Health conditions in the OPT – Report by Israel

FORTY-FIRST WORLD HEALTH ASSEMBLY

Provisional agenda item 33

HEALTH CONDITIONS OF THE ARAB POPULATION IN

THE OCCUPIED ARAB TERRITORIES, INCLUDING PALESTINE

At the request of the delegation of Israel, the Director-General has the honor to transmit to the Forty-first World Health Assembly, for its information, a report by the Ministry of Health of Israel. 1/

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1/ Annex.

ANNEX

HEALTH IN JUDAEA, SAMARIA AND GAZA

1987 – 1988

PREFACE

This report summarizes the development of health services and changes in health conditions of the residents of Judaea, Samaria and Gaza over the past twenty years. Much of this has resulted from improved standards of living, education, roads and transportation, sanitation as well as a rising level of awareness and expectation in health care.

Great stress has been placed in Judaea, Samaria and Gaza on primary health care, including sanitation and hygiene, as well as on personal preventive health services such as immunization, and child and pregnancy care. There have also been dramatic improvements in clinical medicine particularly in hospital care available locally, and through referral to Israeli hospitals. New facilities or equipment, new specialty departments, and extensive staff training programmes in Israeli teaching centers are resulting in improved quality available in local hospitals.

I wish to express my personal thanks to all those health workers, Arab and Jew alike, who through their dedication and devotion have contributed so much toward the advancement of health in Judaea, Samaria and Gaza.

TABLE OF CONTENTS

1. Population, demography and vital statistics

1.1 The population in Judaea, Samaria and Gaza has increased rapidly over the past 20 years as a result of continued high birth rates and declining mortality, especially in infant and childhood mortality, along with a decline in emigration rates. As a result, average annual growth rates are approximately 2-3 percent in recent years.

1.2 Judaea and Samaria vital statistics are shown in the following table:

2. Socioeconomic conditions

2.1 Economic growth in Judaea, Samaria and Gaza over the past 20 years has more than kept pace with population growth, so that their former comparison to least developed countries has been replaced by comparison to middle level developing areas. This is shown in growth of per capita gross domestic product (US$) in the following table:

2.2 Economic development has been based on full employment, on improved agricultural productivity using less manpower, on business and professional service development, on growth of public services and on small scale industrial development.

2.3 Education is compulsory to the age of 14 for both sexes. Male and female participation in secondary and post secondary education has reached high levels. University and other post secondary education is now widespread with institutions and students engaged in scientific and professional studies, as well as in general or religious education. At present there are 4 universities and 4 colleges granting diplomas in education, nursing, paramedical and other professions.

The following table shows the percentage of the population (male and female) in different age groups by their years of education.

2.4 Changes in living conditions are shown in the following table regarding percentage of homes with specific facilities.

2.5 Living standards for most residents of Judaea, Samaria and Gaza have risen as family income, nutrition, housing conditions, electrification, safe water supplies, roads and transportation have improved. The following table indicates changes for the population of Judaea and Samaria and Gaza in terms of food value in calories per capita.

2.6 The following table indicates changes in living standard for the population of Gaza, as indicated by percentages of homes with less than three persons per room:

3. Primary health care

3.1 Emphasis in the Government Health Services of Judaea, Samaria and Gaza has been placed on developing primary health care with the following priorities:

3.1.1 Expanded programme of immunization;

3.1.2 Sanitation – garbage disposal

– safe water supply

– sewage collection

– food safety;

3.1.3 Prenatal care and hospital deliveries;

3.1.4 Oral re-hydration for diarrhoeal disease;

3.1.5 Expanded primary health care in small villages;

3.1.6 Health education;

3.1.7 Nutrition education, and growth monitoring;

3.1.8 Screening for congenital diseases (PKU and hypothyroidism);

3.1.9 School health;

3.1.10 Supervision and training of traditional birth attendants (Dayas);

3.1.11 High risk pregnancy identification, referral and follow-up.

3.2 Primary health care facilities established and operated by the Government Health Services of the Israeli administration in Judaea, Samaria and Gaza are shown in the following table.

3.3 Immunization for the major childhood diseases has resulted in increasing control or elimination of these diseases, as shown in the attack rates for these diseases in the following tables (in rates per 100 000 population).

DISTRIBUTION OF HEALTH SERVICES

GAZA, 1987

DISTRIBUTION OF GOVERNMENT HEALTH SERVICES

ACCORDING TO DISTRICTS

JUDAEA & SAMARIA

Diphtheria, pertussis, tetanus and polio have virtually disappeared. Tuberculosis is at low levels. Measles still occurs in outbreaks, but with a steep overall decline.

3.4 The immunization schedule currently utilized for infants is the following:

MMR vaccine was introduced at the end of 1987; measles vaccine is available for use during measles outbreaks for infants between 6 and 9 months of age.

3.5 The immunization schedule for school children and adults is as follows:

Tetanus toxoid is given to pregnant women during prenatal care, and to young people entering the work force.

3.6 Serosurvey results of two separate random sample studies of school children aged 7-9 years in Judaea and Samaria were as follows (percentage with protective antibodies):

In a 1987 serosurvey among a representative sample of 14 year old school girls in Judaea and Samaria, rubella antibodies were found at a protective level found in 100%, and hepatitis A antibodies in 100%.

3.7 Hospital and medical center deliveries as a percentage of total deliveries in Judaea, Samaria and Gaza has increased steadily over the years, as seen in the following table.

3.8 Birth weights of children born in health care institutions were % born under 2500 grams:

3.9 Studies of growth patterns of infants and school children carried out in Judaea and Samaria showed patterns similar to the US National Center for Health Statistics (NCHS) infants sample, with variation according to socioeconomic level, breast feeding pattern and urban versus rural residence. No differences were seen in growth patterns between male and female children aged 0-2 in studies in Judaea, Samaria, and in Gaza. Breast fed children had growth advantage over non-breast fed in the first year, and urban children showed advantage in growth over rural children.

A random sample of school children studied in 1987 in Gaza showed patterns similar to the NCHS pattern, albeit with a wider standard deviation both above and below the NCHS pattern. Growth monitoring is receiving increased stress in the Government Health Services in Judaea, Samaria, and Gaza as an essential part of routine well child care, accompanied by nutrition education of mothers. New well child care records have been adopted in both areas, and are being introduced into use in community clinics, MCH centers and Village Health Rooms of the Government Health Services.

3.10 Infant mortality has declined very rapidly in the Gaza area as the childhood infectious and diarrhoeal diseases are brought under control through successful immunization and ORS programmes, increased hospital and medical center deliveries, and as a result of increased educational and socioeconomic standards. In Judaea and Samaria infant mortality is more difficult to establish particularly during the 1970s since most births occurred at home and some early neonatal deaths may have gone unreported. Improved reporting and follow-up systems as well as increasing hospital deliveries have substantially increased the reliability of infant mortality in the 1980s. The following table shows reported infant mortality trends in rates per 1000 live births:

3.11 Overall mortality for infants, children and young adults by age growth as a trend in Judaea and Samaria is shown from a study for the period 1975-1983 in rates per 100 000 population as follows:

3.12 Expansion of Primary Health Care (EPHQ in Judaea and Samaria was undertaken as a special project by the Israeli Government Health Service, in conjunction with UNICEF in Hebron District. Thirty-three MCH centers were established over the past 15 years to provide prenatal and well child care coverage in the 120 villages and one city in Hebron District. Immunization of infants and school children in the smaller villages was carried out by visiting immunization teams (initially by sanitarians then later by public health nurses) on a 6 weekly visit schedule. The EPHC project established Village Health Rooms (VHRs) in selected small villages with populations of on average 800 persons, staffed by a trained Community Health Worker (CHW). During 1985, a pilot project was carried out in 4 villages, including the training of local village high school graduates, preparing health records and carrying a household health survey in all the homes in the villages. Following this in 1986, a further 20 VHRs were opened following the six months training programme of CHWs and in 1987 a further 26 VHRs were opened. Currently 50 VHRs are providing a broad range of preventive health activities in the villages. This includes:

Other health issues are being added including preventive dental health, screening for heart disease risk factors and teaching women breast self-examination.

This project is now being expanded to other areas in Judaea and Samaria. Evaluation of the project will be carried out by the Ramallah Health Services Research Center, in consultation with academic staff of the School of Public Health, Hadassah-Hebrew University in Jerusalem. In the villages where the VHRs are operational, most of the pregnant women are participating in prenatal and well child care, with an increasing tendency to go to the district hospital for deliveries.

3.13 Supervision and training of traditional birth attendants (Dayas) has been given strong emphasis in recent years. The Government Health Service in Judaea and Samaria appointed Supervisors of Dayas in each of the Districts who maintain contact with the Dayas in the district. This includes regular visits to the villages, inspection of equipment, ensuring registration of births and deaths, supervision of training of new Dayas, and conducting study days. During 1987 a special project of continuing education for Dayas and their supervisors was carried out both in Judaea, Samaria and Gaza, with assistance of UNICEF which also provided new kits for Dayas completing a programme of study days.

3.14 School health services have been reviewed as part of a study of primary care services, and improved procedures for public health supervision of school hygiene and student health are being implemented.

3.15 ORS is now used throughout the Government Health Services primary care centers in Judaea, Samaria and Gaza. This, in conjunction with improving standards of sanitation, hygiene and nutrition, has resulted in a dramatic decline in mortality and serious morbidity from diarrhoeal disease particularly in infants and children.

3.16 Screening of newborns for phenylketonuria (PKU) and hypothyroidism was started in Judaea and Samaria Government Health Services in 1987 in cooperation with Sheba Medical Center, Tel Hashomer. In this project, infants born in hospital are tested while in the hospital, or in the local MCH center. Infants born at home are referred by the Dayas to the nearest MCH center for this test within the first week of life. In the first year of this project, more than half of all newborns were screened for these serious congenital disorders. Suspect cases are referred to specialty centers at Tel Hashomer (for PKU) and local hospitals (for hypothyroidism) for assessment and follow-up. PKU cases receive free supplies of the special foods they require to prevent serious mental retardation. A similar programme is being started in Gaza during 1988.

3.17 High risk pregnancy screening, referral, and follow-up, systems were developed in the Government Health Service in Judaea and Samaria during 1987. High Risk Pregnancy committees were established in all districts, and High Risk Pregnancy Clinics developed in district Public Health Offices and district hospitals. Staff in MCH centers and village health rooms are receiving instruction in study days on high Risk factors in pregnancy, referral and follow-up systems. This programme is also being implemented in the Government Health Services in Gaza.

4. Hospital services

4.1 Introduction

The hospital services in both areas are mainly governmental, but in Judaea and Samaria in particular substantial non-government hospital systems also serve the population. The hospitals in both sectors have advanced in facilities, professional and support services over the years by adding new departments and diagnostic equipment, as well as improved professional training.

4.2 Judaea and Samaria government hospital service facilities are outlined in the following table, for the year 1987, and as projected in current master plans for government hospitals:

4.3 Gaza hospital facilities are outlined in the following table based on current master plans:

4.4 Utilization of acute hospital care is shown in the following table:

4.5 Master plans for the development of all government hospitals were completed during 1986/87. This has led to improved integration of planning with implementation. Hospital projects completed or in implementation involving local health personnel and Israeli consultants in Judaea and Samaria during the period 1985-1988 include the following:

4.6 Hospital projects completed or in implementation in Gaza during 1985-1988 include the following:

4.7 The development of new departments and completion of training of new specialists has increased the capacity of local hospitals to manage regular and emergency health care needs. The local hospitals in Judaea, Samaria and Gaza have been able to cope medically with persons injured during civil disturbances.

5. Manpower and training

5.1 Manpower and training has received great emphasis, particularly since 1985. This was achieved through cooperation between the Israeli Government Health Services, local health personnel and Israeli institutions. There is a strong and growing interest on the part of local health personnel to take part in full time and part time postgraduate training in Israeli teaching institutions and a matching interest by the Israeli teaching facilities to provide training for them. In recent years large budgetary allocations were provided for this purpose by the Government Health Services, as well as by the United Nations Development Programme and the World Health Organization. The success of a number of manpower projects spurred on new activities in this area which have an immediate demonstrable effect on improving the quality of care for the population.

5.2 Specialty training in two year programmes for local health personnel have been carried out in a number of areas, including the following:

5.2.1   Anesthesia: 25 physicians of the Government Health Services in Judaea, Samaria (11) and Gaza (14) successfully completed in 1987 two years of full time training in 10 different Israeli teaching hospitals, and have returned to their own hospitals. New equipment and organization of anesthesia services in these hospitals has raised the level of this vital service. Continuing education through monthly study days for groups of physicians is ongoing. This project was funded by the UNDP and the Government Health Services.

5.2.2   Various specialties: 7 physicians from Judaea, Samaria and Gaza internal medicine, gynecology, pediatrics, pathology and orthopedics are nearing of two years of training at Beilinson Hospital.

5.2.3   Midwives for Gaza: 12 senior local nurses completed a 9 month training programme at Assaf Harofe Hospital in 1987 and have returned to the government health service.

5.2.4   Sanitarians for Gaza: 25 Gazans completed a year's training programme for qualified sanitarians at Assaf Harofe training center in 1987.

5.2.5   Public health doctors: 9 physicians and one statistician from Judaea, Samaria and Gaza have completed their one year, full time Master of Public Health (MPH) degree programmes at the School of Public Health, Hebrew University – Hadassah, Ein Karem, Jerusalem. Seven of these MPH graduates completed their studies over the past 3 years. All of these graduates are engaged in public health work and research in primary health care, working in the respective Government Health Services.

5.2.6   Intensive care nursing: 18 nurses from government hospitals throughout Judaea and Samaria completed six months full time training at Beilinson Hospital in 1987.

5.2.7   Public health laboratory technicians: 3 laboratory technicians from Judaea and Samaria completed three months full time training at the Jerusalem Central Public Health Laboratory in 1987.

5.2.8   Various medical specialties – 15 doctors began two years full time training in various Israeli hospitals in 1987.

5.3 Continuing education programmes have been developed extensively over the past several years for Judaea and Samaria government health personnel, including the following:

5.4 Continuing education recent programme in Gaza include the following:

5.5 Nursing education is being increased in Judaea and Samaria by expansion of the nursing school in Ibn Sinna. The intake class was increased from 24 to 46 in 1987. Graduates of the non-government nursing schools at El Bireh Arab College of Nursing and Bethlehem University School of Nursing who return to the area.

5.6 The number of physicians in Judaea and Samaria in 1987 totaled 856 or 9.93 per 10 000 population or 1 physician per 1007 persons.

5.7 Health manpower employed in the Government Health Services of' Judaea and Samaria have increased steadily over the years, as shown in the following table (number and per 10 000 population):

5.8 Health manpower employed in the government health service in Gaza increased since 1974, as shown in the following table:

5.9 Health manpower in government hospitals in Judaea and Samaria at the end of 1987 are shown in the following table:

The nurse to bed ratio in government hospitals has increased in recent years from 0.50 to 0.58, and will be increased over the next five years to 0.8, the current ratio in Israeli hospitals. The physician to bed ratio is 0.25, or one physician to 4 beds – similar to the current level in Israel.

6. Administration and finance

6.1 The Government Health Services continue to provide the bulk of services in Judaea and Samaria (estimated at 60% of all services), and in Gaza (estimated 85%). These are funded from the Israeli Civil Administration in each area from the general budget which is based on local taxes and revenues, including funds from health insurance. Health constitutes approximately 32% of the total budget of the Civil Administration in each area.

6.2 Non-government services are funded from private sources both locally and from international agencies, along with charges to the user of services. Community, voluntary and charitable societies provide important services in Judaea and Samaria in particular.

6.3 International voluntary agencies provide major assistance to the development and operation of vital facilities in Judaea and Samaria and Gaza. These include:

6.4 Cooperation between the Israeli Administration, the Government Health Services and Agencies associated with the United Nations has also provided important development funding and initiative. The most important of these is the United Nations Development Programme (UNDP), followed by the World Health Organization (WHO). Various agencies funded by the United States Agency for International Development (AID) have also fostered many development projects in the area.

The following is a list of recent projects of these agencies:

7. Research

7.1 Research in relation to health needs in Judaea, Samaria and Gaza has become an important element of the health service systems, particularly over the past three years as a result of several factors: the establishment of Health Services Research Centers in Ramallah and Gaza; the availability of more local graduates of the School of Public Health at the Hebrew University; WHO/UNDP support and encouragement of research activities through agreements reached between the Government of Israel and WHO; and a general realization of the need for operational research in the planning of health services.

7.2 The Ramallah Health Services Research Center (RHSRC) was established in 1985 as a unit of the Government Health Service of Judaea and Samaria to carry out operational research in primary health care in the area. The RHSRC was recognized as a WHO Collaborating Center with funding by WHO through UNDP to expand its staff facilities and projects. The center initiated and carried out studies in infant mortality, a serosurvey of immune status of school children, and helped to complete a study of growth patterns of infants.

Recommendations for changes in immunization policy arising from the serosurvey results have been adopted by the Government Health Service. The infant mortality study led to adoption of a modified form of review of each infant death which is being adopted by the Government Health Service. The growth study is being followed by an intensive analysis of growth patterns in 10 sentinel MCH centers in the area. The Ramallah HSRC is developing studies for evaluation of the process and impact of the Hebron Project in Expanded Primary Health Care now operating in 50 villages in the Hebron area.

7.3 The Gaza Health Services Research Center was initially established in 1981 by the Government Health Service epidemiology and medical information center which coordinated the vital statistics of the area, and carried out various studies in polio, cholera, rotaviruses and measles in conjunction with Israeli academic research centers. In 1986, this center was recognized as a WHO Collaborating Center and provided with funding for important additional resources and staff to expand its area of activity. Since 1985, the Center has initiated studies in factors relating to infant mortality, growth patterns of infants, and a serosurvey of antibodies in school children to the childhood immunized diseases. Computerization of the basic vital statistics system for Gaza has been completed by the Center. Computerization of basic child health records including birth weight, immunization and growth patterns, has been established in 10 government community health centers and will during 1988/89 be extended to the remaining of the 26 government Community Health Centers in the Gaza area.

7.4 The Ramallah Center for Health Manpower Development was established in 1987 as part of the Government Health Service and a WHO Collaborating Center. It focused initially on collating data regarding health manpower in the public and private sectors of health care in the area. The Director of Hospital Services of the Government Health Service serves as the director of the Center, and other senior persons from the Government Health Services serve as members of the center's steering committee. There is close

coordination with the many manpower training projects initiated and carried out by the Government Health Service in the past several years.

7.5 A Workshop on Research Methods carried out by WHO in collaboration with UNDP, the Government Health Services and the three WHO Collaborating Centers was carried out between December 1986 and June 1987. Five distinguished international and Israeli academics of public health and epidemiology served as tutors for the 5 day workshop in December, at a subsequent meeting in April and the final workshop in June. Twenty-five persons associated with the three WHO Collaborating Centers participated in the workshop. They designed and carried out group research projects which were presented to the final session of the workshop. These projects included surveys of risk factors for heart disease among school teachers, knowledge attitudes and practices (KAP) of women related to childbirth, KAP of Dayas, smoking patterns among high school students, school health practices and health of primary school students, cold injury prevalence and others.

The workshop was successful in raising the enthusiasm and experience of employees of the WHO Collaborating Centers and others associated with the centers in research methods and their evaluation. It was a valuable demonstration of cooperation between local and Israeli health personnel with academic public health persons from Israel and abroad to advance the capacity for health services research in Judaea, Samaria and Gaza.

8. International cooperation

8.1 International cooperation in the development of health in Judaea, Samaria and Gaza has evolved over the years. Direct provision of services for the refugee population by UNRWA has continued, but more recently a variety of international agencies has provided important resources and initiatives to assist in development of key areas of health services – including sanitation, medical equipment, health education and in health services research.

8.2 WHO consultants in a number of areas of expertise have visited Judaea, Samaria and Gaza, working closely with the Government Health Services and the WHO Collaborating Centers. Most recently a group of WHO consultants carried out mid-term review of the activities of the WHO Collaborating Centers in conjunction with two professors from the School of Public Health in Jerusalem, Hadassah – Hebrew University.

8.3 The American Public Health Association provided a team of experts in primary health care and hospital administration to the request of the Arab Medical Welfare Association to consult on health planning in Judaea and Samaria during 1986.

8.4 UNICEF consultants in primary health care have visited the area frequently since 1985 in connection with the four Child Development Centers and the Hebron Expanded Primary Health Care project. Funds for these projects were provided by the government of the Federal Republic of Germany.

8.5 A team of 12 plastic surgeons, anesthetist and operating room nurses from Virginia and other parts of the United States and Canada came for an intensive work and teaching session of 2 weeks in January 1988. The team carried out 75 general plastic surgery and urology plastic surgery procedures at Ramallah Hospital and hand surgery at the Mt. David Orthopedic Hospital of Bethlehem on selected cases from Judaea, Samaria and Gaza, in conjunction with local staff and plastic surgeons from Hadassah Hospital. This team, under the direction of Professor Charles Horton of Norfolk, Virginia will continue its service to the area by training of Ramallah surgeons in working visits to Virginia, and return visits to the area.

9. Sanitation

9.1 Sewage collection systems have been extended and re-equipped in urban areas in Judaea and Samaria. Sewage treatment plants were built in Jenin (1971), Tulkarem (1972), Ramallah (1979), Kalkiliya (1986), Hebron (under construction), and El Bireh (under construction). An integrated sewage treatment system planned for Bethlehem, Beit Jallah – Bet Sahur is now in implementation stages.

9.2 Before 1967 sewage was managed through local septic tanks only Since 1967, extensive sewage projects have been carried out by the local authorities in cooperation with the Israeli authorities. Sewage collection systems are being expanded in Gaza City, Jabliya and Khan Yunis with funding from (UNDP) and Community Development Fund (CDF) in conjunction with the municipalities and the Civil Administration. Expanding water supplies to most homes in the area, as well as the expanding population has put great stress on the sewage system. New projects due for completion during 1988 will result in a major improvement in sanitation in Gaza, Khan Yunis and Rafah. The existing treatment plants in Gaza and Khan Yunis are being upgraded to cope with the increased sewage collection and will produce recycled wastewater for use in local agriculture (citrus orchards). The improved sewage collection systems will also be made available to the Beach, Jabalia and Rafa refugee camps.

9.3 Community water supplies have been expanded in Judaea and Samaria by increased development of local wells and by supplementation from the Israeli National water distribution system. Water consumption for domestic purposes has increased from 5 cubic meters per capita to 25 cubic meters in rural areas, and to 75 cubic meters in urban areas. The number of villages connected to central water supply systems has increased from 50 in 1969 to 120 in 1986 with another 20 in advanced stages of implementation. This provides direct provision of safe supervised chlorinated water to the homes in place of previous reliance on cisterns or container water. Running water reaches 61.6% of homes in the area in 1985, as compared to 23.5% in 1974.

9.4 In Gaza, all towns and villages are now provided with safe, supervised domestic water since the area was linked to the Israeli National Water Carrier in the 1970s. As a result, running water now reaches 75% of homes in the Gaza area, as compared to 13.9% in 1974.

9.5 Garbage disposal is now organized on a municipal basis and has been vastly expanded and modernized. Improved facilities for solid waste collection and disposal have contributed to improved sanitation in Judaea, Samaria and Gaza. Disposal sites have been increased in number with improved management practices.

10. Planning

10.1 Emphasis has been placed on primary health care, sanitation, hospitals and health manpower development of health services in Judaea, Samaria and Gaza. Improved local research capacity contributes to the planning process.

10.2 The Joint Planning Committee on Health Services in Judaea, Samaria and Gaza report of 1985 provided a basic programme for further development to the year 1990 which is in the stages of implementation. In this report emphasis was placed on new stages in:

10.3 Master plans have now been completed for all the nine government hospitals in Judaea and Samaria. These plans include both programme and physical development for the period to 1992 for Judaea and Samaria, and they are being implemented.

10.4 Primary care services are being expanded in Judaea and Samaria by a number of important new initiatives. The Hebron Expanded Primary Health Care has now linked 50 small villages to the PHC system, providing onsite services in villages previously served by visiting immunization teams. This project is now being extended to 10 villages in the Jordan Valley, and further expansion to small villages in the northern districts is being planned.

10.5 The High Risk Pregnancy Committee established by the government health service in Judaea and Samaria is now implementing High Risk Pregnancy centers in all seven districts of the area with improved referral and diagnostic services. All 131 MCH clinics and 50 Village Health Rooms are using new pregnancy care records and high risk referral forms developed by this Committee as well as new child care records. Nursing and medical staff study days on high risk pregnancy identification and care are being carried out to implement this new programme.

10.6 In Gaza, a new master plan for development of hospital services has been completed based on consultation with senior local health personnel and Israeli consultants. This provides for development of the hospital services to the year 2000. It includes transfer of the Children's and Ophthalmic Hospital to the Shifa Medical Center, conversion of the Bureij Tuberculosis Hospital to a chronic care facility, as well as substantial expansion of the Shifa Medical Center bed and outpatient service capacities. A new hospital is to be built to replace the obsolescent Khan Younis Hospital to serve the southern part of the Gaza district. A new 200 bed hospital is planned to serve the middle area of the Gaza district

10.7 The Child Care Committee established in Gaza in 1986 includes senior child health personnel from the Government Health Service of Gaza, from UNRWA, the Ministry of Health of Israel, and from Terres des Hommes. This Committee meets regularly to review and develop plans for dealing with child health issues such as nutrition, immunization policy, parasitosis, anemia of infancy, cold injury, thalassaemia, diarrhoeal disease control, child health records, child development services, phenylketonuria and hypothyroidism screening and related issues. Operational decisions are taken in this committee which become part of the programme development of government and UNRWA health services.

10.8 The High Risk Pregnancy Committee of Gaza's health services has adopted a programme for high risk pregnancy identification and care. This includes improved records and referral forms, district high risk pregnancy clinics, regional birth centers. Two birth centers located in community health centers (CHC) of the Government Health Service in Gaza will be joined by a third one in a new CHC to be opened in 1988, and a further two in 1989. The objective of this programme is to increase hospital and medical center births to provide for all deliveries in the area over the next several years.

11. Summary

The process of expanding and improved quality of health care is a vital element in improving the quality of life of the residents of Judaea, Samaria and Gaza. For a population which is more than 50% under the age of 15, emphasis has been placed on primary health care and sanitation, as well as health education. Improving medical and hospital care has also been emphasized. Rising standards of living have also contributed very substantively to improved nutrition, community infrastructure and education levels. This process is one which takes place outside of the glare of international publicity that is associated with Judaea, Samaria and Gaza, but nevertheless has contributed very much to improved standards of life, and to hope for the future for all the people of the area.

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