Health conditions in the OPT – UNRWA report

WORLD HEALTH ORGANIZATION

FORTY-SECOND WORLD HEALTH ASSEMBLY

Provisional agenda item 29

HEALTH CONDITIONS OF THE ARAB POPULATION IN THE OCCUPIED ARAB TERRITORIES,

INCLUDING PALESTINE

The Director-General has the honor to bring to the attention of the Health Assembly the annual report of the Director of Health of the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) for the year 1988, which is annexed hereto.

ANNEX

UNITED NATIONS RELIEF AND WORKS AGENCY

FOR PALESTINE REFUGEES IN THE NEAR EAST

ANNUAL REPORT OF THE DIRECTOR OF HEALTH

1988

CHAPTER I. INTRODUCTION

Population

1. Overall the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) is caring for approximately 2 267 000 registered refugees (according to last estimate as at 30 June 1988) of whom more than one-third live in camps, while the rest live in cities, towns or village communities. The registered refugee population is distributed as follows: Lebanon 285 000, Syrian Arab Republic 266 000, Jordan 870 000, the West Bank 386 000 and the Gaza Strip 460 000. In the five geographical areas or territories called Fields of Operation 1/ about 2 000 000 refugees are thus eligible for health care services.

Health status

2. The overall crude birth rate of refugee population is estimated at 30 per thousand. However, the rates vary from one Field to another and are higher in Gaza than all the other Fields.

3. The average family size in the population covered by the Agency was estimated at six, with a male to female ratio of 51 to 49. The annual rate of population increase is estimated at 3%. Studies conducted over the last two decades in four of UNRWA's five Fields revealed a steady decreasing trend in infant mortality and that refugee communities have already passed the target of less than 50 deaths per thousand live births set out by the World Health Organization for developing countries by the turn of the century. The rates range from 30-40 per thousand live births. Coupled with a significant drop in these rates the pattern showed continuously decreasing mortality from infectious diseases and an increasing proportion of deaths from congenital causes and from causes which originate in pregnancy and childbirth.

UNRWA health care program

4. The UNRWA health care program, which is basically community-health-oriented, provides primary health care to the eligible refugee population, comprising: medical care services (both preventive and curative), environmental health services in camps and nutrition and supplementary feeding to vulnerable population groups. The level of service responds to the needs of the refugees, which in turn depend on their residence: camp residents use UNRWA facilities because of ease of access; other refugees living in towns or remote villages at a distance from the nearest Agency health center tend to share local community facilities, whether private, voluntary or public.

Overall health policy

5. UNRWA's policy is to maintain preventive and curative health services to eligible Palestine refugees that are consistent with the humanitarian policies of the United Nations and the basic principles and concepts of the World Health Organization and also with the development and progress achieved in public and medical care provided by the host Governments to their indigenous population at public expense. The prime objective of the Agency's health program is to promote the health of refugees and meet their basic health needs.

Coordination and Cooperation

6. The UNRWA Health Service is greatly reinforced by cooperation from several major sources. Within the United Nations system there is major support which reaches its highest expression in WHO and UNICEF. Since 1950, under the terms of an agreement with UNRWA, WHO has provided technical supervision of the program by assigning to UNRWA Headquarters, on non-reimbursable loan, WHO staff members, currently numbering six, including the Agency's Director of Health. The latter is responsible on behalf of the WHO Regional Director for the Eastern Mediterranean for advising the Commissioner-General of UNRWA on all health matters and for the implementation of WHO's policies as they apply to the Agency. The long-standing association with UNICEF has developed further over the period under review as many of the common policy objectives allow effective integrated work. Some new incentives have been made possible by the ready liaison with the UNICEF Regional Director.

7. Complementing the individual activities, several non-governmental organizations have been a ready source of advice and assistance in areas of common interest.

8. Acknowledgement is readily made of the important support and cooperation of the Host Governments. In many areas these authorities render direct assistance to the Palestine refugees, while in others there is valued coordination and integration of services.

Emergency Operations

9. 1988 confronted UNRWA with crisis in three of its five Fields of operation. In the Gaza Strip, West Bank and Lebanon, UNRWA has resumed relief work.

10. The emergency operation in these three Fields reverses the trend of the past years in which the Agency's operations, from providing immediate emergency relief and health services, shifted to place emphasis on education.

11. In the occupied territories the situation is unlikely ever to return to what it was before the beginning of the uprising. Even if the situation is stabilized there will probably be a higher level of activity required by UNRWA. This will have important implications for the Agency's planning and budgeting, and especially for health services, where the largest gaps exist.

CHAPTER II. GENERAL MANAGEMENT

Organization

12. The Director of Health is responsible to the Commissioner-General of UNRWA for the planning, implementation, supervision and evaluation of the health and supplementary feeding programs within the budgetary limits approved by the Commissioner-General. He is assisted in this task by a staff of professional and auxiliary health workers and manual workers, totaling 3078 as at 31 December 1988.

13. Since 1950, under the terms of an agreement with UNRWA, the World Health Organization has provided technical supervision of the Agency's health care programs by assigning to UNRWA Headquarters, on non-reimbursable loan, WHO staff members, currently numbering six, including the Agency's Director of Health. The latter is responsible on behalf of the WHO Regional Director for the Eastern Mediterranean for advising the UNRWA Commissioner-General on all health matters and for the implementation of WHO's policies as they apply to the Agency. Since 1978, the Department's Headquarters has been divided between Vienna and Amman. To attempt to achieve the necessary integrated team approach regular visits and meetings are made to Vienna and Amman.

14. The Department has five divisions: Curative Medicine, Preventive Medicine, Nursing, Environmental Health and Nutrition. The Curative Medicine Division includes the Pharmaceutical and Medical Supply Branch and the Preventive Medicine Division includes the Health Education Branch.

15. This organizational pattern is repeated in each of the five field health offices, located in Jordan, the West Bank, the Gaza Strip, Lebanon and the Syrian Arab Republic, which have departmental status within the Field Offices. In each case, the Field Health Officer reports directly to the Field Office Director for administrative purposes and to the Director of Health on technical matters.

16. The Department of Health continues to attach great importance to team work, coordinated staff planning and consultation in the development of health projects, and the evaluation of health programs. To this end, regular meetings of the senior health staff are held at Headquarters and in the Fields, the more important of which are the weekly staff meetings, the divisional meetings at Headquarters and the annual or biennial conferences of the senior Field health staff.

Direction and supervision

17.  The Director and Chiefs of each Division and Branch undertake regular periodic visits to each Field to review the work of the Department and ensure it reflects the approved policy and standards of the Agency.

18. This activity is reinforced by technical instructions issued by the Director of Health.

19. The supervision at Field level is undertaken by the Field Health Officer and his senior colleagues.

Planning and Programming

20. Comprehensive three-year medium-term plans for the general management and the three sub-programs, i.e., Medical Care Services, Nutrition and Supplementary Feeding, and Environmental Health Services, are prepared and reviewed each year with the main purpose of maintaining the overall framework for the progressive development and management of the programs carried out by the Agency. The 1988-1990 plan formed the basis for establishing policies, objectives and strategies for the health improvements funded from the Agency's operating budget and the Capital Project Fund.

Budget and finance

21. With the exception of the cost of international staff paid by WHO, the health budget is financed almost entirely from voluntary contributions in cash and in kind, mainly from governments and intergovernmental and non-governmental organizations.

22. Each year, budget preparation guidelines and budget ceilings are forwarded to the Fields for preparation of budget estimates which are reviewed by Headquarters, and budget allotments are authorized under each sub-program according to the approved policies for the new budget cycle.

23. Health services in 1988 accounted for US$ 43 940 000 or 20% of the total UNRWA budget as follows:

Health budget, 1988

(in thousands of US dollars)

24. The following table shows 1987 expenditure on the Health Program under the 1988 and 1989 approved health budgets, by Field:

Health manpower development

25. The Agency maintained and further developed its program of education and training in the field of health. Basic professional and vocational training is primarily the responsibility of the Department of Education, while in-service and postgraduate training is the direct concern of the Department of Health.

Basic professional education

26. The assistance provided for medical students includes maintenance grants, payment of tuition fees and an allowance to cover the cost of books, training material, instruments and other essential items. Students of both sexes have been encouraged to enroll in medical, dentistry and nursing education courses at universities and at schools of nursing. Scholarships for nursing education were donated by voluntary agencies.

Vocational training

27. The Agency provides at its vocational training institutions paramedical courses to enable refugee students to become assistant pharmacists, laboratory technicians, public health inspectors, physiotherapy technicians and dental hygienists. On completion of their training, graduates may join the Agency's service or be assisted-by the UNRWA Placement Office to find employment in the region.

In-service training

28. Continuing education was carried out by the Department of Health for its own staff in the various aspects of the program in accordance with the identified training needs and priorities for each Field of UNRWA operations. The objectives of continuing education of the health workers were to up-date the knowledge of those who acquired their basic training a long time ago, to change the attitude and develop the knowledge and skills of all staff and make them conversant with the global objective of achieving health for all by the year 2000 and with the modern strategies and approaches for its realization. The continuing education activities also aimed at orienting the newly appointed, transferred or promoted personnel, or at bridging some of the gaps that might have existed in their basic training in relation to the actual requirements of the practical field work of UNRWA, which is basically oriented to primary health care.

29. A large number of health personnel including medical, dental, nursing, sanitation, administrative and paramedical staff attended training courses, workshops, seminars and conferences of various durations.

30. The areas of training covered a wide range of primary health care activities comprising rational use of essential drugs; expanded program on immunization and cold-chain applications; oral health; communicable and non-communicable disease control; " risk approach" in maternal and child care; family planning; community health; health education; environmental health; laboratory techniques and management.

31. The training was carried out by UNRWA staff or arranged in coordination with WHO, local hospitals, universities, professional associations and non-governmental organizations.

32. Training activities involving several fields of operation included three workshops on control of diarrhoeal diseases (supervisory skills), rational use of essential drugs, and health education and health promotion.

33. The workshop on control of diarrhoeal diseases and supervisory skills was organized by the WHO Regional Office for the Eastern Mediterranean for participants from UNRWA and the Jordanian Ministry of Health. Two medical officers from each of the five UNRWA Fields of operation attended this workshop.

34. The workshop on rational use of essential drugs conducted in collaboration with the WHO Regional Office for the Eastern Mediterranean was attended by 25 medical officers, dental surgeons and pharmacists from the five Fields.

35. The workshop on health education and promotion was organized in collaboration with the University of Science and Technology, Jordan and the University of Jordan, and was attended by 15 medical officers and health education staff from the five Fields.

Postgraduate training

36. Through the sustained support of the WHO Regional Office for the Eastern Mediterranean, UNRWA's Health Department maintained an active postgraduate training program to develop the technical and managerial skills of its staff and to meet future replacement needs.

37. WHO fellowships: Nine WHO-sponsored fellowships were started or completed during the year (for details see Table 13 (B) of the statistical annex).2/

38. Fellowships awarded by non-governmental organizations: Two qualified nurses completed a six-month training course on care of the aged at Ipswich Hospital in the United Kingdom, sponsored by "Help Age" International.

39. One qualified nurse from the West Bank completed a one-year associate diploma program in community health nursing sponsored by Australian People for 'Health, Education and Development Abroad (APHEDA).

40. Two qualified nurses from the West Bank completed a one-year post-basic m midwifery course in Cyprus, also sponsored by APHEDA.

41. One qualified nurse from Gaza completed a one-year post-basic training in public health nursing in Cairo sponsored by British "Save the Children" Fund.

UNRWA's Health Department as a resource for training of-others

42. UNRWA's Health Department made its facilities and programs available for practical field experience to students and trainees of certain teaching and service institutions in the area, particularly in the nursing and paramedical fields.

Research and evaluation

43. Health services research/evaluation aiming at assessing program deficiencies and improving operational activity was carried out through internal reviews, joint planning missions or by WHO short-term consultants. The planned activities in this respect covered the following initiatives:

Research on patient-flow analysis

44. The first phase of a study on "patient flow analysis" was carried out in three health centers in Jordan Field. The main purpose of the study was to assist in finding solutions to operational and managerial difficulties encountered in UNRWA health centers with particular reference to patient flow. The research work was guided by a team from WHO headquarters, Geneva (Dr. R. Guidotti and Mr. N. Dreesch) and the Centers for Disease Control of the United States Public Health Services, Atlanta, GA., USA (Mr. J. Graves and Ms. E. Blaire, consultants), with participants from Jordan and Syrian Arab Republic and the UNRWA Department of Health, headquarters (Vienna and Amman).

Review of UNRWA policies on control of diarrhoeal diseases

45. Dr A. Khan, Regional Advisor, Control of Diarrhoeal Diseases, WHO Regional Office for the Eastern Mediterranean, visited Syrian Arab Republic and Jordan in November 1988 to assist UNRWA in developing policies for the control of diarrhoeal diseases, including target-setting, technical instructions, and prevention and management of diarrhea.

Study of the UNRWA cold-chain system

46. Mr. M. Haghgou, WHO/EMRO Consultant, visited Jordan and Syrian Arab Republic in July 1988 to assess the progress of the UNRWA cold-chain system.

Management review

47. Mr. J. Jorgensen, WHO Management Officer, visited UNRWA Headquarters in Vienna and Amman and Jordan and the Gaza Field in November 1988. The main objectives of the visit were focused on review of UNRWA managerial processes, organizational structure of the Department of Health, achievements and constraints, and overall relationship between WHO and UNRWA.

Assessment of sanitation facilities in refugee camps, Gaza

48. Mr. E. Jansson, WHO short-term consultant, carried out a general review of water supply and sanitation problems in refugee camps in the Gaza Strip with special emphasis on water salinity. The review was carried out from 6 January to 2 February 1989.

Association with the Centers for Disease Control of the United States Public Health Service, Atlanta, GA, US

49. Through the sustained support of WHO/EMRO, the association with the Centers for Disease Control, Atlanta, has been further reinforced by visits of Chiefs of Divisions to the Centers for training on use of minicomputer facilities and the development of health services research projects relevant to the various components of UNRWA's primary health care program, e.g., "patient flow analysis" in Jordan Field.

Conferences

50. Several meetings or conferences of the Health Department's senior staff were held to strengthen technical coordination between the two UNRWA Headquarters units, in Vienna and Amman, and the Fields. These comprised: the field nursing officers' meeting held in Vienna from 3 to 5 February 1988, the field health officers' meeting held in Vienna from 12 to 1~ April 1988, and the deputy field health officers' and field pharmacists' meeting, held in Larnaca, Cyprus from 24 to 26 May 1988.

51. The association with the World Health Organization was maintained through regular contacts, attendance of the Director of Health and Chiefs of Divisions at WHO conferences and meetings and through exchange of visits of senior UNRWA staff to WHO headquarters, Geneva and the Regional Office in Alexandria, and visits of the WHO Regional Directors and Regional Advisors to UNRWA Headquarters in Vienna and Amman, and to UNRWA's Fields of Operation.

52. During the year the Director of Health and Chiefs of Divisions participated in the following WHO meetings and conferences:

– WHO Executive Board, eighty-first session, held in Geneva from 11 to 20 January 1988.

– The Inter-Agency meeting on the aged, held in Vienna on 9 and 10 March 1988.

– Forty-first World Health Assembly, held in Geneva from 2 to 13 May 1988.

– The thirty-fifth session of the Regional Committee for the Eastern Mediterranean, held in Geneva from 3 to 6 October 1988.

– The Fourth Inter-country Meeting for National Managers of Programs for the Control of Diarrhoeal Diseases, held in Cairo, Egypt, from 25 to 29 June 1988.

CHAPTER III. EMERGENCY OPERATION IN THE OCCUPIED TERRITORIES

The population

53. A total population of 1.6 million lives in the Occupied Territories of the West Bank and Gaza Strip, of whom 715 000 are registered refugees who are basically eligible for UNRWA services. Approximately 25% of the refugee population live in 19 camps in the West Bank and 55% live in eight camps in the Gaza Strip. The remaining population live in cities, towns and villages and share the facilities with the resident population.

54. There are significant variations in the health status, socioeconomic conditions and standard of health care facilities between the two Fields.

55. The crude birth rate is estimated at 30 per thousand.

56. Data collected from the West Bank, where infant mortality studies have been closely monitored over more than twenty years, reveal a steady decline in infant mortality rates. In 1987 the rate was estimated at 24 per thousand in camps. In Gaza, where the problems of overcrowding, the ever increasing economic hardship and the squalid environmental health conditions continue to pose serious constraints on UNRWA's ability to attain further improvements in the health status of the refugee population, the rates are still much higher, i.e. approximately 40 per thousand.

UNRWA's health care program

57. UNRWA provides primary health care to the eligible refugee population, comprising: medical care services (both preventive and curative), environmental health services in camps, and nutrition and supplementary feeding to vulnerable population groups.

58. In the Occupied Territories of Gaza and the West Bank these services are provided through a network of 42 health centers/points, 6 maternal and child health care sub-centers, 15 dental clinics, 8 maternity centers, 15 laboratories and 46 supplementary feeding centers.

59. This infrastructure of primary health care facilities is supported by hospitalization schemes providing in-patient care at one private subsidized hospital in Gaza and four in the West Bank, a 36-bed hospital operated by UNRWA in Qalqilia, West Bank and a 70-bed tuberculosis hospital in Buraij, in Gaza (operated jointly by UNRWA and the Public Health Department).

60. In addition 75 beds for mental patients are reserved at a government hospital for treatment of refugees in the West Bank. In Gaza, where hospital beds are extremely inadequate, UNRWA maintains a scheme for reimbursement of hospital expenses incurred by social hardship cases and refugees in need.

61. UNRWA has attained full immunization coverage of pre-school and schoolchildren and pregnant women in camps, has controlled the incidence of major epidemics of communicable diseases preventable by immunization, and has passed the target of less than 50 deaths per thousand live births by the year 2000 set by WHO for developing countries.

Problems and needs

62. In spite of UNRWA's major achievements in primary health care, the prevalence of infectious and parasitic diseases remain at a more or less stable plateau; no major breakthrough is expected to reduce their incidence. The incidence of chronic and degenerative diseases is on the increase and anemia is highly prevalent among children and among women of child-bearing age.

63. Liquid waste in most refugee camps is disposed of through surface drains constructed by the refugees themselves under UNRWA self-help projects.

64. Liquid waste from domestic sources, cesspits and surface drains often flows onto the narrow roads and pathways inside camps and forms large stagnant: pools, producing all kinds of health hazards and offensive smells. During the rainy season, muddy water running down hills and effluents contaminated with human and animal excreta flow into the surrounding agricultural land and are often used for irrigation of vegetable crops. The need for construction of proper sewage disposal systems and treatment plants is one of the major priorities.

65. The problems of water supply, especially the increased chloride and nitrate content in the middle camps and southern parts of the Gaza Strip, have become very serious and are adversely affecting the health status of the population and agricultural welfare.

66. These problems represent major challenges to UNRWA because improvement of camp infrastructure for environmental health facilities would involve a major shift from low-cost, simple-technology projects towards major health development projects requiring substantial funding, technical expertise and full coordination and integration of camp water-supply and sewage disposal systems as part of the related schemes of local authorities or municipalities.

67. The majority of the refugee populations in both Fields cannot meet the high cost of participating in the public health insurance scheme. The situation is even worse in Gaza, where there is one private 65-bed hospital at which UNRWA subsidizes 40 beds. The facilities at this hospital are very modest and the number of beds is hardly sufficient for acute emergencies.

68. There is an obvious need for the construction, equipment and operation of a large hospital for the basic secondary and tertiary care that cannot be provided elsewhere.

Effects of the emergency on health operations

Immediate effects

69. Health services, including medical care, environmental sanitation and supplementary feeding, were all adversely affected by demonstrations, general strikes, curfew measures and the declaration of certain areas as "military zones". These effects were felt, at random, in camps, towns and villages and caused a great deal of suffering both to refugees and the non-refugee population in the Occupied Territories of Gaza and the West Bank. Coupled with the large-scale waves of violence, the economic hardship resulting from loss of working opportunities and depletion of available stocks of food for the local market, rendered the already squalid conditions even worse.

70. Despite repeated assurances of free movement of UNRWA personnel, vehicles and supplies, the attitude of troops was anything but cooperative.

71. In camps under prolonged curfew, garbage could not be collected for several days running, increasing exposure to health hazards of diseases transmitted in the environment.

72. Not only UNRWA health operations were disrupted; clinics and hospitals were vandalized by those searching for wounded or injured persons.

73. Maternal and child health services, including the immunization program, and dental care services and laboratory services were all adversely affected. School health services continue to be disrupted by closure of schools, especially in the West Bank.

74. Supplementary feeding operations suffered with decreased attendances due to difficulty in movement of staff, refugees and supplies. The ever-increasing number of casualties, the complex nature of injuries and the prolonged stay they require, not only taxed UNRWA clinics and subsidized hospitals but also other, private and voluntary medical care facilities.

75. This necessitated additional resources to fund expensive medical equipment and supplies.

76. UNRWA's health care system, which has over the last four decades been developed as a primary health care program focusing on preventive and promotive activities, was neither prepared nor fully equipped to face the large-scale emergency and the heavy toll of casualties. Staff needed short in-service training in first aid. Surgical dressings, sutures, oxygen cylinders and sera were in short supply. The comminuted factures resulting from the use of high-velocity ammunition required special fixators which were not locally available. Physiotherapy facilities for early rehabilitation of disabilities were very modest.

77. The number of ambulances readily available at UNRWA health centers and local hospitals was far from adequate.

78. An immediate response was required from UNRWA to the new situation. However, even with the major change of emphasis, the medical profession is still unable to assess the short- and long-term risks of unknown chemical agents fired or dropped from helicopters around and inside homes, schools and other premises.

Long-term effects

79. Should such a situation continue for a long time the UNRWA primary health care activities will be adversely affected because increasing numbers of newborn infants, children, pregnant women and sick elderly people will be deprived of health care supervision, regular monitoring, immunization, nutritional support and timely case management.

80. UNRWA health personnel have been able to sustain the high level of immunization coverage in camps, but many children were not vaccinated according to schedule. Booster immunizations for schoolchildren, especially in the West Bank, were seriously disrupted.

81. The psychological effects of the situation on children and groups at risk could not so far be assessed, but the large-scale violence would certainly have had adverse effects on them.

82. The heavy toll of injuries and their serious sequelae not only require the establishment of special programs for treating and improving conditions but also necessitate the expansion of UNRWA's social welfare program to compensate the increased loss of working opportunities due to permanent disabilities among bread-winners.

83. Another major challenge is the increasing non-eligible and non-refugee population calling upon UNRWA health centers for emergency medical assistance including in-patient hospital care and nutritional assistance.

84. UNRWA cannot refuse such emergency relief assistance in accordance with the humanitarian policies of the United Nations, but if it continues for a long period, the extra demand will affect UNRWA's mandate and require substantial additional funding.

Casualties

85. As the uprising reached its first anniversary, a total of 336 people had been killed and 17 233 injured. The table on pages 16 and 17 provides a summary showing the number of cases receiving first aid at UNRWA health centers or referred to hospitals. The age-span ranges from two months to 65 years. In Gaza, over 40% of the injured were children below 15 years of age.

86. The injuries included wounds from gun-shot, rubber and plastic bullets, plastic-covered metal balls, severe beatings and poison gas. Each of these forms of injury caused some deaths.

87. A detailed assessment is currently being made of the needs in manpower, additional skills, supplies, equipment and improved facilities to enable UNRWA to provide more adequate emergency medical care and to cope with casualties which seem to increase rather than decrease in number and severity.

88. Tear gas is often used, with typical effects of eye irritation and tears, nose and sinus irritation and a variable degree of throat constriction and breathing difficulty. All too frequently, despite clear labeling in large type stating that tear gas shells, grenades and canisters should not be used in confined spaces, they have been fired or thrown into dwellings, schoolrooms or clinics. With the resultant increased concentration, they cause much greater physical and mental distress. This is particularly dangerous for infants whose bronchial tubes are so small that the mucus resulting from the irritation by the gas can have fatal consequences. Again, with elderly people who have chronic bronchitis, asthma and heart disease, there have been deaths.

89. Other gases have also been used with various serious consequences including severe abdominal colic, muscle paresis, first-trimester abortion and third-trimester premature labor.

90. To assist the victims, details of the composition of the gases, their effects, antidotes and recommended treatment are necessary.

UNRWA’s response

91. By early January it was already apparent that there would be no rapid end to the uprising and to the mounting demands upon the Agency to increase its services to refugees in the occupied territories. At a special meeting with permanent missions accredited to the United Nations at the UNRWA Headquarters office in Vienna, the Commissioner-General emphasized the need for an expanded relief effort and to improve living conditions for camp residents. Later in the month, in his report to the Security Council (document S/19443) the Secretary-General noted that he had asked the Commissioner-General to prepare proposals for improving the infrastructure of the camps and to seek the necessary funds. The Secretary-General also suggested it would be appropriate for UNRWA to be permitted to provide humanitarian assistance as far as practicable, on an emergency basis and as a temporary measure, to non-refugees who were in serious need of assistance because of the current events.

92. At an informal meeting at Vienna on 29 February and 1 March 1988, UNRWA presented to representatives of major donor and host governments a plan of action for addressing these needs. The plan was then estimated to cost some US$ 65 million and to require a period of three years, from 1988 to 1990, for implementation. The Agency's approach was generally welcomed and a detailed account of the views expressed at the informal meeting was presented to an extraordinary meeting of the UNRWA Advisory Commission on 2 March. The Commission members noted the Agency's proposals for expanding and improving its facilities for providing health, education and social services to refugees while continuing to meet immediate emergency relief needs. They supported the recommendation that UNRWA should seek the resources necessary to provide greater assistance to refugees living in sub-standard conditions. They also urged the Commissioner-General to provide humanitarian assistance to non-refugees and, in coordination with other international organizations and voluntary agencies, to seek ways to assist in monitoring the maintenance of basic civil and human rights in the occupied territories.

93. The Commissioner-General approved a special financial plan for extraordinary assistance in the occupied territories, which included the following health measures:

– extension of the midday meal program to 20 000 children, up to the age of 10 years, in addition to some 15 500 children who are normally eligible for the program;

– extension of powder-milk distribution to 13 000 children below three years of age, in addition to 39 500 who are normally eligible for the program,

– extension of the dry-food ration program to all pregnant women and nursing mothers irrespective of category of registration, thus providing for 5000 additional rations over and above the approximately 21 000 normally distributed;

– allocation of additional budgetary provisions to meet hospitalization costs resulting from the emergency;

– establishment of additional medical teams (each composed of a medical officer and a practical nurse) to keep UNRWA clinics open until 1900h in large camps. This included 15 emergency afternoon clinics in the West Bank and eight clinics in Gaza, plus one additional day-time emergency clinic in Beach Camp (Gaza) to ensure easy access of camp residents to the service because the main center is located outside the camp.

94. The Commissioner-General also approved the establishment of two night-duty emergency clinics in Gaza with effect from 1 January 1989; and

– establishment of five physiotherapy clinics in Gaza funded by UNICEF, and establishment of a physiotherapy clinic funded by the European Economic Community and operated by "Médicins sans frontiéres in Balata camp, West Bank;

– addition of 13 ambulances to the present fleet of UNRWA health buses;

– provision of additional equipment for UNRWA health centers and local hospitals to cater for the new needs of treating refugee patients and injured persons.

95. In addition to the immediate extraordinary measures outlined above, the Agency has developed an expanded program of assistance to the occupied territories which aims at the improvement of environmental sanitation in refugee camps and at making health care more accessible by improving the health infrastructure, developing community "outreach" activities and extending support to local hospitals.

96. The international community has responded very positively to the new needs and demands which emerged as a result of the uprising. Contributions in cash and in kind were received or pledged both for the emergency measures and for the expanded program of assistance.

97. The Governments of Italy, the United States of America and of Arab States were among the major contributors. Also, generous contributions were received from the European Community, and international, non-governmental and local organizations.

98. However, the actual needs far exceed the immediate relief effort and the medium-term plans to alleviate the suffering of the population. Much help is still required to improve living and health conditions to the entire population, but even then the final solution to the problem lies in implementing the United Nations resolutions and according to the people of the occupied territories ever their most basic human rights.

INJURIES AND FATALITIES IN THE OCCUPIED TERRITORIES

9 December 1987 – 8 December 1988

[Note: The figures given below are those reported to or made known to UNRWA and include not only registered refugees but other Palestinians not registered with UNRWA. The information is derived from UNRWA health centers and private hospitals. It is by no means exhaustive because the figures do not include persons who sought medical care at private clinics or refrained from seeking medical attention for fear of arrest.]

I. West Bank

A. Injuries

II. Gaza Strip

A. Injuries

Emergency operation in Lebanon

99. In general, UNRWA was able to resume normal health operations in all areas of the Lebanon Field, including medical care, nutrition and supplementary feeding and environmental health services in refugee camps.

100. Health services in Burj el-Barajneh and Shatila camps in central Lebanon and Rashidieh camp in Tyre, which had been under siege by local militia since the last quarter of 1986, started to return to normal after the siege was lifted late in January 1988.

101. However, the health conditions of Palestine refugees in Lebanon continued to be adversely affected by the deteriorating security situation and increased socioeconomic hardship. Despite the special precautions to reduce risks to international and area staff, two UNRWA international staff members were kidnapped on 5 February 1988. The Agency had immediately to adapt to the new situation while seeking to minimize the effects on refugees. Even after the release of the two staff members, movement of UNRWA staff and refugees was on many occasions restricted by fierce fighting and. tension.

102. Israeli air raids on camps represented an added risk to refugees' lives and to their security and stability. Several thousand who fled from areas of intense fighting remained displaced, and UNRWA was obliged to make special temporary arrangements for provision of medical care and nutritional support to families in new places of refuge.

103. In view of mounting and generalized hardship brought about by the worsening economic conditions, the Commissioner-General authorized provision of Agency services to all categories of Palestine refugees in Lebanon up to the end of 1988.

104. The temporary emergency measures comprised the provision of medical care services at UNRWA health centers and subsidized hospitals, as well as nutritional support to additional numbers of Palestine refugees.

105. Special budget provisions for medical supplies and hospitalization were allotted over and above the approved operating budget.

106. Special funds were also allotted to cover the cost of necessary repairs to the damaged health facilities and rehabilitation of water supply and sewerage systems in camps which were under siege.

CHAPTER IV. CURATIVE MEDICAL CARE SERVICES

General

107. UNRWA provides curative medical care services to about two million Palestine refugees and to locally recruited staff members and their authorized dependants.

108. The services comprise out-patient medical care, in-patient medical care, dental care, rehabilitation of physically disabled children, essential support services such as laboratory and radiological services, specialist and special care services and provision of medical supplies.

Mode of operation

109. Out-patient medical care is provided through UNRWA's infrastructure of health centers or points established in and outside camps. The services are provided by locally recruited staff and comprise a wide range of clinical facilities forming tart of primary health care approach. (For details see Table 2 of the statistical annex. 3/)

110. This basic infrastructure of clinical facilities is supported by secondary medical care facilities provided mainly through contractual arrangements comprising specialist out-patient care, in-patient medical care, specialized laboratory investigations, radiological services and physical rehabilitation of crippled children.

Policy

111. The Agency's policy is to provide basic curative medical care services, free of charge, to eligible Palestine refugees and to locally recruited staff members and their dependants who are not participating in Agency-sponsored insurance schemes.

112. Primary, secondary and tertiary care are provided according to the following policies:

113. At the primary level: The policy is to provide essential out-patient services to eligible refugee populations through UNRWA's expanded facilities of general and special care clinics, central and clinical laboratories and dental clinics, which are integrated with the health center as part of the primary health care approach, preventive and curative medical care being supplemented by nutritional and environmental health activities in camps.

114. At the secondary level: The policy is to provide referral and support services to eligible refugees, comprising in-patient care at UNRWA's operated or subsidized hospitals, and specialist and rehabilitative care and other basic support services through contractual arrangements.

115. At this level UNRWA also partially subsidizes the cost of prosthetic devices required for disabled persons.

116. At the tertiary level: The policy is to provide partial subsidies for individual patients for emergency life-saving treatment at the specialized health institutions in the area of operation, provided that it does not involve long-term commitment.

Objectives

117. UNRWA thus aims to reduce morbidity, disability and premature mortality from non-communicable diseases by developing and maintaining appropriate surveillance/intervention strategies based on medical technology.

118. It also aims to enhance the ability of individuals, families and groups at risk to develop to their full health potential by assuming responsibility for their own health, avoiding health-damaging behavior and fostering life-styles conducive to health.

Achievements

Out-patient medical care

119. Analysis of data collected from the five Fields revealed that the overall rate of utilization of UNRWA out-patient clinics (i.e., the proportion of refugees who sought medical care out of those entitled to such services during 1988) was 81%. In general, the demand for out-patient medical care was on the increase in all Fields owing to the expansion or improvement of UNRWA facilities, the increased cost of medical care in the area of operation, and increased socioeconomic hardship. Medical consultations in the whole area covered by the Agency including initial and subsequent visits increased from about 3.0 million in 1987 to 3.8 million in 1988, i.e., by 26%.

120. The highest rate of increase in the number of patient consultations was reported from the West Bank Field in spite of the restrictive measures imposed on camps, towns and villages during the year.

121. The projects for replacement of inferior health premises and extension of health facilities progressed as follows:

– in Jordan Field, new premises for the health center in Marks camp and a cool store at the Field pharmacy were constructed thanks to a contribution front the Canadian Government;

– work on the construction of a new health center in Jarash camp funded by the Danish Refugee Council is nearing completion;

– the projects for expansion of the health centers for Zarqa and Jabel el-Hussein camps were funded from UNRWA's budget. Also, funds were allocated from UNRWA's budget for expansion of the Beqa'a camp's child health clinic and the Irbid camp's health center;

– in the West Bank, construction of a new surgical ward at the UNRWA-operated hospital in Qalqilia was completed, and equipment was made available. The new unit is expected to come into operation early in 1989;

– the projects for construction of a maternal and child health sub-center at the Arroub health center and renovation of the Askar health center were funded by contributions from the Canadian Government. Work on the extension of the Ama'ri camp's health center is nearing completion also thanks to contributions from the Canadian Government. Funds for the construction of a new health point in the Deir Ammar camp and extension of health centers in Balata, Hebron and Fara’a were contributed by the World Center for Studies and "Research of the Green Book", Libyan Arab Jamahiriya;

– in Gaza, work is progressing on the construction of a new health center in Gaza town to replace the old rented premises, thanks to a contribution from the Finnish Government;

– in the Syrian Arab Republic Field, work on the construction of a combined health and nutrition center in Muzereib is progressing, and plans are underway for a similar construction project in Hama. The necessary funds for these two projects were allocated from UNRWA's budget.

122. In all, 114 additional medical, nursing and other professional and ancillary health staff posts were established to reduce workloads in health centers and to implement new primary health care activities.

123. Significant improvement of medical equipment was made possible through allocations from the UNRWA budget and the generous donations by governments and non-governmental organizations.

124. Specialist services and special care clinics were further expanded by the establishment of two eye disease clinics in the Rimal and Khan Younis health centers in Gaza, four diabetes clinics in Lebanon and two in the Syrian Arab Republic Field, one hypertension clinic in Jordan Field and four family planning clinics in the Syrian Arab Republic Field.

125. These improvements brought the number of clinics operating in 1988 to 16 special clinics supported by 46 clinics for diabetes care.

In-patient medical care

126. In all Fields, UNRWA maintained its hospitalization schemes at private subsidized hospitals, meeting the additional cost of their services.

127. The number of beds subsidized in the Syrian Arab Republic and Gaza Fields was increased by seven and five beds respectively, and four additional beds for ear, nose and throat conditions were subsidized in the West Bank.

128. In Jordan Field, arrangements were made for the subsidizing of five beds for pediatric care in Ibn Cina Hospital in Zarqa Town by the redeployment of beds previously contracted at the Red Crescent and the Italian Hospitals.

129. The Agency was also successful in seeking donations for upgrading the standard of facilities and equipment at subsidized hospitals in the West Bank and Gaza.

130. In this regard, the Danish Government contributed funds to upgrade the equipment at St. Johns Hospital in Jerusalem, Ittihad Hospital in Nablus and Makassed Hospital in Jerusalem. The Swedish Government contributed towards the upgrading of equipment at Augusta Victoria Hospital in Jerusalem.

131. In Gaza and Jordan Fields, where wider provision of beds is still needed, the Agency maintained a scheme for reimbursement of costs of hospitalization for special hardship cases and refugees in need.

132. UNRWA continued to meet part of the cost of specialized emergency life-saving treatment, mainly for cardiac and neurosurgery cases. Forty patients benefited from this assistance during the year.

Oral health

133. Major developments in the Agency's oral health program were attained by the establishment of additional dental teams, provision of capital equipment, standardization of supplies and appointment of dental hygienists.

134. In Jordan Field a new dental team was established at the Zarqa camp health center, and two dental hygienist posts were established at the Marka and Irbid camps. A dental unit was donated by the British Embassy in Amman, for the Talbieh camp health center. In the West Bank two additional dental teams were established in Bethlehem town and the Tulkarem camp; in Lebanon a new dental team was established in the Tyre area, and the dental services were expanded to four localities.

135. These major developments provided the necessary infrastructure for developing and maintaining a health strategy based on wider coverage and the "risk approach" directed towards schoolchildren, pregnant women and nursing mothers. The strategy was further reinforced by oral health surveys, active surveillance and health education.

136. The achievements were rewarded by higher coverage rates measured by the number of dental treatments. The overall rate of increase for 1988 over 1987 was 20% for the whole area covered by the Agency.

Laboratory services

137. In line with the Agency's established policy of expanding clinical laboratories, two additional primary health care laboratories were established in the Jalazone and Tulkarem health centers in the West Bank. In the Syrian Arab Republic Field, laboratory services were extended to two additional localities, and in Lebanon a contractual arrangement was made with a private laboratory in Zahle, Beqa'a area.

138. In all, three central and 32 clinical laboratories were operating during the year. UNRWA also maintained contractual arrangements with eight private laboratories for bacteriological tests and other pathological tests of public health importance.

139. The overall increase of laboratory tests performed for the Agency in 1988 compared with 1987 was 23%.

Radiological services

140. Provision of the necessary referral facilities to support primary health care continued through the use of Basic Radiographic System (BRS) machines.

141. Two additional units, one donated by the WHO Regional Office for the Eastern Mediterranean and one by the OPEC Fund, were received and will be installed in the Am'ari camp and Hebron town health centers, West Bank, subject to completion of construction or extension work in the two centers.

142. Other X-ray services continued to be provided at subsidized hospitals or through contractual arrangements.

Rehabilitation of physically handicapped children

143. Facilities for the management of disability among the refugee population are still modest. Greater emphasis is placed on programs aiming at prevention of disability among the vulnerable groups.

144. Crippled children received treatment as out-patients or in-patients at contractual physical rehabilitation centers, both private and governmental. During the year 550 children benefited from this service in the West Bank, Gaza and Syrian Arab Republic Fields. In Jordan Field, crippled children received similar care at the government rehabilitation center in Amman.

145. UNRWA also provided financial support for the purchase of prosthetic devices recommended on medical grounds for schoolchildren and others who suffer functional impairments and disabilities, such as eye-glasses, hearing-aids and orthopedic devices.

146. In Gaza and the West Bank a new physiotherapy program has been started as part of the extraordinary measures within the existing health centers. In the Gaza Strip 1534 patients have been treated in the five physiotherapy clinics which were established in June 1988 thanks to a contribution from UNICEF. In the West Bank 158 cases have been treated by two physiotherapists seconded by "Médicins sans Frontiéres" in the physiotherapy clinic established in the Balata health center in September 1988. The cost of this unit was covered by a contribution from the European Economic Community.

Medical supplies

147. Essential medical supplies and equipment as planned by the Department of Health continued to be purchased on the international market and through UNICEF. Vaccines and cold-chain supplies for the expanded programmme on immunization continued to be met with the sustained support of UNICEF.

148. Occasional shortages were met from the Director of Health's Stock Reserve and through local purchases.

149. The value of medical supplies and equipment received as contributions to UNRWA health centers and subsidized hospitals amounted to US$ 1 776 387, while purchases during the year totaled US$ 2 365 525.

150. A general review of the medical supplies catalogue was carried out, and additions and deletions were made in accordance with the WHO list of essential drugs. Reviews were also made for standardization of dental and laboratory equipment, instruments and supplies, with the aim of increasing efficiency in health care.

CHAPTER V. PREVENTIVE MEDICAL CARE SERVICES

General

151. Preventive medical care services represent the backbone of UNRWA's primary health care program. They comprise epidemiology and communicable diseases control, maternal and child care services, school health services and health education.

152. Increasing emphasis is being placed on the development of preventive and promotive programs directed towards non-communicable disease control, mental health and health care of the elderly.

Mode of operation

153. Preventive medical care services are provided to vulnerable population groups including pregnant women, nursing mothers, infants and children up to the age of three years, to pre-school children needing special care up to the age of five years and to schoolchildren 6-15 years of age.

154. The services are provided through the maternal and child care clinics integrated within UNRWA's network of health centers and points or through maternal and child health sub-centers established in areas where the population do not have easy access to the main centers.

155. The maternal and child care services are complemented by preventive school health services for children 6-16 years of age and by other essential primary health care activities, including communicable disease control, nutrition support and health education.

156. The wide range of preventive and promotive activities is provided in the following manner:

157. Maternal care includes medical supervision and regular health monitoring through monthly visits to the ante-natal clinics, issue of dry rations, treatment of anemia throughout pregnancy and the nursing period and immunization of pregnant women with tetanus toxoid. Special care is provided to pregnant women at especially high risk.

158. Child care services include growth monitoring of children from birth to the age of three years – on a monthly basis for infants, every two months for the age-group from one to two years, and every three months for the age-group from two to three years.

159. The care also comprises immunization against the six target diseases of the Expanded Program on Immunization: tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis and measles. Children failing to grow properly receive special attention and care in the nutrition rehabilitation clinics or at the supplementary feeding centers.

160. Epidemiological surveillance of certain communicable diseases is maintained in the whole area covered by UNRWA through weekly incidence reports from its health centers and points, with special epidemiological investigations where indicated. The UNRWA Department of Health continued to provide WHO and the public health departments of host Governments with information on the incidence and prevalence of communicable diseases.

161. Family planning services are mainly limited to health education on child-spacing and advice on the use of safe family planning methods to avoid high-risk pregnancies, or on demand. However, full family planning services including contraceptive supplies are provided in some health centers in Gaza, Jordan and Syrian Arab Republic Fields. Family life education is provided in preparatory schools for boys and girls in Gaza.

162. School health services comprise thorough medical examination at school entry, including eye-sight screening, and back-up immunization against diphtheria, tetanus and tuberculosis. Vaccination against rubella and a booster dose of tetanus toxoid are given to preparatory school girls. These services are provided either by school health teams or by camp medical officers. Regular visits are paid to schools for health monitoring of the pupils and inspection of school premises. Schoolchildren with suspected visual or hearing defects are referred for investigation in the health centers or by specialists.

163. Non-communicable diseases prevention and control programs are provided by specialists and special care clinics as part of the health center activities. There are clinics for cardiovascular diseases, hypertension, ophthalmology, dermatology, diabetes

and respiratory diseases.

164. Besides early detection and prompt treatment, health education and preventive measures are emphasized.

165. Health education is an integral part of the regular work of health staff at all levels. There is a health education branch, whose activities are geared both to assist colleagues and carry out additional health education work.

166. A major advance in this program has been the mobilization of teachers to give health education as part of normal tuition. The teacher-pupil-parent approach supported by school health committees has already produced good results.

167. Health education material, produced by UNRWA or UNICEF or the public health departments of host Governments, is used.

Policy

168. The UNRWA policy is to provide, free of charge, preventive medical care services to eligible Palestine refugees, with special emphasis on vulnerable groups.

169. In line with this overall health policy the following specific policies are adopted:

Maternal care

170. Medical supervision and protection are provided for pregnant women and nursing mothers through regular monitoring of those registered at its maternal and child care clinics throughout pregnancy, starting as early as possible after confirmation of the pregnancy, at delivery and during lactation.

171. At delivery assistance is provided to women in labor at camp maternity centers where facilities are available or safe delivery at home is ensured by trained midwives or supervised traditional birth attendants; high-risk pregnancies are referred to subsidized hospitals, or financial assistance is provided for such care at government hospitals when no maternity beds at subsidized hospitals are available.

Child care

172. UNRWA also provides medical supervision and protection to infants and pre-school children, through regular growth monitoring and immunization of those registered at its maternal and child care clinics from as early as possible after birth to three years of age, and to children of three to five years of age who require special attention.

Family planning

173. The policy is to provide family planning services focused on health education to women registered at UNRWA's maternal and child care clinics and to provide medical advice and assistance for the use of safe contraceptive techniques to women at risk, or to others on demand, with the objective of child spacing, not "birth control" per se.

Annex

174. Coordination with local health authorities and full acceptance by the population are prerequisites for the establishment or expansion of programs.

Communicable disease control

175. The policy is to protect the entire refugee population at risk against communicable diseases through the expanded program of immunization, management of diarrhoeal diseases by oral rehydration salts, maintenance of close surveillance of other communicable diseases in close coordination with the public health departments of the host Governments.

School health

176. The policy is to provide services to schoolchildren in the elementary and preparatory schools and to students at UNRWA's vocational and teacher training centers through medical examination at school entry, screening for handicapping conditions affecting performance at school, reinforcement of immunization and follow-up of morbidity conditions amenable to management.

Health education

177. The policy is to ensure health promotion and provide health education to refugees attending UNRWA's out-patient and maternal and child health clinics as an integral part of the regular work of all health staff, and to coordinate activities directed towards improving life-styles of groups at risk, through mobilization of teachers and other community organizations.

Objectives

178. The objectives of UNRWA's preventive medical care services are:

– to reduce morbidity, disability and mortality from communicable and non-communicable diseases by implementing the strategies and approaches adopted by WHO for realization of the global goal of health for all by the year 2000;

– to protect, preserve and promote the health of vulnerable population groups through regular monitoring, group screening, prophylactic immunization, nutritional support and implementation of "risk approaches" and strategies in primary health care;

– to discourage health-damaging habits and encourage behavior conducive to good health through health education and health promotion.

Achievements

Communicable diseases prevention and control

179. Target diseases of the Expanded Program on Immunization were well under control. No outbreaks of communicable diseases preventable by immunization were reported, and incidence rates continued to show a steady declining trend or nil incidence.

180. No cases of diphtheria, pertussis, poliomyelitis or tetanus (adult) were reported, and only one case of tetanus neonatorum was reported – from Syrian Arab Republic Field.

181. No cases of meningitis, rubella or cholera were reported during the year.

182. While communicable diseases preventable by immunization thus continued to be kept well under control, the incidence of communicable diseases transmitted through environmental channels, including diarrhoeal diseases among children, dysentery, infectious hepatitis and enteric fevers, did not show any significant decrease. Evidence has been established that brucellosis has become endemic in the region, mainly in Syrian Arab Republic and West Bank Fields. This has further emphasized the need for major improvements in camp sanitation and more intensive health education to interrupt disease transmission.

183. Pediculosis (infestation with lice) and scabies had reached endemic levels among schoolchildren.

Maternal care

184. More than 47 000 pregnant women were registered for ante-natal care at UNRWA's maternal and child care clinics. This represents overall coverage of about 78% of the expected number of pregnant women based on a crude birth rate of 30 per thousand eligible population.

185. Of all deliveries reported in 1988, 55% took place at subsidized and government hospitals and only 28% took place at home attended by Agency-trained midwives or by traditional birth attendants. In Gaza, where UNRWA operates six maternity wards in the large camps, 33% of deliveries took place in these wards, and only 18% at home.

Child care

186. A total of 129 000 children up to the age of three years were registered at UNRWA maternal and child care clinics for health supervision and immunization. This represents about 77% of the expected number of children in this age-group based on a crude birth rate of 30 per thousand and infant mortality rate of 35 per thousand live births.

187. The rate of utilization of the child care clinics, measured by average regular attendance, is estimated at 96%.

188. An important achievement in the maternal and child health services in the five Fields has been the steady overall decline in infant mortality rates. One of the main reasons for this decline was the remarkable drop in the number of infant deaths from gastro-enteritis following the introduction of oral rehydration therapy in early 1980. Respiratory diseases, prematurity and congenital malformations have become the three leading causes of infant deaths.

189. In Jordan Field, AGFUND financed the project for construction of two maternal and child care sub-centers in Beqa'a and Marka camps, and the Canadian International Development Agency (CIDA) pledged funds to construct a third such sub-center in Amman new camp. Construction of the first was completed and it was handed over towards the end of December 1988; the second was expected to be completed in January 1989.

190. In the West Bank, construction of a new maternal and child care center at the Arroub health center was completed and it was handed over in December 1988.

School health services

191. Some 351 000 schoolchildren in 628 elementary and preparatory schools were under the health supervision of school health teams and camp medical officers in 1988.

192. However, the program was severely disrupted in the West Bank by general curfew measures and closure of the schools for almost the whole first three-quarters of the scholastic year. Only 368 of 4627 new entrants were examined. The program in Gaza Field was also disrupted, but to a lesser extent.

193. Oral health education and screening of schoolchildren for dental problems were carried out as an established strategy, facilitated by the use of the mobile dental clinics made available in Jordan, Syrian Arab Republic and Gaza Fields.

194. Arrangements have already been made to provide the Fields with audiometers for mass screening of young schoolchildren for early detection and correction of hearing impairments. In Jordan Field, an audiometer was purchased with a contribution from the Canadian Embassy in Amman. The use of such equipment will be extended to all Fields.

Health education

195. The main emphasis of the program was directed towards fostering inter-sectoral collaboration and community participation in health education and health promotion.

196. Health education staff in all Fields concentrated their efforts on further activation of camp health committees and school health committees to encourage the. refugee population to assume responsibility for their own health and that of the community.

197. Health promotion and health education in relation to the environmental health project in Talbieh camp in Jordan proved to be very successful in increasing community awareness and active participation in reducing environmental health hazards and the proper use of available facilities.

198. A similar project in Qabr Essit camp in Syrian Arab Republic Field was implemented in coordination with UNICEF.

199. More teachers were enrolled in the special teacher/tutor training courses in Jordan, Gaza and Syrian Arab Republic Fields, aiming at enabling teachers to play an active role in health education and promotion through the school health committees and the community at large.

CHAPTER VI. NURSING SERVICES

General

200. UNRWA nurses provided basic and auxiliary medical services to the refugees in 98 health centers and points, in general, specialist and special care clinics, through school health programs, mobile units, and through the community health nursing program.

201. The Agency utilizes professionally qualified nurses to perform administrative, educational and supervisory functions, and practical nurses, midwives and traditional birth attendants to carry out the majority of nursing activities. There are also traditional birth attendants who receive their remuneration in the form of a fee for service; the majority carry out domiciliary care, others assist with simple clinic routine.

Mode of operation

202. At headquarters level the Chief of the Nursing Division is responsible for ensuring, through the proper channels, the organization, supervision and evaluation of the nursing programs in the Fields, as well as the planning and development of new nursing programs.

203. At Field level the Field Nursing Officer is responsible for the supervision and evaluation of the nursing program in the field to which he or she is assigned. At area level the Area Nursing officer (where such post exists) supervises the nursing activities in her respective area.

204. At health center level qualified nurses coordinate, supervise and assist in the evaluation of all nursing activities. They directly supervise auxiliary nursing staff and ancillary staff.

Policy

205. UNRWA policy is to provide nursing care services of good quality to-Palestine refugees as an integral part of its primary health care activities. A problem-solving approach with community participation is utilized.

Objectives

206. UNRWA's objectives are:

– to identify individuals, families and community groups that are in need of health care, particularly high-risk persons or groups;

– to plan nursing activities and measures based on identified health and health-related problems and community needs, according to UNRWA resources and acceptable standards of practice;

– to promote health education as part of nursing care through team efforts and community participation;

– to implement and evaluate a community health nursing program utilizing a problem-solving approach, that assists families and communities in coping with their health and health-related problems;

– to implement regular orientation and in-service education programs for UNRWA nurses;

– to plan higher educational opportunities for qualified nurses.

Current activities

207. Nurses are responsible for carrying out direct nursing care activities in all health centers and points, maternity wards, maternal and child health centers, school health programs and in the community.

Maternal and child health clinics

208. Maternal and child health services form the bulk of the work performed in the health centers and utilize all categories of nursing personnel to carry out pre-natal, intrapartum and postpartum care, as well as home visits, for various reasons, to pregnant or lactating mothers.

209. The services for children provide monitoring of the growth and development of all children, of immunization, referral to the physician of sick children and referral as appropriate for special care or rehabilitation.

210. Health education of mothers and families is carried out on a regular basis.

General clinics

211. Nurses provide various services at UNRWA's out-patient clinics, including injections, dressings and eye treatment. They also assist medical officers in all aspects of patient care and follow-up.

Maternity wards

212. UNRWA-trained midwives care for women in labor and are responsible for safe delivery in the maternity wards in Gaza and the West Bank Fields or at home, when called to perform such services. The postpartum period is monitored carefully, with scheduled home visits according to planned activities.

Nutrition rehabilitation clinics

213. Nurses supervise the running of these clinics and provide education for the mother to use her own or UNRWA's resources in providing adequate nourishment for her child.

214. Special care is provided to malnourished children and to children at risk of malnutrition at these clinics.

Community health nursing program

215. The community health nursing program, which was started in Jordan Field in 1983, has been introduced in all fields. Generalization of the program to all camps will be carried out simultaneously with additional staff provision and training.

216. Objectives.  The objectives of the program are:

– to increase the accessibility of health services for refugees;

– to develop health care according to identified community needs;

– to adapt health education to specific groups and activities;

– to enhance refugee participation in assuming responsibility for their own health and that of the community.

The end result will be improvement of the health status of individuals, families and the community.

217. Procedures. Through the community health nursing program, camps are divided into manageable areas, one nurse being responsible for a designated area of the camp. The nurse carried out the following tasks:

– collection of important family or community data;

– analysis of information, identification of health or health-related problems and priorities;

– decision-making on relevant plans to assist in solving or alleviating the problem;

– implementing the plan together with the family, using other resources as necessary;

– evaluation of the extent to which the objectives of the plan have been achieved.

218. The program has already identified many problems that are not brought to the clinic and thus provided a broader coverage of individuals and families.

Support activities

219. Nurses are directly involved in support activities such as health education, school health services, specialist and special care clinics and the oral health program.

Training and supervision of traditional birth attendants

220. In all Fields UNRWA-qualified nurses train traditional birth attendants each year in coordination with public health authorities and/or UNICEF. A system for close supervision and feedback is maintained, and midwifery kits and supplies are regularly replenished in order to ensure safe deliveries at home.

221. During the year a comprehensive procedure manual for nursing services was prepared and circulated to all Fields for use as a ready reference in the various aspects of the Agency's nursing program.

CHAPTER VII. ENVIRONMENTAL HEALTH SERVICES

General

222. Environmental health services to about 792 000 refugees residing in 60 camps are being provided by UNRWA in cooperation with the host governments, municipalities and other local bodies. The basic program includes provision of potable water in adequate quantity to meet domestic needs, collection and disposal of refuse and liquid wastes, management of storm water and control of insects and rodents of public health importance. Measures to improve environmental health conditions of the refugee camps are being carried out by UNRWA, mainly through Agency-assisted refugee self-help programs, and by the host Governments, which continue to take a keen interest in the well-being of refugees.

Mode of operation

223. Most of the services are delivered by Agency-employed staff who are gradually becoming involved with health education activities in conformity with the well-accepted principles of primary health care. Modest equipment suited to the local conditions and circumstances is provided to the workers for their normal duties, but mechanization is being gradually extended. As and when feasible, refuse removal and disposal are entrusted to municipalities or private contractors under relatively long-term contractual arrangements.

Policy

224. The Agency's policy is to provide basic sanitation services to the camp population that are of a standard compatible with the quality of services generally provided by municipalities and local councils to towns and villages in the host countries. The established strategy is to integrate camp water supply, sewerage and garbage disposal within the municipal or regional schemes of host Governments and their local councils, and to connect refugee shelters to these systems.

Objectives

225. UNRWA's objectives in environmental health are:

– to improve environmental health standards in refugee camps in order to reduce morbidity and mortality associated with poor environmental health activities; and

– to increase community participation in improving environmental health standards by involving the refugee population in self-help activities in camps.

Achievements

Self-help projects

226. The Agency continued to lend support to self-help camp improvement schemes, which comprise pavement of pathways, construction of drains and laying of sewers in localities which can be connected to an existing system. A number of camps in Jordan and Syrian Arab Republic Fields benefited from the program. About 67 000 square meters of pathways were paved in Beqa'a and Marka camps in Jordan Field, funded from UNRWA's General Fund, with contributions by the Canadian Embassy in Amman and camp populations. In Gaza and the West Bank the program showed no progress because of the prevailing situation.

Water supply

227. So far about 86% of camp refugees have indoor water taps. In Syrian Arab Republic Field about 90% of the work for the increased water supply project executed by UNICEF in Qabr Essit camp was completed. UNICEF has recently indicated that it will provide pumping equipment to three wells drilled by the Government at Khan Dannoun, Khan Eshieh and Sbeineh camps. In Lebanon, a new well was drilled at Beddawi camp and a new engine was installed at the Nahr el-Bared water plant. A new electric generator was installed at the Mia Mia camp water plant, and rehabilitation of water networks at the Burj el-Barajneh camp was completed.

Liquid waste disposal

228. The increase of water supplies in most of the camps has further emphasized the need for complementary sewerage facilities. The Agency continued to alleviate the waste-water problem in each camp by supporting self-help drainage schemes, and the host Governments are helping in relatively long-term solutions.

229. In Jordan Field, underground sewerage schemes with sewage treatment facilities were completed by the Government at Zarqa and Beqa'a camps and the sewerage scheme for Irbid camp is progressing. UNRWA installations and shelters for special hardship cases were connected to these schemes thanks to a generous contribution from the Federal Republic of Germany. So far 48% of the camp population had connected their shelters to the sewerage schemes. In the West Bank arrangements have been made for construction of internal sewerage schemes at Ama'ri and Dheisheh camps and connection of the camps' systems to Bethlehem municipal scheme thanks also to a generous contribution by the Federal Republic of Germany. All contract documents for Ama’ri camp have been finalized and the construction works will start in early 1989. As for Dheisheh camp, the design of the proposed scheme is under way.

230. In the Gaza Strip the sewerage scheme at Jabalia camp has been designed by a UNDP consultant. About 90% of the work on the main pumping station has been completed by the Jabalia municipality. A proposal for the construction of the internal network for the camp and connection of the scheme to the municipal treatment plant has been presented to the Italian Government for possible funding. In Lebanon a main sewer was constructed at Ein el-Hilweh camp and work on rehabilitation of the drains and sewers was completed at Shatila and Burj el-Barajneh.

Refuse disposal

231. Refuse collection, removal and disposal facilities have been improved further, either with funds from UNRWA budget or through the cooperation of municipalities.

232. In the West Bank the services at Tulkarem and Nurshams camps were improved by introduction of a skip-lift truck and matching containers.

233. In Gaza two additional skip-lift trucks and matching containers were received and put into operation at Bureij, Nuseirat, Maghazi and Deir el-Balah. In general, sanitation services were adversely affected in the West Bank and Gaza by the prevailing circumstances.

234. In Jordan Field an agreement was concluded with the Ruseifeh municipality for refuse removal from Marka camp, and agreements are being concluded with the joint council of the Hod el-Baqa'a and Irbid municipalities for refuse removal from Baqa’a camp and Irbid camp respectively.

235. In Syrian Arab Republic Field, the Dera'a municipality started to carry out refuse removal from Dera'a camp following the provision of garbage containers thanks to a donation from the Dutch Government. Arrangements are under way for the improvement of refuse disposal from Khan Dannoun and Khan Eshieh camps through provision of a compactor truck and matching containers.

236. In Lebanon two skip-lift trucks and matching containers were also provided and started operation in Saida area and Rashidieh camp.

Rodent and insect control

237. Chemical control of rats, mice and houseflies was carried out rather selectively, and as in previous years attention focused mainly on general cleanliness of the environment. Racumin is still the rodenticide of choice for the rodent control activities in Gaza Field. Dimethoate and residual pyrethroid 25% wettable powder (commonly known as Coopex) continued to be in use for fly-control operations. DDT proved to be the most effective insecticide for the control of sand-flies in Jericho area of the West Bank, where cutaneous leishmaniasis reappears from time to time. The problem is contained through a leishmaniasis control program carried out jointly by UNRWA and the public health department of the municipality of Jericho.

CHAPTER VIII. NUTRITION AND SUPPLEMENTARY FEEDING SERVICES

General

238. The program provides nutritional support to vulnerable groups of Palestine refugees: namely, infants, pre-school and schoolchildren, pregnant women, nursing mothers and tuberculosis patients. Nutrition support is provided through:

– powder milk distribution to children 6-36 months old and non-breast fed babies under 6 months;

– daily midday meals to children up to 6 years of age and, upon medical recommendation, to schoolchildren 6-15 years of age;

– special dry rations to pregnant women from the fifth month of pregnancy to one year after delivery, and to tuberculosis patients.

Mode of Operation

239. The European Economic Community continued to underwrite the Agency's nutrition and supplementary feeding program. Beneficiaries are referred through the Agency's maternal and child care centers or the school health system, and services are provided through 92 supplementary feeding centers or sub-centers or through special distribution centers.

Rations for special hardship conditions

240. A standard monthly ration is provided through UNRWA distribution centers to special hardship cases identified by the Department of Relief Services. The ration provides about 1900 calories and 61 grams of protein per person per day.

Dry rations to pregnant women, nursing mothers and tuberculosis patients

241. Dry rations are issued to eligible pregnant women and nursing; mothers attending UNRWA's maternal and child health clinics for health supervision and monitoring.

242. The rations are issued from the fifth month of pregnancy to one year after delivery. They provide additional nutritional support of approximately 1000 calories and 37 grams of protein per person per day.

243. Dry rations with the same calorie and protein values as those issued to special hardship cases are distributed to non-hospitalized tuberculosis patients.

Midday meal program

244. Nutritionally balanced midday meals are offered six days per week at the Agency's supplementary feeding centers to children below six years of age and, on medical recommendation, to children 6-15 years of age.

245. Meals are prepared and distributed at the supplementary feeding centers and comprise both fresh and dry food commodities, which provide approximately 500 calories and 20 grams of protein per person per meal.

Milk distribution

246. Pre-packed rations of whole and skimmed milk powder are distributed for eligible children 6-36 months of age and non-breast fed infants under six months attending the child health clinics. The ration for children 6-24 months old provides 238 calories and 20 grams of protein per child per day; the ration for children 25-36 months old provides 205 calories and 18 grams of protein per child per day.

Policy

247. UNRWA policy is to provide nutritional support free of charge to vulnerable groups of Palestine refugees eligible for UNRWA services.

Objectives

248. UNRWA’s objectives are:

– to improve the nutritional status of Palestine refugees through the promotion of knowledge and practice of proper dietary habits;

– to improve the nutritional status of vulnerable and target groups through the provision of special programs and assistance, including all children up to the age of 6 years, malnourished children and those at risk of malnutrition up to the age of 15, and special groups suffering from specific nutritional disorders or problems.

Achievements

Midday meal program

249. Average daily attendance under the midday meal program during the year was approximately 35 000. In the West Bank and Gaza Fields the program was seriously interrupted by the unrest and the general curfew measures imposed frequently on the camps throughout the year.

Dry milk

250. Some 93 000 children 6-36 months of age received milk rations during the year. However, the program was also adversely affected by the conditions which prevailed in Lebanon, Gaza and the West Bank.

Dry rations

251. A total of 38 000 pregnant women and nursing mothers received nutrition support through the dry ration distribution.

Emergency and extraordinary measures

252. In order to meet the immediate needs of vulnerable population groups, UNRWA maintained the temporary feeding centers for the displaced refugees in Lebanon. The program was extended to all registered refugees including those who are not normally eligible.

253. In the occupied territories of the West Bank and Gaza, extraordinary measures were implemented to meet the new needs which emerged as a result of the developments since December 1987. The measures included extension of midday meals to children 6-10 years of age, extension of dry ration and dry milk distribution to refugees who are not normally eligible for such services, including pregnant women, nursing mothers and children 6-36 months of age. Donations of baby food and other food supplies were also received through local contributions, government and non-governmental sources, and were distributed to ameliorate the situation.

Nutrition surveillance, education and intervention program

254. The new nutrition surveillance, education and intervention program was further expanded during the year.

255. In 1988, 15 health centers participated in the project in all Fields except Lebanon.

256. The ultimate objective of the new approach is to integrate the nutrition and supplementary feeding program within the Agency's primary health care activities. The full-scale expansion and implementation of the new program is planned to be completed in all Fields by the year 1990. It aims at reorienting the midday meal program to cover malnourished children or those at risk of malnutrition up to the age of 15 years on the sole basis of a medical recommendation.

257. The savings resulting from expansion and implementation of the new nutrition program will be allocated to improve primary health care.

CHAPTER IX. CONCLUSIONS AND SOME FUTURE DIRECTIONS

258. The general economic problems in all Fields increased the demand for UNRWA's medical care services. In Lebanon continued difficulties of access in places, and some destruction due to fighting and air raids, with the additional expenses of reconstruction of destroyed facilities, were an obstacle to progress. It was in the occupied territories of the West Bank and Gaza that interruption of services due to curfews etc., and the need to care for the casualties described in Chapter III, caused the greater setbacks. The rehabilitation and, where needed, the continuing care of those disabled during the uprising and during fighting in Lebanon, merit the support of all benevolent organizations.

259. Despite the added burdens UNRWA, strengthened by increased international assistance, has been able, with few exceptions to maintain and even in some fields extend or improve its health care. For the future, as outlined in its medium-term plan for 1990 to 1992, UNRWA must continue its endeavor to improve the standards and increase the coverage of its health care system, always hoping that thereby it will be making a major contribution to the quality of life of the Palestinian people.

260. The following general and particular aspirations remain a challenge:

– to bring the level of water supply, liquid waste disposal slid general sanitation in the camps of all Fields, and especially the grossly overcrowded Gaza Strip, nearer to international standards and targets. The diarrhoeal diseases, hepatitis and intestinal parasitism caused by the poor environmental conditions are one of the main reasons why mortality and morbidity of the refugees are not yet nearly as low as in southern or eastern Europe. The easy spread of acute respiratory infections in overcrowded shelters is another reason, and these conditions probably contribute much more to the effects of such childhood malnutrition as exists than any inadequacy of diet.

– to improve markedly the quality and coverage of maternal health care, and especially to ensure the detection of high-risk pregnancies and to ensure special prenatal, intrapartum and postpartum care for the mothers; and to reduce the proportion of all pregnancies which involve high risk. In no high-risk case should the mother deliver at home or fail to be advised on how to avoid another such pregnancy. Not only are the woman's own life and health at excessive risk, but neonatal mortality now accounts for an increasing proportion of total infant mortality. It is clear that maternal care improvement is the other main requirement besides environmental health if further major reductions are to be made in child mortality.

– to recognize the change in the disease pattern among the refugee population in all fields and to strengthen the efforts recently begun for the prevention and/or better management of hypertension, diabetes type II, cardiovascular disease and other conditions connected with lifestyle, and in particular smoking.

– to make a major effort to replace the present very unsatisfactory hospital facilities in Gaza, and to study possibilities and plan for a modern hospital of the required size and with all the specialties which a population of nearly a million people could expect.

– to work towards the rationalization of the nutrition and supplementary feeding program to serve better those children in real need of nutritional rehabilitation or supplementation, and to find a way to reduce the prevalence of moderate anemia.

– to work towards the improvement of out-patient care of adults and deal with the problem of overcrowded general medical services at health centers where no patient can at present receive much more than cursory attention.

– to secure the real community participation needed to achieve all these aspirations, and to strive for a situation where the refugees have a greater role in decision-making concerning health service's not only as consumers, but also as providers.

261. All these are medium to longer-term in goals, and much easier to articulate than to achieve, particularly in the present adverse circumstances. Nevertheless, it is vital to think ahead and strive for essential changes if UNRWA is to avoid the danger of becoming set in its ways and is to make the major contribution to the future of the Palestinian people of which its record of achievement and its ability to face emergencies show it to be capable.

Notes

1/ Hereinafter abbreviated to “Fields”.

2/ Appendix 1 to this annex

3/ Appendix 1 to this annex.

ANNEX I

STATISTICAL DATA

1988

Table 1

HEALTH PERSONNEL IN UNRWA

(as at 31 December 1988)

The following is the number of established posts at UNRWA Headquarters and in the Fields:

* The function of the Nutrition Division were integrated within the Office of the Director of Health.

Table 2

OUT-PATIENT SERVICES

a)  Number of health units:

Table 2

OUT-PATIENT SERVICES

(b) Number of Attendances

—–

* Including the tuberculosis hospital in Bureij camp run jointly with the Public Health Department.

** Including one general hospital in Qalqilia, in the West Bank and seven maternity centers integrated within health centers in Gaza and the West Bank.

Table 4

LABORATORY SERVICES

A. AVAILABLE FACILITIES

Table 5

COMMUNICABLE DISEASES

Incidence rates among eligible refugees in 1988

(per 100 000 population)

Table 6

EXPANDED PROGRAM ON IMMUNIZATION:

Vaccination at maternal and child health centers

—–

*  Number of surviving infants estimated according to a calculation based on a crude birth rate of 30 per thousand and infant mortality rate of 35 per thousand live-births.

** High rate due to under-estimate of the number of infants because of the higher birth rate in Gaza, and inclusion of vaccination of infants not basically eligible for UNRWA services.

Table 7

MATERNAL AND CHILD HEALTH CARE

Table 8

PREVALENCE OF MALNUTRITION

(percentage of children with sub-standard weight for age)

Percentage underweight by degree

(1) Infants below one year:

Table 9

SCHOOL HEALTH SERVICES

N.B.: * BCG vaccination of schoolchildren in Jordan is covered by government tuberculosis teams (figures not available).

** Vaccination in the West Bank was seriously affected by closure of schools most of the year.

Table 10

TUBERCULOSIS CONTROL

* Tuberculosis control in the West Bank is still the responsibility of government tuberculosis centers (figures not available).

Table 11

AVERAGE ATTENDANCE FOR MILK AND SUPPLEMENTARY FEEDING

(a) Ration for special hardship cases

(b) Dry rations

Midday meal program

(Average daily attendance)

a/ Post-diarrhea.

b/ Nutrition

c/ Supplementary feeding centers.

* N.B. Centers operated by voluntary societies.

(d) Milk program

(Average monthly attendance)

(e) Vitamin supplementation

Number of vitamin capsules/tablets distributed through UNRWA-operated supplementary feeding centres during the period under review:

N.B.:* Figure represents distribution during the first four months of the year only.

Table 12

ENVIRONMENTAL HEALTH SERVICES

* Remaining population share facilities with other families.

N.B. ** Including final refuse disposal from two camps, free of  

        charge, by local Municipalities, one in the Syrian Arab  

        Republic and one in Lebanon Fields.

Table 13

TRAINING PROGRAM

(A) Vocational training

N. B.: Vocational training centers in the West Bank continued to be closed by military order.

(B) Post-graduate training

Fellowships awarded or completed 1988

LIST OF CONTRIBUTIONS RECEIVED DURING THE YEAR 1988 AND

SPECIFICALLY EARMARKED FOR UNRWA'S HEALTH PROGRAMME

APPENDIX 3

ANNEX III

SENIOR STAFF IN THE HEALTH DEPARTMENT

UNRWA Headquarters staff

as at 31 December 1988

APPENDIX 4

RELEVANT RESOLUTIONS OF THE UNITED NATIONS GENERAL ASSEMBLY

RESOLUTIONS ADOPTED BY THE GENERAL ASSEMBLY

[on the report of the Special Political Committee (A/43/903)]

43/57. United Nations Relief and Works Agency for Palestine

Refugees in the Near East

A

Assistance to Palestine refugees

The General Assembly,

Recalling its resolution 42/69 A of 2 December 1987 and all its previous resolutions on the question, including resolution 194 (III) of 11 December 1948,

Taking note of the report of the Commissioner-General of the United Nations Relief and Works Agency for Palestine Refugees in the Near East, covering the period from 1 July 1987 to 30 June 1988, 1/

1. Notes with deep regret that repatriation or compensation of the refugees as provided for in paragraph 11 of General Assembly resolution 194 (111) has not been effected, that no substantial progress has been made in the program endorsed by the Assembly in paragraph 2 of its resolution 513 (VI) of 26 January 1952 for the reintegration of refugees either by repatriation or resettlement and that, therefore, the situation of the refugees continues to be a matter of serious concern;

2. Expresses its thanks to the Commissioner-General and to all the staff of the United Nations Relief and Works Agency for Palestine Refugees in the Near East, recognizing that the Agency is doing all it can within the limits of available resources, and also expresses its thanks to the specialized agencies and private organizations for their valuable work in assisting the refugees;

3. Reiterates its request that the headquarters of the Agency should be relocated to its former site within its area of operations as soon as practicable;

4. Notes with regret that the United Nations Conciliation Commission for Palestine has been unable to find a means of achieving progress in the implementation of paragraph 11 of General Assembly resolution 194 (111), 2/ and requests the Commission to exert continued efforts towards the implementation of that paragraph and to report to the Assembly as appropriate, but no later than 1 September 1989;

5. Directs attention to the continuing seriousness of the financial position of the Agency, as outlined in the report of the Commissioner-General;

6. Notes with profound concern that despite the commendable and successful efforts of the Commissioner-General to collect additional contributions, this increased level of income to the Agency is still insufficient to cover essential budget requirements in the present year and that, at currently foreseen levels of giving, deficits will recur each year;

7. Calls upon all Governments, as a matter of urgency, to make the most generous efforts possible to meet the anticipated needs of the Agency, particularly in the light of the budgetary deficit projected in the report of the Commissioner-General, and therefore urges non-contributing Governments to contribute regularly and contributing Governments to consider increasing their regular contributions.

71st plenary meeting

6 December 1988

B

Working Group on the Financing of the United Nations Relief and

Works Agency for Palestine Refugees in the Near East

The General Assembly,

Recalling its resolutions 2656 (XXV) of 7 December 1970, 2728 (XXV) of 15 December 1970, 2791 (XXVI) of 6 December 1971, 2964 (XXVII) of 13 December 1977, 3090 (XXVIII) of 7 December 1973, 3330 (XXIX) of 17 December 1974, 3419 D (XXX) of 8 December 1975, 31/15 C of 23 November 1976, 32/90 D of 13 December 1977, 33/112 D of 18 December 1978, 34/52 D of 23 November 1979, 35/13 D of 3 November 1980, 36/146 9 of 16 December 1981, 37/120 A of 16 December 1982, 38/831 B of 15 December 1983, 39/99 B of 14 December 1984, 40/165 B of 16 December 1985, 41/69 B of 3 December 1986 and 42/69 B of 2 December 1987,

Recalling also its decision 36/462 of 16 March 1982, whereby, it took note of the special report of the Working Group on the Financing of the United Nations Relief and Works Agency for Palestine Refugees in the Near East 3/ and adopted the recommendations contained therein,

Having considered the report of the Working Group, 4/

Taking into account the report of the Commissioner-General of the United Nations Relief and Works Agency for Palestine Refugees in the Near East, covering the period from 1 July 1987 to 30 June 1988, 1/

Deeply concerned at the critical financial situation of the Agency, which permits the provision of only minimum services to the Palestine refugees,

Emphasizing the continuing need for extraordinary efforts in order to maintain, at least at their present minimum level, the activities of the Agency, as well as to enable the Agency to carry out essential construction,

1. Commends the Working Group on the Financing of the United Nations Relief and Works Agency for Palestine Refugees in the Near East for its efforts to assist in ensuring the Agency's financial security;

2. Takes note with approval of the report of the Working Group;

3.  Requests the Working Group to continue its efforts, in co-operation with the Secretary-General and the Commissioner-General, for the financing of the Agency for a further period of one year;

4. Requests the Secretary-General to provide the necessary services and assistance to the Working Group for the conduct of its work.

71st plenary meeting

6 December 1988

C

Assistance to persons displaced as a result of the June 1967

and subsequent hostilities

The General Assembly,

Recalling its resolution 42/69 C of 2 December 1987 and all its previous resolutions on the question,

Taking note of the report of the Commissioner-General of the United Nations Relief and Works Agency for Palestine Refugees in the Near East, covering the period from 1 July 1987 to 30 June 1988, 1/

Concerned about the continued human suffering resulting from the hostilities in the Middle East,

1. Reaffirms its resolution 42/69 C and all its previous resolutions on the question;

2. Endorses, bearing in mind the objectives of those resolutions, the efforts of the Commissioner-General of the United Nations Relief and works Agency for Palestine Refugees in the Near East to continue to provide humanitarian assistance as far as practicable, on an emergency basis and as a temporary measure, to other persons in the area who are at present displaced and in serious need of continued assistance as a result of the June 1967 and subsequent hostilities;

3. Strongly appeals to all Governments and to organizations and individuals to contribute generously for the above purposes to the United Nations Relief and Works Agency for Palestine Refugees in the Near East and to the other intergovernmental and non-governmental organizations concerned.

71st plenary meeting

6 December 1988

D

Offers by Member States of grants and scholarships for

higher education, including vocational training, for

Palestine refugees

The General Assembly,

Recalling its resolution 212 (111) of 19 November 1948 on assistance to Palestine refugees,

Recalling also its resolutions 35/13 B of 3 November 1980, 36/146 H of 16 December 1981, 37/120 D of 16 December 1982, 38/83 D of 15 December 1983, 39/99 D of 14 December 1984, 40/165 D of 16 December 1985, 41/69 D of 3 December 1986 and 42/69 D of 2 December 1987,

Cognizant of the fact that the Palestine refugees have, for the last four decades, lost their homes, lands and means of livelihood,

Having considered the report of the Secretary-General, 5/

Having also considered the report of the Commissioner-General of the United Nations Relief and Works Agency for Palestine Refugees in the Near East, covering the period from 1 July 1987 to 30 June 1988, 1/

1. Urges all States to respond to the appeal contained in General Assembly resolution 32/90 F of 13 December 1977 and reiterated in subsequent relevant resolutions in a manner commensurate with the needs of Palestine refugees for higher education, including vocational training;

2. Strongly appeals to all States, specialized agencies and non-governmental organizations to augment the special allocations for grants and scholarships to Palestine refugees in addition to their contributions to the regular budget of the United Nations Relief and Works Agency for Palestine Refugees in the Near East;

3. Expresses its appreciation to all Governments, specialized agencies and non-governmental organizations that responded favorably to General Assembly resolutions 41/69 D and 42/69 D;

4. Invites the relevant specialized agencies and other organizations of the United Nations system to continue, within their respective spheres of competence, to extend assistance for higher education to Palestine refugee students;

5. Appeals to all States, specialized agencies and the United Nations University to contribute generously to the Palestinian universities in the Palestinian territory occupied by Israel since 1967, including, in due course, the proposed University of Jerusalem "Al-Quds" for Palestine refugees;

6. Also appeals to all States, specialized agencies and other international bodies to contribute towards the establishment of vocational training centers for Palestine refugees;

7. Requests the United Nations Relief and Works Agency for Palestine Refugees in the Near East to act as the recipient and trustee for the special allocations for grants and scholarships and to award them to qualified Palestine refugee candidates;

8. Requests the Secretary-General to report to the General Assembly at its forty-fourth session on the implementation of the present resolution.

71st plenary_meeting

6 December 1988

E

Palestine refugees in the Palestinian territory occupied

by Israel since 1967

The General Assembly,

Recalling Security Council resolution 237 (1967) of 14 June 1967,

Recalling also its resolutions 2792 C (XXVI) of 6 December 1971, 2963 C (XXVII) of 13 December 1972, 3089 C (XXVIII) of 7 December 1973, 3331 D (XXIX) of 17 December 1974, 3419 C (XXX) of 8 December 1975, 31/15 E of 23 November 1976, 32/90 C of 13 December 1977, 33/112 E of 18 December 19,78, 34/52 F of 23 November 1979, 35/13 F of 3 November 1980, 36/146 A of 16 December 1981, 37/120 E and I of 16 December 1982, 38/83 E and J of 15 December 1983, 39/99 E and J of 14 December 1984, 40/165 E and J of 16 December 1985, 41/69 E and J of 3 December 1986 and 42/69 E and J of 2 December 1987,

Having considered the report of the Commissioner-General of the United Nations Relief and Works Agency for Palestine Refugees in the Near East, covering the period from 1 July 1987 to 30 June 1988, 1/ and the two reports of the Secretary-General, 6/

Recalling the provisions of paragraph 11 of its resolution 194 (III) of 11 December 1948, and considering that measures to resettle Palestine refugees in the Palestinian territory occupied by Israel since 1967 away from their homes and property from which they were displaced constitute a violation of their inalienable right of return,

Alarmed by the reports received from the Commissioner-General that the Israeli occupying authorities, in contravention of Israel's obligation under international law, persist in their policy of demolishing shelters occupied by refugee families,

1. Reiterates strongly its demand that Israel desist from the removal and resettlement of Palestine refugees in the Palestinian territory occupied by Israel since 1967 and from the destruction of their shelters;

2. Requests the Commissioner-General of the United Nations Relief and Works Agency for Palestine Refugees in the Near East to address the acute situation of the Palestine refugees in the Palestinian territory occupied by Israel since 1967 and accordingly to extend all the services of the Agency to those refugees;

3. Requests the Secretary-General, in co-operation with the Commissioner-General, to resume issuing identification cards to all Palestine refugees and their descendants in the occupied Palestinian territory, irrespective of whether or not they are recipients of rations and services of the Agency;

4. Requests the Secretary-General, after consulting with the Commissioner-General, to report to the General Assembly, before the opening of its forty-fourth session, on the implementation of the present resolution and in particular on Israel's compliance with paragraph I above.

71st plenary meeting

6 December 1988

F

Resumption of the ration distribution to Palestine refugees

The General Assembly,

Recalling its resolutions 36/146 F of 16 December 1981, 37/120 F of 16 December 1982, 38/83 F of 15 December 1983, 39/99 F of 14 December 1984, 40/165 F of 16 December 1985, 41/69 F of 3 December 1986, 42/69 F of 2 December 1987 and all its previous resolutions on the question, including resolution 302 (IV) of 8 December 1949,

Having considered the report of the Commissioner-General of the United Nations Relief and Works Agency for Palestine Refugees in the Near East, covering the period from 1 July 1987 to 30 June 1988, 1/ and the report of the Secretary-General, 7/

Deeply concerned at the interruption by the Agency, owing to financial difficulties, of the general ration distribution to Palestine refugees in all fields,

1. Regrets that its resolutions 37/120 F, 38/83 F, 39/99 F, 40/165 F, 41/69 F and 42/69 F have not been implemented;

2. Calls once again upon all Governments, as a matter of urgency, to make the most generous efforts possible and to offer the necessary resources to meet the needs of the United Nations Relief and Works Agency for Palestine Refugees in the Near East, particularly in the light of the interruption by the Agency of the general ration distribution to Palestine refugees in all fields, and therefore urges non-contributing Governments to contribute regularly and contributing Governments to consider increasing their regular contributions;

3. Requests the Commissioner-General of the United Nations Relief and Works Agency for Palestine Refugees in the Near East to resume on a continuing basis the interrupted general ration distribution to Palestine refugees in all fields;

4. Requests the Secretary-General, in consultation with the Commissioner-General, to report to the General Assembly at its forty-fourth session on the implementation of the present resolution.

71st plenary meeting

6 December 1988

G

The return of population and refugees displaced since 1967

The General Assembly,

Recalling Security Council resolution 237 (1967) of 14 June 1967,

Recalling also its resolutions 2252 (ES-V) of 4 July 1967, 2452 A (XXIII) of 19 December 1968, 2535 B (XXIV) of 10 December 1969, 2672 D (XXV) of 8 December 1970, 2792 E (XXVI) of 6 December 1971, 2963 C and D (XXVII) of 13 December 1972, 3089 C (XXVIII) of 7 December 1973, 3331 D (XXIX) of 17 December 1974, 3419 C (XXX) of 8 December 1975, 31/15 D of 23 November 1976, 32/90 E of 13 December 1977, 33/112 F of 18 December 1978, 34/52 E of 23 November 1979, ES-7/2 of 29 July 1980, 35/13 E of 3 November 1980, 36/146 B of 16 December 1981, 37/120 G of 16 December 1982, 38/83 G of 15 December 1983, 39/99 G of 14 December 1984, 40/165 G of 16 December 1985, 41/69 G of 3 December 1986 and 42/69 G of 2 December 1987,

Having considered the report of the Commissioner-General of the United Nations Relief and Works Agency for Palestine Refugees in the Near East, covering the period from 1 July 1987 to 30 June 1988, 1/ and the report of the Secretary-General, 8/

1. Reaffirms the inalienable right of all displaced inhabitants to return to their homes or former places of residence in the territories occupied by Israel since 1967, and declares once more that any attempt to restrict, or to attach conditions to, the free exercise of the right to return by any displaced person is inconsistent with that inalienable right and inadmissible;

2. Considering any and all agreements embodying any restriction on, or condition for, the return of the displaced inhabitants as null and void;

3. Strongly deplores the continued refusal of the Israeli authorities to take steps for the return of the displaced inhabitants;

4. Calls once more upon Israel:

(a) To take immediate steps for the return of all displaced inhabitants;

(b) To desist from all measures that obstruct the return of the displaced inhabitants, including measures affecting the physical and demographic structure of the occupied territories;

5. Requests the Secretary-General, after consulting with the Commissioner-General of the United Nations Relief and Works Agency for Palestine Refugees in the Near East, to report to the General Assembly, before the opening of its forty-fourth session, on Israel's compliance with paragraph 4 above.

71st plenary meeting

6 December 1988

H

Revenues derived from Palestine refugee properties