Palestine: Feasibility Study to Establish a National Institute of Public ...

Contents Front Cover 1. Introduction .................................................................. 4 2. Public Health Challenges in 2010 and Beyond ................ 5 3. Term of Reference....................................................... 9 4. The Assignment ............................................................. 10 5. The Findings................................................................... 11 6. Concept and Models....................................................... 13 6. Next Steps.................................................................... 18 7. Further Information ...................................................... 20 Appendix 1 Appendix 2 Appendix 3 Back cover © WHO Collaborating Centre ICL 2010 Establishment of a National Institute of Public Health 3 | P age

Feasibility Study: Establishing a National Institute of Public Health in the Occupied Palestinian Territory Introduction The Palestinian people currently live in two geographically separate parts of Palestine, the West Bank including East Jerusalem, and the Gaza Strip. Since 1917, under the British Mandate for Palestine, and, more particularly, since the creation of the State of Israel in 1949, the population of Palestine has suffered incomparable hardship, injustice, discrimination, eviction, displacement, illegal settlement of Palestinian lands, isolation, war and terror by occupying militantly forces. 1 In 1993, under the Oslo Accord (Declaration of Principles on Interim Self-­‐Government Arrangements) the Palestinian National Authority (PNA) was established to run the Government of Palestine. In a population of about 3.8 million, up to 60% live in approximately in 400 villages and nineteen refugee camps, the reminder residing in urban refugee camps and cities. The Gaza Strip, one of the most highly dense populations in the world and where 2/3 of the population live in refugee camps 2 , has 1.3 million people living in an area of 365 km2. The literacy rate in Palestine is 85% among people above 15 years old. GDP/capita was 1,496 US$ in 2000 decreased to 1,230 US$ in 2008 after many years of the unstable events including the Intifada. Today Palestinians living in the occupied Palestinian territory (oPt) are in the middle of epidemiological and demographic transitions. In terms of health care delivery, four main providers are responsible for services—mainly disease orientated—of primary, secondary, and tertiary care: the Palestinian Ministry of Health, Palestinian non-­‐governmental organisations, the UN Relief and Works Agency, and the private sector. Health services are financed through a mixture of taxes, health insurance premiums and co-­‐payments, out-­‐of-­pocket payments, local community financial and in-­‐kind donations, and loans and grants from the international community (including the UN Relief and Works Agency). Such fragmentation of health system responsibilities is one of many public health challenges in today's Palestine (see below). Despite the military occupation and the unacceptable conditions under which Palestinians are living, the work of health professionals under such 1 Britain from 1917-­‐1948; Israel in 1949 occupying further 26% of the UN Mandate territory (namely of the territory to the west of the Jordan River); Israel illegal occupation of all Palestinian territory in 1967. 2 In 2010, currently, more than 4 million Palestinians are living outside Palestine mainly as refugees in neighbouring countries. The term refugees in neighbouring countries may be misleading as status of such camps are better than some of the poor areas in the same city (for example Beirut, Lebanon) © WHO Collaborating Centre ICL 2010 Establishment of a National Institute of Public Health 4 | P age

extreme circumstance is superb and contributes to health indicators 33 which are as good as or better than many neighbouring countries. However, socioeconomic and regional inequalities persist. Incidence of patients seeking help for non-­‐communicable diseases (NCDs) and mental health have increased substantially over the last decade. Public Health Challenges in 2010 and Beyond The complexity of health system development under conditions of military occupation and ongoing political instability within the oPt create many challenges to public health and for health leaders. From policy development to service delivery, these challenges are: 1. Assessing population health needs: restricted movements create unhealthy living conditions for the population. This is a major detriment to health. The impact of military occupation on health outcomes should be fully assessed. Public health expertise in health needs assessment in areas of conflict and the oPt is limited, if not absent. 2. Fragmented health system: within the oPt four separate agencies are responsible for service delivery. The absence of central command and control leads to fragmentation, duplication, inefficiencies, loss of valuable resources and ultimately patient dissatisfaction. The Israeli policy of closures and segregation means that many patients are transferred from one provider to another. Furthermore, a restriction on movement imposed by unnecessarily intimidating multiple checkpoints creates barriers to movement with the separation wall also preventing access for patients and medical staff. Tertiary services in Jerusalem are difficult to access for most of the population because of the separation wall and associated checkpoints and tight Israeli control on exits from Gaza. Many cases are treated in neighbouring countries but at a high cost. Expertise in health system development is needed to help in assessing impact on the public’s health and health system performance. 3. Access: inequitable distribution of health facilities as well as un-­‐affordability makes access to health services difficult (Figure 1 & 2). Access to preventive health services to address risks of NCDs is, in particular, not a priority to a population who cannot move freely and cannot pay for basic services. These are major public health challenges for policy makers. 4. Unsustainable financing of the health system: donations cover a very high percentage of the Ministry of Health budget and operating costs. The flow of funds varies according to the political agenda and international pressures. Donors usually fail to address crucial health determinants in the occupied Palestinian territory: human security and the structural violence imposed by the occupation. Indeed in our experience, in supporting health systems, financial aid is not only ineffective but can be harmful as donors focus on vertical rather than mainstream programmes. Robust health economics, therefore, is essential to address stable, sustainable, less centralised financing in order to meet population health 3 For example antenatal care, nutrition, immunization and vaccination, infant mortality. © WHO Collaborating Centre ICL 2010 Establishment of a National Institute of Public Health 5 | P age

needs without creating additional financial burdens to individual (currently household spending out of pocket payments on health is about 40% on average). 5. Displacement: a high percentage of the population are refugees (in both rural and urban areas). Two thirds of the Gaza population are living in displaced conditions. As a consequence, sections of the population are living in unacceptable and unhealthy conditions including environmental exposure. Some experience loss of material possessions, loss of familiar environment, and traditional way of living and educational routine. Continued threat of violence by the occupation forces exacerbates an already vulnerable population at health risk. Sustained, long-­‐term assessment on the impact of social, economic, military, and environmental determinants of health is essential and requires high levels of social and public health expertise. 6. High level of poverty and deprivation: with more than 22% of the adult population unemployed and many others on incomes below poverty line 44 and it is unlikely that the Millennium Development Goals (MDGs) will be achieved. Focused labour legislation along with coordinated public health actions are needed to address these damaging and long-­‐term serious inequalities. 7. Psychological stress: many families and communities have been subjected to eviction, property demolition, separation (both physical and psychological) by security measures (walls and checkpoints). As well as the immediate and direct physical effects of conflict, there are longer lasting psychological consequences. War-­‐related trauma disrupts the very foundation and infrastructure of healthy development and growth. 55 High level public health research is needed to explore further the impacts of such psychological stress on communities, families and individuals. 4 About 60% of the population income is less than $4 per person per day. 5 Is Ideological Commitment Protective for Post Traumatic Stress Symptoms in Youths in Situations of Political and Ethnic Conflict? The Case of Israel and the Occupied Palestinian Territories. Patel, S. Imperial College London, August 2010. © WHO Collaborating Centre ICL 2010 Establishment of a National Institute of Public Health 6 | P age

Figure 2: Gaza Strip: distribution of health facilities, 2010 10. Human Resources for Health: There are serious issues in the oPt about the number of health professionals needed, their skills and competencies, and much needed continuous professional development (CPD). The skill shortage in public health is quite obvious, in particular in the area of planning, epidemiology, health intelligence, health economics, community development and eHealth. A robust HRH strategy is needed which includes detailed work on how to develop sustainable human resources. This requires high level health expertise and public health inputs. © WHO Collaborating Centre ICL 2010 Establishment of a National Institute of Public Health 8 | P age

11. Digital Technology and Health: many health institutions in the oPt are lagging behind in the area of advanced technology, mainly due to funding and Israeli restrictions (many of Gaza hospitals and health centres for examples are lacking basic medical supply due to Israeli restriction). Careful and expert planning is needed. Term of Reference Public health institutes are a central part of the health infrastructure in many countries. In February 2009, the Norwegian Ministry of Foreign Affairs in cooperation with the Norwegian Institute of Public Health requested that the WHO Office for West Bank and Gaza examine the case for establishing a Palestinian National Health Institute as part of the health infrastructure in the Palestinian territory A number of informal meetings were held between the Norwegian Institute of Public Health and WHO, as well as with the MoH, universities, the Palestinian Central Bureau of Statistics (PCBS) and other relevant institutions. It was agreed to hold an introductory workshop with relevant stakeholders to introduce the concept and various models of PHIs, to examine potential elements and design of a PHI and to discuss whether such an Institute could perform a useful function in the oPt Tasks to be performed The WHO Collaborating Centre, Imperial College London was approached by WHO oPt Jerusalem to provide a senior public health expert, to: 1. Plan and conduct a workshop on modern public health functions for key stakeholders in the oPt. The purpose of such a workshop is to introduce the conceptual framework and possible models to develop and strengthen the public health functions in light of the profound challenges to population's health in general and health services in particular. 2. Undertake a short study to identify: • What current health information is available, how it is interpreted and used. For example, which institutions provide what kind of information, do these institutions co-­‐operate on managing the health information and if so, how? At what level do the institutions co-­‐operate and what kind of information is gathered. If possible, establish a baseline; • The public health functions currently carried out by the relevant institutions in the oPt and the various linkages between them. We need to understand that dynamic, © WHO Collaborating Centre ICL 2010 Establishment of a National Institute of Public Health 9 | P age

the information exchanged and utilization of the health information gathered. The expert may conduct interviews with various stakeholders, like the Palestinian Central Bureau of Statistics, the Palestinian Health Information Centre, universities, civil society organizations and agencies; • The strengths, weaknesses and gaps of current arrangements; • The typical functions of public health institutes around the world that, in the light of the above, may support the establishment of a public health institute in oPt The Assignment Professor Salman Rawaf arrived the West Bank via Jordan on 22nd June 2010 until June 27th. The following tasks were undertaken by this assignment: Arrive 22nd June 2010 1. Upon arrival. Meeting with Mr Tony Laurance (Head of WHO office, oPt) and Dr Katja Schemionek (Deputy Head) for an initial discussion about the programme and to finalise the terms of reference. Excellent background was provided by both colleagues. 2. Meeting with His Excellency the Minister of Health, Dr Fathi Abu Moghli (on arrival). The main focus of the meeting was a briefing and background of the Ministry's public health priorities, what public health functions mean to top policy makers, addressing priorities, and what type of human resources are needed to improve public health. The Minister was open to an approach that would look into building capacities of public health specialists as current arrangements do not produce the appropriate work force needed to address the serious current gaps in the Palestinian Health System. 3. Workshop / Seminar. A number of scenarios on what public health means in a country such as Palestine were presented for interactive discussions and engagement of the 50 participants from the Ministry of Health from various public health background and seniority level. The Director of Public Health and Primary Care as well as many other directors attended. A number of public health functions needed to meet the Palestinian challenges were outlined and the skills and competencies in all areas of modern public health were emphasized. © WHO Collaborating Centre ICL 2010 Establishment of a National Institute of Public Health 10 | P age

the total land mass and 35% of its agricultural land. The Palestinian Authority is not allowed to have offices or provide public services to their citizens living in East Jerusalem. The occupation must end to allow the people of Palestine to begin to live a healthy life in peace and dignity. Many if not all the public health challenges listed above (many are part of the findings of this assignment) can be addressed if the Ministry of Health roles and functions are clarified and fully supported by a skilled and competent workforce, in particular public health and subspecialties. 2. There is recognition by HE the Minister of Health and his team that there is an urgent need to strengthen the public health function within the Ministry of Health. Shortage of expertise and limited supply of high level trained workforce are some of the barriers. 3. Most of the current health system practices are based on a disease model rather than health prevention. This may result in limited, and hence less effective, population-­‐based public health initiatives to address risk factors to health. Such risk factors (obesity, hypertension, salt intake, diabetes etc) are the main determinants of non-­‐communicable diseases such heart diseases and cancers. A population which is fully engaged in their health cannot be achieved without a major shift from only healthcare to health policies (Figure 3). Figure 3: Burden of disease model: most current services are focusing on illness ignoring the health of the majority of the population 4. As result of the illegal occupation by Israel, addressing the wider and social determinates of health in oPt is extremely difficult and complex. Further public health research is needed to explore new and innovative approaches to address these interrelated issues. 5. The complexity of providing health services through multiple unlinked providers with many unsecured and unsustainable funding mechanisms are the product of the occupation © WHO Collaborating Centre ICL 2010 Establishment of a National Institute of Public Health 12 | P age

itself. Command and control to ensure equity in access, quality in service provision and fairness in cost contribution is weak. Courageous health policies and strategic plans are needed to clarify funding, pooling risks, allocating resources, commissioning services, building incentives, ensuring quality and monitoring performance. These are huge tasks for public health expertise which are lacking in the oPt. 6. There are many good academic Public Health Departments in both West Bank and Gaza Strip. However, many gaps exist between the skills and training provided for by existing institutions in Palestine and the skills and practice needed in public health, economics, statistics, health promotion and community development at the levels. A similar gap exists in health service research. University priorities and academic cycles may not fit with that of the Ministry of Health and indeed other relevant Ministries. A new model of training public health practitioners is needed. Concept and Models Possible Models to support the development of Public Health Functions in oPt: Public health is the art of promoting health, preventing disease, and prolonging life through the organised efforts of society. In short, public health regards all that may influence one’s health. To prepare a workforce skilled in public health to meet such diverse needs but equally to face the challenges of policy makers and health leaders in the oPt, requires a model of training based on public health practice. This conceptual, yet still operational model, defines and firmly support the case for establishing a National Public Health Institute (NPHI). However, during the course of this assignment and in formulating this concept, several issues became evident that must be addressed at an early stage in the development of such a national model: i. Multi-­‐disciplinary Public Health: there is a lack of appreciation in many developing countries and governments on the value—and added value—of public health doctors and other public health practitioners such as environmental health officers, health economists, community development workers, health promotion specialist, etc. The new institute, irrespective of the final model selected, should be multi-­‐disciplinary both conceptually and functionally. It will provide multidisciplinary training at all levels and should be widely available. Elsewhere in the world (not yet in EMRO) the appreciation of public health issues in determining the shape of health services underlines the need for a strong national resource centre (or centres) to provide quality post-­graduate training similar to what exists across Europe and North American models (e.g. Schools of Public Health in the United States). © WHO Collaborating Centre ICL 2010 Establishment of a National Institute of Public Health 13 | P age

As part and parcel of this assignment the best dynamic to achieve multi-­‐disciplinary awareness and collaboration between the MoH, Palestinian universities and the Arab Board in the training of both medical and non-­‐medical public health practitioners should be explored further. ii. Understanding the Public Health Function: in the course of my discussions with officials and practitioners in Palestine it became evident that not only is the current approach to public health one mainly based on traditional public health roles (sanitation, prevention) but also a true lack of understanding of the public health function. Further to these observations and in addition to the aforementioned training, I am proposing that the National Institute of Public Health in Palestine become a major resource of health service research (HSR). This is added and essential component is vital for the Ministry and for those responsible for population's health. The format and content of HSR again is very important and should be built upon Government and Ministry of Health priorities for health. Examples of health service research needed are: How health needs should be assessed?Why certain diseases have more impact on health than others?How health services should be organised and delivered?How effective are innovative services?What are the problems of access to services and what are the methods to reduceinequalities?Address variations in the provision and outcome of servicesHow can we engage the public in their own health?Identifying the role of the State and the role of the individual in securing healthWith escalating costs who should fund advancement in technology?iii. Evidence-­‐based Policy: The third major area of the proposed Institute's function is the search for evidence to support policy and decision making. Again it was apparent during my consultation that most policy decisions are based on historic development (e.g. who should provide what), political pressure (e.g. the insurance coverage), and personal preference (mostly provider-­‐led). iv. Multi-­‐faceted Public Health Function: The other key issue surrounding the proposed NPHI is the ability to harness experts from different specialities (public health medicine, infectious diseases, microbiology, sociology, nursing, health economics, health service management, technology, IT, etc) and from a variety of different backgrounds (service, academia) to work together developing and delivering training, initiating and conducting health service research, and producing evidence for policy decision. © WHO Collaborating Centre ICL 2010 Establishment of a National Institute of Public Health 14 | P age

A majority of the Institute’s programmes should be integral to government priorities including those of the MoH. Simply a focus on these priorities by and of themselves is unique hence the descriptive 'National'. Embracing this approach will have very little affect on academic cycles and personal influences which is the nature of current small public health university departments/institutes. Irrespective of the model chosen for the Institute, it will influence funding method(s). How to secure funding mechanisms for such an important national function will be addressed in the Next Stage of the assignment. The range of public health functions coupled with the scope of the proposed Institute will determine the possible development model. Options are as follows: 1. Status quo: As we illustrated above doing nothing is not an option. Current providers are not fully meeting the needs of practitioners to address the complex nature of any health system let alone one operating under military occupation with restrictions on movement and under a veil of intimidation. 2. Building on Current Academic Public Health Departments/Community and Public Health Institutes: Some of these departments/institutes are doing excellent work but unfortunately do not have the capacity to expand and indeed respond to health needs at short notice. Still it is an important option to explore further. Advantages: -­‐ Expand on existing resources -­‐ Capitalise of the current experiences -­‐ Good brand name -­‐ Cost is less Disadvantages: -­‐ Academic priorities may not fit with population and MoH priorities -­‐ Academic cycles -­‐ Lack of independence and flexibility (e.g. immediate response to request from policy makers) © WHO Collaborating Centre ICL 2010 Establishment of a National Institute of Public Health 15 | P age

Risks: -­‐ Medium risks -­‐ Risks can be managed [Financial control, immediacy, flexibility, independence) 3. Virtual National Institute of Public Health: A new concept among public health practitioners which provides opportunity for flexibility, continuous evolution and ability to respond at a very short notice. It requires a very small base and strong and competent leadership. Acceptance by users is essential. Such an institute will operate in a collaborative manner. Existing public health university departments could amalgamate with each leading, within the national priorities identified, on a major public health function. They will act as providers for these functions (which are identified by the Institute's leadership). Using modern communications these functions delivered from multiple sites will be gelled together. Each "provider" has to meet the standards defined by the virtual national institute (and this is some time difficult). Advantages: -­‐ Modern -­‐ Huge flexibly -­‐ Brings in all possible expertise needed (both internal and external) -­‐ Low cost Disadvantages: -­‐ Acceptance by some users is limited due to the lack of physical presence -­‐ It relies on communication technology -­‐ Lack of physical structure -­‐ Providers must be flexible and accept to redefine their standards Risks: -­‐ Medium/High -­‐ Risks can be managed (small physical structure, users support, financial contributions, research credibility) © WHO Collaborating Centre ICL 2010 Establishment of a National Institute of Public Health 16 | P age

4. A purpose-­‐built National Institute of Public Health This will be an Institute with a physical presence. It will function independently as a National Centre of Excellence with the full range of public activities focusing on the Palestinian priorities to address the complex health of the population living under illegal military siege. Advantages: -­‐ Physical presence -­‐ Full range of public health expertise to meet needed functions -­‐ Evolving, rapid response, purposely design -­‐ Independence Disadvantages: -­‐ High cost -­‐ May be perceived as a competitor to existing academic ones (although the functions will focus on the practice, service orientation rather than academic -­‐ Undermine existing institutions staff would prefer jobs in the new National Institute Risks: -­‐ High -­‐ Risks of costs can be managed (think about the huge returns in the future) -­‐ New breed of expertise (practitioners rather than purely academia) -­‐ Work in collaborative ways to minimise competitions -­‐ Research is service/ applied based (health service research) Possible Areas of Activities/Function within the Proposed Institute: Detailed work is needed to identify and quantify the function of the proposed National Institute of Public Health. Below is the list of common functions which are frequently requested by the Ministries of Health around the world, grouped with the (extended) public health competencies. Public Health Activities/Functions/Inputs 1 Research, surveillance and assessment 2 Data processing, interpretation and presenting 3 Health needs assessment 4 Assessment of evidence relating to the effectiveness and cost-­‐effectiveness of public health interventions, programmes and services including screening and diagnostic 5 Monitoring and appraisal of screening © WHO Collaborating Centre ICL 2010 Establishment of a National Institute of Public Health 17 | P age

6 Communicable disease control and all elements of health protection including environment hazards (environmental health) 7 Health Care Service commissioning 8 Population Health initiative commissioning 9 Research 10 Public Health Policy Development 11 Public Health Delivery System 12 Health Leadership 13 Behaviour Change 14 Interpreting health information 15 Innovations in health 16 Introducing new technology into the health system 17 Social care related to health 17 Public health regulations and laws 19 HRH including CPD, new manpower (e.g. Community workers) 20 Other relevant local areas Next Steps This short report provides a platform for further discussion and indeed decision making on how to strengthen the public health function within the Palestinian Authority and in particular the Ministry of Health. The proposed National Institute of Public Health is an important cornerstone of development to supply the support needed to strengthen the public health function at the Ministry of Health. Doing nothing and operating in the current status of public health supply and delivery is not an option as we have managed to illustrate. Any of the other three options are possible (building upon on current academia; virtual Institute of Public Health, and purpose build Institute of Public Health). Each option could be developed further, but in my opinion the model must be able to meet all the challenges identified in this report is the actual physical structure for an Institute of Public Health. With this model you can start in a modest and affordable way but aim to achieve the objective of full range activities within approximately 10 years. The process of developing such an Institute will create the much needed enthusiasm to address the population’s complex health needs. It will focus the attention on priorities and the suffering of the people of Palestine. Once the illegal occupation is ended and an Independent State of Palestine is established, the ability to reach all the population and address the wider determinants of health will be feasible and fruitful. The existence of such National Institute will be a great asset to the new State of Palestine. The next stage will be: 1. Discuss findings, the challenges and models with WHO oPt, the MoH, the Norwegian Government, NIPH, and other key stakeholders (WHO to decide); © WHO Collaborating Centre ICL 2010 Establishment of a National Institute of Public Health 18 | P age

2. Run another workshop with participants from several external stakeholders, including the NIPH and IANPHI (International Association of National Public Health Institutes). The programme for this workshop will be outlined by the WHO Collaborating Centre with input from the NIPH; 3. Professor Rawaf and ICL colleagues to continue the dialogue with WHO and colleagues inside and outside the oPt; 4. Part II of the assignment will be undertaken between September -­‐ November 2010. © WHO Collaborating Centre ICL 2010 Establishment of a National Institute of Public Health 19 | P age

Further Information For further information please contact: Ms Ela Augustyniak Administrator, WHO Collaborating Centre Department of Primary Care & Public Health Imperial College London UK t: 020 7594 8603 m:07818607757 e.augustyniak@imperial.ac.uk whocentre@imperial.ac.uk Please visit our website: http://www1.imperial.ac.uk/medicine/about/divisions/publichealth/pcsm/whocollaboratingcentre/ _______________________________________ © WHO Collaborating Centre ICL 2010 Establishment of a National Institute of Public Health 20 | P age

Appendix 1 The Visit ItineraryJune 22: Tuesday·∙ 10:30 – 11:30 Meeting with His Excellency, the Minister of Health; ·∙ 11:30 -­‐ 12:30 Meeting with GD for PHC ·∙ 13:30 -­‐ 15:00 Meeting with Director of International Cooperation; Director PHIC, Dean of Ibn Sina College (Nablus) June 23: Wednesday ·∙ 10:00 – 14:00 Work shop with respective MoH staff: introduction, concept and various models of Public Health Institutes reviewed ·∙ 14:00 – 16:00 Meeting with various stakeholders, to be determined, e.g. academia, PCBs, NGOs; June 24: Thursday ·∙ 9:00 – 13:00 Meeting with stakeholders, continuation; ·∙ 14:00 – 15:00 Debriefing / next steps meeting with His Excellency, the Minister of Health June 25: Friday Concluding discussions at WHO Office and debriefing with country office team________________________________________ © WHO Collaborating Centre ICL 2010 Establishment of a National Institute of Public Health 21 | P age

Appendix 2: The Workshop Slides Scenarios and modern public health functions© WHO Collaborating Centre ICL 2010 Establishment of a National Institute of Public Health 22 | P age

Appendix 3: The Consultant Professor S Rawaf, MD PhD DPH MPH MCH DCH FRCP FFPH FFPHM(I) He is Professor of Public Health and Director of WHO Imperial College London. With extensive health service management and clinical experience as Director of Public Health in South West London and Medical Director for more than 23 years Prof Rawaf is well recognised in his expertise in health system development including HRH © WHO Collaborating Centre ICL 2010 Establishment of a National Institute of Public Health 23 | P age

The process of developing such a Public Health Institute will create enthusiasm to address the population’s complex health needs. It will focus the attention on priorities and the suffering of the people of Palestine. Once the illegal occupation is ended and an Independent State of Palestine is established, the ability to reach the whole of the population and address the wider determinants of health will be feasible and fruitful. The existence of a National Institute of Public Health will be a great asset to the new State of Palestine. Israel’s Illegal wall: separates communities, restrict movement and intimidate people (BBC) © WHO Collaborating Centre ICL 2010 Establishment of a National Institute of Public Health 24 | P age

WHO Centre Imperial College London © WHO Collaborating Centre ICL 2010 Establishment of a National Institute of Public Health 25 | P age