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Source: World Health Organization (WHO)
23 December 2013



Ref: RAD 11 (Dec. 23, 2013)

Referral of Patients from the Gaza Strip

Summary: November 2013

·Health-seekers: The number of applications for health access through Erez checkpoint is 47% higher this year than the same period in 2012. Due to the access restrictions at Erez Crossing and the frequent closure of Rafah border, hundreds of patients are estimated to be unable to access specialized medical treatment.

·Arrest at Erez: A 24-year-old male patient with a hearing disorder was detained by Israeli security forces when he appeared for a security interview at Erez checkpoint, November 14, after applying for a access permit.

·Outside referrals: Total referrals in November were the second highest of 2013. Referrals to non-MoH facilities within Gaza and the West Bank were at the highest levels of 2013 and to East Jerusalem hospitals were the second highest. Referrals to Egypt were the highest since June, while referrals to Israel were lower than in the previous 3 months.

·Access: In November 2013, 5 male patients were denied permits. 115 patients - 37 females and 78 males (8.54% of total applicants) - received no response to their applications, including 17 children, which delayed their medical treatment. 91.09% of applicants received permits.

·Patients interrogated: Among the 14 patients (10 males; 4 female) requested to appear for Israeli security interviews after applying for permits to cross Erez was one child, a 16-year-old girl. Only one patient was granted a permit after interrogation thus far.

·Medical reasons for referrals: In November 2013 most referrals were for treatment in the following specialties:

oncology--243 patients (15.42%), nuclear medicine--162 (10.28%), heart catheterization—117 (7.42%),
ophthalmology--116 (7.36%), paediatrics--105 (6.66%), orthopaedics--98 (6.22%), neurosurgery--76 (4.82%),
haematology--69 (4.38%), MRI--67 (4.25%), and heart surgery --56 (3.55%).

·Gender gap: There was a gender gap in referrals: 57.4% male patients versus 42.6% female patients. 22.59% of all referrals were children aged 0-17 years and 19.73% were elderly over 60 years.

·Cost: The total estimated cost for Gaza MoH referrals during November was NIS 10,674,914.

Patient detained 12 days at Erez

Abdullah Abu Athra, a 24-year-old patient from Rafah with an inner ear condition affecting his hearing, was detained on November 14 by Israeli security forces at Erez Crossing when he went to appear for a security interview after applying for a permit to travel to an East Jerusalem hospital. Abdullah was released on 26 November 2013 after 12 days of detention. He is still awaiting return of his travel and medical documents in order to try to change his referral destination to Egypt. Eight patients and patient-companions from Gaza have been detained by Israeli security forces in similar circumstances this year, according to Al Mezan Center for Human Rights.

©WHO


Referrals reflect needs and local capacity

The Ministry of Health (MoH) in Gaza referred 1,576 patients to outside hospitals in November; only in September were more patients referred during 2013. Of the referrals, 33.69% were to hospitals in East Jerusalem (531), followed by 22.71% to Israel (358), lower than in the previous 3 months. Referrals to West Bank were the highest for 2013 and 52% higher than the average (Chart 1). Referrals to Egypt remained at lower than usual levels, reflecting the unstable border and internal situation in Egypt, but were higher than in the previous 4 months.

(Table 1).



Referrals for oncology, hematology, ophthalmology, orthopedic surgery, heart surgery and catheterization in particular are a result of a lack of capacity within the MoH due to shortages of drugs and disposable materials, human resources and equipment in these areas. Referrals within Gaza to non-MoH facilities (242 referrals) were the highest in 2013; most were for heart catheterization (89), MRI (84), lithotripsy (50), and rehabilitation (19).

In November, of the 3,798 travellers who left Gaza through Rafah terminal, only 421 were patients (11%), continuing a 5-month trend of patients discouraged from using that route (Chart 2). Previously, from January to June 2013, Rafah terminal data indicated a monthly average of 20,577 passengers to Egypt, including 4,177 Ministry of Health and private patients (20.3%) seeking health care abroad.





Rafah terminal was closed for 20 days in November (15 days for security reasons and 5 Fridays as regular holidays).

Since July 10, 2013, crossing hours have been restricted to 10 am to 2 pm. The first shipments of medical supplies to enter Gaza from Egypt since July 2013 arrived on November 19 and 21, according to Palestinian authorities at the terminal, from the Union of Arab Physicians in Egypt. The medical aid consisted of 4 truckloads of intravenous fluids and drugs.

Access through Erez

In November 2013, 1,227 (91.09%) of 1,347 patient applications were granted permits to cross Erez to access hospitals in the West Bank including East Jerusalem, or in Israel or Jordan (Table 2). Five male patients, who had appointments for treatment in orthopedics, urology, and ophthalmology, were denied access through Erez to specialized hospitals.




According to the Palestinian District Coordination office, 115 applications of patients (8.54%), including 17 children and 6 patients over the age of 60, received no response; 32% were females. Out of the 115 delayed applications, 65% had been destined for scheduled appointments in East Jerusalem hospitals, 14% in hospitals in the West Bank, and 13% in Israel and 8% in Jordan. Patients who were delayed were mainly in need for treatment in orthopedics, ophthalmology, neurosurgery, oncology, or cardiology. Responses from Israeli authorities should be given to applicants within 10 days. Of those delayed, 23 patients were waiting for a response after 3 weeks and 8 for more than 30 days.

14 patients, including 4 females, one of whom is a child, were called for security interviews by Israeli General Security Services (GSS) as a condition to process their application. Thus far, only one patient was granted a permit after interrogation.

Permit for child awaiting cancer treatment delayed almost 3 months

Sabrin, a 16-year-old patient from Khan Younis who suffers from thyroid cancer, was called for a security interview causing her to lose her appointment in Maier hospital in Israel on the same day, where she was to receive radioactive iodine treatment that is unavailable in Gaza. Delays in radioactive iodine treatment for cancer can lead to recurrence of the disease and metastasis and can triple the probability of complications if more than six months after surgery.

¾Sabrin has been under medical care since she was 12 for a prominent goiter from an enlarged thyroid gland.

¾On July 23, 2013 Sabrin underwent surgery in the European Gaza Hospital for removal of her thyroid gland which on biopsy revealed papillary carcinoma of the thyroid.

¾After her post-operative condition stabilized, on September 9, Sabrin was referred by her oncologist for a total body iodine scan (WBIS) and radioactive iodine ablation (RAI).

¾On October 2, Sabrin received the MoH referral with financial coverage with a hospital appointment date of November 3 and immediately applied for a permit to cross Erez.

¾On November 3, Sabrin was called for a security interview, but enroute, at the office of the Palestinian coordination office, she was informed that her name was not on the list for interviews. She returned home with her parents.

¾The Palestinian MoH arranged for a new hospital appointment for Sabrin for December 22 and applied again for her for a permit to cross Erez to reach Maier hospital in Israel.

¾The Palestinian District Coordination Office reported that Sabrin was finally granted a permit on December 23, five months after her surgery, and 82 days after applying. She crossed Erez on the same day and travelled to Maier hospital for her treatment.






9% of permit applications were denied or delayed in receiving responses in November, and 91% were approved, an improvement in the 81% approval rate of May, but still below the level in January 2013 of 93%. (Chart 3).

The volume of permit applications for health access has increased in 2013 compared to the same period in 2012 by 47%, and the approval rate has declined 4.5%. Applicants are twice as likely to be delayed this year (Table 3).








MoH, 7.42% were self-funded, and the remaining patients were funded by Nour Ala-Al-Alam foundation, Physicians for Human Rights-Israel, and Peres Center for Peace. MoH referrals do not cover transportation or companion costs and some items of patient care, for example, medicines not in hospital supply. Patients and companions often face financial problems during long stays in hospitals due to these uncovered costs.

The Palestinian General Authority for Civil Affairs registered 1,100 patients and 1,042 companions travelling through Erez checkpoint to Israel, oPt or Jordan during November. 50 patients were transferred back-to-back by ambulances.

Rafah terminal authorities reported that 421 travellers were seeking health care in or through Egypt; the Emergency medical services of the Ministry of Health coordinated the travel of 208 patients and 188 companions who were transferred by ambulance through Rafah during November in order to facilitate their crossing to Egypt (Table 4).

Patient access at Gaza exit points






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