OMS - L'état de santé dans les territoires occupés palestinien et le Golan - 68e Assemblée mondiale sur la santé - Rapport du Secrétariat Français
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2. The current population for the occupied Palestinian territory is 4 550 368 (2 790 331 of whom live in the West Bank, including east Jerusalem, and 1 760 037 in the Gaza Strip).1 Two million are registered refugees, of whom 800 000 live in 19 refugee camps in the West Bank and eight in the Gaza Strip.2 The population is predominantly youthful: 39.7% of Palestinians are aged 0-14 years, 30.0% are aged 15-29 years, and 4.4% are aged 60 years or more.1
3. The Palestinian economy has been in decline since 2012 and estimates at the end of 2014 indicated a contraction in gross domestic product of 2.5% compared with 2013.3 Restrictions on movement and access, including the blockade of the Gaza Strip, the barrier wall on the West Bank and the permit regime, have contributed to the worsening economic conditions. Private sector development has also been hindered by the fragmented legal and regulatory business environment, which varies in the Gaza Strip, east Jerusalem and the different areas of the West Bank, and by the restrictions imposed on the movement of people and goods, and on trade between the West Bank, east Jerusalem and the Gaza Strip.4
4. At mid-year, the unemployment rate had declined to 16.0% in the West Bank, but had increased to 45.1% in the Gaza Strip. One quarter of the Palestinian population lives in poverty, with the poverty rate in the Gaza Strip twice as high as in the West Bank.4 In addition, 1 9 million Palestinians (1.3 million in the Gaza Strip and 0 6 million in the West Bank) experience food insecurity and need humanitarian aid.1
5. In 2014, the number of Palestinian fatalities and injuries resulting from violence associated with military occupation was the highest since 1967, amounting to 2333 deaths and 15 788 injuries — primarily occurring during the conflict in the Gaza Strip in July—August 2014. The conflict had a significant impact on the daily life of Palestinians, with half a million people being displaced, of whom 100 000 remained homeless at the end of 2014, and some 22 000 homes being either totally destroyed or rendered uninhabitable.1 Widespread damage to infrastructure, including hospitals, clinics and ambulances,2 and educational, water and sanitation facilities,3 has limited access to basic services.
6. In the West Bank, one quarter of the population (668 000) live in five areas where they are particularly vulnerable to social isolation, residency and planning restrictions, house demolition and forced displacement, reduced access to Palestinian services, confrontations with Israeli military forces and settlers, and the threat of violence. The areas are: east Jerusalem; the H2 area of Hebron city; Area C where Israeli military authorities control civilian affairs and security; the so-called seam zone; and closed military and firing zones.1
7. Access to health services is restricted by the separation wall and checkpoints, which prevent patients, health personnel and ambulances from directly accessing major Palestinian referral hospitals located in east Jerusalem. For Palestinians from the West Bank — excluding east Jerusalem — and the Gaza Strip, access to east Jerusalem referral medical centres is only possible after obtaining a permit issued by the Israeli authorities, a complex process which can result in delays and denial of care. According to a WHO update that is currently in preparation, in 2014, of the 18 141 patients who applied for permits to cross the Erez checkpoint in order to attend referral hospitals in Israel, or Palestinian hospitals in east Jerusalem, 17.6% were either denied permits or did not receive timely replies and therefore missed their hospital appointments. The rates are higher than in 2012 (7.5%) and 2013 (11.3%).4 A total of 322 patients (281 males and 41 females) were called for security interviews as a condition of application. The number of permit applications to pass through Erez increased by one third over the figure for 2013, and was almost double that for 2012. The increase in demand reflected mounting difficulties in exiting the Gaza Strip through the Rafah border crossing into Egypt, as well as more serious health needs arising from an inadequate supply of medicines and insufficient medical capacity within the Gaza Strip. Of the 230 712 Palestinians who applied for permits to access Jerusalem from the West Bank, including patients, companions and visitors, 22.6% were either denied permits or experienced delays in receiving them.1
8. Patients from the Gaza Strip seeking specialized health care were significantly affected in 2014 by the closure of the Rafah border crossing between the Gaza Strip and Egypt, one of only two exit points for its residents. The volume of patients and companions decreased by 93% after the July 2013 closure, with travel permitted only sporadically and in a limited number of humanitarian cases.
9. It has been reported that access to health services for the 5447 Palestinian political prisoners2 from the West Bank and Gaza Strip in detention and prison facilities in Israel, and for Palestinians held in Israeli military facilities in the West Bank, lacks transparency and supervision by the Israeli Ministry of Health, and that independent external physicians are denied access. More than 200 cases challenging the lack of access to medical services, and three court petitions requesting access for independent doctors were reported to have been filed in 2014 on behalf of prisoners.3 According to recent statistics, there were 163 children in prison or military detention in 2014, including 18 children aged less than 16 years.4 These prisoners are particularly vulnerable because of the “widespread, systematic and institutionalized” ill-treatment of children,5 which can affect their mental well-being.6
10. The Palestinian Ministry of Health re-unified its health system in 2014 under the Palestinian Authority, following agreement with the de facto government to end the seven-year political separation between West Bank and Gaza Strip. While the Ministry of Health, UNRWA and nongovernmental organizations together provided geographical coverage of primary and hospital level services, the financial crisis affecting the Palestinian Authority continued to have a serious impact on the scope and quality of Ministry of Health services. Budget shortfalls have resulted in chronic shortages of essential drugs and medical disposables in the Gaza Strip, and, most recently, in the West Bank, prompting an increase in referrals. Health services have been disrupted by frequent strikes by health workers and stoppages by health suppliers. The restrictions imposed on the movement of health staff and goods also hinder the overall functioning and development of the health system.
11. So far, service delivery in the public sector has followed a selective, service-centred approach whereby specific areas, such as maternal health or noncommunicable diseases, are managed by dedicated staff. The Ministry of Health is now moving towards a patient-centred approach, with the adoption of a family practice model for primary health care. This approach is essential in addressing the high burden of noncommunicable diseases in the occupied Palestinian territory, where the leading causes of death remain cardiovascular disease, cancer, cerebrovascular diseases and diabetes,1 and the prevalence of related risk factors (smoking, unhealthy diet and physical inactivity) remains unacceptably high.
12. Infant and under-five mortality rates continued to decline. In 2013, infant mortality was 12.9 deaths per 1000 live births, compared with 20.8 deaths per 1000 live births in 2005. The under-five mortality rate was 15.5 deaths per 1000 in 2013, down from 24.6 deaths per 1000 in 2005.2
13. The prevalence of disability was 2.7% in the West Bank and 2.4% in the Gaza Strip,3 although disabilities increased notably in the Gaza Strip in 2014 as a result of the large number of persons with traumatic injuries, including more than 100 amputations, resulting from the July—August 2014 conflict. An increase in the burden of mental and psycho-social disorders can be expected in a population experiencing prolonged occupation, lack of personal security, severe movement restrictions and human rights violations, including displacement in a post-conflict situation.
14. Water quality and quantity is at crisis level in the Gaza Strip where 90-95% of public water supplies are not potable without treatment and the main aquifer will probably be unusable by 2016.4
15. In response to a request made by the Sixty-seventh World Health Assembly in decision WHA67(10), a more detailed account of health conditions in the occupied Palestinian territory has been made available.5 The report concerned is based on a field assessment conducted by an external consultant, supported by WHO staff.
KEY AREAS OF WHO SUPPORT TO THE PALESTINIAN MINISTRY OF HEALTH
16. Progress was made by WHO and the Palestinian Ministry of Health in advancing the family practice agenda, including conducting a family practice costing study, establishing a multistakeholder family practice steering committee, organizing a family practice workshop, and initiating preparations for implementation in three pilot districts.
17. During 2014, WHO, in collaboration with the Ministry of Health, conducted a multistakeholder assessment of the status of efforts to address key noncommunicable disease risk factors, as a basis for targeting future interventions. WHO further supported the Ministry of Health in strengthening noncommunicable diseases service delivery through expanding implementation of the WHO package of essential noncommunicable disease interventions for use at primary-care level in six districts. A total of 513 Ministry of Health staff received training in the interventions during 2014. Routine data collection and supervision systems related to noncommunicable diseases were also strengthened. An evaluation, conducted 18 months after initial implementation of the package, has shown improvements in targeted metabolic parameters.
18. WHO continued to support the Ministry of Health through the implementation of a three-year project funded by the European Union aimed at improving access to quality mental health care. In 2014, the integration of mental health services in primary care was expanded to five districts, making mental health services accessible at the point of first contact with the health system. The provision of specialized mental health services was also enhanced through the training of over 100 service providers in the “recovery in practice” approach to severe mental illness. In addition, during 2014, a day care centre was established in the Gaza Strip and occupational therapy services reinforced in the West Bank in order to further promote the recovery and social integration of mental health patients. Lastly, progress was made in strengthening the analysis and use of mental health services data.
19. With the backing of the Norwegian Government, WHO continued to support the establishment of a Palestinian Institute of Public Health. During 2014, the activities focused mainly on (i) building a viable and sustainable organization and (ii) ongoing work in core scientific and technical areas, including completion of the audit of the death notification form and the performance assessment of mammography screening and discussion of the results with stakeholders. A census of health human resources in the West Bank was conducted in order to establish a human resources observatory. Work also began on the harmonized reproductive health registry project, a detailed description of the cancer registry, a road traffic accident registry and a mammography screening service registry. The plan of action of the Institute for the coming biennium is being updated following a technical meeting involving partners and stakeholders.
20. In support of activities against HIV/AIDS, and with funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria, WHO continued to act as technical adviser to the United Nations thematic group for tuberculosis and HIV/AIDS in the West Bank and Gaza Strip. The Organization continued to support people living with HIV, mainly in the Gaza Strip, and carried out surveys among the most at-risk populations to gain an understanding of the epidemiological pattern of HIV/AIDS in this low-prevalence setting. Regular monitoring visits ensure that the best quality services are delivered to patients and that any necessary corrective measures are carried out.
21. WHO participated in the coordinated response to the Middle East poliomyelitis outbreak in 2014 by working with other United Nations country offices to ensure continuous support for high vaccination coverage (97.6% in 2012)1 and effective monitoring of surveillance indicators.
22. With support from the European Union, WHO continued its work to improve the quality of services at the six specialized medical referral facilities in east Jerusalem which comprise the East Jerusalem Hospitals Network. To date, four of the hospitals have been accredited by the Joint Commission International, the international body for hospital quality accreditation. WHO is also working to strengthen the Network in order to promote collaboration and continued improvement across the member facilities. As part of this effort, a coordinator has been appointed to ensure functioning and sustainability of the Network, a chairperson designated, and terms of reference developed for the working committees.
23. WHO continued to support the Ministry of Health in enhancing its institutional capacity and that of the health system, including through the development of a monitoring and evaluation mechanism for its three-year strategy and annual action plans, and a hospital planning task force, in line with a health strategy goal to develop a comprehensive plan for health service coverage. As a first step, a comprehensive assessment of the hospital sector in the West Bank, including east Jerusalem, was completed by a WHO consultant. To support health financing improvements, the Ministry of Health and WHO jointly completed a WHO Organizational Assessment for Improving and Strengthening Health Finance (OASIS) review. Plans for a policy dialogue workshop to address universal health coverage and options for sustainable health financing are being discussed.
24. With WHO support, the Ministry of Health decided to implement the Patient Safety Friendly Hospital Initiative in all its hospitals. Hospital quality coordinators received support to expand their knowledge to build the capacity of local teams and enable them to implement the Initiative's critical standards. Relevant patient safety indicators will be identified and measured in all hospitals and intensive quality management training carried out during the coming year.
25. With the support of the Government of Switzerland, WHO continued its advocacy work, especially in connection with key health determinants in the Gaza Strip during the July—August 2014 conflict, including deaths and injuries of health personnel and damage to health facilities: WHO also supported the Ministry of Health in gathering information and coordinating donor efforts.2 Activities with major health partners aimed at better protecting the right to health and improving reporting of health violations continued. WHO issued its third annual report on the barriers impeding access by referral patients from the Gaza Strip and West Bank to medical care and by health personnel to the main east Jerusalem hospitals.3 The Organization continued to provide information to the international community on shortages experienced in the Gaza Strip, and to advocate for international interventions to improve access for the health sector. According to a Ministry of Health communication from March 2015, the following shortages are being experienced: essential medicines (24.5%) and medical supplies (37%). In addition, chronic fuel shortages are reported for health services.
26. Under the United Nations Partnership to Promote the Rights of Persons with Disabilities, WHO worked jointly with the Ministry of Health, five United Nations agencies and line ministries to review the compliance of laws and policies relevant to persons with disabilities, using a rights-based approach and advocating for a wider definition of disability based on functional abilities, and protection of their rights to health care, education and employment opportunities. The project is coordinated by the Office of the United Nations Special Coordinator for the Middle East Peace Process.
27. WHO continued to lead the Health and Nutrition Sector, which it co-chairs with the Ministry of Health. The Sector includes 38 humanitarian health organizations, including United Nations agencies and nongovernmental and private sector organizations, providing essential primary health care services to vulnerable communities with restricted access to services. WHO conducted monthly meetings with partners to discuss humanitarian health updates and identify gaps and needs for a better coordinated response.
28. In 2014, the Health and Nutrition Cluster was reactivated in order to respond more effectively to the humanitarian challenges affecting health during the conflict and emergency situation in the Gaza Strip. The Cluster held weekly meetings to share information and coordinate the response efforts so as to meet the priority needs of the population and plug gaps in health services during the emergency and its aftermath. A joint health emergency room was established by the Ministry of Health, with WHO support, to coordinate information, humanitarian donations for health, and assistance from medical delegations.
29. Following the crisis, WHO led health partners in conducting a rapid analysis of the health situation in the Gaza Strip for the multi-cluster initial rapid assessment. WHO also coordinated a comprehensive health assessment by the Health Cluster, which highlighted the impact of the conflict on the health sector, as well as the main gaps and needs:1
30. Before and during the crisis, WHO, as the lead agency for the Health and Nutrition Cluster and provider of last resort, worked to minimize shortages in critical life-saving drugs and medical disposables, with support from the governments of Italy, Norway, Switzerland and Turkey, and through the United Nations Central Emergency Response Fund. The Organization also provided urgently needed technical assistance, medical equipment and spare parts to maintain, repair and improve existing equipment, especially generators and medical equipment damaged as a result of the unstable power supply and frequent blackouts caused by fuel shortages. WHO also assisted in coordinating the delivery of medical supplies from various donors to the Gaza Strip, and the distribution of donated fuel to health facilities according to need to ensure continuity of health service delivery.
31. Together with the Ministry of Health and partners in the Health and Nutrition Cluster, WHO contributed the health component of the Humanitarian Needs Overview for 2015,2 containing an analysis of the humanitarian health situation and highlighting priority needs, vulnerable communities and groups, and obstacles to and difficulties in accessing essential health services in priority areas of the Gaza Strip, east Jerusalem, Area C in the West Bank, closed military areas, and the “seam zone”. The Overview enabled the Health and Nutrition Cluster to develop its Strategic Response Plan for 2015, whose main objectives are: ensuring access to essential health services; the referral of victims of violence to protection organizations and related advocacy; and ensuring that vulnerable communities receive emergency preparedness support and assistance to enable them to cope with disasters.
32. WHO continued to support the Ministry of Health in developing the core capacities required under the International Health Regulations (2005), including building the capacity of the public health laboratory. It also contributed towards enhancing regional preparedness for the control of Ebola transmission by coordinating with the Ministry of Health in an external WHO assessment mission in November 2014. The mission identified gaps in country preparedness and made recommendations on further action and support. Awareness raising materials for health workers, communities and border crossings were printed and disseminated, and a mass risk communication and medical awareness campaign was conducted to encourage public awareness and wide community engagement, including by the UNRWA, the tourist sector, security, religious and media organizations, and traditional leaders.
33. WHO continued to support the Ministry of Health in implementing all-hazards emergency risk management, using a multisectoral approach, in accordance with a new emergency and disaster risk management framework for health. Accordingly, the Health Ministry and WHO conducted joint planning workshops on emergency preparedness for civil defence groups, major health partners and other main stakeholders in order to introduce participatory planning in an all-hazards approach. Workshops on emergency preparedness planning were also conducted in hospitals and primary health care facilities.
SITUATION IN THE OCCUPIED SYRIAN GOLAN
34. WHO has no access to the occupied Syrian Golan and thus cannot provide a report on the prevailing health conditions there.
ACTION BY THE HEALTH ASSEMBLY
33. The Health Assembly is invited to note the report.
1 Palestinian Central Bureau of Statistics (http://www.pcbs.gov.ps/site/881/default.aspx#Population, accessed 1 April 2015) and State of Palestine Ministry of Health, Health annual report, Palestine 2013 (http://www.moh.ps/attach/704.pdf, accessed 1 April 2015).
2 UNRWA, “Where we work” www.unrwa.org/where-we-work/, accessed 1 April 2015.
3 Palestinian Central Bureau of Statistics (http://www.pcbs.gov.ps/site/512/ default.aspx?tablD=512&lang=en&ItemID=1294&mid=3171&wversion=Staging, accessed on 1 April 2015).
4 World Bank. Economic Monitoring Report to the Ad Hoc Liaison Committee, September 22, 2014 (http://www.worldbank.org/content/dam/Worldbank/Feature%20Story/mena/WBandGaza/wbg-docs/wbg-ahlc-report-2014-eng.pdf, accessed 1 April 2015).
1 Occupied Palestinian territory. Humanitarian Needs Overview 2015. Factsheet issued by the United Nations Office for the Coordination of Humanitarian Affairs (http://www.ochaopt.org/documents/hno2015_factsheet_final9dec.pdf, accessed 1 April 2015).
2 Health Cluster, “Gaza Strip: Joint Health Sector Assessment Report” http://www.emro.who.int/images/stories /palestine/documents/Joint_Health_Sector_Assessment_Report_Gaza_Sept_2014-final.pdf?ua=1, accessed 1 April 2015).
3 Fact sheet issued by the United Nations Office for the Coordination of Humanitarian Affairs on Gaza water, September 2014 (http://www.ochaopt.org/documents/gazastrip_water_vl.pdf, accessed 1 April 2015).
4 Right to health: crossing barriers to access health in the occupied Palestinian territory, 2013. Geneva: World Health Organization; 2014 (http://www.emro.who.int/images/stories/palestine/documents/WHO_-_RTH_crossing_barriers_to_access_health.pdf?ua=1, accessed 1 April 2015).
1 Palestinian General Authority for Civilian Affairs office, communication, 27 January 2015.
2 The Israeli Information Center for Human Rights in the Occupied Territories. Statistics on Palestinians in the custody of Israeli security forces (http://www.btselem.org/statistics/detainees_and_prisoners, accessed 1 April 2015).
3 Physicians for Human Rights — Israel, communication to the WHO Health in Prisons Programme, August 2014.
4 The Israeli Information Center for Human Rights in the Occupied Territories. Statistics on Palestinian minors in the custody of the Israeli security forces (http://www.btselem.org/statistics/minors_in_custody, accessed 1 April 2015).
5 UNICEF. Children in Israeli detention: observations and recommendations, 2013 (http://www.unicef.org/oPt/UNICEF_oPt_Children_in_Israeli_MilitaryDetention_Observations_and_Recommendations_-_6_March_2013.pdf, accessed 1 April 2015).
6 The impact of child arrest and detention. Paper issued by the Madaa Creative Center, Silwan (http://resourcecentre.savethechildren.se/sites/default/files/documents/2012-madaa-report-on-child-arrest-and-detention-in-silwan.pdf, accessed 1 April 2015) and Solitary confinement for Palestinian children in Israeli military detention. Defence for Children International/Palestine Section (http://www.dci-palestine.org/sites/default/files/report_doc_solitary_ confinement_report_2013_final_29apr2014.pdf, accessed 7 April 2015).
1 State of Palestine Ministry of Health, Health annual report, Palestine 2013 (http://www.moh.ps/attach/704.pdf, accessed 1 April 2015).
2 Ministry of Health. Health status in Palestine 2005 (http://www.moh.ps/attach/128.pdf, accessed 1 April 2015).
3 Palestinian Central Bureau of Statistics (http://www.pcbs.gov.ps/site/512/default.aspx?tablD=512&lang =en&ItemID=1165&mid=3172&wversion=Staging, accessed 1 April 2015).
4 Gaza in 2020: a liveable place? Report issued in 2012 by the United Nations Country Team in the occupied Palestinian territory (http://issuu.com/unrwa/docs/gaza_in_2020/1?e=0, accessed 1 April 2015).
5 See http://applications.emro.who.int/docs/Cons_Rep_2015_EN_16311.pdf (accessed 12 May 2015).
1 See http://rho.emro.who.int/rhodata/?theme=country&vid=21500, accessed 1 April 2015).
1 See http://www.emro.who.int/pse/publications-who/gaza-situation-report-update-july-september-2014.html?format=html, accessed 1 April 2015.
2 See http://www.emro.who.int/pse/palestine-news/, accessed 1 April 2015.
3 Right to health: crossing barriers to access health in the occupied Palestinian territory, 2013. Geneva: World Health Organization; 2014 (http://www.emro.who.int/images/stories/palestine/documents/WHO_-_RTHcrossing_barriers_to_access_health.pdf?ua=1, accessed 1 April 2015).
1 Health Cluster in the occupied Palestinian Territory, “Gaza Strip: Joint Health Sector Assessment Report” http://www.emro.who.int/images/stories/palestine/documents/Joint_Health_Sector_Assessment_Report_Gaza_Sept_2014-final.pdf?ua=1, accessed 1 April 2015.
2 Occupied Palestinian territory. Humanitarian Needs Overview 2015. Factsheet issued by the United Nations Office for the Coordination of Humanitarian Affairs (http://www.ochaopt.org/documents/hno2015_factsheet_final9dec.pdf, accessed 2 April 2015).