health system operational in all Fields. The expansion <strong>of</strong> <strong>the</strong> ready developed e-health module on NCDs to o<strong>the</strong>r Fields ra<strong>the</strong>r than Lebanon largely depends on <strong>the</strong> available human and technical resources including infrastructure and staff training on computer skills. At <strong>the</strong> same time, <strong>the</strong> Agency should try to free its staff <strong>of</strong> <strong>the</strong> burden <strong>of</strong> referable curative care in favour <strong>of</strong> streng<strong>the</strong>ning preventive care. Addressing quality concerns should be part <strong>of</strong> <strong>the</strong> same approach. Improving quality indicators is likely to be reached by implementing a combination <strong>of</strong> strategies. Prioritization is <strong>the</strong> key. If <strong>the</strong> above mentioned areas are defined as <strong>the</strong> priority, it means that all efforts will be directed towards achieving better performance on <strong>the</strong>ir improvement. Defining priorities allows teams to focus and enables <strong>the</strong>m to deal with situations (e.g., longer waiting time for general consultations) that can generate complaints and misunderstandings. Setting targets in terms <strong>of</strong> screening coverage or control rates helps teams to plan for <strong>the</strong> necessary amount <strong>of</strong> time (and work), and distribute resources accordingly, much in <strong>the</strong> same way as setting coverage targets for EPI. Incentives should be designed to influence both staff and user behaviour. Incentives do not need to be salary complements, but can take <strong>the</strong> form <strong>of</strong> additional budget for <strong>Health</strong> Centre improvement, signature for scientific journals, or resources to be used in specific training, for example, as long as <strong>the</strong>y are related to a minimum level <strong>of</strong> performance. Negative incentives can be considered too; in its most basic form, long waiting time can be an incentive (a negative one, since it tries to avoid an action) for people with trivial diseases to avoid consultations or look for care elsewhere (although incentives need to be well designed to avoid losing patients with important conditions). Re-define team members’ roles. With suggestions from Field programs, <strong>the</strong> <strong>Health</strong> <strong>Department</strong> at HQ should design new job descriptions for <strong>the</strong> PHC team, increasing <strong>the</strong> autonomy and level <strong>of</strong> responsibility attributed to nurses, who should become able to perform, without close supervision, most activities related to <strong>the</strong> control <strong>of</strong> NCD patients, thus freeing medical <strong>of</strong>ficers’ (MO) time for <strong>the</strong> most complicated cases. Increase contact time between staff and users should have a positive impact on <strong>the</strong> quality <strong>of</strong> care <strong>of</strong>fered by Medical Officers. However, to increase <strong>the</strong> average duration <strong>of</strong> a contact (a strategy) to produce higher quality (a goal); this should be linked to o<strong>the</strong>r, complementary tactics, that ensure that “freed time” is devoted to achieve strategic goals. Some approaches can help increase <strong>the</strong> mean contact time: - Enforcement <strong>of</strong> an appointment system. Designing a sound appointment system is relatively easy. The difficult part is making it work in front <strong>of</strong> complaints and misunderstandings. The key is for both staff and users to focus on <strong>the</strong> gains (in terms <strong>of</strong> capacity for devoting time to improve quality <strong>of</strong> care) obtained by its implementation. Also important is <strong>the</strong> support from <strong>the</strong> field program senior management to organize and shape <strong>the</strong> system, as well as an adequate information campaign directed to beneficiaries. Any system should be flexible enough to ensure that serious cases, even without an appointment, will be identified and assisted without delay; - In addition to saving drugs and containing costs, limiting access to (free) non-essential medicines may have an effect on <strong>the</strong> number <strong>of</strong> patients visiting <strong>the</strong> facility and, consequently, on <strong>the</strong> amount <strong>of</strong> time available for <strong>the</strong> remaining users. Of <strong>the</strong> three ways <strong>of</strong> reducing consumption <strong>of</strong> non-essential drugs (charging even subsidized prices, supplying only to specific users, or removing <strong>the</strong>se medicines from <strong>the</strong> HC stocks), <strong>the</strong> easiest to implement and clearest <strong>of</strong> purpose probably is taking those medicines out <strong>of</strong> <strong>the</strong> supply list; - In addition to <strong>the</strong>se specific measures, UNRWA HQ should begin a far-reaching reform process, in order to transform its health services into a comprehensive, horizontal, population-focused health system. This has been <strong>the</strong> approach taken by many developed systems, based on government-like provision <strong>of</strong> health care, and, reportedly, this is <strong>the</strong> approach that <strong>the</strong> Jordan MoH envisions in <strong>the</strong> long term. In this regard, Jordan Field, with strong links to <strong>the</strong> public sector and a relatively small hospital program, has possibilities barred to o<strong>the</strong>r Fields, where UNRWA has to assume <strong>the</strong> bulk <strong>of</strong> health care and relations with <strong>the</strong> host country MoH are less smooth. THE HEALTH PROGRAMME STRATEGIC PLANNING <strong>2010</strong> was also an important year in strategic planning for <strong>the</strong> <strong>Health</strong> Programme with <strong>the</strong> finalization <strong>of</strong> <strong>the</strong> Programme budget <strong>2010</strong>-2011. The HQ Implementation Plan (HIP) identified <strong>the</strong> strategic priorities and approaches within <strong>the</strong> framework set by <strong>the</strong> Agency’s Medium Term Strategy (MTS) that will translate into UNRWA outcomes, outputs and indicative budgets. A full scale <strong>of</strong> indicators (outcome, output and impact) were defined to guide monitoring and evaluation <strong>of</strong> progress and data will be available in <strong>the</strong> next financial term reports. The results <strong>of</strong> <strong>the</strong> HQ and Field Implementation Plans were presented to <strong>the</strong> Advisory Committee meeting in June 2009 for approval and are now part <strong>of</strong> <strong>the</strong> Programme budget <strong>2010</strong>-2011. 107
Contents Annexes The annexes to <strong>the</strong> UNRWA annual report <strong>of</strong> <strong>the</strong> department <strong>of</strong> health are grouped in four sections: 1. <strong>Health</strong> Fact sheets, <strong>2010</strong>; 2. <strong>Health</strong> Maps, <strong>2010</strong>; 3. Contacts <strong>of</strong> Senior Staff <strong>of</strong> <strong>the</strong> UNRWA <strong>Health</strong> Programme; and 4. Abbreviations. 108
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