Health conditions in the occupied Palestinian territory, including east Jerusalem, and in the occupied Syrian Golan: report by the Director-General

SEVENTY-FIRST WORLD HEALTH ASSEMBLY A71/27 Provisional agenda item 14 18 May 2018 Health conditions in the occupied Palestinian territory, including east Jerusalem, and in the occupied Syrian Golan Report by the Director-General 1. In 2017, the Seventieth World Health Assembly adopted decision WHA70(12), in which it requested the Director-General inter alia to report on progress in the implementation of the recommendations contained in the report on the health conditions in the occupied Palestinian territory, including east Jerusalem, and in the occupied Syrian Golan, based on field monitoring, to the Seventy-first World Health Assembly. This report responds to this request. SUPPORT AND TECHNICAL HEALTH-RELATED ASSISTANCE TO THE POPULATION IN THE OCCUPIED PALESTINIAN TERRITORY, INCLUDING EAST JERUSALEM, AND THE OCCUPIED SYRIAN GOLAN 2. In 2017, WHO continued providing support and technical assistance to the population in the occupied Palestinian territory, including east Jerusalem, consistent with the provisions of decision WHA70(12). WHO identified four strategic priorities with the Palestinian Ministry of Health to prioritize work for the Country Cooperation Strategy for WHO and occupied Palestinian territory 2017–2020.1 3. The first strategic priority of the Strategy is to contribute to strengthening and building resilience of the Palestinian health system and enhance Ministry of Health leadership to progress towards universal health coverage. In this regard, with funding from the Government of Italy, the Secretariat supported the Ministry of Health to implement tools for the extraction and analysis of hospital-based data. Information from such analyses enables policy-makers to better identify patient needs and hospital capacities in order to improve care pathways and health care effectiveness. With regards to attainment of Sustainable Development Goal 3 and universal health coverage, WHO supported a workshop to reach consensus on interventions and policies needed, building on the final recommendations of a technical expert mission with the World Bank to strengthen systems for health financing so as to progress towards universal health coverage. WHO supported the Ministry of Health in the implementation of the Patient Safety Friendly Hospital Initiative. This initiative assesses the level of patient safety in health care facilities and provides tools for improvement. The Ministry of Health has implemented the assessment in 16 hospitals in the West Bank. 1 World Health Organization. Regional Office for the Eastern Mediterranean Country cooperation strategy for WHO and occupied Palestinian territory 2017–2020. Cairo: WHO Regional Office for the Eastern Mediterranean; 2017 (http://www.emro.who.int/images/stories/palestine/documents/CCS_Palestine_2017-2020_WEB_-_Final.pdf?ua=1&ua=1, accessed 6 April 2018). A71/27 2 4. The second strategic priority is to strengthen voluntary core capacities for the International Health Regulations (2005) in the occupied Palestinian territory, and the capacities of the Ministry of Health, its partners and the communities in health emergency and disaster risk management, and to support humanitarian health response capacities. In 2017, the Secretariat supported the finalization of a three-year workplan for strengthening core capacities of the Regulations in 2017 to 2019, on the basis of findings of a joint external assessment conducted in 2016. The plan focuses on building the institutional framework for coordination by the IHR Contact Point within the Ministry of Health to enhance surveillance, laboratory, infection prevention and control, and emergency preparedness functions, in collaboration with non-health partners in agriculture, veterinary sciences, food safety and other sectors. The Secretariat continued its logistical support to supply vaccinations to health facilities, and the occupied Palestinian territory boasts high rates of childhood immunization. Technical assistance was also provided to the Emergency and Ambulance Directorate in the Ministry of Health for building its capacities for all-hazards emergency preparedness and risk management, using a multisector approach, in accordance with the emergency and disaster risk management framework for health. This included the development of contingency plans for 14 governmental hospitals and 13 primary health directorates, in addition to the central units. Training was conducted for more than 300 health workers on emergency medicine protocols and a simulation exercise was carried out in Hebron to test contingency plans. 5. The third strategic priority is to strengthen the capacity of the Palestinian Ministry of Health and its partners to prevent, manage and control noncommunicable diseases, including mental health disorders, and to reduce risk factors for violence and injuries. WHO continued to support implementation of the family practice approach in primary care, with funds from the Government of Italy, and piloted this in two districts in the West Bank. The initiative aims to ensure the continuity of integrated care, to enhance patient and family registration and appointment systems, and to apply the use of unified patient medical records. The project also aims to introduce a family practice diploma with a local university in the Gaza Strip, in addition to a primary care training programme for nurses in the West Bank, and to support implementation of WHO’s Package of Essential Noncommunicable Disease Interventions throughout the occupied Palestinian territory. The Secretariat, through its Project “Building Palestinian Resilience: improving psychosocial and mental health response to emergency situations” and supported by the European Union, continues to support the Ministry of Health and its partners to scale up emergency preparedness and response for mental health support; to support the integrated delivery of evidence-based interventions for common mental health problems in primary care; and to improve the quality of and access to specialized mental health care, including the availability of essential pharmaceuticals. 6. The fourth strategic priority is to strengthen the capacity of the Ministry of Health and health partners to advocate with all legal duty-bearers to protect the right to health of the population under occupation, reduce barriers to accessing health services, and improve the social determinants of health. In 2017, WHO conducted workshops with the Ministry of Health and health partners in the West Bank and the Gaza Strip to review current mechanisms for monitoring and accountability for the right to health and to explore the integration of a human rights-based approach to health services. The Secretariat, supported by the Government of Switzerland and the Humanitarian Pooled Fund, continued to produce regular monitoring reports on barriers to health access and attacks on health care facilities, workers and transports, as well as contributing to the monitoring of human rights treaties following Palestine’s accession to seven human rights treaties and one substantive protocol in 2014. 7. WHO operates as the lead United Nations agency for the health cluster humanitarian coordination mechanism in the occupied Palestinian territory. This mechanism supports the assessment of health needs for the Humanitarian Needs Overview and assists health agencies to plan humanitarian activities and mobilise resources through the Humanitarian Response Plan. The health A71/27 3 cluster implements its coordination role through monthly meetings co-chaired by WHO and the Palestinian Ministry of Health, and through technical working groups such as the Mobile Medical Teams Working Group for the West Bank. Continued power cuts in the Gaza Strip are placing an increasing burden on the health sector and disrupting the delivery of essential services such as health, water and waste management. As provider of last resort, WHO supported the procurement of fuel for generators to prevent the closure of 14 public hospitals and 18 nongovernmental hospitals in the Gaza Strip, with contributions from the Government of Switzerland and the United Nations Central Emergency Response Fund. WHO also supported the procurement of essential medicines and medical disposables to address critical shortages in the Gaza Strip, with contributions from the European Union, the Humanitarian Pooled Fund and the Central Emergency Response Fund. 8. The Secretariat, with funds from the Government of Norway, has continued to support the establishment of the Palestinian Institute of Public Health, with its legal framework adopted by the Palestinian Cabinet of Ministers and President in 2016. The Institute produces evidence for informed health policy decisions and aims to strengthen data collection and utilization by the Ministry of Health, for instance through the establishment of electronic registries for cause of death, cancer, maternal and child health, road traffic injuries and mammography screening. The Institute has also developed geographical information systems for mapping health care and health outcomes, and an observatory of human resources for health. 9. There are a number of pending issues related to the report on the health situation in the occupied Syrian Golan, 1 and work is continuing regarding these issues, which will lead to providing the information needed for the report and for recommendations mandated by decision WHA69(10) (2016). REPORT ON THE HEALTH CONDITIONS IN THE OCCUPIED PALESTINIAN TERRITORY, INCLUDING EAST JERUSALEM Demographics, health outcomes and health inequalities 10. The estimated population living in the occupied Palestinian territory in 2017 was 4.95 million, with 3.01 million in the West Bank and 1.94 million in the Gaza Strip. 2 More than 2.1 million are registered refugees, of whom 1.3 million live in the Gaza Strip and comprise 67% of the total population there. One quarter of the refugees in the West Bank live in the 19 camps located there and more than half a million refugees in the Gaza Strip live in the eight camps there. 3 The overall Palestinian population is predominantly young: nearly 40% of Palestinians are aged 0–14 years, and 5% are aged 65 years or older. 4 11. Life expectancy at birth for Palestinians in the occupied Palestinian territory was 73.7 years in 2016; in the same year, infant mortality for Palestinians in the occupied Palestinian territory, including 1 WHO document A70/39 and decision WHA70(12) (2017). 2 Palestinian Central Bureau of Statistics and National Population Committee (http://www.pcbs.gov.ps/post.aspx?lang=en&ItemID=1975, accessed 9 April 2018). 3 UNRWA, Where we work, 2017 (https://www.unrwa.org/where-we-work (accessed 9 April 2018). 4 Palestinian Central Bureau of Statistics, 2018 (http://www.pcbs.gov.ps/site/lang__en/881/default.aspx#, (accessed 9 April 2018). A71/27 4 east Jerusalem was 10.5 per 1000 live births and under 5 mortality was 12.2 per 1000. 1 Health inequalities exist with generally worse health outcomes in the Gaza Strip compared to the West Bank: for instance, the Ministry of Health reported maternal mortality to be 15.5 per 100 000 births in the Gaza Strip compared to 12.4 in the West Bank in 2016. The year 2017 marked 10 years of blockade of the Gaza Strip, with a concerning stagnation or deterioration of several health indices, including infant and neonatal mortality. There also exist considerable health inequalities between the Palestinian population and the 611 000 Israeli settlers in the West Bank. 2 In 2016, life expectancy at birth in Israel, which includes the Israeli settler population in the West Bank, was 82.5 years – almost nine years more than for Palestinians living in the same territory. 3 12. While the occupied Palestinian territory boasts consistently high rates of childhood vaccination and well-established systems for the surveillance of communicable diseases, the burden of noncommunicable diseases is rising. Cardiovascular disease, cancer and cerebrovascular disease cause just over half of all deaths among Palestinians in the occupied Palestinian territory, according to data from the Ministry of Health. 4 13. Exposure to violence has an immediate impact on health: 77 Palestinians were reportedly killed and 8359 were injured as a result of clashes with Israeli security forces and Israeli settlers in 2017. Violent incidents also impacted Israelis with 15 deaths and 156 injured reported as a result of attacks by Palestinians. 5 There are also longer-term effects of continuing military occupation and recent conflicts in the Gaza Strip. An estimated 900 people were permanently disabled, a third of them children, with 100 undergoing amputation of limbs, as a result of the 2014 conflict, and at least 36 Palestinians in the Gaza Strip, 14 of whom were children, died as the result of detonation of explosive remnants of war. 6 The mental health of the population is detrimentally affected, with 312 000 children in need of psychosocial support in 2018, the majority in the Gaza Strip. 7 The occupied Palestinian territory has one of the highest burdens of mental disorders in the Eastern Mediterranean Region. About 54% of Palestinian boys and 47% of Palestinian girls aged 6 to 12 years reportedly have emotional and/or behavioural disorders, and the overall disease burden for mental illness is estimated to account for about 3% of disability-adjusted life years. 8 1 Palestine Health Information Centre, Health Annual Report: Palestine; 2016. 2 OCHA, Humanitarian facts and figures. Occupied Palestinian Territory, 2017, p 2 (https://www.ochaopt.org/content/humanitarian-facts-and-figures, accessed 9 April 2018). 3 Israeli Central Bureau of Statistics, 2018 (http://www.cbs.gov.il/reader/cw_usr_view_SHTML?ID=591, accessed 9 April 2018). 4 Palestine Health Information Centre, Health Annual Report: Palestine; 2016. 5 OCHA, 2018. Data provided directly from OCHA. 6 OCHA, Humanitarian facts and figures. The humanitarian impact of major escalations, Factsheet. Occupied Palestinian Territory, 2017 (https://www.ochaopt.org/content/humanitarian-facts-and-figures, accessed 9 April 2018). 7 OCHA, Humanitarian Needs Overview 2018: occupied Palestinian territory, 2018 (https://reliefweb.int/sites/reliefweb.int/files/resources/hno_20_12_2017_final.pdf, accessed 9 April 2018). 8 Charara R, Forouzanfar M, Naghavi M, Moradi-Lakeh M, Afshin A, et al. The burden of mental disorders in the Eastern Mediterranean Region, 1990–2013. PLOS One, 2017 (http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0169575, accessed 9 April 2018). A71/27 5 Legislation, financing and availability of health care 14. The legislative and physical division of the occupied Palestinian territory, in terms of both the separation of the Gaza Strip from the West Bank and the fragmentation of the occupied West Bank into Areas A, B and C and Israeli control in Area H2 in Hebron and east Jerusalem, presents major difficulties for the cohesiveness of the health system and for access for staff, ambulances, patients and relatives. Under the Israeli-Palestinian Interim Agreement on the West Bank and the Gaza Strip (the Oslo II accord), the West Bank was divided into Areas A, B and C, with Palestinian civil and military control in Area A; Palestinian civil control and Israeli military control in Area B; and Israeli civil and military control in Area C. After 1967, Israel incorporated east Jerusalem into the municipality of Jerusalem, according its residents a different status to Palestinians in the remainder of the occupied Palestinian territory. Palestinians from east Jerusalem can move freely within Israel, while most Palestinians from the remainder of the occupied Palestinian territory require permits to enter Israel (most women over 50 years and men over 55 years from the West Bank are exempted from this requirement). Palestinians from east Jerusalem can also access Israeli health insurance, but Palestinians from the remainder of the occupied Palestinian territory cannot. Physically, access for patients and health staff in the West Bank is complicated by checkpoints in place between the different areas, which can lead to unpredictable delays. Israel’s construction of a separation barrier since 2002 has additionally complicated access to health services for Palestinians residing in the “Seam Zone” – the area between the Green Line separating Israel from the West Bank and the barrier. These Palestinians must now navigate additional checkpoints and take convoluted routes to nearby towns and health facilities. In Area C, Israel’s civil control has led to expansion of its settlement infrastructure, while development efforts for the some 300 000 Palestinians who live in this Area, including development of health services, have been severely hampered. 15. According to the Palestinian Central Bureau of Statistics, about 82% of the Palestinian population living in the West Bank and the Gaza Strip is covered by some form of prepayment for health care. The major providers of health coverage, the Government Health Insurance and UNRWA, account for more than 90% of the coverage provided and overlap significantly. The government health insurance covers primary services including maternal and child health services, secondary care, prescription medicines on the essential medicines list, and tertiary care services needed but not available in Ministry of Health facilities, purchased from non-Ministry of Health facilities within and outside the occupied Palestinian territory. UNRWA provides services for Palestinian refugees in the occupied Palestinian territory, and covers comprehensive primary health services, with limited support for hospital care. Some 38% of health financing comes from out-of-pocket payments, with roughly 1% of the population encountering catastrophic financial payments and a further 0.8% made impoverished owing to payments for health care. 1 The Palestinian Authority faces substantial challenges to ensure the sustainability of its health service provision, with little control over the many natural resources in the occupied Palestinian territory, a lack of sovereignty over tax revenue for health financing, a lack of full control over health spending on referrals to Israel and a high level of donor dependency. The Ministry of Health reported that it was charged for about 400 referrals to Israel in 2017 that had not been approved through the Services Purchasing Unit of the Ministry. 16. The Palestinian Ministry of Health is the major provider of primary health care in the West Bank, accounting for more than 70% of the 587 clinics. 2 In the Gaza Strip, the Ministry of Health 1 WHO-World Bank Mission Report, 2016. Improving Health System Financing and Service Provision for Universal Health Coverage in Palestine – Addressing the Challenges for a Sustainable and Equitable Health System Development. 2 Palestine Health Information Centre, Health Annual Report: Palestine; 2016, p 132. A71/27 6 accounts for about one third (32%) of the 152 primary health clinics, with a larger role played by UNRWA and nongovernmental organizations. Additionally, there are 24 mobile clinics operating in Area C of the West Bank, most provided by UNRWA and nongovernmental organizations. There are 81 hospitals in total in the occupied Palestinian territory, with 51 in the West Bank and 30 in the Gaza Strip. Bed capacity is approximately 1.3 beds per 1000 of the population, which is the same in the West Bank and the Gaza Strip. The Ministry of Health accounts for 44% of bed capacity in the West Bank and 69% of bed capacity in the Gaza Strip. Nongovernmental organizations account for 40% of bed capacity in the West Bank and 24% in the Gaza Strip, while private institutions provide 14% of bed capacity in the West Bank and none in the Gaza Strip. 1 17. Health services in the occupied Palestinian territory face chronic shortages of medical supplies. The Central Drug Store of the Ministry of Health in Ramallah reported an average of 23% of essential medicines and 19% of essential medical supplies as completely depleted over the course of 2017. 2 Gaza’s Central Drug Store reported a monthly average of 32% of essential drugs and 24% of essential medical disposables to be completely depleted over the last four months of the year. 3 Shortages disproportionately affected certain specialties and treatment pathways. For instance, 61% of essential medicines for oncology and haematology had less than a month’s stock remaining in the Gaza Strip in December 2017, compared to a figure of 44% for all essential medicines that month. Of note, the number of items on the Essential Medicines List and the Essential Medical Disposables List reported by the Ministry of Health in the West Bank and in the Gaza Strip is different and may contribute to the discrepancies reported between the two areas. Outside east Jerusalem, facilities completely lack certain treatments and diagnostic options, including radiotherapy and nuclear imaging technology, making many cancer patients dependent on referral to east Jerusalem and hence dependent on obtaining security permits from Israeli authorities. East Jerusalem hospitals have historically been – and remain – the main referral centres for Palestinian patients, particularly for cancer treatment, cardiac surgery and paediatric tertiary care. 18. The continuing blockade and successive conflicts have impacted on the health sector capacity in the Gaza Strip. From 2010 to 2016 there has been a 9% reduction in the number of hospital beds, a 5% reduction in nurses, and a 21% reduction in doctors, per head of the population. 4 The 2014 conflict in the Gaza Strip damaged 75 health structures (17 hospitals and 58 clinics), with the closure of 44 facilities at different stages due to damage or for security reasons. 5 Aside from direct damage to facilities and injuries to staff, longer-term consequences for the health sector have resulted from the diversion of resources to meet emergency needs and recovery and away from development, holding the health sector back from the improvements possible from longer-term investment. From April 2017 the Gaza Strip faced an exacerbation of its electricity crisis, with only 4–6 hours of electricity per day available following measures by the Palestinian Authority that led to temporary closure of the Gaza 1 Palestine Health Information Centre, Health Annual Report: Palestine; 2016, p 132. 2 Ministry of Health Central Drug Store, West Bank 2018. Data provided directly to WHO and health cluster. 3 Ministry of Health Central Drug Store, Gaza Strip 2018. Data provided directly to WHO and health cluster. 4 Palestinian Health Information Centre statistics, 2017. 5 OCHA. Health services continue despite damaged facilities, 2014 (https://www.ochaopt.org/content/health-services- continue-despite-damaged-facilities, accessed 9 April 2018). A71/27 7 Power Plant and reductions in supply of electricity from Israel. Hospitals were forced to postpone elective surgeries, discharge patients prematurely and to reduce cleaning and sterilization services. 1 Access to health services 19. According to research by WHO, lack of medical equipment, essential medicines and diagnostic services accounts for about three-quarters of patient referrals out of the Gaza Strip. 2 Oncology is the single largest reason for referrals outside the Gaza Strip, with almost one third (31%) of patient referral applications in 2017 for cancer treatments and investigation. Dependence on referral out of Ministry of Health facilities is expensive for the Palestinian Authority and a challenge to the sustainability of health care provision for Palestinians. All referrals to non-Ministry of Health facilities, including those outside the Gaza Strip and the West Bank, must be approved by the Services Purchasing Unit of the Ministry of Health. Referrals to non-Ministry of Health facilities accounted for 34% of the Ministry of Health’s expenditure in 2016, with 13% of expenditure on referrals to Israel. In 2017, the Services Purchasing Unit approved 94 939 referrals to non-Ministry of Health facilities. In the Gaza Strip, this figure included 20 505 referrals to facilities outside the Gaza Strip, mainly to east Jerusalem hospitals (42% of all referrals to non-Ministry of Health facilities), to Israel (20%) and the West Bank (15%). 3 Of the referrals in the Gaza Strip 16% were to non-Ministry of Health facilities within the Gaza Strip and 6% were to Egypt. In the West Bank, the Services Purchasing Unit approved 74 434 referrals, with 46% of referrals to non-Ministry of Health facilities in the West Bank outside east Jerusalem, 37% of referrals to east Jerusalem and 16% of referrals to Israel. There were small numbers of referrals to Jordan (12) and Turkey (5) from the occupied Palestinian territory. 20. Patients referred to facilities outside the Gaza Strip are exempted from the general travel ban placed on Palestinians in the Gaza Strip, allowing them to apply for exit permits to access health care. Access to health services through the Erez crossing deteriorated further in 2017: a mere 54% of patient applications received security approval in time to travel for health care appointments outside, the lowest approval rate since WHO began actively monitoring access for patients from the Gaza Strip in 2006. 4 Trends have shown a continuous decline since 2012, when 93% of patient applications to travel for health care were accepted by Israeli authorities. 5 Bureaucratic delays to processing patient permit requests have increased: in May 2017 there was a doubling of the previous non-urgent processing time for patient permit applications from 10 to 20 working days; in November 2017 this processing time 1 OCHA. . Humanitarian facts and figures: The humanitarian impact of the internal Palestinian divide – factsheet. OCHA; 2017 2 Lafi, M., Ammar, W., Vitullo, A., Al-Farah, N. & Daher, M. “Reasons for medical referrals of Gaza patients, 2015.” Poster at the Lancet Palestine Health Alliance conference, 2016 3 Services Purchasing Unit of the Palestinian Ministry of Health, 2018 4 WHO. Health access for referral patients from the Gaza Strip: summary – annual overview and December 2017. Monthly report, December 2017. Cairo: World Health Organization Regional Office for the Eastern Mediterranean, 2018 (http://www.emro.who.int/images/stories/palestine/documents/WHO_monthly_Gaza_access_report_Dec_2017- final.pdf?ua=1, accessed 9 April 2018). 5 WHO. Right to health: crossing barriers to access health in the occupied Palestinian territory. Cairo: World Health Organization. Regional Office for the Eastern Mediterranean; 2017 (http://www.emro.who.int/images/stories/palestine/documents/WHO_-_Access_Report_2016_Book_Final-small.pdf?ua=1). A71/27 8 increased further to 26 working days. 1 In 2017, 596 patients and 91 patient companions were called for security interrogation as a precondition to health access outside the Gaza Strip. 2 21. Israeli authorities require all patients from the Gaza Strip to apply for security permits to exit for health care. Patients in the West Bank must also apply for security permits to access care in east Jerusalem and Israel, but Israeli authorities exempt most women older than 50 years and men older than 55 years. Other patients in the West Bank are dependent on security permits from Israeli authorities to be able to access key referral centres in east Jerusalem and specialist services in Israel that are unavailable in Palestinian health facilities. Again, the single largest reason for referral out of the West Bank is for cancer treatment and investigation, with oncology referrals comprising some 23% of the 61 732 referrals from the West Bank in the first 10 months of 2017. Twelve per cent of all patient applications and 18% of companion applications to exit the West Bank to east Jerusalem or to Israel last year were denied in 2017. 3 WHO received records of 54 patients who died while awaiting security approval by Israeli authorities for referral out of the Gaza Strip. Three deaths were in children under the age of 18 years. 22. East Jerusalem hospitals are the cornerstone of the Palestinian health system, but control by Israel makes access difficult for the 35 000–40 000 Palestinian patients referred there each year (40 220 patient referrals in 2016 and 36 414 in 2017). Augusta Victoria Hospital remains the main referral centre for cancer patients, while Makassed Hospital operates as a major centre for paediatric tertiary care and cardiology. Staff members too must obtain permits to access their workplaces. Data from east Jerusalem hospitals show that 98% of the 1708 applications for staff members to access from the West Bank and the Gaza Strip were accepted in 2017. This figure included 1599 permits issued for six months to staff members from the West Bank and 83 permits issued for three months to staff members from the Gaza Strip, staff members previously denied and staff members who had already applied for family reunification. Twenty-six applications for health staff members were denied access. Direct access for ambulances from the West Bank is problematic, with ambulances stopped and delayed for security checks. Of the 2125 ambulances requiring entry to Jerusalem from other parts of the West Bank each year 90% have to transfer patients to another ambulance at checkpoints, delaying transit. 4 Health care for the prison population 23. Palestinian prisoners in Israeli detention face barriers to accessing independent health care, with the Israeli Prison Service as opposed to the Ministry of Health responsible for providing primary care services. Civil society human rights organizations report issues with oversight, with the provision of timely and appropriate treatments and with review or implementation to ensure effective care pathways. These organizations also report being unable to access prisons for monitoring purposes. The International Committee of the Red Cross accesses prison services, but does not report publicly on 1 WHO monthly reports on referral of patients from the Gaza Strip, for May and November 2017, available at: http://www.emro.who.int/pse/publications-who/monthly-referral-reports.html (accessed 9 April 2018). 2 WHO. Health access for referral patients from the Gaza Strip: summary – annual overview and December 2017. Monthly report, December 2017. Cairo: World Health Organization Regional Office for the Eastern Mediterranean, 2018 (http://www.emro.who.int/images/stories/palestine/documents/WHO_monthly_Gaza_access_report_Dec_2017- final.pdf?ua=1, accessed 9 April 2018). 3 Data provided by the Palestinian Coordination and Liaison Office data, 2018. 4 Data from the Palestinian Red Crescent, 2018. A71/27 9 conditions for the 6119 Palestinian prisoners who were reported to be held by the Israeli Prison Service in February 2018, of whom 330 were minors. 1 There are reports of inadequate nutrition for prisoners, including those suffering from cancer or other severe conditions, and a lack of access to psychosocial support, with denial of family visits and communications. 2 Following the mass hunger strike by Palestinian prisoners in mid-2017, Israeli prison authorities agreed to bimonthly visits for the families of prisoners. Health attacks 24. WHO defines a health attack as “any act of verbal or physical violence, threat of violence or other psychological violence, or obstruction that interferes with the availability, access and delivery of curative and/or preventive health services”.3 WHO monitors health attacks in the occupied Palestinian territory, in collaboration with health partners and the Palestinian Ministry of Health. Data on health attacks are recorded in addition to the systematic denial and delay of patient access to health care outside the Gaza Strip or the West Bank. The Palestinian Red Crescent Society recorded 84 violations against its staff members and ambulances, including prevention of ambulances from reaching patients, injuries to staff and attacks towards and damage of vehicles. WHO verified a further 18 incidents affecting hospitals and primary care clinics. Seven patients and four patient companions were arrested. Of the six arrests that took place at the Erez crossing (for three patients and three companions), four (two patients and two companions) were subsequently released without charge, one patient is awaiting trial and one companion was sentenced to two years’ imprisonment. Seven incidents against medical facilities were long-standing, with UNRWA, the Palestinian Medical Relief Society and Handicap International (renamed Humanity & Inclusion in 2018) denied access for at least six weeks to five communities in Area C of the West Bank comprising a population of 1371. Underlying determinants of health 25. The occupation of the Palestinian territory, and especially the closure of the Gaza Strip affect the social determinants of health for Palestinians, with 31.5% experiencing moderate or severe food insecurity, 36.4% of the population dependent on humanitarian assistance for water and sanitation and 5.3% facing gaps and vulnerabilities in accessing adequate shelter. 4 These vulnerabilities negatively impact on health outcomes, with the estimated prevalence of stunting in the Gaza Strip at 10%, highest among children from refugee and low-income families. 5 The sewage crisis in Gaza, with some three million cubic metres of poorly treated wastewater pumped into the sea off the Gaza Strip each month, presents a major public health risk to the population for waterborne diseases, exacerbated by 1 Addameer, 2018. Available at: http://www.addameer.org/statistics (accessed 9 April 2018). 2 Physicians for Human Rights – Israel, 2018. 3 WHO. Surveillance System for Attacks on Health Care, 2017, Annex 3. https://publicspace.who.int/sites/ssa/SitePages/PublicDashboard.aspx 4 OCHA. Humanitarian Needs Overview 2018: occupied Palestinian territory, 2018 (https://reliefweb.int/sites/reliefweb.int/files/resources/hno_20_12_2017_final.pdf, accessed 9 April 2018). 5 Palestinian Ministry of Health, 2017. National Nutrition Surveillance System, 2016: Preliminary report; see also El Kishawi RR, Soo KL, Abed YA, Muda WAMW. Prevalence and associated factors influencing stunting in children aged 2–5 years in the Gaza Strip-Palestine: a cross-sectional study. BMC Pediatrics. 2017;17:210. doi:10.1186/s12887-017- 0957-y (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5740756/). A71/27 10 the poor quality of drinking water as a result of contamination of the coastal aquifer. 1 Access to water averages 53 litres per capita per day in the Gaza Strip and 79 litres per capita per day in the West Bank – well below WHO’s recommended delivery of 100 litres per capita per day. UPDATE ON THE 2017 RECOMMENDATIONS OF THE DIRECTOR-GENERAL FOR IMPROVING THE HEALTH CONDITIONS IN THE OCCUPIED PALESTINIAN TERRITORY, INCLUDING EAST JERUSALEM, AND IN THE OCCUPIED SYRIAN GOLAN 26. As noted above, there are number of pending issues related to the report on the health situation in the occupied Syrian Golan, as referred to last year in WHO document A70/39 and noted in decision WHA70(12), and work is continuing regarding these issues, which will lead to providing the information needed for the report and for recommendations mandated by decision WHA69(10), to be presented by the Secretariat for consideration by the Seventy-second World Health Assembly. 27. In 2017, the Seventieth World Health Assembly made recommendations to Israel and to the Palestinian Authority to improve health conditions in the occupied Palestinian territory. This section provides an update on the progress made towards achieving those recommendations. Recommendation 1: Israeli authorities have the following obligations under international law: • To establish procedures, which enable undelayed access 24/7, for all Palestinian patients requiring specialized health care, including exit out of Gaza and access into Jerusalem, and which at the same time safeguard Israeli security concerns; • To establish procedures that ensure Palestinian health care personnel to be able to work, train and specialize in the occupied Palestinian territory, including east Jerusalem, and abroad; • Establish procedures that enable ambulances to have free access to patients and health care institutions without unnecessary delay. Recommendation 6: Israeli authorities should ensure that health care workers have unhindered access to their workplace, and have possibilities for professional development and specialization. 28. Although in a meeting in 2017 senior officials from the Coordination of Government Activities in the Territories (the Israeli government’s unit, subordinate to Israel’s Minister of Defense, responsible for implementing the civilian policy in the territories) had informed WHO that new procedures were envisaged, no tangible improvements have ensued. Access restrictions for Palestinian patients deteriorated further in 2017, particularly for patients in the Gaza Strip, where there was a decline in the approval rate for patient permits to 54% from 62% in 2016. There was no noticeable progress to enable undelayed access 24 hours a day, seven days a week, as recommended. There was no tangible improvement that ensured that Palestinian health workers were able to work, train and specialize in the occupied Palestinian territory. Again, health workers from the Gaza Strip faced the greatest restrictions in this regard, according to data recorded by WHO. The back-to-back procedure 1 OCHA. Humanitarian Needs Overview 2018: occupied Palestinian territory, 2018 (https://reliefweb.int/sites/reliefweb.int/files/resources/hno_20_12_2017_final.pdf, accessed 9 April 2018). A71/27 11 for ambulances to transport patients from the West Bank into east Jerusalem continued because of ongoing restrictions on access, with 90% of patients transferred in this way. Recommendation 2: The Palestinian Authority in collaboration with international partners should continue to improve the referral system, including further improvement of technical solutions and procedures to make the process easier, quicker, more transparent, more equitable and less costly. 29. The system for referral of patients to non-Ministry of Health facilities continued to be a substantial financial challenge for the Palestinian Ministry of Health. The process remains bureaucratic for patients and patient families. Recommendation 3: The Palestinian Authority should consolidate efforts to progress towards universal health coverage through a policy dialogue for equitable and sustainable quality health services. 30. The Palestinian Ministry of Health continued its coordination with local and international partners towards the realization of universal health coverage by means of different platforms. A more concrete policy dialogue is planned by the Ministry of Health, supported through a new partnership between WHO and the World Bank. Recommendation 4: The Palestinian Authority should explore options for medical goods to be exempt from the Paris Protocol trade restrictions, and medical supplies should be considered essential humanitarian items. 31. No substantial efforts have been made by the Palestinian Authority to explore the exemption of medical goods from the effective trade union outlined in the Paris Protocol. Trade restrictions severely impede the ability of WHO and other actors to import emergency medical supplies to meet humanitarian health needs. For example, an in-kind donation of inter-agency emergency health kits faced delays of several months to obtain the necessary permits and customs clearance, in spite of support from the Israeli Ministry of Health. Recommendation 5: The Palestinian Authority in collaboration with the Palestinian Medical Council should develop a comprehensive health workforce strategy linked to the disease burden and projected speciality service's needs. 32. The Palestinian Institute of Public Health is currently finalizing the establishment of the first comprehensive observatory of human resources for health in the occupied Palestinian territory. As a second step, projections of needed specialties will be developed as the basis for the first comprehensive health workforce strategy. Recommendation 7: Consolidated efforts should be considered to overcome the political divide between the West Bank and the Gaza Strip, including agreement on a viable solution to ensure equitable and sustainable payment of all health care workers. 33. There was modest progress towards political reconciliation towards the end of 2017. This process continues in early 2018. A71/27 12 Recommendation 8: All parties should adhere to the United Nations Security Council resolution 2286 (2016) stating relevant customary international law concerned with the protection of the wounded and sick, medical personnel engaged in medical duties, their means of transport and medical facilities. 34. The situation regarding health attacks is outlined in paragraph 24 above. Recommendation 9: • Relevant authorities should consider organizing the prison health services independently from the prison services to ensure impartiality, and independent quality health services; • Security-controlled Palestinian physicians should be allowed to visit patients regularly in Israeli prisons. 35. There has been no substantive change to the situation regarding the delivery of health care to Palestinian prisoners. Recommendation 10: The mental health strategy developed by the Palestinian Ministry of Health involving all major stakeholders should be expanded to improve data generation on the mental health disease burden, to enhance capacity-building of mental health professionals and to strengthen monitoring and evaluation of the progress of integrating mental health services. 36. The Palestinian Ministry of Health reactivated the Mental Health Thematic Group in order to follow up and monitor mental health initiatives in accordance with with its Mental Health Strategy priorities and objectives. ACTION BY THE HEALTH ASSEMBLY 37. The Health Assembly is invited to note the report. = = =