1. Ministry of Health Referrals System Realities and Challenges Ramallah December 15 th 2014 1

2. Presenter Name Presenter title Date Font: Segoe UI Bold Economic and Financial Health Context Health expenditures as percentage of GDP: 12.3% in 2012 MOH budget for 2014: 1.414 million NIS (around 10.2% of total budget), 100% disbursed in the first ten months. Budgeted 5% for recurrent expenditures Actual deductions for referrals to Israel: 323 million NIS (23% of the budget). Government Health Insurance covers 65% of Palestinians:  53% of West Bank citizens; 83% - 100% of Gaza Strip citizens. 2

3. Presenter Name Presenter title Date Font: Segoe UI Bold NDP & National Strategic Health plan 2014- 2016 related to Health Referrals Implement reforms within MOH to revise clinical and financial auditing in clear procedures Conduct a comprehensive review of the current referrals system; invite tenders from Israeli and Jordanian hospitals Rationalize and nationalize health referrals, from 82% in 2012, to the target of 85% in 2014 and 90% in 2016 Health expenditure percentage from GDP targeted 15% by 2016 3

4. Presenter Name Presenter title Date Font: Segoe UI Bold 4 Health Electricity water sewage Others 323,027,436 806,670,292 203,273,141 63,265,819 2,959,815

5. Presenter Name Presenter title Date Font: Segoe UI Bold Reasons for high cost of referrals 5 Poor quality of care in Palestinian health system (Lack of certain specialized Services, Shortage of drugs, limited skills and capacities Weak controls of referrals: No contracting No DRG’s Non-effective communication Weak control and audit systems Many referrals, Open ended procedures Self-referrals to Israeli hospitals Millions NIS

6. 6 Current status of health referral bill Overall bill of referrals is very high, deductions for Israeli Hospital invoices reached 25 million NIS for November 2014 Cost of referrals to Israeli Hospital constitute 47% of the total cost of referrals. Other Referrals to: East Jerusalem Hospitals, West Bank Palestinian NGO and privates hospitals, and few cases are treated in Jordan and Egypt Oncology and hematology referrals are 53% of the total referrals to Israeli Hospitals,which represent 48% of the total cost of the top five referrals. Shortage of Drugs and Medications is one leading cause for referrals particularly for Oncology and Hematology.

7. Presenter Name Presenter title Date Font: Segoe UI Bold Referrals Reform Improve Health Care Capacities: Promote investment in the Palestinian health sector to improve the quality of health care services. Enhance MOH Health Systems: Partner with the MOH to develop strong systems to manage health care costs. Reduce Referrals: Reduce the cost and number of referrals to Israeli hospitals without compromising quality of health care. 7

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14. Presenter Name Presenter title Date Font: Segoe UI Bold 14 Source: PHCP Invoices analysis 14

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16. Presenter Name Presenter title Date Font: Segoe UI Bold Four Pillars supporting health referrals reform Better Referral Protocols DRGs developed Continuity of Care ensured I- Clinical Reform Streamline referrals unit audit & control processes and build skills Use of electronic systems (HIS, Referral’s Website) II- Management systems reform Managed contracts with max six hospitals. DRG based contracting with Hospitals. III- Fiscal Reform Licensing and accreditation Raise standards in education Ensure access to information IV- Improve quality of health services Reduced Cost of referrals to Israel 16

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18. Presenter Name Presenter title Date Font: Segoe UI Bold Next Steps Sign transitional contract with one Israeli hospital - Hadassah (Dec. 14): – Legal review by MOH and MOF – Authorization for MOH to sign the contract (Direct Purchase) – MOH assigns a committee in coordination with MOF Introduce DRG system, and train staff on implementing them Sign competitive contracts Prepare for National Health Referrals Strategic plan, that encourages complementarity between donors (eg. World Bank,USAID). Activate mechanisms of coordination and effective communication among Palestinian Health Sector Providers,International organizations and MOH (Technical working group on Referrals ) 18

19. Presenter Name Presenter title Date Font: Segoe UI Bold Other Supporting Tasks Analyze the Israeli hospitals’ monthly invoices Expand and sign new contracts with additional Israeli Hospitals Control the shortage of medicines (oncology and immunosuppressive drugs in particular) Mainstreaming the required actions and procedures in dealing with Referrals to Israeli hospitals Implement Referrals procedure Manual,promote MOH hospital referral committees role and revise and update referrals protocols Introduce and implement all procedures into Gaza referral committee work and make the proper connection with Computerized system used by Referral Department. 19

20. Presenter Name Presenter title Date Font: Segoe UI Bold 20 Thank You