RACING AGAINST TIME World Bank Economic Monitoring Report to the Ad Hoc Liaison Committee September 2023 Racing Against Time World Bank Economic Monitoring Report to the Ad Hoc Liaison Committee September 2023 © 2023 International Bank for Reconstruction and Development / The World Bank This report is a product led by the Equitable Growth, Finance and Institutions (EFI) Practice Group of the World Bank’s Mid- dle East and North Africa (MENA) Region, in collaboration with the Human Development (HD) Practice Group of the MENA Region. It is part of a larger effort by the World Bank to contribute to the dialogue on economic monitoring and development policy coordination, in support to the people of the West Bank and Gaza, in its capacity of Rapporteur to the Ad Hoc Liaison Committee (AHLC). Visit www.worldbank.org/en/country/westbankandgaza for more information. 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COVER: photo by Ahed Izhiman TABLE OF CONTENTS Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii 1. Recent Economic Developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.1. Economic Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 1.2. Public Finances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 a) Fiscal Performance, January–June 2023 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 b) Fiscal Forecast for 2023 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Toward Fiscal Sustainability: Policy Priorities for the PA, GoI, and Development Partners . . . . . . . . 7 c)  1.3. Money and Banking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 2. Improving Access to Sustainable, High-Quality Health Services . . . . . . . . . . . . . . . . . . . . . . 15 2.1. Health Services in the West Bank and Gaza: Quality and Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 2.2. Fiscal Sustainability Implications of Outside Medical Referrals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 2.3. Policy Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 ANNEX (Executive Summary in Arabic) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 List of Figures Figure 1 GDP Continued Its Moderate Growth in 2022/23… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 Figure 2 GDP Continued Its Moderate Growth in 2022/23… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Figure 3 Direct and Indirect Exposure to the Palestinian Authority . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Figure 4 Flowchart of Outside Medical Referral Permit and Reimbursement Process . . . . . . . . . . . . . . . . . 16 Figure 5 The Distribution of Outside Medical Referrals by Origin and Destination . . . . . . . . . . . . . . . . . . . . 17 Figure 6 OMR Volumes and Expenditures in Nominal NIS, 2013–2022 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Figure 7 OMR to Hospitals in the EJHN and Israel by Volume and Expenditures in Nominal NIS, 2020–2022 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Figure 8 Unit Costs of Top Drivers of Referrals in Israeli and EJHN, 2020–2022 . . . . . . . . . . . . . . . . . . . . . .20 iii List of Tables Table 1 Contribution to y/y Growth by Sector, Q-2023 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Table 2 Labor-Market Statistics, Q2-2023 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Table 3 Key Macroeconomic Indicators, 2019–2025 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Table 4 Budget Support to the Palestinian Authority . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 Table 5 Key Fiscal Indicators, 2019–2025 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Table 6 Policy Recommendations to Improve Access to Health Essential Services . . . . . . . . . . . . . . . . . . .21 List of Boxes Box 1 Fiscal Multipliers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Box 2 The Palestinian Public Pension System: Challenges and Recommendations . . . . . . . . . . . . . . . . .10 iv AGAINST TIME – WORLD BANK ECONOMIC MONITORING REPORT TO THE AD HOC LIAISON COMMITTEE RACING  PREFACE O perating in environments marked by fragil- Palestinian territories and the wider region. In line with ity, conflict, and violence poses complex and the above, the findings of this report are unsurprising. distinct challenges, and the Palestinian case Unlocking the economic potential of the West Bank is no different. A significant body of literature has and Gaza requires urgent action, in order to spur emphasized the specific bottlenecks that exist, rang- per capita growth beyond near-stagnation levels, as ing from—in the first place—the movement, access, well as to put the fiscal situation on a sounder foot- trade, and investment restrictions imposed by the ing. The removal, or at least a significant reduction, Government of Israel (GoI) on the West Bank, and of restrictions by Israel is a vital prerequisite. Simul- the near-blockade of Gaza, the noncontiguous geog- taneously, steadfast commitment by the PA to the raphy of the territories, to the program advanced by implementation of a comprehensive reform agenda the Palestinian Authority on structural reforms lack- will be paramount to bolster both recovery and resil- ing momentum, and increasing penury of foreign ience, along with reinforcing institutional governance. aid. Numerous analytical and policy papers—span- In addition, as this report indicates, addressing short- ning at least three decades, since the establishment falls in the health sector will be pivotal to improve the of the AHLC forum—have emphasized the severity of efficiency of public spending, safeguarding human the challenges at hand and the imperative of foster- capital, improving service delivery, and revitaliz- ing cooperation among all parties. Despite relative ing economic opportunities in a context marked by clarity on the objectives, progress on the implemen- decades of fragility. While underscoring the burn- tation of priorities has been modest, resulting in ing pressure of these challenges, the World Bank increased complexity and urgency at the present day. remains fully committed to continuing its close techni- At the behest of the AHLC, this report aims to guide cal collaboration with the PA, the GoI, and all relevant the renewed efforts of the PA and the GoI, the global development partners, to help forging a path towards community, and—more broadly—all relevant policy- stability, security, economic progress and prosper- makers and stakeholders, as they lay the groundwork ity, and to contribute to the collective aspiration for a for sustainable growth and shared prosperity in the brighter future. v EXECUTIVE SUMMARY T he Palestinian economy slowed during program lacking conclusiveness and momentum on the first months of 2023. Preliminary data the Palestinian Authority (PA) side. These constraints for the first quarter (Q1) of 2023 indicate will continue to hinder economic activity and discour- that growth slowed to 3.1 percent, year-on-year (y/y), age private-sector development, preventing the Pal- largely due to the waning of post-pandemic recov- estinian economy from reaching its potential. Under ery. Meanwhile, systemic restrictions imposed by the these assumptions, economic growth is expected Government of Israel (GoI)1 continue to curtail eco- to hover around 3 percent over the medium term, nomic activity, especially in Gaza, where the economy and due to rapid population growth, the real income contracted by 2.6 percent in Q1 2023, according to per capita is expected to stagnate at best. More- data by the Palestinian Central Bureau of Statistics over, downside risks remain elevated. An escalation (PCBS). This is largely on account of a decline in the of Russia’s invasion of Ukraine could further strain agricultural, forestry, and fishing sector, which shrank global supply chains and increase pressure on food by almost 30 percent following a decision by the GoI and energy prices, slowing the growth of the Palestin- to restrict the sale of Gazan fish in the West Bank in ian economy. Meanwhile, renewed clashes between August 2022.2 On the other hand, in the West Bank Palestinians and Israeli forces in the West Bank and the economy grew by 4.3 percent y/y in Q1 2023, Gaza would increase the already elevated levels of thanks to continued expansion of private consump- political and economic uncertainty and could further tion which in turn supported the growth of wholesale and retail trade and services. 1 These restrictions are for the purpose of enhancing the The economic context in the West Bank security of Israel and Israeli citizens, according to the and Gaza continues to be marked by elevated Government of Israel. risks. The economy will continue facing a com- 2 According to the Israeli NGO Gisha, the GoI imposed bination of slow growth and high poverty rates, a total ban on the sale of fish from Gaza in the West unless substantial policy change takes place. Bank in August 2022 after a truck was caught transship- Under the baseline scenario, the Palestinian econ- ping Gazan fish into Israel. Several weeks later, a quota of 40 tons per month was imposed, which was raised omy is expected to continue languishing under the to 80 tons per month in February 2023—just over half multi-layered system of Israeli restrictions on move- the monthly average of 150 tons prior to the initial ban. ment access and trade in the West Bank, the near- https://gisha.org/en/israel-continues-to-restrict-sale-of-fi​ blockade of Gaza, the internal divide, and a reform sh-from-gaza-10-months-on/. vii limit Palestinian workers’ access to the Israeli labor foster private-sector expansion. Nonetheless, com- market. The PA has little fiscal scope to counter such prehensive analysis by the World Bank and other shocks, and political uncertainty in Israel could con- development institutions clearly reveals that the larg- tribute to exacerbate the macroeconomic and fiscal est hindrances to growth and private-sector develop- risks facing the West Bank and Gaza. ment3 are related to the GoI-imposed restrictions on The PA’s fiscal situation is predicted to movement and economic activity in the West Bank, worsen as we move further into 2023, and along with the near-total blockade of Gaza. Despite financing options are more and more limited, extensive and constructive dialogue among all par- worryingly raising fiscal sustainability risks. Pub- ties about these issues, action continues to lag lic revenue is performing well and expected to grow behind. Until the restrictions are removed, the Pales- by 6 percent, to around 24 percent of GDP in 2023, tinian economy is projected to persist in operating thanks to increased tax efforts and economic growth below its full potential. in the West Bank; however, expenditures are esti- Meaningful cooperation by the GoI mated to rise by 2.4 percent, reaching 26.5 percent remains crucial to improve the PA’s fiscal situ- of GDP. This increase is driven by as yet partial imple- ation and enable the Palestinian economy to mentation of recent agreements with labor unions, reach its full potential. For instance, the 1995 leading to a significant rise in the wage bill. As a interim agreement states that the Israeli civil admin- result, the overall deficit before grants is forecast to istration is expected to collect revenues from Israeli be US$561 million, equivalent to 2.8 percent of GDP. businesses operating in Area C and remit them to When accounting for Israeli deductions from clear- the PA.4 While these funds are collected by the GoI, ance revenues, the deficit could reach US$817 mil- thus far they have not been transferred to the PA. lion or 4.1 percent of GDP. Aid inflows are expected The GoI must also work with the PA to implement to partially narrow the deficit to US$493 million or institutional measures to sustainably reduce fiscal 2.5 percent of GDP, with US$324 million coming in leakages from clearance revenues, which are vital the form of budget support and development financ- to reinforce the PA’s finances. The following recom- ing. If pressure from unions results in the full imple- mendations (detailed on pages 11–12) can help mentation of labor agreements by September 2023, advance these objectives while yielding a number of the deficit could further increase to US$533 million. mutually beneficial outcomes: In the absence of clear policy change, the fis- cal deficit is anticipated to hover around 2.5 per- A. Fully implement the e-VAT clearance system. cent of GDP over the medium term, but financing B. Transfer customs responsibilities to the PA and options will become increasingly limited. Domes- establish Palestinian bonded warehouses. tic bank financing is no longer viable, leading to the C. Remit all VAT on Israel-Gaza trade to the PA. deficit being financed through the accumulation of arrears to the private sector, public employees, and the pension fund. The accumulation of such arrears 3 Laursen, T.B, and N. Nasser Eddin (2017). Prospects for growth and jobs in the Palestinian economy: a general over time poses meaningful risks to macro-fiscal sta- equilibrium analysis (English). Washington, D.C.: The bility, as it reduces market liquidity and can reverber- World Bank Group. http://documents.worldbank.org/cu​ ate in the banking sector. rated/en/952571511351839375/Prospects-for-growth​ PA reform efforts are necessary but not -and-jobs-in-the-Palestinian-economy-a-general-equilibri​ sufficient to establish the strong macroeconomic um-analysis. foundations required to achieve much-needed 4 See Annex III, Appendix I, Article 8, Paragraph 2(a), 2(b) and Article 18, Paragraph (4) of the Interim Agreement fiscal sustainability. The PA can and needs to con- on the West Bank and the Gaza Strip, Washington, D.C., tinue its efforts to substantially decrease the fiscal September 28, 1995 (the Interim Agreement) accessed deficit through reforms, while implementing further here: https://www.gov.il/en/Departments/General/the​ actions to enhance the business environment and -israeli-palestinian-interim-agreement-annex-iii. viii AGAINST TIME – WORLD BANK ECONOMIC MONITORING REPORT TO THE AD HOC LIAISON COMMITTEE RACING  D. Establish greater transparency regarding deduc- stable at about US$1.3–1.4 billion, the banking sys- tions from clearance revenues. tem’s exposure to the public sector increased consid- E. Renegotiate the fee charged by the GoI for han- erably, reaching US$2.5 billion in December 2021. By dling Palestinian imports. June 2023, PA borrowing had fallen to US$2.3 billion, F. Exempt the PA’s fuel imports from taxes. slightly above the PMA-imposed prudential limit and G. Collaboratively determine the exit fee collected at pre-pandemic levels.5 In addition to direct borrowing the Allenby Bridge and allocate the resulting reve- by the PA, bank loans to public employees, which are nue according to the shares specified in the Paris fully or partially backed by future PA salaries have cre- Protocol. ated indirect exposure to the public sector. Together, borrowing by the PA and public employees amounts Similarly, donor support is an irreplaceable to about US$4.2 billion, representing almost 37 per- factor to the success of the PA’s reform agenda, cent of total banking-sector credit. particularly in the short and medium term. Despite Limited progress on securing stable cor- broad-based agreement on this, there are few-to-no respondent banking relationships (CBRs) con- signs of increase on aid flows. To prevent adverse tinues to threaten the stability of cross-border social and economic repercussions, the PA should payments. In recent years, Israeli banks have sig- adopt a gradual approach in reforming revenue and naled plans to curtail or terminate CBRs with Pales- expenditure management, especially given the large tinian banks, citing concerns around potential money fiscal multipliers. At the same time, ongoing fiscal con- laundering and the financing of terrorism. Serious dis- solidation efforts are susceptible to external shocks, ruptions to CBRs would significantly impact the Pales- and success will also depend on the political climate tinian economy. Both the West Bank and Gaza heavily and cooperation by the GoI. In such a context—where rely on Israel as their primary trading partner, and ensuring a smooth fiscal consolidation path and miti- their predominantly cash-based economies depend gating political and economic uncertainty remain top on the Israeli Shekel.6 Limits on the repatriation of of the agenda—having adequate and predictable bud- shekels from Palestinian banks to Israel has contrib- get support becomes a pivotal and indispensable uted to an estimated accumulation of NIS 4.5 billion element for attaining success. In the medium term, in excess shekel-denominated liquidity in Palestinian donor assistance should be redirected towards devel- banks, equivalent to 6.4 percent of their assets as of opment projects that stimulate economic growth. end-September 2022.7,8 To mitigate the risk of immedi- Additionally, implementing further public financial ate disruptions to CBRs between the two banking sys- management reforms and cross-cutting governance tems, the GoI approved a temporary indemnity and measures could attract additional donor resources. immunity package for Israeli banks engaging with Pal- While discussions with the international community to estinian banks in 2017. This arrangement has been increase foreign aid to the PA are ongoing, their ulti- extended multiple times, most recently until March mate materialization remains uncertain. 2024, as the PA and GoI strive to establish a more sta- A recent positive development is a gradual ble framework for cross-border payments. However, stabilization of the Palestinian banking sector’s direct exposure to the public sector, at pre-COVID 5 The COVID-19 pandemic was one of several factors driv- levels. At the same time, the combination of direct ing the increase in PA borrowing during 2021. and indirect exposure remains sizeable overall, 6 The value of payment activity between Israel and the and warrants continued monitoring by the author- West Bank and Gaza is estimated at over NIS44 billion ities. During periods of heightened fiscal stress, per year. 7 Banks in the West Bank and Gaza must manage large the PA has repeatedly increased its borrowing from amounts of excess cash due to limits on the amount of domestic banks, at times exceeding the public-sec- cash that can be shipped to Israel. tor exposure limits set by the PMA. Following several 8 IMF Selected Issues Paper on West Bank and Gaza, years in which annual PA borrowing remained broadly September 16, 2022. Executive Summary ix progress has been limited due to several unresolved (23 percent from Gaza and 73 percent from the West disagreements, including the status of proposed Bank) have been referred from public health facilities Israeli legislation and the pending due diligence pro- to private or NGO-run hospitals in the east Jerusalem cess of participating Palestinian banks. Hospital Network (EJHN).12 the West Bank, Gaza, or This report also offers a focus chapter on Israel, resulting in an average annual financial bur- the Palestinian health system, demonstrating den of about NIS 850 million (almost US$250 million), large resource constraints hinder the health sys- equivalent to one-third of annual PMOH health expen- tem’s ability to cope with the mounting burden ditures or roughly 1.3 percent of GDP (2022). This of non-communicable diseases (NCDs). The ris- is in addition to over US$345 million in cumulative ing incidence of NCDs such as cancer, cardiovascular arrears to hospitals for services provided. Between conditions, diabetes, and kidney disease is increas- 2020 and 2022, the top three conditions for these out- ing the cost of health services across the Palestinian side medical referrals (OMR) were cancer, cardiovas- population. Moreover, the Israeli occupation and the cular conditions, and urological conditions. Together, broader macro-fiscal context in the Palestinian territo- these conditions represented a combined 60 percent ries have a significant impact on the Palestinian health of all referral expenditures.13 system’s ability to deliver services, by reducing invest- The Israeli and Palestinian authorities ments in facilities and infrastructure and restricting the should coordinate more effectively to ensure movement of people and goods. As a result, medicine access to essential health services, reduce the stockouts are common, particularly in Gaza. A recent financial burden of healthcare, and strengthen official joint WB-IMF mission to Gaza9 directly observed the Palestinian health system. Significant physical the critical conditions of the hospitals in the Strip, and— constraints limit timely access to high-quality essential in particular—the challenges faced by cancer patients, OMR services, and the PA’s current spending on these especially in relation to the availability of local treatment services is unsustainable. The focus chapter of this as well as to the acquisition of timely permits to travel report describes in detail the constraints on access to outside Gaza. Such hurdles often make it impossible health services and the respective roles and respon- to provide adequate and/or timely healthcare, in sev- eral cases resulting in the serious worsening of health 9 The mission took place in August 2023, and included conditions or even the death of patients. Importantly, in visits to local hospitals, schools, and private sector rep- recent years, the average availability of essential med- resentatives. icines in Gaza has been equivalent to just 55 percent 10 World Health Organization, Regional Office for the East- ern Mediterranean, 2023. “Right to health: barriers of need, compared to 90 percent in the West Bank.10 In to health and attacks on health care in the occupied addition, unfavorable work conditions and low salaries Palestinian territory, 2019 to 2021”. License: CC BY-NC- intensify human-resource constraints. Finally, recur- SA 3.0 IGO. rent armed conflict episodes have directly affected the 11 Ibid. delivery of health services: between 2019 and 2021, 12 Hospitals in the east Jerusalem Hospital Network (EJHN) 563 attacks affected 151 health facilities and injured include Augusta Victoria Hospital, Makassed Hospital, Saint John Eye Hospital, Palestinian Red Crescent Soci- 463 health workers.11 ety Hospital, Princess Basma Center for Children with Many patients are referred to hospitals that Diabetes, and Saint Joseph’s Hospital. While other hos- are not managed by the Palestinian Ministry of pitals in east Jerusalem also receive referrals, EJHN Health (PMOH), resulting in increasingly unsus- hospitals receive almost the totality of referrals. tainable health expenditures, which further exac- 13 All data pertaining to referral volumes and expenditures erbates an already strained fiscal position. NCDs in this chapter, unless cited otherwise, is from a cumula- tive analysis of OMR for January 2020 – October 2022 often require sustained treatment and continuous using eReferrals data obtained from the PMOH. This access to preventive, curative, and palliative care, analysis was conducted by the World Bank in 2023 as which the Palestinian public health system is not able part a forthcoming Public Expenditure Review (PER) in to offer. Since 2015, almost 90,000 cases per year early 2024. x AGAINST TIME – WORLD BANK ECONOMIC MONITORING REPORT TO THE AD HOC LIAISON COMMITTEE RACING  Objective Israeli authorities Palestinian authorities GoI + PA Improve access to quality Establish an expeditious, time-bound, Clearly define patient care pathways and Establish a coordination body to health services systematic, and transparent process for clinical guidelines for referrals, especially promote timely access to essential granting travel permits to Palestinian for Israeli hospitals. health services by reducing the patients and their companions. frequency of permit delays and Build the SPU’s capacity to manage denials. Offer multiple-entry permits to patients and audit referral cases, and continue with chronic conditions. streamlining the OMR process. Strengthen information systems and reporting to collect detailed patient, Strengthen the physical protection of procedure, and case-specific data, medical personnel and facilities. and integrate data collection with Facilitate the entry of essential existing information systems from all medicines, medical equipment, spare OMR-receiving hospitals, including parts, and medical supplies, particularly those in Israel. to Gaza. Enhance the fiscal Improve the reporting of unit costs, total Formulate an investment plan for reducing Ensure the financial sustainability of sustainability of the health expenditures, and clearance deductions expenditures by strengthening primary service delivery in EJHN. system for OMR treatment provided in Israeli care and building hospital capacity at Negotiate contracts stipulating the hospitals, and identify opportunities to PMOH facilities, with investments to be costs of services delivered in Israeli reduce prices. funded by the PA and its development hospitals, and align those costs with partners. Align Israeli Health Maintenance service-delivery costs in hospitals in Organization reimbursement rates Finalize contract negotiations with all EJHN and in the West Bank. directed to hospitals in the East referral-receiving hospitals and include Jerusalem Hospital Network with those provisions to address past arrears. of comparable Israeli hospitals. Conduct a detailed costing of care for priority conditions to move from a procedure-based to a case-based provider payment system, and strengthen purchasing arrangements, to reduce costs. sibilities of the Israeli and Palestinian authorities (Sec- vides some actionable policy recommendations for all tion 1 of Chapter 2), analyzes the fiscal implications of stakeholders to improve access to quality health ser- OMR expenditures (Section 2 of Chapter 2), and pro- vices, as summarized in the table below. Executive Summary xi 1 RECENT ECONOMIC DEVELOPMENTS 1.1.  Economic Activity other spending items in 2023, given the fiscal stress. By contrast, according to the PCBS, Gaza’s economy The Palestinian economy slowed during the first contracted by 2.6 percent due to the worsening per- few months of 2023. Following a major contraction formance of the agricultural, forestry, and fishing sec- of –11.03 percent in 2020 due to the COVID-19 cri- tor (Table 1), which shrank by almost 30 percent after sis, the GDP growth rate rebounded to 7.0 in 2021 the GoI restricted the sale of Gazan fish in the West and 3.9 percent and 2022. However, preliminary data Bank in August 2022.14,15 for the first quarter (Q1) of 2023 indicate that growth The unemployment rate increased in slowed to 3.1 percent, year-on-year (y/y), due to the Q2-2023. It rose from 24.4 percent in 2022 to waning post-pandemic recovery coupled with spill- 24.7 percent in Q2 2023, mostly driven by an overs from Russia’s invasion of Ukraine (Figure 1). increase in Gaza’s unemployment rate, which rose Meanwhile, systemic restrictions imposed by the Gov- ernment of Israel (GoI) continue to curtail economic activity, especially in Gaza. 14 According to the Israeli NGO Gisha, the GoI imposed a total ban on the sale of fish from Gaza in West Bank The West Bank drove growth in Q1-2023, in August 2022 after a truck was caught transship- while Gaza’s economy contracted. Economic ping Gazan fish into Israel. Several weeks later, a quota activity in the West Bank rose by 4.3 percent y/y in of 40 tons per month was imposed, which was raised Q1-2023, as the continued expansion of private con- to 80 tons per month in February 2023—just over half sumption supported the growth of wholesale and the monthly average of 150 tons prior to the initial ban. retail trade and services. The increase in private con- https://gisha.org/en/israel-continues-to-restrict-sale-of-fi​ sh-from-gaza-10-months-on/. sumption was mostly financed through the earnings 15 Gaza’s economy contracted in Q1-2023, y/y, despite an of Palestinian workers in Israel. Public consump- increase in exports compared to the same quarter in the tion declined (y/y) as the PA has been paying par- previous year and a rise in the number of Gazan work- tial wages since late 2021 and has also squeezed ers exiting the Strip. 1 FIGURE 1 • GDP Continued Its Moderate Growth in 2022/23 25.00 20.00 15.00 10.00 5.00 0.00 –5.00 –10.00 –15.00 –20.00 –25.00 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 2019 2019 2019 2019 2020 2020 2020 2020 2021 2021 2021 2021 2022 2022 2022 2022 2023 Palestinian Territories West Bank Gaza Strip TABLE 1 • Contribution to y/y Growth by Sector, Q1-2023 (%) Sector West Bank Gaza Combined Average Agriculture, Forestry and Fishing –0.2 –3.1 –0.7 Mining, Manufacturing, Electricity and Water 0.1 0.3 0.1 Construction 0.1 –0.8 0.0 Wholesale and Retail Trade 1.3 0.6 1.2 Transportation and Storage 0.1 0.1 0.1 Financial and Insurance Activities 0.4 0.4 0.4 Information and Communication 0.0 0.0 0.0 Services 0.5 –1.3 0.2 Public Administration and Defense –0.1 0.4 0.0 Households with Employed Persons 0.0 0.0 0.0 FISIM 0.0 0.0 0.0 Customs Duties –0.1 –0.1 –0.1 VAT on Imports, net 2.2 1.1 2.0 GDP growth 4.3 –2.6 3.1 Source for Fig 1 and Table1: Palestinian Central Bureau of Statistics. from 45.3 percent to 46.4 percent (Table 2). Rising Inflation remained relatively stable in the unemployment in Gaza largely reflects the contrac- first half of 2023 at close to the 2022 average. tion in economic activity, as explained earlier in the The post-pandemic recovery and Russia’s invasion report, and the lasting impact of the near-total Israeli of Ukraine have driven up food and fuel prices world- blockade. In the West Bank, the unemployment rate wide. In the Palestinian territories, the CPI increased reached 13.4 percent in Q2-2023, up from 13.1 per- to 3.7 percent (y/y) in 2022, from negative territory cent in 2022. in 2020. It has since remained relatively stable with 2 AGAINST TIME – WORLD BANK ECONOMIC MONITORING REPORT TO THE AD HOC LIAISON COMMITTEE RACING  TABLE 2 • Labor-Market Statistics, Q2-2023 Indicator (%) West Bank Gaza Combined Average Unemployment rate 13.4 46.4 24.7 Full employment 85.5 51.6 73.9 Underemployment 1.1 2.0 1.4 Labor force participation rate 47.8 39.9 44.8 Youth unemployment (15–29 years) 22.4 59.3 35.7 Male 17.0 54.0 30.1 Female 42.8 77.1 56.0 Source: Palestinian Central Bureau of Statistics. the CPI reaching 3.8 percent in the first half of 2023. 1.25 million people living below the poverty line. The In Gaza, the inflation rate was just 1.8 percent in the poverty rate is projected to hold steady at around first half of 2023, while in the West Bank it reached 24.2 percent until 2025. 4.4 percent, reflecting a continuous divergence in the In the absence of distinct policy change, cost of living between the two territories. The mod- the West Bank and Gaza are expected to con- est uptick in inflation was driven by an increase in all tinue facing a combination of slow growth and major expenditure groups, including food, tobacco, high poverty rates, in a context of elevated risks. and transportation. Under the baseline scenario, the Palestinian econ- Rising consumption boosted imports, wid- omy is expected to continue languishing under the ening the current-account deficit. While imports multi-layered system of Israel restrictions on move- and exports both increased during Q1-2023, exports ment access and trade in the West Bank, the near- remained low due to ongoing trade restrictions. Con- total blockade of Gaza, the internal divide, and a sequently, import growth widened the trade deficit reform program lacking conclusiveness and momen- from US$2.1 billion in Q1-2022 to US$2.4 billion in tum on the PA side. These constraints will continue to Q1-2023. Meanwhile, net foreign income improved, hinder economic activity and discourage private-sec- driven by increased private transfers and official tor development, preventing the Palestinian economy transfers to the government. However, the increase from reaching its potential. Under this scenario, eco- in transfers was not sufficient to offset the growth of nomic growth is expected to hover around 3 percent, the trade deficit, and as a result the current-account and due to the rate of population growth, the average deficit widened from US$602 million in Q1-2022 to real income per capita is expected to stagnate. More- US$754 million in Q1-2023. over, downside risks remain elevated. An escalation The latest estimates indicate that the pov- of the war in Ukraine could further strain global sup- erty rate peaked in 2020, then dropped slightly ply chains and increase pressure on food and energy in 2022. In the West Bank, poverty rates are lower prices, slowing the growth of the Palestinian economy. but sensitive to economic shocks, while in Gaza Meanwhile, a further escalation of clashes between changes in social assistance flows significantly affect Palestinians and Israeli forces in the West Bank and the population’s wellbeing. Estimates based on the Gaza would increase economic uncertainty and could Upper Middle Income poverty line, and taking into further limit Palestinian workers’ access to the Israeli account trends in real per capita GDP, suggest that labor market. The Palestinian Authority (PA) has little the poverty rate peaked at 26.5 percent in 2020. As fiscal scope to counter such shocks, and uncertainty the impact of pandemic-related economic restric- on the political front in Israel could contribute to exac- tions faded, the overall poverty rate dropped to an erbate the macroeconomic and fiscal risks facing the estimated 24.3 percent in 2022, representing almost West Bank and Gaza. Recent Economic Developments 3 TABLE 3 • Key Macroeconomic Indicators, 2019–2025 2019 2020 2021 2022 2023e 2024f 2025f Real economy, annual percent change, unless indicated otherwise Real GDP 1.4 –11.3 7.0 3.9 3.2 3.0 2.7 Nominal GDP 5.3 –9.3 16.6 5.5 5.0 4.9 4.6 GDP Per Capita (nominal) 2.7 –11.6 13.8 3.0 2.5 2.4 2.2 Real GDP growth, at constant market prices Private Consumption 4.1 –13.1 7.5 20.5 4.0 3.8 3.7 Government Consumption –3.5 0.3 10.3 –10.5 –3.0 4.0 3.7 Gross Fixed Capital Investment –2.6 –20.9 13.7 11.8 3.0 2.8 2.2 Exports, Goods and Services 2.0 –11.2 17.3 6.2 5.0 5.0 5.0 Imports, Goods and Services 1.4 –14.2 14.8 25.7 5.0 5.0 5.0 Real GDP growth, at constant factor prices Agriculture 0.9 –9.1 –0.7 –5.7 –1.0 –1.0 –1.0 Industry –0.5 –19.4 4.5 3.4 3.2 3.0 2.8 Services 2.0 –10.0 7.5 1.5 3.6 3.4 3.0 Labor force participation rate (%) 44.3 40.9 43.4 45.0 45.0 45.0 45.0 Unemployment Rate (%) 25.3 25.9 26.4 24.4 24.4 24.5 24.5 GDP Deflator 3.8 2.2 9.0 1.5 1.8 1.8 1.8 Consumer Price Index (year-average) 1.6 –0.7 1.2 3.7 3.8 3.0 2.7 Overall Fiscal Balance (% GDP) –7.4 –7.5 –5.8 –1.8 –2.5 –2.5 –2.5 Current-Account Balance (% GDP) –10.4 –12.3 –9.8 –15.0 –13.8 –13.2 –12.7 Memorandum items: Nominal GDP (US$ million) 17,134 15,532 18,109 19,112 20,073 21,049 22,013 Source: PCBS, PMA, and Palestinian Ministry of Finance. Note: e = estimate. 1.2.  Public Finances a local tobacco-distribution company that had been deferred from the previous year. Nontax revenue   a) Fiscal Performance, January– remained almost constant y/y as rising revenue from June 2023 domestic fees and charges offset the decline in invest- ment profits received by the PA during H1-2023, y/y. Most PA revenue is generated in the West Bank, Clearance revenues16 also performed rela- and recent economic growth boosted tax collec- tively well in H1-2023, increasing by 6 percent y/y tion in the first half (H1) of 2023. Domestic tax despite additional GoI deductions. Customs duties, revenue grew by 13 percent, supported by a broad- based increase across most tax categories. Domestic 16 “Clearance revenues” are revenues collected by the customs revenue rose by 21 percent, while income GoI and transferred to the PA after certain deductions tax increased by 6 percent. In addition, revenue from have been made. Most clearance revenues are VAT and excise taxes on tobacco spiked by 82 percent in H1 import duties, and they should be remitted on a monthly 2023 due to the receipt of a one-off payment from basis according to the Paris Protocol. 4 AGAINST TIME – WORLD BANK ECONOMIC MONITORING REPORT TO THE AD HOC LIAISON COMMITTEE RACING  which are collected on imports from countries other Budget Support to the Palestinian TABLE 4 •  than Israel,17 fell by 4 percent as trade data for the first Authority, US$ Millions five months of 2023 show a slight decline in third-coun- Budget Support Partners Jan–June 2022 Jan–June 2023 try imports. Unlike customs duties, VAT is collected on Arab Donors 5 0 all imports, including those from Israel. Following an Multilaterals 37 118 increase in imports from Israel by 9 percent in the first five months of 2023, VAT revenue grew by 15 percent EU PEGASE 1 63 y/y. In addition, petroleum excise taxes increased by World Bank DPG 30 30 about 18 percent. The GoI’s deductions from clearance World Bank PURSE a 6 22 revenues to account for some of the payments made World Bank CTP 0 3 by the PA to Palestinian prisoners in Israeli prisons, ex- Total 42 118 prisoners, and families of those deceased as a result Source: Palestinian Ministry of Finance. of violence were doubled from NIS51 million to NIS102 a Some of the contributions from PURSE donors, including Norway, were committed in 2022 but materialized in 2023, hence they are reflected (above) in the H1 2023 million per month between February and July 2023. figures and not in the H1 2022 figures. The increase, according to the GoI, was to account for funds not withheld during a temporary COVID-19 pan- demic-related suspension in 2019. The deductions were very close to the previous year’s level as the PA reduced again to NIS51 million in July 2023. It has been priori-tized other budget categories. The cost of the reported, though, that the GoI may increase the monthly fuel sub-sidy, which has been reclassified as an deductions again by NIS20 million to offset some of the expenditure item rather than a negative revenue electricity debt owed by the Jerusalem electricity distri- item since Janu-ary 2023, fell by about 18 percent y/ bution company to the Israeli supplier, the IEC. y in the H1-2023, due in part to easing pressure on Recurrent public spending rose on a com- global fuel prices. mitment basis by 1.3 percent y/y in H1-2023, Given expenditure constraint and high driven by increases in the wage bill and transfers, reve-nue growth, the PA faced a relatively small the PA’s two largest expenditure categories. The deficit in H1-2023, though it was significantly wage bill increased by 4.9 percent y/y on a commit- widened by Israeli deductions. The total deficit ment basis due to the implementation of the yearly before grants reached US$82 million over the step increase and the recently agreed increases for period, but the GoI’s deductions from clearance specific professions, including 10 percent for medical revenues amounted to US$157 million, raising doctors, 5 percent for medical support staff, 5 percent the overall deficit to US$239 million. Meanwhile, for engineers, and 5 percent for teachers.18 How- donor financing increased significantly to US$156 ever, on a cash basis the PA has been paying around million from US$80 million during the same 80–85 percent of the salaries of its public employ- period in 2022 (US$118 million in budget support ees since November 2021 while protecting the lowest and US$38 million in development financing). earners. Government transfers increased by 7 percent After aid, the deficit reached US$83 mil-lion. While y/y in H1-2023 after a delayed National Cash Trans- no funding was received from Arab donors in the fer Program (NCTP) payment from 2022 was executed first six months of 2023 (unlike the previous year), in April. Due to the fiscal stress, the PA has not been the y/y increase in budget support reflected making regular quarterly payments through the NCTP, 17 The 1994 Paris Protocol regulates economic relations which has had a large impact on the most vulnerable, between the GoI and the PA. It established a quasi-cus- especially in Gaza. Net lending, reflecting unplanned toms union between Israel and West Bank and Gaza subsidies to Local Government Units (LGUs) covering under which the two parties apply the same import pol- accumulated utility bills to Israeli suppliers, increased icy on trade with third countries and maintain free trade in all goods between them. by 3.5 percent during the first six months of 2023. In 18 According to the Palestinian Ministry of Finance, the contrast, spending on goods and services was kept increases have so far been only partially implemented and will be paid in full once funds are available. Recent Economic Developments 5 the reinstatement of EU funding and access to addi- in previous years, was filled through the accumulation tional funding through the World Bank’s Multi-Donor of arrears and additional borrowing from the domestic Trust Fund (PURSE) (Table 4). The remaining gap, as banking sector. In fact, the stock of domestic public TABLE 5 • Key Fiscal Indicators, 2019–2025 2019 2020 2021 2022 2023e 2024f 2025f Figures expressed as percent of GDP Overall Balance –7.4 –7.5 –5.8 –1.8 –2.5 –2.5 –2.5 Primary Balance –7.1 –7.1 –5.1 –1.1 –1.8 –1.8 –1.8 Total Revenues and Grants 22.4 25.7 25.0 27.3 24.1 24.1 24.1 Domestic Tax Revenues 4.5 4.7 5.5 6.0 5.7 5.7 5.7 Income tax 1.2 1.2 1.2 1.5 1.4 1.4 1.4 Value added tax 1.8 2.0 2.0 2.2 2.0 2.0 2.0 Customs 1.1 1.0 1.6 1.7 1.7 1.7 1.7 Excises on beverages 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Excises on tobacco 0.4 0.5 0.6 0.6 0.6 0.6 0.6 Property tax 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Non-Tax Revenues 2.1 2.4 2.2 2.4 1.9 1.9 1.9 Earmarked collectionsa 0.5 0.6 0.8 0.9 0.7 0.7 0.7 Clearance Revenuesb 12.8 15.1 15.3 16.5 14.4 14.4 14.4 Grants 2.8 3.1 1.7 1.8 1.6 1.6 1.6 Tax Refunds –0.3 –0.3 –0.6 –0.2 –0.3 –0.3 –0.3 Total Expenditures 29.9 33.2 30.7 29.1 26.5 26.5 26.5 Current Expenditures 24.7 28.0 26.0 23.7 21.8 21.8 21.8 Wages and Compensation 13.0 14.2 14.6 13.9 12.9 12.9 12.9 Goods and Services 3.7 4.2 4.4 4.2 3.9 3.9 3.9 Interest Payments 0.3 0.4 0.7 0.7 0.7 0.7 0.7 Current Transfers 7.7 9.2 6.3 4.8 4.3 4.3 4.3 Capital Expenditures 2.1 2.0 1.5 1.6 1.3 1.3 1.3 Net lending 1.9 2.2 2.1 1.9 1.8 1.8 1.8 Earmarked Payments 0.5 0.6 0.8 0.9 0.7 0.7 0.7 Fuel subsidy 0.7 0.4 0.4 1.1 0.8 0.8 0.8 Government Financing 7.4 7.5 5.8 1.8 2.5 2.5 2.5 External Borrowing (net) 1.1 0.7 0.0 –0.1 0.0 0.0 0.0 Domestic Borrowing (net) 3.6 2.9 0.5 –0.5 –0.5 0.0 0.0 Domestic Arrears (net) 2.8 3.9 5.3 2.4 2.9 2.5 2.5 General Government Debtc 39.2 55.1 56.0 53.2 53.1 53.2 53.3 Note: e = estimate, f = forecast. a Earmarked collections and payments are collections from taxes and revenues due to local government units. b Revenue collected by Israel on behalf of and transferred to the Palestinian Authority. c General government debt figures include foreign debt, domestic debt, and arrears. 6 AGAINST TIME – WORLD BANK ECONOMIC MONITORING REPORT TO THE AD HOC LIAISON COMMITTEE RACING  debt increased from US$2.24 billion in December arrears will eventually pose a risk to macroeconomic 2022 to US$2.42 billion in June 2023. stability, as they pull liquidity from the market and may The stock of arrears owed by the PA to the also weaken the banking sector. private sector, public employees, and the pen- sion fund remains large. According to the Minis-   c) Toward Fiscal Sustainability: Policy try of Finance’s monthly fiscal reports, the stock of arrears to the private sector stood at US$0.9 billion in Priorities for the PA, GoI, and June 2023. Wage arrears to public employees are cur- Development Partners rently estimated at US$0.6 billion. In addition, arrears Fiscal sustainability requires a strong macroeco- to the pension fund for the civil service are estimated nomic foundation, which the PA’s reform efforts at about US$3 billion, while no data are available on are necessary but not sufficient to establish, the security-service pension schemes. and additional actions by the GoI remain cru- cial to enable the Palestinian economy to reach b) Fiscal Forecast for 2023 its potential. Reforms by the PA could over time significantly reduce the size of the fiscal deficit, and The PA’s fiscal situation is expected to worsen additional measures to improve the business environ- during the latter part of 2023. According to ment could accelerate private-sector growth. However, World Bank estimates, public revenue will continue previous World Bank analytical work has shown that to perform well and is expected to grow by about 6 GoI restrictions on movement and economic activ- percent in 2023, reflecting rising tax effort and con- ity in the West Bank and the near-blockade of Gaza tinued economic growth in the West Bank. Increased remain the most important obstacles to growth and domestic and clearance revenues will both drive rev- private-sector development.19 Until these challenges enue growth. Meanwhile, expenditures are projected are addressed, the Palestinian economy will continue to rise by 2.4 percent as the partial implementation to operate below its potential. of recent agreements with labor unions drives a sig- Reforms are urgently needed to strengthen nificant increase in the wage bill. As a result, the the PA’s fiscal position and to set the foundation for overall deficit before grants will reach US$561 million more robust growth once a long-term political reso- or 2.8 percent of GDP by end-2023. GoI deductions lution is in place. The unreliable funding of key pub- from clearance revenues are estimated at 1.3 per- lic services and the high level of payment arrears to cent of GDP and are expected to push the deficit to the private sector are inhibiting economic develop- US$817 million or 4.1 percent of GDP. Aid inflows are ment and tightening liquidity constraints. Efforts to expected to reach US$324 million (US$240 in budget improve the equity, effectiveness, and efficiency of support and US$84 in development financing) nar- public spending must encompass the wage bill, the rowing the deficit to US$493 million or 2.5 percent generous public pension system (see Box 1), and the of GDP. If pressure from the unions results in the full allocation of transfers to avoid untargeted payments implementation of the labor agreements by the start and ensure that transfers support the poorest and of the school year in September, the deficit could most vulnerable households. As described in Chap- reach US$533 million or 3.7 percent of GDP by the ter 2, strengthening the management of referrals is a end of the year. If current policies remain unchanged, the deficit is expected to hover around 2.5 percent of GDP over the medium term, while financing options 19 Laursen, T.B, and N. Nasser Eddin (2017). Prospects for will become even more limited. Given that domestic growth and jobs in the Palestinian economy: a general equilibrium analysis (English). Washington, D.C.: The bank financing is no longer an option, the deficit is World Bank Group. http://documents.worldbank.org/cu​ expected to be financed through the further accu- rated/en/952571511351839375/Prospects-for-growth​ mulation of arrears to the private sector, public -and-jobs-in-the-Palestinian-economy-a-general-equilibri employees, and the pension fund. These additional um-analysis. Recent Economic Developments 7 BOX 1: FISCAL MULTIPLIERS The short-term impact of discretionary fiscal policy on output is measured using fiscal multipliers. Fiscal multipliers are defined as the ratio of a change in output (DY) to a discretionary change in government spending or tax revenue (DG or DT). Put simply, the fiscal multiplier measures the effect of a $1 change in government spending or tax revenue on the level of GDP. Fiscal multipliers are not widely used by economists in operational work given the difficulty to isolate the direct effect of fiscal measures on GDP, because of the two-way relationships between these variables. In addition, data availability limits the scope for estimating multipliers. Econometric and model-based methods need 15 years of quarterly data to produce unbiased estimates. There is an emerging consensus in economic literature that spending multipliers vary both across countries and across time. Recent research has shown that the size of government spending multipliers (DY/DG) depend on the key characteristics of the economy in question. For example, the higher trade openness of a country leads to a lower multiplier as part of the extra demand can be met from abroad. Also, the nature of the exchange rate regime matters as countries with flexible exchange rate regimes tend to have lower multipliers. In addition to the structural characteristics of economies, temporary factors tend to increase or decrease multipliers from their “regular” levels as well. For example, the stage of the business cycle in which an economy finds itself affects the size of the multipliers as they tend to be larger in a recession. Given lack of data, a simple approach outlined in Batini, et al. (2014) was utilized to calculate the fiscal multipliers for the Palestinian economy. These authors propose to group countries into three groups that are likely to have similar multiplier values based on their characteristics. They employ a three-step approach where they: i) assign scores based on the country’s structural characteristics; ii) sum the scores to determine the likely level of the first-year multiplier (low, medium, or high) in “normal” times; iii) scale up or down the range assigned through the scoring method depending on whether the country is undergoing any of the “temporary” characteristics. Following this approach, the estimate for the government spending multiplier in the Palestinian territories is in the range of 0.2–0.6. Source: The World Bank’s report to the AHLC, September 2021. key priority in the health sector. Reforms to reduce net which recruitments should not exceed 50 percent of lending are also urgent, as the current system results retirements and other departures. Data for the first in large unplanned subsidies to local governments. half of 2023, however, show that the policy has not The PA’s reform agenda has not advanced been enforced, as the ratio of recruitments to exits in equally in all areas. The PA has made impressive the overall public sector reached 94 percent (131 per- gains in revenue mobilization, and in 2022 central cent in the security sector and 79 percent in the civil- government revenues (before grants) reached 25 per- ian sectors): urgent attention is required to ensure the cent of GDP, relatively high by the standards of an consistent implementation of reforms in this and other operating environment marked by decades of fragility. areas where progress has been slower than expected. The PA continues to make progress in improving the Increased donor support will be vital to public financial management system: the production the success of the PA’s reform agenda. However, and auditing of financial statements has accelerated, there are few-to-no signs of significant increases and the five-year backlog of audited financial state- from current two-decade lows. The PA’s efforts to ments has been fully cleared. The PA has also com- reform revenue and expenditure management must mitted to implementing a commitment-control system remain gradual to avoid adverse social or economic for all expenditure categories by end-2023, which consequences. Large cuts in public spending would should strengthen arrears management. The passage likely have a negative impact on economic activity of a new law has bolstered the anti-money-launder- given the existence of large fiscal multipliers (Box 1). ing and combating the financing of terrorism (AML/ The ongoing fiscal consolidation is also highly vulner- CFT) framework. The consistent implementation of able to exogenous shocks, as economic growth and this framework will require continued commitment the fiscal balances continue to hinge on the politi- from the PA and the donor community. To control the cal context and on cooperation with Israel. Adequate growth of the wage bill, the Cabinet adopted an attri- and predictable budget support will be necessary tion target for net public employment in 2023, under both to facilitate the fiscal consolidation and to hedge 8 AGAINST TIME – WORLD BANK ECONOMIC MONITORING REPORT TO THE AD HOC LIAISON COMMITTEE RACING  FIGURE 2 • GDP Continued Its Moderate Growth in 2022/23 1.400 20 18 1.200 16 1.000 14 12 Percent of GDP 800 USD million 10 600 8 400 6 4 200 2 0 0 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 External Budgetary Support, USD million Development Financing, USD million Total Aid (Grants), % GDP Source: Palestinian Ministry of Finance. against political and economic uncertainty. Aid, how- tive size of the issue is more significant for the ever, has been on a steep declining trend (Figure 2). PA since around two thirds of its trade is with In the medium term, donor support should be redi- Israel, while the volume of Israeli exports to the rected toward development projects that will bol- Palestinian territories is not significant. The Paris ster economic growth, and further public financial Protocol allows the parties to implement an “inter- management reforms and cross-cutting governance connected computer system for tax rebates to measures could attract additional donor resources. dealers and for VAT clearance between the two Ongoing discussions with the international commu- sides,”21 and in 2022 they launched a pilot e-VAT nity about potentially expanding the volume of foreign system under which traders on both sides can aid to the PA are a positive development, but their ulti- voluntarily issue digital transaction receipts. The mate impact on donor funding is not yet clear. challenge now is to bring all traders and transac- The GoI’s cooperation is essential to improve tions into the system. The PA has made encour- the PA’s fiscal situation. The 1995 interim agreement aging progress in updating digital systems and states that the Israeli civil administration is expected to enrolling traders. However, the GoI has yet to collect revenues from Israeli businesses operating in legally mandate that traders use the system, and Area C and remit them to the PA.20 While these funds progress on this point is urgent. The GoI reports are collected by the GoI, thus far they have not been that the e-VAT legislation is scheduled to be pre- transferred to the PA. The GoI must also work with the sented at the Knesset during the Winter session. PA to implement institutional measures to sustainably The ultimate goal should be to fully link the inter- reduce fiscal leakages from clearance revenues, which is vital to reinforce the PA’s finances. The following rec- 20 See Annex III, Appendix I, Article 8, Paragraph 2(a), 2(b) ommendations could advance these objectives while and Article 18, Paragraph (4) of the Interim Agreement yielding other mutually beneficial outcomes: on the West Bank and the Gaza Strip, Washington, D.C., September 28, 1995 (the Interim Agreement) accessed here: https://www.gov.il/en/Departments/General/the​ A. Fully implement the e-VAT clearance system. -israeli-palestinian-interim-agreement-annex-iii. The Palestinian and Israeli authorities both face 21 See article VI paragraph 9 of the protocol on economic fiscal leakages from bilateral trade, but the rela- relations. Recent Economic Developments 9 BOX 2: THE PALESTINIAN PUBLIC PENSION SYSTEM: CHALLENGES AND RECOMMENDATIONS The PA’s public sector pension system is in transition from a fragmented to a unified scheme. T he new, unified scheme (introduced in 2006), despite notable improvements, continues to confront major issues, notably a dramatic worsening of the dependency ratio in the long run, which will require policy adjustments. In addition, the main Defined Benefit (DB) component remains costly due to a combination of a generous formula (2 percent for each year of service), relatively low age of retirement (60), and early retirement privileges. The Defined Contribution (DC) component has never properly been implemented as the individual DC accounts held at the Palestine Pensions Authority (PPA) are notional (i.e.: there is no real money) and accrue no interest. The schemes’ financing mechanism is complex, lacks transparency and needs to be consistent with the Unified P e nsion Law. Th e MoF Treasury is required to cover the costs of pensions under the old schemes (I, III, and IV), and additionally, to pay contributions for all public sector employees that are part of the new Scheme (II). Both of these contributions are of the same magnitude, financially. H owever, t he Treasury is de facto only financing the current pension payouts. The stock of contribution arrears is allegedly at over 15 percent of GDP (subject to reconciliation between the PPA and MoF), and on a growing trend. Reform efforts should proceed on four parallel tracks: Parametric adjustments to alleviate the costs of future pensions, including: a) gradually raise the retirement age to 63, for women and men, by three months annually, over a 12-year period, to keep pace with the increasing life expectancy, b) restrict early retirement to 5 years under the retirement age (initially 55), no matter what total service has been accumulated, c) gradually reduce the accrual rate of pension benefits from the current 2% down to 1.75%, d) reduce the minimum service from 15 to 10 years to enhance access to pensions, while the span of the pensionable wage at retirement could expand to cover at least 5 years of wages, and e) reform the benefit indexation policy, combining wage growth and inflation. Systemic changes to split the DB benefit package into two. The DB scheme could be made partially non-contributory, by splitting it into two components: (i) one that is linked to regular contributions, while (ii) another component would be a non-contributory basic pension, building on the precedent of the personal allowance (NIS300), paid to all that have the right to the contributory component. Such an approach would allow for a more transparent budgeting process, better link to the wage bill policy, and would give more flexibility to the government in responding to various policy challenges. Transforming the DC benefit into an early-separation (indemnity) payment. The DC component d e facto operates now as an end-of- service indemnity scheme with a lump sum benefit linked to earnings. It is recommended to convert it into such de jure, so it becomes an unemployment and early separation insurance. Removing the matching 3 percent contribution of the government to that scheme—and possibly making the employee contributions to such scheme voluntary—is also an option. Restructure and rationalize the institutional and financial responsibilities of PPA and MOF as regards the pension system. If the MoF financially guarantees all future pension payments, it could legally assume the full financial responsibility for all current and future pension obligations by financing any deficit of the consolidated system, without differentiating between schemes. In exchange, all the DB contribution arrears that the MoF has accumulated so far, along with interest and penalties, would be annulled. Among other things, this would result in a reduction of the current explicit public debt. Source: Public Expenditure Review of The Palestinian Pension System: A Roadmap for Unfinished Reform, The World Bank, September 2022. faces of both authorities, enabling them to reduce high-value goods such as cigarettes, tobacco, VAT leakage by exchanging real-time information and alcohol—as well as the scope of the transfer on all purchases being made.22 of responsibilities and the number and location of B. Transfer customs responsibilities to the the customs transfer points to be established as PA and establish Palestinian bonded ware- this would affect the transportation costs. On the houses. Recent meetings between the Pal- PA side, assessments of the existing legal frame- estinian and Israeli Ministries of Finance have work and customs capacity have shown that, produced a draft memorandum of understand- ing on the transfer of customs responsibility from 22 According to the GoI, the Israeli and Palestinian tax the GoI to the PA. However, several contentious authorities signed a memorandum of understanding in issues remain, including the type of goods that August 2023 to settle the dispute over VAT payments would be under the purview of the PA—specifically since 2016. 10 AGAINST TIME – WORLD BANK ECONOMIC MONITORING REPORT TO THE AD HOC LIAISON COMMITTEE RACING  despite recent improvements, additional efforts will result in additional revenues being remitted are needed to successfully implement the trans- to the PA. fer of responsibilities. According to the GoI, the F. Exempt the PA’s fuel imports from taxes. Under parties may resume the talks soon to resolve out- the Paris Protocol, fuel imported by the PA should standing issues. meet specific standards that fuel produced by C. Remit all VAT on Israel-Gaza trade to the PA. regional countries does not meet. As a result, PA tax officials ceased operating in Gaza after the PA purchases all its fuel from Israeli compa- the establishment of the Hamas-led government nies on which it pays all applicable taxes. These in 2007. Since then, the PA has rarely received taxes are then remitted to the PA after 45 days as information on purchases of Israeli imports by part of the clearance process, minus the handling businesses in Gaza, making it impossible to col- fee. Following recent meetings between the par- lect VAT from the majority of those imports. As the ties, the handling fee on fuel was reduced from GoI controls and approves the entry of all Israeli 3 percent to 1.5 percent. While this is a positive goods into Gaza via the sole commercial cross- step, the resulting savings are limited to about ing at Karem Abu Salem, Israeli officials should US$1.7 million per month. Enabling the PA to pur- be in a position to levy and transfer to the PA all chase fuel without the embedded taxes would VAT revenue collected from bilateral trade with help it maintain financial liquidity. The PA should Gaza. As a next step, PA officials could be pres- also consider eliminating the subsidy on retail fuel ent at Karem Abu Salem to collect trade invoices prices, which are costly and regressive.24 and formalize their claims on VAT revenue. G. Collaboratively determine the exit fee col- D. Establish greater transparency regarding lected at the Allenby Bridge and allocate the deductions from clearance revenues. The GoI resulting revenue according to the shares reports that it does exchange information with the specified in the Paris Protocol. Under the proto- PA about the monthly deductions from clearance col, revenue from exit fees shall be shared between revenues. The PA, however, reports that it has the PA and the GoI on a 46/54 basis for the first had difficulty reconciling Israeli deductions with 750,000 passengers and on a 62/38 basis for actual LGU expenditures on energy, water, waste- each passenger thereafter. The GoI should remit water, and health services provided by Israeli to the PA its full share of previously collected suppliers due to the lack of detail provided by funds according to this formula, and future trans- the GoI. These discrepancies have widened over fers should be made on a regular basis. the years, creating the need for a mechanism that would reconcile LGU data on service consump- tion with billing by Israeli providers and enable 1.3.  Money and Banking independent verification on an ongoing basis. Persistent risks notwithstanding, the financial E. Renegotiate the fee charged by the GoI for sector in the West Bank and Gaza remains sta- handling Palestinian imports. In 1995, the par- ble and increasingly profitable. According to ties agreed that the GoI would deduct 3 percent preliminary reporting by the Palestine Monetary of the import taxes and VAT revenue it collects Authority (PMA) through Q2-2023, the profitability on Palestinian trade to cover its administrative costs.23 Based on the size of Palestinian trade in 1995, the fee was considered acceptable to both 23 Paragraph 4 of the supplement to the Protocol on Eco- parties. However, Palestinian imports have sig- nomic relations, Annex V of the Interim Agreement. 24 World Bank (2022) Economic Monitoring Report to the nificantly increased over the last 30 years, and Ad Hoc Liaison Committee – September 2022. https://​ while the GoI’s administrative costs have also www.worldbank.org/en/country/westbankandgaza/pu​ increased, the current fees significantly exceed blication/economic-monitoring-report-to-the-ad-hoc-liais​ cost-recovery levels. Reducing the handling fee on-committee-september-2022. Recent Economic Developments 11 FIGURE 3 • Direct and Indirect Exposure to the Palestinian Authority (US$ Millions) 3,000 50% 2,500 40% 2,000 30% Million ($) 1,500 20% 1,000 500 10% 0 0% Dec.-14 Jun.-15 Dec.-15 Jun.-16 Dec.-16 Jun.-17 Dec.-17 Jun.-18 Dec.-18 Jun.-19 Dec.-19 Jun.-20 Dec.-20 Jun.-21 Dec.-21 Jun.-22 Dec.-22 Jun.-23 PA Exposure % of Direct Credit (right axis) Direct PA Loans (left axis) PA Employee Loans (left axis) Source: Palestinian Monetary Authority. of the banking sector has increased in line with the times exceeding the public-sector exposure limits set pace reported in previous periods. Return on equity by the PMA. Following several years in which annual and return on assets reached 14.98 percent and 2.22 PA borrowing remained broadly stable at about percent, respectively, in Q2-2023, up from 10.42 per- US$1.3–1.4 billion, the banking system’s exposure cent and 1.45 percent in Q2-2022. Returns exceeded to the public sector increased considerably, reaching pre-pandemic levels in both periods, pointing to a US$2.5 billion in December 2021. By June 2023, PA stable recovery. Total banking-system assets slightly borrowing had fallen to US$2.3 billion, slightly above increased to US$20.9 billion, with owners’ equity the PMA-imposed prudential limit and exceeding pre- reaching US$2.3 billion in June 2023. Consistent with pandemic levels.26 In addition to direct borrowing by 2022 trends, deposit growth remained slow at 3.5 per- the PA, bank loans to public employees, which are cent over the 12 months ending in June 2023. Credit fully or partially backed by future PA salaries have cre- growth stood at 10 percent during the period, exceed- ated indirect exposure to the public sector. Together, ing its 2022 rate. Private-sector lending drove credit borrowing by the PA and public employees amounts growth, while lending to the public sector remains to about US$4.2 billion, representing almost 37 per- substantial. Nonperforming loans (NPLs) stabilized cent of total banking-sector credit. at 4 percent of total loans,25 while classified loans Given the unstable economic context and continued to increase in line with 2022 trends. The other sources of risk, financial regulators should PA’s growing reliance on private-sector arrears could maintain their efforts to limit the banking system’s increase the NPL ratio by disrupting the flow of liquid- direct and indirect exposure to the public sector. ity to suppliers. Sound prudential regulations and a robust super- The banking sector’s direct exposure to vision framework are critical to safeguard the stabil- the public sector is gradually stabilizing near pre- ity of the financial system. Particular attention should COVID levels, while the combination of direct and indirect exposure remains sizeable and warrants 25 The NPL ratio for loans to the private sector likely continued monitoring by the authorities. During exceeds the aggregate ratio of 4.2 percent. periods of heightened fiscal stress, the PA has repeat- 26 The COVID-19 pandemic was one of several factors driv- edly increased its borrowing from domestic banks, at ing the increase in PA borrowing during 2021. 12 AGAINST TIME – WORLD BANK ECONOMIC MONITORING REPORT TO THE AD HOC LIAISON COMMITTEE RACING  be devoted to the relationship between the fiscal bal- estinian AML/CFT system in line with international ances and the stability of the financial sector, as multi- standards. The authorities are currently updating the ple policy tools that are normally available to modern 2018 AML/CFT National Risk Assessment (NRA). economies are not available to the PA. Respect for The Financial Follow-up Unit and the PMA are coordi- the PMA’s independence as supervisor and pruden- nating this effort with support from the National AML/ tial regulator of the banking system in the West Bank CFT Committee.30 The NRA update builds on a 2022 and Gaza is crucial to a stable financial framework. effort to modernize the legal framework by issuing Limited progress on securing stable cor- new laws and regulations, including a new AML/CFT respondent banking relationships (CBRs) con- law (39/2022), a Presidential Decree (14/2022) on tinues to threaten the stability of cross-border the implementation of UN Security Council sanc- payments. In recent years, Israeli banks have sig- tions, and several instructions aimed at strengthen- naled plans to curtail or terminate CBRs with Pales- ing AML/CFT controls. Prior to the pandemic, the tinian banks, citing concerns around potential money Middle East and North Africa Financial Action Task laundering and the financing of terrorism. Serious dis- Force (MENAFATF) agreed to conduct an external ruptions to CBRs would significantly impact the Pales- evaluation of the PA’s AML/CFT regime. Along with tinian economy. Israel is the primary trading partner of the NRA, this represents a step toward implement- both the West Bank and Gaza, and their largely cash- ing the standard conditions for MENAFATF member- based economies rely on the Israeli Shekel.27 Limits ship. The evaluation was originally scheduled to start on the repatriation of shekels from Palestinian banks in 2020, but the onsite visit by MENAFATF assessors to Israel has contributed to the accumulation of an esti- was repeatedly postponed, due first to the pandemic mated NIS 4.5 billion in excess shekel-denominated and then to security developments on the ground. liquidity in Palestinian banks (equivalent to 6.4 per- Technical reports required for the assessment have cent of assets) as of end-September 2022.28 In 2017, been prepared by the PA and shared with the asses- the GoI approved a temporary indemnity and immu- sors, and the PA and MENAFATF are setting a new nity package for Israeli banks working with Palestinian date for the onsite visit. banks to mitigate the risk of immediate disruptions to CBRs between the two banking systems. The GoI has repeatedly extended this arrangement, most recently 27 The value of payment activity between Israel and the to March 2024, while the PA and GoI are working to West Bank and Gaza is estimated at over NIS44 billion develop a more stable arrangement for cross-border per year. payments. However, progress has been limited due 28 IMF Selected Issues Paper on West Bank and Gaza, to several unresolved points of disagreement, includ- September 16, 2022. ing the status of proposed Israeli legislation and the 29 This is the official name of the Financial Intelligence Unit in the West Bank and Gaza. pending due diligence process of participating Pales- 30 The committee includes representatives from the Minis- tinian banks. tries of Finance, National Economy, Justice, Interior, and The PMA and the Financial Follow-up Unit29 Foreign Affairs, as well as the Public Prosecutor’s Office, are coordinating a national effort to bring the Pal- the Customs Services, and other relevant stakeholders. Recent Economic Developments 13 2 IMPROVING ACCESS TO SUSTAINABLE, HIGH- QUALITY HEALTH SERVICES31 Health Services in the West Bank 2.1.  coordination in the delivery of essential health ser- and Gaza: Quality and Access vices. According to the WHO Israel has a responsibility to protect Palestinian civilians, which includes ensur- The Israeli and Palestinian authorities have a joint ing timely access to essential health services.32 responsibility to ensure access to quality health The OMR process involves a complex sys- services in the West Bank and Gaza. Providing tem of patient and financial flows. The PMOH, health services is a critical function, which faces unique through its Services Purchasing Unit (SPU), over- structural challenges. Most of the 3.2 million Palestin- ians in the West Bank and east Jerusalem live in 165 noncontinuous enclaves (areas A and B), and check- 31 This chapter is an extract of a larger analytical effort that points present substantial barriers to accessing health will be discussed in further detail - and encompassing services, including for patients who need to leave the more sectors - in an upcoming Public Expenditure West Bank for OMR. The implementation of a complex Review (PER) by the World Bank. permit regime, as well as the expansion of settlements in Area C, constrain movement within and across the 32 76th World Health Assembly, provisional agenda item 18. “Health conditions in the occupied Palestinian territory, territories. Two million Palestinians live in Gaza, which including east Jerusalem, and in the occupied Syrian has been under a near-blockade and effectively cut Golan: Report by the Director-General.” 17 May 2023. off from the West Bank since 2007. The political divide https://apps.who.int/gb/ebwha/pdf_files/WHA76/A76​ between the West Bank and Gaza further complicates _15-en.pdf. 15 FIGURE 4 • Flowchart of Outside Medical Referral Permit and Reimbursement Process Medical and Permit finnancial Access to application reviewlapproval care Financial and process Medical reconciliation decision Regional Referral Crossing of Patientslrelatives with Committees (3 of them in Checkpoint(s), Billing received from approved appointment Medical staff at West Bank and 1 in including intensive referral receiving submit permit PMOH public Gaza) and the security in Gaza hospitals (except for in application to be hospital refer Specialized Referral resulting in delays Israel); SPU reviews, reviewed by the patient for Committee within SPU audits, negotiates, Palestinian Health treatment not review the application, Most patients stay for and approves Liaison Office (HLO) available at the and SPU provides inpatient care and payment, which is in Gaza or the hospital decision & requests cross multiple disbursed by Ministry Palestinian General appointment if approved Checkpoints during of Finance Authority of Civil & provides an initial their care journey Affairs (GAGA) committed price amount Source: Authors’ elaboration based on PMOH and WHO reportsa (Red boxes indicate the involvement of Israeli authorities). a PMOH, 2023. “Objectives-Work Mechanisms-Systems for medical referrals” & World Health Organization, Ibid. sees the medical and financial aspects of the refer- of OMR from Gaza and 45 percent of OMR from the ral process with the involvement of public hospitals West Bank require an exit permit (Figure 5). As a result, and regional coordination entities (Figure 4).33 Once about 42,000 permit applications are filed each year by a referral has been approved by the SPU, the patient patients alone, excluding companions.36 Fifty percent applies for a permit through coordination bodies. of referrals for cancer patients both from the West Bank Upon issuance of the permit, which may arrive after and Gaza and almost 80 percent of referrals for car- the medical appointment date, the patient travels diovascular conditions from Gaza require exit permits. through checkpoints to access care and then returns Movement restrictions, including an unpre- home. The SPU also coordinates with the PMOH’s dictable Israeli permit system, negatively impact Government Health Insurance (GHI) Directorate. For access to essential and basic health services. patients covered under the scheme, the SPU pro- According to WHO data, between 2019 and 2021 only cesses invoices for 90–100 percent of their treatment 65 percent of patient permit applications from Gaza expenditures to be paid by the Ministry of Finance and 84 percent of applications from the West Bank were to the referral-receiving hospitals.34 The process approved on time. It should be noted, however, that includes paper-based records as well as the eRefer- timely approval of referrals from Gaza has increased rals system, which enables PMOH hospitals to send since November 2022, at 80 percent of applications referral applications to the SPU. It also allows the SPU to coordinate with referral-receiving hospitals and 33 These include the Regional Referral Committees in the referral committees and to organize reimbursements northern, central, and southern parts of the West Bank through the Bisan system35 for referrals used in the and in Gaza. hospitals of the East Jerusalem Hospital Network, the 34 Almost all OMR patients are covered under GHI, or West Bank, and Gaza. The cost of referrals to Israel is enroll prior to requiring OMR services, indicating that all automatically deducted from the clearance revenues OMR costs are covered by the PMOH, except any out- remitted by the GoI to the PA. However, cost reporting of-pocket spending related to non-medical expenses or pharmaceuticals purchased by private pharmacies. is inconsistent at the patient level. 35 Bisan is the financial management system used by the PA As most patients need to obtain a permit to 36 As OMR data is available at the case level, not the access OMR, coordination between Israeli and Pal- patient level, this number refers to the number of cases, estinian authorities is essential. Seventy-six percent not patients. 16 AGAINST TIME – WORLD BANK ECONOMIC MONITORING REPORT TO THE AD HOC LIAISON COMMITTEE RACING  FIGURE 5 • The Distribution of Outside Medical Referrals by Origin and Destination Gaza Referral origin West Bank 0% 20% 40% 60% 80% 100% Referral destination (% of referrals from origin) bars with border around them: OMR for which an exit permit is needed Gaza West Bank East Jerusalem Israel Other Source: eReferrals data, January 2020-October 2022. being approved on time, even as timely approval of patients die while waiting for the permit process or patient referrals from West Bank has been declining, because they are unable to obtain quality care, as to 75 percent.37 The rates for companions were even 69 percent of requests to allow the entry of medicines lower at 46 and 78 percent, respectively.38 Timeliness and spare parts for X-ray machines and computerized is an essential to high-quality care, and these delays tomography scanners are denied.42 and denials pose a substantial health risk, particularly for cancer patients. A study assessing referral-per- 2.2. Fiscal Sustainability mit applications for radiotherapy and chemotherapy Implications of Outside Medical in Gaza during 2015–17 found that even after adjust- Referrals ing for age, sex, type of procedure, and type of can- cer, the mortality rate for patients with unsuccessful Severe constraints on health spending by the PA permit applications was 1.45 times higher than the result in a vicious cycle of underinvestment and rate for those with successful applications.39 Between high OMR rates. Since 2014, the PA has devoted over 2019 and 2021, the mortality rate six months after the 10 percent of its budget to health, and health spending first permit application was close to 10 percent, which peaked at 13.2 percent in 2022, or US$126 per capita.43 underscores both the severity of medical conditions among referred patients and the consequences of any 37 World Health Organization, office for occupied Pales- delay in processing applications.40 tinian Territory, 2023. Monthly Health Access Report: The rate of OMR permit approvals varies Barriers for patients in the occupied Palestinian territory: from year to year, and the same patient can be July 2023” https://www.emro.who.int/images/stories​ denied, delayed, or accepted at different phases /July_2023_Monthly_2.pdf?ua=1. of the care continuum, highlighting the arbitrari- 38 World Health Organization, Ibid. 39 Bouquet, B., Barone-Adesi, F., Lafi, M., Quanstrom, K., ness of the evaluation process.41 Permit approval Riccardi, F., Doctor, H., Shehada, W., Nassar, J., Issawi, rates also vary by condition, with a 75 percent rate S., Daher, M., Rockenschaub, G., Rashidian, A., 2021. for cancer patients but a 44 percent rate for urology Comparative survival of cancer patients requiring Israeli patients. Between 2019 to 2021, only 20 percent of permits to exit Gaza for health care: A retrospective cohort permit applications from Gaza were processed by study from 2008 to 2017. PLoS ONE 16, e0251058. Israeli authorities within a week, and 66 percent of the https://doi.org/10.1371/journal.pone.025​1058. 40 World Health Organization, Ibid. permits that were issued were for a single day, com- 41 Ibid. plicating care for conditions that might require an 42 ibid inpatient stay. The blockade of Gaza has increased 43 World Bank, 2023 (Forthcoming). Health Public Expen- mortality among the civilian population because diture Review. IMPROVING ACCESS TO SUSTAINABLE, HIGH-QUALITY HEALTH SERVICES 17 In 2022, the largest expenditure items were wages and context. Arrears are expected to increase in a vicious salaries for health workers (42 percent), OMR (34 per- cycle given the current fiscal constraints, as (i) unit cent), and the purchase of medicines and supplies costs for medicines remain elevated due to delays (20 percent). While offering NCD services in PMOH in payments, as well as limited use of reference pric- facilities is more cost-effective than referring patients ing from comparator countries and import restrictions to private or NGO-run facilities, OMR are unlikely to be due to the Paris Agreement, and (ii) limited availability reduced in the immediately near future, as less than of medicines in public hospitals is one of the main driv- 5 percent of the PA’s limited health budget (or less than ers of OMR, resulting in larger unit costs per patient. US$10 million per year) is allocated to investments in Given this fiscal context, OMR spending has public hospital capacity. A recent UN analysis revealed continued to increase, even as investments and the difficulty of increasing the PA’s fiscal space, high- policy interventions have contained the rate of lighting the impact of the GoI’s withholding of tax growth. OMR volumes and expenditures have grown clearance revenue, obstacles to the growth of agri- steadily since 2014, though the movement restrictions culture and industry in the West Bank and Gaza, and adopted in response to the COVID-19 pandemic caused an overreliance on the Israeli economy, which inflates a temporary decline in OMR and disrupted the delivery prices and further constrains households’ ability to save of essential health services (Figure 6). OMR expendi- and contribute tax revenue.44 tures amount to about US$250 million a year for the Driven by high OMR expenditures, health- government. Over 90 percent of OMR expenditures are sector arrears constitute over half of the PA’s paid by the GHI through the SPU, which manages the total arrears to the private sector. Since 2019, the process for reimbursing hospitals in the east Jerusalem total accumulated arrears on medicines and OMR Hospital Network, the West Bank and Gaza through amount to US$575 million, out of which US$345 mil- a mix of fee-for-service and case-based payments. lion is due to OMR receiving hospitals and US$200 million to suppliers of medicines respectively. Cumu- 44 United Nations Conference on Trade and Development, lative health arrears are almost equal to annual pub- August 2022. “Report on UNCTAD assistance to the lic health spending, demonstrating the difficulty of Palestinian people: Developments in the economy of the increasing health spending within the current fiscal Occupied Palestinian Territory”. FIGURE 6 • OMR Volumes (left) and Expenditures in Nominal NIS (right), 2013–2022 150,000 30% 1,500 60% 40% 20% 100,000 1,000 20% 10% Millions ILS 0% 0% 50,000 500 –20% –10% –40% 0 –20% 0 –60% 2013 2014 2015 2016 2017 2019 2020 2021 2022 2013 2014 2015 2016 2017 2019 2020 2021 2022 Volume % change Amount (ILS) % change Source: eReferrals data, January 2020-October 2022. 18 AGAINST TIME – WORLD BANK ECONOMIC MONITORING REPORT TO THE AD HOC LIAISON COMMITTEE RACING  For referrals to Israeli hospitals, the PMOH and the SPU ners, the SPU and the PMOH have been investing in have no control over prices, as costs are deducted from priority medical equipment, such as for neonatal incu- the PA’s clearance revenues with limited reporting and bators, thus reducing maternal, neonatal, and child- transparency at the case or patient level.45 Investments health-related referrals by 50 percent. in improving the efficiency of OMR processes and stra- OMR to EJHN and Israeli hospitals together tegically purchasing equipment to build public-sector constitute over 50 percent of total OMR expendi- hospital capacity reduced the average annual growth tures, underscoring the importance of strength- rate of OMR expenditures from 17 percent between ening coordination between the parties. Most 2013 and 2015 to 2 percent between 2019 and 2022. OMR to these hospitals is for cancers, cardiovascu- The PMOH has been making progress in lar conditions, and urinary conditions. Between 2020 strengthening OMR management and reducing and 2022, combined referrals to EJHN and Israeli expenditures, but challenges remain. Improved hospitals represented about 40 percent of total refer- OMR management to enhance access to care remains rals, and combined expenditures exceeded 50 per- a top policy priority for the PMOH.46 Over the last five cent of total expenditures (Figure 7). In 2022, EJHN years, the SPU has updated clinical guidelines for all hospitals received 36 percent of OMR and accounted conditions, defined standard operating procedures for 25 percent of OMR expenditures, highlighting the for the OMR process, and standardizing auditing, impact of price negotiations between the SPU and financial management, and case management. The these hospitals. By contrast, Israeli hospitals received introduction of the eReferrals system has digitized the referral submission and evaluation process for all hos- pitals in the West Bank, the EJHN, and Gaza. The SPU 45 Costs per case for OMR to Israeli hospitals are not pro- has also signed memorandums of understanding with vided and are therefore estimated through using a most referral-receiving hospitals in these areas negoti- multiplier on the basis of the variation between the maxi- mum committed funds and final invoice amount. ating and standardizing prices based on patient char- 46 Duran et al., 2021. Towards Effective Chronic Case Man- acteristics, flows, and geographic areas. Negotiations agement: Improving the Efficiency of Outside Medical for priority conditions with referral-receiving hospitals Referrals in the West Bank and Gaza. https://openknow​ are ongoing. With support from development part- ledge.worldbank.org/handle/10986/37264. FIGURE 7 • OMR to Hospitals in the EJHN and Israel by Volume (left) and Expenditures in Nominal NIS (right), 2020–2022 50,000 40 800,000,000 40 40,000 Share of overall OMR expenditure, % 30 600,000,000 30 Share of overall OMR cases, % OMR cases per year 30,000 Expenditures, ILS 20 400,000,000 20 20,000 10 200,000,000 10 10,000 0 0 0 0 2020 2021 2022 2020 2021 2022 Israel (total) East Jerusalem (total) Israel (total) East Jerusalem (total) East Jerusalem (%) Israel (%) East Jerusalem (%) Israel (%) Source: eReferrals data, January 2020-October 2022. IMPROVING ACCESS TO SUSTAINABLE, HIGH-QUALITY HEALTH SERVICES 19 FIGURE 8 • Unit Costs of Top Drivers of Referrals in Israeli and EJHN, 2020–2022 2020 2020 disorders Diseases of Diseases of disorders Diseases of Diseases of immune genitourinary circulatory immune genitourinary circulatory system system the the 2021 2021 2022 2022 2020 2020 Neoplasms mechanis… system Neoplasms mechanis… system the 2021 2021 the 2022 2022 2020 2020 involving the involving the Diseases of Diseases of blood-form- blood-form- and certain and certain ing organs ing organs the blood the blood 2021 2021 and and 2022 2022 2020 2020 2021 2021 2022 2022 0 40.000 80.000 0 10.000 20.000 Unit cost in ILS Unit cost in ILS Israel East Jerusalem Source: eReferrals data, January 2020-October 2022. just 5 percent of OMR but accounted for 28 per- Israeli hospitals could save over NIS 120 million cent of OMR expenditures, demonstrating very high each year, or about 15 percent of annual referral unit costs. As referrals to EJHN and Israeli hospitals expenditures. These savings would be equal to a require permits both for the West Bank and Gaza res- 5 percent increase in the PMOH budget, creating idents, and as these hospitals receive patients both new fiscal space for investment. from Palestinian and Israeli hospitals, there is a sub- stantial need for additional coordination, as well as greater price transparency. Coordination for referrals 2.3. Policy Options to EJHN is particularly important, as these hospitals Overcoming access and financial barriers to care, also rely on reimbursements from Israeli Health Main- especially for NCDs, will require sustained coordi- tenance Organizations, which reimburse them at less nation between Israeli and Palestinian authorities. than half the rate of comparable Israeli hospitals.47 Administrative and policy reforms can expand access While average unit costs paid to Israeli hos- to essential health services while improving the fiscal pitals have been declining for most conditions sustainability of the health system in the West Bank since 2020, they remain over four times that of and Gaza (Table 6). Some measures are under the pur- EJHN hospitals or the West Bank. Average unit view of either the Israeli or Palestinian authorities, while costs for most conditions have fallen since 2020 both others can only be implemented through collaboration. in EJHN and Israeli hospitals (Figure 8), demonstrat- Easing movement restrictions for essential ing the positive impact of price negotiations between health services and strengthening the OMR man- the SPU and EJHN hospitals. However, unit costs for agement process can improve access to quality urinary conditions in Israel and cardiovascular condi- healthcare. GoI needs to ensure that patients and tions in EJHN increased during the period. Average healthcare workers can access the appropriate facil- cancer treatment costs NIS 51,000 in Israel, versus NIS 11,000 for EJHN. Additional data and analysis are needed to account for the case mix, as referrals to 47 Courey M, Keuffel E, Sharif D, 2023. east Jerusalem Hos- Israel likely tend to be for more complex conditions. pital Network (EJHN) Assessment Report for the USAID A 50 percent reduction in referral volumes to West Bank and Gaza Mission. 20 AGAINST TIME – WORLD BANK ECONOMIC MONITORING REPORT TO THE AD HOC LIAISON COMMITTEE RACING  TABLE 6 • Policy Recommendations to Improve Access to Health Essential Services Objective Israeli authorities Palestinian authorities GoI + PA Improve access Establish an expeditious, time-bound, Clearly define patient care pathways and Establish a coordination body to promote to quality health systematic, and transparent process for clinical guidelines for referrals, especially for timely access to essential health services services granting travel permits to Palestinian Israeli hospitals. by reducing the frequency of permit delays patients and their companions. and denials. Build the SPU’s capacity to manage Offer multiple-entry permits to patients with and audit referral cases, and continue Strengthen information systems and chronic conditions. streamlining the OMR process. reporting to collect detailed patient, procedure, and case-specific data, and Strengthen the physical protection of integrate data collection with existing medical personnel and facilities. information systems from all OMR-receiving Facilitate the entry of essential medicines, hospitals, including those in Israel. medical equipment, spare parts, and medical supplies, particularly to Gaza. Enhance the fiscal Improve the reporting of unit costs, total Formulate an investment plan for reducing Ensure the financial sustainability of service sustainability of expenditures, and clearance deductions for expenditures by strengthening primary care delivery in EJHN. the health system OMR treatment provided in Israeli hospitals, and building hospital capacity at PMOH Negotiate contracts stipulating the costs of and identify opportunities to reduce prices. facilities, with investments to be funded by services delivered in Israeli hospitals, and the PA and its development partners. Align Israeli Health Maintenance align those costs with service-delivery costs Organization reimbursement rates directed Finalize contract negotiations with all in hospitals in EJHN and in the West Bank. to hospitals in the East Jerusalem Hospital referral-receiving hospitals and include Network with those of comparable Israeli provisions to address past arrears. hospitals. Conduct a detailed costing of care for priority conditions to move from a procedure-based to a case-based provider payment system, and strengthen purchasing arrangements, to reduce costs. ities in a timely manner, as this is crucial to the suc- and clinical guidelines clearly stipulating eligible con- cessful provision of essential health services, while ditions and procedures for referrals to Israeli hospitals. containing the fiscal costs of OMR as much as pos- There are two substantial opportunities for collabora- sible. Creating a swift and non-arbitrary process for tion between Israeli and Palestinian authorities—spe- granting permits to patients and their companions cifically the Coordinator of Government Activities in would be critical in that regard. The Israeli authori- the Territories (COGAT) and the Palestinian General ties should begin issuing multiple-entry permits for Authority of Civil Affairs (GACA)—first, to improve coor- patients with chronic conditions, and the SPU should dination and reduce permit delays and denials; and streamline medical approvals for routine patients while second, to improve the scope and quality of data on also integrating referral applications for patients and OMR to Israeli hospitals, including detailed informa- their companions. Permits for companions, espe- tion on costs per procedure, which would inform fur- cially for sick children, should be expedited. Check- ther reductions in OMR to these hospitals. points should also offer direct access for ambulances Coordination is also essential to improve and healthcare staff, and the Israeli authorities should the fiscal sustainability of the health system. As ensure the physical protection of medical personnel previously discussed, OMR represent a major finan- and facilities.48 Given the substantial impact of the near- cial burden for the PA. To reduce the burden of OMR, blockade on the availability of medicines and medical Israeli authorities need to ensure the transparent supplies, Israel should guarantee the entry of lifesav- reporting of OMR-related deductions from clearance ing medicines, equipment, spare parts, and medical supplies into Gaza. To reduce reliance on costly Israeli 48 These recommendations on ensuring right to health are referrals, the SPU should define patient care pathways aligned with: World Health Organization, Ibid. IMPROVING ACCESS TO SUSTAINABLE, HIGH-QUALITY HEALTH SERVICES 21 revenues and explore ways to reduce these prices, ing hospitals, including provisions to address past which should be formalized through contractual arrears. The SPU can leverage its bargaining power arrangements similar to those between the PMOH in this effort, as most patients at these facilities are and hospitals in EJHN, the West Bank, and Gaza. referred by the PMOH. Prices should be defined to The PMOH must rapidly implement pur- reflect fiscal sustainability as well as the cost of ser- chasing reforms to improve fiscal sustainability vice delivery. Finally, ongoing capacity-building will while ensuring consistent access to care. Given be needed to implement purchasing reforms that can the PA’s tight fiscal constraints, health-sector reform help maximize the quality of care. These measures must focus on improving purchasing arrangements.49 could include introducing case-based payment meth- The first step is to finalize an investment plan priori- ods; strengthening auditing, financial management, tizing conditions that drive the largest shares of OMR and provider-network management; and improving expenditures, particularly in Israeli hospitals, such information and claims-management systems. that these can be offered in PMOH hospitals. Devel- opment partners would need to continue to align their efforts with these plans and support the expansion of PMOH hospital capacity. The SPU also needs to 49 World Bank, 2023 (Forthcoming). Health Public Expen- finalize contract negotiations with all referral-receiv- diture Review. 22 AGAINST TIME – WORLD BANK ECONOMIC MONITORING REPORT TO THE AD HOC LIAISON COMMITTEE RACING  ‫‪ANNEX (EXECUTIVE‬‬ ‫)‪SUMMARY IN ARABIC50‬‬ ‫تقرير المراقبة االقتصادية المقدم من البنك‬ ‫الدولي إلى لجنة االرتباط الخاصة‬ ‫(نُرش هذا امللخص التنفيذي يف األصل باللغة اإلنجليزية‪ .‬يف حالة وجود اختالفات ‪ ،‬فإن اللغة األصلية (اإلنجليزية) هي التي تحكم)‪.‬‬ ‫‪ .2‬ال يزال السياق االقتصادي يف الضفة الغربية وقطاع غزة محاطً ا‬ ‫ملخص تنفيذي‬ ‫مبخاطر متزايدة‪ .‬وما مل يحدث تغيري جوهري يف الوضع السياسايت‪،‬‬ ‫‪ .1‬شهد االقتصاد الفلسطيني تباطؤاً خالل األشهر األوىل من عام‬ ‫‪ .2023‬وتشري البيانات األولية للربع األول من عام ‪ 2023‬إىل أن النمو‬ ‫ ‪50‬‬ ‫‪This Executive Summary in Arabic is offered merely as‬‬ ‫تباطأ إىل نسبة ‪ ،3.1%‬وذلك عىل أساس سنوي‪ ،‬ويرجع ذلك إىل حد كبري‬ ‫‪a convenience version. The original Executive Summary‬‬ ‫إىل ال رتاجع الذي حصل يف مرحلة ما بعد التعايف من جائحة كورونا‪.‬‬ ‫‪is produced in English at the beginning of this report.‬‬ ‫وبالتزامن مع ذلك‪ ،‬ت ُواصل الحكومة اإلرسائيلية فرض قيود إلعاقة‬ ‫‪In the event of discrepancies or errors, the original lan-‬‬ ‫النشاط االقتصادي‪ ،‬وال سيام يف غزة‪ ،‬حيث شهد االقتصاد انكامش اً‬ ‫‪guage will rule.‬‬ ‫بنسبة ‪ 2.6%‬خالل الربع األول من عام ‪ .2023‬ويرجع ذلك إىل حد‬ ‫ وفقًا ملنظمة «مسلك» غري الحكومية اإلرسائيلية‪ ،‬فقد فرضت الحكومة‬ ‫‪51‬‬ ‫ما عىل بيع األسامك من غزة يف الضفة الغربية خالل‬ ‫ح رجي وصيد األسامك‪ ،‬والذي‬ ‫كبري إىل التدهور يف القطاع الزراعي وال ُ‬ ‫اإلرسائيلية حظ ً‬ ‫را تا ً‬ ‫آب من عام ‪ ،2022‬وذلك بعد ضبط شاحنة تنقل أسامكًا من غزة إىل‬ ‫انكمش بنسبة ‪ ،30%‬وذلك بعد ق رار الحكومة اإلرسائيلية تقييد‬ ‫نا شهريًا‪ ،‬ثم‬ ‫إرسائيل‪ .‬وبعد عدة أسابيع‪ ،‬تم تحديد حصة قدرها ‪ 40‬ط ً‬ ‫بيع أسامك غزة يف الضفة الغربية‪ ،‬وذلك يف آب من العام ‪.202251‬‬ ‫نا شهريًا خالل شباط من العام ‪ – 2023‬مبا يزيد‬ ‫تم زيادتها إىل ‪ 80‬ط ً‬ ‫من ناحية أخرى‪ ،‬حقق االقتصاد منوا ً يف الضفة الغربية بنسبة ‪4.3%‬‬ ‫نا قبل الحظر األويل‪.‬‬ ‫قليالً عن نصف املتوسط الشهري البالغ ‪ 150‬ط ً‬ ‫عىل أساس سنوي وذلك يف الربع األول من عام ‪ ،2023‬ويرجع ذلك إىل‬ ‫​‪https://gisha.org/en/israel-continues-to-restrict-sale-of-fi‬‬ ‫التوسع املستمر يف االستهالك الخاص والذي بدوره دعم منو تجارة‬ ‫‪./sh-from-gaza-10-months-on‬‬ ‫الجملة والتجزئة والخدمات‪.‬‬ ‫‪23‬‬ ‫املدى املتوسط ‪ ،‬لكن خيارات التمويل ستصبح محدودة بشكل‬ ‫فإن االقتصاد سيواجه مزيج اً من التباطؤ يف النمو إضافة إىل‬ ‫متزايد‪ .‬كام أن التمويل من البنوك املحلية مل يعد قاب الً لالستم رار‪ ،‬مام‬ ‫ق ا لسيناريو خط األساس‪ ،‬فمن‬ ‫معدالت مرتفعة من الفق ر‪ .‬ووف ً‬ ‫أدى إىل اللجوء إىل متويل العجز من خالل ت راكم املتأخ رات للقطاع‬ ‫املتوقع أيض اً أن يواجه االقتصاد الفلسطيني مزيدا ً من الضعف‬ ‫الخاص واملوظفني العموميني وصندوق املعاشات التقاعدية‪ .‬ولكن‬ ‫يف ظل نظام متعدد املستويات من القيود التي تفرضها إرسائيل‬ ‫ت راكم هذه املتأخ رات مع مرور الوقت سيشكل مخاطر كبرية عىل‬ ‫عىل حرية الوصول والتجارة يف الضفة الغربية‪ ،‬إىل جانب الحصار‬ ‫االستق رار الكيل للاملية العامة‪ ،‬ألنه يقلل من السيولة يف السوق‪ ،‬كام‬ ‫شبه الكامل عىل قطاع غزة‪ .‬وعليه‪ ،‬فإن هذه القيود ستستمر يف‬ ‫ميكن أن يلقي ذلك بظالله عىل القطاع املرصيف‪.‬‬ ‫إعاقة النشاط االقتصادي وتثبيط تنمية القطاع الخاص؛ مام مينع‬ ‫االقتصاد الفلسطيني من الوصول إىل األداء املحتمل ‪ .‬ويف ظل هذه‬ ‫‪ .4‬يعترب تحقيق االستدامة املالية أولوية قصوى‪ :‬وهذا يتطلب أسس اً‬ ‫االف رتاضات‪ ،‬من املتوقع أن يصل النمو االقتصادي إىل ‪ 3%‬عىل املدى‬ ‫قوية لالقتصاد الكيل‪ ،‬عل امً أن جهود اإلصالح التي تبذلها السلطة‬ ‫املتوسط‪ .‬من جانب آخ ر‪ ،‬ونظ را ً للنمو السكاين ا‪ ،‬فمن املتوقع أن‬ ‫الفلسطينية إلرساء دعائم هذه األسس رضورية ولكنها وحدها غري‬ ‫يتباطأ الدخل الحقيقي للفرد يف أحسن األحوال‪ .‬عالوة عىل ذلك‪ ،‬ال‬ ‫كافية‪ .‬إن السلطة الفلسطينية تحتاج إىل مواصلة جهودها لتقليل‬ ‫تزال املخاطر مرتفعة‪ .‬إذ إن أي تصعيد يف الحرب الروسية يف أوك رانيا‬ ‫العجز املايل بشكل كبري من خالل القيام بهكذا إصالحات‪ ،‬وهي‬ ‫سيؤدي إىل زيادة الضغط عىل سالسل التوريد العاملية وكذلك‬ ‫تستطيع ذلك‪ ،‬إىل جانب تنفيذ مزيد من اإلج راءات ال رامية إىل تعزيز‬ ‫زيادة الضغط عىل أسعار الغذاء والطاقة‪ ،‬مام يؤدي إىل إبطاء منو‬ ‫بيئة األعامل مبا يفيض إىل املساهمة يف توسع أعامل القطاع الخاص‪.‬‬ ‫االقتصاد الفلسطيني‪ .‬يف غضون ذلك‪ ،‬قد يؤدي تجدد االشتباكات‬ ‫ومع ذلك‪ ،‬فإن التحليل الشامل الذي أج راه البنك الدويل ومؤسسات‬ ‫بني الفلسطينيني والقوات اإلرسائيلية يف الضفة الغربية وقطاع غزة‬ ‫التنمية األخرى يكشف بوضوح أن بعض العوائق الرئيسية أمام‬ ‫إىل زيادة حالة عدم اليقني االقتصادي وزيادة تقييد وصول العامل‬ ‫تحقيق النمو وتنمية القطاع الخاص‪ 52‬مرتبط بالقيود التي تفرضها‬ ‫الفلسطينيني إىل سوق العمل اإلرسائييل‪ .‬فض الً عن أن السلطة‬ ‫الحكومة اإلرسائيلية عىل الحركة والنشاط االقتصادي يف الضفة‬ ‫الفلسطينية لديها نطاق مايل محدود ملواجهة مثل هذه الصدمات‪،‬‬ ‫الغربية‪ ،‬وذلك إىل جانب الحصار شبه الكامل عىل غزة‪ .‬وعىل الرغم‬ ‫وبالتايل فإن حالة انعدام اليقني عىل الجبهة السياسية يف إرسائيل‬ ‫من الحوار املكثف بني جميع األط راف حول هذه القضايا‪ ،‬إال أن مثة‬ ‫ميكن أن يساهم يف تفاقم مخاطر االقتصاد ا‪ f you‬لكيل وكذلك‬ ‫قصورا ً يف اتخاذ إج راء عميل بشأنها‪ ،‬وإىل أن يتم التعامل مع هذه‬ ‫املخاطر املالية التي تواجه الضفة الغربية وقطاع غزة‪.‬‬ ‫القضايا بشكل فعال‪ ،‬فإن االقتصاد الفلسطيني سيستمر يف العمل‬ ‫دون إمكاناته وفاعليته الكاملة‪.‬‬ ‫ءا مع‬‫‪ .3‬من املتوقع أن يزداد الوضع املايل للسلطة الفلسطينية سو ً‬ ‫تقدم العام ‪ ،2023‬حيث تصبح خيارات إعادة التمويل محدودة أكرث‬ ‫حاساًم لتحسني الوضع‬ ‫ً‬ ‫‪ .5‬إن تعاون الحكومة اإلرسائيلية يبقى أم ً‬ ‫را‬ ‫فأكرث‪ ،‬مام يزيد من املخاطر املتعلقة باالستدامة املالية بشكل مثري‬ ‫املايل للسلطة الفلسطينية ومتكني االقتصاد الفلسطيني من الوصول‬ ‫للقلق‪ .‬وعىل الرغم من أن أداء اإلي رادات العامة جيد ومن املتوقع‬ ‫إىل إمكاناته الكاملة‪ .‬فعىل سبيل املثال‪ ،‬تنص االتفاقية املؤقتة لعام‬ ‫أن ينمو إىل نسبة ت رتاوح ‪ 6%‬إىل ‪ 23.7٪‬من إجاميل الناتج املحيل‪،‬‬ ‫‪ 1995‬عىل أنه من املتوقع أن تقوم اإلدارة املدنية اإلرسائيلية بجمع‬ ‫وذلك بفضل جهود االصالحات الرضيبية املتزايدة والنمو االقتصادي‬ ‫اإلي رادات من الرشكات اإلرسائيلية العاملة يف املنطقة (ج) وتحويلها‬ ‫يف الضفة الغربية‪ ،‬إال أن التقدي رات تشري يف املقابل إىل أن النفقات‬ ‫إىل السلطة الفلسطينية‪ .53‬ولكن عىل أرض الواقع‪ ،‬يتم جمع هذه‬ ‫سرتتفع بحوايل ‪ 2.4٪‬لتصل إىل ‪ 26.5٪‬من إجاميل الناتج املحيل‪ .‬هذه‬ ‫األموال من قبل الحكومة اإلرسائيلية‪ ،‬إال أنه مل يتم تحويلها إىل‬ ‫الزيادة سببها التنفيذ الجزيئ لالتفاقيات األخرية التي تم التوصل‬ ‫السلطة الفلسطينية حتى اآلن‪ .‬وعليه يجب أن تعمل الحكومة‬ ‫لها مع النقابات العاملية‪ ،‬مام أدى إىل ارتفاع كبري يف فاتورة األجور‪.‬‬ ‫اإلرسائيلية أيضً ا مع السلطة الفلسطينية لتنفيذ إج راءات مؤسسية‬ ‫ونتيجة لذلك‪ ،‬من املتوقع أن يبلغ العجز اإلجاميل (قبل املنح) إىل ‪561‬‬ ‫للحد بشكل مستدام من الترسب املايل من عائدات املقاصة‪ ،‬وهو أمر‬ ‫مليون دوالر أمرييك‪ ،‬أي ما يعادل ‪ 2.8%‬من إجاميل الناتج املحيل‪.‬‬ ‫كام أن العجز ميكن أن يصل إىل ‪ 817‬مليون دوالر أو ما نسبته ‪4.1%‬‬ ‫ لورسن‪ ،‬ت‪.‬ب‪ ،.‬ونرص الدين (‪ .)2017‬آفاق النمو وفرص العمل يف‬ ‫‪52‬‬ ‫من الناتج املحيل اإلجاميل وذلك مبا يشمل االقتطاعات اإلرسائيلية‬ ‫االقتصاد الفلسطيني‪ :‬دراسة تحليلية للتوازن العام (باللغة اإلنجليزيية)‪.‬‬ ‫من عائدات املقاصة‪ ،‬ومع ذلك‪ ،‬فمن املتوقع أن يؤدي التدفق يف‬ ‫واشنطن العاصمة‪ :‬مجموعة البنك الدويل‪http://documents.worl​.‬‬ ‫املساعدات الوافدة إىل تضييق العجز جزئي اً ليصل إىل ‪ 493‬مليون‬ ‫​‪dbank.org/curated/en/952571511351839375/Prospects-for‬‬ ‫دوالر أمرييك أو ما يعادل ‪ 2.5%‬من إجاميل الناتج املحيل‪ ،‬حيث متوقع‬ ‫​‪-growth-and-jobs-in-the-Palestinian-economy-a-general‬‬ ‫أن يصل ما مجموعه ‪ 324‬مليون دوالر أمرييك دعم للميزانية ومتويل‬ ‫‪-equilibrium-analysis‬‬ ‫التنمية‪ .‬من ناحية أخرى‪ ،‬فإذا ما أدت ضغوط النقابات‪ ،‬وخاصة نقابة‬ ‫ انظر امللحق الثالث‪ ،‬امللحق األول‪ ،‬املادة ‪ ، 8‬الفقرة ‪( 2‬أ) ‪( 2 ،‬ب)‬ ‫‪53‬‬ ‫املعلمني‪ ،‬إىل التنفيذ الكامل التفاقيات العمل بحلول سبتمرب ‪،2023‬‬ ‫واملادة ‪ ، 18‬الفقرة (‪ )4‬من االتفاقية املؤقتة للضفة الغربية وقطاع غزة‪،‬‬ ‫فإن هذا من شأنه أن يتسبب يف زيادة العجز إىل ‪ 533‬مليون دوالر‬ ‫واشنطن العاصمة ‪ 28‬سبتمرب ‪ ( 1995‬االتفاقية املؤقتة) ميكن الوصول‬ ‫إليها هنا‪https://www.gov.il/en/Departments/General/the​ :‬‬ ‫أمرييك‪ .‬ويف ظل غياب تغيري واضح يف املشهد السيايس‪ ،‬فمن املتوقع‬ ‫‪-israeli-palestinian-interim-agreement-annex-iii‬‬ ‫أن يدور عجز املالية العامة حول ‪ 2.5٪‬من إجاميل الناتج املحيل عىل‬ ‫‪24‬‬ ‫‪AGAINST TIME – WORLD BANK ECONOMIC MONITORING REPORT TO THE AD HOC LIAISON COMMITTEE‬‬ ‫ ‪RACING‬‬ ‫مبارش‪ .‬األمر الذي يستدعي استم رار امل راقبة من قبل السلطات‪ .‬وقد‬ ‫حيوي لتعزيز املوارد املالية للسلطة الفلسطينية‪ .‬وميكن للتوصيات‬ ‫زادت السلطة الفلسطينية بشكل متكرر من اق رتاضها من البنوك‬ ‫التالية (املفصلة يف صفحة ‪ )12–11‬أن تساعد يف تحقيق هذه األهداف‬ ‫املحلية‪ ،‬السيام يف أوقات الضغط املايل‪ ،‬متجاوزة يف بعض األحيان‬ ‫مبا يسهم يف الوصول إىل نتائج مفيدة للطرفني‪:‬‬ ‫حدود انكشاف القطاع العام التي وضعتها سلطة النقد الفلسطينية‪.‬‬ ‫وبعد عدة سنوات ظل فيها االق رتاض السنوي للسلطة الفلسطينية‬ ‫را عىل نطاق واسع عند حوايل ‪ 1.4–1.3‬مليار دوالر أمرييك‪ ،‬إال‬ ‫التطبيق الكامل للنظام اإللكرتوين لتسوية وتخليص رضيبة القيمة‬ ‫أ‪ .‬‬ ‫مستق ً‬ ‫أن انكشاف النظام املرصيف للقطاع العام ازداد بشكل كبري‪ ،‬حيث وصل‬ ‫املضافة‪.‬‬ ‫إىل ‪ 2.5‬مليار دوالر أمرييك يف كانون أول ‪ .2021‬وبحلول يونيو ‪،2023‬‬ ‫نقل املسؤوليات الجمركية إىل السلطة الفلسطينية وإنشاء‬ ‫ب‪ .‬‬ ‫انخفض اق رتاض السلطة الفلسطينية إىل ‪ 2.3‬مليار دوالر أمرييك‪ ،‬وهو‬ ‫مستودعات جمركية فلسطينية‪.‬‬ ‫مستوى أقل بقليل من الحد الذي تفرضه سلطة النقد الفلسطينية‪،‬‬ ‫تحويل جميع رضيبة القيمة املضافة املفروضة عىل التجارة بني‬ ‫ج‪ .‬‬ ‫ولكن ال يزال أعىل من مستويات ما قبل الجائحة‪ .54‬وباإلضافة إىل‬ ‫إرسائيل وغزة إىل السلطة الفلسطينية‪.‬‬ ‫االق رتاض املبارش من قبل السلطة الفلسطينية‪ ،‬فقد أسهمت كل من‬ ‫تحقيق قدر أكرب من الشفافية فيام يتعلق باالقتطاعات من إيرادات‬ ‫د‪ .‬‬ ‫ي ا من‬ ‫املقاصة‪.‬‬ ‫القروض املرصفية ملوظفي القطاع العام‪ ،‬املدعومة كل ً‬ ‫ي ا أو جزئ ً‬ ‫رواتب السلطة الفلسطينية‪ ،‬يف انكشاف غري مبارش للقطاع العام‪.‬‬ ‫إعادة التفاوض بشأن الرسوم التي تفرضها الحكومة اإلرسائيلية عىل‬ ‫هـ‪ .‬‬ ‫حيث يبلغ حجم اق رتاض السلطة الفلسطينية وموظفي القطاع العام‬ ‫تخليص الواردات الفلسطينية‪.‬‬ ‫ع ا حوايل ‪ 4.2‬مليارات دوالر أمرييك‪ ،‬وهو ما ميثل حوايل ‪ 37%‬من‬ ‫مً‬ ‫إعفاء واردات الوقود للسلطة الفلسطينية من الرضائب‪.‬‬ ‫و ‪.‬‬ ‫إجاميل ائتامن القطاع املرصيف‪.‬‬ ‫تحديد رسوم املغادرة التي يتم تحصيلها عند جرس اللنبي بشكل‬ ‫ز‪ .‬‬ ‫تعاوين‪ ،‬وتخصيص اإليرادات الناتجة وفقًا للحصص املحددة يف‬ ‫‪ .8‬التقدم املحدود يف تعزيز عالقات البنوك امل ُراسلة (‪ )CBRs‬اليزال‬ ‫بروتوكول باريس‪.‬‬ ‫يهدد استق رار عمليات الدفع املايل عرب الحدود‪ .‬ففي السنوات األخرية‪،‬‬ ‫أشارت البنوك اإلرسائيلية إىل خطط لتقليص أو إنهاء التعامالت‬ ‫‪ .6‬وعىل نحو مامثل‪ ،‬فإن دعم املانحني هو عامل ال ميكن االستغناء‬ ‫املرصفية املعتمدة مع البنوك الفلسطينية‪ ،‬مشرية إىل مخاوف بشأن‬ ‫عنه لنجاح أجندة اإلصالح للسلطة الفلسطينية‪ ،‬وخاصة عىل املدى‬ ‫احتامل غسل األموال ومتويل اإلرهاب‪ .‬ومن شأن االضط رابات الخطرية‬ ‫القصري واملتوسط‪ .‬فعىل الرغم من االتفاق الواسع عىل هذا األمر‪،‬‬ ‫التي تحدث يف العالقات املرصفية امل راسلة أن تؤثر بشكل كبري عىل‬ ‫إال أنه ال يلوح يف األفق مؤرشات عىل زيادة تدفق هذه املساعدات‪.‬‬ ‫االقتصاد الفلسطيني‪ .‬حيث تعتمد كل من الضفة الغربية وقطاع‬ ‫وميكن القول أنه من أجل منع التداعيات االجتامعية واالقتصادية‬ ‫غزة بشكل كبري عىل إرسائيل كرشيك تجاري أسايس لهام‪ ،‬ويف الغالب‬ ‫السلبية‪ ،‬فإن عىل السلطة الفلسطينية أوالً أن تتبنى نهج اً تدريجي اً‬ ‫تعتمد اقتصاداتهام يف مجال النقد عىل الشيكل اإلرسائييل‪ .55‬وقد ثبت‬ ‫يف إصالح عملية إدارة اإلي رادات والنفقات‪ .‬السيام وأن جهود الضبط‬ ‫م رارا ً أن إعادة الشيكل من البنوك الفلسطينية إىل إرسائيل هي عملية‬ ‫املايل املستمرة ما زالت عرضة للصدمات الخارجية‪ ،‬وعليه‪ ،‬فإن‬ ‫شاقة‪ ،‬مام أدى إىل ت راكم يقدر بنحو ‪ 4.5‬مليار شيكل‪ ،‬وقد متثل هذا‬ ‫النجاح يف هذا السياق يعتمد أيضً ا عىل املناخ السيايس‪ ،‬وكذلك عىل‬ ‫ال رتاكم يف سيولة زائدة للشيكل يف البنوك الفلسطينية‪ ،‬أي ما يعادل‬ ‫تعاون الحكومة اإلرسائيلية‪ .‬ويف هذا السياق‪ ،‬يبقى من األهمية مبكان‬ ‫‪ 6.4%‬من أصولها وذلك حتى نهاية سبتمرب ‪ .562022‬وللتخفيف‬ ‫امليض قدم اً يف مسار الضبط املايل عىل نحو سلس‪ ،‬وكذلك العمل عىل‬ ‫من مخاطر االنقطاع الفوري للبنوك املركزية بني النظامني البنكيني‬ ‫تخفيف حالة عدم اليقني السيايس واالقتصادي‪ .‬فهذان األم ران يجب‬ ‫(الفلسطيني واإلرسائييل)‪ ،‬فقد وافقت الحكومة اإلرسائيلية عىل حزمة‬ ‫أن يبقيا عىل رأس جدول األعامل‪ .‬كام أن الحصول عىل دعم ٍ‬ ‫كاف‬ ‫تعويضات وحصانة مؤقتة للبنوك اإلرسائيلية املتعاملة مع البنوك‬ ‫للميزانية‪ ،‬عىل أن يكون دع امً ميكن التنبؤ به‪ ،‬يبقى أيض اً عن ً‬ ‫رصا‬ ‫الفلسطينية يف عام ‪ .2017‬حيث تم متديد هذا الرتتيب عدة م رات‪،‬‬ ‫محوريً ا وال غنى عنه لتحقيق النجاح‪ .‬أما عىل املدى املتوسط‪ ،‬فال بد‬ ‫كان آخرها حتى آذار (مارس) ‪ .2024‬من جانب آخ ر‪ ،‬تسعى السلطة‬ ‫من إعادة توجيه مساعدات املانحني نحو مشاريع التنمية التي تحفز‬ ‫الفلسطينية والحكومة اإلرسائيلية جاهدتني إىل إنشاء إطار عمل أكرث‬ ‫النمو االقتصادي‪ .‬وباإلضافة إىل ذلك‪ ،‬ميكن أن يؤدي تنفيذ املزيد‬ ‫من اإلصالحات يف إدارة املالية العامة واتخاذ تدابري حوكمة شاملة‬ ‫إىل جذب موارد إضافية من املانحني‪ .‬ويف حني أن املناقشات الجارية‬ ‫مع املجتمع الدويل لزيادة املساعدات الخارجية للسلطة الفلسطينية‬ ‫‪ 54‬كانت جائحة كوفيد‪ -19‬أحد العوامل العديدة التي أدت إىل زيادة‬ ‫هي مناقشات واعدة‪ ،‬إال أن تجسيدها النهايئ بصورة عملية ال يزال‬ ‫اقرتاض السلطة الفلسطينية خالل عام ‪.2021‬‬ ‫أم را ً غري مؤكد‪.‬‬ ‫‪ 55‬تقدر قيمة عمليات الدفع بني إرسائيل والضفة الغربية وقطاع غزة‬ ‫بأكرث من ‪ 44‬مليار شيكل يف السنة‪.‬‬ ‫‪ .7‬إن التطور اإليجايب األخري هو ال رتاجع التدريجي النكشاف القطاع‬ ‫‪ 56‬يتعني عىل البنوك يف الضفة الغربية وقطاع غزة إدارة مبالغ كبرية من‬ ‫املرصيف الفلسطيني املبارش للقطاع العام‪ .‬ولكن يف الوقت نفسه‪ ،‬ال‬ ‫النقد الفائض بسبب القيود املفروضة عىل كمية النقد التي ميكن‬ ‫يزال هذا االنكشاف كب ريًا بشكل عام سواء كان انكشاف اً مبارشاً أو غري‬ ‫شحنها إىل إرسائيل‪.‬‬ ‫)‪ANNEX (EXECUTIVE SUMMARY IN ARABIC‬‬ ‫‪25‬‬ ‫يستطيع نظام الصحة العامة الفلسطيني تقدميها‪ .‬ومنذ عام ‪،2015‬‬ ‫را للمدفوعات املالية التي تتم عرب الحدود‪ .‬ومع ذلك‪ ،‬فقد كان‬‫استق را ً‬ ‫تم تحويل ما يقرب من ‪ 90،000‬حالة سنويً ا (‪ 23%‬من غزة و ‪73%‬‬ ‫التقدم يف هذه املساعي محدودًا بسبب العديد من الخالفات التي‬ ‫من الضفة الغربية) من امل رافق الصحية العامة إىل املستشفيات‬ ‫مل يتم حلها‪ ،‬مبا يف ذلك الترشيعات اإلرسائيلية املقرتحة‪ ،‬وكذلك أن‬ ‫الخاصة أو التي تديرها املنظامت غري الحكومية يف القدس الرشقية أو‬ ‫عملية التحقق أو العناية التي مبوجبها تقوم املصارف اإلرسائيلية‬ ‫الضفة الغربية أو غزة أو إرسائيل‪ ،‬وقد بلغ املعدل اإلجاميل للنفقات‬ ‫بتقييم نظ رياتها الفلسطينية ال تزال معلقة‪.‬‬ ‫املرتتبة عىل هذه الحواالت سنوي اً حوايل ‪ 850‬مليون شيكل إرسائييل‬ ‫(ما يقرب من ‪ 250‬مليون دوالر أمرييك)‪ ،‬وهو ما يعادل ثلث النفقات‬ ‫‪ .9‬يقدم هذا التقرير أيضً ا فص الً يركز عىل النظام الصحي‬ ‫الصحية السنوية يف وزارة الصحة أو ما يقرب من ‪ 1.3%‬من الناتج‬ ‫الفلسطيني‪ .‬ويُ ظهر التحليل املقدم يف التقرير أن القيود عىل‬ ‫املحيل اإلجاميل (‪ ،)2022‬يضاف إليها أكرث من ‪ 345‬مليون دوالر أمرييك‬ ‫املوارد الكبرية تعيق قدرة النظام الصحي عىل التعامل مع العبء‬ ‫من املتأخ رات امل رتاكمة لصالح املستشفيات مقابل الخدمات‪ .‬وبني‬ ‫املتزايد لألم راض غري املعدية (‪ .)NCDs‬إن ارتفاع معدالت اإلصابة‬ ‫عامي ‪ 2020‬و ‪ ،2022‬كانت هناك ثالثة حاالت مرضيه متثل النسبة‬ ‫باألم راض غري املعدية مثل الرسطان وأم راض القلب واألوعية الدموية‬ ‫األعىل لهذه الحواالت الطبية الخارجية‪ ،‬وهي ‪ .1‬الرسطان و‪.2‬أم راض‬ ‫والسكري وأم راض الكىل من شأنه أن يؤدي إىل زيادة تكلفة الخدمات‬ ‫القلب واألوعية الدموية و‪.3‬أم راض املسالك البولية‪ .‬ومتثل هذه‬ ‫الصحية بني السكان الفلسطينيني‪ .‬وعالوة عىل ذلك‪ ،‬يقيد االحتالل‬ ‫الرشوط الطبية يف مجموعها ما يقدر بـ‪ 60%‬من جميع نفقات‬ ‫اإلرسائييل باألضافه إىل السياق املايل الكيل األوسع قدرة النظام‬ ‫‪58‬‬ ‫الحواالت الطبية‪.‬‬ ‫الصحي الفلسطيني عىل تقديم الخدمات‪ ،‬وذلك عن طريق الحد‬ ‫من االستثامرات يف امل رافق والبنية التحتية والحد من حركة األشخاص‬ ‫‪ .11‬يجب عىل السلطات اإلرسائيلية والفلسطينية التنسيق بشكل‬ ‫والسلع‪ .‬ونتيجة لذلك‪ ،‬تظهر مشكلة نفاد األدوية‪ ،‬وال سيام يف غزة‪.‬‬ ‫أكرث فاعلية لضامن الوصول إىل الخدمات الصحية األساسية‪ ،‬وتقليل‬ ‫وقد قامت‪ ،‬مؤخ را ً‪ ،‬بعثة رسمية مشرتكة بني البنك الدويل وصندوق‬ ‫العبء املايل املرتتب عىل الرعاية الصحية‪ ،‬وتعزيز النظام الصحي‬ ‫النقد الدويل إىل غزة‪ ،57‬مب راقبة األوضاع الحرجة للمستشفيات يف‬ ‫الفلسطيني‪ .‬وميكن القول إن القيود الكبرية تحد من الحصول يف‬ ‫القطاع‪ ،‬وعىل وجه الخصوص التحديات التي يواجهها مرىض الرسطان‪،‬‬ ‫الوقت املناسب عىل الحواالت الطبية عالية الجودة‪ ،‬كام أن اإلنفاق‬ ‫وال سيام فيام يتعلق مبدى توفر العالج املحيل‪ ،‬وكذلك الحصول عىل‬ ‫الحايل للسلطة الفلسطينية عىل هذه الخدمات غري مستدام‪ .‬ويف‬ ‫تصاريح السفر خارج غزة يف الوقت املناسب‪ .‬وميكن القول إن هذه‬ ‫هذا التقري ر‪ ،‬يصف الفصل األسايس عىل نحو موسع ومفصل القيود‬ ‫العقبات غالب اً ما تجعل من املستحيل توفري رعاية صحية كافية و‬ ‫املفروضة عىل الوصول إىل الخدمات الصحية‪ ،‬وكذلك أدوار ومسؤوليات‬ ‫‪ /‬أوتوفريها يف الوقت املناسب‪ ،‬مام يؤدي يف العديد من الحاالت إىل‬ ‫كل من السلطات اإلرسائيلية والفلسطينية (املبحث ‪ 1‬من الفصل‬ ‫تدهور خطري يف الظروف الصحية – أو إىل وفاة املرىض بشكل كبريأيض اً‪.‬‬ ‫‪ ، )2‬كام ويحلل اآلثار املالية للحواالت الطبية الخارجية (املبحث‬ ‫واألهم من ذلك‪ ،‬أن متوسط توافر األدوية األساسية يف السنوات‬ ‫‪ 2‬من الفصل ‪ ، )2‬ويقدم بعض التوصيات يف مجال السياسات ذات‬ ‫األخرية يف غزة بلغ ‪ 55%‬فقط‪ ،‬مقارنة بـ ‪ 90%‬يف الضفة الغربية‪.‬‬ ‫الصلة‪ ،‬وهي توصيات قابلة للتنفيذ من جميع األط راف املعنية‪،‬‬ ‫وباإلضافة إىل ذلك‪ ،‬تؤدي ظروف العمل غري املواتية واألجور املنخفضة‬ ‫وذلك من أجل تحسني الوصول إىل الخدمات الصحية الجيدة‪ ،‬والتي‬ ‫إىل تفاقم القيود التي تواجه املوارد البرشية‪ .‬وأخ ريا ً وليس آخ را ً فيام‬ ‫تم تلخيصها أيضً ا يف الجدول أدناه‪.‬‬ ‫يتعلق بهذه التحديات‪ ،‬يؤثر الرصع املسل املتكرر بشكل مبارش عىل‬ ‫تقديم الخدمات الصحية‪ :‬فبني عامي ‪ 2019‬و ‪ ،2021‬تعرضت ‪151‬‬ ‫منشأة صحية إىل ‪ 563‬هجوم اً‪ ،‬كام وجرح ‪ 463‬من العاملني يف القطاع‬ ‫الصحي‪.‬‬ ‫‪ 57‬متت املهمة يف أغسطس ‪ ، 2023‬وتضمنت زيارات إىل املستشفيات‬ ‫املحلية واملدارس وممثيل القطاع الخاص‪.‬‬ ‫‪ .10‬يجري تحويل العديد من املرىض إىل مستشفيات ال تديرها وزارة‬ ‫‪ 58‬جميع البيانات املتعلقة بحجم الحواالت ونفقاتها يف هذا الفصل‪ ،‬ما‬ ‫ ‬ ‫الصحة الفلسطينية‪ ،‬مام يؤدي إىل زيادة النفقات الصحية االمر‬ ‫مل يُذكر خالف ذلك‪ ،‬مأخوذة من الحواالت الطبية لشهر يناير ‪- 2020‬‬ ‫الذي يزيد تفاقم الوضع املايل‪ .‬إن األم راض غري املعدية تتطلب عال ً‬ ‫جا‬ ‫أكتوبر ‪ 2022‬باستخدام بيانات الحواالت اإللكرتونية التي تم الحصول‬ ‫م ا وإمكانية للوصول املستمر إىل الرعاية الوقائية والعالجية‬ ‫مستدا ً‬ ‫عليها من وزارة الصحة الفلسطينية‪ .‬وقد أجرى البنك الدويل هذا‬ ‫وكذلك الرعاية التلطيفية (هي الرعاية الهادفة إىل التخفيف من‬ ‫التحليل يف عام ‪ 2023‬كجزء من مراجعة النفقات العامة املتوقعة‪.‬‬ ‫معاناة املصابني باألم راض وتسكني آالمهم)‪ ،‬وهي أشكال من الرعاية ال‬ ‫‪26‬‬ ‫‪AGAINST TIME – WORLD BANK ECONOMIC MONITORING REPORT TO THE AD HOC LIAISON COMMITTEE‬‬ ‫ ‪RACING‬‬ ‫الحكومة اإلرسائيلية‪ +‬السلطة‬ ‫الفلسطينية‪ +‬أصحاب العالقة‬ ‫السلطات الفلسطينية‬ ‫السلطات اإلرسائيلية‬ ‫الهدف‬ ‫إنشاء هيئة تنسيق لتعزيز‬ ‫تحديد مسارات رعاية املرىض واملبادئ‬ ‫استحداث عملية رسيعة ومحددة زمني اً‬ ‫تحسني الوصول إىل‬ ‫التوجيهية الرسيرية للحواالت الطبية بوضوح‪ ،‬الوصول إىل الخدمات الصحية‬ ‫وممنهجة وشفافة ملنح تصاريح التنقل‬ ‫الخدمات الصحية‬ ‫األساسية يف الوقت املناسب عن‬ ‫وخاصة للمستشفيات اإلرسائيلية‪.‬‬ ‫للمرىض الفلسطينيني وم رافقيهم‪.‬‬ ‫الجيدة‬ ‫طريق تقليل اإلج راءات التي من‬ ‫تطوير قدرة وحدة رشاء الخدمات فيام يخص شأنها تأخري استصدار التصاريح‬ ‫تقديم تصاريح دخول متعددة للمرىض‬ ‫ورفضها‪.‬‬ ‫إدارة وم راجعة وضع الحواالت‪ ،‬ومواصلة‬ ‫املصابني بأم راض مزمنة‪.‬‬ ‫تبسيط إج راءات الحواالت الطبية الخارجية‪.‬‬ ‫تعزيز نُ ظُم املعلومات وأنظمة‬ ‫تعزيز الحامية املادية للطواقم وامل رافق‬ ‫اإلبالغ‪ ،‬من أجل جمع بيانات‬ ‫الطبية‪.‬‬ ‫مفصلة عن املرىض‪ ،‬واإلج راءات‬ ‫تسهيل دخول األدوية األساسية‬ ‫ذات الصلة‪ ،‬وكذلك جمع‬ ‫واملعدات الطبية واملعدات االحتياطية‬ ‫البيانات الخاصة بالحواالت‪،‬‬ ‫وغريها من املستلزمات الطبية‪ ،‬وخاصة‬ ‫ودمج ذلك كله يف أنظمة‬ ‫إىل غزة‪.‬‬ ‫املعلومات الحالية لدى جميع‬ ‫املستشفيات املستقبلة‪ ،‬مبا يف‬ ‫ذلك تلك املوجودة يف إرسائيل‪.‬‬ ‫ضامن استدامة تقديم الخدمات‬ ‫صياغة خطة استثامرية لخفض النفقات من‬ ‫تحسني اإلبالغ عن تكاليف الوحدة‪،‬‬ ‫تعزيز االستدامة‬ ‫يف مستشفيات القدس الرشقية‪.‬‬ ‫خالل تعزيز الرعاية األولية وتطوير إمكانية‬ ‫وإجاميل النفقات‪ ،‬وخصومات التخليص‬ ‫املالية للنظام‬ ‫املشايف يف كل م رافق وزارة الصحة الفلسطينية‪،‬‬ ‫مقابل العالج من خالل الحواالت‬ ‫الصحي‬ ‫التفاوض عىل العقود التي تنص‬ ‫وذلك ضمن االستثامرات التي سيتم متويلها‬ ‫الطبية يف املستشفيات اإلرسائيلية‪،‬‬ ‫عىل تكاليف الخدمات املقدمة‬ ‫من قبل السلطة الفلسطينية ورشكائها يف‬ ‫وتحديد فرص خفض األسعار‪.‬‬ ‫يف املستشفيات اإلرسائيلية‪،‬‬ ‫التنمية‪.‬‬ ‫ومواءمة هذه التكاليف مع‬ ‫مواءمة معدالت السداد التي تقدمها‬ ‫تكاليف تقديم الخدمات يف‬ ‫إنهاء املفاوضات الخاصة بالتعاقد مع جميع‬ ‫منظمة الصيانة الصحية‪ 1‬اإلرسائيلية‬ ‫مستشفيات القدس الرشقية‬ ‫املستشفيات التي تتلقى الحواالت الطبية‪،‬‬ ‫ملستشفيات القدس الرشقية مع تلك‬ ‫ومستشفيات الضفة الغربية‪.‬‬ ‫وتضمني أحكام ملعالجة املتأخ رات السابقة‪.‬‬ ‫الخاصة باملستشفيات اإلرسائيلية‬ ‫املامثلة‪.‬‬ ‫إج راء تقدير تفصييل لتكاليف الرعاية للحاالت‬ ‫التي تحظى باألولوية‪ ،‬وذلك لالنتقال من نظام‬ ‫قائم عىل اإلج راء اإلداري إىل نظام دفع خاص‬ ‫باملزود أو مقدم الخدمة عىل أساس الحالة‪،‬‬ ‫وتعزيز ترتيبات ال رشاء‪ ،‬من أجل تحسني‬ ‫التكاليف من خالل وفورات الحجم (التوفري‬ ‫بسبب حجم التوريدات الكبري)‪.‬‬ ‫ منظمة الصيانة الصحية هي مجموعة تأمني طبي تقدم خدمات صحية مقابل رسوم سنوية ثابتة‪.‬‬ ‫‪1‬‬ ‫)‪ANNEX (EXECUTIVE SUMMARY IN ARABIC‬‬ ‫‪27‬‬ 1818 H Street, NW Washington, DC 20433