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Source: World Health Organization (WHO)
31 December 2012



Community-Based Initiatives Series


Good practices in delivery of
primary health care in urban settings





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Rapid urbanization and its economic, social, environmental and health impacts affect all countries and regions of the world, particularly developing countries. The theme of World Health Day 2010 “Urbanization and Health” was selected in recognition of the formidable health challenges faced in urban areas. Urban health encompasses social determinants of health, environmental health, violence, road safety, healthy lifestyles, food safety and security, healthy housing and space, facilities for recreation and a sense of individuals belonging to the community.

Since 1986, WHO has been actively involved in promoting urban health through the healthy city programme. In 1992, the WHO Regional Committee for the Eastern Mediterranean discussed the subject of rapid urbanization and its impact on health and adopted a resolution (EM/RC39/R.2) urging Member States to promote the concept of healthy cities. Since the implementation of the healthy city programme in the Islamic Republic of Iran in December 1991, good progress has been achieved in the Region. The programme has expanded to Afghanistan, Bahrain, Iraq, Oman, Pakistan, Saudi Arabia and Sudan, covering a population of nearly 13 million. However, the programme still requires additional resources and commitment by all stakeholders.

According to World health statistics 2010, in 2008 the Region’s total population was 580 208 million. Almost half (49%) of the Region’s population are urban dwellers. Rapid urbanization is characteristic of many countries in the Region. It is driven by rapid population growth and by economic and development policies that have encouraged a change from agrarian to urbanbased economic activities. Currently, in 14 countries in the Region, the annual population growth rate is between 2.2% and 8.4%. Notably, in 16 countries in the Region the average urban population is far above 50%.

Health security is also a major concern in the Region, particularly in countries facing complex emergencies (Afghanistan, Iraq, Lebanon, Pakistan, occupied Palestinian territory, Somalia, South Sudan, Sudan and Yemen) and in cities and large towns in middle-income and low-income countries where urban planning, management and safety standards are often below average or deficient. Furthermore, large-scale metropolises have sizeable slums and suffer from many shortcomings in health and health-related services. Chronic urban problems related to the environment, nutrition, poverty, health services and other health-related factors are addressed in the WHO report Health security in cities in the Eastern Mediterranean Region.

However, there is an urgent need to address acute health threats and conditions. In order to endorse health in urban policy-making, it is crucial to put urban health challenges on national and local development agendas and to seek and secure high-level political commitment, raise awareness and public understanding and promote intersectoral partnerships and community leadership in urban health planning. Countries are encouraged to work closely with municipalities, civil society, academia and interested partners to reduce urban health inequity and promote social determinants of health-oriented health systems. Further attention on building stronger health systems, based on The world health report 2008: Primary health care: Now more than ever, is required.

The core values of primary health care give direction for reforming health systems in terms of universal coverage, service delivery, leadership and public policy reforms. The creation of strong health systems remains a means to an end. All the health-related Millennium Development Goals depend for their achievement on strong health systems that are based on strong intersectoral collaboration and community leadership to respond to equity gaps. The Millennium Development Goals are not freestanding but are mutually synergistic, with poverty reduction as their ultimate goal. As of March 2012, 11 countries (Afghanistan, Djibouti, Egypt, Iraq, Morocco, Pakistan, occupied Palestinian territory, Somalia, South Sudan, Sudan and Yemen) are not on track to achieve some, or all, of the health-related goals by 2015.

This report was prepared by the WHO Regional Office for the Eastern Mediterranean, in collaboration with the WHO Centre for Health Development, Kobe, Japan. The good practices in urban health care delivery documented from the Islamic Republic of Iran, Jordan and Oman can be used by health system policy-makers, city planners, mayors, governors, midlevel managers, nongovernmental organizations and members of academia as evidence for advocacy and raising political commitment to improve health care delivery in urban settings.




Executive summary

Rapid urbanization and its economic, social, environmental and health impacts are distinct characteristics of many countries in the WHO Eastern Mediterranean Region. Urbanization is driven by rapid population growth and changes in economic and development policies. Most capital, investment and public facilities are concentrated in cities. The large cities and metropolitan areas also have most of the non-agricultural jobs and income-earning or educational opportunities. The imperatives of national economic growth are focused on urban areas. As a result of these factors, in 16 countries in the Region the average urban population is far above 50% of the total population.

The lack of adequate urban planning, management and an enforceable legal framework, as well as poor governance, are the root causes of health challenges and poor quality of life in cities. Access to safe drinking water, sewerage, air pollution, environmental hazards and unsafe housing is still below standard in many cities, particularly in the urban slum areas where vulnerability is higher compared with advantaged areas. In these areas, violence and injuries are rising and health coverage is often poor for many reasons, including lack of a well-structured health system; the presence of a variety of health care providers with no coordination mechanism; and the long working hours of most family members that mean that little attention is paid to health care services, particularly preventive care.

Health managers face many challenges in urban areas. The lifestyle-related health risks for both the rich and the poor have increased substantially due to urbanization. Unhealthy diets and a sedentary lifestyle with little physical activity are common characteristics of people living in urban areas. Tobacco and illicit drug use is rising.

Delivery of quality health care services to the urban inhabitants of the megacities of the Region is a complex issue that should be assessed and corrective measures should be taken by city planners and managers. To encourage city planners to move towards improving urban primary health care services, the WHO Regional Office for the Eastern Mediterranean, in collaboration with the WHO Centre for Health Development, Kobe, Japan, documented good practices in delivery of urban health care in the Islamic Republic of Iran, Jordan and Oman. These practices can be used as evidence for advocacy and raising political commitment for improving health care delivery in urban settings.

In 1990, the women health volunteers programme was initiated as part of the Islamic Republic of Iran’s health care system. In urban areas, this programme builds a bridge between households and their respective health centre. At present, nearly 100 000 women health volunteers cover more than 20 million people in urban areas across the country. According to the case study, 93% of households consider these volunteers to be the key to their behavioural changes, and 92% are quite satisfied with their work. The study concludes that the women health volunteer initiative in the Islamic Republic of Iran is one of the best examples of low-cost health interventions, worthy of being examined and promoted.

The Ministry of Health in Oman considers primary health care to be the first and main entrance to its health care systems at the different levels, providing the first level of contact between the community and the health system. Moreover, the ministry acknowledges that health is part of the development process in the community and is influenced by social, economic and educational aspects. Health care services are planned and managed through district (wilayat) health committees and community support groups. The wilayat health system plays a pivotal role in addressing social determinants of health and provides the ideal platform for intersectoral collaboration and community participation. The three selected cities for this case study – Seeb, Sohar and Sur – have all shown sociodemographic growth and expansion, which reflects on the health of the population and affects the health indicators. The success of this intersectoral collaboration requires increased community awareness on health issues, and involves maintaining and motivating health volunteers and sustained collaboration between the Ministry of Health and other sectors.

The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) has been the main comprehensive primary health care provider for Palestine refugees for the past 60 years. It promotes a comprehensive approach to health care from preconception to old age, with a strong focus on primary health care and prevention. Primary health care services are provided free of charge for Palestine refugees living in Jordan through UNRWA’s network of 24 primary health care facilities and mobile clinics (16 inside and 8 outside the camps). There is emphasis on maternal and child health services, including family planning, disease prevention and control, and on reimbursement of costs of secondary and tertiary medical care at public and private health care facilities. UNRWA's health care programme offers comprehensive medical care for less than US$ 15 per capita per year.

The study covers two of the largest refugee camps in Jordan and shows that universal coverage and access to quality, comprehensive, integrated and continuing care is well practised in UNRWA camps. A life-cycle approach to health care services is applied at the health centres. The UNRWA health care system has developed a proactive system of risk assessment, surveillance and management. Among the major successes of this practice are keeping and maintaining “healthy family” files; home visits to follow up special cases; a clear mechanism for active participation of refugees in health care assessment; and planning, implementation, monitoring and evaluation through the camp health committee. In-service training is regularly offered for all health care providers and more than 72% of staff said they had extremely excellent or very good overall satisfaction. Patient satisfaction is high: about 90% of the interviewed clients in both centres rated their overall satisfaction as excellent/very good or good. Based on the outcome of these three case studies, to ensure that the urban poor have access to quality primary health care services, countries will need to:

• build a sustained mechanism for intersectoral collaboration for health development;
encourage community participation in urban health planning and management;
allocate sufficient resources to cover the needs of the most vulnerable citizens living in the urban slums.

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UNRWA




Introduction

This case study documents good practices in the provision of primary health care services provided by the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) to Palestinians living in refugee camps and urban areas in Jordan.

UNRWA was established in 1949 and is the largest United Nations programme in the Middle East. It provides assistance and protection to Palestinian refugees in fields of operation in Jordan, Lebanon, Syrian Arab Republic, and West Bank and Gaza Strip. It does so by offering to a population of some 5 million registered refugees a range of human development and humanitarian services in primary health care, along with a social safety net, education, community support, camp improvement and microfinance, with the aim of mitigating the effects of socioeconomic determinants on their health (1).

Palestinian refugees are persons whose normal residence was Palestine during the period 1 June 1946 to 15 May 1948 and who, as a result of the Arab–Israeli conflict in 1948, lost both their homes and their means of livelihood. To be eligible to receive UNRWA assistance, refugees and descendants of such persons in the male line born after 14 May 1948, must be registered with UNRWA and live in the areas of UNRWA operations.

While the refugee population compares well with middle-income countries on some indicators of human development, such as infant mortality, life expectancy, adult literacy and immunization, the picture is less positive in other areas. The prevalence of noncommunicable diseases related to lifestyle is increasing, in line with global trends. There is extreme poverty and vulnerability in all fields of operation, and clear signs that this is worsening in some fields. Unemployment levels among refugees are also high in all fields (1). The context in which UNRWA operates adds more challenges and pressures on the programmes it offers to the refugees, including health.

UNRWA works against a backdrop of significant trends and pressures. These affect UNRWA’s ability to realize its objectives and present challenges to which UNRWA strategy seeks to respond. The factors include the absence of a peaceful solution to the Israeli–Palestinian conflict, ongoing denial of refugees’ rights and recurrent armed conflict in some UNRWA locations, the policies and contributions of UNRWA’s donor countries, and changes taking place within the refugee population itself. (2)
About 2 million Palestinian refugees live in Jordan and constitute 42% of all registered Palestinian refugees with UNRWA (Table 11). Most of the refugees have been granted citizenship and have the same access to health care as other Jordanian citizens. However, refugees who are not citizens, such as those who emigrated from the Gaza Strip in 1967 (about 130 000 refugees), face restrictions on access to state-funded health care, making UNRWA their main health care provider. They also face restrictions on access to higher education and jobs. Therefore, they are the most vulnerable group (1).




Jordan is a lower-middle-income country with limited agricultural land, no oil resources and considerably scarcity of water. Its only natural resources are potash and phosphate. Including its large Palestinian population, it has 6 million people.

The population is highly (80%) urbanized. Most of the urban dwellers live in the capital, Amman. Most of the nearly 2 million Palestinian refugees in the country live in the neighbouring city of Zarqa. Jordan’s population is one of the youngest among lower-middle-income countries, with 35% of the population being under the age of 14 years. Although demographic growth is slowing, the total population is expected to reach almost 7 million by 2015. Jordan’s per capita gross national income in 2010 was US$ 4335 (3).

Refugees in Jordan benefit from considerable integration into Jordanian society, which increases their prospects for human development and poverty alleviation compared with refugees living in other UNRWA fields. The socioeconomic gap between the Palestinian refugee population and the host population in Jordan is minimal. However, substantial socioeconomic gaps remain between camp refugee populations, and non-camp refugee and host populations. Palestinian refugees in Jordan have achieved similar results for selected Millennium Development Goal (MDG) indicators such as infant mortality rate, immunization, deliveries attended by skilled health personnel and maternity death rate as those achieved by the host country (Table 12).




UNRWA health programme

Goals and policies

UNRWA’s goal to provide the best possible health care to Palestinian refugees is part of the greater joint mission of the United Nations and national governments to address the social determinants of health and to achieve health equity. Under this goal, UNRWA has three strategic objectives for the medium term:

• to ensure universal access to quality comprehensive services;
to protect and promote family health;
to prevent and control disease;
to sustain acceptable environmental conditions in refugee camps.

The primary objective of UNRWA’s health programme is to protect, preserve and promote the health status of Palestinian refugees and to meet their basic health needs consistent with basic WHO principles and concepts, and standards of public sector health services in the Region.

UNRWA's overall health policy focuses on the direct provision of essential health services to the Palestinian refugee population. These services fall into two main categories:

• medical care services comprising primary health care provided free of charge through UNRWA’s network of primary health care facilities and mobile clinics, with emphasis on maternal and child health services, including family planning, disease prevention and control, and assistance towards the cost of secondary medical care at public and private health care facilities;

• basic sanitation and related environmental health services, including the planning and implementation of projects for sustainable development in refugee camps.

Health policies, strategies and procedures are clearly defined through a series of technical guidelines, management protocols and manuals that cover all programme components and are periodically updated to be consistent with recent advances in medical technology and best public health practices.

It is evident that primary health care best practice principles and core values are clearly reflected in the goals, strategic objectives and policy directions of the UNRWA health programme.

Governance and management

The Department of Health headquarters in Amman is managed by the Director of Health and his Deputy. The Director of Health reports to the UNRWA Commissioner General on administrative and policy matters and to the WHO Regional Director for the Eastern Mediterranean Region on technical matters. In each of the five fields of UNRWA's area of operation (Jordan, Lebanon, Syrian Arab Republic, West Bank and Gaza Strip), the Health Department is headed by a Field Health Programme Chief, who reports directly to the Field Director on administrative issues and to the Director of Health on technical matters (Figure 4).

Health policy, establishment of targets and development of plans of action to achieve them are usually decided at meetings between the Field Health Programme Chief and headquarters senior staff, and at divisional meetings between staff from the technical units in headquarters and the fields.

This clearly indicates that the organizational structure and the health system governance at UNRWA are built around best practice principles.




UNRWA health programme in Jordan

Health services for Palestinian refugees living in Jordan are provided through a network of 24 health centres (16 inside and eight outside the camps) and through reimbursement of costs of treatment at public hospitals for secondary and tertiary care.

Almost all of the health centres (23) are located in the middle and northern regions of Jordan. The UNRWA annual budget for health in Jordan for 2010 was 18 million US dollars, with an annual per capita expenditure on health of $US 15, the lowest among host countries. The health centres deal with 2.3 million visits each year. The Field Health Programme in Jordan employs about 1064 staff members, including 112 medical officers and 262 nurses.

Objectives of the study

This study was designed to:

• provide a sociodemographic and geopolitical background to the Palestinian refugees living in Jordan;
assess and document the organization of primary health care services delivered by UNRWA to Palestinian refugees (e.g. access, utilization, appropriateness, comprehensiveness, continuity);
assess community participation and intersectoral collaboration for health development;
assess level of satisfaction of clients and health care providers;
share lessons learnt in relation to the objectives, processes, achievements, obstacles, results gained and present options for replicability of the selected best practices that enhance delivery of primary health care services in the study area.

Study setting

The study documents good practice in the provision of primary health care services provided by UNRWA to Palestinians living in refugee camps and urban areas in Jordan. Two UNRWA primary health care centres were selected for this purpose: Nuzha and Baqa’a. These two health centres were selected because they are among the largest UNRWA health centres in Jordan providing comprehensive primary health care services and are located in urban areas highly populated by Palestinian refugees.

Nuzha health centre provides primary health care services for an estimated population of 98 800 Palestinians living outside refugee camps in Nuzha urban area, north-east of Amman. Baqa’a health centre provides primary health care services for 100 000 Palestinian refugees living in Baqa’a camp, which is located north-west of Amman in Balka governorate. Baqa’a camp is considered to be the largest Palestinian refugee camp in Jordan.

Methodology

The study mainly adopted a qualitative approach. Secondary data about the structure of UNRWA health services and the primary health care programme in Jordan were derived from relevant reports and studies prepared by the UNRWA Health Department and field visits and interviews with referents. Figure 5 shows the framework design that was followed throughout the study.



Specific data about the study setting (Nuzha and Baqa’a health centres) were collected during the following interviews. It is important to emphasize that neither the client satisfaction interview nor the staff satisfaction survey were designed to serve as stand-alone surveys, as the sample size for each tool was very small and was not necessarily representative of the study population. Rather, the tools were used to perform quick assessments to complement the results of the qualitative analysis.

Facility survey interview

The facility survey interview included questions about the catchment area; access to care; ongoing care; coordination of patient care; information systems; comprehensiveness of care; family focus and community participation. The questions were answered by the Director of each health centre during an in-depth interview with the researcher. This tool was adapted from the Primary Care Assessment Tool (PCAT), 2009 version. The PCAT instrument was developed by the Primary Care Policy Centre, John Hopkins University in 1998 and has been used to evaluate primary health care services in the Canada, the United States of America and other countries (3).

Client exit interview

A client exit interview was used to perform a quick assessment of client satisfaction with the health care services provided by each centre. This tool was adapted from the PCAT, 2009 version (4) and covered topics related to accessibility of service; waiting time; medical and nursing staff; continuity and availability of services; cost of services; facilities and supplies; and privacy and confidentiality. The exit interview was conducted after the client had received health care services.

A total of 25–30 clients (five or six from each clinic: noncommunicable diseases, maternal and child health, general practice, gynaecology, dentistry) were selected from each centre using a convenient cross-sectional sample. The interview was conducted by a trained interviewer (a health management graduate student) and verbal consent was taken before initiating the interview. A room was assigned by the Director of the health centre for the interview, which usually lasted 15–20 minutes. Interviews were with adult patients, or with the parent (usually the mother) if the patient was a child. The main purpose of the interview was to reflect customer perception and experience about the health services provided.

Staff satisfaction survey

A staff satisfaction survey was also used to perform a quick assessment of the job satisfaction of the staff working in each health centre. The survey covered topics related to job satisfaction, work environment, supplies, management, staff competences, patient satisfaction as perceived by staff, and overall satisfaction. This tool was adapted from different staff satisfaction surveys that were used to assess provider satisfaction in primary health care facilities. The survey was completed by 15 and 20 technical staff from Nuzha and Baqa’a health centres, respectively. The staff, representing doctors, nurses and other staff, were randomly selected from the staff log in each centre. Both the client exit interview and the staff satisfaction survey used a five-point scale (very poor: 1; poor: 2; good: 3; very good: 4; and excellent: 5).

Limitations of the study

It is important to emphasize that the patient satisfaction interviews and the staff satisfaction survey were not designed to serve as stand-alone surveys; because of time and budget limitations, the sample size for each tool was very small and did not necessarily represent the study population. Rather, they were quick assessments to complement the results of the qualitative analysis.

Findings

Primary health care services

Nuzha and Baqa’a health centres, like all UNRWA health centres, provide comprehensive primary health care services with a focus on mother and child care, family planning and disease prevention. These services are detailed below.

Maternal health services

Antenatal and postnatal care services are provided in both health centres according to defined standards and procedures with the ultimate objective of reducing pregnancy-related morbidity and mortality as well as reducing neonatal mortality. Women are registered for antenatal care as early as possible after pregnancy confirmation in order to ensure early assessment of the risk status and to carry out effective and timely intervention, as and when necessary.

The risk approach is used as a tool to provide preventive care to the majority of pregnant women whose condition is normal and to give special attention and care to those identified at risk. In addition, UNRWA subsidizes the hospital delivery of high-risk pregnancies and women who experience complications during labour.

UNRWA places special emphasis on surveillance of maternal deaths, with the main objectives being to investigate the direct and indirect causes contributing to such deaths and to adopt appropriate intervention strategies to reduce mortality from preventable causes.

Family planning

The main objective of the family planning service is to promote the health of mothers, children and subsequently their families. This is achieved through the provision of a high-quality family planning programme that advocates birth spacing to avoid too frequent, too early and too late pregnancies. Both health centres offer a wide range of modern contraceptive methods, including pills for breastfeeding mothers, pills for non-breastfeeding women, intrauterine devices, condoms and spermicide vaginal suppositories. These methods are offered to clients free of charge to increase accessibility and acceptability.

Training on proper counselling of clients enrolled in the family planning programme is maintained as an ongoing process aiming at enhancing the skills and capabilities of staff leading ultimately to behavioural changes in reproductive health practices.

Child health

In addition to maternal health services and family planning, both health centres provide several cost-effective preventive measures to reduce mortality among infants and young children. These include immunization, growth monitoring, promotion of breastfeeding, oral rehydration for diarrhoeal diseases, food supplementation for the malnourished, and iron supplementation for the anaemic.

Prevention and control of noncommunicable diseases

UNRWA has made commendable efforts to integrate noncommunicable disease management within primary health care in order to address the changing health needs of the refugee population. An opportunistic screening programme is in place in both health centres for detection of diabetes and hypertension in adults over 40 years who attend the health centres. All new patients have a clinical examination, urine analysis, blood sugar estimation, lipid profile and serum creatinine assay at their first visit. Patients are followed up in general outpatient clinics based on an appointment system.




Oral hypoglycaemic drugs, insulin and antihypertensive drugs are provided free of charge. Counselling on healthy lifestyles is given by nurses and medical officers. Both health centres have introduced a system to monitor follow-up visits of patients and to improve compliance rates.

Curative medical care services

Curative medical care services are also provided in both health centres and consist of outpatient care, dental care and rehabilitation of physically disabled persons, complemented by essential diagnostic and support services such as laboratory and radiological facilities, specialist and special care, and provision of medical supplies.

Table 13 summarizes the primary health care and medical services provided by Nuzha and Baqa’a health centres.

Staff and workload statistics

Table 14 and Table 15 list the staff categories and the monthly workload statistics for each centre, respectively. The health centre operates 6 days weekly (Saturday to Thursday), from 8 am to 2 pm. The two centres have heavy patients’ workload with an average of 90 daily consultations per medical officer.



Best practices in UNWRA primary health care, including at Nuzha and Baqa’a health centres

The evidence provided by the site visits, along with the review of UNRWA documents, interviews with referents and the findings of the data collection tools demonstrate that, with limited resources, UNRWA has succeeded in building a health care system based on the criteria and principles of primary health care best practice. In addition to the best practice principles relating to sound policy, legal and institutional framework (structure and governance) that are adopted at the macro level of UNRWA’s health care programme, the following best practices were found in both Nuzha and Baqa’a health centres and would most likely be found in all UNRWA’s health centres.

Universal coverage and accessibility

All registered Palestinian refugees, irrespective of their income, social status or gender, are eligible for UNRWA health services. Nuzha and Baqa’a health centres, as other UNRWA health centres, are located in refugee camps or in residential areas within walking distance for most of the targeted population.

UNRWA health services are provided according to the needs of the patients and not according to their ability to pay. All primary health care services, including medicines, are provided free with no charges or copayment. Most of the primary health care services and programmes are designed to serve the vulnerable refugee population, i.e. mothers, children and the elderly.

Comprehensive, integrated and continuing care

The health centre provides comprehensive and in¬tegrated primary health care, comprising outpatient medical care services, disease prevention and control, maternal and child health and family planning services.

UNRWA has adopted the life-cycle approach to health care as a tool for providing comprehensive, integrated and continuing for refugees from preconception to active ageing (Figure 7) (5). In the maternal and child health clinic at Nuzha and Baqa’a health centres, comprehensive and integrated care is offered to women of reproductive age, to infants and children of 0–3 years of age, and to school-age children. Strong emphasis is placed on continuity of care and finding those who, for whatever reason, stop attending scheduled follow-up visits. There is a proactive system of risk assessment, surveillance and management in place. Family planning services are fully integrated within the maternal and child health services in each health centre.

As in all UNRWA's primary health care centres, noncommunicable disease care is also fully integrated within activities. It is based on technical guidelines and standard management protocols, emphasizing the risks factors and supporting appropriate health-promoting activities.




UNRWA also has much experience in the Region with regard to integration of special programmes into its primary health care activities, including control of noncommunicable diseases, prevention of micronutrient deficiencies, school health and family planning services.

Emphasis on promotion and prevention

All UNRWA’s health programmes are designed and built on health promotion and prevention of disease, death and disability. The following objectives of the maternal and child health programme, which are directed at more than 60% of the registered Palestinian refugee population, clearly reflect this principle:

• to reduce pregnancy-related morbidity and maternal mortality from preventable causes by regular monitoring of women registered at mother and child health clinics;
to reduce infant and early child morbidity and mortality through regular growth monitoring and protective immunization of children registered at mother and child health clinics, as well as by early detection and management of morbidity conditions;
to promote the health status of school children by regular monitoring, booster immunization and early detection and treatment of morbidity conditions amenable to management;
to reduce maternal, perinatal and infant morbidity and mortality by offering family planning services to women of reproductive age, with special emphasis on child spacing.

An opportunistic screening programme is in place for detection of diabetes and hypertension in adults over 40 years who attend any of the health centres.

UNRWA's school health programme places special emphasis on regular screening for early detection of physical impairments and morbidity conditions amenable to management. Preventive oral health is an essential component of the programme.

UNRWA continues to devote special attention to early detection and management of micronutrient disorders, especially iron-deficiency anaemia, which is still highly prevalent among preschool children and women of reproductive age.

Neonatal screening for phenylketonuria and hypothyroidism was integrated into URWA’s health programme in Jordan in August 2009. The programme aims at quick identification of neonates with rare, serious but treatable disorders. Early diagnosis and treatment of affected infants results in normal growth and development and significant reduction of human and financial costs for families and society.

Family and community-based programmes

Most of UNRWA’s health programmes and the services provided by the health centres are family focused. “Healthy family” files, which contain the medical history of each family member including a list of any chronic and familial diseases, are maintained in the health centres. Despite their heavy workload at the UNRWA health centres, health professionals also carry out home visits to follow up special cases, including high-risk deliveries and communicable diseases. They are also involved in activities to improve the environment of populations served by the health centre.

Mechanisms to encourage community participation

UNRWA tries to increase community participation and involvement in all activities and programmes aimed at health development in line with the WHO Global strategy for health for all policies. Health education and promotion programmes are implemented at facility and community levels through materials developed by UNRWA and other health-related agencies such as WHO.

A camp health committee has been established to ensure that community members are involved in the assessment, planning, implementation, monitoring and evaluation of primary health care services. The committee also follows up daily health issues in each camp. Members of the committee include representatives from the health centre, the camp administration, the education department, local leaders, the police, and frequent users of the health centre.

Intersectoral partnership and collaboration

UNRWA’s health department has adopted the integrated community-based actions framework as an integrated, bottom-up approach to socioeconomic development along with other UNRWA programmes. It aims to reduce poverty in camps, improve health and environmental conditions, achieve better quality of life for Palestinian refugees and integrate health policies and programmes in all UNRWA strategic development agendas. UNRWA's health programme is partnered with national institutions, nongovernmental organizations, the private sector, academia and international organizations. It cooperates and coordinates with WHO and other United Nations agencies by participating in different thematic groups.

UNRWA's health department coordinates with the Jordanian Ministry of Health through a number of technical committees on immunization, nutrition, tuberculosis and reproductive health. Contraceptives and vaccines are supplied through the Ministry of Health according to a Memorandum of Understanding between the Ministry of Health and the UNRWA. Contractual arrangements are also made with the Ministry of Health for services that are not provided by UNRWA, including secondary and tertiary hospital care.

For the third time, UNRWA participated in the annual National Breast Cancer Awareness Campaign in Jordan in October 2010, in collaboration with the Ministry of Health. The campaign includes health staff training; clinical breast examination; health education and counselling; training on breast self-examination; and referral of highly suspicious cases for mammography.

In partnership with the Ministry of Health, neonatal screening for phenylketonuria and hypothyroidism was integrated into UNRWA’s health programme in August 2009. Specialist training of nursing and laboratory staff to conduct such screening was accomplished with support from the Ministry of Health.

Quality control

The health programme has highly standardized technical procedures, guidelines and management protocols that reflect WHO standards, international evidence-based criteria, approved UNRWA policies and best practice in public health. Monitoring of implementation is carried out through a systematic assessment of outcomes based on measurable indicators and fostered through regular visits to the fields by headquarters staff.

UNRWA had initiated the Total Quality Management Programme, in which each health centre chooses a weak point in its results and designs various ways of addressing this. The working culture of UNRWA is oriented towards improvement of quality of care and performance. This is one of its notable strengths.

Affordability, sustainability and responsiveness

Owing to funding shortfalls and ever-increasing demands, UNRWA's health policy focuses on selection of effective and affordable preventive interventions that yield the greatest possible improvement in population health for the available resources.

The success of UNRWA's health care system can largely be attributed to its ability to adjust programme policies and strategies consistent with the concepts and principles of WHO, as well as to its ability to respond to the changing needs and priorities of the population it serves. As described, UNRWA health centres provide primary health care according to WHO strategies in infant and child health, maternal health, family planning and diagnosis and treatment of common diseases.

The organizational structure of UNRWA, with established field offices, provides the kind of decentralized network, knowledgeable and attentive to local sensitivities, that is capable of responding to the particular needs of refugees within each host country.

Efficiency and cost effectiveness

UNRWA's health care programme offers comprehensive medical care to the Palestine refugee population for less than US$ 15 per capita per year. Considering the programme's tangible achievements and the wide range of services, UNRWA is considered one of the most cost-effective health care providers in the Region.

By using a limited number of effective and essential drugs and efficient methods for procurement of drugs and medical supplies, UNRWA has been able to provide a wide range of services to patients at a relatively modest cost. UNRWA has considerable experience in providing effective primary health care services for relatively modest expenditure and the strategies and overall approach used could provide useful lessons to other agencies.

Though UNRWA is very efficient in making the best possible use of limited resources, more funds should be secured by the international community to sustain and develop existing health services and achieve future improvement of the health status of the refugees.

Human resources

Developing human resources for health is a key element of UNRWA's health strategy. In-service training is regularly offered in health services management, reproductive health and family planning, child health, school health, prevention and control of communicable and noncommunicable diseases, communication and counselling skills, and quality assurance of laboratory services.

UNRWA has embarked on a development project to enhance the skills and capabilities of its medical and nursing staff in the areas of epidemiology, reproductive health counselling, total quality management and information technology.

The results of the health care provider satisfaction survey conducted at Nuzha and Baqa’a health centres show that more than 72% of staff had excellent or very good “overall satisfaction” (Table 16). General satisfaction with job-related factors such as “skills and experiences match job requirements”, “reasonable methods and standards to do the job and measure performance”, “training needed to do the job” and “stimulating jobs tasks” scored highest in both hospitals. A total of 75% and 65% of staff had excellent or very good satisfaction with these factors at Baka’a and Nuzha health centres, respectively. Staff were least satisfied with “rates of pay” and “opportunity of career advancement within the organization”.




In general, the administrative, medical and supporting staff at Baka’a and Nuzha health centres are highly motivated and strive to deliver a high-quality service, despite heavy workloads and insufficient resources.

The providers recommend that UNRWA redistribute the workload among staff in a more equitable manner, relate payment to performance, provide more opportunities for career development, add separate rooms for waiting areas, renew equipment and recruit more medical and nursing staff.

It is evident that most of the staff recommendations could be met if UNRWA had sufficient financial resources.

Electronic health information system

The electronic health information system is an integrated computerized health information system that streamlines the collection of data and consolidates information to enhance patient data management and decision-making. The system has been piloted since 2009 at Nuzha health centre. It covers the master patient index, appointment system and three modules: noncommunicable diseases; mother and child health; and pharmacy. The electronic health information system is designed to enhance the quality of health care; increase collaboration among health care teams; increase contact time and decrease waiting time; improve patients’ health outcomes through enhanced disease management and rational drug use; and improve the statistical reporting system. The two quick satisfaction surveys that were performed at Nuzha health centre as part of this study showed that clients and providers were happy with the new electronic health information system project.

“The electronic health information system project is one of the things I like best at the health centre; it decreases clerical work and saves more time for patient care.” Medical officer, Nuzha health centre

Client satisfaction

The results of the limited and quick client exit survey conducted at both Nuzha and Baqa’a health centres (Table 17) revealed that clients were highly satisfied with the accessibility of services (more than 84% rated it as excellent or very good), followed by “privacy and confidentiality” and “medical staff skills”, while they were least satisfied with areas related to “waiting time” and “availability of medicines”. They reported that they usually experienced problems with availability of medicines at the end of the month. About 90% of the interviewed clients in both centres rated their “overall satisfaction” as excellent/very good and good.




Most of the clients surveyed, and especially those who visited maternal and child health clinics, reported that they had received health education and counselling during their visits to the centre. They received counselling in areas such as antenatal and postnatal care; family planning; breastfeeding; immunization; child growth monitoring; and nutrition.

Clients expressed a wish that UNRWA would increase the number of doctors; make medicines more available; expand facilities; and raise the level of cleanliness, especially in bathrooms. They also urged UNRWA to provide emergency and ambulance services.

Research

Since the 1990s, UNRWA has become increasingly interested in policy analysis and research and its Health Department is now integrating research, policy analysis and knowledge management into its work. Tens of research studies and assessment reports have been performed during the past 15 years in areas related to mother and child health and family planning; noncommunicable disease prevention and control; supplies and drugs; utilization of health services; health information; and cost–benefit analysis. The information derived from these studies has been translated into evidence-based policies and programmes.

Conclusion

The impressive achievements of UNRWA in almost all aspects related to best practices in primary health care as presented in this study are not without challenges. The following challenges were identified.

• The workload of doctors at the two centres is excessive and may have a negative impact on delivery of quality care.
Underfunding is negatively impacting on the availability of the necessary workforce and technology.
The chronic imbalance between the health needs and demands of the refugee population on the one hand, and the human and financial resources available to the health programme on the other, may lead to the discontinuation of some health services to cope with budget constraints.
The growing burden of demographic transition and noncommunicable diseases among Palestinian refugees is placing increased demands on an already stretched and underfunded health care service.
There is a lack of provision for early detection and management of cancer and disabilities.
There is an absence of a peaceful solution to the Israeli–Palestinian conflict, ongoing denial of refugees’ rights, and recurrent armed conflict in some UNRWA locations.

The following action points were identified.

• Explore new means and strategies for resource mobilization to tackle financial problems.
Engage active participation by the communities to facilitate positive responses from communities to change, whether in relation to existing services or to the introduction of new services.
Explore possibilities of further collaboration with the Jordanian Ministry of Health and other concerned agencies to obtain human and technical support to sustain its best practice in primary health care.
Assess the need for services relating to screening for cancers of the breast and cervix and take appropriate measures.
Adopt volunteers’ programmes to attract national and international health professionals to work in overcrowded UNRWA health centres.
Share best practice in primary health care with host countries.
Extend or modify health centre operating hours to provide more equitable health service access to those in employment.
Extend the electronic health information programme to all facilities and train staff in information technology.


References
1. Annual report of the Department of Health 2009. Amman, United Nations Relief and Works Agency for Palestine Refugees in the Near East, Department of Health, 2010.
2. UNRWA Medium term strategy 2010–2015. (www.unrwa.org/userfiles/201003317746.pdf, accessed september 2010).
3. Government of Jordan. Department of Statistics. (http://www.dos.gov.jo/sdb_pop/sdb_pop_e/index.htm, accessed 12 September 2010).
4. Starfield B, Shi L. Manual for the primary care assessment tools. Baltimore, John Hopkins University, 2009.
5. Long and healthy lives: The life cycle approach to health. Amman, United Nations Relief and Works Agency for Palestine Refugees in the Near East, Health Department, 2009

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