External Evaluation At Caritas France – Secours Catholique

TERMS OF REFERENCE : External Evaluation

Project title: Protect and promote the right to health of all vulnerable communities under Israel’s responsibility and control

Location: Israel and the occupied Palestinian territory

Project period: 01 January 2021 – 31 December 2023

1) Introduction

Briefly introduce the context (who is requesting an evaluation? What is to be evaluated?) and the nature of the evaluation (objectives, period evaluated)

As we approach the halfway point of the project, implemented by Physicians for Human Rights Israel (PHRI) with the generous support of Secours Catholique-Caritas France (SCCF), we are seeking an external evaluator to conduct a mid-term review of the project.

The project aims to protect and promote the right to health of all those who live under Israel’s responsibility and control, and to provide assistance to specific vulnerable communities: people who lack legal status in Israel; Palestinians in the West Bank and Gaza; and prisoners and detainees in Israeli prisons.

The evaluation will focus on the first eighteen months of this three-year project and will review activities implemented between January 2021-June 2022. These activities were funded by SCCF, who is requesting the evaluation. The donor wishes to evaluate the project’s first half to draw conclusions and lessons learned for its second half.

Physicians for Human Rights – Israel is an Israeli human rights organization that advocates for the full and equal fulfillment of the right to health for all persons in Israel and the occupied Palestinian territory (oPt). Founded in 1988, PHRI provides direct humanitarian aid and healthcare to vulnerable communities through two volunteer-operated clinics. To protect the right to health more broadly, PHRI combines its humanitarian mission with individual casework and advocacy, and works to overturn unjust and discriminatory policies that negatively impact the health of many. This is coupled with media outreach to the Israeli public, legal action, and educational activities to promote a human rights perspective with the future generation of Israeli health professionals.

Secours Catholique-Caritas France is a recognized association of public interest and a service of the Catholic Church, a member of the Caritas Internationalis global network. SCCF is committed to fighting against poverty, exclusion, and inequalities, and promotes the development of each person. SCCF has supported PHRI since 2012.

Available documentation (to be listed below)

The evaluator will have access to internal monthly reports, databases, correspondence with the various project stakeholders, and any other relevant documents as needed. Project related documents including the proposal, contract and reports submitted to SCCF will be shared with the evaluator. Public documentation including minutes from court hearings and court rulings can also be shared, as needed. Links to relevant media and social media coverage will also be available.

The following is a non-exhaustive list of PHRI reports and position papers published since the start of the project:

Fev 2022 : Physicians for Human Rights Israel – 2021 Annual Impact Report

Oct 2021 : Full System Scan: Gender-Based Violence in Israel’s Healthcare System | Position Paper

Aug 2021 : Responsibility shirked | Israel and the Right to Health in the Occupied West Bank During COVID-19

July 2021 : Excluded From Care – Status-less Cancer Patients in Israel | Report

May 2021 : Nearly 150 Healthcare Workers and Organizations Call on Israel to Supply Vaccines to oPt

March 2021 : Nearly 150 Healthcare Workers and Organizations Call on Israel to Supply Vaccines to oPt

March 2021 : Cancer Patients in the Gaza Strip During COVID Time | Update

Feb 2021 : COVID-19 Vaccination Center for Individuals Without Status Opens in Tel Aviv

2) Project presentation

Detailed presentation of the project to be evaluated and scope of the evaluation.

The partnership between PHRI and SCCF predates the current project, as SCCF has supported PHRI through various projects since 2012. Through the current project, PHRI is promoting the right to health for all people living under Israel’s control and responsibility, utilizing direct healthcare provision at our two clinics; individual casework; legal interventions; advocacy to local duty bearers, decision makers and international stakeholders; and education work and outreach to civil society, the medical community, and the general public. The project encourages a public discussion on equal rights to all communities and a political system that secures their rights.

The project’s general objective is to protect and promote the rights, in particular the right to health, of all vulnerable communities under the responsibility of Israel’s government.

The project’s specific objectives are:

1. Provide individual medical assistance, case-work support and medical training where relevant, to individuals from vulnerable communities whose health rights and other basic human rights are denied.
2. Promote policy reform and lobby against official guidelines to remove the barriers to the right to health facing vulnerable populations.
3. Raise awareness of the public at large and the medical community specifically, mobilize concerned individuals and organizations to combat violations of the right to health and structural injustices.

Background

Historical, political, economic, and social context of the country and of the project.

The project seeks to build public awareness of the linkages between the 55-year occupation of the West Bank, East Jerusalem and Gaza, and other policies that deny the right to health in Israel such as privatization, xenophobia, anti-democratic processes, and neglect of the country’s social and geographic periphery. Efforts to challenge these trends can be strengthened through the creation of clear linkages, demonstrating to policy makers and members of the medical community the ways in which these policies of discrimination and neglect are all connected.

The project provides direct services to three main communities: asylum seekers and other status-less people, prisoners and detainees, and Palestinians in the oPt. While each of these communities faces specific challenges, there are links and similarities between the forms of discrimination faced by each group.

In the oPt, the occupation and blockade have resulted in continuous deterioration of the Palestinian healthcare system, which is split into three virtually separate entities that function almost independently of one another in the West Bank, East Jerusalem, and the Gaza Strip. By far in the worst condition, the healthcare system in Gaza is severely underfunded and faces chronic shortages of basic medical equipment and medication. Local healthcare professionals in Gaza face an inability to pursue training and professional development due to movement restrictions enforced by Israel, and a lack of local expertise in many areas. Further, Israel imposes blanket bans on the entry of certain medical equipment to Gaza, including all equipment needed for radiation therapy, based on the claim that these materials are of “dual usage potential”. The occupation, the protracted conflict, and the fragmentation of the oPt have thus barred the development of the Palestinian healthcare system, and thousands of Palestinians are unable to access the healthcare they need in their areas of residence. This situation is happening while very nearby, Israel – the occupying power in the oPt – has one of the most developed healthcare systems in the world. Added to these ongoing issues are the challenges created by the COVID-19 crisis, which has put an additional strain on the Gazan healthcare system and resulted in even further movement restrictions.

Another issue addressed by the project is access to health in the Israeli prison system, which currently houses approximately 14,000 inmates, over 4,000 of whom are Palestinians defined as “security detainees”. Although in theory the health needs of inmates are provided for, this is often not the case in practice. While public health services in Israel are administered by the Ministry of Health, healthcare in prisons is provided directly by the Israel Prison Service (IPS), and the quality of healthcare provided by the IPS is significantly lower than that provided to the general public. Inmates have extremely limited access to specialist medical care while in prison, and their ongoing care is often administered by people who are ill-suited to the task. For example, an issue PHRI is currently working on is access to mental healthcare within the prison system, which is extremely limited despite the high rate of mental illness among inmates. Separately, inmates are highly vulnerable to various forms of ill-treatment, including physical abuse and denial of adequate conditions of detention.

Migrants and asylum seekers in Israel are similarly an extremely vulnerable population. According to Israel’s Ministry of Interior, some 200,000 people live in Israel without legal status (residency or citizenship). This category includes some 28,000 asylum seekers from Eritrea and Sudan, as well as work migrants, Palestinians persecuted due to their sexual orientation, and others. Although some of these populations are protected from expulsion, many live in Israel with limited or no access to basic public services, including healthcare. Their only option for obtaining basic healthcare is through non-profit services. Without on-going access to healthcare, many status-less people develop serious conditions which go untreated, and chronic conditions are exacerbated, despite the availability of treatment in Israel’s developed healthcare system.

In parallel to these challenges, a lack of government investment in Israel’s health system has resulted in a deterioration in critical indicators of medical care and increased inequalities in the provision of care. The impact of the lack of government investment is seen most strongly in peripheral areas, namely the north and south of the country, where most of the Bedouin and Palestinian-Israeli populations live. Steps taken to address these issues are often too little too late, as investment of new resources is always a step behind the country’s fast-growing population. Meanwhile, the needs of vulnerable populations, including transgender women and long-term patients in psychiatric institutions, are largely neglected by the medical system, as are the needs of the general population in Israel’s social and geographic periphery.

The Israeli medical community is largely unaware of the challenges faced by marginalized communities in the country. While certain segments of the medical community may recognize the need to integrate a human rights perspective into medical work, they are generally not active in doing so and have not been mobilized to do so in a consistent manner. As medical education by and large does not cover the health needs of the vulnerable communities served by PHRI, the mainstream of the medical community has generally remained silent regarding violations of their right to health.

The current project aims to tackle these and other challenges, providing healthcare to vulnerable communities that have no access to the public healthcare system in Israel, pushing for policy change to better protect the right to health, and mobilizing the healthcare community in Israel to act as defenders of the right to health and of medical ethics.

Beneficiaries

Mention the target groups and the problems they face.

1. Status-less communities: as noted above, there are currently approximately 200,000 individuals in Israel who lack legal status (citizenship or residency). Of these, approximately 28,000 are asylum seekers from Eritrea and Sudan. While they reside in Israel legally and are protected from expulsion, they are not granted legal status or access to social rights in the country. The majority of this community arrived in Israel 10-15 years ago and have lived in the country for over a decade without access to the public healthcare system. An estimated 10% are survivors of the Sinai torture camps, and many have suffered human trafficking and sexual abuse. Members of this population thus have a great need for physical and emotional healthcare, but they are currently excluded from the public health system. In late 2021, Israel’s Ministry of Health announced for the first time ever, and following years of concerted lobbying by PHRI, that it intends to grant state-subsidized health-insurance to this group, but this plan has not yet materialized.

A further nearly 100,000 foreign workers reside in Israel legally, having arrived in the country to work in specific industries such as care for elderly people, agriculture, and infrastructure. Members of this group typically have health insurance through their employers, providing some limited coverage. This insurance often expires when people most need it, because it is contingent on their continued employment. Thus, if a work migrant is diagnosed with cancer and is no longer able to work, they lose their health insurance within 3 months, often at the moment when they most need it and when they are halfway through treatment.

Further, an estimated 20,000 foreign workers reside in Israel illegally, having overstayed their visas. They have no insurance coverage and rely on free healthcare offered by non-profit organizations. There are also an estimated 50,000 people in Israel who overstayed tourist visas to live and work in the country illegally.

A final status-less population in Israel are Palestinians living in the country without legal status. Approximately 10,000 Palestinians live in Israel or East Jerusalem by virtue of family unification with Israeli spouses. The Palestinian spouses, originally from the West Bank or Gaza, are issued temporary stay permits and are not eligible for citizenship or residency, even though their partners hold legal status in the country. People in this category now have an option, thanks to PHRI’s past litigation, to register with an Israeli health provider – though this is a complex, expensive bureaucratic process and many struggle to meet the cost and benefit from healthcare. An additional few hundred Palestinians live in Israel because they are persecuted in their original areas of residence due to their sexual orientation or gender identity, or because they are suspected of collaboration with the Israeli authorities.

1. Palestinians in the West Bank and Gaza: an estimated 5 million Palestinians live in the West Bank and Gaza, under the stifling control of Israel’s occupation and the long-term blockade of the Gaza Strip. Israel employs strict restrictions on movement of people and goods into and out of the oPt and between its different parts, impacting virtually every aspect of daily life. The Palestinian healthcare system is heavily impacted by these restrictions, which make it virtually impossible for a fully functioning independent system to develop and meet the needs of the Palestinian population. Patients are dependent on Israeli permits if they wish to access healthcare outside their areas of residence; physicians require permits to travel to professional conferences, studies, and other educational opportunities; Israel maintains full control over the types and quantity of medical equipment and medication that can enter the Gaza Strip. Many people are thus unable to freely access the care they need, and treatable conditions go untreated, leading to death and suffering. The Gazan healthcare system is particularly underequipped and underfunded and faces shortages of virtually every type of medication and medical equipment, as well as ongoing limited access to electricity. The repeated rounds of violence between Israel and Hamas also result in periodical damage to infrastructure and have caused harm to hospitals and medical centers on several occasions.
2. Prisoners and detainees: there are currently approximately 14,000 inmates in Israel’s prison system, of whom over 4,000 are Palestinians defined as “security” detainees. The conditions in Israel’s prisons are inadequate in many ways, including overcrowding – an issue which has proven particularly problematic since the outbreak of the COVID-19 pandemic. In addition, the healthcare offered to inmates is far inferior to that offered to the general population, as described in the previous section.

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Partners and stakeholders

List all project’s stakeholders (donors, institutional partners…), explaining their role in the project and the existing connections between them, and with the beneficiaries

The current project reflects all PHRI’s activities and is in essence a core project. As such, the project’s partners and donors include the entire spectrum of PHRI’s partners. Our current donors include Bread for the World, Bader Philanthropies, Diakonia, Fidelio Foundation, the Glezerman Family Fund, Hilti Foundation, Manos Unidas, Medici Per I Dritti Umani, Medico International, Medico Swiss, Porticus, SIVMO, SDC, The British Embassy in Israel, The European Union, The Foundation for Middle East Peace, The German Embassy in Tel Aviv, The New Israel Fund, and UNHCR. In addition, hundreds of individuals in Israel and around the world support our work through private donations.

In addition to our work with a wide range of institutional and individual donors, PHRI collaborates and works closely with dozens of local and international organizations, due to the broad spectrum of issues we cover. Our work relating to the oPt involves close coordination with several Israeli and Palestinian human rights organizations, including ACRI, B’Tselem, Breaking the Silence, HaMoked, Yesh Din, Gisha, and others. We are members of the anti-occupation coalition which employs a joint Knesset lobbyist, who brings issues relating to human rights in the oPt to discussion in the Israeli parliament. We work in a similar coalition of organizations supporting the rights and needs of status-less individuals in Israel, including the Hotline for Refugees and Migrants, ASSAF, Kav LaOved, and others. This coalition also employs a joint lobbyist.

Through both lobby coalitions and other activities, we also work closely with Members of Knesset who are aligned with our worldview and are willing to help promote our interests within the Knesset and government. Since the formation of a new Israeli government in June 2021, our relationships with two key ministries have improved greatly: the Ministry of Health and the Ministry of Public Security, both of which are now led by people more closely aligned with our world view. These improved ties have allowed us to promote positive policy change and solutions for individuals whose right to health was violated.

PHRI also conducts international advocacy activities, targeting locally-based diplomats, staff of UN agencies and international organizations, and formal UN procedures (special rapporteurs and treaty bodies). Recently, PHRI submitted a shadow report to the UN Human Rights Committee in advance of its review of Israel’s implementation of the ICCPR.

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The final and most important group of stakeholders are our beneficiaries. During the project’s first year, PHRI provided individual healthcare and assistance to over 12,000 individuals. Our beneficiaries help inform and shape our activities at every stage of our work, as our activities are designed based on their requests and the issues they bring to us. It is our contact with thousands of individuals that enables us to identify the policies and practices that deny the right to health of many, and then challenge them through principled interventions.

Objectives, activities, results

Indicate the overall objective, the specific objectives, the activities and expected results

Overall objective:

Protect and promote the rights, in particular the right to health, of all vulnerable communities under the responsibility of Israel’s government.

Specific objectives:

1. Provide individual medical assistance, case-work support and medical training where relevant, to individuals from vulnerable communities whose health rights and other basic human rights are denied.
2. Promote policy reform and lobby against official guidelines to remove the barriers to the right to health facing vulnerable populations.
3. Raise awareness of the public at large and the medical community specifically, mobilize concerned individuals and organizations to combat violations of the right to health and structural injustices.

Results per S.O.1:

1. Improved access to health for vulnerable men, women and children from the WB and Gaza.
2. Improved access to health for asylum seekers and migrants.
3. PHRI staff undertake casework including legal action for Palestinians whose permits to access treatment outside of the OPT have been denied; for prisoners incarcerated in Israeli prisons to ensure they obtain fair access to health; and for asylum-seekers and other status-less persons.

Results per S.O.2:

1. Policies that violate the right to health of Palestinians in the oPt, asylum seekers and migrants, prisoners and detainees and residents of Israel’s geographic and social periphery, including through insufficient funding to the health system are challenged.

Results per S.O.3:

1. Public at large made aware of unjust policies that negatively impact health of vulnerable communities
2. Medical community is mobilized to combat violations of the right to health

Activities:

Medical Work: Through our Mobile Clinic in the West Bank and Gaza, and our Open Clinic for status-less individuals in Jaffa, PHRI provides medical care to approximately 15,000 individuals annually. Special mobile clinics staffed by female volunteers directly address the health needs of women and girls, returning three times in a row over three months to the same village, with sessions often followed by a lecture on women’s health issues, while each year roughly 35 Open Clinic serve as days where most healthcare volunteers focus on women’s health.

Casework & Litigation on Behalf of Individuals: Each year we submit freedom of movement and access appeals on behalf of Palestinian patients, medical personnel, and medical students from the occupied Palestinian territory, who are unable to access medical services or education due to restrictions imposed by the occupation. Where this proves ineffective, we submit legal petitions to district courts and the High Court of Justice.

In addition, we intervene to facilitate legal representation and independent medical care and opinions on behalf of prisoners and detainees whose right to health has been denied, either through lack of provision of appropriate treatment or through prison policies that negatively impact the health of prisoners. We also assist status-less persons living in Israel addressing discriminatory barriers to health and wellbeing, including access to affordable treatment and ensuring relevant private insurance coverage for status-less people.

Training for Palestinian Medical Professionals: To share global advancements in science and medicine and develop professional capacities in medicine while expressing solidarity with colleagues under occupation, PHRI arranges for senior physicians and mental health experts from Israel to carry out training seminars in Gaza and the West Bank. In the scope of these seminars, we bring together hundreds of Palestinian physicians for day-long trainings in the fields of gynaecology, diabetes, orthopaedics, oncology, cardiology, paediatrics, and trauma resilience. Meanwhile, volunteer medical personnel from PHRI carry out complex operations in Gaza, with the observation and involvements of local physicians, so that they may hone their surgical techniques.

3) Objectives of the evaluation

Mention explicitly the evaluation objectives. This should include:

1. A global appreciation of the quality of the work accomplished and the results, based on the DAC criteria (relevance, effectiveness, efficiency, impact, sustainability)

PHRI and SCCF wish to receive a global appreciation of the work accomplished thus far by the project based on DAC criteria, answering the following questions:

Relevance:

· To what extent are the objectives of the programme still valid?

· Are the activities and outputs of the programme consistent with the overall goal and the attainment of its objectives?

• Are the activities and outputs of the programme consistent with the intended impacts and effects?
• How has the project adapted to the changes in the local context thus far?

Effectiveness:

• To what extent have the objectives been achieved thus far?
• What were the major factors influencing the achievement or non-achievement of the objectives?
• Does the management of the project allow fulfillment of the requirements towards the donor?
• Has the project encouraged the empowerment of its beneficiaries? If not, what were the limits of the means employed and how can they be improved?

Efficiency:

• Are project activities cost-efficient?
• Has the programme or project been implemented in the most efficient way possible?
• Are the human resources adequate for the project?

Impact:

• What has happened as a result of the project? What concrete differences has the activity made to the beneficiaries? For example in terms of receiving treatment; ensuring insurance continuation; empowerment though raised awareness of their rights and information; promotion of policies.
• How many people have been affected by the project?
• How relevant are advocacy strategies regarding the project’s target populations in such a hostile environment?
• Are there any unexpected or unexplained consequences resulting from this project?
• About the work with volunteers: what added value does it bring to the project, and what challenges? In particular in terms of the spreading of the organisations’ message and change of mentalities?

Sustainability:

• To what extent will the benefits of the project continue after it has ended?
• What are the major factors influencing the achievement or non-achievement of sustainability of the programme or project?
• What benefits would stop, in case activities carried out by PHRI were to stop after the project’s end? What strategy could be implemented to better secure the sustainability of these benefits?
• Do the various project stakeholders have a good capacity to adapt and support the intended changes for future projects?

2. Recommendations: what should be done next?

The current strategy employed by PHRI has been to assist people to realize their right to health at the individual level, while simultaneously advocating with key decision makers to push for wider positive change. We are currently pursuing the strategies that have proven most effective through our past experience. The evaluation should help us assess the impact and effectivity of our principled/policy change activities, and should help us explore other avenues for positive policy change.

We expect the evaluation to result in recommendations for our future activities: which practices and activities have been effective? How could we improve them and fine-tune or strengthen our strategy? Are there more practices that could help towards the same end-result? What has stopped being effective, has been worn out? Have some strategies run their course?

3. Strategic considerations: what lessons should be learned from this experience in order to improve the intervention strategy?

PHRI is highly interested in drawing lessons learned from the project and evaluating best practices, to help inform the second half of the project and shape our activities in the long run.

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PHRI recommends a qualitative evaluation.

A qualitative evaluation is favored, whereby project materials are reviewed and key project staff and stakeholders are interviewed. This could include PHRI partners from other organizations, project beneficiaries, and other people targeted by the project activities.

4) Evaluator profile

The evaluation can be carried by one person. It is necessary that the evaluator is a Hebrew speaker, familiar with Israel’s political environment, and with the way things work – i.e. the formal and non-formal way by which information flows and agreements are reached. The evaluator must be familiar with the topics at hand, i.e. human rights issues in Israel and the oPt. The evaluator should have relevant experience in project evaluation, specifically in the fields of human rights advocacy.

5) Timeframe of the evaluation mission

The evaluation should take place somewhere between 01 July – 30 September 2022, for an approximation of 30 working days.

Detailed timetable:

Call for evaluators: 26 April 2022

Deadline for submission of the applications: 13 May 2022

Selection: 31 May 2022

Contract signature: 30 June 2022

Field visit: July 2022

Submission of first draft: 15 August 2022

Comments and feedback from PHRI and SCCF: 31 August 2022

Submission of final report: 15 September 2022

Restitution of the conclusions for all interested parties: 30 September 2022

6) Expected documentation

Expected documents and deadlines

A final evaluation report due is expected at the end of the period, followed by a presentation of the results to all interested parties, as deemed necessary by PHRI and SCCF. The report, which must include recommendations, must be written in English.