Health conditions in the OPT – Report by Israel – WHO 38th World Health Assembly paper

THIRTY-EIGHTH WORLD HEALTH ASSEMBLY

Provisional agenda item 32

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 Thirty-eighth World Health Assembly, for its information, a report 1/ by the Ministry of Health of Israel.

____________

1/ Annex.

ANNEX

MISSION PERMANENTE D'ISRAEL

AUPRES DE L'OFFICE DES NATIONS UNIES

ET DES ORGANISATIONS INTERNATIONALES A GENEVE

Geneva, 15 April 1985

Dear Dr Mahler,

Please find enclosed "A report by the Ministry of Health of Israel to the Thirty-eighth World Health Assembly, Geneva, May 1985." on the Health and Health Services in Judea, Samaria and Gaza 1984-1985.

I would appreciate it if the Report could be circulated as an official document of the Thirty-eighth World Health Assembly.

State of Israel

Ministry of Health

Jerusalem, March 1985

TABLE OF CONTENTS TO THE REPORT

TABLE OF CONTENTS TO THE APPENDIX

PREFACE

This report is presented to the World Health Organization in order to record the continuing development of health services and health conditions of the population of Judaea, Samaria and Gaza. We record not only the development of the past year, but also the ongoing process of change over the past eighteen years.

Change in health status is the result of a sustained process requiring day to day and year to year effort. Continuous build-up of primary health care and sanitation at the local level, accompanied by hospital and specialty services at the regional level, establish the basis for this expansion. These services are being provided in the context of rapid social and economic growth.

The total effect of these aggregate changes is the substantial improvement in the quality of life for the people of Judaea, Samaria and Gaza. This improvement can be evaluated through objective measures of socioeconomic well-being as well as by morbidity, mortality, and other health data.

A deepening involvement of the local population in the planning and administration of their own health services also contributes to the process. Much more remains to be done, however, by voluntary, charitable and international agencies as well as by the government.

We believe that this report fairly represents the real changes which have occurred in the areas, and moreover, provides a basis for planning future stages of health care development for the people of Judea, Samaria and Gaza.

INTRODUCTION

Complete physical, mental and social well-being is an ideal to which the world health movement aspires. Member states of the World Health Organization have pledged to work toward attainment of a level of health that will permit all to lead a socially and economically healthy productive life by the year 2000. It is essential, however, to focus upon specific health and socioeconomic objectives in order to achieve progress towards these general goals.

Central elements of social and health progress include full employment, fair wage and income scales, adequate housing and education, electrification, safe water supplies, garbage and sewage systems, maternal and child health care facilities, expanded immunization programmes and primary health care as well as general and specialty hospital services. While this complex developmental process naturally takes time to implement, these services are becoming widely available throughout Judaea, Samaria and Gaza. Their positive effects on health status is evidenced by the reduction of the morbidity and mortality rates of the populations.

Previous Israeli reports to the WHO have presented data documenting the changes in overall health status indicators. These data illustrate the dynamics of health service development and identify areas where further expansion of services is needed. This report reviews the outstanding data; it presents an overview of both existing programmes and planning strategies for addressing unmet needs. The following priority areas have been central in the planning process:

These principles in health planning have been the basis for the development of the health service programmes in Judaea, Samaria and Gaza

THE REGIONAL CONTEXT

Health care and health status of the people of the areas must be seen in the context of the region, not only for geographic reasons, but also because of the socioeconomic and cultural aspects of the health of a population. There has been progress in many countries in the region in health status indicators and in the development of health services.

Table 1 shows comparative data on socioeconomic status, crude birth and death rates, infant mortality and measles immunization coverages as reported from United Nations sources in UNICEF's "The State of the World's Children 1984", for a number of countries in the region, and comparable data for Judaea, Samaria and Gaza.

Table 2 provides data also from UN sources on hospital bed supply and utilization for Judaea, Samaria and Gaza and various Arab countries in the region.

These data suggest that the people of Judaea, Samaria and Gaza compare favorably with Arab countries of the Middle East and North Africa with respect to health care.

Table 1: CHILD HEALTH STATISTICS (selected countries)

Sources:

1. United Nations Children's Fund (UNICEF) The State of the World's Children 1984: Basic Statistics from the United Nations Population Division.

2.  See Appendix for data re Judaea, Samaria and Gaza.

Table 2: GENERAL HOSPITAL SUPPLY & UTILIZATION DATA

VARIOUS COUNTRIES/AREAS IN THE MIDDLE EAST

     (1979-1981)

Source: From World Health Statistics Annual. Geneva 1983,  Hospital Institutions and Care Units in Israel, and Health & Health Services in Judaea, Samaria and Gaza (Appendix).

HEALTH CONDITIONS/BACKGROUND

The health of a population is intimately related to demography and socioeconomic conditions. Demography, in turn, is highly dependent upon culturally determined patterns such as birth rates. Death rates among infants and children, in particular, are closely related to socioeconomic status of a population.

Economic expansion has brought significant improvement in the quality of community and family living standards, and these are important to the health condition of the people.

Demography

Statistical and demographic data are essential for evaluating both the socioeconomic and health status of a given population. Despite traditional difficulties in compiling vital statistics in the Middle East, much progress has been made in the collection of data for assessment, research and evaluation. Basic demographic data for both Judaea Samaria and Gaza is provided in Tables 1 and 2. 1/

Recent data show that estimated life expectancy in Judaea, Samaria and Gaza has increased substantially over the past two decades. In 1967, life expectancy at birth was estimated to be 48 years; in the mid 1970's, 55 years; and in the early 1980's, 62 years. Infant mortality has decreased substantially in this period; prior to 1967, this rate has been estimated at 150 deaths/1000 live births; in the mid 70's, 100/1000; and in the early 1980's, 70/1000. 2/ Infant mortality rates are considered to be even lower than these estimates, based on actual reported deaths in health systems of increasing coverage and contact with the population.

Unreported infant deaths have been significantly decreased due to several factors; improved follow-up systems in the expanding network of primary care units (MCH centres and community clinics), direct visits by public health workers to villages without MCH centres and UNRWA supervision of refugee camp populations. Furthermore, increasing proportions of births are taking place in hospitals and medical centres (48% in Judaea and Samaria, 72% in Gaza. See Graph 1 for further data on Judaea and Samaria).

One source of discrepancy between estimated and reported infant death figures arises from the difficulty in closely supervising traditional birth attendants (dayas) in the villages. Field surveys designed to assess the accuracy of reported infant births and deaths, however, are being conducted to maximize and improve empirical data. In summary, because of improved registration and wide-scale contact with preventive health services, the likelihood of the death of an infant occurring outside the medical care system is diminishing rapidly. Consequently, active follow-up of the newborns, coupled with immunization programmes and curative health services utilization, has contributed to more accurate data. Government health and statistical information departments use this data based on actual reported events as the basis for published vital statistics.

The overall effect of the health services currently available, along with the improved standards of family and community living, in Judaea, Samaria and Gaza has been a decrease in child mortality. Moreover, extensive programmes instituted to reduce specific causes of death in young children, such as the expanded programme of immunization (EPI) and the oral rehydration therapy programme (ORT), have been successful.

The demography of Judaea, Samaria and Gaza is also strongly influenced by very high birth rates (approximately 42/1000 population) and high fertility rates (over 200/1000 women between the ages of 15 to 44). The result of these factors in conjunction with the enhanced child care is a relatively young population with 45 to 50% under the age of 14, a demographic situation characteristic of developing countries.

Another aspect of the demography of these districts is the migration due to employment opportunities elsewhere. A significant number of young adults emigrate temporarily in search of highly paid work in the Gulf States and other neighboring countries that also draw workers from Europe, the United States and other parts of the world. Because high levels of education and technical training are now available in Judaea, Samaria and Gaza, these workers are sought after by the countries that have the resources for building industrial and other infrastructures, but lack the trained manpower. Many of these young people benefit from the high salary scales and then return home with their savings. Still, the effect due to this migration has declined significantly in recent years. Furthermore, there has been an overflow of workers from Middle Eastern countries due to the economic downturn of the oil industry.

Table 1: HIGHLIGHTS – JUDAEA AND SAMARIA

    Area: 5600 km²

Note: Data are corrected to the Statistical Abstract of Israel, 1984. Other data from Government Health Service, Judaea and Samaria, Annual Report, 1983.

Table 2:  HIGHLIGHTS – GAZA

Area: 363 km²

Note: Population data corrected to current estimates of Central Bureau of Statistics, Statistical Abstract of Israel 1984. Other data from Health Department, Gaza.

Socioeconomic Conditions

Social and economic conditions, both major factors in the health conditions of a population, have improved steadily in the past 18 years. Chronic unemployment and underemployment prior to 1967 in Judaea, Samaria and Gaza have been replaced by full employment (with about 1% of the labour force unemployed). This contrasts sharply with most of the industrial world, including Israel, where unemployment rates range from 5-12% of the work force. Full employment and steadily increasing real wage scales have resulted in a buoyant cash economy which has increased local economic activity, employment potential and standards of living as well as the regional gross national product. In addition, the free flow of labour and goods to and from Judaea, Samaria and Gaza into Israel, Jordan and other neighboring countries has contributed to the cash economy of these districts.

Large-scale technical training programmes combined with modern agricultural equipment and techniques learned from Israeli agricultural experts have revolutionized agriculture, resulting in an expansion of output using less manual labor. This has increased the amount of manpower available to agriculture, to the services sector, to the building trades and to industry. 3/

The per capita gross national product in Judaea and Samaria has increased from US $170 in 1968 to US $1379 in 1982. The per capita GNP in Gaza has increased from US $104 in 1968 to US $1054 in 1982. Agricultural production per capita has increased in both areas many fold as a result of improved education and application of agricultural technology. Food supplies have increased, and agricultural export has stimulated the local economy.

Schooling has become universal at the primary school level and increasingly so at the secondary school level. The educational system provides twelve years of free schooling; six years of compulsory elementary education, three years of compulsory junior high school and three years of non-compulsory high school. Government schools in Judaea and Samaria now include over 278 thousand pupils in 8125 classrooms staffed by over 7300 teachers. There are today four university level academic institutions providing professional studies such as nursing and teaching, as well as general and religious studies. Over 50 000 persons – nearly one fourth of the work force – in Judaea and Samaria have graduated from vocational training. In Gaza, there are over 154 000 pupils in government schools, including some 3700 classrooms.

Public water systems have developed water conservation and thus increased total water supplies. Urban centres and over 200 villages in Judaea and Samaria alone have been linked to regional water systems, providing indoor running water 24 hours a day. Road networks have been improved and expanded. Electrification based on regional electrical networks has been extended to towns and many villages in Judaea and Samaria. Modern digital telephone exchanges and a major increase in telephones connected has also been established in recent years.

Construction in the private and public sectors has nearly doubled from 1974 to 1982 in residential building completions in Gaza. Similarly, the total number of buildings built in Judaea and Samaria increased by nearly two-thirds during the same period. New housing constructions are serviced by electrification, water and sewage systems, all indications of modernization and development. In addition, current housing units, including those in refugee camps, are increasingly being linked to these modern services. 4/

Major changes in employment, economic activity, housing, education and other public services have had an important beneficial impact on the health conditions of the people.

Morbidity and Mortality

High incidence rates of infectious diseases are the hallmark of morbidity and mortality in societies with low levels of economic, social and health services development. As a result of the overall economic growth and expansion in Judaea, Samaria and Gaza, infectious disease has become less prominent as a factor in the morbidity of the area, while disease patterns characteristic of developed countries are emerging. Monitoring for this change is dependent upon direct indicators such as diseases and deaths reported to the health system. Indirect measures are also essential in the evaluation of health status, for example: immunization rates, birth weight distribution patterns, hospital admission rates, diagnostic data, growth patterns of children and other data related to the delivery of health care. 5/

Detailed data are presented in the appendix.

PRIMARY CARE AND PREVENTIVE SERVICES

The international health community has declared primary health care to be the key to health progress in developing areas. The definition of primary health care in the Alma Ata concept 6/ includes nutrition, safe drinking-water, sanitation, immunization against the major infectious diseases, maternal and child health care, provision of essential drugs and health education. This approach has been the basis for the successful development of health services in Judaea, Samaria and Gaza over the past eighteen years.

Maternal and Child Health

Maternal and child health has been one of the main priorities in developing the health care system. The experience in Israel and in many other countries during their development stages has shown that emphasis on MCH has a high payoff in public health terms, especially in a population with very high fertility rates and a high proportion of young people. Health planning therefore has stressed prenatal care, hospital deliveries, improved prenatal care and expansion of the immunization programme and its coverage.

The basis for expansion of the MCH programme has been the distribution of and access to MCH services. A fourfold increase in the number of MCH centres (from 23 in 1968 to 110 in 1984) in Judaea and Samaria and an increase in general community clinics from 89 in 1968 to 148 in 1983 has resulted in improved access to services. In Gaza, 24 MCH centres have been established, providing a centre in every village or neighborhood, in addition to the 9 UNRWA centres in the refugee camps. Consequently, utilization of MCH services has vastly increased. For those using MCH services in Gaza, an average of 15 visits per live birth and infancy took place in 1979 in the government MCH centres. A full prenatal monitoring service is also available along with routine iron and folate supplementation. These services have increased the rate of hospital and medical centre births. For example, in Judaea and Samaria this rate has risen from 13.5% in 1968 to 30% in 1974 and to 40% in 1983. In Gaza, the rate increased from less than 10% in 1967 to 47% in 1974, to 75% in 1982.

In order to improve prenatal care for those women using traditional birth attendants, licensing, supervision and educational programmes for the dayas have been increased by the government health services with support from WHO and UNDP. During 1982, registered nurse supervisors for dayas were appointed in all districts of Judaea and Samaria and Gaza. These supervisors are monitoring the treatment provided by the dayas and have initiated subsequent educational programmes geared for entire families.

Nutrition education for women during pregnancy is being expanded in order to improve fetal and infant development. Pilot studies of growth patterns of infants are being developed along with a review of current infant feeding practices. New nutrition instructional guidelines for public health nursing staff of the MCH centres are being prepared for Judaea and Samaria MCH centres.

Prenatal care services are being improved by re-equipment of facilities and training programmes for medical and nursing staffs; two Gaza doctors have returned from studies in England on WHO fellowships where they received specialized training in neonatal care and public health. Birth weights are now routinely monitored for hospital deliveries, providing a valuable health status indicator.

The current follow-up care of infants covers many basic aspects of health, including immunization, monitoring of physical growth and development, morbidity and parental health education. The basic data that are being used in the programme for monitoring infant and child development are height- and weight-for-age; weight-for-height will be incorporated in the future. These are important indicators of the overall nutritional status of the population and the well-being of individual children.

In addition to monitoring infant mortality reported to the public health systems in the areas, further analysis of infant deaths by primary cause and residence of the infant is now being added to routine outcome measure indicators. Respiratory disease deaths, perhaps associated with cold injury, has replaced diarrhoeal disease as the major cause of infant and child deaths. Staff orientation projects have been commenced to raise the consciousness of medical and nursing personnel to these conditions, particularly for the winter months.

Graph 1:  % HOSPITAL DELIVERIES BY YEARS 1967-1984

      Judaea and Samaria

Expanded programme of Immunization

The importance of EPI as an essential component of maternal and child health and primary health care has been emphasized in WHO resolutions and in the Declaration of Alma Ata in September 1978. EPI is an essential, indeed central, element within WHO strategy to achieve health for all by the year 2000; immunization coverage of children has been included among the indicators which WHO proposes to use to monitor the success of that strategy at a global level. 7/ A recent WHO report on immunization in the Eastern Mediterranean Region includes Judaea, Samaria and Gaza in what are termed it areas of control" for the six diseases of childhood that represent public health problems in almost all developing countries. 8/ In 1979, in the Region as a whole, only 17.7% of eligible infants received three doses of DPT and TOPV by the age of one year and 36% received those immunizations by the age of five years, representing a substantial increase in the rates of coverage since 1975. 9/ These figures contrast sharply with the almost universal coverage of the well established childhood immunization programmes in Judaea, Samaria and Gaza. These rates compare favorably with those in countries with advanced preventive programmes. Community acceptance and participation in these programmes have been vital to their success; general public education regarding the vital role of immunization in child health has been emphasized along with establishing extensive contact with the religious and lay leadership in the area.

The success of the EPI and the addition of new vaccines to the basic programme have resulted in reduced childhood mortality and morbidity. Diphtheria, pertussis, and polio are being brought under control; tetanus cases are rapidly declining in response to a WHO-supported expanded project to eliminate tetanus by an immunization programme among women in the age of fertility and among young adults. 10/ Although outbreaks of measles still occur in the area, good progress is being made in the control and future elimination of measles through wide-scale sustained immunization coverage.

A major effort in BCG immunization has been carried out in Judaea, Samaria and Gaza; children between ages 6 and 18 have been immunized in the schools; in Gaza, newborns are given BCG in their first month of life as part of routine immunization in the MCH centres. All new school-children aged 6 are Mantoux tested and if found negative are immunized with BCG when they enter school. These measures will have long-term benefits in the prevention of tuberculosis. A recent review of the tuberculosis situation in Judaea and Samaria by a WHO consultant indicates that the area may now be considered low prevalence for tuberculosis. Substantial progress in tuberculosis control was also noted in Gaza and suggested improvements in diagnostic techniques are being implemented. 11/

During 1983 a serosurvey of antibody levels to polio, measles, rubella, and tetanus was carried out on a sample of school-children age 6-8 in urban and rural schools in each district of Judaea and Samaria. Protective antibody levels were present in over 90% of cases for polio (types I, II and III), 90.6% for measles, 98% for tetanus and only 49% for rubella (used as a marker disease not yet included in the routine child immunization programme). These findings indicate excellent levels of coverage for the immunization programme. Professor J. Melnick visited the area as a WHO consultant to recommend further methods of monitoring the immunization programme, and further expansion of the programme. For example, immunization against German measles has been established for girls at age 12. A wide-scale programme of rubella vaccination has also been proposed to prevent Rubella Syndrome.

Nutrition

The food balance sheets of Judaea, Samaria and Gaza indicate an adequate per capita energy availability which is within the Food and Agriculture organization (FAO) and WHO recommended dietary allowance. Per capita energy availability is considered by WHO to be the best indicator of total food availability. 12/ Total per capita energy in the food balance information for Gaza was 2516 calories, and 2833 for Judaea and Samaria in 1982/3.

Special attention is being given to the nutritional status of infants and young children, and a proposed nutritional survey of these groups is being planned in conjunction with WHO. Birth weights were recorded for children born in government and non-government hospitals in Judaea and Samaria in 1983 and 1984; in 1984 6.8% were under 2500 grams (i.e. LBW or low birth weight). 13/ A similar survey in Gaza in 1983 showed a just over 5% low birth weight rate. Studies of growth patterns of children attending MCH centres are now under way in Judaea and Samaria.

Health Education

Health education is an area that is not easily evaluated and it is difficult to attribute specific outcomes to health education activities. It is nevertheless clear that real progress in health depends to a very great extent on the understanding and motivation of people in regard to health matters. Measurable success, in both quantitative and qualitative terms, has been achieved with the immunization and ORS programmes which have been key elements of the MCH programme in the areas. Over 90% immunization coverage has been achieved based on making the appropriate service available and by the active participation of the people. Similarly good results have been achieved in the ORS programmes to reduce morbidity and mortality from complications of diarrhoeal disease. Pilot ORS programmes were started in 1980 in Judaea and Samaria and in 1974 in Gaza with expansion to cover the whole region since 1981. The community education aspect of the ORS programme is a central factor in its success; placards, posters, radio announcements, home meetings and other educational activities are integral parts of this programme.

Inclusion of health studies for school directors was initiated in Judaea and Samaria in the 1980/81 school year. The goal is to increase consciousness of public health issues, hygiene, and first aid in the significant school-age population. A similar programme is also being planned for Gaza.

Emphasis is being placed on the education of parents regarding the nutrition of infants and toddlers in keeping with changing international standards. Breast-feeding and appropriate food supplementation during infancy are currently being stressed in the villages.

Environmental Health

An adequate supply of safe water and basic sanitation is listed as one of eight essential components of primary health care required for the achievement of Health for All by the Year 2000 (HFA/2000). 14/ Environmental health programme development has been a major commitment in the area since 1967. This has entailed the establishment and broadening of the community infrastructure, including safe water systems, solid waste disposal systems, sewage systems, electrification, food safety and monitoring systems and surveillance of imported foods. These projects have been and are continuing to be developed in collaboration with local authorities and international agencies. Progress in these areas over the past 10 years in particular has been considerable. Municipality-assisted and self-help schemes for providing indoor delivery of piped and safe water to many homes in refugee camps have continued to make steady progress. 15/ New projects to connect the refugee houses to sewage mains and to enlarge sewage treatment facilities are currently being implemented with UNDP collaboration.

More of this kind of international assistance to improve housing and sanitary conditions for the refugee population is needed. International interest in the health conditions of the population of the refugee camps might profitably focus on these real and immediate concerns. 16/

Control measures for surveillance and prevention of epidemics and epizootics have been established in the areas so that people, their animals, their crops and their water are kept safe from disease. Two examples of ongoing efforts are the constant testing of sewage for cholera and salmonellosis and of water for dissolved chemicals. A large scale surveillance and animal immunization programme from Rift Valley Fever has been carried out since 1978 in order to prevent this very serious human and animal arbovirus disease from entering Judaea, Samaria and Gaza.

SECONDARY AND TERTIARY HEALTH SERVICES

Health care at the hospital and specialty service levels is clearly an essential element of a comprehensive health care programme. Development of these services, however, must take place in the context of adequately developed primary health care, appropriate manpower supply, and available resources. Such specialized medical care must also be distributed in such a way that it is accessible to the population within reasonable travel time.

Hospital Services

The development and integration of hospital services has involved the complete organizational and physical restructuring of existing facilities in order to provide high quality services at the regional level. A parallel development of infrastructure services such as laboratory, X-ray, pharmacy, supply, kitchen and laundry has been emphasized. In Judaea and Samaria, hospitals in all seven government districts have been reorganized and upgraded in the basic medical departments, as well as in the infrastructure and support services. Many expansion and renovation projects are under way or nearing completion.

Continuing development of many specialized services in local hospitals is planned in keeping with the needs of the region and the pace of specialized personnel training. For example, specialty services have been added in Judaea, Samaria and Gaza to all government hospitals. These services include orthopedics, ear, nose and throat, coronary care, oncology, gastroenterology, renal dialysis, vascular surgery, pediatric surgery, ophthalmology, hematology, allergology, rehydration services, cardiology, endocrinology, neonatal care units and genetics. For those services currently beyond the scope of local facilities, patients are referred to supraregional hospitals.

Changing morbidity and health needs, in particular, have necessitated redevelopment of some special hospitals. Tuberculosis hospitals, such as the Bureij Hospital, have reduced their bed capacity as a result of falling incidence rates and improved ambulatory care. Similarly, the number of long-term psychiatric beds have been reduced due to improved community mental health services and more active in-patient care.

Government hospitals are improving their emergency care services both through improved equipment and ambulances, but also through staff training programmes. Specialty emergency care is available for services such as coronary care in intensive coronary care units and for trauma emergencies in hospital surgical services. Another basic addition to local facilities is the development of laboratory services similar to previous clinical laboratories which were attached to hospitals. Finally, central public health laboratories with trained staff have been established in Judaea, Samaria and Gaza.

Mental Health

As is the case for physical well-being, as long as valid positive indicators of social and mental well-being are scarce, it is necessary to use indicators of social and mental pathology. Examples of possible indicators are the rate of suicide, homicide, acts of violence and other crime; road traffic accidents, juvenile delinquency, alcohol and drug abuse; smoking; consumption of tranquilizers; and obesity. 17/

According to a key WHO study, mental disorders account for up to 30% of illness brought to the attention of doctors in the Middle East. This statistic is linked to the stress and cultural conflict people encounter in a society undergoing rapid economic growth, increasing employment and vastly expanded educational opportunities. 18/

The current emphasis in the planning of mental health programmes is on the rehabilitative and out-patient care in the community as opposed to the historical emphasis on hospital custodial care. Similarly, in-patient psychiatric facilities foster a more active therapeutic environment. Comprehensive treatment and follow-up in the community, thus, have become the cornerstone of long-term management of mental health problems.

Problems of Special Groups

Problems of special groups have also been studied and efforts have been made to solve them. There has been a recent attempt to decentralize the prison system so that prisoners are housed closer to their homes and families, increasing the potential for earlier discharge. Furthermore, all prisons have clinics and infirmaries, and medical staff has been assigned to meet the prisoners' needs. Specialized services are given on request, when appropriate complicated cases are transferred to local hospitals or supraregional hospitals. The food and medical care provided meet current international standards. As part of the rehabilitation process, prisoners are encouraged to take part in manual crafts and training classes in other skills.

The elderly as a special group needing health care will demand more attention in the future as acute health care needs are better addressed and as long-term care needs come to the fore. The tradition of family care for the elderly may need additional help from ambulatory care, home care and other social support services, particularly as costly acute care services find difficulty coping with long-term care needs.

The health problems of the Bedouins, particularly those who are still nomads, have centreed around the difficulty of establishing contacts with the health system. Access to health care, however, has been improved through wider availability with expansion in the distribution of facilities. Thus, considerable progress has been made with respect to integrating the Bedouins into the health system. Settlement of Bedouin families in permanent housing is a key factor in improved sanitary and living conditions, as well as in improving their access to health services.

MANPOWER AND TRAINING

Trained people are the key to the health infrastructure. Institutions can be built, but institutions cannot function without trained people. Without the right kind of trained manpower the other resources of a health system are under utilized, if not wasted. 19/ Priority has been given to manpower training and in particular to the development of local training programmes for nursing and paramedical staff in order to meet the growing needs of community health services staffing. As a result, nursing schools and other health manpower training programmes have been initiated in Judaea, Samaria and Gaza with entrance and curriculum standards and supervision provided by the Nursing Division and other relevant divisions of the Israeli Ministry of Health.

In Judaea and Samaria, the Ramallah School for Registered Nurses (Ibn Sina) which opened in 1971 has, to date, graduated 141 registered nurses from the 3 year course. This programme includes a strong element of community health nursing, with recently added field work in vital statistics. Practical nurse training in government hospitals is now concentrated in Nablus and other practical nursing schools are operated by private organizations such as St. Luke's and El Ithidad. Two university level nursing courses offering B.A. programmes have now graduated several classes of nurses at El Bireh College and Bethlehem University. A new practical nurse training programme has been started at Bethlehem Mental Hospital. A training centre for nursing and paramedical staff is being planned for Bethlehem. The UNDP has undertaken to fund the building for this essential training centre.

In Gaza 614 practical nurses have graduated from the Shifa Hospital Nursing School, which opened in 1973 and expanded in 1975. The course lasts 18 months. The Gaza School of Registered Nurses, opened in 1976, which emphasizes community health nursing, has thus far graduated 97 students, and 65 students are currently enrolled in the 3 year programme. Graph 2 illustrates the distribution of manpower by profession since 1967.

In-service education, staff conferences, a medical journal (The Gaza Medical Bulletin) and visiting lectureships by Israeli and foreign professors all contribute to the improvement of standards in government health services. Referral and consultation with Israeli hospitals have also served to help upgrade standards as have the visiting specialists from WHO. A number of publications on health services developments in Gaza and presentations at an international congress on this subject have been forthcoming recently. A number of health care research projects are in the process of implementation or preparation in Judaea, Samaria and Gaza.

Medical personnel are recruited into the government health service from local residents returning from medical training abroad. With the assistance of WHO and UNDP fellowship programmes, physicians are being sent abroad for specialty training in many clinical and public health fields. Many short-term postgraduate courses have also been arranged in Israeli teaching hospitals.

Recently in Gaza, an interdisciplinary journal club was established with active participation of leading figures in the medical profession. Hospital teaching trends and journal clubs have been established throughout the districts' hospitals.

Staffing of government health services in Judaea, Samaria and Gaza has expanded substantially over the years, at rates faster than the population growth. In Gaza 97 doctors were working before May 1967; in 1982 there were 242 doctors working in this region. This represents an increase from 2.7 per 10 000 population to 5.3 per 10 000 population. In Judaea and Samaria medical personnel in government health service increased from 97 in May 1967 to 210 in 1984 (an increase from 186 in 1982): this is an increase from 1.6 per 10 000 population to 2.7 per 10 000 population. When non-governmental physicians working in Judaea and Samaria are included, the physician to population ratio is approximately 6.5 per 10 000 population. Nursing and other health care personnel in the government health service have similarly increased.

Graph 2: DISTRIBUTION OF MANPOWER BY PROFESSIONS AND YEARS

GOVERNMENT HEALTH SERVICES

Judaea and Samaria

Some professional health staff migrate to neighboring Arab countries, particularly to the Gulf States which seek this type of skilled manpower to meet their own rising health needs. These countries offer very high salary scales, desirable working and living conditions and good opportunities for professional development. Nursing and other paramedical staff trained in Judaea, Samaria and Gaza are very much in demand in the neighboring countries. As a result, efforts are being made to encourage trained health workers to remain in the area. Incentives provided include career advancement through professional training abroad with WHO and UNDP fellowships as continuing medical education opportunities in nearby Israeli hospitals or educational facilities. Professional pay scales are linked to the cost of living and the basic salary scales periodically come under review. Major salary increases for health workers have in recent years exceeded cost of living increments, so that personnel have benefited from real wage increases which are closing the gap between local personnel and Israeli health workers. As a result of the growing number of trained nurses graduating from the local nursing schools, and despite the emigration factor, the total number of nurses practicing in these districts has increased very substantially over the years, more than doubling in number.

In 1984, 25 physicians from Judaea, Samaria and Gaza began a two year training programme in anesthesia in Israeli hospitals. This programme is funded by the UNDP.

ADMINISTRATION AND FINANCE

As health services have developed in scope and complexity in Judaea, Samaria and Gaza, organizational and financial issues have evolved. Government services in Judaea and Samaria constitute approximately 60% of total health services, while in Gaza they comprise 85% of all health services. Additionally, health insurance introduced as a supplementary financing system has gained increasing importance as a primary funding source. Finally, there is a growing involvement of local health personnel in the management and planning of the health service system.

Health Insurance

The problem of the escalating costs of health services and community infrastructure is one that all countries are now facing. Expenditures have likewise risen in Judaea, Samaria and Gaza, while expansion of services and programmes continues. To counteract the inevitable debt this combination imposes on governments, many countries employ a compulsory system of national health insurance. In Judaea, Samaria and Gaza, however, voluntary health insurance plans have been established over the past several years with quite high participation rates (40% in Judaea and Samaria, 80% in Gaza). Participation through voluntary insurance induces a greater demand of rights to service by the consumer, thus increasing the quality of service offered by the provider agency.

Health insurance premiums are charged for each family, irrespective of family size or pre-existing medical condition. Workers in government and all employees working in Israel are automatically entered into the insurance plan. In addition, families receiving social assistance are enrolled in the plans free of charge.

The insurance plans provide for preventive and curative ambulatory services, as well as hospital services in government health facilities and supraregional hospitals. It should also be stressed that many government health services, particularly maternal and all child health care up to the age of 3, are unconditionally provided without charge.

Community and Voluntary Agencies

Extra-budgetary funding, appropriately coordinated, is encouraged and provides important community services. Specifically, it is a needed source of funds for equipment, medical supplies and special projects in government health facilities, as well as fellowships for post-graduate training of medical personnel. These funds make an important contribution to the continuing build-up of an increasingly comprehensive, sophisticated and, thus, costly health care system.

Active and widespread community participation is instrumental in bringing about the rapid expansion of MCH and general clinic distribution in Judaea, Samaria and Gaza. For example, both facets of primary care are housed in buildings provided by the local authorities. As such, improved services are the result of a process whereby the community may not only request a government service, but may actually take part: in assuring that it reaches fruition. Furthermore, a Scientific Council was established in Gaza in 1982 in line with recommendations of the WHO Special Committee of Experts, in order to assist in defining future planning needs.

Important health services are operated directly by voluntary and charitable agencies both local and international. These include the Caritas Hospital, the St. David Hospital, the Terres des Hommes Child Nutrition Centre in Bethlehem, St. John's Ophthalmic Hospital in Jerusalem and many others. These agencies provide key elements of the overall health services of Judaea and Samaria, in particular. A number of hospital development programmes have also been initiated and developed by the voluntary organizations of "Societies of Friends" with the approval of the government health authorities. This has enabled more rapid implementation of the plan to meet needed specialty and sub-specialty services development in the district hospitals of Judaea and Samaria. In Gaza, a local voluntary association called "Friends of the Sick", staffed by public figures and community leaders, has been established for the purpose of raising funds for hospital equipment and health education. The Arab Medical Welfare Association has contributed to hospital development projects in Ramallah and other hospitals in Judaea and Samaria.

International Agencies

A variety of international agencies provide important project development funds for government and non-government health services in the areas. These agencies also allocate funds for social and economic development projects directly and indirectly linked to health conditions of the areas.

The UNDP in particular has launched large scale financial assistance to help foster development of health services. Between 1981 and 1983, the UNDP carried out projects totaling US$ 3.5 million, and budgeted some US$ 12 million over the next four years for a variety of programmes in the health, education, manpower, development, community and social service infrastructures. This includes health manpower development (US$ 948 000), health institutions expansion (US$ 668 000), the Bethlehem health manpower training centre (US$ 2 500 000), sewage-disposal schemes at Khan Yunis and Rafah and the Ahli Arab Hospital (ex-Baptist) in Gaza. 20/ UNDP staff are present locally and senior medical consultants frequently visit the areas to review equipment, facilities and training programme needs both in government and non-government facilities.

Other agencies such as ANERA (American Near East Refugee Association) and CDF (Community Development Fund) have over the past three years funded a great variety of health related projects. ANEF projects include expansion and improvement of a centre for mentally retarded children in Nablus, a degree course in nursing at El Bireh College Ramallah, equipping a laboratory, and laying sewer pipes in Gaza. CDF projects include sewage projects in El Bireh, Jabaliyeh, Khan Yunis and Gaza; equipment for Caritas Women's Union; Red Crescent Societies' clinics in Bethlehem, El Bireh and Gaza; laboratory and clinic equipment for charitable agency clinics in Ramallah and a grant toward a sewage treatment plant in Khan Yunis.

UNICEF has available a grant of US$ 1.7 million from the government of West Germany for projects in the period 1984-86 for ORS, breast feeding, dayas' education, child guidance centres and kindergartens.

A religious organization, the Catholic Relief Society (CRS), has funded clinics in a number of villages in Judaea and Samaria, and conducts health and nutrition education projects in some 100 villages in Judaea and Samaria. The Near East Council of Churches (NECC), and American Institute for the Middle East (A Mid East) are also active in the area. The United States Agency for International Development currently budgets over US$ 6 million for projects of American voluntary agencies in Judaea, Samaria and Gaza.

Between 1978 and 1982, a total of US$ 31 million was budgeted by the US Congress for developments in health, education, cooperatives, electricity, water supplies, access roads and sewage systems. Other international agencies have provided major financial assistance for physical development of the Mt. David Orthopedic Hospital, and the Beit Jallah Hospital.

PLANNING AND EVALUATION

Planning and evaluation have been part of the process of developing health services in Judaea, Samaria and Gaza over the years, both in formal committees and in an ongoing consultative basis and includes many forms of external as well as internal evaluations.

Health Planning

Planning in health services, particularly in a developing area, is a dynamic process which requires evaluation, feedback, reevaluation And replanning. From its inception the development of the health care system has been based on planning, and the participation of committees of Israeli and local health authorities. Subsequent review by visiting WHO committees and experts has made important contributions to health planning by providing objective and highly professional analyses related to specific health problems. Resources are limited but improvements in the health care system, based on recommendations resulting from evaluation and research, have been and will continue to be made.

In 1983 a Joint Planning Committee for Health Services in Judaea and Samaria was appointed, consisting of senior local and Israeli health officials, to review the existing health situation, to define health needs, and to develop a health plan for the next four- year period. The report of this Committee has been presented to the government and is seen as a basis for health planning for the period 1985-1990. The Scientific Council is carrying out a review of health services and is actively involved in the planning process.

In order to develop a comprehensive evaluation process, sophisticated data systems are required. The better the system, the better the information derived from it. Continuing efforts are being made to improve data systems through improved collection of data related to the measurement of health status and related quality of life indicators. These include vital statistics, morbidity and mortality data, ambulatory care and hospital data as well as data related to socioeconomic change in the society.

Judaea, Samaria and Gaza have improved their statistical reporting over the years. The Judaea and Samaria government health service now issues annual reports providing a continuous flow of health information. A monthly health information bulletin was established in 1983 in Judaea and Samaria. This bulletin includes reported births, deaths (by age and cause for children) by districts, as well as ambulatory care and hospitalization, reportable diseases and immunizations. It is circulated to all districts of public health, hospitals and other relevant agencies. Since 1981, the Gaza health authorities established a monthly and annual medical information bulletin which publishes information on births, deaths, infectious diseases, vaccinations, primary care and hospital utilization. This provides a two-way flow of information between field personnel and central staff. It is also a basis for continuous monitoring of different aspects of the health situation of the population and for evaluation of future needs and development.

In-depth studies of particularly important issues such as infant and child mortality, polio, diarrhoeal diseases, ORS, immunization coverage by sero surveys, nutrition status of children, iron deficiency anemia and others, as well as the monthly health statistical bulletins are all contributing to a better potential for internal and external evaluation for programme planning purposes.

The government health service in Judaea and Samaria established a Health Services Research Centre to develop and carry out such studies. This centre has been recognized as a WHO collaborating centre for primary health care research.

WHO Visiting Consultants and WHO Collaborating Centres

WHO consultants who have visited Judaea, Samaria and Gaza have made major contributions to the analysis of specific health problems within their areas of expertise and thus have added a great deal to the continuous process of planning and evaluation related to health conditions. Dr R. Cook in the field of maternal and child health, Dr T. Harding in mental health, Professor J. Melnick in polio and immunization programme monitoring control, Dr K. Styblo in tuberculosis and Dr Barua in diarrhoeal diseases have all provided extremely valuable analysis, consultations and a flow of important professional material for specific programme development within the overall context of services in Judaea, Samaria and Gaza.

The Health Services Research Centre for Judaea and Samaria, located in Ramallah, and funded partially by UNDP and the government health service, is being designated as a WHO collaborating centre to carry out research projects in health services and health needs, particularly at the primary health care level. The possibility of establishing the Health Services Research Unit of the Gaza Health Service as a WHO collaborating centre for similar purposes is also under active consideration, through the auspices of UNDP.

The WHO Special Committee of Experts has been visiting Judaea, Samaria and Gaza annually for a number of years investigating issues related to health planning, rural primary care, expanded immunization, communicable and epidemiological disease control, environmental health, epidemiology of mental health, manpower training and development, regional public health laboratories, health information systems, hospital bed supply, hospital outpatient specialty services, emergency transportation and working conditions and pay. These issues have and are receiving attention by government planners, some with the cooperation of UNRWA, others with UNDP and WHO collaboration, as well as with participation by local and international voluntary agencies.

Table 3 outlines the WHO Special Committee recommendations and the relevant activities of the health authorities.

Table 3: WHO SPECIAL COMMITTEE RECOMMENDATIONS 1984 AND

         RELATED ACTIVITIES IN THE HEALTH SERVICES

Introduction

In the 1984 report the Special Committee of Experts takes as a basis the framework contained in WHO's Seventh General programme of Work; this framework outlined trends in the health field and in related socioeconomic sectors, health protection and promotion; and diagnostic, therapeutic and rehabilitative technology. The Committee report discusses these areas making relevant observations; for specific recommendations references are made to its reports of 1983 (A37/13) and 1982 (A35/16).

Notes

 1/ These data are gathered from a 1967 Census of Population in Judaea, Samaria and Gaza and an update registry for Gaza in 1981. The Central Bureau of Statistics of Israel submitted population estimates derived from the empirical data and demographic modeling techniques. The population models are based on assumptions that infant deaths are underreported. Cumulative corrections up until 1981 subsequently result in an increase in population for Judaea and Samaria of approximately 24 500 (about 3.5%) and an increase in Gaza of approximately 17 300 about (3.8%). Most of this increase is concentrated in the under 15 age-group.

 2/ Israel Central Bureau of Statistics:  Statistics of Judaea, Samaria and the Gaza Area, Vol. XIII, 1983.

 3/ Ministry of Labor and Social Affairs – Labor and Employment in Judaea, Samaria and the Gaza District. Jerusalem, March 1983.

 4/ Ministry of Defense, Judaea and Samaria and Gaza District – A Sixteen Year Survey (1967-1983), Jerusalem, November 1983.

 5/ World Health Organization (1981) Development of Indicators for Monitoring Progress Towards Health for All by the Year 2000, Geneva.

 6/ World Health Organization, Health for All by the Year 2000 Series, Geneva 1981.

 7/ WHO (1982) Expanded programme on Immunization: progress and evaluation report by the Director-General A35/9, 25 March 1982.

 8/ The Expanded programme on Immunization in the Eastern Mediterranean Region: An account of progress, etc. EM/RC 30 *82/11, June 1982.

 9/ WHO (1981) Progress in Immunization programmes in the Eastern Mediterranean Region. WHO Chronicle 35; 179-181.

10/ WHO-EM (1982) – Neonatal tetanus. Regional Committee for the Eastern Mediterranean EM/RC 30(82)/12.

11/ Styblo, K. (1982) – Assignment report: Tuberculosis Control in Israel; 9-21 January 1982 WHO-EM/TB/157, EM/ICP/SPM/00l/RB May 1982.

12/ WHO (1981) Development of Indicators for Monitoring Progress Towards Health for All by the Year 2000. WHO, Geneva, p. 25.

13/ WHO – Seventh General programme of Work. 90% or more of births with over 2500 grams birth weight is indicative of good prenatal nutrition.

14/ WHO EM (1982) – Water, Sanitation and Health. Regional Committee for the Eastern Mediterranean WHO-EM/RC 30 *82, Tech. Disc. 1, May 1982.

15/ United Nations Relief and Works Agency (1982). Report of the Director General to the thirty-seventh session of the General Assembly of the United Nations, supplement No. 12 (A/37/13), New York.

16/ United Nations Relief and Works Agency (1981). Annual Report of the Director of Health 1980. Also see WHA document A35/INF.DOC./6., 7 May 1982.

17/ Simon, Jan *(1980) "Middle East Health. The outlook after 30 years of WHO assistance in a changing region." EMRO, WHO, Alexandria, p. 37.

18/

19/ WHO (1982) Seventh general programme of work: covering the period 1984-1989, Geneva, p. 65.

20/ UNDP – Report of the Administrator 1983.

21/ WHO Development of Indicators for Monitoring Progress Towards Health for All by the Year 2000.

22/ WHO (1982) Seventh general programme of work covering the period.

A P P E N D I X

to the

REPORT OF THE MINISTRY OF HEALTH OF ISRAEL ON

HEALTH AND HEALTH SERVICES

in

JUDAEA, SAMARIA AND GAZA

1984-1985

INTRODUCTION

The statistical data for Judaea, Samaria and the Gaza strip are presented in a parallel fashion to enable the reader ease in identifying similarities and differences in development of the regions. The socioeconomic, cultural and political differences of Judaea and Samaria and the Gaza strip naturally necessitate individualized planning strategies tailored to the needs of the indigenous populations. However, it is helpful to view the two areas simultaneously in order to gain a proper picture of health development issues and problems specific to the Middle East. It is hoped that the continual improvement of health in Judaea, Samaria and the Gaza strip will both serve as models for each other, generating new and successful strategies readily applicable to both areas.

Judaea and Samaria is an area of approximately 5600 square kilometers divided into seven administrative districts. In 1968 the population was 583 000, and has subsequently increased to an estimated 770 000 in 1983.

The population in 1968 was settled in 10 urban locations, including some 30% of the total population, in 45 large villages (of over 2000 persons each), including 25% of the total population, 391 small villages comprising 38% of the population, and some 7% of the population residing in refugee camps. Of the total of 458 villages, 122 were over 2000 in size of population, 100 were between 1000-2000, 76 between 500-1000, and 160 under 500 population. The population density in 1968 was 104 persons per square kilometer, increasing to 138 persons per square kilometer in 1983.

In 1967 the area came under Israeli jurisdiction. Health planning along with other social and community service developments must take into account the wide geographic distribution of the population in mainly small population centres.

The Gaza district is 363 square kilometers. In 1968 the population consisted of 381 000 persons and in 1982 476.3 thousand for a current population density of 1312 persons per square kilometer. The population in 1967 was settled in 6 urban localities with 315 000 persons or 80.7% of the population; of this 133 000 or 34.2% were living in refugee camps within urban localities, and a further 43 000 in other refugee camps. The population living in 4 large villages made up 5% of the total population, and 2.5% of the population lived in 11 small villages.

The area is therefore largely urban and densely populated with a high proportion (46% in 1968) living in refugee camps.

HEALTH PLANNING: Judaea and Samaria

Up to 1967 the health situation in Judaea and Samaria was characterized by a pattern of morbidity and mortality seen in developing countries, especially those in the Middle East, 1/ with high infant mortality and high rates of infectious disease. Since 1967, the picture has changed to that of middle-level developed countries.

Epidemiological surveillance, based on reports of communicable diseases, death certificates, ambulatory clinic and hospital diagnostic data, indicate that diseases such as polio, malaria, trachoma and many childhood diseases as new causes of morbidity have been nearly eliminated. Other diseases such as tuberculosis and measles are of declining importance as causes of death and morbidity. Gastrointestinal disease is less prominent as a cause of death, being replaced by acute respiratory disease as the most frequent cause of childhood mortality which as a whole is declining.

In 1970, a health plan for Judaea and Samaria was developed by local health personnel under the direction of the late Dr Daniel Pridan, Chief Medical Officer for the region. This plan spelled out important deficiencies in the health situation and recommended that attention be given to a number of specific developments in health service facilities and health manpower over a period of years. This plan served as a guide to the government health service. It placed particular emphasis on MCH services, immunization, ambulatory care, sanitation, hospital services, health -insurance and regional rural health centres. A programme emphasizing development of the four basic departments in the regional hospitals (internal medicine, general surgery, obstetrics and pediatrics) was commenced, with subsequent addition of further specialty departments. Rural and regional health centres were developed, and basic public health programming was expanded vigorously over the years since 1970 in keeping with this plan.

In 1978, a committee of senior officials of the Judaea and Samaria government health service and of the Israel Ministry of Health reviewed the health situation in Judaea and Samaria to recommend future priorities and organization of services. This committee, under the chairmanship of Prof. B. Modan, former Director-General of the Israel Ministry of Health, included the Director of Public Health of Judaea and Samaria, the Director of the Public Health Service in Israel, the Director of Hospital Services in Judaea and Samaria and other local health officials. A programme of further development of sanitation, school health immunization, health insurance, primary care, health manpower training programmes and hospital specialty services was outlined providing a framework for detailed planning and subsequent developments. Figure 1 presents the stages in the development of the health programme in Judaea and Samaria.

In late 1983, a new Joint Planning Committee was appointed by the Civil Administration and the Ministry of health to review the present situation of health needs and current services, and to prepare a programme for future development of the services. The Committee consisted of five senior local and three senior Israeli health officials to review the existing health situation and prepare a programme for development of health services for the period 1985-1990. The Joint Committee held over 18 meetings including hearings of presentations about government and non-government health care programmes, with deliberations especially on primary health care, hospital planning, financing and organization, manpower, and environmental issues. The report of the Joint Committee was presented to the civil administration and Ministry of Health in March 1985 as a planning base for the development of document health services for Judaea and Samaria for the period 1985-1990.

 1/ Simon, Jan (1980). "Middle East Health. The outlook after 30 years of WHO assistance in a changing region." EMRO, WHO, Alexandria.

Figure 1:  DEVELOPMENT OF HEALTH SERVICES, Judaea and Samaria

HEALTH PLANNING: Gaza

Prior to 1967, the health situation in Gaza was characterized by a high prevalence of malnutrition and infectious diseases with very high infant mortality and other characteristics of an underdeveloped region in terms of health and socioeconomic status*. Consequently, the development of health services in the area since 1967 was planned to focus on establishing preventive care systems (particularly sanitation and maternal and child health or WR services): secondly, on upgrading hospital care by completely renovating and expanding equipment, facilities, specialty services and programmes in the government hospitals; and thirdly, on developing health manpower by expanding the number of health care providers, and by developing health manpower training programmes. As a result of these efforts, and of the much improved socioeconomic situation, there has been a major shift in the morbidity and mortality rates away from those of a developing country in the Middle East, toward patterns reflecting those of middle-level developed countries. Further planning based on identified needs will continue the process of improvement in these and other health status indicators.

_______________

*Simon, Jan (1980). "Middle East Health. The outlook after 30 years of WHO assistance in a changing region." EMRO, WHO, Alexandria.

Figure 2 presents the stages in the development of the health care system, showing increasing levels of sophistication, both at the community and hospital levels of service.

The second stage of programming began with greater stress on integrated community health services, combining preventive and primary care in comprehensive health centres, and bringing specialist services from the hospitals to the community health centres.

Stage three represents the development of subspecialty services, teaching opportunities and special projects aimed at dealing with particular risk factors.

Figure 2: STAGES IN DEVELOPMENT OF HEALTH SERVICES, Gaza

ORGANIZATION OF HEALTH SERVICES: Judaea and Samaria

The government health department in Judaea and Samaria is responsible for supervision of the public health, as well as the provision of preventive and curative services, for a large proportion of the population. Non-governmental providers of health care include UNRWA, a variety of voluntary and charitable agencies as well as private services.

The government health service is structured according to the table of organization set out in Figure 3. The Chief Medical Officer with his immediate professional and administrative staff is responsible administratively to the government authority, and

professionally to the Director-General, of the Ministry of Health. The operational divisions, which include Hospitals, Public Health and Professional Training, are directed by local professionals.  Laboratories are located within the Hospitals Division. However, the two public health laboratories located in Ramallah and Nablus Hospitals are supervised by the Public Health Division. The Health Services Research Centre was established in 1984.

Figure 3: ORGANIZATION OF GOVERNMENT HEALTH SERVICES: Judaea and Samaria, 1984

ORGANIZATION OF HEALTH SERVICES: Gaza

Figure 4 presents the new organizational structure of the government health services implemented during 1982, which reflects the health system development plan.

During 1982, a Scientific Council was established made up of local physicians, nurses, pharmacists and other senior health personnel representing all the major medical and paramedical professions. The Council has undertaken to develop guidelines and priorities for the development of medical services over the next 5 to 10 years. This process began with two seminars with participation by Prof. R. Salmon, Professor of Urban and Medical Planning for Rutgers University in New Jersey (USA) Prof. Salmon was previously advisor on health planning to President Johnson, and was Secretary of the U.S. National Academy of Science.

The Scientific Council has continued to be active and provides an ongoing forum for consultations in health planning, professional and scientific matters including medical licensure and specialty training.

Figure 4: ORGANIZATION OF GOVERNMENT HEALTH SERVICES: Gaza

Director of Health Services – Joint Planning Committee

– Staff – Administration, technical and financial

Director-General of Health

DEMOGRAPHIC AND VITAL STATISTICS for Judaea, Samaria and Gaza

Reporting

Population figures are derived from estimations, which are based upon the last census taken in 1967, and subsequent reported births, deaths (derived from a mortality function estimation model) and net migration. The population projection model used by the Central Bureau of Statistics is based on that developed by the United Nations. Population estimates have recently been revised based on a revised population estimation model. Other data are derived from periodic surveys, such as Labor Force Surveys.

Birth and death data depend upon reporting by local service providers. In the early 1970s there was considerable under reporting of births and deaths, especially in the neonatal period. Reporting has improved during the later 1970s and subsequently as a result of the increasing contact with the health system prior to birth (in hospitals and maternity centres), during well-child care (as part of the immunization and primary care programmes) or during sick-child care which is provided free in hospitals and clinics. Births and mortality events are highly likely to be officially recorded. In addition, the requirement of death certificates prior to burial is enforced insofar as possible.

The total effect is that the vital statistics data of the latter part of the 1970's are more complete than in earlier years. Some under reporting must be assumed, especially of early neonatal deaths particularly in rural areas where births occur at home. Migration of population, based on departures of residents minus arrivals of residents indicates a net outward migration, primarily to the oil producing countries within the region, for temporary employment. This net out-migration has been smaller during the 1980s.

Prior to 1968 the population from Judaea, Samaria and Gaza remained relatively static in spite of very high birth rates, as a result of high infant, child and general mortality and because of extensive migration.* Since 1967 the population of Judaea and Samaria has grown steadily, increasing by some 180 000 persons, to 763.7 thousand in 1983 (Tables 1 and 2). This growth is due to a continuing high birth rate (40 per thousand population) and fertility rate (about 200 per thousand women), as well as to the low crude mortality rate (under 6 per thousand population). Net out-migration continues, but at a reduced rate as a result of improved economic opportunities and social conditions in the area.

_____________

* Lifschitz Yaakov (1974). "Development of population in Judaea and Samaria -1922-1972:" University of Tel Aviv; data based on: Hashemite Kingdom of Jordan (1952). "Housing Census," and (1961) Population and Housing Census.

Table 1: POPULATION – AGE, SEX DISTRIBUTION, Judaea and Samaria, 1983 (000s)

Source: Statistical Abstract of Israel, 1,984, Table 27/3.

Mortality rates for specific age groups for Judaea and Samaria are shown in Table 3. These have declined substantially since 1975 most dramatically in the infancy and childhood periods.

As a result of the high fertility, 46.2% of the population was under 15 in 1983 (Table 4). The proportion of those 65 and over is 3.8% of the population.

Since 1969, the population of Gaza and Sinai has experienced very rapid growth (Table 5), increasing from 364 000 to 493 000 persons in 1983. With the transfer of El Arish to Egypt, the population in Gaza declined to 433 000 in 1979. A continuing very high birth rate (recently declining from over 50 to 45 per 1000 population per year), declining mortality rates and reduced net emigration are the basis of this population growth. The population of Gaza has grown approximately 31% over the years since 1968, an average of 1.8% annually.

Table 2:  POPULATION; REPORTED BIRTH AND DEATH RATES

Judaea and Samaria, 1968 to 1983

Source: Population data from Statistical Abstract of Israel 1984, Central Bureau of Statistics.

Note: 1. Population estimates are based on the 1967 census and subsequent estimates based on births, deaths and net migration. The Central Bureau of Statistics population estimate is based upon "demographic models based on the experience of other countries chosen in accordance with the characteristics and level of development of the population and are based upon partial empirical tests in the field. Various surveys, tests and comparisons recently conducted brought to a reassessment of the estimates of mortality (mainly infant mortality). As a result, the estimates of mortality decreased as compared to population estimates of the past."

2. There was some under reporting of births in the 1968 to 1975 period, but reporting is considered to be nearly complete in more recent years.

3. Estimate by Central Bureau of Statistics – See Statistical Abstract of Israel 1984, Table 27/1.

4. Statistical Abstract of Israel 1984, Table 27/4.

Infant deaths were under reported, particularly in the 1968 to 1975 period, as in other areas of similar socioeconomic and health service development. Reporting has improved substantially in recent years, but cannot yet be considered complete, particularly for neonatal deaths. Field studies of infant mortality are in progress and the results will be included in subsequent reports.

Table 3:  AGE SPECIFIC MORTALITY RATES FROM ALL CAUSES (per 10 000 Population)

         Judaea and Samaria 1975 to 1983 (selected years)

Table 4:  POPULATION – AGE/SEX DISTRIBUTION, Gaza 1983 (000s)

 Source:   Statistical Abstract of Israel 1984, Table 27/3.

Table 5:  POPULATION, REPORTED BIRTHS AND DEATHS, Gaza 1968-1983

Note: 1.   A population census was carried out in 1967. Subsequent population figures are estimated based upon population projection models used by the Central Bureau of Statistics, and the data are corrected as per the 1983 population estimates.

2. Until 1978 the data include areas of Sinai under Israeli jurisdiction; since 1979 the El Arish area population was transferred to Egypt.

3. Reporting of births and deaths has improved during the 1970s and since.

4. Net migration of residents (departures minus arrivals) is a factor in the total population.

  5. A population registry was carried out in 1981.

MORTALITY: Gaza

There has been a steady shift in the patterns of disease in Gaza as the infectious diseases are brought under control, and are much less prominent as causes of mortality. At the same time the diseases of modern life (ischaemic heart disease, hypertension, cerebrovascular disease, diabetes, malignancies, and car accidents) have become much more prominent as causes of death (see Table 6). Reported deaths by specific cause for 1981 and 1982 are shown in Table 7.

A study of infant and child mortality shows an absolute and relative decline in deaths due to infective and parasitic diseases, as well as prenatal causes, indicating a major shift in childhood morbidity patterns (see Table 8). Reported infant mortality rates for the years 1976 to 1982 show a very marked decline in postneonatal mortality in particular. It should be noted that reporting of deaths has improved significantly over the years because of improved follow-up of births and more access to health services especially for children.

The child mortality rate in 1982 for Gaza (reported deaths under age 5) was 10.3,* a relatively low rate for a developing area.

______________

* WHO (1981) Development of indicators for monitoring progress towards Health for All by the Year 2000, p. 69. "In countries with very poor health conditions the rate exceeds 100. In highly developed countries it is as low as 2."

Table 6:  PERCENTAGE DISTRIBUTION OF MORTALITY, Gaza 1976, 1981, 1983

Table 7:  REPORTED DEATHS BY PRIMARY CAUSE – ALL AGES, Gaza 1981-1983

Note:   Data derived from death certificates reported to Government Health Services, Gaza.

Table 8:  PRIMARY CAUSE OF DEATH BY AGE-GROUP

        0-5 years, as per ICDA 8, Gaza 1982, 1983.

Note: 1. * of these 219 are premature.

2. 0-1 = 0 – end of 11th month; 1 and 2 = 12th to end of 35th month; 3 to 5 =

36th to end of 59th month.

3. Rate calculated from reported deaths x 1000 divided by the number of children

in each age-group. The total under 5 mortality rate in least developed

countries is around 100 and in most advanced countries under 2 per 1000.

SOCIOECONOMIC CONDITIONS: Judaea and Samaria

Prior to 1967, the economy of Judaea and Samaria was characterized by widespread unemployment, dependence on welfare, subsistence level farming and laboring, with few opportunities for skilled labor. As a result there was a large-scale emigration from the area. Since 1967, there have been major improvements in the socioeconomic situation of the region.*

Income and Employment

Since 1967, the economy of Judaea and Samaria has been characterized by rapid growth, along with a very substantial increase in the standard of living of the residents. A major factor in this dramatic change, as in Gaza, has been the economic interaction with neighboring countries including free movement of labor, agricultural and manufactured goods.

Nearly full employment, large-scale vocational training, unionization of labour and a major emphasis on the conditions of workers have been very influential factors in the socioeconomic conditions of Judaea and Samaria since 1967. As a result, local business activity has expanded tremendously and the standard of living in the area has shown a constant rise. Specifically, industrial and commercial employment have increased within Judaea and Samaria as the economy has begun to shift away from traditional labor-intensive agriculture. Employment of residents of Judaea and Samaria within Israel has risen from 14.7 thousand in 1970 to 48.1 thousand in 1983.

From 1968 to 1982, the gross national product (GNP) per capita has increased eight-fold in current US dollars, and private consumption per capita has increased six-fold in current US dollars (Table 9). Between 1970 and 1979 the average annual growth rate in real GNP for Judaea and Samaria was 8.1%; for real per capita GNP it was 6.4%. The comparable growth figures during this same period for Israel were 4.6% and 1.6%, for Jordan 4.1% and 0.7% and for Egypt 6.3% and 3.9%.**

While the population has grown in the region and a growing proportion of the labour force is employed (89.2% in 1968 to 98.7% in 1982), an increasing proportion of the total population over age 14 is in the labour force (rising from 30% in 1968 to 35.2% in 1982) (Table 11). The total labour force has increased from 114.5 thousand in 1970 to 147.2 thousand in 1983 (Table 13).

SOCIOECONOMIC CONDITIONS: Gaza

Socioeconomic conditions continued to improve as a result of virtually full employment, with a nearly nine-fold increase per capita gross national product (GNP) in current US dollars from 1968 to 1982 (from $ 104 to $ 1054.6), while the increase in per capita private consumption in this period was more than fivefold in current US dollars (from $ 112.6 to $ 719.6) (see Table 10).***

Between 1970 and 1979 the average annual growth rate in real GNP for Gaza was 6.9%, and for real per capita GNP, 4.9%. The comparable growth figures during this same period for Israel were 4.6% and 1.6%, for Jordan 4.1% and 0.7%, and for Egypt 6.3% and 3.9%.****

The dramatic economic growth is largely based on growth in agricultural productivity, massive construction programmes, the beginnings of industrial development, widespread transfer of technology and vocational training in agriculture and industry, as well as the employment of the Gaza-residents in Israel and elsewhere. The net effect of all this activity has been the advent of continuing full employment (averaging 99% since 1972) of the labour force (Table 12) which has grown from 59 thousand persons in 1970 to 85.3 thousand in 1983. Prior to 1967, unemployment in Gaza stood at 43% and those receiving welfare at 70%.

Free mobility of labour of the Gaza population has also been a major factor in that area’s economic growth. Increased productivity and construction in Gaza itself has been achieved with the relatively stable labour force, while the number of workers working in Israel has grown substantially over the years, absorbing a large proportion of the increase in the Gaza workforce (Table 14). This mobility has been beneficial to Gaza where the money earned in Israel has had a stimulatory effect on the local economy.

It should be noted that salaries and working conditions of persons employed in Israel are equivalent to those of Israelis in similar jobs.  Furthermore, salaries and conditions of the labour employed within Gaza, Judaea and Samaria are increasingly approaching Israeli levels. This includes cost of living rises, rights to severance pay, Work accident insurance, annual vacation with pay, sick pay, child allowance pay, seniority increments, religious holiday pay, health services insurance and health services in Israel. Periodic review of the labour situation by the International Labour Organization has generally reflected the favorable employment and working-conditions of Gaza-residents within the area and in Israel.

________________

* Ministry of Defense (1983) Judaea and Samaria, the Gaza District: A Sixteen Year Survey (1967-1983), November 1983, Tel Aviv.

** Derived from Central Bureau of Statistics and United Nations Conference on Trade and Development.

*** In a majority of developing countries, the gross national product per capita is below US$ 1000 – see WHO Seventh General programme of Work (1982), p. 23.

****Derived from Central Bureau of Statistics – National Accounts of Judaea, Samaria, Gaza and North Sinai 1975-79, and for the decade 1968-1977; also from United Nations Conference on Trade and Development Handbook of International Trade and Development Statistics (Table 6).

Table 9: PER CAPITA GROSS NATIONAL PRODUCT AND PRIVATE CONSUMPTION

        Judaea and Samaria, 1968 to 1982 (in current US$)

Table 10: PER CAPITA GROSS NATIONAL PRODUCT AND PRIVATE

           CONSUMPTION, Gaza 1968 to 1982 (in current US$)

Table 11:  EMPLOYMENT INDICATORS, Judaea and Samaria

         1968 to 1982 (selected years)

       (percentages)

Source:   Statistical Abstract of Israel 1984, Table 17/17.

Table 12:  EMPLOYMENT INDICATORS, Gaza 1968-1983

Source:  Statistical Abstract of Israel 1984, Table 17/17.

Table 13:  LABOUR MOBILITY AND PLACE OF EMPLOYMENT

          Judaea and Samaria, 1970 to 1983 (selected years)

        (000s)

Table 14:  LABOUR MOBILITY, PLACE OF EMPLOYMENT

         Gaza 1970-1983 (000s)

AGRICULTURE: Judaea, Samaria and Gaza

Agriculture is still the principal economic branch of Judaea, Samaria and Gaza, but has undergone a massive reformation from a backward, inefficient and low productivity industry to a highly productive, relatively modern farming economy, producing for domestic and foreign consumption (Table 15). Productivity has grown mainly as a result of agrotechnical improvements, some brought from Israel, such as mechanization of irrigation systems, and other capital intensive activities. In Gaza there has been a shift in emphasis as to other cash crops, particularly in milk and egg products, each of which increased fivefold (Table 16). As a result, the number of persons employed in agriculture has been reduced, while productivity per unit of land and water has been doubled. The number of tractors in Gaza increased from 199 in 1974 to 703 in 1981. Improved production has contributed to economic growth, nutritional standards, exports and well-being of both the rural and the urban populations.

Increased agricultural production of the district has been accompanied by increased purchasing power. This has resulted in a sufficient per capita energy availability and the increased ability of the population to purchase the available food (Tables 17 and 18).

Water utilization for agricultural and domestic use in Judaea, Samaria and Gaza has been expanded and improved through education, conservation methods, modern irrigation techniques, improved control measures to prevent over utilization and the development of new groundwater sources. Public water supply treatment and distribution systems have been vastly improved. In Gaza this includes routine continuous chlorination to improve drinking-water safety. In Judaea and Samaria regional public waterworks systems increased from two to 10 additional wells have been sunk, storage pools built, water mains extended and household connections developed in 60 villages.

Domestic water consumption in Judaea and Samaria has increased from 5.4 to 14.6 million cubic meters between 1967 and 1979. The area under irrigation has expanded by 150%, and yields increased twelve-fold. Domestic Water consumption has increased from 5 cubic metres per person in 1966 to more than 20 cubic meters per person in 1980.

Table 15: AGRICULTURAL ECONOMIC ACTIVITY INDICATORS

          Judaea and Samaria, 1967 to 1983

   Conversion to US$ at exchange rate current in first

 quarter of second year – Statistical Abstract Table 9/13.

Table 16:   AGRICULTURAL OUTPUT ACTIVITY INDICATORS – SELECTED

PRODUCTS AND TOTAL VALUE, Gaza, 1967 to 1983

Table 17:  DAILY PER CAPITA ENERGY AVAILABILITY AND NUTRITIVE VALUE

Judaea and Samaria, Selected Years 1968 to 1982

Table 18:   DAILY PER CAPITA ENERGY AVAILABILITY AND SOME

NUTRITIVE VALUES, Gaza, 1968 to 1983

HOUSING AND HOME SERVICES IN JUDAEA, SAMARIA AND GAZA

Civilian construction activity grew very dramatically during the 1970s, particularly in the residential field. In Gaza nearly 250-300 thousand square meters of construction was completed and started in each of the recent years as compared with 20 thousand square meters in 1970. This construction boom continued into 1983, in spite of major slow-downs in construction activity within Israel in the past several years (Tables 19 and 20).

Housing has long been a particularly acute problem in Gaza. Since 1967, the administration has undertaken massive housing development, particularly to provide adequate housing to refugees maintained over the years in grossly unsatisfactory conditions. In 1976 alone 1000 new housing units were built. New housing is under construction in the entire area. Refugees are helped to build their own homes in the vicinity with the aid of land grants and mortgages, or by being given a new house built by the government that the family generally expands and improves. These houses all include electricity, running water and indoor toilets connected to a central sewage disposal system. These new areas are served by streets, lights, school health centres, playgrounds and other amenities including shopping areas.

New townships have been developed in Rafiah (1350 units), Khan Yunis (1118 units) and Gaza areas – Sheikh Radwan and central refugee camps (1470 units). In Gaza-Beit Lahya, a project for individual families to replace refugee housing with self-built and fully serviced permanent housing (which can be expanded to meet growing family needs) began in 1978 and continues.

Tables 21 and 22 show a steady increase in both Judaea, Samaria and Gaza in the percentage of households with three or fewer persons per room, and a steady decline in the percentage of households with four or more persons per room. These changes indicate an improvement in housing conditions with respect to crowding, a positive social indicator, particularly as seen in the context of the continuing very high birth rate and population growth.

Standards of home services have also risen substantially with large increases in the proportion of homes having electricity, refrigerators, radios, television sets, home baths and showers and home toilets (Tables 23 and 24)  Increased home electrification and basic service improvement are important basic conditions associated with improved quality of life. Major cities and many villages have been connected in recent years to modern electric grids for the first time. There is an increasing proportion of individual home flush toilets connected to newly expanding sewage collection systems. There are differences between urban and rural populations in terms of home services, but the differences are declining as rural areas are developed.

Increased economic activity and personal purchasing power are also indicated by a tenfold increase in the number of private vehicles and drivers between 1968 and 1982 (Tables 25 and 26).

Table 19:  CIVILIAN BUILDING ACTIVITY, PUBLIC AND PRIVATE,

    Judaea and Samaria, 1968 to 1983 (thousands of square meters)

Table 20:  CIVILIAN BUILDING ACTIVITY, PUBLIC AND PRIVATE

Gaza 1968 to 1983 (selected years)

  (thousands of square meters)

Note: * 1980 excludes El Arish which was transferred to Egypt.

Source: Statistical Abstract of Israel 1984, Table 27/32.

Table 21: HOUSING DENSITY: PERCENTAGE OF HOUSEHOLDS WITH

 LOW AND HIGH PERSONS-PER-ROOM RATIOS

    Judaea and Samaria, 1973 to 1983 (selected years)

Table 22:   HOUSING DENSITY: PERCENTAGE OF HOUSEHOLDS WITH

 LOW AND HIGH PERSONS-TO-ROOM RATIOS

         Gaza, 1972 to 1983 (selected years)

Table 23: HOME SERVICES OR APPLIANCES, Gaza, 1967 to 1983

       (% of homes with services)

Table 24:  HOME SERVICES AND APPLIANCES, Judaea and Samaria, 1967 to 1983

    (selected years)

    (% of homes with services)

Table 25: MOTOR VEHICLES AND DRIVERS, Judaea and Samaria

1970 to 1983 (selected years) (000s)

Table 26:  MOTOR VEHICLES AND DRIVERS, Gaza, 1968 to 1983

(000s)

EDUCATION:  Judaea, Samaria and Gaza

Educational standards have risen sharply in Judaea, Samaria and Gaza in terms of the number of facilities, the supply of trained teachers and the number of pupils in the school system (Tables 27-30). Education is now universal at the primary and intermediary level, with large increases in secondary and the establishment of post-secondary education.

Not only has the number of pupils increased in absolute terms by more than two-thirds, but major changes have taken place in the quality of education, with more children staying on in school to more advanced education, more girls staying in school, extensive vocational schooling, and more students entering higher education, including the technical and professional fields. One expression of these changes can be found in the fact that, whereas in 1970, 49% of the working age population in Gaza had zero years of school, by 1980 only 29% had no schooling. Similarly 35% of the working age population had nine years or more of schooling in 1980, as opposed to 19% in 1970.

Judaea and Samaria

The educational system uses the Jordanian curriculum and textbooks, and operates with local teachers, supervisors and administrators. In addition to government schools, UNRWA and private schools serve some 10% of the school-aged population.

Vocational training has been emphasized and 26 vocational courses in 19 cities with some 2500 places for students have been developed since 1967. Courses are based on vocational standards in Israel and are taught by local Arab instructors. Graduates are much in demand for work in Israel, in the territories and in Arab countries. Between 1968 and 1980, a total of 37.5 thousand students graduated from vocational training in Judaea, Samaria and Gaza.

Higher education in Judaea and Samaria has expanded vigorously in this period. There are four new universities with modern facilities including libraries, laboratories and enlarged staff. They are coeducational and accept students from Gaza and Israel, as well as from other countries. The number of students increased from 4654 in 1979-1980 to 6218 in 1980-1981, while the number of lecturers increased from 311 to 374 in the same period. Graduates are employed in the local school system and in neighboring countries. Large numbers of local residents study in universities abroad.

Table 27:   PUPILS BY EDUCATIONAL INSTITUTION, Judaea and

  Samaria, 1970 to 1983 (selected school years) (000s)

Table 28.  PUPILS BY EDUCATIONAL INSTITUTION

Gaza, 1970 to 1983 (selected school years)

(000s)

Table 29:  EDUCATIONAL SERVICES – GOVERNMENT, UNRWA AND PRIVATE

Judaea and Samaria 1967 to 1983 (selected school years)

Source: Statistical Abstract of Israel 1984, Table 27/43.

Note: Includes government, UNRWA and other educational institutions.

Table 31:  EDUCATIONAL SERVICES, Gaza, 1967 to 1983 (selected school years)

Note: Data include Sinai up to June 1979.

Source: Statistical Abstract of Israel 1984, Table 27/43.

SOCIAL SERVICES: Gaza

Since 1967 governmental and private agency welfare offices reopened but have gradually modified the welfare payment approach to a stress on assessment of needs and rehabilitation potential. This has led to an increase in the number of persons gainfully employed, and significantly reduced the population on welfare.

Rehabilitation, youth programmes, community development projects, summer camps for children, local and international social agency involvement have vastly expanded services in the area.

Social services are provided by trained Arab social workers. The pronounced increase in employment and wages has reduced the number of welfare cases of the population. Several community development projects have been initiated and carried out jointly by various international organizations, community resident groups and the governing authorities.

HEALTH SERVICES: Judaea and Samaria

Health services in Judaea and Samaria include extensive networks of both governmental and non-governmental health facilities, both at the hospital and community level, serving the widely distributed population of the area. There have been major developments in both government and non-government hospital facilities over the past 18 years, raising the quality of care available, access to that care, and access to more specialized medical care in supraregional hospitals on the basis of medical need. At the community level 153 community clinics, and 110 MCH centres and community clinics serve urban areas and all villages over 3000 population. Now all villages over 2000 population will have combined community clinic/MCH centres. Since 1980 there has been an increase from 85 to 110 in MCH centres.

Many voluntary or charitable society clinics also serve the area in urban areas, and increasingly in rural areas as well.

Stress has been placed upon primary health care at the community level, but hospital care is also undergoing rapid change in the area.

Figure 5 shows a schematic mapping of the distribution of government health services in Judaea and Samaria.

HOSPITAL SERVICES

Hospital services for Judaea and Samaria are divided among seven hospital districts, each of which is served by a general hospital with the four basic departments of medicine, surgery, obstetrics/gynaecology and pediatrics. Nablus district, since the completion of the Rafidia Hospital in 1976, is now served by two general hospitals. Two district hospitals, such as Nablus and Ramallah, also serve as regional hospitals, and provide the southern and northern regions respectively with other specialty services, as outlined in Table 47.

Emphasis and financial resources have been placed on increased and improved hospital services, by expanding public hospitals, and improving basic infrastructures including "hotel" services and supportive medical services, such as laboratory and radiographic units.

Hospital redevelopment in the area has involved a number of stages. In the first stage, the goal was to ensure that the four basic services (medicine, surgery, obstetrics/ gynaecology and paediatrics) were headed by specialists in all district hospitals. As a second stage (1972 to present), further specialized units, both for the regional and district hospitals, were developed with full coordination and cooperation of local medical staff, which was expanded in number and specialty training during this period. A third stage, begun several years ago, emphasized development of specialty outpatient clinics, and increasingly sending specialist services to conduct clinics in the community.

Medical staff has been increased in all government hospitals in keeping with the added specialty services. Considerable upgrading in overall medical staffing has also occurred as a result of the return of qualified specialists who have returned from specialty training abroad. At present, about half of the hospital medical staff are physicians who had gone abroad for specialty training to the United States, Western Europe, Australia or Arab countries. Between 1981 and 1983, 25 new physician positions have been added to the government health service.

Figure 5: DISTRIBUTION OF GOVERNMENT HEALTH SERVICES

Judaea and Samaria, 1984

     (According to medical regions)

Table 47:  NEW SERVICES ADDED IN GOVERNMENT HOSPITALS SINCE 1967

Judaea and Samaria

Source: Adapted from Report of the Special Committee on the Planning of Health Services, Ministry of Health, Jerusalem, and from Chief Medical Officer, Judaea and Samaria.

Voluntary public hospitals also continued to advance. Caritas Hospital in Bethlehem is a newly rebuilt pediatric hospital of 79 beds including seven incubators, with the finest of facilities and modern equipment provided by the Caritas organization of Germany and Switzerland. It is staffed by nuns, volunteers from abroad, as well as local professionals. This hospital has a premature newborn unit which serves the whole region: more difficult cases are sent to Hadassah Hebrew University Hospital, Mt. Scopus, Jerusalem. Other public voluntary hospitals sponsored by Christian organizations in the Bethlehem area include the French Hospital (a general hospital of 34 beds), and the Mt. David Hospital for orthopedics which has completed a new facility (with 73 beds in 1983). In the Nablus area, with its predominantly Moslem population, two public voluntary general hospitals have been operating for many years, sponsored by local women's organizations, El Ithiad Hospital (75 beds) and the Evangelical Arabic Hospital (65 beds).

In 1968 three blood banks were functioning, a central blood bank in Jerusalem and two blood banks in Hebron and Nablus Hospitals. Since then, three more blood banks were opened: in Ramallah (in 1970), Jenin (1972), and Tulkarem Hospital (1973). Another blood bank has been built in Beit Jallah Hospital and another in El Ithiad Hospital in Nablus (1977). With the completion of development of the blood banks needed at the hospital level of service, the central blood bank in Jerusalem was closed.

The oncology service was established in 1978 at Beit Jallah Hospital in cooperation with Assaf Harofeh Hospital in Israel, under the direction of Dr. Yoav Horn. This service provides modern diagnostic, treatment and referral services, with chemotherapy provided locally and radiotherapy carried out by the same team in a specialized cancer centre. A second cancer clinic has operated in the old Nablus Hospital since December 1981.

A breast cancer screening clinic was also recently opened in Beit Jallah Hospital.

Referrals of cancer cases are received from all 17 hospitals in the region, governmental and non-governmental. Patients requiring further care are treated in Assaf Harofeh Hospital and cases requiring radiotherapy are treated in Sheba Medical Centre, where overnight stay in a hostel is arranged during treatment. The services are free and the costs are borne either by the health insurance plan or by the governing authority of Judaea and Samaria. Tables 101 and 102 enumerate the cancer treatment services and primary cancer sites experienced in this oncology service.

Table 101:   CANCER TREATMENT SERVICES, Judaea and Samaria, 1978 to 1983

Note:    * 1978 to 1982 only.

Source:  Horn, Yoav (1984) The Cancer programme in Judaea and Samaria, unpublished manuscript.

Table 102:  DISTRIBUTION OF PRIMARY CANCER SITES TREATED IN ONCOLOGY SERVICE

Judaea and Samaria, 1978 to 1983

________________

Source:   Horn, Yoav, op. cit.

Other recent developments include an intensive coronary care unit in Old Nablus Hospital; physiotherapy in Beit Jallah Hospital; new sterile supply centre in Rafidia Hospital; dialysis departments with four units in Nablus Hospital and three units in Hebron Hospital; an audiometer in Old Nablus Hospital; X-ray facilities in Jenin, Tulkarem and Beit Jallah Hospitals; and a central oxygen and nitrous oxide supply in all district hospitals. A surgical pediatric service was added to Ramallah Hospital with consultation services in other hospitals. In 1984 a neurology consultative service was added in Beit Jallah Hospital outpatient department serving the whole region, training new staff and operated by Hadassah Mt. Scopus.

Hospital outpatient services have been developing rapidly since 1973, in all district hospitals, with an increasing range of specialties. In 1981 alone a cancer clinic was opened in Nablus, psychiatric clinics in Hebron, Jenin and Tulkarem, and a dermatology clinic in Hebron. During 1982 ophthalmology clinics were added in Nablus, Jenin and Tulkarem. Hospitals, hematology in Nablus and Beit Jallah Hospitals and dermatology in Nablus, Jenin and Tulkarem Hospitals.

Specialty services are increasingly being brought to the community at the public health offices. In all districts, hospital-based specialists in pediatrics, obstetrics, internal medicine and surgery regularly have outpatient clinics in public health offices for patients referred for consultation by MCH centres and community clinics in the district. Psychiatric clinics are now held in Nablus, Tulkarem, Jenin and Hebron, on a weekly and bi-weekly basis.

Diagnostic radiology services have been developed since 1978 in Rafidia Hospital – fluoroscopic radiology is conducted weekly by Dr M. Weder who also consults in other X-ray departments in the area. A second radiology department operates in Ramallah Hospital. in 1983, a new diagnostic radiologist was employed full time in Beit Jallah Hospital. A refresher course for radiological technicians began in early 1984 and is to continue in weekly sessions at Shifa Hospital in Gaza for one year.

At the beginning of 1984, all hospitals began weekly clinical medical conferences including all medical staff with rotation by department. Nursing in-service education in Ramallah, Rafidia, Hebron and Tulkarem Hospitals has been operating for some years through monthly subject presentations by hospital staff nurses.

Pathology services are arranged with Hadassah Mt. Scopus which reports on specimens received from Judaea and Samaria hospitals. Referral and consulting services also in pediatric surgery, pediatric intensive care, neurology and hematology are with Hadassah Mt. Scopus or Hadassah Ein Karem. Referral and consulting services with Shaarei Zedek Hospital in Jerusalem in urology, nephrology, plastic surgery, gastroenterology and hematology have been developed over recent years. Similar arrangements exist with Bikur Holim Hospital, Jerusalem, in ENT and cardiology, and Tel Hashomer Hospital in thoracic and cardiac surgery. Medico-legal problems are investigated by arrangements with the Medical-Legal Pathology Institute at Abu Kabir, Tel Aviv.

Utilization of Hospital Services

Hospital utilization by Judaea and Samaria residents has increased both quantitatively and qualitatively in local hospital facilities as well as in Israeli hospitals (Table 103).

Table 103A:   HOSPITALS – SUPPLY AND UTILIZATION,

Judaea and Samaria, 1968 to 1983

Table 103B:  HOSPITAL OUTPATIENT SPECIALTY CLINICS

  Judaea and Samaria, 1984

Note:  As on 31/12/1984.

Source: Judaea and Samaria Government Health Department – Hospital Division.

continued – A38/INF.DOC/6 (Part II)