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Source: World Health Organization (WHO)
31 July 2013

Ref: RAD 7 (August 28, 2013)
Referral of Patients from the Gaza Strip

High volume of permit requests: 1,299 patients sought access through Erez, the highest monthly number since 2006.
Access: 85.14% of patients’ applications for permits were approved, 7% lower than the 2012 average rate; 7 patients, all males, were denied permits, compared to 6 denied from January through June. 186 patients (14.32%; 56 F; 130 M) received no response, including 61 children, which delayed medical treatment. The number of permits approved during July was the highest monthly total in the last 8 years.
Patients interrogated: 21 male patients who had applied for permits to cross Erez checkpoint were requested to appear for Israeli security interviews. None were later granted permits.
Arrest: Two patient companions were detained while travelling through Erez checkpoint; one is still in detention.
Outside referrals: 141 patients were referred to Egypt, a drop of more than 50% of the usual number.
Medical reasons for referrals: Most July 2013 referrals were for treatment in oncology/215 patients (17.05%), nuclear medicine/105 (8.33%), paediatrics/90 (7.14%), haematology/78 (6.19%), orthopaedics/78 (6.19%), heart catheterization/76 (6.03%), ophthalmology/75 (5.95%), urology/67 (5.31%), neurosurgery/64 (5.08%), MRI/54 (4.28%) and heart surgery/46 (3.65%).
Cost: The total estimated cost for Gaza MoH referrals during July was NIS 9,239,487.

Referrals reflect needs and local capacity

The Ministry of Health (MoH) in Gaza referred 1,261 patients in July, 7% less than the monthly average of the first half of 2013 (1353). Most referrals were to hospitals in East Jerusalem (474-- 37.6%), followed by Israel (312--24.7%), NGO and private hospitals inside the Gaza Strip (167--13.2%), West Bank hospitals (165 –13%), Egypt (141 --11.2%), and Jordan (2—0.16%), following previous trends (Table 1).

Limited access to Egypt

Patients chose or were forced to delay their medical treatment in Cairo in view of the unstable situation and following restrictions on access to Egypt. Fewer than half the usual number of patients was referred to Egypt in July. The Rafah terminal was completely closed for 4 days for security reasons, in addition to 5 days for holiday and weekends. Rafah terminal authorities reported that after July 10, hours were restricted to only 10 am-2 pm, and only patients with official referral documents from the MoH-Ramallah were permitted to exit. In addition to the usual monthly average of 300 patients referred to Egypt by the MoH, estimates of private patients from Gaza who seek medical treatments every month in Egypt are between 1,000 (MoH-Gaza estimates) and 4,100 (Rafah terminal data). A total of 549 patients and companions were coordinated through Rafah in July, according to MoH EMS.

Only 2 referrals were made to Jordan, reflecting a June 2012 decision by most Jordanian hospitals to halt new MoH referrals due to outstanding PA debts (Chart 1). Referrals within Gaza to non-MoH facilities were for heart catheterization (64), lithotripsy (42), MRI (42), and (19) other services. Referrals for heart surgery increased again this month reflecting shortages of disposable materials needed for surgery. There was a significant gender gap in referrals in July: 57.65% male patients versus 42.35% female patients. 29.7% of all referrals were children aged 0-17 years and 18% were elderly over 60 years.

Reduced health access

In July 2013, 1,106 of 1,299 patients (85.14%) received permits to cross Erez to access hospitals in the West Bank including East Jerusalem, or in Israel or Jordan (Table 2). 7 men, aged 18-60, were denied access to specialized hospitals, among them a 43-year-old man suffering from lymphoid leukemia and a 40-year-old man with heart disease.

According to the Gaza coordination office, 186 patient applications (14.32%), including those of 61 children, received no response, or were reapplications after previous delays. Of these, 51% had been destined for scheduled appointments in East Jerusalem hospitals, 31% in Israeli hospitals and 17% in hospitals in the West Bank; 30% were females. Responses from Israeli authorities should be given to applicants within 10 days. 72 applications were pending between 1-2 weeks, 27 for 2-4 weeks and 1 application was still pending after more than a month.

21 male patients aged 18-60 years were called for security interviews by Israeli General Security Services (GSS) as a condition to process their application. None were granted a permit after interrogation.

The permit approval rate has been rising since May, but still has not risen back to the levels of January 2013. The rate of denials rose slightly (Chart 2).

The volume of applications increased in 2013 by 30%, compared to the same period in 2012, while the approval rate declined by 8%, and the rate of delay was 2.6 times higher (Table 3).

A number of factors may be responsible for the drop in approval rate and the increase in delays including staff changes in February 2013 in the Palestinian District Coordination office, the increase in volume of applications and the nature and length of the security review.

In July, 91.4% of referral patients applying for Israeli permits were financially covered by the Palestinian MoH, 5% were self-funded, and the remaining patients were funded by Nour Ala-Al-Alam foundation, Peres Center for Peace, and Physicians for Human Rights-Israel. MoH referrals do not cover transportation or companion costs and some items of patient care, for example, medicines not in hospital supply.

Patient access at Gaza exit points

Two relatives accompanying patients detained at Erez during July 2013
Nea’ma Shamallakh, a 35-year-old woman from Sheikh Ajlin in Gaza, with an ophthalmic condition, was referred to Msalam center in Ramallah for treatment during July. After she applied for a permit to cross Erez, the Israeli liaison office informed the Palestinian coordination office that she should come for a security interview. When she arrived at Erez accompanied by her husband on July 12, the Israeli authorities returned her back to Gaza and asked her husband, 42-year-old Mahmoud, to attend a security interview. He was then arrested by the Israeli security. The family reported that Israeli security services called on July 16 to inform them that Mahmoud had been sent to Ashkelon prison and would have a hearing after one week. As of August 28, Mahmoud was still being held in detention.

54-year-old Mohammed Abu Harbid was arrested at Erez July 10 as he was returning to Gaza with the body of his brother. Suleiman Abu Harbid, 58, had died in Ikhilov hospital in Tel Aviv from cancer stomach. The body was returned to family members in Beit Hanoun in Gaza, while Mohammed was held for 3 hours at Erez before being released and missed his brother’s funeral. The brothers had travelled together to the hospital on June 16, 2013.

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