Health conditions in the OPT, including East Jerusalem and Syrian Golan – WHO 65th World Health Assembly – UNRWA report

Health conditions in the occupied Palestinian

territory, including east Jerusalem, and in the

occupied Syrian Golan

The Director-General has the honour to bring to the attention of the Health Assembly the attached report of the Director of Health, UNRWA, for the year 2011.

ANNEX

REPORT OF THE DIRECTOR OF HEALTH, UNRWA, FOR 2011

HEALTH CONDITIONS OF, AND ASSISTANCE TO, PALESTINE REFUGEES

IN THE OCCUPIED PALESTINIAN TERRITORY

DEMOGRAPHIC PROFILE

1. The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) is one of the largest United Nations programmes, with a population of 5 116 000 Palestine refugees (in 2011) registered in the Gaza Strip, the West Bank, Jordan, Lebanon and the Syrian Arab Republic. The Agency’s mission is to assist Palestine refugees in achieving their full potential in human development until a durable and just solution is found to the refugee issue. This refugee population is predominantly made up of young people, as observed in many countries in the Near East. More than half were younger than 25 years of age in 2011.

2. Over two million Palestine refugees are registered with UNRWA in the occupied Palestinian territory: 1 218 000 refugees in the Gaza Strip and 875 000 in the West Bank. By the end of 2011, 35.3% of those refugees were living in 27 refugee camps: eight in the Gaza Strip and 19 in the West Bank.

3. The number of refugees eligible for UNRWA’s health services in the occupied Palestinian territory increased by 3.8% (about 76 000 people) in 2011 compared with 2010. This increase is partly attributed to natural population growth and partly to the inclusion of additional refugees married to non-refugee family members (i.e. husbands and descendants of women who are registered refugees and are, or were, married to husbands who are not registered refugees). Approximately 72% of all eligible refugees in the occupied Palestinian territory were estimated to use UNRWA’s health services in 2011.

HEALTH CONDITIONS

4. Through the support of UNRWA, governmental and other health-care providers, the health conditions of Palestine refugee mothers and children have shown continued improvement since the Agency’s establishment. Progress in achieving Millennium Development Goals 4 (Reduce child mortality) and 5 (Improve maternal health), for example, has been on track. The infant mortality rate among Palestine refugees is comparable to, if not better than, rates in other countries of the Near East and in 2011, the percentage of deliveries attended by skilled health personnel continued to be very high (99.7% in the West Bank and 99.9% in the Gaza Strip).

5. However, the combination of prevailing insecurity, political instability, increasing poverty (particularly in the Gaza Strip) and potable drinking-water are having a negative impact on the health status of Palestine refugees. Severe restrictions on the movement of people and goods within the West Bank and between the Gaza Strip, the West Bank and areas abroad remain a major obstacle to socio-economic development and health-care provision.

6. The main health concerns remain on noncommunicable diseases or chronic lifestyle-related illnesses, which are exacerbated by the lack of freedom of movement. As in neighbouring countries in the Near East, the epidemiological transition from communicable to noncommunicable diseases has taken place in the occupied Palestinian territory. Consequently the number of people with diabetes and/or hypertension under care in UNRWA’s health services has been constantly increasing in recent years.

7. In addition, exposure to violence and uncertainties associated with occupation/settler-related violence in the West Bank and with the blockade in the Gaza Strip¹ are having a profound impact on the refugee population. Stress-related disorders and mental health problems are increasingly affecting women, children and adolescents. The stress of occupation, the inability of men to provide for their families and the consequent reversal of gender roles have resulted in domestic violence. Tackling psychological and behavioural disorders, as well as domestic violence, has therefore emerged as a health priority for UNRWA in the occupied Palestinian territory.

8. Continued food insecurity is also affecting health conditions. After years of political instability and impoverishment, the level of food insecurity among Palestine households is still very high. According to a 2011 study published by the World Food Programme, the Food and Agriculture Organization of the United Nations and UNRWA, 60% of households in the Gaza Strip remain food insecure or vulnerable to food insecurity even after having received food assistance from UNRWA and other agencies. Approximately 26% of the population have “poor and borderline” diets, such as a reduced consumption of fruits and dairy products. Large shares of the population in the Gaza Strip reported relying on adverse coping strategies in times of economic hardship: 54% by reducing food quality and 34% by reducing the number of daily meals.

UNRWA HEALTH ASSISTANCE

9. UNRWA has been the main primary health care provider of Palestine refugees for 62 years and is the largest humanitarian operation in the occupied Palestinian territory. UNRWA aims to ensure a “long and healthy life” for refugees as one if its four Human Development Goals. In order to do so, the Agency provides primary health care services addressing the health needs of registered refugees from birth to old age.

10. UNRWA delivers primary health care in the occupied Palestinian territory through a network of 63 primary health care centres: 21 in the Gaza Strip and 42 in the West Bank. UNRWA also facilitates the access of refugees to secondary and tertiary care to the contracted hospitals in the West Bank and the Gaza Strip and by providing care directly in the UNRWA hospital in Qalqilya, in the West Bank. In 2011, 54.4% of all registered refugees in the West Bank and 84.2% of those in the Gaza Strip accessed UNRWA’s preventive and curative services. The number of refugee patients from the West Bank and the Gaza Strip who were admitted to hospitals increased by 5.3%, rising from 31 789 in 2010 to 33 478 in 2011.

11. In response to the challenges in health conditions, UNRWA adopted the family health team approach as the core of its health reform, the implementation of which began in 2011. This is a family- and person-centred approach to provide holistic primary care at UNRWA health primary centres.  Families are registered with a team consisting of a doctor, a midwife and nurses. The team is responsible for all the health care needs of the families registered with them. Strong patient-provider relationships and long-term continuity of care, particularly important in the management of the increasing number of noncommunicable disease patients, are important elements of the approach.

12. Considerable progress has been made in the family health team approach. UNRWA started the first pilot in two health centres (one in the Gaza Strip and the other in Lebanon) in October 2011. In these centres, both patients and health centre staff have shown very positive responses to the family health team approach, and although the pilot is in its early stages, there have been signs of quality and efficiency gains such as equitable workload distribution. UNRWA is now expanding this pilot. At the end of March 2012, a total of 11 health centres, covering around 500 000 Palestine refugees, have adopted the family health team, including six centres in the Gaza Strip and two in the West Bank. UNRWA plans to roll out the family health team approach to all 138 health centres in its five fields of operation by 2015.

13. In addition to introducing the family health team approach, UNRWA conducted around 6.3 million medical consultations for adult and adolescent refugees in the occupied Palestinian territory in 2011: around 4 400 000 in the Gaza Strip and 1 900 000 in the West Bank. In addition, around 400 000 oral health consultations and 123 000 oral health screening sessions were held, and 14 435 refugees received physical rehabilitation (27% of whom suffered from the consequences of physical trauma and injuries, including those due to conflict, occupation and violence).

14. Care for noncommunicable diseases expanded. Almost 94 000 patients with diabetes and/or hypertension were treated in the occupied Palestinian territory: 60 431 in the Gaza Strip and 33 439 in the West Bank. Collaborations with specialized centres have been expanded for diabetes care in order to improve control rates and prevent late complications of the disease. 15. In 2011, the total number of continuing users of modern contraceptive methods increased by 10.4% compared with the previous year (the new total being 78 776 clients). Antenatal care services were provided to 57 682 pregnant women with a coverage rate of an estimated 97% in the Gaza Strip and 53.6% in the West Bank. On average, an estimated 73% of pregnant women registered with UNRWA during the first trimester. Of all pregnant women assisted by the Agency, 99.8% delivered in a health institution and over 95.2% received postnatal care.

CHALLENGES AND CONSTRAINTS IN HEALTH SERVICE DELIVERY

16. Despite the above-mentioned progress, UNRWA continued to face challenges in providing its health services. Mobility restrictions for Palestinians in the West Bank and the complicated referral permission to the hospitals in east Jerusalem from other parts of the West Bank and the Gaza Strip² are still causing difficulties with respect to access to health care. Moreover, nearly all referrals to care outside the Gaza Strip require coordination with Israel. These coordination processes can be slow and cumbersome, often resulting in patients missing their hospital appointments. In the West Bank, UNRWA mobile health teams have been operating since February 2003 to provide a full range of essential curative and preventive medical services to about 13 000 patients per month living in over 59 isolated locations. Still the health teams’ mobility was jeopardized by frequent closures and checkpoints in 2011.

17. Clinical evidence in 2011 suggests that stress-related disorders and mental health problems are increasing, including family violence, domestic abuse, and violence among children and youth.³  UNRWA has been actively addressing such health issues; however, the degree of the problem is widespread.

18. Violence against women and children is also at alarming levels in the occupied Palestinian territory. According to a 2011 study by the Palestinian Central Bureau of Statistics, 30% of ever married women in the West Bank and 51% of ever married women in Gaza experienced violence from their husbands in the prior 12 months. Approximately 28% of children between 12 and 17 years in the West Bank reported experiencing physical abuse at the hands of their parents in the past year. For children between 12 and 17 years in the Gaza Strip, the figure rises to nearly 45%. The figures for psychological abuse from parents hover near 70% across the occupied Palestinian territory. A variety of internal and external influences on Palestinian society – including forced displacement, dispossession and occupation – are likely to have contributed to this high prevalence of violence in Palestinian society. UNRWA’s health programme plays a central role in the Agency’s efforts to combat, reduce and respond to this violence.

19. High patient loads (the average number of patients per doctor per day was 104 in 2011), increasing numbers of chronic patients on costly medications, combined with the prevailing insecurity and social and economic difficulties of UNRWA’s working environment, have led to increasing challenges in delivering health services. This is aggravated by substantial increases in the costs of medicines and hospitalization fees in the context of a global financial crisis that is negatively impacting donor funding availability. Funding for UNRWA health services has therefore not increased at the pace needed.

20. Financial constraints still remain a serious concern. In 2011, UNRWA faced difficulties in attracting and retaining certain categories of medical professionals and the health expenditure per registered refugee was US$ 25.90 in the Gaza Strip and US$ 26.40 in the West Bank, below the target of US$ 30-US$ 50 per capita that WHO recommends for the provision of basic health services in the public sector.

21. Since 2009, UNRWA has not been able to reimburse costs for all deliveries taking place in hospitals due to budget shortfalls. The Agency has been forced to limit its support to only high-risk pregnancies. The health care offered to persons with noncommunicable diseases is not yet comprehensive and is still predominately curative. Life-saving tertiary care treatments such as dialysis are still not reimbursed and UNRWA has yet to achieve full capacity for early detection and promotion of a healthy lifestyle within the community and acquire optimal technologies for diagnosis and control.

CONCLUSIONS

22. Palestine refugees are victims of health access inequalities and of factors such as conflict, violence, occupation, political instability, poverty and hardship that are impacting negatively on their right to achieve the highest attainable standards of health. UNRWA aims to mitigate the effects of these socioeconomic disparities on health through the provision of the best possible comprehensive primary health care services.

23. Internal health care reform efforts have changed UNRWA’s service delivery approach from a disease-centred to a family-centred one. This, in conjunction with the ongoing and progressive strengthening of the Agency’s health information system, is expected to improve efficiency.

24. However this effort alone is not enough. It is vital for the international community to renew its support to UNRWA so that the Agency, in collaboration with hosts and international stakeholders, can pursue necessary health reforms and continue protecting the health status of Palestine refugees in the context of financial difficulty, socioeconomic hardship and political instability in which it operates in the occupied Palestinian territory.

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1 United Nations Office for the Coordination of Humanitarian Affairs, Monthly Humanitarian Monitor | December 2011, available at http://www.ochaopt.org/reports.aspx?id=118 (accessed 25 April 2012).

2Office of the United Nations Special Coordinator for the Middle East Peace Process. Palestinian state-building: an achievement at increased risk, 2012, available at http://www.unsco.org/Documents/Special/UNSCO%20AHLC%20report%20March%202012.pdf (accessed 25 April 2012).

1 In 2010, around 4000 refugees in the West Bank received counselling services or participated in support group activities through UNRWA community mental health services. This represents double the number of clients in 2009. In the Gaza Strip, around 6000 refugees were assisted through the UNRWA community mental health programme in 2010.