Crossing barriers to access health in
the occupied Palestinian territory, 2013
The Palestinian Ministry of Health (MoH) refers patients in the West Bank and Gaza for specialized care if unavailable in local MoH hospitals, and financially supports their treatment in outside medical facilities. Most referrals are to private/non-profit health facilities in the occupied Palestinian territory, while one in five are to neighbouring countries: Egypt, Israel or Jordan. The aim of this WHO study is to examine the problems encountered by patients in 2013 in accessing needed health services due to the movement restriction policies imposed by the Israeli occupation.
WHO has been monitoring the barriers to health care access since 2003 and has advocated for full unrestricted access for Palestinian patients to health care facilities both within the occupied Palestinian territory (oPt), and beyond. Previous WHO annual reports highlighted problems with health access from Gaza in 2010 and from both Gaza and West Bank in 2011-12. WHO also issues detailed monthly reports about the access situation of Gaza patients.
Patients referred by the Palestinian Ministry of Health, and also private patients who are referred by private physicians and insured by other health insurance or self-funded, require Israeli-issued permits to travel to
treatment outside Gaza or the West Bank. Patients and patient-companions are one of the few categories of Palestinians who may apply for Israeli-issued access permits.141The restrictive permit system is enforced by physical barriers --- walls, fences and checkpoints --- imposed by Israeli military authorities on Gaza and West Bank residents, and made more restrictive after 2006. The permit system applies to patients who need to travel through checkpoints within the occupied Palestinian territory --- that is, between Gaza and the West Bank, including to East Jerusalem, as well as for travel to Israel and Jordan. Travel from Gaza to health facilities in Egypt or beyond requires access permission through Egyptian-controlled Rafah border, also vulnerable to frequent closures for political reasons.
This third annual report presents the most comprehensive quantitative and qualitative data available for 2013 concerning barriers experienced by West Bank and Gaza Palestinian patients, companions and health personnel in reaching hospitals outside of their region. Information on ambulance access and staff access to East Jerusalem hospitals is also included. Health access is a key factor in realizing the right to health and must be protected by all duty bearers.
No individual should be physically restricted from accessing health care in their country, or arbitrarily denied when they need to leave their country for health care abroad. The right to health is one of the most widely acknowledged and respected of human rights and enshrined in major international laws and conventions as a "fundamental human right indispensable for the exercise of most other human rights."
Article 56, Geneva Convention 1V; Article 12, International Covenant on Economic, Social and Cultural Rights; General Comment 14 (2000), Committee for Economic, Social and Cultural Rights.
The study aimed to collect and examine the data from 2013 concerning barriers to patient access to referral health services due to the movement restriction policies imposed by the Israeli occupation. Information on the access barriers for ambulances and staff of East Jerusalem hospitals was also examined.
2.1 Data sources
Referrals: Baseline quantitative data on patient referrals were obtained from the Palestinian Ministry of Health on the number and estimated cost of referrals from Gaza and the West Bank in 2013, disaggregated by region, age, sex and destination hospital. Data on the medical service to which patients were referred, and the aggregate cost by medical classification of the services were also obtained.
Access: Data on Israeli responses to patients' permit applications to travel outside of Gaza through Erez checkpoint were obtained from the Palestinian Coordination Office in Gaza. Data on Israeli responses to all West Bank permit applications for health access were obtained from the Palestinian General Authority for Civil Affairs and disaggregated by district coordination offices. However, the West Bank data were cumulative for all health access applications, whether patients or patient-companions and others. To separate the data according to category of applicant, WHO recruited fieldworkers to visit the 15 district offices and collect the monthly data for the last quarter of 2013 according to a matrix of actual responses.
Ambulance data for access to Jerusalem were obtained from the Palestinian Red Crescent Society in the West Bank. Data on staff permits to travel to the East Jerusalem hospitals were obtained from the individual hospitals.
Cases: For a deeper understanding of the problems in accessing referral health care in 2013, interviews were conducted with 67 patients and patients' families in the West Bank (17) and Gaza (50) who had been denied permits (46) or delayed permits (21).
Case studies of patients were collected by field workers in Gaza and the West Bank through face-to-face or telephone interviews, after obtaining informed consent. Families were interviewed in the cases of children and in the cases of deaths of patients following denial or delay of access. Information collected by interviews was triangulated whenever possible with information from hospitals and Palestinian coordination offices.
2.2 Data limitations
Referrals: The Gaza Referral Abroad office of the Ministry of Health is operated under the authority of the Palestinian Ministry of Health Referral Abroad Department (RAD) in Ramallah. WHO reports on a monthly basis the data on Gaza referrals which are processed in Gaza. For end-of-year totals WHO uses data for Gaza referrals as reported by the RAD office in Ramallah which reflects the MoH final decisions about the destination hospital and financial coverage of patients, but which also includes Gaza ID holders who bypassed the RAD office in Gaza and applied directly through the Ramallah office.
The Palestinian MoH reports on estimated cost of referrals rather than the actual cost incurred in hospitals after a lengthy auditing process.
Access: Patient age and sex is not normally recorded by West Bank district offices when registering permit application data; therefore it was not possible to carry out sex and age disaggregation in order to examine groups experiencing greater likelihood of being denied or delayed.
Israeli responses to permit applications were collected from the Palestinian district offices as received and recorded as approved or denied. Not all district offices maintain digital archives of permit data; this necessitated manual collection of records and introduced risk of human error in data collection. Responses from one of the West Bank district offices could not be disaggregated by patient and companion due to a change in the office's recording methods in 2013. Therefore WHO estimated the 2013 approval rates for that office by applying the rates obtained from WHO's analysis conducted in 2012.
Data about patient access to Egypt in 2013 was obtained from different sources according to availability, either directly from the Emergency Medical Services (EMS) or indirectly from the International Cooperation Department of the Ministry of Health in Gaza, until the registration of patients and companions in the EMS was stopped and patients' and companions' travel was coordinated by the Ministry of Interior. Data were also obtained from the terminal authority directly, but registration methods and procedures differed among employees, especially for patient-companions, so this data should be used with caution.
Permit data are published on the website of the Coordinator of Government Activities in the Territories (COGAT), a unit in the Israeli Ministry of Defense, but are not disaggregated, and therefore not useful for triangulation with WHO data.
A draft of this report was sent to the COGAT authorities responsible for health access, prior to publication. No comments were received by publication date.
4Categories of eligible persons, criteria for eligibility and conditions of travel for applicants are different for residents of Gaza and of the West Bank and are not transparent nor subject to formal appeal.