28 September 2021
The occupied Palestinian territory reforms its hospital sector to make progress towards universal health coverage
THE LONG READ
As COVID-19 spread across the occupied Palestinian territory, Dr Bassel Bawatneh, Acting Director of the Hugo Chavez Hospital, found himself not only serving as a medical professional but also performing social care to help fill the gap in hospital staff to carry out all the necessary duties. The hospital had been turned into the COVID-19 treatment and isolation centre for patients from Ramallah District.
In March 2021, Dr Bawatneh, found his retired Arabic language teacher, Mohammed Mhanna, critically ill in one of the wards. He visited Mohammed’s bedside regularly, providing friendship, comfort and kindness until Mohammed succumbed to the disease. Despite the tragic circumstances, Dr Bawatneh knew that Mohammed was pleased that one of his former students was looking after him.
“More than half my time is given to social support for elderly people. It’s hard for them to understand why their children can’t visit. If we don’t focus on the social aspect of our elderly patients, we might lose them. I cannot lose a patient with respiratory problems just because of lack of social support, so we try to control all other aspects in order to give them the medical care they need,” said Dr Bawatneh.
Social care is one of the many important functions that the health system needs to provide. The gaps in this area demonstrate how much the hospital sector in the occupied Palestinian territory struggles to meet all the needs of patients.
WHO, through the Universal Health Coverage Partnership (UHC Partnership), is working closely with the Ministry of Health to support the development of the hospital sector. This is part of overall efforts to strengthen the health system, enhance linkages to primary health care (PHC), and make progress towards universal health coverage (UHC).
The occupied Palestinian territory is among the 115 countries and areas to which the UHC Partnership helps deliver WHO support and technical expertise in advancing UHC with a PHC approach. The Partnership is one of WHO’s largest initiatives on international cooperation for UHC and PHC. It is funded by the European Union (EU), the Grand Duchy of Luxembourg, Irish Aid, the Government of Japan, the French Ministry for Europe and Foreign Affairs, the United Kingdom – Foreign, Commonwealth & Development Office, Belgium, Canada and Germany.
On 7 March 2021 Dr Bassel Bawatneh, Acting Director of the Hugo Chavez Hospital, treats Mohammed Mhanna for COVID-19 at the Hugo Chavez Hospital in Ramallah, occupied Palestinian territory. Mr Mhanna is a retired Arabic language teacher and Dr Bawatneh is his former student.
© WHO/Noor-Tanya Habjouqa
Dr Bassel Bawatneh, Acting Director of the Hugo Chavez Hospital, is photographed in Ramallah, occupied Palestinian territory on 7 March 2021. In addition to medical care, Dr Bawatneh aims to provide social support for elderly patients who cannot see their families. Habjouqa
Strengthening the hospital sector to accelerate universal health coverage
Hospitals, combined with effective PHC, are essential in achieving UHC. In practice, this means that an effective PHC system, operating within or closer to communities, serves as the first point of contact of patients and their pathway to hospital care. This can be improved through strengthening the referral system, which will send patients from PHC to hospital and vice versa.
A renewed focus on hospital roles, functions and operations through an integrated and people-centred lens is critical. It brings a fresh perspective on the features of hospitals that are needed to meet present and future challenges to health and health systems. The experience of COVID-19 shows the importance of hospital care when needed. By mid-July 2021, the occupied Palestinian territory had over 340,000 cases and 3,800 deaths.
The WHO Regional Office for the Eastern Mediterranean has previously developed a regional framework for action for the hospital sector, which is now informing WHO’s work in the occupied Palestinian territory in collaboration with the Ministry of Health.
WHO has also promoted the use of simulation exercises to help ensure that effective emergency response systems are in place and that plans and procedures are practiced. In 2019, for example, the occupied Palestinian territory, in collaboration with WHO, conducted a simulation exercise to help develop, assess and test functional capabilities of emergency systems, procedures and mechanisms to be able to better respond to outbreaks or public health emergencies.
On 7 March 2021 head nurse Hayel Ishtaye checks on a patient in the COVID-19 treatment and isolation centre at Hugo Chavez Hospital, Ramallah, occupied Palestinian territory.
© WHO/Noor-Tanya Habjouqa
Developing the hospital sector
According to the cooperation strategy between WHO and the occupied Palestinian territory, ‘The health of Palestinians in the occupied Palestinian territory has been uniquely affected by occupation by Israel, which has been ongoing since 1967. Health concerns relate not only to the direct effects of conflict and military action but also to the impact of the occupation on human security, well-being and the wider determinants of health. Periodic escalations of violence especially affect the Gaza Strip, and geographical fragmentation and restrictive policies further compound public health risks and constrain opportunities for development. In addition to the health consequences of the occupation and frequent bouts of violence, the Palestinian people face the challenge of a rising burden of noncommunicable diseases, similar to neighbouring countries.’
In 2020, there were 87 hospitals in the occupied Palestinian territory with 6,552 beds, a ratio of 13.2 beds per 10,000 people. This ratio compares favorably to Jordan and Egypt with a ratio of about 14 beds per 10,000 population.
The Ministry of Health is the main provider of hospital care, running just over 3,500 hospital beds in 28 hospitals throughout the area. Other providers are the United Nations Relief and Work Agency for Palestine refugees, the private sector, and non-governmental and faith-based organizations.
A complementary relationship exists between the different health care levels, with a referral system between the PHC and hospital care. Nevertheless, self-referral is common and both public and non-government or private hospitals may receive patients who are not referred through PHC. Anecdotal reports indicate that a sizeable proportion of patients seeking care in the outpatient clinics or emergency departments of hospitals could have been managed properly at the PHC level instead of being attended to at the hospital level. This has implications on the increased workload of hospital staff and cost for the system.
On 7 March 2021 head nurse Hayel Ishtaye treats patient Raed Taweel in the COVID-19 treatment and isolation centre at Hugo Chavez Hospital, Ramallah, occupied Palestinian territory.
© WHO/Noor-Tanya Habjouqa
THE STORY CONTINUES BELOW
“There are many challenges facing the hospital sector in the occupied Palestinian territory. The increasing demand for hospital services is noticeable, mainly due to increased incidence and morbidity rates of noncommunicable diseases, rapid population growth and the aging population. Additionally, there is a huge financial burden caused by an influx in referrals especially to areas outside the occupied Palestinian territory. Among others, these challenges put a strain on the ability of hospitals to operate and makes hospital service planning an issue of high priority for the Ministry of Health,” said Dr Anan Rashid, Hospital Directorate, Ministry of Health.
Following a high-level mission in 2019 conducted by a team from WHO headquarters and the WHO Regional Office for the Eastern Mediterranean to support the occupied Palestinian territory on its trajectory to UHC, the Ministry of Health decided to put service planning as a top priority for achieving UHC. In March 2021, WHO supported the Ministry to develop a hospital sector profile for the occupied Palestinian territory to understand the current situation, identify challenges and set the future outlook. This profile will be used to initiate policy and societal dialogue to agree on entry points for strengthening hospital sector policy.
“We consider hospitals key players of the Palestinian health care systems. Hospitals, however, face major challenges; at certain times occupancy rates even exceed 100%. The population is growing with an increased ratio of the elderly. We are also short of specialized human resources and this puts a pressure on existing staff and is causing an influx in referrals. This was apparent during the COVID-19 pandemic and caused challenges in response. There is definitely a need for service planning to efficiently use our resources and to ensure that services are provided to the people as needed,” said Dr Ola Aker, Director of Planning at the Ministry of Health.
The Ministry of Health is currently preparing to adopt the WHO-promoted strategic framework for action on the hospital sector according to national priorities. The main goal is to ensure the provision of comprehensive services for all citizens within the occupied Palestinian territory by reducing referrals abroad and increasing the availability of services in Palestinian public and private hospitals based on public-private partnership.
On 23 March 2021 nurse Eman Hamarsheh administers a COVID-19 vaccine to Khalil Khalil, 77, at a vaccination site by the Health Directorate in Ramallah district, occupied Palestinian territory.
© WHO/Noor-Tanya Habjouqa
“Service planning is important to ensure all the people in need receive quality health services on time. In countries where conflict exists, the need for service planning becomes more apparent and difficult due to the presence of additional challenges in infrastructure, management, human resources, medical supplies and equipment and the limited financial resources. WHO supports the Ministry of Health in service planning to ensure the hospital sector is transformed to provide hospital care efficiently and effectively and to meet the most challenging needs in referral, inpatient and outpatient care, ” said Dr Richard Peeperkorn, WHO Representative for the occupied Palestinian territory.
While a strategic policy framework for hospital development and distribution has yet to be prepared, the development of the hospital sector and distribution of hospital beds over the occupied Palestinian territory has been addressed as part of the National Health Strategy. The current plan for the period 2017-2022 has been updated for the period 2021-2023, which takes into consideration the impact of COVID-19 on the context and strategic direction. WHO will facilitate the dialogue with and further support the Ministry of Health in the process of developing a hospital strategy and hospital master plan. These two documents will be key to setting the direction for investments and reforms in the hospital sector, which will ultimately lead to improved health outcomes.
The Ministry of Health has also recently adopted the family practice approach in its PHC services, to streamline the relationship with hospitals and augment two-way referral and communication. The essential health service package includes secondary health care services in public hospitals, emergency care, free services for children under the age of 6, and free services for patients with chronic mental disorders. All these efforts contribute towards the occupied Palestinian territory taking steps to achieve UHC and health for all.
On 24 March 2021 nurse Haya Shujaiya administers the COVID-19 vaccine at a vaccination site by the Health Directorate in Ramallah district, occupied Palestenian territory.
© WHO/Noor-Tanya Habjouqa
Drawing on the WHO regional framework for action in the hospital sector, WHO, through the UHC Partnership, has provided technical support to the Ministry of Health in the occupied Palestinian territory to strengthen its hospital sector development and policy. At least 53 hospitals in the West Bank with around 520,000 annual patient admissions, as well as 34 hospitals in Gaza, will benefit from improved services once the hospital sector policy is implemented. This effort strengthens the capacity of the occupied Palestinian territory to ensure that more people receive the health services they need, even in the face of conflict and a pandemic.