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Source: World Health Organization (WHO)
30 January 2014





Ref: RAD 12 (Jan. 30, 2014)


Referral of Patients from the Gaza Strip

Summary: December 2013



  • More health seekers: The number of applications for health access through Erez checkpoint was 48% higher this year than in 2012 due to various factors including reduced access through Rafah border to Egypt in the second half of 2013. MoH referrals were also higher than average in December.
  • Arrest at Erez: A 33-year-old male patient with an ophthalmic condition was detained by Israeli security forces at Erez checkpoint while enroute to a hospital in Ramallah, West Bank, December 4.
  • Destination changes: Total referrals were higher than usual in December. Referrals to Egypt remained lower than in the first half of the year, while referrals to Israel remained higher. Referrals within non-MoH facilities in Gaza were the highest of 2013.
  • Access: 86.71% of applicants received a permit in December 2013. 4 male patients were denied permits. In addition, 177 patients---70 females and 107 males (13% of total applicants) --- received no response to their applications, including 47 children whose medical treatment was delayed as a result.
  • Patients interrogated: 14 patients (13 males/ 1 female) were requested to attend an interview with Israeli security after applying for a permit to cross Erez. To date, only one patient has been granted a permit following security interviews in December.
  • Medical reasons for referrals: In December 2013 most referrals were for treatment in the following specialties: oncology--228 referrals (15.09%), MRI--194 (12.84%), nuclear medicine--132 (8.74%), orthopaedics--111 (7.35%), paediatrics--90 (5.96%), ophthalmology--79 (5.23%), neurosurgery--70 (4.63%), heart catheterization--70 (4.63%), haematology--60 (3.97%), and general surgery --57 (3.77%).
  • Gender gap: There was a gender gap in referrals: 57.8% male patients versus 42.2% female patients. Some 25% of all referrals were children aged 0-17 years and 17.8% were patients aged over 60 years.

A patient arrested at Erez checkpoint

Mohammed Saber Abu-Amsha, a 33-year-old patient from Beit Hanoun, was referred for treatment for an ophthalmic condition; he also suffers from chronic hepatitis. He was detained on December 4 by Israeli security forces at Erez crossing en route to hospital in Ramallah. According to his lawyer, Mohammed has been under interrogation in Ashkelon prison since his detention. Mohammed's personal items were confiscated, including his mobile phone and $900 he was carrying when he crossed the Erez checkpoint. Mohammed's wife and 4 children cannot visit or speak with him, but have received assurances from the lawyer that he has had medical checks in the prison and his health condition is good. As of this date, Mohammed was still in detention.

During 2013, 5 patients and 6 patient-companions from Gaza were detained by Israeli security forces in similar circumstances, according to Al Mezan Center for Human Rights.

Referrals reflect needs and local capacity

The Ministry of Health (MoH) in Gaza referred 1,511 patients to outside hospitals in December, 8% higher than the monthly average for 2013. 31.8% of referrals were to hospitals in East Jerusalem (480) and 23.8% to Israel (360). Referrals to Gaza non-MoH facilities were highest of 2013 (294) (Chart 1). Referrals to Egypt remained lower than usual; the average number of referrals in the first half of 2013 was 300, but fell to half that (150) in the second half of the year, reflecting the unstable border and internal situation in Egypt (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 specialties. December had the highest number of referrals within Gaza to non-MoH facilities (294 referrals) of 2013: most were for MRI (184), heart catheterization (65), rehabilitation (18), lithotripsy (14) and intensive care (7). The remaining 6 referrals were in various specialties.



Of the 3,101 travellers who left Gaza through Rafah terminal in December, only 154 were patients (5%), continuing a 6-month trend of patients (Chart 2). From January to June 2013, Rafah terminal data had indicated a monthly average of 20,577 passengers to Egypt, 20% (4,146) of which were second half of 2013, the average monthly number of travelers dropped by 75% (to 5,251) and monthly average of patients to 305 (6%).

Limited access to Egypt
Rafah terminal was closed for 23 days in December, allowing only 8 partial days for travellers to exit or enter; one day it was open only one hour before being closed by Egyptian terminal authorities due to non-functioning computers. Since July 10, 2013, crossing hours have been restricted to 10 am to 2 pm. No medical delegates or medical aid passed through the terminal during December. In November a shipment of medical supplies passed through, the first to enter Gaza from Egypt since July 2013. This shipment comprised four truckloads of intravenous fluids and drugs.

Access through Erez

In December 2013, 1,181 (86.71%) of 1,362 patient applications were granted for permits to cross Erez to access hospitals in the West Bank, including East Jerusalem, or in Israel or Jordan (Table 2). Four patients (1 female; 3 males) with appointments for treatment in ophthalmology and orthopedics were denied access through Erez to specialized hospitals in the West Bank and Jerusalem.




According to the Palestinian District Coordination office, 177 applications by MoH and private patients (13%), including 47 children and 21 patients over the age of 60, received no response; 39% of these applicants were females. Of the 177 delayed applications, 47% had scheduled appointments in East Jerusalem hospitals, 19% in West Bank hospitals, 29% in Israel and 5% in Jordan. Patients who were delayed mainly required treatment in orthopedics, ophthalmology, pediatrics, oncology, nuclear medicine or cardiology. The Israeli authorities should give a response to applicants within 10 days. Of those delayed, 55 patients were still awaiting a response after three weeks and 15 waited more than 30 days.

Fourteen patients, including one female, were called for security interviews by the Israeli General Security Services (GSS) as a condition to process their application. To date, only one patient has been granted a permit following the interview.





In December, 13.29% of permit applications were denied or the response was delayed and 86.71% were approved, a decline following an improvement in the previous 4 months (Chart 3).

The volume of permit applications for health access increased by 48% in 2013 compared to the same period in 2012 and the approval rate declined by 4.5%. Applicants were twice as likely to be delayed in 2013 (Table 3).

11 kidney transplant staff from Shifa hospital denied access through Erez checkpoint for UK training

Eleven MoH medical staff participating in a kidney transplant program supported by a Liverpool hospital and the PalMed-UK Association were denied access through Erez to travel to Jordan for flights to the UK. The team, comprising a nephrologist, a radiologist, a histopathologist, a vascular surgeon, an ICU nurse, a nurse supervisor, two operation theater nurses, and two lab technicians, was due to travel to the UK on January 5, 2014, for a three-month training program. Permit applications for the 11 team members were submitted on December 18 by the WHO office in Gaza, but all applications were rejected. The team was forced to change their route to exit via Rafah terminal, which has allowed limited passage in recent months, and eventually succeeded in crossing.





In December, 90.68% of patients applying for Israeli permits were referrals from the Palestinian MoH, 6.39% were self-funded, and the remaining patients were funded by Physicians for Human Rights-Israel, Nour Ala-Al-Alam foundation, and the Peres Center for Peace. MoH referrals do not cover transportation or companion costs and some items of patient care such as medicines not in the regular 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 1,053 patients and 1,022 companions travelling through Erez checkpoint to Israel, oPt or Jordan during December; 61 patients were transferred via back-to-back ambulances. Erez terminal was closed for 7 days during December: 4 Saturdays, plus 3 days due to flood damage of the pedestrian passageway from Gaza to Erez terminal. In view of the severity of the winter storm the Palestinian Coordination office canceled patient appointments during the period and rescheduled them for later. Israeli authorities announced that any urgent cases would be permitted to leave through the commercial crossing at Karm Abu-Salem (Kerem Shalom). One urgent case was transferred by ambulance through the vehicle route at Erez.

The ambulance station at Rafah terminal reported that 154 patients and 142 companions were transferred by ambulance from the Palestinian side to the Egyptian side of the terminal during December (Table 4).



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