28 April 2008, 13:59
Even countries in deep conflict can unite behind the idea of science to improve health, Palestine shows.The first of a series of studies on connecting health research with policy-making low- and middle-income Arab states has Palestine lighting a beacon for others to follow. RealHealthNews Editor Robert Walgate interviewed its author, Joan Jubran of the Center for Continuing Education at Birzeit University.
>RHN: Could you give us an outline of the health situation and the chief health problems in Palestine?
JOAN JUBRAN: Well you should take into consideration that Palestine is under occupation, so the development of the health system is extremely affected by that, and even by the internal political situation – I mean what is happening now in Gaza and the West Bank, with Hamas and Fatah. With the Israeli occupation within the Palestinian territory, that is the West Bank, and in Gaza previously, we’re talking about the segregation of land in the West Bank. For example, we’re talking about a village five kilometres away from another, but to get between them you have to take long bypass roads and travel through checkpoints.
We’re also talking about the Israeli separation wall, which is within the West Bank territories, within the internationally agreed 1967 borders. So we’re not talking about security any more, separating Palestinians from Israelis, we’re talking about occupation within the West Bank.
So we cannot talk about the health system as a coherent health system, because you’re talking about three different parts within the West Bank. The north, the midlands, and the south, are totally separated. And the hospitals, for example, are concentrated in the centre, Ramallah, and the people in the north find it difficult to access specialised hospitals there.
>RHN: Can’t they pass down through Nablus, for example?
JJ: They do, but it takes more time. Sometimes you hear about cases of women who have given birth at checkpoints or people who weren’t able to get kidney dialysis because of the delay at checkpoints.
>RHN: Are these checkpoints throughout the West Bank?
JJ: Yes. There were, I think, 300 within the West Bank, but now they have been reduced somewhat.
>RHN: So you are saying it’s very hard, if you need it, to get to a health centre? But what about the bottom-line statistics? A lot of the published statistics, for example on education in the West Bank, are very good, aren’t they? So how do you stand on the standard sorts of developing country indices like maternal mortality and infant mortality?
For example the health budget per dollar of GDP in Palestine is actually quite high, I believe. The average in OECD countries is 9%, and I believe it’s something like 13% in Palestine, so despite the external and internal violence there appears to be a high priority placed upon health in Palestine. Is that right?
JJ: Actually before the year 2000 many of the indicators, even the infant mortality, were better than in other developing countries, so yes, Palestine stood high in terms of its health status. Then in 2000 you know that there was the Second Intifada [Palestinian uprising], and so there were lots of factors that influenced the health of the Palestinians so this has deteriorated a little bit.
But even that wasn’t a major issue [for health] because there was a lot of international donor aid to Palestine for the development of the health sector, so in general the indicators are generally not that bad in comparison to other developing countries. Did you know that there was a lot of effort, for example, up to the year 2000, to decrease the infant mortality rate and provide programmes for maternal health? So the indicators are not that dramatic and we have witnessed an improvement until 2000. However, during the last few years some of the indicators dropped.
>RHN: One of the interesting things I notice about your report is actually how you did it, because despite the problems you’ve outlined you appear to have been very comprehensive. You’ve looked at every side of the issue and you’ve involved, as it appears to us, people from the ground right up to the ministers and also the academics. Is that right?
JJ: Yes. Actually this study is part of a larger one in non-oil Arab states, and I also participated in how the research was conducted in other countries. I noticed that in Palestine and Lebanon mostly, the participation of civil society, and even the interaction with the government and the unions was very easy. What it showed me is that we have a viable civil society.
It also showed that the connection with the government was not that difficult for us. In other countries, for example in Egypt, there were problems with meeting the government officials. We had the same methodology, but sometimes we had difficulties. But in Palestine, in our focus group we had many different stakeholders participating, from the ministry, from civil society, unions, researchers, and this enriched the discussion because we heard different opinions.
>RHN: Why do you think that was possible?
“I think we have a democratic and participatory approach to dealing with individual issues. It’s not only in health; this is done in other areas too.”
JJ: I think we’re used to that. Probably because of the status of Palestine, and the occupation before, civil society found a very important role in the provision of services – before we had the PNA [Palestinian National Authority, created by the signing of the Oslo accords between Israel and the Palestine Liberation Organization in 1993]. Although we talk about democracy, and democratic systems, in Palestine, I think we have a democratic and participatory approach to dealing with individual issues. It’s not only in health; this is done in other areas too.
>RHN: I see, that’s interesting. You’re saying that at the ground level there’s a kind of informal democratic government – despite the political conflicts.
JJ: Yes… and because in the health sector, before the creation of the Palestinian National Authority, civil society was the provider of health, education and social services. When the PNA came we had policy dialogue with the government to implement some partnerships, and there are some clinics that are jointly implemented or are managed by the Ministry of Health and civil society organisations.
>RHN: To analyse that a little bit, would you say that’s because ordinary Palestinian people feel under threat and, therefore, bond together?
JJ: Yes, probably. We saw that in the Second Intifada, where this was very evident as emergency committees were formed because we couldn’t get medication and services through. Committees were formed between the government and the and NGOs, so, yes, probably because we are under threat, and we have to cooperate because of the situation here.
>RHN: Let me come on to some of the real content of your report. Under the ‘main policy concerns’ you mention an overdependence on donors. What fraction of the budget is donor-originated?
JJ: Actually one major problem with policy and planning in Palestine is that we don’t have exact figures for how much we depend on donors, because the PNA budget is separated from what we get from donor assistance. The national budget submitted by the Minister of Health, for example, for the health sector, does not incorporate donors’ funding, although we have a major dependence on it. In 2002, donor funding for the health sector reached 48%.
>RHN: One of the things that many developing countries complain of is that they’re actually driven by the donors; and there are many different donors, so they get lots of conflicting and overlapping programmes and demands on human resources for actions and reporting, and so forth. Do you face the same problem in Palestine?
JJ: We do face it, actually, but it wasn’t ever one of the discussions [during the making of our report], but we do face it.
>RHN: Well if it didn’t come up at the discussions it wasn’t important.
JJ: It’s probably because we influence donors. Not every donor or every agenda but, as we say in the report, we mention that projects are donor-driven.
>RHN: Ah, they’re more prepared to listen to you, maybe, than they are to some other people?
>RHN: Or you make your points more forcefully!
JJ: Maybe. Also, yes, we talk more! [Laughing]
>RHN: Let me come right on to the conclusions. One of the things that’s striking about this work, as I said, is that it wasn’t purely an academic exercise and that you involved everybody – and yet you’re talking about research priorities. Now, usually in a typical research academic environment, these research priorities are defined by the researchers themselves, alone or in committees, with some important steerage by the amounts of money available from government. But here you create a whole series of research proposals that are originating from integrating civil society, and government, and researchers. What occurs to me is will they be acted upon and, if so, who will act upon them?
JJ: I hope they will be acted upon. The challenge, and you frequently refer to it in your magazine, in RealHealthNews, is how research can help policy, and how can we link research to policymakers. This is a major problem in Palestine because we do lots of research and it does not get implemented into policy. This is why also we tried to gather all the stakeholders, from policymakers to researchers, and to try to see how we can cooperate.
“Now this has been put on the agenda of the newly formed committee for national policy and strategic planning, and it includes research institutions and civil society providers, health providers, and the Minister of Health, Minister of Planning, Minister of Finance. It was a very good step.”
So now this has been put on the agenda of the newly formed committee for national policy and strategic planning, and it includes research institutions and civil society providers, health providers, and the Minister of Health, Minister of Planning, Minister of Finance. It was a very good step and they have put into action some areas for implementation, including some that were mentioned in the report.
Yet there is no national driver for [connecting health research with policy], unfortunately. Research institutions are separated from the governmental body. But the governmental body has also put in place also a new health policy and planning unit.
And the thing is that of course all of this can become stagnated by the political situation, or by a change of minister, or whatever happens in Palestine, so it all depends actually on specific agendas.
>RHN: Of course.
>RHN: Who is funding most of the health research?
JJ: Canada’s International Development Research Centre [IDRC] is very interested. And we have a major research institution here, the Birzeit University Institute for Community and Public Health. And there are other research centres such as the Palestinian Central Bureau of Statistics, a governmental body. The Ford Foundation is interested in research. And the Italian Cooperation sometimes funds research initiatives.
>RHN: So the question is will these people listen to this report?
JJ: This is what we seek with IDRC – we want to put pressure on funders to fund these proposals. But it is a problem in Palestine, I think, that this research has been submitted to the Minister of Health, and all the people concerned in the Ministry of Health, but sometimes the funders come through to a certain key person who doesn’t participate [with the ministry], and since there is no systematic mechanism, research is duplicated.
>RHN: So your conclusions need to be quite widely distributed amongst all those who have an influence on research in Palestine?
JJ: Hopefully, yes. We have distributed it to everyone, basically to all who participated, but we didn’t do a dissemination plan for any more than this.
>RHN: But if IDRC is one of the major donors and you’re talking with them, that’s a good move?
JJ: Yes, but actually it’s also partly funding this research [so it was expected].
>RHN: You consulted with the researchers, and you’re a researcher yourself. Are researchers as a body, convinced by these proposals?
JJ: Yes. They are.
>RHN: And they would like to do this work?
>RHN: That’s very interesting too, because another factor in research, of course, as I’m sure you know, is that it’s often (and inevitably) driven by academic priorities, and academic career-making, and getting your publications in the right journals, and so on – and it doesn’t necessarily relate to the real world outside.
JJ: Yes, but the thing is, this was discussed between researchers and policymakers from all areas and from the government, so this was an interesting discussion.
>RHN: I guess the researchers have to be sure that they can make a career out of this, as well?
JJ: Yes, but I think these proposals respond to the actual needs, even of research in Palestine – because it responds to the priorities, and what we need.
>RHN: Of the whole country?
JJ: Yes, and for the policy aspects – we need research for this.
>RHN: Is there anything else you would like to stress about your specific conclusions?
JJ: The thing is, and this is a pessimistic aspect, because people who are stakeholders [in health] are involved in day-to-day operations, emergencies, and humanitarian aspects, they tend to forget the policy, and long-term planning for the health sector, and the development aspects. This is why we have the problem in Palestine that we didn’t have a development plan until now, and we didn’t work on policy issues.
We have been discussing these issues for years, and these abuse questions, and policy and research aspects, are not new to stakeholders, but unfortunately, because of the situation internally, and due to the occupation, we haven’t been taking a strategic view on the development of the health sectors. We’ve been focusing on our day-to-day operations.
>RHN: Just living from moment to moment.
JJ: Yes, and this is bad.
>RHN: But it’s rather forced on you by your situation.
JJ: Yes, but we need to think strategically, as well, we really need to take this into consideration.
>RHN: Do you want to say anything about your actual, specific conclusions about what research is needed, and for example, on health insurance, and so on?
JJ: Yes. I think we need to revise the current health insurance system because this hasn’t been changed, due to the political situation and the emergency. Health insurance is covering around 80% of the population. This has been overloading the Ministry of Health, and the financial system – and I think we need to revise this, and [to research] what kind of systems we need to develop.
This also links to the tertiary services needed on a national level, and to revise this… A lot of financial resources are going to refer patients abroad, even under the health insurance, so we need to revise this in terms of health financing.
In human resources we need to see what exists in the market and plan our educational programme based on this and develop incentive plans and licensing systems, because these are important in Palestine. But all of the non-state sectors, because we have successful pilot experiences in cooperation we need to develop this and probably think about more partnership with the government and the private sector.
>RHN: I would say that you’ve also got many lessons here, which are exportable. That’s to say, it would be great if other countries could do the same thing you’ve done; although, of course, not being in the same kind of situation of civil society involvement in health that we discussed it may be more difficult. Nevertheless, have you thought about how you can advise other countries on how to conduct this kind of study?
JJ: I have been thinking with Fadi El-Jardali on how to take this further. We have been discussing experiences with researchers from other countries, so this has been the sharing that we’ve had, but we didn’t think further about that aspect.
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