Dr. Asad Ramlawi DG PHC & PH

Current Health situation Challenges

Future perspective

04/19/23 7

Apartheid wall

04/19/23 8

Black fill

Qalqilia Ghetto

More than 40,000 Palestinians are almost completely cut off from the world in open air prisons, with the wall completely surrounding Qalqilya, Ras Atiya and Arab Abu Farda, Health Inforum 2004

04/19/23 9

…Now looks like this.

04/19/23 10

The Jerusalem Envelope

The Wall through Abu Dis…

04/19/23 11

70km of wall will carve East Jerusalem in two and cut off an estimated 249,000 Palestinian residents

from the rest of the West Bank

04/19/23 12

QUALITY OF CARE

Low status of women

Poverty

Restrictions of movement

Unemployment Poor nutritional status

Accessibility restrictions

Poor health indicatorsPoor quality of care

Population & demography/ 2012Indicator / Palestine 2012 Value Total population Gaza Strip 1,672,865West bank 2,684,066

4,356,931

Males Gaza 849,577 West Bank 1,363,315

2,212,892

FemalesGaza 823,288West Bank 1,320,751

Male / Female ratio in general pop. 103.2

Life expectancy / male 71.3

Life expectancy / male 74.1

Total dependency ratio 85 in GS & 70.7 in WB. 75.9

Population natural increase rate3.5 in GS & 2.7 in WB. 3.0

Percentage of refugees in GS out of total pop. 67.4

Percentage of refugees in WB out of total pop. 29.7

PROPORTION OF POP.AGED UNDER 5 YRS (16.4 IN gs & 13.6 IN wb)

14.7

Indicator / Palestine 2012 Value Proportion of pop. Aged under 15 yrs (43.7 GS & 38.1 in WB)

40.2

Proportion of pop. Aged 65 yrs & above ( 2.3 GS & 3.3 in WB) 2.9

No. of reported births ( GS 56,140 & 61,876 WB ) 118,016

No of reported deaths ( GS 4,048 & 7,016 in WB ) 11,064

Reported CBR /1000 pop ( 33.6 in GS & 23.1 in WB) 27.1

Reported CDR /1000 pop ( 2.5 in GS & 2.6 in WB) 2.6

Reported mortality rate under 5 /1000 16.2

Reported infant mortality rate /1000 13.5

Percentage of low birt weight < 2500 gm ) of total births ( males 7.3, female 8

7.6

Percentage of refugees in WB out of total pop. unemployment rate ( 31.5 in GS & 20.1 in WB

23.9

Crude marriage rate /1000 8.7

Crude divorce rate /1000 1.5

Woman HealthIndicator / Palestine 2012 Value % of women at child bearing age of total pop. ( 25.2 in GS & 23.6 in WB) 24.6

total fertility rate (( 4.9 in GS & 3.8 in WB ) 4.4

% Reported of pregnant woman attended care out of total live births ( pre natal rate )

84.2

% of deliveries in health institution 99.1

Maternal mortality rate ( 19.6 in GS & 27.5 in WB 23.7

%. of reported anemia among pregnant women 29.2

% of reported anemia among high risk pregnant women 37.7

% of reported children under six months received exclusively breastfeeding 29.9

% of deliveries in home 0.9

% of productive age women deaths of total deaths 3.8

Primary Health Care Indicator / Palestine 2012 Value No. of PHC centers in Palestine 750

Pop/PHC centers in Palestine 5,476

No. of MoH / PHC centers 460

% of MoH / PHC centers of total PHC centers 61.3

Hospitals Indicator / Palestine 2012 Value No. of hospitals 79

Population / hospital ratio 55,151

No. of bed 5,487

Population bed ratio 794

Beds / 10,000 13

MoH hospital indicators Indicator / Palestine 2012 Value No. of hospital 25

Population/ hospital ratio 174,277

No of beds 2,979

Population bed ratio 1,463

Beds / 10,000 6.8

admission 357,346

Average length of stay / days 2.4

Bed occupancy rate % 82.7

No. of hospitalization days 842,247

No. of Births 78.280

% of caesarian sections 18.7

No.of operations 114,302

No. of deaths 4,369

Treatment without hospi. 2,956,643

Human Resources Specialty Rate/10,000 popPhysicians 20.2

Dentists 6.1

Pharmacists 11.5

Nurses & midwifery 19.7

Conti,,,

Indicator WB GS Total Total no of patient referred to treatment outside MoH facilities

41,597 14,279 56,076

Estimated cost /NIS 335,293,037 151,488,171 486,781,208

Total no of patient referred to treatment outside MoH facilities inside Palestine

37,858 8,348 46,206

Estimated cost /NIS 247,774,477 81,139,234 328,913,711

Total no of patient referred to treatment outside MoH facilities out side Palestine

3,739 6,131 9,870

Estimated cost /NIS / outside Palestine

87,518,560 70,348,937 157,867,797

Estimated cost /NIS / inside Palestine

6,545 9,720 7,118

Estimated cost /NIS/outside Palestine

23,405 11,474 15,995

NCDs Indicator / Palestine 2012 Value Reported cancer IR / 100,000 pop 74.0

Reported DM IR /100,000 pop 222.2

% of Reported CV deaths of all deaths 31.2

% of reported cancer deaths of all deaths 13.7

% of reported cerebrovascular deaths of all deaths

12.2

% of reported DM deaths of all deaths 6.4

Indicator / Palestine 2012 IR/ 100,000AFP /100,000 child < 15yrs 1.2

Poliomyelitis 0

Measles 0

Rubella 0

Diphtheria 0

Plague 0

Cholera 0

Rabies 0

Yellow fever west Nile fever 0

Malaria 0

Neonatal tetanus 0

AIDA 0.1

Indicator / Palestine 2012 IR/ 100,000HIV infection 0

Hep. A( 60.4 in GS , 12.3 in WB ) 30.8

Hep B cases 0.6

Hep B carriers ( 21.2 in GS , 30.0 in WB ) 26.6

Hep C cases 0

Hep C carriers ( 4.2 in GS , 3.7 in WB ) 3.9

Pulmonary TB ( 0.7 in GS, 0.4 in WB 0.6

Extra pulmonary TB 0.2 in GS , 0.1 in WB 0.2

coetaneous Leishmaniasis ( kalazar) 0.0 in GS , 0.3 in WB 5.2

Meningococcal disease 6.2 in GS , 0.1 in WB. 0.2

Viral meningitis 86.9 GS, 5.4 WB 2.4

Other bacterial meningitis 29.5 GS , 4.2 WB 36.7

HOMOPHILUS Influenza meningitis 0.1 GS, 0.0 WB 13.9

Brucellosis 0.4 GS , 5.3 WB 3.4

Immunization schedule

Age Vaccine against Vaccine Birth TB , Hep B BCG, HepB

1 month Poliomyelitis, IPV1

2 months Poliomyelitis,, diph, petrusis, tetanus, hemoph. influenza type B, Hep B, pneumococcal disease.

IBV2,OPV1, DTP+ Hib + Hep B1pneumovax1

4 months Poliomyelitis,, diph, petrusis, tetanus, hib infection , Hep B, pneumococcal disease

OPV2, DTP+ Hib + Hep B2Pneumovax 2

6 months Poliomyelitis,, diph, petrusis, tetanus, Hib infection , Hep B,

OPV3, DTP+ Hib + Hep B3

12 months pneumococcal disease, measles , mumps, rubella

Pneumovax 3, MMR1

18 months Polio , measles , mumps, rubella, tetanus, diph, petrusis

OPV4, MMR2, DTP

6 years tetanus, diph, polio OPV5, DT

15 years tetanus, diph, DT

Reported new cases of vaccine preventable diseases 2012Disease West Bank

Number Rate 100,000

Gaza StripNumber Rate 100,000

Palestine Number Rate 100,000

TB, Pul. 12 0.4 12 0.7 24 0.6

TB , Extr Pul 3 0.1 4 0.2 7 0.2

Total Hep B 830 31. 354 21.2 1184 27.2

Acute Hep B 26 1 - - - -

Chro. Hep B 804 30 - - - -

Poliomyelitis 0 0 0 0 0 0

Acute AFP 12 1.2 9 1.3 21 1.2

Diphteria 0 0 0 0 0 0

Pertussis 177 6.6 - - - -

Tetanus neo. 0 0 0 0 0 0

Tetanus adult 0 0 0 0 0 0

Hib Men. 1 0.1 1 0

Measles 1 0 0 0 1 0

Mumps 29 1.1 60 3.6 89 2

Rubella 1 0 0 0 1 0

Reported new cases of active TB ( pulmonary & extra pulmonary , 2009-20012

Region & rate

2009Pulm. Extra

2010Pulm. Extra

2011Pulm. Extra

2012Pulm. Extra

WB 8 7 10 1 6 3 12 3

IR 0.3 0.3 0.4 0 0.2 0.1 0.4 0.1

GS 10 6 7 10 12 11 12 4

IR 0.7 0.4 0.5 0.7 0.8 0.7 0.7 0.2

Palestine

18 13 17 11 18 14 24 4

IR 0.46 0.33 0.4 0.3 0.4 0.3 0.6 0.2

Distribution of reported cases of active pul. TB by age group , 2012

Age Group West Bank Gaza Total

< 15 0 1 1

15 – 25 3 0 3

26 – 45 3 4 7

46 – 60 1 4 5

> 60 5 3 8

Total 12 12 24

The Palestinian PHC Statement

• Political commitment to HFA through PHC• Institutional reforms ( departments of PHC) & decentralization

( district health systems)• Strengthening preventive & health promotion programs ( vertical programs)• Integration of preventive programs at various levels

The Palestinian PHC Statement

• Promotion of community participation & inter sectoral collaboration (several modalities according to countries)

• Development of community based initiatives ( promotion of social determinants of health, community empowerment, healthy settings) initiated with support from WHO since late 80s

The Palestinian PHC Statement

• Promotion of PHC models for service delivery ( family health)

• Reforms of health personnel education ( community oriented & problem based learning )

• Use of community health workers• Networking among countries & institutions

(contribution of WHO)

Outcomes

• Increased access to essential health care services ( preventive coverage)

• Improvement of health status ( life expectancy) but inequalities persist between countries & within countries

• Improvement of social determinants of health ( literacy, access to safe water & sanitation)

Challenges

• Unfavorable socio-economic environment ( economic recession of 80s, structural adjustment programs, reduced public spending on health)

• Moves towards market economy & privatization ( weakening social role of government)

• Epidemiological & demographic transitions

Challenges

• Political determinants ( wars, occupation, civil strife)

• Globalization movement• Environmental & climate changes • Food crisis• Financial crisis

Objectives of PHC in Palestine

Is to ensure that essential health care is available to everyone in the community with high quality standard.

Patient SafetyPatient Safety

»» The greatest challenge we face as a nation is to guarantee everyone access to health care and equity within the community.

» » FCM physicians must work to keep their professionalism and pride intact.

» Family and Community Medicine is well-suited to lead health care reform in the 21 century.

I wish every FCM physician becomes the master of community based services, primary care physician, central / focal referral point where he / she can acquire a niche in the society to help the patients and families and live up to the definition of “ Friend, Philosopher , Guide and Leader ".

VISION

Our vision is that Primary Health Care Our vision is that Primary Health Care Centers will be Palestinian first choice for Centers will be Palestinian first choice for health care.health care.

Lead the way to quality health care providing comprehensive, integrated, appropriate & wellness oriented services.

Our VisionOur Vision

Our mission is to promote, maintain and improve health & well-being of Palestinian and achieve better personal & population health outcomes by working proactively to provide integrated, efficient and effective health care services in a caring & professional manner, and by advancing the ability of individuals & communities to effectively respond to their health needs.

Our Mission

NorthouseNorthouse defined leadershipleadership as :

“ A process whereby an individual influences a group of individuals to achieve a common goal ” .

The future is now

- FCM practice has long promoted outcomes, teams , accountability & LEADERSHIP in health care facility

• Declare your values in what you do. • Demonstrate the value of what you do. • BE & FEEL YOU ARE A LEADE• Prepare the future for yourself ,for your Prepare the future for yourself ,for your

patients and community …. patients and community ….

Dr. Tawfik A. Khoja, Dr. Ali Al – shehri 42

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Right to Health

Underlying determinants Health-care

water, sanitation, food, nutrition, housing, healthy occupational and environmental conditions, education, information, etc.

AAAQAvailability, Accessibility, Acceptability, Quality

(General Comment No. 14 of the Committee on Economic, Social and Cultural Rights, explains

CESCR Art 12. “The right of everyone to the highest attainable standard of physical and mental health”)

Right to Health

The Burden of Data

Too much (mostly irrelevant) data is a common problem

When choosing indicators, remember:

Information is like water…

Too much and you drown in it; Too little and you die of thirst

Theo Lippeveld, from Dr. Burghri, Pakistan MOH

Millennium development goals – related to reproductive and women's health

• MDG 3 – achieve gender equality• MDG 4 – reduce child mortality• MDG 5 – improve maternal health• MDG 6 – to halt the spread of HIV and

other diseases

Not everything that can be counted counts, and not

everything that counts can be counted.

Albert Einstein