HEALTH CONDITIONS OF THE ARAB POPULATION IN THE OCCUPIED ARAB TERRITORIES, INCLUDING PALESTINE

Transcription

1 (K c;8n WORLD HEALTH ORGANIZATION 该 ORGANISATION MONDIALE DE LA SANTE ^ A43/INF.D0C./5 12 May 1990 FORTY-THIRD WORLD HEALTH ASSEMBLY 4 Agenda item 31 HEALTH CONDITIONS OF THE ARAB POPULATION IN THE OCCUPIED ARAB TERRITORIES, INCLUDING PALESTINE At the request of the delegation of Israel, the Director-General has the honour to transmit to the Forty-third World Health Assembly, for its information, a report by the Ministry of Health of Israel. See Annex.

2 STATE OF ISRAEL MINISTRY OF HEALTH JUDAEA, SAMARIA AMD GAZA April Jerusalem

3 TABLE OF CONTENTS Page 1. Demography and vital statistics 1 2. Socioeconomic conditions 3 3. Primary health care 5 4. Hospital services Manpower and training Sanitation Administration and finance Research International cooperation Planning Summary 49

4 1. DEMOGRAPHY AND VITAL STATISTICS 1.1 Population Density, Gaza, with an area of 362 square kilometers, has a population density of some 1,700 persons per square kilometer, with 52% of the population living in urban areas. There are five main urban centers, including Jebaliah (population thousand), Gaza City (252 thousand), Dir el Balah (97 thousand) Khan Younis (153 thousand), and Rafah (48 thousand) There are 7 refugee settlements located near the main urban areas in the Gaza Strip. Judaea/Samaria includes an area of 5,500 square kilometers, so that the population density is 167 persons per square kilometer. Approximately 30% of the population live in 15 urban areas, 60% in some 450 villages ranging in size from several hundred persons to over 25,000, and 10% in 18 refugee settlements. 1.2 Population Growth The population of Judaea/Samaria and Gaza continue to grow at high rates due to the high birth rates, and reduced infant, child and crude mortality rates. It is also affected by changing migration patterns in the area. The population is young, with some 47% of the total between the ages of 0-14 years. ч Data is from the Central Bureau of Statistics, except that for 1989 which are preliminary from the Civil Administration in each area. Population data for Judaea/Samaria and Gaza, along with rate of annual growth are shown in the following Tables (1 and 2) Table 1: Population in Judaea/Samaria # and Gaza, Population/ Year * Judaea/Samaria Gaza * * 1989 data, preliminary estimates of the Civil Administration. Note: The population for 1989 in Gaza is based on a recent registry of population, and excludes those with residential status who have lived abroad for more than 6 years.

5 Table 2 : Percentage Annual Growth, Judaea/Samaria and Gaza, % annual growth/ Year * Judaea/Samaria Gaza * 1989 data, preliminary estimates of the Civil Administration. 1.3 Fertility Births, birth rates and location of births are seen in the following Tables (3 and 4), as well as the % of births taking place in medical facilities. The total number of births in Judaea/Samaria has increased steadily over the years, but the birth rate has declined, from 45.4/1000 population in 1975 to 38.6 in There was a slight rise in the birth rate from 1988 (37.2) to 1989 (38.6), representing some 2000 additional births, while the number of births in medical facilities remained the same. Table 3: Births (000 1 s); and Birth Rates, Judaea/Samaria, Judaea/Samaria/ Year f Total births (000 f s) Birth rate/1000 population , % born in medical ". facilities 15.0 : , Births in Gaza also increased in 1989, and the birth rate remains over 45/1000 population. Births in medical facilities has increased over the years f from 10% in 1970 to over 63&% in The number of medical center deliveries increased slightly in 1989, but as there was a nearly 2000 increase in total births, the % born in medical facilities decreased from 1988 to 1989.

6 Table 4: Births, and Birth Rates. Gaza Gaza/Year Total births (000's) 16.0, Birth rate/1000 population % born in medical facilities Note: Data for 1970 includes hospital deliveries only; data from 1975 includes hospital and medically supervised delivery units. Data for 1989 is preliminary. 2. SOCIOECONOMIC CONDITIONS 2.1 GNP per Capita Economic conditions showed dramatic increases in gross national product per capita over the years 1968 to 1987; data for the period are shown in Table 5 (in US $). Economic indicators for the years suggest an economic adverse effect of the political situation, with effects on family disposable income and economic activity in general. Table 5: Gross Domestic Product. Judaea/Samaria and Gaza, in ÜS $ Years " Judaea/Samaria $410 ^ " Gaza Judaea/Samaria have reached per capital GNP levels within the "middle level of development" ie. over $1500 GNP per capita; Gaza is close to that category.

7 2.2 Economic Development Economic development has been based on full employment f improved agricultural productivity, business and service industries and small scale industrial development. During the period recurrent general and commercial strikes and disturbances have adversely affected the local economic situation, including business activity and family incomes. 2.3 Education Education has been compulsory to the age of 14 for both sexes for the past 15 years which has been associated with a rapid expansion of the network of schools, literacy rates and enrollment in the many new post secondary education facilities opened over the past 20 years. In Judaea/Samaria over 60% of the total population aged 18-24, and over 42% of those in the age group have 9 or more years of education. Educational levels are higher in Gaza, 63% of those in the age group and 61% of those in the group having 9 or more years of education During the education system has been disrupted by strikes, disorders and administrative closures. Table 6: Home Facilities in Judaea/Samaria and Gaza, 1972, 1981 and 1985 Area/ Years Judaea/Samaria Electricity 24 hours/day part time Running water in dwelling TV set Gas/electric cooking range Gaza Electricity 24 hours/day Running water in dwelling 13.9 TV set Gas/electric cooking range

8 2.4 Home Facilities Changes in living conditions are shown in the Table 6 regarding percentage of homes with specific facilities. 2.5 Living Standards Living standards for most residents of Judaea/Samaria and Gaza have risen as family income, nutrition, housing conditions, electrification, safe water supplies, roads and transportation have improved. Table 7 indicates changes for the population of Judaea/Samaria and Gaza in terms of food value in calories per capita. Table 7 : Calories per Capita in Food Supply^ Judaea/Samaria and Gaza Calories/caoita/Years Judaea/Samaria Gaza Housing The following table (Table 8) indicates changes in living standard for the population of Judaea/Samaria and Gaza, as indicated by percentages of homes with less than three persons per room. Table 8: Homes with Less Than Three Persons Per Room, Judaea/Samaria and Gaza, Area Judaea/Samaria Gaza PRIMARY HEALTH CARE 3.1 Program Priorities Emphasis in the Israel government health services in Judaea/Samaria and Gaza has over the years been placed on developing primary health care with the following priorities:

9 3.1.1 Expanded program Sanitation of immunization (EPI); garbage disposal, -safe water supply and chlorination f -sewage collection, -food safety; Hospital or medical center deliveries; Oral rehydration (ORS) for diarrhoeal diseases? Primary health care located close to the population; Health education/community involvement; Growth monitoring and nutrition education; Screening for congenital diseases (PKU and hypothyroidism); School health? Supervision and training of traditional birth attendants (Dayas); High risk pregnancy identification, referral, followup; Expanded primary health care in small villages - the Hebron project; Control of infectious diseases; Control of non-infectious diseases. 3.2 Primary Health Care Services Primary health care facilities established and operated by the Government Health Services of the Israeli administration in Judaea/Samaria and Gaza are shown in Table 9... Table 9 : Primary Care Facilities Operated by the Government Health Services in Judaea/Samaria and Gaza, Area Judaea/Samaria General clinics MCH Centers 25, Village Health Rooms Specialized Clinics NA Gaza Community Clinics

10 In Gaza, UNRWA operates 9 Health Centers, providing MCH and some other primary health care services. The government health service operates 27 Community Health Centers which provide immunization and well child care services, as well as treatment services. Twenty-two of the centers now provide pre- and post-natal care with an obstetrician in attendance. Three of the Community Health Centers operated by the government health service in Gaza operate delivery units on a 24 hour per day basis, and three additional centers are to open delivery units over the next several years. Six of the Centers work an afternoon shift and 24 hour emergency service. Four of the Centers operate ambulance services in different areas of the Gaza Strip. Services in these Community Health Centers are free of charge for children up to age 3, and for prenatal care.all services are free of charge for those with government health insurance. MCH Centers operated by the government health service in Judaea/Samaria provide free immunization and well child care services as well as free pregnancy care. General clinics provide treatment services, free for children up to age 3, and for persons with health insurance. Those without health insurance are treated with modest fees charged. Current planning for primary health care in Gaza calls for 32 Community Health Centers each serving a population of about 25,000 persons. Each will include MCH services, a Family Care Unit, a Pharmacy, and a consultation clinic for certain specialty out-patient services. Twenty of the Health Centers will have small laboratories, and the six with delivery centers will have minor X-ray units. 3.3 Control of Childhood Infectious Diseases Immunization for the major childhood diseases has resulted in increasing control of elimination of these diseases, as shown in the attack rates for these diseases in the following tables (in case rates per 100,000 population) г " Diphtheria f pertussis, tetanus and polio have been largely controlled or virtually disappeared. Measles still occurs in outbreaks, but with a steep overall decline. Major outbreaks of measles occurred in 1975, 1979, 1982, and An outbreak is expected during , and a mass immunization campaign among preschool and school aged children is planned for the fall of 1990, along with the introduction of routine immunization with MMR at 15 months and 7 years of age. - Gastroenteric and parasitic disease is still prevalent, particularly in Gaza due to the sanitary conditions, especially in the refugee settlements, although these are much less as causes of morbidity, hospitalization and mortality than in previous years.

11 Judaea/Samaria Gaza Table 10: Infectious Diseases Rates (per Population) Reported in Judaea/Samaria and Gaza, Rates 1989 Disease/Year No. Rate Diphtheria Pertussis Tetanus (adult) Polio Measles Diphtheria О 0.2 Pertussis О Tetanus (adult & neonate) Polio Measles X 13 о Immunization Program The routine immunization schedules used in Judaea/Samaria and Gaza have recently been modified following extensive discussions and consultations with local and international experts in this field. Table 11: Immunization Program for Infants. Judaea/Samaria. Age (Months) 2 3^5 5 6_, D'PT elpv DPT elpv TOPV DPT TOPV TOPV DPT elpv TOPV MMR Table 12: Immunization Program for Infants, Gaza, 3 Age (Months) 1 2 3_=_ _ 15 BCG - OPV(I) TOPV - elpv - DPT TOPV TOPV TOPV TOPV elpv - - DPT DPT - DPT - - M MMR

12 Table 13: School Age Immunization Procrranu Judaea/Samaria and Gaza Age (years) 一 Vaccine DT - TT TOPV - TOPV MMR Measles* Measles* BCG G.Measles - Note: * - See measles campaign below. DPT= Diphtheria, Pertussis, Tetanus TOPV= Triple Oral Polio Vaccine (Sabin) eipv= Enhanced Inactivated Polio Vaccine (Salk) MMR= Measles, Mumps Rubella M= Measles BCG= Bacillus Calmette-Guerin (ТВ) TT= Tetanus Toxoid 3.6 Special Immunization Programs Hepatitis В Vaccine for Newborn Carriers This was introduced in Judaea/Samaria government health services in Pregnant women are tested during prenatal care for the presence of Hepatitis В antibodies. The vaccine is given to a newborn whose mother is found to have antibodies to HB virus during pregnancy or who has known to have had Hepatitis B. In such cases the husband is checked for HB antibodies, and if these are lacking, he too is immunized with Hepatitis В vaccine Hepatitis В Vaccination of Health Workers Hospital employees in Judaea/Samaria, particularly those working with blood products such as in laboratories, blood banks, operating rooms, dialysis and intensive care units, emergency rooms and delivery rooms, are given prophylactic immunization with Hepatitis В vaccine Meningococcal A Vaccine This vaccine is given to pilgrims making the pilgrimage to Saudi Arabia 10 days prior to departure Measles A second dose catch-up campaign will be conducted during in order to cover children between the ages of 2 to 17 years of age. This campaign is designed to improve the coverage and to move toward total control and eradication of measles in the area.

13 3.7 Antibody Serosurveys Serosurvey results of two separate random sample studies of school children aged 7-9 years in Judaea/Samaria are seen in Table 14, showing the percentage of persons in the samples with protective antibody levels. Table 14 : Circulating Antibodies Determined in Serosurveys in Schoolchildren Aged 6-7 Years in Judaea/Samaria Polio Year (I, II, III) Measles Rubella Tetanus (types I,II and III) In a 1987 serosurvey among a representative sample of 14 year old school girls in Judaea/Samaria, rubella antibodies were found at a protective level found in 100%, and hepatitis A antibodies in 100%. Following the serosurveys, a number of changes have been made in the immunization schedule. A polio serosurvey for children at various ages is planned for Poliomyelitis During 1988 an outbreak of poliomyelitis occurred in Israel mainly in one subdistrict where enhanced IPV was used exclusively for 6 years; a total of 15 cases occurred among persons with OPV only as their previous immunization. r,,. A mass immunization campaign with OPV was carried out in October 1988 on everyone aged 0 to 4 0 in Israel, as well as in Judaea/Samaria and Gaza. In this campaign, 798 thousand persons were immunized in Judaea/Samaria in a large number of immunization centers The success of these campaigns organized by the Government Health Service involved the participation of all health and many other agencies, as well as the general public. The combined OPV/IPV polio immunization program carried out over the past ten years was recently reported in a leading journal of public health.

14 3.9 Tuberculosis Tuberculosis has generally declined as seen in the following Table (15), with a greater decline in Gaza. A review of current preventive and diagnostic services for ТВ is currently under discussion in Gaza, with regard to the role of BCG in ТВ control, since Gaza has not had miliary or meningeal ТВ among children over the past 15 years. Data since 1979 for Gaza does not include population from the Sinai. Table 15: Tuberculosis Incidence Rates. Judaea/Samaria and Gaza Year Judaea/Samaria Cases Rates 108 NA Gaza Cases Rates Note: Rates per 100,000 population 3.10 Deliveries in Medical Institutions Hospital and medical center deliveries as a percentage of total deliveries in Judaea/Samaria and Gaza has increased steadily over the years, from 15% to 62% in Judaea/Samaria, and from 10% to 80% in Gaza from 1970 to 1988 (see section 1.3). During 1989 there was an increase in total births and a slight decline in the number of births in medical facilities, so that the of the latter declined Birth Weights Birth weights are recorded for children born in government hospitals or other medical facilities. The following Table shows the percentage born with birth weight less than 2,500 grams (LBW). Table 16: Birth Weights of Newborns in Government Hospitals/Medical Facilities Years Judaea/Samaria Gaza

15 The small increase in percentage of LBW reflects the increase of percentage of births taking place in hospitals or medical facilities, and fertility pattern changes Growth of Infants Studies of growth patterns of infants and school children carried out in Judaea/Samaria showed some differences with patterns of the US National Center for Health Statistics (NCHS) infants sample, but with variation according to socioeconomic level, breast feeding patterns, and urban versus rural residence. No differences were seen in growth patterns between male and female children aged 0-2 in studies in Judaea/Samaria and Gaza. Breastfed had growth advantage over non-breast fed in the first year, and urban children showed advantage in growth over rural children. A random sample of school children studied in 1987 in Gaza showed patterns similar to the NCHS pattern, albeit with a wider standard deviation both above and below the NCHS pattern. Growth monitoring is receiving increasing stress in the Government Health Services in Judaea/Samaria and Gaza as an essential part of routine well child care, accompanied by nutritional education of mothers. i «New well child care records have been adopted in the government health í services in both Judaea/Samaria and Gaza for use in community clinics f MCH centers and Village Health Rooms. Emphasis has been placed on the subject of infant nutrition in staff training and maternal health educational programs Infant Mortality Infant mortality has declined very rapidly in the Gaza area as the childhood infectious ánd diarrhoeal diseases are brought under control through successful immunization and ORS programs. Increased hospital and medical center deliveries as well as rising educational and socioeconomic standards have contributed to this improvement. In Gaza infant mortality has declined from 86/1000 in 1970 to under 25 in In Judaea/Samaria infant mortality rates have declined, but the rates are more difficult to determine, particularly during the 1970s, since most births occurred at home and some early neonatal deaths are unreported. Improved reporting and follow up systems as well as increasing hospital deliveries have substantially increased the reliability of infant mortality in the 1980 f s.

16 A recent visit by a WHO consultant in perinatal epidemiology suggested methods of improving reporting and data analysis in infant mortality. Table 17 shows reported infant mortality trends in rates per 1000 live births based on reported cases. Table 17: Reported Infant Mortality Rates, Judaea/Samaria and Gaza, Area/Year Judaea/Samaria Gaza Note : Reported deaths per 1000 live births. In both areas the Health Services Research Centers are conducting studies of infant deaths as to direct and indirect contributing factors, cause and location of deaths. As a result of this work, routine investigation of infant deaths is now being carried out by the public health service program in each area. A 1989 study of infant mortality in the refugee camp population in Judaea/Samaria showed a decline in infant mortality from 83.7/1000 live births in 1975 to 48.5 in 1980, 35.8 in 1985 and 27.3 in Child and Adult Mortality Overall mortality for infants, children trend in Judaea/Samaria is shown from a seen in Table 18. and young adults by age growth as a study for the period are Table 18: Mortality rates for..ages up to 44 ^ Judaea/Samaria 一 Age Note: Rates per 100,000 population

17 Changing patterns of morbidity and mortality have reduced the former leading role of infectious disease and increased the prominence of heart disease, cancer, strokes and accidents as the major causes of death. This requires the greater stress on reduced smoking, lesser use of fatty foods, and other self care features that are being introduced into school and health education programs Diabetes Mellitus Three Diabetic Clinics have been established in Tulkarem and Nablus Public Health Offices, and in Kalkilya over the past two years. These were established and are operated under the supervision of a local public health staff member following his return from specialization in this subject in Glasgow, Scotland. The clinics are staffed by specialized nurses to supervise the follow up of diabetics, under the supervision of a diabetologist. Health education for diabetics is emphasized. This includes diet, hygiene, medication, self care and self evaluation. Protocols for care of diabetics in hospital are under development and staff training programs are being carried out. Health education material on diabetes is also being prepared. An epidemiologic survey of diabetes is under preparation Rehabilitation Services., Judaea/Samaria A Rehabilitation and Physical Therapy Center has been approved by the Civil Administration for Bet Jallah, to be operated by the Friends of the Sick Society. This center will develop in stages, with the opening of ambulatory services during The center is planned for a 100 bed capacity. It is funded jointly by the Government of Italy, the CDF, and UNDP. A 30 bed rehabilitation center is being funded by the Government of Sweden for operation by thé Swedish organization Diakonia. A building in Ramallah is being renovated for this purpose) and the center will become operational for out-patient care during 1990., 3.17 Expanded Primary Health Care (EPHC) Hebron Project Expansion of Primary Health Care (EPHC) in Judaea/Samaria was undertaken as a special project by the government health service, in conjunction with UNICEF in Hebron District. Thirty-three government MCH centers provide prenatal and well child care coverage for the 120 villages and one city in Hebron District.

18 Primary health care in these small villages was limited to childhood / immunization, and other services required travelling to the nearest MCH center or Community Clinic. Immunization of infants and school children in the small villages was carried out by visiting immunization teams (initially by sanitarians then later by public health nurses) on a 6 weekly visit schedule. The EPHC project was formulated in order to extend primary care to the small villages in the district. It established Village Health Rooms (VHR 1 s) in villages with populations of an average 800 persons which requested the service and provided the VHR. They are staffed by a trained Village Health Worker (VHW). During 1985 a pilot phase was carried out in 4 villages. This included an 6 month training program for local village high school graduates, preparation health records and carrying a household health survey in all the homes in the villages. In 1986, a further 20 VHR 1 s were opened following the six months training program of VHW 1 s, and in 1987 a further 25 VHR 1 s were opened. Currently 50 VHR 1 s are providing a broad range of preventive health activities in the villages. These include: * a household survey in all homes in the village * preparing a demographic map of the village; * registration of births and deaths as well as all infants and pregnant women; * pregnancy care - coordinating/assisting the visiting doctor/ nurse team, as well as high risk pregnancy identification/ referral ;. * well child care - coordinating/assisting the visiting doctor/ nurse team? * coordination and follow-up of immunization of infants, primary schoolchildren, and pregnant women; * nutrition monitoring and intervention in cases of Failure to Thrive (FTT) ; ". * health education - re: pregnancy, child care, nutrition,immunizations, ORS, sanitation and hygiene, breast self examination, and heart disease risk factors * coordinating visits by the public health team; * referrals to district hospital emergency room; * coordinate with Mukhtars re: sanitation, emergency transportation?. * visiting all newborns at home; * visiting the sick - environmental health f water monitoring. Other health issues are being added including preventive dental health, screening for heart disease risk factors, teaching women breast self-examination, and supervision of water and other sanitation in the village.

19 Planning is underway to expand this project to other areas in Judaea/Samaria. Proposals for this expansion have been submitted to various funding agencies; WHO is currently considering a proposal to fund this project for the Jordan Valley. Evaluation of the project is being carried out by the Hebron Public Health Office, and the Ramallah Health Services Research Center, in consultation with the academic staff of the School of Public Health, Hadassah-Hebrew University in Jerusalem. Preliminary results of data analysis show a substantial impact on pregnancy care and well child care. Follow-up studies will be carried out to monitor the effectiveness of the project. In the villages where the VHR 1 s are operational, virtually all of the pregnant women are participating in prenatal and well child care, with an increasing tendency to go to the district hospital for deliveries. Over 1,500 pregnancies and 3,000 infants under care have been completed to date Traditional Birth Attendants There are some 400 traditional birth attendants (TBAs or Dayas) in Judaea/Samaria, and over 90 in Gaza. They carry out home deliveries, but do not provide prenatal care. Supervision and training of traditional birth attendants (Dayas) has been given strong emphasis in recent years. The Government Health Service in Judaea/Samaria appointed senior nurses as Supervisors of Dayas in each of the Districts. They maintain contact with the Dayas in the district; this includes regular visits to the villages, inspection of equipment, ensuring registration of births and deaths, supervision of training of new Dayas, and conducting of study days. The Dayas supervisors visit the homes of newborns delivered by the Dayas as soon as possible following birth. During 1987 a special project of continuing education for Dayas and their supervisors was carried out both in Judaea/Samaria and Gaza, with assistance of UNICEF, rwhich also provided new kits for Dayas who successfully completed a program of study days. Continuing education for Dayas was expanded both in Judaea/Samaria and in Gaza during In Judaea/Samaria, a further program of Dayas training was carried out at the end of This involved 16 senior public health nurses and Daya Supervisors, as well as 40 qualified midwives and 100 Dayas. The program was sponsored by the government health service with UNICEF support and assistance School Health Immunization of school children is carried out in primary schools, in both areas. Health examinations of primary school children is carried out in Judaea/Samaria. School health services are being reviewed as part of a

20 study of primary care services, and improved procedures for public health supervision of school hygiene and student health are being developed. In Judaea/Samaria, school health services are provided to some 280,000 students, and includes the following; * general medical examination of pupils entering first year primary school, including assessment of immunization status? * vaccination for: -DT and BCG (after Mantox testing); -Rubella for 3rd year elementary class girls (until 1995, )r as MMR has been given since 1987); -Tetanus Toxoid (2 doses) to third elementary class? -OPV to be given to primary school entry pupils and to 15-year olds; * surveillance of infectious disease among students ; * supervision of hygiene in schools; * health education working with the teaching staff to introduce health studies in the classroom work Oral Rehydratión Salts ORS is now used throughout the Government Health Services primary care centers in Judaea/Samaria and Gaza. This, in conjunction with improving standards of sanitation f hygiene and nutrition, has resulted in a dramatic decline in mortality, hospitalization and serious morbidity from diarrhoea] disease particularly in infants and children. ORS is well accepted and understood by the population as a result of extensive television coverage and health education work in the government and UNRWA health services PKU and Hypothyroidism Screening Screening of newborns.for Phenylketonuria (PKU) and Hypothyroidism was started in Judaea/Samaria government,, health services in 1987 in cooperation with Sheba Medical Center f Tel Hashdmer. In this project, infants born in hospital are tested while in the hospital, or in the local MCH center up to 2 weeks after birth. Infants born at home are referred by the Dayas to the nearest MCH center, or Village Health Room for this test within the first week of life. Suspected cases of these serious congenital disorders are referred to specialty centers at the Child Development Center at Tel Hashomer (for PKU) and local hospitals (for hypothyroidism) for assessment, treatment and follow-up. Confirmed PKU cases receive free supplies of the special foods that are required to prevent serious mental retardation from the government health service.

21 During 1989, 9,078 newborns in Judaea/Samaria were screened for PKU and hypothyroidism during the first 7-10 days of life. Two cases of PKU were identified and confirmed then placed on treatment. Three confirmed cases of neonatal hypothyroidism were identified and placed on treatment. Staff and maternal acceptance of this program has been good during the first year of its introduction. Gaza is preparing to introduce this screening program Vitamins and Iron Vitamins A and D and iron are provided routinely to all infants attending government health centers in Judaea/Samaria and Gaza. Vitamin К injections are given to all newborns in government facilities for prevention of hemorrhagic disease of the newborn. Iron and folate are given routinely to pregnant women attending government health services for prenatal care, for prevention of iron deficiency anemia. The Gaza Health Services Research Center is carrying out studies of the current prevalence of anemia among pregnant women and 12 month old infants. 3,23 High Risk Pregnancy Care High risk pregnancy screening, referral, and follow up systems were developed in the Government Health Service in Judaea/Samaria during High Risk Pregnancy committees were established in all districts, and High Risk Pregnancy Clinics developed in district Public Health Offices and district hospitals. During 1988 this program developed further, and the High Risk Referral forms, guidelines and orientation were carried out for all MCH and village health room staff. Adoption of new pregnancy care records during 1988 helped to increase staff consciousness of high risk pregnancy factors and care. In Judaea/Samaria, 8 High Risk Pregnancy Clinics were opened in 1988, and systematic referral, investigation and follow up began. This program is under surveillance of the High Risk Pregnancy Committee. In Gaza, a High Risk Pregnancy program is also being implemented in the Government Health Services with the establishment of 2 High Risk Pregnancy Clinics, and development of referral systems. Of 27 community health centers, 20 provide prenatal care, including high risk referral' and followup. The High Risk Pregnancy Committee is active in reviewing the function of the centers, defining deficiencies in the service, and monitoring the referrals follow-up. In late 1988, Dr.Brian McCarthy, Director of the Center for Perinatal Epidemiology at the Center for Disease Control, Atlanta, a WHO Collaborating Center, visited the area to review the high risk pregnancy

22 programs f and the role of the Gaza and Ramallah WHO Collaborating Centers in Primary Health Care Research. Dr. McCarthy 1 s visit provided encouragement and stimulation of the staff and policy level personnel in developing these programs as essential, integral parts of the government health service, including family planning. He also provided valuable technical and professional advice to the programs, including use of computers for program analysis AIDS Two cases of AIDS were diagnosed in Judaea/Samaria All blood donations are routinely tested for AIDS, Beit Jallah, Hebron and Gaza hospital blood banks. in 1988, both imported, in Nablus, Ramallah, Screening of donated bloods in Gaza has revealed a number of false positive samples which were negative on confirmatory testing in cooperation with, Israel's Central Blood Bank operatedy(magen David Adom, the Red Star of /Wtj David, at Sheba Medical Center, Tel Hashomer Brucellosis Brucellosis has again become a major public health problem in Judaea/Samaria, with the number of reported cases peaking in 1988, with a small decline in Gaza has also experienced an increase in Brucellosis cases, from 115 in 1988 to 367 in The Veterinary Service of the Department of Agriculture in cooperation with the government health services of the civil administration is expanding its immunization and surveying of flocks for infected animals. A four year program for control and eradication of Brucellosis will commence in May The first stage of this project will be a pilot project in two villages in Hebron District. An estimated 5000 sheep and goats will be marked and bloods taken for laboratory testing to identify those infected with Brucellosis. Infected animals will be slaughtered at municipal slaughterhouses, and the owners compensated for between % of current market value of the animal. Laboratory staff (4) are currently undergoing training for this project in Bet Dagan Veterinary Research Institute in Israel 2-3 days per week. Following completion and evaluation of the pilot project, the program will be expanded to all villages in Hebron, Bethlehem and Jericho Districts. The veterinarian/sanitarian teams visiting the villages will develop the program based on the experience of the pilot phase A Brucellosis education program is being carried out by public health offices with a focus on medical staff, and the general public. Random samples of milk products are tested for Brucella.

23 The incidence of human cases of Brucellosis among humans in the Judaea/Samaria is seen in Table 19. Table 19: Brucellosis? Reported Cases and Incidence Rates, Judaea/Samaria, Years No Rate Note: Reported cases and rates per 100,000 population The key issues which seem to require urgent attention control, and eradication are as follows; for Brucellosis * health education to promote use of safe milk products; * testing and slaughter of infected animals; * immunization of animal flocks ; * epidemiologic studies. Gaza has also experienced a recent increase in cases of Brucellosis Supervision of Drug Manufacture There are seven local pharmaceutical manufacturers in Judaea/Samaria. The Government Health Service supervises the quality of the manufacture using standard "good manufacturing practice" criteria. Tests on these and cosmetic products are carried out by the Israeli Ministry of Health Institute for Medical Standards. The Government Health Service purchases local products very extensively Ambulance Services Ambulance services have developed substantially over the past several years. Table 20 shows the ambulance services currently operating, not including vehicles used for administrative and non-urgent patient transportation. vu- In Gaza the Benevolent Society opened its well equipped ambulance center in Gaza City with 5 fully modern ambulances and a cadre of drivers trained by Magen David Adom. The first MDA course for Gaza ambulance drivers produced 25 qualified drivers in 1989, and a second course for 25 will be held in Additional ambulance stations are to be opened in Jabalyah (5 units), the Eastern Villages (3 units), Khan Younis (5 units), and in Rafah (5 units).

24 Driver training will be continued with Magen David Adorn in Ashkelon, including classroom and practical experience. Five courses for ambulance drivers have been held in Jerusalem by Magen David Adorn for all agencies operating ambulances in Judaea/Samaria over the past 2 years, with a total of 82 graduates completing the training. Drivers participating in these courses have come from many health care organizations, including UNRWA, the Red Crescent, Patients Friends Societies f as well as from the government health services. Table 20: Ambulance Services in Judaea/Samaria and Gaza, 1989 Agency/Area Judaea/Samaria Gaza Gov't hospitals 8 12 Non-Gov 1 t hospitals 3 3 Red Crescent Society 15 5 Cities/municipalities 9 一 Patient's Friends Societies 4 5 UNRWA 2 10 Total Epidemiology The health department in Judaea/Samaria established an Epidemiology Department in 1989 as part of the Public Health Division. This unit is staffed by three of the physicians (part-time) who completed public health MPH training at the School of Public Health at Hadassah-Hebrew University, and have since had further courses in epidemiology at Edinburgh University, Beersheva University and the Center for Disease Control in Atlanta. 4. HOSPITAL SERVICES Introduction :: The hospital services in both areas are primarily operated by the government health services. Non-government hospitals also serve the population. The hospitals in both sectors have advanced in terras of facilities, professional and support services over the years by adding new departments and diagnostic equipment, as well as improved professional training. 4.2 Hospital Facilities in Judaea/Samaria Judaea/Samaria government hospital service facilities are outlined in Table 21, for the year 1989, and as projected in current master plans for government hospitals :

25 1. 二 Table and Projected Hospital Beds, Judaea/Samaria. Government 1989 Projected Hospitals Beds Beds* Jenin Tulkarem Nablus-Watanee Nablus-Rafidia Ramallah Beit Jallah Jericho Hebron Total Mental Hospital Bethlehem Grand Total Non-Government Hospitals 1989 Beds Shifa, Jenin 10 UNRWA f Kalkilia 36 Al Ittihad, Nablus. 90 Evangelical Mission, Nablus 53 Mt. David Orthopedic, Bethlehem 50 Caritas Children 1 s Hospital, Bethlehem 79 Red Crescent Pediatric Hosp., Hebron 30 Total 348 Private Maternity ** 52 Grand Total 400 Total Acute Care Hospital Beds, Judaea/Samaria 1989 Government Acute Care Beds 682 Non-Government Acute Care Beds 400 Total 1082 Projected beds are based on current planning for the mid-1990s. A new private hospital, the Holy Family, opened in Bethlehem in January 1990, with 28 obstetrics and gynecology beds, as well as 3 incubators.

26 4.3 Hospital Facilities in Gaza Gaza hospital facilities are outlined in the following table based on current master plans: Table 22: Hospital Beds in Gaza, Projected I 广 Government Hospitals* El Ahli (private) El Bureij Tuberculosis Conversion. (government and UNRWA) " ' w-oi ' ^ v : ' : ' ' : ~ : ). ; ' to Chronic Care Total Note: Government hospitals include Shifa, the Children 1 s f the Ophthalmic and the Psychiatric Hospitals in Gaza City, and the Khan Younis Hospital serving the southern portion of the Gaza Strip. Planning for hospital services for the year 2000 is based on an estimated population of 1 million, with some 40% under the age of 14 years. This plan provides for the hospital services as in Table 23. Table 23: Projected Acute Care Hospitals and Beds, Gaza Strip, 2000 Hospital Location Beds Shifa North Hospital Central Hospital Khan Younis Ahli Gaza City 660 Jabalyah 220 Central area 200 Southern area 400 Gaza City 100 Total 1580 In this plan, Shifa Hospital will be the tertiary care and referral center for the Gaza Strip, and will include pediatric, ophthalmic, psychiatric hospitals, as well as specialized services such as cardiac surgery, pediatric surgery, neurosurgery and others. The new Northern and Central Hospitals may be operated by private f non-profit agencies, but as part of the overall health program for the area.

27 5938Jj y 4.4 Utilization of Hospital Care in Judaea/Samaria Utilization of acute hospital care in local hospitals (both government and non-government) is shown in Table 16. Occupancy rates have remained under 65%, while average length of stay has gone down, while the number of surgical procedures has increased. The total number of admissions, and days of care per 1000 population have decreased reflecting both improved levels of health in lesser morbidity from childhood and infectious diseases particularly, as well as lack of universal health insurance coverage. Table 24: Hospital Utilization, Judaea/Samaria, Utilization/Years Admissions per 1000 population Days of care per Average Length of Stay Surgical procedures per Occupancy rate (%) Hospital Utilization in Gaza Hospital utilization has declined in Gaza as a result of changing morbidity patterns, as well as the lack of universal health insurance. Table Hospital Utilization, Gaza, Utilization/Years Admissions per 1000 population Days of care per 1000 Average Length of Stay Surgical procedures per 1000 Occupancy rate (%) 4.6 Referral to Hospitals in Israel Hospitalization of referred patients to hospitals in Israel for inpatient and outpatient services is concentrated on services not available locally. This includes services in the following specialty areas? radiotherapy, hematologic oncology f pediatric nephrology, pediatric urology, complicated neurosurgery, pediatric, infant and respiratory intensive burn cases and others. The government health service referrals to Israeli hospitals in 1988 involved 649 cases, and in 1989, 625 cases.

28 Referrals for ambulatory diagnostic and day hospital care services in many specialty areas for specialized services not available locally is also carried out. As new specialty departments develop locally, services in these specialty areas do not need to be routinely referred as in the past, as in the case of open heart surgery and some neurosurgery, which are now available in Ramallah Hospital. 4.7 Hospital Development in Judaea/Samaria л Master plans for the development of all government hospitals were completed during 1986/87. This has led to improved integration of planning with implementation. Hospital projects completed or in implementation in Judaea/Samaria during the period include the following: Rafidiah Hospital, Nablus Radiology Center, 1987 Out-patient Department, 1988 New Wing- in final stages of construction, to be completed in 1990 includes: Emergency Room Physiotherapy Pharmacy Administration Doctor 1 s residence New Section - with planning completed, is ready for construction, includes : Laboratories Kitchen Dining Room Medical Records Wattanee Hospital, Nablus Intensive care unit, Ramallah Hospital Diagnostic Radiology Center, 1985 Elevator and central heating, 1985 Neonatal and premature intensive care unit, 1986 Surgical suite, 1987 Open heart surgery department, 1987 Coronary care unit, 1987 Recovery room, 1988 Emergency room - equipped and operational in 1988 Outpatient department Neurosurgery department 一 operational, 1988

29 CT scan - operational Digital Fluoroscopy - operational, 1988 Peritoneal dialysis (CAPD) - operational r 1988 New operating theater and recovery room in construction New sewage system - completed, 1988 New electrical system - in construction New Outpatient Department - completed 1989 New CT/X-ray/Heart Institute Building - to be completed 1990 Hospital entrance, bridge connectors and elevator tower - construction during Beit Jallah Hospital Emergency and Outpatient Department, 1984 Radiology Center, 1987 New Wing-to be built with the assistance of the Government of Italy commencing in 1990 will include the following; Neonatal Intensive Care Unit Pediatrics Department Central Supply Delivery Suite Newborns Unit Elevators Operating room suite Electro-mechanical floor Sewage treatment plant - under construction currently, with funding by the Swedish-Jerusalem Society Hebron Hospital Central Sterile Supply Department - equipped and operational, 1988 Surgical suite/operating theatres, 1987/88 Service elevator r 1987 Radiology Department, completed and operational, 1988 Outpatient and Laboratory Wing - equipped and operational, 1988 Recovery room, 1988 New North Wing - planning coispleted; his wing will include; Emergency Room Delivery Suite ICU Phys iotherapy Pharmacy Kitchen Dining Room - Storeroom New East Wing- to be built with the assistance of the Government of Italy - planning completed, and construction to begin in 1990; this wing will include ; New out-patient department, Cardiac Institute New surgical department - Laboratories

30 4.7.6 Bethlehem Mental Hospital Chronic care department (male) - completed and operation, 1986 New Chronic and Acute Departments (for males), planning completed Government of Italy Hospital Development Projects The Government of Italy is working with the Government Health Services in Judaea/Samaria on hospital development and projects in both government and non-government hospitals. This includes major construction and equipment projects at the Beit Jallah and Hebron government hospitals, as well as at the Ittihad non-government hospital. The cost of these projects will be a total of $7.5 million; A further $1 million will be spent on providing modern equipment for hospital laboratories in Judaea/Samaria World Health Organization Projects in Judaea/Samaria Representatives of the WHO who recently visited the area proposed that WHO fund the development of important health projects in Rafidiah, Ramallah and Hebron and in some private hospitals. The projects selected include: intensive care units, a burn unit, a histo-pathology laboratory, as well as some staff training projects in government hospitals and funding of an Expanded Primary Health Care project in the Jordan Valley Private Voluntary Organization Hospital Projects The Red Crescent has recently opened a 30 bed children 1 s hospital in Hebron. The Patients Friends Society in Hebron is currently building a 300 bed hospital in Hebron, which will be opened in stages f commencing with the Emergency Room in The Patients Friends Society in Ranj^llah is developing a Rehabilitation Center. The first stage of the project is the Out-Patient Department to be opened in 1990 with staffing by a specialized team from Sweden, which will include medical, physiotherapy f and occupational health personnel. The Friends of the Handicapped Society in Bethlehem have recently opened a new medical and occupational health center in Bet Jallah. The occupational health unit is now in operation. This center is planned to reach 100 bed capacity. 4.8 Hospital Development in Gaza Hospitals Projects completed or in implementation in Gaza during, period include the following:

31 4.8.1 Shifa Hospital, Gaza City Obstetrical Department (100 beds), 1986 Radiology center, 1987 Neonatal Intensive Care Unit, 1987 Dialysis department 一 completely renovated in 1989 Building 8 - with new surgical, gynecology and orthopedic departments will be opened in mid Khan Younis Hospital Refurbished surgical suite, 1987 Emergency room Ophthalmic Hospital, Gaza City Extensive renovation and reequipping of this hospital was carried out in Hospital Specialty Departments The development of new specialty departments and completion of training of new specialists has increased the capacity of local hospitals to provide regular and emergency health care needs Open Heart Surgery, Ramallah Hospital Ramallah Hospital opened this department in early The department has now carried out more than 150 open heart operations, mostly prosthetic placement for rheumatic valvular disease, or congenital heart diseases. A survival rate of 90% has been achieved. Diagnostic workups are carried out locally in conjunction with a cardiac catheterization laboratory in an Israeli hospital until the planned catheterization unit is opened at Ramallah Hospital Neurosurgical Department, Ramallah Hospital This department is now doing spinal surgery, as well as minor and moderate brain surgical procedures, with more complex cases referred to Israeli hospitals pending further development of the department. The new CT unit in Ramallah Hospital will greatly encourage this development. The volume of cases looked after in this department, increased from 1927 in 1988 to 3356 in 1989.