Health conditions in the OPT – Report by Israel

WORLD HEALTH ORGANIZATION

FORTY-SECOND WORLD HEALTH ASSEMBLY

Agenda item 29

HEALTH CONDITIONS OF THE ARAB POPULATION IN

THE OCCUPIED ARAB TERRITORIES, INCLUDING PALESTINE

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

____________

1/ Annex.

Ministry of Health

State of Israel

Health in Judaea, Samaria & Gaza

1988-1989

PREFACE

During 1988-1989 the health services of Judaea, Samaria and Gaza have continued to function without one day of stoppage of even one medical institution, providing preventive and curative services to the population. Despite financial limitations due to cutbacks in tax revenues, regular health services in the government sector, which constitute 65% of hospital and over 90% of primary health care services in Judaea and Samaria, and 90% of hospital services in Gaza, have continued to function and even to develop further. The strength of the health services is seen not only in that they continue to serve, but that the people utilize those services, and expect them to function.

This report continues the series of annual reports on health conditions in Judaea, Samaria and Gaza. I wish to pay my deepest respects to all those Palestinian and Israeli health workers, who stand by their professional ethics and responsibilities to carry on and develop these essential services. Their work serves the cause of peace.

Yaacov Zur

Minister of Health

7 April 1989

Jerusalem

TABLE OF CONTENTS

1. Demography and vital statistics

2. Socioeconomic conditions

3. Primary health care

4. Hospital services

5. Manpower and training

6. Administration and finance

7. Sanitation

8. Research

9. International cooperation

10. Planning

11. Summary

1. DEMOGRAPHY AND VITAL STATISTICS

1.1 Population Density

Gaza with an area of 350 square kilometers has a population density of over 1,700 persons per square kilometer, with 52% urban. Judaea & Samaria includes an area of 5,600 square kilometers, so that the population density is 158 persons per square kilometer. The population of Judaea & Samaria and Gaza continue to grow at high rates due to the high birth rate and greatly reduced infant, child and crude mortality rates., and as a result of declining emigration from the area, as well as the return of many persons from abroad over recent years. The population is young with some 47% of the total between the ages of 0-14 years. Data is from the Central Bureau of Statistics, except that for 1988 which are preliminary.

1.2 Population Growth

Population data (in 000's) are shown in the following table:

*1988 data preliminary

1.3 Fertility

Births (000's), birth rates and location of births are seen in the following table. Data for 1970 includes hospital deliveries only; data from 1975 includes hospital and medically supervised delivery units. Data for 1988 is preliminary.

2. SOCIOECONOMIC CONDITIONS

2.1 GNP per Capita

Economic conditions showed dramatic increases in gross national product per capita over the years; data for the period 1982-1987 are shown in the following table (in US $).

Judaea & Samaria has reached GNP per capital levels well within the category of development", while Gaza is close to that category.

2.2 Economic Development

Economic development has been based on full employment, improved agricultural productivity, business and service industries and small scale industrial development. During the 1988-89 period recurrent general and commercial strikes and disturbances have severely affected the local economic situation.

2.3 Education

Education has been compulsory to the age of 14 for both sexes the past 15 years which has been associated with a rapid expansion the network of schools, literacy rates and enrollment in the many post secondary education facilities opened over the past 20 years. In Judaea and Samaria over 60% of the total population aged 18-24, and ever 42% of those in the age group 25-34 have 9 or more years of education. In Gaza, education trends are even higher, with 63% of those in the 18-24 age group, and 61% of those in the 25-34 group having 9 or more years of education.

2.4 Home Facilities

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

2.5 Living Standards

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

2.6 Housing

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

3. PRIMARY HEALTH CARE

3.1 Program Priorities

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

3.1.1  Expanded program of immunization (EPI)

3.1.2  Sanitation – garbage disposal

3.1.3  Hospital or medical center deliveries;

3.1.4  Oral re-hydration (ORS) for-diarrhoeal diseases;

3.1.5  Primary health care located close to the population;

3.1.6  Health education/community involvement;

3.1.7  Growth monitoring and nutrition education;

3.1.8  Screening for congenital diseases (PKU and hypothyroidism;)

3.1.9  School health;

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

3.1.11 High risk pregnancy identification, referral & follow up;

3.1.12 Expanded primary health care in small villages (Hebron project).

3.2 Primary Health Care Services

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

3.3 Control of Childhood Infectious Diseases

Immunization for the major childhood diseases has resulted in increasing control of elimination of these diseases, as shown in the attack, rates for these diseases in the following tables (in rates per 10.0,000, population)

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

3.4 Infant Immunization Program

The routine immunization schedule currently utilized for infants is the following, with the earlier dates used in Gaza, and the later dates in Judaea and Samaria.

MMR vaccine was introduced at the end of 1987 at 15 months of age. Measles vaccine is available for use during measles outbreaks for infants between 6 and 9 months of age, and is given routinely in Gaza for infants at 9 months of age in view of recent outbreaks in this age group. During 1988 and 1989 IPV vaccine has not been

available so that OPV 5.or 6 feedings is used alone.  New enhanced strength IPV is on order so as to continue the combined OPV/IPV polio control program.

3.5 School Age and Adult Immunization

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

DPT = Diphtheria, Pertussis and Tetanus

DPTV  = Diphtheria, Pertussis and Tetanus + Polio (Salk inactivated vaccine)

TOPV  = Triple Oral Polio Vaccine (Sabin – live vaccine)

DT    = Diphtheria and Tetanus

MMR = Measles, Mumps, Rubella

BCG   = Bacillus Calmette Guerin – in Judaea and Samaria only for school children found on routine testing to be tuberculin negative; in Gaza BCG is given early in infancy

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

3.6 Special Immunization Programs

3.6.1

Hepatitis B vaccine was introduced in Judaea and Samaria, government health services; it is given to a newborn whose mother is found to have antibodies to HB virus during pregnancy or who has known to have had Hepatitis B. Hospital employees working with blood products (in laboratories, blood banks, operating rooms, dialysis and. intensive care units, emergency rooms and delivery rooms.

3.6.2

Meningococcal A vaccine was recommended and given in 1988 to pilgrims travelling to Saudi Arabia, 10 days prior to departure.

3.7 Antibody Serosurveys

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

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

3.8 Poliomyelitis

During 1988 an outbreak of poliomyelitis occurred in Israel mainly in one sub-district where enhanced IPV was used exclusively for 6 years; a total of 16 cases occurred among persons with OPV only previous immunization. A mass immunization campaign with OPV was carried out in October 1988 on everyone aged 0 to 40 in Israel, as well as in Judaea, Samaria and Gaza. In this campaign, 798 thousand persons were immunized in Judaea and Samaria in a large number of immunization centers. The success of these campaigns organized by the Government Health Service involved the participation of all health and many other agencies, as well as the general public.

3.9 Deliveries in Medical Institutions

Hospital and medical center deliveries as a percentage of total deliveries in Judaea, Samaria and Gaza has increased steadily over the years, from 15% to 62% in Judaea and Samaria, and from 10% to 8O% in Gaza from 1970 to 19aa (see section 1.3).

3.10 Birth Weights

Birth weights are recorded for children barn in government hospitals or other medical facilities. The following table shows the percentage born with birth weight less than 2,500 grams (LBW).

The small increase in percentage of LBW reflects the increase of percentage of births taking place in hospitals or medical facilities, and fertility pattern changes.

3.11 Growth of Infants

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

A random sample of school children studied in 1987 in Gaza showed patterns similar to the NCHS pattern, albeit with a wider standard deviation both above and below the NCHS pattern. Growth monitoring is receiving increasing stress in the Government Health Services in Judaea, Samaria and Gaza as an essential part of routine we1l child care, accompanied by nutritional education of mothers. New well child care records have been adopted in both areas for use in community clinics, MCH centers and Village Health Rooms of the Government Health Services.

3.12 Infant Mortality

Infant mortality has declined very rapidly in the Gaza area as the childhood infectious and diarrhoeal diseases are brought under control through successful immunization and ORS programs. Increased hospital and medical center deliveries, and increased educational and socioeconomic standards also contribute to this improvement.

Infant mortality in Gaza has declined from 86/1000: in 1970 to under 30 in 1985. In Judaea and Samaria infant mortality is more difficult to establish particularly during the 1970's. Since most births occurred at home, some, early neonatal deaths have gone unreported. Improved reporting and follow up systems as well increasing hospital deliveries have substantially increased reliability of infant mortality in the 1980's. A recent visit by a WHO consultant in prenatal epidemiology suggested methods of improving reporting and data analysis in infant mortality. The following table shows reported infant mortality trends in rates 1000 live births (reported):

In both areas the Health Services Research Centers are conducting studies of infant deaths as to direct and indirect contributing factors, cause and location of deaths. This will help, to establish routine investigation of infant deaths as part of the routine public health service program.

3.13 Child and Adult Mortality

Overall mortality for infants, children and young adults by age growth as a trend in Judaea & Samaria is shown from a study for the period 1975-1983 in rates per 10,000 population as follows:

3.14 Diabetes Mellitus

Diabetic clinics have been established in Tulkarem and Nablus Public Health Offices in the past year, under the supervision of a local public health staff member following his return from specialization in this subject in Glasgow, Scotland. The clinics are staffed by specialized nurses to supervise the follow up of diabetics, under the supervision of a diabetologist. Health education is stressed, including diet, hygiene, medication, self care and self evaluation. Protocols for care of diabetics in hospital are under development, and staff training programs are being carried out in different areas of the area. Health education material for health staff and patients is also prepared. An epidemiological survey of diabetes is under preparation.

3.15 Rehabilitation Center

A Rehabilitation Center (Abu Rajah) has been approved by the Civil Administration for Ramallah, to be operated by the Friends of the Sick Society.

3.16 Expanded Primary Health Care (EPHC) – Hebron Project

Expansion of Primary Health-Care (EPHC) in Judaea and Samaria was undertaken as a special project by the Government Health Service, in conjunction with UNICEF in Hebron District. Thirty three government MCH centers provide prenatal and well child care coverage for the 120 villages and one city in Hebron District. Immunization of infants and school children in the smaller villages was carried out by visiting immunization teams (initially by sanitarians then later by public health nurses) an a 6 weekly visit schedule. The EPHC project was formulated in order to extend primary care to the small villages in the district. It established Village Health Rooms (VHR's) in villages with populations of an average 800 persons which requested the service and provided the VHR. They are staffed by a trained Village Health Worker (VHW). During 1985 a pilot phase was carried out in 4 villages. This included an 8 month training program for local village high school graduates, preparation health records and carrying a household health survey in all the homes in the villages. In 1986, a further 20 VHR's were opened following the six months training program of VHW's, and in 1987 a further 25 VHR's were opened. Currently 50 VHR's are providing a broad range of preventive health activities in the villages. This includes:

– a household survey in all homes in the village;

– preparing a demographic map of the village;

– registration of births and deaths as well as all infants and pregnant women;

– pregnancy care – coordinating/assisting the visiting doctor/nurse team, as well as high risk pregnancy identification/referral;

– well child care – coordinating/assisting the visiting doctor/nurse team;

– nutrition monitoring and intervention in cases of Failure to Thrive (FTT);

– health education – re: pregnancy, child care, nutrition, sanitation and hygiene;

– coordinating visits by the public health team;

– referrals to district hospital emergency room;

– coordinate with Mukhtars re: sanitation, emergency transportation;

– visiting all newborns at home;

– visiting the sick.

– environmental health – e.g. water quality monitoring.

Other health issues are being added including preventive dental health, screening for heart disease risk factors, teaching women breast self-examination, and supervision of water and other sanitation in the village.

Planning is underway to expand this project to other areas in Judaea and Samaria. Evaluation of the project is being carried out by the Hebron Public Health Office and the Ramallah Health Services Research Center, in consultation with the academic staff of the School of Public Health, Hadassah-Hebrew University in Jerusalem. In the villages where the VHR's are operational, virtually all of the pregnant women are participating in prenatal and well child care, with an increasing tendency to go to the district hospital for deliveries.  Over 1,500 pregnancies and 3,000 infancy care periods have been completed in the 50 VHR’s to date.

During 1989, a proposal was prepared for expansion of this project to other rural areas of Judaea and Samaria and was sent to an international charitable agency for possible funding.

3.17 Traditional Birth Attendants

7 Supervision and training of traditional birth attendants (Dayas) has been given strong emphasis in recent years. The Government Health Service in Judaea and Samaria appointed senior nurses as Supervisors of Dayas in each of the Districts. They maintain contact with the Dayas in the district; this includes regular visits to the villages, inspection of equipment, ensuring registration of births and deaths, supervision of training of new Dayas, and conducting of study days. During 1987 a special project of continuing education for Dayas and their supervisors was carried out both in Judaea, Samaria and Gaza, with assistance of UNICEF, which also provided new kits for Dayas who successfully completed a program of study days. Continuing education for Dayas was expanded in Judaea, Samaria and in Gaza during 1988.

3.18 School Health

Immunization of school children is carried out in primary schools, in both areas. Health examinations of primary school children is carried out in Judaea and Samaria. School health services are being reviewed as part of a study of primary care services, and improved procedures for public health supervision of school hygiene and student health are being developed.

3.19 Oral Rehydration Salts

ORS is now used throughout the Government Health Services primary care centers in Judaea, Samaria and Gaza. This, in conjunction with improving standards of sanitation, hygiene and nutrition, has resulted in a dramatic decline in mortality, hospitalization and serious morbidity from diarrhoeal disease particularly in infants and children. ORS is well accepted and understood by the population as a result of extensive television coverage and health education work in the government and UNRWA health services.

3.20 PKU and Hypothyroidism Screening

Screening of newborns for Phenylketonuria (PKU) and hypothyroidism was started in Judaea and Samaria Government Health Services in 1987 in cooperation with Sheba Medical Center, Tel Hashomer. In this project, infants born in hospital are tested while in the hospital, or in the local MCH center up to 2 weeks after birth. Infants born at home are referred by the Dayas to the nearest MCH center for this test within the first week of life. Suspect cases of these serious congenital disorders are referred to specialty centers at the Child Development Center at Tel Hashomer (for PKU) and local hospitals (for hypothyroidism) for assessment and treatment follow up. PKU cases receive free supplies of the special foods from the government health service that is required to prevent serious mental retardation. During 1988, over 36% of all births in Judaea and Samaria were screened for PKU and hypothyroidism during the first 7-10 days of life. Staff and maternal acceptance of this program has been good during the first year of its introduction. Gaza is preparing to introduce this screening program.

3.21 Vitamins and Iron

Vitamins A and D and iron are provided routinely to all infants attending government health centers in Judaea, Samaria and Gaza. Vitamin K injections are given to all newborns in government facilities for prevention of hemorrhagic disease of the newborn.

3.22 High Risk Pregnancy Care

High risk pregnancy screening, referral, and follow up systems were developed in the Government Health Service in Judaea and Samaria during 1987. High Risk Pregnancy committees were established in all districts, and High Risk Pregnancy Clinics developed in district Public Health Offices and district hospitals. During 1988 this program developed further, and the High Risk Referral forms, guidelines and orientation were carried out for all MCH and village health room staff. Adoption of new pregnancy care records during 1988 helped to increase staff consciousness of high risk pregnancy factors and care. In Judaea and Samaria 8 High Risk Pregnancy Clinics were opened in 1988, and systematic referral, investigation and follow up began. This program is under surveillance of the High Risk Pregnancy Committee.

In Gaza, a High Risk Pregnancy program is also being implemented in the Government Health Services with the establishment of 2 High Risk Pregnancy Clinics, and development of referral systems. Of 26 community health centers, 20 provide prenatal care, including high risk referral and follow-up. The HR Pregnancy Committee is active in reviewing the function of the centers, defining deficiencies in the service, and monitoring the referrals follow-up. In late 1988, Dr. Brian McCarthy, director of the Center for Prenatal Epidemiology at the Center for Disease Control, Atlanta, a WHO Collaborating Center, visited the area to review the high risk pregnancy programs, and the role of the Gaza and Ramallah WHO Collaborating Centers in Primary Health Care Research. Dr. McCarthy's visit provided encouragement and stimulation at the staff and policy level personnel in developing these programs as essential, integral parts of the government health service, including family planning. He also provided valuable technical and professional advice to the programs.

3.23 AIDS

Two cases of AIDS were diagnosed in Judaea and Samaria in 1988, both imported. All blood donations are routinely tested for AIDS, in Nablus, Ramallah, Beit Jallah, Hebron and Gaza hospital blood banks.

3.24 Brucellosis

The current wave of Brucellosis in Judaea and Samaria is primarily due to use of unpasteurized milk from infected flocks of sheep. Education is carried out by public health offices with a focus on medical staff, and the general public. Random samples of milk products are tested for Brucella.

3.25 Supervision of Drug Manufacture

There are now 7 local pharmaceutical manufacturers in Judaea and Samaria. The Government Health Service supervises the quality of the manufacture using standard "good manufacturing practice" criteria. Tests on these and cosmetic products are carried out by the Israeli Ministry of Health Institute for Medical Standards. The Government Health Service purchases local products very extensively.

4. HOSPITAL SERVICES

4.1 Introduction

The hospital services in both areas are mainly governmental, 90% in Gaza and over 60% in Judaea and Samaria where non-government hospital also serve the population. The hospitals in both sectors have advanced in terms of facilities, professional and support services over the years by adding new departments and diagnostic equipment, as well as improved professional training.

4.2 Hospital Facilities in Judaea and Samaria

Judaea and Samaria government hospital service facilities are outlined in the following table, for the year 1988, and as projected in current master plans for government hospitals:

Note: 1988 beds as of Aug. 1988. Projection of beds depends on development on budgets in the years ahead.

Non-Government

4.3 Hospital Facilities in Gaza

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

4.4 Utilization of Hospital Care

Utilization of acute hospital care in local hospitals (government and non-government) is shown in the following table:

4.5 Referral to Hospitals in Israel

Hospitalization of referred patients to hospitals in Israel for inpatient and outpatient services is concentrated on services not available locally such as radiotherapy, hematological oncology, pediatric nephrology, pediatric urology, neurosurgery, pediatric, infant and respiratory intensive burn cases and others. Referrals for ambulatory diagnostic and day hospital care services in many specialty areas for specialized services not available locally is also carried out. As new specialty departments develop locally, services in these specialty areas do not need to be routinely referred as in the past, as in the case of open heart surgery and some neurosurgery, now available in Ramallah Hospital.

4.6 Hospital Development

Master plans for the development of all government hospitals were completed during 1986/87. This has led to improved integration of planning with implementation. Hospital projects completed or in implementation in Judaea and Samaria during the period 1985-1990 include the following:

Ramallah Hospital

Radiology Center 1985

Elevator and central heating 1985

Neonatal and premature intensive care unit 1986

Surgical suite 1987

Open heart surgery department 1987

Coronary care unit 1987

Recovery room 1988

Emergency room – equipped and operational in 1988

Outpatient department – in final construction stages

Neurosurgery department – operational 1988

CT scan – operational – 1988

Digital Fluoroscopy – operational 1988

Peritoneal dialysis – operational 1988

New operating theater and recovery room in construction

New sewage system – completed 1988

New electrical system – in construction

Wattanee Hospital

Intensive care unit 1987

Hebron Hospital

Central Sterile Supply Department – equipped and operational 1988

Surgical suite/operating theatres 1987/88

Service elevator 1987

Radiology Department 1988 – completed and operational 1988

Outpatient and Laboratory Wing 1988 – equipped and operational

1988

Recovery room 1988

Beit Jallah

Emergency and Outpatient Department 1984

Radiology Center 1987

Rafidiah Hospital, Nablus

Radiology Center 1987

Ambulatory Care Department 1988

Physiotherapy Department – in construction

Pharmacy – new department in construction

Doctors’ residence – in construction

Laboratory, kitchen and elevator – in construction

Bethlehem Mental Hospital

Chronic care department (male) – completed and operation 1986

The Government of Italy is working with the Government-Health. Services in Judaea and Samaria on hospital development and projects in both government and-non-government hospitals. This includes-major construction and equipment projects in at Beit Jallah, Rafidiah and Hebron government hospitals and El Ittihad non-government hospitals, for a total of $7 million, including assistance to other hospital laboratories.

4.7 Hospital Development in Gaza

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

Shifa Hospital

Obstetrical Department (100 beds) 1986

Radiology center 1987

Neonatal Intensive Care Unit 1987

Surgical suite/operating theatres 1988

CT scan unit 1989

New surgical department 1989

New gynecology department 1989

Khan Younis Hospital

Refurbished surgical suite 1987

Emergency room – 1988

4.8 Hospital Specialty Departments

The development of new specialty departments and completion of training of new specialists has increased the capacity of local hospitals to provide regular and emergency health care needs.

4.8.1 Medical equipment was purchased for 3.2 million NIS in 1988 for government hospitals in Judaea and Samaria.

4.8.2 The Open Heart Surgery Department at Ramallah Hospital opened in early 1987 has now carried out 100 open heart operations, mostly prosthetic placement for rheumatic valvular disease, or congenital heart diseases. A survival rate of 9EX has been achieved. Diagnostic work-ups are carried out locally in conjunction with a cardiac catheterization laboratory in an Israeli hospital. The Neurosurgical Department at Ramallah Hospital is now doing spinal surgery and hydrocephalus bypass procedures, with more complex cases referred t6 Israeli hospitals pending further development, of the department. The new CT unit will greatly encourage this development.

In Gaza medical and nursing staff are-completing training in Israeli hospitals for 1989 opening of pediatric surgery, neurosurgery, pediatric oncology and adult oncology services at Shifa Hospital.

5. MANPOWER AND TRAINING

5.1 Introduction

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

5.2 Specialty Training

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

5.2.1.  Anesthesia:  25 physicians of the Government Health services in Judaea, Samaria (11) and Gaza (14) successfully completed in 1987 2-1/2 years of full time training in 10 different Israeli teaching hospitals, and have returned to their own hospitals. New equipment and organization of anesthesia services in these hospitals has raised the level of this vital service. Continuing education through monthly study days far this group of physicians is ongoing. This project was funded by the UNDP and the Government Health Services.

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

5.2.3 Midwives for Gaza: 12 senior local nurses completed a 9 month training, program at Assaf Harofe Hospital in 1987 and have returned to the Government Health Service.

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

5.2.5 Public health doctors: 9 physicians and one statistician from Judaea, Samaria and Gaza have completed their one year, full time Master of Public Health (MPH) degree programs at the School of Public Health, Hebrew University – Hadassah, Ein Karem, Jerusalem. Seven of these MPH graduates completed their studies over the past 3 years. All of these graduates are engaged in public health work and research in primary health care, working in the respective Government Health Services. One physician from Judaea and Samaria, and one and one administrator from Gaza, are now in the MPH program in the 1988/89 academic year.

5.2.6 Intensive care nursing: 18 nurses from government hospitals throughout Judaea and Samaria completed six months fu1l time training at Beilinson Hospital in 1987.

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

5.2.8 Various medical specialties: 15 doctors from Judaea and Samaria government hospitals began two years full time training in various Israeli hospitals in 1987. 13 of these physicians completed their 2 year programs in 1988, and are continuing for a third year. The specialties include neurology, hematology, pediatrics, orthopedics, pediatric surgery, neurosurgery, cardiology (at Hadassah); internal medicine and urology (at Shaarei Zedek); pathology (at Beilinson), and psychiatry War Shaul Hospital).

5.2.9 Specialty training for 3 physicians from Judaea and Samaria began in 1988 in traumatology (Hadassah), ENT Surgery (Bikur Holim) and Pediatrics (Hillel Yaffe, Hadera Hospital) for periods of 1 -1-1/2 years.

5.2.10 Midwifery training for 9 registered nurses from Judaea and Samaria was carried out in Assaf Harofe Medical Center. This 10 month program carried out in English, was according to the standard training program for Israeli midwives, I and was completed in late 11988. These midwives have now returned to the government hospitals.

5.2.11 Two registered nurses from Ramallah Hospital spent 3 days per week over a month's period in the Neurosurgical Department at Hadassah Hospital, Ein Karem, and have returned to help set up Ramallah's Neurosurgic Department.

5.2.12 Eight nurses from Gaza completed four months of training in March 1989 in pediatric surgery, pediatric oncology, adult oncology and neurosurgery at Hadassah Hospital, Ein Karem, in preparation for new departments to be opened in Shifa Hospital in 1989.

5.3 Continuing Medical Education in Judaea and Samaria

Continuing education programs have been developed extensively over the past three-four years for Judaea and Samaria government health personnel. Training programs have continued, and new ones begun during 1988/89/

The following is a list of these continuing education programs:

5.5 Nursing Education – Judaea and Samaria

Nursing education is being increased in Judaea and Samaria by expansion of the nursing school Ibn Sinna. The intake class was increased from 24 to 40 in 1987. Graduates of the non-government BA academic schools of nursing at El Bireh Arab College of Nursing and Bethlehem University School of Nursing are recruited to government and non-government health services.

5.6.1 Health Manpower Judaea and Samaria

The number of physicians in Judaea and Samaria in 1987 totaled 66 or 9.93 per 10,000 population of 1 physician per 1,007 persons.

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

5.7 Health Manpower – Gaza

Health manpower employed in the government health service in Gaza increased since 1974, as shown in the following table (numbers and rates per 10,000):

5.8 Hospital Manpower – Judaea and Samaria

Health manpower in government hospitals in Judaea and Samaria at – he end of 1988 are shown in the following table including rated positions, rated beds and staff to bed ratios:

The nurse to bed ratio in government hospitals has increased in recent years from 0.50 to 0.58. The physician to bed ratio is 0.25, or one physician to 4 beds.

5.9 Specialty Qualification in Gaza – 1988

During 1988, 23 Gaza physicians from the government health service or 8.2% of the total number of physicians working in the service were currently in full time training in Israeli university hospitals for specialty training in various specialties for periods of 1-3 years. Six physicians had just completed periods of specialized training, and 5 have in 1989 begun 2 full years of training in Intensive Care (2 in pediatric and 3 in adult IC). Most of those entering specialty training in Israeli hospitals had previously been working in related fields in Gaza, and already had some training in the field.

The Medical Scientific Council in Gaza has now completed criteria and classification of medical specialization. Of 300 specialist physicians in the area, 100 are from those previously recognized as specialists. From 1 January 1989 all new candidates for specialty recognition will be required to have specific periods of experience in Gaza hospitals as well as extra training. Family medicine is also recognized as a specialty with specific requirements, such as those now being fulfilled in the Beersheva course for 30 doctors, now in its semester; the first semester was in basic medical sciences and the 2-11 semester in clinical family medicine, including diabetes, and other clinical subjects, as well as clinic administration and medical records.

6. ADMINISTRATION AND FINANCE

6.1 Government Health Services

The Government Health Services continue to provide the bulk of services in Judaea and Samaria (estimated at 60% of all services), and in Gaza (estimated 90%). These are funded from the Israeli Civil Administration in each area from the general budget which is based on local taxes and revenues, including funds from health insurance. Health constitutes approximately 32% of the total budget of the Civil Administration in each area.

6.2 Non-Government Health Services

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

6.3 International Voluntary Agencies

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

Caritas Hospital in Bethlehem

Mt. David Orthopedic Hospital in Bethlehem

St. John's Ophthalmic Hospital in Jerusalem

Terres de Hammes Child Nutrition Center in Bethlehem, and

Nutrition Center, Gaza

Child Development Centers in Ramallah, Hebron, Gaza and Jenin

funded by UNICEF

The Arab College of Nursing in El Bireh

6.4 United Nations and Other Agencies

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

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

7. RESEARCH

7.1 Introduction

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

7.2 Ramallah Health Services Research Center

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

Recommendations for changes in immunization policy arising from the serosurvey results have been adopted by the Government Health Service. A review of infant deaths will be incorporated into routine of the Public health district offices of the Health Service. The growth study is being followed by an intensive analysis of growth patterns in 10 sentinel MCH centers in the area. The Ramallah HSRC has carried out Knowledge Attitudes and Practices (KAP) studies for evaluation of the process and impact of the Hebron Project in Expanded Primary Health Care now operating in 49 villages in the Hebron area.

7;3 Gaza Health Services Research Center

The Gaza Health Services Research Center was initially established in 1981 as the Government Health Service epidemiology and medical information center. The center's main role was development of vital statistics of the area, but it also carried out various studies in polio, cholera, rotaviruses and measles in conjunction with Israeli academic research centers. In 1986, this center was recognized as a WHO Collaborating Center in Primary Health Care and provided with funding for important additional resources and staff to expand its area of activity. Since 1985, the Center has initiated studies in factors relating to infant mortality, growth patterns of infants, and a serosurvey of antibodies in school children to the childhood immunized diseases. Computerization of the basic vital statistics system for Gaza has been completed by the Center. Computerization of basic child health records including birth weight, immunization and growth patterns, has been established in 10 government community health centers.

The Gaza HSRC now has four major roles; one, gathering vital statistics and epidemiologic data, their computerization, analysis and continuous reporting. Secondly, the Center carries out research in primary health care with current emphasis on a retrospective analysis of infant mortality, and growth of children studies. Thirdly, the HSRC serves as an educational center with a library and courses in scientific English and computers for Center staff and associated health workers. Finally, the Center is closely involved in policy formulation, playing an active role in development of primary health care, the Child Health Committee, the High Risk Pregnancy Committee and other policy groups in the Government Health Service.

7.4 Ramallah Center for Health Manpower Development

The Ramallah Center for Health Manpower Development was established in 1987 as part of the Government Health Service and a WHO Collaborating Center. It focussed initially on collating data regarding health manpower in the public and private sectors of health care in the area. The Director of Hospital Services of the Government Health Service serves as the director of the Center, and other senior persons from the Government Health Services serve as members of the Center's steering committee. There is close coordination with the many manpower training projects initiated and carried out by the government Health Service in the past several years.

7.5 Workshop on Research Methods – WHO/UNDP

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

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

7.6 Workshop on Health Information and Health Policy

The Government Health Service in Gaza is carrying out in Feb-May 1989 a workshop on health information and health policy with 33 senior doctors, nurses and administrators participating. This consists of 15 study days in an Ashkelon hotel, utilizing the case study method of problem identification and analysis by the participants, and a stress on management objectives with critical analysis in policy formulation. Workshop topics selected by the participants fit with ongoing project work of the Gaza Health Services Research Center, as well as other topics such as continuity of care, dental health, growth patterns of school children, attitudes of providers or care, utilization of prescription drugs.

8. INTERNATIONAL COOPERATION

8.1 Introduction

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

8.2 WHO Consultants

WHO consultants in a number of areas of expertise have visited Judaea, Samaria and Gaza, working closely with the Government Health Services and the WHO Collaborati6g Centers. Most recently a group of WHO consultants carried out mid-term review of the activities of the WHO Collaborating Centers in conjunction with two professors from the School of Public Health in Jerusalem, Hadassah – Hebrew University. In 1988, a WHO consultant from CDC Atlanta visited in regard to the High Risk Pregnancy program.

8.3 Other Consultants

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

8.4 UNICEF

UNICEF consultants in primary health care have visited the area frequently since 1985 in connection with the four Child Development Centers and the Hebron Expanded Primary Health Care project. Funds for these projects were provided by the government of the Federal Republic of Germany. This funding terminated at the end of 1988.

8.5 Plastic Surgery Volunteer Group

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

9. SANITATION

9.1 Sewage

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

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

9.2 Community Water Supplies

Community water supplies have been expanded in Judaea and Samaria by increased development of local wells and by supplementation from the Israeli national water distribution system. Water consumption for domestic purposes has increased from 5 cubic meters per capita to 2 5 cubic meters in rural areas, and to 75 cubic meters in urban areas. The number of villages connected to central water supply systems has increased from 50 in 1969 to 120 in 1986 with another 20 in advanced stages of implementation. This provides direct provision of safe supervised chlorinated water to the homes in place of previous reliance on cisterns or container water. Running water reaches 61.6% of homes in the area in 1985, as compared to 23.5% in 1974; this has contributed to improved hygiene and health standards.

9.4 Water Supplies – Gaza

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

9.5 Garbage Disposal

Garbage disposal is now organized on a municipal basis and has been vastly expanded and modernized. Improved facilities for solid waste collection and disposal have contributed to improved sanitation in Judaea, Samaria and Gaza. Disposal sites have been increased in number with improved management practices. A master plan for garbage disposal for Judaea and Samaria was finalized and approved in 1987. In 1988, a 2 million shekel budget was expended for improved gathering and disposal of garbage.

10. PLANNING

10.1 Introduction

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

10.2 Health Planning – Judaea and Samaria

The Joint Planning Committee on Health Services in Judaea, Samaria and Gaza report of 1985 provided a basic program for further development to the year 1990 which is in the stages of implementation. In this report emphasis was placed on new stages in: primary health care, environmental, health, hospital specialized department developments, emergency health services, and manpower development.

10.3 Hospital Development Plans

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

10.4 Primary Health Care

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

10.5 High Risk Pregnancy Care – Judaea and Samaria

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

10.6 Hospital Planning – Gaza

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

10.7 Child Care Committee – Gaza

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

10.8 High Risk Pregnancy – Gaza

The High Risk Pregnancy Committee of Gaza's health services have adopted a program for high risk pregnancy identification and care. This includes improved records and referral forms, district high risk pregnancy clinics, regional birth centers. Two birth centers located in community health centers (CHC) of the Government Health Service in Gaza will be joined by a third one in a new CHC opened in 1988, and a further two to be opened in i989. The objective of this program is to increase hospital and medical center births to provide for all deliveries in the area over the next several years.

11. SUMMARY

The long process of expanding and improved quality of health care is a vital element in improving the quality of life of the residents of Judaea, Samaria and Gaza. For a population which is 50% under the Age of 15, emphasis has been placed on primary health care and sanitation, as well as health education. Improving medical and hospital care has also been emphasized. Rising standards of living have also contributed very substantively to improved nutrition, community infrastructure and education levels. This process has contributed very much to improved standards of life, and to hope for the future for all the people of the area.

The health services operated by the governments in each area, and non-government health services have continued to function in providing regular health care, as well as emergency health services. They have also continued to improve facilities, add new services, and continue staff training and education programs. Respect for the sanctity of health is the politics of the day.

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