Health conditions in the OPT – WHO report

FORTY-FIRST WORLD HEALTH ASSEMBLY

Provisional agenda item 33

HEALTH CONDITIONS OF THE ARAB POPULATION IN THE OCCUPIED ARAB

TERRITORIES, INCLUDING PALESTINE

The Director-General has the honor to bring to the attention of the Health Assembly the report of an Assessment Mission, carried out at the request of the Director-General, which is annexed hereto.

ANNEX

THE WHO COLLABORATING CENTERS IN

PRIMARY HEALTH CARE RESEARCH

WEST BANK AND GAZA

Report of an Assessment Mission to the

Director-General of the World Health Organization

December, 1987

This report embodies a brief technical review of the three WHO research centers on the West Bank and Gaza and an assessment of their achievements and impact on local health care. It contains a number of recommendations.

The centers are modest attempts to create a channel through which WHO can help to improve care in a situation fraught with difficulty. The position of the staff of the centers who are operating within the Health Services of the Government of Israel is complex and their work astride a politically contested and inevitably highly charged boundary an example of how concern for health care can surmount obstacles. In our view all concerned are to be congratulated.

March, 1988

Prepared by:

Dr E. Maurice Backett, Professor Emeritus of Community Health,  

University of Nottingham, England,

and Dr Daniel Tarantola, Medical Officer, World Health Organization

Headquarters, Geneva, Switzerland

1. EXECUTIVE SUMMARY

1.1 Whatever the administrative structure of the health services of the West Bank and Gaza, information support and research into ways of improving care will always be needed. Also needed, and in some areas even more urgently, is help in the development of human resources for health.

1.2 In responding to the request of the World Health Assembly to "establish three health centers in the occupied Arab territories, including Palestine"* the Director-General recognized these information support and research and development needs. Identifying three units or centers, two in the West Bank and one in Gaza, he designated them as WHO Collaborating Centers in Primary Health Care Research. The international contribution to these centers is administered and managed by the UNDP/Program of Assistance to the Palestinian People on behalf of WHO. Two of the centers are in health services research and one in health manpower development research. Each is manned for the most part by Palestinian doctors, health professionals and social scientists.

1.3 This is a report of a two-man mission which reviewed the achievements and impact of the centers and made recommendations after the centers had been functioning for one and a half years (the Health Manpower Development Center), nearly two years (the Gaza Health Services Research Center) and two and a half years (the Ramallah Health Services Research Center)**.

1.4 The Directors and staff of the centers are Palestinian employees of the health services of the Government of Israel and an effective modus vivendi has been established. Each center was given an agreed list of subjects to address, all of them seeking to promote increased coverage and appropriate technology in primary health care. At first there was a considerable staff training task and since even now the centers do not have enough trained staff to do all that has been requested of them, this task continues. To make the centers viable a modest increase in staff has been recommended (see below Section 4).

1.5 The centers are under the control of Directors who are senior members of the Government Health Services. They are steered by committees composed of Israeli health administrators, the Directors and some senior Palestinian doctors in charge of local services. The role of the Steering Committees in decision making and management has been very supportive to the centers but has intruded into too much detail particularly in research design and method.

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  * Resolution WHA35.15

 ** A parallel but not overlapping Israeli Mission reported to its  

    own Government.

1.6 The centers are isolated intellectually; islands of research endeavor with none of the academic links normally associated with health systems research. Connections with the School of Public Health of the Hebrew University of Jerusalem have been very helpful in a number of ways but cannot replace the much needed exchange of

ideas which would come from normal university links. The WHO linkage is therefore a vital channel, both to sustain the centers and through them to promote improvements in health care among the Palestinian people.

1.7 The centers have been called WHO Collaborating Centers and this has sometimes been misunderstood. The Mission recommended that this title be dropped, at least locally, but there is still much to be done to improve the local image both of the centers and of WHO.

1.8 The Ramallah Health Services Research Center has three medically qualified staff, all part-time, and four others including a statistician and a secretary. It is well equipped and housed. The Gaza Center is also well equipped and housed and though having a wider remit than the Ramallah Center (being involved in routine information provision as well as research), also has three part-time medical doctors, two part-time nurses, a statistician, a secretary and clerical and coding assistance. The Health Manpower Development Center shares some facilities with the Ramallah Health Services Research Center and has a medically qualified Director, two graduate social scientist staff and a secretary. Members of the Ramallah Centers are attending courses in the School of Public Health in Jerusalem and all staff from the three centers have attended the WHO Health Services Research Workshop in PHC.* From this workshop have sprung a number of studies which have become part of the programs of the centers. There has been, therefore, much "learning by doing" both among staff and informal associates.

1.9 A feature of the health systems research undertaken both in Gaza and in Ramallah is its practical, "rough and ready" and immediately applicable nature. With the exception of the Directors, who are already well qualified, health survey, design and analysis skills are being learned "on the job" and the research is refreshingly "action" oriented and concerned mostly with PHC, with coverage and, though this is not recognized as much as it should be, with health education. The catalytic effect of the centers upon the work of all health professionals both Israeli and Palestinian, is marked and there is an important though difficult to measure impact upon the local population where response rates in surveys are of the order of 100%.

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*  WHO Health Services Research Workshop for the West Bank and

   Gaza, December 1986 to June 1987.

1.10 The HMD Center whose two graduate social scientist staff have only just returned from training, is involved in a number of continuing education courses for local health professionals. The Mission is of the opinion that it can make a singular contribution to curriculum planning and to the teaching and learning methods used, as well as to sponsoring new courses in PHC and related subjects.

1.11 The Ramallah Health Services Research Center is presently concerned with the following studies**: reviews of infant and child mortality, a serological survey among West Bank children, some important growth and development studies of infants and children, related studies of nutrition of children and pregnancy care, the supervision of Dayas (traditional birth attendants) and a study of risk factors in pregnancy. A study of great interest and potential is of the development of Primary Care in Hebron and the Mission is strongly of the opinion that this could develop into a series of long-term studies of innovations in a defined population cohort in a cared-for population. Such a development could attract independent funding.

1.12 The Gaza Health Services Research Center is reviewing infant mortality, antenatal care and delivery coverage with particular reference to institutional delivery and deaths occurring at home. They are also studying the growth patterns of infants and the role of the Days in home deliveries. Like the Ramallah Center they are studying antibody patterns in various population groups through serosurveys. The vaccination patterns among seven year old school children and the nutritional status of older children are the subject of two studies which have just started and the WHO workshop yielded a study of the prevalence of cardio-vascular risk factors. A study of the prevalence of anemia. in women of reproductive age has also started recently.

1.13 In addition to these surveys the Gaza center runs an impressive computerized health information system which occupies much of its time. The Center is overloaded to such an extent that its protocols, reports, etc., its attendance at meetings, seminars and some of its training activities have suffered. The Mission has recommended a modest increase in its research staff.

1.14 While greatly impressed with the achievements and impact of the Centers, particularly when faced with the sometimes overwhelming and massive constraints of the West Bank and Gaza, the Mission is concerned that all the potential of the Centers be realized. The Centers are only just viable and an increase in scientific skills is essential in order to ensure, in turn, an increase in the region of research design and method and congruence

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** As well as a heavy training program.

with objectives in the allocation of priorities. The Mission has no doubt at all as to the value of these Centers; first, at a most practical level in the improvement of care of the population, and then at a more subtle level in sustaining the morale of health professionals and in stimulating a spirit of inquiry and innovation.

2. INTRODUCTION AND GENERAL REVIEW

2.1 Objectives of the Mission

At the request of the Director-General Drs Backett and Tarantola. were asked to visit the three WHO Collaborating Centers in Primary Health Care Research in the West Bank and Gaza, to review their achievements to assess their impact, and to make recommendations. The Mission took place from 27 November to 7 December 1987. The two members of the Mission agreed to interpret their task in broad terms having as their background some experience of the constraints within the area and its health services, a working knowledge of many of the difficulties of research in the West Bank and Gaza and access to all the relevant documents. They were assisted by Dr Alexander Robertson, Special Adviser to the Director-General, as resource person. Much but not all of their review for the Director-General was carried out in parallel with an Israeli Mission (Drs Davies and Palti) who will be reporting to their own Ministry. This report summarizes the findings of the WHO team arising from review of documents and reports, group meetings and private interviews.

2.2 History and objectives of the Research Centers

Three research centers are now functioning; the Ramallah Health Services Research Center since June 1985, the Gaza Health Services Research Center since January 1986, and the Health Manpower Development Center for the West Bank, also located in Ramallah, since June 1986. For research in health services and in manpower development to mature in such a short time would be difficult under any circumstances and perhaps in part because their objectives are broad and allow them considerable scope (for example, "to support the undertaking of health systems research aimed at ensuring total coverage of the local population with primary health care, using the most appropriate technology") they have done remarkably well.

At the beginning of its report therefore the Mission makes its most important recommendations:*

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* Other recommendations are to be found at Section 4.

Recommendation 1:

that continuing and, if possible increasing technical and financial support be provided to each of the WHO centers with the UNDP remaining in its present managerial role. As this role grows more complex it will be necessary for it to become the full time responsibility for a WHO staff member in the UNDP office.

In spite of the breadth of their development objectives all three centers were given more immediate objectives which included a substantial amount of training of staff and in each case there was an agreed list of research topics. Most of these are under way and some have been completed (see below Annex 6.2). In addition each center has developed de novo a series of interests in certain priority subject areas – often dictated by changes in health service organization or by the Government of Israel health policy, for example in the health education of the population. These ad hoc developments may well mature into full research projects; at the moment and although they are not listed objectives, they must be counted as falling well within the centers, remit. Some may eventually achieve greater importance than current commitments.

Another and important research activity is also to some extent opportunistic. A number of health professionals interested in health systems research but only tenuously attached to the centers (and some having attended the WHO sponsored Workshop on Health Systems Research in Primary Health Care from November 1986 to June 1987) have had their research activities incorporated into the programs of the centers. An example of this mode of entry into the research field would be a cardio-vascular risk factor study which was first proposed at the Workshop and later approved by the appropriate Steering Committee. These ad hoc studies, a welcome sequel to the Workshop, could nevertheless run the risk of overloading the centers. They are another reason for increasing resources since this "clearing house" function plays an important part in the morale of personnel and in the development of health care in the territories.

2.3 Previous Reports

The Mission has found particularly useful the reports and documents furnished by the Director-General on the subject of the proposals for the centers (1), their designation (2) and especially the Progress Reports of 1986 and 1987 (3). The relevant paragraphs of certain resolutions of the World Health Assembly (4) and reports of the discussions which took place before, during and after them have also been of great help. The work of the Special Committee (5) and a number of reports from individuals and special teams in particular the report by Dr Robert Cook, (6) and that of Dr Susi Kessler (7) are also important to the understanding of the rapidly changing role of the centers.

2.4 Conduct of the Mission

Support for the Mission came from the Directors and all staff and associated research workers in the centers, from UNDP and officials of the health services of the Government of Israel concerned with work in the area, from representative individuals in the private sector and from numerous health professionals (see Section 5, Acknowledgments).

The methods used by the Mission in their assessment of achievements and impact were only quantitative in so far as full documentary reviews were made of all reports and products of the centers as well as summaries of their finances. Qualitative assessments were made by each member of the Mission in three ways, then discussed and agreed. Introductory questions and answers with all members of the centers to explain the review and to establish the Mission's friendliness and neutrality. Next, individual interviews of about one hour each with all staff and finally a group discussion with all staff including secretaries.

The Mission transcribed their individual notes and agreed conclusions under a number of predetermined headings which had already been prepared and bound into a form of questionnaire which was used as an aide memoir or framework.* The headings were used to characterize the performance of the centers according to:

– Relevance

– Adequacy

– Progress

– Efficiency and

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(1) Unpublished WHO documents.

(2) Correspondence with the Government of Israel.

(3) A39/24 and A40/10.  

(4) WHA35.15, para. III.(2), 1982; WHA36.27, para.8.2, 1983; WHA37.26, para.7, 1984; WHA38.15, para.6, 1985; WHA39.10, para.6 (4), 1986; WHA40.12, para.7 (4), 1987.

(5) Special Committee Reports of 1983, 1984 and 1985.  

(6) "Report on a visit to the WHO Collaborating Centers in Primary Health Care Research, 18-28 February 1986", Dr Robert Cook, Senior Medical Officer, Family Health Division, WHO/Geneva.

(7) "West Bank Health Care Assessment Opportunities for Improvement", Dr Susi Kessler of the American Public Health Association.

* See Annex 6.3.

– Effectiveness in achievements and impact**

Achievements were seen as more tangible and immediately measurable than impacts but in the setting of the West Bank and Gaza (see below: 2.5) were often less important.

Under each descriptive heading the aide memoir or framework defined the kinds of questions to be asked, the indicators likely to be of use and the variables involved with their sources of information. At each discussion a number of additional elements (such as the magnitude of constraints) were considered along with possible recommendations. These latter were then discussed with the Directors of the centers.

2.5 The Setting of the Centers Today

Any description of the achievements and impact of the WHO Research Centers must be seen in the context of the tense and disturbed life of the West Bank and Gaza, the changing health needs and demands of the population, and particularly in the context of the developing health care system of the area in which important improvements are reported to be taking place. The Mission was told that demand for health care by the people is increasing but that it is predominantly for curative care and high technology. Except in projects like that to be found in Hebron, and in spite of some valiant efforts of the private sector, primary health care still has a long way to go and the utilization of services at that level is poor. There is therefore much that is challenging in the work of the centers, oriented as they are towards increasing primary care coverage and graduate education.

The place and status of the research centers within the health service is still equivocal but becoming less so as their contributions become clearer. This lack of clarity is in part because all but six research personnel*** are employed by the health services of the Government – they therefore, in a sense, have two conflicting roles. Adding to this difficulty and to a confusion of method and management is the fact that the tasks of the centers are defined – sometimes in excessive detail – by Steering Committees which are usually composed of senior Israeli Government health planners and administrators, including the Directors themselves. In addition it must be said that the

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 ** These terms are defined in No.6 of the Health For All series, Health Program Evaluation: Guiding Principles for its Application in the Managerial Process for National Health Development. WHO publication, 1981.

*** Six support staff are UNDP contract staff paid for by WHO.

Mission found little evidence of understanding in the general population of the roles of WHO and the centers or of what they are doing for health and health care. The centers appear to need a number of new connections; academic, popular and scientific, to stimulate the flow of ideas and methods and above all to keep them in touch with the outside world of health systems research.

Another contribution to the manifold problems of the centers (and therefore necessary to an understanding of the setting in which they work) is the uneven distribution of skills. The centers are so new and such important training has been taking place that there are some inevitable shortages of specific skills, for example in research management and design. One result has been a shortage of what are often called "work  plans", of detailed "protocols", "activity" reports and forward looking financial plans *. There is also a serious shortage of internal scientific meetings and discussions – some of it a result of prevailing conditions.

If to these problems are added those of health systems research and manpower development in a turbulent and divided society in which are found such contrasts as a high literacy rate and little abject poverty but mediocre general health, the work of the centers will be seen to be commendable. The Mission is agreed that the future potential of the centers is great, that they are a vital channel of access to WHO technical support and that their objectives are particularly relevant to the needs of the Palestinian people.

In view of these and many other problems in the early life of the research centers the Mission has made a number of general recommendations. They are to be found at Section 4.1. More specific recommendations are to be found at 4.2.

3. THE WHO COLLABORATING CENTERS

3.1 Ramallah Health Services Research Center

3.1.1 History and tasks

This Research Center has been in place and functioning for some two and a half years. Much of the early period has rightly been spent on building up staff and equipment and in staff training (see Annex 6.2.1) which of course continues. The inaugurating project document is clear in its emphasis on primary care, its objective of increased coverage and appropriate technology and the agreed activities of the Center. Ten projects were optimistically listed, in which the Center was to participate, all of them important. The proposed projects however, constituted an unrealistic target for a center which has only three medically qualified staff, all

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* This shortage was partially compensated for by access to annual and other reports and a useful summary report on research activities from each Director (see Annex 6.2).

part-time, and four others including the secretary. As an example of how thinly are the Center staff spread, the first of the agreed activities, the Hebron Primary Health Care project, even though shared with local health services, could have occupied the group full time. As it is, the contribution of the Center was to this and at the same time to at least five other studies and to a substantial training program (see Annex 6.2.1). In consequence the Mission is of the opinion that the Research Center is operating at or just below the critical size necessary (Recommendations 7, 15)**.

3.1.2 Personnel and skills available and needed

The Health Services Research Center in Ramallah is well run under an able Director. It is very well equipped having its own transport, premises, office equipment and micro-computer with plenty of the necessary programs (except some needed for training, see Recommendation 11). Two members of staff have good statistical skills and others are learning fast, but these do not include skills at the level of research design and management that are demanded by some of the projects to which the Contra has been directed. Nor are such special skills always available in the Steering Committee. It implies no criticism of Director, staff or Steering Committee to say that as a consequence there is heavy responsibility on people whose skills lie elsewhere. While recognizing the able assistance in this field which is available at the School of Public Health of the Hebrew University in Jerusalem, the Mission is of the opinion that the Center should be self-sufficient in this respect (Recommendation 15).

3.1.3 Achievements

Some idea of the achievements of the Ramallah Health Services Research Center can be seen from their report (Annex 6.2.1). From this it is clear – that the objectives and activities of the Center are consistent with those outlined in the report of the Director-General in May 1986 (A39/24) and with PHC principles in so far as these are themselves congruent with Government policies. In fact, all the present projects are refreshingly relevant to PHC though perhaps not all stressing immediate priority needs (see Recommendations 12, 13, 16, 17). For example, Primary Care is soon by most as medical care and much more community participation and involvement is needed. Constraints in this area are however, formidable, being closely dependent upon the prevailing socio-political situation.

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** There is an inevitable overlap between some of the general and the more specific recommendations.

Resources are adequate except in the two respects already mentioned: more and greater management and research skills are needed in order to undertake and complete the research programs already started.

The commitment of all of those professionally involved (Government, WHO and UNDP) to the objectives of the Center was impressive and, though the situation imposes a political scrutiny of research findings, this is not at present onerous. Survey response rates of the general population remain high though the staff interviewed expressed-their concern about the extent of understanding of the objectives of the Center among this population (Recommendations 2, 5).

Another inevitable deficit of particular importance in Ramallah is in information about the work of the private sector in health care. This sector makes a large contribution which ranges widely from costly private practice through to some well organized primary care and unofficial Dayas services. It was found that the cooperation between this sector and the research centers was still insufficient. With a wider understanding of the work of the centers and of WHO some improvement in relations may be expected. However, research findings, if properly distributed, may well be of value to the private sector in its work (Recommendations 2, 5, 9).

It is difficult to judge what will be the quality of final reports of research from the Center for at present only interim reports are available. All of these were available to the Mission and all have been submitted on time from the beginning. The constraints of skill, continuing training, lack of access to the flow of ideas in health systems research in the outside world and the justifiable and perhaps over-enthusiastic embracing of a large and complex research program point to a need for consolidation and assistance rather than criticism. In the face of such constraints and the major tensions in that society, progress has been satisfactory, even remarkable.

The Mission would have welcomed a more detailed plan of action and a corresponding increase in the detail of the protocols of studies under way (including a full justification as a prelude to the protocols). Such detailed planning would have had three uses. First, it would have guided better the researches and provided more detailed designs; second, it would have facilitated essential consultation between the Steering Committee, the Director and his more junior staff and finally, suitable parts of the plans could have been used to inform the public of the essentially altruistic nature of the activities of the Center and perhaps even to involve them (Recommendations 5, 6).

There is little doubt that the efficiency and effectiveness of the Ramallah Health Services Research Center would be enhanced by more outside contacts with the community, the private sector, UNRWA (at present only on a personal basis) with UNICEF (as in the Hebron project) and with more WHO/UNFPA sponsored activities such as the 1986-87 Workshop, the Infant Mortality studies and the High Risk pregnancy work. However, the five research projects in which it is mainly involved (as well as some others started as Workshop projects) are progressing according to plan and show considerable promise (Recommendations 3, 5, 9).

3.1.4 Impact

Serological Surveys of antibody patterns, particularly among school children are difficult to carry out and then even more difficult to interpret. The EPI (Expanded Program of Immunization) group in WHO Geneva have commented on the report of this project the impact of which has been twofold. While it can be argued that EPI coverage would represent a more cost-effective indicator of the performance of the vaccination program, the sero-epidemiological surveys have demonstrated the feasibility of such an approach in the West Bank. Second, and perhaps more important, it has alerted the population to the need to vaccinate mothers and children. The extent of this popular response should be measured and the project evaluated. This evaluation should also include a measure of how far the health needs which were uncovered by the research were met. The Mission was satisfied that the principles of "action research" (particularly of "no research without service") were adhered to in this and other studies.

The Infant Mortality studies have followed much the same pattern. They are difficult to carry out and to interpret (and there are particular problems at a political level with interpretation and at a survey level with denominators) but they have an important health educational impact.

The involvement of the Ramallah Center in the Hebron Expanded Primary Health Care Project is technically as evaluator. However, this involvement is much greater than implied and the project is serving as a very important training and testing as well as "action research" site. The health education implications, both for the population and for the health professionals concerned, are profound. The opportunity is clearly offered to make of the Hebron experiment a permanent "cared for" population from which further research (aimed, among other things, at the improvement of the quality of primary care and community involvement) could be undertaken. (Recommendation 17).

The impact of the two other studies; growth and development of children and the supervision of the Daya will be easier to assess (like those mentioned above) when final reports are available. In the meantime the effect of such studies in sensitizing the local population to new and higher standards must not be underestimated nor must their catalytic effect on the work of local health professionals be ignored.

The High Risk Pregnancy studies which grew out of the study of the growth and development of children show well the necessary and characteristic mix of research and service provision. They also show the important contribution made in several settings by UNFPA to the development of this "action" research. To determine the relative importance of risk factors in pregnancy in this area and to involve the health professionals and the population in their early recognition and, where possible, their control, would be a substantial contribution to primary care and should be a high priority.

In summary therefore, the Mission sees as a profoundly Important effect of the work of the Research Center the sensitizing of education of the health professionals of the area – particularly to the preventive aspects of primary care, and to a lesser extent, of the general population. This effect is over and above the applications of the results of the research (which may be expected soon) and is, in the view of the Mission, itself a sufficient reason for continued and enhanced support. Education and prevention should become overt objectives of the centers and the basis of rigorous studies. At least one application of findings about risk factors is through community involvement in their early recognition. The Mission would wish that WHO be more active in reinforcing these ideas by the provision of substantial short-term consultancy in community health education (Recommendations 14, 16). If to this is added the "research attitude" which is being nurtured and referred to as the promotion of the "inquisitive mind" in the WHO workshop, the increased professional satisfactions and enhanced staff morale which result, the impact of the Center must be considerable.

3.2 Gaza Health Services Research Center

3.2.1 History and tasks

The Center in Gaza originated as a health information center (The Epidemiology and Health Information Center established in 1981) providing for the Government health services both routine and special data on the health of the Gaza non-refugee population. Since January 1986 the name and the approach have changed somewhat and though the Center carries on the tradition of routine reporting and surveillance through its comprehensive record and data linkage system, it is now more concerned with research projects in the field of PHC.

The inaugurating document makes clear some nine interrelated project areas which were agreed tasks for the Center and were

clearly intended as examples rather than as mandatory research programs. *

Any one of the nine areas of concern could have occupied a substantial and experienced research unit of, say, five or six research workers (with appropriate infrastructure) for three to five years. It is therefore a matter, for considerable surprise that the Center, composed of three part-time medical doctors, two part-time nurses and a full-time statistician (with clerical, records, and some other occasional assistance) should have achieved so much (see Annex 6.2.2). Much of the credit must go to the good relations which exist between the Center staff and the rest of the Government and other health services, including those of UNRWA, and some more to the excellent data base which has been built up. The productivity of the Center is more than ever surprising considering the tensions which exist in Gaza and the confusion of services arising from the occupation. Survey response rates of nearly 100% are especially commendable under these or any other circumstances while the refugee status of many who live outside the camps adds to the complexity of surveys and data collection.

It was soon apparent to the Mission that the Primary Health Care Research Center at Gaza was of considerable importance to the health of the local population in its two almost separate roles; that of health information gathering and of health systems research.

Relevant to the latter is a new development which results in part from the encouragement given by the WHO Workshop to all participants to pursue their own inquiries – and in part from the open attitude of the Steering Committee and Director. This new development is the sponsorship and free assistance given to loosely associated health professionals in their own studies. The Research Center is therefore fast becoming a clearing house and elementary training center in survey techniques for local doctors and nurses. While this is wholly admirable and strictly in accordance with the partly inspirational purpose of the recent workshop, it poses an obvious strain on resources both physical and intellectual.

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* A computerized Public Health Reporting System

Studies in Child Health Care Utilization

Studies of Population Knowledge, Attitudes and Practice in Health Studies of Growth and Development of Children

Studies in the Prevention of Selected Causes of Child Mortality Prevention of Rheumatic Heart Disease

Epidemiology of non-Infectious Diseases

Coronary Heart Disease and Related Risk Factor Studies

Nosocomical Infection Control.

3.2.2 Personnel and skills available and needed

The Director of the Gaza Center is an able and highly qualified public health professional with a sound background in epidemiology. He is supported by a team which, as in Ramallah, makes up for its relative lack of research expertise by dedication and enthusiasm. The statistician to the group is also well qualified but spends much of her time on the routine work of the information system.

Both Director and Statistician have multiple technical tasks in research design, protocol writing, survey instrument design, and research management. To this must be added for the Director much administration, report writing, financial control and his health service tasks as Assistant Director for Primary Health Care for the area. For the statistician there is additional data analysis, coding and computing.

It is in no sense a criticism of the members of the Research Center or of the Steering Committee to draw attention to the fact that too much responsibility for research design, administration and management rests with the director and statistician. Additional mature epidemiological skills are needed and to these should be added skills in research design and management (Recommendation 19).

If this recommendation is accepted it inevitably means the recruitment of at least two part or full time epidemiologists (preferably as permanent staff members), and one administrator. There is also a need here for some useful short-term consultancies from WHO and elsewhere.

The exceptionally heavy work load has also delayed and in some cases prevented the production of enough appropriate reports – both technical and popular – dealing with the work of the Center (Recommendations 20, 21).

3.2.3 Achievements

All of the eleven studies (fifteen if all research activities are included) mentioned in the summary report of the Gaza Center (Annex 6.2.2) are congruent with the notions of PHC though the concern is mainly (and reasonably) with medical care. All studies are also congruent with (and in many cases are a part of) local health policies and strategies. The Mission was particularly impressed with the importance of the Center and its health information system to the development of health care locally and it is clear that the health services of the Government of Israel (which provide the bulk of health care outside the camps) must continue to lean heavily upon it. (See document A40/INF.DOC./3: Health Conditions of the Arab Population in the Occupied Arab Territories, including Palestine – submitted to the Health Assembly in May 1987.) It is particularly important to the workers in the Center that this collaboration in the improvement of community health care is not misconstrued locally as political collaboration. To this end the Mission would stress the importance of their Recommendations No. 2 (that the word "collaborating" be dropped) and No. 5 (the improvement of the public image of the three centers).

There are four "consumers" of the work of the Gaza Center; the health care planners, the health professionals, the Center itself and a variety of other people, mostly health professionals, interested in research. The Mission felt strongly that a fifth "consumer", the community, ought to be involved more directly than at present (see for example, recommendation No. 5). Proper consultation with village leaders and community groups is particularly difficult in Gaza but the passing of health information and research results to them in palatable form might lead eventually to improved communication and even to some participation.

The resources of the Gaza Center are, with the exception of the skills mentioned above, beyond reproach. It appears that the health services of the Government of Israel, the UNDP and WHO are all committed to the success of the Center and the former has evolved a mechanism quickly to apply some of its findings. A specific example of this would be the acceptance by the Chief Medical Officer of the recommendation that certain antenatal and delivery services be free of charge. The private sector is also helpful and a second micro-computer has recently been donated by them.

The main constraints to be found in the Gaza Center, apart from those associated with living astride the boundary between rulers and ruled, are associated with a need for more highly trained staff. For very good reasons too many studies are under way with the result that problems of priorities, of design and of "writing up" intrude. (See for example recommendations 19 and 20.) However, the Mission was of the opinion that "rough and ready" though some of the studies will be the output of the Center is wholly commendable and all members of the team are to be congratulated. Particularly useful were the actions taken to implement study findings (see Annex 6.2.2).

It follows from this brief description that staff of the Center have learned a great deal about research method by carrying out their own studies. This is An excellent method of learning but must be supplemented by internal scientific meetings (see Recommendations 9 and 10), by the development of self-teaching programs (Recommendation 11), the library (Recommendation 10), and by increasing contacts at home and abroad (Recommendation 8) including formal training courses, workshops and tuition by visiting short-term consultants. An impressive level of interest and enthusiasm has been achieved and it is important that it be sustained. The courses offered by the School of Public Health of the Hebrew University in Jerusalem and those planned will make an important contribution but should not be the only source of epidemiological and statistical training.

An ad hoc approach to research priorities, so long as they fell within one or more of the nine areas of concern, was probably the best way to respond initially to the many health problems of Gaza. However, it is time to prepare a forward looking work plan, based on the wealth of experience gained in the last two years, for the next two. This work plan should result from a strict priority review (see Recommendation 12) and would accommodate the necessary training periods, courses, etc. and the usual financial projections, as well as detailed descriptions of the studies contemplated. It might also be submitted to a referee for review and comment (Recommendation 21).

The Gaza Health -Services Research Center has achieved a high level of efficiency in its relations with UNDP, WHO and the Government services. However, necessary liaison with UNDP and WHO would be made easier if it was the main task of a WHO staff member in the UNDP office (see Recommendation 1).

3.2.4 Impact

The Gaza Center has seen a number of indirect repercussions of their work. Notable among these is a modest increase in the visibility accorded locally to PHC and the widespread interest in health systems research (reflected in the number of volunteer workers in the Center and the continuing flow of new research proposals before the Steering Committee). Some repercussions fall short of expectation however, and the WHO part of the image of the Gaza Center needs further promotion – if only to re-emphasize the neutrality and altruism of the project, but also to promote the exchange of ideas and literature on health matters. There is also much to be done in the more general field of health education and the promotion of preventive medicine.

The Mission found some difficulty in assessing the effect of the Center on other sectors concerned with health (e.g., education, environment and social development) but suspect that more inter-sectoral effects may be seen in future. The Mission noted that some Joint Committees do exist and in the field of child health are certainly active.

The Mission would have had to spend more time with individual research workers in the West Bank and Gaza to do more than comment briefly on the studies. However, it was clear that the implementation of findings, in some cases not far short of social policy changes, had been taken as a result of work done in the center.

The Measurement of Infant mortality rates is a politically sensitive objective (see 2.1.4) and without complex data linkage and large populations an unrewarding one. But so much is preventable and so responsive to intervention are the causes of death that this series of studies (particularly the home deaths) when linked with the studies of growth patterns provide a good starting point for analyses of utilization, risk factors and the promotion of hospital/community communications. The gender differences in home deaths (an excess among females) prompts further studies of morbidity and culture and attitudes to family planning.

Studies of the Health of School Children provide in "pilot" form a series of challenges which can hardly now be abandoned. If confirmed the findings must have most impact for community health education and rather less for the school health programs. There is here another opportunity for community groups (and perhaps the schools themselves) to participate in the definition and the solution of their own problems. Experiments in this field are needed and the Center is in a good position to undertake and evaluate them.

The Studies of Reproductive Care and Performance (particularly those concerned with changing the role of the Daya) are of special importance in view of the scattered and patchy areas of high and low utilization of services and the Government Health Service objective of 100% institutional delivery. Not much is known about the determinants of attitudes and behavior and it is tempting to suggest further problem definition through group discussions and workshops with the community itself.

The Study of Anemia in Reproductive Ave in Gaza Women is only just starting and will provide further clues as to the extent of this problem. However, at present it seems unrelated to the other studies and it is not clear what social or medical policy actions would follow if the hypothesis of an excess of anemia is supported. Nor is it clear whether the Gazan women themselves understand and support this study (see Recommendations 12 and 13).

Serosurveys are, as in the West Bank (3.1.4), of questionable value, difficult to conduct and even more difficult to interpret. Collecting blood from large populations does not improve relationships and may lessen goodwill. Technical and sampling problems abound and unrecorded past epidemics and breakdowns in cold chains conspire to make the surveys "once and for all" undertakings.

The Cardio-Vascular Risk Factor studies including those of the nutrition of School Children were said to be started (for the Workshop) in response to popular anxiety about myocardial infarction. Preliminary findings support this anxiety but the complexity of the necessary research methods now needed demands the advice of competent cardio-vascular epidemiologists and nutritionists. If the risk factors are as prevalent as is suggested a general community health education program, i.e. one not specifically targeted, should embrace them and be carefully designed and evaluated.

3.3 Health Manpower Development Center, Ramallah

3.3.1 History and tasks

The HMD Center in Ramallah was started in June 1986 with the object of promoting research and development into the problems of human resources in health of the West Bank. The idea of a rationally planned supply of suitably trained health personnel must lie at the base of any proposal to improve health care and the inaugurating document saw the Center as contributing to the Health Manpower Development Program Working Group (HMDPWG). This HMDPWG was to be served by the Research Center in eight ways. It would project future manpower needs and set priorities for training, pilot in-service continuing education programs, run orientation programs for young physicians returning to the area, run short-term intensive and specialist courses, evaluate all training and arrange fellowships. The focus of all this HMD work would be the manpower needs of the Government Health Services and the emphasis being once more on total coverage and PHC.

Many ad hoc and uncoordinated efforts in HMD already exist in the West Bank. For example, UNRWA offers continuing education to its own physicians and there are courses in Public Health and others in Statistical Methods arranged through the School of Public Health. The private sector too has its own training programs (such as the training scheme for nurses in Bethlehem) and the Israeli Government its own health manpower policies and policy makers. The School of Public Health of the Hebrew University is planning a massive program of health education for the West Bank and Gaza which will embrace nutrition, accidents, AIDS, health in the workplace, etc., and be aimed at PHC and health promotion. Finally, the School of Public Health is also planning to introduce junior members of their faculty into the Research Centers themselves as a "mutual learning experience". The HKD Center is expected to be involved in all of these interrelated yet uncoordinated activities and at the same time be involved (though how it is not clear) in the new developments in the West Bank Public Health Services in Epidemiology, Primary Health Care, Environmental Health and Health Education, as well as in three projected "Continuing Education Centers" in the West Bank.

From this review it will be seen that there is a major task ahead in HMD in the West Bank (the same applies, of course, to Gaza) involving first an assessment of need in relation to existing human resources. From this information about need would derive policies and training programs. Next, there are the challenges of the manifold problems of the curriculum, course content and the methods to be used in the new training programs, and finally the need to coordinate and then to evaluate it all.

The Mission has no doubt as to the commitment and devotion of the very small but expert HMD unit to contribute to all of these activities but feels that in the light of the new HMD developments the time has come to review its task priorities (Recommendation 22).

3.3.2 Personnel and skills available and needed

The Center staff consists of the Director, a senior psychiatrist with an international reputation in community mental health, who is also the Director of the Hospital Division of the West Bank, two full-time graduate social scientists with some training in HMD research and a secretary administrator. Premises and equipment, including a micro-computer, are shared with the Ramallah Health Services Research Center. The two graduate staff members have recently returned from an overseas training course and are preparing an analysis of what is known of West Bank Health Manpower (excluding some but not all of the private sector and all of UNRWA). Ideally this analysis should then be related to population needs but there are few data available and the morbidity and mortality information from the work of the other two research centers is not readily translatable. Recognized deficiencies in human resources for all aspects of Primary Health Care, for Health Education and Public Health and Preventive Medicine have prompted many of the excellent ad hoc courses and there is an inevitable, but by no means wasteful, tendency to start a course wherever a sudden clinical deficiency is encountered, for example in Anesthesiology.

The Mission recognized that whatever the future tasks of the HMD Center it will be involved in training courses designed to make-up deficiencies. Until improved coordination and an increase in staff permit a contribution to policy making, the center has much to contribute at the level of curriculum planning and teaching/learning method (Recommendations 22 and 25).

3.3.3 Achievements and impact

Since the two graduate staff members have only just finished periods of training no great achievements could be expected in the few weeks since their return. Nevertheless five courses in areas of recognized deficiencies have been planned.* One of these courses proposes to use overseas consultants, one to work with the Hadassah School of the Hebrew University in Jerusalem, one is linked tenuously with the University- of Bethlehem, and another aims to use Jordanian consultant resources. None is yet formally approved.

A major problem facing all the centers is a lack of institutional connections and this is more serious for the HMD unit for it is cut off from other teaching and research. It is essential that some institutional ties, however tenuous, The developed and every attempt should be made to permit and encourage them both locally and overseas (Recommendation 3).

The impact of the HMD Center is potentially great for the necessary expertise is available and the task is formidable. It appears to the Mission that the contribution of the Center is at the moment less likely to be in the field of Health Manpower Policy, where there is a plethora of plans, but more in the field of curriculum planning, course content and method – where there are severe deficiencies. However, there is much local need and enthusiasm for increased sophistication and expertise in several subjects not yet contemplated by the private or Government services (Recommendation 26).

4. RECOMMENDATIONS

The Mission to the Research Centers in the West Bank and Gaza called upon their previous experience of the area and discussed all the problems brought to their attention and particularly their recommendations with Health Service representatives and, separately, with staff and Directors of the Centers.

Many suggestions were canvassed in the course of these discussions and some were considered by the Mission to have the force of formal recommendations. These they classified as follows:

4.1 General Recommendations which could apply to all of the Research Centers.

4.1.1 Research Center Organization, resources and public image.

Recommendation 1 – Increasing Technical and Financial Support

that continuing and, if possible, increasing technical and financial Support be afforded to each of the Centers with the UNDP remaining in its present managerial role. As this role grows more complex it will be necessary for it to become the full-time responsibility for a WHO staff member in the UNDP Office.

—-

Basic Psychiatry

Occupational Therapy

Pediatrics

Physiotherapy

Administration.

Recommendation 2 – A Change of Name

that, as part of the necessary improvement of the public image of the Collaborating Centers, the word "collaborating" be dropped from all local uses.

Recommendation 3 – Academic and Scientific Contacts

that the centers should continue to develop and maintain vigorous two-way links with the health services of the Government of Israel, but also develop linkages, academic and scientific, with other agencies and universities.

Recommendation 4 – Role of Steering Committees

that there should be a redefinition of the roles of the Steering Committees to make clear their part, and the part of the center staffs, in the separate functions of priority setting, research management and detailed scientific control. This should include agreement as to the criteria to be used in selecting projects.

Recommendation 5 – Improved Communications and Public Image

that the centers should begin to plan at once the public improvement of their image including the dissemination of information about WHO and the objectives of their own research. Frequent summary reports of work in progress should pass to local community groups. Academic scientific reports should also be prepared and published anonymously. One potential vehicle for such publications would be the journals of WHO.

Recommendation 6 – Improved Internal Communications

that to facilitate a general improvement in internal communications, as well as to keep WHO and UNDP better informed, the centers should ensure the production and dissemination not only of their quarterly activity reports and financial plans but also of timely and detailed work plans, schedules and protocols.

4.1.2 Strengthening the Human Resources of the Centers

Recommendation 7 – Additional Staff

that the centers should ensure the provision of the special skills that are sometimes missing, for example, in administration, research management and design, preparation of documents, etc., and that detailed job descriptions be made of staff of the centers.

Recommendation 8 – Increased Training

that to ensure an eventual correct balance of skills and to exploit current enthusiasms, the task-oriented training programs of the centers be reviewed and as much use as possible be made of the courses and opportunities for consultation being offered by the School of Public Health of the Hebrew University as well as by as many other institutions as possible, both local and overseas. The WHO Workshop on Health Systems Research should be repeated on an annual basis and all available fellowships exploited.

Recommendation 9 – Scientific Meetings

that, as part of the strengthening of the intellectual, scientific and academic aspects of the centers, regular scientific meetings between the three centers (including their Steering Committees) should be arranged. These should include workshops and seminars and other opportunities for peer reviews and, where possible, involve both the public and the private sectors.

Recommendation 10 – Journal Clubs, Libraries, Medlar/Medline

                    Facilities and WHO Mailing Lists

that, as part of the same strengthening each center should hold frequent and regular "Journal Club" type seminars to review current literature, should increase the size of its library with one or two abstracting journals, use the Medlar/Medline facilities of the Hebrew University, and maintain their addresses on the mailing lists of relevant WHO programs.

Recommendation 11 – Self Teaching

that as a supplement to the training courses that are available the teams at each center should design and program their own micro-computer based courses in survey techniques and elementary epidemiology.

4.1.3 Research Priorities

Recommendation 12 – Research Priority Allocation – The Method

that as current research nears completion new projects be reviewed with the utmost care to ensure that priority be given only to the solution of those problems with high prevalence and/or seriousness, a high benefit to cost ratio, which are within the scope of the center and thus amenable to its research attack and which are congruent with the other principles of primary health care. Research projects, even some currently under way, which do not meet these criteria should be terminated or brought to a conclusion as soon as possible.

Recommendation 13 – A Primary Health Care Priority

that so great is the need for change in health care at the primary level, a top priority should be given to it and particularly to aspects of community participation and responsibility in care.

Recommendation 14 – Short-Term Consultancies in Health Education

that WHO should recognize the special importance of community health education in the West Bank and Gaza and provide support in the form of short-term consultancies to the centers in this subject.

4.2 Recommendations which apply specifically to one of the Research Centers

4.2.1 The Ramallah Health Services Research Center

Recommendation 15 – The Need for Specialist Staff

that the Center should at once meet the evident need for more epidemiological, research design, and research management skills, perhaps at first on a part-time or shared basis. In practice this would mean an increase of two in the scientific staff of the Center, perhaps combining for this purpose initially with the Health Manpower Development Research Center.

Recommendation 16 – New Emphases in Existing Studies

that when the Ramallah Primary Health Care Research Center produces its detailed work plan for the next two years special emphasis should be given to the preventive and health educational components of each of the existing and proposed studies.

Recommendation 17 – A Reference Population in which to study

                    Innovations in PHC

that the Ramallah Primary Health Care Research Center and its Steering Committee give serious attention to the possibility of developing jointly a fully documented and cared for population, a "test bed" for numerous primary health care inquiries based on the Hebron or similar project. Such a defined population cohort could be the site of studies ranging from the necessary data linkage (which is proving so difficult in some studies) through to Days training and community involvement in child health services. Such a reference population is particularly appropriate to the health needs of the population and to the research interests of the Center and might well attract independent funding. Such a development would not, of course, exclude the application of findings elsewhere but would assist in their promotion.

Recommendation 18 – The Need for Closer Integration with Local

                    Services

that when the Government expand the formal structure of the public health services of the West Bank to include units or departments of Epidemiology, Primary Health Care, Environmental Health and Health Education, great care should be taken by the Center to integrate its activities with the new units.

4.2.2 The Gaza Health Services Research Center

Recommendation 19 – Over-commitment

that the heavy program of work of the Gaza Center be reviewed in terms of the time and skills available and that an attempt be made to lighten the load presently carried by the Director and statistician, particularly in epidemiology, research design and management and administration. This means the early recruitment of at least two part or full time epidemiologists (preferably as permanent staff members) and one administrator. There is also a need here for short-term consultants from WHO and elsewhere.

Recommendation 20 – Report Writing

that because of the special circumstances of the Gaza Center particular attention should be given to the need for writing skills. All reports of work, plans, protocols, financial and other projections, etc., both interim and final should be very carefully produced. Where appropriate they should be passed regularly to the Steering Committee, to the Centers in Ramallah, to UNDP, WHO and to local professional groups including the private sector.

Recommendation 21 – Forward Planning

that a comprehensive work plan be prepared for the next two years and circulated for discussion along with summary reports of completed studies and justifications for new ones.

4.2.3 The Health Manpower Development Center

Recommendation 22 – An Urgent Review of Priorities

that a review of tasks and priorities for the HMD Center be undertaken forthwith under the chairmanship of the Director and with the objectives of using best the skills available and of contributing fully to the many aspects of HMD on the West Bank and in Gaza.. In such a review the resources of WHO should be exploited and its expert advice obtained.

Recommendation 23 – The Need for Specialist Staff

that additional skills in selected aspects of HMD should be added to those already available to the Center. This would mean the addition of at least two and preferably three staff.

Recommendation 24 – Short-term Consultancies

that closer connections be established with the WHO HMD Program and that frequent contacts with short-term consultants from WHO and elsewhere are essential.

Recommendation 25 – New Emphasis on Curriculum Planning and

                    Training Methods

that in the light of the many training activities proposed by the health services of the Government of Israel And of the many currently in train, both Government and private, the HMD Unit should pay particular attention to the important contributions it can make to curriculum planning, to the methods of training which are used and to evaluation.

Recommendation 26 – Training Needs

that the HMD Center should proceed at once with the preparation of proposals for modest "Refresher Courses", workshops or local training in the following subject areas:

(a) Health systems research (a sequel to the 1986-87 Workshop)

(b) Principles and practice of primary health care

(c) The new health education

(d) Communicable disease control

(e) Emergency care

(f) Writing for publication

(g) Writing in English

(h) Elementary micro-computing (including programming)

(i) Survey methods in health care

(j) Appropriate technology

(k) Health behavior

Such proposals would be developed in association with local health services and with the two WHO research centers whose active participation would be necessary.

Recommendation 27 – Continuing Assessment of the work of the

                    Centers

that similar assessments be undertaken in the future, perhaps at two-yearly intervals.

5. ACKNOWLEDGMENTS

The Mission wishes to thank all the governmental and local authorities and all the people with whom it met during the visit, for the efforts and arrangements made to facilitate its task.

The Mission would also wish to thank the Director of the UNDP Program of Assistance to the Palestinian People and his staff for facilitating the process of establishing and managing the support from WHO to the Centers, and would like to thank them for the most useful information provided during the course of the visit.

6. ANNEXES

6.1 Persons met

6.2 Summary of research from each Center

6.2.1 Ramallah Health Services Research Center – research projects (attached)

6.2.2 Gaza Health Services Research Center – research projects (attached)

6.2.3 Health Manpower Development Center – research projects (attached)

6.3 Example of Aide Memoire used in the assessment process.

Annex 6.1

PERSONS MET

1. WEST BANK

Ramallah Health Services Research Center

Director: Dr Nadim Toubassi (Senior Medical Officer, Ramallah)

Staff: Dr Jawad Abu Munshar, Public Health Doctor, Hebron

Ms Jamileh Abu Douhu, Statistician (UNDP)

Dr Mamdouh Afaneh, Part-time Epidemiologist, SMO Salfeet

   Mr Omar Arqoub, Statistician

  Miss Samar Hussary, Administrative Assistant/Secretary (UNDP)

Health Manpower Development Research Center

Director: Dr Mohammed S. Kamal (Director, Hospital Division, West Bank)

Staff: Mr Jamil Rabah, Associate Research Officer (UNDP)

Mr Samer Shehadeh, Associate Research Officer (UNDP)

  Miss Irene Khawaja, Administrative Assistant/Secretary (UNDP)

Other West Bank Health Services Staff

Dr Y. Sever, Chief Medical Officer

Dr S.M. Abdel-Jabbar, Physician, Jenin Health Department

Ms C. Acker, Chief Area Nursing Supervisor

Mr M. Blum, Environmental Engineering Department

Dr Abdulla Muheisen, Head Pediatrician, Ramallah Hospital

Dr H.F.A. Nahhas, Ob./Gyn. Specialist, Ramallah Hospital

Dr Yaser Obeid, Vice-Director, Ramallah Hospital

Dr I.G. Salti, Director, Ramallah Hospital

Dr S. Shaheen, Director, Public Health Division & SMO, Nablus

Dr A. Shunnar, Director, Ob./Gyn. Specialist, Rafidia Hospital, Nablus

Dr A. Zeir, SMO & Mayor, Hebron

2. GAZA

Gaza Health Services Research Center

Director: Dr Yehia Abed (Assistant Director, Primary Health Care)

Staff: Ms Iman Diazada, Statistician (UNDP)

Mr Mahmoud El Dama, Nurse/Epidemiologist

Mr Shehadeh El-Ebweini, Chief Nurse, Primary Health Care

Dr Abd El Gabar El Tebe, Health Officer, North Area

Dr Wa'il Shawwa, Deputy Chief of Medical Section

Other Gaza Health Services Staff

Dr Nimrod Shoshan, Chief Medical Officer

Dr Khairy Abu-Ramadan, Director-General

Ms Aliza. Ben David, Public Health Nurse

Dr Munjed Jamal Hammouri

Dr Dola Mahmoud, Pediatrician.

3. MINISTRY OF HEALTH, Jerusalem

Professor Yoram Lass, Director-General

Mrs Pnina Herzog, Director, External Relations

Dr T.H. Tulchinsky, Coordinator for Health Services for the Territories

4. SCHOOL OF PUBLIC HEALTH, HEBREW UNIVERSITY OF JERUSALEM

Dr Charles Greenblatt, Dean

Dr Michael Davies, Professor of Public Health

Dr Hava Palti, Associate Professor & Head of Maternal and Child Health

5. UNDP, Jerusalem

Mr John Olver, Special Representative of the Administrator, UNDP

Mr N. Nevrodis, Program Director, Program of Assistance to the Palestinian People

Mr Willy Kwan, Program Officer in charge of Finance and Administration

Annex 6.2.1

Ramallah Health Services Research Center

A W.H.0. Collaborating Center

in Primary Health Care Research

GOVERNMENT HEAITH SERVICES UNDP

I – RESEARCH PROJECTS

– TITLE: Serological Survey for the Presence of Various Antibodies in Children on the West Bank.

STARTING DATE: December 1985.

DATA COLLECTION ENDED: March 1986.

REPORT SUBMITTED: March 1987.

FINAL REVISED EDITION OF THE REPORT: December 1987.

DESCRIPTION:

The Sero Survey Study was to find out the titre of antibodies level for the following selected infectious diseases:

Poliomyelitis, Tetanus, Measles, German Measles (Rubella), Hepatitis A and B, in the population of the West Bank School Children and Cord Blood of women delivering at Government Hospitals in order to evaluate and improve the methods of prevention and control of these diseases.

– TITLE: Infant and Child Mortality Review (0-5 years of age).

FIRST STAGE:

STARTING DATE: 1 November 1985.

DATA COLLECTION ENDED: 1 May 1986.

EXPECTED DATE.OF REPORT SUBMISSION: June 1988.

DESCRIPTION:

This Study was initiated by the Government Health Services to identify the major causes of death in Infants and Children and the related risk factors. And to identify this investigation as a priority service in the Government Health Services.

SECOND STAGE:

TITLE: Infant Mortality Review (0-1 years of age).

STARTING DATE: 1 January 1988.

ENDING DATE OF DATA COLLECTION: 31 March 1988.

EXPECTED DATE OF REPORT SUBMISSION: September 1988.

DESCRIPTION:

It was evident from the first stage of the study that if the IMR investigation is going to be implemented as a routine work in the Government Health Services, it is essential to improve the methodology of the first stage. Therefore, this second stage of the study was evolved.

– TITLE: Evaluation of the Expanded Primary Health Care Project in

          Hebron District.

STARTING DATE OF THE CENTER'S INVOLVEMENT IN THE PROGRAM: June 1985.

DATE OF SUBMITTING THE PRELIMINARY REPORT ON FINDINGS OF THE HOUSEHOLD SURVEY: September 1985.

EXPECTED MID-TERM EVALUATION STARTING DATE: 1 January 1988.

TYPE OF INVOLVEMENT:

A- Developing and revising a Household Survey questionnaire to be carried out in the villages.

B- Training of the interviewers (Community Health Workers) who carried out the survey.

C- Data analysis of the Household Survey.

D- Developing and carrying out an evaluation protocol for the Primary Health Care Project in Hebron District, by designing KAP questionnaires for the Community Health Worker and the mothers in child-bearing age.

– TITLE: Monitoring of Growth and Development of Infants and  

            Children up to Three (3) Years of Age.

FIRST STAGE:

STARTING DATE: 1 January 1985 (by the Government Health Services).

ENDING DATE OF DATA COLLECTION: 1 July 1985.

CENTER'S INVOLVEMENT:

Analyzing the collected data and submitting a report in reference to the analysis done.

DESCRIPTION:

This study which was designed by the Government Health Services to assess the growth and nutritional status of children under two (2) years of age in the West Bank who attended selected MCH centers, was done by using NCHS wall charts.

SECOND STAGE:

STARTING DATE: 1 May 1986.

ENDING DATE OF DATA COLLECTION: 1 May 1988

EXPECTED DATE OF REPORT SUBMISSION: January 1989.

DESCRIPTION:

This stage of the study was developed by the Center using NCHS individual charts to assess the nutritional status of children under 2 years of age, in addition to developing new pregnancy care forms with a stress on High Risk Pregnancy factors.

Ten (10) sentinel Centers have been selected to conduct this study all over the West Bank.

A Mid-Term evaluation was attempted but is not finished yet, due to the work load of the Center.

TITLE: Supervision of Traditional Birth Attendants (Dayas).

STARTING DATE OF INVOLVEMENT OF THE CENTER: September 1986.

DESCRIPTION:

a- Collecting data about the Dayas in the West Bank, the functions of the Dayas and getting data about births in hospitals and by Dayas on yearly basis for the West Bank.

b- Meeting days with District Nurses and Days Supervisors in order to get their opinion and views on the work and the role of Dayas.

c- As a result of the above-mentioned meetings, the RHSRC prepared a note-book for the Dayas with instructions to register all deliveries conducted by them, and to register mortality and morbidity cases occurring among these deliveries, which will be checked and reported on by the Daya Supervisor in each district.

d- Refer to the Training Workshop Research Projects (The Role of Dayas).

II – TRAINING WORKSHOP ON HEALTH SERVICES RESEARCH – WEST BANK AND

     GAZA

PERIOD OF THE WORKSHOP: 7 December 1986 – 25 June 1987 (3 sessions).

EXPECTED DATE OF FOLLOW-UP SESSION (4TH SESSION): 1 June 1988.

DESCRIPTION:

Out of the activities of the Training Workshop were certain research projects enumerated as follows:

1- Prevalence of 5 Risk Factors for Cardio-Vascular Diseases and their Use for prevention and control among Government School teachers of the West Bank; age (30-59): still under finalization.

2- School Health, Screening of School Children – Aged 6 and 12 years, and the Evaluation of the Present Health System: A recommendation of implementing a new school health system was submitted to the Government Health Services and was adopted. This new school health system is under implementation discussions.

3- Improving Antenatal and Institutional Delivery Coverage in the West Bank (Nablus and Hebron districts): Continuation of data collection and more data analysis are still under way and is expected to be finished by April 1988.

4- Delivery and Outcome of Pregnancies who come to deliver at Ramallah Hospital without previous booking at any Antenatal Care Clinic during the year 1987.

5- A study of Neonatal Hypothermia Admitted to Ramallah Hospital During Winter (1986-1987) and planning of Health Education Program: A case control study is under way.

6- The Role of Days in Home Deliveries and its outcome (Hebron district).

7- The Prevalence of Smoking among Preparatory and Secondary School Children on the West Bank.

III – TRAINING COURSES

– TITLE: Statistics Course as Applied to Public Health.

EXPECTED STARTING DATE: 15 January 1988.

EXPECTED ENDING DATE: Mid-May 1988.

DESCRIPTION:

a- A basic course for physicians and potential collaborators involved in the Center's projects who have not had any previous training in statistics and who would like to acquire some understanding of the basics, while going on with their jobs.

b- A more advanced but informal set of lectures and consultations/seminars for those with previous training but feel the need for an exchange of ideas on applications, help with the solutions to problems encountered in research and an introduction to further methods and techniques.

IV – TRAINING OF RHSRC STAFF AND STEERING COMMITTEE MEMBERS

a- Dr Toubassi and Dr S. Shaheen joined the International Track of the Epidemic, Intelligence Service Course at Centers of Disease Control, in Atlanta, Georgia, USA, between 30 June and 25 July 1986.

b- Miss Abu-Douhu joined the Epidemiological and Statistical Course in the Summer Program Course held at Ben Gurion University, Beer Sheva between 4 and 21 August 1986.

c- Dr Afaneh joined the XI Scientific Meeting of the International Epidemiological Association, Helsinki, Finland, between 1 and 22 August 1987.

d- Dr Abu-Munshar is expected to join the International Track of the Intelligence Service (EIS) course which will be hold at Atlanta, Georgia, USA, between 30 June and 25 July 1988.

V – THE HIGH RISK PREGNANCY

STARTING DATE OF THE CENTER'S INVOLVEMENT: 9 November 1986.

DESCRIPTION:

According to the UNFPA Project which is one of the activities of the Center, a High Risk Pregnancy committee started on 9 November 1986 with Dr Toubassi, RHSRC Director, as one of the steering committee members.

The Center is involved in:

a- Preparing guides on how to fill out the High Risk Pregnancy Forms.

b- Preparing seminars and study days to train the personnel involved in this project.

c- Preparing and carrying out an evaluation protocol in the future.

d- Help in establishing the high risk clinics by providing some equipment and health education materials.

Annex 6.2.2

Gaza Health Services Research Center

A W. H. 0 Collaborating Center

in Primary Health Care Research

Government Health Services UNDP

Project No. 1

Review of infant Mortality in the Gaza Strip

in the five years 81-85

Started on: January 1986

Ended on: March 1986

Infant mortality was reviewed and analyzed using special cards where causes of death are classified. (According to I.C.D 8th, 9th). Place of death was considered. Infant mortality had declined in the last five years. That was true in the neonatal and is not in the post-neonatal period. Prematurely is the main cause of death in neonatal period, while Respiratory and diarrhea diseases are the main causes in the post-neonatal period. 50% of children who die from diarrhea diseases die at home while this percentage reaches up to 72% in case of Respiratory diseases.

Actions:

Investigation of home deaths.

Gaza Health Services Research Center

A W. H. 0 Collaborating Center

in Primary Health Care Research

Government Health Services UNDP

Project No. 2

Growth patterns of Infants in GAZA

Started on: 22/11/86

Ended on: 22/3/87

This study describes and demonstrates a simple, universally applicable community survey system for monitoring anthropometric measurements of infants and children that affords both cross-sectional and longitudinal data. Growth patterns from different socio-economic population groups observed in this study are in keeping with the N.C.H.S. growth curves. Feeding patterns data were collected from the mothers during their routine visits to the M.C.H. Centers for the basic vaccination of the children, therefore we could have immediate feedback of the general situation of our children about growth and nutrition. The total study population was 2 782 in 5 different areas aged 0-52 was. divided to 3 groups. The findings of the study were (76%) of the children up to 14 months of age were breast fed fully or partially, and male and female growth patterns were similar and close to NCHS pattern especially in the urbanized locality.

Actions taken:

Institution of a standardized growth curves to be used for the surveillance of the children growth in the area.

Gaza Health Services Research Center

A W. H. 0 Collaborating Center

in Primary Health Care Research

Government Health Services UNDP

Project No. 3

Investigation of home infant Deaths

in Gaza Strip 1987

Started on: Dec. 1986

Ended on: June 1987

On basis of the review of the infant mortality for 5 years conclusions:

A follow-up study was done to explain the home death reasons of infants. A questionnaire was constructed which was attached to the death notification to be filled by the physician who attends the death of the baby. 125 infant deaths were studied. More females die at home than males (60.8% and 39.2% respectively). In the south there are more deaths than in the north. The main causes of home death were large size family (53.2%), the father doesn't allow admission (16.5%), distrust in the service (10.1%), or other unclear answers (12.6%).

Actions taken:

1. Meetings with the staff of the pediatric hospital in GAZA and Pediatric section in Khan Younis Hospital (south) to stress avoidance of premature discharge of the sick infant.

2. Instructions to the primary health worker, to instruct women to consult a physician if child got a disease as early as possible.

3. Strengthening the communication between hospitals and primary health care.

4. Recommendation: to establish a special small unit in the hospital to accept children without their mothers in exceptional situations (as large size families).

Gaza Health Services Research Center

A W. H. 0 Collaborating Center

in Primary Health Care Research

Government Health Services UNDP

Project No. 4

HEALTH OF SCHOOL CHILDREN 6-12 Ys

GAZA STRIP – RURAL AND URBAN LOCALITIES

Started on: 7/12 – 12 – 1986

Ended on: 21/25 – 6 – 1987

During the given period of the research 450 pupils girls and boys aged 6-12 years were screened. Demographical data of these pupils including the socio-economic variables were tested. Physical exam and testing of the Hb., Urine, and stool were done also. The most prominent problems were tooth decay 39.2% rurals, 42.6% urban, and parasitic infestations were 64.8% rurals and 39.2% urban and anemia 36.5% among the pupils of the schools.

Action taken:

1. Consultation with Professor Man – Hadassah Medical School to plan a preventive program to prevent dental caries.

2. Joint committee from health department and Education department is planning for school health service program.

3. The subjects of Anemia and parasitic infestation were discussed intensively by the child care committee.

4. The investigated children were treated.

5. Examination of the Vacc. status of the school children and the availability of the vaccination cards.

Gaza Health Services Research Center

A W. H. O Collaborating Center

in Primary Health Care Research

Government Health Services UNDP

Project No. 5

Improving Antenatal Care and Institutional

Delivery Coverage in Gaza

Started on: Dec. 1986

Ended on: June 1987

A cross sectional study for 700 deliveries within 10 days period was carried out in Gaza Strip, this study was instituted to assess the Under-Utilization of antenatal care delivery services. We have concluded that: (18.5%) of women were home delivery. The percentage of women using A.N.C. is (87.3%). (43.7%) of pregnant women were examined by nurses while 14% only were examined by gynecologists, and 55.3% of home deliveries are not medically insured. The Average No. of visits is 4.3 visits/pregnant woman.

Actions taken:

– Recommending to have free antenatal care service including

   institutional delivery.

–  Establishing high risk pregnancy committee.

Gaza Health Services Research Center

A W.H.0 Collaborating Center

in Primary Health Care Research

Government Health Services UNDP

Project No. 6

The Role of the Daya in

HOME DELIVERIES AND ITS OUTCOME

GAZA STRIP – 1987

Started date: Dec./86

Expected end date: Dec./88

The purpose of the study is to assess the Role of IBA (DAYA) is pre, intra and post-natal care.

In order to achieve these objectives, the study was divided into stages.

Stage 1:

Assessment of the dayas knowledge and practice. Interviewing all the Dayas in the Gaza Strip (92 Dayas).

Stage 2:

Assessment of the Dayas outcome. Interviewing 1 500 mothers, and babies. Stage 1 of the study was achieved in March 1987 and was presented at the WHO workshop on June 1987.

Stage 2 of the study will be starting on Dec. 20 and will be finished about 3 months later (according to the statistics of 500 home deliveries by TBA per month).

Gaza Health Services Research Center

A W. H. 0 Collaborating Center

in Primary Health Care Research

Government Health Services UNDP

Project No. 7

SEROSURVEY FOR ANTIBODIES AMONG VARIOUS

POPULATION GROUPS IN GAZA STRIP

Started on: Feb. 1987

Expected ending date: March 1988

In a process to assess the level of immunity in some sectors of our community we have collected blood samples from 200 different groups (7ys, 14ys and neonates). The blood was separated and preserved in deep freeze waiting to be shipped for testing.

The Co-ordinator will be: Mr Mahmoud El Dama.

Gaza Health Services Research Center

A W.H.0 Collaborating Center

in Primary Health Care Research

Government Health Services UNDP

Project No. 8

Prevalence of Five Risk Factors for

Cardio-Vascular Disease – its

Prevention and Control

Started on: Dec. 1988

Expected to be ended on: Dec. 1988

The study plan was to select 3 different areas in Gaza Strip. The investigator started to collect his information about Smoking, Hypertension, diabetes, B.M.I., and family history to study these risk factors.

The Survey was community based and the results are suspicious and selection bias was considered where wore sick people appeared in the study, and accordingly the investigator is intending to change the study population and to focus on school teachers 30-60 years of age.

Gaza Health Services Research Center

A W. H. 0 Collaborating Center

in Primary Health Care Research

Government Health Services UNDP

Project No. 9

Activity: Nutritional survey among school children in Gaza Age 12, 18 years

Date of starting: January 1987

Date of expected end: August 1988

This survey is a part of studying the CHD Risk Factors among 613 school children aged 6, 12, 18 years.

We already collected the date by interviewing 409 children using a semi-quantitative food frequency questionnaire, the interview was dealing with frequency of food intake, cups, glasses, plates, spoons and bread were used to assist the respondent: in estimating amount of food consumed. The universal variables for each child was collected. We entered the data to the computer.

Need:

A consultant in the field of "Nutrition" to evaluate the Results and to help in writing the final report.

Gaza Health Services Research Center

A W.H.0 Collaborating Center

in Primary Health Care Research

Government Health Services UNDP

Project No. 10

Activity: Anemia in reproductive age in Gaza Women.

Date of starting: December 1987

Date of expected end: June 1988

Two governmental clinics will be chosen, one in Gaza city and the other in a village in the north, 500 women aged 15-45 years from Gaza city and a similar group from a village in the north. The women will visit these clinics in two days a week. For each area we will invite them to fill the questionnaire and to take blood samples for Hb. level.

Investigator: Dr DINA ABU SHA’ABAN

Gaza Health Services Research Center

A W. H. 0 Collaborating Center

in Primary Health Care Research

Government Health Services UNDP

Project No. 11

Investigation of Basic Immunization

for children aged 7 years

(lst primary grade in the schools)

Started on: Oct. 1987

Expected to be ended on: April 1988

This study was done to evaluate the coverage of vaccination among this group of pupils, to measure the community response to health projects, and to determine how far the community preserve on the health documents. Also it was a tool to arouse the health spirit into the community especially in the preventive field. The study population was 5 619 pupils who have filled in a questionnaire. Computerization and analysis of data will follow.

Gaza Health Services Research Center

A W. H. 0 Collaborating Center

in Primary Health Care Research

Government Health Services UNDP

1. Computerized public Health Reporting System

Stage 1: Preparation of the staff and the software (March-June

   1986)

Stage 2:

A – Computerization of live birth data and the Birth Related Reports started from 1 July 1986 and is kept on.

B – Computerization of Death Reports and the mortality reports started from: 1 January 1987 and is kept on.

Stage 3: Follow up of infant for their preventive services, and

         curative services.

A – A pilot trial in Rimal Clinic started from June 1987.

B – 6 Centers will be covered on January 1988.

C – All health service centers will be covered by the year 1990.

2. Surveillance of the infectious diseases:

The center designed special forms to investigate each infectious disease. The new system is going on.

3. Regulations of the daily work

The center has built standardized Regulations and scientific Basis for the work in the primary health care including the daily work in out-patient clinics M.C.H. Centers, Maternity centers and the health services Research Center.

Gaza Health Services Research Center

A W. H. 0 Collaborating Center

in Primary Health Care Research

Government Health Services UNDP

Plan for 1988 Projects

_____ Data collection

—– Data analysis

xxxxx Writing the report

N.B.: New projects could be accepted on July lst 88.

Annex 6.2.3

Health Manpower Development Center

A W.H.O. Collaborating Center

in Primary Health Care Research

GOVERNMENT HEALTH SERVICES UNDP

HEALTH MANPOWER RESEARCH PROJECTS

1. TITLE: Basic Psychiatry

Expected Starting Date: Early February, 1988

Expected Ending Date: The course will continue for one year.

Description: A consultant in "Basic Psychiatry" from the United Kingdom is being invited to the West Bank to help plan, with the cooperation of the Dean of the local Psychiatrists, a training program of basic psychiatry for general physicians.

This course will be run for 10 days by Dr. J. Orley, Senior Medical Officer, Division of Mental Health and then it will be continued by the local psychiatrists. Dr. Orley is expected early February, 1988.

2. TITLE: Occupational Therapy

Expected Starting Date: Spring 1988

Expected Ending Date: Fall 1988

Description: The center responded and participated in developing a training course in Occupational Therapy for those already working and are interested in this field. It will include participants from Governmental and Non-Governmental institutions. It is hoped to start Spring 1988 (financially permitting) in cooperation between the Center, the Government Mental Hospital and the Hadassah School of Occupational Therapy.

The Center is cooperating with the Arab Colleges of Medical Professions at El-Bireh in developing a school for occupational therapy and one for biomedical training.

3. TITLE: Pediatrics

Expected Starting Date: Early 1988

Expected Ending Date: The course will last for 6-8 weeks.

Description: A local continuing program in Pediatrics was set up by a local distinguished pediatrician, Dr. Mohayya Kilfeh, to be offered to Governmental and Non-Governmental participants.

4. TITLE: Physiotherapy

Expected Starting Date: October 1988

Description: The Center is actively involved through its Directors participation with setting plans for a school of Physiotherapy at the Bethlehem University. The planning group includes the initiator of the Bethlehem Arab Society for the physically handicapped with the encouragement of UNDP. It is a three-year course.

5. TITLE: Training Course for Administrative Directors

Expected Starting Date: Summer 1988

Expected Ending Date: this course is for six months.

Description: This course will be developed summer 1988 pending approval by the Steering Committee and all the concerned parties.

6. The Center has been involved from the start in preparing a reliable record of workers in the health field in the West Bank. Most of the data is already available and being processed by the two research officers.

Starting Date: January, 1987

Expected Ending Date: January, 1988

Annex 6.3

AIDE MEMOIRE

USED IN THE ASSESSMENT PROCESS

Recorded by _________________________

Site ___________________

Name of Person interviewed _______________________________

Occupation _______________________________________________

Date ________________

Or GROUP consisting of

Name Occupation

___________________   __________________

___________________   ___________________

___________________   ___________________

Documents involved

___________________________________________________

___________________________________________________

___________________________________________________

Relevant Sections for interview _______________________________

_______________________________________________________________

The assessment focuses on six main elements characterizing the performances of the Centers:

Relevance

Adequacy

Progress

Efficiency

Effectiveness

Impact

These terms are defined and the proposed assessment approach described in volume 6, "Evaluation", of the Health for All Series published by WHO.

In the "Assessment" column of the following matrix, specific topics for assessment are suggested, for each of which indicators, variables and sources of information are proposed. The recording of an assessment finding will include indications as to why things did or did not happen as planned and, in the latter case, what remedial action is being considered.

IMPACT -The degree to which the CCs have influenced the improvement of health in West Bank and Gaza

Considering the recent development of the CCs, it would seem premature to evaluate their impact on health in the area concerned.

In practical terms, the direct impact of research activities on health may not be a measurable entity.  The determinants of health improvement will largely depend on the capacity of the health system to apply research findings effectively.

CONCLUSION/RECOMMENDATIONS

-Are the projects progressing towards the achievement of stated objectives?

-What are factors of success? How can they be enhanced further?

-What are drawbacks? How can they be minimized?

-What are new directions which the centres could take?

-How internally consistent are stated objectives? Activities? Imputes and outputs?

-Any recommendation for improvement?

-Is there a need for re-planning?

-What process should be initiated to facilitate future monitoring and assessment activities?