Health conditions of Palestine refugees – WHO – Report by UNRWA

Health conditions in the occupied Palestinian territory,

 including east Jerusalem, and in the occupied Syrian Golan

The Director-General has the honour to bring to the attention of the Health Assembly the attached report of the Director of Health, UNRWA, for the year 2009.

ANNEX

REPORT OF THE DIRECTOR OF HEALTH, UNRWA, FOR 2009 HEALTH CONDITIONS OF, AND ASSISTANCE TO, PALESTINE REFUGEES  IN THE OCCUPIED PALESTINIAN TERRITORY

DEMOGRAPHIC PROFILE

1. Of the 4.8 million Palestinians who are refugees registered by the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), 1 885 000 live in the occupied Palestinian territory, constituting approximately half the total population. A total of 1 106 000 refugees live in the Gaza Strip (constituting 74% of the resident Palestinian population) and 779 000 in the West Bank (making up 31% of the resident Palestinian population).¹

2. There are 27 refugee camps in the occupied Palestinian territory (19 in the West Bank and 8 in the Gaza Strip). Approximately one third of Palestinian refugees still live in refugee camps (making up 45.4% of all refugees in the Gaza Strip and 25.4% of those in the West Bank); the remaining refugees live in towns and villages with the host population.

3. In 2009, the proportion of Palestinian refugees below 18 years of age in the occupied Palestinian territory was 37.6% in the West Bank and 45.5% in the Gaza Strip. Parity has stabilized in the last five years: in 2008, the mean parity among Palestinian refugee women accessing UNRWA services was found to be 4.5 in the West Bank and 4.4 in the Gaza Strip,² compared with 4.2 and 4.7 respectively in 2003. In 2009, the refugee dependency ratio (refugees under 15 and over 65 years as a proportion of the population) was 85.3% in the Gaza Strip and 72.1% in the West Bank, maintaining the high economic burden on family units.

4. Although refugees in the West Bank are more likely than non-refugees to be unemployed, the gap narrowed in 2008. The broad unemployment rate rose from 24.5% in 2007 to 25.3% in 2008, with the refugee rate falling from 26.7% to 25.9%.3 In the Gaza Strip the intensified siege that began in mid-2007 affected both refugees and non-refugees. The end of 2008, which saw the most destructivemilitary operation in the history of the Gaza Strip, also witnessed a dramatic increase in unemployment rates. Adjusted broad unemployment rose to 49% from about 38% in 2007.³

EPIDEMIOLOGICAL PROFILE

5. Despite a widespread offer of health services and high immunization coverage rates, health indicators did not improve substantially in 2009. Vaccine-preventable diseases are well under control both in the Gaza Strip and in the West Bank and measles vaccination coverage, monitored as part of efforts to achieve the health-related Millennium Development Goals, is consistently above 95%. Tuberculosis, HIV/AIDS, and endemic zoonoses such as brucellosis continued to have a low incidence. Diseases associated with poor environmental health are a public-health threat reflecting local endemicity patterns. Prevalence data for Palestinian refugees in 2009, confirmed the difference between the Gaza Strip and the West Bank in the incidence of infections such as acute hepatitis (75.3 per 100 000 in the Gaza Strip and 15.9 per 100 000 in the West Bank) and typhoid fever (12.4 and 0.0 per 100 000 respectively). No cases of poliomyelitis, acute flaccid paralysis, cholera, tetanus, diphtheria, or pertussis were reported and no outbreaks took place among the refugee population in the occupied Palestinian territory in 2009.

6. The population of the occupied Palestinian territory is facing the socioeconomic consequences of the growing prevalence of invalidity related to noncommunicable diseases and the economic burden of the growing number of patients suffering from chronic diseases who require medical care. The detection rate of diabetes mellitus among Palestinian refugees aged over 40 attending health centres in 2009 was 11.7% in the West Bank and 13.1% in the Gaza Strip. The detection rate of hypertension in the same population was 16% and 19.7% respectively.

7. Both the acute and chronic forms of malnutrition still pose major problems, in particular in the Gaza Strip where the agricultural sector has been struggling to cope with the Israeli blockade and the damage caused by the recent conflict, and where the amount of affordable fresh fruit and protein has been significantly reduced as a result of closures.⁴ According to the most recent FAO assessment,⁵ food security in the Gaza Strip in 2008 and early 2009 decreased compared with 2007 and a survey conducted by the Palestinian Central Bureau of Statistics indicates that after the war a further 16.2% of households decreased their food consumption and 33.7% reduced the quality of the food they buy.⁶

8. Post-traumatic stress and other psychological and behavioural disorders, a documented consequence of exposure to traumatic events, are an emerging health priority. The year 2009 was an extremely difficult one for Palestinian refugees in the Gaza Strip, while refugees in the West Bank

continued to suffer the effects of closures and curfews. UNRWA offered psychological support operations in the midst of the 2009 conflict in the Gaza Strip. About 16,000 people received supportwithin shelters, 20% of the adults manifested “disturbing psychological symptoms” and 30% of

children expressed symptoms that were absent before the war experience. Twelve people were referred to psychiatric services for severe post-traumatic reactions.

9. The difference between the West Bank and the Gaza Strip in terms of Millennium Development Goals and other health indicators is still evident. Overall, the Gaza Strip compares unfavourably with the West Bank, despite the fact that they share the same health-care providers and have comparable populations. The Gaza Strip has consistently higher infant mortality rates (UNRWA data for the West Bank, 19.5/1000; for the Gaza Strip, 20.2/1000; United Nations Millennium Development Goal data for the occupied Palestinian territory, 24.0/1000) and a lower life expectancy (West Bank, 74.5 years; the Gaza Strip, 73.4 years).⁷ Both territories compare unfavourably with Israel (Infant mortality rate monitored for the Millennium Development Goals, 4.0/1000; life expectancy, 80.73 years).⁸

10. The factors contributing to the observed differences in health indicators between Palestinian refugees in the Gaza Strip and the West Bank are diverse. It is relevant to note that West Bank residents have some level of access to Israeli health services of higher quality that are more difficult to access for Gazans. Moreover the Gaza Strip has to cope with siege-like conditions and a prolonged humanitarian crisis that lead to death, disability, infrastructure damage and that worsen dysfunctions in the provision of health care.

UNRWA’S LIFE-CYCLE APPROACH TO HEALTH CARE

11. UNRWA has been the main comprehensive primary health care provider for Palestinian refugees for the past 60 years and is the largest humanitarian operation in the occupied Palestinian territory. It promotes a comprehensive approach to health care from preconception to old age, with a strong focus on primary health care and prevention.

12. The Agency operates through two Field Offices in the West Bank and the Gaza Strip and a network of 61 primary health care facilities. Access to secondary and tertiary care is ensured by one hospital in the West Bank (Qalqilya) and by contracted hospitals in both territories. Almost two million refugees residing in the occupied Palestinian territory (70% of all registered refugees in West Bank and 82% in the Gaza Strip) accessed UNRWA’s preventive and curative services in 2009. Oral health services are provided through 19 clinics and three mobile dental units in the Gaza Strip and 23 clinics in the West Bank.

13. Perinatal care comprises preconception and postnatal care. In 2009, the preconception care programme was fully implemented. Couples receive counselling when planning a pregnancy and are advised to avoid pregnancies that are too close, too frequent, too early or too late by means of modern family planning. In the occupied Palestinian territory almost 11 000 new families were enrolled in2009 and the total number of continuing users of modern contraceptive methods increased by 1.9% compared with the previous year.

14. Antenatal care was offered to almost 60 000 refugee women, with a coverage rate of 100% in the Gaza Strip and 64.3% in the West Bank. The proportion of pregnant women under UNRWA care who paid at least four antenatal visits during their pregnancy in 2009 was 93.6% in the Gaza Strip and 83.3% in the West Bank; on average, 77% registered during the first three months of pregnancy and over 99% gave birth in a health institution. Over 90% of the women concerned were followed up after delivery either in UNRWA clinics or at home.

15. Infant and child health care focuses on providing paediatric curative and preventive services as well as school health services, including medical examinations, immunization, screening for vision and hearing impairment, oral health consultations, vitamin A supplementation, de-worming and health education and promotion activities. In 2009, almost 30 000 additional children enrolled in UNRWA

schools in the occupied Palestinian territory.

16. Control of communicable diseases is achieved in part by high vaccination coverage and in part by the early detection and management of outbreaks through a health centre-based epidemiological surveillance system. The full immunization coverage rate for infants of 12 months of age in 2009 was 94.6% in the Gaza Strip and 99.7% in the West Bank, while the coverage rate for children aged 18 months receiving booster doses was above 99% in both territories. Communicable disease surveillance was also enhanced in 2009 through the application of revised guidelines, extensive training and the establishment at the end of January 2009, following the recent conflict in the Gaza Strip, of an early warning system for communicable diseases that is still the only reliable and timely source of epidemiological information in this area.

17. Adolescent and young adult refugees in the occupied Palestinian territory accessing UNRWA’s health services, on average pay five visits a year for medical consultations.⁹ In 2009, the number of medical consultations conducted by UNRWA physicians in the occupied Palestinian territory increased to almost 6 million (1.9 million in the West Bank and 4 million in the Gaza Strip). Almost 380 000 oral health consultations and almost 130,000 oral health screening sessions took place; and physical rehabilitation was provided to 13,763 refugees, of whom 25% suffered from sequelae of physical trauma and injuries. During the same period, 400 patients were admitted for the treatment of injuries sustained during the Gaza War in January 2009; of these, 30% were children. Over 8000 refugees benefited from individual mental health counselling sessions, over 30,000 from group counselling and almost 6000 received home visits from UNRWA mental health staff.

18. Five mobile health teams have been operating in the West Bank since February 2003. Their objective is to deal with the additional burden on the health system and particularly to facilitate access to health services in locations affected by closures, checkpoints and the West Bank barrier. They offer a full range of essential curative and preventive medical services to some 11 000 patients per month – refugees and non-refugees – living in over 126 isolated locations. Since they came into operation, the mobile clinics have played a crucial medical role and have treated an increasing number of Palestinian refugees, rising from 69 500 in 2003 to 133 582 in 2009.

19. The number of refugee patients from the West Bank and the Gaza Strip who were admitted to hospitals increased by 6% from 23,488 in 2008 to 24,831 in 2009. In addition to outsourced hospital services, UNRWA operates a 63-bed hospital in Qalqilya, West Bank. The hospital offers medical care, surgery, gynaecology and obstetric services to refugees and needy non-refugees in the northern West Bank. In 2009 the average daily bed occupancy rate was 57.3% with over 6000 people admitted.

20. Active ageing is the last phase of UNRWA’s life-cycle approach to health care. It principally addresses high prevalence noncommunicable diseases like diabetes and hypertension, focusing on secondary prevention of late complications. By the end of 2009, a total of over 80,000 patients with diabetes and/or hypertension were under care in UNRWA health centres in the occupied Palestinian territory (52,941 in the Gaza Strip and 30 666 in the West Bank).

CHALLENGES AND CONSTRAINTS IN HEALTH SERVICE DELIVERY

21. Access restrictions for Palestinians and the aftermath of the conflict in the Gaza Strip have put strain on an already overstretched health-care delivery system in the occupied Palestinian territory. Difficulties in the movement of UNRWA’s staff and goods and increases in the prices of goods –  including medicines and food commodities – are two of the main issues that affected UNRWA’s health programme in 2009, alongside the complication of logistics and consequent increases in operational costs stemming from the restrictions on movement and the closure regime imposed on the occupied Palestinian territory.

22. In the West Bank, the movement of staff and beneficiaries is extremely restricted and unpredictable at several Israeli checkpoints, notably those controlling access to east Jerusalem. These restrictions limit the Agency’s ability to meet the needs of increasingly vulnerable communities.¹⁰ In 2009, entering operational areas remained problematic for UNRWA’s health staff. Health programme staff reported 31 access incidents affecting 76 staff members and the loss of 56 working hours. This however underestimates the issue as regular difficulties at checkpoints are not always reported and no information is collected from areas that UNRWA's staff are no longer visiting because of access difficulties, such as the Bart’a enclave. Moreover the negative effects on service delivery of measures taken to avoid difficult checkpoints, such as preferring longer routes, are not measurable. Notwithstanding, it is clear that access constraints in 2009 have resulted in increased waiting time for patients and disturbance of routine and regular activities at health centres due to the delayed arrival or absence of staff. Many pregnant women who had appointments for follow-up care in UNRWA’s health centres were unable to reach them on time because of closures and restrictions on movement. The lack of access to UNRWA’s health services has also undermined the status of patients affected by chronic diseases who could not be regularly monitored and treated.

23. UNRWA’s mobile medical teams have been unable to access Bart’a village since October 2007 as well as other areas between the West Bank barrier and the armistice line. The entrance to Bart’a was controlled by Israeli military forces who demanded to search UNRWA’s vehicles and personnel. Responsibility for security checks has recently been handed to a private security company (under the authority of the Ministry of Defense). This has also been the case at other crossing points at the barrierand in Jerusalem and is increasingly hampering access to the seam zone in other areas of the West Bank.

24. In order to cater to the health-care needs of refugees of Bart’a enclave, Dher Al Malih and Um Al Rihan in Jenin Area and overcome accessibility problems, a Memorandum of Understanding with CARE International/Palestinian Medical Relief Society was signed and made effective on 1 December 2009. UNRWA provides the CARE International/Palestinian Medical Relief Society team with medicines, replenishing them according to need.

25. Access to tertiary care for patients residing in the Gaza Strip is a chronic problem that was exacerbated by drastic restrictions in the first half of 2009 as a consequence of the recent hostilities.¹²

26. Financial constraints remain a serious concern for the Agency. In 2009, the health programme was not able to reimburse costs for all deliveries taking place in hospitals opting to select cases at high or moderate risk. For the same reason, life-saving tertiary care treatments, such as dialysis are still not reimbursed by the Agency.

27. Even so, UNRWA’s health system is overstretched with each doctor in the occupied Palestinian territory seeing on average 103 patients a day. In 2009 a shift from curative to preventive care within UNRWA’s health system was formalized as part of an extensive and ongoing health-care reform. This aims to decrease the burden on UNRWA’s health providers and increase service quality and efficiency while addressing the aspects less likely to be covered by other health providers in the occupied Palestinian territory.

CONCLUSIONS

28. Palestinian refugees are victims of health inequalities. UNRWA aims to address these socioeconomic disparities and mitigate their effects on refugees’ health through the provision of the best possible comprehensive primary health care services. UNRWA’s ultimate objective is to enable

beneficiaries to live the fullest, most healthy and productive lives.

29. The chronic imbalance between the needs and demands of the refugee population on the one hand, and the human and financial resources available to the programme on the other, has led to a constant renegotiation and prioritization of activities to cope with budget constraints. The effort to satisfy the needs of Palestinian refugees will continue to require the mobilization of additional human and financial resources and the support of individuals, governments and institutions from all over the world.

30. With its cross-cutting approach to comprehensive primary health care, UNRWA is in a unique position to implement targeted preventive and curative services and to address the social determinants of health. The health programme addresses the issue of refugees’ health from birth to old age, implementing health prevention and promotion activities at various levels. Health education from exclusively medical environments reaches schools and other community aggregation centres, allowing the development of community-based initiatives; the impact of infrastructure on health is directly supervised; and essential drugs are made freely available and their management is constantly monitored to comply with WHO’s standards.

31. Supported by the international community, UNRWA has, over the years, developed a refined, tailored and effective package of measures to mitigate the effects of the conflict on refugee communities in the occupied Palestinian territory. These measures comprise employment programmes, cash and in-kind assistance, food aid, reconstruction and repair of conflict-damaged infrastructure, emergency medical care, psychological counselling and support, and monitoring and reporting of violations of international law.

32. Given the vital importance of health as a fundamental human right, indivisible from other human rights, it is critically important for all stakeholders to exert every effort to ensure sustainable access to health care for Palestinian refugees in the occupied Palestinian territory.

33. It is necessary for all parties to ensure that, in keeping with UNRWA’s status as a neutral and impartial United Nations agency, the privileges and immunities of its staff are respected and the security of its personnel is guaranteed at all times. The access of UNRWA’s health staff to their duty stations as well as to isolated communities should be ensured, in accordance with international law.

34. It is vital for the international community to renew its financial support to enable UNRWA to: sustain the planned activities of its health programme; overcome the current logistical difficulties due to access and movement restrictions; face the rising cost of supplies; adjust services to meet the growing needs of the refugees; and continue to respond to the seemingly unending humanitarian emergency in the occupied Palestinian territory.

¹ UNRWA Annual Report of the Department of Health 2009, in press; and press release issued on 20 June 2009 by

the Palestinian Central Bureau of Statistics. Available online at http://www.pcbs.pna.org/Portals/_pcbs/PressRelease/refugees_E.pdf. Accessed 21 April 2010.

² UNRWA report entitled “UNRWA infant mortality survey: causes and determinants of infant death among Palestine refugees in the Near East”, 2009.

³ UNRWA. The West Bank Labour Market in 2008: a briefing paper December 2009. Available online at http://www.unrwa.org/userfiles/201001196450.pdf. Accessed 21 April 2010.

⁴ UNRWA. The Gaza Labour Market in 2008: a briefing paper December 2009. Available online at http://www.unrwa.org/userfiles/2010011974016.pdf. Accessed 21 April 2010.

⁵Integrated Regional Information Networks (IRIN). OPT: signs of worsening malnutrition among children, 21 April 2009. Available online at http://www.unhcr.org/refworld/docid/49f012bb9.html. Accessed 21 April 2010.

⁶ Report of the Rapid Qualitative Emergency Food Security Assessment (EFSA) Gaza Strip. FAO/WFP, 2009. Available online at http://unispal.un.org/pdfs/FAO-WFP_EFSAreport.pdf. Accessed 26 April 2009.

⁷ The impact of war and siege on Gaza Strip, 2009. Available online at http://www.pcbs.pna.org/Portals/_PCBS/Downloads/book1595.pdf (Arabic only). Accessed 21 April 2010.

⁸ CIA World Factbook. Available online at https://www.cia.gov/library/publications/the-world-factbook/index.html. Accessed 21 April 2010. NB.UNRWA data on infant mortality refer only to Palestinian refugees; the latest survey was conducted in 2008 and is attributable to the situation in 2005–2006. Data for the United Nations Millennium Development Goals and CIA refer to the entire population residing in the occupied Palestinian territory. The Millennium Development Goals data were last updated in 2007.

⁹ See United Nations Millennium Development Goals and CIA World Factbook, available online at, respectively,

http://www.un.org/millenniumgoals and https://www.cia.gov/library/publications/the-world-factbook. Accessed 26 April 2009.

¹⁰ UNRWA report entitled “Analysis of UNRWA outpatient services. Patient profiles, causes of consultation and antimicrobial prescription in UNRWA primary health care clinics”, 2009.

¹¹ The communities concerned are those affected by movement restrictions and the closure regime (including those affected by the West Bank barrier, settlement expansion, closed military areas, and communities such as those living in Area C of the West Bank, Jordan Valley and the Jerusalem periphery).

¹² WHO Gaza Health Fact Sheet January 2010.