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Source: World Health Organization (WHO)
12 October 2004



EFFECT OF THE CURRENT CRISIS ON HEALTH CARE IN NORTH GAZA STRIP
SITUATION REPORT,
OCTOBER 12, 2004

1. OVERVIEW

A military operation in Northern Gaza Strip (about 210.000 people) has been ongoing for nearly two weeks. Israeli tanks currently remain deployed on Sika Street to the east of Salah ed Din road, Tal el Zatar, Glebo and Um Al Nasr bedouin village to the north of the Beit Lahia sewage treatment plant. All movements in and out of Beit Hanoun are under the control of the IDF.

According to the situation described in paragraph 2, no major health crisis has developed so far. The local health services have been coping reasonably well despite the increased burden of diseases represented by the high number of Palestinian casualties, since September 28th (up to date 115 killed and three hundred and ninety nine injured in northern Gaza, according to the Palestinian Ministry of Health (MoH).

Drugs and medical supply have been reported to be sufficient in the majority of PHC health facilities and in the two hospitals. However, the central drug store of the MoH is quickly running out of emergency and surgical drugs and supply, and a list of urgent needs has been circulated through WHO. Care International, through EMAP II; have already responded to partially fill the needs.

In the health services in the area, staff has been redeployed, to compensate the lack of access to usual working place of several health workers. This has been especially the case in Beit Hanoun clinics, where the total number of staff increased (from 66 to 78) despite the fact that 27 staff of UNRWA Beit Hanoun clinic is not being able to reach the clinic.

Among the health staff of Kamal Adwan hospital, consisting of 68 doctors, and 72 nurses, 10 doctors and 6 nurses have not been able to reach the hospital in the last two weeks due to the presence of Israeli forces around their homes. These staff members have been replaced by local volunteers – eight doctors and 10 nurses. In addition, an orthopedic surgeon has been redeployed by the MoH to Kamal Adwan from Gaza Shifa hospital.

The period of working hours of PHC services have been extended, especially in Beit Hanoun and in Jabalia camp where the cumulative number of working hours among all centers almost doubled. This reorganization appears to be appropriate and effective to compensate for the reduction of available staff in some centers, to cope with the increased burden of diseases, and to guarantee a response to emergency/first aid care.

Access to PHC centers seems to have been roughly maintained, according to the number of visits to PHC centers. Only in Beit Hanoun, despite the availability of PHC services, the number of visits to the centers decreased from an average of 710 visits/day, to 500 visits/day. This is reflected by the sharp decrease in UNRWA clinic visits (180 visits/day compared to 550 visits/day before the incursion) not entirely compensated by the other two clinics (220+100visits/day compared to 120+40 visits/day before the incursion).

The type of services provided by the PHC clinics does not seem to be significantly affected by the incursion. Only in one clinic in Beit Hanoun, the immunization activities have been stopped by a break in the cold chain. However, several episodes of patients with chronic diseases running out of drugs and not able to reach the clinics have been reported by PRCS and by the clinics themselves.

Systematic data on communicable diseases are currently collected only by few clinics. Though, no comprehensive information is available on the actual health status of the people in the northern area, and on the possible occurrence of epidemics. However, according to the majority of PHC clinic Directors, the number of detected cases of the main communicable diseases (diarrhea, respiratory infections, measles, meningitis, and hepatitis/jaundice) has not increased during the crisis. Only in MoH Ezbat Beit Hanoun clinic, it has been reported a tenfold increase in the daily cases of diarrhea accessing the health center (from 3 to 30). The reason for this reported figure is under investigation.

The referral hospitals for the Northern area are MoH Kamal Edwan hospital in Beit Lahia and UHWC Al-Awda hospital in Jabalia. So far, these hospitals are coping with the additional demand for emergency care, in terms of availability of health personnel and medical supply. Both hospitals adopted a preparedness referral policy of providing first aid and stabilization measures to the injured patients and then transferring them to Shifa hospital in Gaza city, a tertiary care hospital with far greater capacity. Patients seeking non-urgent referral care are directed on to primary health care clinics, as a strategy to rationalize the resources and to give priority to the high number of injured people in need of emergency care. Access to hospital from Beit Hanoun has been difficult during the crisis. MoH and the PRCS reported difficulties in coordination with the IDF to ensure referral of patients to secondary health care, that does not exist inside the town.

2. DESCRIPTION

2.1 Beit Hanoun: (28,000 populations)

2.1.1 MOH Shohada Beit Hanoun clinic

Drug supply: There are no shortages in PHC drug supply. Required drugs are delivered to the PHC clinics by the MoH from the central drug store through any ambulance that has coordination to enter Beit Hanoun. However, some drugs for specialized treatment are not available in the clinics and the patients usually find them in hospital (e.g drugs for chemotherapy, hyperlipidemia, renal diseases) or in pharmacies in Gaza city. As a result of the closure, patients in need of these drugs cannot access to them.
Health personnel: Currently the number of health personnel working in the clinic is 60, compared to 26 health personnel in the normal situation The MoH redeployed to Shohada clinic all the health staff that is living in Beit Hanoun since all of them cannot leave. Most of redeployed staff are specialized doctors.
Type of services: Since the incursion, further to usual primary health care services, the clinic started to offer specialized services, because of the current presence of specialized doctors working in the clinic. The clinic also provide care for normal delivery: since the beginning of the incursion, 20 deliveries took place in the clinic and about 10 were referred to either Kamal Edwan hospital or Al Awda hospital. The referral needed coordination with the IDF which took from 1 to 8 hours.
Visits/ day: The average number of visits/ day increased from 120 visits/ day before the incursion to 220 visits/ day. This can be explained by two reasons: a) The presence of specialized doctors encourages many people to visit the clinic; b) UNRWA clinic of Beit Hanoun is currently under staffed as most of its staff is not able to reach their working place. However, according to the clinic director, there are some patients living in areas under total curfew that do not have any access to any health services.
Working hours: the clinic extended its working hours to 24 hours/ day in order to cope with the emergency, compared to 12 hours/day (from 8 am to 8 pm) in the normal situation.
Surveillance: although no systematic surveillance system is in place, no increase in the incidence of the communicable diseases as been reported.
Referral: Extremely difficult

2.1.2 UNRWA Health Centre of Beit Hanoun

Drug supply: There are no shortages in drug supplies. The clinic has a drug stock for 1 month.
Health personnel: In the normal situation the clinic has 35 staff, whilst after the incursion the health personnel is limited to those staff who are living in Beit Hanoun, that is 4 doctors and 4 nurses.
Type of Services: Usually the clinic provides all PHC services and several specialized services. However, during the incursion, the clinic offers only emergency services and care for chronic patients . PHC programs such as immunization are suspended since most of the staff are not allowed to enter Beit Hanun.
Visits/ day: the no. of visits in the normal periods is 550 visit/day which declined to 180 visits/day during the incursion. Several calls from patients living in areas under curfew have been reported by the staff.
Working hours: there is a 24 hours access to the clinic, 2 doctors and 2 nurses are working from 8 am to 8 pm and the other 2 doctors and 2 nurses are working from 8 pm to 8 am.
Surveillance: A higher frequency of contacts by patients with chronic conditions has been reported by the clinic. Also, the frequency of the psychiatric visits as been reported as increased.
Referral: Extremely difficult

2.1.3 MoH Ezbat Beit Hanoun clinic

The clinic has been closed from the beginning of the incursion on 28th of September until October 6th. During this period there has been no access to primary health care for all people living in Ezbat Beit Hanoun area, al Nada towers and Al Awda towers.
Drug supply: There are shortages in drug supply because of the increased number of daily visits, since the clinic was reopened. The MoH is aware of the shortage and is providing the necessary drugs from the central store.
Health personnel: In the normal situation, the totals number of staff is 5, with 2 doctors and 3 nurses. At the moment, the number of health personnel increased to 10 personnel including 3 doctors, 4 nurse and 3 pharmacists. Two of them are the official personnel but the others are workers of other clinics living in Ezbat Beit Hanoun, Al Awda towers and Al Nada towers and temporary redeployed.
Type of services: Normally the clinic provides all primary health care service, but at the moment the immunization program is suspended because of the lack of electricity during several days, affecting the cold chain, therefore the effectiveness of the vaccines.
Visits/ day: In the normal situation the average no. of visits is 40 / day, which, since the 6th of October, has increased to 100 visits/ day, after 10 days of having been closed.
Working hours: is the same before and after the incursion: 6 hours, from 8 am to 2 pm.
Surveillance: According to the health center monthly statistics, there is an increase in diarrhea to 30 cases/ day, from 3 cases/ day in the same period of last year.
Referral: Extremely difficult

2.2. Jabalia (120,000 population)

2.2.1 MoH Jabalia old clinic, Jabalia camp
Drug supply: Shortages in drug supply have been reported by the clinic director
Health personnel: the no. of health personnel currently working in the clinic is 25 staff compared to 40 before the incursion, since 15 are living in area under total curfew.
Type of services: In the normal situation the clinic provides all the primary health care services except the immunizations. The incursion is not affecting the clinic in this regard.
Visits/ day: The average number has decreased to 80 visits/ day compared to 150 visits/ day before the crisis. Some people living in Seka Street and Shoshaa Street that normally visit this clinic are currently under curfew. Many of them are patients with chronic conditions. Also, other people living in areas far from the IDF military operation still are afraid to visit the clinic because the clinic itself is not far from an area of military operation.
Working hours: the n. of working hours did not change: from 8 am to 2:30 pm.
Surveillance: No increase in the in incidence of infectious diseases has been reported.
Referral: Although there are no difficulties in referral cases from the clinic to one of the two hospitals in the north, Kamal Edwan hospital gives priority to injured cases, and other cases may not be received.

2.2.2 UNRWA Jabalia clinic, Jabalia camp
Drug supply: There is no shortage in drug supply: stocks of PHC drugs for 15 days and of drugs for chronic condition sufficient for 2 months are available.
Health personnel: In the normal situation the no. of health staff is 73, increased during the crisis to 79. The additional 6 staff is working for emergency cases during the night shifts.
Type of services: the clinic provides all the PHC services, which are not affected by the incursion.
Visits/ day: Normally the average no. of the visits is 1000 / day, but after the incursion this no. decreased to 500 visits/ day for almost 5 days as the intensive military operation in the area affected the access. Since 5 days, the no. increased to 1200 visits/ day, including many patients with chronic conditions in need of medications.
Working hours: The usual working hours are 12/day, extended to 24/day during the incursion.
Surveillance: The incidences of the infectious disease are reported to be in the normal range.
Referral: No major problems have been reported

2.2.3 UNRWA Al- Fakhorah clinic, Jabalia camp
Drug supply: no shortages in drugs
Health personnel: in the normal situation 7 health personnel works in the clinic. This no. did not change during the incursion.
Type of services: the provision of all preventive services (immunization, growth monitoring, and pre-natal care) is not affected by the incursion.
Visits/ day: in the normal situation, the average no. of visits is 100 / day, decreased to 70 visits/ day during the incursion.
Working hours: the clinic is working 3 days/ week from 7: 30 am to 1:00 pm. The no. of working hours did not change since the incursion.
Referral: No major problems have been reported

2.2.4. Union of Palestinian medical relief committee (UPMRC) clinic, Jabalia camp
Drug supply: There is no shortage in drug supply
Health personnel: 10 staff are normally working in the clinic. This no. increased to 13 after the incursion.
Type of Services: The ongoing military operation does not affect the services offered by the clinic, so the clinic keeps providing all PHC services, except delivery care. A mobile clinic team provides with medications for chronic and acute disease to families leaving under curfew.
Visits/ day: The average no. increased from 25 visits/ day to around 50 visits/ day, after the incursion, mainly of patients with chronic diseases.
Working hours: In the normal situation the clinic works from 8 am to 2 pm, but the no. of working hours has been extended to 24 /day during the incursion.
Surveillance: An increase in the incidence of upper respiratory infection (12 cases /day, from 6 cases /day in the same period last year) and diarrhea (12 case/ day, from 4 cases /day in the same period last year) has been reported by the clinic Director. Also the frequency of visits of patients with chronic diseases increased, presumably due to stress and lack of medication leading to a destabilization of the patient conditions.
Referral: No major problems have been reported

2.2.5. Jabalia Martyr center, Jabalia Al Balad
Drug supply: There is no shortage in drug supply
Health personnel: The normal no. of health personnel working in the clinic is 120 staff, reduced to 110 during the incursion, as 10 staff could not reach the clinic, being residents in occupied areas.
Type of services: The clinic offer all PHC services, specialized services, immunizations and delivery care. The type of services has not been affected by the incursion, except for the orthopedic ambulatory, as the orthopedic could not reach the clinic.
Visits/ day: The average no. of visits before and after the incursion is the same, 500 visits/ day.
Working hours: There is 24 hours access to the clinic before and after the incursion.
Surveillance: The incidence of Infectious diseases has been reported to be in the normal range.
Referral: No major problems have been reported

2.2.6 MoH Abu-Shebak Medical Centre, Jabalia Al Jurn area
Drug supply: No shortage in drug supplies has been reported.
Type of services: The incursion of the northern area does not affect the services in the clinic since the clinic is located far from the IDF tanks.
Visits/ day: The number has decreased from 150 visits/ day in the normal situation to 120 visits/day during the current military operation.
Health personnel: Usually 25 staff works in the clinic. Currently the number decreased to 24 as one of them live in one of the invaded are as.
Working hours: The clinic keeps its normal working hours, from 8 am to 2: pm.
Surveillance: The incidence of infectious diseases has been reported to be in the normal range.
Referral: No major problems have been reported

2.3. Beit Lahia (61,000 population)

2.3.1 Beit Lahia old clinic
Drug supply: there are some shortages in drug supply.
Health personnel: The usual number of staff is around 40, decreased to 35 during the incursion because 5 of them are living in the invaded areas.
Type of services: The clinic provides all the PHC services except the delivery care.
Visits/ day: The number of visits/ day increased from 140 to 180 visits/ day. The clinic is located far from the IDF troops and its access is easy. Therefore, many people from different areas who cannot reach their usual clinic come to this clinic for medications, especially for chronic diseases.
Working hours: In the normal situation the clinic works 6 hours, from8 am to 2 pm. After the incursion, the clinic’s working hours increased to 12 hours from 2pm to 8pm for emergency purposes only.
Surveillance: the incidences of infectious diseases are reported to be in the normal range

2.3.2 Al Sheima centre
Drug supply: There is no shortage in drug supply. Patients with chronic diseases are receiving from the clinic medications lasting for 15 days. However, some patients living in the areas under curfew are calling the clinic to ask for medications.
Health personnel: in the normal situation, the health personnel working in the clinic is 34, this number decreased to 32, as 2 staff are living in the invaded area and cannot reach their work. Type of services: The clinic keeps providing all PHC services except delivery care.
Visits/ day: in the current situation, the average no. is 60 visits/day compared to 100 in the normal days. The catchments area of this facility includes some invaded areas and people do not have access to PHC facilities.
Working hours: is not changed before and after the incursion. The clinic is working 12 Hours/day, from 8 am to 8 pm.
Health status: No increase in the incidence of infectious diseases has been reported.
Referral: Delay in the arrival of the ambulance because of the close location of the clinic to an Israeli settlement.

2.3.3 Al Atatra health clinic: currently closed for maintenance until the end of this week.


3. SUMMARY TABLE


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