OMS - L'état de santé dans les territoires palestiniens occupés, y compris Jérusalem Est et le Golan Syrien. 67e Assemblee mondiale de la Santé - Rapport du Secrétariat Français
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Health conditions in the occupied Palestinian
territory, including east Jerusalem, and in the
occupied Syrian Golan
Report by the Secretariat
2. The current population of the occupied Palestinian territory is 4 420 549 (2 719 112 in the West Bank and 1 701 437 in the Gaza Strip).1 It is a predominantly youthful population: 40.1% of Palestinians are aged 0-14 years and 29.9% are aged 15-29 years. The proportion of the population living in urban areas increased from 62.5% in 19802 to 73.8% in mid-2012, while the proportion living in rural areas and refugee camps was 16.8% and 9.4% respectively.3 In the fourth quarter of 2013 the unemployment rate was 18.2% in the West Bank and 38.5% in the Gaza Strip. For the Gaza Strip, this was the highest quarterly rate in the past three years.4 Palestinian exports have been in steady decline since 1994, dropping to 7% of gross domestic product in 2011, one of the lowest rates in the world.5
3. Restrictions on the movement of people remain; these involve the blockade on the Gaza Strip, the presence of checkpoints and barriers within the West Bank, and the travel permit regime. Four of the 14 checkpoints around Jerusalem are accessible to non-Jerusalemite Palestinians with permits; thecity has been separated from the rest of the West Bank by a barrier wall since 2006.6 In order to access health care, 14.3% of Jerusalem's Palestinian population of 404 165 must cross the wall .7
4. The Palestinian Ministry of Health, UNRWA and nongovernmental organizations together provide extensive geographic coverage of public health and non-profit primary health care services, especially preventive health services and immunizations. However, the burden on households is high (39.8% of health expenditure comes from the general population) and two thirds of health expenditure concern curative care.8 The restrictions imposed on the movement of patients, health staff and goods have hindered the functioning and development of the health system. In recent years, the functioning of the Ministry of Health, the main health provider, has been seriously affected by the financial crisis of the Palestinian Authority. This has reduced the Ministry of Health's ability to procure adequate stocks of essential drugs and medical disposables; the Ministry reported that for 2013, an average of 29% of essential drugs and 52% of disposables were out of stock in the Gaza Strip. Although referrals increased by 10% compared with 2012 — in part owing to shortages of medicines — the financial crisis has also lead to an increase in debts to specialized hospitals for the care of patients referred within and outside the occupied Palestinian territory.
5. The Ministry of Health operates four different levels of primary health care clinics according to population size and anticipated demand, but the distribution of both service components and human resources within the system remains inequitable. The current model is out-dated, providing services through a vertical, disease-focused approach, aimed predominantly at the main health challenges of the past, namely: communicable diseases and maternal and child mortality. The leading causes of death are cardiovascular disease, cancer, cerebrovascular disease and diabetes, reflecting the high prevalence of noncommunicable diseases and their risk factors. Data indicate that unhealthy behaviours start early in life.9
6. Infant and under-five mortality rates have declined over the last decade. In 2012, infant mortality was 19.2 per 1000 live births, compared with 23.9 per 1000 live births in 2002. The under-five mortality rate was 22.6 per 1000 in 2012, down from 28.5 per 1000 in 2002.10
7. The prevalence of disability in Palestine is 2.7% using a narrow definition, with about 113 000 persons reporting at least one disability; the rate is higher for males and higher in the West Bank. Some 53.1% of persons with disabilities are illiterate; more than one third of persons with disabilities over 15 years of age have never been enrolled in school; 22.2% dropped out of school because of access difficulties; and 87.3% are not employed:11
KEY AREAS OF WHO SUPPORT TO THE PALESTINIAN MINISTRY OF HEALTH
8. WHO and the Palestinian Ministry of Health have engaged in a continuing dialogue on modernizing the primary health care system based on a family practice model. In September and October 2013 in collaboration with the Ministry of Health, WHO conducted a comprehensive situation analysis of the current primary care system as a foundation for the necessary transformation.
9. Noncommunicable diseases constitute a key public health concern in the occupied Palestinian territory. WHO supported the Ministry of Health in implementing the WHO package of essential noncommunicable disease interventions for primary health care. The interventions aim at improving access to good-quality, evidence-based noncommunicable disease care in a close-to-client environment. Between January 2013 and 2014, the package was successfully introduced in three pilot districts. The Ministry of Health and WHO are currently working on expanding the implementation of the package of interventions to all districts.
10. In 2013, WHO continued to work closely with the Ministry of Health focal point for tobacco control, focusing on raising public awareness of the dangers of tobacco use. With technical guidance from WHO, the Ministry of Health conducted a mass media campaign on the theme "It is my right to live in a smoke-free world". WHO also supported the Ministry of Health and the Ministry of Education to reach over 12 000 secondary school students through an online competition aimed at improving their knowledge of tobacco-related health and social issues.
11. WHO, with the support of the Norwegian Government, maintained its support to the establishment of a Palestinian National Institute of Public Health. During 2013, the project team pursued the implementation of several recommendations of the qualitative assessment of the Cause of Death Registry; began a detailed description of the Cancer Registry; developed a draft report of the systematic review of water quality and health in the Gaza Strip; created the Hospital Management Dashboard and presented it to hospital directors in the West Bank and Gaza Strip for their use; finalized and printed the National Health Information System Strategy and the Health Information System assessment report; and began activities to establish a national Road Traffic Accidents Registry.
12. WHO is currently implementing a three-year mental health and psychosocial support project. The project represents the second phase of a European Union-funded initiative to strengthen mental health care in the occupied Palestinian territory. Over the past decade, WHO has supported the Palestinian Ministry of Health in reforming mental health services, with a move from institutionalized care in psychiatric hospitals towards community-based care and rehabilitation. In 2013, WHO supported the Ministry of Health in drafting a human resource plan for mental health professionals and an operational policy for community mental health centres. Mental health professionals were trained on cognitive behavioural therapy and child and adolescent mental health. Mental health has been fully integrated into primary health care in two districts in the Gaza Strip. As part of this effort, friends and family associations provided the general population and health professionals with a range of community-level education and advocacy activities on the rights of service users.
13. In support of activities against HIV/AIDS and with funding provided by the Global Fund to Fight AIDS, Tuberculosis and Malaria, WHO continues to act as technical adviser to the United Nations thematic group for tuberculosis and HIV/AIDS in the West Bank and Gaza Strip. With regard to HIV/AIDS, WHO conducted the first bio-behavioural survey among injecting drug users in the West Bank in 2013. The aim of the survey was to understand the epidemiological pattern of HIV/AIDS in this low-prevalence setting, following a similar survey conducted in 2010 in Jerusalem, which has a different social context. WHO further provided a range of capacity-building support for voluntary counselling and testing, antiretroviral therapy and adherence to treatment. The Ministry of Health has integrated HIV/AIDS treatment into primary health care services in the Ramallah and Gaza Strip governorates and has added dental services to its Ramallah special clinic. A technical mission by an external international expert monitored patients clinically to ensure that WHO standards of treatment and care continue to be used. An inventory study on tuberculosis was also conducted in the West Bank and Gaza Strip. The aim of the study was to determine the extent of: (a) tuberculosis case notification by the national tuberculosis programme; (b) tuberculosis case ascertainment in the country; and (c) tuberculosis under-detection through underreporting and under-diagnosis. In addition, a screening survey was undertaken of the Bedouin population in the West Bank.
14. With support from the European Union, WHO is working to improve the quality of hospital services at the six specialized medical referral facilities in east Jerusalem which comprise the East Jerusalem Hospitals Network. WHO is collaborating with the hospitals to build local capacity in the areas of quality management, risk management, facility safety and infection prevention. The objective is to ensure that standards at all the hospitals are ultimately ratified by the Joint Commission International, the international body for hospital quality accreditation. In 2013, the first two hospitals were accredited by the Commission. WHO supported the Network to develop a sustainable five-year strategy with a work plan. Network committees were established to facilitate coordination and collaboration, as well as joint activities. Since December 2013 the Network has been registered as an official body, which will enable it to appoint staff, conduct joint initiatives, and begin fundraising.
15. WHO is working with the Palestinian Ministry of Health to improve the Ministry's service delivery system. A focal point for quality improvement and patient safety has been appointed at each of the district hospitals and in the primary health care department. A national team was trained in Jordan on the Patient Safety Friendly Hospital Initiative. This national team will work in collaboration with the national patient safety focal point to train government and nongovernment hospital staff on the Initiative, conduct initial assessments and ensure regular follow-up on implementation with participating facilities. To date, three hospitals (two governmental and one nongovernmental) have begun implementing the Patient Safety Friendly Hospital Initiative. In 2014, it is anticipated that all government hospitals in the West Bank, one government hospital in the Gaza Strip, and one non-government hospital in the West Bank will begin implementation.
16. WHO continues to support the Ministry of Health to develop its institutional capacity as well as the national health system. WHO supported the Ministry's policy and planning department to lead the national health planning process and develop the 2014-2016 national health strategy. WHO is also working with this team to institutionalize a monitoring and evaluation mechanism to ensure accountability among all stakeholders in the health sector, particularly the Ministry of Health and the donor community. In order to improve human resource planning and policy development, WHO is supporting the Ministry of Health in the development of a Human Resources Observatory. In late 2013, a Palestinian delegation conducted a study tour to observe the implementation of the human resources observatory at the Ministry of Health in Khartoum. To support national health financing improvements, WHO collaborated with the Ministry of Health to complete the WHO's health financing assessment tool.
17. With funding from the Government of Switzerland, WHO is working in the area of health advocacy in order to: improve data quality regarding human rights indicators and social determinants of health; monitor critical humanitarian issues affecting the public health sector; and provide advocacy with, and to, legal duty-bearers under international humanitarian and human rights law. Barriers to patient access from the West Bank and the Gaza Strip to the east Jerusalem hospitals, which serve as the main referral centres for tertiary care, are a major issue, as are barriers to the access of ambulances, hospital employees, and medical and health students from the West Bank. In 2013, 38 083 patients from the West Bank and the Gaza Strip were referred by the Palestinian Ministry of Health to hospitals in east Jerusalem, Egypt, Israel and Jordan. In the same year, 20.5% of requests for travel permits to access medical treatment made on behalf of West Bank patients, and 12.0% of requests on behalf of Gaza Strip patients, were denied or not answered:12 For the Gaza Strip, this rate represents a 60% increase compared with 2012. WHO also undertook advocacy to the Ministry of Health and the humanitarian community concerning shortages of essential drugs, disposables and fuel in the Gaza Strip13 and to the Government of Israel for access to health services on the part of Palestinian prisoners.
18. Under the United Nations Partnership to Promote the Rights of Persons with Disabilities, WHO began to work jointly with five other United Nations agencies on mainstreaming disability rights in the agencies concerned and in their counterpart line ministries, including the Ministry of Health. The project was launched in January 2014, supported by the United Nations Humanitarian Coordinator for the occupied Palestinian territory.
19. WHO continues to lead the Health and Nutrition Sector, which it co-chairs with the Ministry of Health. The Sector provides a platform for joint coordination and partnership that aims at strengthening the collective capacity to respond efficiently to humanitarian health needs. The Ministry of Health and 30 humanitarian health organizations from United Nations agencies, nongovernmental organizations, and the private and public sectors are participating in the activities of the Sector. The partners provide essential primary health care and nutrition services to vulnerable communities with restricted access. WHO conducts monthly meetings with partners to discuss humanitarian health updates and to identify gaps and needs in support of better coordinated responses.
20. Together with the Ministry of Health and partners in the Health and Nutrition Sector, WHO developed the Humanitarian Needs Overview for 2014. The Overview provides an analysis of the humanitarian health situation and highlights priority needs, vulnerable communities and groups, and obstacles and difficulties in accessing essential health services in the following areas: the Gaza Strip, east Jerusalem peripheries, Area C in the West Bank, closed military areas, and the "seam zone". Based on this, the Health and Nutrition Sector was able to develop its Strategic Response Plan for 2014, the main objectives of which are: to ensure the access by vulnerable communities to good-quality and affordable essential health services, and the referral of victims of violence to protection organizations and advocacy; and to ensure that vulnerable communities are better prepared to cope with the impact of current and potential man-made and natural disasters.
21. In 2013, as lead agency for the Health and Nutrition Sector and provider of last resort, WHO continued to support the reduction of shortages in life-saving drugs and medical disposables. Furthermore, WHO assisted in filling some of the gaps in the supply of pharmaceuticals and continued to help to coordinate the importing of medical supplies donated to the Gaza Strip. 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 the frequent blackouts caused by fuel shortages.
SITUATION IN THE OCCUPIED SYRIAN GOLAN
22. WHO has no access to the occupied Syrian Golan and thus cannot provide a report on the prevailing health conditions there. The Secretariat has requested the Governments of the Syrian Arab Republic and Israel to provide information in this regard.
ACTION BY THE HEALTH ASSEMBLY
23. The Health Assembly is invited to note the report.
1Palestinian Central Bureau of Statistics (http://www.pcbs.gov.ps/site/881/default.aspx#Population, accessed 17 March 2014) and Palestinian Ministry of Health, Health report, Palestine mid year 2013 (http://www.moh.ps/attach/ 546.pdf, accessed 17 March 2014).
2World urbanization prospects, the 2011 revision (http://esa.un.org/unup/unup/index_panell.html, accessed 18 March 2014).
3Palestinian Central Bureau of Statistics (http://www.pcbs.gov.ps/Portals/_pcbs/PressRelease/int_Pop_2012e.pdf, accessed 18 March 2014).
4Palestinian Central Bureau of Statistics (http://www.pcbs.gov.ps/portals/_pcbs/PressRelease/Press_En_ LFSQ42013E.pdf, accessed 18 March 2014).
5World Bank. Fiscal challenges and long term economic costs. Economic Monitoring Report to the Ad Hoc Liaison Committee (http://siteresources.worldbank.org/INTWESTBANKGAZA/Resources/AHLCMarchfinal.pdf, accessed 18 March 2014).
6Factsheet issued by the United Nations Office for the Coordination of Humanitarian Affairs (http://www.ochaopt. org/documents/ocha_opt_Jerusalem_FactSheet_December_2012_english.pdf, updated in February 2014, accessed 18 March 2014).
8Palestinian Central Bureau of Statistics (http://www.pcbs.gov.ps/Portals/_PCBS/Downloads/book2032.pdf, accessed 18 March 2014).
9Global school-based student health survey (http://www.who.int/chp/gshs/2010_GSHS_FS_Gaza_and_ West_Bank.pdf, accessed 18 March 2014).
10The United Nations Inter-agency Group for Child Mortality Estimation. CME Info database (http://www.childmortality.org/, accessed 18 March 2014).
11Palestinian Central Bureau of Statistics (http://www.pcbs.gov.ps/portals/_pcbs/PressRelease/Press_ En_Disability2012E.pdf and http://www.pcbs.gov.ps/site/512/default.aspx?tablD=512&lang=en&ItemID= 969&mid=3171&wversion=Staging, accessed 18 March 2014).
12Right to health: barriers to health access in the occupied Palestinian territory, 2013. Geneva: World Health Organization; 2014 (in press). http://www.emro.who.int/countries/pse/.