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Source: United Nations Population Fund (UNFPA)
16 October 2014





The Palestinian Ministry of Health is proud to make available this study that reflects the impact of crisis on our people in Gaza. While the war had devastating effects on the lives of all families and resulted in major destruction of civil infrastructure, the impact on health in general and on reproductive health in particular has been significant, with pregnant women killed and thousands denied access to essential services. This assessment has been a collaborative exercise between the Ministry of Health and national and international partners. Together with the health system assessment conducted by the World Health Organization, the reproductive health assessment forms a key resource to guide our relief and recovery efforts and the development of the health system in Gaza. The Palestinian Ministry of Health extends its thanks to the United Nations Population Fund for financing and undertaking this study, and looks forward to a fruitful partnership toward implementing the recommendations stemming from this study.

Dr. Jawad Awwad,
Minister of Health,
State of Palestine

On behalf of the UNFPA Palestine Country Office, it is an honor for me to witness the release of this assessment on the impact of the Gaza Crisis on reproductive health. The report is the result of a joint effort of the Palestinian Ministry of Health and local and international agencies working tirelessly to identify the effects that this crisis has had on the most vulnerable Palestinians in Gaza. The title "Victims in the Shadows" reflects the unfortunate fact that reproductive health needs are often forgotten in the midst of crisis situations, with devastating consequences—particularly for women and girls. I would like to congratulate the authors of the report, who have done a remarkable job drawing out this important reality. I hope that the findings and recommendations of the report will enable partners to formulate the humanitarian response and recovery efforts urgently needed to improve health care, particularly in the area of reproductive health, to safeguard the dignity and rights of families, women and girls in Gaza and in Palestine as a whole.

Anders Thomsen, Representative,


The United Nations Population Fund (UNFPA) would like to extend its thanks and appreciation to the Palestinian Ministry of Health, represented by H. E. Dr. Jawad Awwad, Dr. Mohamed Al-Kashef and Dr. Sawsan Hammad, for supporting and facilitating field work and enabling open access to health facilities.

UNFPA would also like to extend its thanks and deep appreciation to the data collection teams, who demonstrated an unprecedented level of dedication, commitment and professionalism in conducting this important assessment at a high level of quality.

UNFPA also extends its appreciation to the United Nations Relief and Work Agency/Health Department, Union of Health Work Committees, Palestinian Medical Relief Society, Near East Church Council, Red Crescent Society for the Gaza Strip for cooperating and facilitating access their health facilities for data collection.

Many thanks go to UNRWA for technical input, cooperation and facilitation of data collection in the field and for enabling smooth access to health facilities and shelters throughout the Gaza Strip.

Many thanks go to UNICEF for cooperation, dedication and technical input to this assessment.

The constructive partnership and support provided by the World Health Organization office in Jerusalem and Gaza have been instrumental in conducting this assessment, which we hope will contribute to the health cluster efforts in addressing gaps in the humanitarian response and recovery.

It is our honor to extend thanks to national and international members of the reproductive health sub-cluster, who enriched the development of the assessment's concepts and tools and were instrumental in reviewing and finalizing this report.

Last but not least, we would like to acknowledge the academic and professional guidance offered by Professor Bassam Abu Hamad in designing and finalizing the assessment.

1. Executive summary

The recent violent crisis in Gaza was the third major military operation during the last six years. For the past seven years, the Gaza Strip has been subject to strict closure and siege, resulting in a massive deterioration in living conditions, increased unemployment and poverty, impaired development and a significant decline in the standard of health care.

Prior to the start of the recent escalation, a World Health Organization (WHO) report on Gaza exposed major shortages in the capacity of the health system to cope with routine health care services due to a severe lack of resources (1).

The extremely high number and severe nature of casualties during the recent military assaults on Gaza have further stretched an already overburdened health care system and challenged its coping capacity. Three weeks after the start of military operations, the Ministry of Health declared that 50 percent of all medical equipment was not functioning, and the rest was likely to break down if the current demand continued (2).

The impact of the crisis on women was significant: More than 250 women were killed, including at least 16 pregnant women. Due to damage to six hospitals and extremely unsafe operations in some Gaza Strip locations, six maternities were closed (3). Furthermore, the high number of wounded patients overloaded hospitals and made it necessary to transform part or all of maternity wards into surgical care units. This resulted in reduced care for women in need for emergency obstetric care, including surgical interventions, and reduced post-operative care, as women were immediately discharged after giving birth.

As part of the overall assessment of health system, UNFPA undertook this post-crisis assessment to review the magnitude, scope and impact of the recent hostilities on reproductive health. The assessment took place under the health cluster approach led by WHO and the Palestinian Ministry of Health, in coordination with relevant national and international partners.

Recognizing the importance of continuity of care between the communities and primary and secondary levels of health care, and because such continuity has been disrupted during past crises, the assessment collected evidence on responsiveness, functionality and outcomes related to reproductive health at all three levels of care.

To ensure the quality of information and validity of conclusions and recommendations, the assessment team used a triangulated research methodology, combining quantitative and qualitative methods. While the bulk of data collection in the field was devoted to qualitative research—interviewing groups of stakeholders and key informants—the team obtained quantitative data from facility registries, checklists and published literature.

The quantitative data-collection tools were consistent with WHO standards and verified by the research team. For the qualitative research, UNFPA developed an interview guide and questions to capture different stakeholders' perspectives on the crisis and to identify issues that arose related to reproductive health and rights.

All hospitals, including maternities, entered the crisis with severe shortages in resources and materials, as indicated by stock-outs in medications and disposable supplies. Due to the extremely high number of serious injuries, maternity ward space and facilities, including operating theatres, were designated for treatment and hospitalization of the injured. Wounded women were hospitalized in the maternity departments, and obstetricians on duty had to provide general surgery for wounded patients. Hospital staff suffered additional stress as they helped and witnessed the death of their own family members.

Major hospitals in the Gaza Strip were used as displacement shelters by fleeing families, creating an additional logistical burden on the facilities. At the peak of military operations, around 20,000 people inhabited the garden of Shifa Hospital and used its facilities and resources such as toilets, corridors, hygiene supplies and food.

Difficult transportation during the crisis also resulted in significant shortages of staff and severe shortages of life-saving medications, such as antibiotics and surfactant (a medication used to enhance the maturity of the lungs). Shortages of surfactant resulted in extended hospitalization of newborns under ventilation, and hence increased the risk for infection and other complications, leading to increased fatality rates.

Neonatal units usually support breastfeeding by ensuring direct contact and early attachment between the mother and child. When direct contact is not possible, the hospital policy is to encourage bringing the mothers' expressed breast milk to the hospital. This practice almost came to a halt because of limited access to the hospital during the attacks. As a result, milk formula had to be introduced for hospitalized infants.

Only 50 percent of primary health care facilities were operational during the war. In addition, many health workers were not able to reach their duty stations because of security, and therefore more than half of the facilities surveyed operated with significantly reduced staffing. At facilities with staffing levels at 100 percent, health care professionals reported to the nearest facility regardless of the provider or their original duty station. Furthermore, to cope with staff shortages, primary health care centers benefited from private sector practitioners available within the geographic area.

Military operations continued for a period of 51 days, and heavy bombardment occurred during the months of July and August. The intensity of military operations declined after a ceasefire was declared on August 1st, which led to 13 ceasefire days during the month. This explains the rise in reproductive health service utilization during August at all of the facilities surveyed.

Family planning services suffered during the crisis, with Ministry of Health clinics in Gaza showing a 60­90 percent decline in the number of beneficiaries in July. While the uptake of family planning services improved in August, it did not reach the pre-crisis level. Also, while injectables would have been a good medium-term method of choice during emergency conditions, Depo-Provera injections were not given during the 51 days of war.

Due to the extremely high number of internally displaced persons (IDPs) fleeing their homes in a short time, existing aid organizations did not have the capacity to respond to their needs. According to a report by the Office of Coordination of Humanitarian Affairs (OCHA), the number of IDPs exceeded 500,000, representing 28 percent of Gaza's population and 10 times the worst-case scenario anticipated in the contingency planning prior to the crisis. As a result, the adequacy and appropriateness of aid during the crisis period fell far short of needs.

This assessment was conducted after most of the displaced people returned to their homes; only about 53,000 displaced people remained in the 12 United Nations Relief and Works Agency (UNWRA) schools. Therefore, understanding the actual conditions during the crisis would require more analysis; they were likely to be far more severe.

Because of the short notice given prior to the bombardment of houses, people fleeing to shelters left their personal belongings and assets behind, and therefore came to UNWRA schools with almost no clothing, money or even identification documents. At the time of assessment, the organization of services and resources available within UNRWA and aid organizations had begun to improve.

After the ceasefire, UNRWA assigned health practitioners to each school to provide basic medical services and health education. During the crisis period, however, medical care was only available through mobile teams visiting the shelters or at Ministry of Health, UNRWA and NGO centers. Shelter residents reported that these options were not feasible because of the need to leave the shelter during hostilities, the need to pay for medications and/or transportation and, for women in particular, the fear of leaving children alone in the shelter while seeking services.

According to the data collected during this assessment, health services at UNRWA shelters did not include the reproductive health package, and women who needed such services were referred to outside facilities. The Deir Balah shelter employed a midwife as part of the health team, but even in this shelter, reproductive health services were not provided. Only the Tuffah shelter in Gaza provided reproductive health services.

Many women from the shelters and host communities reported gender-based violence. Because of the sensitivity of this issue, UNFPA conducted a special assessment on this topic, which will be presented in a separate report.

The poor living conditions of host families experiencing high unemployment were further aggravated by the influx of fleeing families coming without any resources. The situation was made worse by the fact that the displaced families were not registered for entitlement to aid, increasing their dependency on host families. This resulted in significant discomfort and reduced living standards for both the hosting and hosted families, along with other economic and psychological problems.

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