Question of Palestine home
World Health Organization (WHO)
7 April 2006
Possible consequences on the health sector due to the reduction of
support to the public services
Expected scenario in case of donors cutting budgetary support to the PA and Israeli suspension of VAT transfer.
MoH acute financial crisis, salaries will not be paid to a certain proportion of MoH staff, and medical supply will be in shortage.
Rapid decline of the public health system towards a possible collapse.
Shift of control and management of health service system away from the public sector to NGOs, UN system and the private sector.
No access -or limited access- to preventive programs and curative services for an important part of the population, particularly for the poor (1,564,137, 43% of total population)
2. CONSEQUENCES ON HEALTH AND THE HEALTH SYSTEM
A WHO analytical framework for health priorities has been used, to analyze the possible consequences of the described scenario
A. CONSEQUENCES ON THE HEALTH SYSTEM
- Paralysis of the MoH, or an MoH less capable of developing health policy, regulatory and coordination related functions.
- Increased fragmentation of the health system resulting from lack of homogeneity of standards and protocols, which will produce inequities in the access to health services.
2. Health care financing
- Lack or decreased amount of funds
to cover MoH needs, disruption or reduced capacity in public health financing.
- Salaries of the civil servants (57% of all health workers)
not paid or increased difficulties in paying them
- Large absenteeism among public sector health staff, increased drain of MoH professionals to NGO and private sector.
- Severe shortage of drugs and medical supplies
- Increased proportion of health financing through user charges, as a consequence of increased use of private providers.
3. Resource generation
- Training and capacity building activities suspended.
- Maintenance, rehabilitation and development of health facility network equipment and infrastructure suspended.
4. Service provision
- Breakdown of more than half of total PHC centers (56.5% of all PHC facilities are MoH run), due to irregular or non-attendance of health staff, and to lack of drugs and supply.
• Drastic reduction of service availability and accessibility
• Efficiency and quality compromised
• Equity compromised
• Reduced sustainability
B. CONSEQUENCES ON THE HEALTH PROGRAMMES
1. Preventive and promotive programs
413 PHC centers (357 in the WB and 56 in Gaza) and 140 to 252 maternal and child health clinics (208 in WB and 44 in Gaza) will be affected, leading to an important or drastic reduction of their service provision capacity towards their closure.
Programs likely to be affected (numbers refer to 2004 data):
• Immunization: 65,796 children (35% of the children in Gaza and 85% of the children in the WB) were immunized in the MoH facilities.
• Supplementation: 63,736 children (72.8% and 47.9% of the children 3 weeks -12 months in the WB and Gaza respectively) received Vitamin A and D supplementation.
In addition, 79,037 pregnant women (78.9% of all pregnant women in the WB and 71.8% in Gaza) received iron supplements
• Growth monitoring: 65,796 children receive monitoring.
• Antenatal and postnatal services: services received by 90,409 women (96.5% of all pregnant women) and 31,263 (33.5% of all pregnant women) respectively, received ante-natal and post-natal care mainly through the MoH MCH centers
• Delivery services: 59,731 deliveries (55.2% of total deliveries) occurred in MoH hospitals and clinics in 2004.
• Health education and promotion
2. Curative and rehabilitative programs
Reduction or closure of secondary and tertiary level curative and rehabilitation care in MoH hospitals.
Services likely to be affected:
• Maternity: 47% of maternity beds are located in MoH hospitals. In 8 (over 15) districts, 100% of maternity facilities are from MoH.
• General hospitals: 61% of general hospital beds are located in MoH hospitals (66% of internal medicine beds, 71.3% of pediatric beds and 58% of the surgical beds are located in MoH hospitals)
. No general hospital beds are present in 5 districts.
• Other hospital services
Admissions: 278,839 patients (7.67% of the total population) were admitted to the MoH general hospitals; 8,732 admissions to the emergency hospitals and 879 to the mental hospitals.
Out-patients: 751,988 patients (20.67% of the total population) benefited from the MoH out-patient departments.
Surgical operations: 72.4% were performed in the MoH hospitals.
482 patients are on regular hemodialysis in the MoH hospitals.
• Tertiary care services:
Tertiary care services are provided in two MoH hospitals in Gaza and the WB. The majority of patients in need of tertiary care are referred to the non- MoH hospitals in Gaza and the West Bank or abroad to Israel, Egypt or Jordan, and are financially covered by the MoH. In 2004, 31,744
patients were in need of tertiary care services that are not available in the MoH hospitals.
• Emergency services: 976,400 patients (26.84% of the total population) received emergency services in MoH hospitals.
C. CONSEQUENCES ON SOCIAL DETERMINANTS OF HEALTH
Unemployment will increase and purchasing capacity, including purchasing of health services, will decrease. Further deterioration of the situation of an already vulnerable population is expected
The overall environmental situation will be degraded. Sanitation, drainage and cleaning services will be hampered, increasing the possibility of more infections and infestations. 72.9% of the total population depends on the public water network, 50.9% depend on the public sewage disposable system
228,677 non-refugee women of child bearing age (57.9% of total Palestinian women) will be more vulnerable, due to reduced capacity of ante-natal care services and safe-delivery facilities
Reduced ante-natal care, safe delivery services and post-natal care may lead to increased health related susceptibility for infants. Levels of other services such as immunization, micronutrient supplementation and health promotion activities will also determine the level of health risks.
Stress levels (frustration, helplessness, hopelessness) will increase, resulting in increased physical and psycho-social problems and social unrest.
Difficulties in the implementation of social policies due to the under-funding of public services.
The population will have reduced access to the transportation due to the economic problems.
Increasing nutritional problems.
The poverty line is defined as per capita consumption of US$ 2.3 per day for a benchmark household of two adults and four children, under a consumption-based definition (43%) of poverty compared to the income-based definitions (64%).
The analytical framework includes:
A. Health system: Governance (information, policy formulation, organization and management, partnership building, regulation, accountability); Health care financing (collection, pooling, purchasing); Resource generation (human, physical including technology assessment); Service provision (access, efficiency, equity, quality, sustainability)
B. Health programs: Preventive and promotive programs (disease control, health education); Curative and rehabilitative programs (hospital and health care services); Emergency programs (emergency health assistance)
C. Health determinants: Globalization; poverty; environment; gender. WHO Eastern Mediterranean Region: Health systems priorities in the Eastern Mediterranean Region: challenges and strategic directions. September 2004.
The MoH expenditure in 2004 was US$ 134,222,222 (59.8% for salaries,18.9% for medications and medical supplies and lab reagents, 18.7% for operating costs and 2.6% for capital expenditure).MoH: Health status in Palestine, Annual Report 2004: August 2005.
The MoH health staff are distributed as follows: (physicians: 2,017, nurses: 3,042, midwives: 222, health workers: 104, dentists: 179, pharmacists: 341, paramedical: 1,214 and administrators: 4,005). MoH: AnnualReport 2004, op.cit.
Health workforce crisis is having a deadly impact in the ability to fight disease and improve health, new WHO report warns. World Health Day 2006, Media Advisory WHO/1.
In 2004 the MoH spent US$ 25,333,333 ( 70.5% for hospitals and 29.5% for the Primary Health Care. Ibid.
PCBS- Demographic and health survey (DHS) 2004,June2005.
PCBS DHS 2004, op.cit.
Growth monitoring in the MOH clinics coincides with the vaccine schedule. The state of nutrition , West Bank and Gaza Strip: A comprehensive review of nutrition situation of West Bank and Gaza Strip: June 2005.
PCBS DHS 2004, op.cit. In 2004, the total no. of pregnant women was 104,235, out of which, 10% are followed by the UNRWA clinics and the others followed mainly by the MOH facilities, so the presented numbers could be over estimated to be followed by the MOH MCH centers since there are other centers that are managed by NGOs and provided the MCH services.
WHO West Bank and Gaza Strip, MoH, PHIC: Health facility database, August 2004.
All the services provided by the MoH have steadily increased since 2000, with an annual average increase in the last five years of 10.09% for admissions, 12.7% for the out-patients, 15.58% and for the surgical operations. MoH annual report 2004, op.cit.
These patients were referred for hospitalization and consultation to the non MoH hospitals in Gaza (2,097), West Bank (9,283), East Jerusalem (8,264) and abroad to Egypt (4879), Jordan (4,665) and Israeli (2,556), with a total cost of US$ 58,079,245,which formed 45.92% out of the MoH actual health expenditure.
The emergency services have steadily increased since 2000 with an annual average increase in the last five years of 19.77%. MoH annual report 2004, op.cit.
Marmot M, Wilkinson RG. (Eds.) Social Determinants of Health. Oxford: Oxford University Press, 2006.
By the end of 2006, unemployment rate and poverty rate will increase to 39.6 % and 67%, respectively, in and in the presence of the movement restrictions that the Israelis imposed on the Palestinians and reductions of the Aid flow. World Bank: Economic update and potential outlook, March 2006.
PCBS: DHS 2004, op.cit.
WHO calculation bases on the proportion of women in child bearing age in the West Bank and Gaza Strip and the proportion of the refugees in each region, MoH annual report 2004, op.cit.
Currently, wasting amongst children under five stands at 18,133 (2.8%) , stunting at 64,112 (9.9%), and 31,732 (4.9%) are underweight. PCBS: DHS 2004, op.cit
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