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Source: World Health Organization (WHO)
25 February 2014
January 2014

Referral of Patients from the Gaza Strip

Summary: January


  • Historic high in access need through Erez: The number of applications for health access through Erez checkpoint in January 2014 was twice that of January 2013, and the highest since 2008, when WHO began monitoring. The increased demand reflects the continuing problems of access through Rafah border to Egypt and lack of drugs, especially for chemotherapy.
  • Drop in approval rates of permits: 87.78% of applicants received a permit in January 2014. 37 patients (27 male; 10 female) patients were denied permits, the highest monthly denial rate since Aug 2010. In addition, 151 patients---46 females and 105 males (9.82% of total applicants) --- received no response to their applications, including 30 children whose medical treatment was delayed as a result.
  • Patients interrogated, the highest since June 2010: 33 patients (29 males/ 4 female) were requested to attend an interview with Israeli security after applying for a permit to cross Erez. To date, only two patients had been granted a permit following security interviews in January.
  • Two arrests at Erez: One patient and one patient-companion were arrested at Erez checkpoint during January.
  • Historic high in MoH referrals: Total MoH referrals of Gaza patients were also the highest recorded and 32% higher than the monthly average in 2013. The MoH referrals marked 3-year highs for hospital destinations in West Bank and Israel. Referrals to non-MoH facilities within Gaza were the highest since 2012.
  • Medical reasons for referrals: In January 2014 most referrals were for treatment in the following specialties: oncology--319 referrals (17.26%), MRI--219 (11.85%), nuclear medicine--155 (8.39%), ophthalmology--134 (7.25%), orthopaedics--116 (6.28%), paediatrics--110 (5.95%), heart catheterization--103 (5.57%), neurosurgery-­102 (5.52%), haematology--71 (3.84%), and general surgery --58 (3.14%).
  • Gender gap: There was a gender gap in referrals: 54.11% male patients versus 45.89% female patients. 23% of all referrals were children aged 0-17 years and 19% were patients aged over 60 years.
  • Estimated cost of referrals for January 2014: NIS 10,421,692

Referrals reflect pressure on public health system

The Ministry of Health (MoH) in Gaza referred 1,848 patients to outside hospitals in January, 32% higher than the monthly average for 2013 and 22% higher than the previous month. 30.19% of referrals were to hospitals in East Jerusalem (558) and 25.16% to Israel (465). Referrals to Gaza non-MoH facilities were 18.7% (347), 68% higher than the monthly average for 2013 (Chart 1). Referrals to West Bank were 53% higher than the average for 2013. Referrals to Egypt remained lower than usual; the average number of referrals in the first half of 2013 was 300, but fell to half that (150) in the second half of the year, reflecting the unstable border and internal situation in Egypt. In January 10.7% (198) of referrals were to Egypt. (Table 1)

Referrals for oncology, hematology, ophthalmology, orthopedic surgery, heart surgery and catheterization in particular are a result of a lack of capacity within the MoH due to shortages of drugs and disposable materials, human resources and equipment in these specialties. January had the highest number of referrals within Gaza to non-MoH facilities since October 2011 (347 referrals): most were for MRI (216), heart catheterization (87), and rehabilitation (28). The remaining 16 referrals were in various specialties.

Limited access to Egypt

Of the 2,335 travellers who left Gaza through Rafah terminal in January, only 88 were patients (3.77%), continuing a 7-month trend of patients discouraged from 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 January, allowing only 6 partial days for travellers to exit or enter; one day of the 6 days was open only for 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 January. The last shipment of medical aid was in November 2013, it was the only medical shipment through Rafah in the second half of the year 2013.

Access through Erez

In January 2014, 1,350 (87.78%) of 1,538 patient applications were granted permits to cross Erez to access hospitals in the West Bank, including East Jerusalem, or in Israel or Jordan (Table 2). 37 patients, were denied access through Erez to specialized hospitals in the West Bank including East Jerusalem, Israel and Jordan. This is the highest number of patients denied in one month since August 2010 when 87 patients were denied. Of those patients denied, 31 were funded by the MoH, 2 by Physicians for Human Rights-Israel and the rest (4) were self-funded. Among them 3 children and 2 patients over 60 years (10 females; 27 males), with appointments mainly for treatment in orthopedics, nuclear medicine, neurosurgery, ophthalmology, urology, and neurology.

According to the Palestinian District Coordination office, 151 applications by MoH and private patients (9.82%), including 30 children and 8 patients over the age of 60, received no response; 30.5% of these applicants were females. Of the 151 delayed applications, 40.4% had scheduled appointments in East Jerusalem hospitals, 28.5% in West Bank hospitals, 22.5% in Israel and 8.6% in Jordan. Patients who were delayed mainly required treatment in ophthalmology, orthopedics, urology, cardiology, nuclear medicine or general surgery. The Israeli authorities should give a response to applicants within 10 days. Of those delayed, 19 patients were still awaiting a response after three weeks and 9 waited more than 30 days.

Thirty-three patients, including four 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. This is the highest number of patients called for interrogation in one month since June 2010. To date, only two patients in January had been granted a permit following the interview.

In January 2014, 12.2% of permit applications were denied or the response was delayed and 87.78% were approved, a decline following an improvement in the previous 5 months (Chart 3). The volume of permit applications for health access in January has increased by 34% higher than the monthly average in 2013 and almost twice that of January 2013. The approval rate declined by 4.9%. Applicants were 9 times as likely to be denied in January 2014 compared to January 2013 and more likely to be delayed (Table 3).

In January 2014, 90.38% of patients applying for Israeli permits were referrals from the Palestinian MoH, 6.44% were self-funded, and the remaining patients were funded by Nour Al-Alam foundation, Physicians for Human Rights-Israel and the Peres Center for Peace. 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.

The Palestinian General Authority for Civil Affairs registered 1,232 patients and 1,183 companions travelling through Erez checkpoint to Israel, oPt or Jordan during January; 71 patients were transferred via back-to-back ambulances. The ambulance station at Rafah terminal reported that 88 patients and 82 companions were transferred by ambulance from the Palestinian side to the Egyptian side of the terminal during January (Table 4).

Two Arrests at Erez crossing

Yousef Abu-AlJedyan, 28 year old man from Deir Al-Balah was detained on January 6, 2014 by Israeli security forces at Erez Crossing when he was on his way for treatment at Specialized Surgical SURGI-Care hospital in Beitunia, Ramallah. Yousef, who has been blind in one eye since the age of four, suffered a lacerated iris and corneal abrasion in his other eye in March 2013 when he was injured while he was trying to fix his car. Yousef had previously been treated at Al Nasser Ophthalmic Hospital in Gaza and then referred abroad as an urgent case to St John Eye Hospital in East Jerusalem, but his permit request was delayed by Israeli authorities who rejected his brother as his companion and asked for a new companion.

Preferring not to wait for uncertain Israeli approval, the patient and his family decided to change his destination to Egypt. It took 10 days to obtain a passport and travel to Egypt where he was admitted to the International Eye Hospital in Cairo. Yousef underwent surgery twice, in March and August, but his vision did not improve. The RAD referred him for treatment to Ramallah and on January 5, 2014, Yousef and his family were informed that Yousef had permission to cross Erez the next day. Yousef, accompanied by his mother, went to Erez but Yousef was arrested at the Israeli checkpoint by two Israeli plain-clothed security men. The mother was told that Yousef would be released in one or two hours and waited. At 5 p.m. the family was informed that Yousef had been detained for interrogation and that could be one or two days. He was detained in Ashkelon prison and was prohibited from meeting with his lawyer. The ICRC contacted the family and provided them information about Yousef that he is in good situation and he received a medical check in the prison. On February 5, 2014, Yousef was released from Israeli detention and sent back to Gaza without obtaining the treatment he needs. His vision is very poor and he requires assistance from others for simple activities. He is still seeking health care outside of Gaza.

Mahmoud Abu Shammas, 34 years old, from Deir Al-Ballah, was arrested on January 16, 2014 by Israeli security forces at Erez Crossing. He was on his way to Assuta hospital in Tel Aviv upon the hospital's request to sign a consent form for his father's treatment who was hospitalized in their facility.

The father, Salem Abu Shammas, 70 years old, had undergone open heart surgery in a Nablus hospital, in November 25, 2013 but his medical situation deteriorated gradually after surgery. He developed a hospital- acquired pneumonia and bilateral pleural effusion. He was referred to Assuta hospital in Tel Aviv in December 16, 2013, upon the family's request. The family paid NIS 80,000 to secure a bed in the hospital for the father; he was accompanied by a nephew. Salem improved slowly in Assuta in the first two weeks, then his situation deteriorated again. The hospital said a first-degree relative was required 'to sign papers', which Mahmoud agreed to do and applied for a permit to travel to the hospital. On January 15, 2014, he received a phone call from the Palestinian coordination office official saying that a permit had been issued for him to cross Erez, and on the following day he travelled to Erez, whereupon he was arrested at the terminal. He was detained in Ashkelon prison. A lawyer succeeded to visit Mahmoud once and reported that he was under interrogation. The family reported that Salem's situation deteriorated dramatically after hearing that his son had been arrested. The father died on January 19, 2014, 3 days after Mahmoud's arrest at Erez. Mahmoud was released on February 18, after 32 days of detention.

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