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Source: World Health Organization (WHO)
22 May 2017

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

Report by the Director-General

1. In 2016, the Sixty-ninth World Health Assembly adopted decision WHA69(10), which requested the Director-General to report and make practical recommendations on the health conditions in the occupied Palestinian territory, including east Jerusalem, and in the occupied Syrian Golan, to the Seventieth World Health Assembly. This report responds to these requests.


2. In 2016, WHO's support and technical assistance focused on the occupied Palestinian territory, including east Jerusalem, consistent with decision WHA69(10). WHO supports the Palestinian Ministry of Health to enhance access to high-quality, safe health care and medical services. WHO focuses on enhancing service delivery, and information and research, and sustainable health financing, on which it collaborates with the World Bank to facilitate dialogue on universal health coverage.

3. With WHO's support, the family practice model was adopted and training initiatives implemented in three district centres in 2016. A 10-year strategy is being drafted to advance family practice further, and an online training programme for general practitioners was developed to build family practice and general medicine capacity. A unified patient medical record is ready for piloting. WHO and the Ministry of Health have raised awareness of patient safety standards, and are conducting a baseline assessment of all West Bank hospitals. With support from the Government of Italy, WHO is continuing work to strengthen hospital information systems, promoting evidence-based decision making. With funding from the Government of Norway, WHO began a one-year project to reduce neonatal deaths and complications in the Gaza Strip through an evidence-based package of care.

4. WHO supported the Palestinian authorities and partners to develop a five-year noncommunicable disease national strategy (2015-2019) and a two-year action plan. The Ministry of Health is improving surveillance through screening programmes and service delivery through the WHO package of essential noncommunicable disease interventions. With WHO support and funding from the European Union, the Ministry is improving access to quality, sustainable mental health services and medications, including in emergency response, consistent with the national strategy.

5. WHO supported the Ministry of Health to sustain high vaccination coverage for communicable diseases and effective surveillance indicator monitoring. WHO and UNICEF jointly monitored the post-oral polio vaccine switch validation and the switch from trivalent to bivalent oral polio vaccine. WHO continues to provide technical advice as required to address HIV/AIDS and tuberculosis.

6. At the request of the Palestinian Authority, WHO provided technical assistance in establishing the Palestinian National Institute of Public Health, approved by the Ministerial Cabinet and the President in 2016. The Institute's technical and scientific work focuses on: health surveillance and registries; health system analysis and research; capacity-building; and advocacy. The Norwegian Government has committed funding for the next phase of the Institute.

7. With support from the Government of Switzerland, WHO collected, analysed and reported data and continued to discuss with international duty-bearers the barriers to health access. WHO also supported increasing the sustainability of the six east Jerusalem hospitals — the major providers of referral care for residents of the Gaza Strip and West Bank — teaching sites for clinical training, and the main providers of emergency and secondary care for the Palestinian community in east Jerusalem.

8. WHO ensured that the Health Cluster humanitarian coordination mechanism functioned well, with a dedicated team providing administrative and logistic support. The Palestinian Ministry of Health co-leads the Health Cluster and co-chairs the regular joint meetings between partners. With the Ministry of Health and Health Cluster partners, WHO coordinated the health section for the Humanitarian Needs Overview for 2017, including needs, vulnerable groups and obstacles to accessing health services. WHO assisted in filling urgent gaps in essential drugs, coordinated medical supply delivery to the Gaza Strip and ensured delivery of fuel donated to health facilities through contributions from the Governments of Japan, Turkey and Norway, and through the European Union. WHO, the Ministry of Health and the Norwegian Institute of Public Health conducted a joint assessment of International Health Regulations (2005) core capacities, which will result in a three-year action plan tailored to the context in the occupied Palestinian territory. WHO provided technical support in emergency preparedness and response, developing capacity in the Emergency and Ambulance Directorate and supporting the adoption of hospital contingency plans.


9. Consistent with decision WHA69(10), WHO conducted two separate, but methodologically similar, independent field assessments of health conditions in the respective geographies. The assessments were undertaken by multidisciplinary teams, which conducted in-person reviews of health care facilities and interviews with key stakeholders.

10. A team of three independent experts in public health, communicable disease surveillance, mental health, water and sanitation, and emergency preparedness and response were recruited by the WHO office for West Bank and the Gaza Strip to carry out a field assessment on the health conditions in the occupied Palestinian territory, including east Jerusalem, from 3 to 7 February 2017. The assessment was conducted in cooperation with counterparts from the Palestinian Ministry of Health, the Government of Israel, and other relevant stakeholders and included interviews of 86 key informants. The report drafted following this assessment provides a full review of the findings of the team, and encourages continued assessment and reporting. These findings were used to develop the recommendations presented in this report for improving health conditions in the occupied Palestinian territory.

11. A team of three WHO experts in public health, clinical medicine, and emergency preparedness and response carried out a field visit in the occupied Syrian Golan from 17 to 20 March 2017. The limitations of the assessment included time constraints, additional information needed — including through interviews with relevant authorities and stakeholders — and lack of availability of disaggregated data for the Syrian Arab population. Tackling these limitations will require further steps. The 17-20 March visit laid the groundwork for a more complete assessment, in implementation of the mandate provided by decision WHA69(10) requesting the Director-General to report to the Seventieth World Health Assembly, and for which planning is ongoing.


12. With regard to the occupied Palestinian territory, the estimated population living in the occupied Palestinian territory in 2016 was 4.8 million• 2 9 million in the West Bank and 1 9 million in the Gaza Strip.' More than 2 million are registered refugees, of whom 1.3 million are in the Gaza Strip. About one third of the refugees live in refugee camps located both in the West Bank and in the Gaza Strip.2 The population is predominantly young: nearly 40% of Palestinians are aged 0-14 years, and 5% are 65 years or older.3 With one of the youngest populations in the region, the occupied Palestinian territory is experiencing a demographic and an epidemiological transition. National health indicators during the past decade demonstrate an improvement in indicators related to life expectancy, maternal mortality, infant and under-5 mortality, and decreasing incidence of communicable diseases.4

13. In 2015, the infant mortality rate in the occupied Palestinian territory was 10.9 deaths per 1000 live births and the under-5 mortality rate was 13.9 deaths per 1000, a significant improvement over the 2005 rates.5 However, a recent validation study on infant deaths in Gaza conducted by WHO in 2016, in coordination with United Nations Relief and Works Agency for Palestine Refugees in the Near East and the Ministry of Health, indicates a lack of decrease in neonatal mortality levels.6 Life expectancy has increased between five and eight years during the past two decades' and vaccine-preventable diseases have been largely eliminated due to successful immunization programmes. A substantial disease burden is represented by noncommunicable diseases, particularly cardiovascular diseases, diabetes and cancers, which are on the rise and contribute significantly to premature death.

1 See (accessed 20 January 2017).
2 See (accessed 20 January 2017).
3 See (accessed 20 January 2017).4 See Palestine health profile 2015 (, accessed 22 May 2017).
5 State of Palestine, Ministry of Health, Health Annual Report 2015 (October 2016).
6 The WHO study referred to is currently under review for publication (February 2017).
7 See 512&lang=en&ItemID=1755&mid= 3171 &wversion=Staging (accessed 10 February 2017).

Health access

14. Physical and procedural barriers restrict access to health care in the occupied Palestinian territory. The physical barriers, including the separation wall and checkpoints that prevent patients, health personnel and ambulances from directly accessing the referral hospitals located in east Jerusalem, did not change in 2016. For Palestinians from the West Bank, excluding east Jerusalem and the Gaza Strip, access to east Jerusalem referral medical centres is only possible after obtaining a permit issued by the Israeli authorities, a complex process that can result in delays in and denial of care. In 2016 the Palestinian Coordination Office in the West Bank recorded a total of 190 733 referral applications and 153 241 permit approvals. Whereas the permit approval rate for patients and companions from the West Bank has been more or less stable around 80% in past years, for the Gaza Strip it has dropped sharply from 92% in 2012 to only 62% in 2016. One problem highlighted with permit applications was that they were frequently submitted with insufficient time for processing; however, that has been improved, and in 2016, only 12% of the permit applications in the Gaza Strip were submitted less than eight days before the hospital appointment day, compared with 33% in 2015.

15. The World Bank with the Palestinian Authority is engaged in a project to improve and simplify the referral process and to assist in developing a costing tool. Through the Intra-health project, the United States Agency for International Development is supporting these improvements. The project has resulted in clearer referral processes, the prices are agreed upon and documented, and improved tools have increased the overall efficiency and accountability of the system. Costs of referrals to Israeli hospitals have decreased and stabilized. The average deductions in the second half of 2015 and first half of 2016 fell by around 30% compared with the previous period.

16. Israeli Coordination of Government Activities in the Territory reports a 28% decrease, from 6914 in 2015 to 4985, in 2016 in issued permits of various kinds to Palestinian health personnel to travel through Israeli checkpoints. This presents a challenge to east Jerusalem hospitals to recruit personnel and to offer specialist training.

Ambulance services

17. For residents of the occupied Palestinian territory, ambulance services are mainly operated by the Palestinian Red Crescent Society, serving both the West Bank and Gaza Strip. Restrictions to ambulance transport of patients remain a concern, with delays at checkpoints. To avoid checkpoint delays, the Palestinian Red Crescent Society uses the "back-to-back" procedure, where the ambulance from the Palestinian side stops at the crossing point, unloads the patient, undergoes a security check and the patient walks or is transported on a wheeled stretcher to the waiting ambulance on the other side. In 2016, 9% of ambulance transfers from the West Bank to east Jerusalem hospitals were allowed direct entry; 91% were by "back-to-back" transfers. Recent discussions have indicated a willingness to consider an increase in the number of ambulances and personnel with security clearance to facilitate improved access from the West Bank to east Jerusalem hospitals.

Physical injuries and disabilities, damage to and destruction of medical infrastructure and facilities and attacks against health services

18. All Ministry of Health hospitals and primary health care facilities in the occupied Palestinian territory damaged in 2014 have been repaired, but some private and nongovernmental organization facilities are still damaged. Construction material and equipment for health care facilities have been allowed to be imported into the Gaza Strip, although the process has been slow at times. Attacks and violence against health services and patients reported in 2015 was a new development in the West Bank and east Jerusalem: In 2016, the Ministry of Health did not report any damage or destruction of Ministry of Health hospitals in the West Bank. The United Nations Relief and Works Agency for Palestine Refugees in the Near East reported damage to three clinics and incursions into two clinics in 2016, and the Palestinian Red Crescent Society reported 46 episodes of attacks on ambulances, of which 12 resulted in damages. The Palestinian Red Crescent Society also continued to report episodes of attacks on staff on a regular basis in 2016, most at the beginning of the year.2

Access to health care in the prison population

19. Primary health care services for Palestinian prisoners are provided by the Israeli Prison Service, which are part of the prison management. Secondary health care is provided by regular hospital services in Israel, paid for by the Israeli Prison Service. The main reported issues of concern related to the physical well-being of the 5998 Palestinian security detainees and prisoners held in Israeli prisons are: lack of access to timely and adequate medical care and mental health services, both diagnosis and treatment; inadequate nutrition and housing conditions; and denial of family visits and communications. The assessment team did not have access to Palestinian prisoners, and was not able to validate independently the reported conditions.

Mental, physical and environmental health and development of a sustainable health system

20. Regarding mental health in the occupied Palestinian territory, the occupation itself was noted as a major cause of problems. Mental health professionals reported: an increase of impulsive behaviours in the general population; a weakening of secure relationships leading to emotional and behavioural problems among children; and an increase of personality disorders. Complete data on patient admissions or treatment for mental health concerns are not available. Gaps in mental health services include insufficient capacity, the need for additional professional training and the need for better cooperation between private and public health care providers, in the referral system and in the integration of mental health in primary health care.

21. Regarding the development of a sustainable health system, the Ministry of Health located in Ramallah is responsible for all Ministry-delivered health care services. The Ministry of Health provides health services through a network of primary health care centres, 422 of which are in the West Bank and 49 in the Gaza Strip, and 26 hospitals, 13 of which are in the West Bank and 13 in Gaza Strip. Nongovernmental organizations play an important role, especially in providing tertiary care, ambulatory care services, mental health counselling, physical therapy and rehabilitation. The United Nations Relief and Works Agency for Palestine Refugees in the Near East provides services to registered refugees through fixed and mobile primary health care clinics as well as contracted hospitals. The private sector is growing, including hospitals, as well as pharmacies, laboratories and rehabilitation centres. A pharmaceutical industry has also developed, which is able to supply about one half of the total Palestinian demand for prescription medicines. The Ministry of the Interior runs primary health care clinics and three hospitals for military employees.

1 See Report of a field assessment of health conditions in the occupied Palestinian territory, February 2016 ( Palestinian_ territory/Report Palestinian_ territory-en.pdf, accessed 22 May 2017).
2 See Palestine Red Crescent Society — operational updates.

22. A national health plan 2017-2022 was approved by the Cabinet of Ministers at the beginning of 2017.1 A "5-year hospital needs study" covering the hospitals in the West Bank will be finalised in the first half of 2017. In June 2016, the establishment of the Palestinian National Institute of Public Health was endorsed by the Cabinet of Ministers, and the law was formally approved by the President in October 2016. The Institute's functions include supporting the Ministry of Health to strengthen health system core functions including through the development and improvement of health registries, disease surveillance and assessments of health services.

23. The health system in the occupied Palestinian territory is operating under severe pressure due to rapid population growth, lack of economic opportunities and adequate financial resources, shortages in basic supplies, and the inherent limitations of occupation or blockade. Coordination and collaboration challenges between the West Bank and the Gaza Strip are further impediments to efficient health sector planning and management. Interviews indicate that there are challenges in the development of a sustainable system, including financial and human resource deficiencies, fragmentation of service provision, gaps in coordinated planning and in a systematic approach to quality assessment of the services. In particular, funding for Ministry of Health services relies heavily on increasingly unpredictable donor funding. While substantial donor assistance has been provided to improve the health care system for the occupied Palestinian territory, aid flows have shown large fluctuations, and in the short term, donor aid is projected to decrease further in 2018.2

Water, sanitation and food insecurity

24. Water consumption in the West Bank and Gaza Strip is well below the WHO-suggested service delivery level of 100 L per capita per day. Water and sanitation has been a continuous challenge in the occupied Palestinian territory, due to demographic growth, infrastructure damage and the blockade. The water quality varies widely in the West Bank and is at crisis levels in the Gaza Strip. Of particular concern are the rising bacteriological and pesticide concentrations in the water supply and the lack of resources for chemical analyses and water treatment. Wastewater treatment infrastructure is also largely inadequate, creating environmental hazards. Repair of 2014 damage to water and sanitation infrastructure, and implementation of long-term solutions, has been delayed due to restrictions on the import of necessary equipment and construction materials.

25. Recently, the Palestinian Water Authority developed a comprehensive medium- and long-term strategy to improve the piped water supply in the Gaza Strip, with the first of three planned seawater desalination plants finalized. These will be sufficient until 2020, when the large central seawater desalination plant should be in place. There has also been an increase in the amount of water sourced from the private sector, in addition to support from a dedicated supply line from the grid to receive extra power supply from Israel. According to the Oslo peace accords, all water projects need to be approved by the Joint Water Committee. While in the past, administrative delays have presented challenges, in January 2017, there was an agreement to renew the activity of the Joint Water Committee to improve the water infrastructure and supply in the occupied West Bank and the Gaza Strip.

1 Personal communication from His Excellency Dr Jawad Awad, Minister of Health, Palestinian Authority (8 February 2017).
2 IMF. Report on macroeconomic developments and outlook, I.M. Fund, Editor 2014, International Monetary Fund: Ramallah, Palestinian territories.

26. Food security has been affected by the protracted nature of the occupation, restrictions on freedom of movement, constrained production capacities and a lack of economic opportunities, resulting in high unemployment and low household incomes. These factors and the high cost of living — particularly for food — have resulted in 1 6 million Palestinians (27% of households) experiencing food insecurity, though many receive food assistance or other forms of social transfers.

Financial and technical assistance and support by the international community

27. WHO support, including reference to the projects of partners and donor support, to the occupied Palestinian territory, including east Jerusalem, is presented in the previous section of this report.


28. In accordance with decision WHA69(10), practical recommendations for improving the health conditions in the occupied Syrian Golan are expected to be developed following additional research, discussion and information gathering, in particular through further field assessment, which will collectively provide the background necessary for recommendations to be presented to the Seventy-first World Health Assembly.

29. The Director-General has developed the following 10 recommendations for improving health conditions in the occupied Palestinian territory, including east Jerusalem:

Recommendation 1: Israeli authorities have the following obligations under international law:

Recommendation 2: The Palestinian Authority in collaboration with international partners should continue to improve the referral system, including further improvement of technical solutions and procedures to make the process easier, quicker, more transparent, more equitable and less costly.

Recommendation 3: The Palestinian Authority should consolidate efforts to progress towards universal health coverage through a policy dialogue for equitable and sustainable quality health services.

Recommendation 4: The Palestinian Authority should explore options for medical goods to be exempt from the Paris Protocol trade restrictions, and medical supplies should be considered essential humanitarian items.

Recommendation 5: The Palestinian Authority in collaboration with the Palestinian Medical Council should develop a comprehensive health work force strategy linked to the disease burden and projected speciality service's needs.

Recommendation 6: Israeli authorities should ensure that health care workers have unhindered access to their workplace, and have possibilities for professional development and specialization.

Recommendation 7: Consolidated efforts should be considered to overcome the political divide between the West Bank and the Gaza Strip, including agreement on a viable solution to ensure equitable and sustainable payment of all health care workers.

Recommendation 8: All parties should adhere to the United Nations Security Council resolution 2286 (2016) stating relevant customary international law concerned with the protection of the wounded and sick, medical personnel engaged in medical duties, their means of transport and medical facilities.

Health care workers need to be respected and protected, and should not be prevented in their provision of health care to sick or injured patients. Information about this obligation to respect and protect health care workers and facilities and not to impede the provision of health care by preventing passage of medical personnel should be disseminated to security personnel at checkpoints and borders, armed forces and law enforcement personnel.

The Ministry of Health and the Palestinian Red Crescent Society should continue systematically to document and monitor attacks on health care personnel and facilities to ensure accountability of perpetrators.

Recommendation 9:

No one should be subjected to torture or to cruel, inhuman or degrading treatment or punishment. All complaints of torture should be investigated.

Recommendation 10: The mental health strategy developed by the Palestinian Ministry of Health involving all major stakeholders should be expanded to improve data generation on the mental health disease burden, to enhance capacity-building of mental health professionals and to strengthen monitoring and evaluation of the progress of integrating mental health services.


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

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