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2. The occupied Palestinian territory has a well-developed, though fragmented, health-care system which provides a full range of primary, secondary and tertiary services, including the option of referring patients for specialty care in neighbouring countries if the relevant expertise is not available locally. The main providers are the Palestinian Ministry of Health (referred to hereafter as the Ministry of Health), United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), Palestinian nongovernmental organizations and the private sector.
3. There has been a small rise in life expectancy over recent years but progress towards achieving the health-related Millennium Development Goals has stagnated. Infant and child mortality trends have shown little improvement, especially in the Gaza Strip, where there are indications of a growing gap between the infant mortality rates there and those in the West Bank.1 Child and infant deaths are mostly concentrated within the neonatal period, with many neonatal deaths occurring within the first week of life.2 The infant and child mortality rates could be substantially reduced by improving the quality of perinatal care. According to some preliminary recent data, there were 30 maternal deaths in 2008 and 2009 in the Gaza Strip3 and 23 maternal deaths in 2009 in the West Bank4. This indicates a maternal mortality ratio of 29 per 100 000 live births in the Gaza Strip and 36.4 per 100 000 live births in the West Bank although the differences in the methodology used in the West Bank and in the Gaza Strip mean that the figures are not strictly comparable.5 The identified causes of these deaths suggest that many of them could have been prevented by more effective antenatal, childbirth and early postnatal health care.
4. Anaemia and micronutrient deficiencies are further areas of concern. It is estimated that 50% of infants and young children under two years of age in the West Bank and the Gaza Strip suffer from iron deficiency anaemia which is associated with inappropriate infant and young child feeding practices and limited access to, or compliance with, micronutrient supplementation. Anaemia levels in pregnant women are routinely measured and monitored. A high prevalence of anaemia is revealed among those women visiting antenatal services (45% of pregnant women in the Gaza Strip and 20.6% in the West Bank). The burden of noncommunicable diseases is growing, and there is evidence that unhealthy lifestyles are also increasingly widespread. Effective population-based interventions for preventing and controlling risk factors and noncommunicable diseases still need to be implemented.
5. In terms of health-care services, disaster risk reduction and emergency preparedness have been given a low relative priority. Health sector actors have increasingly developed capacity to deal with the consequences of armed conflict and manage mass casualties, however they have less capacity to plan for and mitigate such events or other natural or man-made disasters. Furthermore, there is insufficient standby capacity to respond should the current situation deteriorate. This increases the vulnerability of populations in the Gaza Strip and the West Bank to future hazards and risks as well as to natural disasters.
6. WHO has continued supporting the Ministry of Health in its work on the Palestinian health strategy and action plan. The Organization is also working with the Ministry of Health on the preparation of the health information system strategy based on an assessment, in order to establish a comprehensive, responsive and reliable system of health information.
7. In order to fill the current gaps in the public health system and to strengthen policy-making and decision-making, WHO – with the support of the Ministry of Health and the Government of Norway – is exploring the case for the establishment of a public health institute to strengthen core public health functions such as evaluation and analysis of health status, public health surveillance, quality assurance and public health research. The institute would be an independent body providing reliable health information and advice to the Ministry of Health, other decision-makers and the general public.
8. WHO has continued its work on quality of hospital care, and has moved into the second phase of a programme involving six specialized hospitals in east Jerusalem, to enable them to achieve international accreditation. A scientific conference will be held in 2011 to promote the work of those six hospitals which serve as referral centres for tertiary care for Palestinians from the West Bank and the Gaza Strip.
9. WHO has been continuing its efforts to ensure easier access to the six specialized hospitals in east Jerusalem for patients from the West Bank and the Gaza Strip, with a particular focus on patients with chronic disorders and on staff living in the West Bank. In July 2010, WHO highlighted the issues of access in a joint report with the United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA).6 Among other recommendations, the report called on Israel to ensure access to all Palestinians from the West Bank and the Gaza Strip to the six hospitals in east Jerusalem, and enable 24-hour access to health-care services and emergency medical services for residents of the same territory.
10. Quality improvement in processes, equipment, procedures, services and patient safety, among other areas, were the themes of the Ministry of Health’s annual health conference in May 2010. A focal point for quality has been appointed at each of the district hospitals and the primary health care department. A pilot assessment of the quality of services at primary health care clinics is ongoing in the Ramallah Governorate. WHO is supporting this programme and has included the occupied Palestinian territory in the initiative on patient safety in hospitals. The Ministry of Health is working on developing standards of care towards accreditation of health facilities.
11. WHO provided technical assistance in three ways: in contributing to the development of a policy and strategy for the occupied Palestinian territory on the prevention and management of noncommunicable diseases; in the preparation of operational plans; and in supporting a number of key components of the plan. The first survey has been conducted in the West Bank to obtain data on risk factors for noncommunicable diseases (such as smoking, hypertension, obesity and the lack of physical activity) and is also under way in the Gaza Strip. The first global school-based student health survey was conducted of school students between 13 and 15 years of age. Results will provide information on risk factors including unhealthy dietary behaviours, smoking and drug use, and will be used to design interventions and programmes to address these issues. The Ministry of Health is also committed to introducing WHO’s package of essential interventions to integrate noncommunicable disease prevention and management of noncommunicable diseases at primary health care level. WHO will provide training on the integrated approach and utilize the results of the health facility assessment.
12. WHO co-chairs the Working Group on Tobacco Control that supports and oversees the implementation of tobacco control activities. The Working Group has been commissioned to facilitate the establishment and work of an intersectoral committee to propose a ban on smoking in public places and to prepare the revision of the existing anti-smoking law for alignment with the WHO Framework Convention on Tobacco Control.
13. The Secretariat continues to assume its responsibilities under resolution WHA63.27 in fulfilling its role as technical adviser to and co-chair of two United Nations thematic groups, one for HIV/AIDS and the other for tuberculosis. For tuberculosis, WHO supported the formulation of a Palestinian strategy, treatment guidelines and training modules. For HIV/AIDS, WHO conducted a biobehavioural survey among injecting drug users in east Jerusalem – a first of its kind – to understand the epidemiological pattern in this low-prevalence setting. A special clinic for HIV/AIDS has been established in the Ramallah Governorate which is integrated within the primary health care services. Two of its medical doctors received training from a WHO medical expert.8
14. Within the “healthy cities” framework, WHO has initiated a health and environment-friendly schools programme in the cities of Ramallah and Nablus. The programme is implemented in partnership with the two municipalities, the Ministry of Health, the Ministry of Education and wide participation from public and community organizations, as well as sponsorship from the private sector. This year, 14 schools in Ramallah and five schools in Nablus are participating in the initiative.
15. In collaboration with the Ministry of Health and health cluster partners, WHO finalized the compilation of information on health facilities in the occupied Palestinian territory. The health facility database includes information on the geographical distribution of health facilities by district and locality, the types of services provided, the availability of human resources and specialized health-care staff and equipment, and a summary of health-care activities in each facility.
16. In collaboration with the Ministry of Health, WHO facilitated 12 health district workshops to identify health priorities and needs in each district in the West Bank. The information is being used to produce “district health profiles” which map available health facilities, analyse specific health indicators, identify health needs and suggest ways to improve the health situation.
17. WHO has supported the development of community-based mental health services in the West Bank and the Gaza Strip. Over the last three years, the Ministry of Health has established mental health units in the West Bank and the Gaza Strip to lead the mental health reforms. A new Strategic Mental Health Plan 2010–2013 has been developed. Other activities include the establishment of postgraduate mental health programmes in local universities, capacity building of staff, the creation of a nongovernmental organization bringing together family associations, public education to raise the awareness of the general public and combat stigma towards people with mental health problems. The project is scheduled to finish at the end of May 2011.
18. WHO has continued to support the Ministry of Health’s nutrition programme including training of the Ministry’s staff and providing needed equipment. This support has focused on strengthening the Nutrition Surveillance System in the occupied Palestinian territory, which monitors the levels of nutrition of infants, pregnant women and schoolchildren. In addition, WHO is supporting the Ministry of Health to implement the strategy on infant and young child feeding practices.
19. Since January 2009, WHO has been leading the health and nutrition cluster of the occupied Palestinian territory, which provides a joint coordination forum for 55 partners from United Nations organizations, nongovernmental organizations, and the private and public sectors. The cluster provides humanitarian health services in the West Bank and the Gaza Strip. WHO also represents the health sector at the Humanitarian Country Team and at the Inter-cluster Coordination Group as well as at fortnightly donor meetings convened by the European Union’s Humanitarian Aid Department. In the period from June to October 2010, the health and nutrition cluster developed its response plan to improve access to essential health services. The response plan formed a basis for the section on health of the Common Humanitarian Action Plan and provided a framework for development and selection of individual health and nutrition cluster partner projects for the Consolidated Appeal for 2011.
20. To better address the challenges of the changing humanitarian context in the occupied Palestinian territory, the health and nutrition cluster conducted a participatory evaluation of its performance and identified objectives for 2011. WHO led the process of defining emergency health sector standards and helped in standardizing mobile clinic services and compiling a mobile clinic database. It also developed a system for monitoring emergency aid services to the Palestinian population of east Jerusalem and helped to address restrictions on access to the east Jerusalem hospitals.
21. WHO has provided support to fill the gaps in the supply of pharmaceuticals and continued to help in handling the large volume of medical supplies donated to the Gaza Strip. This entailed renting additional warehouses and helping to sort, register, store and deliver medical supplies, as well as disposing of expired or unusable medicines. The Organization also provided urgently needed medical equipment, spare parts and technical assistance to maintain, repair and improve existing equipment.
22. WHO has developed and implemented a project in the maternity units of public hospitals in the Gaza Strip to improve the quality and safety of patient care during childbirth. The project is targeting maternity and neonatal units in seven hospitals, covering about 90% of births in the Gaza Strip. Critical changes in childbirth care routines and environment have been introduced. In the next 12 months, WHO is aiming to promote a shift in the approach to childbirth care and culture. The shift will reduce the risks from the current over-medicalized management of normal labour, from insufficient medical attention for high-risk pregnancies, and from premature discharge of mothers and babies after birth.
23. WHO continued to monitor and provide a monthly report on the referral of patients from the Gaza Strip. About 12 000 patients were referred for specialized treatment to health facilities within the West Bank, east Jerusalem, Egypt, Israel and Jordan. These referrals were necessary because the Gaza Strip lacks the capacity to treat such patients. Of 11 175 applications for permits to the Israeli authorities to use the Erez Crossing, one fifth were denied or delayed.
24. Resolution WHA63.2 requested the Director-General, inter alia, to establish in cooperation with the International Committee of the Red Cross, an international committee of specialized medical teams to diagnose the serious health conditions of Palestinian prisoners and detainees in Israeli jails and provide them with all necessary and urgent treatment in accordance with relevant international conventions and agreements. The Secretariat was informed subsequently by the International Committee of the Red Cross that it was not in a position “to give suit to the resolution. In order to preserve the confidence of all sides, it is necessary that all parties see the ICRC as being neutral and independent, and that it is recognised for its autonomous decision-making process without the interference of Governments. Thus, the ICRC cannot base its action on a resolution adopted by an international organization, including the World Health Organization (WHO).”
ACTION BY THE HEALTH ASSEMBLY
25. The Health Assembly is invited to note the report.
1 Palestinian Central Bureau of Statistics Demographic and Health Survey 2004, and Monitoring the Situation of Children and Women 2006. In 2006, the infant mortality rate was 25.34 per 1000 live births (22.9 per 1000 live births in the West Bank, 28.8 per 1000 live births in the Gaza Strip), the mortality rate for children under the age of five years was 28.23 per 1000 live births (25.7 per 1000 live births in the West Bank and 31.7 per 1000 live births in the Gaza Strip).
2 In surveyed hospitals, 66% of neonatal deaths occurred within the first week of life in 2007 and 2008. This analysis is based on information published in several issues of the WHO Health Sector Surveillance Indicators (World Health Organization, 2008).
3 Ministry of Health and United Nations Population Fund (UNFPA), 2011, preliminary findings (unpublished).
7 Resolution WHA63.2 requested the Director-General, inter alia, to continue providing necessary technical assistance in order to meet the health needs of the Palestinian people, including the handicapped and injured.
8 Resolution WHA63.2 requested the Director-General, inter alia, to continue to support the development of the health system in the occupied Palestinian territory, including development of human resources.
DETERMINANTS OF HEALTH IN THE OCCUPIED PALESTINIAN TERRITORY
2. The occupation of Palestinian territory, including east Jerusalem, continues to cause economic and social hardship for Palestinians. Restrictions on the movement of people, goods and services during the past decade have severely weakened the Palestinian economy. Output per person was estimated to be 30% less at the end of 2010 than it was in 2000;1 the output per person in the Gaza Strip in 2010 was around half that of the West Bank. Employment levels have deteriorated, affecting especially young people and those living in the Gaza Strip. Economic growth has, however, picked up in 2009 at an estimated 6.8%. Real gross domestic product (GDP) growth was much higher in the West Bank at 8.5% than in the Gaza Strip at about 1%. In the first half of 2010, the growth rate in the West Bank was estimated at 8%. This constitutes the third consecutive year of GDP growth and could indicate a recovery of the economy in the West Bank.2 The recent economic growth may not be sustainable, though, as it is mostly due to government spending funded by donors and an increase in the employment of Palestinians in Israel and Israeli settlements.3
3. Overall, unemployment in the West Bank dropped from 15.9% in the second quarter of 2009 to 15.2% in the second quarter of 2010. During the same time, figures increased from 36% to 39% in the Gaza Strip.4
4. Poverty rates have decreased though they remain persistently high. In 2009, 21.9% of the population fell below the poverty line compared to 31.2% in 2007. The poverty rate in the Gaza Strip (33.2%) is twice the rate of the West Bank (15.5%). Deep poverty affected 7.5% of the population in the West Bank compared to 20.0% in the Gaza Strip.4
5. Private investment is reportedly picking up in some sectors, however, not enough to take the place of donor funding as the main growth factor. Concurrently, there is and has been a continuous increase in new enterprises since 2006. These businesses are mostly involved in the commerce and service sectors, while sectors such as industry, agriculture and tourism lag behind.3
6. The blockade imposed by Israel on the Gaza Strip since June 2007 remains in effect. In June 2010, Israel announced an easing of the blockade which has resulted in an increase of imports. But the restrictions on the movement of people, the import of basic construction materials and the export of goods remain in place. While the relaxation of the blockade has helped private sector activity, an economic impact cannot be seen yet. With the ongoing export limits, the Gaza Strip’s potential to increase its economic activity and employment from a very low base remains restricted.5
7. The separation of east Jerusalem from the rest of the occupied Palestinian territory adversely affects the economy, for instance in terms of employment opportunities for the population from the West Bank. A report by the International Peace and Cooperation Center notes that the separation barrier has had unfavourable economic effects on residents of east Jerusalem, such as decreased family income or relocation of workplace.6
8 The lack of access to land in Area C impacts significantly on economic activities and development in the occupied Palestinian territory. Apart from limiting physical access, the restrictions affect land use, agriculture, industries, housing and tourism. These measures apply to more than 50% of the land in the West Bank.5
9. Access to water further impedes on the economic sector, particularly on the agricultural potential. According to estimates of their potential, the aquifers under the West Bank and Israel are significantly over-extracted by Israel. This leads to less water availability through shallower wells for Palestinians. Among those dwelling within the region, Palestinians have the least access to fresh water.5
10. In the Gaza Strip, 90–95% of the water supplies do not meet the drinking water standards. According to WHO guidelines, the levels of chlorides and nitrates in these water supplies are up to six times too high. As the water table is shallow and sewage infiltration likely, there is a public health risk of waterborne diseases such as typhoid or hepatitis.7
11. Close to two thirds of the population in the Gaza Strip and 25% in the West Bank face food insecurity.8 On average, households in the Gaza Strip spend 72% of their income on food, compared to 54% in the West Bank.9 Over one million Palestinians remain in need of food assistance.10
12. The Gaza Strip continues to have an inadequate supply of electricity, which affects service provision as well as the daily life of the population. The cuts in electricity supply have various adverse effects, including on the water supply to households: reportedly, one in five households is supplied with running water once every five days; one in two households have water once every four days; and one in three households receive water every second day. Service providers continue to ensure electricity provision through backup generators.11
ACCESS TO HEALTH CARE
13. The Ministry of Health, UNRWA, nongovernmental organizations and private, commercial organizations constitute the four main health providers of health services. The Ministry of Health runs 59 primary health care centres in the Gaza Strip and 381 in the West Bank. UNRWA operates 18 primary health care centres in eight refugee camps in the Gaza Strip and 41 centres in the West Bank. The nongovernmental organization sector manages 194 primary health care centres and general clinics (57 in the Gaza Strip, 137 in the West Bank).12
14. There are 75 hospitals in the occupied Palestinian territory (50 in the West Bank, 25 in the Gaza Strip), with a total of 5058 beds in government and nongovernment hospitals. Almost three quarters of them are general beds, 16.0% specialized beds, 3.8% beds for rehabilitation and 7.5% maternity beds. Overall, there are 12.9 beds per 10 000 population (12.7 beds in the West Bank and 13.5 beds in the Gaza Strip).12
15. The Ministry of Health, with the support of donors, has continued to develop the scope and range of public health services in the West Bank. The hospital sector in particular has benefited from significant investment in infrastructure and equipment with several hospitals being rehabilitated and services developed. The Ministry of Health has also sought to strengthen its institutional and governance capacity, not least by further efforts to improve the planning process. However, the Palestinian health-care system continues to face many challenges. These include restriction of movement and access to health services. Movement within the West Bank has become a little easier over the past year as a result of the removal of some of the checkpoints, but many checkpoints and closures still remain. There are particular difficulties of access to east Jerusalem, where the main tertiary health services are provided. Administrative restrictions also have an impact on the provision of health care in rural areas classified as “Area C” under the Oslo Accords.
16. In the Gaza Strip, the provision of adequate health services to the population continues to be severely affected both by the Israeli blockade and Palestinian internal political divisions between the West Bank and the Gaza Strip. While the hospitals and primary care clinics in the Gaza Strip continue to function, they face multiple challenges. For example, there have been growing shortages of essential drugs and consumables: 38% of essential drugs were out of stock at central store level at the beginning of January 2011. Recurrent power cuts and an unstable power supply have adversely affected medical care: sensitive medical equipment is damaged, supportive services have had to be suspended, treatments can be interrupted or need to be postponed. The functionality of medical equipment has also been deteriorating because of inadequate maintenance capacity and lack of spare parts (although a programme supported by the Government of Italy and WHO has been seeking to address this). Many qualified health staff are not working because of the factional divide. It is also difficult to maintain or upgrade the professional knowledge and clinical skills of health staff because the Israeli restrictions on the movement of people in and out of the Gaza Strip prevent access to appropriate and up-to-date education and training. The closure of the Gaza Strip is undermining the functioning of the health-care system, hampering the provision of medical supplies and the training of health staff and preventing patients with serious medical conditions receiving timely specialized treatment outside the Gaza Strip.
17. A total of 8161 patients were referred to treatment outside the occupied Palestinian territory in 2009: 3399 patients came from the West Bank and 4762 from the Gaza Strip.
18. Overall life expectancy is 70.5 years for males and 73.2 years for females. The population of the occupied Palestinian territory grows at a rate of 2.9% (2.6% in the West Bank and 3.3% in the Gaza Strip). The crude birth rate declined over the last decade from 42.7 in 1997 to 29.6 in 2008.13
19. The total fertility rate in the occupied Palestinian territory was 4.6 in 2009 (4.1 in the West Bank and 5.3 in the Gaza Strip), which is comparatively high in the region. In terms of pregnant women, four out of 10 attend antenatal care while virtually all women deliver in health institutions.13 There were 30 maternal deaths in 2008 and 2009 in the Gaza Strip14 and 23 maternal deaths in 2009 in the West Bank,15 indicating a maternal mortality ratio of 29 per 100 000 live births in the Gaza Strip and 36.4 per 100 000 live births in the West Bank.16 Many pregnant women suffer from anaemia (45% of pregnant women in the Gaza Strip and 20.6% in the West Bank).17 About a third of newly pregnant women are immunized against tetanus in the West Bank.18
20. The leading causes of deaths in the occupied Palestinian territory are mostly noncommunicable diseases, the four leading causes being heart diseases, cerebrovascular diseases, cancer (led by trachea, colo-rectal and anal cancer) and inflammations of the respiratory system.18
21. The infant mortality rate has shown little improvement in recent years (25.34 per 1000 live births: 22.9 per 1000 live births in the West Bank, 28.8 per 1000 live births in the Gaza Strip).19 The main causes of death among infants are pneumonia and other respiratory disorders (34.5%), congenital malformations (16.3%) followed by prematurity and low birth weight (13.4%).18