Gaza crisis – WHO emergency operational plan

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WHO Emergency
Operational
Plan
Gaza Crisis
13 January 2009
Health Action in Crises

Background

As Israel’s military operation in Gaza enters its third week, the civilian population is bearing the brunt of the violence. More than 880 people have been killed and over 4000 injured in just sixteen days. Gaza is one of the world’s most densely populated places; it is clear that more civilians will be killed and more homes, buildings and civilian infrastructure destroyed if the conflict continues.  Health services in Gaza are under enormous strain and require urgent and wide-ranging support.

Pressures include:

1. Exhausted health service providers.

Emergency medical services (EMS) and trauma teams (physicians, nurses and other emergency staff) have worked constantly since the current conflict began on 27 December 2008. Urgent reinforcements are needed to help care for the critically wounded and avoid the risk of serious medical/surgical errors.

2. Restricted movement. The intensity of aerial bombardment and ground hostilities (dividing Gaza into three distinct, impenetrable portions) are seriously constraining the movement of patients, EMS, referral care, and critical health personnel.

3. Inefficient use of hospital capacity. Hospital emergency operations (emergency admissions, intensive care units, operating theatres) have been overwhelmed due to reportedly ineffective triage and restrictions on movements of the health workforce and patients. There have been reports of wounded lying on the ground in health facilities while beds lie unused elsewhere.

4. Damage to infrastructure of hospitals/health facilities. There are reports of damage to hospitals and health facilities close to targets that have been bombed/shelled – shattered glass, damage to walls and windows, and water/electricity pipes, all of which are essential to the effective functioning of these facilities.

5. Limited electricity/fuel supplies are seriously affecting infection control, blood transfusion, instrument sterilization, and basic sanitation and hygiene in hospitals, operation theatres and ICUs, with the potential for life-threatening hospital-borne infections (gangrene, septicaemia, tetanus, shock, etc.).

6. Difficulty in transferring the critically wounded outside Gaza due to insecurity, movement restrictions and the closure of crossing points.

7. Critical gaps in life-saving supplies. IV fluids, parental antibiotics, corticosteroids, surgical supplies/consumables, parental analgesics and other medicines and supplies are needed urgently. Many donations are held up at the border because of security constraints.

Since the ground incursion was launched on 3 January 2009, over 28 116 people have been displaced with no or extremely limited support services (health care, safe water, food, basic sanitation and hygiene) because of poor access and insecurity. The physical and mental trauma of the civilian population in Gaza, the continuing and prolonged disruption of basic health services, andithe added burden of displacement, are compounded by the increased risk of communicable diseases. Any disease outbreaks (e.g. acute respiratory infections, measles, acute watery diarrhoea) are likely to result in higher morbidity and mortality rates among children, newborns, and new and expectant mothers. Moreover, there are increasing numbers of patients with unmanaged chronic diseases and mental and psychosocial illnesses among the displaced populations.

The health system in Gaza

1. Hospitals

Gaza has 27 hospitals, 13 of which are managed by the Ministry of Health (MoH) with a capacity of about 1500 beds. Private and NGO hospitals together account for another 500 beds. MoH hospitals have been overwhelmed by the initial influx of patients. They have switched to emergency mode, discharging non-urgent patients whenever possible (some to NGO hospitals).

All MoH hospitals face daily power cuts and have been working solely on back-up generators since 3 January. UNRWA is working to provide hospitals with additional fuel. Seven more electricity generators for medical facilities have been sent to the Gaza Strip since the crisis began, and have been installed as emergency back-up at the main hospitals and the Central Drug Store.

Patient referral is one of the main challenges facing the health system. The MoH’s previously well-functioning referral system – in 2007 alone, some 9000 patients in Gaza were referred for treatment abroad – has been disrupted. Patient referrals are currently being arranged by the ICRC and the PRCS, in consultation with the MoH.

2. Primary health care

The MoH manages 56 primary health care centres (PHCCs) in the Gaza Strip, 24 of which are currently functioning as emergency centres. The MoH has reassigned several PHCC staff to work in hospitals. Some PHCCs have been damaged; others are able to function only intermittently because of their proximity to areas of high-risk.

UNRWA manages 18 PHCCs in the Gaza Strip. The agency is responsible for basic health services including maternal and child health, vaccination, non-communicable diseases and outpatient care.  UNRWA has assigned four PHCCs to act as emergency and evacuation centres. Staff of these PHCCs are working in two shifts, with a third shift

operating on-call. All UNRWA PHCCs are equipped with two months of medical supplies.

3. Mental health

MoH mental health teams are functioning, with all facilities open until 11am daily. Gaza’s community mental health programme, however, has been suspended after its premises were severely damaged by the shelling of a nearby police station.  Mental health staff make daily hospital visits to dispense mental health care to wounded and traumatized people.

4. Health personnel

Since the crisis began, health personnel have been working continuous 12-hour shifts. Staff who were on strike have returned to duty. Several health staff have been killed as a result of the violence. Intensive care units are overstretched, and there is limited capacity to carry out neurovascular, orthopaedic and open-heart surgery. The ICRC has

brought in a team of war surgeons to work at Shifa Hospital, where two Norwegian surgeons are also operating. More surgical teams are reported to be on their way.

Consolidated Appeals Process

The activities in the present proposal are in line with those outlined in the 2009 Consolidated Appeal (CAP) for the occupied Palestinian territory.  The main objective of the health component of the 2009 CAP is to reduce the health impact of the crisis and meet essential health needs, particularly of the most vulnerable. The CAP focuses on the need to ensure access to essential health services to the entire population, particularly vulnerable groups. Activities under the CAP will also advocate for health as a basic human right.

Activities

Activities completed/ongoing through strategically located operational hubs:

1. Jerusalem

• Health Cluster Coordinator (HCC) and two logisticians already deployed.

• Health Cluster activated and led by WHO in tandem with the Ministry of Health (MoH).

• Joint MoH/WHO emergency operations room set up in Ramallah.

• Delivery of supplies to Gaza from MoH, donors and health partners organized and facilitated.

• Delivery needs for public health interventions being assessed:

− supplies and equipment;

− provision of technical inputs and staff.

• 50 trauma kits (enough for 5000 interventions) and nine inter-agency emergency health kits (IEHKs) (basic medicines for 90 000 patients for three months) sent into Gaza.

• Daily situation reports on the health sector in Gaza produced and widely circulated.

2. Gaza

• Health Cluster activated and led by WHO in tandem with the MoH.

• Joint MoH/WHO emergency operations room set up.

• Delivery of supplies for Gaza from MoH, donors and health partners, organized, coordinated and facilitated.

• Delivery needs for public health interventions being assessed:

− supplies and equipment;

− provision of technical inputs and staff.

3. Rafah

• WHO staff working with Egyptian Red Cross at Rafah border.

• Operational and logistical platforms being set up.

• Delivery needs for public health interventions being assessed:

− supplies and equipment;

− normative guidelines and standards;

− provision of technical inputs and staff.

Response plan

The overall objective of the project is to reduce preventable mortality and morbidity caused by the incursion. Four specific objectives must be met in order to provide a rapid, coherent and effective response to the immediate challenges facing the health sector. WHO and partners will work to meet these objectives through strategically located

operational hubs:

1. Provision of life-saving trauma care to injured patients;

2. Ensuring that critical and basic health needs (including reproductive health/mother and child health (RH/MCH), immunizations, chronic/noncommunicable diseases) are met;

3. Psychosocial support and relief of Gazans;

4. Prevention, early detection and timely response to communicable disease outbreaks.

The proposed activities to meet these objectives, together with the main constraints, are set out in the matrix below.

WHO, in collaboration with health cluster partners is mobilizing all possible resources to mount an appropriate health sector response in pursuit of the above objectives.

Recognizing the strong operational presence in Gaza of the United Nations Relief Works Agency (UNRWA), WHO is coordinating all its operations with and in support of UNRWA. WHO will also take advantage of UNRWA’s operational and outreach platforms when scaling up its own operations, as and when security and access permit.

Human resource requirements

1. Immediate

• Health Cluster Coordinator and emergency coordinator (2) – Jerusalem and Gaza

• Emergency coordinator/trauma surgeon (1) – Rafah Border, Egypt

• Logisticians (4, including logistics supply system experts) – Jerusalem, Gaza, Rafah

• Communications specialist (1) – Jerusalem

2. To be deployed to Gaza as soon as circumstances allow

• Communicable disease epidemiologists/surveillance officers (3)

• Logistician (1)

• RH/MCH specialists (2)

• EH specialists (2)

• Hospital/trauma/referral care specialist (1)

• Humanitarian health information management officer (1)

• Mental health specialists (2)

• Field security officer (1)

• Health education/social mobilization specialist (1)

Barring radical improvements in security following a ceasefire, effective operations in Gaza will also depend on the availability of armoured vehicles and other ground support, including additional local staff in Gaza. These costs have been factored into WHO’s budget.

Assumptions

• An immediate cease-fire will be granted to allow humanitarian access for a brief period;

• The Rafah border will remain open in order to allow regular medical evacuations and the steady movement of relief supplies;

• A cease-fire within the next few days will be accompanied by a relaxing of restrictions on humanitarian agencies and improved access to Gaza.

Risks

• The conflict may worsen and spiral out of control, in which case access will be further curtailed and working through national staff may be compromised;

• The UN may have to evacuate all its staff;

• The conflict may also widen within the region, with population displacement in neighbouring countries. This could increase operational and service needs to support new areas of displacement and affected populations.

Estimated funding

requirements (US$)