2014 Activities

AMAN issues a report showcasing how the Medical Service Procurement Department,is being pressured by senior officials,to take exceptional decisions regarding medical referrals Furthermore, the Medical Referrals File has been turned over to the Anti-Corru

AMAN issues a report showcasing how the Medical Service Procurement Department,is being pressured by senior officials,to take exceptional decisions regarding medical referrals  Furthermore, the Medical Referrals File has been turned over to the Anti-Corru

AMAN Coalitionhelda workshop to discuss themedical referrals process pertaining to specialist treatment outside of the Ministry of Health’s network of institutions. Moreover, it prepared a report regarding the establishment of an "environment of integrity, transparency and accountability within the process medical referrals to specialist treatment outside of the Ministry of Health’s network."  The report aims to identify the most important challenges and gaps, generate effective recommendations that will enable decision-makers to promote an environment of integrity withinthe medical referrals space, and catalog the services which can be developed to reduce or limit medical referrals outside of the MOH network. All of which, will aid in the rationalization of public spending. 

A group of competent official institutions took part in the workshop, to include the Undersecretary of the MOH, Dr. Anan Al Masri, and Mr. Osama al-Najjar,Director General of medical referrals in the MOH. This is in addition to, representatives of the State Audit & Administrative Control Bureau SAACB, the Red Crescent Society, Al Maqasidhospital, members of the Legislative Council, as well as a number of charitable and civil society institutions.

The workshop was launched byDr. Azmi Al Shuaibi, AMAN’s anti-corruption Commissioner,to discuss the report’s first draft. Dr. Al Shuaibinoted thatthe MOH was targeted by AMAN, citing very early collaboration between the two bodies, due to the ministry’s extremely valuable role and the valuable services it providesto citizens; who in turn, expect nothing less than stellar service from the ministry. He further added that, the MOH’s performance was affected,primarily by the occupation and to a lesser degree by the internal factions split within the country, ultimately increasing the Ministry of Health’s responsibilities.He explained that the report was prepared by AMAN as a result of information and complaintsreceived from citizens that illustrated the Israeli side’s exploitation of the referral process, as they continue to charge the PNA extremely elevated prices for these services. This reflects a misuse of public money and added burdens on the State Treasury.

Researcherand report writer,Mr. Jihad Harb, presented the report’s following main conclusions:

Higher authorities’ exceptions overstretch the Ministry of Health’sbudget.

The report illustrates how exceptional decisions made by official bodies to exemptcertain individuals from paying health insurance fees or to allow them to receive treatments outside of the basket of services provided by their insurance, without securing payment for these services from their budgets, will generally weakens the Health Insurance Fund’s reserves, and will allow for a disorderly use of its resources. Including, utilizing some of the funds to pay for medical treatment abroad.

Weak control over the billing for treatment received in Israeli hospitals

The report illustrates how the MOH did not audit anyof the Israeli hospitals’ bills that are directly deducted by the Israeli side - on a monthly basis - from the clearing. TheMinistry of Health did not demand any of the bills issued by Israeli hospitals for the period between 1994 and the beginning of 2013.

In other words, the Ministry of Health failed to audit payments to Israeli hospitals, estimated at 600 million NIS, for treatments received during the period of 2003 – 2012. This figure represents about 22% of the total spending on treatment outside the Ministry of Health medical network.

Data indicates that the parties managing the referral file from the Israeli side, who share mutual and abiding interest with Israeli hospitals, take advantage of the Palestinian side’s lack of knowledge regarding theintricacies of procedures and treatments offered. They utilize this unawareness to demand and receive fees and payments that are multiple the amounts they are owed. 

The Ministry of Health was successful in localizing treatment and reducing reliance on treatment abroad

The report demonstrates that the MOH was successful in imposing a policy to localize treatment withincivil and private Palestinianinstitutions.The percentage of cases referred to these institutions stood at about 82% of the total rate of referrals. However, the ministry has failed to reduce of the number of referrals for treatment outside of the ministry’s network of health institutions. It failed to reduce the cost of these referrals, or adopt a developmental policy pertinent to Public Health Services.

The government’s decision to exempt Gaza residents from paying health insurance fees has overstrained the Health Insurance Fund.
The report clarifies that, the presidentialdecree exempting residents of the Gaza Strip from paying insurance fees or deductibles and failing to specify a financial allotment for this purpose, was burdensome to public health insurance. And thus, this situation must be re-evaluated to correct the standing of the health insurance in the Gaza Strip, as well as its implementation mechanisms.

The Medical Referrals File has been turned over to the Anti-Corruption Commission

The report demonstrates that the MOH’s Medical Services Procurement Department has yet to establish clearly defined and written fundamentals that control the mechanism of defining the location of treatment for patients with benefits to receive treatment outside the MOH’s medical services network.

Dr. Anan Al Masri, Undersecretary of the Ministry of Health, indicated that the issue of medical referrals is a verycomplicated matter, and stressed that the ministry has turned over the medical referrals file to the Anti-Corruption Commission for investigation.DrAl Masriillustrated a set of procedures that are being designed by the Ministry to ensure the transparency and integrity of the medical referrals process. The most important of which is the launch of an electronic linking system to commence this coming month of May.The system will link the Ministry of Health, the Ministry of Finance, and the Israeli hospitalsoffering the medical service, in a manner which will prevent the Israeli side from manipulating medical bills in anyway. A group of lawyers and auditors were commissioned by the MOH as well as the MOF to review all medical bills received from the Israeli side for specialist treatment rendered. In the event any manipulationto these bills was proven, the PNA will resort to the judicial system to demand payment of any and all owed sums.He further explained that the Ministry of Health will adopt clear mechanisms to define and set the prices of medical services offered, with Israeli hospitals. It will bargain with them so as to get the best service at the best prices.

To tackle the pressures faced by the Medical Services Procurement Department, the Ministry has formed three regional committees; in the North, Center and South. Said committees will be responsible for making all pertinent decisions. The Procurement Department will bear the sole responsibility of executing these decisions and will not be permitted to approve any referralsoutside the authority of these committees.

Mr. Osama al-Najjar, Director General of Referrals, pointed out that the ministry is currently working on the implementation of all recommendations included in the AMAN report. He confirmed that the Medical Services Procurement Department was in fact subject to various pressures, coercions, and interference from higher-up officials to obtain medical referrals for treatment in Israeli hospitals. He noted that the Department has developed an administrative procedures manual and will work towards developing a medical procedures guide, which must be referenced during the medical referralsprocess. He further noted that awareness campaigns aimed at increasingthe citizens’ confidence in national hospitals must be conducted. Moreover, he stressed that the majority of public medical spending is aimed at the treatment of cancer patients. Thus, he called for the establishment of an independent national medical institution or center,with an independent budget, that specializes in the treatment of cancer cases. Ultimately, this will ease the MOH financial burden. He added that, since currently there are no signed agreements in place with any Israeli hospitals, the Israeli side continues to have the upper hand and the clear advantage to alter the treatment protocols without prior coordination with the Ministry of Health. Therefore, if the Ministry’s proposed electronic linkage projectsucceeds, real cost will be adopted, putting an end to Israel financial exploitation of the medical referral billing.

Dr. Sahar Al Qawasmi, member of the Fatah Legislative Council, indicated that the Palestinian citizen’s contribution to the cost of treatment is about 40% of the total cost. Further explaining how this is one of the highest rates of citizens’ contributions in the world, calling upon the government to work towards reducing it.However, it is a well known fact that - in Palestine - insurance coverage is extended to all, and only 60% of the population is required to pay insurance fees.

Dr. Fathi Abu Moghli, former Minister of Health, has also indicated that the Ministry of Health worked diligently since its inception to build a functionality system. However, being burdened with innumerable responsibilities, it stands in desperate need of a reform process; a process that must be cumulative to succeed.


All those attending the workshop have agreed upon the recommendations mentioned in the AMAN report, namely:

• The need to adopt a universal health insurance system that takes into account the different entities providing health services to Palestinian citizens, including international organizations. This system must ensure equality, solidarity, and cost contributions (deductibles) by all insured individuals.
• A presidential decree must be issued putting a halt to all decisions to exempt any citizen from paying insurance coverage fees or deductibles, unless such exemptions can be covered by a defined budget that is dedicated for this purpose. Meaning, exemption amounts may not be deducted from the Public Insurance Fund’s resources.
• The need to further implement the policy of treatment localization within civil and private Palestinian institutions.
• The need to adopt a policy for the development of public health services and for building the capacities of the human capital. All in an effort to reduce the necessity to procure medical service from outside of the National Institutions Network, as well as to reduce the PNA Treasury’s high the cost for this item of expenditure.
• All medical bills pertaining to services rendered by Israeli hospitals must be revised and audited.
• An electronic system aimed at putting an end to the Israeli side’s exploitation of this service must be adopted.
• The needs to establish clearly defined, written, and circulated fundamentals that control the mechanism of defining the location of treatment for patients with benefits to receive treatment outside the MOH’s medical services network.
• The need to activate the code of conduct and ethical standards for workers in the public health sector.


 This project funded by the EU 

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