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2. This report is a summary of the assessments carried out in the West Bank and Gaza Strip between December 2015 and February 2016 by five independent experts, recruited by the WHO Office for the West Bank and Gaza Strip in cooperation with counterparts from the Ministry of Health, with the overarching aim of reporting on the health conditions of the Palestinian population through a field assessment in line with decision WHA68(8). The assessment report complements the Secretariat's report.1 WHO, through its Regional Director for the Eastern Mediterranean, sent a letter, dated 20 December 2015, to the Permanent Representative of Israel to the United Nations Office and other international organizations in Geneva to provide information on the planned field assessment and to seek support from and collaboration with the Israeli authorities; mission members had a consultative meeting with representatives of the Israeli Ministry of Health on 14 December 2015. Over a period of 44 days in December 2015 and in early 2016, the experts interviewed 114 key informants at locations in the West Bank and east Jerusalem (61), Gaza Strip (46), Tel Aviv/west Jerusalem (5) and Amman (1) including health facilities, ministries, field sites and offices of governments and international and national nongovernmental organizations.
3. The health system in the occupied Palestinian territory is operating under severe pressure due to rapid population growth, lack of economic opportunities and adequate financial resources, shortages in basic supplies, and the inherent limitations of occupation or blockade. The coordination and collaboration challenges between the West Bank and Gaza Strip are further impediments for efficient health sector planning and management.
4. Health access. Access to health services is restricted through the separation wall and checkpoints, which prevent patients, health personnel and ambulances from directly accessing the main Palestinian referral hospitals located in east Jerusalem. The over-60 years age group represented 23.3% of referrals in 2015, although constituting only 4.5% of the population, reflecting the burden of noncommunicable diseases. 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 in and denial of care. In 2015, more than half of Ministry of Health referrals were to destinations requiring permits for access.
5. Of the 168 278 applications for health access permits submitted to Israeli authorities, 16.4% (12.8% for patients and 19.5% for companions) were denied or received no answer. For patients in the Gaza Strip, permit applications to exit through Erez checkpoint for referral medical care increased by 17% over one year to more than 22 000, while the percentage of requests denied almost doubled (from 2.89% to 5.72%). Orthopaedic, neurosurgery, general surgery and psychiatry referrals are more likely to be denied. The number of referrals from the Gaza Strip to Egypt continued to decline in 2015 owing to the closure of the Rafah border. Reconstruction of health facilities, especially in the Gaza Strip, is hampered by the lack of funds in addition to the restrictions to import construction material and medical equipment. Since October 2015 an escalation of violence in the occupied Palestinian territory has triggered new road blocks and checkpoints, restricting ambulance movements with consequent delays in access to health care.
6. Attacks against health services and physical injuries and disabilities. Violence against health services and patients is a new development in the West Bank and east Jerusalem. In October and November 2015, several health facilities, including the largest Palestinian hospital in east Jerusalem, were forcefully entered by security forces in search of individual patients and their respective documentation. In one incident, this resulted in the death of a visitor in a Hebron hospital. Other acts of violence against ambulances, personnel or patients were also reported.
7. Mental and physical health, including in the prison population. The population of the occupied Palestinian territory is experiencing threats to their mental well-being. According to reports' and interviews, the situation deteriorated further in late 2015 as a result of increasing violence starting in September 2015. The United Nations Office for the Coordination of Humanitarian Affairs recorded 15 377 Palestinians and 350 Israelis injured during 2015, with more than 80% of casualties recorded in the last quarter of the year.1
8. Regarding mental health, the occupation itself was noted as a major cause of problems. Depression, anxiety disorder and psychological distress are the most common mental disorders. Research in east Jerusalem has shown that the psychological toll of demolitions and forced evictions hits women harder.2 Also, the imprisonment of Palestinians in Israeli jails affects not only the prisoners (mainly men) but also their families. A high percentage of the male population has spent time in some form of confinement with long-term effects on their mental well-being. There are severe mental health consequences for children and their families. The time spent in detention for these children represents a period of chronic stress, traumatic experiences (threats to physical integrity which are experienced as overwhelming and are accompanied by intense fear and helplessness), loneliness and loss of faith in adults, possibly even their own parents. The actual mental health damage inflicted on the detainees themselves as well as their families is likely to have a long-term health impact.
9. The main reported issues of concern related to the physical well-being of the 6066 Palestinian security detainees and prisoners held in Israeli prisons are: lack of access to timely and adequate medical care, both diagnosis and treatment; inadequate nutrition and housing conditions; and denial of family visits and communications. Physical and psychological abuse especially in interrogation, the use of arbitrary punishments and administrative detention without trial, are seen as important problems for many prisoners. The assessment team did not have access to Israeli prisons and Palestinian prisoners therein, and was not able to validate independently the reported conditions.
10. Food/water. Water consumption in the West Bank and Gaza Strip is well below the WHO-suggested service delivery level of 100 L per capita per day. The Palestinian water network in the West Bank only connects 81% of localities owing to separation walls and roads in Area C, which is under Israeli civil and security authority, according to the Oslo peace accords. In the Gaza Strip, although almost all households (more than 98%) are connected to the water supply network, 90-95% of that water is not potable due to wastewater leakage, seawater intrusion or other contamination. The water quality varies widely in the West Bank and is at crisis levels in the Gaza Strip. Of particular concern are the rising bacteriological and pesticide concentrations in the water supply and the lack of resources for chemical analyses and water treatment. Wastewater treatment infrastructure is also largely inadequate, creating environmental hazards. Administrative delays in the Joint Water Committee and its associated bodies are another factor impacting water quantity, water quality, and wastewater management in the West Bank.
11. Financial and technical assistance. International assistance is closely tied to the peace process and is provided despite critical unresolved political, economic and security issues. Donor support has significantly declined in recent years, mainly due to other competing crises in the region.
12. Palestinians continue to be negatively affected by occupation-related policies and practices; they are at risk of conflict and violence, house demolitions and displacement, denial of access to livelihoods, administrative detention, psychosocial distress or exposure to explosive remnants of war. The root causes of the conflict remain unaddressed. Social resilience, seen as a positive adaptation in the face of adversity, is still holding Palestinian society and its economy together, including the health system.
13. Recommendations formulated in previous reports to the Health Assembly remain valid; and some immediate concrete steps are proposed in addition. These include the upholding of the right to health, the strengthening of coordination of national and international partners, advocacy to support inter-Palestinian reconciliation and the strengthening of the Israeli Ministry of Health's Health Coordination Unit. Health-specific recommendations focus on improvement of health data collection and analyses, and strengthened integration of mental health into primary health care services
1 Document A69/44.
1 See WHO situation reports for October and December 2015 (http://www.emro.who.int/pse/palestine-infocus/situation-reports.html, accessed 25 April 2016).
1 United Nations Office for the Coordination of Humanitarian Affairs press release, 30 December 2015 (https://www.ochaopt.org/documents/press_release_170_palestinians_and_26_israelis_killed_in_2015_english.pdf, accessed 25 April 2016).
2 Women's Centre for Legal Aid and Counselling, 2010: Forced evictions. Assessing the impact on Palestinian women in east Jerusalem (http://www.wclac.org/english/etemplate.php?id=29, accessed 25 April 2016).