Examining West Bank Mental Health Systems

Chapter 1: INTRODUCTION

Palestine has been known to be a low income country that has scarce resources and seeking independence at the same time. The strenuous conditions seen in Palestine has attracted attention towards examination of the mental health across the Palestinian people with a critical focus directed towards the West Bank. The refugee camps on the Gaza Strip and the West Bank are said to have existed since 1948, which is also recorded as the time of uprooting of the Palestinians. History has it that over 2 million people lived in the Gaza Strip making the place to be overcrowded. The condition of the refugee camps is thought to have led to scarcity of the health resources, economic malaise as well as medical resources. The subsequent psychological experience must have led to such feelings of depression, grief, anxiety, shame, shattered assumptions, helplessness, and sensitivity to injustice, somatization and survivor guilt among others. A focus on the West Bank as the key settings of the study seemingly pre-empts the role of stressors that helps in explaining the rates of the psychological distress detected across survivors. With this prerequisite in place, the thesis sets in motion a research on the relationship between mental health system and the social wellbeing. It also focuses on the measures and strategies that have been or can be put in place to contain the mental health state in Palestine while integrating the case study of the West Bank. The chapter points at the background details, the research problem, and the scope of the study, aims and objectives, as well as the structure of the dissertation.

Background of the study

The history of Palestine largely takes the conflict dimension, which has a severe impact on the Palestinian lifestyles and mental wellbeing. The war between Israel and the Arabic countries in 1948 was regarded as the starting point of a lasting catastrophe, known as “Nakba” by the Palestinians. History has it that over three quarters of the entire Palestinian people were displaced while others fled as a result of the conflict and took refuge under the United Nations. The aftermath clearly brought out a remorseful message portraying massive losses of lives, homes, villages and land with survivors experiencing trauma (Horton, 2009). The subsequent war of 1967 also had a negative impact on the people’s daily lives as well as the Palestinian wellbeing. Most of the people experienced deprivation, injustice, discrimination and persecution. A series of events that followed included the uprising of Intifada that fueled the Israeli punishment practices, boycotts against the Palestinian government in 2006, and military operations along the Gaza Strip with a series of crimes said to have been conducted against the Palestinians. The West Bank had its people concerned more about their relatives following the military operations, which challenged their social wellbeing and the mental health system. The incidents and events in Palestine caught the attention of the world. The United Nation later passed the partition plan which is said to have divided Palestine into Arab and Jewish state in 1947. Peace agreements followed thereafter with one witnessed in 1993 and 1994 with Gaza and the West Bank remaining as the occupied territory governed by the international law. The West Bank is among the areas that were geographically separated with both Gaza and West Bank sitting on a total area of land that amounted to 6170 square kilometers. The demographic profile of this area is also captured in the books of history. Both Gaza and the West Bank had a total population of 3637000 people with a significant portion living in the 27 refugee camps, as well as 400 villages. Years of frustrations and fear also lead to questions associated to the health status of the entire population. The Palestinian health system has largely been deemed to be in its development or evolution stage. The behavioral illness, mental health illness and chronic diseases have slightly replaced the infectious disease profile with immediate actions needed in containing the problems. The striking poverty levels and years of Palestinian trauma can be traced when determining the implications of the mental health. However, there has been rare reliable data that point at the prevalence of mental issues within the Occupied Palestinian Territory. However, the anecdotal evidence from various mental health sources indicate that chronic stress and levels of acute illness within the OPT is due to the fluctuating social-political situation. This means that the Palestinian population is likely to be more susceptible to mental health problems, such as depression and anxiety, due to the environment that is full of threats and hopelessness. Research indicates that people who are predisposed to severe mental illness such as bipolar disorder and schizophrenia are likely to experience symptomatic disorders.

Perhaps, the health status of people living in the West Bank and the Gaza Strip remains the key area of focus based on the encroaching danger of mental illness among the young population. The Palestinian youths and children are groups of the population that are likely to suffer from the emotional problems due to the ongoing conflict, humiliation and repeated traumas with scales of poverty ruining their growth. Recent studies indicate that the Occupied Palestinian Territory has shown traces of key stressors as a result of the Israeli occupation. The stressors amount to restricted access to medical facility and healthcare, lifestyle risk factors, man-made hazards and the health system weakness. In a summary, the Palestinian health system is fragmented and is a menace described in terms of institutional, historical, geographic and organizational levels. The analysis of the health care system in Palestine is inconsistent sometimes with strategies having no or less impact on the population. This informs on attention channeled towards the diseases with lack of the same attention towards the social wellbeing of the thousands of Palestinians who live in fear and hopelessness. However, the initiation of the Country Cooperative Strategy, which was spearheaded by the World Health Organization, cannot be ignored. The achievements and challenges noted in 2013 needs a further attention as noted through the 51-day emergency amid the Gaza war. The World Health Organization indicates that the Gaza Strip and West Bank have substantially been served by the Palestinian Military, Ministry of Health, nongovernmental organizations and UNRWA among others. However, their efforts have never been left without challenges. Significant barriers towards access of the health services mean that the efforts have less or no impact on the health of people. Sometimes, the process of applying for permits is delayed and travelling to the West Bank is slightly inconvenient. Therefore, the study of the West Bank and the integration of health services and social wellbeing informs on a research gap of the potential strategies, which can contain issues with the mental health state of Palestinians. The gap can be extended to evaluation of the measures that have been put in place to handle mental illness and emotional problems against the theme of sustainability as stipulated in the UN Sustainable Development Goal 3. Less or no studies have checked on why mental growth is a critical component of the social wellbeing among the Palestinians, and even people living in other parts of the world. The literature only covers events and measures that have been put in place in settling the war and the endless conflicts that have severe impact on the Palestinian children and youths.

Research problem and justification

Mental health, as a component of social wellbeing, is also a significant part of the entire public health. It is closely linked to other relevant factors that are not limited to security-related, economic, political and social anxieties. Somehow, the mental health state can be associated to the low education levels, discrimination and arduous living conditions among other poverty indicators. The research problem, in this context, borrows from the Palestinian society which has been faced by man-made hazard and orchestrated calamities believed to have ruined the social wellbeing of the people. As far as there have been many studies attached to the OPT, only few have touched on the sustainable efforts in stopping the war in Gaza and West Bank and almost none of them touched on the essence of integrating the mental health and social wellbeing of the thousands of Palestinians. While SDGs prove to be tenable, the SDG 3 appears unreachable for most of the Palestinians who believe that the international law has a lesser impact on peace prevalence and less powerful when compared to a sovereign state. Studies also lack evidence or fail to assess key measures that address the mental health and social wellbeing against the theme of sustainability that appears in the Sustainable Development Goals. It is of note that lack of assessment and evaluation efforts resonates with lack of the scientific research on the mental health services in the larger Arab region. Perhaps, medical health research no longer takes a leading position in the region, which means that the OPT is likely to face more problems if no measures are put in place to address the entire scope of the mental health state. There are many factors that define the underdeveloped mental health research and services in such areas like Palestine. Some of the factors include the diversity of cultures, political decisions and social conditions witnessed in the war zone areas such as The West Bank and Gaza. Therefore, the process of developing measures and strategies that can address the components of mental health and the scope of social wellbeing needs more attention while drawing comparisons to the SDGs.

Scope of the study

Lifestyle in the Arab region, politics and many other life aspects are largely influenced by religion. When it comes to healthcare matters, the principles used are still based on the Islamic values. Back in the 10th century, healthcare and research was highly prominent. Today, there is lack of appropriate services and the region is largely underdeveloped. Depending on the nature of the country, the development methods and needs for the mental healthcare are different and they are largely impacted by social factors, income and political views. In general, the Arab world is increasing efforts in training professionals and providing care that can be integrated in the local culture. However, it is of note that Palestinian healthcare system is still facing multiple challenges as a result of occupation and the political situation. This has been the cause of the impediment towards facilitation of a unified healthcare system while making the region to rely on other organizations. The key providers of healthcare in the Occupied Palestinian Territory include the Palestinian Authority, the United Nation Relief and Work Agency for Palestine, Non-Governmental Organizations, Pharmacies and clinics, which act as private healthcare providers. From 2000, the region has witnessed an increase in the number of patients seeking mental healthcare services. Relief and emergency have been areas of focus by the health programs with limited effectiveness remaining undone for the long period of time. The situation has perpetuated reliance on the external funding, which compromises the scope of sustainability and future self-sufficiency. The research keeps an eye on the initiatives that can boost mental healthcare in the West Bank while assessing them against the UN sustainable development goals, which have been given a global priority.

Research aim

The main aim of this research is to assess current development strategies meant to improve the state of mental health and social wellbeing in the society under occupation. This should also resonate with whether the strategies meet the needs of the people in West Bank and the requirements of the UN sustainable development goals.

Research Questions

The aim of this research is supported by the following objectives:

What is the relationship between social wellbeing and mental health state in the OPT? What is the condition of the mental health system in the OPT? Why is it that the mental health system in OPT is in bad shape and what are the consequences? What are the development frameworks of health system and NGOs in the region? What are the gaps, overlaps and effectiveness of the development strategies as related to mental health? Why the social wellbeing and mental health state should be assessed against the UN Sustainable Development Goal 3?

Dissertation outline

The thesis will largely cover the development frameworks in regards to the mental health in a region faced with conflicts and under occupation. The discussion will also point at the strategies that have been implemented by both the local government and internal organizations. Chapter 1 facilitates the introductory part while chapter 2 gives the context of the Palestinian health system while revisiting the background of the study in chapter 1. Chapter 3 provides the frameworks and methods that would be used to collect opinions and suggestions from people while chapter 4 records results from the field. Chapter 5 expands on the findings from interviews on the current mental health before giving the conclusion.

Chapter 2: Literature review

2.1 Overview of the chapter

This chapter presents an overview of the case studies and researches that have been conducted before within the same area of study. The coverage includes the theoretical concepts that will appear throughout the paper including such terms and concepts like conflict, mental health and man-made hazards among others. The chapter will further delve into elements and discussion of the existing findings and ideas within the scope of mental health before identifying the research gap.

2.2 Elements and discussion of existing findings and ideas in mental health

2.2.1 Mental health and conflict

“Mental health is defined as the state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” (World Health Organization, 2014). In order to make conscious decisions, a society needs to be functional. In other words, the population needs to be able to fully participate in their society. The WHO state, in their mental health and development report, that people with poor mental health “are not able to participate fully in their society by taking part in public affairs such as policy decision making process”. People in low and middle-income countries are less likely to have access to mental health care and generally have a low level of wellbeing. The reasons for this are likely to be lack of funding and resources and in many cultures, it is simply not considered as a priority. One quarter of the world population is affected by mental health disorder and only one tenth have access to proper health care. According to the WHO (World Health Organization, 2014), 804000 people committed suicide in 2012 as a result of poor mental health and is the most common cause of death for people between 15 and 29. Deaths by suicide in developing countries account for 75% of the world total. The World Health Organization (2013) estimated for mental health services over the next 20 years is expected to cost the global economy $16 trillion. According to the WHO (2018), most mental disorders occur in people during their teenage years. It has been observed that this occurs in most cultures around the world and that many countries with a higher percentage of children happen to be in the developing world, and have limited resources for mental health. Disabilities that occur on a global level are most often caused by mental disorders along with substance abuse. Another major cause of mental disorders includes disasters. Societal post conflict or having experienced emergency situations have increased the rate of mental health issues due to experiencing higher levels of stress and trauma. Attending to mental disorders does not only benefit general mental health and wellbeing but also decreases the risk of other illnesses (Who.int, 2018). People suffering from mental health issues have proven to be more vulnerable to caching other diseases such as HIV or diabetes. The understanding of mental disorders and treatments have improved and evolved over the past decades. However, it is still widely misunderstood and is a common factor for discrimination, isolation and abuse (Who.int, 2018). Though treatments exist, there is still a common belief that certain mental disorders are untreatable and often the resources available are less than adequate. A consequence of this misunderstanding or denial is the violation of human rights. Though in first world countries there are laws that protect these rights, a big proportion of the world mistreat and deny basic human needs to people with mental disorders. The principle barrier to carrying out and treating mental health issues are the scarcity of human recourses. According to the WHO (2013), middle to low income countries only have 0.05 psychiatrist and 0.42 nurses per 100000 people. In order to improve mental health services, there are five steps according to the WHO that should be considered, “the absence of mental health from the public health agenda and the implications for funding, the current organization of mental health services, lack of integration within primary care, inadequate human resources for mental health, and lack of public mental health leadership” (Who.int, 2018) In normal contexts, three percent of people worldwide suffer from mental health issues. Studies have shown that populations under occupation or in conflict have a much higher occurrence of mental disorders (Scholte et al 2004). There are many conditions that affect ill health such as low income, inadequate housing, unsafe workspace and lack of access to health facilities, but conflict decreases health conditions not only because of injuries, death and disability but it also increases physical displacement, discrimination, and marginalization and lowers access to health services. Social capital is the understanding between the members of a society of a norm or the value of the networks that ensure a good function of the society (Social Capital Research & Training, 2018). When in conflict, social capital is disrupted and the system is no longer functional. In this case, there are talks of negative social capital where groups of the society will form bonds as a strategic coping mechanism (Social Capital Research & Training, 2018). This decline in cooperation creates an obstacle when in post conflict reconstruction. Palestine is a sensitive country in all political, economic and social contexts and faces a particularly difficult situation in regard to mental health and wellbeing. The nature of the political conflict is cause of a vast amount of mental health issues but also physical health as well as a poor economy and a fragile political system. Giacaman et al (2009) reviews the disjointed and inadequate public health and health service response to health problems. A few health care system problems are the ongoing colonization, fragmentation of communities and land, acute and constant insecurities, routine violations of human rights, poor governance and mismanagement in the Palestinian national authorities and their dependence on international aid for resources. Palestinians created an independent Palestinian service to health, women, agricultural and student social action groups promoting community involvement on the land, and led to the development of the health and medical infrastructure independent of the Israeli military, which was unable to provide adequately for people’s needs especially in tertiary healthcare. A report on mental health and quality of life in the occupied Palestinian territory argue the action to support the sustainable development of the Palestinian health sector ‘and other vital infrastructures, with particular emphasis on developing services prepared to attend to current mental health challenges and able to provide effective local models of care’ (Medical aid for Palestine, 2016). The relationship between exposure to conflict and human rights abuse, psychological trauma and affective disorders such as depression and anxiety is well established. Exposure to multiple violent events is also associated with higher levels of trauma and depression symptoms in ongoing conflict affected communities. (Giacaman et al., 2009)

A study on the demographic characteristics on the health status of the Palestinian population, drawing on the perception of their health status and quality of life, as well as the human security framework. This was meant to understand the effects on health and wellbeing of the socio-political conditions indicated that their primary concern was the safety of their family and the ability to provide for their children. The consequences of ill health of social economic and political exclusion and the lack of basic freedoms, disempowerment, fear and distress lead to a shared sense of need for community security (Giacaman et al., 2009).

2.2.2 Relationship between the mental health state and social wellbeing in the OPT

Giacaman et al. (2011) reviewed the international discourse across mental health and biomedical. The mental health is viewed from the analogous point of physical ill-health and the positivistic enquiry. Giacaman et al. (2011) also indicated that socio-economic and cultural factors can influence or lead towards ill-health and mental health viewed from the societal point of view. The study presents the framework of social justice, as well as human rights with medical indicators pointing at the Palestinian mental health. A brief history on the Palestinian mental health reflects on European societies that suffer from exclusion and condemnation. In early 20th century, Giacaman et al. (2011) indicates that mental health and mental illness was a responsibility left to families. However, the advent of the colonial psychiatry in 1920 under the British Mandate, Palestine started experiencing some of the coercive practices. The theory as well as the practice of psychiatry squarely focused on what was commonly referred to as the indigenous mind. The approach ignored the impact of racial oppression and the nature of politics at the time. Following the military occupation of the Gaza Strip and West Bank in 1967, history has it that Israel became in charge of the welfare and the health of the people in the society. Despite the dominance of the European psychiatry, it is evident that the indigenous understanding still exists albeit the change and adjustment of the new social realities. In the 1980s, history has it that the population in the Ramallah District Villages fostered the biomedical approaches that incorporated the traditional beliefs. The scope of mental health of war largely affected the Palestinian population. This alerted the humanitarian aid providers, as well as the health practitioners with increased media attention that covered the Israeli military violence. The worsening psychological trauma became one of major concerns that attracted the international initiatives, which became a sign of the western cultural trends. However, the incoming of the international agencies never stopped most of the Palestinians from relying on the family support, as well as community intervention. The Oslo Accords in the year 1993 as well as the Palestinian Authority went ahead appreciating the traditional approaches and the trauma programs, which also adopted the community intervention and the family support. Some of the epidemiological studies across the Gaza Strip found that families and women were more vulnerable to military violence and anxiety. Some of the studies showcased that poor mental health outcomes commonly led to the psychiatric distress. Harsha et al. (2016) pointed at the connection between the collective disaster and the social suffering, which provides link between the social wellbeing and mental health. The history behind the Palestinian political injustice and social suffering started with Nakba, which also referred to catastrophe. Besides, the loss of lives and other disastrous consequences that befell Palestine points at a history that is over 1000 years old. In most circumstances, dispersion as well as forced dispossession that affected over 700000 lives is said to have touched on over three-quarters of the Palestinian territory as well as the bordering Arab states. Perhaps, the 1967 war led to more losses with Israel taking over the historical Palestine. More than 180000 Palestinians are said to have fled the war seeking refuge in the Arab states. The rise of Intifada pointed at the culmination of the popular resistance that aimed at destabilizing the entire Israeli military occupation. Notably, the violent response to the Palestinian Intifada from Israeli led to dangerous, difficult as well as insecure living status for the Palestinian population. A series of army checkpoints, detentions, curfews and barriers had a severe impact on the populations. Over 4800 people including 950 children were mercilessly killed by the Israeli military between 2000 and 2008. At the same time, over 59% of the total population living in Gaza and West Bank is said to have lived below the poverty line. Even after six decades, there has been no viable solution provided to the Palestinian people. The military occupation and mass trauma made the Palestinian people to suffer from depression and hopelessness. The situation in Palestine has raised discourse following the symptomatic violations and injustices that worsened the mental status of most people in the society.

2.2.3 Causes and consequences of the occupation on the mental health system

Nasir et al. (2018) took a study on Hamm, which is also an Arabic word that refers to the idioms of distress and suffering at the same time. The understanding of the OPT and the diagnosis of the sensitive healthcare have further led to the coverage of the causes and consequences OPT has on the mental health and mental illness in Palestine. Giacaman et al. (2009) pointed at the health status, health services and demographic characteristics as defined factors incorporated in the 60 years of war and the 40 years of the Israeli military occupation. As much as literacy, education and health hit a higher standard, over 52% of all the families in the West Bank still live below the considerable poverty line. Giacaman et al. (2009) considered a UN study that incorporated 3415 adolescents from the larger Ramallah District, which reported trivial scores on the grounds of life satisfaction. A subsequent survey of the representative sample in the West Bank town showed the invasion of the Israeli military. From the study, one can possibly learn of the causes and the consequences of OPT on the entire mental health system. The OPT exposure to violence and humiliation is thought to have led to severe mental health effects and the subjective health complaints. In a 2002 case study, the respondents evidently pointed out the uncontrollable fear, psychological distress, fatigue, shaking episodes and hopelessness as the causes of mental illness in the OPT and the bordering regions. In addition, the uncontrollable crying episodes and enuresis impacted on the children’s general health as displacement, bombing and curfew contributed to high or extreme rates of depression. The UN studies also pointed out a number of psychological problems, which emerged as the consequences of traumatic events in the OPT. Some of the problems included lack of concentration among students, sleeping difficulties, fears, speech difficulties, anger and depression among orphans. Nasir et al. (2018) further noted that Palestinians were people that never enjoyed safety even before the occupation of Israeli. People lived in pain as a result of the history of mass trauma. The expectation of possible threats and danger made most of the people to live in fear. Most people in the region endured social suffering attached to war, which also speaks volumes in terms of the experience of pain and the context of biomedical conceptualization. Apparently, most of the medical problems experienced at the time could not be separated from the societal issues. Horton (2009) tries to review most of the societal issues witnessed in the Occupied Palestinian Territory. One of such issues or events Horton (2009) focused on included humiliation, which was a vice used in war while establishing control over the Palestine population by Israeli. The chronic exposure to periodic humiliation has a direct link to mental illness. Humiliation has been known as an element of suffering of the victims. The experience between 1950 and 1967 saw the Gaza Strip brought under the Egyptian Military Administration, which saw the region face more oppression and servitude. The expansion of oppressive activities to the rural areas further reduced the required attention on mental illness and other medical problems. The subsequent analysis of the entire Palestinian health in the OPT indicates chances of the medical system having the conventional indicators of infant mortality, health status of the refugees and the subjective measures of the social experiences and quality of life. It is of note that the contextual and political constraints in the region impeded the comprehensive agenda of enhancing health and the aligned services. This is because Palestinians have consistently been facing insecurities due to a spree of depression episodes and colonization. The World Health Organization and the United Nations also realized the occupation of the territory left it in tatters and less developed. Mental and the general health of most of the Palestinian seemingly caught the international attention with the United Kingdom’s Parliamentary International Development Committee reporting on the perilous aspects of health in OPT. A study conducted by Marie et al. (2016) incorporated the Norwegian study pointing out that the Gaza Strip never appeared on the Global Positioning System. The study recognized the criticality of mental illness which incorporated only 12% of the total cases with the rest remaining undetected. The Norwegian study additionally noted the attitude towards mental health problems, which also detected the cultural difference and the impact of social stigma across Africa and the Middle East. The cultural composition of the Palestinian society further carried an impeding component, which detected family values as part of the mental health intervention. The description of the collective personality among the Muslims and Arabs questioned the aspect of equality and freedom in receiving healthcare services and mental health attention in the OPT. Marie et al. (2016) further notes that the question of whether the Palestinian society deserves medical attention relies on the value system adopted in OPT. This means that the worsening spree of mental illness can partly be blamed on barriers introduced by the Israeli occupation, as well as the Palestinian themselves who either lack the confidence to approach the facilities in the West Bank, or who are hampered by the values and customs practiced by the region.

2.2.4 The development frameworks of the health system and NGO’s in regards to mental health

World Health Organization (2017) thought of frameworks of the health system in response to the mental health demands in Gaza and the West Bank. The organization devised a logical framework purposed to support a humanitarian action plan in the OPT. One of the strategic objectives developed by the WHO and other NGOs included the need to enhance protection of people in Gaza, East Jerusalem and the Seam Zone through promotion of the international humanitarian law. Besides, other areas that supported the strategic objective included mitigation and prevention of the impact of violations, and boosting the equitable access to services in the West Bank and other regions that had the right infrastructure. Across the humanitarian action plan, the World Health Organization further worked on the key indicators of the strategic objectives including people benefiting from the protection response such as legal assistance and protective presence. Potential indicators on the side of the health sector took note of the Primary Health Care (PHC) partners and the impact of the healthcare programs. While this action plan remained relevant in the course of attending to mental illness in the region, the plan further remained focused on the vulnerable populations both in Gaza and the West Bank as stipulated from the future and current hazards. The most important part included emergency preparedness and the recovery plan in case of an unlikely event. The second strategic objective developed by World Health Organization (2017) was to improve food security across the food-insecure communities. The strategy focused on Area C and Gaza with food assistance aiming at enhancing the diet across the population. This further resonates with the mental health services supported by the Ministry of Health, which worked in conjunction with the Palestinian Authority. AlKhaldi et al. (2018) further took note of the Health System Organization before and after 1994. While East Jerusalem and the West Bank were under Jordan, Gaza was pre-occupied by Egypt before the oncoming of the Israelis. Health Institutions had separate functions that were independent from each other with Gaza observing the Egyptian protocols. Since the year 1948, history has it that UNRWA played a focal role of providing primary health services to all the registered Palestinian refugees including the ones in Gaza and the West Bank. The top managers from the Israeli administration confirmed that UNRWA was meant to facilitate good healthcare using the available resources. The health sector comprised of the Palestinian staff that conveniently provided service to the refugees and other people in the West Bank and Gaza. AlKhaldi et al. (2018) also insinuated that the Palestinian health system allowed support from both the NGOs and the government sector. With such attention, still most of the Palestinians never accessed most of the services. The infrastructure, however, favored and relied on the hospital care, curative and preventive care as well as patient cost sharing arrangements. The undertaking of the government plan means integration of the efforts from the municipal workers and the Palestinian Authority. In the most recent years, the insurance program was embedded under the government plan that was modeled by the Israeli government. The aftermath of the first and second intifada is said to have destabilized the operation of the UNRWA clinics and the larger network of the primary care facilities. Besides, the contribution from both the private sector and Non-Governmental Organizations also played out key roles that supported the framework, which addressed mental illness. Key levels of the entire Palestinian health system that saw NGOs play part included the political, religious and social motivations. Most of the organizations offered the psychosocial support, in-patient care, health education, rehabilitation and emergency care. In addition, most of them are still engaged in health education, health promotion, health planning, human resource development and infrastructure development. The growth of private health institutions was noticed from 1994 to 2000 following the growth of rehabilitation centers, pharmacies, hospitals, clinics, radiology and physiotherapy. However, most of the private insurance plans were eliminated due to the economic hardships that were experienced after the second intifada. On the other hand, the analysis of the Palestinian Civil Society Organizations further led to a cascading arrangement that observed a framework of capacity building. On top of the framework are the first level organization, which incorporates the skill building needs and individual capacity in policy monitoring and project management. This informs on the need to strengthen the relations management as well as the negotiation abilities between the local authorities and the private sectors. The significant reconstruction of the CBOs relationship leads to construction of space at either the community or local level. Under the first level of the development framework are the second level organizations that work in conjunction or partnership with the intermediary organizations and the Non-Governmental Organizations. This level recognizes the support of the CBOs, local governance and transparency and communication functions. The scope goes alongside the efforts of the local governance, public authorities and monitoring of the public policies, which have an impact on the private sector and NGOs. The institutional environment further concerns creation of space for networks and coalitions and coalitions. Finally, the third level organizations fostered aggregations of the CSOs and campaigns that call for support from the civil society platforms. The impact member organizations, activists and volunteers have on the OPT recounts the essence of working on the therapeutic measures that confront psychological problems and social complications that are beyond normal medical services and what the authority can offer. In 1994, the Occupied Palestinian Territory realized a total of 1400 civil society organizations. However, the number reduced after the Palestinian Authority was established. Almost 800 organizations disappeared with the PA finding its way in the structures of the Health Service Council with CSOs declining mergers. Between 2004 and 2005, most of the international funds increased the operations of the NGOs and activities that resurfaced after the second intifada.

2.2.5 Gaps, overlaps and effectiveness of the current development strategies as related to mental health in the OPT

The development strategies attached to mental health has attracted a number of case studies and research that observes the gaps, overlaps as well as effectiveness of the same strategies. World Health Organization (2016) noted that the strategic priority incorporates strengthening as well as enhancing resilience of the entire Palestinian health system. The strategic priority is largely strengthened by the hospital based data, which enables the policy makers to confirm the hospital capacities and the patient needs as one way of impacting the healthcare effectiveness and the care pathways. The key gap in the course of restructuring the strategic priority includes the resonation of the strategic priority with the sustainable development goal 3 as well as the universal health coverage. This has led to a number of recommendations that seek support from the World Bank in strengthening systems as far as health financing is concerned. While the Patient Health Initiative provides the necessary tools for improvement, it is not confirmed whether such tools conform to the standards of SDG 3 in the West Bank and other neighboring and insecure zones (Gordillo-Tobar et al., 2017). The second gap revolves around the voluntary core capacities meant for International Health Regulations as noted in the Occupied Palestinian Territory. The position of the ministry of health points at the role played by partners and communities in containing health emergency and the humanitarian health response. The expansion of the core capacities points out a gap as to whether the intention behind every mission meets the required health regulations as demanded by the international committee. Between 2017 and 2019, the OPT realized a plan that conformed to the institutional framework that fostered emergency preparedness, infection control and prevention, as well as emergency preparedness. Perhaps, the contingency plans observe the medicine protocols but ignores the measures of risk management and the purpose of training. The last strategic priority confirmed by the World Health Organization (2016) included strengthening of the entire Palestinian Ministry of Health while keeping an eye on prevention, management as well as control of the mental health disorders in the West Bank. The gap across this initiative is accessibility and its effectiveness to the populations in the West Bank and the Gaza Strip as far as the Occupied Palestinian Territory is put into consideration. The future of these strategic priorities is not possible for the two districts given that the population is not enlightened on the essence and impact of the healthcare system. Perhaps, the traditional methods should not be ignored but need to be modified for the purposes of meeting contemporary needs. Apart from the gaps left behind by the strategic priorities discussed above, the current development strategies are essentially effective in some aspects. Barber et al. (2017) confirms that a number of assessments that have been conducted before aimed at establishing the efficiency of the main providers identified in the occupied Palestinian territory. However, Barber et al. (2017) still notes that such assessments have always emanated from both economic and political situations. While most of the facilities performed fairly well, most of them only staged a significant performance with constraints noted in the restrictions at checkpoints, the separation wall and barriers to movement. Assessments done in 2007 indicated that over 40 cases of denied ambulances led to an impeded entry in the West Banks, which rendered the service ineffective. Perhaps, this agrees to what was found in 2003 in a survey, conducted by Barber et al. (2017), which showed the period took by Palestinian to reach out to an appropriate health facility, which amounted to at least 1 hour. The presence of the Oslo Accords also led to the assessment of the primary healthcare centers. Strategies applied in these centers are said to emanate from the structures of the Non-governmental Organizations. From the applicable strategies of the healthcare plan and partnership, it could be noted that the number of such centers fell from 242 to 177 from the year 1992 to 1994 (reference). The decline in the number of centers was largely due to changes in terms of the donor aid policies as well as the Palestinian National Authority. While the change spoke volumes about the applicable strategies of primary care and emergency responses, it could further be noted that such strategies only supported a small population of the Palestinians and left the rural coverage to traditional methods.

Shortages in terms of the tertiary health-care services, for example, hampered the population in Jerusalem form accessing the healthcare services with extreme cases referred to other countries for further treatment. Most of the foreign treatments are expensive and could exert financial burdens on the society and the system itself as shared through the Ministry of Health. The extension of the free insurance coverage never matched the quality of care, which was deteriorating at the time as the ministry expressed no capacity to contain the turn-away patients from the Palestinian population. Furthermore, the Amartya Sen hypothesis conducted by WHO (2017) noted the material constraints that led to failure of the system in meeting the basic needs. Perhaps, the inequitable distribution of the possible healthcare facilities in the West Bank and Gaza saw most of them being established in Gaza among other central areas of both the Gaza Strip and the larger West Bank region. Besides, the UN relief and the Works Agencies largely focused on the Palestinian refugee camps, which may not have reflected the composition of the larger population (Choi et al., 2017). Therefore, the analysis of strategies deployed in the region indicates that most of them have been ineffective and of less impact to the populations that depend on it. However, the recent precautions on conflict eruptions portray the essence of emergency preparedness and the risk management action plan, which can possibly impact conflict resolution even before the war erupts.

2.2.6 Assessment of strategies addressing the mental health state and social wellbeing against UN Sustainable Development Goal 3

Both the ministry of health and NGOs have been conscious on the mental health state in Palestine following the years of war, servitude and occupation. As mentioned before, most of the strategies outlined by the NGO’s and the ministry have rarely impacted the lives of young people in rural areas. The National Health Strategy (2014 - 2016), for instance, observed the integrated as well as comprehensive healthcare services for all the people with World Health Organization taking the frontal role. In the light of the publicized strategy, still people had to walk for long distances before they could access the required healthcare services. Gordillo-Tobar et al. (2017) looks at SDG 3 and the requirements the health strategies in Palestine are supposed to meet. Goal 3 concentrates on both the wellbeing and health for all regardless of the age and the settings of the healthcare system. Gordillo-Tobar et al. (2017) insists that before looking at what the system provides, it is important to focus on what the goal provides. Goal 3 largely addresses key health priorities including the newborn, adolescent health, reproductive, a child, access to health and safety, non-communicable and communicable diseases, quality as well as affordable medicines and universal health coverage. The goal, therefore, looks beyond research and development, diversified health financing, strengthened capacity, risk management and enhanced health workforce. Therefore, the assessment looks at whether the initiatives identified in the West Bank and Gaza meet the 2030 agenda, which avails the prerequisite to the health focus with priorities invested in mental health and the emerging issues of the unfinished Millennial Development Goal Agenda. Furthermore, the World Health Organization reviewed the condition of the 31 health-related indicators across the World Health Statistics 2016. Evidence shows that there has been a consistent fight against most of the communicable diseases and mental disorders across the most susceptible regions (Epping-Jordan et al., 2015). However, the World Health Organization (2017) looks at whether the development strategies meant for mental health and social wellbeing met any of the requirements of SDG 3. World Health Organization (2017) noted that the Country Cooperation Strategy has been under assessment since 2013 with the internal workshop pointing at the achievements and challenges at the same time. The assessment focused on the desk review of the broad consultation and documents received from 27 partners, as well as 14 World Health Organization staff in Gaza, the West Bank, Nablus, Jerusalem and Ramallah. It is of note that the CCS strategies were assessed on alignment and consistency with the global and national strategies and plans. These included the UN SDG, WHO Twelfth General Program and the National Health Strategy (Marie, Hannigan & Jones, 2017). Based on the assessments, it was found out that most of the CCS priorities were essentially aligned to most of the national plans and strategies with exception of the emergency response and preparedness. While the SDG 3 fosters the global health agenda, strategies deployed in Gaza and the West Bank are seemingly impeded by social protection and geographical barriers to universal health coverage. Perhaps, the country is in dire need of better and informed strategies that can reduce in neonatal and maternal mortality, as well as boost mental health in the region. On the basis of effectiveness, WHO (2017) concludes that most of the plans and strategies from NGOs and the government seem to focus on the health system development, which calls for sustained efforts over a significant period of time. This implies that most of the health needs in the West Bank have not been met as a result of the insignificant efforts from the ministry of health and other NGOs (Collier & Kienzler, 2018). The World Health Organization insists that having a dialogue among the key players in the health sector will support both the financial and technical capacity in pursuit of the strategic agenda. While the WHO seems to be an ineffective informant, it still reflects on the situation at hand with local consultants demanding for more partnerships that can boost the health standards of the region. Across the assessments, two areas are important in identifying the condition in the West Bank and Gaza. These include the health status and the entire health systems (Ayer et al., 2017). The study of the health status in the Occupied Palestinian Territory has further been a contentious issue with studies trying to value it against the UN Sustainable Development Goal 3. The health status in Palestine has been crowded by a number of challenges, which are said to have been prolonged by conflicts as well as adverse social determinants. Some of the challenges include widespread poverty, natural hazards, lifestyle risk factors, difficult access to some of the health services and health system weaknesses. All these have amounted to an ineffective health system. Despite the deteriorated health status, the health outcomes in Palestine are said to have shown a significant scale of improvement with average performance of health noted in the entire Eastern Mediterranean Region and the neighboring regions. Data from the World Health Organization indicates historical, security, socioeconomic and regional disparities between the health status in the West Bank and Gaza. The World Bank estimates indicate that Gaza and West Bank had their life expectancies increased from 68 to 73 years between the year 1990 and 2013. However, it should be noted that only the modest and partial improvements of the health outcomes were achieved without addressing the target of Millennium Development Goal 4, which underlines the reduction of child mortality by 2/3, as well as Millennium Development Goal 5, which conformed to reduction of maternal mortality by 3/4, in the year 2015. Moreover, mortality rates among children have generally improved with an infant mortality rate of 10.9 deaths out of 1000 live births noted in 2015 (Gordillo-Tobar et al., 2017). This is a bit lower than 18.2 deaths in 1000 live births noted in 2014 showing modest improvements in terms of the health outcomes. As much as the health outcomes do not meet the targets of SDG 3, they still show an improving trend among refugees in Gaza who are supported by the UN Relief and Works Agency in the year 2013. With an increase in terms of health attentions, the validation study by the World Health Organization indicates increased cases of congenital anomalies, infections and birth asphyxia, which remain to be key contributors to neonatal and infant deaths. Similar observations are made in terms of the epidemiological and demographic transition with total fertility remaining high but deteriorating with time. Besides, the Palestinian health system can be described in terms of a fragmentation at institutional, historical, geographic as well as organizational levels. In 2014, World Bank has it that the health human resources remained at almost the same gross levels with around 14000 employees assigned in Palestine (Manenti et al., 2016). The figure seems to obscure the fact that the personnel in health sector seems to have increased in West Bank, as well as decreased in Gaza during the political divide of Hamas and Fatah. With low remuneration, and delays in terms of the salary payments, strikes and low morale among employees looked inevitable. The trend must have taken the opposite of what was expected from the ministry of health after a high out-of-pocket spending on the pharmaceuticals and the general mental health. Therefore, the health status and system in OPT is still developing with better standards expected to be achieved in future. This means that more players are supposed to be invited with the central purpose of boosting the efficiency of the system linked to mental health (Gordillo-Tobar et al., 2017).

2.3 Research gap

The review of several cases as shown in the above discussion only took note of the mental health and conflict, the relationship between mental health and social wellbeing in the OPT, the development frameworks improvised by the ministry of health and NGOs, the gaps and overlaps of the mental health state in OPT and strategies that can improve mental health in the West Bank. With this coverage, the protrusion of the research gap leans towards shaping the strategies towards mental health while boosting their standards to meet those of the UN Sustainable Development Goal 3. The study of the West Bank and the significant integration of social wellbeing and health services should consistently focus on the mental health state of the Palestinians who have endured conflicts, war and occupation for the longest period of time. The gap can further be extended to assessment of measures put in place to counter emotional problems as well as mental illness in the West Bank. Only few studies have checked on the mental growth and reasons as to why it is treated as a critical component of the social wellbeing with the Palestinian perimeters. The Palestinian history largely reflects on the events as well as measures that aimed at ending the war and settling the conflicts that consistently ruined the lives of Palestinian youths and children. With events and catastrophic incidents witnessed in Palestine, this research finds it reasonable to expound on the social context, and how standardized strategies can confront emotional problems witnessed among children and youths in the OPT. This informs on the shortcomings of the recent strategies such as the National Health Strategy, which have survived for some years without creating a significant impact in most of the rural areas and refugee camps.

2.4 Summary

This chapter has been consistent and explicit in exploring the research topic by capturing the informative prerequisite. First, the chapter provided an overview of the coverage by mentioning the researches and case studies felt relevant to the research topic. Theoretical concepts covered the pervasive meaning of the research topic and terms that support it in terms of the health status and health system. The coverage on mental health and conflict explores on the essence of integrating the two sides while addressing mental disorders. However, the understanding of the findings indicates that treatment of disorders has evolved with time. This informs on the strategies that have been adopted with time as regards the efforts of the Ministry of Health and NGOs that. Furthermore, an overview of the relationship of social wellbeing and the mental health looked at the Palestinian social suffering and collective disaster. The same review was extended to the causes and consequences of OPT on the mental health system. Palestinian never enjoyed peace and safety especially in Gaza and West Bank, which has made the region to be more susceptible to mental disorders and mental illness. The review also focused on the development frameworks considered by the Ministry of Health and Non-Governmental Organizations. Some of the strategies included the improvement of food security and primary health services supported by the insurance programs. Besides, the review looked at the strategies put in place to address the social wellbeing and mental health in OPT, and assessed them against the UN Sustainable Development Goal 3. In the assessment, the review looked at the requirements of SDG 3 and evaluated the status and performance of the strategies while focusing on the 2030 agenda. Lastly, the chapter identified a research gap, which was identified along the need to shape the strategies towards the mental health and boosting them to meet the required standards.

Chapter 3: METHODOLOGY

This chapter forms one of the most critical sections in research because it defines the course of the entire research process. Research methodology can be described as the systematic as well as theoretical analysis of methods used in any field of study. Methodology consists of the theoretical models, paradigm and techniques applied in the research process. In studying the mental health in Palestine, the research considers a set of methods that focus on addressing the research topic.

3.1 Overview of the chapter

As mentioned before, this chapter will focus on a set of methods that define the research process engaged in addressing strategies meant to enhance the mental health among people in OPT. The chapter will look at the philosophical framework, the research approach, research method, the sampling process, data collection and data analysis. It is of note that developing the research process, in this case, will be aligned to qualitative description that avoids numerical data and adopts explorative and descriptive approach.

3.2 Philosophical framework

Life in Palestine is regarded as one of the critical components faced with numerous challenges for many years. Research around the OPT has been given equal attention following the trauma and depression people endure in the aftermath of wars and conflicts in the region. A focus on the mental health of people in the West Bank amounts to a social concern that attracts the Interpretivism philosophical framework (Walliman, 2015). The framework dictates that social researchers are expected to interpret key elements of the study and integrate human interest into the entire research. Based on the research topic on the strategies to enhance mental health in West Bank, Interpretivism helps in developing the social constructions that conform to language, shared meanings, instruments and consciousness as part of the reality (Rosenberg, 2017). The philosophy puts a strong emphasis on qualitative analysis, which is essentially applied in determining the position of idealism. The qualitative position groups together different approaches such as hermeneutics, phenomenology and social constructivism in describing and analyzing the situation in West Bank. The use of Interpretivism provides two key advantages in this research (Tsang, 2014). First, data is heavily determined by personal values and viewpoint, which are important in determining the emotional situation and frustrations people go through in OPT. Secondly, the framework exerts significant levels of validity as the studies are more honest and trustworthy at the same time.

3.3 Research approach

The research invests in observations and theories that describe the kind of life in Palestine and looks into applicable strategies that can boost the strategies put in place to improve the mental health. With inductive research approach, commonly referred to as inductive approach, in place, the research process stands a better chance of establishing a pattern that runs form observation to development of explanations (Duke, 2016). With relevance of the research topic to social research, the inductive approach aims at generating meaning from the collected data for the purposes of identifying the patterns and developing relationships between strategies, and the mental health in West Bank. Apparently, regularities, resemblances and patterns are important in determining the conclusion at the end of the research process (Steffen, Rüthing & Huth, 2018). The primary purpose of this approach is to give room for the research findings to emanate from the dominant, frequent and important themes that are inherent in raw data. Most of these themes are normally obscured, left invisible and reframed due to preconceptions noted in data analysis procedures and data collection. However, the inductive approach still presumes that data analysis should be dictated by interpretation of data, research objectives and multiple readings as well (Steffen, Rüthing & Huth, 2018). This means that findings should be derived from the research objectives and analysis of data. Besides, the approach presumes that the primary analysis should be done categorically and later transformed into a framework that reflects significant processes and themes linked to the research topic.

3.4 Research method and design

The context of OPT reflects on a social life that has seen people being barred from accessing healthcare services. Other people are depressed over their family members who lost their lives as a result of war. While focusing on OPT, the research process heavily invests in the opinions and experiences of people in the West Bank, which can be made more significant through a qualitative research method (Csikszentmihalyi & Wolfe, 2014). The method suits this context in the way it facilitates the insights into conditions or problems while constructing relevant ideas. Qualitative research constitutes “development of concepts which help us to understand social phenomena in natural settings giving due emphasis to the meaning experience and views of the participants” (Pope and Mays, 1995). The method is picked for the research process because, first, qualitative data is preferred for understanding the context and environment that fosters political, economic, and social or a health matter such as mental health and social wellbeing in Palestine (Carr, 1994). Qualitative data provides means of understanding people and their interactions such as their health or experiences and views of organizations and activities. The purpose of qualitative data is to describe and get an opinion on a certain topic or practice related to the research in context (O'Byrne, 2007). Secondly, data collected is more personal, in depth and on a smaller scale than the quantitative data. This means that results are explanations of individual reasons and sampling is theoretical rather than statistical. Besides, qualitative data is as a result of a contextual, flexible research question and the outcome is not usually predefined. Data is collected by individuals who form a significant instrument that is more flexible, adaptive and responsive with participants feeling the freedom from any control in their own environment. The qualitative method is more effective when it works along a research design (Smith, 2015). In this context, the research focuses on West Bank as the key area of study. This means that a case study design is more appropriate especially when handling mental health problems faced by most of the Palestinians in West Bank. The design gives room for application of tools while studying complex phenomena in relevant contexts in the society. Upon application of the research, the design becomes more valuable in developing theory, evaluating programs as well as constructing significant interventions. Making use of a case study is more relevant in cases where behaviors within the study cannot be manipulated, when contextual conditions are relevant to the significant phenomenon under study, when boundaries are not established between context and phenomenon and when decision making is the key purpose of the research. The design provides a number of advantages to the research process (Tjora, 2018). First, detailed qualitative accounts facilitated in case studies help in exploring the data especially in the real-life environment. The design also helps in explaining the complexities of different real-life situations such as cases of trauma witnessed in the Occupied Palestine Territory. Lastly, case studies provide descriptions of behaviors within a considerable social environment (Mackey & Gass, 2015). As much as the designs are advantageous, they still have their own shortcomings. Case studies are prone to criticism because they lack the rigor.

3.5 Data collection and justification

3.5.1 Data collection

Data collection is regarded as a process of gathering as well as measuring information on the basis of the targeted variables, as well as in systemic fashion that gives room for provision of answers to the research questions. As mentioned in the philosophical framework, conducting research in OPT demands personal interaction while recording opinions from people regarding their lifestyle in a region that has been prone to war and conflicts. This defines the process of collecting data with the requirements of establishing personal contacts calling for application of interviews (Taylor, Bogdan & DeVault, 2015). The latter is regarded as one of the most significant data gathering techniques that largely involve verbal communication between the subject and the researcher. Interviews work in line with survey deigns noted across descriptive and exploratory studies. In this context, engaging workers living in West Bank demands the application of the semi-structured interviews (Quinlan et al., 2019). This involves open-ended questions that reflect on the key topic areas that need to be covered. The nature of the interview gives room for both the interviewee and interviewer to delve into more details that regards the topic or question. This means that the interviewee also has the freedom to elaborate on the responses especially when attitudinal information is required in the course of the research process (Research Methodology, 2017). Making use of the semi-structured interview has various advantages that can make the research to be more effective. First, the researcher is likely to get extra information from the interviewees as a result of the freedom given to the respondents. Secondly, the method is more conveniently in collecting primary data, which is essentially considered to be original.

3.5.2 Data collection process

Semi-structured interview will be used in interviewing workers in the mental health sector having relevant experience in West Bank. All candidates will be adults and a total of 10 people will be interviewed. Each interview will take place at a convened time over video call. Interviews will last up to 20 min and will be audio recorded upon written consent. The interview will start with an introduction and explanation of the research, a written consent will be previously agreed over email regarding animosity, full confidentiality and an agreement to be recorded. During the interview, a set of questions will be used as part of the guideline. Additional questions may be asked as part of the discussion during the research process.

3.5.3 Pilot Study

Before taking the research to the field, a pilot study is always needed to test on various constraints and how they can be handled before engaging the interview. The pilot study will be conducted within the school. It will only involve 8 interviewees, who will still be students. The 8 will be asked questions while gauging the kind of challenges respondents are likely to face in the field, and possible solutions that can be provided before the eve of the research. Various elements will be assessed during the pilot study. First, the time factor remains critical and the pilot study will look at whether 20 minutes are enough for a single session. Secondly, the study will look at whether the questions are insensitive or sensitive. Sensitive questions are likely to raise unexpected emotions that can interrupt the data collection process. Lastly, the study will focus on the kind of answers that are likely to be received in the field depending on the kind of questions asked. After the assessment of the three areas, the interview will be adjusted for the purposes of meeting the desirable changes.

3.6 Sampling process

When sampling in qualitative research, the aim is to gather a sample that will allow understanding of the social process that are being studied. This can be done through positive sampling which is choosing the most relevant samples to answer the question or an ongoing interpretation of data that will help identify the missing viewpoints (Etikan, Musa & Alkassim, 2016). Sampling techniques for qualitative data are snowball / chain sampling, extreme/deviant case sampling, homogeneous sampling, maximum variation sampling, convenience sampling, opportunistic sampling to site the most common(Marshall, 1996). However, the most convenient technique to be used in this context is homogenous sampling. The technique applies where the researcher wishes to choose a sample that has items with identical or similar traits. In the case of people, the researcher expects them to be of the same age, employment status and even from the same location (Kelly, 2015). The research will make use of the sampling technique to pick on workers who work under the mental health sector. The workers are expected to have had an experience in handling people with mental problems in the West Bank. It is also expected that all the respondents should be adults and of the required working age (Sandelowski, 1995). With all the specifics in place, the research anticipates to interview only 10 interviewees who are believed to be in a position to give robust and verifiable responses.

3.7 Data analysis

Qualitative data, in this context, will be analyzed on the basis of the interpretive philosophy which is based on the assumption that reality is based on social constructs (Research Methodology, 2017). The analysis of qualitative data is producing an explanation or interpretation of the situation that was being studied from the data collected (Pope, Ziebland and Mays, 2000). When analyzing qualitative data, it is important to evaluate not only the content but to keep in mind the attitude of the individual or if it was group ideas, and whether the interviewee was speaking from actual experience or hypothetical experience. In the face of mental health state in OPT and emotions read from the mood of the workers, it is more convenient to pick on thematic analysis as the key tool of digesting meaning, and establish theories or conclusions (Braun, Clarke & Terry, 2014). Thematic analysis is more convenient for qualitative research because it insists on pinpointing, examining as well as recording patterns from the collected data. Themes are regarded as patterns identified across the data sets, which can be scaled in describing a phenomenon linked to a research question (Braun & Clarke, 2014). This means that the research process adopts the top-bottom approach with the basis drawn from the objectives. The research will also observe the stages involved in thematic analysis before establishing meaning from the findings. First, researchers will become familiar with the data collected during the research process. This will be accompanied with re-reading the transcripts, listening to the recorded discussions and relooking at the interview extracts (Vaismoradi et al., 2016). At this stage, notes will be made while determining early impressions around data corpus. For example, if the workers indicate that they commonly receive cases of headaches and depressions, then one is able to establish causes even when some can be wrong as regards the situation in the Occupied Palestine Territory. Secondly, the research will generate initial codes, which prompts a systemic way of organizing data. The step involves reducing data into small chunks, which creates a perspective linked to the research questions. Transcript coding can be slightly challenging especially in a situation where respondents are given the freedom to argue and expound on their answers. The third step includes searching for themes, which is simply a pattern that essentially captures significant elements that can be quite captivating. Any theme is normally characterized by its significance. For example, themes attached to emotional problems and mental disorders in OPT can be similar and therefore linked to same codes. This context adopts descriptive themes, which effectively applies to qualitative research (Greenfield, 2016). The fourth step involves reviewing themes where modifications and development on preliminary themes are done. This looks into the understanding and interaction of the theme while determining the similarity and differences. For instance, strategies meant to boost mental health can meet the requirements of MDG and SDG. This means that there are requirements in the millennial goals that still appear in the sustainable development goals. The fifth step entails definition of themes, which incorporates the process of identifying the essence of the constituents of each theme (Grass, 2014). This will be accompanied by negotiating with each them to relate to the main them noted in the research topic on mental health in the Occupied Palestine Territory. Lastly, the research will establish a write-up, which is simply a report that sites examples, findings, facts and arguments that justify a particular reason that is subject for conclusion.

3.8 Ethical consideration

The research involves an interview that attracts participation of workers from the mental health sector in the West Bank. The research is concerned about their security and anonymity during and after the process of collecting data. This is why ethical consideration stands out as the key component in executing the components of research. Various ethical issues will be addressed in the course of the research. First, the idea of informed consent forms one of the critical issues that need attention (Roberts, 2015). Informed consent informs the respondent’s rights to autonomy declared through self-determination. It also seeks to impede or prevent assaults in the scope of integrity while ensuring that interviewees make informed decisions even before they are engaged in the interview. A consent form will be send via the email giving room for the workers to read the requirements and the responsibilities of the researchers. Once the worker confirms his or her safety through a declaration on the form, the researcher is allowed to make phone calls and conduct the review. In the process, the researcher will not cause discomfort or physical harm (Grass, 2014). Secondly, the researcher will respect the confidentiality as well as anonymity of the respondents. Issues of anonymity and confidentiality are closely attached to the respect for fidelity and dignity, and the rights of beneficence. The researcher pledges to protect the respondent’s identity and observe the confidentiality of the subjects. At no time the researcher is allowed to ask for personal details, area of residence or family relations. In case the respondent is subjected to threat or any inconveniences, he or she has the freedom to pull out of the research regardless of the progress. Besides, the research understands the bill of rights and respect for privacy, which declares that the respondent has to determine the extent, time as well as general circumstances in which private details need to be shared (Roberts, 2015). The research will respect the decision made by the respondents regarding the feedback received from the field. In addition, the researcher will have to declare interest in the data collected from the field in the consent form. This allows the respondent to determine whether the use is within the acceptable limit or not. Based on this, the respondent has mandate over the information and should agree to whether recording gadgets should be used or not. This is done in the interest of protecting and observing rights reserved for the respondent during the research process.

3.9 Summary

The chapter covers a collection of methods to be used in the research process. First, the chapter captures interpretivism as the philosophical framework that posits the human interests and shared meanings across social constructs. The research further incorporates a research approach to be used, which revolves around the inductive reasoning. The approach establishes patterns and constructs relationships among the research questions. Furthermore, the research underlines the need to interpret data as themes are transformed into framework s that reflects on the research topic. Qualitative research was picked as the most convenient research method that was determined on the basis of the nature of data to be collected in the field. Qualitative data was thought to be more effective in establishing an understanding of the context described through the social wellbeing and mental health state in Palestine. The research method worked perfectly alongside the case study design, which gives room for application of tools in describing a phenomenon. On the side of data collection, semi-structured interviews were more convenient in terms of giving the respondents time to expound on their opinions. The interviews will only be conducted on adults who are working under the mental health sector in West Bank. Moreover, the research chose homogenous sampling as the technique to be used in determining the sample population that can be extended to the research process. This paves way for data collection, which can best be analyzed through thematic analysis. Lastly, the chapter touched on ethical considerations, which aim at protecting the rights of the respondents during the research process.

Chapter 4: FINDINGS

4.1 Overview of the chapter

The chapter presents the findings from the research process. The findings include the demographic profile of the respondents, the opinionated responses to the research questions and an overview of the common feedback from the participants. In this regard the chapter gives the outlook and a true account of what the mental health workers had to say about mental health system in the OPT.

4.2 Findings

4.2.1 The demographic profile of the mental health workers

The research aimed at interviewing only 10 respondents. This section, therefore, covers the findings on the demographic profile of the 10 participants that turned up for the interview. The findings on the demographic profile covers interview questions 1, 2 and 3, which asked about the age of the participants, their areas of specialization in the mental health sector and the years of experience under the same sector. All the 10 mental health workers were aged 25 years and above. The oldest person in the group of 10 was aged 37 years and worked as a psychotherapist with an experience of 7 years in the same field. Three participants out of the remaining 9 were occupational therapists with each having a working experience of 3 years. The three were aged 27 years and above with each having resided in West Bank for more than 10 years. This means that they had details on the events, conflicts and wars that have ever occurred in Palestine. Three of the remaining 6 participants were mental health caregivers that only attended to patients admitted to a local hospital in West Bank. The caregivers were aged more than 30 years with a working experience of 6 years and above. The remaining three were clinicians that attended to mental issues and cases that were received on daily basis following the frequency of trauma, cases of depression and other mental disorders. The clinicians were aged 25 years and above and had a working experience of more than 3 years each. Out of the ten participants, 4 were female and 6 were male thereby striking a gender balance in the participation. Therefore, there were four groups of professionals including a psychotherapist, occupational therapists, clinicians and mental health caregivers.

4.2.2 Mental health problems, emotional problems and the social wellbeing

This section provides answers to question 4, 5 and 6 which inquired about the frequency of the health problems and emotional problems in the OPT, the relationship between mental health and social wellbeing, as well as the impact of mental and emotional problems on the people of West Bank. The findings indicate that OPT witnesses cases of mental disorders and emotional problems. The three clinicians admitted that in almost 900 admissions in a day, at least 25% of the admission constitutes cases of suicidal attempts. This marks the highest rate of mental and emotional problems compared to any other state in the world. The psychotherapist indicated that “in at least 10 Palestinians admitted in a local hospital, at least 3 of them must be suffering from the acute stress, anxiety disorder and depression”. This means that almost 30% of the admitted patients must be experiencing mental disorders, which also means that Palestinians are more likely to be exposed to traumatizing events from time to time. The mental health caregivers further noted that the adolescents in the society are hopeless thereby making it hard to restore hope and good health for most of them. 2 of the three occupational therapists admitted that they normally handle over 35 cases of traumatic incidents on daily basis, which makes their schedule tight for them to even have a break. 1 admitted that even “running a night shift makes one to handle at least 20 cases which is a bit overburdening for a person who is dozing off”. The tight schedules for the occupational therapists indicate that mental and emotional problems in the OPT is an endless issue that keeps reiterating on daily basis. All the 10 participants admitted that there is a significant relationship between the mental health and social wellbeing of the Palestinian living under strenuous conditions. The question “Is there any relationship between the social wellbeing and mental health in OPT?” was understood as events and factors that influence behavior, health outcomes and learning. At least 4 out of the 10 respondents explained of scenarios of restlessness in the society as a result of mental problems. Most of the psychological distresses were as a result of the unpleasant events that interfered with the social wellbeing of the OPT. The events created a culture of sleeplessness, shaking episodes, hopelessness, and fatigue and crying episodes among children. This further indicated that anything that interfered with the social wellbeing of the society must also lead to one or many mental and emotional disorders that appeared dominant in youths and children. The remaining 6 admitted that the use of excessive force during the Palestinian demonstrations result into traumatic events, which include demolitions and destructions, noise due to rockets and bullets as well as shelling, which had led to negative attitudes and ailing perceptions of an area that has never witnessed peace. The question of “Do mental and emotional problems impact the people’s way of life in West Bank?” was unanimously responded to by pointing out cases of hopelessness, displacements and death. People become less productive and more aggressive leading to destruction of properties in the territory.

4.2.3 Mental health systems, consequences and partners

This section captures the findings of question 7, 8, 9, 10 and 11 which questioned on the state of the mental health system in OPT, consequences of the health system being in bad shape, as well as concerns from the partners over the problems facing the territory. The question of “What is the state of the mental health system in OPT?” found two of the respondents unaware of what was expected of them. At least the physiotherapist and two occupational therapists indicated the mental health system is still devastated with no significant changes witnessed over the years. One of them said that, “Israel has failed to meet the obligation of ensuring that the welfare and health of the Palestinian population is always independent and under control”. This meant that even in the presence of the medical services, more Palestinians were still suffering and more people were dying as a result of the mental problems and other complications. The remaining five respondents either indicated that the system was in bad shape or it is still in the developing or evolution stage. They indicated that mental health illnesses are gradually replacing the most infectious diseases, which is something that indicates lack of enough attention. On the question of “What have been the consequences of the mental health system being in bad shape?”, at least 7 respondents admitted that the poor mental health system has to failure of handling critical issues in the society. The Palestinian territory is continuously encountering more threats, which damage the mental wellbeing of the population. 3 of the respondents indicated that the situation has even deteriorated compared to the incidences they witnessed in 2015. Perhaps, there are more cases of psychological distress, anxiety disorder and depression that are being witnessed in Palestine compared to the same case 2 years ago. The 3 sited general mental health consequences that attack children and their respective families. In addition, cases of traumatic experiences and chronic stress has led to more lonely children compared to the dominance of the detainees 3 years ago as noted by one of the respondents. Besides, the question of “Have there been any partners who paid attention to the mental health problems in OPT?” attracted almost same answers from the 10 respondents. They all admitted that the Ministry of Health has been a frontier in terms of facilitating the primary health care in West Bank. They also agreed to the fact that the Non-Governmental Organizations came to their aid as they provided the rehabilitative, ambulatory and tertiary care services. Most of the NGOs, as the clinicians and health caregivers admitted, showed efforts in terms of supporting services in hospitals. Some of the NGOs included the World Health Organization. Furthermore, all the respondents agreed that UNRWA has been providing health services both primary and fixed as seen the contracted hospitals and care clinics. Lastly, 8 respondents admitted that the Ministry of Interior has been helpful in terms of providing medical support to employees, families and hospitals.

4.2.4 Improvements, development frameworks and strategies

The section records the findings for question 12, 13, 14 and 15. On the question of “Have there been any improvements of the mental health system compared to 3 years ago?” received mixed responses from the participants. One psychotherapist, three occupational therapists and two clinicians agreed to the fact that there were improvements in the mental health system, but the change was modest. With such trivial changes, the respondents failed to comment on whether the system was doing well or not. One clinician and the three mental health caregivers noted that improvements in terms of the mental health system can be aligned to the mortality rates, which have been improving with time. They tried to link the birth and mortality rates to the scale of how the system has changed with time. However, the clinician was unsure of whether the mental problems and mental health can have a direct link to the mortality rates, which are currently hitting friendlier figures. On the question of “What are some of the development frameworks and strategies introduced by the government and NGOs in the region?” also attracted a number of options and perceptions from the 10 interviewees. 4 respondents admitted that the World Health Organization developed an action plan that aimed at protecting people living in Gaza and West Bank. The four also lauded the action plan, which constituted the framework of strengthening the voluntary capacities that can support the ministry of health and the communities around. The support included emergency preparedness, infection control and prevention and health surveillance. 3 respondents alluded to the fact the framework of the universal health coverage has been supported by the Ministry of Health and the entire Palestinian health system. One of the respondents noted that “the resilience of the universal health coverage essentially the capacity of mental health”. This meant that the “Patient Safety Friendly Hospital Initiative” can perfectly work in West Bank if the available tools can support universal health coverage. The remaining three respondents noted two important strategies, which also doubled as the development framework. One of them said that “the government-private partnership yields the strengthening capacity provided to the ministry of health in providing the required control of the non-communicable diseases, thereby boosting the effort of reducing mental health disorders”. This means that the government-private framework can aim at constructing a synergy that can boost the outcomes of primary care. The remaining two supported the monitoring and accountability framework, which fosters evaluation of the mental health system and the coverage of human rights in West Bank. On the question of “What has been the impact of the frameworks and strategies laid down by the government and NGOs?” all the 10 interviewees had common answers to the question. They all had an idea of the primary care, healthcare access to the population in West Bank, increased involvement of the international community and increased medical funding in the region. On the question of “Do you feel there are still gaps and overlaps in the effectiveness of the existing development strategies?” all the interviewees agreed that there were still gaps in the development strategies invested in mental health. Some of the gaps include the restricted barriers to the population from Gaza, selective attention in delivering the healthcare services, the unpredictable political violence and lack of consistence in the services offered.

4.2.5 Assessment of the strategies against the Sustainable Development Goal 3

This section focused on the findings from question 16, 17 and 18, which attracted comments than opinions from the interviewees. On the question of “Is there any need of focusing on the UN SDG 3 when handling the social wellbeing and the mental health system in the OPT?” attracted an affirmative answer from all the respondents. Some cited reasons as to why the SDG 3 is important in defining the social wellbeing and health status of the society. The interviewees believed that if Palestine can consider the framework of the Sustainable Development Goal 3, there will be no doubt that Palestine stands a chance of competing with other systems around the world. One of the respondents narrated that “SDG 3 means well for the people and no one can deny its effectiveness in influencing positive changes in the mental health system of Palestine”. On the question of “Which look do you want the new development strategies to take when addressing the social wellbeing and mental health of the society under the occupation?” the respondents cited different frameworks for the system. For example, 8 respondents wanted the strategies to take the universal look that allows the locals to benchmark with other systems around the world. The respondents believed that this will convince the authorities to consider significant changes that have been ignored in the recent past. The remaining two proposed on more partnerships that can allow Palestine to receive more help from other able countries, as the OPT looks forward to a better and freer system that can be accessed by any person. On the question of “Is the sector doing anything in terms of educating and counseling people in the society on how to deal with depression?” the respondents had a feeling that the sector has not done enough in terms of extending the services to families. This means that apart from the mental health sector extending the treatment services to people, additional activities have rarely been witnessed in the Occupied Palestinian Territory.

Chapter 5: ANALYSIS and DISCUSSION

The study on whether the development frameworks and strategies improved the mental health state in Palestine attracted the case study of The West Bank. The study attracted 10 respondents who are said to have served under the mental health sector in the region. From the findings, the research process learnt of the mental health problems, emotional problems as well as the social wellbeing of the population living in the Occupied Palestinian Territory. The findings agreed to the fact that Palestinians frequently encounter mental health disorders and emotional problems with extreme cases involving suicidal attempts. This means that mental health is a critical issue in the territory affecting the social wellbeing of the people. The findings also confirmed that scenarios of restlessness, hopelessness, anxiety and depression have dominantly been witnessed among children and youths in West Bank. Such cases have consistently interfered with the normal life in the society while creating ailing perceptions and negative attitudes across the population. The findings resonate with the studies conducted by Giacaman et al. (2011) and Harsha et al. (2016). The epidemiological studies convened by Harsha et al. (2016) indicate that children, youths and women became more susceptible to military violence, as well as anxiety. This means that the chances of the psychiatric stress were extremely high in Palestine following the incidences of social suffering and collective disaster. The studies also agree with the findings on the inevitable relationship between the mental health and social wellbeing of the thousands of the Palestinians who have endured episodes of war. In the case studies by Giacaman et al (2011), the loss of lives and forced dispossessions in the Palestinian territory during the first and second Intifada essentially described the society the Palestinians lived in. The military occupation of the area made people to live in fear and hopelessness, which rendered the population less active and less industrious thereby attracting poverty in the region. The violations and injustices in the region must have led to extreme levels of depression, anxiety and hopelessness among other disorders. However, Giacaman et al (2011) noted that the dominance of the mental disorders remain to be under-reported, under-treated, under-resourced and underfunded. Subsequent coverage in the Palestinian adolescents indicated increased exposure to traumatizing events, which fuels mental disorders especially in Tarqumia. Among the adolescents, cases of suicidal attempts amounted to 25.28% of the total cases of mental disorders. While the scenario points at the state of mental health, the disorders also interfere with normal growth of children and the process of learning among the adolescents. The second class of findings looked at the mental health systems, the consequences and the potential partners that intervened to save the situation in the Occupied Palestinian Territory. From the findings, it could be noted that the mental health system was still unstable following the failure of the Israeli military in controlling the system. This means that mental illness became an issue that attacked the populations without proper interventions being noted in time. Based on this, the state of the mental health system led to a number of consequences such as making the population to be more susceptible to threats. Cases of chronic stress as well as traumatic experiences could no longer be avoided because the system was not strong enough to counter the effect. The findings also noted that mental illnesses are slowly replacing the infectious diseases, which is a clear indication of lack of proper attention.

The territory is subsequently more threats in terms of conflicts and wars, which heavily contributes towards conspicuous cases of mental disorders such as anxiety, depression and psychological distress. This also resonates with consistent health attacks on children and families at the same time. The incident is attracting attention form the NGOs such as UNRWA, the World Health Organization as well as the Palestinian Ministry of Health. The findings on the causes and consequences of the entire occupation on the mental health conform to the studies convened by Nasir et al. (2018) and Giacaman et al. (2009). The two groups indicated health services, health status as well as demographic characteristics define significant factors incorporated in the 40 years of occupation and the 60 years of war. The OPT has consistently been susceptible to violence as well as humiliation making people to live in fear and hopelessness. The occupation has also been under surveillance, which restricts the way of life among the people living in the territory. The displacements, enuresis, crying episodes, curfew and bombings in the region are thought to be the potential causes of the miseries that befell the territory. With such cases in place, the ultimate consequences include a collection of mental illnesses led by psychological distress and depression, while the rest include shaking episodes, fatigue and hopelessness. The UN studies in region also took note of similar psychological problems that emanated from the traumatic events that occurred in the territory. Among most students, most of them faced issues related to speech difficulties, depression, anger and lack of concentration s noted by Nasir et al. (2018). UN studies, therefore, agreed to the findings by confirming social suffering in the region with endless seasons of pain and medical problems, which amounted to a routine. The studies further conform to the findings by Horton (2009) who focused on humiliation and chronic exposure to traumatic events of the children, youths and women. Humiliation, as indicated by Horton (2009), was propagated by the Egyptian Military Administration before the Israeli occupation. A series of the oppressive activities instigated by the authorities led to frustrations among the populations while the political and contextual restrictions in the territory are thought to have impeded the significant agenda of improving the healthcare services. Colonization and occupation of the territory, as noted by UN and the World Health Organization, left the population and the region in a struggling situation thereby influencing the scale of poverty. While some of the consequences are thought to be driven by external factors, even the cultural values of the Muslim community has led to the bad shape of the health system with part of the population distrusting the services offered by the partners. The third class of the findings focused on the improvements, development frameworks, as well as the prevailing health strategies in the region. There have been modest improvements in the health system in the OPT with the mental health workers failing to comment on the future of the health system. Some of the respondents saw sense in linking the performance of the mental health system to the mortality rate among children and youths. As much as there could be no significant facts linking the mental health system to the mortality rates, the recent improvements in terms of the birth rates and mortality rates have raised hopes of realizing a convenient system that can as well impact the mental disorders. The shape of the mental health system is well analysed by the World Health Organization (2017), which observed the institutional framework in the OPT from the year 2017 and extrapolated it to 2019. The assessment looked at the emergency preparedness, the contingency plans, inflectional control and the scale of prevention identified in the course of handling mental disorders in the OPT. The World Bank estimates attempted to assess the system against the UN Sustainable Development Goal 3 where the life expectancies moved from 68 to 73 years between 1990 and 2013. The changes, however, never reflected the significant target behind the Millennium Development Goal 4. Other improvements that were noted by the World Health Organization (2017) included the reduction of the infant or child mortality by almost 2/3 and the maternal mortality by 3/4. With such changes in the health outcomes, the improvement process seems to be in progress with significant infant deaths witnessed in West Bank. Significant health challenges are still hitting the system thereby impeding the improvement process. Prolonged wars and conflicts is the leading challenge that ruins the improvement process of the mental system with widespread poverty, and blockades hindering the people’s access to the health system. Other challenges include natural hazards, increased shaking episodes and other lifestyle risk factors. Sometimes, the shortage in tertiary healthcare services has been blamed for the increased tendency of people moving outside the territory to seek better treatment. Inadequacy of the facilities has further declined or deteriorated the condition of the mental health system, which must have been the leading cause of the insignificant changes in the mortality rates among children and young mothers.

On the quest for development frameworks and strategies noted in the Occupied Palestinian Territory, the West Bank seemingly enjoys significant support from significant frameworks. From the findings, some of the frameworks included an action plan supported by the World Health Organization in support of the voluntary capacities. The support involves the infection control and emergency preparedness. The findings also established that the universal health coverage framework received support from the Ministry of Health due to its resilience and performance over the years. Other strategies pointed out by the respondents include the government-private partnerships and monitoring and accountability framework. The studies on strategies and development frameworks have been well articulated in the coverage by World Health Organization (2017) and World Health Organization (2016), which yield a requisite support towards the humanitarian action plan in the Occupied Palestine Territory. Under the action plan, the WHO supported the protection of people in West Bank while reflecting on the requirements of the International Humanitarian Law. The action plan further supported access to mental health services by putting up the right infrastructure. Secondly, the thought of universal health has attracted the studies on food security, international support and the aim of providing primary health care as noted by AlKhaldi et al (2018). Even the Israeli administration confirmed a significant support from UNRWA as good infrastructure gave room for curative, preventive and hospital care. The third strategy involved the increased partnership between the ministry of health, private sector and the Non-Governmental Organizations in relation to mental health. Most of the partnerships essentially worked on the health education, emergency care, psychological support as well as the inpatient care. Other areas include human resource development and health promotion and health insurance plans. AlKhaldi (2018) further noted that most of the health and insurance plans were later eliminated due to hard economic times that were encountered during the second intifada. As much as the plans never took a significant shape, the rebirth of the CBOs gives new hopes over the roles of the partnerships. This has paved way for the dominance of the civil society platforms with over 1400 societies realized in 1994. Apart from the scope of the strategies, the research process further invested in identifying gaps and realizing the effectiveness of the development frameworks and strategies mentioned before. The findings established the fact that the development frameworks and strategies had an impact but still left gaps in the mental health system. The respondents indicated that key gaps included unstoppable and unpredictable violence, selective attention while delivering the services and barriers that block people from accessing the healthcare services. Marie, Hannigan & Jone (2017) indicated that the prime gap in the mental health system includes restructuring strategic priority to reflect the requirements of the universal health coverage, and Sustainable Development Goal 3. The gap has attracted a number of recommendations from the World Bank including health financing among others. The second gap identified by Epping-Jordan et al. (2015) includes the intention of the missions and whether such mental health missions meant the obligations of the international committee. The gap resonates with selective attention towards health services noted in the Occupied Palestinian Territory, which leaves other health priorities unattended to. The question of accessibility still cites the barriers meant to block the populations to access mental health services especially in West Bank (Manenti et al., 2016). Apart from the gaps, the strategies are thought to be somehow effective as far as the changes in the primary healthcare centres are put into consideration. In addition, the ministry of health played a frontal role in terms of partnering with the communities and NGOs in developing the humanitarian health response. The institutional framework that was developed between 2017 and 2019 focused on the emergency preparedness, infection control and mental health. With all these in place, the strategies can only be said to be convenient and effective but lack necessary resources to be implemented in a war prone areas such as OPT.

The last class of the findings include the fact that all the respondents supported the assessment of the development frameworks and mental health strategies against the UN SDG 3. The findings established reasons as to why the SDG 3 was necessary in boosting the performance of the Palestinian Health System, and its impact on the mental health and social wellbeing. The SDG 3 is thought to influence positive changes in the health system as most of the Palestinians would want their system to take the universal look. The findings also established the fact that people would like to engage partnerships that can compel the authorities to consider changes that they ignored before as far as mental health is put into consideration (Collier & Kienzler, 2018). While the OPT had never focused ion awareness and education programs, it is evident that the issue of mental health and the recent performance of the available structures is way below the standards established by SDG 3. Gordillo-Tobar et al. (2017) noted that the SDG 3 calls for universal access to mental health when Palestinians are forced to walk for distances before accessing any help. This is also accompanied with the absence of quality mental health care and affordable medicines, which are limited by a missing research and development, lack of proper strengthened capacity, unstable health financing and poor structures for risk management practices. With all the indicators in place, West Bank lags behind the 2030 agenda in terms of failing to meet the requisite standards established under the SDG 3 and the Millennium Development Goals. However, the mental health system cannot be discredited in all accounts and the World Health Organization (2017) chose to also assess the Country Cooperation Strategy since 2013 with the central purpose of setting a promise of a better system, which can impact the society. The assessment narrowed down to the rate at which the OPT is receiving mental health partners and whether the CCS can be aligned to what the partners want to contribute towards the territory. On the basis of the assessments, it was clear enough that the CCS was essentially aligned to the national plans and contributions from partners excluding the emergency preparedness and response (Ayer et al., 2017). Therefore, the pursuit of the strategic agenda in conformity to elimination of the mental disorders in the territory seems to be on course with NGOs and other Partners expressing interest in supporting mental health system, and general healthcare. The WHO has consistently insisted on the dialogue among the key players in the sector where local consultants are given the priority of reflecting on the situation in West Bank and the neighbouring zones. As much as the SDG 3 is way above the potential of the system in West Bank, there is still room for improvement for the mental health system.

Chapter 6: CONCLUSION

Summary of the chapters

The research captures ideas, arguments, theories and insights as regards the topic under the study. Chapter 1 established an introduction where background details on the research topic were outlined. The background informed on the history of Palestine, which is characterized by conflicts and wars. This has posited a severe impact on the Palestinian way of life and mental wellbeing. The background further provides the contribution of the United States in the partition plan that saw Palestine being divided into the Jewish and State and the Arab state in the year 1947. The West Bank and Gaza remained governed by the international law and became among other areas under occupation. The background clearly indicates that that the Occupied Palestinian territory has been susceptible to wars and conflicts, which made the population to constantly experience chronic illness and mental problems. The health status of the territory became a critical issue as far as the mental health and social wellbeing are concerned. Chapter 1 further handled the research problem and justification. The problem in this research is essentially borrowed from the Palestinian society that has been experiencing man-made hazards from time to time. While Palestinians believe the international law has no impact on the welfare of the people, the territory has turned its eyes towards Sustainable Development Goal 3 which is believed to restore piece in the region. The scope of the study is determined by the occupation and political situation in the territory while focusing on the contributions of the United Nation Relief and Work Agency, the Palestinian Authority, pharmacies as well as clinics and Non-Governmental Organizations. The aim of the research has been the assessment of the current development strategies believed to improve the mental health state, as well as the social wellbeing of the Occupied Palestinian Territory. This is accompanied by several research questions include the connection between mental health and social wellbeing, the mental health system in the OPT and consequences it has on the population when tampered with among others. Chapter 2 of the research is a literature review that collected ideas and arguments from other case studies and researches. Key areas placed into consideration include mental health and conflict where the World Health Organization observed the population of the world that is being affected by the mental disorders or mental illness. However, WHO appreciates the fact that mental health has shown an improvement over the past few decades with noticeable traces of isolation, discrimination and abuse describing the causes of the current disorders. Another area under the review was the link between the social wellbeing and the mental health state in OPT where the framework of social justice, human rights, cultural and socio-economic factors describe the ill-health in the 20th century as described by some of the studies. The link was established on the basis of social suffering and collective disaster s it appears in the study of Nakba with disastrous consequences befalling the Palestinians in the longest period in history. Another area constituted the causes and consequences of the OPT on the mental health system where the traumatic experiences and humiliations witnessed in the territory are thought to have led to worse scenarios. The review also revisited the development frameworks and strategies behind the health system following contributions from the private sectors, Non-Governmental Organizations and the Ministry of Health in Palestine. Some of the development frameworks and strategies include the humanitarian action plan in West Bank and Gaza, which aimed at bolstering protection of people in the region. The second strategy focused on the enhancing diet among people living in the territory. Most of the efforts are directed towards improving mental health and whether this can be worked from the dietary side. Other frameworks and strategies include government-private sector partnerships and monitoring and accountability plans. In addition, the literature focused on the gaps, overlaps as well as the effectiveness of the existing development strategies in relation to mental health in the territory. Most of the gaps identified include the ones under the strategic priority where health capacities and the resonation of the SDG 3 are put under question. On the other hand, the assessment constituted the mental health and social wellbeing and their position when assessed against the sustainable development goal 3.

Other areas included under the literature review include the research gap, which took note of the need for assessment of the development frameworks and strategies aligned towards health services in the occupation. Chapter 3 of the research handled the methodology section where a collection of methods were identified and aligned to the research process. The thought of the philosophical framework looked at the convenience of interpretivism and how its description could suit a social research like the one on mental health system in the Occupied Palestinian Territory. The research approach pointed at inductive reasoning which is purposed to generate meaning from the data collected for fundamental reasons of identifying relevant patterns, as well as develop relationships in the course of the research process. Inductive approach insists that findings need to be derived from the research objectives or research questions identified before. The research method and design pointed a qualitative research method which is convenient in unleashing insights on the conditions as well as problems while developing ideas and concepts. Qualitative data became a preferable element in the research because it helps in understanding the environment and context behind the social wellbeing in the Palestine. The research used semi-structured interviews in collecting data and measuring the targeted variables. The tool was picked in resemblance to the philosophical framework chosen before. The process focused on a total of 10 mental health workers in the West Bank who agreed to be interviewed through the BOS website. The research also retained stratified sampling as the main criterion applied in identifying the sample to be interviewed. The criterion included such factors like age, work experience and the number of years the mental health worker stayed in West Bank. The chapter picked in thematic analysis as the prime method applied in reducing the data collected to reasonable and conclusive ideas. Chapter 4 of the research included the findings with the first bit pointing at the demographic profile of mental health workers involved in the research process. The second bit included mental health problems, the social wellbeing and the emotional problems witnessed in the Occupied Palestinian Territory. The section pointed at instances of mental health disorders and cases that involved traumatic incidents. Some of the problems noted from the interviewees included restlessness, the persistence of the crying episodes, hopelessness, suicidal attempts and depression. Some of the traumatic scenarios included demolitions, destructions, shelling and noise from rockets. The subsequent bit of research focused on the mental health systems, partners and consequences. The findings established that the Israeli occupation has led to deterioration of the Palestinian territory. The endless scenarios of chronic stress and traumatic experiences have led to increased attention towards the mental health problems. The third bit of the findings focused on the improvements, development frameworks as well as the strategies. The research noted trivial or modest improvements in the mental health system. The last bit of the findings constituted the assessment or evaluation of the development frameworks and strategies against SDG 3. This led to the findings of an underperforming system, which has not reached the standards of other systems elsewhere. Chapter 5 of the research focused on analysis and discussion, which expounded on the findings in the previous chapter.

Recommendations

The extensive coverage of the research informs on the states and conditions of the mental health system and social wellbeing in the occupied Palestinian territory. However, the following recommendations still stand.

To the World Health Organization

The WHO should pedal the support towards the Palestinian Ministry of Health and Authority while consolidating the strategic capacities that can support the health system recover

WHO should bolster the endeavours of the health coordination while looking at the improvements of the primary health care

The organization should focus on spreading awareness, counselling and educating masses on mental health problems and the precautionary strategies that can be adopted.

To the Ministry of Health

The ministry should introduce a working Health Coordination Unit that can support the humanitarian action plan in West Bank

The Ministry should bolster the security forces that can provide protection to the people, as well as work on the barriers that impede people from accessing the services

To the International community and the rest of the world

The community should support the efforts of the World Health Organization in providing support towards primary healthcare in the Occupied Palestinian Territory as far as mental health is concerned

Limitations and strengths

The use of semi-structured interviews in the course of the research process almost led to instances of unreasoned answers, which could not be connected to other ideas, theories and arguments in other case studies. Secondly, mental health workers are professionals who are likely to have never encountered mental problems in their lifetime. This made it hard to realize the exact experiences from the villages. However, the research also enjoyed areas of strength where primary data can led to justifiable conclusion. The target outcomes were also comprehensive, valid and reliable due to an informative research process.

Future Research

The study on mental health system in OPT attracts similar studies of psychological problems, and how technology has helped in solving them. This will also go along the connection between the technological impact and mental problems in the same area.

References

Abdeen, S. (2016). 7.1 A Comprehensive School-Based Training Program For Student Mental Health In Palestine. Journal of the American Academy of Child & Adolescent Psychiatry, 55(10), S11.

AlKhaldi, M., Abed, Y., Pfeiffer, C., Haj-Yahia, S., Alkaiyat, A., & Tanner, M. (2018). Assessing policy-makers’, academics’ and experts’ satisfaction with the performance of the Palestinian health research system: a qualitative study. Health research policy and systems, 16(1), 66.

Ayer, L., Venkatesh, B., Stewart, R., Mandel, D., Stein, B., & Schoenbaum, M. (2017). Psychological aspects of the Israeli–Palestinian conflict: A systematic review. Trauma, Violence, & Abuse, 18(3), 322-338.

Barber, B. K., McNeely, C., Allen, C., & Belli, R. F. (2017). Adult functioning in the occupied Palestinian territory: a survey and event history calendar assessment. The Lancet, 390, S22.

Braun, V., & Clarke, V. (2014). What can “thematic analysis” offer health and wellbeing researchers?. International journal of qualitative studies on health and well-being, 9.

Choi, Y. J., Lee, W. Y., & Al-Sughayir, M. A. (2017). Background Community health workers can help to address the substantial unmet need for child mental health care in low and middle income countries. However, little is known about their training needs for this potential role. The aim of this study was to examine training needs and perspectives of community health extension workers (HEWs) in relation to providing child mental health care in rural Ethiopia... International Journal of Mental Health Systems, 11(1), 1-11.

Collier, J., & Kienzler, H. (2018). Barriers to cardiovascular disease secondary prevention care in the West Bank, Palestine–a health professional perspective. Conflict and health, 12(1), 27.

Csikszentmihalyi, M., & Wolfe, R. (2014). New conceptions and research approaches to creativity: Implications of a systems perspective for creativity in education. In The systems model of creativity (pp. 161-184). Springer, Dordrecht.

Epping-Jordan, J. E., Van Ommeren, M., Ashour, H. N., Maramis, A., Marini, A., Mohanraj, A., ... & Suveendran, T. (2015). Beyond the crisis: building back better mental health care in 10 emergency-affected areas using a longer-term perspective. International journal of mental health systems, 9(1), 15.

Etikan, I., Musa, S. A., & Alkassim, R. S. (2016). Comparison of convenience sampling and purposive sampling. American Journal of Theoretical and Applied Statistics, 5(1), 1-4.

Giacaman, R., Khatib, R., Shabaneh, L., Ramlawi, A., Sabri, B., Sabatinelli, G., Khawaja, M. and Laurance, T. (2009). Health status and health services in the occupied Palestinian territory. The Lancet, 373(9666), pp.837-849.

Giacaman, R., Rabaia, Y., Nguyen-Gillham, V., Batniji, R., Punamäki, R. L., & Summerfield, D. (2011). Mental health, social distress and political oppression: The case of the occupied Palestinian territory. Global public health, 6(5), 547-559.

Giacaman, R., Rabaia, Y., Nguyen-Gillham, V., Batniji, R., Punamäki, R. L., & Summerfield, D. (2011). Mental health, social distress and political oppression: The case of the occupied Palestinian territory. Global public health, 6(5), 547-559.

Harsha, N., Ziq, L., Ghandour, R., & Giacaman, R. (2016). Well-being and associated factors among adults in the occupied Palestinian territory (oPt). Health and quality of life outcomes, 14(1), 122.

Manenti, C., Reinicke, C., MacDonald, J., & Donald, J. (2016). Report of a field assessment of health conditions in the occupied Palestinian territory. World Health Organization Reports.

Marie, M., Hannigan, B., & Jones, A. (2017). Challenges for nurses who work in community mental health centres in the West Bank, Palestine. International journal of mental health systems, 11(1), 3. method for nursing?. Journal of Advanced Nursing, 20(4), pp.716-721.

Mills, D., Abushanab, S., Elhaloul, A., El Nuweiry, H., Shaaban, M. A., & Salman, Z. (2017). Unique Barriers to Care and Outcomes of Pediatric Acute Lymphoblastic Leukemia Treatment in Gaza City, Occupied Palestinian Territory.

Nasir, A. A., Salah, R., Ahmad, A. S., Hijleh, S. A., Kattab, S. E. A., Al Kurd, A., ... & Shqerat, K. (2018). Definition, causes, and consequences of Hamm (idiom of distress in Arabic) in the Palestinian context: a qualitative study. The Lancet, 391, S1.

Pope, C., Ziebland, S. and Mays, N. (2000). Qualitative research in health care: Analysing qualitative data. BMJ, 320(7227), pp.114-116.

Rosenberg, G. N. (2017). Positivism, interpretivism, and the study of law. In Law and Social Movements (pp. 33-53). Routledge.

Steffen, B., Rüthing, O., & Huth, M. (2018). Inductive Approach: Potential, Limitations, and Pragmatics. In Mathematical Foundations of Advanced Informatics (pp. 209-218). Springer, Cham.

Tjora, A. (2018). Qualitative Research as Stepwise-Deductive Induction: A Stepwise-Deductive Inductive Approach. Routledge.

Vaismoradi, M., Jones, J., Turunen, H., & Snelgrove, S. (2016). Theme development in qualitative content analysis and thematic analysis. Journal of Nursing Education and Practice, 6(5), 100.

World Health Organization. (2016). Health conditions in the occupied Palestinian territory, including east Jerusalem, and in the occupied Syrian Golan. Sixty-Ninth World Health Assembly. World Health Organization.

World Health Organization. (2017). Country cooperation strategy for WHO and the Occupied Palestinian Territory: 2017–2020 (No. WHO-EM/PME/008/E). World Health Organization. Regional Office for the Eastern Mediterranean.