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Source: World Health Organization (WHO)
25 November 2013

Ref: RAD 10 (Nov. 25, 2013)

Referral of Patients from the Gaza Strip

Summary: October 2013

Health-seekers: The number of applications for health access through Erez checkpoint is 44% higher this year than the same period in 2012.

Arrest at Erez: A man who was accompanying his elderly mother to a Jerusalem hospital for orthopaedic surgery was arrested at Erez checkpoint on October 15.

Outside referrals: Referrals in October remained high, although slightly below the 2013 average, due primarily to chronic drug shortages and unavailability of specialists and equipment. As in recent months, referrals to Egypt remained at low levels and one referral only was issued to Jordan. 45.6% of Gaza referrals were to hospitals within the occupied Palestinian territory (in West Bank and East Jerusalem).

Denials/Delays: The number and rate of denials for October was the highest in 2013. 11 patients (1 female and 10 male) were denied permits. 95 patients---34 females and 61 males (6.69% of total applicants) --- received no response to their applications, including 17 children, which delayed medical treatment. 92.54% of applicants received permits.

Patients interrogated: 22 patients (18 males; 4 female) who had applied for permits to cross Erez checkpoint were requested to appear for Israeli security interviews. This was the highest monthly number of patients for interrogation this year. One patient was granted a permit after interrogation.

Medical reasons for referrals: In October 2013 most referrals were for treatment in the following specialties: oncology--226 patients (17.17%), ophthalmology--98 (7.45%), nuclear medicine--97 (7.37%), urology--94 (7.14%), paediatrics--81 (6.16%), neurosurgery--76 (5.78%), orthopaedics--75 (5.7%), heart catheterization--73 (5.55%), MRI--59 (4.48%), and haematology--52 (3.95%).

Gender gap: There was a gender gap in referrals: 56.69% male patients versus 43.31% female patients. 25% of all referrals were children aged 0-17 years and 19.4% were elderly over 60 years.

Cost: The total estimated cost for Gaza MoH referrals during October was NIS 8,411,796.

Son arrested while accompanying his disabled elderly mother to hospital

Gaza resident Ne’man Ali Rihan, 41 years old, was accompanying his mother, 68-year-old Diba Rihan, to a Jerusalem hospital, when he was arrested at Erez checkpoint on October 15. Ne’man was stopped by Israeli security forces although he had been issued a permit to accompany his mother. Diba Rihan, who had been referred for total knee replacement, was forced to return to Gaza after her son’s arrest. Her medical documents remained with her son and have not been returned by Israeli authorities. Ne’man Rihan is being held in Askelon prison and is awaiting trial, according to his lawyer.

Referrals reflect needs and local capacity

The Ministry of Health (MoH) in Gaza referred 1,316 patients to outside hospitals in October, slightly below the monthly average of 1,372 in 2013. Of the referrals, 32.37% were to hospitals in East Jerusalem (426), followed by 28.12% to Israel (370), higher than the average for 2013 (Chart 1). Referrals to Egypt remained much lower than usual levels, from 300 to 132 patients, reflecting the unstable border and internal situation in Egypt (Table 1).

Referrals for oncology, hematology, ophthalmology, orthopedic surgery, heart surgery and catheterization in particular reflect the lack of capacity within the MoH due to shortages of drugs and disposable materials and human resources and equipment in these areas. Referrals within Gaza to non-MoH facilities (213 referrals) were lower than the previous month but higher than the monthly average for 2013; most were for lithotripsy (61), heart catheterization (57), MRI (51), rehabilitation (32), and other specialties (12).

Limited access to Egypt

In October, of the 7,166 travelers who left Gaza through Rafah terminal, only 308 were patients (4%), continuing a 4-month trend of patients discouraged from using that route (Chart 2). According to Rafah terminal data for January-June 2013, a monthly average of 20,577 passengers usually travel through the terminal to Egypt, including 4,177 Ministry of Health and private patients (20.3%) seeking health care abroad.

Rafah terminal was closed for 16 days in October (12 days for security reasons and 4 Fridays as regular holiday, although on 2 Fridays the border was open for pilgrims). Crossing hours have been restricted since July 10 to 10 am to 2 pm. According to Palestinian authorities at the terminal, no medical delegations or humanitarian aid entered Gaza from Egypt during October.

Access through Erez

In October 2013, 1,314 (92.54%) of 1,420 patients applying received permits to cross Erez to access hospitals in the West Bank including East Jerusalem, or in Israel or Jordan (Table 2). Eleven patients, including one female, who had appointments for treatment in orthopedics, urology, and neurosurgery were denied access through Erez to specialized hospitals in Jerusalem, elsewhere in West Bank and in Jordan.

According to the Palestinian District Coordination office, 95 applications of patients (6.69%), including 17 children and 6 patients over the age of 60, received no response; 36% were females. Out of the 95 delayed applications, 53% had been destined for scheduled appointments in East Jerusalem hospitals, 19% in hospitals in the West Bank, and 25% in Israel and 3% in Jordan. Patients who were delayed were mainly in need for treatment in orthopedics, ophthalmology, or general surgery. Responses from Israeli authorities should be given to applicants within 10 days. Only 4 patients had received a response by the first 2 weeks of November, of the 95 patients waiting for permits.
22 patients, including 4 females, were called for security interviews by Israeli General Security Services (GSS) as a condition to process their application. Only one patient was granted a permit after interrogation.

The permit approval rate has been improving since May, but is still below the level of January 2013. The number and rate of denials for October was the highest in 2013; 0.77% (11 patients) (Chart 3).

The number of permit applications for health access has increased in 2013 compared to the same period in 2012 by 44%, and the approval rate has declined 5%. Applicants are twice as likely to be delayed this year (Table 3).

In October, 89.58% of referral patients applying for Israeli permits were financially covered by the Palestinian MoH, 6.83% were self-funded, and the remaining patients were funded by Nour Ala-Al-Alam foundation, Physicians for Human Rights-Israel and Peres Center for Peace. MoH referrals do not cover transportation or companion costs and some items of patient care, for example, medicines not in hospital supply. Patients and companions face financial problems during their stay in hospitals for various reasons including long stay, and personal expenses.

The Palestinian General Authority for Civil Affairs registered 1,212 patients and 1,157 companions travelling through Erez checkpoint to Israel, oPt or Jordan during October, 51 patients were transferred back-to-back by ambulances. Rafah terminal authorities reported that all patients and their companions (159 patients with 149 companions) were transferred by ambulance to the Egyptian side during October in order to facilitate their crossing to Egypt (Table 4).

Patient access at Gaza exit points

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