THE PUBLIC HEALTH SUPPLY CHAIN IN THE STATE OF PALESTINE: A TRIBUTE TO RESILIENCE

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1 PALESTINE 1 CASE STUDY: PALESTINE THE PUBLIC HEALTH SUPPLY CHAIN IN THE STATE OF PALESTINE: A TRIBUTE TO RESILIENCE ABSTRACT The State of Palestine is a nation in conflict and has been so for the past fifty years. The political and socio-economic context, as well as its relationship to neighbouring countries and the world at large is highly complex and controversial. There appears to be no progress towards peace and no lasting solution in sight. Access to quality health care for Palestinian citizens is becoming increasingly difficult, due to ever tightening security measures and movement restrictions imposed by the Israeli authorities. Despite this, the public health programme in Palestine is one of the most successful in the region; its child immunization program being a prime example. Contrary to common expectations, a visitor to the State of Palestine encounters a high-performance health supply chain system, led by a dedicated and committed leadership. Notwithstanding the many challenges, including restriction of movement, trade embargoes and import blockages, this nation has established a comprehensive childhood vaccination programme with some of the highest vaccination coverage rates in the world. The reasons behind this remarkable achievement may be found in the commitment and determination of the people that make up the Palestinian public health workforce. Valuable lessons can be learned from this country, not only for health supply chains in similar contexts, but also for those operating within more stable environments.

2 2 PALESTINE PALESTINE: A STATE IN CONFLICT The State of Palestine, also referred to as the occupied Palestinian territories (OPT), consists of a small area in the Middle East, west of the Jordan River. The two geographical areas that make up the OPT are the West Bank (including East Jerusalem) and the Gaza Strip. The total population is around 4.6 million (2016 estimate). A comprehensive historic and political account of the Israel Palestine conflict is well outside the scope of this study. There are, however, excellent resources available for readers who wish to dig deeper. Israeli occupation of the Palestinian territories started after the Six- Day War in Parts of the OPT came under the legal and political control of the Palestinian National Authority (PNA) after the Oslo Accords in Currently, Israeli occupation is present in almost two-thirds of the West Bank. Palestinian frustration is expressed by frequent demonstrations, hostilities and in some cases extremism. Many attempts have been made to broker peace deals, but thus far these have been futile, partly due to Palestinian protests against continued new Israeli settlements. The economy has not been able to create enough jobs, resulting in high unemployment rates. This, in turn, has a direct impact on household poverty rates. The practice of demolitions and seizures of Palestinian property accelerated in the first month of 2017 with 140 structures destroyed or seized, more than 50 per cent higher than the monthly average in 2016 (UNICEF, 2017). Such demolitions create significant numbers of children being displaced and exposed to vulnerabilities. PUBLIC HEALTH PROVISION There are four major health service providers in Palestine: the MOH, the United Nations Relief and Works for Palestine Refugees in the Near East (UNRWA), non-governmental organisations (NGOs), and private for-profit providers. MOH provides primary, secondary and tertiary health services through its own system and through domestic private and abroad providers. In addition, mobile health clinics are an essential lifeline for movement-restricted Palestinian communities. UNRWA was established by the UN General Assembly in Funded almost entirely by voluntary contributions, it is mandated to provide assistance and protection to around 5.7 million registered Palestine refugees in Jordan, Lebanon, Syria, West Bank and the Gaza Strip. UNRWA s services encompass education, health care, relief and social services, camp infrastructure and improvement, microfinance and emergency assistance.

3 PALESTINE 3 KEY CHALLENGES TO THE SUPPLY CHAIN Displacement and Restriction of Movement Access restrictions to health services in the West Bank and Gaza Strip remain a key concern for patients and health workers alike, in particular in areas of containment, surrounded by security walls and checkpoints. For public health institutions it is difficult to maintain a high level of service to patients, difficult to have long-term plans and difficult to expand services to Palestinian areas that are under full Israeli control. The so-called Separation Wall around West Bank is over 700 km long and 8 meters high. Gaza is surrounded by a 60 km wall. The fragmentation of the West Bank and Gaza strip due to Israeli-imposed movement restrictions has a profound impact on the functioning of the public health system and the immunization program in particular. Security Wall around Gaza. Trade Embargoes and Import Blockages Israeli-imposed trade barriers present a huge challenge to the Palestinian health authorities, in that they are forced to get documented permission for every shipment in and out of Palestine. As a result, in Gaza in particular, health facilities struggle with shortages of drugs, disposables and essential equipment. The matter is made worse by severe fuel shortages and frequent and prolonged electricity outages. Outdated Infrastructure and Equipment Many years of conflict and import restrictions have had their toll on the condition of physical assets in the public health sector (EVM Report, 2016). Much of the health infrastructure in the West Bank and Gaza Strip are deteriorated and in need of renovation. Especially in the Gaza Strip, but also in West Bank, years of blockades and frequent outbreaks of hostilities have eroded the basic infrastructure for service delivery. Cold Chain and other health care equipment are generally in a poor state. A large proportion of the equipment stock has passed its useful lifespan. According to the recent EVM assessment, around 44% of vaccines refrigerators in West Bank have become obsolete and need to be replaced. The situation is Gaza is thought to be worse. IMMUNIZATION PROGRAM PERFORMANCE Surprisingly, despite the many challenges that the Public Health sector in the State of Palestine is facing, their Public Health programme is highly successful. Evidence of this are the indicators for child immunization, as shown in the graph below (Source: UNICEF, 2016).

4 4 PALESTINE WHO AND UNICEF ESTIMATES OF DTP3 COVERAGE (%) State of Palestine MENA Region Global 90% Target SOURCE: State of Palestine: WHO and UNICEF estimates of immunization coverage: 2016 revision. The data clearly shows that the State of Palestine not only outperforms the regional and global average, but also that they somehow manage to run an immunization programme that results in a national immunization coverage that exceeds the globally set minimum target of 90%. The question arises as to why is the case. How do the Palestinian health authorities ensure that virtually all their children are fully immunized, despite the very difficult circumstances in which the Palestinian health system operates? CRITICAL SUCCESS FACTORS Long Term Vision The Palestinian public health service and its routine immunization programme have a long history. The MOH authorities firmly believe that every Palestinian citizen has the right and access to basic health services. Despite the enormous challenges, the government has worked diligently to sustain and improve the health system in order to better serve its people. A key element of their efforts is the development and retention of a competent workforce. The EPI programme has been one of the driving forces of the health system since 1994, with strong support from UNICEF, especially for its logistic and procurement components. To date, UNICEF Supply Division continues to provide vaccines and immunization devices to the MOH, while supporting strengthening the Cold Chain system for safeguarding temperature-sensitive vaccines.

5 PALESTINE 5 Top Management Leadership Strong leadership and coordination is provided by two main actors who oversee and manage immunization services: the MOH and UNRWA. A high level of political and decision maker commitment supports the MOH leadership in taking a holistic approach to public health. As one managers commented: The focus is on people and not on their disease. The vaccination programme is intricately linked to Early Childhood Development (ECD) programmes. NGOs support the government by providing primary, secondary and some tertiary services, while the private for-profit sector provides specialised medical facilities. Inter-agency collaboration is facilitated through the Central Immunization Advisory Technical Group (NITAG) which consists of representatives from MOH, Pediatric association, University, UNRWA, WHO and UNICEF. Commitment to Success The commitment of communities and health workers at all levels of service is evident. Taking immunization as an example, health workers pull out all the stops to reach every child. As one nurse commented: When a mother and child don t turn up at our clinic for their vaccination, we call them. If they don t answer the phone, we go to their house. If they still don t respond we call the police!. Palestine has top indicators in education with high literacy rates. Palestinian mothers generally are well-informed and proactive in seeking immunization services for their children. Rumors of adverse effects following vaccination are killed in the bud by way of health promotion programmes. Most of the unvaccinated children are in so-called Area C of the West Bank belonging mainly to the Bedouin-nomads community. To ensure that all populations are covered, the health service uses mobile clinics that move into remote areas. As a result of this commitment to reach every child and despite being cut off from its surroundings by a tall barrier wall, the immunization coverage in Gaza is close to 100%. A Resilient Workforce Conflict state populations tend to display certain qualities that enable them to survive and persevere in the face of hardship. The Palestinian health workforce has learned to be resilient. They cope and function despite adversity, trauma, tragedy and stress. They continually bounce back from difficult experiences. In the space of over half a century, the Palestinian people have experienced many setbacks and they continue to endure widespread discrimination. Despite this, they have shown to be resilient. The Palestinian health workforce is a prime example of this. Mobile Clinic.

6 6 PALESTINE LESSONS LEARNED Considered one of the most intractable conflicts in history, hostilities between Palestine and Israel have been ongoing since the formation of the Israeli state in The end of the Palestine-Israeli conflict is not in sight. This continuous state of war has serious consequences for the management of the Palestinian health system. Yet, the EPI program in Palestine remains one of the most successful in the region. High immunization rates have been sustained above 95% for well over a decade and vaccine-preventable diseases are either absent or at very low incidence. Palestinian health authorities and health workers regard the volatile context in which they live and work as a given and, despite enormous challenges, manage to vaccinate the vast majority of their children. The reasons behind this remarkable accomplishment are found in the resilience of the Palestinian people and the leadership and resolve of health authorities. Despite living in a constant state of conflict and vigilance, mothers of children and the public health workforce are determined to give their children all the protection they can against common childhood diseases. REFERENCES CBS (2015). Multiple Indicator Cluster Survey 2014, State of Palestine, Palestinian Central Bureau of Statistics. Final Report. December MOH (2015). Effective Vaccine Management Assessment in the State of Palestine. Findings, recommendation and Improvement Plan. June SWEILAH (2016). Pharmacy Practice in Palestine. Waleed M. Sweileh, Sa ed H. Zyoud, Mahmoud S. Al-Haddad. UNICEF (2016). A Process Guide and Toolkit for Strengthening Public Health Supply Chains through Capacity Development. UNICEF (2016). State of Palestine: WHO and UNICEF Estimates of Immunization Coverage. UNICEF (2017). State of Palestine Situation Report. UNICEF. January March, UNRWA (2015). Annual Report 2015.

7 PALESTINE 7 WHO (2016). Right to Health: Crossing Barriers to Access Health in the Occupied Palestinian Territory. WHO (2013). Immunization Summary. A statistical reference. WHO (2017). Occupied Palestinian Territory, Humanitarian Response Plan.

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