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OMS - L'état de santé dans les territoires occupés palestinien et le Golan - 69e Assemblée mondiale sur la santé - Rapport du Secrétariat Français

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Source: World Health Organization (WHO)
18 May 2016

Health conditions in the occupied Palestinian
territory, including east Jerusalem,
and in the occupied Syrian Golan

Report by the Secretariat

1. In 2015, the Sixty-eighth World Health Assembly adopted decision WHA68(8), which requested the Director-General, inter alia, to report on the health conditions in the occupied Palestinian territory, including east Jerusalem, and in the occupied Syrian Golan, to the Sixty-ninth World Health Assembly. This report responds to that request.

2. The estimated population living in the occupied Palestinian territory in 2015 was 4.75 million: 2.90 million in the West Bank (61.0%) and 1.85 million (39.0%) in the Gaza Strip).1 Two million are registered refugees, of whom 800 000 live in refugee camps, 19 located in the West Bank and eight in the Gaza Strip.2 The population is predominantly youthful; 39.4% of Palestinians are aged 0-14 years (37.0% in the West Bank and 42.8% in the Gaza Strip), and 2.8% are 65 years or older.3 There has been an increase in the median age over a generation, from 16.4 years in 2000 to 19.8 years in 2015.4

3. The Palestinian economy has been in decline since 2012 and contracted further following the conflict in the Gaza Strip in mid-2014. In early 2015, gross domestic product was still lower than in the previous year. Real gross domestic product per person has been shrinking since 2013. Unemployment among youth in the Gaza Strip exceeds 60%, and 25% of Palestinians currently live in poverty. Full implementation and updating of Palestinian—Israeli economic agreements, an increase in donor aid to the Palestinian Authority and fiscal reforms are needed to improve Palestinian economic health and prevent another year with a financing gap.5

4. The estimated poverty rate in the occupied Palestinian territory overall was 25% in 2014, but diverged sharply by region: 39% in the Gaza Strip and 16% in the West Bank.1 Altogether 2 3 million Palestinians are in need of humanitarian assistance (including 1.2 million refugees), and 1 6 million experience food insecurity.2

5. In 2015, the number of fatalities of Palestinians from military occupation and security violence totalled 170,3 of which 152 occurred within the occupied Palestinian territory (25 in the Gaza Strip);4 the number of injured totalled 15 377, of which 14 925 occurred in the occupied Palestinian territory (1375 in the Gaza Strip).3 Of all injuries, 39% were from live and rubber-coated metal ammunition and 61% from tear gas inhalation and other causes.3 During the year, 85% of fatalities and 65% of injuries of Palestinians from military occupation violence occurred after 1 October.2.,5 The scale of violence in the West Bank reached the highest recorded by United Nations Office for the Coordination of Humanitarian Affairs in a single year since it began monitoring in 2005.

6. In October barricades were erected near the entrances to the Palestinian hospitals in east Jerusalem. West Bank health facilities reported ten incidents of incursions by security forces in 2015. One fatality occurred in a patient's room in a West Bank hospital during the course of an arrest operation of a patient by security forces.6

7. In the West Bank including east Jerusalem, one quarter of the population (668 000) live in five areas where they are particularly vulnerable to social isolation, residency and planning restrictions, house demolitions and forced displacement, reduced access to Palestinian services, confrontations with Israeli military forces and settlers, and the threat of violence.

8. Access to health services is restricted by the wall and checkpoints, which prevent patients, health personnel and ambulances from directly accessing major Palestinian referral hospitals located in east Jerusalem. For Palestinians from the West Bank — excluding east Jerusalem — and the Gaza Strip, access to east Jerusalem referral medical centres is only possible after obtaining a permit issued by the Israeli authorities, a complex process that can result in delays and denial of care.

9. Patients from the Gaza Strip seeking specialized health care have been significantly affected since 2013 by the closure of the Rafah border crossing between the Gaza Strip and Egypt, one of only two exit points for its residents, and the most important for private patients for travel and cost reasons. Only 178 patients were able to exit through Rafah in 2015 owing to the closed borders.1

10. Access to health services for the 5936 Palestinian prisoners2 from the West Bank and Gaza Strip in detention and prison facilities in Israel, and for Palestinians held in Israeli military facilities in the West Bank, lacks transparency and supervision by the Israeli Ministry of Health, and independent external physicians lack timely or sufficient access. WHO co-signed a United Nations Joint Statement in 2015 warning against forced feeding and bringing attention to ethical issues in the treatment of hunger strikers.3

11. The Palestinian Ministry of Health, UNRWA, nongovernmental organizations and the private sector together provide geographical coverage of primary and hospital-level health services. However, the financial crisis affecting the Palestinian Authority continued to have a serious impact on the scope and quality of the health ministry's services. Budget shortfalls have resulted in chronically high shortages of essential medicines and medical disposables in both the West Bank and the Gaza Strip, with average shortages of medicines of between 20% and 30% in 2015, prompting an increase in referrals of patients to outside care.4 The restrictions imposed on the movement of health staff5 and goods hinder the overall functioning and development of the health system. Health services have been disrupted by frequent strikes by health workers and stoppages by health suppliers.

12. The burden of noncommunicable diseases is high in the occupied Palestinian territory, where the leading causes of death remain cardiovascular disease, cancer, cerebrovascular diseases and diabetes,6 and the prevalence of related risk factors (smoking, unhealthy diet and physical inactivity) is high. Chronic disease and its complications also represent a high proportion of referrals by the Ministry of Health in both number and cost.

13. In 2013, the infant mortality rate was 12.9 deaths per 1000 live births and the under-5 mortality rate was 15.5 deaths per 1000, a significant improvement over the respectively 2005 rates of 20.8 deaths per 1000 live births and 24.6 deaths per 1000.7 More recent partial and preliminary data have been a cause for concern: according to the final report of the Palestinian Multiple Indicator Cluster Survey 2014, the infant mortality rate and under-5 mortality rate in 2015 were higher than the rates in 2013 (18 deaths per 1000 live birth and 22 deaths per 1000 live births, respectively).8

14. Life expectancy increased overall to 73.5 years, higher in the West Bank (73.9) than in the Gaza Strip (72.9) and higher for females in both regions (75.0) than for males (72.0).1

15. The prevalence of disability was 2.7% in the West Bank and 2.4% in the Gaza Strip.2 Disabilities increased notably in the Gaza Strip in 2014 as a result of the large number of persons with traumatic injuries, including more than 100 amputations, resulting from the conflict in July—August 2014. An increase in the burden of mental and psychosocial disorders can be expected in a population experiencing prolonged occupation, lack of personal security, severe restrictions on movement and violations of human rights, including displacement in a post-conflict situation.

16. Both the quality and quantity of water supplied are problematic in the occupied Palestinian territory. According to the WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation, the proportion of the population served by piped water services dropped from 88% in 1995 to 56% in 2015; the steepest decline of any country during this period.3 In the Gaza Strip4 faecal indicator bacteria have been detected in a high proportion5 of the sampled drinking-water supplies, for example in desalinization plants, tanker trucks and in individual reservoirs. Bacterial contaminants enter the system at the source, in supply lines or delivery methods, and through contamination at the household level. The coastal aquifer is well below ideal levels, threatened by overuse and contaminated from improperly treated wastewater. Some mitigation measures are already in place, but in the long term the entire watershed of the aquifer is at risk of contamination. The shortage of available testing capacities and materials in the Gaza Strip, particularly for testing for viruses and chemical contaminants including pesticides, impedes water quality analysis and documentation of the potential impact of poor water quality on human health. Wastewater treatment capacity is inadequate, with untreated sewage overflows resulting in contamination of coastal seawater.6

17. About 60% of wells, 20% of hospital water reservoirs and 20% of bottled water inside the West Bank contained at least some bacterial coliforms at some point in the previous year.7 Monitoring of the water supply is in place, but lack of resources and poor infrastructure make mitigation and improvement measures lengthy or impossible.8 The infrastructure for wastewater treatment is also largely inadequate. Further research is urgently required to improve the scientific understanding of the short- and long-term health effects of the poor water supply and wastewater systems in both the West Bank and the Gaza Strip.


18. The WHO Office for the West Bank and Gaza Strip has been engaged in several activities pertaining to health systems strengthening in the occupied Palestinian territory. Through a health systems approach, comprising the six building blocks (leadership and governance, health care financing, health workforce, medical products and technologies, information and research, and service delivery), the Secretariat is supporting the Palestinian Ministry of Health in order to enhance access and coverage to quality and safe health care and medical services.

19. In 2016, WHO is focusing further on health financing, enhancing the building blocks of service delivery, and information and research. Under the health financing building block, WHO will initiate a policy dialogue on the pursuit of universal health coverage for improved health financing and coverage of patients.

20. The family practice model has been adopted by the Palestinian Ministry of Health and, with the Secretariat's support, progress made in applying this approach, including conducting training in three district centres where the initial roll-out and implementation is being focused in 2016. Other activities in primary health care included a standardized assessment and trainings for quality improvement, and integration and improvement of noncommunicable disease and mental health services into the primary health care approach.

21. At the hospital level, WHO has led a project over the past two years, with funding from the European Union, to enhance the capacity of the East Jerusalem Hospital Network, representing the six nongovernmental hospitals in east Jerusalem. Results include achieving Joint Commission International accreditation for five out of the six hospitals, establishing a quality committee, increasing advocacy work through an East Jerusalem Hospital Network Coordinator, and enhancing capacities in at least one of the jointly identified developmental areas for each hospital.

22. WHO has been working on improving the service delivery and health workforce in the West Bank through the patient safety initiative, started in 2011. In line with WHO's recommendations on patient safety, the Secretariat and the Palestinian Ministry of Health have raised awareness on the three levels of patient safety standards, and are conducting an assessment of the achievements of all hospitals in the West Bank to establish a baseline for further improvement. With support from the Government of Italy the WHO Office is also working on a project to strengthen hospital information systems through standardized data collection and indicator generation from all hospitals for better information collection, monitoring and evaluation of hospital performance.

23. The Secretariat provides technical and logistic support to the Palestinian Ministry of Health for tackling noncommunicable diseases, including support for policy development, surveillance and prevention, and service delivery. The WHO STEPwise approach to Surveillance survey in 2010-2011 provided the Ministry with baseline information necessary to understand the prevalence of chronic disease risk factors at the country level. The survey will be repeated in 2016 to monitor trends and update surveillance information. The Ministry will use the results to support prevention efforts, which will be undertaken with the Secretariat's support, using health promotion campaigns to encourage the population to reduce risk factors. Technical support will also be provided at the local and regional levels, in addition to support for policy development and planning. Over the past three years the Secretariat has concentrated its support to the Ministry in its work on noncommunicable diseases on improving service delivery at the primary health care level through the implementation of the WHO package of essential noncommunicable disease interventions.

24. The Secretariat is further supporting the Ministry, with funding from the European Union, to improve access to quality mental health services through integration of mental health services into primary health care, human resource development, and policy development, as well as improving awareness, and addressing stigmatization and discrimination. The Palestinian reform process, led and sustained by the Ministry, has involved interventions implemented at multiple levels and across all areas of the West Bank and Gaza Strip, with potential impact on the entire population. A national mental health strategy for 2015-2019 has been formulated, along with a human resource plan and an operational policy plan for integration of community mental health centres and primary health centres.

25. The process of the integration in the Gaza Strip was piloted in one district over six months and, following its success, was expanded to cover four districts in 2015; extension to the final fifth district is planned for 2016. The successful integration of mental health services into primary health care has shown that it is possible to deliver mental health services in low-resource and conflicted-affected settings. Community mental health centres and psychiatric hospital staff will be trained on a range of topics. The capacity of family associations will be strengthened, and a range of awareness and anti-stigmatization activities will be implemented. Rehabilitation programmes in the two psychiatric hospitals are being strengthened and a day care centre in the Gaza Strip is being developed.

26. At the request of the Palestinian Authority and in close cooperation with the Palestinian Ministry of Health and other stakeholders, the Secretariat has continued its work of establishing a Palestinian National Institute of Public Health. In 2015, a draft law on the governance of the Institute was drafted through consensus building, and the approval process is progressing through the Cabinet of Ministers. In addition to institutional capacity-building, the core technical work of the Institute has included finalizing guidelines for an electronic computerized system for a harmonized reproductive health registry; implementing improvements in the registries on cause of death and civil registration and vital statistics using WHO recommendations; development of an electronic system to record road traffic injuries for use by the police and the Ministry of Interior; discussion with the health ministry of research findings on the prevalence of malnutrition and intestinal infections in the Jordan Valley area; a comprehensive assessment of the neonatal health services among private and public hospitals in Palestine, for which data collection and field visits will take place later in 2016; a health workforce census in the West Bank for the Human Resources for Health Observatory in Palestine, which will be extended to the Gaza Strip in 2016 and for which an electronic system is being developed; and creating a geographic information system of health facilities.

27. WHO continued to provide support to the Ministry of Health to sustain high vaccination coverage for communicable diseases and effective monitoring of surveillance indicators. In support of activities against HIV/AIDS, and with funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria, WHO continued to act as technical adviser to the United Nations thematic group for tuberculosis and HIV/AIDS in the West Bank and Gaza Strip. Activities supported by the Global Fund ended in November 2015; although WHO as technical adviser has supported technical preparatory efforts for a further application for Global Fund financing, a political decision was taken to not pursue this further at this stage. The Secretariat has therefore scaled down its activities accordingly, while continuing to support the Ministry of Health with technical advice as required.

28. WHO is building on the foundation of a previous project in the Gaza Strip (2009-2013) that focused on enhancing staff skills and the environment in order to improve the quality of maternal and newborn care by de-medicalizing care for low risk cases and paying more attention to high risk cases. In response to the lack of progress in Palestine in reducing the under-5 mortality against the target for 2016,1 a one-year project with funding from the Government of Norway was begun in the Gaza Strip in January 2016 to reduce neonatal deaths and complications. The project builds on the achievements of previous work and introduces an evidence-based package of care for sick and low-birthweight babies, as well as healthy babies, including providing appropriate technologies and pharmaceuticals in routine and emergency situations.

29. With the support of the Government of Switzerland, WHO continued its advocacy work through data collection, analysis, reporting and dialogue with international duty-bearers concerning the barriers to health access, and attacks on health facilities which impact health services, especially in view of the increase in violence in late 2015.2 Work continued with major health partners on better protecting the right to health, promoting gender and equity considerations, and improving reporting of health violations, including efforts to assist the Ministry of Health with preparations of reports on human rights treaty monitoring due in 2016. WHO prepared its fourth annual report on the barriers impeding access by referral patients from the West Bank and Gaza Strip to medical care and by health personnel to the main east Jerusalem hospitals. WHO supported the health section of a joint survey by the United Nations Office for the Coordination of Humanitarian Affairs and the Palestine Central Bureau of Statistics to examine the extent of vulnerability in Palestinian communities, especially in Area C in the West Bank.3 WHO continued to provide information to the international community on trends in social determinants of health in the Gaza Strip, where there are growing shortages of essential medicines (35%) and medical supplies (42%) as well as chronic fuel shortages for health services, and to advocate international interventions to improve access for health vulnerable populations.4

30. WHO concluded its cooperation with the Ministry of Health, and five other organizations in the United Nations system and line ministries under the United Nations Partnership to Promote the Rights of Persons with Disabilities, to improve the mainstreaming of a rights-based agenda for targeted services in health, education and employment for persons with disabilities. The project, which was coordinated by the Office of the United Nations Special Coordinator for the Middle East Peace Process, will seek further support from the Partnership in 2016-2017 for capacity-building for organizations of persons with disabilities.

31. WHO continued to lead the Health and Nutrition Cluster, which it co-chairs with the Ministry of Health. The Cluster includes more than 30 humanitarian health organizations, including United Nations agencies and nongovernmental and private-sector organizations, providing essential primary health-care services to vulnerable communities with restricted access to services. WHO held monthly meetings with partners to discuss humanitarian health updates and identify gaps and needs for a better coordinated response. In late 2015, health cluster partners coordinated the collection of good-quality number and kind of injuries in the period of increased violence in the West Bank and the Gaza Strip.

32. Together with the Ministry of Health and partners in the Health and Nutrition Cluster, WHO wrote the health section of the Humanitarian Needs Overview for 2016,1 with an analysis of the humanitarian health situation and highlighting priority needs, vulnerable communities and groups, and obstacles to and difficulties in accessing essential health services in priority areas of the Gaza Strip, east Jerusalem, Area C in the West Bank, closed military areas and the seam zone. The overview enabled the Health and Nutrition Cluster to prepare its Strategic Response Plan for 2016, whose main objectives are: ensuring access to essential health services; the referral of victims of violence to protection organizations and related advocacy; and ensuring that vulnerable communities receive emergency preparedness support and assistance to enable them to cope with disasters. An estimated 1.4 million people (more than 1 1 million in the Gaza Strip and 253 000 in the West Bank) are in need of humanitarian, health and nutrition interventions. Of these, 0 9 million people are targeted by the health cluster partners, including those living in the catchment area of totally destroyed primary health care centres; people living in the access-restricted areas, Area C and east Jerusalem. WHO was able to ensure further donor support for its humanitarian work, in particular for that in the Gaza Strip, from the governments of Japan, Norway and Turkey, and is currently negotiating support from the United Arab Emirates.

33. WHO also assisted in coordinating the delivery of medical supplies from various donors to the Gaza Strip, and the distribution of donated fuel to health facilities according to need to ensure continuity of health service delivery.

34. In 2015, WHO and the Norwegian Institute of Public Health assessed whether the existing capacities in Palestine were adequate to fulfil the core capacities required under the International Health Regulations (2005). A qualitative assessment combined interviews, table-top exercises and inspection of health care facilities and laboratories. The combination of desk review of data and table­top exercises, both facilitated by external technical experts, was in line with the methods for monitoring national public health capacity under the International Health Regulations. An initial on-site review and assessment was completed by a private-sector expert who advised the public health laboratory in Ramallah and assessed the adequacy of its current biosafety level. Recommendations included upgrading the laboratory to biosafety level 3 with a three-phase plan, which has been incorporated into the 2016-2017 operational planning.

35. WHO is working closely with the directorate of emergency and ambulance services in the Ministry of Health, and provides technical assistance in emergency preparedness and response. Field visits to Ministry of Health hospitals were done and staff members were briefed about planning for emergencies and potential hazards. Contingency plans for 13 public hospitals were developed.

36. The Ministry of Health adopted all-hazards emergency risk management, using a multisectoral approach, in accordance with a new emergency and disaster risk management framework for health. Accordingly, the Ministry of Health and WHO conducted joint planning workshops on emergency preparedness for civil defence groups, health partners and other stakeholders in order to introduce participatory planning with an all-hazards approach. Workshops on emergency preparedness planning were also conducted for workers of hospitals and primary health care facilities.


37. WHO has no access to the occupied Syrian Golan and thus cannot provide a report on the prevailing health conditions there.


38. The Health Assembly is invited to note the report.

1 Palestinian Central Bureau of Statistics (, p. 19, accessed 12 April 2016).
2 See (accessed 12 April 2016).
3 (accessed 12 April 2016).
4 Palestinian Central Bureau of Statistics (, accessed 12 April 2016).
5 World Bank. Economic Monitoring Report to the Ad Hoc Liaison Committee, September 29, 2015 ( Oreport.pdf accessed 12 April 2016).

1 World Bank. Economic Monitoring Report to the Ad Hoc Liaison Committee, September 29, 2015 ( main0report.pdf, accessed 12 April 2016).
2 Humanitarian Response Plan, occupied Palestinian territory (January—December 2016) ( documents/2016_hrp_22 january%202016.pdf, accessed 28 January, 2016).
3 (accessed 8 February, 2016).
4 (accessed 8 February, 2016).
5 (accessed 8 February, 2016) and health_attacks_12.2015_-_final.pdf?ua=1 (accessed 8 February, 2016).
6 health_attacks_12.2015_-_final.pdf?ua=1 (accessed 8 February, 2016).

1 Communication from Rafah terminal officials, February 2016.
2 The Israeli Information Center for Human Rights in the Occupied Territories. Statistics on Palestinians in the custody of Israeli security forces (, accessed 27 January 2016).
3 (accessed 13 April 2016).
4 Ministry of Health communications to WHO for the Gaza Strip (2015) and for the West Bank (2016).
5, para 10 (accessed 26 January 2016).
6 State of Palestine Ministry of Health, Health annual report, Palestine 2014.
7 Palestinian Central Bureau of Statistics, 2015. Palestinian Multiple Indicator Cluster Survey 2014, Final Report, Ramallah, Palestine.
8 Palestinian Central Bureau of Statistics, 2015. Palestinian Multiple Indicator Cluster Survey 2014, Final Report December 2015, Ramallah, Palestine (, accessed 12 April 2016).

1 Palestinian Central Bureau of Statistics (, p. 21, accessed 2 February 2016).
2 Palestinian Central Bureau of Statistics ( &ItemID=1165&mid=3172&wversion=Staging, accessed 5 February 2016).
3 WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation. Palestine country file. June 2015. stine&Ix_displaycontroller%5Btype%5D=country_files
4 Internal reports, Department of Environmental Health, Palestinian Authority Ministry of Health.
5 Internal reports, Palestinian Water Authority & Coastal Municipalities Water Utility
6 Internal reports, Department of Environmental Health, Palestinian Authority Ministry of Health.
7 Hilles, A H, Al Hindi, A I, Abu Safieh, YA. Assessment of parasitic pollution in the coastal seawater of Gaza city. Journal of Environmental Health Science and Engineering. 2014;12:26 (, accessed 2 May 2016).
8 Selby, J. (2013). Cooperation, domination and colonisation: The Israeli—Palestinian joint water committee. Water Alternatives, 6(1):1. orth%20Africa/State%20oPY020Palestine/2014/Final/State%20oPY020Palestine%202014%20MICS_English.pdf, accessed 12 April 2016).

1 Latest available data indicate an under-5 mortality rate of 22 per 1000 live births during 2010-2014. Palestinian Multiple Indicator Cluster Survey 2014 (, accessed 2 May 2016). The national target is 12 per 1000 live births by 2016, National Health Strategy 2014-2016, Palestine Ministry of Health. SlA32h2ttvlY_DOHrIaecDFU GDcRA4784Q4cmum3zeBPhP6pp1SENYMOmYQ8L5OcWb2.pdf (accessed 2 May 2016). Also, see van den Berg MM, et al. Increasing neonatal mortality among Palestine refugees in the Gaza Strip. PLOS ONE I DOI:10.1371/journal.pone. 0135092, 4 August 2015 ( _in_thegaza_strip.pdf, accessed 2 May 2016).
2 health_attacks_122015_-_final.pdf?ua=1 (accessed 2 May 2016).
3 (accessed 2 May 2016).
4 Ministry of Health communication, March 2015.

1 Occupied Palestinian territory. Humanitarian Needs Overview 2016 ( hno_december29_final.pdf, accessed 4 February, 2016).

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