Health conditions in the OPT, including East Jerusalem and Syrian Golan – WHO 66th World Health Assembly – UNRWA report

Health conditions in the occupied Palestinian

territory, including east Jerusalem, and in the

occupied Syrian Golan

The Director-General has the honour to bring to the attention of the Health Assembly the attached report of the Director of Health, UNRWA, for the year 2012.

ANNEX

REPORT OF THE DIRECTOR OF HEALTH, UNRWA, FOR 2012

HEALTH CONDITIONS OF, AND ASSISTANCE TO, PALESTINE REFUGEES

IN THE OCCUPIED PALESTINIAN TERRITORY

DEMOGRAPHIC PROFILE

1. The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) is one of the largest United Nations programmes, with a population of 4 912 000 Palestine refugees registered in the Gaza Strip, the West Bank, Jordan, Lebanon and the Syrian Arab Republic in 2012. The Agency’s mission is to assist Palestine refugees in achieving their full potential in human development until a durable and just solution is found to the refugee issue. This refugee population is predominantly made up of young people, as observed in many countries in the Near East. More than half were younger than 25 years of age in 2012.

2. Over two million Palestine refugees are registered with UNRWA in the occupied Palestinian territory: 1 263 000 refugees in the Gaza Strip and 896 000 in the West Bank. There are 27 refugee camps (8 in the Gaza Strip and 19 in the West Bank) and 35.1% of the refugees (some 758 000 people) have registered their residence in these camps. The number of Palestine refugees eligible for UNRWA’s health services in the occupied Palestinian territory increased by 3.2% (about 66 869 people) in 2012 compared with 2011. It is estimated that approximately 78.7% of all eligible refugees in the occupied Palestinian territory used UNRWA’s health services in 2012.

HEALTH STATUS

3. Through the support of UNRWA, governmental and other health-care providers, the health of Palestine refugee mothers and children has shown continued improvement since the Agency’s establishment. Progress in achieving Millennium Development Goals 4 (Reduce child mortality) and 5 (Improve maternal health), for example, has been on track. The infant mortality rate among Palestine refugees is comparable to, if not better than, rates in other countries of the Near East. In 2012, 93.5% of pregnant women in the Gaza Strip and 81.5% of those in the West Bank had four or more antenatal care visits, and the percentage of deliveries attended by skilled health personnel remained very high at 99.9% in the West Bank and 99.9% in the Gaza Strip.

4. The main health concerns, however, continue to stem from noncommunicable diseases or chronic lifestyle-related illnesses, which are exacerbated by the increase of behavioural risk factors like smoking, physical inactivity and unhealthy diet. As in neighbouring countries in the Near East, the epidemiological and health transition from communicable to noncommunicable diseases has taken place in the occupied Palestinian territory. Consequently, the number of people with noncommunicable diseases, such as diabetes and/or hypertension, under care in UNRWA’s health services has been steadily increasing in recent years.

5. Furthermore, the combination of conflict and insecurity, political instability and increasing poverty (particularly in the Gaza Strip) continues to have a negative impact on the health of Palestine refugees. The severe restrictions on the movement of people and goods within the West Bank, and between the Gaza Strip, the West Bank and areas abroad, remain a major obstacle to socioeconomic development and provision of health care. Eight days of conflict in November 2012 further compounded the plight of the inhabitants of the Gaza Strip, the majority of whom (more than 80%) were already in need of humanitarian assistance and relief. During the eight-day conflict that commenced on 14 November 2012, 165 Palestinians were killed by Israeli action, including 99 believed to be civilians, 33 of whom were children. UNRWA’s own rapid assessment indicated that over 450 homes were totally destroyed and approximately 8000 were partially destroyed, displacing over 15 000 people. The provision of health care was also affected: three hospitals, four Ministry of Health primary care clinics and five UNRWA clinics were damaged during the operations. This conflict also significantly increased the need for psychosocial support for Gazan children, adolescents, and families, with North Gaza and the “Middle Area” reporting the highest incidence of psychosocial symptoms and other mental disorders among both adults and children during and after the conflict.

6. The stress of occupation, the inability of men to provide for their families, and the consequent reversal of gender roles have also contributed to an increase in domestic violence. Tackling psychological and behavioural disorders, as well as domestic violence, has therefore emerged as a health priority for UNRWA in the occupied Palestinian territory.

UNRWA ASSISTANCE

7. UNRWA has been the main primary health care provider for Palestine refugees for 62 years and is the largest humanitarian operator in the occupied Palestinian territory. UNRWA’s aim is to ensure a “long and healthy life” for refugees as one of its four Human Development Goals. Accordingly, the Agency provides primary health care services, meeting the health needs of registered refugees across their life span – from birth to old age.

8. UNRWA delivers primary health care through a network of 64 primary health care centres: 22 in the Gaza Strip and 42 in the West Bank. The Agency also facilitates the access of refugees to secondary and tertiary care through a network of contracted hospitals in the West Bank and the Gaza Strip in addition to providing this level of care directly in the UNRWA hospital in Qalqilya in the West Bank. In 2012, 53.0% of all registered refugees in the West Bank and 96.9% of those in the Gaza Strip accessed UNRWA’s preventive and curative health services. The number of refugee patients from the West Bank and the Gaza Strip who were admitted to hospitals increased by 12.6%, rising from 33 502 in 2011 to 37 716 in 2012.

9. In response to the changing disease profile and the increasing burden of noncommunicable diseases, UNRWA is implementing major health reforms with the family health team approach at its core. Health reforms that began in 2011 under this approach, use a family- and person-centred approach to provide holistic primary care at UNRWA primary health care centres. Families are registered with, and assigned to, a provider team consisting of a doctor, a midwife and nurses. The provider team is responsible for all the health care needs of the families concerned over their life cycle. These strong patient‒provider relationships coupled with the longevity of care will ensure effective, efficient and timely health care delivery, which is especially critical in the management of noncommunicable diseases.

10. Considerable progress has been made in the implementation of the family health team approach. At the end of March 2013, a total of 20 health centres, servicing approximately 800 000 Palestine refugees, had adopted the approach, including 13 centres in the Gaza Strip and seven in the West Bank. Moreover, nine health centres (8 in the Gaza Strip and one in the West Bank) had introduced electronic medical records (eHealth) by March 2013. In these centres, improvements in the quality of services were validated by a decrease in the workload of medical doctors, and also extremely high satisfaction rates among patients. UNRWA plans to roll out the family health team approach to all 139 health centres in its five fields of operation by the end of 2015.

11. In addition to staged implementation of the family health team approach, UNRWA conducted approximately 6.2 million medical consultations with adult and adolescent refugees in the occupied Palestinian territory in 2012: approximately 4 418 000 in the Gaza Strip and 1 786 000 in the West Bank. In addition, around 379 163 oral health consultations and 110 000 oral health screening sessions were held, and 14 797 refugees received physical rehabilitation, 27.2% of whom were suffering from the consequences of physical trauma and injuries, including those due to conflict, occupation and violence.¹

12. The provision of care to those suffering from noncommunicable diseases also expanded in 2012. Almost 95 896 patients with diabetes and/or hypertension were treated in UNRWA clinics in the occupied Palestinian territory: 60 900 in the Gaza Strip and 34 996 in the West Bank. Collaborations with specialized tertiary care/teaching centres have also been expanded for care of diabetic patients in order to improve disease control rates and prevent late complications from diabetes.

13. In 2012, the total number of continuing users of modern contraceptive methods increased by 6.1% compared with the previous year (the new total being 83 544 clients). Antenatal care services were provided to 54 852 pregnant women with an estimated coverage rate of 88.3% in the Gaza Strip and 50.7% in the West Bank. On average, an estimated 79.4% of pregnant women registered with UNRWA during the first trimester. Of all the pregnant women assisted by the Agency, 99.9% delivered in a health institution and over 92.1% received postnatal care.

CHALLENGES AND CONSTRAINTS IN HEALTH SERVICE DELIVERY

14. Despite the above-mentioned progress, UNRWA continued to face challenges in health service provision and operations, with implications for the health of refugees. Mobility restrictions for Palestinians in the West Bank and the complicated process for the issuance of referral permission to the hospitals in east Jerusalem from other parts of the West Bank and the Gaza Strip continue to pose major obstacles for timely access to good-quality and life-saving health care. Moreover, nearly all referrals to care outside the Gaza Strip continue to require permits from, and coordination with, the Israeli authorities.

15. Access to health care is a key component of the right to health. These permits are difficult to obtain and the process, even when successful, is slow and cumbersome. While there are no published eligibility criteria for obtaining a permit, data collection and interview findings indicate that factors that appear to affect eligibility include age, sex, residency, civilian status, timing of travel, type of medical treatment needed, and family relations. In addition, unexplained ‘security’ reasons cited by the Israeli authorities also affected the ability of the Palestine refugees to obtain permits to travel for purposes of health care referrals.

16. According to the WHO Special Report (“Right to health: barriers to health access in the occupied Palestine territory, 2011 and 2012”),² the overall approval rate of the applications for health access permits was 80.2% in 2012, and 81.4% in 2011. In the Gaza Strip, 9329 patients applied for health access permits in 2012, and 8628 of them (or 92.5%) received approvals. In the West Bank, 222 188 patients and patients’ companions and visitors applied for health access permits in 2012, and 177 051 of them (or 79.7%) received approvals. There is no administrative process whereby patients who are denied permits can appeal against the decision of the Israeli civil administration, or seek an explanation of the denial. The only option is to submit another permit application to the Israeli authorities or to accept less specialized health care locally. Data shows patients aged 18-40 are most likely to be called for a security interview, and to be denied a permit, or delayed.

17. In order to improve and facilitate access to health care and utilization of services in the West Bank, UNRWA mobile health teams have been operating since February 2003 to provide a full range of essential curative and preventive medical services to approximately 13 000 patients per month, living in over 59 isolated locations. Notwithstanding such efforts, the mobility of health teams was hampered by frequent closures and checkpoints in 2012.

18. In 2012 clinical evidence suggested an increase in stress-related disorders and mental health problems, including family violence, domestic abuse, and violence among youth and children. According to a 2011 study by the Palestinian Central Bureau of Statistics, 30% of married women in the West Bank and 51% of married women in the Gaza Strip had experienced violence from their husbands in the preceding 12 months. Approximately 28% of children between the ages of 12 and 17 in the West Bank reported having experienced physical abuse at the hands of their parents in the past year. For children between 12 and 17 years of age in the Gaza Strip, the figure rises to nearly 45%. The figure for psychological abuse from parents hovers near 70% across the occupied Palestinian territory. A variety of internal and external influences on Palestinian society – including forced displacement, dispossession and occupation – are likely to have contributed to this high incidence of violence in Palestinian society. UNRWA’s health programme plays a central role in the Agency’s efforts to combat, reduce and respond to this violence. The problem, however, is widespread and largely underreported, making it difficult to identify those affected for counselling and care.

19. In response to the situation of continuing and often severe psychological stress, the UNRWA community mental health programme provided: counselling to individuals, groups and families; home visits; referrals; group intervention sessions; supportive group sessions; summer and winter camps; and open days. These efforts reached 179 255 individuals in the Gaza Strip and 128 641 individuals in the West Bank.

20. As a result of the implementation of the family health team approach, patient loads decreased in 2012. However, the increasing numbers of patients with noncommunicable diseases who require resource-intensive care and costly medications, coupled with the prevailing insecurity and social and economic hardships that burden UNRWA’s working environment, have increased the challenges faced by the Agency in delivering timely, equitable and good-quality health services. Palestine refugees are victims of restricted access to health care and of the factors such as conflict, violence, occupation, political instability, poverty and hardship that are having a negative impact on their right to achieve the highest attainable standards of health. UNRWA aims to mitigate the effects of these socioeconomic and health disparities through the provision of the best possible comprehensive primary health care services using the family health team approach.

21. The funding available for UNRWA’s health services has not kept pace with the rise in demand for costly and resource-intensive care and services, especially for noncommunicable diseases. Owing to funding shortfalls, in 2012, UNRWA faced difficulties in attracting and retaining certain categories of medical professionals. The health expenditure per registered refugee was approximately US$ 26 in both the Gaza Strip and the West Bank – well below the US$ 34 per capita target recommended by the Commission on Macroeconomics and Health to provide an essential package of health services in low-income countries. Since 2009, UNRWA has not been able to reimburse costs for all deliveries taking place in its contracted hospitals owing to budget shortfalls. The health care offered to persons with noncommunicable diseases is not yet comprehensive and is still predominately curative rather than preventive.

CONCLUSIONS

22. The plight of Palestine refugees continues in face of health disparities, conflict, violence, occupation, political instability, poverty and economic hardships that are having a negative impact on their right to achieve the highest attainable standard of health. UNRWA aims to mitigate the effects of these socioeconomic disparities on health through the provision of the best possible comprehensive primary health care services.

23. Internal health care reform efforts are striving to improve efficiency and continuity of care. UNRWA’s service delivery model has shifted from a disease-focused approach to a person- and family-centred one. The health reforms are also supported concurrently with the modernization and strengthening of the Agency’s health informatics and information technology infrastructure to realize anticipated efficiencies.

24. However these efforts alone are not enough. It is imperative and vital for the international community to increase its support to UNRWA so that the Agency, in collaboration with hosts and international stakeholders, can pursue necessary health reforms and continue protecting and improving the health status of the Palestine refugees.

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Notes

¹ See the report of the Director of Health, UNRWA, for 2011 (document A65/INF.DOC./5).

² Document WHO-EM/OPT/004/E, available at http://www.emro.who.int/palestine-press-releases/2013/wholaunches-report-on-health-access-barriers-in-the-opt-5-march-2013.html (accessed 6 May 2013).