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Source: World Health Organization (WHO)
13 May 2010





SIXTY-THIRD WORLD HEALTH ASSEMBLY
Provisional agenda item 13
A63/28
13 May 2010

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

Report by the Secretariat

1. In 2009 the Sixty-second World Health Assembly adopted resolution WHA62.2. The purpose of the present report is to outline implementation of that resolution. Among other things, the resolution requested the Director-General to implement a series of activities to support the development of services to support the health care provided to the Palestinian people.1

2. Standards of health care in the Gaza Strip are reported to be declining. Several reports highlight deterioration in some key health indicators, such as rates of infant mortality. Unemployment, poverty levels and environmental standards are also reported to be worsening with possible long-term adverse effects on the health of the population. Access to essential goods including humanitarian goods remains restricted. This hinders many aspects of the humanitarian response.

3. There are continuing problems of access to health-care facilities for both patients and staff, including to the specialized hospitals in east Jerusalem which serve the populations of the West Bank and the Gaza Strip.

4. WHO has continued to lead the health cluster for the occupied Palestinian territory. The Organization convenes and chairs regular health cluster meetings in the Gaza Strip, the West Bank and east Jerusalem. WHO also convenes and co-chairs, with the Ministry of Health, central and district
coordination meetings in the West Bank. WHO represents the health sector at United Nations Humanitarian Country Team meetings as well as monthly donor meetings convened by the European Union’s Humanitarian Aid Department. WHO produces periodic reports on health sector
developments and specific health issues.2

5. The health cluster prepared the health component of the 2010 Consolidated Appeal, the overall objectives of which are to ensure essential health-care services are provided, especially to vulnerable groups; to strengthen the coordination of the humanitarian health response; and to advocate for health as a human right.

6. The health cluster has established a disability sub-cluster in Gaza. This group’s activities have focused on: identifying all organizations working in the field of disabilities; strengthening communication and coordination among those organizations; creating a database of injured people; promoting the production of prosthetic devices; supporting training for physiotherapists, social workers and other health staff; and conducting workshops on the rights of people with disabilities.

7. Improvements in the quality of maternal and newborn health care in the Gaza Strip have been tackled, initially from April to December 2009, in selected health facilities. Drawing on the lessons learnt during this initial period, the project has been expanded to cover all the main Ministry of Health hospitals in the Gaza Strip. The project is expected to improve health outcomes by decreasing infant mortality and morbidity, maternal mortality and obstetric complications, and related ensuing disabilities.

8. In collaboration with the Ministry of Health and health cluster partners, WHO is compiling information on health facilities in the occupied Palestinian territory. The health facility database includes information on the geographical distribution of health facilities by district and locality, the
types of services provided, the availability of human resources and specialized health-care staff and equipment, and a summary of health-care activities in each facility. The database will allow health stakeholders to identify vulnerable areas and gaps in health-service delivery. The health cluster has also collected comprehensive information on mobile health services in the West Bank. The database contains detailed information on 261 West Bank localities visited by mobile health teams, including health providers and partners, on the types of health services offered, and the frequency of visits to each locality.

9. WHO is also producing health profiles for districts, in collaboration with the Ministry of Health. The profiles will map available health facilities, analyse specific health indicators, identify health needs and suggest ways to improve the situation. WHO is convening district workshops to review
information on health needs, identify health gaps and priorities, and decide whether to conduct health assessments to collect additional data.

10. As part of its efforts to advocate for the enjoyment of the highest attainable standard of health, WHO conducted the first of a series of workshops for the Ministry of Health on health and the law in the occupied Palestinian territory. Special attention was given to the restrictions on access to hospitals in east Jerusalem. WHO prepared a detailed report on the impact of new restrictions imposed by the Government of Israel in July 2008 on hospital staff living in the West Bank. WHO held meetings with representatives of the Israeli Ministry of Defense and the Palestinian and Israeli Ministries of Health, during which access difficulties were acknowledged and agreement was reached to reverse the new restrictions. More flexible access arrangements were introduced in November 2009 but rescinded in January 2010.

11. WHO is supporting the Ministry of Health’s Health Policy and Planning General Directorate through the financing of local staff and an international consultant. Efforts have focused on strengthening and institutionalizing planning within the Ministry of Health, including monitoring and evaluation of its strategic plan. The Directorate has successfully developed plans of action for 2009 and 2010. It has also, with WHO’s support, led the development of the 2011–2013 National Health Strategy which addresses health sector development and reform areas to be addressed in the next three years.

12. WHO has continued to support the Ministry of Health’s nutrition programme through technical assistance and capacity-building activities.

13. With WHO support, the Ministry of Health has established a national committee on the prevention and control of noncommunicable diseases and set up a department for noncommunicable diseases under the General Directorate for Primary Health Care. Another unit addressing research and surveillance for chronic diseases has been created under the General Directorate for policy and planning.

14. With financial support from the European Union and technical support from WHO, hospitals in east Jerusalem (Makassed, Augusta Victoria, Red Crescent Maternity, St John Ophthalmology, St Joseph Hospital and Princess Bassma Rehabilitation Centre) have been undertaking strategic reforms. This has included a wide-ranging review of: internal governance and networking; policies; organizational structures; as well as systems and procedures. The initial two-year phase of the project was completed in February 2009. The second phase is expected to commence in the second half of 2010.

15. WHO continues to act as technical adviser to and co-chair of the United Nations thematic group for tuberculosis in the West Bank and Gaza Strip. In support of activities against HIV/AIDS, WHO is a subrecipient of a grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria. WHO’s focus is on technical support to the National HIV/AIDS committee, with an emphasis on blood safety and universal precautions, antiretroviral treatment and monitoring as well as strengthening health information systems and operational research.

16. WHO has supported the development of community-based mental health services in the West Bank and the Gaza Strip though a project funded by the European Commission. The project is supporting the implementation of a strategic operational plan signed in 2004 by the Ministry of Health, WHO, and the Governments of France and Italy. Over the last two years, the Ministry of Health has established mental health units in the West Bank and Gaza Strip to lead mental health reforms. Other activities include the establishment of post-graduate mental health programmes in local universities, capacity building of national staff, the creation of a nongovernmental organization bringing together family associations, and other activities. The strategic operational plan has been reviewed and updated, and a strategy to integrate mental health into primary health-care services has been formulated. The project is scheduled to continue until the end of 2010.

17. WHO is providing technical support to the Ministry of Health’s Environmental Health Unit. The Organization is helping build capacity through training courses on vector control, solid and wastewater management, water and food safety and licensing of industries and handicrafts. It has also provided technical assistance to the Environmental Health Unit and donated environmental health supplies.

18. WHO and its health cluster partners carried out an initial health needs assessment in the Gaza Strip shortly after the end of Israeli military operations in early 2009. The results of the assessment were published in February 2009.3 This provided the baseline data that allowed health partners to plan, implement health interventions, monitor risks and measure progress. A second health assessment was conducted by the specialized health mission to the Gaza Strip requested in 2009 by the Executive Board in resolution EB124.R4. The report was published in May 2009 in line with the Health Assembly’s request to make the detailed report available.4 It identifies issues of major concern in the health sector, as well as the risks highlighted in the earlier assessment which had not been fully addressed. In early 2010, WHO worked with the United Nations Humanitarian Coordinator and the Association of International Development Agencies to draft and publish a statement on the status of
health in Gaza one year after Israeli military operations.

19. Following Israeli military operations in the Gaza Strip from 28 December 2008 to 18 January 2009, WHO helped to handle the large volume of medical supplies donated to the Gaza Strip by various entities. This entailed renting additional warehouses and helping to sort, register, store and
deliver medical supplies, as well as disposing of expired or unusable medicines. Using funds from the Italian Government, WHO provided urgently needed medical equipment and spare parts. The Organization also provided technical assistance to maintain, repair and improve existing equipment. Under the second phase of this project, with continuing funding from the Italian Government, WHO is supporting the Ministry of Health in its efforts to strengthen the maintenance system for medical equipment.5

20. To help the Ministry of Health to prepare for and respond to pandemic (H1N1) 2009, WHO supported the development of plans for national pandemic preparedness and response and vaccine deployment, and donated a stock of pandemic vaccine to the Ministry of Health. The Organization has also assessed case-management and capacity-building needs, provided case-management guidelines, and developed educational materials.

21. With regard to the necessary support to veterinary services, WHO has maintained close liaison with FAO. This has been especially important in respect of the provision of information and advice on pandemic (H1N1) 2009 and on the steps to be taken to build capacity to detect, confirm and respond to potential outbreaks of avian influenza, as well as to other zoonotic diseases.

22. The Government of Israel and the Government of the Syrian Arab Republic submitted letters in connection with the health conditions of the population of the occupied Syrian Golan, but there was no possibility for the Secretariat to establish disaggregated data on those health conditions.

ACTION BY THE HEALTH ASSEMBLY

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

ANNEX
FACT-FINDING REPORT ON THE HEALTH AND ECONOMIC SITUATION
IN THE OCCUPIED PALESTINIAN TERRITORY, INCLUDING
EAST JERUSALEM, AND IN THE OCCUPIED SYRIAN GOLAN

1. This report has been prepared in response to resolution WHA62.2. The Secretariat has conducted a review of reports available from reliable sources that address the situation in the occupied Palestinian territory. It has also conducted telephone interviews with selected persons working on health and related issues in the occupied Palestinian territory. In addition, information provided by the Governments of Israel, Syrian Arab Republic and the Palestinian Authority was reviewed.

DETERMINANTS OF HEALTH IN THE OCCUPIED PALESTINIAN TERRITORY

2. Economic growth in the occupied Palestinian territory has continued to decline since 2006. A recent World Bank report6 shows that real per capita gross domestic product is now 30% below its level in 1999 as the economy shrinks and the population grows. In 2008, gross domestic product was just above US$ 1000 per capita compared to around US$ 1500 per capita in 1999.

3. There is rapid demographic change, with an overall annual population growth of around 3%, and a projected doubling of the Palestinian population in approximately 20 years. The Palestinian economy is becoming increasingly aid dependent. The blockade is eroding the occupied Palestinian territory’s industrial backbone and paralysing its municipal services.

4. Since the beginning of 2009, the Government of Israel has taken steps to ease movement restrictions in the West Bank and to allow greater access to West Bank markets for Arab citizens of Israel. At the same time, the security environment in the West Bank has improved through the joint efforts of the Palestinian Authority and the Israeli security forces. Together these developments have led to increased investor confidence and more economic activity. However, access to both internal markets (between West Bank and the Gaza Strip) and external markets (such as Israel and other countries) is still severely limited.

5. The West Bank economy is showing signs of growth, so much so that it appears possible it may achieve positive per capita gross domestic product growth in 2009. However, this appears to be driven by the influx of donor assistance, and it may not be sustainable.

6. The latest available information on poverty levels indicates that 51% of Palestinians live below the poverty line, with 19% of them living in extreme poverty in the third quarter of 2008. During the same period, poverty rates in the West Bank were at 48% and at 56% in the Gaza Strip while the poverty rate in the Gaza Strip was 51.8% in 2007. Poverty in communities affected by the barrier stands at over 65% in 2008.7

7. Overall unemployment in the occupied Palestinian territory decreased by a modest amount in the third quarter of 2009 (31.4% compared with 32.7% in the third quarter of 2008). Unemployment among young people stands at 67%. Half of males aged 15 and above are employed, and just one in seven women is working. In May 2008, 70% of families were living on an income of less than one dollar per person per day.

8. Repeated droughts in the past few years and limitations on access to cultivation and grazing lands and irrigation have also contributed to a decrease in local food production and a negative effect on agricultural livelihoods. Food and fuel prices have decreased compared to 2008 but remain at a higher level than their average over the past five years.

9. One third of West Bank households and 71% of households in the Gaza Strip received food assistance in the second half of 2008. Food accounts for approximately one half of total household expenditures, making families highly susceptible to variations in food prices and income levels. According to the results of a joint UN rapid food security survey published in May 2008, 38% of the Palestinian population is food insecure (compared to 34% in 2006). Food insecurity in the Gaza Strip is more widespread, reaching 56%, and in the West Bank it is 25%. Food insecurity is higher among refugees (44%) compared to non refugees (33%) however, both population groups faced a similar increase (10%) in their food insecurity in the past two years. Food insecurity reaches 50% in camps.8

10. In the Gaza Strip, private enterprise is practically at a standstill as a consequence of the blockade. Almost all (98%) industrial operations have been shut down. The construction sector, which before September 2000 provided 15% of all jobs, has effectively halted. Only 258 industrial establishments in Gaza were operational in 2009 compared with over 2400 in 2006. As a result, unemployment rates have soared to 42% (up from 32% before the blockade). The expansion of the public sector and the growth of the tunnel economy have partially compensated for the massive loss of jobs. The blockade has led to acute shortages in fuel, cash, and cooking gas and other basic supplies.

11. There have also been restrictions on the transfer of cash from West Bank financial institutions to the Gaza Strip. The resulting cash shortage and the halting of private sector investment in the Gaza Strip have led to a precipitous decline in real private sector credit.

12. FAO has reported9 that the recent Israeli military operations in the Gaza Strip led to the destruction of over 24 820 000 square metres of crops.

13. The area in which fishermen are allowed to fish has been progressively reduced, and fell to three nautical miles in 2009. As a result, employment in fishing has fallen by 66% since 2000, with only 3400 fishermen active at the beginning of 2010.

14. The ban on the importation of building materials has prevented the reconstruction of most of the 3500 homes destroyed and the 2900 homes severely damaged in the Gaza Strip in December 2008 and January 2009. The ban has also prevented the construction of 7500 planned housing units to cater for the Gaza Strip’s rapidly expanding population. More than 3500 families are still displaced. While most families live in rented
apartments or with relatives, about 200 families are still living in tents or makeshift shelters without proper roofing, windows or doors. Moreover, construction projects valued at around US$ 76 million that were under way before 2007 remain on hold. These include housing projects and programmes to repair and construct public infrastructure including water, sewage and solid waste removal systems.

15. The Israeli military operations of December 2008 – January 2009 are reported to have damaged 11 wells and four reservoirs as well as 19 920 metres of water pipes and 2445 metres of sewage pipes. The sewage network, including sewage treatment plants and pumping stations, suffered damage at four sites. The electricity network was also damaged, and the resulting power cuts affected water supplies and wastewater pumping and treatment systems. UNEP has reported that nearly 840 households (with an average size of 7.25 persons) suffered damage to their water supply.10 A total of 5200 households lost their roof water tanks, and another 2355 household water tanks were damaged. Nearly 10% of the population of the Gaza Strip (over 100 000 people) had no proper water supply in February 2009. Three months later, 32 000 people still had no proper water supply.

16. Many residents in Gaza depend on desalinated water for drinking, but restrictions on electricity have impeded the operation of desalination plants. The blockade has at times prevented the entry of essential chemicals and chlorine necessary to operate desalination plants and disinfect drinking water, placing people’s health at risk. As a result, water-related health problems are wide spread in the Gaza Strip. UNRWA reports that among the infectious diseases affecting the refugee population in the Gaza Strip, those that have the highest rates of occurrence are those directly related to inadequate supplies of safe water and poor sanitation: watery diarrhoea, acute bloody diarrhoea and viral hepatitis.11

17. The electricity crisis in the Gaza Strip continues. There is not enough money to buy fuel to operate the Gaza Power Plant, and recently there have been recurrent technical failures due to the lack of spare parts. The electricity network is now able to meet only 70% of demand. Since the beginning of 2010, the quantity of fuel delivered to the power plant has declined from an average of 2.2 million litres per week to 1.7 million litres per week. The Gaza Power Plant authorities have indicated that at least 2.2 million litres of industrial fuel are needed per week to maintain production levels of between 55 and 60 megawatts of electricity. At these levels, most of the population still faces power cuts of six to eight hours per day for four to five days each week.

ACCESS TO HEALTH CARE

18. There has been continued investment in the development of health-care services in the West Bank over the past year through the efforts of the Palestinian Ministry of Health and the support of donors and other stakeholders. Access to health-care services in some parts of the West Bank has improved slightly thanks to a recent reduction of internal barriers and movement restrictions. However, there are still many obstacles to the free movement of people and goods, which impede the efficient functioning and delivery of health-care services. There are particular concerns about services to rural and herder populations in Area C, where restrictions on movement and access are particularly severe. The impact of the Separation Wall and the difficulties of access to east Jerusalem are also issues of growing concern.

19. East Jerusalem hospitals are important providers of health care for Palestinians and the main providers of specialized tertiary services including treatment for diabetes, cancer and cardiovascular diseases (these services are not generally available in the West Bank and Gaza). In 2006, 26% of Ministry of Health referrals were to hospitals in east Jerusalem. By 2008, this figure had increased to 48% of all referrals. Palestinians continue to face considerable difficulties when accessing hospitals in east Jerusalem from the West Bank, because of checkpoints and the need to obtain permits to cross the Separation Wall. New restrictions introduced in June 2008 are making access to these hospitals even more difficult for both hospital staff and patients. Prior to that date, staff and patients had been able to use any checkpoint into east Jerusalem. Now, all staff except doctors can use the main checkpoints only, which are very busy and considerably delay their daily journeys to and from work. WHO and the
international community are continuing to press for these restrictions to be eased and for staff and patients to be allowed to use any checkpoint to enter east Jerusalem.

20. The closure of the Gaza Strip is undermining the functioning of the health-care system, hampering the provision of medical supplies and the training of health staff and preventing patients with serious medical conditions receiving timely specialized treatment outside the Strip.

21. The Israeli military operations in December 2008 – January 2009 damaged 15 of the Gaza Strip’s 27 hospitals and damaged or destroyed 43 of its 110 primary health care facilities. The ban on construction materials has meant that the health authorities have been unable to rebuild or repair these facilities. The lack of building materials is also affecting other essential health facilities: for example the new surgical wing in Shifa hospital, the Gaza Strip’s main facility, has remained unfinished since 2006. Many facilities urgently need maintenance and repair as well as expansion in
some cases to cope with the growing population.

22. While supplies of drugs and disposables have generally been allowed into the Gaza Strip, there are often shortages on the ground with 15%–20% of essential medicines commonly out of stock. Certain types of medical equipment, such as X-ray equipment and electronic devices have proved very difficult to bring in, and there are often shortages of essential spare parts, with the result that clinical staff frequently lack the medical equipment they need. Medical devices are often broken, missing spare parts, or out of date.

23. Health professionals in the Gaza Strip have been cut off from the outside world. Since 2000, very few doctors, nurses or technicians have been able to leave the Gaza Strip for training to update their clinical skills. This is severely undermining their ability to provide quality health care.

24. Many specialized treatments (e.g. for complex heart surgery and certain types of cancer) are not available in the Gaza Strip. Many patients who are referred for treatment to hospitals outside the Gaza Strip have had their applications for exit permits denied or delayed by the Israeli authorities and have missed their appointments. Several have died while waiting for referral. WHO has published a case study of five patients in critical condition who died while waiting to exit the Gaza Strip in April 2008.12

HEALTH STATUS

25. The steady decline in the infant mortality rate over recent decades has stalled in the last few years. The mortality rate may have risen slightly in Gaza, where it is now around 30% higher than in the West Bank.

26. Infant deaths are mostly concentrated within the neonatal period, and many neonatal deaths occur within the first week of life. The main causes of neonatal mortality are asphyxia, infections and low birth weights. Watery diarrhoea as well as acute bloody diarrhoea and viral hepatitis remain the major causes of morbidity among reportable infectious diseases in the Gaza Strip. Immunization coverage remains high (over 95%) across the Gaza Strip.

27. The proportion of children suffering from anaemia was 65.5% in February 2009, which represents a slight decrease compared to 2006 (68.2%) and 2007 (72.1%). The proportion of pregnant women suffering from anaemia was 37.5% in February 2009, which is the same as in 2006 and higher than in 2007 (33.3%). Noticeable differences were shown among governorates, with the highest levels of anaemia in the Gaza Strip (44.7 %) and the lowest in Khan Younis (19.5%).

28. A household sample survey13 to collect information on living conditions was carried out in the Gaza Strip, 3–12 March 2009. The survey showed that around 1% of the population was suffering severe acute psychological distress. Children between five and nine years old (especially girls) seem to have been particularly affected. A few weeks later, WHO carried out a second survey to measure the prevalence of psychological distress among 500 adult patients visiting five primary health-care centres in the Gaza Strip. The results revealed that 37% of the adults surveyed showed psychological distress. There were no discernible differences between males and females. Older patients showed higher rates of prevalence (70%).

29. Other indicators of health status such as life expectancy do not show any clear trends. Reliable health data on maternal mortality and morbidity trends are not generally available.

30. Acute malnutrition rates among children under five years of age are low, but chronic malnutrition in the Gaza Strip has risen over the past few years and has now reached 10.2%. Micronutrient deficiencies among children and women have reached levels that are of concern. All
nutritional status parameters are worse in the Gaza Strip than in the West Bank.14

SITUATION IN THE OCCUPIED SYRIAN GOLAN

31. No significant changes have been recorded between 2008 and 2009 regarding employment conditions and opportunities for Syrian citizens in the occupied Syrian Golan. These citizens have few employment opportunities in their communities, with no prospect of economic development.
Discriminatory water quotas and tariff schemes restrict their access to land and water. This severely constrains the agricultural activities of Syrian citizens, who have traditionally relied on such activities for their livelihoods.

Endnotes
1 Resolution WHA62.2 also asked the Director-General to submit a fact-finding report on the health and economic situation in the occupied Palestinian territory, including east Jerusalem, and in the occupied Syrian Golan. The report is attached at Annex.
2 http://www.who.int/hac/crises/international/wbgs/en/index.html.
3 http://www.who.int/hac/crises/international/wbgs/gaza_early_health_assessment_16feb09.pdf.
4 Resolution WHA62.2.
5 http://unispal.un.org/UNISPAL.NSF/0/F909F34DF5D27962852576B1004D8D8E.
6 http://siteresources.worldbank.org/INTWESTBANKGAZA/Resources/AHLCJune09Reportfinal.pdf.
7 http://www.undp.ps/en/newsroom/publications/pdf/other/fastfactspoven08.pdf.
8 http://unispal.un.org/pdfs/RapidAssessmentReport_May08.pdf.
9 FAO, Agriculture Sector Report, Impact of Gaza Crisis at: http://www.reliefweb.int/rw/RWFiles2009.nsf/FilesByRWDocUnidFilename/EDIS-7QQPS6-full_report.pdf/$File/full_report.pdf.
10 UNEP Environmental assessment of the Gaza Strip at: http://unispal.un.org/pdfs/DEP_1190_GE.pdf.
11 UNRWA, Epidemiological Bulletin for Gaza Strip, Volume 1, Issue 11, (August 2009).
12 http://www.emro.who.int/palestine/reports/monitoring/WHO_special_monitoring/access/access%20to%20health%20services%20(April%202008).pdf.
13 http://unispal.un.org/UNISPAL.NSF/0/5A91FECBD86B30F08525759B004E178A.
14 http://unispal.un.org/UNISPAL.NSF/0/FC44A5D7F00AA567852576960059BEB4.






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