registration. Out of total diabetic cases, the incidence of diabetic patients with
obesity is 58.3% (42.3% in males and 69.3% in females).
Recommendations
Emphasis on medical awareness of hospital physicians on importance of epidemiology and
surveillance of chronic diseases.
Emphasis on medical awareness of hospital physicians on importance of Death certicate
and how necessary it is to show both the direct and the underlying cause of death complications.
Improving diabetic education of health professionals by continuous education and training.
Encouraging research in the eld of chronic diseases. _Surveillance system for chronic diseases
should be established through preventive medicine department in primary health care.
Incidence and prevalence should be estimated based on cases and not on visits, also morbidity
data should be collected from all types of clinics.
Clinical information system project is very important for chronic diseases surveillance and
avoidance of any service duplication. It should reach all clinics. _
Guidelines and protocols should be disseminated for all health providers, with emphasis on
its use.
Development of comprehensive diabetes network that follow unied criteria of diagnosis and
management of diabetes.
Improving laboratory services.
Increasing regional and international cooperation to gain and share experience in the eld
of diabetes.
Early detection of diabetes in high-risk groups starting in PHC clinics.
3. Accidents:
Accident denition in this report includes those resulted from the following: trafc accidents, falls, acci-
dents caused by rearm missiles, drowning and submersion, exposure to re, smoke and ames, poisoning
by exposure to noxious substances, intentional self harm (suicide attempted), assault and social violence.
Since the start of the Intifada, the leading cause of mortality among all kinds of accidents is the rearm
missiles as result of Israeli attacks. The rate in 2002 reported 53.4 and 5.4 per 100,000 for males and
females respectively. Due to the current situation, accident mortality trend has increased from 9.1 per
100,000 in 1995 to 38.9 per 100,000 in 2002 and to 19.7 per 100,000 in 2003.
According to interviews with physicians working in Emergency Department in different hospitals, 35-50%
of all admissions are related to accidents. Road trafc accidents (RTA) come second with a rate of 4.4 and
1.3 per 100,000 for males and females respectively.
Accidents in Palestine are the rst leading cause of death among children (1-4 Y); it constituted 19.7% of
total deaths. And for adults (20-59Y), it constituted 31.6% of total deaths, whereas for children (5-19Y) it
constituted 50.2% of total deaths. For all ages also it comes second (after the heart diseases) and constitute
(12.5%) of total deaths.
According to the data provided in the MOH annual reports, conclusion can be made that transport acci-
dents are more likely to happen within the rst four years of life, increasing trend again can be seen at the
age 20-59 and very sharp increase at age 65+.
This, of course, can be supported by the analysis of reasons behind, such as no use of safety belts and child
restraint seats, reckless driving during youth, and for old ages: crossing the roads without full attention to
crossing cars because of (but not limited to) hearing and seeing problems, as well as inability to drive ap-
propriately, especially for those who have diabetics or hypertension.
The third leading cause is the social assault and violence; it counts for the rate 2.7 per 100,000 among
males, but only 0.4 for females. It is more likely to be seen in Gaza because of many reasons: more honor
revenge, low social economic situation, high population density, overcrowded residential areas and unem-
ployment, all factors which make people more frustrated, depressed, hopeless and stressed.
Readiness and capacity to manage injured patients is different from hospital to hospital, e.g. Ramallah hos-
pital has many subspecialties and is therefore more effective in dealing with trauma than other hospitals
in West Bank. However, a specialized trauma centre is still not available, and also trauma specialists and
specialized nurses are still very few, which in turn leads to referral of some cases with serious and complex
conditions to neighbor countries, including Israel, Jordan and Egypt. This may delay patient management
and lead to unsatisfactory outcome.
Classication of mortalities due to accidents mentioned in MOH annual reports usually takes place ac-
cording to the ICD10. There is a general tendency for accurate reporting of the cause of death, but under-
reporting does occur.
Mortality connected to accidents as a result of work, i.e. occupational accidents, is usually not registered
because of the unavailability of work insurance; the death certicates tend to indicate misleading causes.
There are good reasons to believe that people tend to provide misleading information about the causes of
the accidents. Accident mortality resulting from trafc accidents is very likely to be underreported due to
insurance issues, licensing and registration. The same is the case for murder of females as a result of what
is called family honor defamation, which is less likely to be reported or to be announced. Some remote and
rural areas do not reach the hospital at all, and a local physician may issue death certicate. Also, in some
cases where the cause is not clear, the system does require post-mortem examination.
Further, medical practice related accidents that lead to mortality and morbidity are not reported at all and
have no classication in the MOH annual report. This of course leads to the quality and performance
measurement issues and how be judged.
The emergency room charts are general and not specic for traumas and accidents, and a lot of data, e.g.
type, time, source, procedure, diagnosis, are not written.
There is no registration form in the emergency rooms and PHC clinics to register accidents with the re-
quired details that help identifying sources and locations, types and severity, cost, disabilities and or im-
pairment resulted, triage time, transportation, activities and diagnosis done to the patient.
Such valuable information with adequate analysis can help decision and policy makers adopting a national
policy regarding prevention, resource allocation, coordination and collaboration with different institu-
tions, including ministries and police.
A small-scale pilot study of the accident registration developed by Carl Bro was conducted at selected hos
pitals and PHC clinics both in WB & GS. The results of the data collected coincide with the information
reported by the MOH regarding the age, sex, and the cause of accident.
Recommendations
Based on the analyses of the present situation, the Task Force concludes that a proper registration system
in the Emergency Department, creation of a comprehensive and applicable ling system for accidents, and
a computerized database system are urgently needed. The Task Force recommends the following:
Accident registration and data collection should be given the highest possible priority
Necessary legislative measures must be taken to introduce a common accident surveillance
system covering all health care providers in Palestine
Preparation of principles for extraction of information (statistics) from a central database and
adoption of a plan for dissemination of information to all relevant ministries and institutions to
reach all decision and policy makers
Creation of specialized trauma centers in West Bank and in Gaza
Development of a protocol and guidelines with a detailed plan for accident administration and
management
Training of nurses and physicians in trauma and emergency room management
Creating triage system outside and inside hospitals helping nurses to optimize their work.
Creation of a continuous quality management (CQM) for accident management in general with
specic measurement units.
According to data collected, a well planned public health awareness program is to be adopted for
all preventable accidents

4. Physical Disability:
The subgroup has chosen to deal not only with physical (motor) disabilities, but with disabilities and reha-
bilitation in Palestine as a whole.
Since the Palestinian Authority was established, the administrations have encouraged the introduction
of rehabilitation services in several hospitals in the West Bank, including Radia, Ramallah, Jericho and
Hebron hospitals. And the National Health Plan for year 1999-2003 has adopted a full strategy to address
the problem of a rehabilitation system in Palestine. However, the current crisis with all its limitation of
resources has prevented the implementation.
It has been decided to buy the services from the private sector and NGOs. There are 52 rehabilitation
centers distributed throughout West Bank and Gaza, of which the largest are considered to be Abu Raya,
Basma Centre, Arab Rehabilitation Society in Bethlehem.
A database system at national level is not available. Generally speaking, data available are likely to cover
the disabilities caused during the Intiada period only. There is no systematic way of collecting data on
disabilities resulting from all causes, e.g. care accidents, social violence, genetic abnormalities, delivery ac-
cidents, and accidents related to work.
MOH and PCBS collect data from household surveys. However, it is most likely that these data are not
representative and that the cultural barriers lead to underreporting (social stigma). The census of the year
1997 included only two questions about disability. Of course this was not enough to give a clear or good
view. In addition, the cultural barriers prevented disclosure of all disabled members of households.
Access to data from the NGOs and private rehabilitation institutions are limited to their own use and in-
stitutional purposes. They do not give access to others in a systematic and accurate way.
Besides the ling system does not include complete information on history, source of the disability, loca-
tion, age of detection, treatments used, stage of disability, and rehabilitation history.
Further, the public awareness (as in developed countries) about the denition of disability in relation to
environmental factors and occupational surroundings, e.g. persons who have lost one nger do not con-
sider themselves disabled even though it may have prohibited them from doing their normal job. Strictly
speaking, we may nd many cases of disability unrecognized either by the individual himself or by the
community.
The real number of cases is still unknown, but it is expected to be much higher, especially when talking
about mentally disabled persons.
The resulting lack on information on these aspects of the health care services clearly demonstrate that
a National Information System is highly required, that includes one unied database system for Gaza
and West Bank. This system should also include all the non-governmental partners, and the government
should nd a legal way to enforce them to adopt it and comply with it, e.g. by making it a condition for
renewal of the registration and licensing.
A le system including the name and identity number of the patient would secure the case identication,
following up, equity, avoidance of service duplication and waist of resources.
Public awareness about disability services and the rehabilitation system is highly required. This would help
disabled person in self-referral in a way that respects the privacy of the individual. It should be a much
more efcient way than depending on the family or the household where cultural barriers may limit the
disclosure.
All relevant ministries (Ministry of Education, Ministry of Social Affairs, Ministry of Health, and Ministry
of Interior) should have access to such a complimentary system.
In the coming census which is to be held in the coming year it would be worth having a complete ques-
tionnaire addressing disability with all relevant questions. Also, it is worth to add a question in the birth
certicate about abnormalities or birth defects. This would help to get a much better and comprehensive
idea about most of the disabilities.
A data dissemination plan may be adopted to secure that relevant information on a regular basis reaches
all stakeholders and decision makers, including the working organizations, donors, and the ministries. This
would allow all to set up the priorities, needs and resources, as well as a qualitative analysis that could help
improving prevention, and early detection of preventable cases. In addition this data could help to deter-
mine the technical efciency of the facilities and to react accordingly.
Recommendations
Rapid evaluation of the size of the disability problems and the available local resources on a
realistic basis.
Rapid assessment of the need with priority setting.
National Disability Plan based on a holistic multi-sectoral approach must be prepared using the
information obtained from the proposed Disability Information System.
Improvement of planning for better use of services and reallocation of the available limited
resources.
Community based rehabilitation should form a base of management of public sectors and
UNRWA and should include preventive and promotion approaches of disability, wherever
lacking.
Community based rehabilitation should be carried through the primary health care centers
in West Bank and Gaza.
Expansion of the disability services in order to achieve geographical balance for all regions.
Increase of trained staff and development of the employees in order to increase their
qualications and production. Health staff in governmental sector, UNRWA sector and NGOs
sector should be trained in good clinical practice and use of effective tools.
Development of a comprehensive Disability Information System within the existing Health
Management Information System (HMIS). This would assist the national health authorities,
health providers, and other concerned entities. DIS would also contribute to the calculation of
cost related to the service delivery system.
The establishment of DIS requires:
o An Inspection Committee for assessment of resource availability and general tting of the
system according to the listed services.
o Development and implementation of selected operational programs on disability.
o School health should include testing for different avoidable disabilities with emphasis on student
awareness on healthy practices.
o Development of a comprehensive framework for disability prevention, early detection, and
management in Palestine.
o Implementation of programs for early detection, prevention and increasing awareness of the
community regarding different types of disability and how to accept the disabled as normal,
programs for families of disabled to learn how to deal with their disabled in all aspects
of daily living.
o Strengthening of maternal, newborn, and child health and nutrition services to minimize or
control disabilities related to prenatal and genetic causes either in public sectors, NGOs or
UNRWA by developing approaches to genetic counseling, risk approach, detecting
obstructive labor, WHO mother-baby package, birth asphyxia.
Part 2. Executive Summary Task Force 5 Report Health Sector Per-
formance
This report describes the current situation and a number of ways to strengthen the Palestinian health sys-
tem, to help achieve specic health targets, including access, quality improvement, and technical efciency
(non-clinical).
The methodology followed in this report preparation includes a review of available documents and studies
and interviews with many key informants in the Ministry of Health. Furthermore piloting of technical ef-
ciency (non-clinical) survey, as well as client satisfaction survey in several MOH health facilities, includ-
ing PHC clinics and hospitals, both in WB & GS. The overall objective is to strengthen the capacity and
increase the knowledge about what kind of data should be included in a database system in order to opti-
mize technical efciency and facilitate quality assessment and help decision makers in meaningful policy
making regarding cure and prevention.
The purpose of the technical efciency survey was also to get information about the key technical ef-
ciency indicators, some of which, like average number of outpatients per general practitioner per working
hour, do not appear from the ofcial statistics like the MOH-PHIC Health Status in Palestine 2003. The
purpose was not to use the specic indicators for longer-term changes in policies/strategies, as this would
entail a more in depth analysis over a longer period of time.
Summary of each subgroup is followed by Recommendations
1. Access to Health Services
Since the onset of Al-Aqsa Intifada, patients have difculty in reaching appropriate health care facilities,
while health care providers face logistical, nancial, and professional constraints to proper treatment of
clients, especially those with chronic conditions or in need of physical rehabilitation.
In Palestine, there is a steady increase in the number of Public Health Centers (PHC) from 454 in 1994
to 619 in 2003, with an increasing percentage of 36.3%, i.e. 1.7 PHC centre per 10,000 persons. Generally
speaking there is good distribution and access to the clinics throughout WBGS. However, several were
completely isolated by the Wall. _ Bed Occupancy Rates (BOR) in MOH hospitals were on average around
67% in the last three years with a sharp increase of full bed occupancy from 65.3% in 2002 to 82.4% in
2003. The lowest rate was recorded in Al Najar hospital in Rafah (53.7%), and the highest rate in Jenin hos-
pital (112.9%). In GS, the rate was 79.6%, while the hospitals in WB were more crowded (86.9%). When
compared to the rate in all hospitals working in Palestine, MOH hospitals seem to be more accessible and
occupied than non-MOH hospitals. For illustration, the NGOs BOR in 2003 is 37.2.
The regional variations in this ratio are wide in favour of the urban centers and indicate an unequal dis-
tribution of health services in the territory at large. Jerusalem exhibits an over-concentration of hospital
beds dedicated primarily to tertiary care which is mainly absent elsewhere in the West Bank. The number
of persons per PHC centre ranging from 1,642 in Jenin in the WB to more than 16,500 in Rafah and Gaza
city in the Gaza Strip. Some of this variation is the result of a difference in population density; however, it
reects real differences in access to care.
Generally speaking access is limited to those living in rural areas and remote villages, but is less likely to
be a problem for those living in urban and central areas. In Palestine there are 78 hospitals. The popula-
tion/hospital ratio is 47,922. The average bed capacity per hospital is 59.99 beds. In Gaza Strip (GS), there
are 24 hospitals (30.77%). The population/ hospital ratio is 57,098. The average bed capacity per hospital
is 79.88 beds. In West Bank, including Jerusalem, there are 54 hospitals (69.23%). The ratio of population
per hospital is 43,844. The average bed capacity per hospital is 51.15 beds. Delays in reporting to work
(transportation time is part of normal working hours) is quite signicant, however, it differs from region
to region and from day to day. The number of physicians per capita generally conforms to targets in the
national health plans. There are 1,722 physicians working in different MOH facilities, with a ratio of 4.6 per
10,000 persons (2.7 in WB and 7.9 in GS). Out of total physicians, 1,056 (61.3%) are general practitioners
and 666 specialists (38.7%). However, the supply of specic specialties is still minimum, among others
psychology, psychiatry, neurology, oncology, radiology, and anaesthesia, as well as specialized nurses.
Available evidence suggests that some of the problems in accessing needed health services seem to have
been more severe in 2002 than in the rst part of 2003 (the most recent data available). These improve-
ments may, in part, be the result of donor and PA efforts to improve access by upgrading clinic facilities,
building new maternity homes and providing mobile clinics. However, due to the political situation the
problem is still ongoing on unpredictable bases and varies from day to day and from one region to another.
The problem is also likely to be acute in places affected/to be affected by the Wall.
Rising poverty, aid dependency and vulnerability, coupled with the isolation and fragmentation brought by
the Wall pose a systematic change both to local and national health care service systems.
Along the rst and second phases of the Wall, the lives of 583,660 Palestinians3 will be affected: 19,260
elderly people, more than 250 thousand ages below 15, 105,642 children (18.1%) under the age of ve who
need periodic vaccination, 33,268 chronic patients (5.7%) and 17,510 disabled (3%) needing specialized
healthcare and rehabilitation mainly found in cities. In this area, around 23,400 babies are born annually.
In e.g. the western face of the West Bank, 45 clinics will be isolated between the green line and the Wall,
and 7 Palestinian communities (population of 3,950) will have no access to health care inside the Wall.
Along the entire rst phase, 26 primary health care clinics have been isolated or are likely to be isolated,
either between the Wall and green line, within depth barriers, or within the Walls loops. In these areas,
15,000 people living in 19 communities have been stranded between the Wall and the Green Line and cut
off from the rest of the West Bank.
The greatest number of isolated clinics will be located in two enclaves in the Ramallah and Jerusalem
districts. In total, 20% of the isolated clinics in the communities completely enclosed by the Wall will be
located in Qalqilia, 14.3% in Salt, 25.6% in Ramallah, 25.7% in Jerusalem and 14.3% in Bethlehem4.
The Walls second and third phases will multiply the magnitude of this looming health crisis. After com-
pletion of the Walls rst and second phases, Jerusalem and Tulkarem will loose the greatest number of
clinics: 22.5% of the isolated clinics between the Wall and the green line will be located in the Jerusalem
district, and 16.9% will be located in the Tulkarem district. The districts of Qalqiliya (11.3%), Ramallah
(12.7%) and Hebron (11.3%) will be relatively less affected in these terms. Areas surrounding Jerusalem
that has been encircled by the Wall, have been among the most affected. They are Jerusalem ID holders
and use Jerusalem hospitals as referral system (Israel obligatory insurance system).
Abu Dis areas with a population of over 11,000 Palestinians are located 5 km from the old city. Three
health clinics service the population, but there is no major hospital in the town for surgery, emergencies
or deliveries. Before the Barriers construction, residents used hospitals approximately 4 km or 10 minutes
away - in Jerusalem. With the Barriers construction; the nearest hospital will be in Bethlehem. This route
is 18 km long and takes at least two hours.
In Al Ram & Dahiet Al Barid (North Jerusalem), with a population of 65,000 according to the council;
around 60% of them are holding Jerusalem IDs, you can nd no emergency health services or secondary
health care.
Access in terms of sector delineation and roles among stakeholders is unregulated, and a situation of com-
petition is always created between different suppliers in terms of quantity rather than quality. In general
this has led to duplication of services among NGOs, Private and MOH without addressing the needs ap-
propriately5. This is partly due to lack of clear MOH visions about its role and its relationship with other
providers.
Moreover, the existing services are not equally distributed in both territories of WBGS6. In particular, the
population number for primary health care centers in the Gaza Strip is almost three times that of the West
Bank. In contrast the population size for one hospital bed is higher in the West Bank.
Recommendations
Before going to any further expansion of existing services, (although sometimes urgently needed), there is
an urgent need for a clear division of roles and responsibilities, and for the denition of the essential pack-
age of services that the main providers in the health sector should agree upon for an overall clear short
term, medium term and long term plan for expansion of services.
Upgrading the levels of clinics to improve & make the best use of them in terms of access and
efciency.
Address the necessary needs for physicians and nurses with required specializations.
Establishment of birth centers and MCH centers where needed.
Mobile clinics should provide more specialized care than the xed facilities, operated by
local health care providers.
There is an urgent need for provision of basic lab facilities and x-ray in the community
clusters isolated by the Wall.
Specic attention should be focused on the more sever isolation effected by the Wall.
Fundraising for the establishment of new facilities in isolated areas, where it has become
encircled by the Wall and soon will be completely cut off from available resources.
Harmonization between the different health providers to avoid duplication and therefore
overuse of resources, and organization of the relation between the public and private sector
to avoid conict of interest.
Humanitarian assistance should not be combined by political assistance.
2. Quality of Care in MOH Health Facilities:
Beginning with the establishment of the Central Unit for Quality of Health Care within the Palestine
Council of Health in 1994. This unit developed the Strategic plan for Quality of Health Care in Palestine
and the Operational Plan for Quality of Health Care in Palestine (SPQHC), the overall goals of which were
to introduce and institutionalise the use of modern QI methods in the government health sector and in the
Palestine health system generally.
When the central Unit for Quality of Health Care was discontinued in June 1995, its responsibilities were
assumed and expanded by the Quality Improvement Project (QIP) within the MOH. The QIP operated
dozens of successful QI projects in several demonstration sites and worked to expand the number of
facilities in which it operated. It also provided formal training in QI methods to several hundred health
professionals. By the late 1990s, however, the QIP had ceased to function effectively because of lack of
institutional support within the MOH and travel restrictions within Palestine.
From 1996 up till now, the World Bank has been supporting the formal body of the Quality Improvement
in Palestine represented by the Quality Improvement Program (QIP) at the Ministry of Health through
two consecutive projects; Education, Health Rehabilitation Project (EHRP) and the Health System De-
velopment Project I (HSDP). The program was run by leaders in quality management and improvement
and devoted highly trained team. The QIP has achieved satisfactory results starting from many successful
process improvements at the level of primary and secondary care in clinical and non clinical aspects of the
quality of care to successful clinical practice guidelines as a step to standardization of the care delivered
to the chronic patient (e.g. diabetes and hypertension). One result is the development of an essential drug
list (joint effort by WHO and WB) including around 450 items at a time; they used to have a list exceeding
700 items. This in turn has its impact on rational drug use and cost effectiveness. Also training course on
this list has been carried out by joint efforts of WHO and WB. Part of the QIP included training in micro-
biology, diabetes and rational drug use initiated in WB & GS. The Chronic Disease Steering Committee
successfully developed a guideline for the 10 most chronic diseases and a clinical laboratory manual.
Computerization of selected systems in the different health facilities, e.g. Remal Jabalia, Nablus and Ra-
mallah clinics as part of the Clinic Information System (CIS) has given signicant results in controlling the
different processes and systems, e.g. patient registration, especially chronic patients, medications, labora-
tories, admission and discharge. In addition, these computerized systems increased the accessibility to data
and reports and therefore facilitated management by data which is one of the key indicators to a quality
culture in these facilities. Still this system is facing both administrative and technical obstacles due to the
lack of clear communication channels between the different parts, WB\GS teams and at the management
level as well.
Under the MARAM project/ USAID, concrete changes in emergency practice have been a result of the
Emergency Medical Assistance Project (EMAP II) which convinced MOH and practitioners of the need
for a triage system, as part of extensive overhaul of emergency care and management in 5 referral hospi-
tals. Primary healthcare facilities, four maternity homes, and referral hospitals are equipped and upgraded
to common international standards. 845 healthcare providers are being trained in state-of-the art medical
practices that ultimately increase the quality of care in areas of antenatal and postpartum care, obstetrical
care, good baby and childcare, and nutrition.
The issue of standardization covered other subjects than chronic diseases, e.g. nutrition guidelines and
infection control guidelines for PHC and the Integrated Management of Childhood Illnesses (IMCI).
In spite of all above-mentioned achievements, still many efforts needed to make changes in a systematic
way. Activities so far have primarily been related to the structure part of quality but not the process and
the outcome. Yet it is not possible to tell if the Structure activities have resulted in changes in the actual
process of delivering quality services and even with a resulting outcome.
The implementation of the projects was concentrated mainly in the primary health care, and, not being
able to cover all other affecting administrative and supporting departments, to build an atmosphere and
environment for the action to take place. Policy, procedure and clinical practice guidelines as ways of intro-
ducing standardization to the health care system are not implemented in a systematic way, partly because of
the lack of a monitoring and evaluation system. Besides, a clear quality indicators are not available.
Available evidence suggests that patient satisfaction with Palestinian health care system is low. Patients
generally regard health care services in Palestine as inferior and seek care in Jordan, Israel, and elsewhere.
Patient satisfaction with private and NGOs services is higher than with the government sector, particularly
in the last several years when NPAs waiving of government health insurance premiums led to a doubling of
enrolment without a corresponding increase of capacity. Through our survey, opinions among providers
and other health system leaders mirror those of the patients. In spite of the limitations of our study, results
were consistent between WB and GS and emphasized the need to improve health care quality in respect to
primary, secondary, and tertiary care and in all sectors of the health.
While data are limited, there is evidence indicating that the vast majority of PHC patient consultation time
is less than ve minutes. In Remal clinics, 33.3 % were having a consultation time of ve minutes and less,
and in Qabatia clinics, physicians see more than 200 patients in 6.5 hours, i.e. less than 2 minutes, which
is unlikely to be sufcient to provide appropriate quality care. In some settings, this was supported by the
preliminary ndings of the conducted pilot study of an internal/external client satisfaction survey. As for
EGH, patient satisfaction towards the interest shown by the doctor/nurse in what he said varied over the
scale with 16.7% dissatised and 16.7% being very dissatised. A major complaint was raised about the
Qabatia facility, of which around 40% of the patient were dissatised with the condition of the registra-
tion area, waiting area, and toilets. 25% were dissatised with the consultation room and health facility
overall.
Recommendations
The quality of health care strategic and action plan should be evaluated and updated.
The Quality Improvement Program should be supported as the formal devoted body to
coordinate quality efforts.
Strengthen the professional code of ethics.
Enhancement of patient code of rights.
A human resource development plan should be developed.
Service and facility indicators should be derived from the national core set of indicators.
A monitoring and evaluation system should be established at the MOH according to
pre-established criteria.
Quality management involves measurement and feedback. To seek levels of performance, it helps
to nd out what works and what does not.
It is always good to have a person who is deemed appropriate to receive the alert value.
The clients as well the workers to know about.
External clients (community) should be partners in the activities of improving quality of
health care.
Criteria for licensure for organization should be reviewed and updated. Criteria for individual
licensure should be developed and requirement for licensure maintenance should be established.
Patient safety issue should be more elaborated to include not only medication errors but also
other steps on patient care.
The role of the Palestinian Medical Council and Professional (Physicians, nursing etc)
association should be strengthened in licensing and training.
Quality management curriculum and course should be updated and integrated into the formal
education curriculum at the university and higher education. It has to be further integrated into
the internship (house ofcers) courses of the HRD department.
Policy, procedure and clinical practice guidelines as ways to introduce standardization to the
health care system should be expanded to cover clinical and non-clinical aspects of care.
Policy, procedures and guidelines should be linked with the different national health legislations
and medical courts in order to manage mal- practices and mistakes.
A medical and clinical audit system should be established and an audit council should be formed
and trained to take this responsibility.
Exposure to TQM and QA through conferences, courses and others.
Institutionalization of health care quality should be adopted to assure sustainability.
It is very important to emphasize the principle of quality management: process, clients, variation,
continuous improvement, scientic method, and view of people, transformation.
C. Technical Efciency in MOH Health Facilities
Addressing in-efciency is particularly important in settings where resources are scarce and needs great,
as in WB & GS. In short, efciency can be dened as the amount of output realized compared with the
input provided. Although efciency is usually thought of in terms of cost, it can equally well be measured
in other ways, such as time. For example, the number of outpatient visits per doctor per working hour.
One of the strategic objectives of the National Strategic Health Plan (1999-2003) is to Improve the ef-
ciency and cost-effectiveness of organizational management for integrated and sector-wide health systems
development in Palestine. However, the start of the Intifada in September 2000 has had great impact on
the health system. In terms of nancing, resources and their allocation, quality improvement and system
development, which in turn have prevented the implementation of many of the Strategic National Health
Plan Objectives; yet evaluation of this National Plan has not taken place to know the extent of achieve-
ments.
On district level, initiatives to achieve efciency have taken place. However, it cannot be considered sys-
tematic or policy related. It is more related to the health director vision and understanding as well the abil-
ity to be in command of the system in the district.
Also, different donors projects have contributed in an indirect way to more efcient systems, e.g. im-
proving rational drug use, distribution, dispensing and storage. However, several PHC clinics have been
upgraded in a way that meets the requirement by the area, using the already available resources in a more
efcient way, expanding the service to include, e.g. x-ray, chronic diseases services like diabetes, and hy-
pertension.
These patients used to use the hospital for getting their monthly prescription, routine check or simple lab
tests and x-ray.
Since 1994 Palestinian Authority has started a policy of quantitative growth in the health system in all
aspects. However in spite of this increase, there is no assurance of efciency7.
MOH ofcials believe that most of the cases can be managed in the MOH facilities; a small portion re-
ally needs more specialized centers. This leads to conclude that there is an inefcient use of available
resources.
The current low salary system in fact may be a factor among others that affects the efciency and quality
of the system. Qualied physicians and nurses usually go out searching in the private sector where they get
paid double or even triple the amount they get paid at the MOH. Highly qualied physicians with special-
ties and subspecialties, e.g. neurosurgeons, cardiologists, orthopaedics, do not work at full capacity in the
governmental sector, where they encourage in one way or another the referral of cases, knowing that the
MOH has the capacity to deal with such cases.
The Palestinian health sector includes many different participants, NGOs, local and international,
UNRWA, MOH, and private. Lack of coordination and cooperation between different players sometimes
leads to duplication of services, as well as scarcity in another.
The pharmaceutical sector is still suffering from duplication of services and shopping from one facility to
another and exaggeration in drug combination and listing in the prescription. A signicant difference can
also be seen in medicine expenditure in PHC between one district and another. For example in Jericho, the
medicine cost/ patient/2003 is estimated at 19.30 NIS, whereas in Jenin district only 7.46. In Nablus area
the cost of medicine of 278,587 attendances to physicians/2003 was around 3 million NIS; in Jenin the
cost of 371,648 attendances was only around 2.7 million.
The same is applied to lab materials expenditure. In Jenin district, the estimated cost/test is 1.11 NIS, in
Jericho 2.19 NIS, in Hebron 1.71, in Ramallah 2.7, in Bethlehem 1.46.
The only explanation for such variations is that the distribution of lab material is not correlated to the load
of work, irrational use of lab materials in some districts, overspending in some PHC labs, and absence of
standardized practice.
Access problems have also contributed to inefcient use of certain areas in the system, e.g. choosing one
facility on another only because of access problems. This has always resulted in misallocation of patients
and inadequate distribution of resources, e.g. a new PHC clinic only because areas were cut off from the
nearest health facility by the Wall, in spite of the fact that, if the Wall is removed, there will be no need for
this new facility, e.g. in Al Aqaba village with 300 residents only (close to Tubas), a military camp made it
impossible for the residents of this village to reach the PHC located in Tubas area.
MOH hospitals seem to be more accessible and occupied than non-MOH hospitals. By reviewing the rate
over the last ve years, the occupancy rates in MOH hospitals was around 67%, and the last three years
have shown a sharp increase from 65.3% in 2002 to 82.4% in 2003. The Intifada and the free health insur-
ance are the two factors that contributed to this increment. A reciprocal decline has occurred in the NGO
hospitals and private hospitals. The average bed occupancy rate recorded in NGO hospitals was
36%.
Apart from mental hospitals, the Average Length of Stay (ALOS) was 2.7 days. In GS, it was 2.9 days while
in WB 2.4 days. The longest ALOS was recorded in European Gaza Hospital (4 days) while the shortest
ALOS was reported in Tulkarem Hospital (1.7), days. Except for EGH, one can conclude that it was almost
xed at 2.8 days. In high-income countries, the lowest ALOS is about 5 days, suggesting that 2.8 days may
indicate that patients are either being hospitalized for too short a period of time (to obtain appropriate
quality care) or that many patients may be hospitalized for indications and/or treatment that do not require
hospitalizations from a medical perspective. Anecdotal evidence suggests that especially the latter is the
case, partly because of a local preference for specialist care, partly because of an ineffective referral system
and lack of gatekeepers at the primary care level to ensure that care is provided at the most cost-effective
level. Another reason could be that patients who travel a long time and reach the hospital after the special-
ist has left are admitted and checked the next day when the specialist is back.
Often the situation of overcrowded outpatient departments is exacerbated by the presence of a large num-
ber of patients who require only basic curative care that could be provided in a lower-cost setting health
centre. In the West Bank an increasing number of patients 30% (self referral) come to the hospital directly
especially in the afternoon shift, i.e. after opening hours of the PHC clinics. This of course leads to the use
of the hospital as a PHC facility but at a much higher cost per patient/visit.
Nurses in most of the PHC clinics do many other things beside their job as a nurse, e.g. registration, clean-
ing of the toilets and accounting, drug dispensing, and x-ray. This is mainly due to nancial problems in
the MOH and inability to recruit adequate resources. Also heavy workload in PHC clinics leads to ques-
tionable quality and efciency in performance.
Lack of job description is a common issue in the MOH recruitment for employees. Which in turn has a
consequences on who should be doing what, who is in charge and responsible for what. The system is not
employing them in an efcient way that allows getting things done in the right and proper way. General
Directors are often politically nominated, regardless of their qualications and background.
Maintenance of equipment takes time. It may take months, or even a year, to x a certain machine that
costs hundred of thousands of dollars, either because there is no expertise, or we do not have the parts
needed (procurement plan is fragile or no existing).
Preventive maintenance plan is still not applicable. Training of biomedical engineers by the company is
usually limited to the operation process only, and there is very limited theoretical information about the
machine. Another constraint is that equipment is acquired from many different sources and donors, which
results in a large variety of equipment, and inability to nd capacities who are able to deal with it.

Recommendations
Survival of various hospitals depends on a clear plan that identies the role of each hospital.
Also, on improving the contractual agreement between the public and private or NGOs and out
of country health services.
Each hospital should formulate its own needs for employing various types of personnel
depending on the type of services provided.
Upgrading of PHC clinics and increasing physicians attendance will decrease unnecessary use
of ER, and hospital days.
Investment in public health programs that focus on prevention and education of the population,
e.g. preventable accidents, nutrition related diseases, and disabilities care and health awareness.
A reward (monetary and recognition) system should be created depending on performance
appraisal, also improving the efciency and the quality of performance by increasing salary scale,
the living standard and the pension system. An integrated hospital health care delivery that
contributes to the well being of the Palestinian population should be established.
Finding contractual agreement systems between the health insurance structure and various
NGO hospitals is presently an essential matter of inquiry.
The PA may consider using the private sector and NGOs to deliver public services, more
effectively, before continuing to expand its own management of public service delivery.
Attention should be given to day care centers and their role in decreasing hospital cost, such as
a day care system for specialties, e.g. minor surgical operations (tonsillectomy, adenoidectomy,
hernia, haemorrhoidectomy...etc).
Minimizing the cost of referral abroad through utilization of PHCs and hospital resources with
full capacity.
Plan preventive maintenance
Contracting with Private Sector / specialized companies
Recruit well trained biomedical engineers
Upgrade the staff of Maintenance Dept. through continuous training in new equipments
(Dental clinic)
Improve procurement and management process for electro biomedical equipment.
Train medical staff in hospitals and PHCs to optimal use of electro-biomedical equipment.
Allocation of resources should match workload in PHCs and hospitals Quality of supplies
Provide supplies to PHCs and hospitals with the right quantity at the right time
Give more freedom to the Palestinian Ministry of Health to utilize its nancial resources in a
useful and effective manner and set its human resource structure and employment policies.
Assuring respect to the individual requires some adjustment of health insurance policies,
freedom in choosing health care, and a unied health care cost.
A review of the insurance system and the co-payment system, broadening this system to
include the NGO and private sectors can assist in building a health care delivery system that is
more effective and comprehensive in nature. This would help achieving equity, efciency, and
nancial sustainability.
Integration between CIS, HIS, TAO and MIS is a necessity for achieving the intended goals in
terms of efciency, quality and cost effectiveness.
End notes
3 Press Release, the impact of the apartheid Wall on Palestinian health, the health work committees (HWC), December 2003
4 Health and segregation, the Wall impact of the Israeli separation Wall on access to health care services, HDIP 2004
5 An illustration can be given by the CT scan services in Gaza city, introduced by private investment and nanced by service
purchase from MOH until the services were created in the public hospital through a bilateral aid project, resulting in a collapse
of the private service.
6 In WB PHC clinics there is zero x-ray centres, but in GS there are 11 x-ray centers distributed in different regions
7 For illustration, in spite of the huge increase in MOH human resources achieved from 4,758 in year1995 to 9,069 in 2003, as
well as the tremendous increase in bed capacity from (3,386 in 1999) to (4,679in 2003). Referral abroad (treatment outside MOH
facilities) with an increasing rate (6176 in 1996 to(20235 in 2003).
Annex 2
Task Force 2 Health Care Financing
Health Expenditure Review 2003: detailed tables
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Annex 3
Treatment Abroad
Table 1
Rules and Regulations referrals to treatment abroad
The treatment abroad operation procedure is based on a pragmatic approach where the standard way is as
follows:
1. Patient goes to general practitioner (GP);
2. GP refers patient to specialist in hospital;
3. Specialist nds out that patient needs treatment which is not available in the Palestinian
MOH hospital;
4. Specialist prepares referral form called (no.1) with patient biomedical data, and a referral report
is prepared comprising patient medical history, recommendation for treatment outside MoH,
photocopy of patient ID card and insurance card;
5. Referral report is submitted by TAO to Superior Medical Committee (SMC) in Gaza Strip
or to the Higher Committee of Referrals (HCR) in West Bank. Members are appointed by
MOH and representing all medical specialties.
6. SMC/HCR studies referral report and decides Yes/No;
7. After approval, the TAO contacts the patient;
8. TAO issues le number for referral, selects and contacts hospital for treatment
(based on TAO experience);
9. Patient gets nancial commitment from TAO and goes for treatment (waiting list is dependent
on patient status, waiting time can be from 1 hour to 6 weeks and over);
10. Contracted hospital submits invoice to TAO when patient is discharged. TAO checks invoice
and transfers to Financial Department in the Palestinian MOH for payment.
11. Some cases, the patient can also receive an approval based on an alternative approach by
12. Passing directly through the Palestinian Minister of Health or through the Palestinian
Presidents ofce. The treatment abroad approved by the presidents ofce is nanced
directly from the Ministry of Finance (MoF). However, the two Treatment Abroad Ofces
(Specialized Treatment Department) manage all treatment abroad cases from either the one
in Gaza Strip or in West Bank.
The criteria for referral of patient for special treatment in Gaza Strip and West Bank are not uniform.
There are no written regulations or guidelines that the two committees can follow in the process of deter-
mining referrals of patients.
Table 2
Treatment Abroad
By Place of Referral
Gaza Strip
Gaza Diagnostic Center cases are mainly concerned with Computer Technology diagnostic
procedures. For example, of Gaza Diagnostic Centers 154 cases 128 are Extracorporal
Shock-Wave - Lithotripsy (ESWL) and 24 are biopsy. In Al-Quds Hospital the key cases are
ICU management and in Al-Quds Hospital and Patient Friend Society the main number of
cases are within gastroscopy and colonoscopy. And at Al-Helo Center and Al-Basma Center,
all cases are In Vitro Fertility (IVF) in total 150 cases. Further cases were referred for
Tomography (CT) scan and related diagnostic procedures.
West Bank
Main procedures carried out in Arab Care Center cases are Magnetic Resonance Imaging
(MRI) scan, Mohtaseb Hospital cases are Pediatric Intensive Care Unit (P.I.C.U.), Annahda
Womens Associations is hearing aids and Medicare cases are CT scan. The highest number
of cases at Ramallah Hospital is 717 cardiac catheterization. At Arab Care Center the key
procedure is 226 MRI cases. Msalam Center is specialised in ophthalmology and cataract
extraction with 52 as the highest number of cases. At Razan Center all cases are IVF with 166,
Medicare 64 IVF and Al-Amani 51 IVF. Arab Association for Rehabilitation carries out 41 cases
of physiotherapy, 41 cases of rehabilitation and 3 cataract extractions.
East Jerusalem
Makassad Hospital provides mainly services within P.I.C.U.. It carried out 100 cardiac
catheterisations and a lot of different surgical procedures and diagnostic procedures. It also
provides management and specialised laboratory analyses. Half of Augusta Victorias cases
are concerned with Endoscopic Retrograde Cholangiopancreatography (ERCP) and
haemodialysis. At Sant Jhun the number one case is cataract extraction with 177, followed by
laser therapy for the eye with 50. The Princess Basma Centre provides rehabilitation services
and aid equipment.
The Palestinian National only purchases specialised treatment from neighbouring countries
Egypt, Jordan and Israel. The main procedures which are carried out at the institutions in these
countries are as follows:
Egypt
Palestine Hospital receives only patients from Gaza Strip and main procedures are urology,
vascular surgery, plastic surgery. Itl carries out all specialties and the most important ones in
terms of cost and number are neurosurgery and follow-up, lumbar disc surgery, retinal
detachment repair, vitrectomy, orthopaedic management, plastic surgery and medical
management.
Nasser Institute Hospital treats more or less all types of patients and the key areas are
neurosurgery management, spinal xation, retinal detachment repair, cardiac catheterisation,
oncology mana gement, orthopaedic management and follow-up, orthopaedic surgery and
surgical managemen. Nasser Institute Hospital has only patients from Gaza Strip and treat
all types of patients; however, 8 bone marrow cases take 58% of the patients expenses cost all
at the hospital.
El-Salam Oncology Center has 73 radiation procedures.
Jordan
Jordan Hospital has mainly patients from West Bank and key procedures are bone marrow
transplantation and kidney transplantation. At Jordan Hospital the key procedures are
cardiac management, urology management, neurological management, neurosurgical
management, ophthalmic management, cardiac catheterisation, oncology management,
chemotherapy, orthopaedic management, cardiac surgery, paediatric cardiac surgery,
Coronary Artery Bypass Grafting (C.A.B.G) and surgical management.
Hussein Medical City key procedures are within oncology management, chemotherapy, plastic
surgery management, cardiac surgery, paediatric cardiac surgery. Amman Hospital has carried
out 6 cochlear implantation.
Al Bashir Hospital is mainly concerned with 143 cases of radiotherapy
Israel
Tel-Hashomer Hospital is concerned with paediatric consultation, haematological investigations,
oncology follow -up, ICU management, paediatric cardiac surgery, vascular management.
It offers specialised services, such as 2 bone marrow transplantations and 13 radiotherapy cases
that consumes more than 60% and18% of the total costs respectively.
Echelof Hospital takes care of different procedures such as neurosurgical management,
chemotherapy and ICU management within oncology, 20 cases take 72% of total cost.
Soroka Hospital provides ICU management, burn and surgical care management.
Hadassa-Ein Karim Hospital has carried out key procedures: neurosurgical management,
oncology management, chemotherapy, burn management, paediatric cardiac surgery. Three
cases of bone marrow transplantation and 4 radiotherapy cases consumed 82% and 10%
of the total cost.
Table 3 : Top ten main procedures based on costs are selected for
outpatients.
Total Inside and
Outside
Only Inside Only Outside Both Inside Both Outside Total Ins ide and Outside

Total 1,609 5,937,536 95 273,386 109 416,094 1,033 4,210,237 372 1,037,819
dd
ddd
No. Cost No Cost No Cost No Cost No. Cost
11 INFERTILITY Out 431 3,072,600 0 0 0 0 429 3,052,600 2 20,000
23 ONCOLOGY Out 107 585,083 0 0 42 314,694 2 5,000 63 265,389
10 UROLOGY Out 189 564,550 9 3,100 22 27,200 152 493,050 6 41,200
31 M.R.I. Out 354 350,980 23 20,080 4 4,000 265 233,200 62 93,700
25 REHABILITATION Out 131 341,366 62 248,706 2 4,100 67 88,560 0 0
18 OPHTHALMOLOGY Out 148 243,995 0 0 0 0 54 74,465 94 169,530
30 ISOTOPE & NUCLEAR Out 127 243,100 1 1,500 21 34,900 30 61,900 75 144,800
9 NEPHROLOGY Out 34 210,652 0 0 8 23,100 24 185,352 2 2,200
13 PAEDIATRICS Out 27 209,950 0 0 0 0 8 14,950 19 195,000
17 NEUROSURGERY Out 61 115,260 0 0 10 8,100 2 1,160 49 106,000
Table 4: For each group the main medical procedures, numbers of
cases and costs.
10
Procedure Total Ins ide
and Outside
Onl y Inside Onl y Outside Bo h Both Outside

No. Co st No. No. Co st Co st Co st No. Co st No.
1. Cardiology 163 1.555 0.148 80 0.608 39 0.382 0.418
2. Heart Ca the terisation 1,142 2.657 0.255 37 0.256 829 0.774 202 1.372
3. Heart Surgery 164 3.201 0.157 76 1.631 28 0.434 0.979
4. Vascular Surgery 0.892 0.025 60 0.818 3 0.025 3 0.024
5. Chest 0.260 0.069 15 0.123 4 0.023 3 0.042
6. Ches t Surg ery 0.251 3 0.015 16 0.236 0 0 0 0

219 0.806 0.135 124 0.472 10 0.059 0.140
8. General Surgery 199 1.246 0.196 83 0.697 48 0.121 0.233
150 1.702 0.120 71 1.132 47 0.359 0.091
347 1.575 0.210 141 0.825 109 0.359 0.181
443 3.158 0.394 0 0 386 2.711 6 0.053
0.217 0.105 13 0.048 9 0.029 5 0.036
152 0.928 0.363 67 0.456 12 0.065 0.045
0.277 0.062 15 0.115 5 0.044 8 0.057

0.083 3 0.004 15 0.072 1 0.003 1 0.004
136 1.184 0.128 90 0.832 12 0.082 0.142
449 4.211 7 0.071 246 2.607 23 0.253 173 1.280
998 3.844 110 0.325 197 0.841 484 1.561 207 1.117
19. E.N. T. 118 1.181 7 0.023 95 1.065 9 0.049 7 0.044
0 0 0 0 0 0 0 0 0 0
0.329 7 0.050 24 0.202 2 0.018 4 0.059
3.094 9 0.069 78 3.013 1 0.005 2 0.007
740 8.431 3 0.025 595 6.128 24 0.254 118 2.024
468 3.620 0.317 265 1.766 67 0.641 0.896
351 2.091 325 1.713 6 0.147 17 0.151 3 0.081
0.153 0 0 20 0.153 0 0 0 0
119 0.960 9 0.095 88 0.529 8 0.094 0.244
28. Burns 9 0.242 1 0.020 1 0.017 3 0.050 4 0.155
29 . I.C.U. 139 1.717 102 0.875 26 0.708 7 0.070 4 0.064
166 0.423 0.02 7 72 0.175 26 0.058 0.164
31. M.R.I . 366 0.373 135 0.121 21 0.027 157 0.136 0.089
133 0.053 127 0.043 6 0.010 0 0 0 0
0.037 0.022 24 0.014 1 0.001 2 0.002
7,639 50.7 51 1,450 6.182 2,667 25.723 2,371 8.811 1,151 10.043
100 100 35 51 31 17 20
Ins ide
Total All11
33. Laboratory
Analysis
32. C.T. scan &
Diagnostic Procedures
30. Isotope Scan &
Nuclear Medicine
27. Plastic
Surgery
26. Dermatology
& Venereology
25. Rehabilitation
24. Orthopaedics
23. Oncology
22. Haematology
18. Ophthalmology
17. Neurosurgery
16. Neurology
15. Endocrinology
12. Gynaecology &
Obstetrics
11. Infertility
13. Pediatrics
10. Urology
9. Nephrology
7. Internal Medicine
14. Pediatrics
Surgery
21. Maxillo-Facial
Surgery
20. Oro-Dental
Surgery
31.
29.
28.
19.
%
84
35
19
49
27
16
27
16
24
61
42
10
37
90
20
14
58
53
60
19 12 15
10
Total Cost in million NIS
Annex 4
Rome Recommendation
Working groups Rome
December 2004
1. HEALTH OBJECTIVES
Quality and Equity
Recommendations : Quality
Activation of the policy and planning unit within the MOH to overview all the quality
related issues at all levels;
Activities must be extended to all the service providers in Palestine, who should be supported
to implement them and monitored;
The process should be participatory and empower the stakeholders and service providers;
Ensure human resources development and appropriate regulation for the implementation
of the policies concerning the quality;
Ensure intersectoral coordination, as appropriate
Recommendations : Equity
The health services are a right for people, and people must access them according to
their needs and their ability to pay.
Ensure appropriate allocation of resources
Good information system to identify where the needs are
Take into account the persons with special needs i.e disabled
Empowerment : gender, youth,etc
Coordination with other sectors including the private sector
The time being insufcient, due to the utmost importance of the topics, the discussions
should resume in oPt, in a frame to be established
Institutional changes
1. Reorganisation of the MOH in order to:
create a unied structure with clear lines of responsibilities and authority
update organisational chart and establish unit/personnel job descriptions
establish clearly identiable policy and planning functions
increase autonomy of individual public providers (e.g., hospitals, PHCs)
promote a health focus in policy development, planning and programming
2. Establish a Change Team within the MOH to address reform implementation issues and
liaise with the Prime Ministers reform unit
3. Establish a mechanism to allow for meaningful input into policy and planning from all relevant
govern mental and non-governmental stakeholders in the health sector
4. Establish a clearly dened legal framework for the MOH and establish unied regulations.
Management and Organization
Develop unied strategies, policies and Systems with Prioritization criteria and timelines based
on needs analysis;
Reorient the health care system towards more balanced primary health care (reduce bias towards
curative).
Coordination and collaboration between Gov., Private, NGO, etc.,
Focus on strengthening the services at all levels
Delegation to direct line health centers providers
Development of a unied, functioning oversight and monitoring body
A system of execution, monitoring, evaluation, and taking corrective action, documentation and
reporting
Introduce new systems to reduce inappropriate hospital admissions (i.e daycare units, one day
surgery units, and delivery careless.,)
Development of qualied Human Resources; Integration
Development of a Systems Wide Approach (SWA)
Coordination, collaboration and community participation (MOH,other ministries, civil societies,
educational systems, private sector, etc.,)
Develop a platform for dialogue on health
How?
Health technology
Less techno-centric to more human-centric
Planning
Emphasis on prevention and promotion
Finance
Develop cost center approach with cost benet analysis
Self reliance
Public health orientation
Training
Monitoring
Human Resources
Development of a Database on the Human resources.
Review and update the data available within the National Plan for HRD and education in
Health.
Empowering the existent health professionals .
Follow up on the review of the existent training programs and identify the needed orientation of
the health professionals and the needed support.
Prioritization of needs in terms of HRD-Short term and long term basis
Develop a plan that address the immediate needs. ( training,...etc).
To identify a certain budget within each of the health providers including the MOH budget for
the development of the HR
( developing poilcies, training, ..etc)
Address shortages and excesses in specialties and sub-specialties.
Standardizations of licensing the health professionals.
Strengthening the residency program in Palestine .
Provide incentives for physicians, nurses, health workers, especially those working within the
PHC.
Raising the capacity of the local trainers.
Strengthening the continuing education programs .
Shortages identied: Health economists, mental health workers, policy planning and
management, research and monitoring and evaluation.
Strengthen available specializations and establish new one based on need and resources.
Develop monitoring and evaluation system to follow up the implementation of the upgrading
and continuing education.
Formal and informal continuing education not only by universities but MOH professional
associations,...etc.
Accreditation process and relicensing based on coherent national strategic plan.
MOH, MOEHE, MOP and MPF should work closely to enforce accreditation decisions.
HRD based on technical but more important policy and strategic planning to be strengthened
by concerned ministries
Health Sector Financing
Recommendation
To assign authorized (and accountable) body to work on achievable short term and mid term ob
jectives and outputs
Short Term
Short term contingency approach Short term crisis management
Which short term strategy?
Who will be accountable?
Mid Term
Mid term development approach
Which strategy (BBP, BBP costing, BBP nancing, public/private expenditure, Public
budget + Health Insurance Schemes + co-payment (OOP), public/private providers,
autonomy of hospitals, incentives, provider payment mechanisms,...)?
MTEF, which will dene a reasonable estimate of nancial resources likely to be available
in the medium term
Who will be accountable?
Annex 5
Employment process in the WB and Gaza
Employment process in WBGS
There is a difference between the process used in WB and that used in Gaza. The most important dif-
ference is that the employing institution has more inuence in WB. This process has been considered
effective in recruiting the best candidates and considering the place of residence to overcome the Israeli
closures. The budget limitations in the MoF is the main controller of the number of new staff in both WB
and Gaza. Stages of employment process are described below.
Stage 1: Budget Stage:
This stage is similar in both WB and Gaza.
The units of the MOH provide estimates of needed additional staff every year.
These are aggregated and modied and presented to the MoF as part of the annual budget.
According to the anticipated resources; the MoF modies the request and allocates a
budget for recruitment in the MoH.
The number of the new recruits is usually less than the total number requested.
Stage 2: Allocation within the MoH
This stage differs between WB and Gaza.
In West Bank:
Distribution of the new staff managed according to the requests prepared by the provider units.
The shortage caused by budget limitation managed through negotiations between
Headquarters of the MOH and the provider units to set the priority of the new staff
according to the real needs.
In Gaza:
The Headquarters of the MOH agrees with the MoF on the ceiling of the new recruits.
The Headquarters of the MOH establishes the priority for the new recruits
according to the requests forwarded by the units of the Ministry.
The individual unit has no role in this stage.
Stage 3: Advertising for new recruits
This stage differs between WB and Gaza.
In West Bank:
Advertisement by MOH alone
Advertisement for specic post, the applicants know where they will be working if selected.
In Gaza:
The advertisements are issued by General Personnel Council (GPC).
Advertisement is not linked to specic health facility.
Applicants have no information where they will be working if selected.
Stage 4: Short listing and selection of candidates
This stage varies between Gaza and WB.
In West Bank:
The Headquarters of the MOH and PHC directorates advertise the vacancies and receive
the applications.
Selection subcommittees are formed by the Director General (DG) of MOH for each
health facility.
previewing the applications for the needed qualications and making sure of registration
from the Palestinian Medical Council.
Competition tests and short listing
Short listed candidates invited for interview and selection done considering the shortage
of health personnel in districts.
The decisions of subcommittees are referred to the D G of MOH for ratication.
In Gaza:
GPC receives applications.
GPC forms selection committees from GPC, MOH and representative of a third Ministry.
The MOH representative in each subcommittee comes from the relevant health disciplines.
No involvement of the health institution that will employ the applicant in this process.
Stage 5: Employment of the candidates
This stage differs between Gaza and WB. GPC is The formal employer for all public servants in Palestine.
Selection committees notify the GPC of the selected candidates.
In WB:
The MOH issues the letter of appointment to the successful candidate indicating the working place of the
employed candidate.
In Gaza:
The GPC issues the letter of appointment in the MOH to the candidate, then, the Headquarters of the
MOH allocates him to the health facility where the employee will be working.
European Gaza Hospital (EGH)
EC project implemented by UNRWA then by Palestinian MoH. According to the MoH, it has its own
special identity and special budget. Recruitment of specialists according to a planned program began in
the middle of 1998. Opening for admitting inpatient for rst time was in October 2000. One year later,
the hospital gradually stopped to have its special budget and then it lost the major part of its independent
identity.
E.G.H. recruitment process
The Management Board of the EGH determines the stafng requirements according to the gradual open-
ing program (Numbers and grades). The staff costs were included in the global budget agreed with the
MoF.
The Headquarters of the MOH and GPC have no role in staff allocation within the Hospital. EGH adver-
tises for new jobs directly in the newspapers local and or international. The Human Resources Department
of the Hospital receives the applications and make short listing. Short listed candidates interviewed by a
committee formed by the Human Resources Department of the Hospital, the Employment Department
and a third department. No role to the MOH and the GPC in selecting the employee candidates.
Annex 6
Procurement of Medical Treatment Services
and Contract Management
The general steps comprise the following:
1. Advertisement for pre -qualication
a. Invitation shall contain information on the scope of procurement, deadline for
submitting pre-qualication applications and the name and address of buyer
2. Pre-qualication
a. Institution, established year
b. Experience and performance from similar assignments, experience in diagnostic and
treatment services according to main medical procedures
c. Experience and performance in the region
d. Key personnel, stafng professional skills, number specialists etc. and
management available for the assignment
e. Work previously carried out for the buyer
f. Facilities and equipment available for the assignment, standard of medical technology
g. Financial status (annual turnover in similar assignment during last 3-5 years)
h. Present workload
i. Involvement in litigation
j. Depending on the type of services then; overall level of activity within each
specialty, average length of stay, number of admissions, discharge,
accreditation, quality programmes, staff policy, patient policy, hospital hygiene
and infection control, re-operation, standard treatment procedures, medical
preparedness, average waiting time, research and development activities
k. Minimum requirements for qualications
3. Tender documents
a. Invitation to bid
b. Instructions to bidders, general and special
c. Form of bid
d. Forms of contract, conditions of contract (general and special)
e. Technical specications
f. Evaluation criterias
g. Forms of verication of qualications
h. Schedule of completion
i. Formats for various securities
4. Receipt and opening of bids procedures
5. Evaluation and comparison of bids, criteria
6. Evaluation reports structure
7. inalising the contract and award procedures
Annex 7
Planning Criteria
At the same time planning criteria for the different health facilities at the various levels (as stated) include
these items:
1. Catchment area,
2. Public coverage (public/NGOs/private mix),
3. Indicative norms for number of outpatient visits and admissions (per year, per 1,000
population, per level),
4. Indicative norms for beds per department/specialty (per 1,000 population),
5. Average length of stay, expected bed occupancy rate, etc.
6. Minimum caseload per specialty, etc. and
7. Standardized names of departments and specialties
Besides planning criteria, these norms for stafng pattern at various levels need to be considered:
1. Minimum standard requirements for physical infrastructure, standard schedule of
accommodation with equipment at various levels
2. Calculation of standard annual cost per facility to ensure affordability
3. Health support facilities (e.g. ambulance stations, blood banks, medical stores,
maintenance organizations, health care waste management, laboratories, etc.)
4. Design manual for health facilities (e.g. standard for what a treatment room design
should include to organize the use of space).
Annex 8
Persons Met by
HEALTH RESEARCH FOR ACTION (HERA)
2003
Gaza Strip
Dr Kamal E-M Al Shara, Minister of Health
Dr Shibi, Minister of Health
Dr Emad S. Shaat, Director General International Aid coordination
(Later Minister of Foreign Affairs)
Dr Maged Aba-Ramadan, Director General International Cooperation
Walid Tawk Shaqura, Director of International Cooperation
Dr Khaled Abu Ghali, Director of Planning
Mr Jamal Abu Nada, Director Administrative and Financial Affairs
Mr Soheil S Hammad, Finance Director, Minister Ofce
Mr Mithqal F.Abu Ramadan, Financial Ofcer PIU Health System Development
Dr Salah A.EL-Khaldi Human Resources Development Department
Mr Ghali Mohamed, Health Insurance Department
Mr AL Nouarmah Monier, Health Insurance Department
Mrs Aman H Fatmah, Director of Health insurance Department
Dr Riyad Awad, Director HMIS
Dr Abdel Eljabbar Y.El Tibi, Director General PHC
Dr Ali Kweider, Deputy Director, PHC
Dr Younes, Head, IMCI
Dr Faysal Abu Shahla, Hospitals administration department
Dr. Fuad H. Ahmed, Laboratory services
Dr. Randa El Khodari, Laboratory services
Dr Zmeilli, Director of Central Medical Stores
Dr Taha Khitam D, Director of Medical Disposables department
Dr Yusuf Awad Allah, Director Coordination with NGO
Mr Mahoud Eddama, National expert
Dr Semwar, Brigadier General, Director MSD
Dr Kamel Hassan, Colonel Paediatrician, Head Studies and statistics, MSD
Dr Bechir Harara, Colonel, Head Operations, MSD
Dr Attal, Colonel, MSD
Dr. Radhwan Akhras, Deputy Director Yousef Al Najar Hospital
Mr Mohamed, Nurse i/c PHC, Martyr M. El Najjar Hospital, Rafah
Mrs Suhaila S Tarazi, Director Ahli Arab Hospital
Dr. Mahmoud Asali, Director Jabalia Hospital
Mrs Samira G Farah, Ahli Arab hospital
Mr Nazem D Al Sarraj, Managing Director Target Medical Services
Pr Mohammad E Shubair, President of the Islamic University of Gaza
Pr Riyad H EL-Khoudary, President Al-Azhar University-Gaza
Dr Sosan Shosha, School of Public Health
Dr Haider Abd El Sha President, PRCS Gaza
Dr Rabah Mohanna, Union of Health Work Committee
Mr Salah Abdel Sha, Director General Community Mental Health Programme
Dr Taysir M Diab, Senior Medical Director Gaza Community Mental Health programme
Mr Ibrahim H Ghandour, Director Patients Friends Benevolent Society
Dr Aed Yaghi, Union of Palestine Medical Relief Committee
MrsJaleela Dahlan, Chairwoman, Palestinian Center of Human Perseverance
Dr Mofeed Mokhallalati Palestinian Medical School Medical Coordinator PINGO
West Bank
Dr Alawneh Atef, Deputy Minister of Finance
Dr. Monzer Sharif, Deputy Minister of Health
Dr. Anan Masri, Assistant Deputy Minister
Dr. Nadim Toubassi, DG PHC Directorate
Dr Asad Mohammad Ramlawi, Director Preventive Medicine
Mrs. Wijdan Siam, DG Womens Health Directorate
Dr. Zohira Haba Sh, DG Health Promotion and Education
Dr. Raji Musleh, DG of Dental Health Directorate
Dr. Rasad Jaber, Director of Coordination with NGOs
Mr. Omar Abu Arqub, MIS Director
Dr. Akram Samhan, Director of Specialized Care Department
Mr. Thieb Ahmad, DG Insurance Department
Mr Atiany Mohamed, Director Finance Department
Mr Nasalmeh Nizar, Director of Medical and support stores
Mr Othman Rezeq, Director of Central Medical store
Dr. Fahed M. Es-Sayed, Consultant Policy and planning
Ms. Rania Shahia, Consultant Pharmaceutical controls
Dr. Kamal Aboyish, Consultant accreditation
Dr. Qasem Maani, Consultant International coordination / Human Resource Development
Mr Jaudat Imran, Consultant Personnel management
Mr Daghara A Suan, PCBS Director Industrial statistics
Dr Asad, Director PHC
Dr Kamal Wazanad, Director Private Sector Department (Nablus)
Mr Nabil Idris, Direcor Health Insurance Department
Dr Rizik Othman, Director of Drug Stores
Mr Fathi Abumoghli, Project Coordinator HSDP
Mrs Siham Mousa, Financial Chief accountant
Dr. Zeid M. Abu Shawish, Dep Gen Dir of Hospitals
Dr Atari, Director Ramallah hospital
Dr Batrawi Mohamad, Director of Cath Lab Ramallah hospital
Mr Abdo N George K, Abu Raya Rehabilitation Center, Administrative Director
Dr Ahmad Abubakr, Director, Tulkarem Hospital
Dr Said Hannoun, Director PHC, Tulkarem
Dr Mohammed I Abu-Ghali, Director Jenin Hopsital
Dr Mohd K Tafakji, Director PHC, Jenin
Dr Agyel Adnan, Al Itched Hospital Financial Manager
Dr Eshaulf Izat, Al Itched Hospital Administrator
Dr Quail Adnan, Al Itched Hospital Deputy, General Director
Dr Afx Barbara Nobles, Specialist Hospital Director
Dr Chilli, Medical Ofcer Betunia Clinic
Dr Abdul-Aziz L Shukeir, Director of PHD of Alkhalil (Hebron)
Dr. Abdelrazek Abu Mayaleh, Director of Red Crescent Hospital Hebron
Dr. Abdelaziz Shukair, Director of Hebron District PHC Directorate
Dr Musallam, Director, Musallam Eye Clinic, Ramallah
Dr Awne, Medical Director, Al Zakat Hospital, Tulkarem
Dr Awni T Shahrour, Dental Surgeon Tulkarem
Dr Rak Husseini, Welfare Association
Dr Younes Khateb, Director, PRCS
Dr Hossam K Sharkawi, Emergency response coordinator PRCS
Dr Hekmat Ajjiri, Director, Primary Health Care PRCS
Dr Abdel Rahim Abusaleth, Primary Health Care PRCS
Dr Ahmad Maslamani, Director HWC
Dr Kamal Zaineh, Health Manager HWC
Dr Jihad Mashal, Director General UPMRC
Dr Heidar Abu Ghosh, Director UPMRC
Dr Nadim Barghouti, GP UPMRC
Mr Hazem Kharouf, Administrative Director Medical Relief Society
Mr George Abdo, Administrative Director Patients Friends Society
Dr Ismail M Mussallam, Ophtalmic Surgeon Institute of Excimer Laser
Mr Lawyer Tariq I Al-Disi, Asst General Manager Trust International
Mrs Suzanne Shashaa, Assistant Dean School of public Health Al Quds University
Dr Khuloud Khayyat, Dajani Community Medicine Al Quds University
Dr Mahammad Shahin, Center for Development in PHC Al Quds University
MrSuleiman Ibrahim, Al Khalil An-Najah National University
Pr Ghassan A Abu-Hijleh, Dean Arab Americana University Jenin
Mr Hussein Jabareen, Hebron University
Dr Macha Fatho, Nursing Faculty Bethlehem University
Mr Rita Giacaman, Director Institute of Community & Public Health Birzeit University
Dr Nidal Rashid Sabri Director of MBA Program Birzeit University
Dr Mustafa Barghouti, Director HDIP
Mr Motasem Hamdan, Centre for Health Services Katholieke Universiteit Leuven
International cooperation
Mr Guy Siri, Deputy Director UNRWA operations West Bank
Mrs Elena Mancusi-Materi, Research Ofcer UNRWA
Mr Mohammad Odeh, UNRWA
Dr Ayoud El Alem, UNWRA
Mr Suan Mshasha, Head of Human development Unit UNDP
Mr Pierre Poupard, Special Representative UNICEF
Mr David Bassiouni, Special representative UNICEF
Dr Nadim Al-Adili, Health Programme Ofcer UNICEF
Mr Mohamed Abdel-abad, Representative UNFPA
Yiad Yaish, UNFPA
Dr Ronald Quist, Public Health Adviser WHO
Dr Ricardo Sol Arqus, Heatlh coordinator WHO
Dr Zanoun Rak, National programme ofcer WHO
Mr Ambrogio Manenti, Desk ofcer WHO
Mr Silvia Pivetta, WHO
Pr Anne S Johansen, Senior Health Specialist World Bank
Mrs Salam Kanan, World Bank
Dr Lim Meng Kin, Consultant World Bank
Dr Bjorne Lading, Consultant World Bank
Dr Dennis J Streveler, Consultant Health Technologies World Bank
Mr. Bassam Abdul-Rahim, Local Aid Coordination Committee Secretariat Ofce
Mr Hami Abu-Diab architect JDC Islamic Bank
Mrs Sherry Carlin, Ofce Director, Health & Humanitarian Assistance USAID
Mrs Melanie Mason, Humanitarian assistance coordinator USAID
Dr Umaiyeh Khammash, MARAM project West Bank
Dr Yehia Abed, MARAM project Gaza
Dr Antonio Aloi, Director of the Ofce of Development Cooperation, Consulate General of Italy
Dr Rino Pappagallo, Health project coordinator, Italian Cooperation
Mrs Sawsan Aranki-Batato, National Health Consultant, Italian Cooperation
Mr Marco Barone, Health project coordinator, Italian Cooperation
Pr Ranieri Guerra, Director Instituto Superiore di Sanita
Mr Thomas Kergall, Insitiuto Superiore di Sanita
Dr Jrgen Schmidt, Health Adviser, DFID
Mrs Helen Winterton, Deputy Programme Manager, DFID
Mr Mohammad Barakat, Development Programme Ofcer, DFID
Mr Adnan Abu Ghazaleh, Senior technical Assistant, British Council
Mr Mahmoud Al-Hindy, Senior technical Assistant, British Council
Mr Swart Sheperd, MAP UK
Mrs Zikr Shaltoot, Deputy Manager, MAP UK
Mr Yves Couvreur, Resident representative, BTC
Mr Jan Pirouz Poulsen, Head of section, Royal Danish Ministry of Foreign Affairs
Mr Khaled Huseini, Consulate General of Greece
Mrs Ulrike Metzger, Counsellor, Development Ofce of Federal Republic of Germany
Mr Jean Bretch, Head of Delegation, European Union
Mr Patrick Berckmans, Health Advisor, CE/AIDCO
Mrs Raffaella Iodice de Wolff, First Secretary, ECTAO
Mr Alfonso De la Fuente Garrigosa Second Secretary, ECTAO
Mrs Mirca Barbolini, Task Manager Health, ECTAO
Mr Francis Olbrechts, Principal Administrator, ECTAO
Mr Richard Guilford, Task Manager Economic and Financial Sector Reform, ECTAO
Mr Ayman Fteiha, EC Technical Assistance Ofce Gaza
Annex 9
List of Participants
Cyprus
Ahmed Zanoun, European Gaza Hospital Administration, Director
Alfonso Mazzaccara, Istituto Superiore Sanita, International Consultant
Alice Fauci, Istituto Superiore Sanita, International Consultant
Ambrogio Manenti, WHO, Head of Ofce
Anan El Masri, MoH-WB, Deputy Minister of Health
Bjarne Lading Rasmussen, Dept for Intnl Health,
Carl Bro, Intnl, International Consultant
Garth Singletown Health, Partners Intnl, International Consultant
Ghaleb Abu Bakr, MoH-WB, General Director of Research, Planning & Dev.
Hasan Barqawi, MoH-WB, Director of Audting and budget (MoH).
Hasan Jadallah, MoH-G, Director of Jericho Hospital
Husni El Atari, MoH-WB, Director of Ramallah Hospital
Imad Dweik, World Bank, Health Consultant
Juan Tello, EC, Health Expert
Klaus Beck, Dept for Intnl Health,
Lina Atallah, EC
Maged Abu Ramadan, MoH-G, General Director Dept. International Cooperation
Majed Majdi Al- Rayess MoH-G Director of Medical Referral Directorate
Mohammed Abu Shahla, European Gaza Hospital General, Director
Mohammed Tafakji, MoH-WB, Director of Jenin Public Health Directorate
Mohammed Zmeili, MoH-G, Director of Medical Stores
Nabil Baraqoni, MoH-G, Consultative Pediatrics
Nassim Bishara Saliba Nour, DfID Deputy Programme Manager
Nizar Masalmeh, MoH-WB, Director of Central Stores
Patrick Vaughan, LSHTM - UK TF Coordinator
Qasem Maani, MoH-WB, Director Dept. International Cooperation (WB)
Rino Pappagallo, Italian Cooperation, Health Program Coordinator
Rizq Othman, MoH-WB, Director of Central Drug Stores
Sarah Newton, DfID, Deputy Programme Manager
Sawsan Aranki-Batato. Italian Cooperation
Subhi Skaik, MoH-G, Director of Surgery Department
Walid Shaqura, MoH-G, Deputy Director Dept. International Cooperation
Walter Seidel, EC, Health Expert
Fahed Al Saied, MoH-WB, Director General
REFERENCES
(1) MoH-HMIS. The Status of Health in Palestine: Annual Report. Gaza, HMIS, 2004
[Under processing for printing].
(3) World Bank. West Bank and Gaza: Medium Term Development Strategy and
Public Financing Priorities for the Health Sector. Human Development Sector.
Middle East and North Africa Region. Document of the World Bank,
24 December 1997.
(4) World Bank Country Study. Medium Term Development Strategy for the Health
Sector. Washington DC, World Bank, 1998.
(5) European Commission . A draft report on Health Sector Review in West Bank and
Gaza Strip: An assessment study conducted by a team of health and economics experts
recruited by Hera & Alter Organizations in Belgium. 2003
(6) Palestinian Central Bureau of Statistics. Jerusalem Statistical Year Book. Jerusalem,
2004. [Under processing for printing].
(7) World Bank. Fifteen Months Intifada, Closures and Palestinian Economic Crisis: An
Assessment. World Bank, March 2002.
(8) Palestinian Central Bureau of Statistics. Jerusalem Statistical Year Book No. (4).
Ramalla, June 2002.
(9) A survey was conducted by a local NGO in March-May 2003 in Jabalia Camp, Gaza.
[Non-published].
(10) WHO. The World Health Report: 2004: Changing History. Switzerland. WHO 2004.
(11) MoH-HMIS. The Status of Health in Palestine: Annual Report. Gaza, HMIS,
July 2003.
(12) Hamdan, M. et al. Organizing health care within political turmoil: the
Palestinian case. International Journal of Health Planning and Management. 2003,
18: 36-87. [Published on line in WileyInterSience (www.interscience.wiley.com).
DOI: 10.1002/hmp.691]

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