1. Health in Gaza Current Situation and Future Challenges Occupied Palestinian Territory Mahmoud Daher Head of Gaza sub-office

2. 2 |2 | WHO-oPt Health determinants Health Services Health Status Conclusions

3. HUMANITARIAN OVERVIEW Settlements (pre-2005) Crossings Sea restrictions Fence Erez Crossing Point Nahal Oz Crossing Point Karni Crossing Point Sufa Crossing Point Kerem Shalom Crossing Point Rafah Crossing Point 3 nautical miles Effective since January 2009 ARA Tunnels Gaza Strip Movement and access highly restricted 1.6 million (70% refugees) ~ 4,000 persons km 2 54% under 18 No go zone - officially: 0-300 meters, in practice: 0-500 meters High-risk zone: 500- 1/1.5 km 35% of agricultural land 85% of fishing areas off-limits, 65,000 affected Erez Crossing: 167 (2011) vs 26,000 (2000)people/day 200-300 operational tunnels Mostly construction materials Source: The Economist 9,000 settlers and 21 settlements 15% of Gaza Strip chart map Beit Hanoun 2008Beit Hanoun 2003

4. 4 |4 | WHO-oPt September 2005 : Israeli Disengagement from Gaza January-March 2006 : Elections in oPt and forming of new Palestinian Government. June 2006 : Israeli soldier kidnapped - Israel retaliate by destruction of power plant and closure of borders. June 2007 : Internal disputes lead to separation between West Bank and Gaza, Hamas take over control of Gaza and Israel imposed siege on Gaza. December 2008 : Israeli military assault (Alforqan or Cast lead) November 2012 : Israeli Intensive airstrike assaults (Column of clouds or stones of hill) April 2014 : Palestinian reconciliation…?? Key recent events in the last decade had implications on the health in Gaza

5. 5 |5 | WHO-oPt Severe restrictions on access and exit for people and goods Major impact on economy, reconstruction and daily life of citizens Tunnels until recently were providing alternative route for supplies of all kinds, including fuel and construction materials, now these are completely closed. The Siege

6. 6 |6 | WHO-oPt Demographic indicators Population in oPt : 4.42 Million Population in Gaza Strip mid-2012 : 1.7 million (38.5% of oPt), estimates to be 2 million in 2018 (PCBS) Registered refugees in Gaza : 66.1% of Gaza population Less than 18 yrs : 51% of Gaza population

7. 7 |7 | WHO-oPt Socioeconomic Indicators Unemployment first quarter 2014: 40.8% (38.5% 4 th qrt 2013) PCBS 38.8% of Gazans lived under the national poverty line. (World Bank) 57% of households in the Gaza Strip are food insecure (2012) WFP Gross domestic product per capita $1156. PCBS “Ever more aid dependent”

8. 8 |8 | WHO-oPt Education & Literacy Literacy age 15+ – 92% Primary completion rate – 83% in 2007. Down from 95% in 2005. Schools in Gaza recorded failure rates of 40 to 50 percent in 2006 and 2007, according to UNRWA. UNWRA schools overcrowded. Children attend classes in two shifts—one in the morning and one in the evening.

9. 9 |9 | WHO-oPt Environment/ Water UNEP report- Environmental assessment of Gaza Strip: “Underground water supplies in danger of collapse from over-use and contamination War impact: sewage; rubble; land; waste disposal. concerns about water shortages, lack of chemicals for water disinfection, pollution (levels of nitrates) - access to safe water for the population Av. consumption of potable water estimated at 52 litres per capita per day, (half the international standard of 100 to 150 l/cap/d.) Sewage and waste water management systems totally inadequate. Sanitary inspection of water-supply systems and use of water safety plans limited; corrective measures are not done promptly. Water authorities dumping 60,000 cubic meters of sewage daily into Mediterranean Sea since January 2008 to avoid flooding residential areas. Increased risk of water and sanitation related diseases such as diarrhoeal diseases, hepatitis A

10. 10 | WHO-oPt Health providers MoH UNWRA NGOs Private

11. 11 | WHO-oPt Primary Health care MoHNGOsUNRWATotal West Bank40614041 587 Gaza Strip546621 141 Total 46020662728 Population/ PHCC Gaza: 11480 West Bank: 4147 Palestine: 5476

12. 12 | WHO-oPt Provider Gaza StripPalestine No. of HospitalNo. of Beds% of BedsNo. of HospitalNo. of Beds% of Beds Ministry of Health13157867.925297954.3 UNRWA0001631.1 NGOs1459624.533178932.6 PMS31777.631773.2 Private174798.7 Total302324100765487100 Distribution of in-patient beds GS vs Palestine 2012

13. 13 | WHO-oPt o Palestine: 13.5 o Gaza 17.3 o West Bank 12.8 o Jordan: 17 o Egypt: 22 o Lebanon: 36 o Israel: 63 o Increase in MoH beds 2005-2012: o Gaza 60% o West Bank 44% o Av. occupancy rates for MoH hospitals: o Gaza 78% o West Bank 85% Total number of hospital beds per 10,000 population

14. 14 | WHO-oPt Health workforce in Gaza (MOH, UNRWA, main NGOs) Gaza StripPer 1000 pop Profession/RegionNumberPer 1000 popJordanIsrael Physicians27842.72.03.8 Dentists2770.20.11.2 Pharmacists6030.350.10.7 Nurses30201.83.06.3 Midwives2340.20.30.2 Paramedicals12330.721.2 Administration42482.53.2 Grand Total12406

15. 15 | WHO-oPt August to Dec 2008 –strike by Gaza MoH staff. 1,1171 MoH staff as of December 2013 of whom 8992 working Out of the total of 11171 5949 paid by PNA 2179 paid by PNA but not working 5222 paid by de facto authorities

16. 16 | WHO-oPt Some key Health status indicators Life expectancy 71-72 CDR: 3.1 IMR: 20/1000 live births MMR: 23.4/100,000 live birth 48% of Gaza population are not doing enough physical activity 61.7% of all Gaza population are overweight (while 31.8% obese) 44.8% of Gaza population 15-64 with high BP 8.4% of Gaza population 15-64 with DM 32.5% of Gaza population have high cholesterol blood level

17. 17 | WHO-oPt Challenges in this area: Main health challenges facing Palestine in 21 st century are non- communicable diseases o cardiovascular diseases, diabetes, chronic lung disease, cancer, mental disorders UNDAF thematic area: Health The United Nations Country Team in the State of Palestine People 15-64 years with high blood pressure (2011)36% People 15-64 years with diabetes mellitus (2011)9% Adult primary care users with mental problems (2012/2013) West Bank 26% Gaza Strip 38% Leading causes of death in Palestine (2012) Heart disease31% Cancer14% Cerebrovascular diseases (stroke)12% Mental hospital ward

18. 18 | WHO-oPt The prevalence rate of post-traumatic stress disorder among children in Gaza ranged from 10.6-54% The prevalence rate of post-traumatic stress disorder among adolescents in Gaza is 25.8% The prevalence of mental health problems among adults attending governmental primary healthcare centers is 37.8% in Gaza In General, the mental health resources are scarce and fragmented to respond to the extensive burden of mental disorders. Mental health

19. 19 | WHO-oPt Some other challenges Referral and access to outside Gaza health services Pharmaceutical shortages

20. 20 | WHO-oPt Referrals for specialized care - oPt Referrals by MoH (WBG) increased 10 folds from 2000 to 2011. (world Bank) Costs also increased from $10 m in 2000 to $121m in 2011 (world Bank) Main specialties: cancer, cardiovascular, opthalmology, neurosurgery

21. 21 | WHO-oPt Total Number of Monthly Referral in 2011, 2012 and 2013

22. 22 | WHO-oPt Referral Cost in 2011, 2012 and 2013 Total cost in Million USD 2011: 44 M 2012 : 40 M 2013: 49 M

23. 23 | WHO-oPt Total number of approved permits out of the total number of applications (2011-2013)

24. 24 | WHO-oPt Shortage in drugs and disposables

25. 25 | WHO-oPt Challenges Tightening restrictions of movement of populations, goods and activities of humanitarian actors Deterioration of determinants of health in the West Bank and Gaza Reduction of funding for humanitarian health programs Limited human recourses to implement the cluster/sector coordination activities.

26. 26 | WHO-oPt THANK YOU