FINAL REPORT PALESTINIAN HEALTH SECTOR REFORM AND DEVELOPMENT PROJECT

OCTOBER 1, 2008 TO NOVEMBER 14, 2014 This publication was produced for review by the United States Agency for International Development. It was prepared by Chemonics International Inc. CHEMONICS INTERNATIONAL INC. Palestinians livinginthe West Bank. records through theHealthInformation Systemto77percent of By 2014, ofHealthwasable toupdateelectronic theMinistry medical FINAL REPORT PALESTINIAN HEALTH SECTOR REFORM AND DEVELOPMENT PROJECT Contract No. 294-C-00-08-00225-00

The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States government. CHEMONICS INTERNATIONAL INC. CONTENTS

ACRONYMS...... iv

CHARTS...... v

CHAPTER ONE. PARTNERING FOR HEALTH...... 1

CHAPTER TWO. PROMOTING EFFECTIVE HEALTH MANAGEMENT...... 7

CHAPTER THREE. IMPROVING HIGH-QUALITY SERVICES. . . . 35

PALESTINIAN HEALTH SECTOR REFORM AND DEVELOPMENT PROJECT ANNEXES 1 – 10. . . SEE PDF FILE ON CD

LEFT: Doctor at the Palestine Medical Complex in the West Bank where the project partnered with the Ministry of Health to establish triage areas in the emergency room.

INSIDE FRONT COVER: By 2014, the Ministry of Health was able to update electronic medical records through the Health Information System to 77 percent of Palestinians living in the West Bank. CHEMONICS INTERNATIONAL INC.

FRONT COVER: NICU Director Dr. Hassan Fitian checks on progress of a prematurely born baby in a USAID-procured incubator. With project support, Rafidia Hospital upgraded its neonatal intensive care services and is the only hospital providing NICU services in Nablus District. CHEMONICS INTERNATIONAL INC.

BACK COVER: Three-year-old Mohammed learned to walk after being equipped with his first artificial limb at the Princess Basma Jerusalem Center for Disabled Children, where he was referred as a result of project-supported community outreach. Mohammed had never been provided with assistive devices, despite being born with only one leg, because his divorced mother could not afford to pay the high costs. CHEMONICS INTERNATIONAL INC.

iii ACRONYMS

BCC behavior change communications

CBO community-based organization

CHCE continuing health care education

CT computerized tomography

EPS Essential Package of PHC Services

ER emergency room

EWAS Emergency Water and Sanitation

HEPD Health Education and Promotion Department

HIS health information system

HR human resources

IDP institutional development plan

IPC infection prevention and control

NCD non-communicable disease

NICU Neonatal Intensive Care Unit

NCTC National Calibration and Training Center

OJC on-the-job coaching

PHC primary health care

PMC Palestine Medical Complex

PMP performance monitoring plan

SHC secondary health care

SOC Standards of Care

iv Acronyms CHARTS

CHART 1. HOUSEHOLD SATISFACTION WITH MINISTRY OF HEALTH SERVICES...... 17

CHART 2. APPLICATION OF TRAINING AMONG TRAINEES SURVEYED...... 21

CHART 3. CLIENT SATISFACTION WITH MINISTRY OF HEALTH PHC SERVICES...... 38

CHART 4. HIS IMPACT ON AVAILABILITY OF PHC INFORMATION...... 41

CHART 5. CLIENT SATISFACTION WITH PHC BCC SERVICES. . 45

CHART 6. ACTION TAKEN ON PROJECT BCC MESSAGES. . . . 46

CHART 7. MANAGER SATISFACTION WITH INFORMATION SOURCES FOR PATIENT CARE...... 47

CHART 8. USER PERCEPTION OF HIS IMPACT ON PERFORMANCE AND ACCOUNTABILITY...... 47

CHART 9. SATISFACTION WITH GRANTEE SERVICES...... 56

CHART 10. PROCUREMENT VALUE BY NGO SERVICE...... 57

Charts v CHEMONICS INTERNATIONAL INC. CHEMONICS INTERNATIONAL

With support from the project, the Ministry of Health is empowering marginalized female health professionals to be leaders for change within the ministry. CHAPTER ONE PARTNERING FOR HEALTH

USAID has supported the goal through: 1) improving gover- Palestinian Authority’s Ministry nance and management practices of Health in its development of in the health sector, 2) improving the public health sector since the the quality of essential clinical and ministry was established in 1994. community-based health services, Recognizing the ministry’s com- and 3) increasing the availabil- mitment to creating a successful, ity of essential commodities to integrated health sector, 1 USAID achieve health and humanitarian supported its National Health assistance goals. In 2014, the proj- Reform Strategy through the ect continued exclusively on one Palestinian Health Sector Reform component, which was to work and Development Project. toward improving governance and management practices and the Through the project, USAID quality of clinical services in the supported the Ministry of Health, health sector through expansion NGOs, and select educational of a computerized health informa- and professional institutions in tion system (HIS). strengthening their institutional capacities and performance to During its six years of imple- promote a functional and demo- mentation, the project’s focus cratic Palestinian health sector and scope evolved in response to that is able to meet public health USAID technical directives and priorities. From 2008 to 2013, funding limitations. In Year 2, the project worked to achieve this USAID expanded the contract

1. National Strategic Health Plan – Medium Term Development Plan (2008-2010), Ministry of Health.

PARTNERING FOR HEALTH 1 by $29 million, to $86 million. 2014) to continue to focus ex- The additional funding allowed clusively on the HIS component. the project to fully respond to key In September 2014, the project priorities identified by the Min- received a level-of-effort increase istry of Health during its 2008 and contract extension (until No- needs assessment. It also expanded vember 14, 2014) to implement opportunities for procurement of the HIS at Ministry of Health medical equipment, supplies, and central warehouses. This report pharmaceuticals, and expanded covers October 1, 2008 through its integrated approach and grants November 14, 2014. to the NGO sector, ensuring that reform encompasses all areas of Throughout its six years, the proj- the health sector. In Year 3, US- ect’s interventions were designed AID modified the project scope to support the Ministry of Health in response to a mid-term evalu- and select NGOs throughout the ation that described the scope West Bank and in East Jerusalem. as an “enormous” endeavor and The project also worked with eli- recommended focusing on areas gible NGO health service provid- in which the project had achieved ers in Gaza, with a limited focus “impressive accomplishments,” on provision of overall capacity particularly its support for high- strengthening, complemented by quality improvement in primary targeted grants and procurement health care (PHC) services, com- support. modity procurement reform, a grants program, and the ongoing Chapter One presents an over- establishment of an automated view of the project’s achievements. HIS.2 In Year 4, a U.S. Congres- It also includes as a supplement sional hold on all funding for the “Voices of Impact,” a multimedia USAID/West Bank and Gaza series in which Palestinian health mission resulted in a six-month care providers describe how the hold and ultimately a reduction project has improved their capac- in force and implementation. ity to serve Palestinian citizens. The project scope was reduced Chapter Two highlights the effec- for the final two years of imple- tive management promoted by the mentation to concentrate on the project in the health sector, and aforementioned activities. In Year Chapter Three demonstrates the 5, another Congressional hold improvements in quality achieved on funding resulted in a further in health services provided by the reduction in the project scope, Ministry of Health and NGOs. focusing project activities solely At the end of each of those two on rollout of the HIS. chapters, the project shares prom- ising practices and lessons learned To further this work, USAID during implementation and extended the project for one year recommends future interventions (October 2013 – September to support the Ministry of Health

2. USAID/West Bank and Gaza: Health Sector Reform and Development Flagship Project – Mid-term Evaluation (December 2010).

2 PARTNERING FOR HEALTH STORY: “We did not have the tools we needed before — not the space, nor the medical equipment. Thanks to USAID, we are now able to meet international standards in giving care to patients,” said Dr. Farid Abu Leil, Ministry of Health Rafidia Hospital. The project supported the ministry in upgrading the hospital’s capacity to provide pediatric and neonatal care, with $1.7 million in lifesaving equipment and technical assistance in training, emergency services,

CHEMONICS INTERNATIONAL INC. CHEMONICS INTERNATIONAL and pediatric care.

in reforming and developing the ment reforms initiated by Prime health system. Annexes provide Minister Salam Fayyad.5 additional information, including key technical deliverables, inter- Challenges to reform and devel- ventions by region, and a sum- opment abound in this fragile mary table of indicators for the context.6 The health status of Pal- project’s performance monitoring estinians has been compromised plan (PMP) and HIS manuals.3 by decades of conflict. As a result, a population with comparatively CONTEXT FOR REFORM good health indicators for the re- AND DEVELOPMENT gion is still struggling with access, Since 2008, the Palestinian Min- availability, and sustainability in istry of Health has been actively its health services, as well as a sig- managing the transition from a nificant rise in non-communicable “chronic emergency” response to diseases (NCDs) during the past a more integrated development- 10 years. The ministry also rec- oriented approach for the health ognizes that citizens have limited sector,4 in line with larger govern- participation in health planning

3. The indicators in the summary table are listed in the last approved PMP, which was the Year 5 PMP (approved by USAID on June 5, 2012). The project did not receive official approval of the Year 6 PMP, but indicators measuring implementation of the Year 6 work plan are included in a separate table. 4. National Strategic Health Plan – Medium Term Development Plan (2008-2010), Ministry of Health. 5. Palestinian Reform and Development Plan (2008-2010) and National Development Plan (2011-2013). 6. Health in the Occupied Palestinian Territory, the Lancet (http://www.thelancet.com/health-in- the-occupied-palestinian-territory-2011).

PARTNERING FOR HEALTH 3 for their communities, resulting is one of the largest employers in in a gap between citizen expecta- the West Bank, but it has short- tions and the ministry’s delivery of ages of hospital specialists and services. primary health care staff. It must balance its mandate for oversee- The Palestinian health system is ing all health care for Palestinian complex, with four major catego- citizens with working to provide ries of health care providers: the the best-quality care possible in an Ministry of Health, the United efficient, cost-effective manner. Nations Relief and Works Agency, local NGOs, and the private sec- The ministry underwent institu- tor. The health system was further tional changes during the project, fragmented by the political divi- including a senior leadership sion of the West Bank and Gaza, change in Years 4 and 5 and which has resulted in both scarcity recurrent strikes across its facili- and duplication of services. ties during the last three years of implementation. Despite these The Ministry of Health juggles contextual challenges, the proj- often-contradictory roles. It is ect was able to achieve or make the principal administrative and significant gains toward the goals regulatory body for the health of all components, as will be system, as well as the largest demonstrated in Chapters Two provider of health services. It also and Three.

4 PARTNERING FOR HEALTH Voices of Impact

Reaching the Disabled VIDEO: USAID expanded rehabilitation and referral services through $9 million in support to specialized organizations. This support resulted in stronger community services for Palestinians with disabilities, says grantee Director Maha Tarayra.

Supervising Quality Care VIDEO: The Ministry of Health adopted a new and more supportive approach to supervising health care in the community, with assistance from USAID. Primary health care services have improved permanently, says Mai Safarini, a nursing director.

Engineering Health VIDEO: A new medical equipment maintenance system introduced by USAID is improving health care provided by the Ministry of Health. At the heart of this system is the first National Calibration and Training Center, built with USAID’s support, says center Director Ibrahim Allayan.

Championing Community Health VIDEO: Palestinian citizens partnered with their local government clinics to compete in a project-sponsored health championship. In the process, 82 health committees improved services for local residents. Citizens have greater trust in the Ministry of Health, says Nadine Imran, a Champion Community coordinator.

Delivering Quality Care VIDEO: The project supported the Ministry of Health to improve community health services. Clinics now provide a higher quality of care to Palestinian citizens, says clinic nurse Samira Qabaja. CHEMONICS INTERNATIONAL INC. CHEMONICS INTERNATIONAL

A laboratory technician is now able to sort blood samples by barcode stickers placed on the samples, ensuring test results are accurately transferred to patients’ electronic medical records through the Health Information System. CHAPTER TWO PROMOTING EFFECTIVE HEALTH MANAGEMENT

HEALTH CARE tion, more efficiently plan and MANAGEMENT allocate its resources, and monitor MODERNIZED public health trends. Health information management is crucial to ensure the sustainable By 2014, the ministry was able to reform of the Palestinian health provide health services through system and support the Ministry the HIS to 77 percent of Pales- of Health’s ambitions to provide tinians living in the West Bank the best possible quality of care for through 17 facilities in eight gov- all citizens. No health system can ernorates. The system expanded function properly without rapid, to include the first non-ministry accurate, and structured gathering facility in 2014. Al-Makassed and analysis of data for decision- Hospital in Jerusalem adopted the making, management, and track- HIS, after signing a memorandum ing of the population’s health. of understanding with the min- istry, which now has an open-li- With project support, the cense software package purchased ministry created a national-level, by USAID. Al-Makassed is the computerized health information first private facility to come on system. The HIS is a facility-based line with the system. and patient-centered system that provides relevant, timely, and With two-thirds of the public accurate data to support evidence- hospitals accessing the HIS, the based policymaking. In line with ministry is well placed to continue its National Health Information to roll out a national HIS that Strategy, the ministry uses the will provide an integrated net- HIS to promote and sustain the work through which health data health of the Palestinian popula- and patient information can be

PROMOTING EFFECTIVE HEALTH MANAGEMENT 7 shared, improving patient care and time, with the ministry develop- providing relevant and timely data ing an HIS strategy in 2012 for for decision-makers. The ministry the paper process, then gradually now maintains comprehensive moving to the electronic system medical records for more than that is rolling out today. In the 800,000 patients across health early stage, health data manage- facilities, which is a foundation ment was divided among depart- for enabling better decision- ments, with limited coordination, making by health providers on and was further fragmented by three levels: national, district, and disease-focused demands by facility. In addition, providers are donors and international initia- now referring patients to other tives. These divisions created data HIS facilities (within levels and duplication, burdened staff with across levels), passing patient re- excessive reporting requirements, cords, including prescriptions and and prevented the analysis and use laboratory results, directly to the of data collected. next physician who will examine the patient. Through the project, the intro- duction of an electronic system The health information systems that could be used for data-based at the ministry have evolved over health management was a dramat-

VIDEO: A computerized health information system donated by USAID has modernized health care for the Palestinian Ministry of Health. Change is visible everywhere, according to hospital administrators and

clinicians. INC. CHEMONICS INTERNATIONAL

8 PROMOTING EFFECTIVE HEALTH MANAGEMENT STORY: A nurse documents notes during rounds in the Urology Department using the new health information system. “The HIS continues to prove itself to be the most valuable tool in improving the quality of patient care and services,” said Dr. Khaled Saleh, general director of the Ministry of Health’s Rafidia

CHEMONICS INTERNATIONAL INC. CHEMONICS INTERNATIONAL Hospital.

ic innovation and culture shift in Ramallah, and Salfeet governor- the Ministry of Health’s manage- ates. Al-Makassed Hospital in ment practices. For the first time, Jerusalem is also using the HIS the ministry hospitals and key to manage its outpatient services, primary care facilities have real- with plans to integrate inpatient time, reliable data on distribution services soon. and demand for resources at the patient level. As a result of unique Ministry facilities can now better patient numbers created by the track patients, staff, and non-med- HIS, each patient’s full medical ical commodities as a foundation history is available at the click of for a national HIS system that can a mouse, eliminating the need for be used in the future to analyze paper records and creating a more data trends and plan accordingly. efficient means to access vital Examples include using the HIS information. More than 819,960 to provide data-driven — rather individual patient records were than estimated — pharmaceutical stored in the ministry’s HIS in requests during the annual min- November 2014, exceeding the istry budgeting process (Rafidia life-of-project target of 250,000 Hospital),7 increase the capacity records set by USAID. The HIS is of an orthopedic clinic that the operational in 18 ministry facili- system showed was overbooked ties in the Bethlehem, Hebron, (Rafidia Hospital), and improve Jenin, Jericho, Nablus, Qalqilya, monitoring of the actual oc-

7. When surveyed, hospital managers reported the system gave them greater ability to monitor and control the hospital environment and resulted in significant cost savings. For instance, the pharmaceutical director at Rafidia Hospital was able to use the HIS to calculate actual – not projected – pharmaceutical procurement needs as input for the annual budget development.

PROMOTING EFFECTIVE HEALTH MANAGEMENT 9 cupancy rate (Darwish Nazzal constitutes generally a third of the Hospital). ministry’s annual budget.11

The project conducted client Hospital managers at Rafidia satisfaction surveys in the five and Darwish Nazzal hospitals hospitals that introduced the HIS, report that the system gives them using user perception indicators a greater ability to monitor and to evaluate the impact of the HIS control the hospital environment on health service delivery, quality, and has resulted in significant cost and management.8 Satisfaction savings.12 For example, control with the computerized system is of the use of pharmaceuticals at high among facility management both hospitals became stricter as staff. Eighty-six percent of HIS a result of the HIS. About 64 per- users surveyed report enhanced cent of users surveyed described performance monitoring, with reduced expenditures for patient managers describing the highest care because unnecessary or dupli- impact, and nearly 90 percent cate tests, drugs, or treatment were were able to report more effec- eliminated.13 tively than before.9 Anecdotal reports suggest that By improving inventory controls pharmaceutical purchases by and coordination between facili- Rafidia Hospital fell 17 percent ties, the HIS has the potential to after installation of the HIS, even minimize waste and inefficiencies, though the patient load rose 27 particularly in hospitals’ use of percent in the same period. The consumables (e.g., pharmaceu- HIS is predicted to be cost-neutral ticals and disposables),10 which at the facility level for system con-

8. The assessment included an HIS user survey, group in-depth interviews with facility managers about their experience with HIS during the past year, and a management survey to assess satisfaction with the overall availability of information for reporting and decision- making purposes. 9. User Perception of HIS Effectiveness - Nablus and Qalqilya (Year 5). 10. In-depth interviews from Rafidia and Darwish Nazzal Hospitals revealed that control of the use of pharmaceuticals became stricter as a result of the HIS. Rafidia Hospital was able to support the cost savings with numbers from its Pharmaceuticals Department, showing that there was a 17 percent decrease in the hospital expenditure on pharmaceuticals between 2009 and 2012 despite a 27 percent increase in the number of patients for the same period. (“Assessing the Effectiveness of the Palestinian Ministry of Health, Health Information System,” Alpha International, 2013.) 11. The 2013 Ministry of Health budget allocated about $75 million (281.7 million new Israeli shekels) to consumables, which includes pharmaceuticals (around 80 percent), medical disposables, laboratory reagents, and other procured items. 12. As indicated by empirical and anecdotal evidence, the HIS is enabling the ministry to better manage its limited resources. The HIS significantly reduces waste and inefficiencies at the ministry by improving inventory controls and coordination between facilities. Hospital managers reported that major cost savings are in consumables, including pharmaceuticals, medical disposables, and other procured supplies. Demand for these consumables has dropped in HIS facilities as the system increases the ministry’s capacity to monitor distribution and use. In addition, doctors and pharmacists can now use inventory data to favor generics and better avoid expiration of drug supplies. 13. User Perception of HIS Effectiveness - Nablus and Qalqilya (Year 5).

10 PROMOTING EFFECTIVE HEALTH MANAGEMENT sumables (e.g., paper and toner), driving licenses). The ministry as a result of its waste reduction adopted the methodology to sup- and greater efficiency in resource port service costing in other facili- management.14 ties. (For the impact of the HIS on service delivery, see Chapter An important aspect of hospital Three. Improving High-Quality management costs was introduced Services.) through the HIS in the select hospitals, following a project-sup- In the sixth year, the ministry acti- ported standardization of service vated the HIS Human Resources pricing triggered by the HIS. As (HR) Module as a tool for reform- the project rolled out the HIS in ing human resource management. select ministry facilities, it became The HR module is a timekeeping evident that there were discrepan- module in the HIS that extends cies in prices paid by patients for to ministry facilities in the West services across facilities. The varia- Bank. With its universal connec- tions in pricing affected financial tivity, the module is a tool that the management at the facility level ministry can use to reform human due to a lack of pricing data, with resource management. Through facility finance teams using unveri- the module, the ministry has ac- fied costs in recording patient pay- cess to a comprehensive HR time ments. Without a complete and management system (MenaHR) unified list of services, ministry and a web-based self-service finance staff were unable to enter tool for employee/manager HR all payments into the HIS finance transactions (MenaME). The HR module, resulting in discrepancies module minimizes paperwork between manually recorded and and enhances the quality and HIS-generated accounting data. efficiency of the management of employee working files and related The project supported the min- transactions, including recruit- istry in the costing and pricing ment, appraisals, sanctions, and of services at Rafidia Hospital training. and subsequently supported it to unify the list of services and the By the end of Year 6, all Ministry pricing of those services across of Health employee files were up- the ministry. With project sup- loaded into the module. Personnel port, the ministry unified the transactions were required to be names and most costs for more carried out using the automated than 1,800 services. The ministry system, including roster manage- was also able to capture previ- ment and personnel requests. The ously unrecorded services (such project also increased the minis- as orthopedic surgical implants) try’s capacity for automated HR and eliminate redundancies (such reporting by unifying job titles as duplicate listings of tests for across all the ministry’s facili-

14. “Assessing the Financial Impact of HIS on the Ministry of Health,” Nicholas Skibiak (short- term technical assistance No. 071), submitted to USAID on April 28, 2013.

PROMOTING EFFECTIVE HEALTH MANAGEMENT 11 The project supported the ministry in producing national guidelines for quality improvement in PHC services. The ministry institutionalized 25 reform processes and products, including service guidelines, training manuals, protocols, and job aids developed or updated by the

project. INC. CHEMONICS INTERNATIONAL

ties and providing it with a new, ing manuals, protocols, and job licensed HR statistical reporting aids developed or updated by the feature.15 project.

REGULATION OF The ministry now uses consolidat- NATIONAL HEALTH ed service definitions to evaluate CARE STRENGTHENED and plan health services provided During the project, the ministry through its clinics, following its developed and adopted key regu- adoption of the Essential Package latory tools that strengthen its cul- of PHC Services (EPS) and five- ture of quality improvement and part Standards of Care (SOC). its capacity to plan health services, including clinical and operational The EPS clarifies the responsi- standards. The project facilitated bilities and needs of each clinic. the ministry’s efforts to move Medical staff will be aware of forward with regulatory priori- — and accountable for — the ties by standardizing health care services required for their clinic. delivery and strengthening quality This was a critical step for the management at the primary and ministry outlining the essential secondary health care levels. The services. The package can be used ministry institutionalized 25 in each clinic as a user-friendly reform processes and products, job aid, a monitoring checklist for including service guidelines, train- supervisors, a tool for evaluation

15. The Qlikview statistical reporting tool enables the Ministry of Health to easily consolidate, search, and visually analyze all of its human resource data. During Year 6 Quarter 4, after orienting the ministry’s HR unit in its usage, the project handed over the licenses to the ministry for its use by HR management.

12 PROMOTING EFFECTIVE HEALTH MANAGEMENT of medical records, an instrument user-friendly job aides for clini- for donor coordination, and a cians (covering diabetes mellitus, mechanism to raise citizen aware- hypertension, nutrition related ness of the essential services to to NCDs, and clinical breast which they are entitled. exams). Technical checklists were also developed to standardize The SOC are now available in procedures among clinics for IPC ministry clinics in a user-friendly and supportive supervision and packet of five essential PHC monitoring. tasks: the treatment of NCDs, nursing services, integrated child Along with the project’s other health management, reproductive PHC interventions, these PHC health, and health center man- service guides have enhanced min- agement. The project produced istry accountability to meet fun- the unified SOC in response to a damental standards and measur- ministry request. After reviewing ably improved the quality of care existing protocols and guidelines, provided by ministry clinics. The the project discovered that many quality of PHC services improved of the topics were out of date, by as much as 52 percent on aver- some did not exist (e.g., nursing age as a result of a new culture of services), and existing protocols quality improvement adopted in were underused because they PHC directorates, according to a were not user-friendly or in an pre-/post-client satisfaction sur- accessible language. The proj- vey conducted at targeted PHC ect worked with the ministry, clinics.16 (See Chapter Three. NGOs, the World Health Orga- Improving High-Quality Services: nization, and USAID to ensure Culture of Quality in Primary the up-to-date SOC are also in Health Care Created.) line with international standards. An-Najah National Univer- Other reform products, protocols, sity initiated a donor-funded job aids, and manuals were devel- training-of-trainers course on the oped with the ministry and insti- SOC after the ministry adopted tutionalized with project support the guide. to ensure high-quality care that meets international standards. In addition to the EPS and SOC, (See Chapter Three. Improving the project supported the ministry High-Quality Services: Capacity in developing key guidelines and to Provide High-Quality Sec- protocols (including infection ondary Health Care Enhanced.) prevention and control (IPC) pro- Examples include protocols for tocols, a PHC Nursing Orienta- the operation and clinical use tion Guide, First Aid Manual, and of computerized tomography First Aid Training Manual) and (CT) scanners,17 provision of

16. “PHC Quality Assessment Results,” Flagship Project (Pre: June 2012 and Post: March 2013). 17. The project provided four CT scanners to Ministry of Health hospitals (valued at $3.4 million) to enable the ministry to provide advanced diagnostic services that were previously only available to Palestinian citizens through costly referrals in the private sector or abroad.

PROMOTING EFFECTIVE HEALTH MANAGEMENT 13 emergency medical care, man- result, the ministry has enhanced agement of neonatal intensive its capacity to regulate through care units (NICUs), manuals for coordinated health planning with behavior change communications multiple sector stakeholders and (BCC), preventive maintenance, standardized health information. and the Champion Community The ministry can capitalize on the Approach. The ministry has also new clinical and operational stan- institutionalized training guides dards and guidelines developed developed by the project, in- in coordination with other health cluding for BCC, performance providers to evaluate and lay the improvement, and the HIS. (See foundation for working to enforce Chapter Three. Improving High- quality across the health sector. Quality Services.) With project support, the The project also enabled the min- ministry also made progress on istry to expand its health system strengthening national capac- regulation beyond the borders ity for licensing providers and of its own facilities. During its facilities. Before the narrowing in 2008 self-assessment exercise, the project focus in Year 3, the minis- ministry recognized that a lack of try was able to oversee, participate coordination among service pro- in, or contribute to the drafting of viders was a major weakness of the licensing and re-licensing bylaws health system. Through an inte- for 13 health professions, with grated multi-sectoral approach to project support. The ministry improving health care services, the obtained national endorsement project brought representatives of bylaws governing community from all health service providers health workers, leading to offi- together, including the ministry, cial recognition of their work as NGOs, United Nations Relief and health professionals. The mostly Works Agency, the private sector, female health workers engage health education institutions, communities to improve the and civil society organizations, to health status of the local popula- coordinate health planning and tion — primarily through health improve services to the com- education and community mobi- munity. Throughout its life, the lization — and play a key role in project supported the ministry in providing antenatal and postnatal collaborating with health provid- care and health education on ers and donor technical teams on women’s and children’s health planning and implementation of topics in rural communities. (See services, including development Chapter Two. Recommendation of the HIS, the EPS and SOC, No. 6.) NCD response, and emergency preparedness plans. By engaging In Year 5, an e-learning and testing stakeholders in these processes, portal was launched, procured the project supported the ministry by the project, and housed at the in unifying health sector practices Palestinian Medical Council, and promoting the uptake of new which is the licensing body for systems and guidelines, such as the medical specialties. The council HIS and the PHC standards. As a uses the new testing system to

14 PROMOTING EFFECTIVE HEALTH MANAGEMENT STORY: “This will strengthen the education process in our country and improve the health situation in the Palestinian society,” said Dr. Said Hammouz, secretary general of the Palestinian Medical Council. As the Palestinian licensing body for medical specialties, the council is responsible for testing graduates to certify them to practice as doctors in a variety

CHEMONICS INTERNATIONAL INC. CHEMONICS INTERNATIONAL of specialties.

provide standardized medical cal specialists practicing in the specialization exams for doctors Palestinian health sector, establish seeking licensing. The system standards and medical criteria for also supports continuing medical CHCE, and identify the resources education by providing an online and training needed by doctors resource library for medical pro- working toward licensure/re- fessionals and a virtual academic licensure. It can be used as a basis forum for residency programs. By for the council to work toward supporting the council, the proj- establishing a continuous medical ect increased the national capacity education system for improving to regulate medical competency the quality of health professionals. and enable doctors to continually improve their professional skills Similarly, the newly opened through continuing health care National Calibration and Train- education (CHCE). ing Center provides the Ministry of Health with the potential to The online resource center also certify medical equipment used by serves as a practical step toward public and private health provid- application of the concept of ers as part of the facility accredita- re-licensing medical professionals. tion process. The Palestinian Medical Council will be able to use analysis from With the introduction of the HIS examination results to design new at the national blood bank, the exams to respond to demonstrated ministry can now use the HIS to gaps in knowledge, attitude, skills, regulate national blood supplies. and practice among health profes- The National Blood Bank and sionals and care providers. The the blood banks in all eight HIS council also used the system to hospitals are now ordering blood digitize its personnel files of medi- units through the system. The

PROMOTING EFFECTIVE HEALTH MANAGEMENT 15 STORY: “We built this health clinic together. This is the fruit of collaboration using community resources to bring positive changes to our quality of life,” states Dr. Inshirah Nazzal, a Ministry of Health mother-child health specialist, pictured checking a baby at

the new Deir Abu Deif clinic. INC. CHEMONICS INTERNATIONAL

standardized work flow created strengthened by engaging in — by the direct communication and integrating at the directorate channel between the blood banks level — the project’s community provided a long-awaited solution mobilization initiative (known as for the ministry to the challenge the Champion Community Ap- of managing multiple regional proach). The approach provides centers. an opportunity for district health supervisors, community represen- COMMUNITY tatives, and local authorities to PARTICIPATION IN work together through commu- HEALTH PLANNING nity-clinic boards to systemati- ACTIVATED cally address public health issues. The ministry governance goal of Ministry PHC directorate and enhancing community participa- clinic staff joined with residents tion in health planning was greatly to form the community-clinic

16 PROMOTING EFFECTIVE HEALTH MANAGEMENT CHART 1. HOUSEHOLD SATISFACTION WITH MINISTRY OF HEALTH SERVICES People Surveyed: 1,100 pre-HIS, 1,088 post-HIS

66.0 I am satisfied with the Ministry of Health performance 82.3 58.7 My confidence in the Ministry of Health is high 78.1 59.9 My confidence in the Ministry of Health is rising 77.2

Pre Post 0 20 40 60 80 100 Percent

boards to identify and respond to Satisfaction with PHC services local health priorities in 82 com- rose significantly in communities munities in the West Bank. The benefiting from the project’s qual- community-clinic boards bridged ity improvement and community a historical gap between commu- mobilization interventions. For nities and clinics by soliciting and example, overall satisfaction with acting on citizen feedback. ministry PHC services rose 20 percent among surveyed house- The increased citizen participation holds, with 82 percent reporting in and advocacy for health has satisfaction. Trust in the ministry created a feedback mechanism to also increased: 78 percent of guide the ministry in increasing household residents surveyed had the effectiveness of the health sys- more confidence in its services, tem to meet the needs of commu- and 77 percent said their confi- nity residents. For example, when dence was rising.18 a ministry district manager visited remote Deir Abu Deif village, she Citizen participation in health found that many residents failed planning was institutionalized to seek health care because the at the directorate level when the nearest clinic was too far away. ministry adopted the Champion The community formed a commu- Community Approach, and nity-clinic board and mobilized district managers began using it as local resources to build a clinic, a means of working with commu- for which the ministry provided nities to identify health priority staff and equipment. As a result, needs and set strategies for im- residents are now able to access proving the services provided by high-quality services in their own the clinic. (For more information community without facing the about the Champion Commu- financial and social obstacles as- nity Approach and the project’s sociated with travel. integrated PHC interventions, see

18. Household survey, Champion Community Approach subcontractors partners (Year 3 Annual Report).

PROMOTING EFFECTIVE HEALTH MANAGEMENT 17 VIDEO: “The routine maintenance of an anesthesia machine depends on a (onsite) daily test. In addition, we have to test it with a calibration machine specifically for the device,” said Sa’ed Basheer, Ministry of Health biomedical engineer on the impact of the

new NCTC. INC. CHEMONICS INTERNATIONAL

Chapter Three. Improving High- The project worked with the Quality Services.) ministry to establish and institu- tionalize an integrated procure- PROCUREMENT ment system that reflects the real AND OVERSIGHT OF needs of health facilities, reduces MEDICAL EQUIPMENT inefficiencies and costs, extends SYSTEMIZED the life expectancy of equipment, Health technologies are essential increases equipment usage, and for a functioning health system. improves access to health care Medical devices in particular are services for all Palestinians. With crucial in prevention, diagno- project support, the ministry sis, and treatment of illness and ensured that equipment, supplies, disease, as well as patient rehabili- and pharmaceuticals procured tation. The Ministry of Health is were based on actual need by visit- reliant on international donors ing health facilities to discuss their and/or foreign governments for needs, analyze patient flow and procurement and provision of human resource capacity, assess medical equipment and supplies. how equipment is currently used, Although most donations are and identify equipment needed to made with good intentions, the improve services. outcomes are not always positive if the donations are not properly The project also helped the min- planned and coordinated. The istry adopt the concept of preven- ministry prioritized the need to tive maintenance, which requires adopt a more strategic approach its biomedical engineers to con- to procurement of equipment and duct scheduled maintenance on supplies as a key part of health medical equipment to detect and reform. correct potential failures. This ap-

18 PROMOTING EFFECTIVE HEALTH MANAGEMENT proach represented a dramatic and The ministry can use the NCTC positive shift from the ministry’s to calibrate and maintain medi- previous reactive repair approach. cal equipment, enforce preven- Before the project, the biomedi- tive maintenance, and upgrade cal engineers had not prioritized technical skills of its biomedical routine evaluations of equipment engineers. Through the HIS, the performance and usage and did ministry can manage and main- not have preventive maintenance tain its medical equipment in all schedules. The project introduced HIS facilities through the system, preventive maintenance through which can feed procurement bud- its own medical equipment geting with real-time data. For the procurement process, by requir- first time, all equipment and med- ing medical equipment suppliers ical supplies can be inventoried to provide formal and on-the-job and tracked through the comput- training on preventive mainte- erized HIS developed through the nance to the biomedical engi- project, allowing decision-makers neers. The approach was further to quickly determine gaps and institutionalized by the ministry’s identify the need for new equip- adoption of a Preventive Main- ment and services. The center tenance Manual developed with can reduce annual expenditures the project. The application of for equipment service through preventive maintenance across reduced equipment failures and the ministry plays a major role in elimination and/or reduction of extending the usable life of the shipping equipment outside of the equipment donated by USAID country for repair. and other donors. It is also reduc- ing costs, improving the quality of The Ministry of Health will care, and ensuring patient safety. also be able to use the center to strengthen its regulation of the na- The initiation of the preven- tional health sector. As its regula- tive maintenance effort was the tory capacity grows, the ministry first step toward establishment can use the center for potential of the first medical equipment certification of NGO and private calibration and training center, sector facility equipment. opened in Year 5 with more than $600,000 in project procurement LEADERS FOR CHANGE and technical assistance. The min- DEVELOPED istry’s National Calibration and During the 2008 needs assessment, Training Center (NCTC) further Ministry of Health staff stressed strengthens its capacity to manage the importance of building their and regulate medical devices. The capacity to use data for manage- NCTC is the culmination of the ment, planning, and informed project-ministry partnership to policy formulation, leading to create needs-based, sustainable better service delivery and public procurement of medical equip- satisfaction with the public health ment that is actively and accu- system. The project responded rately used to diagnose and treat to this need for enhanced health Palestinian citizens. (See Chapter management capacity through Two. Promising Practice No. 2.) formal and informal training

PROMOTING EFFECTIVE HEALTH MANAGEMENT 19 STORY: “Participation in the USAID Leadership Development Program provided by the project helped me realize that leadership is not dependent on a position or a title. Leadership is taking the initiative to change and make a difference in health facilities,” said Nablus Health Director Nazmyia Abu Samra, pictured directing nurses and doctors

on their daily schedule. INC. CHEMONICS INTERNATIONAL

designed to build leadership and mid-level managers from across administrative skills. The project the ministry and health service identified and supported “change delivery NGOs who were trained agents” throughout the ministry, to lead change from within the its grantee partners, and at the Palestinian health sector. The community level to promote insti- managers were coached to identify tutionalization of new skills and and then move forward with behaviors, highlighted as a “laud- strategic innovations within the able” intervention in the USAID health sector. The courses com- mid-term evaluation. (See Chapter prehensively addressed the eight Two. Promising Practice No. 5.) leadership competencies that the ministry identified as critical to A three-course Leadership effective leadership.20 Changes Development Program was a introduced as a result of the key component of the project’s program include enhanced quality comprehensive capacity-strength- assurance in PHC laboratories, ening program for the ministry, regulations for private sector use health education institutions, and of medical narcotics, improved NGOs. Described as “excellent” managerial skills among nursing by the mid-term evaluation,19 the managers, and establishment of program developed a cadre of 100 the NCTC.

19. USAID/West Bank and Gaza: Health Sector Reform and Development Flagship Project – Mid-term Evaluation (December 2010), p. 82. 20. The eight critical leadership competencies identified by the ministry are strategic thinking and planning, communication, leading change, situational leadership, performance monitoring and feedback, coaching, team development, and decision-making.

20 PROMOTING EFFECTIVE HEALTH MANAGEMENT CHART 2. APPLICATION OF TRAINING AMONG TRAINEES SURVEYED 366 trainees surveyed in 2011, 2012, 2013 (N = 366)

Can apply skills from training 12 56 30

Have ability to do new tasks at work 15 61 22

Use of tools led to better results at work 3 60 36

Tools adopted by management at workplace 2 5 12 50 31

0 20 40 60 80 100 Percent Don’t know Strongly disagree Disagree Agree Strongly agree

Health Management Gradu- through sound financial manage- ates. With project support, the ment. The training introduced ministry also increased health a three-pronged approach and management capacity by enroll- familiarized participants with ing 96 managers in a bachelor of health system reform and finance arts in health management degree management systems, in gen- program at Al-Quds Open Uni- eral terms and in the Palestinian versity. By offering this degree, the context. In addition, a module on project supported a more credible provider payment mechanisms and competent leadership team was offered afterward to increase that will ultimately reflect on op- trainee capacity on the policy erations of the ministry. Twenty- implications of financial reform one managers graduated from this in the health sector. In an effort two-year program in June 2013. to ensure sustainability of this program, project consultants With budget constraints on developed a health finance train- health providers and limited ing framework and tailored the affordability by patients, the min- technical material to serve as an istry has identified health financ- e-learning course. The e-learning ing and financial management program will support sustainable as a priority in its institutional capacity building for ministry development plan (IDP). The financial and administrative per- project responded to this priority sonnel by ensuring that they have by providing Financial Capacity the necessary skills for financial Strengthening Program training management and planning. to build the capacity of 63 minis- try staff on financial sustainability, In total, 2,516 people from the transparency, and accountability ministry and NGO providers

PROMOTING EFFECTIVE HEALTH MANAGEMENT 21 were trained on health systems The minister was presented operations.21 When surveyed, with three scenarios aimed at 85 percent of those trained by improving facility-level financial the project reported applying management capacity, which skills/knowledge acquired from was identified as a prerequisite U.S. government-funded train- for the decentralization process. ing provided under the project. In 2011, the ministry’s Finance Furthermore, when tools were Department shared the annual developed during the training, budget with Qalqilya Hospital almost all trainees surveyed (96 for the first time and provided the percent) reported an improve- guidance and tools needed for ac- ment in their work, while 81 counting staff to track and record percent22 said their managers their revenues and expenditures had adopted the new adminis- as a basis for monthly needs. Col- trative or health management lecting this information demon- tools.23 strates a first step in preparing hospital managers to project costs, Piloting Health System Decen- identify needs, and prepare bud- tralization. Decentralization in gets, thereby strengthening their the health sector has been rec- capacity for decentralization. ognized as a means to improve the efficiency and quality of NETWORK OF services and was identified as a COMPLEMENTARY priority by the ministry. Cur- SERVICES EXPANDED rently, most decision-making Palestinians needing referral is at the central level, which services unavailable through the makes it difficult for facilities to ministry depend on the private prepare their own budgets and sector in the West Bank and develop sound financial plans. Gaza, NGO service providers, In Year 3, Qalqilya Hospital and external providers outside the was chosen as a decentralization West Bank and Gaza that provide model. After three staff toured such tertiary services. However, a Jordanian hospital that was in the sustainability of some of these the process of decentralization, services is undermined by limited the ministry determined that it managerial capacities. The project was not yet ready to transfer fis- assisted seven NGO health service cal authority and responsibility providers24 of primary, secondary, to its facilities. rehabilitative, and emergency care

21. In the PMP, health systems operations is defined as including management, finance, leadership, and HIS. 22. Trainee follow-up survey, Flagship Project (Year 3-Year 5). Tools. 23. For example, as part of her participation in the Leadership Development Program, Ministry of Health Dangerous Drugs Department Director Safa’ Blaibleh developed a protocol for dispensing narcotic drugs and psychotropic substances in hospitals and health centers, which was then accredited by the minister of health and distributed to private sector hospitals and health centers in booklet form. 24. Bethlehem Arab Society for Rehabilitation, Nablus Association for Social and Community Development/Askar Camp, Four Homes of Mercy, Palestine Save the Children Foundation, Al-Makassed Hospital, St. John Eye Hospital, and Holy Family Hospital.

22 PROMOTING EFFECTIVE HEALTH MANAGEMENT STORY: Mothers are admitted alongside their children at the Jerusalem Princess Basma Center for Disabled Children and learn to care for their disabled children and help them integrate into their communities, with USAID’s

CHEMONICS INTERNATIONAL INC. CHEMONICS INTERNATIONAL support.

to move toward financial sustain- tinue the funded activities upon ability by making their service grant closure.26 (See Chapter Two. management more efficient.25 Promising Practice No. 6 and Based on self-assessments, the Chapter Three. Recommendation NGOs created five-year plans No. 4.) for institutional development, guided by internal change agents In Year 4, the project continued identified and trained by the to work with these grantees to project on key governance, plan- strengthen their capacity to ning, financial management, and identify and respond to fund- administrative skills. The USAID ing proposals. The approach, mid-term evaluation described consistent with USAID Forward this approach as an “effective principles, sought to give the model” for the project’s NGO grantees the tools they needed to partners and noted anecdotal explore funding options that best evidence of sustainable impact, in- fit their organization. The project cluding one grantee’s description provided a two-day workshop of the project’s support as having for 13 grantees on responding “a real strengthening impact for effectively to solicitations and a small NGO in the long run.” developing successful proposals. Additionally, the grantee credited The project provided the NGOs the capacity building training and with tools to enhance their ability grant assistance as enabling him to secure funds from available to develop income streams to con- resources, particularly important

25. USAID/West Bank and Gaza: Health Sector Reform and Development Flagship Project – Mid-term Evaluation (December 2010), pps. 76-81. 26. USAID/West Bank and Gaza: Health Sector Reform and Development Flagship Project – Mid-term Evaluation (December 2010), p. 80.

PROMOTING EFFECTIVE HEALTH MANAGEMENT 23 STORY: “I feel much more confident in our ability to assist (our premature babies) knowing this equipment is here. Our main goal is to manage our premature babies, keep them growing and thriving until discharge,” said Suha Awadha, NICU nurse, Al-Makassed Hospital. The NGO hospital in Jerusalem, which is a Ministry of Health referral hospital, received a high-frequency ventilator for premature newborns and pediatric patients from the

project. INC. CHEMONICS INTERNATIONAL

in the context of limited Palestin- ment Approach tool for the ian Authority resources. ministry within the Palestinian context, shifting its focus from PROMISING PRACTICES external use (by short-term 1. Enabling the Ministry of international consultants) to Health to take the lead in internal use (by ministry staff ). assessing and planning for This modification provided sector-wide reform and the ministry with a sophisti- development. To further the cated, yet responsive, guide ministry’s reform process and to assessing its needs and was initiate its own implemen- commended by USAID in the tation, the project worked mid-term evaluation.28 with the ministry to assess the public health system and The success of the assessment prioritize areas for interven- goes beyond the critical iden- tions, following the six areas of tification of priority reform health systems strengthening needs of the Palestinian health established by the WHO.27 In sector. The process resulted in recognition of the ministry’s an unprecedented participa- commitment to reform, the tion of staff at the district and project tailored the USAID health facility level, in line Health Systems 20/20 Assess- with the project’s focus on

27. World Health Organization. “Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes.” 2007. 28. The project was commended by the USAID mid-term evaluation for having the ministry do a self-assessment, rather than sending in a team of outside consultants: USAID/West Bank and Gaza: Health Sector Reform and Development Flagship Project: Mid-term Evaluation (December 2010), p.82.

24 PROMOTING EFFECTIVE HEALTH MANAGEMENT capacity-building and decen- 2. Modeling unified PHC tralization. The process also planning practices through enabled ministry staff to take project interventions. The a critical look at the system ministry provided the Palestin- and their role in strengthen- ian health sector with a new ing it, motivating them to PHC quality framework when produce a multi-year institu- it developed and adopted the tional development plan. The EPS with project support. creation of a plan based on the Although the EPS was formally self-assessment empowered the adopted in Year 4, the project ministry to define roles and re- used the draft package to guide sponsibilities of health system its interventions in improving actors and develop an action PHC quality throughout its plan to address gaps in system life. For instance, the project efficacy.29 used the draft EPS to develop the health facility assessment, Based on priorities identi- which was used by the ministry fied in the self-assessment, the and the project to assess and project supported the ministry select clinics for the integrated in developing health planning PHC interventions. In addi- guides and tools, including the tion, procurement needs were EPS. In addition to the EPS’ assessed and verified against use as standards of care for a checklist based on the EPS. PHCs, it is used for evaluating This modeling of the EPS as and planning for services at a strategic planning standard the district and facility level. demonstrated its cross-sector This was one of the first such relevancy and promoted the standards adopted and dissemi- ministry’s practice with and nated throughout all PHC. ownership of the tool prior to The project also used the health its formal adoption. facility assessment (which iden- tified the resources clinics need 3. Modeling best practices in to correspond with the EPS), project procurement to insti- and the Champion Commu- tutionalize Ministry of Health nity Approach (which solicits reforms in the procurement citizen feedback through process. The USAID mid- open dialogue sessions and term evaluation described the community-clinic boards). (For project’s model of coordination, more information, see Chap- training, and follow-up on the ter Three. Improving High- correct use and maintenance Quality Services.) The tools of the equipment procured as have had demonstrated success a best practice among USAID in reforming and developing projects. It noted that the pro- the ministry’s health planning cess was “a good learning experi- processes. ence for the Ministry of Health

29. USAID/West Bank and Gaza: Health Sector Reform and Development Flagship Project: Mid-term Evaluation (December 2010), p.92.

PROMOTING EFFECTIVE HEALTH MANAGEMENT 25 in how to conduct procurement HIS were difficult to measure in a transparent and coordinat- accurately, given the limitations ed way.” 30 From its beginning, of existing recordkeeping and the project used procurement challenges of the current fiscal as a technical reform tool by environment. In addition, major establishing a rigorous, transpar- savings cannot be expected until ent, and collaborative process the data supplied by the HIS are for procuring medical supplies more directly incorporated into and commodities for the min- ministry administrative and istry. The project ensured that planning processes (especially procurement was needs-based, pharmaceutical procurement). verified by ministry biomedical To support the ministry in this engineering staff, coordinated effort, the project conducted with stakeholders, and trans- baseline assessments at the five parent. The project worked new hospitals connected to the to ensure the sustainable and HIS in Year 6 to establish base- effective use of procured equip- lines against which the impact ment by integrating preventive of the HIS can be measured. maintenance into all procure- One of the three indicators was ment activities, with all vendors annual net cash flow (measured mandated to provide preventive by financial records analysis). In maintenance and training on the coming year, the ministry preventive maintenance, and will be able to use the baseline providing clinical training for assessment to measure financial ministry staff using the newly impact of the HIS on these five procured devices. hospitals.31 The project was able to use the study and the sub- 4. Creating a comparative base- sequent impact analysis of the line of facility costs to indicate HIS on the ministry to identify the financial impact of the further reform interventions HIS. The assessment of the needed to promote its capacity financial impact of the HIS on to use the HIS as an effective Rafidia Hospital revealed where management tool. (See Chapter the hospital was experienc- Two. Lesson Learned No. 2.) ing cost savings. The ministry can use this study as a guide 5. A) Identifying (mid-level) in developing comparative “change agents” when reform- baselines for measuring HIS ing management practices. impact on individual facilities, Mid-level managers were the as well as the wider system. At most active agents of change the time of writing, estimates during the project, because they of the financial impact of the were able to apply and see an

30. USAID/West Bank and Gaza: Health Sector Reform and Development Flagship Project – Mid-term Evaluation (December 2010), p. 80. 31. The other two assessment indicators were unit heads’ satisfaction with information (measured by a survey questionnaire) and patient time (measured by patient-administered time stamp cards).

26 PROMOTING EFFECTIVE HEALTH MANAGEMENT STORY: “So many of our staff have been isolated from improving their medical knowledge, with limited access to travel or continuing education…these workshops are invaluable to updating essential knowledge of our staff,” said Dr. Hassan Fitian,

CHEMONICS INTERNATIONAL INC. CHEMONICS INTERNATIONAL Rafidia NICU director.

immediate benefit of the tools noted in Chapter Two. Les- developed through the project. sons Learned, political will for As a result, they continued to system change was inconsistent, use, develop, and institutional- and the system’s impact was ize the tools. Nursing supervi- occasionally limited by insuf- sors in the Nablus and Qalqilya ficient contextual support.B) PHC districts have adopted the Empowering change agents to project’s community mobiliza- lead in institutional develop- tion approach and initiated ment as an effective model their own Champion Commu- for the NGO sector. The nities to engage other villages in mid-term evaluators reported improving their health services. that the NGO hospital provid- Similarly, hospital manage- ers who received institutional ment acted as “champions” in development support were promoting HIS use and argued unanimously positive about the for the system’s expansion support and training provided across the ministry, citing rapid by the project, as part of its sup- improvements in efficiency, port for the NGO sector. The cost-savings, and accountability. evaluators concluded that the (See Chapter Three. Improv- project approach — identifying ing High-Quality Services.) change agents in an organiza- The project also engaged senior tion and leading the organiza- leadership to foster buy-in tion through self-assessment to the changes from mid- — was effective and successful level management. However, as and should be expanded.32

32. USAID/West Bank and Gaza: Health Sector Reform and Development Flagship Project: Mid-term Evaluation (December 2010), p. 79.

PROMOTING EFFECTIVE HEALTH MANAGEMENT 27 STORY: “Words cannot express my gratitude. Now I truly feel when my eyes open up, it’s as if I am opening up to life. Everything is so much more colorful, vibrant, and alive.” Ahmed Abed Elal, a high school student from Gaza, underwent cataract removal surgery in both eyes at St. John Eye Hospital Clinic in Gaza, using the phacoemulsification machine procured by the project. Ahmed suffered from blurred vision since birth, but

surgery restored his vision. INC. CHEMONICS INTERNATIONAL

6. Using practical training ap- year project. The project sup- proaches to create immediate ported the ministry in design- and sustainable changes in ing an IDP that responded to practices and environment. its sector-wide priorities identi- Practical training approaches, fied through the ministry’s self- like on-the-job coaching (OJC) assessment. The USAID mid- or mentoring, enable individu- term evaluation described the als to build their skills in direct process as “a valuable exercise response to the needs of their in terms of capacity building professional environment. and promoting ownership.”33 The project adopted a practi- However, as a sector-wide cal approach to clinical and plan, the scope of the IDP was operational training whenever beyond the project’s timeframe possible, including in hospital and resources. In the last two costing, procurement inven- years, USAID directed the tory, NICU services, preven- project to narrow its focus to tive maintenance, and PHC key ministry priorities in which performance improvement. The impact was already apparent. project also modeled to PHC However, before the reduction supervisors the use of OJC as a in scope, the project supported supportive supervision tool. the ministry in developing strategic plans and resources for LESSONS LEARNED other technical priorities that 1. Sector-wide reform was an can guide future health sector ambitious mandate for a five- reform, including the PMC,

33. USAID/West Bank and Gaza: Health Sector Reform and Development Flagship Project: Mid-term Evaluation (December 2010), p. 5.

28 PROMOTING EFFECTIVE HEALTH MANAGEMENT secondary health care (SHC) project and the core of the in- medical waste management, terventions to strengthen insti- health insurance, emergency tutional capacity and improve preparedness, CHCE, leader- performance in the Palestin- ship development, visiting pro- ian health sector. The project fessionals, and a donor inter- provided training on leader- vention archive. (See Chapter ship, management, finances, Two. Recommendation No. 5.) monitoring and reporting, and clinical topics, designed to 2. The Ministry of Health needs impart new skills and refresh to continue to build capacity existing competencies. Project to realize the potential of the analysis found that its training HIS. The HIS’s impact can be program was effective in meet- expanded as the ministry gains ing the unique training needs of the confidence of the cultural diverse groups, including health shift toward data for decision- providers, managers, com- making. The project’s ability munity members, and journal- to work hand in hand with the ists. More than 85 percent of ministry to introduce a founda- trainees were able to apply what tion for an electronic HIS has they learned, including sharing been tremendous; however, knowledge, from training to continued support for capacity the use of tools developed dur- building is needed. As noted ing or after training. However, above, the HIS has resulted in trainees also reported barriers, a tangible change to manage- including limited availability ment practices at the ministry, of medicines, equipment, and particularly in Rafidia Hospital, electricity at facilities; weak leading to greater efficiencies administrative support (at the and cost savings. However, hos- facility level); an overwhelm- pital managers were not always ing number of patients (at the able to maximize the system’s clinic level); and insufficient potential because they lacked awareness campaigns (at the the capacity to do trend analysis community level). The identi- and budget forecasting on date- fication of barriers at various to-day activities from on the levels serves as a reminder that, data collected by HIS. Engag- in addition to providing train- ing hospital administrators in ing, follow-up is required across using reports generated from all levels to prepare the ground the system on a weekly basis for application of training by and strengthening the minis- trainees. try’s headquarters staff to use the data routinely will engender 4. The time was not right for a more confident ministry team USAID’s support of the working with the HIS system. Palestine Medical Complex (PMC). The project supported 3. The impact of training is the ministry in creating the greater when follow-up cre- PMC from what were previ- ates an enabling environment. ously four independent medical Training was at the core of the facilities. In Year 2, the project

PROMOTING EFFECTIVE HEALTH MANAGEMENT 29 provided the ministry with a it difficult for the project to strategic assessment of the sepa- provide the regular monitoring rate management structures to and hands-on support provided enable it to plan for integration to non-Gaza grantees or the of the facilities. Bylaws were comprehensive procurement created for the PMC and were approach (described above), endorsed by the minister. Also although project staff visited created was a guide for hospital as frequently as permitted. management and operations Despite these restrictions, the for the complex that defines the project was able to significantly organizational structure and upgrade and create new reha- job descriptions. (Both prod- bilitation and referral services ucts can also be used in other available to the population of ministry hospitals and can serve more than 1.6 million, through as a reference for its hospital $273,600 in grants and $1.63 management.) However, a deci- million in medical procure- sion was made to suspend its ment for select NGO health support for the PMC and, fol- providers. (See Chapter Three. lowing guidance from USAID, Improving High-Quality Ser- the project shifted its technical vices.) focus away from support for the PMC management capacity. 6. Data quality is a critical foundation for effective 5. The impact on health systems health data analytics. In Year in Gaza is limited by the regu- 6, the project built the min- latory and political context. istry’s managerial capacity to The project’s original technical understand and use HIS data plans for implementation in analytics to improve health Gaza focused on improving services. The project provided the quality of health services the ministry with a compre- provided by NGOs, primarily hensive managerial reporting through institutional capac- tool to model the use of data ity building, grant support, analysis for assessing health and procurement. However, service quality and efficiency, restrictions on access to Gaza identifying at the same time for project staff and procured gaps or deficiencies in service commodities, conflict-related delivery. Because data analysis suspension of activities, and depends on the quality of col- the limited pool of eligible lected data, the project identi- NGO partners resulted in the fied ICD-10CM34 coding as project narrowing its techni- a source of data weakness for cal approach to focus on grant HIS data quality. The ministry support for rehabilitative must ensure that system users health services and procure- are trained on and motivated in ment for select health institu- their collection of high-quality tions. Access restrictions made data to prevent poor data qual-

34. International Classification of Diseases – 10 Clinical Modification.

30 PROMOTING EFFECTIVE HEALTH MANAGEMENT ity from limiting the scope and ably through systems-building sustainability of the HIS as a support. C) Increase district- performance evaluation tool. level manager support for the HIS installed at PHC clinics. 7. Ministry of Health leaders The HIS is currently opera- have not fully integrated the tional at eight PHC clinics in HIS into their management of the West Bank. The follow-up health services. By the end of and oversight of system use by Year 6, the project identified a PHC district management is lack of appetite for and buy-in critical to ensure the successful from the ministry management continuation of its use by PHC for data-driven approaches to staff. health management. This low level of interest affected the 2. Strengthen the capacity of data quality efforts. the National Calibration and Training Center to institu- RECOMMENDATIONS tionalize strategic procurement 1. A) Continue to institutional- and preventive maintenance ize HIS as a national health practices across the ministry. management system through Continued investment in the sustaining the multi-pronged NCTC will also support the investment in integration/roll- ministry in activating its regula- out at facility level; expanding tion of medical devices across its coverage to non-ministry the health sector, which will facilities (using the USAID- be a key criterion for accredita- funded open license); strength- tion and licensing of health ening leadership use for analysis, sector facilities. Needs listed reporting, and budgeting; and by the ministry for activating continuing cross-health sector the NCTC as a sustainable and dialogue/ownership in prepa- ministry-wide resource include ration for a potential future a greater mandate to supervise national rollout. B) Build the biomedical engineers based in capacity of Ministry of Health its facilities and more physical central institutions to use HIS resources (e.g., spare parts and for strategic planning, particu- transportation). larly in monitoring of service performance indicators and use 3. Facilitate operationalization of data-analytical tools provided of the EPS and SOC as tools in Year 6. As noted in Chapter for planning for PHC service Two. Lesson Learned No. 2, the delivery. Possible institution- ministry needs to strengthen alizing mechanisms include its capacity to use the HIS in continued training/OJC at the its budgeting and procurement central and district levels and processes to realize the reform mobilization of communities to potential of the HIS. The capac- use the EPS as a citizen-focused ity of the ministry’s Health list of mandated ministry Information Department to services and the SOC as a guide use the HIS also needs to be for management and improve- continually enhanced, prefer- ment of these services.

PROMOTING EFFECTIVE HEALTH MANAGEMENT 31 4. Continue a multi-sectoral limits the use of such data and approach to foster coordina- sharing of information to avoid tion in planning and delivery duplication by other donor- of health services nationwide. supported interventions. The Including other health sector project recommends that the stakeholders in ministry-led ministry establish a resource development and reform initia- library that would house all key tives promotes their sustainabil- documentation, training ma- ity by ensuring their immediate terials, presentations, research, relevance to non-ministry and reports in a cataloged and health providers. Ministry pri- systematic manner to be main- orities that would benefit from tained and easily searchable by continued coordination with ministry staff, consultants, and multiple stakeholders include international donors. completion of the HIS, com- munity mobilization around 6. Build on the adoption of com- PHC services, dissemination munity health worker CHCE of and training on the EPS and criteria by providing bridging SOC, regulation of CHCE, training to existing community and finalization of the National health workers to enable them Emergency Plan. to apply for formal recognition. In 2012, more than 200 women 5. Create a resource library at took the first professional the Ministry of Health for accreditation examination ministry planning and donor for community health work- interventions. The project ers delivered by the ministry. supported design and establish- Many more community health ment of a resource library for workers remain uncertified and the ministry before the reduc- lack the training to help them tion in scope in Year 4. Since prepare for the examination. the library’s establishment in The project recommends that 1994, ministry staff, experts, community health workers be and international donors and encouraged and prepared for consultants have written docu- accreditation to expand their ments, guides, training materi- role in supporting the min- als, and presentations that are istry’s community outreach, decentralized across the organi- particularly after the end-of- zation. The lack of a centralized project-supported community knowledge management system health mobilization.

32 PROMOTING EFFECTIVE HEALTH MANAGEMENT STORY: Through project- supported coordination, Al-Makassed NGO Hospital donated a hemodialysis machine to the ministry’s Salfit Kidney Unit. “The donation of the device came at the right time and place… This is a beautiful example of the strengthening of the NGO sector with the public, not as competitors, but using available resources at a national level,” said Salfit Hospital Director Dr. Ghassan

CHEMONICS INTERNATIONAL INC. CHEMONICS INTERNATIONAL Barakat.

PROMOTING EFFECTIVE HEALTH MANAGEMENT 33 CHEMONICS INTERNATIONAL INC. CHEMONICS INTERNATIONAL

The focus on improving quality of service at primary health care facilities led the ministry in establishing triage areas in the emergency rooms in Palestine Medical Complex, a key emergency service center in the West Bank. CHAPTER THREE IMPROVING HIGH-QUALITY SERVICES

CULTURE OF QUALITY nity involvement in clinics, and IN PRIMARY HEALTH enhancing coordination among CARE CREATED health service providers. Improving the quality of health services at the PHC level is The project introduced an fundamental to strengthening integrated quality improvement the health system as a whole. The program for delivery of an es- project triggered immediate im- sential package of primary care provements in the quality of care services, achieving tangible results by activating PHC and citizen in the quality of care provided by leadership to improve Ministry motivated supervisors, enthusi- of Health services through an in- astic clinic staff, and passionate tegrated multi-sectoral approach, citizen advocates. An end-of- centered on enabling PHC staff project assessment of clinics to plan for and provide respon- that received the comprehensive sive services, equipping clinics support found that they improved with essential medical supplies, an average of 52 percent against strengthening the level of commu- quality improvement indicators.35

35. The quality of care improved most in PHC directorates that experienced concurrent project support to the clinic and community mobilization, as explained in Chapter Three. Promising Practice No. 1. For instance, the project provided clinics in the Toubas and Salfit directorates with the full spectrum of quality interventions without the funding-related interruptions experienced in other directorates. Clinics assessed in those two districts improved an average of 52 percent compared to before project interventions, compared to 22 percent in clinics in Hebron, where funding holds resulted in activity suspensions.

IMPROVING HIGH-QUALITY SERVICES 35 As noted by program evaluators, clinics across the West Bank. The the project’s quality improvement project supported the rollout in initiatives created a culture of five directorates before it sus- quality at the facility level, which pended its PHC interventions in can now be built on to develop a Year 5. In those directorates, PHC quality improvement framework. supervisors conducted orientation (See Chapter Three. Recommen- workshops for all PHC staff, with dation No. 7.) 627 clinic staff participating.

The project supported the minis- Building on these quality guide- try in producing national guide- lines, the project used a compre- lines for quality improvement in hensive and integrated approach PHC services, including the EPS, to strengthening, improving, and SOC, protocols, and job aids. sustaining the quality of essential (See Chapter Two. Regulation of PHC services. Launched in the National Health Care Strength- Nablus directorates and then ened.) Following formal adoption rolled out to all 12 West Bank of the guidelines by the ministry directorates, the project’s collab- in Year 4, ministry supervisors orative supportive supervision planned and initiated rollout of approach took PHC supervisors the guidelines to more than 460 into the field to identify vulner-

POSTER: Communities led grassroots health reform. Through the Champion Community program, citizens in the West Bank are finding sustainable solutions to community health needs by partnering with the Ministry of

Health. INC. CHEMONICS INTERNATIONAL

36 IMPROVING HIGH-QUALITY SERVICES STORY: “I used to focus on the negative and berate staff on what they were doing wrong. Now, we are building trust between the ministry, clinics, and communities, sharing new skills and communicating,” said Hanan Al-Salous, Nablus PHC

CHEMONICS INTERNATIONAL INC. CHEMONICS INTERNATIONAL supervisor.

able communities, evaluate service more felt that their questions had gaps against the EPS, develop been answered clearly.36 action plans, and mobilize citizens to join their service improvement Through formal training and fol- initiatives. low-up OJC, the project worked with PHC supervisors to provide Supervisors coached clinic staff assistance and support to staff at on implementing the new service the clinics that help them solve standards and protocols, using problems, improve performance, new and updated health informa- provide on-the-job training, and tion provided in the EPS, SOC, most importantly, build a trusting and job aids provided through the relationship that allows supervi- project. These focused on IPC sors to conduct these visits to sup- and the models of care for NCDs, port, coach, and be a resource for such as diabetes, hypertension, clinic staff to allow them to reach and cardiovascular disease. Citi- higher performance standards. zens noticed; 54 percent more of those surveyed felt that their treat- Throughout the life of the ment provider was professional, project, 1,064 PHC health 30 percent more were treated in professionals received formal privacy, 69 percent more felt they training on such topics as sup- had been treated courteously, 60 portive supervision, NCDs, first percent more felt they were able aid training for trainers, basic life to ask questions, and 67 percent support and advanced cardiac

36 The client satisfaction survey was one of two pre-/post-surveys conducted by the project to evaluate implementation of its integrated PHC interventions. For further information, see Annex 4.

IMPROVING HIGH-QUALITY SERVICES 37 CHART 3. CLIENT SATISFACTION WITH MINISTRY OF HEALTH PHC SERVICES People surveyed: 363 pre-HIS, 383 post-HIS

No one from outside the treatment room could 54.45 overhear my conversation 81.0 53.7 My questions were answered clearly 89.8 55.6 I was able to ask the treatment provider questions 89.0 54.3 Clinic staff treated me courteously 91.9 54.2 Clinic staff were professional 83.5

Pre Post 0 20 40 60 80 100 Percent

life support, IPC, electrocardio- ers and NCD blood tests, enables gram use, mammography use and clinic staff to comply with the new interpretation, and leadership. A publicly available guidelines and total of 350 people at more than standards. Directorate services 50 PHC clinics received OJC were also enhanced through in- by project staff on such topics stallation of pharmaceutical cold as IPC, diabetes mellitus, and rooms in seven PHC directorate hypertension. clinics to ensure the functioning of the cold chain system, thereby The project supported integra- maintaining an efficient vaccina- tion of the EPS and SOC at the tion schedule and safe storage of community level by procuring temperature-sensitive drugs and nearly $2.5 million in essential vaccines. medical equipment and supplies for 156 PHC clinics, with clinical The impact has been significant in and operational training provided remote rural areas, where citizens to ensure effective utilization. As have limited access to medical a result, the ministry was able to services. Clinic staff use the equip- upgrade PHC services, imple- ment to streamline medical checks ment the newly adopted EPS and on waiting patients. As a result, SOC, and respond to community more patients are returning to fol- requests for new services. Clinics low through on health checks and are now able to offer services that treatment because they can receive correspond to their designated more services more quickly and level. For example, the clinic in accurately in their own communi- Sabastya offers testing services ty. When surveyed, 89 percent of in accordance with its Level 2 clients said they would return to classification, with newly installed their PHC clinic for health care, laboratory equipment. The de- compared to 55 percent before livery of equipment required for the project’s interventions. More services outlined in the EPS and than 86 percent said they would SOC, such as chemistry analyz- recommend the clinic to their

38 IMPROVING HIGH-QUALITY SERVICES friends and family, compared to procurement approach, effective 54 percent before. use of the equipment was ensured through follow-on training, and The project also worked with the OJC was provided for mammog- ministry to strengthen and pri- raphy technicians and nurses. (See oritize delivery of breast cancer- Chapter Three. Promising Practice related services to overcome No. 3.) cultural taboos about discussing the disease and inspire women to The project connected eight key take control of their health and PHC clinics in four director- their lives. The project augmented ates to the local hospital through the ministry’s capacity for early the HIS. PHC directorate staff breast cancer detection at the described the HIS system as a PHC level with advanced screen- technological breakthrough that ing methods. Mammography minimizes paperwork and allows equipment was installed in six for better archiving of patients’ PHC centers across the West files. They also noted that the sys- Bank in the Bethlehem, Hebron, tem allows management to better Jericho, Jerusalem, Qalqilya, and supervise staff and performance. Toubas health directorates. In About 82 percent of PHC staff accordance with the project’s surveyed said the HIS helped or-

STORY: “I feel better knowing I can get the care I need nearby and now have more energy to play with my children,” said diabetic patient Nuaf Snobar. Diabetic patients are now able to receive regular specialized counseling and check-ups

CHEMONICS INTERNATIONAL INC. CHEMONICS INTERNATIONAL through their PHC clinics.

IMPROVING HIGH-QUALITY SERVICES 39 VIDEO: “With support of international organizations and support from USAID, we have equipment to provide early-detection mammograms across all parts of the nation. As we’re talking about 40 percent (of women) who can be diagnosed early on and given treatment, it has become part of our duty and commitment (to care for these women). We believe prevention is part of the treatment,” said Assad Ramlawi, PHC director

general. INC. CHEMONICS INTERNATIONAL

ganize information relating to the work with the ministry in mobi- clinic operations, while 74 percent lizing local residents. With the said the HIS gave them easier ac- support of the CBOs, citizens, cess to this information.37 clinic staff, and district supervi- sors formed community-clinic The project actively engaged com- boards to identify health needs munities to ensure that clinics re- and develop community health spond to the specific needs of the action plans focused on promot- communities they serve by work- ing healthy living. In partner- ing with the ministry to establish ship with their local Ministry of the Champion Community Ap- Health clinics, the community- proach. This community-centered clinic boards conducted health approach gives the opportunity education, health screening, and for district health supervisors, environmental-awareness cam- community leaders, citizens, and paigns on topics such as NCDs, volunteers to work together to women’s and children’s health, and improve health services in their environmental health. communities and systematically address public health priorities. The approach led to increased citi- zen participation in and advocacy The approach was established in for health and created a feedback 83 communities in all 12 health mechanism on the effectiveness of directorates, led by community- the health system. The Champion based organizations (CBOs) Community Approach built com- subcontracted by the project to munity capacity to self-identify

37. “Assessing the Effectiveness of the Palestinian Ministry of Health, Health Information System,” Alpha International (2013 and 2014).

40 IMPROVING HIGH-QUALITY SERVICES CHART 4. HIS IMPACT ON AVAILABILITY OF PHC INFORMATION 78 people surveyed at 3 PHC clinics

HIS organizes information 82.0 HIS facilitates access to information 74.6

60 80 100 Percent

priorities, needs, resources, and plained about limited clinic staff solutions, in such a way as to pro- and equipment, the ministry re- mote representative participation, sponded by rotating doctors more good governance, accountability, frequently through the clinics and and change. As citizens pushed hiring additional staff to ease the forward with requests for new administrative burden on nurses. services, ministry district manag- ers gained experience in using the Communities reported feeling EPS to plan new services, better more “in touch” with the ministry allocate resources, and expand and more empowered to commu- overall access to clinics. When nicate directly with them about community-clinic boards com- needs. For example, after requests

VIDEO: “Community coordinators are supporting clinic staff in making tangible changes through health education. I go to people’s homes and introduce the services at the clinic. I tell them they should take advantage of the health services offered by their ministry,” said Haya Awisa, Champion Community

CHEMONICS INTERNATIONAL INC. CHEMONICS INTERNATIONAL coordinator.

IMPROVING HIGH-QUALITY SERVICES 41 STORY: “We reach everyone because the young users tell their families. Old women come to tell us they heard about us via Facebook,” said Areen Jenazreh, Wadi Al-Fara’a, Hebron PHC Directorate. Communities participating in the project’s Champion Community Approach have also increased citizen access to cancer services by hosting screening events. For instance, Bani Naim, a village in Hebron, hosted a multi-day breast screening event in partnership with Augusta Victoria

Hospital’s mobile clinic. INC. CHEMONICS INTERNATIONAL

from residents in Urif (Nablus), tions materials and encourage the ministry added women’s clinic visits. The community- health services to the clinic using clinic boards held community portable ultrasounds requested health days, at which residents from the project. In other commu- learned about healthy lifestyles, nities, the ministry moved clinics received screenings by health to more accessible locations and professionals from the ministry increased doctors’ visits to remote and other health providers, and clinics. were encouraged to seek follow- up care. Communities demonstrated increased knowledge and aware- With project encouragement, the ness of ministry services. Health community-clinic boards used education activities soared, from social media to increase citizen only two or three times a year participation in their community to as many as multiple activities health activities, with more than each week, reaching hundreds of a third (30) of the Champion people a day. Community health Communities creating Facebook coordinators working with the pages by Year 5. With its focus on community-clinic boards ex- networking, Facebook was well- tended the reach of PHC services suited to the Champion Commu- significantly. nity Approach, which emphasizes community-driven PHC reform. The coordinators held education- Announcements for health al sessions on busy clinic days so activities organized by the boards the volunteers could speak with (e.g., health screenings, clean-up residents waiting to see clinic staff campaigns, or health education) and made home visits to distrib- were frequently posted, and ute behavior change communica- advanced medical services, such as

42 IMPROVING HIGH-QUALITY SERVICES cancer screenings, were promoted proach, while more than1,000 through Facebook. community volunteers were mobilized across the West Bank Social media provided the to conduct a variety of health and community-clinic boards with environmental awareness cam- an efficient and wide-reaching paigns and outreach. An estimated communications tool, instantly ac- $373,753 in local community cessible even in large communities contributions was leveraged in and unrestricted by social restric- support of community-based tions common in conservative health activities and in support rural communities. Community of the local PHC clinic. Seven pages even attracted attention and communities in four districts support from abroad, with one were awarded the title Champion community-clinic board raising Community and received second financial donations from expatri- subcontracts. ate residents through its Facebook page. Sustainability of the Cham- pion Community Approach was More than 1 million (1,352,327) demonstrated in Year 4, when participants benefited from the Ministry of Health and four activities carried out through the communities across the West Champion Community Ap- Bank independently conducted

STORY: “When I saw how much (the Ministry of Health) had achieved and how hard the communities worked, I thought others could do the same. We just need to give them the opportunity,” said Marwa Dimyati, PHC nursing

CHEMONICS INTERNATIONAL INC. CHEMONICS INTERNATIONAL supervisor, Nablus Directorate.

IMPROVING HIGH-QUALITY SERVICES 43 community mobilization. The rect support from the project. For ministry piloted its own Cham- example, the CBO and the local pion Community initiative in the ministry clinic in Burin (Nablus) Nablus PHC Directorate in Beit invited two surrounding commu- Imreen. Working directly with nities to join their activities and the community, the ministry led a joint community-clinic board formation of a community-clinic was formed that now coordinates board to identify local health health campaigns. priorities. Health and non-health profes- The new board quickly lever- sionals play an essential role in aged community engagement disseminating behavior change to re-paint the clinic and con- communications to clients and duct health-awareness activities. the community, which is critical Through the ministry’s director- to enhancing the impact of clini- ate staff, the Beit Imreen board cal and community-based health communicated and collaborated service delivery. with the nearby project-initiated Champion Communities of With project support, the Al-Naqura, Burqa, and Sabastya. ministry’s Health Education and Communities also expanded their Promotion Department (HEPD) mobilization efforts, without di- developed a range of materials for

VIDEO: An animated Ministry of Health spot on precautions to be taken when driving while taking medication (developed in partnership with the USAID Palestinian Authority Capacity Enhancement project) was

aired on local television. INC. CHEMONICS INTERNATIONAL

44 IMPROVING HIGH-QUALITY SERVICES CHART 5. CLIENT SATISFACTION WITH PHC BCC SERVICES Client survey (Pre = 363 and post = 383)

59.1% I received health education material at the clinic 77.3% My doctor gave me advice about ways to avoid 52.8% illness and stay healthy 83.5%

Pre Post 0 20 40 60 80 100

promotion of healthy living for 15 evidence-based health education BCC modules, including NCDs, by developing a BCC guide to nutrition, injury and accident train health educators, commu- prevention, women’s health, nity health workers, and other community first aid, and healthy health professionals on adminis- lifestyles. The radio spots, cartoon tering behavior change messages episodes, pamphlets, and booklets and materials and developing bolster ministry efforts to improve strategic campaigns to institution- health care by educating the pub- alize BCC. lic on its role in improving health outcomes. The project found a resulting increase in the provision of health The project also supported the advice to patients during clinic ministry in delivering three annual visits. The provision of health summer camps in communities education material increased participating in the Champion significantly during project Community Approach, with interventions, with more than 77 nearly 3,000 children participat- percent of respondents reporting ing. By Year 4, the healthy living receiving health education mate- summer camps had grown into a rial compared to about 59 percent BCC mechanism for reaching the before.38 Health counseling also entire community. In addition to improved, with 30 percent more teaching children about healthy respondents saying that they had behavior through fun activities, received advice on healthy living. the ministry trained mothers on proper nutrition, hygiene, and Furthermore, the impact of proj- safety to reinforce the basic health ect-supported health education messages the children received at initiatives was higher than that the summer camps so they could for BCC materials from any other pass these messages on to their source, according to a message re- other children and relatives. call survey on BCC. Respondents had the highest recall for BCC The project strengthened the min- materials funded by the project on istry’s capacity for wide-reaching, healthy lifestyles, women’s health,

38. Client satisfaction survey (Year 4). For further information, see Annex 4.

IMPROVING HIGH-QUALITY SERVICES 45 CHART 6. ACTION TAKEN ON PROJECT BCC MESSAGES People surveyed: BCC follow-up survey (2011)

Change to balanced diet

Early prevention/checkup

General change

Less stress in life

More exercise

Visit to health facility

0 20 40 60 80 100 Percent Female Male Total *On average, 69% of respondents took action on project BCC messages (70% of women and 61% of men).

children’s health, and nutrition. quality improvement and quality Most respondents were exposed of care and expanded diagnostic to project BCC materials during and treatment services as a result their visits to ministry clinics. Of of responsive procurement. The the 65 percent of respondents project promoted evidence-based who recalled BCC messages, 69 decision-making for planning and percent took actions to improve provision of health care in select their health and well-being, such SHC facilities and departments, as changing to balanced diets, supported by hands-on training exercising, and visiting health care and follow-up. facilities for screenings and check- ups.39 The ministry is using thecompre - hensive HIS introduced by the HIS LEADS TO IMPROVED project to improve the manage- MANAGEMENT ment and flow of health service PRACTICES delivery to Palestinian citizens. As a result of project support, The HIS is a centralized system the Ministry of Health has that has created greater avail- taken initial steps toward greater ability of accurate, timely data in management of SHC services two-thirds of the hospitals and through the HIS, more respon- several large PHCs. The system sive emergency services, and standardizes patient administra- enhanced clinical and leadership tion and management procedures skills among nurses. The ministry across health facilities. The HIS also introduced new tools for has improved the perception of

39. Behavior change communications recall survey (Year 3).

46 IMPROVING HIGH-QUALITY SERVICES CHART 7. MANAGER SATISFACTION WITH INFORMATION SOURCES FOR PATIENT CARE 74 managers surveyed in 2014

87 SHC 77 100 PHC 60

0 20 40 60 80 100 HIS Mixed (HIS and paper-based) Percent

in-patient tracking at every level, and monitor the performance of according to 80 percent of users hospital departments and staff. surveyed. All managers who have to make When surveyed, users of the patient care-related decisions say system say it is easier to share that patient information is orga- information among staff and de- nized, and 80 percent are satis- partments (89 percent) and facili- fied with information available ties connected to the system (88 for patient care. Managers who percent). As a result, the ministry have to make patient care-related can better supervise and evaluate decisions using the HIS are more health services through the HIS. satisfied. Satisfaction was highest Facility managers say the HIS has at the PHC level: 100 percent of improved their follow-up on pa- PHC managers were satisfied with tient care, control of pharmaceuti- the HIS, compared to 60 percent cal distribution, and calculation who were satisfied with paper- of hospital income. Specifically, based information sources. the HIS enhances their capacity to retrieve information quickly, The system provides a tool that follow-up on patient treatment allows all professionals involved in and nutrition, manage patient a patient’s medical care to share in- flow through outpatient clinics, formation and maintain it in one

CHART 8. USER PERCEPTION OF HIS IMPACT ON PERFORMANCE AND ACCOUNTABILITY 1,136 HIS users surveyed 100 84 82 85 86 89 85 88 89 91 90 91 78 79 78 82 80 74 81 50 Percent 0 Doctor Nurse Pharmacist Administration Management Other HIS improves my performance HIS enhances my performance monitoring HIS increases my confidence in my capacity (job)

IMPROVING HIGH-QUALITY SERVICES 47 centralized electronic database. scribe increased confidence in their The HIS provides attending medi- capacity to carry out their work (78 cal staff with immediate access to percent) and an improved ability a patient’s medical record (within to provide timely care (78 percent). privacy parameters developed by Managers were the highest to the project), which is especially report improved performance and crucial in emergency situations. accountability overall, followed by Patient information is described nurses and doctors. as more available and accurate by 88 percent of users, because The project enhanced the min- the system unifies and enhances istry’s capacity to provide high- procedures in recording patient quality emergency response, information. particularly by improving emer- gency facilities, strengthening Providers think the HIS improves emergency health skills, and their management of patient care. widening strategic planning. One The HIS provides clear instruc- spin-off effect of introducing tions (89 percent) and enables the HIS was the transformation evidence-based decision-making of emergency rooms from static (87 percent), according to a user units into dynamic and integrated survey. Health professionals de- hospital divisions.

STORY: “Triage training is empowering nurses and is part of (the) process of changing mentality from the community up the referral system. Health reform is not only about reshaping walls, but minds,”

said Dr. Mazen Abu Gharbieh. INC. CHEMONICS INTERNATIONAL

48 IMPROVING HIGH-QUALITY SERVICES To this end, the project helped Rafidia hospitals and at the PMC. the ministry establish triage areas To promote a culture of continu- in the emergency rooms (ERs) ing medical education, the project at Alia Hospital, the Palestine procured and distributed text- Medical Complex, and Rafidia books on emergency medicine, Hospital, which are the key pediatric medicine, and nursing at emergency service centers in the the three target hospitals and Ibn West Bank. It also supported use Sina College. of the Emergency Severity Index, which improves patient flow and The project also assisted the emergency care by classifying pa- ministry in planning for emergen- tients according to the acuteness cies at the facility and national of their injury or illness. Emer- levels. With project support, the gency services at the PMC were ministry drafted a national frame- further streamlined by creation of work for emergency preparedness a fast track for critical cases and a planning and began developing pediatric emergency section. The facility-level plans at Alia Hospi- project provided advanced train- tal, the PMC, and Rafidia Hospi- ing for front-line providers: 46 ER tal. Project interventions in these staff received Emergency Severity hospitals resulted in development Index triage training, 27 doctors of a structured planning agenda, and nurses were trained on trauma aligned with district and national life support, and — for the first plans, which can be replicated at time — 54 ambulance drivers hospitals throughout the West were trained as first responders. Bank. The project worked to sustain this planning process by The project also improved supporting the ministry in creat- management of the three ERs, ing a task force involving local and in coordination with USAID’s international stakeholders, such as Emergency Water and Sanita- the Palestine Red Crescent Soci- tion (EWAS) II Program, which ety and the Palestinian Authority provided infrastructural renova- Civil Defense, which clarified tion. Crowd control policies were their roles and responsibilities. established and security personnel at the PMC were trained in man- Despite the fact that nurses serve aging patient and visitor areas in as the principle caregivers in and around emergency rooms to Ministry of Health hospitals, they ensure that medical staff are able have historically not been em- to work without interference. powered. The projectempowered nurses at the central level and the The project supported the minis- hospital level to develop nurs- try to address the scarcity of quali- ing clinical standards that guide fied ER doctors by activating its them to becoming active mem- Emergency Medicine Residency bers of interdisciplinary teams of program. The project provided an caregivers and to make decisions emergency resident curriculum related to patient care. The project and resident log books and OJC, trained nurses to actively lead mentoring, and bedside train- patient care according to the new ing for 15 residents at Alia and standards through practical train-

IMPROVING HIGH-QUALITY SERVICES 49 STORY: “In the past, we would panic when a critical case came to the emergency ward, but with our new technical skills, we are more confident and organized as a team,” said Saleh Hajeer, head ER nurse (PMC). Just days after having completed the project’s basic life support and advanced cardiac life support courses, Saleh was able to apply his newly learned skills to save the

life of a dying woman. INC. CHEMONICS INTERNATIONAL

ing in lifesaving techniques, use ed the ministry in its efforts to of newly procured treatment and adopt and modify selected quality diagnostic equipment, manage- standards. A core group of a num- ment of emergency cases, and ber of donors and the ministry has communication with patients and been established to support the families. The project enabled the ministry in conducting quality three targeted hospitals to expand improvement activities, such as their support to nurses, including implementing the World Health activating an in-service training Organization Patient Safety Initia- committee and developing a nurs- tive in two target hospitals. This ing system framework to tackle pilot project was the initial project staffing deficiencies and patient for the ministry in exploring ways care. The ministry also hosted a to promote a culture of quality series of scientific nursing days to assurances best practices. educate and boost the confidence of nurses. Project staff provided on-the-job coaching on patient identifica- The project provided support in tion, incident reporting, effec- various areas of quality improve- tive communication, and safety ment, working closely with the improvements for high-alert ministry’s Quality Assurance medications as part of interven- Department to launch basic best tions to improve and implement practices to advance ministry standards related to medication support for quality assurance. management and use. The project Using international quality stan- also supported the Ministry of dards such as Joint Commission Health in conducting quality im- International standards and World provement activities in laboratory Health Organization Patient safety, with the project providing a Safety Goals, the project support- draft Laboratory Quality Manual

50 IMPROVING HIGH-QUALITY SERVICES to guide hospital management in nutrition services in hospitals and creating plans for laboratory qual- ensure uniformity of nutrition ity improvements and reviewing services in all facilities. National related laboratory standards of dietary-based guidelines and a practice. Other promising achieve- related training program outline ments in quality improvement, were developed and submitted to such as formation of medication the ministry to assist department management and use and IPC staff in updating their skills and committees in all three hospitals, improving the quality of services were suspended in Year 4. they provide.

The project’s quality improvement The project enhanced care efforts in hospitals also focused provided by ministry facilities on enhancing the ministry’s for newborn babies through an Nutrition Department. Food integrated package of quality and nutrition service assessments improvements, bedside coach- were conducted in all 12 minis- ing, and responsive procurement try hospitals, and reports were for neonatal intensive care units. submitted to the department to The project focused its support serve as a baseline for creating for NICUs on Rafidia Hospi- plans and applying interventions tal, which experiences a heavy to improve the quality of food and caseload as the central referring

STORY: “In the past year, we have seen more upgrades than in decades…this is because of the USAID project and the new direction of the Ministry of Health,” said Dr. Hassan Fitian, Rafidia Hospital NICU

CHEMONICS INTERNATIONAL INC. CHEMONICS INTERNATIONAL director.

IMPROVING HIGH-QUALITY SERVICES 51 NICU center in the northern $6.28 million in medical equip- West Bank. ment by the project. Interventions in pediatrics and emergency medi- The project coordinated upgrades cine at Rafidia Hospital identified to the NICU by USAID EWAS critical lifesaving procurement II, procured vital equipment and needs. Secondary health care sup- trained staff on its proper use and port procurement was provided preventative maintenance, and in the form of high-frequency provided continuing medical edu- ventilators, nasal continuous cation resources for pediatric care positive airway pressure machines, to help staff improve their skills electrocardiograms, hemodialysis and learn the latest techniques and machines, infusion pumps, incu- best practices. The project also bators, orthopedic equipment, introduced a new reference guide defibrillators, CT injectors, and for all NICU staff in the Minis- numerous monitoring systems. try of Health and other health Training on equipment included providers by adapting an Egyptian formal training and countless NICU manual for printing and OJC sessions at the facility. distribution. In the last year of the project, a neonatal working group Procurement was always sup- was created to ensure a direct dia- ported by operational and clinical logue among Ministry of Health training and, where relevant, and NGO hospitals in sharing system development. For instance, information and insight of the the project expanded CT scan- NICU. The project also invested ning services at the ministry by in future NICU doctors by fund- installing a 64-slice CT scanner ing the Holy Family Hospital in at Ramallah Hospital and three Bethlehem to support a neonatal 16-slice CT scanners at Alia, residency rotation for pediatric Beit Jala, and Rafidia Ministry medical students. of Health hospitals. In parallel, the project supported these CT The Ministry of Health highlight- departments with formal and on- ed improving its medical waste the-job capacity building, as well management as a key priority as development of CT depart- during its 2008 self-assessment. ment policies and work instruc- The project responded by provid- tions for hospitals. ing technical assistance in the assessment of the three targeted As part of the project’s compre- hospitals and creation of mitiga- hensive approach to procurement, tion plans. EWAS II used the proj- training on infant incubator use ect’s assessments of medical waste and coaching on IPC within management in its renovations of the NICU was conducted. To the Beit Jala, Jericho, and Rafidia tackle continuing IPC at the unit, hospitals. the project supported the IPC committee at Rafidia Hospital The ministry’s diagnostic and to identify and address causes of treatment services in hospitals the spread of infection, using data were upgraded through needs- collected by the HIS. This was based procurement of more than the first time that many com-

52 IMPROVING HIGH-QUALITY SERVICES STORY: “No more referring patients to other hospitals. We now have the ability to treat them right here,” said Amin Kabha, Ministry of Health CT technician. One of the three 16-slice CT scanners procured by the project is equipped with a cutting-edge ambient experience that provides a relaxing environment during the lengthy scanning process. The ambient experience relaxes the patients, limiting the need for re-scans, therefore increasing safety and

CHEMONICS INTERNATIONAL INC. CHEMONICS INTERNATIONAL saving resources.

mittee members had conducted built health care service capacity. such analysis, offering them a The impact of the grants program framework for conducting similar was deepened through comple- analyses in the future to address mentary procurement and institu- clinical challenges that arise. tional development assistance.

RESPONSIVE HIGH- The project’s grant program was QUALITY REFERRAL described by the USAID mid- AND REHABILITATION term evaluation as “an effective SERVICES mechanism to reach patients in STRENGTHENED local communities.” Evaluators The project improved access for noted that grant assistance had en- Palestinian citizens to high-quali- abled organizational changes that ty health care by supporting local ultimately contributed to systemic NGOs through more than $8.24 change by the grantees. They high- million in grants, procurement, lighted as an example the Prin- and institutional development as- cess Basma Center for Disabled sistance. Through this support, the Children, which has incorporated project enabled NGOs to provide the outreach activities developed services not available through the through the project grant into its ministry and to provide continu- five-year strategic plan. ing health education for Palestin- ian health professionals. The project also assisted seven grantees in moving toward The project provided 21 grants financial sustainability by making ($1.8 million) to 17 NGOs in the their service management more ef- West Bank and Gaza. (See Annex ficient. Based on self-assessments, 8.) These grants have strengthened the NGOs created five-year plans community-based services and for institutional development,

IMPROVING HIGH-QUALITY SERVICES 53 STORY: “The USAID grant gave us a new outlook. We expanded our work and developed the capacity of small organizations,” said Maha Tarayra, from the Princess Basma Jerusalem Center for Disabled Children. “Before, we had only provided in-patient services.” The center can now find and treat disabled children like three-year old Mohammed who was born without a leg and could not walk until he was referred for rehabilitative support through the project-

supported outreach program. INC. CHEMONICS INTERNATIONAL

guided by internal change agents breast cancer screening), which identified and trained by the continued to visit project-sup- project in key governance, plan- ported communities even after ning, financial management, and the grant closed. administrative skills. Overall satisfaction with the Thirteen NGOs used the grants grants program was almost uni- to create or expand outreach versal, according to beneficiary programs to screen children and assessments conducted by the adults, provide rehabilitation project.40 A total of 93 percent of services in the community, and beneficiaries surveyed said they refer at-risk patients for advanced were satisfied with the quality of treatment. The project enlarged services they received from the the outreach potential of the grantees. Nearly 90 percent re- grants program by connecting its ported improved health as a result Champion Community partners of the grantee services. More than to the grant-supported outreach, 87 percent of grantee beneficia- such as the mobile clinics run by ries surveyed said they had been St. John of Jerusalem Eye Hos- educated on home-based rehabili- pital (for visual screening), the tative care, either for themselves or Care for Children with Special their dependents, with a signifi- Needs Society (for speech and cant impact on their capacity to auditory screening), and the proactively cope with the chal- Augusta Victoria Hospital (for lenges they faced. Beneficiaries are

40. The project evaluated the impact of its grants program on rehabilitative services available to the Palestinian people by conducting two rounds of grantee beneficiary satisfaction assessments. For more information, see Annex 4.

54 IMPROVING HIGH-QUALITY SERVICES VIDEO: “We’ve been able to enter and screen children at schools in larger numbers. Before, we could only target 4,000 children. Now we can reach 8,500 children. As a result, children with difficulties in speaking and hearing, those suffering from cerebral palsy or other learning disabilities, are referred to the center for services, and the number of children benefiting from the services provided at the center dramatically increased,” said Sirab Malhas, director of care

CHEMONICS INTERNATIONAL INC. CHEMONICS INTERNATIONAL for children with special needs.

now more empowered. A major- To complement its grants pro- ity of respondents have greater gram, the project improved confidence and knowledge as a health services at 15 NGOs result of their project-supported by procuring more than $7.2 experience (64 percent). Nearly all million in specialized medical respondents (94 percent) would equipment and supplies. Almost recommend the facility to others all the procurement for NGOs seeking treatment, and 95 percent supported grantees; the project said they would return to the supported nine of the 17 grantees grantee if further treatment was through more than $6.8 million in needed. procurement.41 Using the equip- ment, the NGOs were able to The remaining grants to four expand services (e.g., screening for NGOs enabled Palestinians visual disability at Jabalia Reha- to access advanced orthopedic bilitation Society), introduce new treatment through the Ministry services (e.g., advanced surgery at of Health (Al-Makassed Hospi- St. John Eye Hospital Clinic in tal), support residents at the first Gaza and Al-Makassed Hospital), neonatal residency program (Holy and improve rehabilitation for Family Hospital), and support Palestinians with special needs continuing medical education (e.g., physiotherapy at Palestine (Al-Quds Open University and Save the Children). Through its Al-Ahli Hospital). procurement to grantees, the proj-

41. The total value of procurement for NGOs was $7,236,318. Grantees received $6,884,817, as described above. The remaining $351,501 in procurement was provided to six NGOs providing health care or health education. (Five of these NGOs are in Gaza, including Al- Azhar University, Atfaluna Society, Caritas Medical Center, Cystic Fibrosis Friend Center, and El Amal Rehabilitation Center. The sixth NGO [Ittihad Hospital] is in Nablus.)

IMPROVING HIGH-QUALITY SERVICES 55 CHART 9. SATISFACTION WITH GRANTEE SERVICES 300 staff from seven grantees were surveyed

I am more confident dealing with the disability 63.45

I was educated on home-based rehabilitative care 87.30

My child’s health condition improved 89.50

I am satisfied with the quality of services received 93.15

I would recommend the facility to others 94.45

I will come back if treatment is needed again 95.20

0 20 40 60 80 100

ect enabled NGO providers to focus on pediatric cancers, which increase services to meet patient are largely curable if treated im- demand, particularly in parallel mediately. with project-supported health- awareness campaigns. Similarly, an integrated package of grant and procurement support As it assisted the ministry in pro- enabled Al-Makassed Hospital in moting early detection of breast Jerusalem to provide a new service cancer, the project also provided through the Ministry of Health a $4.98 million radiation therapy for patients who previously system to the Augusta Victoria would have been referred abroad. Hospital, the only cancer treat- Advanced arthroscopic surgery ment center in the Palestinian is now available to Palestinians at public health care system. With the hospital, directed by a surgeon the new radiation therapy system, trained through the project and the Augusta Victoria Hospital was using a project-procured $235,000 able to double its capacity and can arthroscopy unit. The ministry has now provide cancer treatment that already started referring patients is comparable to or better than who require arthroscopic surgery other regional medical centers. to the hospital rather than to The project’s intervention has facilities abroad, which will reduce strengthened the hospital’s role as public health care costs. a cancer treatment center, im- proved the quality and availability In addition, the project used of such treatment, and reduced $1.63 million in procurement to the number of costly referrals support nine NGOs in Gaza. The abroad, meeting the priorities of procured equipment upgraded those it serves. Additionally, the high-quality health service and cancer center can now expand its education opportunities for the

56 IMPROVING HIGH-QUALITY SERVICES 1.6 million residents of the coastal rehabilitative care for disabled region, where providers struggle children, and diagnostic services with deteriorating equipment, for cystic fibrosis patients. insufficient stocks, and financial strain. As a result, these NGOs PROMISING PRACTICES can now provide access to higher- 1. Using an integrated multi- quality medical and health sectoral approach to improve educational services. St. John Eye high-quality care at the Hospital Clinic offers a package of community level. The quality screening, diagnostic, and clinical of care improved most in the services previously unavailable PHC directorates that experi- to most of the population in enced concurrent project sup- Gaza. With a high prevalence of port to the clinic and commu- diabetes in Gaza, these diagnostic nity mobilization. For instance, and treatment services are critical the project provided clinics and under great demand. Medical in Toubas and Salfit director- students at Al-Azhar University ates with the full spectrum of are now graduating with hands-on quality interventions without experience with advanced diag- the funding-related interrup- nostic equipment. At the same tions experienced in other time, health NGOs can now oper- directorates. Clinics assessed in ate with increased safety, greater those two districts improved an frequency, and more accuracy. average of 52 percent compared Other institutions were able to to before the project inter- improve screening, dental care, ventions, compared with 22

CHART 10. PROCUREMENT VALUE BY NGO SERVICE $7.209 million Ophthalmology $676,514 Operative care $584,480 Audiology $201,875 Neonatal care $156,805 Supportive services $138,540 Cancer screening Medical imaging and therapy $116,287 $5,108,713 Mother and child $70,500 Lab service $69,880 Physiotherapy $43,590 Emergency $29,164 Speech therapy $12,680

IMPROVING HIGH-QUALITY SERVICES 57 VIDEO: “With the new (radiation therapy system) machine, we are able to (treat) at least 80 to 100 patients per day (compared to) 50 on the old machine. These two machines will be capable of taking the whole current load of the West Bank and Gaza,” said Dr. Tawfiq Nassar, chief executive officer at Augusta

Victoria Hospital. INC. CHEMONICS INTERNATIONAL

percent in clinics in Hebron, living, announce community where funding holds resulted in health training, increase the activity suspensions. The proj- uptake of public health care, ect also widened its impact on and solicit volunteers for community health by achieving environmental clean-up events. community contributions (e.g., With its focus on network- volunteering and financial/ ing, Facebook is well-suited to in-kind donations), building the Champion Community cross-sectoral coordination Approach, which emphasizes (e.g., non-ministry providers community-driven PHC re- participating in ministry health form. days), and linking community- clinic boards to specialized 3. Integrating the community service providers (e.g., screen- into health promotion activi- ings for cancer, health risks, and ties for children. By involving disabilities). mothers in the summer camps, the Ministry of Health created 2. Using social media to spread a network of health champions the impact of Champion across the West Bank, with Community activities. With mothers and campers continu- project encouragement, ing to meet at CBO-sponsored community-clinic boards used activities long after the camps social media to increase citizen ended. In many communities, participation in their commu- the health messages continued nity health activities. By the to inspire new activities. CBOs end of the project, 31 of the 82 held follow-on activities for communities were using Face- campers, their mothers, and book pages to promote healthy other children or created new

58 IMPROVING HIGH-QUALITY SERVICES health-related initiatives for to support high-quality health community residents, including services by using sequential a year-long “Child-to-Child” training as a key activating campaign in Skaka, through component of its procurement which campers taught their approach. The project provided classmates about the health basic operational training on habits they learned at camp. installation of the equipment and then — once the operators 4. Maximizing the effective use were more familiar with the of procured medical equip- equipment — provided follow- ment by providing sequential on training to ensure that clinical and operational train- the equipment was still being ing. Donors are often accused used accurately and effectively. of taking the “shop-and-drop” Technicians received follow-on approach to procurement, training on the safe operation with the delivery of equipment of diagnostic devices, such as and basic operational training ultrasound and mammography signaling the end of donor in- machines and electrocardio- volvement. The project ensured grams, while clinicians were that all procured equipment trained on the full interpreta- was used immediately and fully tion of the results.

VIDEO: Through the Champion Community Approach, the town of Burqa (Nablus Directorate) planned an emergency action day in collaboration with multiple health providers and government organizations. The event was the first of its kind in emergency action

CHEMONICS INTERNATIONAL INC. CHEMONICS INTERNATIONAL preparedness.

IMPROVING HIGH-QUALITY SERVICES 59 LESSONS LEARNED pansion into hospital facilities, 1. The Ministry of Health did the department was dissolved not have a defined structure after appointment of a new to manage development minister in 2012. In addition, of a ministry-wide quality the ministry’s culture of distinct improvement framework. departments is impeding long- Significant and sustainable term development of a system change in quality improvement across the levels of health requires a functional institu- care. However, as described tional counterpart to build and above, the project supported maintain an overarching qual- the ministry to develop, and ity framework and ensure that institutionalize when possible, quality improvement activities quality improvement tools for and tools have the input and the PHC (e.g., health facility ownership of the multiple rel- assessment, EPS, SOC, and evant ministry departments. Al- job aids) and multiple depart- though the project was able to ments (e.g., Emergency Severity activate the ministry’s Quality Index, IPC SOC, draft Labora- Improvement Department in tory Quality Manual, and the its first years and support its ex- NICU Manual). In addition,

VIDEO: “We are passing (on) the messages we learned during the summer camp,” said 11-year old Islam, one of the Child-to-Child leaders. “I learned a lot during that camp. Most importantly, I quit lots of bad eating habits, such as eating fast food and drinking

soda drinks.” INC. CHEMONICS INTERNATIONAL

60 IMPROVING HIGH-QUALITY SERVICES STORY: “We were using the new equipment at minimum capacity, not fully realizing the power of these new machines. What I love is that this is not a one-stop shop; for the next training, I will be armed with new questions,” said Saleh Amro, an operating room

CHEMONICS INTERNATIONAL INC. CHEMONICS INTERNATIONAL nurse.

the project strengthened the to maximize community sup- quality improvement capacity port. An analysis of the quality at the facility and district levels, of PHC clinics supported by particularly through its work the project suggests that the with PHC district supervisors. integrated approach was key to The project team thinks the achieving impact. The project ministry remains interested in completed its interventions in developing a quality improve- 57 clinics in six districts (albeit ment framework and that with lengthy suspensions in future interventions should 37 clinics), but the remaining be designed to strengthen the 25 clinics received only a few ministry’s capacity to translate months of support before the its National Quality Strategy project closed its PHC activi- into a quality improvement ties in Year 5, due to reduced framework. (Further interven- funding. The pre-post-evalua- tions in this area can follow tion suggests that facilities that the roadmap established by the receive the different dimensions project.42 See Chapter Three. of quality support as a compre- Recommendation No. 7.) hensive package (e.g., Toubas and Salfit directorates) perform 2. A) Quality improvement is better than those whose quality most effective when provided improvement support is frag- as an integrated package and mented over time (e.g., Nablus ministry staff are supported Directorate) or is incomplete

42. Arscott-Mills, Sharon and Maha El-Saheb. Quality Assurance and Improvement in Primary and Secondary Care, Flagship Project, February 12, 2010.

IMPROVING HIGH-QUALITY SERVICES 61 (e.g., Hebron Directorate). (See tionally, the project-supported Chapter Three. Promising Prac- Nursing Orientation Manual tice No. 1.) B) Greater training is an important tool for the of PHC staff participating in standardization and enhanced the community-clinic boards performance of PHC nurses. would increase the Ministry The project printed the manual of Health’s capacity to solidify for distribution among Minis- and sustain the boards’ role try of Health PHC directorates as a mechanism for facilitat- and clinics. Ministry support ing and acting on community for the rollout and implementa- dialogue with the ministry. tion of the manual is strongly The community-clinic board encouraged. created through the Champion Community Approach played 2. Strengthen Ministry of a central role in evaluating and Health capacity to partner prioritizing community needs with the community on public for inclusion in the ministry’s health by supporting the con- service delivery. To maximize tinued institutionalization and the partnership opportunities expansion of the Champion resulting from the community- Community Approach at the clinic board, the ministry directorate level. Continued should prioritize training ministry involvement in com- relevant to community-based munity-clinic boards should PHC staff in the Champion be facilitated, particularly to Community Approach to en- sustain open dialogue with sure their active participation in community. Health education the mechanism, if such a board facilities should be encouraged is established in their commu- to include community mobili- nity. zation in curricula nationwide, following incorporation of RECOMMENDATIONS the approach into the nursing 1. Support application of curriculum of Ibn Sina Nursing the EPS as a management College. standard and the SOC as a service provision standard by 3. A) Widen the impact of strengthening the new man- behavior change communi- agement culture of supportive cations by fostering strategic supervision to strengthen qual- planning links between PHC ity improvement at the PHC and SHC, building on the level. Possible institutionalizing manual and training provided mechanisms include continued through the project. There is training/OJC at the central and a need for greater linkage of district levels and mobilization the ministry’s HEPD into the of communities to use the EPS practice of service delivery to as a citizen-focused listing of promote the strategic planning mandated Ministry of Health health messaging to respond to services and the SOC as a guide evolving needs and opportuni- for management and improve- ties of SHC and PHC, includ- ment of these services. Addi- ing donor-supported BCC

62 IMPROVING HIGH-QUALITY SERVICES VIDEO: “If we invest in children, we can improve their health behaviors. We hope that, with the support of their families and communities, they will continue in their healthy habits,” said Lubna Al-Sader, Ministry of Health HEPD director. The summer campers learned about healthy eating habits, such as checking the

CHEMONICS INTERNATIONAL INC. CHEMONICS INTERNATIONAL freshness of food.

initiatives. The capacity of the However, these NGOs need HEPD to measure program im- financial support to maintain pact should also be supported services. Supporting outreach to ensure that BCC campaigns services by referral hospitals are developed and refined based from East Jerusalem (e.g., on assessed population needs. cancer screenings) is a recom- B) Sustain healthy lifestyle mended way to bring high- summer camps, which have level specialist care directly to been a landmark success in be- Palestinian citizens, particularly havior change communications. those unable to access the main The Ministry of Health can and facility. If possible, the grant should continue to work with assistance should be accompa- communities on this effort. The nied with in-depth institutional approach used in Year 4 (in development capacity support, which the mothers of summer using the “change agent-led camp participants were trained assessment” approach taken by on the same health messages to the project (See Chapter Two. be received by their children) is Promising Practice No. 5.) B) an excellent model and should Increase early rehabilitation be replicated. intervention by strengthen- ing the Ministry of Health’s 4. A) Continue or expand on referral links to rehabilitation grants assistance for reha- networks. The ministry’s early bilitative care and outreach detection/screening programs programs. NGOs continue (particularly at the PHC level) to be the main providers in do not always result in a referral this area, with well-established to a relevant rehabilitation pro- networks, and the Ministry of vider, largely due to insufficient Health relies on their services. knowledge by clinic staff about

IMPROVING HIGH-QUALITY SERVICES 63 STORY: Augusta Victoria Hospital’s mobile mamography unit helps support breast cancer awareness and early detection across the Palestinian territories.

the rehabilitation resources fective program, including cur- available. Patients with disabili- ricula, staffing, allocated space ties or special needs have the and time for resident learning, right to receive available care. and coordination. Training of Therefore, the ministry must trainers in the program should strengthen its links at the PHC occur and is a key to its devel- level to rehabilitation networks opment and improvement. to maximize the services avail- able to Palestinian citizens. The 6. Create a national network of Champion Community links high-quality NICU health to rehabilitation grantees are a providers by building on the model that can be adopted by project’s interventions. This the ministry and maintained in includes facilitating rollout future community mobilization of the NICU manual across activities. the Ministry of Health and integrating the centers’ proto- 5. Solidify the Ministry of cols and guidelines to guide Health’s application of the therapy among all NICUs in ER systems to strengthen its the West Bank and Gaza. The emergency care, preferably ministry should also work to- accompanied by investment ward regionalization of NICU in the Emergency Medicine services and definition of Residency program. The proj- individual center scopes of care. ect recommends that support The project recommends that for an emergency residency NICU nurses be empowered program should depend on to implement the Standards the ministry’s capacity for and of Care and improve NICU commitment to supporting the communication with patients’ components required for an ef- families. In addition, the new

64 IMPROVING HIGH-QUALITY SERVICES NICU working group should provement framework, which continue to support improve- is a national priority and a ment of neonatal training and prerequisite for future accredi- care at ministry hospitals. tation of medical facilities. The project recommends that future 7. Activate the Ministry of interventions focus on defin- Health’s capacity to regu- ing and building a multi-focal late high-quality services quality improvement structure by strengthening its quality in the ministry, with a central improvement structure. The department and facility-level ministry was able to develop representation, and supporting and institutionalize quality the ministry in building a qual- improvement tools at the PHC ity improvement framework and SHC level, but it still lacks based on its National Quality an overarching quality im- Improvement Strategy.

IMPROVING HIGH-QUALITY SERVICES 65 CD ROM INDEX

PALESTINIAN HEALTH SECTOR REFORM AND DEVELOPMENT PROJECT FINAL REPORT

PALESTINIAN HEALTH SECTOR REFORM AND DEVELOPMENT PROJECT ANNEXES 1-10

66 CD ROM INDEX FROM THE AMERICAN PEOPLE

PALESTINIAN HEALTH SECTOR REFORM AND DEVELOPMENT PROJECT October 1, 2008 to November 14, 2014 This publication was produced for review by the United States Agency for International Development. It was prepared by Chemonics International Inc. U.S. Agency for International Development 1300 Pennsylvania Avenue, NW Washington, DC 20523 Tel: (202) 712-0000 Fax: (202) 216-3524 www.usaid.gov