Dr. Asad Ramlawi
DG PHC & PH
 Current Health situation
 Challenges
 Future perspective
Apartheid wall
4/8/2015
7
Qalqilia Ghetto
Black
More thanfill
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
4/8/2015
8
…Now looks like this.
4/8/2015
9
The Jerusalem Envelope
The Wall through Abu Dis…
4/8/2015
10
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
4/8/2015
11
QUALITY OF CARE
Accessibility
restrictions
Poverty
Unemployment
Poor nutritional
status
Low status of
women
Restrictions of
movement
Poor health indicators
Poor quality of care
4/8/2015
12
Population & demography/ 2012
Indicator / Palestine 2012
Value
Total population
Gaza Strip 1,672,865
West bank 2,684,066
4,356,931
Males
Gaza 849,577
West Bank 1,363,315
2,212,892
Females
Gaza 823,288
West 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 Health
Indicator / 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 pop
Physicians
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/ 100,000
AFP /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/ 100,000
HIV 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 B1
pneumovax1
4 months
Poliomyelitis,, diph, petrusis, tetanus, hib
infection , Hep B, pneumococcal disease
OPV2, DTP+ Hib + Hep B2
Pneumovax 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 2012
Disease
West Bank
Number
Rate
100,000
Gaza Strip
Number
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
1
0.1
1
0
Hib Men.
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
2009
Pulm.
Extra
2010
Pulm.
Extra
2011
Pulm.
Extra
2012
Pulm.
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
Palestin 18
e
13
17
11
18
14
24
4
IR
0.33
0.4
0.3
0.4
0.3
0.6
0.2
0.46
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.
» 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.
VISION
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 ".
Our Vision
Our vision is that Primary Health Care
Centers will be Palestinian first choice for
health care.
Lead the way to quality health care
providing
comprehensive,
integrated,
appropriate & wellness oriented services.
Our Mission
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.
Northouse defined leadership 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
patients and community ….
•
Dr. Tawfik A. Khoja, Dr. Ali Al – shehri
42
Right to Health
Right to Health
Underlying
determinants
Health-care
water, sanitation, food, nutrition, housing, healthy
occupational and environmental conditions,
education, information, etc.
AAAQ
Availability, 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”)
43
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