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Source: World Health Organization (WHO)
9 May 2007




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

Fact-finding report

Report by the Secretariat

1. Resolution WHA59.3 requested 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. With a team of external experts, the Secretariat has reviewed some 90 reports from reliable sources on the situation in the occupied Palestinian territory.1 In addition, 10 selected persons in key positions working with health and related problems in the occupied Palestinian territory were interviewed by telephone. Sufficient information on the health situation in the occupied Syrian Golan could not be identified for this review and a fact-finding mission by the team of experts was not possible.

HEALTH DETERMINANTS IN THE OCCUPIED PALESTINIAN TERRITORY

The economic crisis

2. Although the Palestinian gross national product has grown in recent years (by some 5% in 2005, for example), estimates indicate a decline of 8% to 10% in 2006. During the first six months of the new government, monthly tax revenues fell to around US$ 17 million (from US$ 104 million a year earlier). Since March 2006 the government has been able to pay only some 40% of the salaries to its public employees (affecting an estimated one million people including dependants). The barriers to movement have contributed to economic decline and rising unemployment. Increased external aid notwithstanding, the number of people living in poverty (and hence experiencing negative effects on health) has doubled since 1999 to almost 70% of the population.

The public service

3. The rapidly increasing poverty and destruction of parts of the infrastructure put the Palestinian authorities under rising public pressure to take action, but the financial means were lacking. A public employee strike further weakened the Ministry of Health and central local authorities, and hurt the economy.

Food and diet

4. According to FAO and WFP, almost half the population faces, or is at risk of, food insecurity. WFP planned to provide food assistance in 2006 to 480 000 people, but because of the rapid rise in poverty the total number grew to 600 000. Increasing poverty has made affordability of food the most significant concern; total food consumption fell in 2006, as many people cannot afford to buy food and have been forced to sell off assets such as land or tools.2 Chronic malnutrition is on the rise and dietary choice is restricted by rising poverty. People are eating fewer dairy products, eggs and vegetables and their increasing consumption of cheaper, starchy foods is leading to obesity.

The environment

5. About one third of communities in the occupied Palestinian territory have no water supply networks and face water shortages in the summer, as do communities with networks connected to a major Israeli water supplier. Electricity cuts rendered inoperable water pumps and refrigerators in many homes (with water running only two to three hours a day) and health centres (over several weeks).

6. More than a third of West Bank refugee camps are not connected to safe sewerage systems, and almost one third of households in the Gaza Strip have no access to solid-waste collection systems. In 2006 the electricity shortages and lack of fuel affected pumping stations and refuse collection. In the West Bank there were worries about the risk of pollution of local springs through the draining of liquid waste from Israeli settlements on to Palestinian lands. In Gaza in March 2007 a sewage-retention basin burst its banks, flooding a village of 5000 inhabitants, killing five people and making 280 families (1800 persons) homeless as well as vulnerable to communicable diseases from multiple risk factors.

7. Palestinian housing was damaged in armed clashes, by retaliatory action against homes of suicide bombers, and by the building of the separation barrier, settlements and roads in the West Bank. In 2006, 56 and 127 residential homes were demolished in the West Bank and in the Gaza Strip, respectively.

Lifestyle

8. Health-related lifestyles in the occupied Palestinian territory reflect a society in both rural-urban transition and experiencing a long-standing conflict. More than 70% of the population have little or no access to recreation or leisure activities and watching television is the most important activity for children over six years of age. The deteriorating situation has had major consequences for the population, which has had to resort to such coping strategies as not paying bills and reducing food consumption (see also paragraph 4).

9. High fertility rates and short intervals between births are linked to anaemia in women, more among the poor. A drop since 2000 in the use of modern contraceptive methods (in contrast to UNRWA’s experience elsewhere) could be attributed to an increased desire to have more children, which may sometimes be expected in conflict areas where there are many fatalities.

The health services

10. The Ministry of Health provides about 60% of all health services (purchasing tertiary care mostly from private providers including some in Egypt, Israel and Jordan) and manages public health programmes. The Ministry’s total expenditure in 2005 was US$ 155.6 million, almost equally divided between salaries and non-salary items. UNRWA provides mainly primary health care services to the refugee population, and purchases secondary and tertiary care services when needed. The non-governmental organization sector includes missionary hospitals, facilities supported by international organizations, and community health centres. The private for-profit health sector is relatively small.

11. Per capita health expenditure was US$ 138 in 2003 (more recent figures are not available), and health expenditure corresponded to 13% of gross domestic product. About half the revenue for health expenditure came from donors. There are shortages of medical specialists, nurses, midwives and public health specialists.

12. The rate of 15.1 hospital beds per 10 000 population is in the low range for the Eastern Mediterranean Region; the occupancy rate is reasonable (about 80%) in Ministry of Health hospitals, but very low in nongovernmental and private hospitals (under 40%).

13. The separation of health-care delivery between the Gaza Strip and the West Bank, and Israel’s control of all movement, complicate the ability of the Ministry of Health to coordinate its activities, often leading to duplication and loss of efficiency.

Impact of key events in 2006

14. The sharp rise in casualties from armed clashes, the substantial increase in obstruction of circulation of people and goods, the economic crisis, disturbances in supplies of electricity and fuel, and the strike posed formidable problems for the health sector. The frequent power cuts for instance hampered laboratory and radiological services, interfered with patient monitoring equipment, and endangered the cold chain for vaccine preservation, especially in half the primary health care centres that lacked generators.

15. In June 2006 a WHO-designed indicator tool was introduced in order to monitor better the impact of the evolving situation. The evidence pointed to an increase in admissions to Ministry of Health hospitals and consultations in Ministry and UNRWA primary health care centres. There were fewer patient referrals abroad. A shift from nongovernmental organizations and the private sector to public providers added to the pressure on the latter. Although health staff had not been paid since March 2006, they were still going to work until late August. Provision of hospital and primary health care services was maintained, but the reduced availability of medicines and other supplies and difficulties in maintaining equipment threatened the quality of care.

16. In July and August 2006 casualties mounted and the financial crisis continued to undermine health-care delivery. Shortages further compromised the capacity of health ministry hospitals to deliver care, especially long-term treatment (e.g. dialysis and cancer therapy). On 28 August health staff and other government employees in the West Bank went on strike, demanding payment of their salaries. Only patients in a critical condition were admitted to hospitals, and some provision was made for emergencies and the vaccination programme. Most primary health care services were suspended, but day-care departments provided chemotherapy and chronic treatments. Tensions between staff and those seeking care were reported, and some staff were threatened or beaten. In October access to health services was severely restricted in the West Bank, but services were preserved in the Gaza Strip. Between December and February 2007, after the strike, hospital and primary health care services returned to normal levels, but equipment problems and shortages continued.

17. In Ministry of Health facilities, despite all the problems, the number of primary health care consultations and hospital admissions in 2006 was only slightly lower than expected. The use of UNRWA’s health services was significantly greater than in 2005, whereas the number of primary health care consultations in nongovernmental facilities remained relatively steady.

18. Although the electricity supply in the Gaza Strip was partially restored, health services still experienced power cuts for several hours a day. Fuel for generators continued to be guaranteed by the Temporary International Mechanism. Availability of medicines improved through the initial delivery of medicines procured with the framework of that Mechanism, which was implemented in mid-2006.

HEALTH IMPACT

19. Between 2002 and 2005 the life expectancy of the Palestinian population rose from 71.1 to 71.7 years for males and from 72.6 to 73.0 years for females. The events of 2006, however, brought considerable suffering to the civilian population, weakened essential health services, and brought the health system to the brink of collapse. In early 2007, international diplomacy showed new momentum which, coupled with enhanced external support and cooperation, could help to turn the crisis into an opportunity for health development.

Violence

20. According to available data, the number of Palestinian deaths more than trebled between 2005 (215) and 2006 (678); almost a fifth were children (127 in 2006), nearly four times as many as in 2005. In January and February 2007, the sharp increase in Palestinian inter-factional violence had already caused 130 deaths, compared with 146 in the whole of 2006 and 11 in 2005. Injuries likewise increased: the total of 3199 Palestinians injured in 2006 was more than twice the figure for 2005, and the respective figure for children (472) was more than three times as high. Injuries result in disabilities, increasing the need for comprehensive rehabilitation services.

Mental health

21. Since 2000 the demand for mental health services has steadily risen. The incidence of new mental disorders registered in community mental-health departments doubled from 2000 to 2005. The separation barrier is reported to have caused significant increases in adverse emotional, physical and behavioural symptoms in the population affected.

Maternal and child health

22. Infant mortality related to birth has increased, but more studies would be needed to establish the trends in neonatal mortality and their determinants. The Gaza Strip and the West Bank have the highest proportion of high-risk pregnancies among all UNRWA refugee areas. Although the maternal mortality rate apparently decreased between 2002 and 2005, concerns remain about shortcomings in quality of care.

23. A recent survey shows an increase in the prevalence of chronic malnutrition and anaemia, particularly in West Bank children.

Communicable diseases

24. The general trend for communicable diseases, especially vaccine-preventable diseases, over the past couple of years has been a decline in incidence rates. However, deteriorating environmental factors (e.g. water, sewerage, housing conditions) could underlie an increase in such diseases as hepatitis A, pneumonia, other respiratory diseases and diarrhoea in the Gaza Strip between May and July 2006.

25. During 2006 strike action affected the administration of vaccines, and cuts in the electricity supply may have broken the cold chain. Concern has grown that the poor state of the public health system will affect vaccination programmes, risking re-emergence of well-controlled or eradicated diseases like poliomyelitis.

Noncommunicable diseases

26. Since 2005 the combined effect of factors such as shortages in basic supplies, restrictions on movement, reduction in referrals, and strikes in the health services has been to reduce access to diagnostic and treatment services (e.g. dialysis, cancer therapy and diabetes treatment). The consequence has been to increase the burden of noncommunicable diseases.

ACTION BY THE HEALTH ASSEMBLY

27. The Health Assembly is invited to note this report.

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1 The list of references and experts is available upon request.
2 60% of West Bank residents and close to 85% of Gaza Strip residents were reducing their living expenditure by the end of 2006.


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