World Health Organization Verdict on Health Care in Gaza

PALESTINE - ISRAEL, 31 Aug 2015

Jews for Justice for Palestinians – TRANSCEND Media Service

28 Aug 2015 – Report of a field assessment of health conditions in the occupied Palestinian territory (oPt), pdf file

By Claude de Ville de Goyet, Ambrogio Manenti, Kenneth Carswell, Mark van Ommeren. WHO

In 2014 “the hostilities left 23 health care workers dead, 16 of whom died while on duty. 83 health care workers were injured. Ambulance drivers were disproportionately affected”. No priority is given to ambulances at the checkpoints. WHO report.

22 March to 1 April 2015

[The first two sections of this report, which give the background to Israel and the oPt have been omitted, as have the footnotes]

3. Health care access

3.1.The health system

First, the geographical challenge to primary health care is distinct in the West Bank and Gaza: Gaza is a geographically contiguous territory under siege while the occupation fragmented the West Bank in dozens of ‘islands’ separated by settlements, military zones and controlled roads, reducing or complicating access to health care. The approach to the management of the health system has also evolved differently over the last decade. For instance, in Gaza, there is no co-payment for local health care (except medicines). The type and number of facilities in the West Bank and Gaza shows also differences.

Beside the challenges that the occupation poses for realizing the full potential of Palestinian economic development, which also affects the health sector development, there are critical and specific issues that limit access to health care:

• A chronic shortage of pharmaceuticals, supplies, spare parts and poor general maintenance led to a deterioration of quality of services in Gaza and to a lesser extent in the West Bank.

The Health Cluster Damage and Needs Assessment following the 2014 conflict observed that “nearly 50 per cent of Gaza’s medical equipment is outdated and the average wait for spare parts is approximately 6 months”. In 2014, the MoH Central Drug Store in Gaza reported that an average of 25.7% of medicines on the essential drug list (124 of 481 items) and 47% (424 of 902 items) of medical disposables were at or near zero stock for MoH facilities. The main reason is an insufficient budget rather than security restrictions imposed by Israel.

• Limited opportunity for health professionals in Gaza to attend trainings outside and access restrictions to get familiar with new medical techniques is also slowing down improvements in developing health care services in Gaza. Political disagreements between the political parties remain a challenge in spite of the May 2014 reconciliation.

In interviews, there were clear signs of continuing disagreements between health officials on both sides (and the respective political parties). The pending progress in consensus building and participative decision-making is hindering collaboration and an integrated approach. Undoubtedly, a unified and fully integrated management system is in the best interest of the health sector.

• Salaries represent 44% of the budget of the MoH. For the 4,508 workers recruited by the Ministry of Health of the Gaza de facto authorities since 2007 and the 530 workers employed by the PA who remained working after 2007 a solution for re-integration and regular salary payment is still pending. As a result, several strikes are carried out or planned by health workers and maintenance staff. At the same time, 2,163 health workers who stood down from their jobs in 2007 at the request of the Palestinian Authority and who are not presently working in the health services have continued to receive their pay. The situation is further aggravated by fiscal difficulties, and lately compounded by the delay in Israel forwarding the tax revenues collected on behalf of the PNA.

The Swiss Government is jointly with partners working on a compromise for health workers re-integration and remuneration -in the context of re-integration for all public sectors – while the World Bank is planning to cover the salary gaps of the cleaning/maintenance workers.

• In the West Bank, travel restrictions for health staff (especially to East Jerusalem) are affecting the health service delivery: Permits are granted on a short but variable term and renewal is occasionally and temporarily denied without apparent reason. Unpredictability is prevalent. Interdiction, so far, to use a West Bank-plated vehicle in East Jerusalem is further complicating the commute of many health workers.

3.2.Access to tertiary care: referrals

Referrals and access to tertiary care have a human rights dimension. A matter determined in most countries by availability of service capacity, treatment urgency and economic considerations is complicated by security concerns and consecutive limitations of movement of patients and ambulances enforced by the Israeli Government. The increasing poverty is the most pervasive barrier to access to specialized health services. Access to tertiary health care, as in many countries, is subject to availability of funding.

Social security insurance coverage (Government, UNRWA or private) normally covers only part of the costs (70% or up in West Bank and 100% in Gaza). Co-payment by the patient for their care and accommodation of accompanying relative and full payment for transportation and incidental medical costs can represent a serious burden.

Access to tertiary health care is limited by many barriers, some but not all related to the occupation.

Data on the referral and permit process are available from various sources: MoH Service Purchasing Department (SPD), UNRWA, and the Government of Israel –Coordination of Government Activities in the Territories (COGAT). Each source is collecting information on different steps and indicators (decision to refer, approval of financing, security travel clearance…), making data cross-referencing and comparison difficult.

The referral process

Requests for medical referrals are made either by the specialist doctor (West Bank) or the director of the hospital (Gaza). Proportionally, the number of referrals from the West Bank (16.3/1000 inhabitants) is higher than from Gaza (10.2/1000) (MoH/PNIPH 2014). The assessment has not been able to determine the relative role of factors such as security concerns, financial burden of co-payment for travel and accommodation, possible bias in the approval of financing or other factors.

Oncological diseases are the main medical conditions for referrals (15%). Referral patients are slightly more male, especially in Gaza (in 2014: West Bank: 52.3% male and 47.6% female; Gaza: 56.7% male and 43.2% female).

Proposed referrals are reviewed by a medical committee of the MoH Service Purchasing Department (SPD) both in Gaza and Ramallah. The main criteria for approval are the unavailability of services on site and the coverage by health insurance. This lack of service locally may often result from a temporary shortage of essential medicines, reagent or spare part or unavailability of the specialist.

Detailed statistics of number of applications received and approved or rejected by the medical committee (SPD) is not routinely released. A rate of 6% of denial of financing in the last month was mentioned as indicative by the MoH in the interview. Disaggregation of approval/denial data (by place of origin among others) would be useful for further analysis. There are several referral destinations: Within the Northern Governorates (West Bank) or Southern Governorates (Gaza) (to a private facility for instance), to East Jerusalem, to Israel or Egypt.

The volume of referrals from Gaza to Egypt has declined by 93% after the July 2013 closure of the Rafah border. This reduction affected particularly self-funded private patients. MoH funded referrals to Egypt declined 37% from 2011 levels, reducing sharply the access to health care for patients or companions who may have potential concern with Israeli security procedures.

Patients approved financially by MoH should secure an appointment with the hospital before applying for an Israeli permit for themselves and one for an accompanying relative.

The choice of the “companion” is particularly critical for young children. Data on responses to permit applications are regularly monitored by WHO and cases of denials leading to further suffering and medical consequences are documented. Challenges in the permit process by the Israel authorities are reported and regularly published by WHO (monthly for Gaza and annually for both Gaza and West Bank). Problems have been confirmed in extensive interviews during this survey:

• Increasing rate of denials or delayed processing of permits for either the patient or the selected companion (mother, husband, etc.): According to a WHO review for Gaza patients, the percentage of permit applications by patients denied or delayed has increased from 10.2% in 2011 to 17.4% in 2014 (and 19.5% for the first 2 months in 2015).

The rate of denial is significantly higher in the West Bank while in Gaza delays or lack of reply (“pending”) are more common. Reasons given for denial, if any, are varied and seen as unpredictable by interviewees. Perceived unpredictability of the process outcome and the contact with Israeli authorities are complaints most consistently mentioned in interviews.

• In Gaza, security interviews before permit issuance or during the actual crossing are increasing in frequency.
• Companions, especially younger adults, are frequently denied permits, forcing senior relatives to accompany the patient, often separating children from parents.
• Finally, holding a permit is no guarantee for being allowed to cross the border. Border guards or military have used and unpredictably can use their authority to deny access to patients.

Health co-ordinators from GoI (COGAT) posted in the West Bank and at the Erez crossing point in Gaza have played a positive role to follow up on individual requests for medical transfers. Their 24 hour availability and willingness to assist on a humanitarian basis has been praised by most Palestinian interlocutors.

Restrictions to ambulance transport of patients are perceived by interviewees as unnecessarily affecting the welfare and dignity of the patients. The “back to back” procedure as it is known requires the ambulance from the Palestinian side to stop at the crossing point, to unload the patient even if under oxygen or perfusion treatment, submit to security check and “walk” to the other side where an Israeli ambulance is waiting. On the West Bank side, ambulances are reportedly often required to take their turn in the queue of Israeli plated vehicles.

Co-ordination of the arrival of the two ambulances is causing additional delays. According to reports from the Emergency Services, security processing of patient transfers is often not adequately accelerated for patients with severe or urgent medical conditions. Such delays to rapid access to emergency referral care are generating considerable resentment without perceivable security benefits for Israel.

Once approved and cleared, long-term referrals (for instance for sessions of cancer treatment) present a financial burden for out patients and companions unable to support the cost of accommodation.

The cost of referrals is representing a significant part of the health budget (26.8% in 2013), second only to the expenditures to cover salaries. It is a significant source of income (60-70%) for the six non-profit Palestinian hospitals in East Jerusalem. It is also a non-negligible source of income for selected Israeli hospitals. Bills were until recently not detailed or respecting the ceiling (days of admission or amount) defined and approved by the MoH and were paid directly by the GoI from the taxes collected by Israel on behalf of the PA. Recently, progress has been made to allow the MoH to review the charges and negotiate pre-agreed reimbursement rates for procedures and diagnoses.

3.3.Implementation of recommendations WHA

The WHA requested a report on “progress made in the implementation of the recommendations contained” in the special report (WHO 2012). Those recommendations are listed in Annex 6.

Selected interviewees were invited to share their opinion regarding whether or not progress was made on some or all of the recommendations. The results are representative of the Palestinian and international community views only, given the lack of interlocutors from GoI.

The majority of interviewees expressed the opinion that little progress has been made in regard to the implementation of the recommendations to facilitate patient access to health care or travel for health workers.

As noted earlier, the support from the Israeli Health Co-ordinating officer (MoH) was usually praised. Regarding the recommendations to the PA, some progress was seen by a few interlocutors in the assistance to patients encountering difficulties in the referral process. Encouraging are the efforts of the new leadership in MoH/SPD to improve management and accountability in the referral process.

Regarding the recommendations on the Rafah Border the closure has substantially reduced the number of referrals to Egypt as well as incoming health or humanitarian supplies.

Although health interlocutors felt that little overall progress was made, independent observers point to very modest but encouraging recent openings: greater flexibility allowing Palestinian doctors and possibly later other health workers to use their own car in East Jerusalem, decrease in the age threshold for travel of West Bank residents and therefore patients and companions (males 55 years and above; females 50 years and above no longer need a special permit), and efforts to build the capacity of referring doctors and stimulate dialogue through workshops sponsored by the MoH of Israel.

3.4.Conclusions

The occupation and restrictions to movements of persons and goods is continuing to restrict the access to health care. Sustained additional advocacy is needed at international level to ensure that the consequences be minimized.

Of particular concern is the unpredictability of the process at all levels including at the checkpoint. Legitimate security considerations of the occupying power do not justify delays in processing genuine emergencies.

The closure of the Rafah access to Egypt has affected the transit of humanitarian goods and personnel and reduced the possibilities of life-saving evacuations from Gaza to Egypt.

4. Access to adequate health services on the part of Palestinian prisoners

The health of Palestinian prisoners is a serious public health issue affecting over the years several hundred thousand boys and men, and hundreds of women held in Israeli prisons. The general situation of Palestinian prisoners is described in the report by the Secretariat. In addition, WHO is currently conducting a study on ex-prisoners. Preliminary results of the ongoing study documenting experiences of ex-prisoners indicate multiple barriers to health.

Jafar Awad, Palestinian prisoner suffered an undiagnosed illness inside an Israeli gaol and did not receive proper treatment. When his condition became desperate he was released – to die a few days later. Photo from Days of Palestine.

NGOs report that prisoners with severe mental health problems often do not receive treatment for their condition and some are held in solitary confinement as a way of managing agitated behaviour, which may exacerbate any mental health problems. Concerning the mental health of prisoners, an important factor is the infrequent, or lack of, contact with parents, relatives and friends for long periods during their stay in prison.

5. Mental health consequences

5.1.The current situation in the oPt concerning mental health

Epidemiological studies in the occupied Palestinian territory (oPt) have shown high prevalence rates of common mental disorders (de Jong et al. 2003), (lbedour et al. 2007). While the observed rates vary by sample and study methodology, rates are consistently higher than those found in Israel (Levinson et al. 2008) or in neighbouring Lebanon (Karam et al. 2008). Further studies have reported reduced quality of life among Palestinians (Mataria et al. 2009). This is relevant as the concept of mental health is broader than that of mental disorder and includes well-being.

An infrastructure of community mental health centres exists in most places across the West Bank and Gaza provided by the Ministry of Health and NGOs. There is good infrastructure of primary health care (PHC) services in every town and village and important steps have been taken to integrate mental health into PHC, especially in Gaza. There is also a range of psychosocial care providers outside the health sector, including within schools.

These existing services provide a good foundation for the further development of effective and comprehensive community mental health care. Whilst in terms of the overall care system the basic structure of a community based mental health system has been established, the quality and quantity of care requires further improvement. WHO is working closely with the relevant governmental departments and coordinating with NGOs to further strengthen the existing system.

5.2.Findings from the literature

Different facets of the occupation, including reported human rights violations, affect the lives of Palestinians (Batniji et al. 2009). The following facets of occupation are relevant to mental health:

military conflict, reduced freedom of movement (blockade of Gaza; roadblocks in West Bank), lack of economic and social development opportunities with high rate of unemployment and difficult management of education and health systems, arrests of children and adults, treatment of child and adult prisoners in the military detention system, the barrier and its impact on access to land and access to economic opportunities, building of settlements and associated military presence in the West Bank, lack of approval of building permits and demolition of housing.

With regards to the relationship between these facets of occupation and mental health, the scientific literature is unequivocal on the negative effects of adversity (e.g. trauma, loss, severe life stressors) on mental health and mental disorder (Dohrenwend, B.P. 1998; Kessler et al. 2010). The facets of the occupation listed above involve a sense of unpredictability and uncontrollability in daily life that have been shown to have a detrimental impact on mental health (Gallagher et al. 2014).

One of a series of photos of a young Palestinian paraded around the Huwwara checkpoint by border police, December 20, 2011. Photos by Nasser Ishtayeh, Jaafar Ashtiyeh, Ayman Nubana

Palestinians report experience of chronic humiliation during the occupation (Giacaman et al. 2007), with humiliation being shown to be associated with health (Giacaman et al. 2007) and mental health complaints (Kendleret al. 2003).

5.3.Findings from the field visit

The findings from the empirical literature were confirmed by interviews conducted during a field visit. Interviewees reported that a substantially negative aspect of the occupation of the West Bank is the sense of insecurity and unpredictability created by aspects such as people having to regularly re-apply for permits, uncertainty about being detained at checkpoints and insecure living conditions due to threat of house demolition, whilst at the same time, few building permits are reportedly provided.

People reported that such events left individuals and families with a sense of entrapment and disempowerment. In turn this was reported as leading to hopelessness and anxiety and other mental health and behavioural problems. In particular, interviewees expressed that experiences of humiliation could be a driver of violence. The effect of detention on child detainees was highlighted, with a number of interviewees expressing the need for initiatives to help detainees with the psychological (e.g. mental health difficulties) and social (e.g. loss of schooling) effects of detention.

Interviewees highlighted the important differences between the situation in Gaza and in the West Bank, in particular the substantially higher exposure to trauma for adults and children in Gaza from the experience of recent episodes of conflict.

These experiences create additional risk for mental health, through exposure to loss, trauma and the destruction of infrastructure caused by these events. In the West Bank, very vulnerable groups such as the Bedouin and rural communities bounded by settlements also face disproportionate risks of displacement and insecurity.

6. Water, food and livelihood

6.1.Access to water

Access to water is an issue pre-dating the occupation. The demographic growth, the conflict between Israel and Palestine, the establishment of settlements in the West Bank and the blockade of Gaza have only made the problem more urgent and difficult to address in a negotiated and fair manner. Access to scarce water is critical for the economic development of each side leading to an unequal war of conflicting statistics on water rights and use.

In Gaza: Water resources are essentially restricted to the coastal aquifer shared with Israel. Already before the occupation, extraction from deep wells was exceeding the recharge capacity of the aquifer. With demographic growth, the rate of extraction exceeds over three times the regeneration capacity. The result is a rapidly increasing salinization of the water. In addition, the unregulated use of fertilizers led to a continuous increase of nitrates. Both chloride and nitrates are reaching levels exceeding 5-10 times the recommended acceptable level. The problem is compounded by the destruction of wells and water infrastructure during the conflicts and incursions.

It is estimated that between 95 to 97% of the water is now unfit for human use. Salted water is unpalatable leading to 95% of the population relying on desalinated water from commercial sources. It is an additional expense difficult to absorb by the poorest sectors. The bacteriological quality of the commercial desalinated water and its storage at home are of concern. The deterioration or destruction of the sewage system constitutes a high risk for contamination and water borne diseases.

An open pool of sewage is seen in the garbage-filled Wadi Gaza area of the central Gaza Strip on Nov. 27, 2013. Marco Longari / AFP / Getty Images

Up to date, there is however no clear epidemiological data confirming a massive impact on health at short term (outbreaks) or long term (chemicals) attributable to the water problem. The absence of data does not preclude the urgency of retuning the quality of water to internationally acceptable levels. Large sea water desalination plants are seen as the solution. That will require massive improvements of power, sewage and water infrastructure as well as adequate availability of fuel and investments. The blockade especially on construction material and the resulting economic stagnation needs to be addressed. Meanwhile damages caused by periodic escalations of the conflict with bombardments and related damages of water supply have to be repaired.

In the West Bank, the water issue is mostly one of quantity (OCHA 2014 (B)).The estimated average daily consumption of water (all use) is 71 litres/person, below the recommended level of 100L. According to UNICEF, 55,000 Palestinians consume less than 30 litres. Under the joint agreement on water resources signed in the context of the Oslo accords, an Israeli-Palestinian Joint Water Committee (JWC) was established. In practice, it gives Israel veto power on the construction or even renovation of wells or water systems throughout the West Bank. The Palestinian Authority is not able to extract the full amount allotted, nevertheless old or new water facilities (wells, water tanks, latrines, cisterns, etc.) are destroyed by the Israeli authorities on the grounds that they lacked the adequate permit from the JWC. The result is an enormous discrepancy between Palestinian and Israeli actual water use.

Waste water treatment facilities are subject to the same approval by JWC, out of 30 Palestinian proposals since 1995, four have been approved (OCHA 2014 (B)) and one project treating 5% of the total waste water has been completed.

That water supply situation represents a clear risk for the public health.

6.2.Food security in the Gaza Strip

Queueing at a WFP voucher shop in Gaza for emergency rations. Photo from WFP.

Food insecurity is primarily a political and economic issue. According to WFP, 95% of vegetables and 100% of white meat and eggs needed are produced in Gaza. The blockade and the recent conflict pushed an increasing number of people into poverty making them dependent on in kind distribution of food by WFP and UNRWA. The rapid assessment following the conflict found 57% of the population exposed to food insecurity. If there were no notable restrictions imposed on food import to Gaza, severe limits are still in place for exports. WFP and UNRWA have launched a special food distribution programme aiming to reach 730,000 conflict-affected people in Gaza. In summer 2014, WFP has reached up to 330,000 people with emergency food assistance including people taking refuge at UNRWA shelters and public shelters as well as people in hospitals, while people staying with host families receive emergency food vouchers. Prior to the Gaza crisis WFP and UNRWA were already reaching 1.1 million people. This effort has maintained the levels of malnutrition within acceptable limits.

6.3. Livelihood and poverty

In the oPt, one of the most important social determinants for health (in its broad Alma Ata definition) is economic development. Unhindered access to health care, water, sanitation and food is restricted by the blockade in Gaza and the fragmentation and Israeli settlements in the West Bank.

As noted by the World Bank, GDP growth (in the West Bank) has fallen from 9 percent in 2008-11 to 5.9 percent by 2012 and to 1.9 percent in the first half of 2013. “This slowdown has exposed the distorted nature of the economy and its artificial reliance on donor-financed consumption”. As a result, real per capita income in the occupied Palestinian territory declined, and unemployment, poverty and food insecurity worsened.

The delays in releasing the tax revenues collected by Israel on behalf of the PA are challenging stable budget allocations by the MoH, causing shortages of supplies, delays in salary payments and postponements of necessary maintenance and infrastructure investments. This fiscal situation reflects at the household level. High unemployment reduces livelihood, preventing access to health care (referrals require out of pocket contributions), food and clean water.

Some concessions considered by Israel at the time of this survey such as easing the permit process to allow travel for some or possibly authorizing Gaza workers to work in Israel are encouraging but will need to be expanded to enhance development.

7. The role and contribution of the international community

The traditionally high support by the international community for the Palestinian population, both in providing development support and humanitarian aid, has been showing a decrease in the funding commitment over recent years. According to UNDP (2015), the overall external budget support to the PA fell significantly between 2009 and 2014. This decline is affecting the health sector although no disaggregated data by sector were available during the assessment.

The phenomenon is evident in the international support to Gaza reconstruction after the recent conflict during July and August 2014. As highlighted in a recent statement by the Palestinian Minister of Health (Gaza speech March 2015), only a small fraction of the donor pledges and commitments confirmed in the September 2014 Cairo conference have been actually disbursed. The substantial gap between pledges and disbursements is perceived as an additional sign of a partial disengagement of the international community from the oPt.

The main donors for the health sector are Brazil, the European Union, Italy, Korea, Kuwait, Norway, Qatar, Saudi Arabia, Switzerland, Turkey, United Arab Emirates, United Sates of America and World Bank. Some well-targeted health initiatives are particularly valuable in addition to those implemented by WHO and mentioned in the report to the 68th WHA (2015):

• Negotiations to facilitate health worker re-integration in Gaza including a solution to ensure sustainable salary payments (in progress) by the Swiss Government;
• The World Bank grant for remuneration of maintenance and cleaning staff in Gaza hospitals.
• The negotiations with Israel to strengthen transparency and control of Palestinian health authorities to rationalize payments for referral health services charged by Israeli hospitals.

International aid coordination addresses both development and emergency needs. While the UN’s annual appeal (Humanitarian Programme Cycle) has remained a mechanism for responding to immediate humanitarian needs in the oPt, a range of bilateral donors and EC have been focusing also on longer-term investment.

Policy dialogue is continuing within the international community focused on the need to strengthen the role and capacities of the Palestinian Authority in managing and coordinating international aid investments, and to better integrate the Palestinian Authority’s aid management and governance efforts.

The technical assistance needs to further integrate humanitarian and emergency aid into sound and constructive sector-wide planning. There are established complex coordination mechanisms to facilitate further integration: The Health Sector Working Group is the main health coordination mechanism; it is chaired by the Ministry of Health and co-chaired by USAID, with WHO as the technical adviser. The Ministry of Planning and Administrative Development, Austria, Belgium, Italy, the delegation of the European Union, France, Japan, United Kingdom, UNFPA, UNICEF, UNRWA, United States, World Bank are members together with NGOs (Health Work Committee, Palestinian Medical Relief Society).

In summary, the continuous flow of foreign aid is supporting the health sector to minimize the health impact of the occupation, a responsibility normally borne by the occupying power. The more gap filling nature of foreign aid is however no alternative to a full and unrestricted realization of the development potential of the oPt and the long term need to further develop and strengthen the health system.

8. Conclusions and recommendations

8.1.Conclusions

Key determinants of health in Gaza are socio-economic and political in nature, as the lack of a functioning economy has impacted the ability of patients to purchase health care services and medications out of pocket, and seek referrals abroad as transportation to treatment destinations must be paid by the patient, as well as to meet food and nutrition needs

(Health Cluster 2015).

However not all health problems can be attributed to the occupation. Internal Palestinian political disagreements remain to be resolved through high level dialogue and consultation between Ramallah and Gaza. Individual permits to allow access to health care in 2013 and 2014 continued to be denied based on sometimes unclear and unpredictable reasons; rising poverty, increasing frustration and lost hopes have had serious mental health implications. However, some signs of Israeli flexibility are visible. The support provided by the Coordinator of Health and Welfare for the Israeli Civil Administration (operated by COGAT, a unit of the Israeli Ministry of Defence), and praised by most interlocutors, suggests that there are opportunities for more constructive dialogue and cooperation between the Palestinian and the Israeli health sectors.

Checkpoints both limit access to health care and impose stress and humiliation on Palestinians, with effects on their mental health.Photo from Tamer Halaseh’s Weblog.

The World Health Assembly, Resolution 34.38, 1981 stated that “the role of physicians and other health workers in the preservation and promotion of peace is the most significant factor for the attainment of health for all”. It remains true and applicable to oPt and Israel. More efforts to place health considerations above political issues are required. Co-operation and dialogue between the two ministries of health should be further strengthened and promoted by WHO in the interest of public health and as a modest contribution to the peace process. There are precedents to support this approach. TheWHO “Health as a Bridge for Peace” initiatives maintained the dialogue and co-operation between Ministries of Health during the Central American conflicts (1984) and had a positive impact during the Yugoslavia conflict in the 90s. They could serve as model to WHO in the Palestinian Israeli context. An initial step was taken between 2005 and 2008 through the publication of the Bridges magazine featuring news and articles from both oPt and Israel.

8.2.General recommendations

The assessment findings translate into the below general and specific recommendations.

• Donors should sustain and consider increasing their longer term funding commitments for sustainable health system and infrastructure development. The amounts pledged should materialize into actual disbursements.
• The Israeli Health Coordination office should strengthen and expand the support provided in facilitating permits for referrals and developing the capacity of their Palestinian counterparts. Budget and staff should be assigned for this purpose.
• Further consensus and trust building is needed between Gaza and West Bank Palestinian institutions to further strengthen the government of consensus and to overcome political disagreements.
• WHO should consider launching a comprehensive Health as Bridge for Peace initiative to strengthen and promote technical dialogue and operational collaboration between the Palestinian and Israeli health authorities on humanitarian and development health issues.
• WHO/oPt should strengthen its engagement and liaison with the Israeli MoH to enhance advocacy for public health and health priorities in oPt.

8.3.Recommendations for access to health care

These short-term recommendations do not address the underlying causes but may greatly contribute to improve access and reduce tensions:

• The Government of Israel should facilitate the rapid and priority transfer of patients from the West Bank to East Jerusalem by allowing passage and security check of Palestinian ambulances on a priority basis. The “back to back procedure should be formally abandoned.
• The Government of Egypt should consider developing a special mechanism to allow a reopening of the Rafah Border crossing for medical referral of patients from Gaza and for the entry of humanitarian foreign personnel and supplies into Gaza, while respecting Egypt’s legitimate security concerns.
• Donors and the PA should increase there funding allocations for procurement of essential health supplies to avoid unnecessary referrals caused by temporary shortages of medicines.
• Health stakeholders should support analysis and development of strategic plans for investments in specific treatment and diagnostic capacities locally, i.e. radiotherapy or MRI capacity, to reduce the number and cost of referrals.
• Capacity building opportunities for health professionals should be further expanded supported by resources from donors and facilitated by Israel authorities through easing travel permit procedures for health professionals.

8.4.Recommendations for access to health care of prisoners

Based on the principle that adequate medical care should be accessible to all Palestinian prisoners:

• The basic determinants of health – such as appropriate living space and conditions, access to adequate food, visits of parents and relatives – should be guaranteed.
• Diagnostic and treatment services for prisoners including for severe mental health issues should be accessible. Special attention should be given to the needs of detainees with mental health problems, including avoiding the use of solitary confinement.
• Health monitoring should be considered.

8.5.Recommendations on mental health

Improving mental health will require improving of living conditions and service integration and respectful attitude by the occupying power’s security forces:

• Donors and WHO need to continue to support the MoH in sustainable development of mental health services to improve both the quantity and quality of mental health care in oPt.
• Specific investments are needed to reintegrate detainees into society (particularly child detainees) with due focus on both psychological and social aspects.

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