The lack of contiguity between Gaza and West Bank and the lack of free movement within the West Bank have severely affected the socioeconomic conditions of the Palestinians since the eruption of the second intifada in 2000. GDP per capita declined by 40%, unemployment increased from 10% to 30% and the population living below the poverty line increased from 21% to 60%.
Palestinians currently have relatively stable health status indicators, but with worrying trends: life expectancy is 72 years, the fertility rate is 4.6, infant mortality rate is 24.2 per 1000 live births and iron deficiency anaemia affects one fourth of children under 5 years and one third of women of child-bearing age. Chronic malnutrition is slowly increasing as well as dietary-related chronic diseases, and mental health is an increasing concern due to everyday life stressors (movement restrictions, feeling of insecurity).
In the years following the Oslo Accord, the oPt received an enormous amount of donor assistance, reaching US$ 300 per capita in recent years. Until 2000, most donor support was in the form of development aid. Near the end of 2000, however, most donors shifted their development programmes into emergency aid. In 2004 international aid disbursed to the health sector was US$ 66.1 million, representing 6.3% of the total disbursed, an increase from 3.2% in 2002 and 4.3% in 2003.
WHO has operated in the oPt through two main bodies: the Regional Office for the Eastern Mediterranean and the WHO headquarters West Bank and Gaza office. In addition WHO has been also working in agreement with UNRWA for the Palestinian refugees. A process of integration between the WHO presences started a few years ago and during 2005 became really operational.
WHO’s mission in oPt is to promote the health of all Palestinian people by improving health sector performance based on equity, effectiveness and sustainability, as well as by addressing the broader social, economic, environmental and cultural health determinants, particularly those which are most affected by the Israeli–Palestinian conflict. Four main strategic directions: coordination, health policy and information, technical support and advocacy, are identified as leading towards a comprehensive public health approach based on the right to health, vulnerability and socioeconomic determinants, with a long-term perspective, while keeping ready to respond to the potential re-emergence of acute crisis.
Section 1. Introduction
The political momentum witnessed since the beginning of 2005 has provided a turning point in a previously static political environment. The election of President Abbas, the Sharm al Sheikh Summit (February 2005), a ‘period of calm’ announced by Palestinian militant groups and decrease of military activity and Israel’s disengagement (although unilateral) of settlers and military infrastructure from within the Gaza Strip and parts of the northern West Bank opened a new window of opportunity for settlement of the Palestinian–Israeli conflict.
Running in parallel, efforts are under way to move towards a development approach. The Palestinian Authority initiated its first three year Medium-Term Development Plan for 2006–2008. The arrival of James Wolfensohn as Special Envoy of the Quartet on Gaza Disengagement resulted in the pledging by donors of up to three billion US dollars to the recovery effort over a period of three years. After five years during which a humanitarian style response was predominant, these developments appear to suggest that the occupied Palestinian territory (oPt) is at a new juncture.1
Historically WHO has operated in the oPt through two channels. One is through the WHO West Bank and Gaza office (main office in Jerusalem, sub-office in Gaza). This office was established in 1994 by a Special Technical Assistance Programme, and has been directly dependent on the Department of Health Action in Crisis (HAC) at WHO headquarters, and has been reliant on extrabudgetary support from donors. The other channel is through the support of the Regional Office for the Eastern Mediterranean to the Palestinian Ministry of Health, where planning of activities is undertaken, as for the other countries of the Region, through the exercise of a biennial Joint Programme Review and Planning Mission (JPRM). In addition WHO has been also working in agreement with United Nations Relief and Works Agency for Palestinian Refugees in the Near East (UNRWA).
A process of integration between the two channels started a few years ago but only during 2005 became really operational. The main goal of this process has been to work for one 2006–2007 WHO plan for oPt, with the two integrated components.
The Country Cooperation Strategy (CCS) exercise for oPt took place at a very appropriate time with regard to strengthening WHO commitment and presence, and took into consideration internal and external factors. The joint effort between WHO headquarters and the Regional and Country Offices in a changing context, enabled reflection, insight and suggestions into creating more solid, stable and far-sighted WHO presence. At the end of 2003 informal discussions within WHO West Bank and Gaza identified the main strategic directions for WHO in oPt and oriented its interventions during the past two years. That collective reflection represented an important starting point for the CCS exercise. Through analysis of past experience, difficulties and achievements, the WHO commitment and intervention should be revised and strengthened in order to better deal with the present and future challenges.
Section 2. Country health and development challenges
2.1 Socioeconomic and geopolitical profile
OPt comprises two areas–Gaza Strip and West Bank–with a total population of 3.7 million. Gaza Strip is a narrow zone of land along the Mediterranean Sea where 1.34 million people live in an area of 362 km2. It has one of the highest population densities in the world. West Bank is a hilly area where 2.36 million people live in an area of 5634 km2. Refugees number 1.5 million, comprising 32% of the total population of West Bank and 71% of the total population of Gaza Strip (see Annex 3).
The Palestinian Authority (PA) was established in 1994 after the signature of the Oslo Agreement. It is a parliamentary system with three distinctive powers: Legislative, Executive and Judiciary. The Legislative Council with elected members conducts legislative practices. The President is the head of the state and is directly elected from the oPt population. The President, with the agreement of the Legislative Council, nominates the Prime Minister. The territory is administratively divided into 15 provinces: 10 in West Bank and 5 in Gaza.
The eruption of the second intifada in September 2000 and the increase in Israeli military action had a dramatic effect. It resulted in weakening the capacity of the Palestinian Authority and the destruction of public infrastructure. From 2000 to 2004, the GDP per capita declined by almost 40%. The unemployment rate increased from 10% to 30% and living standards have been severely compromised. In 2000, 21% of the population were living below the poverty line of US$ 2.1 a day: today, more than 60% are living at that level. Taking into account population growth, this means that the number of poor has tripled, from 650 000 to 1 900 000.2
The unilateral ‘disengagement’ of Israel from Gaza has given both hope and uncertainty regarding the future of Gaza and of a Palestinian State. The lack of territorial contiguity between West Bank and Gaza, the continued construction of the Separation Barrier and the system of closures in West Bank will further limit socioeconomic recovery in the short term. In the medium and long term, a lot will depend on the progress in ensuring a secure environment and building a viable framework for socioeconomic recovery: this includes structures for export and the relaxation of restrictions on the movement of people and goods.
2.2 Health profile
Despite the overall difficulties that Palestinians have faced, their health status is still commendably reasonable. Life expectancy in 2003 was 72.3 years.3 Maternal mortality ratio and infant mortality rate were respectively 2.1 per 10 000 live births and 24.0 per 1000 live births4, better than in neighbouring countries of the Region (although insufficient and controversial data on maternal mortality emphasize the need for vigilance on this issue). The outcomes reflect, in part, the efforts of the basic public health and primary care functions. Consequently, oPt has gone through the “epidemiological transition.” Noncommunicable diseases are the main causes of death (heart diseases 20.1%; cerebrovascular conditions 11.1% cancer 9%; accidents 8.9%), together with perinatal conditions (9.7%).
Mental health is an increasing concern in oPt. Recent studies have shown that stressors such as the severe restriction on movement and lack of access to education and health care are present in everyday life. One study5 showed that 52% of those surveyed had thought of ending their life, 92% felt no hope for the future, 100% reported feeling stressed, and 84% expressed feelings of constant anger because of circumstances beyond their control. Feelings of insecurity have also increased in the areas directly affected by the Separation Barrier: 90% compared to 75% in other areas.
Noncommunicable diseases present important public health problems (Table 1). Of the eight leading causes of death, seven are noncommunicable diseases (Table 1). In 2003, 3893 persons died from cardiovascular diseases (2041 males and 1852 females), with a rate of 99.5 per 100 000 population. Accidents have sharply increased as a cause of death: from 9 per 100 000 in 1995 to 24 per 100 000 in 2003. Accident injuries are mainly caused by road accidents: 85% of all injuries in 2003. Other causes of injuries included poisoning, falling, drowning, fire, and intentional “accidents” like firearms, missiles, suicide and homicide.3
Iron-deficiency anaemia is the major nutritional problem: over one quarter of children under-five and a third of women of child-bearing age are anaemic.4 Other micronutrient deficiencies of concern are sub-clinical vitamin A deficiency,6 rickets and iodine deficiency.7 Chronic malnutrition (stunting) levels among the under-five children appear to be slowly increasing.4 Obesity and dietary-related chronic diseases appear to be increasing, particularly in the older age group, and present a major challenge in nutrition.7
The maternal mortality ratio is relatively low: 2.1 per 10 000 live births in 2003.3 The fertility rate is almost at the same range with neighbouring countries: 3.9 in oPt4 compared with 3.7 in Jordan and 3.2 in Egypt.8 This could be due to early marriage and prevailing traditions. Anaemia is an important problem in women.7 The recent situation has also affected women’s health: from 2000 to 2003, 103 women delivered at checkpoints, according to the Ministry of Health.
The infant mortality profile suggests a medium-income country, with the mortality rate among children less than 4 weeks old (neonatal mortality) comprising more than half of the under-5 mortality rate (U5MR).3 The infant mortality rate (IMR) and U5MR are relatively low, 24.2 and 28.5 per 1000 live births in 2003.4 In terms of trends, the IMR has been very slightly decreasing since 1996.4,9 However, there is an important imbalance between West Bank and Gaza, IMR being 30% higher in Gaza (30.2 per 1000) than West Bank (20 per 1000). The situation in Gaza is actually deteriorating and mortality figures have increased by 15% in comparison with the pre-intifada level.4,9
With regard to causes of death, it is to be highlighted that prematurity and low birth-weight alone made up for 27% of all reported deaths among 0–19 year olds and 41% of all reported infant deaths in 2003.3
Communicable diseases in total account for 10% of all deaths only. Among them, pneumonia and other respiratory infections, particularly among children, represent the highest specific death rate. The immunization coverage is very high: more than 95% for DPT, HepB and MMR.3
Viral hepatitis A, B, C are endemic in oPt. Brucellosis, which was a serious problem a few years ago, is under control, falling from 32 per 100 000 in 1998 to 4 in 2004.3 HIV/AIDS is not yet a significant problem. The reported incidence of tuberculosis is low. However, data on communicable diseases remain inaccurate as the surveillance system is still insufficient.
Table 2 indicates current trends.