Question of Palestine home
World Health Organization (WHO)
12 May 1980
WORLD HEALTH ORGANIZATION
THIRTY-THIRD WORLD HEALTH ASSEMBLY
Agenda item 45
HEALTH CONDITIONS OF THE ARAB POPULATIONS
IN THE OCCUPIED ARAB TERRITORIES, INCLUDING PALESTINE
The Director-General has the honour to bring to the attention of the Health Assembly, in abbreviated form, the annual report of the Director of Health of UNRWA for the year 1979, annexed hereto.
ANNUAL REPORT OF THE DIRECTOR OF HEALTH OF UNRWA
FOR THE YEAR 1979
1. In accordance with its present mandate, which extends until 30 June 1981, the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) continued to maintain its relief, education and health services for those eligible. The total number of refugees registered with UNRWA for assistance as at 30 June 1979 was 1 803 564, of whom approximately one-third live in refugee camps,
while the others mingle with local inhabitants in cities, towns and villages. The registrations are distributed as follows: Lebanon 219 561; Syrian Arab Republic 203 830; Jordan 699 553; the West Bank (including east Jerusalem) 317 614; and the Gaza Strip 363 006. Those eligible for health services provided by the Agency in all the five Fields
of operation numbered some 1.56 million.
2. The distribution of the refugees in the Agency's area of operations and their place of residence in the respective host countries have greatly influenced their relative dependence on UNRWA's health services. In general, the camp residents enjoy easy access to UNRWA health centres and they usually make extensive use of the services provided. By contrast, the refugees living in towns and remote villages are often situated at a greater distance from the nearest UNRWA health centres. They thus tend to share with the indigenous population the private and government medical facilities locally available, to the extent that they can afford them financially.
RELATIONSHIP WITH THE WORLD HEALTH ORGANIZATION
3. The World Health Organization, under the terms of the agreement with UNRWA which has been in force since 1950, has continued to provide technical supervision of the Agency's health programme by assigning to UNRWA headquarters on non-reimbursable loan five WHO staff members, including the Agency's Director of Health. As WHO Programme Coordinator, the Director of Health is responsible, on behalf of the Regional Director for the Eastern Mediterranean, for advising the Commissioner-General of UNRWA on all health matters and for interpreting WHO's policies and principles in their application to the supervision, planning and development of UNRWA's health services. He is at the same time responsible for the technical direction of the health services, on behalf of the UNRWA Commissioner-General, within the framework of Agency policy, of decisions on allocation of resources, and of administrative directives.
4. The WHO assistance to UNRWA is provided as an intercountry project of the Eastern Mediterranean Regional Office in Alexandria and. thanks to the Regional Director's personal interest and active support, close technical supervision is received. The total monetary value of WHO's assistance to UNRWA during 1979 was US$ 336 074. In addition to the salaries and allowances of the five staff members assigned to UNRWA headquarters on non-reimbursable loan, this amount includes fellowships awarded to three Palestinian UNRWA medical officers for postgraduate training in public health. Furthermore, UNRWA benefited from visits made to the Agency's area of operations by various EMRO consultants and regional advisers, particularly in the fields of maternal and child health, nutrition, control of enteric diseases, primary health care and environmental health.
5. Close cooperation was maintained with the Nutrition unit at WHO headquarters for the analysis of the data collected during the survey carried out in 1978 among a sample of the Palestinian children living in refugee camps. Since March 1979, in the Gaza Strip, UNRWA participates in the development of a WHO-assisted project for implementation, in a uniform manner, of oral rehydration therapy in both the government MCH centres and UNRWA health clinics. With the technical assistance of WHO Diarrhoeal Disease Control (DOC) unit, seminars have been held in Gaza for the training of health personnel involved in the study and a detailed protocol was developed for the continuous evaluation of the project. Later in the year, always in coordination with the DOC, EMRO organized travelling seminars in the occupied territories for the benefit of government and UNRWA doctors and nurses working for the Arab population, on recent advances in breast feeding and oral rehydration in the management of acute diarrhoea.
6. As in previous years, WHO continues to provide technical literature and publications of primary importance for ensuring the proper planning, implementation and evaluation of the current UNRWA health programme. The Agency records its deep appreciation of the sustained interest of the World Health Assembly in its health programme and thanks the Director-General and his staff for their close and unfailing support.
UNRWA'S HEALTH POLICY AND OBJECTIVE
7. UNRWA's basic health policy continued to be the preservation of the health of the Palestine refugee population entrusted to its care, through the steady development: of its programme as a comprehensive and integrated community health service with three main components: medical care with strong emphasis on preventive medicine, environmental health, and supplementary feeding.
8. It remains UNRWA's endeavour to maintain health services for eligible Palestine refugees which are concordant with the humanitarian policies of the United Nations and the basic principles and concepts of the World Health Organization, and consistent with the progress achieved in public health and medical services provided by the Arab host governments for their indigenous population at public expense.
UNRWA'S HEALTH PROGRAMME IN 1979
9. The basic budgetary problem, of ensuring equivalence between pledged income and the expenditures required to maintain the Agency's essential services, unfortunately remains unsolved. Consequently, once again services to refugees were reduced - principally the flour component of the basic ration. Some capital costs were also deferred.
10. In the early months of 1980, the regular review of budget assumptions and income expectations was undertaken. Budgeted expenditures were estimated at $ 211.5 million and expected income at about $ 155.2 million, leaving a projected deficit of $ 56.3 million. A list of budgeted expenditures totalling the amount of the deficit was drawn up and approval of disbursements to meet them was suspended. These "not-yet-approved items" are listed by order of priority and they will be moved from the unapproved to the approved category as pledges of additional income are received. The prospective deficit is so large that drastic cuts in UNRWA education programme are unavoidable, unless additional income is forthcoming by an early date.
11. Despite its financial uncertainty, UNRWA continued to maintain its health services in full and to operate them with reasonable smoothness in all fields, except in Lebanon where special operational difficulties were experienced. Over the past 29 years, the services provided have evolved into a comprehensive community health programme whose different components are described in this report. Strong emphasis continues to be placed on preventive and promotional activities, such as continuous surveillance of important communicable diseases, maternal and child health services, nutritional protection of particularly vulnerable groups, camp sanitation projects, and health education programmes. That the communities served have a growing awareness of their health needs and a better understanding of the importance of the preventive approach, is demonstrated by the great popularity of the Agency's maternal and child health services and routine immunization programmes. This attitude is especially apparent in the refugee camps, where in recent years, for example, the residents have effectively participated in Agency-subsidized self-help projects aiming at the improvement of their sanitary facilities: construction of family latrines, improvement of camp water supplies, installation of sewerage systems, construction of surface drains and pavement of pathways.
12. In Lebanon, throughout the year under review, the delivery of health services in the south of the country was repeatedly disrupted by clashes and disturbances of varying degrees between the various militias. The major disruption occurred during the second and third quarter when heavy and persistent attacks against refugee communities located in the Tyre area provoked the repeated displacement of about 40 to 50 000 refugees who moved northwards in search for safer location. For their benefit UNRWA established a temporary emergency programme. By the end of October 1979 most of the displaced refugees had returned to Tyre area.
CURATIVE MEDICAL SERVICES
13. Medical and dental care services continued to be provided to eligible Palestine refugees and UNRWA staff members and their dependants at health centres, health points, polyclinics, hospitals, laboratories, X-ray departments and rehabilitation centres, either UNRWA's own or government, university, private or voluntary ones subsidized by the Agency. However, certain refugees had access to government services and others who could afford payment for some of these services, selected and received care through their own arrangements.
Out-patient medical care
14. These services were made available in 117 health centres and health points (100 UNRWA, 15 government, and two voluntary agency). Attendances for medical consultations increased in all Fields and Agency-wide except in Lebanon where, because of the security conditions which prevailed during the year, a noticeable drop in attendances in all services except dental treatment, was recorded by comparison with the previous year. In Beirut. the refugees who fled from camps and private residences located in the eastern part of the city to the western sector continue to receive services at UNRWA's health centres. The mobile emergency service, which had been established in Damour village to look after the displaced refugees there, continued to provide basic medical care including maternal and child health services.
15. Early in the year, because of the continuous shelling of camps and villages in south Lebanon, the health services in Saida area were temporarily reorganized in order to meet the most essential needs of the refugees displaced from the Tyre area. In addition to the existing health centres, three mobile units routinely serviced the places where the displaced refugees were concentrated. This arrangement was discontinued when the services returned to normal in Tyre area towards the end of the year.
Out-patient dental care
16. This includes consultations, dental X-ray, tooth extraction and simple fillings, gum treatment and minor oral surgery. The preventive aspects of dental health and hygiene among pregnant women and schoolchildren were given special attention. The number of dental clinics remained 24. In certain localities where the number of refugees did not justify the establishment of a clinic, dental care was provided by private dentists renumerated by UNRWA on contractual basis.
17. UNRWA operated three central public health laboratories in Amman, Gaza and Jerusalem, and 23 small clinical laboratories located at the Agency's principal health centres which perform tests of a routine nature, but 15 of them also perform biochemical tests. Additional equipment, such as colorimeters, autoclaves and refrigerators, was provided to the larger laboratories. Elaborate laboratory investigations, however, continue to be performed at seven government, university and/or private laboratories, where they are carried out against the payment of a fee, free of charge, or as a contribution by the host government.
In-patient medical care
18. UNRWA maintained its standing policy of providing in-patient care by securing facilities in government, local authority, university, voluntary agency and privately-owned hospitals and medical institutions. It also administers a small hospital in the West Bank (36 beds), nine maternity centres (totalling 71 beds) mostly in the Gaza Strip, and 21 daytime rehydration/nutrition centres (229 cots) located throughout its area of operation.
19. In all the Fields, the cost of in-patient care continued to rise and the Agency had to increase substantially its subsidy to hospitals where beds are reserved for refugee patients. However. the refugees also had access to government. private and voluntary hospitals, locally available, either freely or against a reasonable charge.
20. In Gaza, the Agency continued to administer, conjointly with the Public Health Department, a tuberculosis hospital which serves both refugees and local inhabitants. During the year, and after a thorough examination of the actual need for in-patient care of tuberculosis patients, the Agency and the Public Health Department, Gaza agreed to reduce the number of beds from 210 to 70 effective September. Following the increase in number of persons who joined the government national health plan, the number of claims submitted to the Agency for partial refund of individual hospitalization cost continued to decrease.
21. Financial provision continued to be made to meet the cost of treatment of a small number of patients requiring highly specialized attention, such as heart, chest, neurosurgery, and kidney transplant cases. Twenty-four patients benefited from such services. In addition, nine children completed their treatment at the King Hussein Medical Centre, Amman, and at Hadassah Hospital, Jerusalem, through the generosity of the Terre des Hommes organization (Netherlands).
22. The demand for out-patient and in-patient care for mental illness has shown a declining trend in all Fields. The Agency continued to give more thought and attention to the preventive aspects of mental health. As a rule, the public health authorities undertake the treatment and custodial care of mental patients. In Lebanon, however, since there is a lack of facilities in the public sector, the Agency subsidizes beds in private mental hospitals. Because of the security situation in this Field, some of the mental hospitals became inaccessible to refugee patients and more had to be treated ambulatorily. Due to the continuous increase in the cost of living in Lebanon, the Agency had also to increase its subsidy to the mental hospitals.
Medical rehabilitation of physically handicapped children
23. Under this programme crippled children are rehabilitated, as out-patients or in-patients, through physical and medical therapy. During the year, 504 children benefited from this service. Orthopaedic devices and prostheses were available in all areas but at a substantially higher cost than hitherto.
24. Throughout the year, the flow of medical supplies to all Fields was, in general, satisfactory. Consignments for Lebanon. however, had to be delivered through Lattakia Port in the Syrian Arab Republic. Most of the drugs and medical supplies programmed by the Department of Health were purchased on the international market and a limited quantity was received in the form of contributions. However, due to lengthy customs clearance at ports of discharge, shortages in a few items were experienced and had to be met from the central reserve stock as well as through local purchases.
PREVENTIVE MEDICAL SERVICES
Epidemiology and control of communicable diseases
25. Agency-wide surveillance was maintained for selected diseases through weekly incidence reports from 82 UNRWA health centres and special investigations when indicated. The incidence for these notifiable diseases for 1979 is shown in Appendix 1.
26. An outbreak of cholera in Jordan, which started in September and ended in December, involved 14 refugees residing in camps. They were all cured. In a similar outbreak in the Syrian Arab Republic seven cases were reported among camp refugees in Damascus area; they, too, were cured. Strict control measures were applied in these two Fields and vigilance was maintained in the remaining Fields where no cases were reported among the refugee population.
27. Compared to 1978, the incidence of diarrhoeal diseases had slightly increased in the area of operation as a whole. Also typhoid and para-typhoid diseases increased from 71 to 85 cases of which 72 were reported from the Syrian Arab Republic and 12 from Lebanon. On the other hand, a remarkable drop had occurred in the incidence of the following: infectious hepatitis from 790 to 324 cases; poliomyelitis from 34 to 9 cases; measles from 2683 to 1776 cases and pertussis from 133 to 61 cases of which 52 were reported from Lebanon. Incidence of conjunctivitis showed a slight increase from 20 131 to 20 868 cases while trachoma dropped from 372 to 236 cases of which 134 cases were reported from Gaza and 91 from Jordan.
28. There was a slight increase again in the incidence of influenza from 18 304 to 19 153 especially in West Bank and Gaza and to a lesser extent in the Syrian Arab Republic. Five cases of cerebrospinal meningitis were reported (three from Gaza and two from Jordan) as against nine in 1978. Three cases of imported malaria (two
contracted in Saudi Arabia and one
contracted in Nigeria) were reported as against two last year. An increase in the number of newly detected respiratory tuberculosis cases was observed: from 149 to 164 cases, mainly from Gaza (62), from Lebanon (56) and from Jordan (36).
29. In regard to prevention of specific diseases, UNRWA's expanded immunization programme was maintained against tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis, typhoid, measles and smallpox, with a view to securing high and sustained levels of coverage. In addition to epidemic control measures, particularly against cholera and poliomyelitis, the routine control programme included early case detection and isolation as necessary, prompt treatment and management of contacts. In this task a close coordination was maintained with the government health authorities. The Agency's environmental sanitation programme in camps and its health education activities provided valuable basic support for communicable disease control.
Maternal and child health services
30. Health protection of mother and child continued to be one of the major components of the community health programme provided by the Agency. A number of local authorities and voluntary agencies supplemented the UNRWA programme. A valuable part of the service was the nutritional support provided to vulnerable groups.
31. In the prenatal clinics, 30 679 women were registered from maternal care, which included regular health supervision and the issue of extra rations, milk and iron-folate tablets through pregnancy and the nursing period. 31 791 deliveries were reported, the majority attended to in homes by Agency-supervised dayahs, the rest in UNRWA maternity centres (mainly in Gaza) and in hospitals, to which women with difficulties or increased risk were referred. Three maternal deaths were reported, i.e. 0.10 per thousand reported live births. The stillbirth rate was 9.3 per thousand reported total births.
32. A total of 98 162 children of 0-3 years of age benefited from the services provided at the 83 child health clinics, including regular health supervision and immunizations. The programme of distribution of milk in powder form to children was extended to include also the children in the age-group 2-3 years. Oral salt solution was introduced in all MCH centres with emphasis on early and effective treatment of diarrhoea. A special study of the effectiveness of oral rehydration therapy started in Gaza in collaboration with the Public Health Department under the guidance of WHO. Twenty rehydration/nutrition centres were in operation. Twenty-six clinics specialized in early detection and treatment of malnutrition: two got started during the year in Gaza Field; the West Bank Field added four more to the existing nine clinics; five clinics are in Jordan, and six in the Syrian Arab Republic. The percentage of children found to be underweight according to local growth curves was 7.5 in the first year, 7.3 in the second year and 2.5 in the third year among those attending the child health clinics.
33. School health services were provided by health centres and school health teams (three in Jordan and one in each of the other Fields) for 333 144 children attending 628 UNRWA/UNESCO elementary and preparatory schools. School entrance medical examinations were given to 33 982 pupils. The necessary health care was provided by health centres and their referral services, while malnourished children were referred for the daily cooked meal at supplementary feeding centres. Vision testing and screening tests for hearing were carried out at school entry, and at least once every two years thereafter. In the various Fields, campaigns for treatment of fungal and parasitic skin infestations were carried out where indicated. Early restorative dental care was extended to school-children to the degree that limited facilities would permit, and oral hygiene was stressed in the health education programme. Efforts continued to bring school sanitary conditions up to acceptable standards.
34. A team of health education workers in each of the Fields promoted the health education programme in collaboration with Agency staff in health centres, schools, welfare centres and camp communities. Special camp committees and school health committees, the latter composed of pupils, participated actively in the programme. From March 1979 on, health education staff was specifically engaged in preventive measures against cholera in the camps, with stress on waste disposal, food, water and personal hygiene. The theme of the 1979 Health Calendar, produced by the Agency's Audio-Visual Branch was devoted to the International Year of the Child (IYC). Other functions commemorating the theme of the year were organized by the various Fields with respective health education workers participating with the education and welfare staff in school exhibitions, group talks etc. The World Health Day on 7 April 1979, was devoted to the theme A Healthy Child - A Sure Future, in commemoration of the IYC, and was celebrated as usual through various health education activities throughout the Agency. A joint committee of senior staff from the Education and Health Departments, with one branch at headquarters, Vienna (the steering committee) and the other at headquarters, Amman (the executive committee) , was formed at the beginning of the year. Its objective was to prepare health education material for use in Agency schools.
35. The nursing services continue to form an integral part of the health services, both curative and preventive. Auxiliary nursing personnel make an important contribution to these services under the supervision of qualified nurses. The ratio of auxiliary to qualified nurses remains high.
36. With in-service training and continuing education of personnel, the quality of service continues to improve. Schools of nursing in some areas use the Agency's MCH services for clinical experience for their students.
37. Traditional Birth Attendants (TBA) , some of whom also assist at MCH centres, attend a large proportion of the deliveries at home in the various areas, and provide post-natal care to these mothers.
38. Recruitment of suitable nursing personnel is becoming more and more difficult in the various fields: Improving conditions in Government service make working conditions with the Agency less attractive.
39. Scholarships, contributed by voluntary organizations, have enabled staff members to gain further education and thus increase their usefulness to the Agency. Assistance has continued for young boys and girls who are enrolled in courses for basic nursing education.
40. In Gaza, the nursing staff continue to participate in the community and family health programme, among others through lectures in UNRWA/UNESCO girls' schools.
ENVIRONMENTAL HEALTH SERVICES
41. The environmental health programme comprises mainly the provision of potable water supplies, sanitary disposal of solid and liquid wastes, drainage of storm water and the control of insect and rodent vectors of disease. The Agency attaches particular significance to further improvements in the services primarily through the refugee self-help programme which has been yielding satisfactory results. A total of 682 691 refugees and displaced persons living in 61 camps benefited from the services, which were maintained at a satisfactory level in most of the camps.
42. The unsettled situation in Lebanon continued to have an adverse effect on the quality of the services, and some of the camp improvement works planned for the year could not be completed. However, a final design for the establishment of a new camp at Bayssarieh in south Lebanon has been completed by the consultants and tender documents are under preparation.
43. With the introduction of a special
compensation allowance for all sanitation labourers in the West Bank and Gaza, the problem of recruitment of labourers for a number of vacant posts has eased. A review of the compensation of sanitation workers in the Syrian Arab Republic is under consideration.
44. During the year, allocations totalling about $ 260 000 subsidized the costs of an on-going self-help camp improvement programme in five Fields, focusing on augmentation of water-supplies, provision of adequate waste-water drainage facilities and pavement of alleys and streets in various camps. Community support to the programme remained steady with the exception of two camps in south Lebanon where it was extremely difficult to mobilize refugee participation. During the period under review fourteen camps in West Bank, ten in Lebanon, seven in Gaza, four in the Syrian Arab Republic and two in Jordan benefited from various self-help schemes. The most significant achievement of the programme has been at Mieh Mieh camp in Lebanon, where the refugee community with the assistance of UNRWA recently completed a sewerage scheme. Mieh Mieh was the first camp where the self-help programme was introduced in 1972 and now the camp has, besides its well-executed sewerage network, an independent water supply system with its own power generating set, indoor tapping, paved pathways and storm water drains. All these facilities were provided by the refugees themselves with modest subsidies from the Agency and technical guidance by the Field staff.
45. Municipal and self-help schemes providing private water connexions to.refugee shelters continued to progress steadily at fifteen camps in the West Bank, two camps in the Gaza strip, two camps in the Syrian Arab Republic, five camps in Jordan and one camp in Lebanon. About 51.5% of camp inhabitants are currently served by private water connexions and the rest draw water from public water points for their domestic needs. A comprehensive water supply scheme (involving the drilling of a deep well, the installation of pumping station, the construction of a water tower, and the modification of water distribution network) has been successfully implemented by the refugee community at Wavel camp in Lebanon with a modest subsidy from the Agency. Under the scheme, all shelters in the camp have been provided with private water connexions.
46. In the Syrian Arab Republic, a programme for providing an independent and more reliable water supply to Agency installations (schools, clinics, supplementary feeding centres etc.) is under execution. A water-pumping station has already been installed on a newly drilled well located in the school compound of Jaramana to complete the scheme in the camp. Schemes for Sbeineh, Khan Danoun and Khan Eshieh camps, involving drilling of wells, construction of elevated water reservoirs, installation of pumping stations and readjustment of water distribution mains are under execution.
47. The programme of phasing out communal latrines and providing private latrines instead has almost been completed and Agency support for the construction of additional private latrine units to meet the needs of a growing camp population continues. The Agency is also providing technical and material support to self-help sewerage schemes at Burj el-Barajneh and Ein el-Hilweh camps in Lebanon where the concerned refugee communities have raised matching funds. Besides subsidizing the costs of the afore-mentioned sewerage schemes, building materials have also been provided for the construction of additional sewer lines at Shatila and Wavel camps in Lebanon and Khan Danoun camp in the Syrian Arab Republic. In Jordan. the Government sewerage schemes at Jabal el-Hussein and Amman New camps, located in Amman Municipal area, are progressing satisfactorily. Almost 50% of the sewerage scheme at Shu'fat camp in West Bank has been completed by the Municipality of Jerusalem. So far, seven camps in the Syrian Arab Republic, two camps in the West Bank and four camps in Lebanon have adequate sewerage systems .
48. Improvement of refuse collection and disposal services continued to receive due attention. In the Syrian Arab Republic, a new tipper truck has been provided to meet the needs of Khan Danoun and Khan Eshieh camps located in a rural area and suitable contractual arrangements were made for the removal of refuse from seven other camps. In West Bank, a tractor-trailer unit is due to be assigned to Nur Shams camp on a part-time basis. Proposals for gradual replacement of tractor-trailer units and tipper trucks with more efficient vehicles are under consideration for Gaza and Jordan Fields.
49. Rodent control activities are being strengthened in Lebanon, the Syrian Arab Republic and the Gaza Fields through selective use of anti-coagulant rodenticides.
NUTRITION AND SUPPLEMENTARY FEEDING SERVICES
50. The Department of Health continued to attach great importance to the supervision, protection and promotion of the nutritional status of the refugees. The services are directed particularly towards the most vulnerable groups, namely infants, preschool and elementary school children, pregnant and lactating women, non-hospitalized tuberculosis patients and medically selected hardship cases. The nutritional support programme comprises the distribution of milk, extra dry rations and preparation of hot mid-day meals. The cost of the programme was almost entirely met from a contribution by the European Economic Community (EEC) under a Convention first signed in 1972. Negotiations are taking place with the EEC for the renewal of the Convention.
51. During 1979 no nutrition surveys were carried out, but nutritional surveillance was maintained through periodic assessment of the growth development of the children attending the Child Health Clinics through weight and length measurements. The data collected during the year indicate that the nutritional state of the refugees is relatively well maintained at a satisfactory level, comparable with that of the non-refugees in the host countries. A moderate percentage of small refugee children was nevertheless found suffering from mild to moderate forms of protein-energy malnutrition.
52. The dry milk distribution already made available to children 6-24 months of age, was expanded effective 1 January 1979 to include the 2-3 years age category of children attending the child health clinics. In addition to being a nutritional support, the dry milk distribution has also generated more regular attendance of the children at the child health clinics and greater utilization of the milk programme. The daily distribution of reconstituted milk to pre-school and school children was discontinued at the end of 1978.
53. The hot meal programme provides nutritionally balanced mid-day hot meals, six days a week, at 87 Agency supplementary feeding centres and four voluntary agencies centres. The meals were made available on an open basis to children under six years of age and upon medical recommendation to older children and adults. Effective April 1979, the hot meal open policy was extended to all eligible children up to the age of eight years. The hot meal places reserved for the displaced refugees 6-15 years old (as part of the emergency feeding programme established in 1967) were eliminated by the end of 1978 on the basis of the 1978 nutrition survey which had demonstrated that the nutritional state of the displaced refugees was not in any way significantly different from that of the non-displaced refugees.
54. Because of the continuing budgetary deficit faced by the Agency, the flour component of the basic ration, which had been reduced from 10 kgm to the equivalent of 6.7 kgm per person per month during 1978, was further reduced to 5 kgm per month in 1979. However, the flour component for certain welfare cases was maintained at or restored to 10 kilograms; about 28 000 persons benefited from this programme by the end of 1979.
HEALTH MANPOWER DEVELOPMENT
55. The Agency maintained and further developed its programme of education and training in the field of health. Basic professional and vocational training is primarily the responsibility of the Department of Education, while in-service training is the direct concern of the Department of Health.
56. The Agency organized at its own training institutions various vocational training courses to enable refugee students to become assistant pharmacists, laboratory technicians and public health inspectors.
57. In-service training was carried out by the Department of Health for its own staff in the various disciplines of the programme. WHO sponsored seminars were held during the first week of December in Hebron, Ramallah, Nablus and Gaza for the benefit of UNRWA medical officers and two WHO consultants lectured on breast feeding and oral rehydration therapy. In collaboration with the Education Department a two-day seminar was held in Gaza for all graduate nurses engaged in the family health programme at the UNRWA/UNESCO preparatory schools for boys and girls with emphasis on teaching methods. Four nurses (two from Jordan and two from Gaza) successfully completed a one-year post-basic midwifery training at the College of Nursing, Amman; and two other nurses from Jordan were undergoing the same training also in Amman. Other in-service training courses conducted by the Agency included: ophthalmology at St. John Ophthalmic Hospital, Jerusalem, for three months for three practical nurses from West Bank and for one month for two practical nurses from Gaza: two MCH refresher courses of one and two days each, the first for 20 and the second for 19 senior staff nurses and staff nurses in Jordan; an MCH course of three months for one staff nurse from Lebanon and a dayah training course for 14 dayahs in Gaza. Three fellowships for post-graduate training in public health were granted by WHO/EMRO in the academic year 1979/80: two to medical officers from Jordan, and the third to a medical officer from Lebanon. Two medical officers from Gaza and West Bank, who had been granted WHO/EMRO fellowships in the academic year 1978/79, completed their training in public health administration. A varied supply of journals and periodicals in Arabic, English and French is provided for the use of health staff both at Headquarters and in the Fields. Scientific documents and communications published by the World Health Organization form a substantial part of this material.
ADMINISTRATION AND PERSONNEL
58. The Director of Health is responsible to the Commissioner-General of UNRWA for the planning, implementation and supervision of the health and supplementary feeding programme within the budgetary limits approved by the Commissioner-General. He is assisted in this task by a staff of professional and auxiliary health workers and manual workers, totalling 3060 persons as at 31 December 1979. Three vacant key posts, one in Headquarters and two in the Fields, were filled during the year. The difficulties experienced in the recruitment of sanitation labourers have somewhat eased in the West Bank and to a lesser degree in Gaza following the establishment of a special compensation allowance for this category of staff.
BUDGET AND FINANCE
59. The Agency's revised budget for 1979, reported to the General Assembly in the Commissioner-General's Annual Report for 1978-1979, totalled US$ 166 346 000. It was made up of: US$ 82 641 000 for education services, US$ 21 037 000 for health services, US$ 33 421 000 for relief services, US$ 24 700 000 for common costs and US$ 4 547 000 for extraordinary costs outside the regular programmes.
60. Insufficient financing prevented the Agency from implementing this budget in full. Reduction in services was unavoidable and cut expenditure and commitments back to US$ 158 871 622. Of this total, US$ 146 144 493 was financed from 1979 income, leaving a deficit of US$ 12 727 129 which reduced working capital by the end of 1979 to US$ 1.9 million.
61. The Commissioner-General had determined, however, that the health programme must be maintained in full in 1979, and it was therefore not affected by the reductions. Expenditure on the three main activities administered by the Department of Health was as follows:
Share of Common Costs
10 714 511
5 910 181
4 038 629
5 346 047
10 327 338
5 885 319
3 589 532
5 195 173
26 009 368
24 997 362
1 012 006
62. With the exception of the cost of international staff, paid by
the United Nations, UNESCO and WHO respectively, UNRWA's budget is financed virtually entirely from voluntary contributions in cash and in kind, mainly from governments, and the remainder from non-governmental sources and other miscellaneous income.
REPORTED CASES OF NOTIFIABLE DISEASES AMONG REFUGEES IN 1979
Population eligible for health services as at 30.6.1979
1 556 383
(over 3 years NOS)
Enteric group fevers
: No cases of plague, yellow fever, smallpox, typhus (louse borne), relapsing fever (louse borne), relapsing fever (endemic), leprosy, endemic typhus, tetanus, rabies, bilharziasis or diphtheria were reported.
INCIDENCE TRENDS OF SELECTED COMMUNICABLE DISEASES
(Rate per 100 000 eligible population)
UNRWA'S NUTRITION AND SUPPLEMENTARY FEEDING PROGRAMME (1979)
Type of benefit, its nutritional value
and average number of beneficiaries
/ Includes 4569 staff rations.
Supplementary feeding programmes
Milk and hot meals
Children 0-2 years
(Dry whole and skim milk)
Children 2-3 years
(Dry whole and skim milk)
Children 2-6 years
(Dry whole and skim milk)
/ Includes 1303 non-refugee displaced persons on behalf of the Government of Jordan (on reimbursable basis).
/ Includes 1174 nonrefugee displaced persons on behalf of the Government of Jordan (on reimbursable basis).
/ Average for two
1 month in West Bank (Programme discontinued as from 1 February 1979)
3 months in Lebanon (Programme discontinued as from 1 April 1979).
For pregnant and nursing women
For tuberculosis outpatients
Vitamin A-D capsules
Total number of capsules distributed during the year: 7 804 513.
HEALTH PERSONNEL IN UNRWA
Health education staff
/ Comprises various categories of health auxiliaries and aides who mainly perform administrative and clerical duties at camp level.
UNRWA HEALTH FACILITIES
Number of health centres/points
Number of prenatal clinics
Number of child health clinics
Number of subsidized hospitals
Number of beds available
UTILIZATION OF UNRWA HEALTH SERVICES
Outpatient medical care
Number of patients attending
2 089 456
1 047 513
Maternal and child health services
Pregnant women registered
0-1 year registered
1-2 years registered
2-3 years registered
School entrants examined
Other pupils examined
CAMP SANITATION SERVICES
Population services by private water connexion
Remaining population service by public point
Annual average supply
per day in litres
Percentage of population served by private latrines
/ There are 61 camps in all, of which 10 were established as emergency camps (six in Jordan and four in Syria) to accommodate refugees and other persons displaced as a result the 1967 hostilities. UNRWA provides services in the camps but has no responsibility for their administration or security.
/ The term "Field" is used by UNRWA to denote a geographical area or territory in which it carries out its relief operation as an administrative entity. They are at present five Fields: the Gaza Strip, Jordan, the West Bank, Lebanon, and the Syrian Arab Republic.