Mapping stakeholders, services, data, and the information system for adolescent health in the West Bank | Reproductive Health

Twenty-one key informant interviews were conducted with different stakeholders engaged in the HIS related to adolescent health. Table 1 provides the characteristics of the stakeholders interviewed.

Service availability

Stakeholder mapping

Over 300 different organizations’ websites, social media pages, and contact information were explored during the stakeholder mapping. The stakeholders identified were categorized into four main types: governmental, private organizations, NGOs, and municipalities. It was found that 35 major organizations provide adolescent health services in the West Bank.

Governmental organizations, making up most of the stakeholders (94.7%), are responsible for providing essential health services, often through health facilities and schools. Private organizations (0.85%) offer limited but specialized services, often in collaboration with larger agencies. NGOs (2.05%) are actively engaged in awareness campaigns and targeted interventions for adolescents. Municipalities (services in towns or cities) (2.3%) provide services through youth centers and population-based initiatives. The maps in Fig. 1 illustrate the distribution of these providers throughout the West Bank. These services usually occur in health facilities, schools, and youth centers or are population-based services. The major funders were found to be the United Nations Population Fund (UNFPA) and the United Nations Children’s Fund (UNICEF), while organizations like Oxfam and Save the Children are newly focusing on adolescent health needs. Municipality-run youth centers play a huge role in providing health awareness, counseling, and vocational training. Table 2 shows a breakdown of the major organizations that provide different adolescent health services in the West Bank and their characteristics. The five most mentioned services provided, with their respective overall percentages in the West Bank, were awareness (93.9%), mental health (2.2%), reproductive health (1.3%), counseling (1.3%), and protection against violence (1.1%). The percentages represent the proportion of service delivery points providing said services. Awareness services are health education on various topics, such as reproductive health and nutrition, and they are given in groups, usually in schools or summer camps. Mental health services refer to individual counseling or psychological support. Reproductive health services also refer to individual medical services that are given to boys and girls, usually in a clinical setting, such as family planning. We were able to map these as well, and the distribution within the West Bank can be found in Fig. 2.

Distribution of adolescent services in the West Bank by the type of provider

Distribution of adolescent services in the West Bank

The analysis of the distribution of adolescent health services across the West Bank, as illustrated in Figs. 1 and 2, reveals several patterns. Services are predominantly concentrated in certain areas, reflecting the centralization of resources and infrastructure in these regions. This bias is evident in the clustering of facilities and programs in cities and towns, leaving rural regions underserved. The unequal geographic distribution leaves adolescents in certain areas facing limited access to essential health services. The type of service provider also shows patterns in governmental organizations providing most of the adolescent health services. NGOs, while fewer in number, appear to target areas with identified gaps in governmental service delivery, suggesting a complementary role. Private organizations and municipality-run youth centers provide additional, limited services focused on specific health needs or community initiatives. The presence of multiple providers in the same region, however, raises concerns about potential overlap and duplication, highlighting the need for improved coordination among stakeholders.

The maps demonstrate that specialized services, such as mental health and reproductive health, are concentrated in areas, while rural areas are primarily limited to general health awareness and counseling. These patterns collectively point to the urgent need for targeted interventions to expand adolescent health services in underserved regions and strengthen coordination mechanisms to optimize resource use and service delivery. After a comprehensive understanding of the major organizations and their distribution, the following exploration focuses on the specific settings where adolescent health services are delivered: health facilities, schools, youth centers, and population-based services.

Service settings

Health facilities

Adolescent health services are provided in all primary health care clinics and mobile clinics as part of family health services and not exclusively for adolescents. Primary health care services are mainly offered by the PMoH, UNRWA, the Palestinian Medical Relief Society (PMRS), and the Union of Health Care Committees (UHCC). The PMRS mobile clinics are also available to provide medical and psychological consultations to underserved communities and regions with inadequate medical care. These clinics are staffed by a general practitioner who performs medical examinations and consultations and a psychologist who provides psychological consultations. The locations of these clinics are determined according to an annual plan, ensuring that they are accessible to those who require them the most.

Schools

As of the 2022/2023 school year, there are a total of 2394 schools in the West Bank. These include 1896 governmental, 96 operated by UNRWA, and 402 private schools. In the school-focused health initiatives, the organizations prioritize comprehensive health education for adolescents, directing efforts towards 9th to 11th-grade students in all government and private schools on an annual basis. The seamlessly integrated school health program is an integral part of their broader child health initiative, offering health checks for students up to the age of 18. They encompass students from kindergarten to 12th grade, addressing critical issues such as adolescence and early marriage awareness. Recognizing the pivotal role of nutrition in schools, policies underscore balanced nutrition and the promotion of healthy habits. Implementation of health awareness campaigns, electronic monitoring systems for students’ nutritional status, and vaccination programs for 6th, 8th, and 9th-grade students all align with the overarching commitment to comprehensive adolescent health within the school environment.

Youth centers

Youth centers in the West Bank, operated by community-based organizations, serve as invaluable hubs providing free services for adolescents and youth, fostering a secure environment for skill development and leisure activities. We were able to map ten youth centers throughout the West Bank, and they were mainly municipality initiatives. These centers deliver educational programs spanning gender equality, mental health, and sexual/reproductive health, with a particular emphasis on encouraging peer-driven knowledge exchange. Complementing these initiatives are awareness programs addressing various health topics. Specific programs, such as the Youth Empowerment Program for girls aged 14–18 and the Big Brother-Big Sister Program, offer targeted support, aiding adolescents in overcoming challenges like social stigma and gender-based violence. These centers not only strengthen community and familial bonds but also provide psychological assistance for issues ranging from sexual/reproductive health to family relationships, ultimately empowering adolescents to navigate societal pressures authentically.

In response to the evolving healthcare landscape in the West Bank, essential services have been established that are accessible to all residents, irrespective of their affiliation with health facilities, schools, or youth centers. Among these newly introduced services is a comprehensive vaccination program, which extends free vaccination services to all children and adolescents. In addition to the introduction of the 121 Hotline by the NGO, Sawa addresses medical concerns by offering free consultations for individuals of all ages, with a dedicated focus on child protection for those under 18. This listening line, complemented by a user-friendly phone application, facilitates virtual appointments with healthcare professionals, which are bookable through WhatsApp. Notably, the 121 Hotline has forged partnerships with major social media platforms, including Facebook, Instagram, and TikTok, enabling the swift removal of harmful content, electronic bullying, or inappropriate material within 72 h.

Gaps in service delivery

Significant gaps exist in the delivery of services in the West Bank, such as comprehensive sexual education and contraceptive access. Comprehensive sexual education programs are absent, leaving adolescents without a full understanding of sexual health. In primary healthcare clinics, married adolescent girls have access to contraceptive services, but these are not available to unmarried adolescents. Data collection in health facilities is limited because adolescents, who are generally healthy, rarely attend these facilities for services. Health information related to awareness and counseling is typically not recorded, further limiting the availability of comprehensive data on adolescent health.

Many services for adolescents are funded based on international priorities rather than local needs. These services often depend on project-based funding aligned with donor priorities, which may not necessarily reflect the specific needs of the local population. The reliance on external funding results in a lack of continuity when priorities shift and was highlighted by funders. When asked how they decide on the projects to implement, the majority indicated that the availability of external funding primarily drives their decisions.

“We mainly fund projects, but we do not provide direct services. Our funds usually come from a call or grant that we have applied for and are granted. We then find the most appropriate organization to provide this service.” Stakeholder ID # 16.

Data sources

Population-based surveys/census

Most of the adolescent health statistics come from population-based surveys, which are household and school-based. The most popular school-based surveys are the Global Health School Survey and the Global Youth Tobacco Survey. The Multiple Indicator Cluster Survey in occupied Palestinian territory only included married women 15–19 from the adolescent age group. A youth survey was also done in Palestine, but the focus was on the ages 18–29. The last census was in 2010, and no adolescent health statistics were obtained from the survey. Surveys are the most used source to understand behavior risk facts such as smoking, nutritional status, educational level, and employment. Population-based surveys are funded by organizations such as UNICEF and UNFPA.

“An organization comes to the PCBS and asks us to do this survey…This is how we decide which surveys are done.” Stakeholder ID #19

A gap of information in the population-based surveys was found amongst the 10–14 age group. When asked about why there was a lack of data and indicators for this age group, a few of the stakeholders recalled that the country’s definition of adolescents starts at the age of 15.

“You will find a gap in the health information of 10–14 because the country defines adolescents and youth as starting at the age of 15. You will find information on work indicators even though the age starts at 15 because 10–14 years is considered to be child labor and taken into consideration.” Stakeholder ID #20.

Challenges in the health information system

A variety of providers offer adolescent health care services. Each provider is tasked with gathering data from their respective facilities, such as the type of service provided, the number of adolescents treated, and supply statistics. This data must be included in the annual report. However, providers utilize different health management information systems, with the Ministry of Health facilities using AVICENNA in hospitals and DHIS2 in primary health care clinics. This variance in systems presents a challenge for integrating data from primary and secondary facilities. When the different organizations were asked about the system of sharing data with others, all answered that they submit an annual report to the MoH every year.

“We submit an annual report to the Ministry of Health every year.” Stakeholder ID #6

“There is a yearly report, and in the yearly report, we give a summary of the statistics and what programs were offered and who attended these programs.” Stakeholder ID #18.

When asked if data is used to decide if a program is a priority, many organizations described using internal needs assessments. When the researchers asked for a copy of these assessments, they were told they were not for publication. It was clear that in most organizations, some monitoring and evaluation is used but has not been published.

“We do need assessments, before and after, to monitor and evaluate our projects internally…. These reports are not published.” Stakeholder ID #4

Also, many health organizations and providers do not have a unified system for data sharing, which results in fragmented data collection efforts, making it hard to make evidence-based decisions. Many stakeholders reported adolescent health data comes from population-based surveys, and the available indicators are derived from these surveys.

In the final phase of the interviews, key informants were queried about the utilization of adolescent health indicators in the decision-making process for implementing services. Several stakeholders expressed concern over the absence of up-to-date adolescent health indicators, emphasizing the necessity of adopting priority indicators. It was noted that adolescent health services, being a new focus, have garnered increasing interest from international organizations and funders in recent years.

“We prioritize which indicators we should focus on, which ones are more relevant and publicize it to all organizations. This will help us when we design new projects, interventions, and programs, refer to these indicators, and see that they are the most relevant to the Palestinian context. Those are the more relevant to SDGs and to the future interventions that we want to make, and then we can unify them for all the organizations.” Stakeholder ID #3.

When asked what indicators they would like to see available on the priority list, a few stakeholders mentioned the importance of mental health indicators as well as employment indicators.

“… Unfortunately, they are out there, and nobody knows what they are doing. So, I think statistics related to adolescence in the labor force would be another important indicator to see how it is influencing their future and how that is influencing their health status, mental status, you know, social, and economic status.” Stakeholder ID #15.

“Definitely, mental health and psychosocial status of science would be another area, and indicators around that would be important given the reality. Unfortunately, that and the Palestinian people are facing, you know, violence on a daily basis, and the mixed results most recently has also indicated the increase of domestic violence.” Stakeholder ID #13.

The findings of this study offer an understanding of the adolescent health services landscape, highlighting gaps in service delivery and coordination. These results serve as a foundation for discussing the implications of improving adolescent health outcomes and strengthening the HIS in the West Bank for evidence-based service allocations.