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Source: World Health Organization (WHO)
5 March 2013


Right to health: Barriers to health access in the occupied Palestinian territory, 2011 and 2012

WHO SPECIAL REPORT

World Health Organization publication number: WHO-EM/OPT/004/E

© World Health Organization 2013

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Right to health: Barriers to health access in the occupied Palestinian territory, 2011 and 2012

WHO Special Report

Right to health: Barriers to health access in the occupied Palestinian territory, 2011 and 2012




Acknowledgments

This study was undertaken in order to examine the barriers to access health care for Palestinians in the occupied Palestinian territory. A presentation based on initial work was first made at the Lancet Palestine Health Alliance Conference in Beirut in March 2012 and the Abstract summarizing preliminary research findings was published in The Lancet in October 2012 --- http://www.thelancet.com/health-in-the-occupied-palestinian-territory-2012. This report presents data through December 2012.

WHO oPt would like to express its appreciation to the Palestinian Ministry of Health and the Palestinian General Authority for Civil Affairs offices in the West Bank and Gaza for their cooperation in providing data and information for this study. Thanks are also due to the East Jerusalem hospitals, the Palestinian Red Crescent Society, and human rights organizations in the West Bank, Gaza, and Israel. Special acknowledgment is extended to the Palestinian patients and families who consented to be interviewed about their experiences in attempting to obtain a health access permit.

This research was carried out by the WHO oPt Right to Health Advocacy project supported by the Swiss Agency for Development and Cooperation (SDC).

The Right to Health and International Law

International Humanitarian Law
“The occupying power has the duty of ensuring and maintaining with the cooperation of national and local authorities, the medical and hospital establishments and services, public health and hygiene in the occupied territory. (…) Medical personnel of all categories shall be allowed to carry out their duties”.

Geneva Convention IV, Article 56

International Human Rights Law
“The States Parties to the Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”.
Article 12, International Covenant on Economic, Social and Cultural Rights

“The Right to Health is comprised of four essential, inter-related elements (1) Availability; (2) Accessibility, both physical and financial; (3) Acceptability; and (4) Quality”.
CESCR, General Comment No. 14

Executive summary

Access to health care is a crucial component of the right to health. Restricting health access violates basic human rights guaranteed by international humanitarian and human rights law. This study examines available information regarding the size and extent of movement restrictions imposed by Israel on Palestinian patients who require access to specialized health referral facilities within the oPt, or to Jordan, Egypt or Israel. These patients are referred either by the Palestinian Ministry of Health (MoH) for specialized treatment that is unavailable in MoH hospitals, or are private patients under other insurance plans, or are self-funded.

The WHO oPt office has monitored referral and access data of patients from Gaza since 2006. This study adds to previous work by examining access for both West Bank and Gaza referral patients and provides a more comprehensive understanding of the particularities of access for Palestinians of both regions of the oPt. The report looks at permit application procedures and the outcome of requests to examine frequency and reasons for denial of permits. It uses interviews with patients and health professionals in the oPt to better understand the range of problems with access.

Palestinian patients depend on access to East Jerusalem’s six non-profit Palestinian hospitals for specialized health services. Patients are referred for critical medical interventions, made more necessary as a result of the blockade of the Gaza Strip since 2007, and restrictions on movement of people and goods from Gaza and West Bank, including restrictions on physicians’ access to continuing training. Drug and disposable shortages due to the financial crisis of the Palestinian Authority have also had an impact on patient referrals. The most frequent reason for referring patients was for oncology treatments (17% of 2012 referrals).

The MoH financed more than 56,000 patient referrals in 2012; 37.1% were to hospitals inside the West Bank and Gaza Strip, 45.3% to hospitals in East Jerusalem, and the remaining to Israel (9.1%), Egypt (5.9%), and Jordan (2.6%).

In 2011, 36.9% of referrals were inside West Bank and Gaza, 40% were to East Jerusalem and 23% to hospitals outside of the oPt.[1] During the two years, applications for permits of 1,783 patients from Gaza and 77,815 patients, patient-companions and patient-visitors from the West Bank (one in five) were denied or delayed.[2]

Obtaining a permit is complicated and difficult, and the uncertainty and last-minute nature of the Israeli response makes the process more stressful for patients and their families. Children can be denied access if their accompanying relative is not approved by the authorities. Gaza patients can be called for security interviews before or during the crossing. In 2012, 206 patients, most of whom were aged 18-40, were called by Israeli security services for an interview as part of the application procedure; in 2011, 197 patients were called.[3]

Restrictions also affected ambulance transfers and the functioning of the East Jerusalem hospitals: in 2011, only 5% of Palestinian Red Crescent ambulances from the West Bank were permitted to enter Jerusalem with their patients, while 95% had to shuttle patients from a Palestinian-plated ambulance to an Israeli-plated one at the checkpoint. This improved slightly in 2012 when 9% of ambulances were permitted direct access into Jerusalem, but almost exclusively from the southern West Bank. As for employees, 1,053 physicians and health workers with West Bank or Gaza IDs who work in East Jerusalem hospitals received short-term permits with conditions limiting how and where they may enter Jerusalem; 21 hospital employees were denied permits to travel to work.[4]

Delays and denials of access violate patients’ right to access and may lead to a deterioration in their health status. While recognising Israel’s security concerns, we hope that the presentation of this information on barriers to health access in the occupied Palestinian territory will be useful in advocacy efforts with duty bearers to ensure that the fundamental right of Palestinians to access health care is protected.

1. Background

Purpose of study

The WHO oPt office has monitored referral and access data of patients from Gaza since 2006. This study adds to previous work by examining data regarding access of both West Bank and Gaza referral patients, and yields a more comprehensive understanding of the particularities of access for Palestinians of both regions to specialized hospitals within the occupied Palestinian territory (oPt) and elsewhere. The report examines permit application procedures and the outcome of requests, using data on applications and responses and interviews with patients, health professionals and administrators in the West Bank, including East Jerusalem, and Gaza.

The number of patient and patient-companion health access permit applications from West Bank residents is higher than for Gaza, reflecting the larger population, as well as more convenient access, greater reliance on private health insurance and on self-funding for health care, and the strong social and historical connections with Jerusalem as a service center. Denials of health access permits affect thousands of persons. The permit regime is an outcome of Israel’s annexation of East Jerusalem, in contravention of international laws, and erection of the separation wall which isolates East Jerusalem from its West Bank environs.

Right to health

Access to health services is a fundamental element of the right to health and hindrances to access can compromise health status. A woman experiencing unforeseen complications in childbirth, a stroke victim in the initial ‘golden hour’ for critical care, a traumatized child with life-threatening burns, all need speedy access to specialized emergency care for which a delay in ambulance transport can be critical. Chronic patients also require timely attention in order to minimize their exposure to increased pain, anxiety and suffering during travel for care and reduce health risk, for example, for kidney dialysis, cancer radiotherapy or chemotherapy treatments, neurosurgery, cardiac disease diagnostics, or for other medical treatment that is unavailable close to home. International humanitarian law and human rights law both uphold the right to health as a basic human right, and particularly call for states to safeguard access to health care, even during conditions of conflict.[5]

Access barriers

Israeli authorities restrict movement of Palestinians between Gaza and the West Bank, between East Jerusalem and the rest of the West Bank, and between rural areas and their traditional service centers. In the West Bank, movement restrictions are implemented through military orders, regulations, policies and practices, as well as physical obstacles such as the separation wall, hundreds of barriers, gates and fences and Israeli settlements and their separate system of road networks. [6] Palestinian patients may travel to East Jerusalem only by permit and are restricted in their mode and point of entry at the 16 checkpoints[7] around the city. Palestinians may also exit the West Bank directly via the Allenby Bridge, contingent on an Israeli permit, as well as a Palestinian passport or Jordanian travel document. In Gaza, there are just two exits for patients, at Rafah to Egypt, and at Erez to Israel and for access to the West Bank, including East Jerusalem, or to Jordan. Israeli authorities have stated that “all security requirements – the checking process at the crossing points, exchanging vehicles or checking them, as well as authorized access permits – are due to legitimate security constraints, taken to protect the lives of Israeli citizens.” (See Addendum, p. 22)

Referrals

Referrals are an important part of the Palestinian Ministry of Health’s public health care system, representing outsourced medical care for certain specialized procedures, treatments, surgeries and tests. They are necessary because of a lack of capacity within Palestinian Ministry of Health hospitals. Sometimes this may be due, for example, to temporary shortage of specific drugs, or to malfunction of medical equipment or unavailability of medical expertise; more often, the expertise and equipment is not available or purchasing the service may be more cost-effective than investing in local treatment.

In the case of Gaza, referrals are more necessary due to the lack of adequate development of the public health care system and quality of care, partly a result of the Israeli blockade of Gaza since 2007 and restricted movement of people and goods. Both West Bank and Gaza physicians and medical students face restrictions on access to continuing training.[8]

The six Palestinian-operated hospitals in East Jerusalem - Maqassed Islamic Hospital, Augusta Victoria Hospital, St. John’s Ophthalmic Hospital, St. Joseph’s Hospital and Princess Basma Rehabilitation Center - have served for decades as the main referral centers for the Palestinian population in the West Bank and Gaza, and the central medical training facilities for Palestinian health professionals. Egypt, Israel and Jordan also provide important referral treatment for Palestinians, both government-insured and private patients.

Permit procedures

In the occupied Palestinian territory, patients with West Bank or Gaza IDs who are referred to East Jerusalem specialized hospitals either by the Palestinian Ministry of Health, or by their private physician, must apply for an Israeli-issued permit to access health care. Patients requiring access to hospitals outside the occupied Palestinian territory, in Israel or in Jordan must also apply for Israeli-issued permits since their access requires passage out of Gaza via Erez checkpoint or travel from the West Bank through checkpoints surrounding Jerusalem.

Gaza patients must submit their referral to the MoH department within the Palestinian General Authority of Civil Affairs (GACA) office in order to apply for a health access permit to travel through Erez checkpoint. GACA sends the application to the Israeli Liaison Office and receives the response which it communicates to the patient. If approved, patients must carry an Israeli-issued identity card, hospital appointment document, referral document and the permit (issued only inside Erez crossing) on their day of travel.[9]

All children, aged 0-17, must be accompanied by a first-degree relative with a valid permit. They undergo the same search procedures as adults at Erez checkpoint, regardless of their medical status. Patient-companions for children, disabled or elderly patients must apply separately for permits.

Gaza patients needing to travel through Rafah to Egypt require an Israeli-issued ID number, referral document and a Palestinian passport.[10] Applying for permits and passports can cause extensive delays for patients. Patient documentation is also scrutinized by Egyptian medical authorities on the Egyptian side of the border.

West Bank patients who need Israeli permits to travel to hospitals in East Jerusalem or to destinations outside of the West Bank must file an application at one of the local offices of the Palestinian General Authority of Civil Affairs (GACA) in the West Bank. The offices are responsible for sending the requests to the Israeli District Coordination Office in their area and receiving the responses. The Israeli procedures for permit applications are not published but are known to involve a number of Israeli authorities, including the Israeli Civil Administration Health Coordination, Israeli Security Services and Israeli police.[11]

Special procedures are required for patients requiring ambulance transfer through Rafah, Erez and Jerusalem checkpoints. The transfer of critical patients for urgent care out of Gaza outside of normal checkpoint working hours (7:30 am to 3:00 pm) or on Saturdays and Israeli holidays is possible but requires additional time, permits, and coordination.[12]

2. Study methods

This is a quantitative and qualitative study of the experience of Palestinians in the West Bank and Gaza who require Israeli approval to access medical treatment or to work in Palestinian hospitals in East Jerusalem. The period under study was 2011 and 2012 in both West Bank and Gaza. [13] The outcome of interest was permit approval; where possible, data were analysed by age, gender and residence location. Data on ambulance access and access for East Jerusalem hospital staff were also examined.

Baseline quantitative data on referral patients were obtained from the Palestinian Ministry of Health, while data on permit applications for patients and health providers were collected from the Palestinian Civil Affairs Offices and East Jerusalem hospitals. Data from the Coordinator of Government Activities in the Territories (COGAT) was also examined. COGAT publishes on its website weekly reports showing the total number of medical patients and companions who crossed through Erez checkpoint. COGAT also publishes the number of West Bank patient and companion permits in an annual report. However, COGAT data does not distinguish between patients and companions and others. Nor does COGAT publish data showing the number of permit applications made by patients which were denied or delayed. COGAT did not respond to a WHO request to provide a breakdown of their data.[14]

Data on ambulance transfers were obtained from the Palestinian Red Crescent Society (PRCS) and Ministry of Health Emergency Medical Services. Health workers and hospital administrators working at the East Jerusalem hospitals were interviewed about access issues for staff and patients. Interviews were also conducted with PRCS emergency service providers and MoH Referral Abroad officials and other health service providers, as well as with the Israeli Civil Administration Health Coordinator, responsible for permits in the West Bank.

In the West Bank, data from GACA, and the Israeli Civil Administration do not distinguish between patients and companions and approval rates differed greatly among districts in both 2011 and 2012. In order to analyze response rates for patients only and overcome these data gaps, a pilot study was conducted in 2012 to examine permit applications and responses from three out of the 15 Palestinian District Coordination Offices of the Palestinian General Authority for Civil Affairs (GACA).[15] Two of the three offices indicated permit approval rates in 2012 above the 79.7% average for the West Bank and so are not representative of all such offices.[16] However, the three offices selected represented 40% of the total patient and patient-companion applications for the West Bank.

In-depth interviews were also conducted with patients and family members who were denied or delayed access to referral care, in order to understand individual experiences with the permit system and impact of treatment delays on health and well-being.[17] In cases of deaths reported in Gaza of patients who died while waiting to access treatment, families were interviewed to identify if there was an association with access delay.

Data Gaps

Data from all sources were limited by gaps in quality and comprehensiveness, and especially by: the lack of detailed patient information recorded on permit applications and responses to applications; patients’ underreporting of calls for Israeli security interviews; and families underreporting of deaths of patients waiting for health access. Discrepancies were also noted in accuracy of information on referrals and permits in the West Bank and in Gaza, due to different systems and criteria for reporting; this is noted in tables and text where relevant.

There is some discrepancy between the data on West Bank permits provided by the Palestinian GACA and by the Israeli COGAT. This is because the GACA data relate to patients, companions and visitors who apply through them for permits, while the COGAT data may include permits issued to Palestinians who apply directly to COGAT. However, COGAT does not provide any breakdown of their data so we were unable to use it for analysis. The Israeli Civil Administration authorities infrequently give reasons for the denial of permits. When these reasons were given, this information was noted, usually due to ‘security’, ‘treatment available locally’, or an administrative error in submission.

The Ministry of Health does not track its referral cases to see if patients attend their appointments. Not all patients who have been denied permits report back to the Ministry for a change in referral destination, or for a new referral document for a repeat application for a permit, and data is not systematically gathered on those who do return. Nevertheless, efforts were made through community organizations and local health providers to identify patients and families willing to be interviewed for the study. Interviews remain ongoing.

In Gaza, the Palestinian General Authority for Civil Affairs office provided some data regarding delays in access, such as the number of patients called for security interviews, or of patients asked to change their accompanying companion, as a condition for processing the application. It is likely that calls for interviews are underreported since patients are sometimes called at home directly by the Israeli General Security Services and asked to report for interview, or sessions can take place during the patient’s crossing at Erez.

Data on the detention of patients at Erez is usually reported by human rights organizations who have been notified by the family and asked to follow up the whereabouts and condition of the patient. When possible, patients or families were interviewed regarding the circumstances of the patient’s detention.

In Gaza, deaths of patients waiting for referral are reported only by families who have sought redress through human rights organizations, lawyers or the media and therefore are also likely to be underreported. In the West Bank, deaths of patients are not systematically reported as such.

3. Findings

Summary data on referrals and access (Tables below and in Annex.)

In the oPt in 2012, a total number of 33,469 patients who were referred by the Ministry of Health from the West Bank (24,385) and Gaza (9,084) to specialist hospitals required Israeli permits to access medical treatment. Of these referrals, 80% were within the occupied Palestinian territory, 15% were to Israel, and 5% were to Jordan, including 41 from the West Bank to Egypt via Jordan. Of referrals within the oPt, 20,647 were West Bank-to-East Jerusalem, 4,734 were Gaza-to-East Jerusalem, and 1,475 were Gaza-to-West Bank. In addition, 3,254 Gaza patients were referred to Egypt and required permission from border officials.[18]

Permits are difficult to obtain. While there is no published eligibility criteria for obtaining a permit, data collection and interview findings indicate that factors which appear to affect eligibility include age, sex, residency, civilian status, timing of travel, kind of medical treatment needed, and family relations, in addition to unexplained ‘security’ reasons of Israeli authorities.

In the West Bank, a total of 222,188 applications for health access permits were submitted by West Bank residents in 2012, according to data from Palestinian GACA, which lumps together applications by patients, patient-companions and family members requesting to visit patients.[19]

Of this total, 177,051 permits were granted, for an overall permit approval rate of 79.7%.[20]

Of those not approved, 17.6% were denied (39,196 applications) and 2.7% of applications (5,941) did not receive a response in time to access their medical appointment.[21] Approval rates were found to vary among the 15 West Bank GACA district offices, ranging from 74.9% to 92.3% with eight districts reporting approval rates below 80%. In 2011, the approval rate was higher, at 81.4% and applications were 27% fewer.[22]

In Gaza, a total of 10,560 applications for health access permits were submitted by Gaza residents in 2011, according to data from the Palestinian GACA. A total number of 9,478 permits were granted, representing a permit approval rate of 89.8%, while 2.2% were denied (237 patients) and 8.0% (845 patients) did not receive a response in time to access their medical appointment. In 2012, 9,329 were submitted, and 8,628 were granted for an approval rate of 92.5%; 84 were denied, and 617 delayed.

In 2011, 37.4% (3,949) of Gaza patients applying for permits to exit through Erez were children, aged 0-17; 95.6% were approved and 4.4% were denied (3) or delayed (171). In 2012, from January to April, 38.8% of patients applying for permits were children (1,195); 97.2% were approved and 2.8% (33) were delayed and missed their appointments, according to Gaza DCO statistics.

In 2011, 13% (1,378) of Gaza patients applying for permits were elderly (over 60 years of age); 0.4% (6) were denied and 4.7% (65) were delayed. In 2012, from January to April, 465 elderly patients applied, and 447 (96.4%) were approved and 18 (3.8%) were delayed and missed their appointment.






Case 1: 16-year-old child crosses checkpoint for dialysis

Mohammed suffers from kidney disease and must access dialysis treatment in Jerusalem via checkpoint three times per week. His younger brother also undergoes dialysis twice weekly at another hospital in Jerusalem.

His family relocated from the northern West Bank to a village outside Jerusalem to make his travel easier. His father travels with his sons and finds it extremely difficult to have steady employment.

Vulnerable groups

1. Children. Access for children, aged 0 to 17, is dependent on their companion being approved for a permit.

Companions must be a ‘first-degree’ relative, usually mother or father, or siblings. Only in exceptional cases are other persons accepted. Mothers below the age of 39 and fathers are the most frequently denied permits. Israeli authorities may ask the family, through the Palestinian DLO, to submit the name of an alternate companion, if the first one is refused. However, because this often occurs one day before the hospital appointment or even days after the hospital appointment, the child is delayed medical treatment while a new appointment is made with the hospital and a new companion seeks permit approval. For critically ill children who require timely care such as surgery or scheduled chemotherapy or radiotherapy, delays can be life-threatening.

2. Patients with physical disabilities and the elderly infirm. Persons with disability or older persons who need assistance or support are allowed to have a patient-companion, also a first degree relative, but can also be delayed if their chosen companion is denied a permit.

3. Patients requiring donors. Patients who need blood or organ donors require prospective donors to have timely access to testing centers and transplantation treatment centers. This requires complicated procedures for the correct travel documentation for multiple members of a family, and Israeli permits, if through Erez.

4. Gaza patients aged 18-40. Patients aged 18-40 are most likely to be called for security interview, and to be denied a permit, or delayed. In 2011, males aged 18-40 represented 11% of total applicants, but 29% of those denied permits or delayed, and 39% of those called for interrogation; female patients in the same age group represented 11% of total applicants and 18% of those denied or delayed, and 24% of those called for interrogation. Five male patients with valid permits were detained in 2011 and in early 2012 when they tried to cross Erez for their appointment; one patient was detained on his return trip to Erez after treatment.

5. Patients with a ‘security file’. No explanation is provided by the Israeli authorities to patients who are told they are denied for reasons of ‘security’. No criteria for the decision could be determined: while some had been detained with or without charge at some time in their life, other patients denied had never been detained and had no awareness of having a security problem. The pilot study in the West Bank shows that 39.7% of all denied patients received their denial because of ‘security’.

West Bank patient access applications - sample survey results

In a sample survey of health access of patients from the West Bank, data was examined for January through April in 2012 from three of the fifteen district level Palestinian coordination offices. The offices were selected based on the 2011 volume of approvals reported and permit approval rates. The three offices together represented almost 40% of permit applications submitted during the period by West Bank residents, both patients and their companions, and 35% of the volume in 2012. Data was disaggregated to examine the results for patients only.

Total volume of patient applications for the 3 offices January to April 2012 was 12,563, of which 10,362 were approved (82.5%) and 2,100 (16.7%) were denied and 101 (0.8%) did not receive an response in time for their hospital appointment; most patients were seeking access to East Jerusalem hospitals. 39.7% of denials were for reasons of ‘security’, according to responses by the Israeli Civil Administration, ranging from 22.0% to 54.0% of all denials. No criteria could be determined for the Israeli Civil Administration’s reasons for denial on basis of security.


Problems in permit procedures

1. Lack of transparency. The criteria for approvals or denial of permits are not transparent, and were found to be inconsistent and unpredictable: patients who had been previously approved may receive a subsequent denial, or a patient denied may be granted a permit on a subsequent application, even within a short period.

2. No right of appeal. One in five West Bank applicants are denied health access permits (with rates varying from 7% to 30% in 2011 and 8% to 25% in 2012 among the 15 district offices) or delayed and forced to miss their medical appointments. There is no administrative process whereby patients who are denied permits can appeal the decision of the Israeli Civil Administration, or seek an explanation of the denial. The only choice is to submit another permit application to the Israeli authorities or to accept less specialized care locally.

3. Complex process. The process of applying for a permit can be very burdensome, and can involve additional cost in traveling to the Palestinian District Liaison Office to submit supplementary papers. Different district offices of the Israeli Civil Administration may ask a patient to provide the original appointment letter from the East Jerusalem referral hospital, which, of course, the patient cannot obtain from the hospital without a permit.

4. Security interviews. Of patients who applied for a health access permit, 1.8% (197 patients: 149 men; 48 women) in 2011 and, 2.2% (206 patients: 141 men; 65 women) in 2012 were called for security interviews.[23] This may deter patients, especially men aged 18-40, from applying for a permit through Erez. Physicians for Human Rights-Israel have documented cases of patients who were pressured to give information to the authorities about other persons during the interview session and who were denied permits when they refused. There are no cases documented of West Bank patients being called formally for security interviews.

5. Effect on health status. Patients who were denied permits or who did not receive a response from the Israeli Civil Administration authorities may suffer deterioration of their health and wellbeing as a result of delay in needed specialized treatment. Six Gaza patients died in 2011 while waiting for health access permits.

Case 2: Elderly disabled man denied permit 6 months

Amr Khattab, 70 years old, is from a Jerusalem area village that has been isolated from Jerusalem since the 2007 completion of the separation wall.

Khattab had been employed in Jerusalem and traveled to the city daily until his retirement 15 years ago. In October 2011, Khattab was referred by the MoH to Makassed Hospital for knee surgery which was complicated by his chronic heart condition. He applied for a permit and on three successive occasions, he received assurances by phone from the Israeli Civil Administration that his permit was waiting at Qalandiya. Each time he made the trip to the checkpoint but did not receive his permit.

Khattab finally received a permit and entered Jerusalem in April 2012, more than 6 months after his initial hospital referral, and after follow up by the MoH and Palestinian Liaison office with Israeli Civil Administration officials. He knew of no reason why he was not granted a permit earlier.





Fewer denials of Gaza patients

WHO data since 2006 indicate that Israeli approval rates of Gaza patient permits have varied significantly but rates have improved in recent years, returning to the level of early 2006 when 90% of permit applications were approved.

Approvals dropped to 82% in 2007 and 61% in 2008, before rising to 68%, 82% and 90% between 2009-2011.[24]

In 2012, approval rates rose to an historic high of 92.5%, although the data still highlights the uncertainty for patients seeking care outside Gaza who need Israeli permits to exit via Erez crossing.

A historical review of the responses to Gaza patients applying for health permits indicates that approvals decrease sharply during times of political turbulence. Three periods of low approval rates are noteworthy:

The steadily rising approval rates over the last three years may be due in part to WHO engagement with the issue, including advocacy efforts and regular meetings with the Israeli authorities in charge at Erez, who have made successful efforts to reduce the number of denials and delays. It may also be partly due to patients’ self-selection and the absence of ‘discouraged’ groups such as males, aged 18-40, ex-prisoners and political activists, who may prefer to exit Gaza to Egypt for more accessible medical care. 30% of outside referral patients from Gaza were referred to hospitals in Egypt in 2012. From 2008 to 2011, the numbers of patients exiting Gaza through Rafah to Egypt more than doubled, from 1,385 to 3,254.[25]

Case 3: Gaza child dies after delayed health access

On June 12, 2011, Lutfi presented to the primary health care clinic in Shejaiya, Gaza, with a sore throat and rash. The PHC referred him to Shifa hospital where he was admitted the next day, bleeding through his nose. CBC and marrow biopsy showed abnormalities in his blood and bone marrow. He was given blood and platelets transfusions. On June 18, he was given a referral to Augusta Victoria hospital (AVH) in Jerusalem for diagnosis and began the process of applying for a permit.

On July 3, Lutfi traveled through Erez and was admitted to AVH where a diagnosis of aplastic anemia was confirmed. He developed fever and was treated and received irradiated blood and platelets in view of his weakened immune condition. AVH contacted Hadassah Ain Karem for bone marrow transplantation but there were no available beds. In addition, they needed a readily available matching donor.

On July 13, Lutfi was discharged from AVH and returned to Shifa hospital in Gaza to wait for his new referral papers to Egypt, for donor matching and marrow transplantation. On July 19 he received the referral along with 5 family members for donor matching, but they required new passports to be processed. In the meantime, Lutfi received blood which was not irradiated since Gaza lacks this equipment.

On July 27, 9 days later, and in a deteriorating condition, Lutfi and family travelled by ICU ambulance to the border. There they waited 4 hours for the arrival of the Egyptian ambulance (not ICU). His condition worsened enroute to Cairo and he was admitted to el-Areesh hospital where he died 30 minutes later.

Access for ambulances into East Jerusalem

Palestinian ambulances are stopped at checkpoints for searches, examination of documents and may be refused entry to the checkpoints. The coordination of access for patients travelling by ambulance to Jerusalem is made between the referring hospital in the West Bank, the referral hospital in Jerusalem, and Israeli Civil Administration authorities, who will assign a checkpoint for the transfer.[26] Even in extreme emergencies West Bank-licensed ambulances are permitted to enter Jerusalem checkpoints only exceptionally, when prior approval has been given by the Israeli Civil Administration, and checkpoint personnel also approve. The most frequented checkpoints are: Bethlehem and Tunnels (South); Hizma and Al Zayyem (East) or Qalandiya (North) in the Jerusalem periphery.

In 2011, ambulances were permitted to enter Jerusalem on only 49 (5%) occasions out of 1,074.[27] Access through Qalandiya checkpoint in the north of East Jerusalem was especially problematic. Only 0.4% of all PRCS ambulances were allowed access through Qalandiya, in contrast to the daily, frequent access granted for Palestinian public transport busses between Ramallah and East Jerusalem.[28]

In 2012, only 116 of 1,292 ambulances (9%) were allowed access to East Jerusalem. Almost all occurred at the Bethlehem checkpoint: 105 via Bethlehem, 10 via Ramallah and 1 from the eastern checkpoint at Hizmeh/Zayyem. Most patients must be shuttled on gurneys between ambulances at checkpoints in a procedure known as ‘backto-back’ transfer. The policy has been criticized by emergency services personnel for causing delay of medical treatment and depriving patients of privacy and dignity.

Access for ambulances out of Gaza

About 50 Gaza referral patients require ambulance transfer monthly. Palestinian ambulances are not permitted to directly transfer patients out of the Gaza Strip but instead must shuttle patients over a distance of approximately 200 meters between a Palestinian and an Israeli ambulance at Erez checkpoint. The Israeli authorities require the ambulance staff to have prior approval in order to be allowed to transfer the patient on a gurney to the Israeli ambulance. The patient’s companion is not permitted to travel with the patient through the crossing; they must be processed through the regular terminal procedures and rejoin the patient on the other side.

Ambulance transfer can be quite costly and, while the MoH covers ambulance costs for patients that are critically ill, need oxygen support or are not ambulatory, other patients needing ambulance transport must bear the costs themselves.[29]

Access for East Jerusalem hospital staff

Two-thirds of the 1,598 hospital staff of the six East Jerusalem Palestinian hospitals hold West Bank IDs and require Israeli-issued access permits to travel to work.[30] In 2011, 1,053 staff applied for permits (202 physicians, 494 nurses, 149 administrative and 208 other staff); 1,033 were approved and 21 were denied. 46 of those approved were limited to 3-month permits (all of the 14 Gaza staff and 32 West Bank staff). In 2012, of the 1,140 staff applying, 5 were denied and 17 received 3-month short-term permits. Physicians may enter any checkpoint with their permits.

Gaza patient deaths following denial or delay of health access permit, 2011
  • WHO identified six patients from Gaza who died after their request for a health access permit to exit Gaza in 2011 was denied or no response was received prior to their hospital appointment, delaying medical treatment.
  • A 2-day-old infant died after the mother, who was a high-risk delivery (polyhydramnios), applied for a permit for herself and a companion to Makassed Hospital in Jerusalem, and three different companions were denied permits. The woman delivered in a Gaza hospital but the infant died on the second day of life.
  • A 45-year-old man with lung cancer died after his request for a permit for surgery in Jerusalem’s Makassed Hospital was not answered in time for his appointment, and he was told to make a new appointment. His family decided to change the referral destination to Egypt, where he was treated but he contracted Hepatitis B from blood transfusions. After returning to Gaza, his health began to slowly deteriorate, he became hemiplegic and depressed. He died on July 18, 2011, from severe bleeding and infection.
  • A 33-year-old male patient with ischemic heart disease was denied two successive urgent applications for a permit during one week. He was admitted to Shifa hospital in critical condition on July 25 and emergency surgery was performed, but he died in the operating theatre the same day.
  • A 54-year-old man suffering from stomach cancer applied for a permit to Augusta Victoria Hospital in Jerusalem but was denied, with no explanation given. The family applied to change the destination to Egypt but his condition had deteriorated. He died in the terminal at the Rafah border, while waiting for processing, and before he could access treatment.
  • A 20-year-old man who suffered from a rare hepatic vascular obstructive disease (Budd-Chiari syndrome) submitted an application for a permit for treatment at Makassed Hospital in Jerusalem. The patient was asked to attend a security interview scheduled 4 days after the date of his hospital appointment. His condition deteriorated while waiting and he was admitted to Shifa Hospital in a semi-coma and in critical condition. Another urgent request was made but no response was received. He died on January 1, 2011, 3 weeks after his first application.
  • A young child, aged 3.5 years, who had suffered from meningitis since the age of 6 months, was denied a permit after her father was denied a permit as her companion, to Tel Hashomer Hospital in Israel. The mother then applied as her companion but no response was received and the child died 2 weeks after the mother’s application. (One week following her death, the family was informed that permits for the child and her mother had been approved.)

Restrictions on permits

1. One-day validity. Patients’ permits are valid to travel only on the date of hospital appointment. Patients must enter checkpoint only on foot, in an ambulance, in an Israeli-plated car, or by special hospital shuttle bus.

2. No choice of checkpoints. West Bank patients generally enter East Jerusalem only at 3 specified pedestrian checkpoints (Qalandiya-north; Zeitun-east; and Bethlehem-south), out of the 16 checkpoints around Jerusalem. The additional costs of travel through out-of-the-way checkpoints can present a barrier for some patients who require health care. These particular checkpoints can be very crowded, especially in early morning, and delays can be considerable.

3. For the very ill, elderly, and disabled, negotiating a checkpoint turnstile, long waiting times in extreme heat or cold weather can be difficult and stressful. Checkpoint personnel or soldiers may also order body searches of patients, especially patients travelling with medical aids or equipment such as oxygen tanks[31]

4. Arbitrary denial at checkpoint. Case studies have shown that patients may be denied access through a checkpoint by checkpoint personnel, or the checkpoint may be closed without warning.

East Jerusalem referral hospitals serve West Bank and Gaza

In East Jerusalem, six Palestinian non-profit hospitals provide secondary and tertiary care, employ almost 1,600 employees and had a total number of 612 beds in 2012, 11.3% of the total number in the oPt. The hospitals have developed historically as the main Palestinian referral centers serving the West Bank and Gaza population; in 1997 they formed the East Jerusalem Hospitals Network (EJHN) to promote coordination and cooperation of their services. The EJHN offer quality specialized services unavailable elsewhere in the oPt, such as pediatric dialysis and oncology chemotherapy and radiation therapy (Augusta Victoria Hospital), the only East Jerusalem 24/7 emergency services and open-heart surgery (Makassed Hospital), specialized neurosurgery (St. Joseph Hospital), comprehensive eye surgery (St. John Ophthalmic Hospital), obstetric care (Red Crescent Maternity Hospital) and comprehensive rehabilitation services (Princess Basma Center).

The East Jerusalem hospitals are an important component of the Palestinian health care referral system, serving patients whose care is financed by the Palestinian Authority and by UNRWA, patients with private insurance, those who are self-funded as well as a substantial number of charity cases.

The East Jerusalem hospitals are the main destination facilities for Palestinian patients referred by the MoH for treatment outside the West Bank and Gaza; almost 70% are referred to EJH. MoH referrals have more than doubled in 5 years from 10,223 patients in 2007 to 25,381 patients in 2012, an indicator that the services provided by East Jerusalem Hospitals continue to be significant for Palestinian health service provision inside oPt.

Makassed and Augusta Victoria hospitals are the major referral centers for Palestinians: the two hospitals served 81% of MoH referral patients to East Jeursalem in 2011. In the first six months of 2012, the largest group of West Bank referral patients to East Jerusalem was females in the 18-40 age group, who were referred to Makassed hospital, while for Gaza the largest group was male children in the 0-3 age group, also to Makassed.


4. Conclusions and recommendations

Data findings show how movement restrictions hinder health access for Palestinians. The Israeli Civil Administration (ICA) denied health access, or delayed responding to requests, to one in five Palestinian patients and patient-companions in the West Bank seeking referral health care in 2011 and 2012. In a pilot study carried out in 2012, the single most frequent reason for denying patients a permit was ‘security’. It was not possible to triangulate data with other sources.

One in 10 Gaza patients was denied or delayed permits to access medical care through Erez checkpoint in 2011; male patients, aged 18-40, were least likely to receive approvals. While approval rates for applications in recent years have risen, this may partly be due to ‘discouraged patients’, that is, patients choosing not to apply for permits to avoid delays, security interviews, and eventual denials. In 2012, only one in 13 Gaza patients were denied or delayed, an improvement in access over 2011 but still indicating a significant problem for an especially vulnerable population.

This study supports the following recommendations as being important to promoting and protecting the right to health in the oPt. WHO calls on duty bearers to protect access to health care as an international legal obligation.

Government of Israel

1. Humanitarian access should be available 24/7 and without delay for all Palestinian patients requiring specialized health care, including exit out of Gaza and access into Jerusalem.

2. Registered ambulances should have direct access through Jerusalem checkpoints to East Jerusalem hospitals.

3. Permit application procedures should be clear, consistent and predictable to all parties and criteria for permit approvals must be written and publicly accessible.

4. Israeli permit personnel should not interfere in health care decisions, including the Ministry of Health’s choice of destination hospitals for patient referrals.

5. Reasons for denial of a health permit should be made in writing and delivered to the patient. There must be a clear and speedy mechanism for appeal of a denied permit.

6. East Jerusalem hospital personnel should be issued long-term permits to access their workplace.

7. Patients needing frequent treatment sessions, such as cancer patients, should be facilitated with timely access.

8. Health professionals in Gaza and the West Bank require access to continuous medical education and opportunities for upgrading skills through training and conferences which is necessary for patients to enjoy the highest sustainable standards of health.

Palestinian Authority

1. The provision of adequate and equitable supply of all essential drugs and medical disposables should be ensured to all MoH hospitals and primary health care centers in the West Bank and Gaza.

2. A mechanism should be established for financial support to poor patients who cannot afford the out-of-pocket costs of the referral process (transportation and daily living costs in hospital; tests and medicines).

3. A help line should be created to support patients who encounter difficulties in the referral process and an effective system should be established to receive and address patient’s complaints.

4. A monitoring system should be established to ensure smooth functioning of the referral process for patients and to detect any problems or rights violations.

Government of Egypt

1. Humanitarian access should be available 24/7 and without delay for all Palestinian patients requiring exit out of Gaza through the Rafah border.

2. Palestinian referral patients from Gaza should have prearranged appointment dates for hospital admission, or immediate hospital review of documents and placement in Egyptian health facilities on the same day, rather than be forced to wait for up to one month for treatment.

Addendum

Comments by Israeli Authorities

WHO shared a draft of this report with the Israeli authorities requesting comments and seeking possible solutions. The following summarizes the comments received:

“All security requirements - the checking process at the crossing points, exchanging vehicles or checking them, as well as authorized access permits - are due to legitimate security constraints, taken to protect the lives of the Israeli civilians.”

“The weekly report of the Coordinator of Government Authorities in the Territories (COGAT) includes the total number of people who crossed through the terminals, how many of them were patients and medical escorts, how many were international organization staff, merchants, businessmen, etc. There is a data gap between the WHO Special Report “Rights to Health: Barriers to health access in the occupied Palestinian territory”, and COGAT’s data,

which raises the issue of whether the Report was not balanced.”

[The differences between the data on permit applications in the report and that published by COGAT are explained in the body of this report - see the sections on Study Methods (page 9) and Data Gaps (page 10).]

“In 2012, the known trends in the coordination and liaison area in general and specifically in the health field have been maintained and even strengthened. On a daily basis, COGAT carries out - via the Civil Administration and the Gaza DCL - hundreds of lifesaving medical coordination actions.”


Endnotes
1Health Annual Report Palestine 2011, Ministry of Health, Annex 187. http://www.moh.ps/attach/440.pdf There is some discrepancy in data on Gaza referrals between MoH Gaza and MoH
Ramallah figures, reflecting financial coverage decisions.
2All health permit applications in three districts during four months in 2012 were disaggregated in order to examine patients-only data. Findings were 16.7% of patients were denied and 0.8% delayed.
3General Authority of Civil Affairs Gaza office, January 2012.
4Data as of November 2011, provided by members of the East Jerusalem Hospital Network.
5For the main Right to health legal protection frameworks, see: Geneva Convention IV, Article 56; International Covenant on Economic, Social and Cultural Rights, Article 12; CESCR General Comment No. 14.
6A total of 542 physical obstacles restrict movement in the West Bank, according to OCHA, http://www.ochaopt.org/documents/ocha_opt_movement_and_access_report_september_2012_english.pdf
7Ibid.
8During the first 4 months of 2012, MoH requested permits for 47 staff (midwives, physicians and nurses) to exit Gaza, of which 19 received no answer and missed their scheduled activity. In a
WHO telephone survey in February 2012, health professionals reported having increasing difficulty since 2000 in obtaining permits to leave Gaza, with some exceptions. Especially after the Israeli
war on Gaza in 2008, it was difficult to obtain permits for their employees, trainers or consultants to enter Gaza to provide continuing training within Gaza.
9Permits are issued only for travel on the day of the patient’s hospital appointment.
10An Israeli-issued ID number is required to obtain a Palestinian passport. To facilitate access to services within Gaza, the Ministry of Interior in Gaza issued approximately 12,500 “temporary” Palestinian ID cards for Gaza residents who are not included in the Population Registry. The number of residents without IDs is likely to be much higher, according to the Norwegian Refugee Council, Fact Sheet: Undocumented and Stateless, March 2012.
11Interview with Israeli Civil Administration Health Coordinator (November 18, 2011).
12During January to April 2012, an average of seven emergency ambulance transfers were conducted each month outside of regular Erez crossing hours, for which special coordination is needed.
13MoH summary referral data covers the period January to June 2012, unless specified otherwise.
14COGAT, part of the Ministry of Defence, is responsible for implementing Israeli policy in the West Bank and Gaza. This report refers to the Israeli Civil Administration office in the West Bank and the District Coordination office in Gaza which are the part of COGAT that process permit applications.
15GACA consolidated their offices from 16 to 15 between March and April 2012.
16The range was 69.6% to 92.5% in 2011, and between 74.9% and 92.3% in 2012.
17Interviewees were selected on the basis of convenience sampling, and gave informed consent. Kidney dialysis patient, Nasser Hospital, Khanyounis, September 2012 - Photo: WHO.
18Palestinian National Authority; MoH, Health Report, Palestine, 2011: http://www.moh.ps/attach/440.pdf A gender gap was noted in Gaza referral referral patients 2011.
19West Bank GACA annual figures 2012.
20GACA records only applications submitted through their offices. An unknown number of West Bank residents submit applications directly to Israeli Civil Administration authorities.
21Israel’s Coordinator of Government Activities in the Territories (COGAT) 2011,1 Summary Report, page 16: “In 2011, 197,713 healthcare permits were issued for people in need of medical care and their companions, representing an increase of 13% in comparison with 2010 figures:” http://www.mfa.gov.il/NR/rdonlyres/72A0201C-EB02-4291-BA00-81935D8C15D9/0/COGAT2011 Summary.pdf. For an explanation of the differences between the figures, see page 9.
22According to Gaza GACA data for Erez crossing, 85% of patient applications for permits are MoH referrals. In the West Bank, GACA does not record information on whether applicants receiving permits are MoH referrals or private patients, or are patient family members requesting permits to accompany or visit patients. In 2012 WHO disaggregated data for health access applications at three GACA district offices and determined that 40% of applications were submitted by patients as opposed to others.
23DCO Gaza.
24WHO health access database.
25Palestinian National Authority, MoH, Health Report, Palestine, 2009: http://www.moh.ps/attach/19.pdf and Palestinian National Authority, MoH, Health Report, Palestine, 2011: http://www. moh.ps/attach/440.pdf; MoH Ramallah, 2012 data. Photo: WHO.
26PRCS reported 140 ambulances in operation in the oPt during 2011. 9 ambulances are operating out of the East Jerusalem substation (5 belonging to PRCS and 4 to the Red Crescent Maternity hospital). PRCS monthly updates and Annual Report 2011: http://www.palestinercs.org/reports/Anual%20Report%20English%202011.pdf27http://www.palestinercs.org/reports/Anual%20Report%20English%202011.pdf The figure of 78 out of 1533 occasions published in the PRCS Annual Report was later revised to exclude double counting, and is reflected here. A written agreement between the Israeli EMS-provider, Magen David Adom, and the main Palestinian EMS-provider, the Palestinian Red Crescent Society, was drawn up in 2005 to facilitate access for ambulances in the West Bank “Memorandum of understanding between Magen David Adom in Israel and Palestine Red Crescent Society” (MoU) and Agreement on Operational Arrangements between Magen David Adom in Israel and Palestine Red Crescent Society” (AoA), signed November 28, 2005.
28Data on ambulance access by checkpoint is from WHO communication with PRCS.
29Information brochure (in Arabic). Palestinian District Coordination Office (Pal DLO) in Gaza, 2011.
30In November 2011, the six hospitals of the East Jerusalem Hospital Network reported a total of 1,598 employees: 545 from Jerusalem and 1,053 from the West Bank (1,039) and Gaza (14).
31WHO oPt (http://www.emro.who.int/pse/information-resources/noor-h-checkpoint.html)


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