The COVID-19 pandemic has caused a global public health, humanitarian, and development crisis [1]. The UN framework for the immediate socio-economic response to COVID-19 includes five streams of investments to ensure essential health services, assist people in coping with adversity, protect jobs, and guide the necessary surge in fiscal and financial stimulus [2].
The Palestinian health sector is divided and under-resourced, limiting its ability to combat the epidemic [3].
Good governance, evidence-based policy, funding, expertise and information sharing, tools and technology, and collaboration between health actors are essential for successful health emergency plans [4]. Palestine's clinics lack supplies and equipment, with just 375 ICU beds and 295 ventilators throughout the West Bank and Gaza Strip combined [5]. More than 700 checkpoints and crossing sites enforce strict border controls and restrict the flow of persons and commodities while keeping an eye on Palestinian traffic in the West Bank [6], The Gaza-Strip blockade makes it difficult to transport medical supplies.
Israeli attacks on Palestinians have caused 48,246 casualties and 452 deaths [7]. All of this puts a greater strain on clinics, and dealing with more COVID-19 cases would almost certainly be an insurmountable obstacle.
Palestinian health sector has performed admirably, but Israeli occupation has struggled to respond to pandemic [8]. Israeli police arrested Palestinian Governor of Jerusalem on COVID-19 charges [9].
This research addresses a key theme that is insufficiently addressed at the policy and execution levels. In actuality, the donated International Fund (IF), which provides humanitarian and development aid, continues to be a vital resource for addressing the needs of those impacted by the COVID-19 epidemic or ongoing instability. It is well known that wealthy (developed) nations give IF to underdeveloped (developing) nations through initiatives and programs. These interventions are funded by bilateral state agencies like the United States Agency for International Development (USAID), Canadian International Development Agency (CIDA), Japan International Cooperation Agency (JICA), and many other international organizations, as well as multilateral development organizations like the World Bank (WB), European Union (EU), United Nations Development Program (UNDP), Inter-American Development Bank (IADB), African or Asian Development Banks, etc. Former colonial powers and industrialized nations set up this system to address the enormous humanitarian needs of emerging nations [10].
This research focuses on the health system (HS) in a specific country's context during the COVID-19 pandemic, Palestine. Palestine is one of the countries that has benefited from IF since the establishment of the PNA in 1994, where the Ministry of Health (MoH) is a national entity responsible for health in Palestine. IF in Palestine has faced various fluctuations due to political stability and peace process progress over the last 25 years. Consequently, our research will answer the key questions: what are the roles and contributions of the IF provided to the HS in Palestine throughout the COVID-19 pandemic, what are the main challenges related to the IF, and how can the PHS's policymakers make the IF well-directed and impactful? Limited studies addressed this central topic, but more evidence is required to update this knowledge for better IF policies and optimal utilization of the HS in Palestine during the COVID-19 pandemic [11]. The research considers the period that started after the WHO announced the COVID-19 pandemic; as the first national assessment targeting the whole Palestinian HS, including the governmental and non-governmental organizations (NGOs), to provide useful insights to inform policymakers on how to take better actions with regards to IF management, allocation, and evaluation.
There is a scarcity of financial resources, which affects the performance of the HS at the governmental or NGO level in providing basic health services. Moreover, there is a lack of forcing the health NGOs as well as the MOH to intensify their efforts to fill gaps that occurred as a result of these crises and changes [12]. Therefore, international efforts to provide financial support to NGOs and MoH have hindered the PHS's ability to move forward, hindering its ability to respond to Palestinian needs [13].
The IF in Palestine is unstable due to political and socio-economic issues, and international aid is one of the three influential elements in determining trends and the evolution of the Palestinian situation [13, 14]. Despite these facts, PHS still lacks the evidence and baseline data on IF aspects, including governance, amount and flows, monitoring and evaluation, and impact and sustainability, whether provided to the NGOs or MOH to be communicated with the policymaking levels.
The dependency on the external fund (around 60.9%) impacts the project capacity, quality, and effectiveness of the implemented programs where the IF failed to reduce the dependency of NGOs and enhance the country's self-development in Palestine. Self-development and sustainability of the projects are the ultimate goals of any fund agency [13, 14]. The IF dimension needs to be tracked and followed to support health evidence-based policymaking, and planning and coordination between different parties is unknown and overlapped.
The fragile, already overwhelmed Palestinian health system is expected to become much more so as a result of the epidemic. This will restrict its capacity to address the epidemic and other critical medical need for Palestinians. Therefore, this research is a substantial attempt tries to fill the knowledge gap by generating new evidence as well as seeks to bring answers to the main question that is rarely investigated and addressed about the contribution of IF in strengthening Palestinian health systems (PHS) and how it governed during the COVID-19 pandemic.
The Palestinian context
Population expected to increase to 5.2 million by 2023 [15]. Palestinians have a life expectancy of 74 years [16]. Non-communicable diseases are the largest cause of death in the occupied Palestinian area, accounting for more than two-thirds of all deaths in 2017 [16]. Palestinian health outcomes negatively impacted by Israeli occupation and closure. [17]. For deprived communities in the Jordan Valley of the West Bank, the stunting rate is higher at 16% [18]. 92,430 children under the age of five are at risk of rickets and diarrhea [19]. Israel demolished 461 structures in 2018, displacing 472 people in East Jerusalem [20].
The structure of the Palestinian health system
The COVID-19 pandemic has impacted the Palestinian health system.
Primary health care
Primary health care has increased since 1994, with 475 centers affiliated with the Ministry of Health in Palestine in 2021. Preventive services include maternal and child health care, immunization, and health education, while therapeutic services include general medicine, dentistry, specialty clinics, specialized medical laboratories, and radiology (Table 1).
Table 1
Distribution of primary health care centers according to the service-providing sector
Primary health care centers | Ministry of Health | Military Medical Services | UNRWA | NGOs | Total |
Frequency (n) | 475 | 17 | 65 | 192 | 749 |
Percentage (%) | 63.4 | 2.3 | 8.7 | 25.6 | 100% |
Secondary and tertiary health care
In 2021, there were 87 operating hospitals in Palestine, with 53 of them in the West Bank and the remaining in the Gaza Strip. The total number of hospital beds is 5.552, with an average of 12.8 beds for every 10,000 people in the population. Specialties include general hospitals, specialized hospitals, maternity hospitals, and rehabilitation and physical therapy centers (Table 2).
Table 2
Distribution of hospitals according to the service-providing sector
Hospitals | Ministry of Health | Military Medical Services | UNRWA | NGOs | Private | Total |
Frequency (n) | 28 | 2 | 1 | 39 | 17 | 87 |
Percentage (%) | 32.2 | 2.3 | 1.2 | 44.8 | 19.5 | 100% |
Medical personnel in the health sector
Ministry of Health is largest employer of human cadres in Palestine (Table 3 and Table 4).
Table 3
Distribution of the available number of human resources working in the health sector by specialization and region
Specialization and region | Physician | Dentist | Pharmacist | Nursing | Midwife |
West Bank and East Jerusalem | 8,427 | 3,720 | 5,152 | 10,140 | 888 |
Gaza Strip | 3,025 | 398 | 696 | 4,040 | 475 |
Palestine | 11,452 | 4,118 | 5,848 | 14,180 | 1,363 |
Table 4
Distribution of the number of human resources in the Ministry of Health by specialization and region
Specialization and region | General Physician | Specialized Physician | Dentist | Pharmacist | Nursing | Midwife | Allied Medical Professions | Administration and services | Total |
West Bank and East Jerusalem | 842 | 519 | 76 | 287 | 2,777 | 398 | 1,309 | 2,106 | 8,314 |
Gaza Strip | 641 | 356 | 93 | 190 | 1,117 | 70 | 620 | 2,608 | 5,695 |
Total | 1,483 | 875 | 169 | 477 | 3,894 | 468 | 1,929 | 4,714 | 14,009 |
Financial impact evaluation of the health sector focusing on healthcare expenditures and financial resource challenges
Expenditure on the health sector: MoH’s budget
The MoH budget for 2018 was NIS 77.1 billion, with salaries and wages being the largest share. Primary healthcare revenues were the largest, followed by health insurance, government hospitals, and administrative centers (Table 5 and Table 6).
Table 5
MoH Budget Items (2015–2018)
| 2015 | 2016 | 2017 | 2018 |
Expenses | 1,745,621,000 | 1,711,900,000 | 1,726,773,000 | 1,767,295,225 |
Salaries | 47% | 50% | 51% | 48% |
Treatment abroad (referrals) | 34.20% | 27% | 25% | 25% |
Medicines and other medical products | 15% | 16% | 18% | 18% |
Additional financial and operational expenses include | 3.80% | 7% | 6% | 9% |
Revenues | 94,260,282 | 121,316,838 | 144,790,729 | 218,624,185 |
Primary healthcare | 45.20% | 46.20% | 41.50% | 50.30% |
Health insurance | 29.70% | 27.60% | 33% | 26.60% |
Governmental hospitals | 23.40% | 24.10% | 23.30% | 16.50% |
Administrative centers | 1.70% | 2.10% | 1.90% | 6.60% |
Back payments | 542,786,939 | 604,700,216 | 955,955,095 | 839,538,906 |
Referrals | 44.70% | 55% | 54% | 56% |
Medicines and other medical products | 46% | 41% | 45.50% | 40% |
Other financial and operational revenues | 9.20% | 4% | 6% | 5% |
Source: General Budget Law, Ministry of Finance and Planning |
Table 6
Actual MoH Budget Needs and Allocations in USD 1,000 (2017–2021)
Year | Actual operational needs | Actual capital needs | Total actual needs | Special budget (expected) | Financing gap |
2017 | 2,013,071 | 173,994 | 2,187,065 | 1,839,753 | 347,312 |
2018 | 2,188,743 | 91,953 | 2,280,696 | 1,892,601 | 388,095 |
2019 | 2,306,512 | 85,181 | 2,391,693 | 1,977,559 | 414,134 |
2020 | 2,575,161 | 77,280 | 2,652,441 | 2,175,336 | 477,105 |
2021 | 2,671,582 | 75,180 | 2,746,762 | 2,256,549 | 490,213 |
2022 | 2,755,200 | 68,580 | 2,823,780 | 2,331,233 | 492,547 |
Total | 14,510,269 | 572,168 | 15,082,437 | 12,473,031 | 2,609,406 |
Source: National Health Strategy 2017–2022 |
The Palestinian health system during the COVID-19 pandemic
Responsibilities for the right to the highest standard of health apply to all duty bearers [21], Economic impacts of restrictions on movement of people, goods, and services [22].
The closure and blockade has had a detrimental effect on the health system, leading to inequities between the Gaza Strip and the West Bank, as well as shortages of essential medicines and medical disposables [23].
Palestinian villages and municipalities surround East Jerusalem [24], East Jerusalem has been disconnected from the rest of Palestinian territory, and Palestinians in the city may apply for residency status based on demonstrating a "center of life" [25, 26]. Palestinians lack access to Israeli health insurance, leading to arrears [27].
The Palestinian Authority declared a state of emergency due to COVID-19 [28]. Palestine released a COVID-19 Response Plan, established the National COVID-19 Health Committee and Epidemiological Committee, and published an Inter-Agency COVID-19 Task Force response plan [29]. Deliveries and procurements of items covered 92% of ventilators, 119% of patient monitors, 88% of oxygen concentrators, 66% of additional beds, 67% of surgical masks, 130% of N-95 respirators, and 117% of surgical gloves [30].
The Palestinian Ministry of Health implemented a national health awareness campaign, with high levels of knowledge about COVID-19 and moderate levels of self-reported adherence to preventive practices [31]. Public adherence to public health measures declined during the pandemic due to economic and social issues [32].
In the occupied Palestinian territories, the public health monitoring system was able to successfully address the COVID-19 epidemic [33]. The Palestinian Authority's lack of control in east Jerusalem caused a major spike in COVID-19 cases [27]. Due to a huge jump in COVID-19 cases and a lack of laboratory testing kits, the positive rate in the Gaza Strip considerably rose. A new ward was built, and health services were improved to recognise and treat COVID-19 patients.
Control of population movements and quarantine measures at entry points is essential for effective public health response to COVID-19, coordinated with Israel [34]. Humanitarian health partners provided training and protocols to minimize COVID-19 risks, and health services were upgraded to detect and treat patients.
The Palestinian Authority and de facto authorities in the Gaza Strip implemented strict quarantine procedures from March 15 to November 14 2020 [35]. Patients with COVID-19 were treated in the West Bank and Gaza Strip, and services from healthcare professionals were arranged.
The Turkish Hospital in the Gaza Strip received patients with moderate severity of COVID-19, with bed capacity of 70 intensive care units, 80 high-dependency beds, and 350 hospital beds for moderate cases. WHO supported the capacity-building of 637 health workers [36]. Lack of testing supplies and undetected cases increase COVID-19 case fatality rate.
Vaccines are an important tool in the fight against the COVID-19 pandemic, and the Palestinian Authority requested COVID-19 vaccinations through the COVAX/AMC facility in December 2020. Concerns have been expressed about Israel's failure to comply with its commitments under the Geneva Conventions [37]. Israel began administering COVID-19 vaccines to Palestinians with residency in east Jerusalem, inmates in Israeli jails, and health care professionals in Israeli hospitals in March 2021. The Palestinian Ministry of Health completed a National Deployment and Vaccination Plan to distribute vaccines to the Palestinian population in the West Bank and Gaza Strip [38].
The need to reallocate limited resources to COVID-19 preparedness and response has had a negative impact on the provision of basic health services. East Jerusalem hospitals saw a 40% drop in hospital admissions in March 2020 and a 54% drop in April 2020 due to access restrictions. Outpatient appointment consultations decreased by 57% and elective surgery rates decreased by 43% and 66% [36]. Hospital utilization decreased significantly from March to May 2020, with large reductions in outpatient appointments, surgical operations, emergency admissions, general admissions, and bed occupancy [38].
COVID-19 hampered health cluster partners' ability to provide essential humanitarian health care, resulting in only reaching 58% of the population and underfunding of activities such as mobile clinic service delivery.
The original COVID-19 Inter-Agency Response Plan for the oPt was extended, with a revised budget requirement of $72.2 million, and a private contributor contributed an additional $30,000 to the cause, raising a total of $54.2 million [39].
The rate of testing for COVID-19 has been reduced across the oPt, with the case fatality rate remaining low at 0.8%. The governorates of Hebron, Bethlehem, and East Jerusalem have the highest verified cases, while Nablus and Tulkarm are seeing an increase in active cases. Health Cluster partners have provided 36,000 testing swabs and testing kits to Gaza, as well as crucial equipment and supplies throughout the oPt. Additionally, partners distributed 63,000 surgical gowns, 25,000 boot coverings, 13,000 coveralls, and 13,000 face shields to 1,500 healthcare professionals [39]. The COVID-19 pandemic's developments, issues, and financial situation are broken down per cluster in Table 7. The entire financing for the COVID-19 response is shown in Table 8 by donors.
Table 7
Developments, concerns and funding status by cluster
Cluster | Funding requirements | Through the Response Plan | % of the Response Plan covered | Outside Response Plan | Total Funding Received |
Health | US$ 31,304,992 | US$ 12,905,035 | 41% | US$ 10,125,602 | US$ 23,030,637 |
Protection | US$ 2,365,740 | US$ 1,917,434 | 81% | US$ 305,434 | US$ 2,222,868 |
Education | US$ 7,120,698 | US$ 1,517,000 | 21% | US$ 1,918,746 | US$ 3,435,746 |
Shelter & and Non-Food Items | US$ 4,092,551 | US$ 1,755,251 | 43% | US$ 2,767,382 | US$ 4,522,633 |
Water, Sanitation and Hygiene (WASH) | US$ 9,504,052 | US$ 7,930,513 | 83% | US$ 2,081,548 | US$ 10,012,061 |
Food Security | US$ 18,017,577 | US$ 9,177,426 | 51% | US$ 1,777,441 | US$ 10,954,867 |
Table 8
Total funding for COVID-19 response by donors
Donors | Through the Response Plan | Outside the Response Plan | Total in US$ |
Austria | | 229,564 | 229,564 |
Canada | 2,215,757 | | 2,215,757 |
CERF | 527,000 | | 527,000 |
DFID | 1,423,772 | | 1,423,772 |
ECHO | 3,720,950 | 6,491,0001 | 10,211,950 |
Education Cannot Wait | 555,000 | 1,550,000 | 2,105,000 |
Foreign Disaster Assistance (OFDA) | 225,000 | | 225,000 |
France | 1,005,415 | | 1,005,415 |
Germany | 4,042,854 | 43,000 | 4,085,854 |
Ireland (Irish Aid) | 235,200 | | 235,200 |
Islamic Relief Worldwide | 307,800 | | 307,800 |
Italian Agency for Development Cooperation [AICS] | 152,008 | 10,970 | 162,978 |
Japan | 878,506 | | 878,506 |
Kuwait | 747,500 | 8,252,500 | 9,000,000 |
Norway | 70,000 | 91,083 | 161,083 |
OPT Humanitarian Fund | 8,064,478 | 347,768 | 8,412,246 |
Other sources | 1,491,198 | 330,155 | 1,821,353 |
Private Sector Fundraising | 386,786 | | 386,786 |
Qatar Fund for Development | | 562,455 | 562,455 |
Qatar Red Crescent | | 410,000 | 410,000 |
Save the Children | 326,435 | | 326,435 |
Start fund | 251,000 | | 251,000 |
Sweden (SIDA) | 500,000 | | 500,000 |
Swiss Agency for Development and Cooperation “SDC” | 1,450,000 | 268,000 | 1,718,000 |
UNFPA Humanitarian Thematic Fund | 332,000 | | 332,000 |
UNICEF | 792,000 | | 792,000 |
USAID | 250,000 | | 250,000 |
War Child Holland | 252,000 | 85,000 | 337,000 |
WFP (loan) | 5,000,000 | | 5,000,000 |
World Vision International | | 304,658 | 304,658 |
Grand Total | $35,202,658 | $18,976,153 | $54,178,811 |