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Source: World Health Organization (WHO)
24 March 2014

February 2014

Referral of Patients from the Gaza Strip

Summary: February


  • Increase in access need through Erez in 2014: The number of applications for health access through Erez checkpoint was slightly less in February than the previous month but the two months were 76% higher than in the same period in 2013, the highest demand since 2005, when WHO began monitoring. The increased demand reflects the continuing problems of access through Rafah border to Egypt and lack of drugs, especially chemotherapy and lack of medical disposables.
  • Drop in approval rates of permits: 86.8% of applicants received a permit in February 2014, and 3.37% of applicants (50 patients and including 7 children: 16 females, 34 males), were denied permits, the highest monthly denial rate since August 2010. In addition, 9.83% of applicants (146 patients: 44 females and 102 males) received no response to their applications, including 27 children whose medical treatment was delayed as a result.
  • 13 patients interrogated: 13 patients (11 males, 2 females) were requested to attend interviews with Israeli security after applying for a permit to cross Erez. To date, only one patient had been granted a permit following security interviews in February.
  • Further drop in access through Rafah: Only 36 Gaza patients travelled to Egypt through Rafah in February, less than 1% of the pre-July 2013 monthly figure.

  • Increase in MoH referrals: Total MoH referrals of Gaza patients (1,868) were the highest recorded and 33% higher than the monthly average in 2013. MoH referrals to health facilities in the West Bank and to non-MoH facilities within Gaza were the highest recorded in recent years.
  • Medical reasons for referrals: The top ten needed specialties were for treatment in the following specialties: oncology--269 referrals (14.4%), MRI--267 (14.29%), orthopaedics--139 (7.44%), heart catheterization--132 (7.07%), nuclear medicine--126 (6.75%), paediatrics--119 (6.37%), ophthalmology--107 (5.73%), neurosurgery-­101 (5.41%), haematology--70 (3.75%), and heart surgery --69 (3.69%). The remaining 25% of referrals were to 20 other specialities.
  • Gender gap: There was a gender gap in referrals: 56.58% male patients versus 43.42% female patients. 25.5% of all referrals were children aged 0-17 years and 17.8% were patients aged over 60 years.
  • Estimated cost of referrals for February 2014: NIS 10,000,201.

  • Referrals reflect pressure on public health system

    The Ministry of Health (MoH) in Gaza referred 1,868 patients to outside hospitals in February, 33% higher than the monthly average for 2013. Referrals were lower this month to hospitals in East Jerusalem (29.18%; 545) and Israel (22.91%; 428). Referrals to non-MoH facilities in Gaza and to West Bank facilities were both higher than the previous month and double or more the monthly average for 2013 (Chart 1). Referrals to Egypt remained low, reflecting the unstable border and internal situation in Egypt prevalent since July 2013. In February 9.37% (175) of referrals were to Egypt. (Table l).

    The MoH referred a high number of patients to non-MoH facilities within Gaza (430) primarily for MRI (245), heart catheterization (95), rehabilitation (31), and urology (12). The remaining 47 referrals were in 14 other specialties. The Referral Abroad Department processed 82.3% of the 1,868 applications for referrals in February within 7 days, 8.2% from 8­14 days, 2.5% from 15-21 days and 1.8% from 22-31 days, the remaining 5% took longer than one month. 92% of referrals were for in-patient admissions in hospitals and 8% were for outpatient services.

    Limited access to Egypt

    Of the 3,225 travellers who left Gaza through Rafah terminal in February, only 36 were patients (1%), the lowest monthly figure recorded in an 8-month downward trend of patients using that route (Chart 2). From January to June 2013, Rafah terminal data had reported a monthly average of 20,577 passengers to Egypt, 20% (4,146) of which were Ministry of Health and private patients seeking health care abroad. In the second half of 2013, the average monthly number of travelers dropped by 75% (to 5,251) and monthly average of patients to 305 (6%).

    Rafah terminal was closed for 25 days in February, allowing only 3 partial days for travelers under the criteria of humanitarian needs. During the closure days the terminal was open on 7 occasions, 4 times for pilgrims exiting with special coordination, and 3 times to allow pilgrims to return. 1,410 (44%) of the 3,225 travelers exiting during February were pilgrims. Since July 10, 2013, crossing hours have been restricted to 9 am to 2 pm. No medical delegates or medical aid passed through the terminal during February. Only one medical shipment, in November, has passed through Rafah since July 2013.

    Access through Erez

    In February 2014, 1,289 (86.8%) of 1,485 patient applications to cross Erez were approved (Table 2). 50 patients were denied access through Erez to specialized hospitals in the West Bank including East Jerusalem, Israel and Jordan --­20% more than the total denied in 2013 and the highest monthly number of patients denied since August 2010 when 87 patients were denied. The 50 patients (16 females; 34 males) denied in February, which included 7 children and 2 patients over 60 years, had been referred mainly for treatment in orthopedics, ophthalmology, urology, neurology, neurosurgery, internal medicine and nuclear medicine. 34 had appointments in East Jerusalem and West Bank hospitals, 13 in Israel and 3 in Jordan. 44 were funded by the MoH, and 6 were self -funded.

    According to the Palestinian District Coordination office, 146 patient applications by MoH and private patients (9.83%), including 27 children and 9 patients over the age of 60, received no response; 30% of these applicants were females. Of the 146 delayed applications, 40.4% had scheduled appointments in East Jerusalem hospitals, 29.5% in West Bank hospitals, 26.7% in Israel and 2.7% in Jordan. The Israeli authorities should give a response to applicants within 10 days. Of those delayed, 29 patients were still awaiting a response after three weeks.

    13 patients, including 2 females, were called for security interviews by the Israeli General Security Services (GSS) as a condition to process their application. The average monthly number of patients called for GSS in 2013 was 15. To date, only one patient in February had been granted a permit following the interview.

    The volume of permit applications for health access in February was one-third higher than the monthly average in 2013 and almost two-thirds higher than February 2013. Compared to February 2013, the approval rate in February 2014 declined by 5.37%, and applicants were 15 times more likely to be denied, and more likely to be delayed (Table 3).

    In February, 92% of patients applying for Israeli permits were referrals from the Palestinian MoH, 4.78% were self-funded, and the remaining patients were funded by the Peres Center for Peace, Physicians for Human Rights-Israel, Nour Al-Alam foundation and other organizations. MoH referrals do not cover transportation or companion costs and some items of patient care such as medicines not in the regular hospital supply. Patients and companions often face financial problems during long stays in hospitals due to these uncovered costs.

    Access through exit points

    The Palestinian General Authority for Civil Affairs registered 1,165 patients and 1,454 companions travelling through Erez checkpoint to Israel, oPt or Jordan during February; 59 patients were transferred via back-to-back ambulances. The ambulance station at Rafah terminal reported that 36 patients and 30 companions were transferred by ambulance from the Palestinian side to the Egyptian side of the terminal during February (Table 4).

    70 patients and their companions unable to cross at Erez

    Israeli authorities at Erez cancelled passage for 70 patients and their companions who had been issued permits to cross on February 12, 2014, to access hospitals in Israel, East Jerusalem and the West Bank. The measure was apparently in protest of the Palestinian Ministry of Health's use of referral stationery printed with the address, "State of Palestine." The form has been in use for several months. Two private patients and 3 urgent cases transferred by ambulance were permitted to cross. After a compromise solution was found, 60 patients with appointments in hospitals in East Jerusalem and the West Bank were able to cross Erez with their companions on the following day. However, 10 patients scheduled for treatment in Israeli hospitals lost their appointments, and had to reschedule treatment and reapply for new permits.

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