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Source: World Health Organization (WHO)
14 May 2002

Health conditions of, and assistance to, the Arab population
in the occupied Arab territories, including Palestine
Supplementary report by the Secretariat

1. This note supplements the information given in document

2. Since September 2000, the international community has witnessed a series of tragic events unfold in the Palestinian territories. These events have led to a dramatic deterioration in the social and economic infrastructure and have had serious impact on the health and well-being of the population living under these difficult circumstances. Between September 2000 and May 2002 the conflict resulted in over 36 522 Palestinian injuries and more than 2195 deaths, many of which were among the prime age group of 15-45 years.1 This has been accompanied by widespread destruction of property and agricultural land, displacement of families, and severe restrictions on movement and travel of the Palestinian population and of goods, including medical supplies and personnel. This report attempts to illustrate the negative impact of events on the health status of the Palestinians since the escalation of conflict in September 2000. The health statistics presented in this report are compiled from various sources, including health-sector partners in the Palestinian territories.


3. Several factors related to the recent military incursions have contributed to the deterioration of the health status of many Palestinians, including lack of access to health facilities, disruption of essential health services and programmes, and damage to the health infrastructure. Endemic vulnerability, economic instability and insecurity have further exacerbated the health situation.

Lack of access to and disruption of routine health services

4. Restricted access to health facilities for both patients and health care providers, as well as damage to health facilities, has disrupted routine health services and crucial preventive public health programmes and services, such as environmental inspections, solid-waste collection and disposal, home visits, medical transportation, immunization campaigns, growth monitoring, antenatal care and school health programmes. Significant numbers of Palestinians live in rural areas where secondary and tertiary health care services are not available. Hence, the general restrictions on movement, curfews and the damage to the health sector have had numerous adverse effects on the overall health status of Palestinians. Initial reports by the Palestinian Ministry of Health and UNRWA indicate the following: 2,3,4,5

  • a dramatic rise in the number of consultations at health facilities (by 29% in UNRWA clinics in the Gaza Strip alone);
  • increases in the number of high-risk and complicated pregnancies and of stillbirths observed (by 12.4% in the West Bank and 16.1% in the Gaza Strip);
  • existing shortages of critically needed medical supplies and equipment compounded by the sudden increase in demand by emergency medical services;
  • blood shortages at hospitals;
  • limited supply of essential drugs and vaccines compounded by difficulty in replenishing supplies because of restrictions on movement of people and goods;
  • a 40% decrease in implementation of school immunization programmes;
  • an increase in malnutrition rates among children below five years in the Gaza Strip;
  • food insecurity in several refugee camps;
  • a 32% decrease in administration of tetanus toxoid for women seeking antenatal care;
  • a 52% decrease in women seeking antenatal care;
  • a 29% increase in home deliveries in the West Bank;
  • lack of clean water and safe sanitation (50% decrease in sampling, testing, chlorination, monitoring and follow-up), and the high probability of epidemics of communicable diseases;
  • further deterioration in the psychological and social well-being of communities;
  • restrictions on the supply of electricity leading to breakdown in the cold chain for vaccines and disruption of safe blood storage and operation of medical diagnostic equipment.

    5. The medium- to long-term implications of lack of access to routine health services are catastrophic in both material and human terms. The immunization coverage rate of 95% before the crisis has been drastically reduced to 65%.1 Specifically, in the past six months some 500 000 children in parts of the West Bank have not been immunized,2,3 thereby creating a cohort of highly susceptible and vulnerable children for whom the risks of epidemics such as measles are tremendous.

    6. Many adults urgently requiring specialized medical care, such as cancer treatment, haemodialysis or physiotherapy, have not been able to seek that care, with the eventual result of high levels of avoidable morbidity, mortality and disability. A recent report by Physicians for Human Rights indicates that, in the aftermath of the recent invasion of the Jenin refugee camp, many patients were unable to get access to appropriate medical care. In particular, some patients reported not having access to medical treatment for more than seven days after sustaining life-threatening injuries! An approach implemented by the Palestinian Ministry of Health to ensure alternative access to tertiary health services had previously established emergency medical support at the periphery, but in the current context, this has become a very costly venture and is difficult to maintain under present circumstances.

    Restricted humanitarian assistance and lack of safe passage for medical workers

    7. Several organizations present in the area, including UNRWA, the International Committee of the Red Cross and various nongovernmental organizations, have reported on events constituting violations of international humanitarian law, the Geneva Conventions and resolutions and the Charters of the United Nations. The crisis has also brought considerable media attention and international condemnation for what has been viewed as an excessive use of military force against the civilian population, as well as for blockading emergency medical response units, violence against health personnel, enforcement of restrictions on movements of populations, and restriction of access for desperately needed humanitarian assistance. The statistics further illustrate violations of internationally accepted codes of conduct:6,7,8,9,10,11

  • destruction of over 160 ambulances;
  • over 107 reported military attacks on various health facilities and health institutions (including universities);
  • extensive damage to more than 29 hospitals and eight health clinics;
  • the death of 17 medical personnel in the line of duty;
  • injuries to more than 340 medical personnel in the line of duty.

    8. Provision of basic commodities, such as clean water and safe sanitation, is reported to have been completely cut in some areas and considerably curtailed in others. Additionally, the build up of solid wastes and the inability to bury the dead will result in an environmental disaster if not dealt with quickly.

    Further deterioration of social and economic infrastructure

    9. The protracted crisis has adversely affected the livelihoods of the newly unemployed and their dependants. On the conservative assumption that each worker supports, in addition to himself or herself, an average of four dependants, loss of employment (for an average of 177 000 persons between October 2000 and the present) has reduced the income of an estimated 885 000 persons, or nearly 30% of the population.12

    10. The decline in economic activity is likely to continue to affect various aspects of the health care delivery system. A substantial proportion of the Ministry of Health budget comes from the Palestinian Authority, and a reduction in the public revenues from taxation and health insurance is drying up the ministry's budgetary support. The governmental sector is the main provider in Gaza, and covers about half the health care needs in the West Bank (where nongovernmental organizations and the private sector are more important than in Gaza). The rest of the budget of the Ministry of Health comes from cost recovery through private health insurance and direct payment. Cost recovery is threatened because of

    (a) increased unemployment, which, along with the declining participation of the labour force, has raised the dependency ratio from an estimated 4.8 in the third quarter of 2000 to 6.7 in the first quarter of 2001,13 and probably higher since then;

    (b) the magnitude of injuries, which is draining the remaining resources of the Ministry of Health as it treats the patients at no cost;

    (c) temporary inability of the injured, most of whom are men of working age, to earn income; and

    (d) difficulties of those who have become disabled in re-entering the labour force - over 1000 persons are estimated to have suffered permanent disability.14 Reduced household income has, in turn, affected capacity to care for the disabled.

    11. Overall, the economic projections for the Palestinian territories are bleak and have implications for the eventual impact on the economic and social security of individuals. Fortunately, the health sector has received partial funding from private donors, the Islamic Development Bank and governments to keep it minimally operational. Funding for future reconstruction and rehabilitation of the health sector will largely depend on assurances of maintaining security and peace.


    12. The health outlook in the Palestinian territories before the current crisis was characterized by a lack of sufficient resources, both human and material, to deal adequately with the increasing demands of the population. In the past the health sector had gradually evolved through rebuilding of hospitals, provision of refresher skills training, promotion of public health programmes and strategic health policy and planning. That process has come to a halt. Resources have now been diverted in order to support the excessive burden on the already dilapidated health system of the high number of cases of injury and trauma. The recent worsening of the conflict has further prevented the health sector from carrying out its regular public health programmes, such as immunizations, family planning and reproductive health, and prevention of communicable diseases. One consequence is the high risk of outbreaks of infectious disease. The long-term impact of the lack of access to care, exacerbated by poverty, economic and social insecurity, on the health of the Palestinians must be studied, monitored and tackled in order to alleviate the negative effect on health. Long-term care for those who have been disabled as a result of this conflict alone will require extensive financial and structural commitment. Similarly, assessing the magnitude of the psychological implications of this crisis is an urgent health concern.


    13. In response to Health Assembly resolutions, WHO developed a special health/assistance programme to support and empower the Palestinian Ministry of Health to meet the emerging health needs of Palestinians. Additionally WHO has maintained a strong programmatic link with the Ministry of Health, at regional and headquarters level, through joint initiatives. WHO has tried to maintain a balance between health initiatives and provision of urgently needed humanitarian assistance. The most recent resolution, WHA54.15, adopted by the Health Assembly in May 2001, requested the Director-General: "to continue to provide the necessary technical assistance to support health programmes and projects for the Palestinian people", "to take the necessary steps and make the contacts needed to obtain funding from various sources including extrabudgetary sources, to meet the urgent health needs of the Palestinian people", and "to continue [...] efforts to implement the special health assistance programme and adapt it to the health needs of the Palestinian people, taking into account the health plan of the Palestinian people".

    14. WHO will continue its efforts to provide technical assistance to the Ministry of Health by coordinating the Field Task Force Group on Health, facilitating emergency response through development of rapid health sector assessments; collecting and disseminating data; monitoring the health situation; drawing up and promoting essential preventive and curative health programmes; and securing donor funds both for use in the emergency and during the reconstruction and rehabilitation of the health sector.

    15. Health is a fundamental human right, which needs to be maintained. WHO will continue to advocate for access to quality health care and to seek to provide essentially needed medical supplies as well as specialized technical assistance to those in need. WHO will work with the international community to reaffirm its commitment and resources for the reconstruction/rehabilitation of the Palestinian health sector. WHO will support and facilitate the initial health needs assessment of the health sector which will lead into developing a comprehensive strategic plan of reconstruction/rehabilitation of the health sector in Palestine.


    1 Ministry of Health, Palestinian National Authority, Annual Report 2001, 2002.

    2 Ministry of Health, Palestinian National Authority, Annual Report 2001, 2002.

    3 UNRWA, Annual Report of the Commissioner-General, 2001.

    4 UNRWA, Emergency Appeal for 2002.

    5 "Vulnerability and the international health response in the West Bank and Gaza Strip: an analysis of health and the health sector", WHO country office, Jerusalem, and Peacepath Consulting, Rome, 2001.

    6 "Physicians for Human Rights Forensic Team Preliminary Assessment, Jenin, April 21-23, 2002", Physicians for Human Rights, Boston, Massachusetts, United States of America, 2002.

    7 Ministry of Health, Palestinian National Authority, Annual Report 2001, 2002.

    8 UNRWA, Annual Report of the Commissioner-General, 2001.

    9 UNRWA, Emergency Appeal for 2002.

    10 Palestine Red Crescent Society,, 2002.

    11 "Health impact assessment: a comparative assessment of the impacts of the current crisis on health and health system delivery in the West Bank and Gaza", a joint initiative of the Palestinian Ministry of Health and WHO, August 2001 (unpublished report available from the Emergency and Humanitarian Action Unit, WHO Regional Office for the Eastern Mediterranean, Cairo).

    12 Data from the Palestinian Bureau of Central Statistics suggest there was an average of 635 000 employed persons in a total population of 3.1 million during the first nine months of 2000. This yields a ratio of about four non-working persons for each working person. The number of persons affected by reduced income is the product of the average number of unemployed (177 000) and the dependency ratio plus one.

    13 Office of the United Nations Special Coordinator in the Occupied Territories calculation, based on data from a labour force survey by the Palestinian Central Bureau of Statistics for the third quarter of 2000 and the first quarter of 2001.

    14 UNRWA, Annual Report of the Commissioner-General, 2001.

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