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Situation sanitaire dans le TPO, y compris Jérusalem et Golan - 67e Assemblée de l'Organisation mondiale de la santé - Rapport de l’UNRWA Français

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Source: World Health Organization (WHO)
16 May 2014

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

The Director-General has the honour to bring to the attention of the Health Assembly the attached report of the Director of Health, UNRWA, for the year 2013 (see Annex).





1. The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) is one of the largest United Nations programmes. It serves a population of 5 429 000 beneficiaries registered with the Agency, of whom 5 030 000 are Palestine refugees in the Gaza Strip, the West Bank, Jordan, Lebanon and the Syrian Arab Republic: The Agency's mission is to help Palestine refugees in Jordan, Lebanon, Syrian Arab Republic, West Bank and the Gaza Strip to achieve their full potential in human development, pending a just solution to their plight. UNRWA's services encompass the provision of: education, health care, relief and social services, camp infrastructure and improvements, microfmance and emergency assistance. Although this population is predominantly made up of young people, it is concurrently experiencing a demographic transition with ageing and increased life expectancy resulting in a growing proportion of elderly refugees, a transition similar to that being experienced throughout the Middle East. In 2013, over 46.5% of registered refugees were under the age of 25 while 18.5% were aged over 50 years.2

2. Over two million beneficiaries are registered with UNRWA in the occupied Palestinian territory: 1 307 014 in the Gaza Strip and 914 192 in the West Bank. By the end of 2013, 34.7% of those registered were living in 27 refugee camps: eight in the Gaza Strip and 19 in the West Bank.

3. The number of persons eligible for UNRWA's health services in the occupied Palestinian territory increased by 2.8% (about 62 000 people) in 2013 compared with 2012. This increase is partly attributed to natural population growth and partly to the inclusion of a number of persons married to non-refugees (i.e. husbands and descendants of women who are registered refugees and are, or were, married to husbands who are not registered refugees). Approximately 78.6% of eligible persons in the occupied Palestinian territory were estimated to use full spectrum UNRWA's health services in 2013.


4. Through the support of UNRWA, governmental and other health-care providers, the health profile of Palestine refugee mothers and children has continued to improve since the Agency's establishment. Progress in achieving Millennium Development Goals 4 (Reduce child mortality) and 5 (Improve maternal health), for example, has been on track. The infant mortality rate among Palestine refugees across all the five fields of operations, including the West Bank and the Gaza Strip, remains at levels comparable to overall rates in other host countries3 and in 2013, the proportion of births attended by skilled health personnel remained at 100% in the West Bank and in the Gaza Strip.

5. Despite these health gains and successes, continuing insecurity, political instability, increasing poverty (particularly in the Gaza Strip), and patchy access to potable water, are having a negative impact on the health status of Palestine refugees. Severe restrictions on the movement of people and goods within the West Bank and between the Gaza Strip, the West Bank and areas abroad remain a major obstacle to socioeconomic development and health-care provision.

6. A main health concern, however, continues to stem from the increasing burden of chronic behavioural and lifestyle-related illnesses and, noncommunicable diseases. As in neighbouring countries in the Middle East, the epidemiological and health transitions from communicable to noncommunicable diseases have also been experienced in the occupied Palestinian territory. Consequently, the number of people under care in UNRWA's health services with life-long illnesses requiring costly and intensive treatment (such as diabetes and hypertension) has risen steadily in recent years. What is fuelling this rise is the alarmingly high prevalence of sedentary lifestyle-related risk factors and behaviours. A recently concluded clinical audit of diabetes care among Palestine refugees in a selected sample of diabetes patients in UNRWA care showed that more than 90% were overweight or obese, and just under 1 in 5 were smokers. The growing disease burden from noncommunicable diseases and related risk factors and the resulting increase in associated health care costs underscore the need for an even stronger focus on a well-tested and cost-effective spectrum of primary to tertiary prevention services, health education and promotion outreach, increased screening for early diagnosis, and good-quality treatment and management of diseases and their complications.

7. Furthermore, exposure to violence and uncertainties associated with the occupation, including settler-related violence in the West Bank and with the blockade in the Gaza Strip, are having a significant impact on the mental health of the refugee population, as are economic hardship and high unemployment. Stress-related disorders and mental health problems are reportedly on the rise in women, children and adolescents. Similarly, there has been a reported increase in incidents of domestic violence; however, this may also be attributable to increased reporting stemming from increased awareness, growing recognition of cases and access to support services. Addressing these concerns has therefore emerged as a health priority for UNRWA in the occupied Palestinian territory.

8. In addition, increasing food insecurity is also adversely affecting health status. After years of political instability and impoverishment, the level of food insecurity among Palestine households has grown. According to a study published by the FAO, UNRWA and WFP in 2013,4 71% of households in the Gaza Strip remain food insecure or vulnerable to food insecurity even after having received food assistance from UNRWA and other agencies. Approximately 46% of the population has "poor or borderline" diets, involving, for example, a reduced consumption of fruits and dairy products. A large proportion of the population in the Gaza Strip reported relying on adverse coping strategies in times of economic hardship: 54% had reduced food quality and 31% had reduced the number of daily meals.


9. For over six decades, UNRWA has been the main primary health care provider to Palestine refugees, with the largest operation of the United Nations agencies in the occupied Palestinian territory. UNRWA aims to ensure a "long and healthy life" for Palestine refugees as one if its four Human Development Goals. In order to realize that aim, the Agency provides primary health care services addressing the health needs of eligible registered Palestine refugees of all ages.

10. UNRWA delivers primary health care in the occupied Palestinian territory through a network of 64 primary health care centres: 22 in the Gaza Strip and 42 in the West Bank. The Agency also provides Palestine refugees with secondary and tertiary care through a network of contracted hospitals in the West Bank and the Gaza Strip; in addition it provides this level of care directly through an UNRWA hospital in Qalqilya, in the West Bank. In 2013, 52.7% of all registered Palestine refugees in the West Bank and 97.3% of those in the Gaza Strip accessed UNRWA's preventive and curative services. The number of beneficiaries from the West Bank and the Gaza Strip accessing hospital care through its network of contracted hospitals decreased by 8.3% (3% in the Gaza Strip and 10% in the West Bank) falling from 31 598 in 2012 to 29 174 in 2013 This decrease is attributable to continuing limitation of referrals outside the Gaza Strip, and increased closures at the Rafah Terminal border with Egypt. In addition, the strike of UNRWA staff in the West Bank may also have precluded beneficiaries from availing themselves of the UNRWA hospitalization scheme.

11. In 2011, UNRWA began to reform its provision of health services to address growing challenges posed by an increase in the beneficiary population and noncommunicable diseases. The main strategy of the reform is the family health team approach — family and patient-centred, based on comprehensive and a holistic care — and e-health, which replaces paper medical records with electronic patient files. The family health team approach, based on principles and practice of family medicine, has long been adopted in industrialized countries to deal with similar pressures from scarce resources in the face of increasing elderly populations, noncommunicable diseases and related risk factors.

12. UNRWA has continued to make considerable progress in the implementation of the family health team approach. After being piloted in October 2011 in two health centres, one in the Gaza Strip and the other in Lebanon, the approach has now been successfully expanded Agency-wide to cover 69 health centres serving over 1.8 million Palestine refugees as at December 2013. In the Gaza Strip, 17 out of 22 clinics and in the West Bank 17 out of 42 clinics are implementing the family health team model. UNRWA plans to roll out the family health team approach to all 137 health centres across the Agency by 2015.

13. While health reforms based on the family health team approach continue, UNRWA provided over 5 8 million medical consultations for adults and adolescents in the occupied Palestinian territory in 2013 — about 4.3 million in the Gaza Strip and 1.5 million in the West Bank. In addition, some 364 000 oral health consultations and 130 000 oral health screening sessions were conducted, while over 14 800 beneficiaries received physical rehabilitation (29% of whom suffered from the consequences of physical trauma and injuries, including those due to conflict, occupation and violence). In the West Bank, the family and child protection programme reported 407 cases of grievous bodily violence. Of these, 17 were referred to health counsellors, 22 to social counsellors and 15 to professionals outside UNRWA. Counsellors in the health centres provided 2350 counselling sessions to 3350 new cases, and 1090 old cases. Of these 831 cases improved and 284 were referred. In the Gaza Strip the Community Mental Health Programme works through the main core programmes of UNRWA with 203 school counsellors, 13 community counsellors, 22 health centres counsellors together with 22 managers, supervisors and support staff providing a wide range of services targeting children, youth, parents, elderly and disabled people as well as local committees, local organizations, professionals and students.

Table — Community Mental Health Programme Activities — Gaza, 2013

14. Care for people suffering from noncommunicable diseases also expanded during 2013. Over 104 000 patients with diabetes and/or hypertension were treated in the occupied Palestinian territory: 67 988 in the Gaza Strip and 36 518 in the West Bank. Collaboration with specialized centres has been expanded for diabetes care in order to improve control rates and prevent late complications of the disease.

15. In 2013, the total number of continuing users of modern contraceptive methods decreased by 5.1% compared with the previous year (the new total being 13 108 clients). Antenatal care services were provided to 54 408 pregnant Palestine refugee women with a coverage rate of an estimated 89.2% in the Gaza Strip and 71.7 % in the West Bank. Of all pregnant women, an estimated average of 80.1% registered with UNRWA during the first trimester. Of the pregnant women assisted by the Agency, 99.9% gave birth in a health facility and over 97% received postnatal care. To address issues of limited health access, UNRWA has also instituted mobile health teams that provide a full range of essential curative and preventive medical services; each year, over 150 000 patients and clients are consulted through a mobile health team.

16. The continuing crisis in the Syrian Arab Republic is now entering its fourth year and has affected over 500 000 Palestine refugees inside that country. Of these, over 250 000 are in need of urgent relief, while over 150 000 have fled to neighbouring countries. The worsening situation of Palestine refugees from the Syrian Arab Republic highlights the extreme vulnerability of Palestine refugees in the region and compounds the feelings of hopelessness and despair already prevalent among that population. UNRWA continues to strive to mitigate the effects of conflict and socioeconomic disparities on health through the provision of the best possible comprehensive primary health care services.

17. Under continuing health reforms based on the family health team strategy, UNRWA's approach to service delivery has changed from being vertical and disease-centred to being holistic, comprehensive, and family- and patient-centred. This new approach, supported by the electronic records (e-Health) initiative has already started producing incremental improvements in efficiency of service delivery, patient and provider satisfaction, and quality of health care.


18. Despite the growing number of Palestine refugees who rely on UNRWA's services, UNRWA is facing numerous challenges in mobilizing the necessary financial resources to see UNRWA's ongoing reforms through to their conclusion and sustain service provision. The resource deficit is the main threat to efforts aimed at improving quality and efficiency of health services through the family health team approach. With the exception of 146 international staff funded from the United Nations regular budget, UNRWA is financed solely by the voluntary contributions of donors. Such contributions have not increased proportionately to either population growth or the increase in the disease burden from costly-to-treat noncommunicable diseases. Health expenditure per registered Palestine refugee continues to hover around US$ 26, below the target of US$ 30—US$ 50 per capita that WHO recommends for the provision of basic health services in the public sector.

19. Moreover, mobility restrictions for Palestinians in the West Bank and the complicated process for seeking referral permission to the hospitals in east Jerusalem from the West Bank and the Gaza Strip have continued to pose significant impediments to efficient and timely access to health care. Moreover, nearly all referrals to care outside the Gaza Strip require coordination with Israel, a process that has at times been slow and cumbersome causing patients to delay or miss their hospital appointments, including those for life-saving treatment such as chemotherapy. Frequent closures and checkpoints also limited the mobility of the UNRWA mobile health teams that have been operating in the West Bank since 2003 to improve health access for the population living in over 59 isolated locations. These mobile teams provide full range of essential curative and preventive medical services to over 150 000 patients and clients each year.

20. Field observations at health centres as well as clinical evidence continued to indicate a growing problem of stress-related disorders and mental health problems, including family violence, domestic abuse, and violence among children and youth in the West Bank and the Gaza Strip.

21. A number of factors, including deepening poverty, forced displacement, and violence associated with the ongoing occupation in the occupied Palestinian territory, may be contributing factors. Although UNRWA has been actively striving to address these problems, including through its protection work, inadequate resources are a continuing constraint.

22. Increasing numbers of patients suffering from life-long and costly-to-treat noncommunicable diseases, coupled with the prevailing insecurity, limited mobility, socioeconomic challenges, and UNRWA's financial constraints, have compounded challenges in enhancing health services to address more complex medical needs. In the context of ongoing conflict in the Syrian Arab Republic and Israeli occupation of the West Bank and the Gaza Strip, increasing regional instability and economic hardship, the funding stream available for providing and expanding health coverage has not kept pace with needs.

23. Funding limitations affect the health care package offered to persons with noncommunicable diseases, who can benefit from the addition of evidence-based interventions, namely the preventive use of Statins on the pharmaceutical side, and the use of HbAl C tests for diabetes on the diagnosis and disease management side. Despite a strong evidence basis and justification, these interventions are not currently routine owing to lack of funds. Similarly, despite proven advantage and cost—effectiveness, widespread community-based early detection and health promotion campaigns are not routine. Additionally, as a result of funding constraints, UNRWA is still unable to reimburse costs of life-saving tertiary care treatments for terminal ailments such as dialysis.


24. The continuing conflict, occupation and the lack of a just and durable solution and their consequences continue to affect the physical, social and mental health of Palestine refugees. They remain severely affected by inequalities in health access and coverage, which are compounded by economic hardship, conflict and the consequences of conflict, which now touch all five fields of UNRWA's operations, and which adversely affect Palestine refugees' right to achieve the highest attainable standards of health on a non-discriminatory and equal basis. The ongoing Syrian crisis has directly affected over 500 000 Palestine refugees inside the Syrian Arab Republic, with over 250 000 in need of urgent relief while over 150 000 have fled to neighbouring countries adding to the burden on UNRWA's health service infrastructure and spreading already scarce resources even more thinly However, UNRWA aims to mitigate the effects of conflict and socioeconomic disparities on health through the provision of the best possible comprehensive primary health care services.

25. As mentioned above, the reform of UNRWA's health service delivery, with the electronic records initiative deployed in support of an approach that is holistic, family- and patient-centred, is already producing gains in efficiency of service delivery, patient and provider satisfaction, and care quality.

26. However these reforms alone will not be sufficient. It is vital for the international community to renew and increase its support to UNRWA so that the Agency, in collaboration with hosts and international stakeholders, can sustain and strengthen necessary health reforms, and continue to provide good-quality health care and improve the health status and quality of life of Palestine refugees, despite the many challenges faced.

1As at 31 December 2013.
2Registration Statistical Bulletin 2013, Department of Relief and Social Services, UNRWA-HQ (Amman).
3UNRWA, unpublished data, 2008. In the five fields of operations, cumulative Agency-wide mortality rates per 1000 live births for Palestine refugees were as follows: Jordan, 19; Lebanon, 28.2; Syrian Arab Republic, 20.2; Gaza Strip, 19.5, and West Bank, 22).
4Palestinian Central Bureau of Statistics, FAO, UNRWA and WFP. Socio-economic & food security survey: West Bank and Gaza Strip, Palestine 2012.

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