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Source: World Health Organization (WHO)
14 November 2008




Old Nablus Road – Sheikh Jarrah
PO Box 54812 – Jerusalem 91547
Tel: +972 2 540 0595
Fax: + 972 2 581 0193
Email: infounit@who-health.org
www.emro.who.int/palestine/

GAZA HEALTH WORKERS STRIKE
Impact of the Strike on Health Services’ Provision

August – October 2008


Summary
– The strike started on 30 August and has been extended to 31 December
– 48% of all staff at the MoH hospitals and 68.0% at the PHC facilities were on strike during the first week of the strike.
– Those figures fell to 20% and 27% respectively in w/c 8 November. Just 6% of hospital doctors are now on strike
– Hospital activity in September was significantly reduced even allowing for the effects of Ramadan. By comparison with Oct 2007 – Consultations at PHCs also fell – by 19% compared with Oct 2007
– Referrals Abroad of patients in need of specialized hospital care fell by almost 50% compared with the monthly average for 2008 - to 449 patients in Sept and 460 in Oct. Only the most urgent cases are being processed
– 94 (22.6%) drug items out of the list of 473 essential drugs were at zero level compared to 63 (15.0%) items at mid September and 48 (11.5%) items at mid August

1 Overview
1.1 The Palestinian union of health professionals declared a total1 health strike in Gaza Strip starting August 30 following the dismissal of 40 health staff in hospitals, primary health care clinics and other administrative positions. A statement by the union to health professionals called for the suspension of all health services, patients to seek alternative health services provided by the non-public sector, and all health personnel to voluntarily serve patients at NGO health facilities during the strike. The union has since then extended the strike on a weekly or biweekly bases to 31 December.
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1 Total strike means: all health employees in different MoH health services.

1.2 Hamas responded that the 40 health personnel were dismissed because they stopped reporting to duty between August and October 2007. A circular was disseminated by the (Hamas) health minister in Gaza to health facilities stating that: all health personnel have to report to work and not go on strike; all general directors, directors and heads of departments have to closely monitor the attendance of the health personnel and report directly to the health minister’s office in Gaza on a daily basis; health personnel who strike will not be allowed to report back to duty after the end of the strike unless authorized by the health minister in Gaza; the health facilities that are managed by the private and the NGO sector should not host or hire any of the health personnel who are on strike and permanent replacement of the health personnel who go on strike will be considered.

1.3 Some MoH hospitals kept most of their services going even with the shortage of staff through working extra hours, the deployment of volunteers and appointment of new staff, mainly nurses, the relocation of staff to hospitals in need and the enforcement of staff attendance by the Internal Security Forces (ISF).

1.4 Health personnel who did not report to work for 15 days were referred to the Strike’s Crisis Management Committee (SCMC) to decide on their return to duty. The SCMC decided to accept the return of technical staff who had gone on strike (physicians, nurses, pharmacists, lab & x-ray technicians), with the exception of heads of departments who were demoted or relocated to other positions upon their return to duty. They have been replaced by their deputies or similarly skilled staff within the same department The return of the administrative employees who went on strike depended on the recommendations of their supervisors and the MoH legal advisor in Gaza.

1.5 All physicians on strike have been forced to close their private clinics. After the third week of the strike, the SCMC made a decision that physicians who returned to their duty needed to submit a written request to hospital directors stating their commitment to duty in order to re-open their clinics.

2 Health Personnel

The number of health personnel on strike has decreased gradually since the beginning of the strike. 48% of all staff at the MoH hospitals and 68.0% at the PHC facilities were on strike during the first week of the strike. Current figures are 20% and 27% respectively.

Data disaggregated by health profession at hospital level show that 77 physicians out of 1,186 (6%), 300 nurses out of 1,580 (19%) and 525 of other health professions out of 4,553 (29%) were on strike in w/c 8 November.
Data also show that the highest numbers of physicians on strike are at Shifa, Nasser and Kamal Edwan hospitals.

Table 1: Numbers and percentage of physicians on strike per hospital and specialty: w/c 8 November

At Primary Health Care level 59 out of the 378 physicians (16%), 96 out of 325 nurses (30%) and 283 out of 922 (31%) of other health professions were on strike. (Annex 1)

The MoH in Gaza has hired new health personnel to cover the shortage of the staff. These comprise so far:
– 108 nurses: 25 in the PHC centres and 83 in the hospitals;
– 70 lab technicians: 29 in the PHC centres and 41 in the hospitals; and
– 11 x-ray technicians: 1 in the PHC centres and 10 in the hospitals.

Those newly hired personnel will be paid by the MoH-Gaza.

3 Health Service Provision

At hospital level, two MoH hospitals, the Gaza psychiatric hospital in Gaza city and the Kamal Edwan hospital in North Gaza declared a state of emergency for two weeks. This meant the suspension of elective surgical operations, the closure of outpatients’ clinics except one to treat emergency cases and limiting diagnostic services to emergency cases.. A third hospital in Gaza (Dorah hospital) declared a state of emergency for one week. Although other MoH hospitals were trying to provide all services, a delay in the provision of some services was reported and the quality of the provided services remains of concern.
At the PHC level, 12 PHC centers and 2 Community Mental Health (CMH) centers were completely closed at the beginning of the strike. 7 PHC centers continued to be closed during the second week of the strike and 1 CMH center was functioning without any psychiatric service. Currently, 2 PHC centers are still closed.

Data on services provided during September has been collected from all the MoH hospitals2 and PHC directorates at district level in Gaza Strip. Comparative data for August 2008, and September and October 2007 has been shown to allow for the effects of Ramadan which results in a drop in activity. (Ramadan was in September 2008 and 20 September to 20 October 2007)
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2 Shifa, Dorah, Gaza Psychiatrics and Gaza Ophthalmic hospitals in Gaza; Beit Hanun and Kamal Edwan hospitals in North Gaza; Aqsa Martyrs hospital in the Mid Zone; Nasser and Gaza European hospitals in Khan Younis; and Yousif Najar and Tal Sultan hospitals in Rafah. Data is not available for Gaza Pediatrics hospital as the health personnel in charge of preparation of the hospital daily reports are on strike.

3.1 Hospitals’ Admissions
Patients’ admissions at the MoH hospital in September 2008 decreased by 26% as compared to August 2008; by 16% as compared to September 2007; and by 18% as compared to Oct 2007.

The highest drop in the number of admissions was detected in Gaza Psychiatric Hospital and in Beit Hanun Hospital.
The lowest drop was noted in Nasser Hospital followed by Tal Sultan Hospital Yousif Najar hospital showed an increase in the number of admissions in Sep 2008 as compared to Sep 2007.

Table 2: Hospitals’ Admissions compared between September 2008 and Aug 2008, Sep 2007 and Oct 2007 per hospital


3.2 Outpatient visits
The number of visits to the out-patient clinics at the MoH hospitals has dropped by 41% in Sept 2008 as compared to Aug 2008, by 31% as compared to September 2007 and by 34% as compared to Oct 2007.

The highest drop in the number of out-patient visits was detected in Kamal Edwan hospital followed by Beit Hanun hospital.
The lowest drop was detected in Gaza Psychiatric hospital followed by Gaza European hospital.


Table 3: Hospitals’ Out- Patient Visits compared between September 2008 and Aug 2008, Sep 2007 and Oct 2007 per hospital


3.3 Emergency Room Visits
The number of visits to the Emergency Room (ER) at the MoH hospitals has dropped by 13% in Sept 2008 as compared to Aug 2008; by 10% as compared to September 2007; and by 3% as compared to Oct 2007.

The highest drop in the number of ER visits was detected in Beit Hanun hospital followed by Dorah hospital.



The lowest drop was detected in Gaza Psychiatric and Kamal Edwan hospitals. An increase in the number of ER visits in these two hospitals was noted in Sep 2008 as compared to Sep 2007. In comparison with Oct 2007 Kamal Edwan hospital showed an increase whilst Gaza Psychiatric hospital showed no change in the number of ER visits. Also, Aqsa Martyrs and Yousif Najar hospitals showed an increase.

Table 4: Hospitals’ Emergency Room Visits compared between September 2008 and Aug 2008, Sep 2007 and Oct 2007 per hospital


3.4 Surgical Operations (SOs)
The number of Major Surgical Operations (Major SOs) performed at the MoH hospitals in September 2008 was 39% lower than the number of SOs performed in Aug 2008; 26% lower than its number in Sep 2007; and 32% lower than its level in Oct 2007.

The highest drop in the number of major SOs was detected in Beit Hanun hospital followed by Kamal Edwan hospital.

Whilst the lowest drop was detected in Yousif Najar hospital as compared to Aug 2008; Tal Sultan hospital as compared to Sep 2007; and in Gaza European hospital compared to Oct 2007. On the other hand an increase in the number of major SOs was detected in Yousif Najar hospital in Sep 2008 as compared to Sep 2007 and in Tal sultan hospital in as compared to Aug 2008.

Table 5: Hospitals’ Major Surgical Operations compared between September 2008 and Aug 2008, Sep 2007 and Oct 2007 per hospital

Minor surgical operations decreased by 18% in September 2008 as compared to the August 2008. However, the number of minor surgical operations was 23% higher than the number performed in September 2007 and 11% higher than its level in Oct 2007.

The highest drop in the number of minor surgical operations was detected in Beit Hanun followed by Gaza European.
The lowest drop was detected in Tal Sultan and Shifa hospitals as compared to Aug 2008. These two hospitals showed an increase in the number of minor surgical operations in Sep 2008 as compared to Sep 2007. Yousif Najar and Gaza Ophthalmic hospitals also showed an increase in the number of minor SOs as compared to Aug 2008 and Sep 2007.

In comparison with Oct 2007, the lowest drop was detected in Kamal Edwan hospital. However, the number of minor SOs has increased in Gaza Psychiatric, Nasser, Yousif Najar, and Tal Sultan hospital.

Table 6: Hospitals’ Minor Surgical Operations compared between September 2008 and Aug 2008, Sep 2007 and Oct 2007 per hospital

3.5 Kidney Dialyses
Currently there are 372 patients with chronic kidney failure in Gaza Strip who need dialysis treatment that is received at four MoH hospitals: Shifa, Aqsa Martyrs, Nasser and Yousif Najar hospitals. During the strike, the provision of the kidney dialyses service has not been affected in terms of quantity or quality. None of the health personnel working in the kidney dialyses departments in the four hospitals had abided by the strike and all of them were reporting to their work regularly and on time.

A shortage in one medical supply (Bi-Bag System) needed for dialysis was reported by MoH hospitals for 1 week. 12 kidney dialyses machines out of the 52 available were at risk of shutting down due to this shortage.

3.6 PHC consultations
The number of consultations in MoH PHC facilities in Gaza Strip during Sep 2009 was 23% lower than in Aug 2008 and 18% lower than in Aug 2007 and 19% lower than in Oct 2007.

Data disaggregated by district shows that the highest drop in the number of PHC consultations was in north Gaza district followed by the mid zone district.

Table 7: PHC consultations compared between September 2008 and Aug 2008, Sep 2007 and Oct 2007 per district.

Correspondingly, the number of UNRWA PHC consultations during Sep was 21% lower than in Aug 2008, 16% lower than in August 2007 and 14% lower than in Oct 2007.

Data collected from the main NGOs in Gaza Strip, Palestinian Medical Relief Society (PMRS) and Union of Health Work Committees (UHWC) on the number of PHC consultations at their clinics shows a different trend. The number of consultations at the PMRS clinics in Sep 2008 is 11% higher than in Aug 2008 and 49% higher than in September 2007.

At the UHWC clinics, the number of consultations in Sep 2008 is 32% lower than in Aug 2008 and 15% lower than in September 2007.

4 Referral Abroad

The Referral Abroad Department (RAD) and the Directorate of Coordination and Liaison (DCL) have been closed since the beginning of the strike on August 30. However, referral documents and applications for permits for urgent/ life saving cases have been processed by the director from home, mainly oncology, cardiology, paediatrics and ophthalmology cases.

The number of patients who applied for permits in September and October 2008 was 49% and 47% lower than the number of patients that applied for permits in August 2008. 449 applied for permits in September and 460 applied for permits in October 2008 as compared to 874 applications during August.

Out of the 449 patients who applied for permits to cross Erez crossing for medical treatment during the month of September, 348 (77.5%) applicants have been approved, and 101 (22.5%) have been denied or delayed including 74 males and 27 females. In October, out of 460 patients who applied for permits, 355 (77.2%) applicants have been approved, and 105 (22.8%) have been denied or delayed including 68 males and 37 females.

During September and October, more than 55% of the applications were for medical interventions in the specialties of Cardiology, Oncology and Ophthalmology.

The number of patients that actually crossed Erez in September and October was 40% and 39% lower than the number of patients that crossed Erez during August: 334 patients in September and 343 patients in October as compared to 560 in August.

No cases were processed between 9 and 14 October after Hamas took over the RAD and the DCL and locked out the director. However, following the intervention of the Minister of Health-Ramallah, the directors of the RAD and the DCL agreed to resume work from their offices starting the 15th of October for urgent cases only. Processing applications for non urgent cases has been postponed until the end of the strike.

5 Pharmaceutical Stock Levels

– The CDS in Gaza reports that it has received less than one quarter of the requested quantities of drugs and consumables since the beginning of this year. According to the procurement plan, the CDS in Gaza requested drug items worth cost of NIS 45 million. Until the end of September, the CDS received drug quantities worth cost of NIS 10.8m (24%).

– The CDS in Ramallah took over responsibility for coordinating all deliveries to Gaza as of September 1. No deliveries have been received by the CDS in Gaza since then apart from two small shipments of urgently needed supplies which were coordinated by WHO.

– The CDS in Gaza reported that at the end of October, 94 (22.6%) drug items out of the 473 essential drug list (EDL) were at zero level; as compared to 63 (15.0%) drug items at the mid September and 48 (11.5%) drug items at the middle of August. 48 (11.5%) drug items were at stock level of 1-3 months; a similar level to mid September. 128 out of 596 medical supplies are at zero level (21.5%).

Annex 1

Table 1: Number of health personnel on strike in the MoH Hospitals

Table 2: Number of health personnel on strike in the PHC districts

Annex 2
Table 1: number of admissions at the MoH hospitals

Table 2: number of Out-Patient Clinics at the MoH hospitals

Table 3: number of emergency room visits at the MoH hospitals


Table 4: number of Major surgical operations at the MoH hospitals

Table 5: number of Minor surgical operations at the MoH hospitals

Table 6: number of Mortalities at the MoH hospitals

Table 7: number of MoH PHC consultations per district



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