Right to Health Barriers to Health and Attacks on Health Care in the OPT, 2019 to 2021 – WHO Report

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Executive Summary

Realization of the right to the highest attainable standard of health and wellbeing (right to health) means safeguarding social conditions of life that determine health, including politically, economically and through legal protections, as well as ensuring the availability, accessibility, acceptability, and quality of health care. It equally means upholding core human rights principles of participation, equity, non-discrimination, and accountability in the delivery of health care.

The central aim of a human rights-based approach to health is to develop the capacities of duty bearers to fulfil their obligations – specifically the state obligations outlined in relevant international treaties – and to empower rights holders to effectively claim their health rights.1 In the occupied Palestinian territory (oPt), duty bearers for the right to health comprise Israel as occupying power; the Palestinian Authority; the de facto authority in the Gaza Strip; and third states of the international community.

From 2019 to 2021, considerable barriers to the right to health for Palestinians continued in the West Bank, including east Jerusalem, and the Gaza Strip. Palestinians’ health is impacted by structural determinants of health inequities that include ongoing occupation, political divisions, fragmentation of territory, blockade of the Gaza Strip, physical obstacles to movement, and implementation of a permit regime. These factors influence health service availability including through financing limitations; health access including to outside medical referrals; and health attacks.

Health services availability: Challenges to sustainable provision

Fragmentation of territory and health service provision presents major challenges to governance of the Palestinian health sector, which faces barriers to sustainable provision, inefficiencies, and the need for stronger transparency, including communication of entitlements, and accountability. The Palestinian health sector consists of four main health service providers: the Ministry of Health (MoH), the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), NGOs and for-profit providers. The MoH provides most health services, especially primary and secondary care, through a network of governmental primary health care centres and hospitals. The MoH also offers tertiary health services and purchases services from other hospitals and medical centres, including non-profit Palestinian hospitals in east Jerusalem.

Public provision of health services in the oPt is challenged by limited government expenditure on health (domestic general government health expenditure per capita 158 US$, 2021). This is attributable to limited overall economic growth in the oPt (GDP per capita 3,664 US$, 2021)2 related to lack of control over natural resources, high unemployment, as well as other challenges to revenue raising such as fiscal leakages due to withholding of customs revenue by Israel.3 Over a third of MoH spending (37.5% in 2021) is on outside medical referrals (i.e. referrals to non-MoH providers, including within and outside the oPt), which represent a significant source of budget inefficiencies.4 The Palestinian Authority faced a severe fiscal crisis throughout the reporting period, with implications for MoH expenditure.5

Gaps in health care availability are additionally due to lack of human resources, essential medicines, supplies and technology, and inability to develop infrastructure – including severe planning restrictions in Area C6 of the West Bank preventing the establishment of permanent or semi-permanent health facilities. Longstanding gaps and inequities in the availability of essential medicines persisted in 2019-2021. In the Gaza Strip, the Central Drugs Store consistently reported lower availability of essential stocks compared to the West Bank, with an average 55% availability (more than one month’s supply remaining) over the three years. The lowest annual availability was in 2019, when 52% of essential medicines had more than a month’s supply remaining at the time of monthly stock takes.

Lack of sub-specialty services within MoH facilities drives outside medical referral. 7 From 2019 to 2021, cancer care continued to be the most common reason for referral (26% of the total). Twenty one percent of referrals were for children and 46% for female patients. A larger proportion of outside medical referrals from the Gaza Strip (97%) were for inpatient services compared to the West Bank (35%), likely linked to reduced accessibility for Gaza patients to referral destinations. Most Gaza patients who were referred outside MoH facilities required permits to reach health facilities (40% to east Jerusalem, 17% to rest of West Bank, 3% to Israeli hospitals, and 1% to Jordan required permits; 24% to Gaza and 15% to Egypt did not), while most outside medical referrals from the West Bank did not require permits (55% within the West Bank, outside east Jerusalem; with most referrals to east Jerusalem (40%) and Israeli hospitals (5%) requiring permits). Further, 69% of requests by private companies through the Presidential Committee for Commodities Coordination of the Palestinian Authority for entry of machines or spare parts to Gaza for x-ray, CT, or oxygen delivery were denied by Israeli authorities in 2021.

The impact of COVID-19 on health service utilization was exacerbated by access restrictions and the end to coordination between the Palestinian Authority and Israel in 2020, when the issuance of outside referrals by the MoH dropped 24%, disproportionately affecting the Gaza Strip (51% decline) compared to the West Bank (8% decline).

Health access: Barriers affecting the Gaza Strip

The blockade of the Gaza Strip since 2007 has severely affected movement of people, as well as goods and services. To reach the rest of the oPt (West Bank, including east Jerusalem), Israel, or Jordan, Palestinians in the Gaza Strip must apply for Israeli permits to cross the checkpoint at Beit Hanoun (Erez). Since 2017, Israel more than doubled the required time for submission of non-urgent patient applications from 10 to 23 working days prior to the hospital appointment.

Patients applying for permits to exit Gaza are vulnerable, with a mortality rate at six months from first permit application approaching one in 10 (8.8%). Despite the severity of their conditions, from 2019 to 2021 only 65% of patient permits were approved in time to reach the patient’s hospital appointment. Over the past 15 years, there has been considerable variation in rates of approval (ranging from a high of 94% approved in 2012 to a low of 54% approved in 2017). Additionally, individual patients can be consecutively delayed or denied permits and then approved, or vice versa, pointing to the arbitrariness of the permit regime and the impact on subsequent access to needed health services. In most instances, there is no explanation for delay or denial of permits, indicating lack of due process and transparency. Different population groups are approved at different rates, with men aged 18 to 40 years experiencing the lowest approval rate (47%). By medical specialty, the lowest approval rates were for urology (44%), orthopaedics (45%) and ophthalmology (48%). Long periods of closure of the Rafah crossing to Egypt further exacerbated restrictions on access to health care during this period, particularly during the COVID-19 pandemic, with a 31% reduction in referrals to Egypt in 2020 compared to 2019.

Companion accompaniment of patients is particularly critical for children, incapacitated patients, and those with disabilities that may affect medical consent, emotional support needs, and capacities for self-care. Yet, from 2019 to 2021, only 46% of companion permits were approved in time for the patient’s hospital appointment. Of child medical permits approved for travel, nearly a third (32%) of did not have the child’s mother or father listed as companion. This is due to non-approval of parent applications, as well as non-application for parent permits (25% of child applications listed a parent as companion in the same period).

Ambulances transporting patients across Erez (Beit Hanoun) checkpoint frequently faced long delays, with ambulances transferring patients out of Gaza having to wait 68 minutes on average during 2019 to 2021, with the highest wait time in 2020 (80 minutes). Of 1493 permit applications via the Palestinian General Authority of Civil Affairs for health and non-health staff to exit the Gaza Strip for conferences from 2019 to 2021, just 10% were approved, with 51% denied and
39% remaining pending.

Health access: Barriers affecting the West Bank

In the West Bank, access between Palestinian urban centres is restricted by Israeli checkpoints, the separation barrier, and an expanding settlement infrastructure, while movement of Palestinians into east Jerusalem and Israel is controlled by the Israeli permit regime. The age distribution for patient and companion permit applications differs from the Gaza Strip, with 19% of patient applications for children (vs. 29% in Gaza) and 7% of applications for patients 65 years and over (vs. 14% in Gaza). Permit exemptions in the West Bank apply to women over 50 years and men over 55 years old, while children on occasion can pass through checkpoints with approved adults. A higher proportion of the West Bank population have permits to enter east Jerusalem and Israel for reasons not related to health, such as work.

The approval rate for patient and companion permits has been consistently higher for the West Bank than for the Gaza Strip, with 84% of patient applications and 78% of companion applications approved between 2019 and 2021, according to the Palestinian General Authority of Civil Affairs. With a higher number of applicants from the West Bank, however, this resulted in nearly 24 000 patient applications and nearly 37 000 companion applications not being approved during the period. As with the Gaza Strip, approval rates vary by age and gender with men aged 18 to 40 years facing the lowest approval (79% vs. 87-88% for all other age/sex categories). Differences were also observable by district and sub-district origin of referrals, with Jenin having the highest rate of denial (19%), compared to Jericho with the lowest (10%).

Most Palestinian health care workers in the West Bank outside east Jerusalem continued to require permits to access their places of work in east Jerusalem and Israel. From 2019 to 2021, 34 staff permit applications to reach east Jerusalem hospitals were denied. Almost all (93%) recorded ambulance transfers to Jerusalem from the rest of the West Bank were required to undergo the back-to-back procedure where the patient is transferred between two ambulances at a checkpoint, demanding use of additional resources and delaying patient transit. Palestinian ambulances entering Israeli hospitals in Jerusalem faced additional hospital security checks, which were reported to be carried out regardless of medical urgency. Communities in Area C, the Seam Zone8 and H2 of Hebron9 face substantial barriers to accessing primary care services, with dependence on expensive mobile clinics that are difficult to maintain and overall under-provision due to funding gaps. For mobile clinics operating in these areas, communities in the Seam Zone may only be accessible through a single point of entry/exit, such as for Arab ar-Ramadin ash-Shamali, where entry is dependent on prior permission and coordination with Israeli authorities. In more remote parts of Area C, poor infrastructure can limit access – particularly in winter – while high costs of private transport to reach health care disproportionately affect women and children, such as in Jubbet adh-Dheib in Bethlehem district.

Health attacks: Protection vulnerabilities for health care

WHO defines an attack on health care as any act of verbal or physical violence or obstruction or threat of violence that interferes with the availability, access, and delivery of curative and/or preventive health services during emergencies.10

The protracted protection crisis in the oPt contributes to vulnerability of health care to attacks, where the incidence of health attacks has correlated with peaks in occupation-related Palestinian casualties and fatalities. Between 2019 and 2021, there were 563 attacks on health care in the oPt. Two fifths (N=235; 42%) occurred in 2021, with 169 of these in the West Bank mostly associated with use of force during demonstrations and 66 in the Gaza Strip, mostly during the May 2021 escalation associated with damage to health facilities from heavy aerial and artillery bombardment. Over a third (N=200; 36%) of health attacks were in 2019, the last year of demonstrations at the Gaza fence for the Great March of Return.11 Overall, four fifths (78%) of health attacks involved acts of physical violence (higher in the Gaza Strip, at 96%), while one fifth (21%) involved obstruction to delivery of health care (higher in the West Bank, at 39%). During 2019 to 2021, one health care worker was killed while providing first aid assistance in Dheisheh refugee camp in Bethlehem and there were 463 health care worker injuries recorded. In the
same period, 207 ambulances were affected, including 114 damaged as the result of attacks, while 151 health facilities were affected, including 148 exposed to physical attack and damage.

There has been growing concern over the criminalization and securitization of health care, with 385 interrogations of patients and companions needing access out of the Gaza Strip and the arrest and detention by Israel at Erez (Beit Hanoun) checkpoint of 35 patients, companions, or health care workers. In 2021, a health care organization was proscribed12 by Israel and charges of supporting terrorism brought against staff working for the organization. The proscription was issued in the context of Israel’s designation of six other NGOs as ‘terrorist organizations’. According to a public statement by nine EU member states who had reviewed dossiers given to them by the Government of Israel in support of the designations, they had not received “substantial information” from Israel that would justify reviewing their policy [of funding the six NGOs].