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Source: World Health Organization (WHO)
31 August 2013

Ref: RAD 8 (September 26, 2013)
Referral of Patients from the Gaza Strip


Outside referrals: Total referrals remained high in August. The continued deep reduction in referrals to Egypt to one-third of normal numbers and halt in referrals to Jordan were countered by year-high referrals to East Jerusalem hospitals and to Israeli hospitals.
Access: 3 patients (a 7-year-old girl and 2 men, aged 18-40) were denied permits. 91.11% of patient applications for permits were approved and 8.6%, (88 patients---29 females and 59 males) received no response to their applications, including 13 children, which delayed medical treatment.
Patients interrogated: 14 patients (11 males; 3 females) who had applied for permits to cross Erez checkpoint were requested to appear for Israeli security interviews. Only one patient was granted a permit after interrogation.
Medical reasons for referrals: Most August 2013 referrals were for treatment in oncology--214 patients (15.45%), nuclear medicine--109 (7.87%), orthopaedics--105 (7.58%), ophthalmology--101 (7.29%), urology--88 (6.35%), paediatrics--83 (5.99%), heart catheterization--82 (5.92%), neurosurgery--76 (5.49%), haematology--71 (5.13%), MRI--53 (3.83%) and heart surgery--44 (3.18%).

Referrals reflect needs and local capacity
The Ministry of Health (MoH) in Gaza referred 1,385 patients to outside hospitals in August, slightly higher than the monthly average in 2013. 36.75% of referrals were to hospitals in East Jerusalem (509), followed by 27.6% to Israel (382). Referrals to both increased by 25% since June, while referrals to Egypt decreased significantly, down from 300 to 113 patients reflecting the unstable border and internal situation in Egypt. For the second consecutive month, Egypt dropped to fifth-place as a referral destination, from third-place (Table 1).
Referrals for oncology, hematology, ophthalmology, orthopedic surgery, heart surgery and heart catheterization in particular reflect the lack of capacity within the MoH due to shortages of drugs and disposable materials in these areas. Referrals within Gaza to non-MoH facilities were for heart catheterization (67), lithotripsy (63), MRI (45), rehabilitation (17), intensive care (6) and other specialties (7).

Limited access to Egypt
Private patients also delayed trips to Cairo for medical treatment due to the unstable situation and restrictions on access to Egypt. According to Rafah terminal data for January-June 2013, a monthly average of 20,577 passengers travelled through the terminal to Egypt, including 4,177 (20.3%) seeking health care abroad. However in July, the terminal registered 8,091 passengers, including 411 (5%) seeking health care. In August 5,869 passengers were registered, including only 259 (4%) for health care, a fraction of the usual number.

Rafah terminal was completely closed for 15 days in August (7 days for security reasons, and 8 days for holidays/weekends). Rafah terminal authorities reported that after July 10, hours were restricted to only 10 am-2 pm. According to the Palestinian authorities of the terminal, there were neither medical delegations nor humanitarian aid entered Gaza from Egypt during August.

No referrals were made to Jordan in August (Chart 1). There was a significant gender gap in referrals in August: 58% male patients versus 42% female patients. 27% of all referrals were children aged 0-17 years and 17% were elderly over 60 years.

Access through Erez
In August 2013, 932 of 1,023 patients (91.11%) received permits to cross Erez to access hospitals in the West Bank including East Jerusalem, or in Israel or Jordan (Table 2). 3 (a 7-year-old girl with a kidney condition and 2 men aged 18-40 with orthopedic problems) were denied access to specialized hospitals.

According to the Palestinian District Coordination office, 88 applications of patients (8.6%), including 13 children and 5 patients over the age of 60, received no response; 33% were females. Out of the 88 delayed applications, 43% had been destined for scheduled appointments in East Jerusalem hospitals, 39% in hospitals in the West Bank, and 17% in Israel.

Responses from Israeli authorities should be given to applicants within 10 days. 31 applications were pending between 1-2 weeks, and 13 for 2-4 weeks. Out of the total 88 delayed patients, 12 patients received approval in the first 2 weeks of September after reapplying with new appointments.

13 patients, including 2 females, and one companion (the father of a child), were called for security interviews by Israeli General Security Services (GSS) as a condition to process permit applications. Only one patient granted a permit after interrogation.

The permit approval rate has been rising since May, but is still below the level of January 2013, due to a number of factors, including staff changes in February 2013 in the Palestinian District Coordination office, the increase in volume of applications and the nature and length of the security review. The rate of denials, while small, is higher than recent months (Chart 2).

The volume of applications increased in 2013 by 34%, compared to the same period in 2012, while the approval rate declined by 7.26 %, and the rate of delay was 2.5 times higher (Table 3).

In August, 90.8% of referral patients applying for Israeli permits were financially covered by the Palestinian MoH, 5.8% were self-funded, and the remaining patients were funded by Physicians for Human Rights-Israel, Peres Center for Peace, Nour Ala-Al-Alam foundation, and UNRWA. MoH referrals do not cover transportation or companion costs and some items of patient care, for example, medicines not in hospital supply.

The Palestinian General Authority for Civil Affairs registered 833 patients and 816 companions travelling through Erez checkpoint to Israel, oPt or Jordan during August. The Emergency Medical Services of the MoH in Gaza coordinated the travel of 372 people to Egypt. 315 patients traveled through Rafah border, most with companions: 56 patients were transferred by ambulances, and 259 patients traveled through Rafah terminal as regular passengers.

Patient access at Gaza exit points

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