unrwa, as part of national health systems of palestine akihiro seita [email protected] 1
TRANSCRIPT
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Gaza(1,240K)
West Bank(754K)
Jordan(2,070K)
Syria(520K)Lebanon
(450K)
Registered Palestine refugees(total: 5 million)
• Established in 1949• Protect & assist Palestine
Refugees – education, health, relief, etc.
• 30,000 staff• Budget: USD 600M/year• Health services
– 138 PHC health centers– 3,100 health staff– USD 100M a year
• MCH• NCD (DM & hypertension)• Acute illness
What is UNRWA?
UNRWA: United Nations Relief & Works Agency for Palestine Refugees in the Near East
http://www.unrwa.org/sites/default/files/2014_01_uif_-_english.pdf
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UNRWA in Palestine
West Bank Gaza Total General - Registered Refugees (RR) 754,411 1,240,082 1,994,493 - Refugee camps (no.) 19 8 27 - RR in camps 220,775 (29%) 552,037 (45%) 772,812 (39%) Education - Schools 97 245 342 - Students 51,327 232,384 283,711 - Staff 2,914 10,080 12,994 Health - Health centers 42 22 64 - Hospital 1 0 1 - Patient visits / year 1,506,044 4,300,637 5,806,681 - Staff 1,011 1,001 2,012
• Almost 2 million Palestine refugees• 40% in 27 camps• ¼ million students in 342 schools• 6 million visits to 64 health centers
http://www.unrwa.org/sites/default/files/2014_01_uif_-_english.pdf
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• What we need to do? What is health problem?
• Epidemiological transition happened• IMR decreased• NCD skyrocketing
• Probably 70-80% causes of deaths
http://www.unrwa.org/sites/default/files/2014_01_uif_-_english.pdf
UNRWA health services
1960 1980 2000 20100
20
40
60
80
100
120
140 127
65
3322
Infant mortality rate among PR (1960-2010)
2004 2005 2006 2007 2008 2009 2010 20110
50,000
100,000
150,000
200,000
No. of PR with HTN / DM(2004-2011)
Diabetes only
Hypertension & Diabetes
Hypertension only
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• From disease centered health centers… to
Ordinary UNRWA health center
• What we need to do? Reform health centers
UNRWA health services
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Q4/11
Q1/12
Q2/12
Q3/12
Q4/12
Q1/13
Q2/13
Q3/13
Q4/13
0
10
20
30
40
50
60
70
29
1520
3642
50
59
69No. of Health Centers with FHT
Reformed UNRWA health center
• What we are doing? Family health team HC
UNRWA health services
• Person-centered health services• Helped with e-health (EMR)• High satisfactions by refugees• Improving quality of services
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• What we will need more? Data analysis & research
UNRWA health services
• Vision FHT in all HC by end 2015• Needs Stable funds• Response Deliver results Evidence-based
Year 1 Year 2 Year 30%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
3-year cohort on diabetes treatment outcome (n=119)
LostTransferred-outDeadNot attended in quarterAttended in quarter
Information for action• Institutional partners• FHT & quality improvement
– Columbia university
• DM cohort analysis– International Union against
TB & Lung Disease– 6 papers & Lancet news
• FHT & DM care– Toronto university
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UNRWA, as part of national health systems of Palestine, and The
Lancet Commission: Global Health 2035
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• Good payoff for refugees• to overall investment in Palestine• Future depend on overall development• And, not yet measured VLYs…
1950 1960 1975 1982 1992 2003 20080
20
40
60
80
100
120
140
160
180
Infant mortality rate among PR in Palestine
(1) Payoff from investing health
1962 1971 1980 1990 2000 20100.0
0.5
1.0
1.5
2.0
40
45
50
55
60
65
70
75
Refugee populations & Palestinian life expectancy
Gaza pop. WB pop. Life Exp
Pop
(mill
ion)
Life
exp
ecta
ncy
(yea
rs)
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• ↓↓in IMR, thanks to MOH & others• Still, further ↓needs more support to,
& collaboration with, MOH & others• Also political solution is needed
1950 1960 1975 1982 1992 2003 2008 20130
20
40
60
80
100
120
140
160
180160
127
92 89
3225 20 21.6
Infant mortality rate among PR in Gaza
(2) Convergence in health
birth complication
accident
infection
congenital malformation
preterm
0% 10% 20% 30% 40% 50%
5%
5%
21%
27%
42%
Causes of infant mortality in Gaza in 2013 (n=63)
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• Any additional funds are welcome• NCD care is expensive• Efforts needed to ↓ commodity cost • Work with MoH & others critical, but…
Staff (total $60M)
Drugs (total $13M)
Labs (total $1M)
0%
20%
40%
60%
80%
100%
33 35 31
Cost (%) of NCD care for 210,000 NCD patients
NCD non-NCD
(3) Fiscal policies to curb NCD
2012 Y1 Y2 -0
1
2
3
Cost for HbA1c test introduc-tion (USD)
A1c ma-chinesA1c kits
All routine lab examsU
SD m
illio
n
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• Unhealthy lifestyle is epidemic• Lifestyle change important & possible• Comprehensive approach needed• Work with MoH & others needed, but…
(3) Fiscal policies to curb NCD
50- 60- 70- 80- 90- 100- 110- 120- 130-0
5
10
15
20
25
Body weight before & after 6-month campaign in WB (n=145)
Before (ave. 96.2kg)
Body weight (Kg)
%
Commodity Current
Flour 30 kg
Rice 3 kg
Sugar 3 kg
Oil 3 L
Milk 1.5 kg
Red Lentils 0
Chickpeas 0
Calorie 1,700
Cost $399
UNRWA’s food-basket in Palestine(3 months quantities)
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Financing to UNRWA health services• Funds are all from donors & limited• Main donors are also those for others• Efficiency needed, but how much…
(4) Progressive universalism to UHC
Lebanon Jordan Gaza West Bank0
100
200
300
400
500
600
700
7516 25 44
612
505
307 307
Total health expenditure per capita (USD)
UNRWA Host country
Review of UNRWA hospitalization policy (X Modol 2014)
Country USD (M)
1 USA 294
2 EU 216
3 Saudi Arabia 152
4 UK 94
5 Sweden 54
6 Germany 53
7 Norway 35
8 Japan 29
9 Switzerland 23
10 Australia 22
Donor contributions including projects & in-kind support (2013)
14
Access to health services• UNRWA is part of national systems• Du/multi-plication of service access• Rational use is needed, but how…
(4) Progressive universalism to UHC
*Health and Education Efficiency in the West Bank (DFID, Feb 2012)
West Bank Gaza -
50
100
150
200
250
300
350
400
No. of primary health centers in West Bank
(2009*)
MoHUNRWANGO
West Bank Gaza Jordan Lebanon0
2
4
6
8
10
12
14
Hospital admission per 100
UNRWA Host country
Review of UNRWA hospitalization policy (X Modol 2014)
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West Bank Gaza Jordan Lebanon
Total hospital expenditure ($)
6.3M 2.1M 1.8M 9.5M
Per capita hp expenditure ($)
13.2 1.7 1.5 37.4
% abject poor 1.6% 5.4% 1.8% 6.6%
% absolute poor 20.3% 41.1% 14.4% 66.4%
% refugee insured
50% + ? 100% ? 50% <5%
Financer of last resort
Ministry of Health (MoH)
MoH MoHRoyal court
UNRWA, NGO, individual
Financial protection (FP)• PHC services, free of charge• Hp support: co-pay. with limited funds• How to make optimal FP for refugees?
Review of UNRWA hospitalization policy (X Modol 2014)
(4) Progressive universalism to UHC
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UNRWA, as part of national health systems of Palestine, and The Lancet Commission: Global
Governance of Health
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Political determinants of health
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UNRWA and Palestine
• (As Rita said)– Health (problem) is political, thus
political solution is needed for health solution• (As Assad explained & Mahmoud will explain)
– Palestine has no shortage of examples– Occupation in West Bank, Seize in Gaza, etc. etc.
• (As I will say now)– UNRWA will do the best to improve services, and
work for solutions through Global Governance for Health
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Conclusions
• UNRWA will continue to support refugees– Focus on NCD, Family health & efficiency
• UNRWA is part of Palestine health services– Part of Payoff, Convergence, NCD & UHC
• Analysis & Guidance is needed – Rational use of (limited) resources in Palestine
• And, will work with Palestine through GGH– Political solutions for Palestine (health)