|SIXTY-FIRST WORLD HEALTH ASSEMBLY|
Provisional agenda item 13
Health conditions in the occupied Palestinian
territory, including east Jerusalem, and in the
occupied Syrian Golan
Report by the Secretariat
1. The continuing crisis in the occupied Palestinian territory, the growing restrictions on the movement of people and goods and the worsening violence continue to affect the social and economic life of Palestinians, with consequences for their health status and access to health services. Deaths and injuries resulting from the occupation and the internal conflict increased during 2007 and continued to rise in the first months of 2008.
2. The slow but steady rise in life expectancy has nevertheless continued; figures for infant and child mortality, however, have remained virtually unchanged in recent years, despite the global commitment to achieving the health-related Millennium Development Goals (see Annex).
3. Chronic malnutrition and associated micronutrient deficiencies remain a public health problem in the occupied Palestinian territory; in addition, more than 30% of the overall burden of disease among adults is caused by noncommunicable diseases (see Annex).
4. Since June 2007, a new emergency Government has been established, sanctions against the Palestinian Authority have been lifted and international aid has resumed. However, internal closure, the construction of the separation wall, and the permit system continue to affect patients’ access to various levels of health care in the West Bank. The Gaza Strip continues to be largely isolated from the outside world as a result of the external closure in place, and the increasing levels of violence experienced there may lead to a humanitarian health crisis.
5. There are reports of decreased access to secondary and tertiary health care. The number of patients unable to access treatment outside the Gaza Strip increased during the second half of 2007. The lack of essential spare parts, basic consumables, supplies and medicines further weakened the health-care delivery system.
6. In June 2006, a WHO-designed tool was introduced in order to improve monitoring of the impact on health of the evolving situation. Information thus generated has been used to improve management, direct response and gap filling, and guide humanitarian advocacy. WHO has facilitated and supported effective communication and the building of strategic partnerships between Israelis and Palestinians, with the aim of advocating for Palestinians’ access to health services and the promotion of health as a bridge for peace. A symposium on health was held in the Gaza Strip, with the participation of both Israeli and Palestinian health stakeholders. An outcome of this symposium was the establishment of an Israeli-Palestinian joint forum on access to health in the Gaza Strip.
7. In response to the suspension by the international community of financial and economic aid during the first half of 2007, and in order to address emergency health needs arising from the closure policy on the West Bank and Gaza Strip, WHO continued to provide essential medical supplies and consumables for primary health care services and worked with the Palestinian Ministry of Health to deliver pharmaceuticals to the West Bank and Gaza Strip.
8. WHO, as the technical advisory agency to the Health Sector Working Group chaired by the Palestinian Minister of Health, provides technical support to the thirteen central and district health coordination bodies that involve local and international nongovernmental organizations, organizations of the United Nations system and local authorities. WHO has held monthly meetings to inform partners about health status, delivery of health services and response to emergency situations.
9. WHO continued to work with the Ministry of Health on strengthening its nutrition department and expanding the newly established nutrition surveillance system. This collaboration involved the provision of technical support and efforts on behalf of the introduction of growth standards in all primary health centres. WHO supported the Ministry of Health in developing and launching a national strategy for feeding infants and young children and is currently helping to develop a national code for the marketing of breast-milk substitutes. WHO has provided technical support to the Ministry of Health’s noncommunicable disease control and prevention programme, responding to specific training needs for specialized health care, preparing diagnosis and treatment guidelines, introducing a surveillance system for risk factors and launching an educational campaign on the prevention of chronic diseases.
10. WHO has seconded an international expert in health policy and systems to the Palestinian Ministry of Health in order to support the implementation of the National Strategic Health Plan Medium Term Development Plan (2008–2010).
11. WHO took lead in the preparing the health component of the 2008 interagency Consolidated Appeals Process, with the overall objective of ensuring that the Palestinian population has access to a comprehensive set of good-quality health services. Through the 2007 Process, humanitarian funds were received from the United Nations Central Emergency Response Fund, the European Commission’s Humanitarian Aid department, the Government of Spain (through United Nations Office for the Coordination of Humanitarian Affairs), and the Government of Norway. EuropeAid and the Government of Italy are funding development projects in the health sector.
12. The six east Jerusalem hospitals receive most of the internal referrals for specialized hospital care from the health centres of the Palestinian Ministry of Health in the West Bank and Gaza Strip. WHO is supporting these hospitals in improving the coordination and quality of their health services. The Organization has also continued to advise and support the Ministry of Health in its development and modernization of the community mental health service, a project that includes the establishment of a Mental Health Directorate within the Ministry in order to improve the capacity to manage development activities and the operation of services and staff. In its work on preparedness and response against avian and pandemic influenza, WHO is collaborating with the Palestinian authorities in supporting them to build capacity to detect and monitor any cases occurring in humans and in putting in place core requirements in order to enable the Palestinian Authority to contain any outbreaks of the disease.
13. In order to build Palestinian institutions and revive the economy, the Palestinian Authority presented the Palestinian Reform and Development Plan containing a three-year fiscal framework, at the International Donors’ Conference for the Palestinian Authority (Paris, 17 December 2007). A total of US$ 7400 million was pledged, of which US$ 3400 million are for humanitarian assistance in all sectors in 2008. The involvement of the Ministry of Health in the Palestinian Reform and Development Plan is guided by the National Strategic Health Plan 2008–20 10.
14. The Governments of Israel and 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
15. The Health Assembly is invited to note the above report.
HEALTH CONDITIONS IN THE OCCUPIED PALESTINIAN TERRITORY, INCLUDING EAST JERUSALEM, AND IN THE OCCUPIED SYRIAN GOLAN
Report by the Secretariat
1. In response to the request in resolution WHA60.2 for 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 Secretariat has reviewed reports available from reliable sources on the situation in the occupied Palestinian territory and interviewed by telephone selected people working on health and health-related problems in the territory.1 Specific information for the occupied Syrian Golan could not be identified.
DETERMINANTS OF HEALTH IN THE OCCUPIED PALESTINIAN TERRITORY
2. The economic recovery between 2003 and 2005 was reversed in 2006, when the gross domestic product fell by 8.8%. In the first quarter of 2007 the trend worsened, with a further decrease of 4.2%. Changes in the structure of the economy have decreased its potential to be self-sustaining and limited the prospects for long-term growth.
3. In the first half of 2007, the Palestinian Authority’s deficit was US$100 million per month. Although the Government of Israel released clearance revenues that had been withheld in June 2007, the Authority’s wage bill exceeds its revenues. The situation is exacerbated by the limited ability to increase domestic revenues given the loss in value-added tax and customs duties due to the suspension of Gaza’s trade.
4. External assistance during the first half of 2007 amounted to nearly US$ 450 million. The Palestinian Authority estimated that at least US$ 1620 million in donor assistance would be needed annually in order to close its fiscal gap, with 94% of that sum being used to meet recurrent expenditures.
5. Unemployment in the Gaza Strip rose from 30% in 2005, to almost 35% in 2006 and to 38% in the third quarter of 2007. In the West Bank, unemployment fell from 20% to 19% in the first half of 2007. These rates, however, do not take into account workers who lost their jobs and engaged in unpaid family labour or took seasonal agricultural work. Also people engaged in UNRWA’s temporary employment programmes are not counted in the unemployment statistics. The Palestinian Central Bureau of Statistics estimates that including underemployed workers and those that have left the labour market because they cannot find employment would raise the 2006 unemployment rate in the West Bank to 28% and to over 39% in the Gaza Strip. If the current conditions continue, unemployment is predicted to rise to more than 50% in the Gaza Strip by mid-2008.
6. Poverty in the Gaza Strip has deepened to an unprecedented level, affecting 80% of households compared with 63% in 2005, with about two thirds experiencing deep poverty. Poverty levels are about 30% lower in the West Bank.
7. In 2007 the average consumer price index for food rose by 6.3% in the Gaza Strip and 5.8% in the West Bank compared with 2006, with the price of wheat flour soaring by more than two thirds. The increase, although largely due to international market prices, further aggravates the deteriorating socioeconomic situation, particularly in the Gaza Strip, because of lower purchasing power. Since June 2007, the average household expenditure in the Gaza Strip on food has been 62%. Of the non-refugee population in the Gaza Strip, 61% is reported to be food insecure and another 11% is at risk of becoming so; 70% of households report increased difficulty in buying sufficient food. Dietary choice is restricted by rising poverty. People are eating fewer dairy products, eggs and vegetables and increasing their consumption of cheaper, starchy foods.
8. The number of households with safe drinking water dropped by more than 8% between 2000 and 2007. Furthermore, as a result of the financial crisis and the closure of the borders, many water institutions lack fuel stocks and vital supplies for, among other things, water treatment, waste disposal and sewerage. Since January 2008, the lack of fuel has led to a daily discharge of 40 000 m3 of only partially treated wastewater into the open sea.
9. The United Nations estimates that the number of checkpoints and fixed impediments has risen from 376 in August 2005 to 563 in January 2008; in the 12 months to February 2008, the number of flying checkpoints decreased from 455 to 243. In addition to reducing movement within and across the Palestinian territory, these policies and procedures restrict access to domestic and international markets, health services, and water and other natural resources, affecting particularly the population of the enclosed (“seam”) zone and those living in areas under direct Israeli control.
ACCESS TO HEALTH CARE
10. As the shortage of resources and the complex internal and external closure systems increase difficulties in delivering supplies, particularly to the Gaza Strip, the quality of health care is gradually deteriorating. They also result in a chronic lack of essential spare parts and consumables. Some special hospital equipment for treatment and laboratory diagnosis is no longer functional; the health of chronically ill people, such as patients with renal failure and cancer, suffers. For example, 10 out of 26 dialysis units in the Shifa hospital are frequently unable to function because of lack of equipment and spare parts; at Ministry of Health facilities elsewhere in the Gaza Strip much diagnostic equipment, for example magnetic resonance imaging, computerized tomography scanners and X-ray machines, is repeatedly reported to be not functioning.
11. WHO’s monitoring of the availability of medicines shows constant shortages during 2007. The report for October–November 2007 indicated that, for instance the stocks of 85 medicines (20%) in the Central Drug Store in the Gaza Strip were sufficient for less than one month’s consumption, and 56 of these items were not available in the occupied Palestinian territory. Additionally, stocks of 17% of consumable items were insufficient for one months supply. Figures for the West Bank were 97 medicines (23%) held in stocks insufficient for one month’s consumption, and 73 of the items not available. In the Central Drug Store in Gaza, no buffer stock is available for a third of essential medicines. Clearly, the public health system is vulnerable to shortages of medicines. In primary health care district pharmacies in the West Bank and the Gaza Strip an average of 11% of essential medicines are not available, and at hospital level, on average 10% of medicines are unavailable in the Gaza Strip and 8% in the West Bank.
12. According to WHO health sector surveillance indicators, intermittent shortages of beds, other furniture, bedside monitors and disposal units were reported. Shortage of qualified staff in various categories is affecting the sector in many areas.
13. During December 2007 electricity shortages increased as a result of winter power consumption, cuts in electricity supply by Israel, and a strike by petrol station owners. Additionally, the Israeli Government reduced the quantity of industrial diesel fuel imported into the Gaza Strip in early January 2008, resulting in daily electricity cuts lasting on average eight hours. Such power cuts and limited fuel supplies for generators especially affect intensive care units, operation theatres, and accident and emergency units, with their X-ray machines, oxygen extractors, central suctions systems, air-conditioning systems, water pumps and laundry facilities. In February 2008, the Shifa hospital in Gaza reported electrical power cuts lasting between four and 18 hours a day; other hospitals operated by the Ministry of Health face similar constraints. Moreover, many Ministry of Health primary health care facilities were obliged to stop emergency generators because of shortages of diesel fuel. Many Ministry vehicles were not operational, preventing transport of staff and supplies and thus impeding service delivery.
14. Deterioration of the primary health care network, mainly due to a lack of vital medical supplies, periodic strikes in the public sector, and the inability of refugees to pay the nominal prescription fees at governmental health centres, has led to increased demand for services from other providers than the Ministry of Health. Thus the demand for health services provided by major nongovernmental organizations increased in 2007 by 20% to 30% compared with 2006, while the demand for UNRWA’s primary health care services increased by 10% between 2005 and 2006 and by another 20% in the first half of 2007.
15. At the end of 2006, there were 78 hospitals in the occupied Palestinian territory with a total capacity of 5014 beds, serving the 11% of the population that is admitted to hospital annually. The rate of 13 hospital beds per 10 000 population is in the low range within the Eastern Mediterranean Region. The occupancy rate is about 80% in Ministry of Health hospitals, but less than half that figure in nongovernmental and private hospitals. Each month some 35 000 people are admitted to hospital, 11 000 surgical operations performed and 9000 deliveries.
16. Access to secondary and tertiary care centres in the West Bank is affected by the restrictions on movement as most hospitals are in cities, including east Jerusalem (with 20% of the West Bank hospital beds). Jerusalem is important for the Palestinian health care delivery system because its six hospitals are the main providers of tertiary health care to the Palestinian population. The movement restrictions have reduced revenues by 40% because fewer patients can attend consultations (90% of outpatients are from the West Bank, as east Jerusalem residents are covered by the Israeli health system). The severe restrictions on movement of both health providers and patients create difficulties in accessing and providing health care services. Every month, 3000–4000 permits have to be requested for staff (75% of staff working in east Jerusalem hospitals are from the West Bank) and patients.
17. The operation of two separate health care systems, one in the Gaza Strip and the other in the West Bank (including east Jerusalem), further complicates attempts by the Ministry of Health to coordinate its activities and is leading to duplication of services, loss of efficiency, and increased costs. The reduction in revenue from the insurance scheme due to increased unemployment and poverty aggravates the increase in costs. Furthermore, the ability of Palestinians to pay out-of-pocket expenses is being compromised, limiting their access to those services that are only available in the private sector (e.g. regular screening for breast cancer).
18. The cost of treatment abroad rose from US$ 6.2 million in 2002 to US$ 32.5 million in 2003 and US$ 53.4 million in 2004, and since 2005 it has been the third highest expenditure of the Ministry of Health. In 2007, the cost of the nearly 9000 such referrals was US$ 25.5 million, and the most common medical reason was cancer (1078 cases). More cases have been referred to Israel, particularly since July 2007, because of the closure of the border with Egypt at Rafah, thereby putting an extra strain on the Ministry of Health budget: services purchased from Egypt are less expensive than those purchased from other neighbouring countries. In addition, the proportion of patients who received permits decreased by 25% during the second half of 2007. For the West Bank 22 729 patients were referred abroad in 2007 at a total cost of around US$ 46.1 million.
19. The Ministry of Health has resumed the payment of salaries to its staff and the distribution of supplies and medicines to the Gaza Strip, facilitated by WHO, UNRWA, the World Bank and the International Committee of the Red Cross. Although the Ministry’s financial crisis seemed to recede in the second half of 2007, funding to nongovernmental organizations appeared to decrease, thereby threatening a large part of the Palestinian health services.
20. Life expectancy has continued to rise slowly, in 2007 reaching 71.8 years for males and 73.3 years for females, and being slightly higher for both sexes in the West Bank than in the Gaza Strip. The infant mortality rate is 25.3 per 1000 live births, higher in the Gaza Strip than the West Bank (28.8 and 22.9 per 1000 live births, respectively). The same trend applies to the child mortality rate (28.2 per 1000 live births: 31.8 in the Gaza Strip and 25.8 in the West Bank). Both mortality rates are higher for males then for females.
21. The maternal mortality rate is 6.2 per 100 000 live births. The fertility rate for the entire territory was 4.6 in 2006 (4.2 in the West Bank and 5.4 in the Gaza Strip), with a marginal difference between rural and urban areas. Overall, just over half of women between 15 and 49 years of age used family planning, the proportion being 13% higher in the West Bank than in the Gaza Strip. Almost all mothers receive antenatal care provided by skilled health personnel. The mean number of health care visits during pregnancy was 7.8.
22. About 10% of the population in the occupied territory suffers from at least one diagnosed chronic disease. The prevalence of chronic noncommunicable diseases has increased with deteriorating living conditions, increased mental distress and shortage of vital medical care including medicines. Diabetes, cancers and cardiovascular diseases continue to be the main noncommunicable causes of morbidity and mortality in occupied Palestinian territory and the main reason for referral abroad. Between 35% and 50% of all emergency admissions to hospital are related to accidents, which are also the leading cause of mortality among children aged 1–4 years. For all ages, accidents are the second leading cause of death (12.5%) after heart diseases.
23. Mental health remains a major concern. In surveys carried out in 2007, 86% of those interviewed reported sleeping problems, 77% reported deteriorating family relations and 72% reported increased tension among children. Almost 40% of people interviewed felt anxious, irritable and frustrated, and about half feared losing their home or their land and being displaced or uprooted.
24. The number of Palestinian deaths increased from 2006 by 8.8% to 953 in 2007, with about half being caused by the internal conflict and violence. Almost 10% of these deaths were in children (93 in 2007). Compared with 2006, the number of injuries increased by almost 14% in 2007 (rising to 4771), with the number of injured children decreasing to 93.
25. About 10% of children under five years of age in the occupied Palestinian territory suffer from chronic malnutrition (13% in the Gaza Strip and 8% in the West Bank, with the highest figure, 30%, recorded in the governorate of North Gaza). Some 1.4% of children are subject to acute malnutrition. The main nutritional problems in the occupied Palestinian territory are due to micronutrient deficiencies, especially iron: more than half all children in the Gaza Strip aged 6–36 months and more than a third in the West Bank suffer from anaemia. The prevalence of anaemia among pregnant women is 45% in the Gaza Strip and 31% in the West Bank.
26. Lack of investment in preventive measures in 2006 may have contributed to the increase observed in some vector-borne and zoonotic diseases in 2007. Between 2006 and 2007 reported cases of leishmaniasis rose from 150 to 181, of salmonellosis from 27 to 70, of hydatid cysts from 2 to 28, and shigellosis from 23 to 113. According to the Palestine Central Bureau of Statistics, 14% of children under five years of age were reported to have had pneumonia during their lifetime. The percentage of pneumonia is higher among males compared to females.
1 The list of references and experts is available on request.
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