Medical Referrals at the Ministry of Health in Palestine

-        The State Audit and Administrative Control Bureau (SAACB) conducted a compliance audit of medical referrals for the years 2018-2019, with the aim of verifying the soundness of the procedures followed in managing medical referrals. The following are the main findings reached by the report and included in the Bureau’s 2020 annual report:

-        The Ministry of Health bases its work on Prime Minister’s Decision No. 113 for the year 2004, on the Governmental Health Insurance System, and does not rely on the Health Insurance and Treatment Outside the Ministry Regulation No. 11 for the year 2006, which should be applied... noting that the Ministry of Health implements some provisions that appeared in the Health Insurance and Treatment Outside the Ministry Regulation No. 11 for the year 2006, with regard to exempting its employees by 100% from the Treatment Outside the Ministry contribution, and in their contribution to the tools and equipment used in surgical operations... which indicates selectivity in application....!

-        Priority was granted in medical referrals to An-Najah Hospital, without clear reasons for granting it priority... and this is according to clause No. 2 of the agreement signed with the hospital dated 25-2-2013.... where the proportion of the hospital’s medical referrals for the years 2016, 2017, and 2018 reached 18% of the total value of medical referrals, which is the highest proportion among the hospitals of the State of Palestine (the northern and southern governorates), indicating the absence of criteria and bases relied upon in selecting the service providers to whom patients are referred.

-        Continuing referrals to hospitals inside the Green Line: the continuation of referring patients to hospitals inside the Green Line, despite His Excellency the President’s decision to stop them in March 2019, where (3,826) medical referrals were issued after the decision to stop them and up to the date 31-12-2019, without clear reasons for continuing the referrals.

-        The cost of treatment was paid in cash to a number of patients, noting that they received medical service in hospitals outside Ministry of Health facilities, and without having been referred by the Service Purchasing Unit for treatment, where exception medical referrals were granted based on the decision of the Minister of Health at the time, for patients located outside Ministry of Health centers and hospitals, in contravention of the referral procedures, in terms of the absence of a medical report issued by Ministry centers and hospitals and duly certified.

-        There is weakness in internal control procedures in following up the procedures that precede issuing referrals... in terms of the lack of some of the required supporting documents in medical referral files (the necessary endorsements by physicians on the referral request are not present, or the referral request itself is not available in the file, and referrals are requested by hospital departments for a number of patients on a date preceding their admission to the governmental hospital...).

-        Weakness in procedures to verify the actual need for referral: in terms of verifying the actual need for referral, verifying the unavailability of drugs, devices, and equipment through coordination with the Ministry warehouses... or verifying the unavailability of a vacancy in the hospitals through actual verification of that, or the existence of a long waiting period by checking the waiting list record.. in the hospitals.

-        There is no reasonable assurance that the Ministry performed sufficient and appropriate procedures to verify that patients who were referred received the appropriate medical service at the required quality, especially in hospitals inside the Green Line.

-        There is no reasonable assurance that the Ministry performed sufficient and appropriate procedures to verify the cost of medical services provided by medical service providers.

-        Referrals are made to non-licensed hospitals, where (410) patients were referred to one of the hospitals during the period from 12-2017 until 9-2019, noting that the hospital was not licensed during that period..!

-        The actual cost of medical referrals for the years 2016-2018 differs between the Service Purchasing Unit and the General Administration of Financial Affairs and the annual health reports issued and published on the Ministry’s website, where its cost according to the Service Purchasing Unit’s schedules and clearing discounts... was ( 817,042,636 shekel)...(849,789,971 shekel), (1,034,698,411 shekel), respectively, and its value according to the annual health reports published on the Ministry’s website was (566,720,668 shekel), (431,074,755 shekel), (724,622,913 shekel) ....!

-        The continued increase in the total cost of medical referrals and in their numbers, from the start of issuing them up to 2018, and the continued rise in the proportion of referrals issued to outside Palestine, where their proportion reached 22.3% in 2016, 33% in 2017 and 26% in 2018 of the total value of medical referrals according to the Ministry’s annual health reports.

-        No confirmation was available regarding the correctness of the data entered into the computerized system for 2018, especially concerning the cost of referrals (the maximum coverage), and it was shown that 62% of the referrals on the system did not have the reason for referral specified.!

-        The medical reports issued by the hospitals and centers that provide treatment services to patients outside the Ministry of Health do not include the names of the physicians who provided the service to the patients, in order to verify through them the absence of a conflict of interest between physicians in Ministry hospitals and centers and physicians in hospitals and external service providers, without verifying that the physician who makes the referral is not the one providing the service in the hospitals and centers outside the Ministry..!

-        It is worth noting that the General Administration for Control of Services in the State Audit and Administrative Control Bureau (SAACB) prepared this report; it is an administration specialized in sectors most related to the public, as it is competent in auditing the Ministry of Health, the Ministry of Education, the Ministry of Social Development, the Ministry of Agriculture, and the Ministry of Awqaf and Islamic Affairs.. and these ministries provide direct services to the Palestinian citizens.

-        Attending to the recommendations issued by the Administration’s reports will lead to improving the services provided to the public.... rather than many of these violations being justified, as stated in the concerned party’s response... and this party also stated in its response to the report.... that it will take up some of these recommendations....!!

-        Date:  15-9-2021