Data and Commentary for 2010
Each year thousands of Palestinians residing in the Gaza Strip are referred by their physicians to hospitals outside of Gaza in order to access necessary, often life-saving, medical services that are unavailable locally. The need for referrals outside of Gaza has been exacerbated by the lack of adequate development of the public health care system for the population of 1.5 million Palestinians in Gaza. The majority of these referrals are for diagnosis and treatment services in five common specialties — cardiovascular diseases, oncology, orthopaedics, neurosurgery and ophthalmology.
In 2010, the Palestinian Ministry of Health (MoH) referred 12,483 patients from Gaza to outside hospitals in order to access specialty services not available in Gaza, at an estimated cost of USD 24 million1 to the Ministry. In addition, an estimated 1,500 patients from Gaza also left Gaza to access health services funded through NGO charitable donations or were self-funded.
The MoH referred 4,064 of its patients to Palestinian facilities in Gaza operated by NGOs or the private sector, and 4,843 patients to Egypt — which is accessible through the Rafah border crossing and under Egyptian control. However, 7,640 of the MoH patient referrals were to hospitals in East Jerusalem, the West Bank, Israel or Jordan. These patients require an Israeli-issued permit in order to access Erez checkpoint at the northern border of Gaza, sometimes multiple times for continuing treatments.
The patient has little control over the various steps in the process of patient referrals and access. The patient first submits a physician’s referral request to the Referral Abroad Department (RAD) of the Palestinian Ministry of Health for a decision regarding support. Patients referred to Egypt exit via the Rafah border crossing to Egypt, but Rafah had an irregular schedule of opening in 2010 and was closed completely for two months. In the case of referrals to East Jerusalem, the West Bank, Israel or Jordan, the patient needs to submit an application to Israeli authorities for permission to exit the Gaza Strip via Erez at least 10 days in advance of their appointment.
Patients waiting for health care require an efficient, timely, dignified and transparent process for applying for referrals and permits for themselves and their caretakers to exit from the Erez checkpoint. The health of critically ill patients is likely to deteriorate while they wait for approval for travel permits, which can take weeks and is always uncertain In urgent cases which have an expedited process, even a delay of hours may jeopardize a patient’s health WHO’s monitoring of the process showed that patients often suffer protracted delays in receiving permits to access medical services; can face interrogation by the Israeli security services as an application condition; experience difficulties during the arduous travel procedures to destinations; and, in worst cases, can be denied access. Six persons with known serious medical conditions, including four children, died after submitting applications for travel permits but before being able to access referral hospitals.
Overall, in 2010, 11,200 requests were submitted to the Israeli authorities at Erez checkpoint on behalf of patients for permits to access hospitals in other areas of the oPt, Israel or Jordan; 9,112 requests (82%) were approved, of which 8,647 actually crossed 646 were denied and 1,418 were delayed. The rate of timely approvals of permits varied considerably depending on the age and sex of applicants: 52% of male applicants aged 18-40 did not receive approvals on time and had to forfeit their scheduled hospital appointment, compared with just 5% of young patients aged 0-17. Six percent of applicants were denied permits, all without explanation (up from two percent in 2009).
In 2010, the Rafah crossing into Egypt, which does not require Israeli travel permits, became an increasingly reliable route for access to Egyptian medical centers for referred patients, especially for males aged 18-60. From January to May, the border was closed except for a few days per month but without advance warning; however, in the last seven months of the year when the crossing had scheduled weekday openings, the percentage of patients accessing Rafah increased from 29% of all referrals to 45% All of these factors hindering referrals compromise patient access to health services, which is an essential element of the fundamental right to health and, as such, protected by international human rights law and international humanitarian law Israel is a state party to the International Covenant for Economic, Social and Cultural Rights and is therefore obligated to observe its provisions protecting the Right to Health Every effort should be made to address the factors that undermine the delivery of health care, and to ensure that patients who need to access hospitals outside of Gaza can do so quickly, easily and in as dignified a manner as possible.
1All data on MoH referrals of Gaza patients used in this report is from the MoH database in Gaza, except where otherwise specified. Data on permits for Erez is from the Palestinian Liaison Office (or District Coordination Office) database. The estimated cost of referrals outside of Gaza was calculated using the estimated total for this group, (from “Health Annual Report, Palestine 2010”, Palestinian Health Information Center, Ministry of Health, April 2011, Annex 165, p. 191) and converting NIS to USD at the average monthly exchange rate of NIS 3.72 / I USD for 2010.