Health conditions in OPT and Golan – 68th World Health Assembly – Report of State of Palestine

territory, including east Jerusalem, and in the

occupied Syrian Golan

At the request of the Permanent Observer of Palestine to the United Nations and Other International Organizations at Geneva, the Director-General has the honour to transmit the attached report to the Sixty-eighth World Health Assembly (see Annex).

ANNEX

The State of Palestine
Ministry of Health

REPORT ON THE HEALTH CONDITIONS
IN THE OCCUPIED PALESTINIAN TERRITORY

Sixty-eighth World Health Assembly

April 2015

1. DEMOGRAPHICS

1. At the end of 2014, according to the Palestinian Central Bureau of Statistics, the number of Palestinians was approximately 12.10 million, distributed as follows by place of residence: 4.62 million in the State of Palestine (38.2% of all Palestinians in the world), 5.34 million in Arab countries (44.1%) and 675 000 in foreign countries (5.6% of all Palestinians in the world). There are about 1.46 million Palestinians (12.1%) residing within the Green Line.

2. In 2014, the population of Palestine was estimated to be 4.62 million, including 409 500 in occupied Jerusalem. The population distribution was 61.2% in the West Bank and 38.8% in the Gaza Strip. Population distribution according to sex indicated a gender ratio of 103.3 males to 100 females.

2.  Economic situation

3.  Estimates by the Palestinian Bureau of Statistics indicate a 2.5% decrease in Palestinian GDP in

2014 compared with 2013, leading to a decrease in per capita GDP of more than 5% in 2014 compared with 2013. The unemployment rate in 2014 increased to approximately 27% from about 24% in 2013, which resulted in a drop in the rate of employment and the absorption of new employees in the local and Israeli labour markets. The unemployment rate was about 17.4% in the West Bank and 42.8% in Gaza Strip in the fourth quarter of 2014.¹

3. The role of the Ministry of Health

4.  The Palestinian Ministry of Health is responsible for the management and administration of the Palestinian health sector. It ensures the appropriate use of resources, delivery of sustainable health services, enacts relevant laws and regulations, and motivates companies and other health-service providers and health partners. The Ministry of Health approves organizational and planning activities in the health sector, including accreditation and licensing. It is also responsible for ensuring sustainable health financing, revising and updating health insurance schemes, and implementing various health strategies, including health information, the national drug strategy, women's health, maternal and child health, noncommunicable (non-infectious) diseases, infectious diseases, vaccines, etc. The Ministry of Health has developed its national strategic plan for 2014-2016 and aims to ensure the fair distribution of health services to all Palestinians, in line with international, regional and national standards, under Palestinian laws and regulations, notably the Palestinian law on public health.

4.  Integrated health services

5.  The continued efforts of the State of Palestine, through the Ministry of Health, to promote human health as a fundamental right, and its drive to provide integrated health services to the Palestinian people in response to economic, demographic and epidemiological changes, have led to a marked improvement in health indicators, in fact surpassing the services provided by some neighbouring countries in terms of health expenditure. This indicates the ability of the Palestinian health sector to cope with challenges and make tangible progress towards the achievement of the Millennium Development Goals (MDGs). The child mortality rate decreased to 12.9 per 1000 of population in 2014, compared to 23.9 in 2002; life expectancy improved and the expected survival rate increased to 73.2 years, i.e. 71.8 for males and 74.7 for females, in 2014.

In recent years, the Ministry of Health has been extremely successful in controlling a number of infectious diseases, and the vaccination coverage rate for many years exceeded 95% among newborns and children. Moreover, no cases of leprosy or diphtheria have been reported in Palestine since 1982. In addition, no cases of polio have been reported since 1988. There have been no reports of rabies or cholera for many years, despite the presence of these diseases in States bordering on Palestine.

Despite the considerable successes achieved by the Ministry of Health in controlling and eradicating a number of infectious diseases, there remains the challenge of reducing and constantly controlling the spread of certain communicable diseases in Palestine, for example meningitis, epidemic hepatitis, brucellosis, tuberculosis and AIDS.

Chronic diseases are increasingly among the leading causes of illness. The increase in chronic diseases is related to changes in lifestyle, behaviour, low physical activity and poor nutrition habits. Such is the case in Palestine, as in other developing countries, with a higher incidence of cancer, cardiovascular diseases, diabetes and mental disorders.

—  In 2013, cardiovascular diseases were the leading causes of death in Palestine (31.9% of all deaths), followed by cancer (13.3% of all deaths), blood clots in the brain (12.2% of all deaths), and diabetes, the fourth leading cause of death in Palestine (6.1%).

5. Delivery of health services

— In addition to the Ministry of Health, which provides the majority of the health services to Palestinians, other health service providers such as UNRWA that provide services to the Palestinian refugees in the West Bank and the Gaza Strip, and several nongovernmental civil society organizations are also active in this field. The health services are delivered across the three levels, i.e. primary, secondary and specialized care.

—  he number of primary health care centres increased throughout the Palestinian governorates from 454 centres in 1994 to 776 Centres in 2014, an increase of 68.9%. The Ministry of Health is the major provider of health care services in Palestine, with its centres, spread across all cities and villages, representing about 61.5% of all primary health care centres. UNRWA oversees 8.1% of primary health care centres and nongovernmental organizations oversee 27.4%.

— The Ministry of Health is the major provider of secondary health care services (hospitals) in Palestine, as it owns and manages 3616 beds, representing 56.4% of the 6407 hospital beds in Palestine. A number of civil society and private institutions, the military medical services, and UNRWA, which runs one hospital with 63 beds, also provide secondary care services along with the Ministry.

— The hospital beds of the Ministry of Health cover almost all specializations, including general surgery and other surgery sub-specializations, internal medicine, paediatrics, psychiatry and other disciplines. Rehabilitation and physiotherapy are provided by civil institutions (nongovernmental organizations).

The Ministry procures unavailable health services from other service providers (namely private sector and non-governmental organizations and Jerusalem hospitals) and from outside Palestine.

6. Mental health

6. Palestinian society is unique in that mental factors are clearly linked to the suffering of the people as a result of the occupation that has existed for decades and negatively affects all aspects and areas of life.

7. The recent war has had a significant effect on mental health in Gaza generally. A study conducted by The Gaza Mental Health Centre indicated an increase in stress levels among children, women and men which is the most important indicator of the feeling of insecurity. 100% of the surveyed persons noted a change in children's behaviour and 99% said that they noted significant changes in the attitude of health care providers due to the psychological and social crisis. The sample defined the pertinent causes of conflict, and the most important reasons of stress, especially the attacks (86% for boys, 72% for girls); the continuous noise from drones (56% for boys, 43% for girls); exposure to violence (29% for boys, 25% for girls); and the death or injury of a loved one (32% for boys, 22% for girls). In its report on the psychological status of children, dated 12 August 2014, UNICEF estimated that 373 000 children in Gaza need direct and specialized psychosocial support, due to family experience of death, injury, or the loss of their home.

8. In 2014 there were 2257 new cases of mental illnesses in the West Bank, with an incidence rate of 89 cases per 100 000 of population, representing an increase in the incidence rate of 87.7 per 100 000 of population among Palestinians in 2013. Reported cases among females reached 56.6% in 2014. The largest proportion was in the 25-49 age group, males and females, accounting for 37.1 of all new cases of mental illness in 2014.

7. Financial situation and health expenditure

9. According to data from the General Department of Finance at the Palestinian Ministry of Health, total health expenditure by the Palestinian Ministry of Health was 2 011 601 009 shekels. The approved budget of the Ministry of Health, under the 2014 budget law, was 1 456 970 000 shekels, including salaries.

10. The implemented budget was 1 356 990 069 shekels. The difference, i.e. 42 000 000 shekels, was covered from the arrears budget annex. Salaries accounted for 52% of the total implemented budget.

8. Health workforce

11. In Palestine, health services are provided by the Ministry of Health, nongovernmental health

organizations, the general security and police medical services, UNRWA and the private sector. The total workforce of the health sector numbers 30 420 (47% employed in the Ministry of Health).

9. Determinants of health

12. The greatest challenge facing the health sector in Palestine is the presence of the Israeli occupation in the West Bank and the Gaza Strip, the isolation of the Palestinian territories from each other and from the rest of the world through the closing of the crossings and borders, and the continued Israeli aggression in the Gaza Strip and its closure since 2007, in addition to daily aggression against Palestinians in the West Bank, perpetrated by the occupying army and settlers, continued detentions, and the presence of hundreds of military barriers and the apartheid wall.

9-1 The Israeli aggression against Gaza in the summer of 2014

13. For the third time in over six years, Israel waged an aggressive war in the Gaza Strip in 2014, lasting for 51 days and killing 2145 people, including 581 children (27%), 486 women (22.7%), and 102 elderly persons (4.8%), and injuring 11 231 people, including 3436 children (30.6%), 3540 women (31.5%), and 418 elderly persons (3.7%). Moreover, 17 hospitals and 50 primary health care clinics were damaged, 6 hospitals and 28 primary health care clinics were closed, 16 ambulances were destroyed, 23 medical staff were killed and 83 were injured.'

14. The recent war resulted also in about 1000 new permanent disabilities (30% among children). This puts an additional strain on public health, as disabled persons need long-term rehabilitation programmes.²

15. The aggression seriously affected life in the Gaza Strip, as half a million citizens were displaced during the war and 22 000 homes were totally destroyed. At the end of 2014, about 100 000 citizens were still homeless.³

9-2 Shortage of medicines

16. The shortage of medicines and medical consumables in Gaza is acute; 40% of medicines are unavailable. Chronic shortages of essential medicines and medical consumables represent a very serious threat to patients and treatment outcomes. The results are as follows:

— Cancellation of many elective surgeries;

— Longer waiting times for treatment in clinics (sometimes for more than a year);

— Increased numbers of patients transferred abroad;

— Heavier economic burden patients and their families (to buy the necessary supplies from private pharmacies).

9-3 Shortage of fuel and electricity in Gaza

17. The electricity supply to the Gaza Strip comes from three sources: 40% from the local power station using industrial fuel arriving in the Strip via Israel; 50% from the direct electricity supply from Israel and 10% from the Egyptian electricity grid.

18. The Strip has endured power cuts of between 12 and 18 hours a day in 2014, which have negatively affected the delivery of essential services, such as health, water and sewage services. Accordingly, the stoppage of sewage treatment plants causes large quantities of untreated sewage to be discharged into the sea, thereby polluting sea water and beaches and killing fish. The sea shores of the Gaza Strip are badly polluted, because untreated sewage water is pumped into the sea, thus exacerbating the environmental crisis and continuously damaging public health.

19. In addition, the frequent instability in the electricity supply and power cuts lasting many hours threaten the lives of hospital patients, including patients in intensive care and cardiac care units, babies in incubators and patients on dialysis. Medical equipment is disrupted.

20. In 2014, the use of electric generators in health centres represented an additional burden on the fragile public health sector in Gaza, because of the need for large quantities of oil, filters and spare parts to maintain the generators. With power cuts lasting 12 hours a day, the Ministry of Health needs 360 000 litres of fuel every month to ensure the operation of electric generators in hospitals and primary health care centres, and 140 000 litres of fuel every month for Ministry of Health ambulances and logistics vehicles.

9-4 Closure of borders and crossings

21. Gaza residents have to endure continual closing of borders and crossings, as well as severe restrictions of movements from and to the Gaza Strip. The rate of closures has increased since the Israeli aggression in the summer of 2014, specially the Rafah border, and has exacerbated suffering and imposed an additional burden on the public health sector, reducing training opportunities for different categories of health workers, complicating the implementation/completion of construction and rehabilitation programmes, the provision and maintenance of medical equipment, and the transfer of patients outside the Gaza Strip.

9-5 Transfer of patients from the Gaza Strip and the West Bank for treatment abroad

22. The deterioration in the level of health services in hospitals in the Gaza Strip due to the various reasons listed above, the most important of which being the lack of maintenance and replacement of medical equipment, the shortage of electricity and medicines and the failure to restore hospitals and medical centres destroyed by Israeli aggression, has led to an increase in demand for treatment outside the Gaza Strip, especially in Egypt, Israel and hospitals in east Jerusalem. Obtaining a permit to leave for treatment outside the Gaza Strip involves considerable hardship. A large number of cases are not authorized by the Israeli authorities for reasons justified as security-related; the issuance of other authorizations is delayed. Many have suffered as a result of their treatment being delayed or refused, which has led to a deterioration in their health condition and to many avoidable deaths among Palestinians. Moreover, the high cost of treatment outside the Gaza Strip overburdens the Palestinian National Authority's budget and affects its capacity to deliver high-quality health services to other citizens.

23. In 2014, 74 683 patients were transferred from the West Bank and the Gaza Strip to hospitals in east Jerusalem, Egypt, Jordan and within the Green Line. Many patients and their relatives faced great difficulties in obtaining the required permits. According to statistics, 20.5% of all requests submitted in the West Bank and 12.0% in the Gaza Strip were refused or ignored.

24. The cost of transferring patients for treatment abroad in 2014 was 569 588 180 shekels, or more than US$ 143 million

25. The Palestinian Red Crescent Society is the sole provider of emergency services; 93% of its ambulances were denied direct access through the barriers to hospitals in east Jerusalem. They had to drop off patients at the barrier to be transferred to ambulances with Israeli licence plates, which causes complications for the patients, especially critical cases, and endangers lives.

9-6 The West Bank

26. Strict limitations imposed by Israel on the movement of Palestinians in the West Bank are implemented through a network of fixed barriers, unexpected mobile barriers, physical obstacles, streets that Palestinians are prohibited from using and gates along the segregation wall. These restrictions enable Israel to control and restrict the movement of Palestinians in accordance with its own considerations and interests through massive violation of the rights of Palestinians.

27. Some 300 000 citizens live in Area C, the areas behind the wall and the areas surrounding Jerusalem. These people face difficulties in accessing basic health services, particularly women, children and the elderly, due to the blockade, the military barriers, settler-related violence and a lack of public transport. In addition, health workers face difficulties in accessing their work places in hospitals in east Jerusalem due to the permit system imposed by Israel. Moreover, it is difficult to undertake construction work in Area C, so no health centres can be established there. Consequently, many civil society organizations and the Ministry of Health provide mobile clinic services.'

9-7 Settler attacks

28. In 2014 settlers carried out more than 887 attacks against Palestinians and their properties, killing 4 persons. These attacks took different forms, including intrusions, beatings, stabbings, throwing stones at houses and cars, and shootings. Additionally, in 52 cases, people were deliberately run over by vehicles. The report also mentioned the policy of execution by burning, one of its most horrible examples being the burning alive of Mohamed Abu Khdeir, a child from Jerusalem, by a group of settlers. This is a crime that the world has not forgotten. The report also highlighted attempts at kidnaping, particularly kidnaping unarmed children?

9-8 Annexation, expansion and apartheid wall in the West Bank and occupied Jerusalem

29. The effect of the wall on the Palestinian land and population has been catastrophic. The construction of the annexation, expansion and apartheid wall has not stopped, nor has its pernicious effect on the lives of Palestinians. It continues to divide and isolate communities, destroying their

livelihoods and preventing hundreds of thousands of people from reaching their workplaces, families, markets, schools, hospitals and medical centres in a normal fashion.

30. The situation in the occupied city of Jerusalem is dire and the wall, settlements and barriers cause serious health problems and isolate entire communities in Jerusalem, such as the village of Anata and the Shufat camp, from major health facilities that provide them with services in the city of Jerusalem, e.g. the Al-Uyoun, Al-Maqasid and Red Crescent hospitals. The report also indicates that more than 70 000 Palestinians with Jerusalem identity cards are threatened, because Israel's next move, after constructing the wall, will be to prevent them from reaching Jerusalem, and then to withdraw their health insurance and Jerusalem identity cards on the grounds that they no longer reside in the city.

31. Furthermore, the report shows that there are no advanced health services in the city of Qalqilya, so its 46 000 inhabitants have no choice but to rely on hospitals in other cities, such as Nablus, in a trip that used to take 20 minutes but that now takes three and a half hours because of the barriers and the wall.

32. In addition, even villages that appear to be remote from the site of the wall are affected, because Palestinians are prohibited from using certain roads. For example, Palestinians are unable to reach Ramallah and occupied Jerusalem because of this policy.

9-9 Sick prisoners¹

33. As of February 2015, there were 6500 Palestinian prisoners in Israeli jails, including 454 administrative detainees (i.e. without trial), 13 members of the Palestinian Legislative Council, 230 children under 18 and 24 women. Prisoners are generally mistreated and suffer from medical neglect.

34. 1200 prisoners suffering from chronic diseases (in a critical condition) are still imprisoned in Israeli jails. They urgently need treatment for serious diseases, such as cancer, diseases of the heart and lungs, cancer, stomach and intestine, nerves, diabetes, high blood pressure, arteries and veins, eyes, chest, liver, amnesia, glands and kidneys. Some of them suffer from hemiplegia or quadriplegia, and some others need surgery. In addition, 21 prisoners have various disabilities.

35. The effect of the deliberate policy of medical neglect continues after many prisoners are released, exacerbating their continued suffering, and resulting in death a few days or weeks after release. This is because they were denied medical treatment by the prison administration. There are dozens of released cases still suffering from a deterioration of their health conditions during imprisonment.

36. The deliberate policy of medical neglect represents a violation of international conventions, notably the Fourth Geneva Convention of 1949, specifically the articles dealing with the right of prisoners and injured persons (Articles 90 and 91).

37. In this context, the deliberate policy of medical neglect pursued by the Israeli prison authorities against Palestinian prisoners and detainees, can be understood through the following data and practices:

— Delay in the diagnosis of diseases;

— Failure to carry out necessary examinations and laboratory tests periodically or as required;

— Delay in delivering treatment and medicines that are only preliminary treatments or pain killers, not curative;

— Failure to provide sick prisoners with medical assistive devices;

— Lack of a healthy environment appropriate for the treatment of sick prisoners. The treatment is delivered inside prison cells or clinics or in the Al Ramla prison hospital, under difficult, inappropriate and unclean conditions;

— Failure to brief the prisoner about the medicines being given to him and about the nature of his disease, or delaying this information, when the disease has already taken hold;

— Failure to transfer sick prisoners to a civilian hospital, and if exceptionally and temporarily transferred, the sick prisoner's hands and feet are manacled;

— The prison administration does not allow specialized physicians to entry for diagnosis and treatment purposes;

— Requiring that prisoners pay for their treatment, surgery, or that they buy medical kits and prosthetic devices, e.g. in the case of Nahed Alaqraa and Mohamed Barash, and the continued policy of preventing any international or medical commissions from seeing the health conditions of prisoners;

— Patients must endure the transfer from the prison to Al Ramla hospital and vice versa;

— Ignoring patients' health conditions, especially those suffering from heart disease, dyspnoea, asthma, neurological disorders, and hazing, restraining and gassing prisoners, thus seriously endangering their lives;

— Limited response by the military courts and competent commissions to urgent requests to release sick prisoners on medical grounds;

— Putting pressure on prisoners needing treatment for diseases or injuries to extract confessions, compromising national dignity;

— Isolation of cases suffering from mental disorders, aggravating their health conditions instead of providing them with health care.

10. Conclusion

38. In conclusion, we confirm that the State of Palestine still believes that peace is the strategic

option for both the Palestinian and the Israeli peoples, and that only peace can bring an end to the long Israeli occupation and lead to the establishment of an independent Palestinian State with Jerusalem as its capital. We also confirm the need to take immediate action to stop the unjust blockade of the Gaza Strip and remove Israeli barriers, and the annexation and expansion walls, so that the Palestinian people can enjoy their right to health and safe access to good-quality and safe health services.

Therefore, the Palestinian Ministry of Health:

• calls on the international community to exert pressure on the Israeli Government to lift the blockade on the Gaza Strip, to prevent the worsening of the humanitarian crisis there, and to take action to fulfil its moral and legal responsibility to protect the basic human rights of civilians in the occupied Palestinian territories;

• calls on the High Contracting Parties to the Fourth Geneva Convention to respect the Convention and fulfil their obligations under Article 1 of the Convention, whereby the High Contracting Parties undertake to respect and to ensure respect for the Convention in all circumstances, in addition to their obligation, under Article 146, to prosecute those accused of grave breaches of the Convention. It should be noted that such breaches are deemed war crimes under Article 147 of the Fourth Geneva Convention relative to the Protection of Civilian Persons and the first Additional Protocol thereto, which guarantees the protection of Palestinian civilians in the occupied territories;

• expresses its thanks to donor countries for their support of the Palestinian people in all areas and appeals to them and to international health agencies to extend their political and financial support to implement the health development plan, and create the political environment necessary for the implementation of the document on ending the occupation and establishing the state, as presented by the Palestinian Government, which is working in earnest to create an environment conducive to the implementation of that document;

• requests the international community to exert pressure on Israel to implement forthwith the consultative opinion of the International Court of Justice on the illegality of building the annexation wall deep inside the occupied West Bank territories. It also requests the cessation of house demolitions, of the displacement of Jerusalem citizens from their homes, the cessation of the judaization of Jerusalem and the construction of settlements in the Palestinian territories occupied in 1967, which constitutes not only a violation of international resolutions, but also a threat to the safety and health of Palestinian citizens, and in particular to their ability to access health services;

• invites all international human rights bodies, and in particular the International Committee of the Red Cross, the World Health Organization, and other international institutions, to intervene urgently and immediately with the occupation authorities and the Israeli prison administration to require them to provide treatment to sick prisoners in occupation jails whose health is deteriorating daily. It calls for the establishment of an international committee composed of specialized doctors to review critical cases and provide immediate and rapid treatment, and appeals to civil society organizations to exert pressure to save the lives of prisoners, treat sick prisoners immediately and release critically ill cases so they can be treated abroad. It also appeals for imprisoned Palestinian women to be allowed to receive maternal, pregnancy, prenatal, delivery and postnatal care and to be allowed to give birth in healthy and humane conditions in the presence of their families; it further demands the immediate release of child prisoners;

• confirms that the blockade of the Gaza Strip is continuing and that crossings are still not fully and permanently open, which means a continuation of the crisis and sufferings that preceded the Israeli aggression in the Gaza Strip in the summer of 2014, and that the Ministry of Health needs to rebuild and rehabilitate the health facilities destroyed in the aggression, to continue work on other essential medical institutions and to obtain essential medical equipment, medical supplies and the fuel necessary for the operation of health centres and institutions.

• exert pressure on the occupation authorities to facilitate the movement of patients and persons accompanying them to health services, both inside and outside Palestine;

• requests the strengthening of formal and civil support for the Palestinian health sector as an important stabilizing factor in order to guarantee the right of the Palestinian people to access health services, as endorsed by international law.

Endnotes

¹ Report on the preliminary results of the Labour Force Survey, fourth quarter, 2014, the Palestinian Bureau of Statistics, 12/2/2014. http://www.pcbs.gov.ps/site/512/default.aspx?tablD=512&lang=ar&ItemID=1319&mid= 3915&wversion=Staging.

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¹ Report of the operations room of the Palestinian Ministry of Health on the health situation in Gaza, 31 August 2014.

² Strategic Response Plan oPt 2015, UN OCHA. www.ochaopt.org.

³ OCHA, "Occupied Palestinian Territory Humanitarian Needs Overview 2015," http://www.ochaopt.org/documents/ hno2015_factsheet_final9dec.pdf.

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¹ Strategic Response Plan oPt 2015, UN OCHA. http://www.ochaopt.org/documents/srp_2015.pdf.

² Report of the Colonization and Wall Resistance Commission, Ramallah, 2014.

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¹ Palestinian Ministry of Detainee Affairs, Ramallah, 2015.

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