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Source: World Health Organization (WHO)
8 May 1987



WORLD HEALTH ORGANIZATION

FORTIETH WORLD HEALTH ASSEMBLY

Provisional agenda item 29






HEALTH CONDITIONS OF THE ARAB POPULATION IN THE OCCUPIED ARAB
TERRITORIES, INCLUDING PALESTINE

The Director-General has the honour to bring to the attention of, the Health Assembly the annual report of the Director of Health of the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) for the year, 1986, which is annexed hereto.




ANNEX

ANNUAL REPORT OF THE DIRECTOR OF HEALTH
OF UNRWA FOR THE YEAR 1986




CONTENTS


PAGE
Chapter I - General introduction

Chapter II - General management

Chapter III - Curative medical care services

Chapter IV - Preventive medical care services

Chapter V - Nursing services

Chapter VI - Environmental health services

Chapter VII - Nutrition and supplementary feeding services

Appendix 1. Communicable diseases

Appendix 2. UNRWA's nutrition and supplementary feeding
program, 1985

Appendix 3. UNRWA’s health personnel and facilities
2

4

10

12

16

19

21

23


17

28



CHAPTER I

GENERAL INTRODUCTION

Population

1. In all the United Nations Relief and Works Agency for Palestine refugees in the Near East (UNRWA) cares for 2 145 794 registered refugees (as at 30 June 1986), of whom more than one-third live in camps, while the rest live in cities, towns or village communities. The registered refugee population is distributed as follows: Lebanon 271 424, Syrian Arab Republic 250 953, Jordan 822 624, West Bank 365 315 and Gaza Strip 435 478. In the five geographical areas or territories called "fields of operation", 1 890 848 refugees are eligible for health care services.


ANNEX

Health status

2. The annual growth rate of the population is estimated at 2.5%. In four out of UNRWA's five "fields of operation", the refugee population has already reached and passed the infant mortality target of 50 deaths per thousand live births set out by the World Health Organization for developing countries by the turn of the century. In the West Bank, where infant mortality statistics have been closely monitored for over two decades, the infant mortality rate was estimated at 36 per thousand compared with 84 per thousand ten years ago.

UNRWA primary health care program

3. UNRWA's health care program, which is basically community-health-oriented, provides primary health care to eligible refugee population comprising: medical care services (both preventive and curative), environmental health services in camps, and nutrition and supplementary feeding to vulnerable population groups. The level of service corresponds to the needs of the refugees, which in turn reflect their residence. Camp residents use UNRWA facilities because of ease of access; other refugees living in towns or remote villages at distance from the nearest Agency health center tend to share local community facilities, whether private, voluntary or public health.

Overall health policy

4. UNRWA's policy is to maintain preventive and curative health set-vices to eligible Palestine refugees consistent with the humanitarian policies of the United Nations and the basic principles and concepts of the World Health Organization, and also with the development and progress achieved in public and medical care provided by the host: Governments to their indigenous population at public expense. The prime objective of the Agency's health program is to promote the health of refugees and meet their basic health needs.

Coordination/cooperation

5. The UNRWA Health Service is greatly reinforced by cooperation from several major sources. Within the United Nations system there is major support which reaches its highest expression from WHO and UNICEF. Since 1950, under the terms of an agreement with UNRWA, WHO has provided technical supervision of the Agency's health care program by assigning to UNRWA headquarters on non-reimbursable loan WHO staff members (currently-six), including the Agency's Director of Health. The latter, as WHO program coordinator, is responsible on behalf of WHO's Regional Director for the Eastern Mediterranean for advising the UNRWA Commissioner-General on all health matters and for the implementation of WHO's policies as they apply to the Agency.

6. With UNICEF the long-standing association has been heightened over the period under review, as many of the policy objectives are common and so allow effective integrated work. Some new incentives have been made possible by the close liaison with the UNICEF Regional Director.

7. Complementary to individual activities several non-governmental organizations are a ready source of advice and assistance in areas of common interest.

8. Finally, but by no means least, the Director of Health readily acknowledges the important support and cooperation of the host Governments. In many areas the authorities render direct assistance to the Palestine refugees, while in others there is valuable coordination and integration of services.

Program reviews

WHO review mission on UNRWA's primary health care program

9. UNRWA requested the World Health Organization to carry out a review of its primary health care program in four fields of operation: Jordan, West Bank, Gaza and Syrian Arab Republic. The review was conducted from 27 February to 10 April 1986. It placed special emphasis on maternal and child health, the Expanded Program on Immunization, the control of diarrhoeal diseases, environmental health and the supplementary feeding program.

10. In general, the sustained efforts of UNRWA in the four fields have been rewarded by significant achievements, as reflected by high coverage of health care and a concurrent improvement of health status measured by the reduction in morbidity, mortality and malnutrition.

11. The review team formed the opinion that UNRWA was very efficient in making the best possible use of limited resources available and that unless more resources were secured, little progress should be anticipated in the health status of the refugees.

WHO assessment of progress of the oral health program

12. Also at the request of UNRWA, the Chief of the Oral Health unit at WHO headquarters, Geneva carried out an assessment to follow up the recommendations originating from the WHO oral health situation analysis conducted in March 1982.

13. The recent review was carried out in three fields of operation: Jordan, West Bank and Gaza, during the period 17-24 April 1986.

14. It was recommended that a two-phase development should be introduced, the first phase being a high-risk approach and the second a more comprehensive treatment coverage.

WHO short-term consultants

15. WHO's Regional Office for the Eastern Mediterranean assigned to UNRWA a number of short-term consultants with the main objective of assessing specific components of the Agency's primary health care program and setting out guidelines for research and intervention strategies appropriate to the problems and available resources. Some of the consultants started or completed their assignment during 1986, and others were promised for early 1987. Those assigned on request of UNRWA included:

Respiratory diseases: Dr. M. Sudlow of Edinburgh visited Gaza from 29 November to 4 December 1986 to assess the problems associated with acute respiratory infections, respiratory tuberculosis and bronchial asthma. The recommendations contained in the assignment report will be considered for application Agency-wide.

Enteric diseases: Professor Z. Bencic, University of Zagreb visited the fields of operation in Syrian Arab Republic and Gaza from 9 to 31 December 1986 in order to review the epidemiological situation, diagnostic and treatment practice and control strategies. His recommendations will also be applied Agency-wide.

Diabetes mellitus: Professor Z. Skrabalo of the University of Zagreb had an assignment from 16 February to 23 March 1987 to review the problem of diabetes among refugee populations, assess the operation of UNRWA special care clinics and recommend a new intervention strategy for disease control with special emphasis on case-finding, management and nutrition education after thorough investigation in fields of operation in Syrian Arab Republic, Jordan, West Bank and Gaza.

Situation in Lebanon

16. While the report covers all five fields of operation with their individual problems, it is necessary to emphasize the continued serious problems of Lebanon, where the health of refugees is seriously imperiled as they continue to be subject to a most adverse social pathology. Their existence is recurrently threatened, their family life disrupted, their food and housing restricted and they are enmeshed in a situation fraught with danger and uncertainty.

17. All possible efforts were exerted to maintain the smooth running of the operation. However, in many instances the services were interrupted or completely paralyzed due to limitations on movement of staff and supplies or inaccessibility for the populations of UNRWA facilities.


CHAPTER II

GENERAL MANAGEMENT

18. The Director of Health is responsible to the Commissioner-General of UNRWA for the planning, implementation, supervision and evaluation of the health and supplementary feeding programs within the budgetary limits approved by the Commissioner-General. He is assisted in this task by a staff of professional and auxiliary health workers and manual workers, totaling 2934 as at 31 December 1986.

19. Since 1978, the headquarters of the Department of Health has been split between Vienna and Amman. In order to attempt to achieve the necessary integrated team approach regular visits and meetings are made to Vienna and Amman.

20. The Department has five divisions: curative medicine, preventive medicine, nursing, environmental health, and nutrition. The Curative Medicine Division includes the Pharmaceutical and Medical Supply Branch, and the Preventive Medicine Division includes the Health Education Branch.

21. This organizational pattern is repeated in each of the five field health offices located in Jordan, the West Bank, the Gaza Strip, Lebanon and the Syrian Arab Republic, which have departmental status within the field offices. In each case, the field health officer reports directly to the field office director for administrative purposes and to the Director of Health on technical matters.

22. The Department of Health continues to attach great importance to team work, coordinated staff planning and consultation in the development of health projects and the evaluation of health programs. To this end, regular meetings of the senior health staff are held at headquarters and in the fields of operation; the more important are the weekly staff meetings, the four-monthly divisional meetings at headquarters and the annual or biennial conferences of the senior field health staff.


Direction - supervision

23. The director and chiefs of each division and branch undertook regular periodic visits to each field of operation to review the work of the Department and ensure that it reflects the approved policy and standards of the Agency.

24. The whole activity is reinforced by Technical Instructions issued by the Director of Health.

25. The supervision at field level is undertaken by the field health officer and his senior colleagues.

Planning and programming

26. Prior to 1986, detailed reviews of each sub-program were undertaken leading to firm decisions for action. Each year the implementation of these decisions with their related resource provisions was regularly monitored.

27. In 1986 the first comprehensive three-year medium-term plan for the period 1987-1989 was prepared with the main purpose of developing an overall framework for the progressive development and management of the programs carried out by the Agency during the period. The plan formed the basis for establishing policy and program guidelines for the annual budgets and for projection of medium-term financial requirements.

Budget and finance

28. With the exception of the cost of international staff paid by the United Nations, UNESCO and WHO, UNRWA's budget is financed almost entirely from voluntary contributions in cash and in kind, mainly from governments, and the remainder from non-governmental and miscellaneous sources.

29. Each year, budget preparation guidelines and budget norms are forwarded to the fields of operation for preparation of budget estimates which are reviewed by UNRWA headquarters, and budget allotments are authorized under each sub-program based on the approved policies for the new budget cycle.

30. Health services accounted for US$ 37 202 496, or 20% of total UNRWA expenditure. Expenditure and commitments on the regular program covering the three sub-programs administered by the Department of Health in 1986 were as follows:



Health expenditure for the year ending on 31 December 1986.

A. General Fund

Cash
In kind
Total
Medical Services

Environmental sanitation

Share of common costs

Sub-total
16,703,579

4,867,857

4,758,971

27,336,407
405,442

529,372

42,747

977,451
17,114,911

6,397,229

4,801,718

28,313,858
B. Project Fund
3,745,587
5,143,059
8,888,646
Grand Total ( A + B )
31,081,994
6,120,510
37,202,504


Health manpower development

31. The Agency maintained and further developed its program of education and training in the field of health. Basic professional and vocational training is primarily the responsibility of the Department of Education, while in-service and postgraduate training is the direct concern of the Department of Health.

Basic professional education

32. The assistance provided for medical students includes maintenance grants, payment of tuition fees and an allowance to cover the cost of books, training material, instruments and other essential items. Young men and women have been encouraged to enroll in medical, dentistry and nursing education courses at schools of nursing and at universities. Scholarships for nursing education were donated by voluntary agencies.

Vocational training

33. The Agency provides at its vocational training institutions paramedical courses to enable refugee students to become assistant pharmacists, laboratory technicians, public health inspectors and dental assistants. On completion of their training, graduates may join the Agency's service or be assisted by the UNRWA Placement Office to find employment in the region.

In-service training

34. Continuing education was carried out by the Department of Health for its own staff in the various disciplines of the program.

35. This was arranged through in-service training courses, workshops, seminars and professional meetings conducted by UNRWA or in coordination with WHO, UNICEF, local universities, ministries of health of the host Governments, and voluntary and non-governmental organizations.

36. Health staff at all levels benefited from these activities, including medical and paramedical, nursing, sanitation and nutrition personnel.

37. The areas of training covered the wide range of primary health care including the Expanded Program on Immunization and the cold-chain, family planning, communicable disease control, health education, the risk approach, oral health, environmental sanitation, nutrition and management.

38. In addition to the in-service training courses conducted by UNRWA for its own staff in the five fields of operation, the following activities were coordinated with WHO, UNICEF, public health authorities and non-governmental organizations:

- A WHO/UNRWA/UNICEF course on-the Expanded Program on Immunization, with emphasis on the cold-chain system, took place in Amman from 8-to 13 February 1986 and was attended by 19 senior UNRWA staff from headquarters and the five fields of operation A WHO short-term consultant attended as facilitator. The course was funded by UNICEF.

- The Chief Pharmacist and Supply Officer (Medical) attended the WHO interregnal course on procurement, storage and distribution of essential drugs for primary health care which was held in Amman from 9 to 20 March 1986.

- A four-week training course in sanitation and health education was conducted as of 12 April 1986 with eight participants from UNRWA (four senior health education workers and four sanitariums) together with 10 other participants from the Ministry of Health and one from Amman Municipality. This course was the result of the coordinated action of UNRWA, WHO's Regional Office for the Eastern Mediterranean and-Regional Center for Environmental Health Activities, and the Jordanian Ministry of Health.

- Dental surgeons in Jordan attended a one-day seminar at,,, the Field Office,, Amman on 20 April 1986. Dr D. Barmes, Chief, Oral Health unit, WHO headquarters, Geneva attended part of the seminar.

- Thirteen UNRWA medical officers (8 from Lebanon, one each from Syrian Arab Republic, Jordan, West Bank and Gaza, and the Chief Training and Research Officer from UNRWA headquarters, Amman), attended the seminar on concepts of community health which was held in Larnaca, Cyprus from 19 to 24 May 1986. The seminar was sponsored by the British "Save the Children" Fund as part of their support services in Lebanon and received technical assistance from the Department of International Community Health of the Liverpool School of Tropical Medicine, United Kingdom.

- The Field Pharmacist, Jordan, attended the national workshop on rational use of essential drugs organized by WHO in Amman from 8 to 10 September 1986.

- A training course on the control and management of diarrhoeal diseases was arranged by UNRWA, WHO' s Regional Office for the Eastern Mediterranean and. the Maternal and Child Health Department, Jordan, at the Government Oral Re-hydration Training Unit at El-Bashir Hospital in Amman, during the period 4-9 October 1986. It was attended by 9 medical officers and 8 qualified nurses from the five UNRWA fields of operation.

- The Field Pharmacist, Syrian Arab Republic, attended the WHO inter-country meeting on drug policies and management held in Damascus from 18 to 22 October 1986.

- Field preventive medicine officers and one dentist from Syrian Arab Republic attended the inter-country workshop on oral health arranged by WHO's Regional Office for the Eastern Mediterranean at the Demonstration, Training and Research Center in Damascus from 25 to 27 October 1986.

- The Field Health Officer and Field Health Training and Research Officer, Jordan, attended the first national conference on medical education which was held at the University of Jordan in Amman on 6 November 1986.

- One UNRWA dentist from each of the fields of operation in Gaza, West Bank, Jordan and Lebanon attended a one-week course on dental public health from 22 to 27 November 1986 at the Demonstration, Training and Research Center in Damascus.

- A workshop/course on health education was held in Amman for 22 UNRWA school-teachers from Gaza, West Bank, and Jordan on 19 and 20 November at the Education Development Center in Amman. A WHO dentist delegated from the Demonstration, Training and Research Center in Damascus, an UNRWA School Medical Officer from Syrian Arab Republic, together with UNRWA headquarters staff, participated as moderator/coordinators.

Postgraduate Training

39. Through the sustained support of WHO's Regional Office for the Eastern Mediterranean and close collaboration with non-governmental organizations, UNRWA's Health Department maintained an active postgraduate training program aimed at developing the technical and managerial skills of its staff-and meeting future replacement needs under the various health disciplines.

40. The following fellowships were granted or completed during the year:

WHO fellowships (Regional Office for the Eastern Mediterranean)

- A medical officer of the Bureij Health Center, Gaza, started a community health course at Liverpool School of Tropical Medicine, United Kingdom, on 6 January 1986 (after a four-week English-language course at Chester, United Kingdom).

- A medical officer of the Beir el-Balah Health Center, Gaza, was awarded a 15-month WHO fellowship to pursue a postgraduate training course leading to the Master of Science degree in mother and child health at the Institute of Child Health, University of London, starting on 30 September 1986.

- A deputy field nursing officer, Syrian Arab Republic, was awarded a 10-month-and-one-week WHO fellowship to pursue a diploma course in maternal and child health at the Institute of Child Health, University of London, starting on 1 October 1986, preceded by a four-week English-language course at Chester, United Kingdom.

- A field sanitation officer, Syrian Arab Republic, was awarded a WHO fellowship for training in environmental sanitation in Egypt, starting on l November 1986.

- The Chief Pharmacist and Supply Officer (Medical), UNRWA headquarters, was awarded a WHO fellowship to pursue a six-week training course in drug procurement, storage and distribution at the Stitching International Dispensary Association in Amsterdam, Netherlands, from 2 November to 13 December 1986.

- A senior practical nurse of the Bedawi Health Center, Lebanon, was granted a 12-month WHO fellowship to pursue a training course in public health nursing at the School of Nursing, Cairo University; she successfully completed her training and resumed her duties on 25 November 1986.

- A medical officer of the Qabr Essit Health Center, Syrian Arab Republic returned from the United Kingdom in December 1986 after completing a WHO fellowship in community health.

- Two medical officers from the Lebanon field of operation completed 12-month WHO fellowships leading to a master's degree in public health at the American University, Beirut.

- A deputy field health officer, Jordan, was awarded a three-month WHO fellowship in community health in Yugoslavia starting on 31 August 1986.

- A deputy field sanitation officer, Lebanon, was awarded a 12-month WHO fellowship to pursue a course in sanitary engineering at the University of Newcastle, United Kingdom, starting on 30 September 1986.

British Council fellowship

- A field sanitation officer, West Bank, returned from Loughborough University, United Kingdom, with a Master's degree in water and waste engineering won on a fellowship sponsored by the British Council. He has been assigned the duties of Field Sanitary Engineer, West Bank, as of November 1986.

British "Save the Children" Fund fellowship

- A senior staff nurse of the Rafah Health Center, Gaza, who was granted a 12-month scholarship by the British "Save the Children" Fund for public health nursing training at Cairo University during the academic year 1985/86, successfully completed his training in November 1986.

APHEDA fellowship

- A senior staff nurse (technical and training), Gaza, and a senior staff nurse, Lattakia Health Center, Syrian Arab Republic, took a twelve-month diploma course in community health nursing at Cumberland college, Sydney on fellowships from APHEDA. Both completed their training and returned in December 1986.

- A medical Officer of the Ein el-Hilweh Health Center, Lebanon, who was granted a 25-month scholarship for a postgraduate training course leading to the Master's degree in public health at the Commonwealth Institute of Health, University of Sydney, successfully completed his training in November 1986.

Conferences

Field health officers' meeting

41. The annual meeting of field health officers was held at headquarters (Vienna) from 17 to 19 February 1986; the participants discussed the future of the supplementary feeding program, the need for development of a program of research, intervention and education, and risk-approach strategy with relevance to maternal and child care.

Senior health staff conference

42. The senior health staff conference was held in Amman from 21 to 22 October 1986; participants reviewed the findings, recommendations and plan of action of the WHO review mission on primary health care in Palestine refugee camps in Jordan, West Bank, Gaza and Syrian Arab Republic.

43. The conference was also attended by the WHO Regional Director for the Eastern Mediterranean, the UNICEF Regional Director, the Minister of Health of Jordan, the personal representative of the Director-General of WHO, and other staff from WHO and UNICEF.

Senior health and education staff conference

44. A joint conference of the senior health and education staff from headquarters (Vienna and Amman) and the fields of operation was held in Amman on 23 October 1986 to follow up progress on the recommendations of the previous joint meeting, held in May 1983.

Deputy field health officers meeting

45. The biennial meeting of the deputy field health officers and field pharmacists was held in Larnaca, Cyprus on 4 and 5 July 1986; it was attended by the WHO Regional Adviser on Pharmaceutical, Diagnostic and Therapeutic Substances.

World Health Assembly

46. The Director of Health represented UNRWA at the Thirty-ninth World Health Assembly, held in Geneva from 5 to 16 May 1986.

WHO representatives and program coordinators' meeting

47. The Director of Health attended the WHO representatives' and program coordinators' meeting held in Alexandria, United Arab Republic, from 29 June to 2 July 1986.

Third inter-country meeting on the Expanded Program on Immunization

48. The Deputy Director of Health and Chief, Curative Medical Division represented UNRWA at the inter-country meeting on the Expanded Program on Immunization held in Nicosia from 7 to 11 July 1986.

WHO Regional Committee for the Eastern Mediterranean

49. The deputy Director of Health and Chief, Curative Medical Division represented UNRWA at the thirty-third session of the WHO Regional Committee for the Eastern Mediterranean, held in Kuwait from 4 to 7 October 1986.



CHAPTER III

CURATIVE MEDICAL CARE SERVICES

General

50. Curative medical, dental and rehabilitation services continued to be provided by UNRWA to about 1.9 million eligible Palestine refugees and to locally-recruited staff members and their authorized dependents who are not participating in Agency-sponsored insurance schemes. These services were made available at various health centers/points, polyclinics, hospitals, laboratories, X-ray departments, and rehabilitation centers - either run or subsidized by UNRWA. Some of the refugee population has access to insurance schemes, and others, who can afford payment for some of these services, receive them direct through their own arrangements.

Outpatient medical care

51. Medical care services were provided in 98 UNRWA health centers/points. Compared with 1985, there was an overall increase of 6% in the number of medical consultations during the year in all fields of operation. Overall, there was an increase of 31% in the reported attendance's for dental treatment. This increase in demand for UNRWA services in all fields is attributed to prevailing economic difficulties and relative improvement of facilities.

52. The situation in Lebanon continued to have adverse effects on the delivery of UNRWA health services, particularly in the refugee camps. Medical services continued to be provided despite the prevailing constraints. Nevertheless, there was a drop in the utilization of UNRWA medical services compared with previous years owing to the poor security situation and inaccessibility for refugees of UNRWA services in many instances.

53. Appropriate arrangements were made for redeployment of staff and establishment of mobile teams to serve the displaced refugees and those who had left their original places of residence in areas of south and central Lebanon and took refuge in safer places.

54. During the year, the Agency's special care program included 138 specialized clinics for diabetes (36), tuberculosis (1), ophthalmology (11), family planning (17), ear-nose-and-throat conditions (2), cardiovascular diseases (2), dermatology (2), chest diseases (1) and hypertension (2). These clinics, as well as the nutrition rehabilitation clinics (64), form part of the activities of health centers, where patients are treated on specified days or by appointment. These specialized services need to be expanded to other health centers.

55. In spite of the Agency's financial difficulties, the Health Department was able to make modest improvements in the working conditions at health units. During the year it supplied new equipment and replaced old equipment where necessary in the Agency's different installations, including X-ray machines, laboratory and dental equipment, cold-chain equipment, etc., Through special contributions and also from UNRWA resources some new construction and replacement or expansion of health premises was possible.

Inpatient medical care

56. The Agency makes provision for inpatient care at 33 private hospitals and hospitals subsidized by voluntary agencies (695 beds). However, it also operates a small hospital in Qalqilya. West Bank (36 beds), eight maternity centers (totaling 65 beds) - six in the Gaza Strip and two in West Bank, and - jointly with the Public Health Department in Gaza - a 70-bed tuberculosis hospital in Bureij camp which serves refugees and indigenous inhabitants from the Gaza Strip and a few from the West Bank.

57. The Agency had to increase its subsidies to hospitals and other facilities serving refugee patients mainly in Lebanon and West Bank owing to the continuous rise in the cost of medical care in the area.

58. In West Bank, the agreement with Augusta Victoria Hospital, Jerusalem has been changed from a regular budgetary basis to a basis of fee per bed per day; through the generous donation of the OPEC Fund the hospital was provided with modern cardiological equipment.

59. In the Gaza field of operation, where the Agency did not have subsidized hospital beds, arrangements were made to subsidize 20 beds at Al-Ahli Arab hospital; it is planned to increase the number to 40 beds in 1987 and 60 beds in 1988.

60. Arrangements were also made for referral of patients from Gaza to Augusta Victoria Hospital and St John's Hospital in West Bank - primarily patients who would require the added skills and facilities not readily available in Gaza.

61. In the Jordan field of operation, the Agency maintained its subsidy for 38 beds reserved for refugees at two voluntary hospitals, but wider provision is much needed. Meanwhile, the Agency maintained a scheme for reimbursement on the basis of service according to needs.

62. In Lebanon the Agency had to amend its contracts with subsidized hospitals in order to meet the continuous increase in cost due to devaluation of the local currency. Beds were re-deployed to cater for the increased demand resulting from mass displacement of refugees and inaccessibility of certain hospitals.

63. UNRWA continued to meet part of the cost of specialized care and emergency life-saving care, mainly for cardiac patients and neurosurgery; 70 patients benefited during the year.

Oral health

64. The Agency's policy is to provide preventive and curative oral health services to the eligible refugee population with special emphasis on high-risk groups including schoolchildren, pregnant women and nursing mothers.

65. The objective of the program is to reduce the prevalence of decayed, missing and filled (DMF) teeth and periodontal diseases among the vulnerable groups by providing sufficient health manpower and adequate equipment.

66. The special activities directed towards this objective comprise the following:

- oral health monitoring of the vulnerable population groups including schoolchildren, pregnant women and nursing mothers through periodic screening And management;

- restorative and minor surgical treatment according to needs;

- promotion of oral hygiene through health education directed towards schoolchildren with the aid of teachers.

Services

67. There are 21 dental health teams providing dental care to 44 refugee localities in and outside camps through 30 fully equipped dental clinics including one mobile unit. In localities where no dental clinics could be established, some dental care is provided by private dentists remunerated by UNRWA on a contractual basis.

68. Plans for improvement aim at extending coverage to refugee localities and population as yet inadequately served. The plans comprise expansion of dental teams, provision of additional equipment and use of dental hygienists to assist in the screening, simple management tasks and oral health education.

Laboratory services

69. While UNRWA has continued to support the development of central laboratories, increasing emphasis is being placed on clinical laboratories at health centers to support primary health care. The three central health laboratories in Gaza, Jerusalem and Amman perform public health and clinical tests. The Agency has developed 34 clinical laboratories located at main health centers in the different fields of operation to perform routine clinical tests, including biochemistry. Elaborate laboratory investigations are per-formed at seven university and/or private and subsidized laboratories. Plans for improvement involve the establishment of additional clinical laboratories to facilitate diagnosis and management.

Radiological facilities

70. The concept of better primary health coverage is promoted by the provision at health centers of essential diagnostic facilities; basic radiological units have been installed in Baqa'a camp in Jordan and Rimal health center in Gaza. Both units were made possible by the generosity of WHO, which provide a third unit for West Bank. In addition, X-ray services are available at subsidized hospitals or by contractual arrangements.

Medical rehabilitation of physically handicapped children

71. The facilities available for management of disability among the refugee population are still modest. Greater emphasis is placed on programs aiming at prevention of disability among the vulnerable groups.

72. Crippled children are rehabilitated through physical and medical therapy as outpatients or inpatients. During the year, 551 children benefited from this services in three fields of operation: in the Jordan field crippled children received such care at the Government Rehabilitation Center in Amman; patients from West Bank and the Gaza Strip are referred to the Jerusalem Crippled Children's Center for outpatient and inpatient care; in Syrian Arab Republic treatment is provided through contractual arrangement with a private physiotherapy center. In Lebanon, the services of Shatila Rehabilitation Center, Beirut, funded by the Norwegian Peoples Aid, were suspended due to damage to the premises; the Tyre Rehabilitation Center, South Lebanon, funded by the Norwegian Refugee Council, also had to cease operations for lack of international staff.

73. Orthopedic devices and prostheses were made available to a limited extent in all fields of operation, and even then at higher cost.

Medical supplies

74. In general, medical supplies provided to all fields of operation have been satisfactory. The range and nature of supplies was reviewed during the year in the light of the WHO list of essential drugs. Most of the medical supplies and equipment programmed by the Department of Health continued to be purchased on the international market and through the UNICEF Packing and Assembly Center in Copenhagen (UNIPAC). However, occasional shortages due to over-consumption or delays in the delivery of overseas consignments were met from the Director of Health's reserve stock and through local purchase. The value of medical supplies and equipment received as contributions amounted to US$ 143 455, while purchases during the year totaled US$ 1 674 405.



CHAPTER IV

PREVENTIVE MEDICAL CARE SERVICES

General

75. Preventive medical care services represent the core of UNRWA's primary health care program. They comprise epidemiology and communicable diseases control, maternal and child care, school health services and health education. Increasing emphasis is being placed on development of programs of disease prevention and health promotion directed towards non-communicable disease control, mental health and health care of the elderly.

Communicable diseases prevention and control

76. Prevention and control of communicable diseases was carried out through the various activities of the Health Centers.

Epidemiological surveillance

77. Surveillance of certain communicable diseases was maintained Agency-wide through weekly incidence reports from the UNRWA health centers and points, and special epidemiological investigation where indicated.

78. UNRWA's Department of Health continued to provide WHO and public health departments of host Governments with information on the incidence and prevalence of communicable diseases.

Trends

79. The following notifiable diseases showed a decrease in incidence: diarrhoeal diseases in children under three years from 2778 per 100 000 population at risk in 1985 to 2452, diarrhoeal diseases in children over three years from 2225 to 990, the enteric group fevers from 28 to 22 and brucellosis from 1.9 to 1.4 per 100 000 population. Infectious hepatitis showed increased incidence from 28 to 50 per 100 000 population. The highest rates of diarrhoeal and enteric diseases were reported from Syrian Arab Republic and Lebanon.

80. The target diseases of the Expanded Program on Immunization were generally well under control, with the exception of a few cases among non-vaccinated refugees. These included: one case of tetanus neonatorum from Lebanon, one case of tetanus (adult) from Gaza, one case of diphtheria from West Bank, one case of pertussis from Syrian Arab Republic and 62 cases of respiratory tuberculosis: 21 from Lebanon, 18 from Gaza, 13 from West Bank, 9 from Jordan and one from Syrian Arab Republic.

81. No cases of malaria, cerebrospinal meningitis, syphilis or poliomyelitis were reported. No cases of cholera were officially reported; nevertheless, anti-cholera measures were stepped up in coordination with public health authorities.

Pattern

82. The pattern of communicable diseases has changed in recent years, in part owing to the impact of the Expanded Program on Immunization and in part to changes in the socioeconomic and educational standards of the population.

83. UNRWA is alert to the increasing threat of malaria, schistosomiasis and cholera in the region.

Maternal and child health services

84. The major component of the primary health care program provided by the Agency was health monitoring of pregnant women and children through a network of 93 child health clinics and 97 antenatal clinics including six maternal and child health sub-centers. Nutritional support was given to vulnerable groups through the nutrition and supplementary feeding program (see Chapter VII).

Maternal care

85. In the antenatal clinics 42 510 women were registered for maternal care, which includes regular health surveillance, Issue of extra dry rations, treatment of anemia throughout pregnancy and the nursing periods and immunization of pregnant women with tetanus toxoid; 36 065 deliveries were registered, approximately 55% of the expected number of deliveries (assuming a birth rate of around 35 per thousand in the eligible refugee population as at 30 June 1986); 34% of the deliveries still took place at home, the majority attended by Agency-supervised dayahs (traditional birth attendants); about 54% preferred delivery in hospital, following modern trends. Even the figures from the Gaza field of operations which provides maternity services as part of the camp health services (maternity wards are attached to six of the nine health centers), show that 49% of the deliveries took place in hospitals, whereas 33% took place in the camp maternities and 18% at home. The still-birth rate reported was 9.5 per thousand total births registered.

Family planning

86. Family planning services continued to be provided by the Agency as an integral part of the maternal and child health program in the Gaza field of operation; contraceptives were provided by the Jordanian Family Planning and Protection Association, through its branch in Jerusalem. The program also included family life education in the! preparatory schools for girls 12-15 years of age and plans are underway to expand the program to boys schools. Nurses took part in this program by giving lessons and demonstrations in mother and child care in schools.

87. In other fields of operation the services are limited to health education on child spacing of age, through the maternal and child health clinics and advice oil the use of safe family planning methods.

88. Measures to expand these services aim at linking family planning to risk factors in pregnancy in order to obtain further reductions in infant mortality and disability.

Child care

89. Some 123 700 children up to the age of three years received regular health supervision in the Agency's child health clinics, and immunization against tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis and measles, following the same schedule as that of WHO's Expanded Program on Immunization (with the exception of poliomyelitis immunization in the Gaza field of operation, where the modified schedule of combining oral and injectable (Salk) polio vaccines is still in effect). Immunization against rubella was also introduced for preparatory school girls and non-pregnant women of child-bearing age. Early and effective treatment of diarrhea by oral re-hydration was carried out in all health centers.

90. Children showing signs of growth failure received special attention and care in the nutrition rehabilitation clinics established in most health centers throughout the fields of operation as an integral part of the child health program. The percentage of children registered in the child health clinics who were found to be underweight according to local growth curves was 4.6% in the first year, 5.1% in the second and 2.2% in the third year.

Risk approach

91. A new intervention strategy for maternal and child health care was implemented in the West Bank field of operation, based on the findings of risk-approach studies conducted there with the assistance of WHO's Regional Office for the Eastern Mediterranean. A field trial and evaluation of the scoring system and the intervention strategy was carried out. Wider application of the findings is well underway.

92. Efforts are being made to expand the program in two other fields of operation, in Jordan and Gaza, and great emphasis is being placed in all fields on identification of risk factors through staff training.

School health services

93. School health services covered 349 224 children (representing about 20% of the refugee population) in 635 UNRWA elementary and preparatory schools.

94. Medical examinations at school entry, including vision screening, and reinforcing immunizations against diphtheria, tetanus and tuberculosis (BCG), were carried out either by a school health team or at health centers. Regular visits are paid to the schools for health monitoring of the pupils and inspection of school premises. Schoolchildren with suspected visual or hearing defects usually identified by their teachers, are referred for investigations through the health centers. With UNRWA assistance eye-glasses and hearing-aids are provided to schoolchildren who need them.

95. Increased emphasis is being placed on development of a preventive oral health program and an incremental dental care research and intervention program for schoolchildren.

Non-communicable diseases prevention and control

96. Programs for control of non-communicable diseases are provided by specialists and specialized clinics and are integrated with the health center activities. Besides early recognition and prompt treatment of such diseases, health education and preventive measures are emphasized in the work of cardiovascular clinics, diabetic clinics, chest disease clinics, etc.

Trends

97. With the changing age structure of the refugee population, both because of the duration of the refugee situation and owing to effective control of communicable diseases, the prevalence and recognition of non-communicable diseases is increasing. UNRWA's primary health care program is at a turning-point in establishing special care services for early detection and prevention of non-communicable diseases well in advance of the need to meet the high cost of treating the complications and disabling effects of these diseases.

98. While this has been recognized by the UNRWA health service there is urgent need for trained staff, adequate equipment and facilities to effectively manage these problems.

99. Already assistance from WHO and UNICEF has enabled some progress to be made.

100. Recent priorities include diabetes mellitus, bronchial asthma, oral health, mental health, cardiovascular diseases and geriatrics.

101. Any activity to meet the needs of the refugee community is necessarily limited by competing priorities and scarcity of resources. Therefore, the interventions to be introduced will not involve structural changes in the health service or the setting-up of specialized facilities for treatment, but more integration within the primary health care services. A useful beginning can be made by reorienting the attitudes and skills of current staff.

Mental health

102. Childhood mental disorders and problems of psychosocial development constitute a serious public health problem to which existing services provide an inadequate response. An increased level of intervention through primary health care could decrease the extent of childhood mental disorders, limit their harmful consequences and improve psychosocial development.

103. The growing need for mental health care for children of Palestine refugees became a matter of particular concern to UNRWA. It has therefore, in coordination with other organizations of the United Nations system, including WHO and UNICEF, together with non-governmental organizations, undertaken the following activities:

- After a review of available literature, and informal consultations at WHO headquarters, Geneva and with UNICEF in Amman, a planning mission assessed mental and psychological problems and designed out intervention-research project. The WHO Regional Adviser on Mental Health was to visit the Jordan field of operations in January 1987 to give the project the benefit of his advice and involvement.

- Follow-up for financial support from WHO, UNICEF and non-governmental organizations is being sought for implementation of the recommended strategy.

- The research and intervention project sponsored by the Danish "Save the Children" Fund (Radda Barnen) in Jabel el-Hussein and Marka camps in the Jordan field of operations, which was started with effect from 1 November 1985, has been extended for another two years up to 31 October 1988 on the same terms and conditions as the old agreement.

Health care of the elderly

104. The elderly refugee population is growing in numbers owing to the success of the UNRWA health program in increasing longevity.

105. There is an apparent need for the establishment of preventive programs aimed at maintaining the well-being of physically active elderly persons and at promoting family care for the disabled elderly.

106. A WHO/UNRWA planning mission visited the Jordan field of operations in December 1986 with the main objective of recommending practical steps within the UNRWA program to address the health and related needs of elderly refugees in camps, with a view to possible application of the recommendations to the other four fields of operation in due course.

107. Implementation of an early model project supported by research and information programs in Jordan will be started subject to availability of funds.

Health education

Strategy

108. Health education strategy embraces improved life-style, which increases personal responsibility for health. Inherent in this program are:

- Encouragement of personal hygiene; environmental pressures, including housing inadequacies, conspire to make a ready approach to personal hygiene more difficult; realistic education leading to personal understanding and response should be integrated fully into health education.

- Realistic nutritional education; this covers promotion of better nutrition practices, emphasizing the major importance of breast-feeding and explaining the relationship between nutrition and disease; approaches involving teachers, children and parents should be used to further understanding about nutrition and nutritional practices.

- Avoidance of behavior damaging to own health; this relates to accidents at home and at school, abuse of medicine, smoking, etc. Vigorous attempts are being made to discourage smoking among health professionals and teaching staff, supported by a health education campaign to alert children to the risks associated with smoking well in advance, of the age at which they may develop the habit.

Activities

109. Health education is an integral part of the regular work of all health staff. The activities of the Health Education Branch are geared both to assisting colleagues and to carrying out special health education work.

110. A major advance in this program has been the mobilization of teachers in health education as part of their tuition work. The teacher-pupil-parent approach has already shown important results.

111. Health education material produced by either UNRWA or UNICEF is used.

112. During the academic year 1985/1986 more teachers were enrolled in the in-service training program in health education; 23 teachers in the Jordan field of operations, 18 teachers in Gaza and 38 teachers in West Bank have completed the course, and they are responsible for the implementation of health education plans in their respective schools.

113. Health educator teachers also received training in oral health at the WHO Regional Center for Training, Demonstration and Research in Damascus.

114. A project on nutritional status among schoolchildren was implemented in Jordan by health education staff, starting with a survey, followed by preventive measures directed towards school canteens and intensive education in the form of open discussions and exhibitions for schoolchildren and mothers. A comprehensive campaign of one month's duration on nutrition and hygiene for food handlers and beneficiaries was conducted in West Bank.


CHAPTER V

NURSING SERVICES

General

115. The nurses of UNRWA provided basic and supportive nursing services to the refugees and displaced persons at health centers and points, in dental clinics, in maternity wards and in antenatal, child health, nutrition rehabilitation, diabetic, ophthalmic, cardiovascular, dermatology, ear-nose-and-throat and family planning clinics, as well as through school health services.

116. The Agency employs qualified nurses to administer and supervise the day-to-day nursing activities. There are also dayahs (traditional birth attendants) who work for the Agency, while others receive their remuneration in the form of a fee for service; the majority of them ensure domiciliary care, but others assist with simple routine work in clinics.

117. The auxiliary nursing staff of senior practical nurses, practical nurses and midwives carry out the majority of the nursing activities at all levels.

Mode of operation

118. At UNRWA headquarters level the Chief of the Nursing Division is responsible, through proper channels, for the organization, supervision and evaluation of the nursing programs in the fields of operation.

119. At field level the Field Nursing Officer is responsible for the supervision and evaluation of the nursing program in the field to which he or she is assigned. At area level the Area Nursing Officer (where such posts exist) supervises the nursing activities in the area.

120. At health center level qualified professional senior staff nurses are an integral part of the health teams responsible for the overall functioning of the clinic services (preventive and curative) and supervise auxiliary health staff in the performance of their routine tasks.

Objectives

121. The objectives of the nursing services are:

- to maintain and promote optimal health conditions of vulnerable population groups, including infants, children, pregnant women and nursing mothers, through regular monitoring and preventive care;

- to identify through the assessment process individuals, families and community groups who are in need of health care, including high-risk individuals or groups;

- to plan nursing activities or interventions based on identified health problems, community needs, UNRWA resources and accepted standards of practice;

- to implement and evaluate a community health nursing program that utilizes a problem-solving approach in assisting families and communities to become more responsible for their own health;

- to assist in the promotion and implementation of health education through intensive team efforts and community participation;

- to plan for an orientation program for all new nursing staff, and regular in-service education programs and higher education for nurses, according to the needs of the Agency;

- to monitor, supervise and assess all planned nursing activities to determine whether or not the planned objectives are being met.

Current activities

122. Nurses are responsible for direct nursing care in all health centers or points, in maternity wards, maternal and child health clinics, school health programs and in the community.

123. The nurses' functions in general, dental and specialized clinics include: injections, dressings, eye treatment and other clinical support.

Maternal and child health clinics

124. Maternal and child health services form the bulk of the work performed in the health centers and utilize all categories of nursing personnel for prenatal, intrapartum and postpartum care, as well as home visits, for various reasons, of the pregnant or lactating mother.

125. The services for children provide monitoring of growth and development of all children up to the age of five years, immunizations, referral of sick children to the physician and referral to the appropriate service or specialist for special care or rehabilitation.

126. Education of mother and families for the purpose of improving health status is carried out on a regular basis.

Maternity wards

127. UNRWA-trained midwives care for laboring women and are responsible for the safe delivery in the maternity wards or at home when called to perform such services. The postpartum period is monitored carefully, with scheduled home visits according to planned activities.

Nutrition rehabilitation centers

128. Nurses assist in the running of nutrition rehabilitation centers, and provide education for mothers and train them in the use of oral re-hydration salts.

129. Nurses are directly involved in supportive activities such as health education in health centers and at the community level, identification of environmental health problems, assistance in health promotion campaigns and school health programs, and identification of persons at risk or in need of other services - rehabilitative care, special care for the physically disabled, social welfare, etc.

130. Home visits are made for specific reasons: tuberculosis or other communicable disease control, follow-up of chronic disease patients, of defaulters from any of the clinics and of those at risk.

Community health nursing program

131. The Jordan field of operation has implemented a community health nursing program in all camps, and all other fields are preparing or have commenced the program in at least two camps. The program is increasingly enhancing community involvement and awareness.

132. Through this program camps are divided into manageable areas, each nurse being responsible for a designated area.

133. The nurse assists in carrying out the following tasks:

- collection of important family and community data;

- analysis of information, identification of health or health-related problems and priority-setting;

- decision-making on plans to assist in solving or reducing problems;

- implementation of the plan with the family and other staff, as necessary;

- evaluation to determine whether the purpose, or objectives of the plan have been achieved or not.

134. The program has identified many problems that are not brought to the clinic and thus provided a broader coverage of individuals and families.

135. Development of nursing manpower has not kept pace with the increased services being provided. This matter is receiving high priority in the Department's development plans.


CHAPTER VI

ENVIRONMENTAL HEALTH SERVICES

General

136. UNRWA provides basic environmental health services to 749 235 refugees and displaced persons living in 61 camps. The services comprise provision of potable water in adequate quantity, sanitary disposal of solid and liquid wastes, drainage of storm water, latrine facilities and control of disease-carrying insects and rodents.

137. The refugee communities continue to take keen interest in self-help schemes for camp improvement which are planned and executed with the assistance of UNRWA. Cooperation of host Governments, municipalities and local councils has been further strengthened to encourage the development of regional water supply and sewerage projects which may also benefit refugee camps.

Mode of operation

138. The basic services, which include some health education activities, are provided mostly through Agency-employed sanitation staff. Appropriate tools and equipment are provided to the staff according to the limited resources, local conditions and acceptability. Where feasible, suitable contractual arrangements are also made with local municipalities or private contractors for refuse-removal.

Policy

139. The Agency endeavors to provide basic sanitation services to the refugee camps of a standard compatible with the quality of services generally provided by municipalities and local councils to towns and villages in the host countries. Community participation and problem-solving meetings are encouraged to enhance the effectiveness of limited financial resources.

140. UNRWA continues to make formal contacts with municipalities and host Governments for the solution of problems which need joint action, particularly in the areas of augmentation of water supplies and disposal of liquid wastes.

Objectives

141. The objectives of UNRWA's Environmental Health Services are:

- to prevent and control communicable diseases transmitted through environmental channels and reduce morbidity and mortality associated with poor sanitary conditions;

- to further improve general cleanliness, make easier access to potable water and provide acceptable waste collection and disposal facilities;

- to involve the beneficiary communities in the decision-making process through the strengthening of health-center activities.

Current activities

142. Through the sustained cooperation and support of local authorities significant developments have taken place which will have a relatively long-term beneficial effect on the environmental health conditions in the refugee camps.

Water supply

143. The water augmentation schemes aiming at the provision of indoor water-taps to all refugee shelters at Baqa'a, Marka, Suf, Jerash and Husn camps have been satisfactorily completed by the Government of Jordan. In West Bank, Deir Ammar camp, has, been connected with a regional water system, and a scheme for the augmentation of water supply to Dheisheh camp is being implemented. h community water supply scheme financed by UNICEF has been completed at Ein el-Hilweh camp in Lebanon. To overcome the chronic water shortage at Wavell camp, a deep well has been drilled and a new water-pumping station has been installed. In. Syrian Arab Republic, the community water supply scheme assisted by UNRWA at Sbeineh camp is nearing completion.

144. The augmentation of water supplies in most of the camps has further highlighted the need for complementary sewerage schemes. The Agency continues to minimize the waste-water problem in each camp through self-help schemes for waste-water drainage, and the host Governments are being persuaded to include refugee camps in their regional sewerage projects. In Jordan, underground sewerage schemes with sewage treatment facilities are nearing completion at Baqa'a, Marka, Zarka and Irbid camps. The surface drainage system at Talbieh camp has been further improved with the assistance of the Government. Owing to the continued hostilities, there has been very little progress in the Lebanon field of operation.

Liquid waste disposal

145. Commendable developments are taking place in the Gaza strip, where flat terrain, sand dunes and depleting sources of water have created some typical problems. UNDP has taken over the task of completing the sewerage and waste-water reclamation scheme of Gaza town. The scheme, which includes utilization of treated sewage for irrigation, is likely to be completed during 1987. There is also a strong possibility that a similar incomplete sewerage scheme for Jabalia district will also receive financial support from UNDP and the United States Community Development Foundation. The Foundation, in collaboration with the municipality, is currently implementing a scheme at Rafah which comprises installation of a permanent sewage pumping station and sewage treatment facility. Under these schemes terminal sewers would be made available to which Beach, Jabalia and Rafah camps could be connected.

Refuse disposal

146. Refuse collection and removal facilities are being improved further with the cooperation of municipalities. In West Bank, contractual arrangements have been made with the municipalities concerned for the introduction of improved services in four more camps. Two skip-lift trucks and matching refuse containers are being procured with a view to generalization of the mechanized system introduced earlier in some camps of the Gaza field of operation. Similar equipment for South Lebanon is also being purchased. The municipality of Dera'a in Syrian Arab Republic agreed in principle to extend improved services to the refugee camp located within its boundary against payment of an agreed fee similar to the arrangement concluded in 1985 for Nairab camp, Aleppo area.

Insect and rodent control

147. Chemical control of rats, mice and domestic f lies is being carried out rather selectively, and attention is being focused mainly on general cleanliness of the environment. Currently Racumin is the rodenticide of choice for the modest rodent control activities in the Gaza, Lebanon and West Bank fields of operation. Owing to its cost-effectiveness Dimethoate continues to be used for fly control operations during the peak season. However residual pyrethroid 25% wettable powder (commonly known as Coopex) is also being used effectively for an abnormal situation in the Lebanon field of operation. DDT proved to be the most effective insecticide for the control of sand-flies in the Jericho area of West Bank, where cutaneous leishmaniasis keeps reemerging from time to time. The problem is contained by a leishmaniasis control program carried out jointly by the Public Health Department, Municipality of Jericho, and UNRWA.

Manpower development

148. To improve supervision in accordance with the growing needs of the environmental health program, a sanitary engineer from Lebanon is under training in the United Kingdom on a WHO fellowship. On completion of his training at the University of Loughborough on a British Council fellowship, an engineer was appointed to a newly created post of Field Sanitary Engineer in West Bank. A civil engineer from the field of operation in Syrian Arab Republic is being considered for an MSc course in sanitary engineering, while a senior sanitarian from the same field is on a seven-month training course in Egypt on a WHO scholarship. In the Jordan and Gaza fields of operation the posts of Field Sanitary Engineer were filled by fully qualified candidates. A WHO-sponsored course conducted at the Center for, Environmental Health Activities in Amman benefited a number of middle-level sanitation supervisors and health educators.


CHAPTER VII

NUTRITION AND SUPPLEMENTARY FEEDING SERVICES

Functions and beneficiaries

149. The program provides nutritional support to vulnerable groups; namely, infants and pre-school children, pregnant women, nursing mothers and tuberculosis patients. Nutritional support is provided through:

- monthly milk distribution to children up to 36 months old, non-breast-fed babies under six months, and pregnant women, nursing mothers and tuberculosis patients;

- daily midday meals to children up to six years of age and, upon medical recommendation, to older children;

- special extra rations to tuberculosis patients, and to pregnant women from the fifth month of pregnancy and for one year after delivery.

Mode of operation

150. The midday meals or sandwiches are prepared in accordance with a menu issued every month and served in 94 supplementary feeding centers. A special diet (the post-diarrhea menu) is also made available to children suffering from diarrhea or malnutrition.

151. In three fields of operation, milk powder is bagged by machine, while in Lebanon and Gaza milk is bagged manually by the supplementary feeding center staff. Distribution of milk rations as well as recording and reporting of issues of rations are the responsibility of the supplementary feeding center staff. As an alternative to bagging of milk powder in the fields of operation, the Agency has made arrangements with the suppliers in Europe to start providing skim milk in one-kilogram bags on trial basis; the procedure will be generalized after the necessary evaluation.

Policy

152. The UNRWA policy is to provide, free of charge, midday meals or sandwiches, extra rations and dry milk to vulnerable groups of Palestine refugees.

Objectives

153. The objectives of the Nutrition and Supplementary Feeding Services are:

- to prevent and correct nutritional deficiencies through the distribution of a midday meal six days a week and through prescribed supplemental diets;

- to overcome protein-calorie deficiency among refugee children;

- to prevent nutritional deficiencies and maintain satisfactory nutritional status of pregnant and nursing women, non-hospitalized tuberculosis patients and other persons selected on medical grounds;

- to promote the nutrition of refugees through effective nutrition education.

Current activities

154. The Agency continued to distribute a special monthly ration to the special hardship cases among the refugees in all fields of operation: about 1900 calories and 61 grams of protein per person per day. About 92 500 persons were receiving this ration.

155. In Lebanon, the program was frequently interrupted owing to the fighting between the various factions. In Gaza and West Bank the program was occasionally disrupted by demonstrations and curfews imposed on refugee camps.

156. UNRWA distributes a monthly ration of whole and skim-milk powder to children from six to 36 months of age and to non-breast-fed infants under six months attending the child health clinics. The distribution of milk during the child health sessions has generated a more regular attendance at the clinics and a greater utilization of the milk. About 81 055 children benefited from the program. In view of the increased number of beneficiaries and the lack of a corresponding increase in the Swiss contribution of whole milk, the Agency was obliged to maintain the monthly issue of whole milk for the children aged six to 24 months at the reduced rate of 300 grams (instead of 500 grams) per child throughout the year. Skim-milk distribution was interrupted occasionally because of shortage of supplies resulting from unforeseen delays in shipment of milk.

157. Nutritionally balanced midday meals are offered daily at the Agency's supplementary feeding centers to children under six years of age and, on medical recommendation, to older children, sick adults and hardship cases. The midday meal was served in the form of a sandwich on most days of the week. This has proved to be more acceptable to the beneficiaries and has resulted in negligible wastage. Fruits were served with the meals. A special high-protein, high-calorie diet (the post-diarrhea menu) was also made available on medical recommendation at the nutrition-rehabilitation clinics and supplementary feeding centers to infants, underweight children and children suffering from diarrhea.

158. Extra rations are distributed twice-monthly to pregnant women from the fifth month of pregnancy and for one year after delivery, as well as to non-hospitalized tuberculosis patients. A total of 34 159 pregnant women and nursing mothers benefited from the program during the year.

159. The Chief of the Nutrition and Supplementary Feeding Division and tile five field food supervisors continued to provide guidance and supervision of the feeding operation in the Agency's vocational and teacher-training centers and maternity centers. Monthly menus are prepared in the fields of operation and are regularly examined.

160. A pilot project aiming at reorientation of the supplementary feeding program, to serve as an intervention program, both preventive and therapeutic, was introduced in September 1986. The project is particularly directed towards malnourished children and those at risk of malnutrition, and provides adequate dietary support, nutrition education of mothers and follow-up of cases. Preliminary observations indicate quick and remarkable improvement of malnourished cases and a receptive attitude to health education by mothers.


* * *

161. Generalization of the scheme, is subject to final evaluation of the project.






APPENDIX I
COMMUNICABLE DISEASES

PART A

INCIDENCE RATES FOR REFUGEE POPULATION IN 1986
(per 100 000 eligible population)





Jordan
West Bank
Gaza
Lebanon
Syrian Arab Republic
All fields of operation
Population eligible for health services as at 30.6.86
750,560
286,312
393,090
235,625
225,261
1,890,848
Brucellosis
Chickenpox
Conjunctivitis

Diarrhoeal diseases:
(0-3 years)
(over 3 years NOS)

Diphtheria

Dysentery (amoebic and bacillary)

Enteric group of fevers

Gonorrhoea

Infectious hepatitis

Influenza

Leishmaniasis (cutaneous)

Measles

Mumps

Pertussis

Scarlet fever

Tetanus (adult)

Tetanus neonatorum

Trachoma

Tubercluosis (respiratory)
0.5
261
1,038


1,628
637

0

113

0.3

0

13

36

0

4.4

161

0

2.5

0

0

1.2

1.2
6.6
633
831


2,086
1,095

0.3

304

0

0.3

67

3,817

0.3

3

274

0

0

0

0

0

4.5
0
660
295


2,389
976

0

314

0

0.2

74

4,008

0

6

290

0

0

0.2

0

0.2

4.6
0.4
662
1,659


4,738
1,660

0

326

1.3

0

5.5

0

0

16

431

0

0

0

0.4

0

8.9
1.3
930
2,620


3,405
1,358

0

972

185

0

160

3,415

2.2

31

799

0.1

39

0

0

0

0.4
1.4
530
1,118


2,452
990

0.05

312

22

0.1

50

1,832

0.3

9

314

0.05

5.6

0.05

0.05

0.5

3.3

N.B.: No cases of ankylostomiasis, bilharziasis, cholera, malaria, leprosy, meningitis, plague, rabies, relapsing fever (endemic), relapsing fever (louse-borne), syphilis, typhus (endemic), typhus (louse-borne), poliomyelitis or yellow fever were reported.



Appendix 1
PART B
INCIDENCE TRENDS OF SELECTED COMMUNICABLE DISEASES
(Rates per 100000 eligible population)





Charts



APPENDIX 2

UNRWA'S NUTRITION AND SUPPLEMENTARY FEEDING PROGRAM, 1985

Type of benefit, its nutritional value,
and average number of beneficiaries

Protein
g/day
Calories
per day
Average monthly
beneficiaries
I. Special hardship rations61.01,881106,500
I. Supplementary feeding programme
A. Milk and hot mealsProtein g/dayCalories per dayAvg. month beneficiaries
Children 0-2 years (dry whole & skim milk)
Children 2-3 years (dry whole & skim milk)
Midday meals
15-30

20.0

18.0
250-700

238

205
30 065 a/

50 211 b/

30 844 c/
B. Extra rations

For pregnant and nursing women

For tuberculosis outpatients
Protein g/day

37.0

61.0
Calories per day

996

1,881
Avg. monthly beneficiaries

34,159

698
C. Vitamin A-D capsules

Total number of capsules distributed during the year: 5,461,542

a/ Includes 1 707 non-refugee displaced persons on behalf of the Government of Jordan (on reimbursable basis).

b/ Includes 1 165 non-refugee displaced persons on behalf of the Government of Jordan (on reimbursable basis).

c/ Includes 779 non-refugee displaced persons on behalf of the Government of Jordan (on reimbursable basis).




APPENDIX 3

UNRWA'S HEALTH PERSONNEL AND FACILITIES

PART A

HEALTH PERSONNEL IN UNRWA
1. Doctors
2. Dentists
3. Pharmacists
4. Assistant pharmacists
5. Nurses
6. Midwives
7. Auxiliary nurses
8. Traditional midwives
9. Sanitation officers
10. laboratory technicians
11. Health education staff
155
21
6
92
125
54
312
38
7
37
23
Other staffs:
Medical
Sanitation
Supplementary feeding
123
125
142
Labour category:
Medical
Sanitation
Supplementary feeding

Total
278
964
421

2,934


a/ Comprises various categories of health auxiliaries and aides who mainly perform administrative and clerical duties in the camps.



PART B

UNRWA HEALTH FACILITIES

Service
Jordan
West Bank
Gaza
Lebanon
Syrian Arab Republic
Total
IOutpatient care
Number of health centres/points
Number of prenatal clinics
Number of child health clinics
16
15
15
32
25
24
9
16
16
20
20
17
21
21
21
98
97
93
IIDental care
A. Subsidized hospitals
Number of health teams
Number of dental clinics
6
10
3
4
4
5
3
4
5
7
21
30
IIIInpatient care
A. Subsidized hospitals
Number of hospitals
Number of beds available
of which:
2
38
5
227
1
2
20
362
5
48
33
695
      general
      pediatric
      maternity
      mental
      ophthalmic
      tuberculosis
25
13
0
0
0
0
88
41
13
75
10
0
0
20
0
0
0
0
208
0
0
144
0
10
48
0
0
0
0
0
389
54
13
219
10
10
B. UNRWA hospitals
Number of hospitals
Number of beds available of which:
0
0
3
42
6
129
0
0
0
0
9
171
      general
      pediatric
      maternity
      tuberculosis
0
0
0
0
28
4
10
0
0
0
59
70
0
0
0
0
0
0
0
0
28
4
69
70
N.B. In Gaza and Jordan refugees benefit from a UNRWA reimbursement scheme.




Appendix 3

PART C

UTILIZATION OF UNRWA HEALTH SERVICES

Jordan
West Bank
Gaza
Lebanon
Syrian Arab Republic
Total
I.Outpatient medical care
Number of patients attending
Total consultations
Injections
Dressings
Eye treatment
Dental treatment
253,811
768,689
141,663
184,270
90,047
68,796
123,676
520,985
145,500
112,022
36,750
35,721
149,920
588,048
416,646
229,261
175,750
35,721
156,150
478.078
105,708
95,571
29,790
20,334
110,807
366,793
93 631
59,839
7,482
42,256
803,364
27222,593
903,148
680,963
339,863
207,681
II.Maternal and child health services
Pregnant women registered
Deliveries attended
Children registered
0-1 years
1-2 years
2-3 years
10,024
11,229

13,331
12,530
13,028
5,898
6,341

5,527
5,846
5,451
18,823
11,651

15,250
13,441
12,038
3,550
3,035

4,222
4,067
3,137
4,215
3,809

5,008
5,704
5,132
42,510
36,065

43,338
41,588
38,786
III.School health
Number of pupils examined a/
22,288
17,212
25,276
7,232
26,296
98,304

a/ Including entry exam and screening.



PART D

CAMP SANITATION SERVICES

Jordan
West Bank
Gaza
Lebanon
Syrian
Arab Republic
Total
I.Water supplies
Population served by private water connection

Percentage

Remaining population served by public point
134,872

66

69,349
78,952

85

13,493
147,200

61

92,846
113,696

81

26,341
46,840

65

25,646
521,560

70

227,675
II.Waste disposal
Percentage of population served by private latrines
99.9
98.2
99.9
95.1
100.0
98.6





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