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SIXTY-SECOND WORLD HEALTH ASSEMBLY
Provisional agenda item 14
A62/24
7 May 2009


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


Report by the Secretariat


1. Between January and October 2008, 45 Palestinians were killed in the West Bank and 389 Palestinians in the Gaza Strip.1 During the latest conflict in
the Gaza Strip between 27 December 2008 and 18 January 2009 another 1380 Palestinians were killed, of whom 431 were children and 112 women.
2 At least 5380 people were injured, including 1872 children and 800 women. Among the casualties, 16 health staff were killed while on-duty and 25 injured.2 Resolution WHA61.3 requested the Director-General to submit a fact-finding report on the health and economic situation in the occupied Palestinian territory, including east Jerusalem, and in the occupied Syrian Golan. That report is attached at Annex.

2. Despite the rise in life expectancy over recent years, progress towards the attainment of the health-related Millennium Development Goals has stagnated. Figures for infant and child mortality until 2007 remained virtually unchanged.

3. Chronic malnutrition and associated micronutrient deficiencies remain a public health problem in the occupied Palestinian territory. More than 30% of the overall burden of disease among adults is caused by noncommunicable diseases.

4. In June 2007, a new emergency Government was established, sanctions against the Palestinian Authority were lifted, and international aid resumed. However, internal closure, the permit system, collapsing infrastructure and acute shortages of power, water and food continue to affect the health of the majority of the population of 1.4 million in the Gaza Strip.

5. WHO, as the technical advisory agency to the Health Sector Working Group chaired by the Palestinian Minister of Health, provides technical support to the 13 central and district health coordination bodies that involve local and international nongovernmental organizations, organizations of the United Nations system and local authorities. The Organization has held monthly meetings to inform partners about health status, delivery of health services and response to emergency situations.

6. The Organization plays an important role in providing support to the Palestinian Ministry of Health in collecting and interpreting health information and coordinating activities with other international agencies. WHO has been active in collecting, compiling and disseminating information on the humanitarian health situation and response activities, and on the status of health facilities and the availability of medical supplies, in order to support decision-making, advocacy and emergency response. This has included activities such as monitoring health status and services, developing a health facilities database and preparing joint responses with other stakeholders and the Ministry of Health.

7. Towards the end of 2008, the health cluster approach was launched in the occupied Palestinian territory. It was operationalized in January 2009, when a health cluster coordinator was deployed in Jerusalem and the Gaza Strip in order to lead the humanitarian health response to the crisis in the Gaza Strip and consolidate the work with international and local partners. The Organization deployed a number of staff from headquarters and the Regional Office for the Eastern Mediterranean to support the WHO team in the occupied Palestinian territory. The initial health assessment prepared jointly by the health cluster was one of the first major outcomes of the cluster approach.

8. The Palestinian Ministry of Health, with WHO’s support, set up an emergency operations room in Ramallah in order to coordinate the response to the health crisis. It maintained regular contact with the Central Drug Store in the Gaza Strip in order to: assess immediate needs (e.g. for pharmaceuticals, consumables, equipment and spare parts); map supplies that had been delivered or were in the pipeline from the international community; and issue daily updates of current needs. WHO resumed responsibility for organizing and delivering all supplies from the West Bank and Israel.

9. The Organization plays a wide-ranging role in advocacy for health. The work involved covers both the general health situation and advocacy on particular topics (e.g. access to health and mental health). Much of the advocacy work is conducted through dialogue with relevant stakeholders such as the Palestinian Ministry of Health, the Israeli authorities, other United Nations agencies, nongovernmental organizations and donors.

10. WHO supported the Health Planning Unit within the Ministry of Planning through an adviser provided full-time from August 2007 to July 2008. The Unit was successful in preparing the 2008–2010 National Strategic Health Plan, which was issued and endorsed in early 2008. The Unit also played a crucial role in finalizing project proposals from all Ministry of Health directorates, units and departments as a basis for allocating resources pledged at the International Donors’ Conference for the Palestinian Authority (Paris, 17 December 2007).

11. WHO took the lead in preparing the health component of the 2009 interagency Consolidated Appeals Process. The overall objectives, agreed in coordination with more than 20 partners, were as follows: to ensure essential services are provided, especially to vulnerable groups; to strengthen the coordination of the humanitarian health response; and to advocate for health as a human right. WHO, through the Health Cluster Coordinator, also took the lead in preparing the health component of the Gaza Flash Appeal 2009. As a result of the integration of the Flash Appeal into the mainstream of the Consolidated Appeals Process the requirements for health increased from US$ 25 million to more than US$ 100 million. To date, 17% of the requirements have been met.

12. Technical support has been provided to the Palestinian Ministry of Health in order to elaborate a “State of Nutrition” document and a nutrition policy and strategy. Over the past two years, WHO’s programmes have supported the Ministry of Health Nutrition Department in establishing an effective nutrition surveillance system. WHO provided support to the Ministry to introduce the new WHO Child Growth Standards as part of the growth-monitoring activities; the Organization also provided support in order to build the capacity of central public health laboratories in both the West Bank and the Gaza Strip to monitor levels of micronutrients in fortified foods as well as the micronutrient status of the population.

13. WHO has provided technical support to the Ministry of Health’s control and prevention programme for noncommunicable diseases, responding to specific training needs for specialized health care, preparing diagnosis and treatment guidelines, introducing a surveillance system for risk factors and launching an educational campaign on the prevention of chronic diseases.

14. The six hospitals in east Jerusalem receive most of the referrals for specialized hospital care from the health facilities of the Palestinian Ministry of Health in the West Bank and Gaza Strip. WHO is supporting these hospitals in improving the quality of care provided and strengthening the functioning of a hospital network.

15. The Organization has also continued to advise and support the Ministry of Health in the area of mental health by implementing a project that moved from policy conception to planning, service delivery and infrastructure-building. The overall policy objective for mental health is to apply a community mental health approach at the primary, secondary and tertiary levels, and to develop, reorganize, improve and expand the current mental health services accordingly.

16. In its work on preparedness for and response to avian and pandemic influenza, WHO is supporting the Palestinian Authority in building capacity to detect and monitor any cases occurring in humans, and in putting in place core requirements that will enable the Authority to contain any outbreaks of the disease.

17. WHO provided support to the Environmental Health Department in the Ministry of Health in assessing environmental health conditions and needs, and in providing capacity building for staff together with supplies and materials in support of activities to address environmental health hazards (involving, for example, water safety and vector control). Technical support has been channelled through the Regional Centre for Environmental Health Activities.

18. The Global Fund to Fight AIDS, Tuberculosis and Malaria has awarded a Round 7 grant in support of activities against HIV/AIDS in the West Bank and Gaza Strip. WHO is a member of the United Nations thematic group for HIV/AIDS and is one of the sub-recipients of this grant with UNDP as primary sub-recipient. Within the broader implementation of this grant, WHO will focus on providing technical support to the national HIV/AIDS committee with special emphasis to voluntary counselling and testing, blood safety and universal precautions, antiretroviral treatment and monitoring as well as health information systems and operational research. In efforts against tuberculosis, WHO led the preparation of the application proposal for a Round 8 grant on tuberculosis from the Global Fund – a process that had a successful outcome. WHO is the technical advisor and co-chair of the United Nations thematic group for tuberculosis and will provide specific support to put in place the high-quality internationally agreed tuberculosis control strategy (the DOTS strategy) within the implementation phase of the Global Fund grant.



ACTION BY THE HEALTH ASSEMBLY

19. The Health Assembly is invited to note the report.


Notes

1United Nations Office for the Coordination of Humanitarian Affairs, Protection of Civilians: Casualties Database accessible at: http://www.ochaopt.org/poc/.
2Ministry of Health, Palestinian Health Information Center, Gaza.


ANNEX

HEALTH AND ECONOMIC SITUATION IN THE OCCUPIED PALESTINIAN
TERRITORY, INCLUDING EAST JERUSALEM, AND IN THE
OCCUPIED SYRIAN GOLAN

Fact-finding report

Report by the Secretariat

1. In response to resolution WHA 61.3, the Secretariat has conducted a review of reports available from reliable sources in respect of the situation in the occupied Palestinian territory. In addition, selected telephone interviews were conducted with persons working with health and health-related problems in the occupied Palestinian territory. Information on the occupied Syrian Golan was provided by the Israeli Government.

DETERMINANTS OF HEALTH IN THE OCCUPIED PALESTINIAN TERRITORY

2. The economic recovery under way between 2003 and 2005 was reversed in 2006, when gross domestic product fell by 8.8%. The economic restrictions have remained in place and the situation in the Gaza Strip continues to deteriorate, with the recent conflict in the Gaza Strip causing a severe downturn. A fall in gross domestic product of 0.5% was recorded in 2007, with a modest growth of 0.8% noted in 2008. The real per capita gross domestic product is now 30% below its level in 1999. Real growth in gross domestic product in the Gaza Strip prior to the crisis was estimated at 0%; if the fact that the population is growing rapidly is taken into account, this suggests that per capita income is falling. In 2008, overall per capita income was estimated to be nearly 40% lower than in 1999.1 Changes in the structure of the economy have limited prospects for long-term growth.

3. The amount of budget support received from foreign countries and institutions during the first six months of 2008 was more than double the figure for the second half of the year (US$ 947 million, as opposed to US$ 438 million). Such external budget support is equivalent to 14% of gross domestic product. However, unless there is a major improvement in movement and access both within and to the occupied Palestinian territory, economic activity and domestic investment will not rebound. External budget support was expected to reach 25% of gross domestic product by the end of 2008.

4. The economic difficulties have been compounded by the limited amount of currency allowed into the Gaza Strip – particularly Israeli shekels, which are needed for day-to-day transactions. Banking activity in the Gaza Strip has dropped from 40% of total Palestinian banking, to about 7% since the commencement of the closure in June 2007.

5. Unemployment in the West Bank and the Gaza Strip stood at nearly 23% in 2007, up from only 10% in 2000. The rate is highest in the Gaza Strip, where nearly 30% of the active workforce is unemployed; in the West Bank unemployment stands at approximately 19%. The unemployment rate is likely to increase as the layoffs in the industrial sector become permanent and as Israel proceeds with plans to levy taxes on Israelis hiring Palestinians.2 In 2008, at 15%, female participation in the formal labour market was among the lowest in the world, and nearly 90% of the women in the informal economy work in the agriculture sector.

6. According to recent estimates by local business associations, only about 2% of industrial establishments are still functioning in the Gaza Strip. These are mainly food processors who can obtain local materials or who use materials that are allowed to be imported on humanitarian grounds. Industrial employment fell from about 35 000 before the Israeli disengagement in 2005 to about 860 at the end of June 2008. In addition, the business associations estimate that another 70 000 workers have been laid off from other sectors. The damage has been so severe, that it is likely that many establishments will not be able to recover once the restrictions are lifted.

7. The poverty rate in the Gaza Strip was 5 1.8% in 2007 compared with 47.9% in 2006. The percentage of the population in the Strip who live in deep poverty has been increasing steadily, rising from 21.6% in 1998 to nearly 35% in 2007. These poverty levels reflect actual consumption; however, if remittances and food aid are excluded so that calculations are based on household income only, the poverty rate in the Gaza Strip and the West Bank soars to 79.4% and 45.7% respectively and the deep poverty rate increases to 69.9% and 34.1%. WFP found about eight out of 10 non-refugee households in Gaza living below the poverty line and with increasing levels of aid dependency. Although the increase in poverty in the West Bank is lower, it is still significant.

8. The consumer price index for food increased by 28% in the Gaza Strip and 21.4% in the West Bank from June 2007 to June 2008. This increase, although largely the reflection of international market prices, further aggravates the deteriorating socioeconomic situation, particularly in the Gaza Strip, because it lowers purchasing power. Despite large inflows of aid, a recent survey found that food insecurity continues to rise in the West Bank and Gaza Strip; it is estimated to have increased from 34% in 2006 to 38% in 2007. Food insecurity is even more pronounced in the Gaza Strip, reaching 56% of all households. Approximately 66% of income earned in the Gaza Strip is spent on food, compared with 56% in the West Bank. Households report increased difficulties in affording sufficient food and people are increasing their consumption of cheaper, starchy foods in place of dairy products, eggs and vegetables.

9. The operation both of wells for drinking-water and of wastewater services is limited by damage and shortages of fuel, closures and restrictions of imports of essential consumables. This is particularly the case in the Gaza Strip. The current water supply has declined since 2006 and is estimated at 75 litres per capita per day (65 and 80.5 litres per capita per day in the West Bank and the Gaza Strip, respectively). This is only half the international standard. Almost 66% of Palestinians are not connected to a sewage network and between 70% and 80% of domestic wastewater produced is discharged into the environment without treatment.

10. As of September 2008, there were 630 check points, road blocks and other obstacles located in the West Bank, as well as military zones and the separation barrier. In January 2009, orders were issued declaring the area between the barrier and the Green Line a closed military area (referred to the “seam zone”), giving rise to serious humanitarian concern. In the northern West Bank, there are approximately 10 000 Palestinians who reside in the closed area. They are physically separated from health services, which are generally located to the east of the barrier. Children, patients and workers have to pass through gates to reach medical facilities and workplaces.

ACCESS TO HEALTH CARE

11. The deterioration of the primary health care network – mainly due to the shortage of vital medical supplies, antenatal care, laboratory and dental services, and to non-functioning medical equipment and periodic strikes in the public sector – has led to an increased demand for services from providers other than the Ministry of Health; for example, the demand for UNRWA’s primary health care services increased by 10% between 2007 and 2008.

12. At the end of 2007, there were 77 hospitals in the occupied Palestinian territory with a total capacity of 4942 beds. The rate of 13 hospital beds per 10 000 population is in the low range within the Eastern Mediterranean Region. The occupancy rate is about 72.5% in Ministry of Health hospitals, but is less than half that figure in nongovernmental and private hospitals. Each month an average of 22 052 people are admitted to the Ministry’s hospitals, and 8404 surgical operations and 4933 deliveries are performed.

13. Access to secondary and tertiary care centres in the West Bank is affected by the restrictions on movement as most hospitals are located in cities; this includes east Jerusalem, which has 19.7% of the West Bank’s hospital beds. Jerusalem is important for the Palestinian health-care delivery system because its six hospitals are the main providers of tertiary health care to the Palestinian population. The restrictions on movement for both health providers and patients lead to difficulties in accessing and providing health-care services. Israeli policies have recently tightened access to the hospitals. Every day, more than 300 hospital staff and more than 310 patients cross the checkpoints around Jerusalem in order to reach the hospitals. The entrance of hospital staff to Jerusalem has been restricted to certain checkpoints where they are exposed to close security inspection, causing them daily delays of between 90 and 120 minutes.

14. The operation of two separate health-care systems, one in the Gaza Strip and the other in the West Bank (including east Jerusalem), further complicates attempts by the Ministry of Health to coordinate its activities; this is also leading to duplication of services, loss of efficiency, and increased costs. The reduction in revenue from the insurance scheme, as a result of increased unemployment and poverty, is aggravating the increase in costs. Furthermore, the ability of Palestinians to pay out-of- pocket expenses is being compromised, limiting their access to those services that are only available in the private sector (e.g. regular screening for breast cancer).

15. Since 2005, the cost of treatment abroad has constituted the third-highest item of expenditure of the Ministry of Health. In 2007, the most common medical reasons were cardiology, ophthalmology and oncology and haematology; these accounted for more than 50% of the total cost. About 67% of the cases were referred to local institutions, 19.5% to Israel, 6.8% to Jordan and 6.7% to Egypt. For the Gaza Strip, of the 9954 patients who applied for permits for secondary and tertiary treatment at hospitals in Israel, the West Bank, including east Jerusalem, 6506 (65.4%) have been granted permits in 2008. During 2008, the proportion of patients who received permits decreased by 20% compared with 2007 (7176 patients were granted permits out of the 8803 that applied in 2007).

16. WHO’s monitoring of the availability of medicines shows that shortages were constant during 2008. The report for October 2008 to December 2008 indicated that, for instance, the stocks held in the Central Drug Store in the Gaza Strip of 45 medicines (representing 11% of the Ministry of Health’s list of essential medicines) were sufficient for less than one month’s consumption. This figure rose to 120 (29% of the list) in December 2008. Additionally, stocks of consumable items stood at 102 in August 2008 (17% of the list), representing less than one month’s supply; these increased to 195 (33% of the list) in December 2008. In the West Bank, the Ministry of Health reported that, during October, 65 drug items and 100 disposables were out of stock.

17. According to WHO health sector surveillance indicators, intermittent shortages of beds, other furniture, bedside monitors and disposal units were reported. The shortage of qualified staff in various categories is affecting the sector in many areas. The situation was exacerbated by the health workers’ strike in the Gaza Strip starting on the 31 August 2008, in which 48% of the staff at Ministry of Health hospitals and 68% of those at the primary health care facilities were involved. These proportions decreased to 18% and 22% respectively in December 2008.

18. In November 2008, electricity shortages increased as a result of the continued tight Israeli restrictions on the Gaza Strip, during which border crossings were closed. Fuel was allowed to transit into Gaza on a few days in November and December. As a result, the Gaza Strip experienced a daily average of eight hours of power cuts in November, rising to 10 hours during December. During the recent Israeli military operation in the Gaza Strip (from 28 December 2008 to 18 January 2009) the number of hours without electricity increased and reached 24 hours per day as a result of the lack of fuel and damage to the power networks. The Gaza and North Gaza districts were particularly severely affected.

19. The prompt response from donors and international agencies to the humanitarian needs resulting from the Israeli military operation in the Gaza Strip prevented major breakdowns from occurring in the supply of medicines during the conflict and allowed stocks at the Ministry of Health Central Drug Store in Gaza City to be replenished rapidly. The central warehouses in Ramallah also provided essential medicines and consumables. The Central Drug Store in Gaza City managed the distribution to health facilities, including to nongovernmental organizations. On 29 January 2009, 96% of priority medicines3 and 81% of priority disposables had either been delivered or were in the process of being purchased and delivered).4

HEALTH STATUS

20. No new data on health status indicators (such as life expectancy, infant mortality rate, maternal mortality rate and malnutrition) have been published since the last report. It can be assumed that the trends observed during the recent years continue.

21. The number of Palestinian deaths in 2007 was 10 357 and the crude death rate was 2.8 per 1000 population (2.5 in the West Bank and 3.2 in the Gaza Strip). The number increased from 2006 by about 10%. The leading causes of deaths among Palestinians are cardiovascular and cerebrovascular diseases, accidents (including conflict and violence-related deaths) and cancers.

22. Although considerable successes have been recorded in preventing and eliminating major communicable diseases, mainly as a result of excellent vaccination coverage (99%) and improved surveillance of infectious diseases, controlling certain diseases continues to present a challenge. This is the case for hepatitis (the prevalence rate of hepatitisِ A is 50.16 cases per 100 000, of hepatitis B 0.9 per 100 000 and of hepatitis C 0.03 per 100 000), brucellosis (5.95 per 100 000), tuberculosis (the prevalence rate of extrapulmonary tuberculosis is 0.4 cases per 100 000), HIV/AIDS (the prevalence rate of AIDS is 0.0 cases per 100 000 in the Gaza Strip, 0.13 cases per 100 000 in the West Bank), meningitis (the prevalence rate of meningococcal disease is 3.22 cases per 100 000, viral meningitis 30.04 per 100 000 and other bacterial meningitis (9.36 per 100 000) and for mumps (5.05 per 100 000). According to the Palestinian Central Bureau of Statistics, 14% of children under five years of age were reported to have had pneumonia during their lifetime, the percentage being higher among males than among females.

23. About 10% of the population in the occupied Palestinian territory suffers from at least one diagnosed chronic disease. The burden of noncommunicable disease is rising owing to the effects of the political and socioeconomic situation, the rise in life expectancy, and unhealthy behaviours that include tobacco use, physical inactivity and unhealthy diet. Fifty per cent of deaths are attributable to cardiovascular disease, cancer, diabetes and chronic respiratory disease. Mortality data from the Ministry of Health indicate that the leading causes of deaths are heart diseases (responsible for 53.7 deaths per 100 000), cerebrovascular diseases (30.2 deaths per 100 000) and malignant neoplasms (24.1 deaths per 100 000). Among women, breast cancer is the most prevalent cancer (7.5 deaths per 100 000), while lung cancer is the most common cancer among males (5.2 deaths per 100 000). Cancers of the trachea, bronchus and lung constitute 14.3% of overall cancer mortality.

24. Mental health remains a major concern. A recent study of the blockade’s economic and social impact, including its effect on the quality of life of Palestinian families, revealed that it had had influenced all facets of life, affecting the whole society and suspending people’s lives. Sadness was affecting up to 96% of the citizens. Among children, 51% did not have the desire to participate in any activities; 47% were no longer able to perform the duties of school and family; 41% complained of aches and physical pains; 61% showed signs of fear and 45.5% signs of anger; 43% complained of sleeping problems; and about 63% presented symptoms of anxiety.

HEALTH SITUATION IN THE OCCUPIED SYRIAN GOLAN

25. The Secretariat has asked for information on the health of the Arab population in the occupied Syrian Golan and on the feasibility of establishing clinics in that territory. The Permanent Mission of Israel in Geneva has replied to this request, indicating that the 18 000 Druze inhabitants of the Golan Heights have access to comprehensive health coverage under the Israeli National Health Insurance Law, including primary, secondary and tertiary care.

26. There are 40 doctors and 96 dentists based in the occupied Syrian Golan: hospital services are provided through the hospital network of northern Israel. The creation of a hospital within the occupied Syrian Golan is not deemed necessary in view of the small population size. However, the health centre in Majdal Shams is equipped to offer primary as well as secondary care.

Notes

1 In view of the collapse that has taken place in the economy of the Gaza Strip since June 2007, gross domestic product in the West Bank must have been positive in 2008. However, given that the population in the West Bank is almost double that of the Gaza Strip, it can be inferred that modest growth in gross domestic product in the former was not sufficient to offset the severe contraction in gross domestic product in the latter.

2These rates of unemployment do not, however, take into account workers who lost their jobs and engaged in unpaid family labour or who took seasonal agricultural work. In addition, people engaged in UNRWA’s temporary employment programmes are not counted in the unemployment statistics. If the current conditions continue, unemployment is predicted to rise to more than 50% in the Gaza Strip by mid-2008.

3 Note: even though some items were delivered, these were not deleted from the list as more quantities are still in need; the following items were deleted from the priority list as enough quantities are available in the Central Drug Store: pethidene 500 mg, saline 0.9% bag of 500 ml, dextrose 4.3% + saline 0.18% and dextrose 5%, 500 ml. These items were heavily consumed during the crisis; however, due to the timely donor intervention, sufficient supply of these drugs is in place.






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