The fragmentation of the West Bank and Gaza Strip due to Israeli movement restrictions has been especially disruptive for the functioning of the Palestinian health system and the continuity of patient care. The Palestinian Ministry of Health purchases referral medical care from other health service providers, most frequently for cancer and subspecialty services from East Jerusalem hospitals, when treatment is not available in its own facilities. Unrestricted access to medical care is crucial for patients. In this report WHO presents data on health access in the oPt in 2016, and focuses on the bureaucratic barriers to Palestinian health caused by policies of the occupation that restrict access for patients, health personnel and ambulances.
Quantitative detailed data for patient referrals, for requests for Israeli permits for health access, and for attacks on health facilities, patients and health personnel were obtained from official Palestinian sources and health providers, in addition to qualitative narratives on patients' experiences with health access. Data was analysed for trends over time.
In 2016, 83.7% of the 91,927 referrals issued by the Palestinian Ministry of Health were to Palestinian medical centres. Fifty-two per cent were located in East Jerusalem, which is accessible for patients with West Bank or Gaza identity cards only if they obtain an Israeli-issued permit. Permits were also required for the 14.3% of referrals to Israeli hospitals, while the 2% of referrals to Egypt and Jordan required the approval of both Israel and the foreign government.
Of note is a small rise in the proportion of total referrals for West Bank patients in recent years, which may reflect their easier access to local care than Gaza patients, who are more dependent on outside referrals requiring permits for exiting the Gaza Strip and have more difficulty in obtaining these. Only a limited number of patients were able to exit through Rafah in 2016 owing to the closure of the borders since mid-2013.
Every year the burdensome permit application process and security procedures result in delays and denial of care for thousands of Palestinian patients, and patient companions. WHO's analysis indicates that there is a declining rate of approval of permit requests for patients since 2012, from 92.5% in 2012, to 88.7% in 2013, to 82.4% in 2014, to 77.5% in 2015 and to 62.1% in 2016. In 2016, the approval rate for permits for Gaza patients to cross Erez checkpoint was the lowest recorded by WHO since 2008, representing a 15% drop from the previous year: 62.07% of 26,282 permit applications submitted for Gaza patients in 2016 were approved, 6.57% were denied, and 31.36% of applicants did not receive a response to their applications in time for their medical appointments, and had to reapply with new appointments, postponing medical care. The approval rate for permits for patient companions was even lower (53%), a particular problem for parents accompanying sick children and for companions of the elderly and disabled. In the West Bank, of 190,733 permit applications submitted by patients and companions, 80.34% were approved, a drop of almost 3% from 2015. The most frequent reason given for permit denial by the Israeli security services is security.
All international legal duty bearers must act to improve health access in the occupied Palestinian territory. We hope that by providing credible and detailed evidence of the difficulties that Palestinians face in accessing necessary health care, this report will assist health advocacy efforts by the international community aimed at holding duty bearers to their legal obligations to respect and fulfil the right to health in the occupied Palestinian territory.