Question of Palestine home
World Health Organization (WHO)
7 May 1986
WORLD HEALTH ORGANIZATION
THIRTY-NINTH WORLD HEALTH ASSEMBLY
Agenda item 38
HEALTH CONDITIONS OF THE ARAB POPULATION IN THE OCCUPIED ARAB
TERRITORIES, INCLUDING PALESTINE
The Director-General has the honor to bring to the attention of the Health Assembly the annual report of the Director of Health of the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) for the year 1985, which is annexed hereto.
ADMINISTRATION AND MANAGEMENT
1. The Director of Health is responsible to the Commissioner-General of the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) for the planning, implementation, supervision and evaluation of the health and supplementary feeding programs within the budgetary limits approved by the Commissioner-General. He is assisted in this task by a staff of professional and auxiliary health workers and manual workers, totaling 2958 as at 31 December 1985.
2. Since 1950, under the terms of an agreement with UNRWA, the World Health Organization has provided technical supervision of the Agency's health care programs by assigning to UNRWA headquarters, on non-reimbursable loan, currently six WHO staff members including the Agency's Director of Health. The latter, as WHO programme coordinator, is responsible on behalf of the WHO Regional Director for the Eastern Mediterranean for advising the UNRWA
Commissioner-General on all health matters and for the implementation of WHO's policies as they apply to the Agency. Since 1978, the headquarters of the Department of Health has been split between Vienna and Amman. To attempt to achieve the necessary integrated team approach regular visits and meetings are made to Vienna and Amman.
3. The Department has five divisions: curative medicine, preventive medicine, nursing, environmental health and nutrition. The Curative Medicine Division includes the Pharmaceutical and Medical Supply Branch and the Preventive Medicine Division includes the Health Education Branch.
4. This organizational pattern is repeated in each of the five field health offices located in Jordan, the West Bank, the Gaza Strip, Lebanon and the Syrian Arab Republic, which have departmental status within the field offices. In each case, the field health officer reports direct to the field office director for administrative purposes and to the Director of Health on technical matters.
5. The Department of Health continues to attach great importance to team work, coordinated staff planning and consultation in the development of health projects and the evaluation of health programs. To this end, regular meetings of the senior health staff are held at headquarters and in the field offices, the more important of which are the weekly staff meetings and the four-monthly divisional meetings at headquarters and the annual or biennial conferences of the senior field health staff.
Direction - supervision
6. The director and chiefs of each division and branch undertook regular periodic visits to each field of operation to review the work of the Department and ensure that it reflects the approved policy and standards of the Agency.
7. This whole activity is reinforced by major Technical Instructions issued by the Director of Health.
8. The supervision at field level is undertaken by the field health officer and his senior colleagues.
9. Overall UNRWA cares for 2 093 545 registered refugees as at 30 June 1985, of whom more than one-third live in camps, while the rest live in cities, towns or communities. The registered population is distributed as follows: Lebanon 263 599, Syrian Arab Republic 244 626, Jordan 799 724, the West Bank 357 704 and the Gaza Strip 427 892. In the five geographical areas or territories called "fields of operation" 1 845 188 refugees are eligible for health care services.
10. UNRWA's health care program, which is basically community-health oriented, provides primary health care to the eligible refugee population comprising: medical care services (both preventive and curative), environmental health services in camps and nutrition and supplementary feeding to vulnerable population groups. The level of service responds to the needs of the refugees which in turn reflects their residence. Camp residents use UNRWA facilities with ease of access; other refugees living in towns or remote villages at a distance from the nearest Agency health center, tend to share with the local community facilities whether private, voluntary or public health.
Overall health policy
11. UNRWA's policy is to maintain preventive-curative health services to eligible Palestine refugees concordant with the humanitarian policies of the United Nations and the basic principles and concepts of WHO and consistent with the development and progress achieved in the public and medical care provided by the host Governments to their indigenous population at public expense. The prime objective of the Agency's health programme is to promote the health of refugees and meet their basic health needs.
Planning and Programming
12. Each year detailed reviews in all these areas are undertaken leading to firm activity decisions. Throughout each year these decisions with their related resource provision are regularly monitored.
13. There is associated preparation of plans and proposals for extra-budgetary support.
14. To ensure maximum delivery of health services coordination is effected both internally within the Agency, among the organizations of the United Nations system and externally with related authorities.
15. The range covered includes the other Divisions of UNRWA: WHO; UNICEF; Host Government Departments of Health and non-governmental organizations.
Health manpower development
16. The Agency maintained and further developed its programme of education and training in the field of health. Basic professional and vocational training is primarily the responsibility of the Department of Education, while in-service training is the direct concern of the Department of Health.
Basic professional education
17. The assistance provided for medical students includes maintenance grants, payment of tuition fees and an allowance to cover the cost of books, training material, instruments and other essential items. Young men and women have been encouraged to enroll in nursing education courses at schools of nursing and at universities. Scholarships for nursing education were donated by voluntary agencies.
18. The Agency provides at its vocational training institutions paramedical courses to enable refugee students to become assistant pharmacists, laboratory technicians, public health inspectors and dental assistants. On completion of their training, graduates may join the Agency's service or be assisted by the UNRWA Placement Office to find employment in the region.
19. In-service training was carried out by the Department of Health for its own staff in the various disciplines of the program. Twenty-five teachers from Jordan attended a two-day first-aid course at Zarqa in January. Eight practical nurses from Amman New Camp (ANC) attended a two-day on-the-job training in injection, in January. Two qualified nurses from the Syrian Arab Republic attended for one week the special workshop for traditional birth attendant training tutors sponsored by the Department of Maternal and Child Health, Ministry of Health, Syrian Arab Republic, in February. Three medical officers from Jordan attended a specialized training course of three months' duration in community medicine organized by the Jordan Medical Association starting 16 March. The Area Sanitation Officer, Irbid, and the Sanitation Foreman, Baqa'a, attended a three-month health inspectors training course at Amman Municipality, starting 2 March. Nineteen senior staff nurses and staff nurses from Jordan attended a four-day seminar on community health nursing at ANC health center in March. Seventeen assistant pharmacists from Jordan attended a three-day seminar on handling and storage of medical supplies and vaccines also at ANC health center in March. Six dental surgeons from Jordan participated in the Fourth Jordanian Dental Conference in Amman on 18 and 19 March
The Field Nursing Officer, Jordan, attended a training course in management by objectives at the Jordanian Institute of Management during the period 4 to 15 May. Food center managers and their assistants in West Bank attended a training course from 10 May to 28 June. Fourteen practical nurses from Jordan attended a two-day in-service training course in community nursing at Jabal el-Hussein and Baqa’a camps in May. The Deputy Field Nursing Officer, Jordan, attended a five-day course on training methodology at the Field Office, Amman, from 23 to 27 June. The Field Health Officer, West Bank, attended a workshop on management, education and communication, organized by the International Planned Parenthood Federation and The Johns Hopkins University, in Baltimore, USA, from 29 July to 16 August. Sixteen health education workers from all fields attended a 10-day UNICEF-sponsored training course in health education at Amman Training Center from 29 July to 9 August. 198 head teachers and 49 assistants from Jordan attended an in-service training course from 12 to 18 August and discussed health education, school environment, accidents at school and common diseases. Five health education workers from Jordan attended a two-day workshop on first-aid at Jordan Field Office on 15 and 16 September. The Acting Chief, Environmental Health Division, Field Sanitation Officer and Health Education Supervisor in Jordan attended the National Seminar on Specifications and Criteria for Drinking-Water in Jordan from 17 to 19 September Two Agency-employed
(traditional birth attendants) attended a refresher course at the Government Maternal and Child Health Center in Jarash from 21 to 26 September. Fourteen health center clerks from Jordan attended a two-day in-service training course at ANC health center on 29 and 30 September. The Field Health Training and Research Officer, Jordan, attended a course on management information systems at the Institute of Management, Amman, from 5 to 16 October. All qualified nurses in Damascus attended a six-week training course in community nursing practice at the rate of one full-day session per week, starting 22 October. Six medical officers from Jordan participated in the Fourth Jordanian Medical Conference at the University of Jordan, Amman, on 17 October. Four health education course tutors (one each from Jordan, the West Bank, Gaza and Lebanon) and four activity leaders from Jordan attended a workshop on health education for health education tutors, in Amman, from 12 to 19 November. One UNRWA-employed
at North Shouneh Health Point attended a two-week refresher course at the Government Maternal and Child Health Clinic, Irbid, in October. A senior clerk, Health Department headquarters (Vienna), attended a three-day course in effective drafting from 26 to 28 November. Three separate scholastic year training courses of 25 seminars each in health education for teachers commenced in November at the Education Development Centers in Jordan (23 teachers), the West Bank (38) and Gaza (18). The Chief Pharmacist and Supply Officer (Medical) attended a seven-day Expanded Programme on Immunization (EPI) Logistics and Cold Chain course, in Cairo, from 14 to 21 December, organized in collaboration with the Egyptian Ministry of Health. Eighteen practical nurses from Jordan received on-the-job training in community nursing at ANC, Zarqa and Irbid camps in December.
20. In-service training of Agency medical officers and other staff is encouraged through scholarships for postgraduate studies, sponsored mainly by WHO's provision of special facilities for attending professional and scientific meetings in the region and refresher courses on subjects of special interest.
21. Five fellowships were granted by the WHO Regional Office for the Eastern Mediterranean in the academic year 1985-1986: two to medical officers of Nahr el Bared Health Center, Lebanon, and Area Health Officer, South Lebanon, to pursue a 12-month postgraduate course each, in public health administration leading to the master's degree in public health at the American University of Beirut starting 1 October; and one each to the medical officer, Bureij Health Center, Gaza, to pursue a 13-1/2-month course in medical community health at the School of Tropical Medicine (University of Liverpool, United Kingdom), starting 18 November; the medical officer "A" Qabr Essit Health Center, Syrian Arab Republic to pursue a 12-month postgraduate course leading to a master's degree in community health at Liverpool School of Tropical Medicine, starting 3 January 1986; a senior practical nurse, Nahr el Bared Health Center, in Lebanon, to pursue a one-year training course in public health nursing at the Cairo University School of Nursing, starting 1 December. WHO fellowships were also granted to 15 qualified nurses from all fields and six from the Ministry of Health of Jordan to enable them to participate in the WHO-sponsored workshop on community needs for health care delivery for staff nurses at the University of Jordan from 6 to 19 July; to six teachers from Jordan to attend a two-week oral health training course at the Demonstration, Training and Research Center (DTRC), Damascus, from 2 to 16 November and to three dentists (two from Jordan and one from the Syrian Arab Republic) to attend a similar one-week course at DTRC from 14 to 19 December. Also on WHO fellowships 14 medical officers (three each from Lebanon, Jordan, the West Bank and Gaza and two from the Syrian Arab Republic), plus two course-facilitators from the West Bank, participated in the WHO/UNRWA inter-country workshop on risk approach, in Amman, from 28 September to 10 October; three medical officers from Jordan attended a 10-day EPI/CDD (Diarrhoeal Diseases Control) course in Amman from 7 to 19 April, organized by the Ministry of Health, Jordan, in collaboration with the WHO Regional Office for the Eastern Mediterranean and seven further medical officers (two each from Lebanon and Jordan and one each from the Syrian Arab Republic, the West Bank and Gaza) attended a similar course in Baghdad from 18 to 30 May.
22. The following five fellows whose fellowships were granted in 1984-1985 were successful in their training: the medical officer, Saida Town Clinic, Lebanon, completed a 15-month course in community health at the School of Tropical Medicine (University of Liverpool, United Kingdom) in March; the Area Sanitation Officer, Hebron Area, West Bank, completed a 22-month course in community health at Bethlehem University, West Bank, in June; the Medical Officer Irbid Health Center, West Bank, completed an 11-month course in public health administration at the High Institute of Public Health, Alexandria, Egypt, in August; the Medical Officer, Zarqa Health Center, Jordan, completed a 12-month course in clinical tropical medicine at the London School of Hygiene and Tropical Medicine, United Kingdom, in October.
23. The Deputy Field Nursing Officer, Jordan, and a senior staff nurse (technical and training), Gaza, completed a six-month study-tour fellowship in community health in New South Wales, Australia, in April. Two other senior staff nurses from Gaza were granted a 10-month fellowship each to pursue a diploma programme in community health nursing at Cumberland College, Sydney, Australia, in February. One of the two nurses dropped out and returned to Gaza, while the other continued her studies and successfully completed her training in December.
British Council fellowship
24. A civil engineer from the West Bank was awarded a one-year fellowship to pursue a postgraduate course in water and waste engineering leading to the master of science degree at Loughborough University, United Kingdom, starting 13 September.
Medical Aid for Palestinians fellowship
25. A Palestinian refugee from Lebanon was granted a 27-month fellowship to pursue a basic midwifery training course at the College of Nursing, Jordan, starting 2 October.
British Save the Children Fund
26. Eight UNRWA-sponsored students from Gaza and one practical nurse from the West Bank successfully completed an 18-month basic midwifery training course in September. A senior staff nurse from Rafah Health Center, Gaza, was awarded a one-year scholarship to pursue a post-basic training course in public health nursing, at Cairo University, starting 1 December.
CURATIVE MEDICAL CARE SERVICES
27. Curative medical, dental and rehabilitation services continued to be provided by UNRWA to about 1.85 million eligible Palestine refugees and to locally-recruited staff members and their authorized dependants who are not participating in Agency-sponsored insurance schemes. These services were made available at various health centers/points, polyclinics, hospitals, laboratories, X-ray departments, and rehabilitation centers - either run by UNRWA, governments, universities, private or voluntary organizations, subsidized by the Agency or paid for on a fee-for-service basis. Some of the refugee population has access to insurance schemes and others, who can afford payment for some of these services, receive them direct through their own arrangements.
Out-patient medical care
28. Medical care services were provided in 98 UNRWA health centers/points. Compared with 1984, the number of medical consultations markedly increased during the year in all fields of operation. Agency-wide, there was an increase also in the reported attendances for dental treatment. This increase in demand for UNRWA services in all fields is attributed to prevailing economic difficulties and relative improvement of facilities.
29. The situation in Lebanon and continued conflicts have adversely affected the delivery of the UNRWA health services, particularly in the refugee camps. Medical services continued to be provided and essential improvements have been made. Nevertheless, a relative drop in the utilization of UNRWA medical services was encountered compared to previous years due to the security situation and inaccessibility of refugees to UNRWA services in many instances.
30. During the year, the Agency's special care programme included 75 specialized clinics for diabetes (33), tuberculosis (2), ophthalmology (11), planned parenthood (14), rheumatic diseases (7), ear-nose-and-throat (3), cardiovascular diseases (2), dermatology (2) and for chest diseases (1). These clinics, as well as the nutrition-rehabilitation clinics (59), form part of the activities of health centers, where patients are treated on specified days or by appointment. These specialized clinics need to be expanded to other health centers.
31. In spite of the Agency's financial difficulties, the Department of Health was able to make modest improvements in the working conditions at health units. During the year it supplied additional new equipment, replaced old equipment where necessary in the Agency's different installations. These included X-ray machines, laboratory and dental equipment, refrigerators, sterilizers, stoves, steel cabinets, etc. Through special contributions and also from UNRWA resources it was possible to complete some new constructions or replacement/expansion of health premises.
32. Dental caries and periodontal disease are the main problems. Both of these conditions are largely preventable. Major emphases sought in this programme are: the promotion of oral health and provision of dental care; training of support staff such as dental hygienists; and the development of health education directed towards children, with the aid of school-teachers.
33. Generally these services comprise dental extractions, restorative treatment and minor oral surgery. With the improvement of the standard of resources allocated to the programme in terms of professional manpower, equipment and supplies, higher coverage of the service was attained, but this still needs expansion. Three additional dental clinics started operation
in the Syrian field of operation, two stationary and one mobile. Also three additional dental clinics were established one each in the West Bank, Lebanon and Gaza fields, bringing the total number, Agency-wide, to 30. In localities where no dental clinics could be established, some dental care is provided by private dentists remunerated by UNRWA on contractual basis. In prospect the further aim of this programme must be to attain an effective preventive programme associated with sufficient oral health manpower and adequate services to extend coverage to those groups as yet inadequately served.
34. While UNRWA has continued to support the development of central laboratories, increasing emphasis is being placed on clinical laboratories at health centers in support of primary health care. The three central health laboratories in Gaza, Jerusalem and Amman, perform tests of public health and a clinical nature. In Damascus a private laboratory performs such tests on contractual basis and in Beirut the Government central laboratory. The Agency has developed 27 clinical laboratories, located at main health centers in the different fields of operation, which perform tests of a routine clinical nature, including biochemistry. Elaborate laboratory investigations are performed at seven government, university and/or private laboratories, either for payment of a fee, or free of charge, or as a contribution from a host government. About 548 935 tests were performed Agency-wide, as against around 520 000 in 1984. There is a continued ambition to further extend the clinical laboratories to cover all health centers.
35. The concept of better primary health care coverage is promoted by the provision at the health-center level of essential diagnostic facilities. For this reason a basic radiological unit has been installed in Baqa'a camp, Jordan, and another one is being installed in Rimal Health Center in Gaza. Both units were made possible by the generosity of WHO. In addition X-ray services are available at subsidized hospitals or under contractual arrangements.
In-patient medical care
36. The Agency makes provision for in-patient care in government, university, voluntary agency, and privately-owned hospitals and medical institutions. However, it also operates a small hospital in Qalqilya, West Bank (36 beds), eight maternity centers (totaling 65 beds), mostly in the Gaza Strip, and operates - jointly with the Public Health Department in Gaza - a 70-bed tuberculosis hospital in Bureij camp which serves refugees and indigenous inhabitants from the Gaza Strip and a few from the West Bank.
37. The Agency had to increase its subsidies to hospitals and other facilities serving refugee patients mainly in Lebanon, the Syrian Arab Republic and the West Bank due to the continuous rise in the cost of medical care in the area. In the Jordan and Gaza fields of operation the Agency has schemes for the reimbursement of refugees on the basis of need. In Amman the Agency maintained its subsidy for 32 beds reserved for refugees at two voluntary hospitals, but wider provision is much needed. In the Gaza field there is a strong demand for provision of subsidized beds.
38. UNRWA continued to meet part of the cost of specialized care and emergency life-saving care, mainly for cardiac patients and neurosurgery; 58 patients benefited during the I year. In addition, 16 children received cardiovascular treatment at specialized centers in the area of operations with support from "Terre des Hommes, Netherlands" which covered a substantial part of hospitalization costs.
39. Childhood mental disorders and problems of psychosocial development constitute a public health problem to which existing services provide an inadequate response. An increased level of intervention through primary health care could decrease the extent childhood mental disorders, limit their harmful consequences and improve psychosocial development.
40. The growing need for mental health care for children of Palestine refugees became a matter of particular concern to UNRWA. It has therefore undertaken the following activities, in coordination with sister United Nations organizations and non-governmental organizations:
1. Review of available information about mental health and psychosocial development of refugee children in general and any references to Palestine children under UNRWA care in particular;
2. Convening an informal consultation at WHO Geneva, from 12 to 14 March 1985, concerning mental health and psychosocial development of children of Palestine refugees;
3. Convening a working group for the development of indicators of mental health problems and effects of intervention in May 1985;
4. A planning mission visited Baqa'a camp, Jordan from 25 October to 1 November
1985 to assess mental and psychosocial problems and design an intervention-research project.
This project will be implemented in Baqa1a camp
UNRWA is seeking The necessary financial support for implementing this project.
This project is being carried out by the. Radda Barnen team in collaboration with UNRWA in Jebal el-Hussein and Marks camps, in Jordan.
. Each summer a camp is organized jointly by, UNRWA and YMCA for refugee orphans at UNRWA training center in Amman. A research-intervention project was undertaken in 1985 to assess the unmet health and psychosocial needs of this vulnerable group and ameliorate their conditions.
41. Any activity to meet the needs of the refugee community is necessarily limited by competing priorities and scarcity of resources. Therefore, the interventions to be introduced will not involve structural changes in the health service or the setting up of specialized facilities for treatment. A useful beginning can be made by reorienting the concerns and skills of current staff.
Medical rehabilitation of physically-handicapped children
42. Crippled children are rehabilitated as either out- or in-patients through physical and medical therapy. During the year, 550 children benefited from this service in four fields of operation. In the fifth field, Jordan, crippled children received similar care at the government rehabilitation centers in Amman. Patients from the West Bank and the Gaza Strip are referred to the Jerusalem crippled children's center for out-patient and in-patient care, whereas in the Syrian Arab Republic treatment is provided through contractual arrangement with a private physiotherapy center. In Lebanon the services of Shatila Rehabilitation Center, Beirut, funded by the Norwegian Peoples Aid, were suspended due to damage to the premises and the rehabilitation center, in Tyre, South Lebanon, funded by the Norwegian Refugee Council, also had to cease operations because of the non-availability of international staff. Orthopedic devices and prostheses were made available to a limited extent in all fields of operation, but even then at higher cost.
43. Medical supplies provided to all fields have been, in general, satisfactory. However the range and nature of these supplies was reviewed during the year and it is intended to continue this process having in mind the WHO model list of essential drugs. Associated with this review process has been enforcement of more active quality control of supplies obtained and distributed. Most of the medical supplies and equipment programmed by the Department of Health continued to be purchased on the international market and through the UNICEF Packing and Assembly Center in Copenhagen. However, occasional shortages due to
and delays in the delivery of overseas consignments; were met from the Director of Health's stock reserve and through local purchase. The value of medical supplies and equipment received as contributions amounted to US$ 149 578, while purchases during the year totaled US$ 863 592.
PREVENTIVE MEDICAL CARE SERVICES
Communicable disease prevention and control
44. Prevention and control of communicable diseases was carried out through the various activities of the health centers.
45. Surveillance of certain communicable diseases was maintained, Agency-wide, through weekly incidence reports from the UNRWA health centers points and special epidemiological investigation, where indicated.
46. UNRWA's Department of Health continued to provide WHO with information on the incidence and prevalence of communicable diseases.
47. Compared with 1985, the following notifiable diseases showed a decrease in incidence: brucellosis from 45 to 35, chicken-pox from 11 338 to 7486, conjunctivitis from 25 064 to 22 490, infectious hepatitis from 861 to 520, leishmaniasis (cutaneous) from 9 to 5, measles from 996 to 163, cerebrospinal meningitis from 2 to 1, mumps from 6535 to 4922, pertussis from 3 to 1, trachoma from 28 to 11, tuberculosis (respiratory) from 105 to 85. On the other hand the following notifiable diseases showed increased incidence: diarrhoeal diseases - in children from birth to 3 years of age - from 48 298 to 51 272, diarrhoeal diseases in persons over three years from 22 216 to 22 615, dysentery, amoebic and bacillary, from 4840 to 5104, the enteric group of fevers from 386 to 513 (almost all in the Syrian Arab Republic), gonorrhea from 2 to 6, influenza from 29 889 to 31 816 (mainly in Gaza and the West Bank), malaria, imported, from 1 to 2 and scarlet fever from 44 to 70 (mainly in the Syrian Arab Republic). No cases of schistosomiasis, diphtheria, poliomyelitis, leprosy, plague, rabies, relapsing fever, syphilis, or typhus were reported. In general it can be said that communicable diseases preventable by immunization were well under control or showed continuous drop in incidence, whereas the incidence of communicable diseases that could be mainly controlled by improvement of the environmental health conditions in camps continued to show increased incidence. Further the potential threats of schistosomiasis and rabies remain a matter of continued concern.
48. The imported cases of malaria were reported by the Gaza and Lebanon fields of operation. The 35 cases of brucellosis, due to consumption of fresh cheese, were reported from the West Bank (33) and from the Syrian Arab Republic (2). The five cases of cutaneous leishmaniasis were notified, two from the Syrian Arab Republic and three from the West Bank. Two of the three cases of tetanus neonatorum were from the West Bank and one from Lebanon, and the only case of tetanus (adult) was reported from Gaza.
49. No cases of cholera were officially reported during the year. However, anti-cholera measures were stepped-up in coordination with the concerned health authorities.
50. The pattern of communicable diseases has changed in recent years, in part due to the impact of the Expanded Programme of Immunization and in part due to changes in the socioeconomic standards.
51. Although the UNRWA Department of Health has a fairly well developed reporting system, there is reason to believe that there is a degree of under-reporting. Efforts are in hand to improve this situation, hopefully by modest computerization, and with the aim of ensuring a speedy feedback to the health workers in the fields of operation.
Maternal and child health services
52. The major component of the primary health care programme provided by the Agency was
health monitoring of pregnant women and children through a network of 98 health units. Nutritional support was given to vulnerable groups through the nutrition and supplementary feeding programme (see Chapter VI of this report).
53. In the antenatal clinics, 41 286 women were registered for maternal care, which includes regular health supervision, the issue of extra dry-rations and treatment of anemia throughout pregnancy and the nursing period. Immunization of pregnant women with tetanus toxoid, implemented in Gaza and Lebanon, was extended to the other fields of operation. 37 718 deliveries were registered which represent a coverage of approximately 51% of the expected number of deliveries (assuming a birth rate of around 40 per 1000 of the eligible refugee population as at 30 June 1985) * 36% of the deliveries still took place at home, the majority attended by Agency-supervised
(traditional birth attendants). But many women nowadays prefer deliveries in hospitals. Even the figures from Gaza field of operation, which is the only one that provides maternity services as part of the camp health services (maternity wards are attached to six of the nine health centers) show that 47% of the deliveries took place in the government hospitals, whereas 31% took place in the camp maternities and 22% at home. One maternal death was reported from the West Bank field. The rate of stillbirths reported was 9.5 per 1000 of the total births registered. An active training programme of traditional birth attendants was conducted in the Syrian field of operation in collaboration with the Ministry of Health and UNICEF.
54. Family planning services continued to be provided by the Agency as an integral part of the maternal and child health programme in Gaza field of operation. Contraceptives were provided by the Jordanian Family Planning and Protection Association through its branch in Jerusalem. The programme also included family life education in the preparatory schools for girls 12-15 years of age. Nurses took part in this programme by giving lessons and demonstrations in mother-and-child care in the schools. In the Syrian field of operation, family planning services were provided to women attending maternal and child care clinics in the health centers in Damascus area. The Ministry of Health provided the contraceptive supplies and training facilities. The Family Planning Services in Jordan field consisted mainly of advisory services by health center staff with designated family planning clinics in Baqa'a, Marks and Amman New camps.
55. 119 016 children up to the age of three years received regular health supervision and immunization in the Agency's child health clinics. Immunizations were given against tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis and measles, following the same schedule as that of the WHO Expanded Programme on Immunization (EPI) (with the exception of polio immunization in the Gaza and West Bank fields of operation, where the modified schedule of combining oral and injectable (Salk) polio vaccines is still in effect). Immunization against rubella was also introduced for preparatory school girls and non-pregnant women in the child-bearing age. Early and effective treatment of diarrhea by oral re-hydration was carried out in all health centers.
56. Children showing growth failure received special attention and care in the nutrition rehabilitation clinics, established in most health centers throughout the fields of operation, as an integral part of the child health program. The proportion of the total number of children registered in the child health clinics, found to be underweight according to local growth curves, was 4.6% in the first year, 5.8% in the second and 2.5% in the third year.
57. A new maternal and child health care intervention strategy was implemented in the West Bank field of operation, based on the findings and conclusions derived from the at risk approach studies conducted in that field with the assistance of the WHO Regional Office for the Eastern Mediterranean. A field trial and evaluation of the scoring system and the intervention strategy is being carried out with a view of wider application of the findings. To facilitate the introduction of a similar approach, where feasible, in other fields of operation a WHO/UNRWA inter-country workshop on risk approach was organized in Amman and attended by 14 medical officers from the five fields of operation, plus two course facilitators from the West Bank.
School health services
58. School health services covered 349 224 children in 635 UNRWA schools. Medical examination at school entry, including vision screening, reinforcing immunizations against diphtheria, tetanus and tuberculosis (BCG), were carried out by either a school health team or at health centers. Regular visits are paid to the schools for health monitoring of the pupils and inspection of school premises. Schoolchildren with suspected visual or hearing defects, usually identified by their teachers, are referred for investigations through the health centers. With UNRWA assistance spectacles are provided to all schoolchildren who need them.
Non-communicable disease prevention and control
59. Control programs for non-communicable diseases are provided by specialists and specialized clinics, integrated with the health center activities. There are clinics for cardiovascular diseases, diabetes mellitus, chest diseases, etc., which besides offering early recognition and prompt treatment give emphasis to health education and preventive measures.
60. With the changing age-structure of the refugee population, due to both the duration of the refugee situation and effective control of communicable diseases, the prevalence and importance of non-communicable diseases is increasing.
61. While this has been recognized by the UNRWA health service there is urgent need for trained staff, adequate equipment and facilities to effectively manage these problems.
62. Already assistance from WHO and UNICEF has enabled some progress to be made.
63. Recent priorities include diabetes mellitus, bronchial asthma, oral health, mental health, cardiovascular diseases and geriatrics.
64. This embraces improved life-style which increases personal responsibility for health. Inherent in this programme are:
Encouragement of personal hygiene
. Environmental pressures including housing inadequacies conspire to make a ready approach to personal hygiene more difficult. Realistic education leading to personal understanding and response should be integrated fully in health education.
Realistic nutritional education
. This must cover a range of particular issues:
(i) Promoting better nutrition practices;
(ii) Emphasizing the major importance of breast-feeding;
(iii) Explaining the relationship between nutrition and disease. The teacher-child-parent approach should be a major tool in highlighting and transmitting nutritional understanding and practice.
Avoidance of self-inflicted health damaging behavior
. This must relate to accidents both in the home and outside, violence, alcoholism, drugs, safe street behavior, etc.
Intense campaign against cigarette-smoking
. Addiction to smoking is spreading like a pandemic throughout the world starting as a predominantly male phenomenon in the
countries. Smoking is now practiced by women and young people both in these countries and in the developing world. The campaign must include:
education and information;
help for smokers in stopping smoking;
involvement of health professionals as well as teachers, social and religious leaders in an exemplary role; and
strengthening of health education.
65. Health education activities are an integral part of the regular work of all health staff. Supporting this is a Health Education Branch, whose activities are geared both to assisting colleagues and carrying out additional health education work.
66. A major advance in this programme has been the mobilization of teachers to give health education as part of their tuition. The teacher-pupil-parent approach has already shown important results.
67. Health education material, produced either by UNRWA or UNICEF, is used for health education activities.
68. A community health education pilot project on sanitation was conducted in Marks Camp, Jordan, for the purpose of promoting cleanliness in all the camp installations and in the houses, with the active participation of Agency staff and the camp community. Subcommittees were formed at sector level for looking after health each in their own sector. Similar activities are being carried out in other camps in Jordan.
69. During the scholastic year 1984-1985 more teachers were enrolled in the in-service training programme in health education. 26 teachers in the Jordan field of operation, 19 teachers in Gaza, 19 teachers in Nablus Area and 26 teachers in Jerusalem have completed the course and they are responsible for the implementation of health education plans in their respective schools. A UNESCO consultant visited UNRWA headquarters in Amman during the year on a health education mission where a 10-day workshop for field course tutors was organized; the major objective was to help these course tutors become trainers. As a result a facilitator's handbook was produced.
70. Nursing activities are central in the on-going health care services of the Agency. Nurses are directly involved in therapeutic care services, preventive and promotive care services, maternal and child care services, nutrition and supplementary feeding services. They also provide supportive and supervisory services in other areas, i.e., environmental health services, special care services, health education, epidemiology and control of communicable diseases and rehabilitative services.
71. Fully qualified nurses with post-basic qualifications in midwifery or community health are responsible for the administration and supervision of the daily nursing activities. These activities are performed by senior and practical nurses, midwives and traditional birth attendants (TBAs). TBAs are utilized in many areas to carry out domiciliary care and in some instances, simple clinic routine. They are an important link between the health services and the community served. Supervision of all nursing activities is the responsibility of the respective field nursing officers and their deputies and/or area nursing officers. This continues to be an important aspect of the total programme as it provides not only supervision but opportunities of assisting nursing staff in problem solving and developing ways of improving and strengthening nursing activities for increased effectiveness of the overall health care.
72. Regular emphasis is given to in-service education for auxiliary nursing staff. Qualified nurses are being provided with post-basic education in midwifery or community health on a continuing basis. The up-grading of nursing staff continues to be a major goal of the nursing program.
73. A limited community health nursing programme has been established in one field of operation and is being implemented in others. A strong community health programme with a community health team carrying out all functions with the cooperation of the community is envisaged for the future.
ENVIRONMENTAL HEALTH SERVICES
74. UNRWA provided basic environmental health services to the refugee population and displaced persons living in 61 camps/locations. These services comprise the provision of potable water, sanitary disposal of solid and liquid wastes, drainage of storm water and control of disease-carrying insects and rodents. The refugees also continue to take an interest in the improvement of environmental health conditions in camps through implementation of aided self-help programs.
75. Cooperation of host governments, local councils and municipalities is steadily growing in the delivery of the service through construction of community water supply and sewerage schemes in some camps
76. Since the establishment of UNRWA, the activities have been gradually evolving from provision of simple and basic sanitation services implemented on an ad hoc basis to a normally provided comprehensive program.
Mode of operations
77. Environmental health services are provided through Agency-employed sanitation staff. At camp level laborers use modest equipment for carrying out the tasks needed.
78. In certain camps local municipalities assume the responsibility for final disposal of refuse and liquid waste, whereas in other localities the services of private contractors are utilized against payment of fees.
79. It is the Agency's responsibility to provide basic environmental health services of an acceptable standard in refugee camps. These services include provision of safe drinking-water, disposal of human excreta, refuse collection and disposal to municipal dump sites and control of insect and rodent vectors of disease.
80. Hygiene education covers responsibility in the home, school, shops, slaughter-houses and food at all stages (preparation, storage, distribution and waste disposal).
81. Where feasible. the Agency coordinates/integrates the technical, financial and operational aspects of the environmental health programme with local municipalities/host governments,
82. UNRWA continues to make formal contact with municipalities/governments and requests cooperation in resolving long-term refugee camp-sewage problems. These solutions should be integrated within the overall master plans.
83. UNRWA continues to encourage water authorities/municipalities to make water connections to all refugee shelters.
1. To maintain cleanliness, and minimize environmental determinants of and exposure to infectious diseases; and
2. To improve health standards, promote community participation and reduce morbidity and mortality associated with poor environmental conditions.
84. The UNRWA aided self-help programme further expanded in the Lebanon field of operation, where in view of the prevailing situation it was expected to progress the least. Refugee communities in this field, besides rebuilding or renovating the destroyed or badly damaged shelters, participated substantially in the speedy rehabilitation of basic sanitation services.
85. In spite of the chronic problem of delays in the procurement and delivery of materials for the self-help program, a number of camps in the five fields benefited from the aided program,
which comprise mainly pavement of pathways, construction of open drains, laying of underground severs and, to a limited extent, construction of private latrines.
86. The Government of Jordan is executing water augmentation schemes aiming at the provision of indoor taps to shelters at Baqa'a, Marks, Suf, Jerash and Husn camps. All shelters at Irbid camp have already been provided with indoor taps which enabled the Agency to phase-out communal water points. In Lebanon, with a generous support of UNICEF, badly damaged water-supply systems at Shatila, Burj-el-Barajneh and Mar Elias camps have been rehabilitated. Burj-el Shemali camp has been provided with a new power back-up system (electric generator) for its water-pumping station. UNICEF financed schemes for providing indoor taps to all shelters at Ein-el-Hilweh camp in South Lebanon and the Bedawi extension in North Lebanon have been completed. In the Syrian Arab Republic almost all shelters at Khan Eshieh camp have been provided with indoor taps and schemes for providing private water taps to refugees are under implementation at the Jaramana and Sbeineh camps. Negotiations with the local authorities are in progress for the linking of Amari camp with a regional water-supply system so that indoor taps could be provided to the refugee shelters.
87. With a gradual increase in water consumption, existing surface drainage systems in some camps are proving to be inadequate, and so the need is being stressed for well-planned regional sewerage systems to serve the camps and surrounding non-refugee communities. An underground sewerage scheme for Mar Elias camp in Beirut area has been successfully implemented with the assistance of UNICEF. Complete integration of sewerage system of
Ein-el-Hilweh camp with the municipal sewerage network of Saida in South Lebanon is in progress. In the Syrian Arab Republic, underground sewerage systems continued to improve in most of the camps, through an Agency subsidized program. In Jordan, the Government has commenced execution of two sewerage schemes at the densely crowded Baqa’a and Marks camps. Similar government schemes are being planned for Irbid and Zarka. A UNDP project to provide sewerage facilities in all the five districts of the Gaza Strip, including refugee camps, and reclamation of waste water is under serious consideration.
88. Efforts are continuing for the improvement of refuse collection and disposal system in the five fields of operation. Slow-moving tractor-trailer units have recently been phased out and two fork-lift trucks with matching containers have been provided to serve Jabalia and Beach camps in Gaza. Similar up-graded refuse transport facilities are planned for the remaining six camps in that field. Non-availability of adequate funds for the purchase of efficient transport equipment and a pressing need for the improvement of roads, streets and alleys in most of the camps is hampering the up-grading of refuse collection and disposal facilities. In Jordan, a suitable contractual arrangement has been made with the municipality concerned for the assignment of a fork-lift truck and matching containers to Zarka camp. Negotiations with municipal officials have been revived for making similar arrangements for Irbid and Marks camps.
89. Chemical control of rodents and insects is being carried out rather selectively in all fields and attention is being focused mainly on maintaining general cleanliness of the environment. Cost-effective insecticides continue to be in use for fly-control operations during the peak season as well as to take care of abnormal situations. In the Jericho area of the West Bank, where some cases of leishmaniasis (cutaneous) are detected, control
measures are implemented including an anti-sand-fly campaign.
90. Despite improvements in this program, there remain a number of problems. These include the provision of adequate and indoor water supply, the construction of sewerage systems, mechanization of refuse disposal, renovation and replacement of dilapidated school latrines and improvements in the workforce of sanitation staff.
NUTRITION AND SUPPLEMENTARY FEEDING SERVICES
Functions and beneficiaries
91. The programme provides nutritional support to vulnerable groups, namely infants and pre-school children, pregnant women, nursing mothers and tuberculosis patients. Nutritional support is provided through:
1. Milk-distribution monthly to children 0-36 months old, to non-breast-fed babies under six months, as well as to pregnant women, nursing mothers and tuberculosis patients;
2. Daily midday meals to children up to six years of age and, upon medical recommendation, those over that age;
3. Special extra rations to tuberculosis patients and to pregnant women from the fifth month of pregnancy and for one year after delivery.
Mode of operation
92. The midday meals/sandwiches are prepared in accordance with a menu issued every month and served in 94 supplementary feeding centers. A special diet (the post-diarrhea menu) is also made available to children suffering from diarrhea or malnutrition.
93. In three fields of operation, milk powder is bagged by machine, while in Lebanon and Gaza milk is bagged manually by the supplementary feeding staff, who are also responsible for the distribution of milk rations, as well as the recording and reporting of issues.
94. UNRWA policy is to provide, free of charge, midday meals/sandwiches, extra rations and dried milk to vulnerable groups of Palestine refugees.
1. To prevent and correct nutritional deficiencies through the distribution of midday meals six days per week and through supplemental prescribed diets;
2. To overcome protein-calorie deficiency among refugee children;
3. To prevent nutritional deficiencies and maintain satisfactory nutritional status of the pregnant and nursing women, non-hospitalized tuberculosis patients and other cases selected on medical grounds; and
4. To promote the nutrition of refugees through effective nutrition education.
95. The results of the nutrition survey carried out in collaboration with WHO, during April-May 1984, in Jordan, the West Bank and Gaza, were published in June 1985. The survey covered about 8800 infants, pre-school children, pregnant and nursing women. The survey showed that acute malnutrition has continued to decrease, since the 1974 survey, in Jordan and the West Bank, but not in Gaza; chronic malnutrition is still a problem in all fields of operation; anemia is highly prevalent among children and women, dental fluorosis is widespread among Gaza refugees, and malnutrition was highly prevalent among the midday meal beneficiaries.
96. The Agency continued to distribute a special monthly ration to the special hardship cases among the refugees in all fields of operation. The ration provides about 1900 calories and 61 grams protein per person per day. About 92 500 persons were receiving this ration.
97. In Lebanon, the programme was interrupted due to the fighting and the supplementary feeding centers became inaccessible to beneficiaries. In Gaza and the West Bank, the programme was occasionally disrupted by demonstrations and the curfews imposed on refugee camps.
98. UNRWA distributes a monthly ration of whole and skim milk powder to children 6-36 months of age and to non-breast fed infants under six months attending the child health clinics. The distribution of milk during the child health sessions has generated a more regular attendance at the child health clinics and a greater utilization of the milk. About 82 000 children benefited from the program. In view of the increased number of beneficiaries, in the absence of a corresponding increase in the Swiss contribution of whole milk, the Agency was obliged to maintain the monthly issue of whole milk for children aged 6-24 months at the reduced rate of 300 grams (instead of 500 grams) per child throughout the year. Skim milk distribution was interrupted occasionally because of shortage of supplies resulting from unforeseen delays in shipment of milk.
99. Nutritionally balanced midday meals are offered daily at the Agency's supplementary feeding centers to children under six years of age and on medical recommendation to those older, to sick adults and to hardship cases. In Lebanon, in view of the continued emergency situation, the authority given in 1982 for the issue of the midday meals on an open basis to children up to the age of 15 years was maintained. The midday meal was served in the form of a sandwich on most days of the week. This has proved to be more acceptable to the beneficiaries with negligible wastage. Fruits were served with the meals. A special high-protein, high-calorie diet (the post-diarrhea menu) was also made available on medical recommendation at the nutrition-rehabilitation clinics and supplementary feeding centers to infants and children suffering from diarrhea and underweight.
100. Extra rations are distributed bimonthly to pregnant women from the fifth month of pregnancy and for one year after delivery, as well as to non-hospitalized tuberculosis patients.
101. The Chief, Nutrition and Supplementary Feeding Division, and the five field food supervisors continued to provide guidance and supervision of the feeding operation in the Agency's vocational and teacher training centers and maternity centers. Monthly menus are prepared in the fields and are regularly scrutinized.
102. The UNRWA General Cabinet Meeting in June 1985 decided, among other austerity measures, to effect a 15% reduction in supplementary feeding staff costs. Elimination of the posts was. implemented by attrition.
GENERAL SERVICES AND SUPPORT SERVICES
103. The level of general support from secretarial and clerical staff with adequate equipment is fundamental to the effective prosecution of the health services. Generally the Agency is well served by conscientious and long-serving staff. As the needs of the refugees change so the response to these needs change. Again this is reflected in the support needs.
104. During the year under review, austerity measures required the loss of one clerical and one secretarial post. While in part this loss was compensated by the ready acceptance of increased workload by the remaining staff, the possibility of increased mechanical support was negated by financial considerations.
105. Despite all this pressure the Administrative Officer not only maintained supervision of the administrative services of the Vienna headquarters but also undertook advisory missions on administrative services to the Amman headquarters and to the Syrian Arab Republic field health team in Damascus. Further such visits will assist the other fields of operation. Realistically the necessary improvement in the clerical and secretarial work will only be possible with improved equipment and staff. The major requirements are for a word processor, a printer and access to more computer time.
Staff changes - Department of Health (headquarters
1. CPMD post was advertised and a new candidate is expected to be selected soon.
2. Ms Barbara Walsh was selected and appointed Chief, Nursing Division, effective 1 July 1985.
3. A post of Chief Training and Research Officer was established in headquarters (Amman). Dr Kamal Abdallah was selected and appointed to this post, effective 18 September 1985.
4. Dr Fathi Mousa was selected and appointed Senior Medical Officer (Statistics Planning), effective 17 July 1985.
5. Mr Isam Asadi was selected and appointed Chief Pharmacist and Supply Officer (Medical), effective 18 June 1985.
1. Two WHO short-term consultants in environmental health have given us the benefit of their advice.
2. A WHO short-term consultant on diabetes mellitus, Dr Dash of India is awaited.
3. A WHO short-term consultant on respiratory diseases for Gaza has been sought.
4. A WHO short-term consultant for help with enteric diseases in the Syrian Arab Republic has been sought.
Budget and finance
107. The Agency's revised budget for 1985, reported to the General Assembly in the Commissioner-General's Annual Report for 1984-1985, totaled US$ 231 552 000. This budget is subdivided into the General Fund and Project Funds as shown below:
1985 General Fund and Project Budgets
(US$ in millions)
108. As the total income estimated for 1985 was US$ 164.4 million, the Commissioner- General ordered, in January 1985, a series of austerity measures to reduce the gap between income and expenditures. These measures reduced all budgetary expenses that did not impair direct services to refugees and resulted in a reduction of US$ 40 million in the 1985 budget, thus narrowing the gap between income and expenditures to US$ 27 million.
109. Expenditure and commitments on the regular programme covering the three main activities administered by the Department of Health in 1985 were as follows:
(US$ in millions)
Share of common costs
110. With the exception of the cost of international staff, paid by the United Nations, UNESCO, and WHO, UNRWA's budget is financed almost entirely from voluntary contributions in cash and in kind, mainly from governments, and the remainder from non-governmental and miscellaneous sources.
111. The Director of Health represented UNRWA at the seventy-fifth session of the WHO Executive Board in Geneva in January, the Thirty-eighth World Health Assembly in Geneva in May, the session of the Regional Committee for the Eastern Mediterranean, in Geneva in October, and the International Consultation on Health Education for School Age Children, in Geneva in September/October.
112. The Director of Health and Deputy Director of Health and Chief, Curative Medicine Division, attended the UNRWA/WHO/UNICEF consultation on mental health for Palestine refugees held at WHO headquarters, Geneva, in March.
113. The Deputy Director of Health and Chief, Curative Medicine Division, attended the Third International Hospital Conference, Copenhagen, in September and the biennial meeting of national fellowships officers for the Eastern Mediterranean Region in Islamabad, in November.
114. The Chief, Preventive Medicine Division, represented the Director of Health at the second inter-country meeting on EPI in Tunis in July.
115. The Chief, Nursing Division, attended a consultation on approaches for policy development on traditional health practitioners, including traditional birth attendants in the Regional Office for South-East Asia, New Delhi, in February.
REPORTED CASES OF NOTIFIABLE DISEASES AMONG REFUGEES IN 1985
for health services
as at 30.6.85...............
1 845 175
(over 3 years NOS)........
Enteric group fevers........
.: No cases of ankylostomiasis, bilharziasis, cholera, diphtheria, leprosy, plague, rabies, relapsing fever (endemic), relapsing fever (louse-borne), syphilis, typhus (endemic), typhus (louse-borne), or yellow fever were reported.
INCIDENCE TRENDS OF SELECTED COMMUNICABLE DISEASES
(rate per 100 000 eligible population)
Part B (continued)
UNRWA'S NUTRITION AND SUPPLEMENTARY FEEDING PROGRAMME 1985
Type of benefit, its nutritional value,
and average number of beneficiaries
Special hardship rations
Supplementary feeding program
Milk and hot meals
Children 0-2 years
(dry whole and skim milk)..................
Children 2-3 years
(dried whole and skim milk)................
For pregnant and nursing women.............
For tuberculosis outpatients ..............
Vitamin A-D capsules
Total number of capsules distributed during the year: 6 324 512
Includes 1936 non-refugee displaced persons on behalf of the Government of Jordan (on reimbursable basis).
Includes 1153 non-refugee displaced persons on behalf of the Government of Jordan (on reimbursable basis).
Includes 793 non-refugee displaced persons on behalf of the Government of Jordan (on reimbursable basis).
HEALTH PERSONNEL IN UNRWA
Health education staff.........
/ Comprises various categories of health auxiliaries and aides who mainly perform administrative and clerical duties at camp level.
UNRWA HEALTH FACILITIES
Number of health centres/points
Number of prenatal clinics
Number of child health clinics
Number of health teams
Number of dental clinics
Number of hospitals
Number of beds available
Number of hospitals
Number of beds available
In addition six maternal child health sub-centers operate in Gaza.
In Gaza and Jordan refugees benefit from UNRWA reimbursement scheme.
UTILIZATION OF UNRWA HEALTH SERVICES
Outpatient medical care
Number of patients attending........
2 675 732
Maternal and child health services
Pregnant women registered...........
Number of pupils examined...........
CAMP SANITATION SERVICES
Population served by
private water connection..........
served by public point.............
Annual average supply
per day in litres...........
Percentage of population
served by private latrines.........
* * *