Assistance to the Palest. people – UNFPA – Proposed projects and programmes

UNITED NATIONS POPULATION FUND

PROPOSED PROJECTS AND PROGRAMMES

Recommendation by the Executive Director

Assistance to the Palestinian People

Proposed assistance by core programme areas (in millions of $):

1. The United Nations Population Fund (UNFPA) proposes to support a population programme over a four-year period starting in January 2001 to assist the Palestinian Authority in achieving its population and development goals. UNFPA proposes to fund the programme in the amount of $7 million, of which $4 million would be programmed from UNFPA regular resources to the extent that such resources are available. UNFPA would seek to provide the balance of $3 million from co-financing modalities and/or other, including regular resources to the extent possible, consistent with Executive Board decision 2000/19 on the allocation of UNFPA resources. This would be the Fund's second programme of assistance to the Palestinian people in the Occupied Palestinian Territory. "The Occupied Palestinian Territory is classified in "Category A" in the Fund's resource allocation system.

2. The proposed programme was developed in consultation with the Palestinian Authority, civil society organizations, United Nations agencies and multilateral and bilateral donors. It takes into account the policies, priorities and strategies expressed in the National Strategic Health Plan for the period 1999-2003 and the Master Plan for Official Statistics (2000-2010). The findings and recommendations of a comprehensive population assessment that was conducted during the period January-June 2000 provided the basis for the proposed programme. The population assessment was carried out by a multi-disciplinary group of Palestinian experts and was coordinated by a working group of members of key Palestinian Authority and civil society institutions, the UNFPA field office and the Country Technical Services Team (CST) in Amman, Jordan. The population assessment exercise coincided with the Palestinian Authority's preparations for a plan for a Palestinian state, the five-year strategic development plan (1999 to 2003), and the Comprehensive Development Framework (CDF) prepared with the assistance of the World Bank. The Fund has harmonized the second programme cycle with United Nations agencies that have full-fledged programmes in the Occupied Palestinian Territory, namely UNICEF, ILO and UNESCO.

3. The goal of the proposed programme is to contribute to improving the quality of life of the Palestinian people through: (a) improved reproductive health status; (b) reduced gender gaps in education and social participation; and (c) balance between population dynamics and socio-economic development. This goal will be pursued through three subprogrammes covering reproductive health, population and development strategies, and advocacy.  Gender concerns will be mainstreamed into the three subprogrammes.

4. The proposed programme was developed within the framework of a human rights approach. All activities under the proposed programme, as in all UNFPA-assisted activities, would be carried out in accordance with the principles and objectives of the Programme of Action of the International Conference on Population and Development (ICPD), which was endorsed by the General Assembly through its resolution 49/128.

Background

5. The Palestinian population in the Occupied Palestinian Territory was estimated to be approximately 3.1 million people in 2000, with 2 million in East Jerusalem and the remainder of the West Bank and 1.1 million in the Gaza Strip. According to the 1997 census, 1 million of the Palestinian inhabitants of the Occupied Palestinian Territory are registered refugees. Declining death rates, including infant mortality and crude mortality, 27.3 per 1,000 and 4.8 per 1,000, respectively, according to the 1995 demographic survey, and a consistently high fertility rate of 6.1 children per woman partly account for the high population growth rate, estimated at 3.6 per cent a year. Population projections for the year 2010 estimate that the Occupied Palestinian Territory will have an additional 1.8 million inhabitants by that date. Such an increase would require the creation of some 500,000 new jobs just to maintain current employment rates and the establishment of an additional 2,000 classrooms annually. The young age structure of the population, with 47.1 per cent of the population under 15 years of age, results in a high dependency ratio of 102.2. Demographic trends are further strained by an imbalance in the geographical distribution of the population: Gaza, with only 6 per cent of the Occupied Palestinian Territory in terms of land, represents 35.5 per cent of the total population.

6. The level of contraceptive use, estimated at 35.3 per cent for modem methods and 46.2 per cent for all methods, according to the year 2000 health survey, would appear to be in contradiction to the high fertility level. This is attributed to the widespread practice of early marriage and to general attitudes that tend to favour large families for a number of reasons, including social security in crisis and old age. As a result, women tend to use contraception as a means of spacing their children or adopt it later in their reproductive years after they have had the desired number of children. The gap between the high knowledge of family planning (99.4 per cent) and relatively moderate use of contraceptives is attributed to fears of side effects of contraceptives, religious prejudice and husband and/or family opposition.

7. The maternal mortality ratio is estimated at 70-80 per 100,000 live births in the optimal years for childbearing but reaches 93-140 per 100,000 in the extreme age categories (15-19 years and 50-54 years). These figures, however, are thought to be underestimations due to poor reporting systems. Statistics on HIV/AIDS and other sexually transmitted diseases (STDs) are not readily available, but the Ministry of Health has reported 60 cases of HIV/AIDS since 1998.

8. The Palestinian Authority provides the largest portion of health services. The United Nations Relief and Works Agency for Palestinian Refugees in the Near East (UNRWA) provides health-care services to the refugee population. However, the NGO sector is also very important, especially in regards to innovative model approaches, health education and health promotion.  Private-sector health services are largely unregulated, but such services are popular since there is a belief that they provide a higher standard of care.

9. Although categorized as being in the lower middle-income rank of countries, the Occupied Palestinian Territory is characterized by high poverty rates, estimated in 1998 at 33 per cent in Gaza and 15 per cent in the West Bank. Unemployment rates are high, and a very high proportion of the adult population is working in low-wage public sector employment. There is a continuing heavy dependency on external monetary contributions.

10. Compulsory education for both sexes to age 16 has lead to improvements in female literacy, especially in recent years. Near gender equality has been achieved in basic school enrolment, while the overall literacy rate among females is 79.7 per cent compared to 82.2 per cent among males. Gender disparities are also manifested in the fact the females amount for a mere 12.3 per cent of the formal labour force but carry out 50 per cent of low paid agricultural jobs. Early marriage is another gender issue. As a result of this practice, the highest fertility and maternal mortality rates are seen in the 15-19 year age group. This also contributes to increased high school dropouts and subsequent decreased female participation in the formal labour force.

11. The Palestinian Authority took part in the ICPD and has demonstrated commitment to the implementation of its Programme of Action. This has been manifested in the establishment of the Women's Health and Development Directorate (WHDD) in the Ministry of Health with the mandate of developing national policies and strategies on women's health. The most recent National Strategic Health Plan (1999-2003) adopted some key strategic objectives for promoting reproductive health: (a) reducing the maternal mortality ratio by 20 per cent; (b) increasing the proportion of deliveries attended by trained professionals to reach 100 per cent (from 94.8 per cent); (c) increasing the number of primary health-care centres providing at least maternal and child health and family planning (MCR/FP) services by 30 per cent and those providing screening for reproductive tract and breast cancers and STDs by 25 per cent; and (d) increasing the use of modem contraceptive methods by 10 per cent. To date, no population policy has been formulated. Although the Palestinian Development Plan (2000-2003) refers to the strains that high population growth rate places on social services, it establishes no demographic targets.

Previous UNFPA experience

12. The first programme of assistance to the Palestinian people, 1996-1999, was approved in the total amount of $7.2 million, of which $5.2 was to be programmed from regular resources and $2 million from multi-bilateral resources. The programme was extended for one year with a total expenditure of $6.3 million. The primary achievement of the programme was in strengthening the human resource and institutional capabilities of the Palestinian Authority and of NGO counterparts.

13. In the area of reproductive health, the programme helped to enhance the capacity of the Ministry of Health at the policy and service delivery levels. The institutional and technical capabilities of the WHDD were promoted and, consequently, it was able to develop a women's health strategy (1999-2003), promote the reproductive health concept within the Ministry of Health and coordinate a series of research studies. The Ministry of Health and NGOs were able to deliver MCH/FP services and primary gynaecological care in 76 service delivery points.  Reproductive health was incorporated into the curricula of nursing and midwifery schools.  Population, reproductive health and gender have become integral components in the curricula of the 11th grade, teacher training and adult education programmes as well as in the activities of eight youth clubs and youth camps.

14. Two model women's centres were established in Al-Bureij and Jabalia refugee camps and provided integrated reproductive health, psychological, social and legal counselling on a pilot basis. The holistic approach to women's health offered by these two centres coupled with improved quality of care attracted a large number of clients and achieved an 80 per cent client satisfaction rate in the Al-Bureij centre according to an evaluation conducted in early 2000.  Initial steps were also taken to integrate psychological, legal and social counselling in an existing reproductive health centre run by the Palestinian Family Planning and Protection Association (PFFPA), an affiliate of the International Planned Parenthood Federation, in Hebron.  In the year 2000, with support from the Government of Italy, UNFPA launched a two-year regional gender initiative that links these three women's centres with two projects in Morocco and Algeria.

15. In the area of population and development strategies, UNFPA assisted the Palestinian Authority to successfully carry out the first Palestinian population and housing census in 1997. As a result, a reliable and up-to-date population database was established as the cornerstone of a comprehensive national statistical data system. The statistical sample framework produced by the census is being used to undertake specialized topical censuses and surveys and to update the population register. The sex-disaggregated data produced by the census and surveys were utilized in conducting a preliminary analysis of gender differentials, which has become a useful tool for raising awareness on gender issues and for policy formulation and planning. The census helped to promote dialogue between users and producers of data and create awareness about the need for quality statistics. It also contributed to strengthening the institutional and human resource capacity of the Palestinian Central Bureau of Statistics.

16. In the area of advocacy, UNFPA contributed to strengthening the institutional capacity of the Department of Health Education and Promotion of the Ministry of Health in planning and coordinating advocacy and IEC prograrnmes in partnership with local NGOs. Advocacy efforts helped to create awareness among media professionals about reproductive health and gender issues and to forge an affiance between UNFPA and a core group of active media professionals who formed a "Journalists Forum". As one result, about 167 newspaper articles were published in 1999 and 2000 on reproductive health compared to only 20 articles in 1998 in the three major local newspapers. Initial progress was achieved in sensitizing policy makers and decision makers on reproductive health and gender issues.

17. Among the key lessons learned was the need to build on the tangible accomplishments of the previous programme to achieve more concrete and sustained results. Maximizing programme achievements, however, requires that UNFPA sharpen its strategic focus, particularly in the area of reproductive health by concentrating assistance in fewer provinces instead of the 11 provinces covered under the previous programme. There is also a need to continue UNFPA's strategy of strengthening the capacity of local institutions and to adopt cost-recovery schemes to pave the way towards sustainability. Investment in training should be made to create a qualified cadre of specialists in population and development strategies and population communication.

Other external assistance

18. It is estimated that only 20 per cent of the total health budget of the Palestinian Authority is allocated to primary health care, of which only a fraction goes to reproductive health. Most reproductive health activities are supported by donors and United Nations agencies. UNFPA has taken a lead role in enhancing the capacity of the Ministry of Health to manage and coordinate external assistance and in promoting collaboration with United Nations agencies and donors. With UNFPA's assistance, the Ministry of Health has finalized the women's health and health education strategies and has taken initial steps towards the establishment of a forum for coordinating reproductive health and population programmes and for maintaining a database on donor inputs in these arm.

19. Several joint interventions have been planned with other United Nations agencies and donors. UNFPA and UNICEF have laid the basis for a collaborative effort to raise awareness on reproductive health and gender issues and to promote responsible sexual and reproductive behaviour among young people. This intervention will also involve UNDP and UNRWA. Partnership with WHO would continue in building the capacity of the Ministry of Health and NGOs to integrate reproductive health into the primary health-care system. UNFPA and the United States Agency for International Development (USAID) have planned their forthcoming interventions in reproductive health in a complementary manner, both geographically and substantively. An expanded health project of USAID, planned to start in 2001, would be coordinated with the UNFPA programme in terms of health information systems, contraceptive logistics management and information, education and communication (IEC).  Similarly, UNFPA's interventions in reproductive health would complement inputs from a project of the European Commission in family medicine, which is due to start by the end of 2001. UNFPA and the United Kingdom's Department for International Development would continue collaborative efforts, begun in the previous programme, in support of census analysis, dissemination and training on utilization of data and pre-service training for nurses and midwives.

20. UNFPA has been recognized as a lead agency in population and reproductive health. The Fund has a full-fledged field office in the Occupied Palestinian Territory and the services of the nearby CST and can tap the expertise of the regional centres of excellence for training and transfer of know-how.  The Fund has also forged strong partnerships and rapport with key Palestinian Authority institutions and NGOs and is in a unique position to advocate for population issues. Entrusted with the establishment of systems for contraceptive logistics management, health information systems, quality assurance, counselling and referral, UNFPA has reaffirmed its pivotal role in helping to lay the foundation of a sound structure for reproductive health care. Due to its lead role in supporting the census, the Fund has become a primary contributor to establishing a comprehensive statistical data system.

Proposed programme 2001-2004

21. Under the proposed programme, UNFPA would continue to attach priority to institutional capacity building in the planning and management of population programmes as a key to promoting sustainability. Efforts would be made to promote coherence, inter-linkages and synergies among the three subprogrammes. The knowledge base would be strengthened by bridging data gaps and promoting connectivity and sharing of information, lessons learned and best practices not only among local institutions, but also with other countries through South–South cooperation modalities. UNFPA would capitalize on the favourable climate for created in the previous programme by helping to establish coordination mechanisms for both reproductive health and population. Due to the sensitivities associated with population issues, advocacy would be a primary strategy to create an enabling environment. Given the special situation in the Occupied Palestinian Territory, in the case of extraordinary circumstances emergency funds may be required in some areas.

22. Reproductive health programme.  The purpose of the reproductive health subprogramme is to contribute to increased utilization of quality reproductive health services by women, men, youth and adolescents and of reproductive health information to bring about behavioural changes in reproductive health practices. Six outputs are anticipated, focusing on three levels: strengthening service delivery, improving management of reproductive health services, and improving IEC on reproductive health issues.

23. The first output would be strengthened integration of quality reproductive health services and information in 39 selected primary health-care service delivery points in six provinces in the North and South West Bank and South Gaza regions. These provinces were selected because they are poor, densely populated and underserved and have some of the highest fertility and mortality rates and the lowest contraceptive prevalence rates in the Occupied Palestinian Territory. In addition to the geographic focus of the programme, a gradual and realistic approach to the integration of reproductive health services into primary health-care programmes would also be adopted. A further aim would be to provide a good testing ground for replication of these interventions in the future. Therefore, in 28 of the 39 service delivery points, the capacity for delivering MCH/FP services would be strengthened. In the remaining 11 service delivery points, more comprehensive services would be integrated, including postpartum care, MCH/FP, screening and management of STDs, screening for breast and cervical cancers, and adolescent reproductive health counselling and services.

24. To achieve this output, a number of strategic activities would be undertaken, including: (a) operationalizing reproductive health service protocols and guidelines; (b) upgrading the quality of care; (c) introducing counselling as a component of reproductive health services; (d) expanding the mix of contraceptives methods; (e) strengthening pre-service training at nursing and midwifery schools; (f) providing in-service training to reproductive health service providers in clinical skills, counselling and interpersonal communication; and (g) conducting JEC activities in the target service delivery points and in the surrounding communities.

25. The second output focuses on strengthening intra-parturn and post-parturn care in 11 comprehensive clinics out of the 39 service delivery points mentioned above. Basic interventions would include: (a) establishing a referral system for emergency obstetric care; (b) establishing postnatal outreach programmes in selected communities; and (c) providing in-service training of service providers.

26. The third service delivery output would be strengthening the women's health centres in Al-Bureij and Jabalia refugee camps in addition to integrating, legal and psycho-social counselling services in a third centre in Hebron. The key interventions to realize this output would involve: (a) expanding current reproductive health services to respond to the needs of adolescent girls, (b) mainstreaming gender within reproductive health services and information; (c) addressing violence against women; (d) promoting male awareness; and (e) improving management capabilities. To help ensure the financial sustainability of such centres, cost recovery schemes, such as sale of services by the Ministry of Health, would be adopted.

27. The fourth output addresses strengthening reproductive health-care management. The strategies intended to realize this output would focus on practices; clarifying the roles and mandates of various institutions; upgrading the skills of managerial staff, and utilizing research as a management tool. Selected research studies would be undertaken to bridge the information gaps in certain areas of reproductive health, such as STIs and HIV/AIDS and breast, uterine and cervical cancers. Additionally, the establishment of a reproductive health observatory located in the Ministry of Health would be considered.

28. The fifth output responds to the needs for reproductive health IEC. The focus would be on raising awareness and expanding knowledge among women and men of reproductive age towards priority reproductive health issues and practices. The key activities would include: (a)  developing standards and protocols for IEC programmes; (b) producing and disseminating IEC materials and programmes addressing the needs of targeted populations and geared towards inducing attitudinal and behavioural change; and (c) investing in human resource development to create a cadre of qualified professionals in IEC. An IEC strategy linked to an advocacy strategy would be developed, aiming, among other things, to promote wider use of modern contraceptive methods.

29. The sixth output would be specifically tailored to meet the needs of young people for reproductive health IEC through the integration of population, sexual and reproductive health, and gender concepts into school curricula, extra-curricular activities, out-of-school programmes and the media. To help create a supportive environment for such an intervention, influential figures in youth and adolescent surroundings, such as parents and teachers, would be targeted. The strategic interventions to achieve this output would include: (a) human resource and institutional capacity building; (b) production of educational materials and programmes for both adolescents and their parents; and (c) advocacy. To this effect, a joint project with UNICEF has been developed.

30. Reproductive health commodity security.  In the Occupied Palestinian Territory, contraceptive needs are determined in a fragmented manner and on a project-by-project basis. PFPPA is the main supplier of contraceptives while a small amount is procured by the private sector. The PFPPA sells contraceptives to the Ministry of Health and local NGOs. The cost is borne by donors, such as the European Commission and USAID. In its first programme of assistance, UNFPA supplied contraceptives in the amount of $148,000. The overall contraceptive needs for the Occupied Palestinian Territory in 2001 are estimated at $300,000. UNFPA would collaborate with USAID and the European Commission to help the Ministry of Health and NGOs, expand contraceptive choices and develop a system for contraceptive logistics management.

31. The amount of $5 million would be allocated to the reproductive health subprogramme, of which $2.3 million would be from regular resources and $2.7 million would be sought from co-financing modalities and/or other resources. To date, the amount of $1 million has been secured from the Government of Italy ($300,000), the Organization of Petroleum Exporting Countries ($100,000) and the United Nations Foundation ($600,000). These external resources would be used to support the women's health centres, the adolescent reproductive health project, a demographic and health survey and the pre-service training of nurses and midwives.

32. Population and development strategies.  The population and development strategies subprogramme was developed with the purpose of contributing to strengthening the management of population issues within development plans.   Five outputs are anticipated. The first output would be a developed system for coordination, monitoring and evaluation of population programmes and ICPD Programme of Action goals through: (a) establishing a relevant knowledge base; (b) promoting networking among ministries and other concerned institutions; and (c) developing and compiling relevant indicators to monitor the implementation of the ICPD Programme of Action.

33. The second and the third outputs would be completed dissemination and analysis of census findings and the integration of the population dimension into national and sectoral development plans. To achieve these two outputs, a series of in-depth analytical studies of the findings of the census and specialized surveys would be conducted and widely disseminated to meet the needs of data users and to create better understanding of population concerns. A database for topical studies would be established. Through training, the human resource capabilities of the Palestinian Authority and civil society would be enhanced to effectively utilize the data produced.  Scenarios on the inter-linkages between population variables and development would be developed to enrich and broaden dialogue on population issues and facilitate the development of population policy directives.

34. The fourth output would be operationalized functional networking between components of the population statistics system through: (a) training to enhance the human resource capabilities of statistical units;  and (b) technical assistance for the development of plans for statistical activities. The fifth output would be a structured training programme on population and development at the post-graduate level at an appropriate academic institute. This output would help create a much-needed cadre of population specialists.

35. The amount of $1 million would be allocated to the population and development strategies subprogramme, of which $800,000 would be from regular resources and $200,000 would be sought from co-financing modalities and/or other resources. If obtained, such additional resources would be utilized to support the post-graduate training programme on population and development.

36. Advocacy subprogramme.  The. purpose of the advocacy subprogramme is to have contributed to increased commitment and support for issues concerning population, reproductive health and gender equity and equality. Three outputs are anticipated. The first output is enhanced institutional and technical capacity of selected Palestinian Authority institutions, NGOs and mass media organizations to advocate for population, reproductive health, and gender issues. In particular, UNFPA’s assistance would be directed towards training and the development of research-based advocacy campaigns and an advocacy strategy.

37. The second output would be increased awareness and understanding among legislators, decision makers, opinion and community leaders, and other key stakeholders of priority issues in population, reproductive health and gender. Such priority issues would include early marriages among females, female school drop-out rates, adolescent reproductive health needs, violence against women, and equality of employment opportunities for women and men. Appropriate communication and advocacy strategies, including mobilizing grassroots organizations and allies in the media, would be used.  Pertinent research activities and knowledge, attitude and practices (KAP) studies would be supported in order to design effective advocacy messages and materials.

38. The third advocacy output would be integrated population communication concepts and themes within the curricula of mass communication departments in two selected Palestinian universities. Associated research activities and development of IEC materials would be supported as well. Media facilities available to such departments would be utilized for training and building the capacity for designing television and radio advocacy programmes.  The amount of $600,000. would be allocated to the advocacy subprogramme, of which $500,000 would be sought from regular resources and $100,000 would be sought from co-financing modalities and/or other resources.

Programme implementation, coordination, monitoring and evaluation

39. The proposed programme would be implemented by Palestinian Authority and civil society institutions. United Nations agencies and international NGOs along with selected competent Palestinian Authority institutions and local NGOs will be entrusted with execution. The mix of local and international agencies as executing and implementing agencies would combine experience in and knowledge of the Palestinian context with global expertise. The technical and managerial capacity of the Palestinian Authority's institutions for implementation and execution would be enhanced through training and transfer of know-how. UNFPA would draw on local experts, where available, particularly those who have been trained by the CST to provide technical assistance. The CST would continue to play an important role in providing technical backstopping to. the programme.

40. The Fund would continue to coordinate its supported programme with the Ministry of Planning and International Cooperation, which coordinates all external assistance to the Occupied Palestinian Territory. UNFPA would coordinate with implementing partners from the Palestinian Authority and NGOs through the steering committees for reproductive health, population and development strategies, and advocacy that were established under the first programme. Emphasis would be placed on strengthening the coordination of programme interventions in Gaza with those in the West Bank. Coordination with sister United Nations agencies and donors would be carried out through the United Nations inter-agency coordination structure. In particular, UNFPA would utilize the newly created subsector working group on reproductive health and population as a forum for enhancing dialogue on related issues and for coordinating programmatic interventions with those of other United Nations agencies and donors.

41. In line with UNFPA programming guidelines, the programme would be continuously monitored by the implementing and executing agencies and the UNFPA field office. To ensure effective operationalization of the results-based management approach, the UNFPA field office would develop a monitoring and evaluation plan. A standard form for results-based reporting would be developed on an annual basis at all levels of programme management. Field monitoring visits, annual programme reviews, a mid-term programme review and end of programme evaluation in 2003 would be conducted. Monitoring and evaluation would be based on quantitative and qualitative indicators linked to each of the programme goals, purposes and outputs.

42. The UNFPA field office is composed of a Representative, one National Programme Officer and three support staff. The current staffing capacity of the field office would be strengthened by appointing a Junior Professional Officer. One National Professional Project Personnel (NPPP) would be entrusted with overseeing the adolescent reproductive health project and the advocacy subprogramme. Two other NPPPs would be recruited and stationed at the pertinent departments of the Ministry of Health, one in Gaza and one in the West Bank, to assist in implementing the reproductive health subprogrammes. Under the proposed programme, the amount of $400,000 from regular resources would be used for programme coordination and assistance.

Recommendation

43. The Executive Director recommends that the Executive Board approve the programme of assistance to the Palestinian people, as presented above, in the amount of $7 million for the period 2001-2004, $4 million of which would be programmed from the Fund's regular resources, to the extent such resources are available, and the balance of $3 million would be sought through co-financing modalities and/or other, including regular, resources to the extent possible, consistent with Executive Board decision 2000/19 on the allocation of UNFPA resources.

—–