The health crisis in the occupied Palestinian territory
18 July 2006
A health crisis is emerging in the occupied Palestinian territory (oPt). During the last five years, the health sector has been negatively affected by movement restrictions, a problem that was recently compounded by the deteriorating security situation and the Ministry of Health (MoH)'s looming financial crisis. Without international intervention, the situation will worsen severely in the coming months.
The humanitarian crisis in the oPt can be divided into three chronological layers: the past five years' Intifada, the MoH funding crisis of March 2006, and the recent Gaza security developments of the past several weeks.
Three layers of the crisis
a) The first layer is a consequence of five years of Intifada and movement restriction, resulting in economic deterioration, growing unemployment and escalating poverty rates. Health indicators remained generally unchanged despite problems of constrained access, malnutrition, injuries and mental health issues. Lack of micronutrients – often leading to iron-deficiency anaemia – is a public health problem among children and women; over one-quarter of all children under five and a third of women of childbearing age are anaemic. Other micronutrient deficiencies of concern are sub-clinical vitamin A deficiency rickets and iodine deficiency, and the level of chronic malnutrition among children under five is approximately 10%.
This time period has also seen an increased vulnerability to psychosocial problems, distress and mental illnesses as well as non-communicable diseases, such as heart disease, hypertension, malignancy and diabetes, which are the main cause of death together with perinatal conditions. The already-burdened health system received an additional threat in the form of avian influenza outbreaks among poultry in the Gaza Strip.
b) The second layer is a direct result of the funding interruption for the Palestinian Authority (PA) since the electoral victories of Hamas in March 2006. The suspension of support to the PA is worth roughly $60m per month, and its absence deprives the PA – and subsequently the MoH – of the majority of its running budget, resulting in major gaps in the delivery of basic health care. If the freeze on funding continues, basic services and essential public health functions provided by the MoH may be severely disrupted.
MOH facilities provide more than 60% of health services in the oPt. The expenditure totaled US$ 155 607 000 in 2005; this amount was divided almost equally between salaries and non-salary items. The collapse of the MoH, around which all other health actors revolve, would most likely lead to a total collapse of the Palestinian health system.
c) The third layer is the recent security developments especially in and around Gaza, which have resulted in several casualties and an increased demand for emergency medical services. This situation is likely to further worsen following the new developments on the border with Lebanon. A critical electricity shortage, resulting from the destruction of the main power plant in the Gaza Strip, is affecting the water supply as well; water pumps for the 132 water wells in the Gaza Strip are not fully functioning. The Palestinian Water Authority (PWA) is distributing water in each neighborhood for 4 hrs/day, and WHO is monitoring incidences of diarrhea in order to track any related potential effects. Generators are available in hospitals and in about 50% of primary health care (PHC) centers.
Additionally, the closure of all crossings into and out of Gaza has an impact on the referral services, as a monthly average of 500-700 patients sought care in Egypt and other countries prior to the increased movement restrictions.
Impact on Health
1. Rise in chronic conditions resulting from years of economic decline and restrictions of movement (malnutrition, mental health and lack of access to essential referral services) .
2. Escalating crisis of the Palestinian health system resulting from the funding crisis: only minimal payment has been delivered to MoH staff, resulting in attrition of staff, reduction of services and shortages of essential supplies. Furthermore, patients with chronic diseases are facing growing difficulties in getting treatment and the referral of patients for tertiary services is increasingly difficult. However, no collapse of the system has yet occurred and health services are still functional.
3. The recent crisis in Gaza is affecting 1,3 million Palestinians as follows:
• Two month emergency stocks of essential drugs held at MoH hospitals in the Gaza Strip are running low in certain selected items, such as several essential medicines, surgical supplies, and disposables including sutures, needles and canulas.
• The possibility of increased casualties raises concern over the sector's capacity to respond to large numbers of injured patients. The disruption to the road network around the middle governorate will further hinder the transfer of wounded patients from southern Gaza to the main referral hospital (Shifa Hospital) in Gaza city.
• All Gazan hospitals have back-up generators which are used during power outages, but continuous power is required for the preservation of cold chain items, food for patients, emergency operations and at the Central Drugs Store.
• MoH reports that about 50% of PHC facilities are equipped with generators, so vaccines were transferred from facilities without generators to other locations. Municipal electricity in Rafah district has been cut off since 7 July at 11:00 am; all health facilities are operating with available generators.
• Per its emergency plan, the MoH assigned 21 PHC in Gaza Strip to function as emergency centers. Currently; twelve of them are working for 24 hours per day and another four are working for twelve hours per day.
• All other PHC services including Mother and Child Health, Food Inspection, Health Education, Nutrition, Surveillance and Epidemiology and others remain functioning. PHC centers have a fuel stock lasting for one to two weeks.
• The shortage of electricity is hampering the pumping of water into the public water network. Solid waste disposal and sewage disposal are also affected by shortages of fuel, necessary to transport garbage away from residential areas.
WHO assistance so far
WHO's program in OPT comprises three sectors: a regular budget programme involving several public health issues, a humanitarian programme within the framework of the Consolidated Appeals Process (CAP), and support to the United Nations Relief and Works Agency (UNRWA). To further advocacy efforts and in line with WHA Resolution 59/3, WHO organized a meeting on 12 June attended by MoH, UNRWA, OCHA, other UN agencies and around 30 donors to consider mechanisms to address the needs of the oPt populations and to avert a health crisis. With information provided from the MoH, WHO is willing to provide support to the international community within the framework of the Temporary International Mechanism. Furthermore, WHO is purchasing certain essential drugs short in the Palestinian health system primarily using its own internal resources.
WHO strategy to address the health crisis
To save lives and reduce avoidable morbidity and suffering in the oPt.
a) To provide immediate, lifesaving assistance to the population of Gaza.
b) To ensure delivery of essential health services and programs until the Temporary International Mechanism (TIM) is established to cover basic MoH salary and non-salary requirements.
c) Reducing the vulnerability of the Palestinian society through a package of public health interventions within the framework of the CAP.
Planned WHO interventions
1) Provision of immediate humanitarian assistance to Gaza (see also "Immediate steps to provide humanitarian health assistance in the oPt")
Key strategic Issues
• Action within UN consortium. Security of WHO national and international staff
• Support to health and environmental workers
• Logistic Support to hospitals and clinics
2) Coordinating the various public health activities carried out by the different health actors and promoting the quality and accountability of assistance and humanitarian relief initiatives. In this framework, WHO will strengthen its presence with public health experts and project, financial, administrative, HR and supply officers. All layers of the crisis must be addressed.
Key strategic Issues
• Support MOH coordination mechanism at district and national level;
• Keep coordination agenda as technical as possible;
• Establish a platform of dialogue with donors and NGOs;
• Sustaining scientific relations between Palestinian and Israeli Health Providers through "Bridges".
3) Mapping of health services and programs, advocacy of universal access to essential health services and addressing humanitarian needs, using objective and evidence-based data (Healthinform). This action package is important to tackle all layers of the crisis.
Key Strategic Issues
• Continue compiling data and information;
• Expand WHO presence through recruitment of national officers in the districts;
• Data based advocacy.
4) Support the delivery of essential health services and programs through basic public health functions, response to urgent needs and provision of vaccines, consumables, and essential supplies until the Temporary International Mechanism (TIM) is fully operational.
Key Strategic Issues
• The international community cannot and should not try to replace the MoH institutions;
• The capacity of health NGOs should be sustained.
5) Filling gaps in public health through technical and operational support to non-communicable diseases, mental health, nutritional surveillance, environmental sanitation, communicable diseases and emergency preparedness. This package is essential to reduce vulnerability and tackle essential health needs of the population as identified in the framework of CAP 2006.
Key strategic Issues
• The health situation in the occupied Palestinian territory is prone to constant changes, both substantial and geographical, and must be continuously monitored to avert further deterioration.
Within the UN CAP for 2006, WHO appeals for $28,109,938, only a small fraction of which has been received so far. The funding crisis of the PA and therefore MoH is evolving into a severe humanitarian health crisis for which around $23 million will be needed for three months, covered by the TIM. The acute health crisis in Gaza needs around $2 million to support health services and for incentives, essential drugs, and logistic support (including generators and fuel). This figure does not include the cost of services provided by other health providers such as UNRWA, private sector providers and NGOs.
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