After introductory remarks this presentation will focus on two broad issues

1. Rebuilding the Palestinian Health System: Infrastructure, Training, Supplies, Salary Base, Administrative Changes, Structural ReformNorbert Goldfield, M.D.

2. After introductory remarks this presentation will focus on two broad issues • Infrastructure, Training, Supplies, Salary Base, Administrative Changes, Structural Reform needed for rebuilding the Palestinian health care system • Costs involved together with systems/options for covering these expenses

3. My background • Executive Director of Healing Across the Divides. Active member of the Jewish Funders Network; e.g. co-organizer health care track for this years annual meeting in Jerusalem. • Medical Director , informatics company (developer of clinical logic for classification systems for payment and quality measurement – used throughout the world) • Internist – see patients two days a week at a group practice that delivery coordinated care in the home.

4. HATD: Mission • Healing Across the Divide (an American not for profit organization) assists Israeli/ Palestinian health care organizations to • improve the health of Israelis and Palestinians, • document that health has, in fact, improved and/or the barriers to improvement from a health and human rights perspective have been removed • bring the barriers to improvement to the attention of policymakers in the US and Europe On my board are representatives/directors of mainstream organizations interested in the Israeli-Palestinian conflict including among others the American Jewish Committee and the American Task Force on Palestine

5. Principle #1 • The position taken here is that systematically differential patterns of health outcomes which have their origins in social/political factors are unfair and unjust. • More importantly, systematically differential health care outcomes between Palestinians and Israelis is not in the interest of any political group that has a stake in Middle East stability. • Furthermore, because these factors are social and they are the product of human agency they are also potentially changeable through human agency. I say this as an American, as a Jew.

6. Principle # 2: • The second principle is a commitment to an evidence based transparent approach to health systems development. Such an approach offers the best hope of tackling the inequities that arise as a consequence of the operation of the social determinants. Further it is assumed that the evidence will provide the basis for understanding and the basis for action

7. Putting aside “what to do” / rights or wrongs the following very significantly impacts the health of Palestinians • The construction of the wall (or barrier) continues; settlements continue to expand; checkpoints remain in force; the Judaization of Jerusalem continues; and the de facto annexation of the Jordan Valley is unaffected. Military incursions, accompanied by arrests, continue unabated. House demolitions remain a feature of life in the West Bank and East Jerusalem. • Number of Palestinians in Israeli jails: 10,000 • Closures • More than 500 checkpoints, roadblocks • Hundreds of completely isolated communities • Long-lasting curfews

8. Similar to the U.S. health system there will always be tensions and there is no one health system. The American tensions: • Private vs public • Private for profit vs not-for-profit • Physician owned vs non • Curative vs public health services. • Academic vs non-academic • Rural vs urban. • Individual consumer responsibility vs community responsibility. • Public health vs curative etc While many organizations put out the magic cure for the American health system, incremental steps are the order of the day. I would recommend the same approach for the Palestinian health system

9. A “successful” Palestinian health system should – (RAND Report- modified by me in bold) • maintain an effective and well-regulated public health system • provide reasonable access to high-quality preventive and basic curative services for all Palestinians that is prioritized • maintain high-quality programs for training health professionals that is prioritized • achieve measurable health outcomes at the population level that meet or exceed international guidelines, such as those recommended by the World Health Organization (WHO) • be effective (documented outcomes), evidence based, efficient, financially viable – i.e. transparent for all customers • contribute to peace and encompass the possibility of cooperation with neighboring countries on issues of common interest; i.e. empower its citizens or put differently – belief that life is worth living.

10. Put differently, health reforms should be • Practical: Palestinians groups have already implemented aspects of each of these efforts (some with HATD). • Feasible: Do not cost a “tremendous” amount of money • Useful: Maximizes outcomes transparently for the most Palestinians using techniques that can be easily replicated

11. In practical terms my recommendations are: • Transparent measurement of outcomes (not processes) of care for each service that is paid for – NGOs, UNWRA and MOH services • Full funding of Community Health Workers for the entire country. Implies adequate support of Schools of CHWs of the type that the Palestine Medical Relief Society has pioneered and documented together with HATD • Full funding of Primary health clinics (including lab services) and Maternal and child health clinics including funding of the basic/inexpensive electronic record as pioneered by the PMRS. • The MOH should at a minimum have adequate supply of basic medications needed for CDs, most common NCDs, and immunizations/well child care. • Prioritized hospital services with emergency services focused on adequate ambulance services. . • In an effort to address widespread childhood, full funding of nutritious biscuit program as pioneered by ANERA. • Full funding of web based continuing medical/health education – minimal cost. Issue is organizational • Note : have not costed out specific public health services TOTAL COST: approximately $200,000,000 per year including public health services.

12. Structural Reform – Focus On • Understanding that health care professionals are extremely involved in political issues and this will not change. • Transparent Evidence based quality improvement linkage with all health services • Prevention services linked to primary health care: The Key Focus of activities in resource limited health care system • Secondary care that is linked to primary care to the extent possible • Tertiary care that is focused on services for which Palestinian health professionals either are already trained in or for which training programs can be easily established • Enhance NGO sector as positive counterbalance to government health services

13. Training • Integrate health care training with training in evidence based practice linked to quality improvement • Best option is to prevent illnesses from happening. Once they develop complications of most chronic illnesses and/or malignancies (often detected in a late stage) – it is simply too late. • Recommendations: • Full funding of School for Community Health Workers to train CHWs for each Palestinian village and town. Cost: at 8,000 per year for 3,000 CHWs: 25,000,000 • Funding for hospitals that are prioritized to most important causes of morbidity and mortality pertaining to chronic illness (nephrology, neurology, cardiac surgeons, pediatric cardiology). Cost: 60,000 per specialist • Funding for mammography screening, treatment coordination, and training program for breast cancer with Augusta Victoria Hospital; preliminary program : 1,000,000. • Training program for NCDs for clinicians – already started by HATD. This is relatively inexpensive and can be largely web based.

14. Supplies • Basic Electronic Medical Record for all public/primary health care monitoring. Cost: 20,000 per clinic; 10,000,000 for all primary health care clinics • Primary Health Care Supplies excluding Meds. Cost: 60,000 per clinic; 30,000,000 per year for 500 clinics • Hospital Services excluding Meds. Cost:?? This needs to be prioritized. • Lab Services: 3,000 per month for 10,000 patients with chronic illnesses • Ambulance Services: 6,000 per ambulance per month • Medications. The MOH needs to identify list of needed (in the following order of importance) • Maternal and child health. Cost: • Primary health care for NCDs. Cost: • Hospitalization services. Cost: • 1000 tablets metformin: $80; one month supply insulin: $25/VIAL; 1000 tablets lisinopril: $80

15. Salary Base • CHW salary- 6,000 • Other salaries – 60,000 per specialist.

16. Costs can be paid by • Health insurance • Individual consumer co-pays • International donors and the World Bank are key and yet this needs to be significantly revamped as there is limited attention span for most international donors with little attention to evidence base demonstration of improvement. • WHO: limited capabilities.

17. Implementation Challenge • Currently the PNA is asking that all moneys for health care delivery be given to them to “strengthen” depleted government services. While moneys can be given to the government, I would strongly suggest that the NGO sector not be eviscerated. • Outcomes based transparency and continued funding of essential services to private and public sectors are key to success in this sector of the economy without which we literally cannot live.

18. I have pessimism of the intellect, optimism of the will – Gramsci, 1920’s I try to be cynical but I can't keep up- Lilly Tomlin