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Source: World Health Organization (WHO)
12 April 2013



Health conditions in the occupied Palestinian
territory, including east Jerusalem,
and in the occupied Syrian Golan

Report by the Secretariat

1. In 2012, the Sixty-fifth World Health Assembly adopted resolution WHA65.9, which requested the Director-General, inter alia, to report on its implementation to the Sixty-sixth World Health Assembly.

2. The current population for the occupied Palestinian territory is 4 293 313 (2 649 020 in the West Bank and 1 644 293 in the Gaza Strip).1 At the end of 2012 unemployment in the West Bank was 18.3% and in the Gaza Strip 32.2%,2 due to restrictions on movement, imports and exports, and low private sector investment. Poverty remains widespread and the gap between the West Bank and the Gaza Strip is widening: the poverty rate in the occupied Palestinian territory based on consumption patterns in 2011 was 25.8% (17.8% in the West Bank, and 38.8% in the Gaza Strip).3 Restrictions on the movement of people remain in place.

3. The Ministry of Health, UNRWA, nongovernmental organizations and private organizations constitute the four main providers of health services. The functioning of the Ministry of Health, the main health provider, has been seriously affected by the financial crisis being experienced by the Palestinian Authority. In particular, there have been reductions in the numbers of patients being referred outside the occupied Palestinian territory for specialized treatment and there have been growing and substantial shortages of medicines and disposables: the Ministry of Health reported that 24% of essential medicines were out of stock in the West Bank and that 33% of essential medicines were out of stock in the Gaza Strip at the end of 2012.4

4. The leading causes of death are cardiovascular disease, cancer, cerebrovascular disease and diabetes, reflecting the main health challenges currently facing the occupied Palestinian territory. The prevalence of noncommunicable diseases and their risk factors are high. Among Palestinians aged 15–64 years, data indicate that 58% are overweight, 36% have high levels of cholesterol, and 8.5% have diabetes mellitus. Some 38% of men smoke tobacco daily; 75% of people do not engage in any vigorous physical activity.5 Survey results indicate that unhealthy behaviours start early.6

5. Infant mortality rates have declined in recent years in both the West Bank and the Gaza Strip. Infant mortality in 2011 was 18.8 per 1000 live births and the under-five mortality rate was 21 per 1000 for the occupied Palestinian territory. Two thirds of infant deaths occurred within the neonatal period, mostly during the first days of life. Conditions originating in the perinatal period are the leading cause of under-five mortality in the West Bank, representing 36.7% of all causes of death for this age group in 2011. The maternal mortality ratio was reported as being 26.3 per 100 000 live births in 2011 in the West Bank and 29.9 per 100 000 live births in the Gaza Strip.7

6. Anaemia and micronutrient deficiencies are longstanding areas of concern. There is a high prevalence of anaemia among pregnant women at 27.8% (17.4% in the West Bank and 36.8% in the Gaza Strip) but the vast majority of cases are mild (72%) or moderate (27.7%). Overall anaemia prevalence among children aged 9–12 months old was 57% (48.9% in the West Bank and 68.1% in the Gaza Strip) but less than 1% were cases of severe anaemia.8

7. Water quality and quantity is also an area of concern in the Gaza Strip as 90% to 95% of the water aquifer is considered unfit for human consumption due to high levels of salts and nitrates.

8. Communicable diseases have low incidence rates, although viral hepatitis A, B and C are endemic in the occupied Palestinian territory. In 2011, hepatitis A had an incidence rate of 23.1 per 100 000 population. The incidence rate for bacterial meningitis was 13.8 and that for viral meningitis 24.3 per 100 000 population, however incidence rates were much higher in the Gaza Strip (31.1 and 50.3 respectively) than in the West Bank (3.14 and 8.4 respectively). The incidence rate for leishmaniasis was 7.3 per 100 000 population for the occupied Palestinian territory as a whole, but found solely in the West Bank (11.9). The incidence rate for pulmonary tuberculosis was 0.5 per 100 000 population and 0.02 for HIV.9 There were 600 patients with confirmed cases of H1N1 virus admitted to hospital in early 2013, among whom there were 20 deaths reported.10 The Ministry of Health responded rapidly to the outbreak and WHO procured 38 000 doses of influenza vaccine to provide protection for the most vulnerable.

KEY AREAS OF WHO SUPPORT TO THE PALESTINIAN MINISTRY OF HEALTH

9. WHO has continued to provide technical advice and support to the Palestinian Ministry of Health across a range of priority areas including public health, primary care and the hospital sector. It has provided advice on strategy and policy and training for health ministry staff on a variety of topics. It has supported the coordination of donor support for the health ministry, in its capacity as the technical adviser to the Health Sector Working Group. WHO has also continued to lead and coordinate the work of the health cluster in responding to emergency health needs arising from the on-going conflict.

10. The main causes of morbidity and mortality in the occupied Palestinian territory are noncommunicable diseases. WHO provided technical support to the Ministry of Health for the implementation of a national strategy to prevent and manage noncommunicable diseases. During 2012, WHO has been working with the Ministry of Health to pilot the introduction of the WHO package of essential interventions to integrate noncommunicable disease prevention and management at primary health care level. WHO has used the pilot to develop the capacity of the national noncommunicable disease unit to support the introduction of the package across the occupied Palestinian territory. WHO has also supported the national noncommunicable disease unit in its development of guidelines, its strengthening supervision systems and improvement of data collection and analysis at primary care level.

11. WHO is a member of the Working Group on Tobacco Control that supports and oversees the implementation of tobacco control activities. A national multi-sectoral tobacco control strategy has been developed. An anti-smoking, inter-sectoral committee has prepared by-laws on tobacco control to align with the WHO Framework Convention on Tobacco Control. The committee continues to work on a number of measures to reduce demand for tobacco.

12. In order to strengthen the public health system and policy and decision-making, WHO initiated a project in 2012 with the support of the Norwegian Government to support the establishment of a Palestinian National Institute of Public Health. The Institute will work in close cooperation with the Palestinian Ministry of Health, universities, the Norwegian Institute of Public Health, and other stakeholders. The aim is that it will be legally established as a functioning, semi-autonomous public body within the Palestinian Authority by the end of 2014. The objective is to build core public health functions including strengthening surveillance systems and registries, developing capacity in analysis of hospital health management, commissioning and conducting applied public health research, and increasing the effective use of data in setting health policies and priorities. During 2012, a project team was recruited, premises were provided and equipped by the Ministry of Health, and an Expert Advisory Committee was appointed. The project team has completed an overview of the existing national health surveillance systems and registries, conducted an assessment of the cause-of-death registry and the death notification form, and initiated an assessment of the effectiveness of mammogram screening. Standard operating procedures for research and ethics review procedures have been developed and an application submitted for research funding for doctoral students. Work has also started on creating a human resources observatory for the health sector.

13. The project team has also continued the work started by WHO, in collaboration with the Ministry of Health, to finalize the National Health Information Assessment and the National Health Information Strategy. Implementation of the strategy will be led by the Health Information System thematic group chaired by the Ministry of Health and supported by WHO and the Public Health Institute. The project team is also updating the Health Facilities Database for the West Bank and the Gaza Strip. The health facility database includes information on the geographical distribution of health facilities, types of services provided, availability of human resources and equipment, and a summary of hospital activity.

14. WHO, with funding from the European Union, is supporting the development of community-based mental health services in the West Bank and the Gaza Strip. The second phase of a six-year project commenced during 2012. The project aims to strengthen mental health care at all levels of the health system, with particular emphasis on community level services, as well as improving awareness of mental health issues and combating stigma in the community. Activities include development of a mental health human resources strategy, integration of mental health into primary care services, capacity building of staff, strengthening supervision systems and improving the availability and quality of mental health data. Working through local nongovernmental organizations, the project also supports patients and their families to advocate for their rights.

15. With the financial support provided by the Global Fund to Fight AIDS, Tuberculosis and Malaria, WHO has been working with the Ministry of Health and other United Nations agencies on a five-year programme to improve the prevention and treatment of HIV/AIDS and tuberculosis. WHO supported the formulation of a national strategy, treatment guidelines and training modules on tuberculosis. For HIV/AIDS, it has continued to train staff responsible for treatment and counselling, has monitored patients to ensure the adoption of WHO standards of treatment and is preparing to repeat a bio-behavioural survey of injecting drug users, first carried out in east Jerusalem in 2010.

16. In the hospital sector, WHO has been working with the Ministry of Health on a number of quality improvement initiatives. Training was conducted for staff from the Ministry of Health on the Patient Safety Friendly Hospital Initiative. These staff will expand the Initiative, involving governmental and nongovernmental hospitals by raising awareness, providing training, and setting national patient safety goals.

17. With support from the European Union, WHO has continued its programme of support for the east Jerusalem hospitals, which serve as the main referral centres for tertiary care for Palestinians from the West Bank and the Gaza Strip. WHO is working with the hospitals to improve the quality of hospital services and to build a culture of patient safety and quality improvement. The hospitals have been working to achieve accreditation by the Joint Commission International11 in 2013. WHO is also supporting the institutionalization of the East Jerusalem Hospitals Network.

18. WHO has continued to monitor patient access from the West Bank and the Gaza Strip to the east Jerusalem hospitals, as well as access of ambulances, hospital employees, and medical and health students for training from the West Bank. A study was carried out on barriers to health access for patients, ambulances and east Jerusalem hospital staff in the period 2011–2012. The study found that a total of 35 265 patients from the West Bank and Gaza Strip were referred by the Palestinian Ministry of Health for medical treatment in hospitals in east Jerusalem, Egypt, Israel and Jordan in 2012. In 2012, 20.3% of all West Bank requests and 7.5% of Gaza Strip requests for travel permits to access medical treatment were denied or not answered. A report of the findings was published in early 2013.12

19. WHO has continued its project in the maternity units of public hospitals in the Gaza Strip to improve the quality and safety of patient care during childbirth. Extensive training, coaching and technical support has been provided to hospital staff and managers and a new information system for perinatal care has been introduced. A new model of care including a midwifery-led approach for low-risk deliveries and an improved system for early detection of complications has been successfully established in two hospitals and efforts began in a third hospital in 2012.

20. WHO plays a key humanitarian role in the health sector as leader of the Health and Nutrition Cluster/Sector, which comprises approximately 50 partners from United Nations agencies, nongovernmental organizations, and the private sector. The partners provide essential health and nutrition services to vulnerable communities in the West Bank (mainly Area C) and the Gaza Strip and build local capacities for rapid response to new emergencies. The Health and Nutrition Sector response plan was updated to improve access to essential health services, strengthen protection of civilians and health staff and build local emergency response capacities.

21. The health sector partners, led by WHO, responded rapidly to the urgent health needs arising from the escalation in hostilities in the Gaza Strip in November 2012, which included critical shortages of essential medicines and medical disposables, and treatment and rehabilitation for the injured. WHO and partners provided emergency supplies of medicines and disposables. WHO helped in coordinating the import of medical supplies to the Gaza Strip and provided technical assistance to maintain the functioning of public health services.

22. WHO has also continued its work monitoring access to health of disadvantaged or vulnerable groups, including residents of communities outside the security wall in the West Bank, within movement-restricted areas of cities, persons with disabilities and Palestinian prisoners. WHO has publicly expressed its concern about the health conditions of Palestinian prisoners held in Israeli jails and called on Israel to ensure appropriate health care for the ill and those on hunger strike.


SITUATION IN THE OCCUPIED SYRIAN GOLAN

23. WHO has no access to the occupied Syrian Golan and thus cannot provide a report on the prevailing health conditions there. Instead, the Secretariat has requested the governments of the Syrian Arab Republic and Israel to provide information on the health conditions in the occupied Syrian Golan.

24. The construction of medical facilities is outside WHO’s remit. Therefore, the Secretariat was not able to meet the request made to the Director-General in resolution WHA65.9.

ACTION BY THE HEALTH ASSEMBLY

25. The Health Assembly is invited to note the report.

= = =


Notes
1 Palestinian Ministry of Health, Health Report, Palestine Mid Year 2012, Palestinian Health Information Center, September 2012. http://www.moh.ps/attach/453.pdf, accessed 22 March 2013.
2 Palestinian Central Bureau of Statistics, Press Report on Labour Force Survey Results, Q4, 2012. http://www.pcbs.gov.ps/portals/_pcbs/PressRelease/Press_En_LFSQ42012E.pdf, accessed 22 March 2013.
3 http://www.pcbs.gov.ps/Portals/_pcbs/PressRelease/int_Pop_2012e.pdf.
4 Ministry of Health Gaza, Central Drug Stores.
5 Occupied Palestinian territory STEPS survey 2010–2011. http://www.emro.who.int/pse/programmes/ncds-pal.html, accessed 22 March 2013.
6 Global School-based Student Health Survey. http://www.who.int/chp/gshs/2010_GSHS_FS_Gaza_and_West_Bank.pdf, accessed 22 March 2013.
7 Ministry of Health, Palestinian Health Information Center, Health Status in Palestine 2011, May 2012 http://www.moh.ps/attach/440.pdf, accessed 22 March 2013.
8 Ministry of Health National Nutrition Surveillance System 2011 Report. http://www.moh.ps/attach/402.pdf, accessed 22 March 2013.
9 Ministry of Health, Palestinian Health Information Center, Health Status in Palestine 2011, May 2012 http://www.moh.ps/attach/440.pdf, accessed 22 March 2013.
10 Ministry of Health, Disease Prevention Department. http://www.moh.ps/?lang=0&page=3&id=1630, accessed 26 March 2013.
11 The Joint Commission International (JCI) is the international body for hospital quality accreditation.
12 WHO, Right to health: Barriers to health access in the occupied Palestinian territory, 2011 and 2012. http://www.emro.who.int/palestine-press-releases/2012/who-launches-report-on-health-access-barriers-in-the-opt-5-march-2013.html (accessed 05 March 2013).


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