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INSIDE The magazine of real action and research • No.9 • May 2008 HEALTH SYSTEMS RESEARCH Agenda for Middle-East and 6 > Real Health North Africa • Fadi El-Jardali ‘Assess primary health care’ 13 • WHO ADG Carissa Etienne Used and abused: community 9 volunteers Goa, health at the front line US$ 500m for health systems 16 Health seen from the ground shows the real problems • GAVI’s Craig Burgess WHO research strategy 11 • WHO’s Robert Terry > see article on page 30 Carso Salud’s research for 26 Latin America • Julio Frenk DISEASES Artemisinin: diversifying the 20 sources • Elspeth Bartlet TB vaccine trial promising 22 • Aeras’ Jerald Sadoff Diabetes: the agenda from 24 the South Preventing HIV/AIDS in young 28 Colombians • Lisbeth Fog OPINION PAPERS Where have all the bednets 39 gone? • Andy Crump FOOD CRISIS: Plan for ‘pro-Poor GM’ • Mike May, Marc van Montagu, and 40 M S Swaminathan EVENTS Bamako Ministerial Forum 44 > Health systems Palestine unites for research plans Even countries in deep conflict can connecting health research with policy- unite behind the idea of science to making in low- and middle-income Arab improve health, Palestine shows. states has Palestine lighting a beacon The first of a series of studies on for others to follow. continuing on page 2 > 2 RealHealthNews • the magazine of real action and research • No. 9 • May 2008 >>INTERVIEWS WITH JOAN JUBRAN & FADI EL-JARDALI SUMMARY • Joan Jubran of the Center for Continuing Education at Birzeit University, in cooperation with the Palestinian Health Policy Forum, brought together people from all over Palestinian society to discover exactly what health system research might be useful. We interviewed her and the leader of a series of such studies in the Middle East and North Africa, Fadi El-Jardali of the American University of Beirut. >RHN: Could you give us an outline of the health situation and more, separating Palestinians from Israelis, we’re talking about the chief health problems in Palestine? occupation within the West Bank. Joan Jubran: Well you should take into consideration that So we cannot talk about the health system as a coherent health Palestine is under occupation, so the development of the health system, because you’re talking about three different parts system is extremely affected by that, and even by the internal within the West Bank. The north, the midlands, and the south, political situation – I mean what is happening now in Gaza and are totally separated. And the hospitals, for example, are con- the West Bank, with Hamas and Fatah. With the Israeli occupa- centrated in the centre, Ramallah, and the people in the north tion within the Palestinian territory, that is the West Bank, and find it difficult to access specialised hospitals there. in Gaza previously, we’re talking about the segregation of land in the West Bank. For example, we’re talking about a village >RHN: Can’t they pass down through Nablus, for example? five kilometres away from another, but to get between them you have to take long bypass roads and travel through check- JJ: They do, but it takes more time. Sometimes you hear about points. cases of women who have given birth at checkpoints or people who weren’t able to get kidney dialysis because of the delay at We’re also talking about the Israeli separation wall, which is checkpoints. within the West Bank territories, within the internationally agreed 1967 borders. So we’re not talking about security any >RHN: Are these checkpoints throughout the West Bank? The mobile clinic of the Palestinian Medical Relief Society – a Palestinian NGO. RealHealthNews • the magazine of real action and research • No. 9 • May 2008 3 JJ: Yes. There were, I think, 300 within the West Bank, but unions, researchers, and this enriched the discussion because now they have been reduced somewhat. we heard different opinions. >RHN: So you are saying it’s very hard, if you need it, to get >RHN: Why do you think that was possible? to a health centre? But what about the bottom-line statistics? A lot of the published statistics, for example on education in JJ: I think we’re used to that. Probably because of the status the West Bank, are very good, aren’t they? So how do you of Palestine, and the occupation before, civil society found a stand on the standard sorts of developing country indices very important role in the provision of services – before we had like maternal mortality and infant mortality? For example the the PNA [Palestinian National Authority, created by the signing health budget per dollar of GDP in Palestine is actually quite of the Oslo accords between Israel and the Palestine Liberation high, I believe. The average in OECD countries is 9%, and I Organization in 1993]. I think we have a democratic and par- believe it’s something like 13% in Palestine, so despite the ticipatory approach to dealing with different issues. It’s not only external and internal violence there appears to be a high prior- in health; this is done in other areas too. ity placed upon health in Palestine. Is that right? >RHN: I see, that’s interesting. You’re saying that at the JJ: Actually before the year 2000 many of the indicators, even ground level there’s a kind of informal democratic government the infant mortality, were better than in other developing coun- - despite the political conflicts. tries, so yes, Palestine stood high in terms of its health status. JJ: Yes… and because in the health sector, before the creation Then in 2000 you know that there was the Second Intifada [Pal- of the Palestinian National Authority, civil society was the pro- estinian uprising], and so there were lots of factors that influ- vider of health, education and social services. When the PNA enced the health of the Palestinians so this has deteriorated a came we had policy dialogue with the government to imple- little bit. ment some partnerships, and But even that wasn’t a major there are some clinics that are issue [for health] because there “We cannot talk about the health jointly implemented or are man- was a lot of international donor system as a coherent health system, aged by the Ministry of Health aid to Palestine for the develop- because you’re talking about three and civil society organisations. ment of the health sector, so in different parts within the West Bank. >RHN: To analyse that a lit- general the indicators are gener- The north, the midlands, and the south, tle bit, would you say that’s ally not that bad in comparison to are totally separated.” because ordinary Palestinian other developing countries. Did Joan jubran people feel under threat and, you know that there was a lot therefore, bond together? of effort, for example, up to the year 2000, to decrease the infant JJ: Yes, probably. We saw that mortality rate and provide programmes for maternal health? in the Second Intifada, where this was very evident as emer- So the indicators are not that dramatic and we have witnessed gency committees were formed because we couldn’t get medi- an improvement until 2000. However, during the last few years cation and services through. Committees were formed between some of the indicators dropped. the government and the and NGOs, so, yes, probably because we are under threat, and we have to cooperate because of the >RHN: One of the interesting things I notice about your report situation here. is actually how you did it, because despite the problems you’ve outlined you appear to have been very comprehensive. You’ve >RHN: Let me come on to some of the real content of your looked at every side of the issue and you’ve involved, as it report. Under the ‘main policy concerns’ you mention an over- appears to us, people from the ground right up to the minis- dependence on donors. What fraction of the budget is donor- ters and also the academics. Is that right? originated? JJ: Yes. Actually this study is part of a larger one in non-oil JJ: Actually one major problem with policy and planning in Arab states, and I also participated in how the research was Palestine is that we don’t have exact figures for how much we conducted in other countries. I noticed that in Palestine and depend on donors, because the PNA budget is separated from Lebanon mostly, the participation of civil society, and even the what we get from donor assistance. The national budget sub- interaction with the government and the unions was very easy. mitted by the Minister of Health, for example, for the health What it showed me is that we have a viable civil society. sector, does not incorporate donors’ funding, although we have a major dependence on it. In 2002, donor funding for the health It also showed that the connection with the government was sector reached 48%. not that difficult for us. In other countries, for example in Egypt, there were problems with meeting the government officials. >RHN: One of the things that many developing countries com- We had the same methodology, but sometimes we had difficul- plain of is that they’re actually driven by the donors; and there ties. But in Palestine, in our focus group we had many different are many different donors, so they get lots of conflicting and stakeholders participating, from the ministry, from civil society, overlapping programmes and demands on human resources 4 RealHealthNews • the magazine of real action and research • No. 9 • May 2008 for actions and reporting, and so forth.

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