1. UNRWA, as part of national health systems of Palestine Akihiro Seita a.seita@unrwa.org 1

2. 2 Gaza (1,240K) West Bank (754K) Jordan (2,070K) Syria (520K) Lebanon (450K) Registered Palestine refugees (total: 5 million) Established in 1949 Protect & assist Palestine Refugees – education, health, relief, etc. 30,000 staff Budget: USD 600M/year Health services – 138 PHC health centers – 3,100 health staff – USD 100M a year MCH NCD (DM & hypertension) Acute illness What is UNRWA? UNRWA: United Nations Relief & Works Agency for Palestine Refugees in the Near East http://www.unrwa.org/sites/default/files/2014_01_uif_-_english.pdf

3. 3 UNRWA in Palestine West BankGazaTotal General - Registered Refugees (RR)754,4111,240,0821,994,493 - Refugee camps (no.)19827 - RR in camps220,775 (29%)552,037 (45%)772,812 (39%) Education - Schools97245342 - Students51,327232,384283,711 - Staff2,91410,08012,994 Health - Health centers422264 - Hospital101 - Patient visits / year1,506,0444,300,6375,806,681 - Staff1,0111,0012,012 Almost 2 million Palestine refugees 40% in 27 camps ¼ million students in 342 schools 6 million visits to 64 health centers http://www.unrwa.org/sites/default/files/2014_01_uif_-_english.pdf

4. What we need to do?  What is health problem? 4 Epidemiological transition happened IMR decreased NCD skyrocketing Probably 70-80% causes of deaths http://www.unrwa.org/sites/default/files/2014_01_uif_-_english.pdf UNRWA health services Diabetes only Hypertension & Diabetes Hypertension only

5. From disease centered health centers… to 5 Ordinary UNRWA health center What we need to do?  Reform health centers UNRWA health services

6. 6 Reformed UNRWA health center What we are doing?  Family health team HC UNRWA health services Person-centered health services Helped with e-health (EMR) High satisfactions by refugees Improving quality of services

7. 7 What we will need more?  Data analysis & research UNRWA health services Vision  FHT in all HC by end 2015 Needs  Stable funds Response  Deliver results  Evidence-based Information for action Institutional partners FHT & quality improvement – Columbia university DM cohort analysis – International Union against TB & Lung Disease – 6 papers & Lancet news FHT & DM care – Toronto university

8. UNRWA, as part of national health systems of Palestine, and The Lancet Commission: Global Health 2035 8

9. 9 Good payoff for refugees to overall investment in Palestine Future depend on overall development And, not yet measured VLYs… (1) Payoff from investing health

10. 10 ↓↓in IMR, thanks to MOH & others Still, further ↓needs more support to, & collaboration with, MOH & others Also political solution is needed (2) Convergence in health

11. 11 Any additional funds are welcome NCD care is expensive Efforts needed to ↓ commodity cost Work with MoH & others critical, but… (3) Fiscal policies to curb NCD

12. 12 Unhealthy lifestyle is epidemic Lifestyle change important & possible Comprehensive approach needed Work with MoH & others needed, but… (3) Fiscal policies to curb NCD CommodityCurrent Flour30 kg Rice3 kg Sugar3 kg Oil3 L Milk1.5 kg Red Lentils0 Chickpeas0 Calorie1,700 Cost$399 UNRWA’s food-basket in Palestine (3 months quantities)

13. 13 Financing to UNRWA health services Funds are all from donors & limited Main donors are also those for others Efficiency needed, but how much… (4) Progressive universalism to UHC Review of UNRWA hospitalization policy (X Modol 2014) CountryUSD (M) 1USA294 2EU216 3Saudi Arabia152 4UK94 5Sweden54 6Germany53 7Norway35 8Japan29 9Switzerland23 10Australia22 Donor contributions including projects & in-kind support (2013)

14. 14 Access to health services UNRWA is part of national systems Du/multi-plication of service access Rational use is needed, but how… (4) Progressive universalism to UHC *Health and Education Efficiency in the West Bank (DFID, Feb 2012) Review of UNRWA hospitalization policy (X Modol 2014)

15. West BankGazaJordanLebanon Total hospital expenditure ($) 6.3M2.1M1.8M9.5M Per capita hp expenditure ($) 13.21.71.537.4 % abject poor1.6%5.4%1.8%6.6% % absolute poor20.3%41.1%14.4%66.4% % refugee insured 50% + ?100% ?50%<5% Financer of last resort Ministry of Health (MoH) MoH Royal court UNRWA, NGO, individual 15 Financial protection (FP) PHC services, free of charge Hp support: co-pay. with limited funds How to make optimal FP for refugees? Review of UNRWA hospitalization policy (X Modol 2014) (4) Progressive universalism to UHC

16. UNRWA, as part of national health systems of Palestine, and The Lancet Commission: Global Governance of Health 16

17. Political determinants of health 17

18. 18 UNRWA and Palestine (As Rita said) – Health (problem) is political, thus political solution is needed for health solution (As Assad explained & Mahmoud will explain) – Palestine has no shortage of examples – Occupation in West Bank, Seize in Gaza, etc. etc. (As I will say now) – UNRWA will do the best to improve services, and work for solutions through Global Governance for Health

19. 19 Conclusions UNRWA will continue to support refugees – Focus on NCD, Family health & efficiency UNRWA is part of Palestine health services – Part of Payoff, Convergence, NCD & UHC Analysis & Guidance is needed – Rational use of (limited) resources in Palestine And, will work with Palestine through GGH – Political solutions for Palestine (health)