Values of policy analysis

Prior to commencing this study, I had been working in Palestine as a registered nurse for more than 15 years. I then thought I had a good understanding of the Palestinian Health care system and policy. When analysing the Palestinian health care policy, I used various sources including governmental, NGO, national and international literature related to the health care policy in Palestine

The various sources pertaining to health care policy in Palestine point to one main underpinning value implicit in the domestic policy documents which is respecting human rights and social justice (MoH, 2013). The Palestinian Law and the Public Health Law both ensure the right to health protection for every Palestinian (MoH, 2013). The Public Health Law also highlights the right of access to health care for all Palestinians (MoH, 2013). The Palestinian Authority is also committed in its Charter to the protection of

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individuals with special needs and the elimination of all types of discrimination against women (MoH, 2014).

Although this value is evident in the various health care policies, there was a clear indication that the political instability of the country did not promote and safeguard such an important value.

Violation of human rights and the overwhelming injustice across the Palestinian territories are manifested by the constraints of the separation wall, military barriers and the occupation which undermine all attempts to build a modern health care system in Palestine. This injustice is also acerbated by insecurity and economic blockade that influence four main values (partnership, effectiveness, efficiency and equity) that underpin health care policy in Palestine.

Partnership is an integral value that is reflected in the Palestinian health policy (MoH, 2013; UNRWA, 2015). Partnership between public, NGO, UNRWA and private health care providers is a common theme that may reflect the current level of fragmentation of health care provisions. Due to the large number of health care providers, such a partnership appears central to promote collaboration, coordination and liaison amongst all stakeholders. Health care policies value the contribution of all health care providers and advocate for effective partnerships amongst all stakeholders. This is directed at achieving better use of scarce resources to avoid duplication of services, competition and moreover enhance affordability and services accessibility especially to those who are disadvantaged, poor and unemployed. However, and despite this prevailing value, it is still

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argued that one of the main challenges facing the Palestinian health care system is the lack of coordination amongst all partners and stakeholders (Gordon, 2012).

Another form of partnership which is reflected in the health policies relates to the collaboration between various governmental sectors and ministries. Such collaboration is directed mainly at areas related to creating an emergency national plan. As a result, a national emergency and disaster plan has been formulated to respond to conflicts and other major emergencies ensuring preparedness amongst all partners.

Effectiveness is another value that underpins health care policy in Palestine. Effectiveness focuses on the outcomes of health care services and the level of health improvement achieved (Seavey et al, 2014). Health policy in Palestine emphasizes the importance of better management of care facilities to promote quality of the care provided (MoH, 2013, UNRWA 2014). Under this value, policy analysis examined health outcomes (physical, psychological and emotional), mortality rates, life expectancy, prevalence and incidence of diseases (Walt, et al, 2008). Two dimensions of effectiveness were identified: medical and population (Seavey et al, 2014). Medical effectiveness deals with medical treatment of individual patients whereas population effectiveness focuses on interventions to prevent diseases at the public level.

Under this value, the researcher critically analysed issues related to health care provisions, health care providers, types of services provided at each level (primary, secondary and tertiary), regulation, licensure of health care professionals and public health practices. Health outcomes such as causes of death, infant mortality rates, life expectancy, disability rates, and the burden of both communicable and chronic diseases were critically appraised

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and compared to neighbouring countries.

Efficiency as a third value underpinning health policy in Palestine, refers to a comparison between the inputs (resources allocated to health care such as the percentage of GNP spent on health care) and the outputs (the volume of the health services provided at the lowest cost) (Seavey et al, 2014). Under this value, health care policies advocate the efficient use of financial resources (MoH, 2013). Although, it does not provide a clear mechanism for governance, health care policies advocate transparency with regards to allocation of funds that are based on the provision of cost effective health care services (MoH, 2013). In this regard, this policy analysis examined issues related to health care expenditure comparing Palestine and neighbouring countries. Given the fact that Palestine has limited resources, the researcher examined health care expenditure per providers and the level and volume of services provided by the main health care providers. Issues related to numbers and distribution of health care workers, their education and regulation were also critically appraised. Areas of disease prevention, health promotion and vaccinations coverage were also examined. Walt et al (2008) argue that disease prevention and health promotion to reduce disabilities in the first place, are key aspects of health care efficiency. Therefore, public health provisions in the area of health promotion and disease prevention particularly chronic diseases were critically analysed.

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Equity as the fourth value underpinning health policy in Palestine refers to the examination of fairness within the Palestinian health care system. Equity is concerned with the distribution of services and the status of health for all population subgroups (Walt et al, 2008). It was evident from this policy analysis that equitable geographical distribution of health care facilities and provisions is compromised by the security and political situation of the country (MoH, 2013; UNRWA, 2014; WHO, 2015). Analysis of the Palestinian health policy related to equity included studying certain aspects such as access to health care (including eye care services) by all and particularly comparing rural and urban populations. In addition, types and levels of health insurance coverage for all the Palestinian population were also critically appraised. This analysis examined the impact of poor health insurance coverage on the health of the marginalized and the health status of all the population.

The researcher explored types of health care service and provisions by the multiple providers. Given the fact that refugees are marginalized with poor living conditions and that chronic diseases are particularly prevalent amongst the refugee population, there was a particular emphasis on health care provisions for the refugees as compared to that provided to the non-refugees. It was evident that various health policies advocated for a more comprehensive national health insurance scheme to promote access to health care by all including the marginalised, poor and unemployed sectors of the Palestinian society.

On the personal level, undertaking this policy analysis was enlightening as my prior belief that the Palestinian health care system is primitive was changed at an early stage of

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this analysis. Although the health care system was only established in 1993, I was surprised to learn that critical health care indicators such as infant mortality rate in Palestine, was comparable if not better than many neighbouring Arab countries.

From experience, I believed that access to health care facilities was complicated by the political instability of the country which prevented many from receiving basic primary and community care. I however, lacked adequate appreciation for the complexity of the health care system operating in Palestine. This triggered the researcher to study and analyse the structure, financing and provisions of the health care system. Analysis of these complexities revealed a number of challenges facing the Palestinian health care system. This analysis was also underpinned by objectivity and reliability principles to minimize preconceptions. In order to achieve this, the researcher endeavoured to analyse pertinent data and literature from various sources. In addition to the local government official publications, information was also obtained from reliable and credible international non- governmental agencies such as the World Health Organization and the United Nations. Triangulating these various sources of information enabled the researcher to present a more reliable and objective analysis of the Palestinian health care system and policy.