Assistance to the Palestinian people – UNFPA projects, recommendations

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 million of $):

_______________________

* Reissued for technical reasons.

1. The United Nations Population Fund (UNFPA) proposes to support a programme of assistance to the Palestinian People in the occupied Palestinian territory over the period 1996-1999 in order to assist the Palestinian Authority to achieve its population and development objectives. UNFPA proposes to fund the proposed programme in the amount of $7.2 million, of which $5.2 million would be programmed from UNFPA's regular resources. UNFPA would seek to provide the balance of $2 million from multi-bilateral and/or regular resources to the extent possible, consistent with Executive Board decision 96115 on the allocation of UNFPA resources. This would be UNFPA's first cycle of assistance although the Fund has provided some project-by-project assistance in the past. Please note that this country programme document does not include a demographic data sheet because of the lack of official United Nations statistics.

2. The proposed programme of assistance was developed on the basis of: (a) the policies and priorities of the Palestinian Authority; (b) the findings and recommendations of a reproductive health needs assessment mission undertaken jointly by UNFPA, UNRWA and WHO in September/October 1995; (c) the outcome of meetings and consultations with representatives of the Palestinian Authority, non-governmental organizations (NGOs), United Nations agencies and other relevant donors; (d) the recommendations of technical backstopping missions conducted by Country Support Team (CST) advisers to the occupied Palestinian territory since 1994.

3. In the area of reproductive health, including family planning and sexual health, UNFPA's programme would help to build the capacity of the Women's Health and Development Department and the Primary Health Care Department of the Ministry of Health and would also directly assist in providing reproductive health services in 100 primary health care centres and in two women's centres. The proposed programme would assist the Palestinian Authority in carrying out a much-needed census. Advocacy activities would concentrate on sensitizing policy makers to gender issues. The programme would also work to strengthen the capacity of women's NGOs and would help to integrate population into the curricula of schools at the basic educational level and in teachers training and literacy programmes.

4. All activities under the proposed programme of assistance, 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. Given the gradual assumption of responsibility by the Palestinian Authority, Gaza and the West Bank present unique challenges in carrying out an effective programme in population and reproductive health. The total Palestinian population in the West Bank and Gaza was approximately 2.3 million at the end of 1995. This population is growing at an annual rate of 5.8 per cent in the West Bank and 6.3 per cent in Gaza, and the overall population is expected to double in about 15-18 years. These are some of the highest population growth rates in the world. There is considerable difference between the West Bank and Gaza, with Gaza lagging behind in all indicators. For example, the per capita gross domestic product of $1,500 in the West Bank is twice that of Gaza; it is estimated that one third of all Gaza families subsist below the official poverty line of $470 per year. A significant gender gap is shown by the fact that women make up only 4 per cent of the formal labour force and that 37 per cent of females leave school with 9 years or less of schooling compared to 22 per cent of males.

6. The high population growth rate is the result of declining mortality levels, while fertility levels have remained stable over the past two decades. The total fertility rate is estimated at 5.6 births per woman in the West Bank and 7.4 births per woman in Gaza. This high fertility rate is attributed to such factors as attitudes favouring large families, the lack of access to reproductive health, including family planning and sexual health, services and the lack of awareness about family planning choices. These trends have resulted in a very young population structure.

7. Infant mortality rates are estimated at 25 per 1,000 live births in the West Bank and 32 per 1,000 live births in Gaza. Maternal mortality rates per 100,000 live births are estimated at 72 in Gaza compared to 36 in the West Bank. Since 37 per cent of women marry before the age of 17, early marriage is considered a primary factor leading to the increased risk of complications from pregnancy and childbirth. It is estimated that more than 30 per cent of pregnant women do not have access to adequate prenatal care. More than 25 per cent of deliveries in the West Bank and 50 per cent in Gaza are not attended by trained midwives. Post-natal care is provided for 17 per cent of the women in Gaza and 30 per cent in the West Bank.

8. At the request of the Ministry of Health, a joint UNFPA/UNRWA/WHO needs assessment mission on reproductive health was conducted in September/October 1995. The mission noted that of the 444 health facilities in the West Bank and 80 in Gaza that provide primary health care only a few provide reproductive health care services. Out of 31 health centres of the Ministry of Health in Gaza, 20 centres provide maternal and child health (MCH) services and three provide family planning services. Five more family planning clinics are to be established in 1996. Among the 230 centres of the Ministry of Health in the West Bank, 155 provide MCH services, but as yet no family planning clinics have been established. There are plans for NGOs to assist the Ministry of Health in establishing two family planning clinics in Nablus. Only 74 of the clinics run by NGOs in the West Bank and 11 in Gaza provide MCH services, and less than half provide family planning services. UNRWA provides comprehensive MCH services within its health care services to the refugee population, and many have integrated family planning services.

9. In terms of human resources, the number of general practitioner physicians currently available is sufficient, but there is a shortage of specialists. It is also estimated that two to three times the current number of trained nurses and midwives are required. The needs assessment mission also identified a need to build up the technical and managerial capabilities of the Women's Health and Development Department of the Ministry of Health. At the primary health care level, there are needs to integrate family planning services into existing services and to make them more accessible; to address the issue of reproductive health in a more comprehensive manner; to improve the quality of service delivery through training programmes; to establish standardized referral feedback systems; and to develop an effective management information system. At the secondary level, obstetric services need to be expanded and quality of care needs to be improved.

10. The Palestinian Authority is committed to achieving the goals of health for all by the year 2000 with a strong emphasis on primary health care. The establishment of the Women's Health and Development Department in July 1995 at the Ministry of Health underscores the importance being attached to women's health and well-being. The Palestinian health policy and plan incorporates a holistic approach to women's health, with a focus on reproductive health. Its goals for the year 2000 include reducing maternal mortality by 50 per cent, decreasing high risk pregnancies by 50 per cent, introducing family planning counseling and screening in 50 per cent of all health facilities, increasing the contraceptive prevalence rate (currently estimated at 12 per cent) to 25 per cent, and providing postnatal care to all women.

12. In view of the great need for reliable statistics, a master plan for Palestinian official statistics was developed by the Palestinian Central Bureau of Statistics (PCBS), approved by the Palestinian Authority in January 1995 and widely discussed at the Second International Conference on Palestinian Statistics held in April 1995. The plan gives priority to conducting a population and housing census  not later than 1997.

External assistance

13. UNFPA's support in the area of reproductive health started in 1987 with small-scale MCH training and research activities organized by the WHO Primary Health Care Centre in the occupied Palestinian territory. UNFPA's assistance increased considerably starting in 1992. During the period 1992-1995 two maternal and child health and family planning (MCH/FP) projects in the amount of $550,000 were implemented in cooperation with UNRWA for Palestinian refugees in the occupied Palestinian territory. The projects made considerable progress in improving the quality of prenatal care, provision of post-natal care and integration of family planning services within existing MCH programmes. In addition, the Fund has carried out a family planning knowledge, attitude and practice (KAP) survey, which highlighted a latent demand for family planning and a need to broaden the contraceptive choices and method mix.

14. One of the most important achievements of previous UNFPA assistance was the establishment of a multi-disciplinary women's centre for reproductive health care, social assistance, legal counseling and community education in the Al-Preuj camp between Gaza and Khan Yunis. The centre was inaugurated in December 1995, and activities are being implemented by a Palestinian NGO in cooperation with the Italian Association for Women in Development.

15. During the period 1986-1994, UNFPA sponsored five Ph.D. fellowships in population-related fields, thereby helping to establish a qualified cadre of population specialists. In 1995, the Country Support Team (CST) based in Amman, Jordan, assisted in formulating a population and housing census project. In 1995, $325,000 was allocated to carry out preparatory activities. The actual conduct of the census is a central element of the proposed programme. In 1994 and 1995, the Fund sponsored four training workshops for about 125 members of Palestinian NGOs in preparation for the ICPD and the Fourth World Conference on Women. The workshops contributed to the effective participation of NGO representatives in both conferences.

18. UNDP's current programme of assistance to the Palestinian People for the period 1996-1998 encompasses a number of ongoing activities complementary to the proposed UNFPA programme, including support for the women's departments established within the ministerial structure of the Palestinian Authority, technical assistance in producing statistics disaggregated by gender, help in ensuring that the curricula of Palestinian schools are gender-sensitive, and a task force on issues relating to poverty eradication that will include a focus on the gender determinants of poverty. UNICEF's programme of assistance (1996-1997) in the amount of $35 million includes activities to strengthen the health system. The European Union is embarking on a project in the amount of $5.3 million for the period 1996-1998 to support family planning in the occupied Palestinian territory aiming, inter alia, at promoting favourable attitudes towards family planning and at integrating family planning in about 30 public health clinics.

Proposed programme

19. In view of the disparities in the levels of development among the various areas of the Palestinian territory, the proposed programme of assistance would concentrate on poor, densely populated and underserved areas, particularly in Gaza. Taking into account that the civil society is very active, the proposed programme of assistance would help to promote partnership between the Palestinian Authority, NGOs and the private sector. Given the current lack of access to integrated reproductive health services, the proposed programme would focus on reproductive health. The different elements of the programme would be designed to reinforce one another. For instance, census and survey data disaggregated by gender would be used as an advocacy tool to sensitize policy makers towards the integration of women's concerns in development plans.

20. Reproductive health. In the area of reproductive health, the programme would help build institutional capabilities both at the policy and the service delivery levels with emphasis on primary health care. At the policy level, the Fund would assist in strengthening the capacity of the Women's Health and Development Department of the Ministry of Health to implement policies promoting women's health. To this end, a training programme would be designed and implemented in collaboration with relevant agencies, such as WHO. Technical assistance would help the Department to develop a masterplan for women's health. The Fund would also provide technical assistance to upgrade the capabilities of the Primary Health Care Department to complement management training being sponsored by the Government of Italy.

21. At the operational level, the Fund would help to improve reproductive health services by building on inputs in the health field from donors such as the European Union, the World Bank and UNRWA. Assistance would be extended to both the Ministry of Health and NGOs to integrate reproductive health into the programmes of 100 primary health care clinics and to strengthen the referral system at the secondary and tertiary levels.

22. UNFPA would assist in training health providers (physicians, nurses and midwives), including the training of trainers, in clinical aspects of reproductive health as well as counselling and interpersonal communication. At the pre-service level, support would be provided to the Nursing Schools in the occupied Palestinian territory, while at the in-service level assistance would be extended to the Institute of In-Service Training at al-Shifa Hospital in Gaza.

23. The Fund would help to strengthen the infrastructure of health facilities through provision of medical equipment, supplies and essential drugs related to reproductive health services, including a wide range of contraceptives. UNFPA's support to reproductive health services and IEC would focus on family planning, safe motherhood, prevention and management of reproductive tract infections, prevention of HIV/AIDs, and adolescent reproductive health. Other services, such as screening and diagnosis of breast and uterine cancer and diagnosis of high-risk pregnancies, would be supported on a limited basis. UNFPA would assist a local NGO affiliated with Care International in a pilot project for community-based distribution of contraceptives and family planning awareness creation in Jenin, an underserved area of the West Bank.

24. UNFPA would take the lead in developing appropriate IEC strategies with a focus on reproductive health. The Fund would support activities, through mass media and interpersonal and community channels, to create awareness about the disadvantages of early marriage and to promote favourable attitudes towards girls' education, responsible male sexual and reproductive behaviour, women's reproductive health and rights and their involvement in community development. To provide necessary inputs for the strategy, UNFPA would also support socio-behavioural research on attitudes of women, men and youth towards contraception and other aspects of reproductive and sexual health.  Since the existing reproductive health awareness creation activities have traditionally targeted women, the EC strategy would ensure that men are reached as well In addition, the Fund would help strengthen the capacity of the Health Education and Promotion Unit of the Ministry of Health and would assist in establishing a task force to plan, coordinate, monitor and evaluate population IEC activities.

25. UNFPA would complement activities of the World Bank and UNICEF in strengthening health management information systems by integrating reproductive health information and assisting in identifying relevant indicators to monitor performance of reproductive health programmes. The Fund would collaborate with UNICEF in conducting a maternal and child health survey that would also include preparation of a reproductive health module.

26. The proposed programme would build on its current support for the Women's Centre in the Al-Preuj refugee camp. The centre extends integrated reproductive health services, counselling and IEC to cover the whole reproductive life cycle of women. The centre also provides legal and psychological counseling, particularly in cases of domestic violence, and sensitizes the community to the adverse consequences of violence against women. The Fund would assist in establishing another women's centre in the town of Jabalia, north of Gaza.

27. Population and development strategies. No census has been conducted in the occupied Palestinian territory since 1967. Therefore, there is no reliable and up-to-date data on the size, characteristics and distribution of the population. Census data are badly needed by the Palestinian Authority, United Nations agencies, donors and NGOs for development planning. UNFPA would therefore continue its support, including training, to the Palestinian Central Bureau of Statistics in conducting the census and collecting and analysing other demographic data. The census would allow for the construction of a master sample frame to be used in conducting subsequent surveys. UNFPA's support would focus on building the institutional and technical capabilities of the PCBS.

28. Advocacy.  Women have been severely affected by the unfavourable socio-economic situation in the occupied Palestinian territory. Therefore, the Fund's advocacy activities would be targeted primarily at improving the educational and socio-economic status of women. To this effect, UNFPA would assist in conducting workshops for policy makers and planners at various levels to create awareness about women issues and ensure that women concerns are integrated in development plans. The Fund would provide technical assistance and training to strengthen the managerial, administrative and operational capabilities of women's NGOs.

29. The Palestinian Authority is at the initial stage of developing an indigenous education system. For this purpose, a Curriculum Development Centre has recently been established with assistance from UNESCO. UNFPA would collaborate with this centre and the Ministry of Education to integrate population education in the curricula of schools at the basic educational level as well as teachers training and literacy programmes.

Implementation, monitoring and evaluation

30. The Ministry of Health and NGOs, such as the Palestinian Family Planning and Protection Association and the Culture and Free Thought Association (CFTA), would implement reproductive health activities. The Palestinian Central Bureau of Statistics would carry out the housing census and the population statistics training activities. The Ministry of Education would incorporate population education into the education curricula of schools at the basic educational level. The Ministry of Social Affairs, the Ministry of Youth and Sports and the Ministry of Information, local NGOs and youth unions would implement awareness creation activities.

31. The Ministry of Planning and International Cooperation is the agency in charge of coordination of population and development programmes. UNFPA would work closely with all concerned ministries in programme formulation, coordination, execution and management. UNFPA would also continue to enhance coordination and collaboration with the pertinent United Nations agencies and bilateral donors within the coordination mechanisms that have already been established and through the continuous exchange of information.

32. All programme activities would have built-in monitoring and evaluation components. All activities would be subject to standard progress reports, monitoring field visits and tripartite review meetings. The UNDP/UNFPA field office in Jerusalem would closely monitor programme activities. The UNFPA Country Support Team in Amman, Jordan, would provide technical assistance and participate in monitoring activities. A mid-term review would take place in 1998.

Recommendation

33. The Executive Director recommends that the Executive Board approve the programme of assistance to the Palestinian People, as outlined above, in the amount of $7.2 million, of which $5.2 million would be programmed from UNFPA's regular resources, to the extent such resources are available, and the balance of $2 million would be sought from multi-bilateral and/or regular resources to the extent possible, consistent with Executive Board decision 96/15 on the allocation of UNFPA resources.

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