Table 1 Summary of categories and subcategories of the policymakers

Category (1): Nature of current PC healthcare services

• Lack of recognition for holistic PC services

“…the psychological aspect is the aspect that has not received the required focus. If we want to say it is ignored, some people may be upset, as they are not completely ignored, but rather in attempts, but they are not within a specific template or protocol. They are semi-autonomous activities, but we hope, through the work of the mental health committees, that there will be clear protocols and programs for oncology patients”. (P2, Male, Deputy GD)

“Most of the care provided to patients with chronic diseases is medical treatment and follow-up in outpatient clinics. About cancer, they are not different from the rest of the chronic patients, although they have a special peculiarity as they are the most patients who need psychological, social and other supports” (P7, Female, Head Clinical Department)

“…some of the services provided to oncology patients are insufficient, as most of the services focus on physical services. Some psychological, social, and nutritional support services are provided to cancer patients, but they are not in a systematic manner”. (P11, Male, Nursing Consultant)

• The subordinate status of PC to acute care

“To be honest, in the MOH strategic plan 2021–2025, PC is mentioned as one of the priorities”. (P12, Male, Medical Director)

“This is a difficult and embarrassing question, specifically for the MOH, because sometimes the priorities fluctuate. If we talk about the past year, PC was among the main plans of the Ministry. Still, the Corona pandemic changes the priorities and focuses on Coronavirus… Perhaps in the period before Corona, the Ministry’s concerns were focused on emergencies due to the wars. Sometimes some priorities could advance, while others might be delayed based on the unstable conditions in the GS”. (P2, Male, Deputy GD)

“I cannot answer accurately whether PC is among the Ministry’s priority or not, but I mean they have formed a PC committee, and I am a member of it. I believe that the Ministry has placed PC within the Ministry’s strategic plan, but I do not know to what extent. Putting PC into the plan is one thing and putting the capabilities to implement the plan is another thing”. (P4, Male, Representative Palestinian Medical Council)

“To be honest, in the MOH strategic plan 2021–2025, PC is mentioned as one of the priorities. There is a timetable for providing PC within the health system, and it is over the next five years. The MOH plans to have PC in every hospital in Gaza. Uh, all this is in the plan, but nothing is happening yet”. (P12, Male, Medical Director)

“….PC is not among the MOH priorities. All cancer patients are not among the priorities of the Ministry. You are talking about patients who suffer from chronic diseases throughout their lives, and the Ministry does not care about them. MOH focuses on saving cases where there is hope for recovery, such as a case under operations. I mean, the disease is treated, but MOH deals with cancer patients as if they are dead”. (P9, Female, Deputy Head Pharmaceutical Department)

• Healthcare policies and practice that ignore family needs for PC

“….We, as a health staff, strive to provide the families with the information they request, as most of them ask about disease progress and the length of time for the patient to live, and we try as much as possible to give them information and support them psychologically…. There is no special place where we provide information. We provide information in the corridor or on the counter”. (P8, Male, Head Clinical Nursing Department)

“Of course, there are no services provided to the patient’s family. The reason may be due to the lack of interest from the Ministry, and the political situation may also play a role, as most patients are referred to receive service outside the GS. In addition to the pressure on a health system that may play a role in the incompleteness of health services”. (P1, Female, Head Policy Department)

Category (2): Potential benefits of PC

• Healthcare system benefits

“PC is critical to the GS…Introducing PC into Gaza hospitals will enhance the quality of services provided as well as will decrease hospital readmission.” (P4, Male, Representative Palestinian Medical Council)

• Patients’ benefits

“…by God, in general, the entire GS needs PC (hahaha). We all have chronic diseases. However, cancer patients and patients with chronic diseases in the first place are the most people in need of comprehensive and complete PC because we are talking about a lifelong concern that is not a passing issue like an acute appendicitis patient”. (P2, Male, Deputy GD)

Category (3): Challenges to PC provision

• Lack of political and social infrastructure for PC

“Although there are no PC policies in the GS, which is one of the obstacles, there is no problem in developing policies and adopting the policies of neighbouring countries that are similar to us in the system and culture”. (P3, Male, Nursing supervisor- Shifa Hosp.)

“…The lack of policies is one of the major challenges in introducing PC into the Gaza HCS. We do not have national policies for PC. Perhaps because this is a new issue in the country”. (P12, Male, Medical Director)

“…We don’t have a specific budget. All budget-related issues of the MOH are managed centrally with the Ministry of Finance… the MOH does not have its own independent budget for development; its budget is at the Ministry of Finance… As I told you, we do not have a special budget to develop the basic services of the MOH, such as purchasing equipment and others, Not to talk about PC…To allocate a budget for PC, we need to have a special budget, and this is difficult in the GS because this is an old system, which is that all ministries’ revenues are directed to the Ministry of Finance, and the latter is the one that pays salaries, development, and others.” (P12, Male, Medical Director)

“…No, no, no one represents us in the Ministry of Finance. There is no special budget for the MOH, will they develop PC. There was only a budget for the Norwegian project “Pain Management” because it was from external funding, so it had a budget. I mean, if the donor did not support the project, it would not have been accomplished”. (P12, Male, Medical Director)

• Limited human resources in PC

“Unpreparedness of HCPs in terms of knowledge and training is one of our problems. The training we are currently carrying out is based on the personal diligence of the committees and YouTube follow-up. No experts are preparing the teaching and training material, which is also one of the obstacles”. (P3, Male, clinical nurse supervisor)

“A major problem is that we have an increase in the number of cases, but unfortunately, there is no increase in the number of medical staff, including specialized doctors and nurses”. (P1, Female, Head Policy Department)

“…The most important issue is that we are trained by ourselves, and from my point of view, this training is still insufficient. We do not have staff in Gaza who have trained abroad or have fellowship in PC”. (P7, Female, Head Clinical Medical Department)

“We don’t fully understand the concept of PC. PC may mean that the patient lives the remaining days of his life without pain. Most of our focus is on pain medication such as morphine”. (P2, Male, Deputy GD)

“….policymakers are not aware of the importance and benefits of PC. I think it is important for people who have experience in this field to knock on the doors and talk with decision-makers about the importance of PC”. (P1, Female, Head Policy Department)

“…I prefer to attract experts who speak Arabic because a number of health teams find it difficult to understand English. We know medical terms, but there are words we don’t know. For example, my English is weak, and this honestly did not make me benefit a lot from the course because I could not understand the whole course”. (P7, Female, Head Clinical Medical Department)

• Unavailability of essential Medication

“Of course, we, as the Palestinian MOH, adopt the WHO essential drug list. Unfortunately, many medicines are not available for several months, and this is a problem that affects the lives of patients…Continuous interruption of narcotic drugs is among the problems. The interruption and lack of medicines can last for a month or two, and patients suffer a lot from that…. this requires families to buy them…The stores of the MOH in Gaza do not contain medicines. I mean, those here in Gaza don’t want to buy medicines from their budget and wait for the MOH in Ramallah to send them medicine. Here the patient is in a big problem between the two ministries and the conflict between them…For instance, the medicine of Bicalutamide, that the patient takes them at home - of course not available in the Ministry… There are medicines that you find available this month and the next month will not be available…. The interruption and lack of medicines can last for a month or two, and patients suffer a lot from that.” (P9, Female, Deputy Head Pharmaceutical Department)

“Some doctors write a prescription for the patient so that they can buy it from external pharmacies, but unfortunately, some pharmacies say that they do not have it, they hide it and they sell it to addicted people at a higher price. It means the patient is lost. Or if the outside pharmacist wants to sell the Tramadol, he sells it at a high price for the patient. I mean the addicts in Gaza ruined the patients. I mean, some pharmacies blackmail patients and sell them treatment at a high price” (P9, Female, Deputy Head Pharmaceutical Department)

“…we are forced to refer a patient to Ramallah for treatment due to the unavailability of medicine in Gaza. I mean, if treatment were available, we would spare the patient the suffering of travel. Some patients travel only to receive a dose of medicine, although we have the capabilities in Gaza to give doses, but Not available”. (P12, Male, Medical Director)

“…we just want money to solve the problem of the medicine. I mean, if the dispute between Gaza and Ramallah is resolved, the whole problem will be resolved. I mean, most of the medicines are cut off in Gaza are available in Ramallah. Because of the conflict and division, we have two ministries, one in Gaza and the other in Ramallah, and the people and patients are lost among them. I mean, hospitals in the West Bank, the health service situation in them is excellent, and all medicines are available, but Ramallah punishes Gaza, so some medicines are prevented from them, but if there is reconciliation, I think things will improve and medicines will be available”. (P12, Male, Medical Director)

Category (4): Considerations for PC

• Beginning PC in a centralised location

“The GS being small, I believe that we need PC program in major hospitals. For example, the PC unit in major hospitals and three community teams cooperate with these hospitals”. (Male, A representative of Palestinian Medical Council)

We need the Hospital Approach for the acute cases for the patients hospitalised for one or two days. Then when the patient is discharged, their house will be followed by telephone or visited at home”. (Male, A representative of Palestinian Medical Council)

• Development of PC Policies

“…. During the next five years, policies for cancer and PC will be developed and will be reviewed by experts and will train the staff on them”. (P1, Female, Head Policy Department)

“There are treatment protocols for cancer, and these are drug protocols according to the type of disease and the degree of its progression. Also, chronic diseases have their own protocols. There is no problem in the availability of treatment protocols and policies despite the siege.“ (P2, Male, Deputy GD)

• Healthcare professional capacity building

“…In 2011, I began the initiative to spread the culture of PC among physicians because the idea did not exist at all. This is the reason why I did not know anything about PC… From 2011 until 2015, 5 workshops were carried out for medical staff… In 2015, I started expanding this work by including a team from Britain and Scotland who are experts in PC… We formed a Steering Committee for PC, and the goal of the committee was to spread the culture of PC and integrate it into the curricula of medical, nursing and physiotherapy students and present it within the services provided by the Palestinian MOH and the UNRWA”. (P4, Male, Representative Palestinian Medical Council)

“We recently started training the staff and we focus only on nursing. I think nurses are more familiar with the concept of PC than doctors. Doctors do not read about this aspect compared to nurses in the GS who are interested in PC… Also, in the curriculum, the concept of PC is not comprehensively and adequately addressed”. (P1, Female, Head Policy Department)

“…We have focused on PC in recent years in hospitals, so the health staff will certainly have limited knowledge. The number of courses that dealt with PC is few, and their duration is very, very short, and they were limited to nursing only and medical students at the Islamic University. Physicians working in hospitals need training that is not targeted in PC courses. Also, we did not focus in our courses on Advanced PC, it was the concept in general”. (P3, Male, clinical nurse supervisor)