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World Health Organization (WHO)
18 May 2012
Health conditions in the occupied Palestinian
territory, including east Jerusalem, and in the
occupied Syrian Golan
At the request of the Permanent Observer of Palestine to the United Nations and Other International Organizations at Geneva, the Director-General has the honour to transmit the attached report to the Sixty-fifth World Health Assembly (see Annex).
Palestinian National Authority
Ministry of Health
A REPORT ON THE HEALTH CONDITIONS
IN THE OCCUPIED PALESTINIAN TERRITORY
Sixty-fifth World Health Assembly
1. In 2011, the population of the occupied Palestinian territories was estimated to be 4 168 860, including 389 298 in occupied Jerusalem. The population distribution was 61.9% in the West Bank and 38.1% in the Gaza Strip.
2. Population distribution according to sex revealed that men accounted for 50.8% of the population and women 49.2%.
Crude birth and death rates
3. Data from the Palestinian Central Bureau of Statistics indicate that in 2011, the crude birth rate was 32.8 per 1000 and the crude death rate was 4.0 per 1000.
4. Palestinian society is still young. In 2011, children under five years of age constituted 14.7% of the total population living in the occupied Palestinian territories; 40.8% were in the age group (0–14 years) and 2.9% were in the age group 65 years and above.
Determinants of health
5. It is obvious that the determinants of health in Palestine are no better than those observed last year. Poverty and unemployment rates in the Gaza Strip have considerably worsened owing to the enduring stranglehold of the Israeli blockade. Besides, the demographic indicators such as high fertility rate, high population growth rate and epidemiological changes exemplified by the prevalence of chronic diseases still constitute formidable challenges facing the Palestinian health system. The presence of the Israeli occupation forces however, is the greatest challenge facing the health sector, not to mention the daily acts of violence perpetrated by the occupying army and the exactions of the hordes of Jewish settlers against Palestinians. Factors such as the presence of hundreds of military barriers, the apartheid wall that dismembers Palestinian territories and isolates them from the rest of the world, in addition to closures of crossings and borders, contribute to making life miserable for all Palestinians.
6. Israel as an occupation force continues its aggression against Palestinian civilians and children for organizing peaceful protest against occupation army and settlers daily acts. Such acts aim at seizing their land and destroying their crops which represent their main source of income especially olive trees. Actually, settlers continue their daily aggression on olive cultivated land by burning or uprooting olive trees.
7. Recently, the Israeli occupation army has been using dogs to terrify and attack peaceful protesters thus causing several injuries.
8. Israel also uses different methods to assassinate resistance figures by aerial bombardment in Gaza where citizens were killed and assassinated and by direct shooting of peaceful protesters in the West Bank and Jerusalem.
9. The blockade imposed on the Gaza Strip since 2005 combined with tightening restrictions on individuals and goods movement via all crossings and borders controlled by Israel, hinder economic growth and exacerbate unemployment and poverty thus throwing its dark shadow on health services. This is quite evident in the deterioration of services provided to mother and child and increase of deliveries at home. This was accompanied with more high risk pregnancies and deaths among mothers and newborn babies, and limit the ability of the ministry of health to achieve the millennium development goals.
10. It has been estimated that the health status of nearly 40% of those suffering from chronic diseases in the Gaza Strip has deteriorated significantly as a result of the reduction in health-care services. Also the ever-increasing transfer for treatment abroad at the expense of the National Palestinian Authority overburdens the Ministry of Health budget and cause Palestinian citizens untold hardships in getting the requested authorizations to exit the Gaza Strip, in addition to the travel and living expenses uncured by the patients and those accompanying them abroad.
11. The concern of the Palestinian National Authority, through the Ministry of Health, for promoting the health of Palestinian citizens as a basic right, and its efforts to provide integrated health services to Palestinian citizens in response to economic, demographic and epidemiological changes has markedly improved health indicators, thus giving national health services an edge over the services provided by some neighbouring countries, taking into account the differences in rates of health expenditure. This is evidence of the resilience of the Palestinian health sector and its ability to cope despite all manner of challenges, and demonstrates concrete results in efforts to achieve the Millennium Development Goals.
The economic situation
12. In 2010, the rate of unemployment reached 37.8% in the Gaza Strip compared with 17.2% in the West Bank, and the rate of poverty according to consumption patterns reached 40% in the Gaza Strip and 18.3% in the West Bank. Also 23% of the population in the Gaza Strip and 8.8% in the West Bank suffer poverty as a result of measures taken by Israel and the blockade imposed on the Gaza Strip in particular, and on the Palestinian people in general. The perpetuation of the occupation and the measures taken against the Palestinian people constitute a major obstacle that prevents patients from paying for treatment costs, thereby adding to the burdens that the Ministry of Health is compelled to bear on behalf of the people.
Health conditions of Palestinians in Israeli jails
13. More than 4000 Palestinians are still held in occupation jails for combating occupation, some of them have spent several years as administrative detainees without any trial. Palestinian children like adults are subjected daily to arrest and detention without specific charges. They are subjected to all manner of torture and ill treatment as nude inspection which represent a stark insult to human dignity and clear sexual assault. Actually administrative detention for various terms ranging from months to years violates the simplest international norms and laws. Battling against administrative detention, several detainees go on hunger strike for around 66 days amid fears for their lives as their health deteriorates. Yet the Israeli occupation forces still continue its oppressive practice of administrative detention of peaceful administrative Palestinians without trial or release.
SHORTAGE OF FOOD SUPPLIES
14. The continuation of the blockade of the Gaza Strip has led to a continued and acute shortage of essential materials, foodstuffs, energy supplies, and other vital necessities. This situation has resulted
in the emergence of chronic nutritional diseases, including stunting or excessive underweight. Eleven out of every 100 children under five are chronically or acutely undersized according to the data of the Palestinian Central statistical office in October 2011. Also the nutritional monitoring of the ministry of health, indicated that the prevalence of anaemia in the Gaza Strip is high among children and women, and data show that the prevalence of anaemia has reached 76.2% among children aged 9–12 months, 58.6% among school children aged 6–18 years, and 47.4% among pregnant women. Lack of access to food and high food prices due to the continuing military barriers, restrictions on movement and confiscation of land in the West Bank have resulted in high levels of unemployment and limited purchasing power among a large segment of the population, which in turn has led to the occurrence of malnutrition-related diseases in the West Bank, although to a lesser extent than in the Gaza Strip.
SHORTAGE OF FUEL AND ELECTRICITY IN THE GAZA STRIP
15. The electricity supply to the Gaza Strip comes from three sources: the local power station (40%) using industrial fuel arriving in the Gaza Strip via Israel; the direct electricity supply from Israel (50%); and the Egyptian electricity supply (10%). This means that Israel has total control over the electricity supply required for city lighting and for allowing the activities of everyday life to function. Since 2007, as indicated in a report by the United Nations Office for the Coordination of Humanitarian Affairs on 8 February 2007, most families and health institutions in the Gaza Strip suffer from power cuts for eight to 12 hours a day or more. On 7 February 2008, on the instructions of the Israeli defense ministry, the Israeli electricity company reduced the supply of electricity to the Gaza Strip by 0.5 megawatts per week. The reduction in electricity and energy puts immense pressure on the already crumbling electricity network in the Gaza Strip, affecting the infrastructure for drinking-water and the sewage system, and disrupting the provision of health care for civilians in the Gaza Strip.
16. Figures documented by the Palestinian Centre for Human Rights indicate that the Gaza Strip’s supplies of fuel and combustibles have been reduced since the decision taken on 25 October 2007 by the Israeli authorities to reduce supplies by more than half. Hence, supplies of petrol, diesel and gas for domestic use declined by 60% to 73%. On 28 November 2007, the Israeli authorities issued a new decision that further reduced the quantities of fuel supplied to the Gaza Strip (to less than 10% of its needs). On 30 January 2008, the Israeli High Court of Justice rejected the appeal by human rights organizations against the Israeli authorities’ reduction of the quantities of fuel and electricity supplied to the Gaza Strip. Consequently, since Monday 7 April 2008, the association of owners of oil and gas companies, and fuel and fuel derivative stations in the Gaza Strip have refused to accept delivery of combustibles and gas supplied to the Gaza Strip because of the continuing policy of cutting the supplied quantities, which are not enough to meet even basic needs.
17. On 16 April 2008, the Head of the UNRWA office, Mr Mathias Bergard, said that eight organizations of the United Nations system had issued a joint statement that the current situation in the Gaza Strip represented a danger to the health and welfare of the population in the Gaza Strip, of whom 56% were children. He added that the eight signatory organizations had stressed that the current situation was disrupting the work of the United Nations organizations in the Gaza Strip, by affecting schools, health facilities and food distribution; he also pointed out that in the absence of fuel at petrol stations, normal transport operations within the Gaza Strip had stopped. The Palestinian Centre for Human Rights stressed on the same day that the stoppage of fuel supplies to the Gaza Strip by the occupation authorities had paralysed 85% of transport and communications, disrupted 50% of the education system and closed 145 petrol stations. It was feared that all basic vital services such as delivery of drinking-water, sewage treatment and waste collection from the streets and neighbourhoods would be totally paralysed.
18. The shortage of fuel required to operate the Gaza power station, as well as the regulation of the electricity supply from Israel are continuing at the same rate, leading to many health, social, and economic impacts, notably the following:
1. Impact of shortage of fuel and electricity on the health situation in the Gaza Strip
• The stoppage of many surgical interventions – only those of an urgent and critical nature took place.
• The shutting-down of a number of oxygen-generating stations, which need high levels of power that cannot be supplied by small generators.
• X-ray units running at 50% capacity.
• The increased suffering of kidney failure patients owing to disruption and stoppage of dialysis units because of power outages.
• The halting of central air-conditioning systems in hospitals is adversely affecting the performance of duties, especially in enclosed areas such as operating theatres and intensive care units, particularly for newborn infants.
• The compromised validity and viability of blood and plasma supplies, which can be damaged when power outages last more than two hours.
2. Impact of shortage of fuel and electricity on drinking-water and sewage systems in the Gaza Strip
19. There are 180 water and sanitation facilities in the Gaza Strip, including 140 wells, 37 water pumping stations and sanitation plants and three sewage treatment plants, all of which require regular maintenance, spare parts and technical equipment not available in local markets owing to the Israeli blockade and closure. In December 2007, the Water Authority secured only 50% of its fuel needs, resulting in the sustained irregular supply of drinking-water. Also the stoppage of sewage treatment plants also causes large quantities of untreated sewage water to be discharged into the sea, thereby polluting sea water, fish and beaches. The sea shores of the Gaza Strip are badly polluted, because untreated sewage water is pumped into the sea, thus exacerbating the environmental crisis and continuously damaging public health.
20. Some 76 134 families, 12.2% of the total, have no access to safe drinking-water. The cuts in power to the Gaza Strip hinder the operation of water pumps, domestic refrigerators and health centres, since water is pumped for only two to three hours a day.
Treatment abroad for Gaza Strip patients
21. The level of health services at the Gaza Strip hospitals has deteriorated for the reasons outlined above and, most importantly, because of the lack of maintenance, new medical equipment, electrical power supply and medicines, in addition to the lack of rehabilitation of those hospitals and medical centres destroyed by the Israeli aggressive. This has created an ever-increasing need for treatment abroad, mainly in Egypt, Israel and east Jerusalem hospitals. However, authorizations to cross the border for medical treatment are occasioning increased hardship. The Israeli authorities either refuse to issue such authorizations “for security reasons” or issue them after long delays. Many patients experienced delays in treatment or were denied access to treatment. This attitude has exacerbated their health conditions and led to many avoidable deaths among Palestinian patients. Moreover, treatment outside the Gaza Strip is very costly and burdensome for the budget of the National Palestinian Authority, thereby weakening its potential to deliver high-quality health services to the rest of its citizens.
22. In 2011 a total of 17 923 cases were referred for treatment outside the Gaza Strip. Their overall cost was US$ 42 million.
THE ANNEXATION, EXPANSION AND APARTHEID WALL IN THE WEST BANK AND OCCUPIED JERUSALEM
23. In defiance of the advisory opinion of the International Court of Justice in 2004, the construction of the annexation, expansion and apartheid wall did not stop, nor did its destructive effects on the lives of Palestinians. It continues to divide and isolate communities, destroy their livelihoods and prevent hundreds of thousands of people from travelling normally to their workplaces, families, markets, schools, hospitals and medical centres.
24. In 2002, Israeli occupation forces began building the annexation, expansion and apartheid wall. Upon its completion, the proportion of villages unable to access health facilities in the region will be about 32.7%, rising to 80.7% if the isolated pockets are taken into account as well as the “seam zone”. After completion, the wall will cut off a total of 71 clinics: 41 clinics were already totally cut off. Some 450 000 Palestinians will be directly affected, and a further 800 000 indirectly.
25. The establishment of the wall is part of a comprehensive Israeli policy which began with the building of settlements, then barriers, and finally the wall that dismembers the West Bank and turns it into ghettos. The aim of building the wall 35 kilometres deep inside Salfit and Qalqilya – thereby isolating the occupied city of Jerusalem from the West Bank, and expanding the settlements of “Ma’aleh Adumim”, Bethlehem and Hebron – is to create ghettos; there are about 28 ghettos containing 64 Palestinian communities.
26. The report of the Palestinian Centre for Information in Ramallah states that the situation in the occupied city of Jerusalem is horrendous and that the wall, settlements and barriers cause serious health problems and isolate entire communities in Jerusalem, such as Anata village and Shufat refugee camp, from those major facilities that provide them with services in the city of Jerusalem, such as Al-Uyoun, Al-Maqasid and the Red Crescent hospitals. The report also shows that more than 70 000 Palestinians with Jerusalem ID cards are threatened, as Israel’s next move, after constructing the wall, will be to prevent them from reaching Jerusalem, and then to withdraw their health insurance and Jerusalem identity cards on the grounds that they no longer reside in the city.
27. Furthermore, the report shows that there are no advanced health services in the city of Qalqilya; so its 46 000 inhabitants have no choice but to rely on hospitals in other cities, such as Nablus, in a trip that used to take 20 minutes but now takes three and a half hours because of the barriers and the wall.
28. Moreover, the separation wall even directly affects the villages that seem to be remote from the construction site, because of the road network that Palestinians are forbidden to use. For example, Palestinians are unable to reach Ramallah and occupied Jerusalem because of these roads.
29. In the same visit to the West Bank, Mr Holmes stated that the wall, the settlements and the Israeli permit system are destroying the economic and social life of the population in the West Bank, and are responsible for exacerbating poverty and unemployment. Thus, the first step towards an economy that is conducive to strengthening peace talks is to stop building the wall, prevent the expansion of settlements and lift the barriers.
Providing health services
30. Over the last two years, the Ministry of Health has endeavoured to improve the quality of health services and has drawn up an ambitious workplan (for the period 2008–2010) to reform and further develop the health sector. Despite the actions of the Israeli occupation forces and the lack of financial resources, the Ministry of Health has pressed ahead with the workplan and health system reform and was gratified by the positive response from many donor countries and from the United Nations agencies involved in the health sector. The Ministry has recorded several achievements such as the rehabilitation and re-equipping of health facilities, and the development and starting the implementation of ambitious programmes to train health cadres. The only important obstacle hindering the National Strategic Reform and Development Plan for the Health Sector 2008–2010 is the blockade against the Gaza Strip and the unusual political situation.
31. The following paragraphs offer an overview of the Palestinian health system and its main services, together with the principal health indicators for 2009, which highlights the deterioration of the health situation in the Gaza Strip. The only hope of saving the health sector from total collapse lies in ending the blockade, returning the political situation to normal and, above all, returning the entire Gaza Strip to the control of the central management of the Palestinian National Authority.
PALESTINIAN HEALTH SYSTEM
Primary health care
32. Primary health care is delivered by a variety of health staff working for the Ministry of Health, non-governmental organizations, UNRWA, the military health service, and the Palestinian Red Crescent. In this regard, the central administration of primary health care at the Ministry of Health plays a remarkable role. The network of health-care centres has been extended throughout the national governorates, from 454 centres in 1994 to 706 in 2010 – an increase of 55.5% compared with 1994. Government-run centres represent 64.2% of all centres operating in the area of primary health care of which UNRWA supervises 8.3% whereas nongovernmental organizations supervise 27.5%. 33. In the West Bank in 2010, the number of visits to primary health care centres administered by the Ministry of Health totalled 2 299 052 for consultations with physicians. Thus representing 0.9 for every citizen in the West Bank and 1 187 894 for visits to nurses.
34. The proportion of Palestinian women of reproductive age (i.e. 15–49 years) is 48.8% of the total number of women in Palestine. The mortality rate recorded at the national level was 38 per 100 000 live births in 2009 and 32 per 100 000 live births in 2010. The Ministry of Health has set up a high-level national committee to monitor the recording and reporting of maternal mortality. Due to the current political situation in the Gaza Strip, reporting of these rates is extremely poor. The reported rates do not always reflect reality.
Total fertility rate
35. According to the Palestinian Central Statistical Office, the total fertility rate among women of reproductive age (15–49 years) is 4.2 at the national level in 2010 (4.9 in the Gaza Strip and 3.8 in the West Bank).
36. The annual health report 2010 prepared by the Palestinian Centre for Information in the Ministry of Health showed that most births in Palestine occur in hospitals or in maternity homes (99.2%), and that hospitals administered by the Ministry of Health (56.5%) play a pivotal role in this respect. This confirms that most Palestinian women prefer to give birth in a hospital setting, and especially hospitals administered by the Ministry of Health, in view of the good service they offer, and because most of the Palestinian population benefits from the health insurance system covering childbirth. Government hospitals therefore represent the most appropriate choice.
Family planning programmes
37. Family planning programmes are a major priority for health service providers in general and for the Ministry of Health in particular. The number of primary health care centres offering such services has increased to reach 167 in the course of 2010 in different governorates. There are currently 147 such centres in the West Bank and 20 centers in the Gaza Strip.
38. In 2010, a total of 84 309 women visited family planning centres (14 873 in the Gaza Strip and 69 436 in the West Bank). The number of first visits to a planning service during the same period was 19 094. Intrauterine devices were the most common birth-control method among women making their first visit to such services, amounting to 36.6% in 2010 against 14.7% in 2009 whereas contraceptive pills decreased from 64.8% in 2009 to 29.7% in 2010.
Radiographic examination of breast
39. In 2010, the Ministry of Health provided radiographic examination of breast services through primary health care in the different governorates in the West Bank. Therefore, the number of examined women reached 9849 of which findings were abnormal for 3219 cases (around 32.9% of examined cases) and were followed up for further examinations.
40. The Ministry of Health administers and operates 53 dental clinics at primary health care centres, including 29 in the West Bank and 24 in the Gaza Strip. There are several hundred such clinics in the private and public sectors.
41. In 2010, the Ministry of Health recorded a total of 149 396 visits to dental clinics (30.5% in the West Bank and 69.5% in the Gaza Strip). A total of 58 585 operations to insert dental fillings (all types) were performed (37.5% in the West Bank and 62.5% in the Gaza Strip). There were 215 minor surgical acts (12.1% in the West Bank and 87.9% in the Gaza Strip), 37 663 cases involving tooth extractions (33.7% in the West Bank and 66.3% in the Gaza Strip), and 37 285 cases where gum treatment was provided (1% in the West Bank and 99% in the Gaza Strip).
Laboratories and blood banks
42. The Ministry of Health runs 198 laboratories, with a 3.1% increase compared to 2009, including four central laboratories (two in the West Bank and two in the Gaza Strip). There were 23 hospital laboratories (12 in the West Bank and 11 in the Gaza Strip) and 171 laboratories located at primary health care centres (134 in the West Bank and 37 in the Gaza Strip).
43. In 2010, a total of 751 545 laboratory tests were carried out at laboratories run by the Ministry of Health, of which 26% were carried out in the primary health care laboratories, and 74% in the Ministry of health.
44. Six hundred and ninety-three technicians and professionals are employed at laboratories administered by the Ministry of Health of which 287 representing around 41.49% work in the West Bank and the remaining number in the Gaza Strip.
45. The total number of blood donors was 44 564, of whom 37% were voluntary donors, while 63% donated their blood to relatives or to friends.
46. Laboratory tests for bloodborne diseases are carried out on all units of donated blood prior to transfusion. In 2010, the rate of viral hepatitis B detected was 1.6%, against 1.8% in 2009, and 0.25% of donations were found to be infected with viral hepatitis C.
47. Four patients tested positive for HIV in preliminary tests. These four cases require further tests for confirmation.
48. The Ministry of Health is considered the major provider of secondary care (hospitals) in Palestine. It owns and administers 3002 beds in 25 hospitals in all governorates with 2.9% increase in the number of beds in the Ministry of Health hospitals in 2009. These hospitals are among the 76 hospitals operating in Palestine with a total capacity of 5108 beds. Fifty one of these hospitals, with 3063 beds, are in the West Bank; and the rest are in the governorates of the Gaza Strip.
49. In addition to hospitals administered by the Ministry of Health, there are 28 hospitals owned by community-based organizations with capacity for 1495 beds, and 20 privately-owned hospitals with 476 beds.
50. UNRWA owns a single hospital in Qalqilya governorate with 63 beds. The Ministry of Health’s services cover almost all specializations including general and specialized surgery, internal medicine, paediatrics, psychiatry and others.
51. Rehabilitation and physiotherapy are provided by private hospitals (i.e. non-governmental hospitals), which also offer other services such as outpatient and emergency treatment. Dialysis is provided by 13 units distributed among government-administered hospitals. These units performed 107 852 dialysis interventions in 2010.
52. The main services offered by government hospitals include diagnostics such as radiology. In 2010, Palestinian government hospitals produced a total of 918 298 radiological images. Other important services in this area include laboratory tests.
HEALTH INDICATORS, 2010
53. In conclusion, we can confirm that the Palestinian National Authority still believes that peace is the strategic option for both the Palestinian and the Israeli people, and that peace alone can bring an end to the long Israeli occupation and lead to the establishment of an independent Palestinian State with Jerusalem as its capital. We also confirm the need to take immediate action to end the unjust blockade on the Gaza Strip and to remove Israeli annexation and extension blocks and walls, so that the Palestinian people can enjoy its right to health and safe access to high-quality health services. Therefore, the
Palestinian Ministry of Health
• calls on the international community to exert pressure on the Israeli Government to lift the blockade on the Gaza Strip, to prevent the worsening humanitarian crisis there, and to take action to fulfil its moral and legal responsibility to protect the basic human rights of civilians in the occupied Palestinian territories;
• calls on the States Parties to the Fourth Geneva Convention to fulfil their obligations under Article 1 of the Convention, whereby the Contracting Parties undertake to respect and to ensure respect for the Convention in all circumstances, and their obligation, as provided for in Article 146, to pursue those accused of grave breaches of the Convention. It should be noted that such breaches are deemed war crimes under Article 147 of the Fourth Geneva Convention and the Additional Protocol thereto, which guarantees the protection of Palestinian civilians in the occupied territories;
• expresses its thanks to donor countries for their support of the Palestinian people in all areas and appeals to them and to international health agencies to extend their political and financial support to implement the health development plan 2008–2010 in order to create the political environment necessary for the implementation of the document entitled “Ending the Occupation, Establishing the State”, as presented by the Palestinian Authority. The Palestinian Authority is now focusing its efforts on creating an environment conducive to the implementation of this text;
• requests the international community to exert pressure on Israel to implement forthwith the consultative opinion of the International Court of Justice on the illegal building of the annexation wall deep inside the West Bank territories. It also requests the cessation of house demolition, the displacement of Jerusalem Palestinians from their homes, the Judaization of Jerusalem and the construction of settlements in Palestinian territories occupied in 1967 which constitute not only a violation of international resolutions, but also a threat to “the safety and health of the Palestinian nationals” and a restriction of their access to health services;
• invites all international human rights bodies and the International Committee of the Red Cross, in particular, to intervene, urgently and immediately, with the occupation authorities and the Israeli prison service to compel them to provide treatment to sick prisoners in Israeli jails whose health is deteriorating daily. It calls for the establishment of an international committee composed of medical specialists to review critical cases and treat them immediately and rapidly, and appeals to civil society organizations to exert pressure to save the lives of prisoners, treat sick prisoners immediately, and release critically ill prisoners so they can be treated abroad. It also appeals for imprisoned Palestinian women to be allowed to receive prenatal and postnatal treatment and to be allowed to give birth in healthy and humane conditions in the presence of their families; it further demands the immediate release of child prisoners;
• confirms that the blockade is continuing and that crossing points are still not fully open, which means a continuation of the crisis and sufferings that preceded the Israeli aggression in the Gaza Strip at the end of 2008, and that the Ministry of Health needs to rebuild the health facilities destroyed in the aggression, to complete works on other needed medical institutions and to provide them with essential medical equipment;
• and requests the strengthening of formal and local support for the Palestinian health sector as an important stabilizing factor and to guarantee the right of the Palestinian people to have access to health services, as approved by international legislation.