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April 1992
The Health Services in the Areas of
Judea-Samaria and Gaza since 1967
A Review and Comparative Data
From a presentation given by Dr. Sever, Chief Medical Officer,
before the Palestinian Delegation,
during the Israeli-Palestinian Talks in Washington
Introduction
As of June 1967, the health offices headed by the chief medical officers
in Judea-Samaria and Gaza, hold the responsibility for the management of
the health and medical services, functioning as a ministry of health in
each one of the two areas.
In Judea-Samaria the health system management is carried out according
to the Jordanian law - the public health law no. 43 of 1966, with some
amendments and supplementary regulations introduced by the Israeli
authorities.
The management of the health system in Gaza follows the Egyptian rules
and regulations, with similar amendments and supplementary regulations
introduced by the Israeli authorities.
The health ministry in Judea-Samaria is responsible for health in an
areas of 5,500 sq.km whose population in 1967 was around 600,000 and in
1992 around 975,000. The health ministry in Gaza is responsible for
health in an area of 362 sq.km whose population in 1967 was around
390,000 and in 1992 around 690,000. The ministries deal with planning,
budgeting, organization, functioning, supervision and development of the
government services. Concerning the non-government services, the
ministries have top responsibility and deal with supervision.
CHAPTER A: THE HISTORY OF THE GOVERNMENT HEALTH SERVICES SINCE 1967
1. The Medical Administration in the Two Areas
In Gaza:
Basically, the system which existed till 1967 has not been changed. The
director of the health services is the Arab director-general of the Gaza
ministry of health acting with two assistants - one is responsible for
hospitals and the second is responsible for public health and primary
health care. This structure was kept after June 1967, but since then the
director-general is subjected to the chief medical officer.
In Judea-Samaria:
The Jordanian system of management in the two banks was based on 6
regional medical directors, 3 in each bank, being subjected to the
minister of health and his deputy. Each regional director was in charge
of all health services in his region, including hospitals, primary
health care and public health.
This system continued in the West-Bank till 1972. In 1972, the Israeli
system was implemented, the system of separation between hospital
services and public health services. The director of the public health
services became concomitantly the director of the primary health care.
The two directors of services are subjected to the chief medical
officer.
2. Health Insurance
In Judea-Samaria, till 1967, the Jordanian system insured military
people, policemen and government employees 100% insurance without fee
payment, while their families received 50% exemption for any fee for any
medical service. The Jordanian regulations fixed a list of fees for
government services, but mother & child care services, school health
services, immunizations, venereal diseases, tuberculosis - were free of
tax as well as services for the poor assisted by the social-welfare
ministry.
Between the years 1967-1978, collection of fees for medical services was
not made regularly and medical directors used their authority to decide
upon exemption of payments.
During the period 1967-1978 only government employees working in Israel
through the official employment office and social cases were included in
the health insurance. On February 1, 1978 a government health insurance
system on a voluntary basis was implemented in the areas of
Judea-Samaria and Gaza and all members in the insurance project became
entitled to get any medical services in the areas and supplementary
service in Israel. Presently, 1992, around 30% of the population in
Judea-Samaria and about 50% of the population in Gaza, have government
health insurance. People who are considered refugees, holders of refugee
cards, are insured medically in the framework of UNRWA.
3. Public Health Services and Preventive Medicine
Throughout the years, since 1967, we have succeeded to improve, to
develop and to strengthen the infrastructure of public health and
preventive medicine. We have accomplished the building of a modern and
stabile infrastructure, which is considered as a foundation-stone in any
health system. This was our first goal.
Concomitantly with our preoccupation in implementing the assignments for
reaching the first goal, we have been dealing with the strengthening and
expansion of the network of primary health care. This was our second
goal . After the the two first floors of a modern health system have
been erected, we could invest more efforts and more resources towards
our third goal strengthening and developing hospitals, although since
1967 we have been dealing with the improvement of existing hospitals by
equipping them and by promoting the professional level of personnel.
During the last 10 years till this very moment, intensive work is being
done, not only in planning of hospital development, but especially in
the actual work and construction in the various sites.
a) Immunization Program:
Till June 1967 the immunization program in the areas included
immunizations against Diphtheria, Pertussis, Tetanus, Tuberculosis and
Poliomyelitis. Throughout the years we have improved and enriched the
program by adding immunizations against Measles, against Rubella, a
joint vaccination against Measles-Mumps-Rubella (MMR), and Tetanus
vaccination for pregnant women and women at the age of fertility. As a
rule we have implemented the Israeli system of immunization.
It is important to emphasize that in 1978 we implemented the combined
immunization against Polio, consisting of the Sabin and Salk vaccines,
leading to the outcome of eradication of polio in the areas. Other
immunizations which have been implemented are: immunization against
Hepatitis B given to hospital staff at risk and to infants born to
mothers found to be positive to Hepatitis B, and immunization against
Meningococcal Meningitis A to pilgrims leaving for Saudi Arabia.
Concerning our success in the routine immunization project - we have
reached a coverage of over 90% of infants and school age children.
b) Infectious Diseases:
We have attained remarkable achievements in the eradication of
infectious diseases over the years 1970-1990.
Infectious disease rates (per 100,000 population)
Reported in Judea-Samaria and Gaza, 1970-1990
Judea-Samaria: 1970 1990
Pertussis 8.0 0.0
Tetanus 53.3 0.1
Polio 4.7 0.0
Gaza:
Pertussis 30.1 0.0
Tetanus 13.6 1.0
Polio 14.3 0.0
Twenty years ago the areas were declared as malaria free areas by the
WHO, and about 15 years ago the areas were declared as free from
smallpox.
c) Deliveries in Hospitals and Maternities:
Since 1967, a significant improvement in the rate of deliveries in
medical institutes has occurred.
1967 1991
Judea-Samaria 11% 67%
Gaza 10% 80%
This improvement has a positive impact on maternal mortality and infant
mortality, leading to a decrease in the mortality rate, and enables the
newborn to be under medical care, treatment and surveillance with the
possibility of early detection and treatment of congenital malformations
and endoctrinic or metabolic disorders of the newborn.
d) Infant Mortality Rate:
Infant mortality rate has declined in the areas as the childhood
infectious diseases and diarrhoeal conditions were brought under control
through successful immunization and oral-rehydration system (ORS)
programs. Increased hospital and medical center deliveries, as well as
rising educational, and economic standards, have also contributed to
this improvement.
Gaza infant mortality has declined from 86 deaths per 1,000 live births
in 1970 to 26 deaths per 1,000 live births in 1990.
In Judea-Samaria infant mortality rates have declined, but the rates are
difficult to determine, since 33% of all births occurred at home and
some early neonatal deaths are unreported.
Considering reported deaths, the IMR in Judea-Samaria declined to 22
deaths per 1,000 live births in 1990. A study of infant mortality in the
refugee population in Judea-Samaria showed a decline in IMR from 83.7 in
1975 to 27.3 deaths per 1,000 live births in 1988.
A study of infant deaths carried out during the winter months of 1988 by
the Ramallah Health Services Research Center showed an underreporting of
infant deaths of 20%, primarily in the neonatal period.
Another study of infant mortality in the rural sector of Hebron district
showed a decline in IMR for pregnant women attending village health
rooms from a cumulative IMR prior to 1985 of 80/1000 live births, to
33/1000 in the period from 1985-1989.
e) Maternal and Child Health Care:
Hereby are listed the projects and activities introduced by us,
activities which did not exist prior to 1967:
- Anemia prevention among pregnant women, by treatment with iron and
folic acid
- Anemia prevention among infants, with iron treatment
- Vitamins A + D administration to infants
- Bleeding prevention among infants, by treatment with Vitamin K1
injections
- Development of the project of High Risk Pregnancy
- Detection and treatment of Phenyl-ketaurine and Hypothyroidism among
infants
- Oral treatment with electrolyte solutions to dehydrated infants
suffering from diarrhoea
- Diagnosis of children suffering form Thalassemia and treatment with
desferal and blood transfusions.
4. Primary Health Care Services
The number of general clinics and mother-and-child health centers in
Judea-Samaria and the number of community clinics in Gaza has increased
significantly since 1967, and new units that did not exist before 1967
have been established, like:
Village primary health care units, high risk pregnancy clinics,
specialty clinics in district health offices and mobile clinics. In Gaza
maternal and child health services did not exist until 1967. These
services were developed afterwards within the community clinics that
increased-in number and delivery-units have been opened therein.
Some comparative data are mentioned as follows:
Judea-Samaria 1967 1991 Explanation:
General clinics 89 170 136 buildings include
Mother & child 23 144 clinic & MCH center
centers in 34 buildings -
only clinic
in 8 buildings -
only MCH
Village primary
health care units 0 49
Specialty clinics 0 13
Mobile clinics 0 2
Gaza
Community clinics 3 28 including MCH centers
and delivery units
The number of ambulances increased gradually throughout the years in
both areas. The ambulances belong to the government, the Red-Crescent
societies, to UNRWA, to patients' friends societies and municipalities.
We now have 54 ambulances in Judea-Samaria and 47 in Gaza. Tens of the
ambulance drivers from all sectors were trained in first aid and
resuscitation procedures, in courses organized by Magen David Adom in
Israel.
Yesterday's presentation put an emphasis on the up-to-date network of
primary health care in the areas, as well as on the present public
health status and preventive medicine programs.
The aim was to describe the entire set-up of services, units and
activities that ought to be included in the negotiations towards
delegation of powers and responsibilities to the Palestinian Arabs
during the interim self-government arrangements. Similarly, and for the
same purpose, today's presentation emphasizes the present layout of
hospitals, and the condition of health manpower and of environmental
health in the areas.
5. Hospital Services
General beds in government and non-government hospitals in Judea-Samaria
and Gaza in 1967 and 1991.
Government Non-government Total general
beds beds beds
1967 1991 1967 1991 1967 1991
Judea- 553 680 328 469 881 1,149
Samaria
Gaza 755 789 72 75 827 864
General government General government beds
beds 1991 planned for 2000
Judea- 680 1,070
Samaria
Gaza 789 1,580
Approval has been given in Judea-Samaria for the establishment of new
non-government hospitals, medical centers and maternities.
a) Till 1967 there was no distinction among departments in hospitals.
Departments for Gynaecology and Obstetrics in government hospitals
did not exist.
b) After 1967 the existence of the 4 basic departments were imposed in
each general hospital: Internal medicine, General surgery,
Pediatrics, and the establishment of new departments for
Gynaecology and Obstetrics.
c) The medical service in the peripheral district hospitals has been
improved by adding consultative services, neonatal units and the
improvement of medical equipment.
d) The medical service in the central regional hospitals has been
promoted by improvement of medical equipment, improvement of the
diagnostic radiology and ultrasound institutes, renewal and
expansion of operating sections and the development of out-patient
clinics and emergency rooms.
e) In 1976 a new hospital was inaugurated in Judea-Samaria,
Rafidie-Nablus hospital, following completion of the building. This
surgical hospital of 122 beds complements Watani-Nablus hospital of
80 beds for non-surgical professions. The two Nablus hospitals
serve as a top medical center for the Samaria region, including the
hospitals of Jenin and Tul-karem.
f) Ramallah hospital has been developed to a secondary medical center
for the Judea regions and to a tertiary medical center for the
whole area. Beit-Jala hospital has been developed as a
complementary hospital to the Ramallah Medical Center.
g) Hebron hospital has been developed to a level of a community
district hospital, but this hospital, as well as the small
peripheral hospital in Jericho, refer to the Ramallah and Beit Jala
hospitals for complementary services.
h) Shifa-Gaza hospital has been developed to a level of a large
medical center, secondary and tertiary for the Gaza area.
i) We have master-plans for development for all government hospitals
in Judea-Samaria and Gaza. Actual development projects are being
carried out in 5 hospitals -
Rafidie-Nablus, Ramallah, Beit Jala, Hebron, Shifa-Gaza.
j) Complementary services, ambulatory and hospitalization are given in
Israeli hospitals in specialties with no departments and no
specialists existing in the areas. Patients with complications and
patients who need sophisticated diagnostic procedures or treatment,
are also referred to Israeli hospitals.
k) We have been employing till now Israeli senior physicians as
consultants in the hospitals of the areas - for advisory
assignments and for professional instruction for Arab physicians.
The hospitals are of two types:
i. Peripheral-primary district hospitals, include the four basic
departments (Internal medicine, General surgery, Gynecology-
Obstetrics, Pediatrics). Some of them contain consultative services
in other clinical professions.
ii. Central-secondary regional hospitals (part of them are tertiary),
consisting of departments and units of other specialties and
ambulatory consultative services. Three complexes exist in the
areas which can be called leading medical centers:
The complex of Rafidie-Watani in Nablus (for Samaria region);
The complex of Ramallah & Beit Jala (for Judea region);
The complex of Shifa-Gaza (for Gaza area).
In these centers we find departments/units/services in the
following specialties:
Internal medicine, General surgery, Gynecology & Obstetrics,
Pediatrics, Neonatology, Coronary intensive care, General Intensive
care, Anaesthesiology, Cardiology, Pulmonology, Gastroenterology,
Hematology, Nephrology and Hemodialysis units, Oncologic-
Chemeotherapy, Neurology, Neurosurgery, Cardiac surgery, Thoracic
surgery, Vascular surgery, Pediatric surgery, Orthopedic surgery,
Urology, Ear-Nose-Throat surgery, Ophthalmology, Physiotherapy
units and consultative services in Dermatology and Allergology; as
well as institutes for Diagnostic Radiology, Ultrasound and
Computerized Tomography.
Patients from the abovementioned departments, units or services are
referred, if needed, to Israeli hospitals for further investigation
or treatment, either through hospitalization or ambulatory methods.
The mental health services accessible to the population are
hospitalization (especially in the psychiatric hospital in
Beit-Lehem with 320 beds), and ambulatory consultative services in
the framework of the district public health offices, since the
community mental health services have been developed.
6. Pharmaceutical Industries and Quality Control of Medicines
As of 1983 we have imposed compulsory quality control of medicines
produced in pharmaceutical industries in Judea-Samaria.
We cooperate persistently with the Ministry of Health, Institute for
Quality Control of drugs and pharmaceuticals for analyzing items
produced in the area.
7. Manpower Development, Training and Specialization
Para- Admini-
medical stration
MDs Nurses Staff & Services Total
Judea & End 1967 48 237 88 336 709
Samaria 1992 333 856 235 580 2,004
Gaza End 1967 31 212 49 548 840
1991 343 694 173 635 1,845
Throughout the last 24 years, hundreds of physicians from Judea-Samaria
& Gaza participated in various training programs in Israeli hospitals,
as post-graduate studies in clinical branches on behalf of the medical
schools in the universities of Jerusalem, Tel-Aviv and Beer-Sheva, and
residency programs of 1-4 years in various clinical specialties. Some
physicians completed their academic studies for the degree of Master in
Public Health in the Hebrew University in Jerusalem. Physicians from the
areas who had their residency and specialization abroad were granted
scholarships. Presently, physicians from the areas can apply and be
accepted to a complete syllabus of specialization in Israel towards an
official recognition awarded to foreigners.
Tens of registered nurses completed their studies in the government
nursing school established in 1971 and in the government schools for
practical nurses and midwives, schools operated by Israel in Nablus
(until 1967 only one small school for practical nurses existed in
Judea-Samaria, located in a private hospital in Nablus). Many registered
nurses completed post-graduate studies in nursing branches in various
fields such as intensive care.
Tens of administration and services employees participated in courses of
manpower management, accountancy, computers, etc. Many community health
workers and ambulance drivers were trained in first aid and
resuscitation procedures on behalf of Magen David Adom in Israel.
About 400 traditional birth attendants from Judea-Samaria and 90 from
Gaza participated in refresher courses in their branch of activity.
8. Developments in Environmental Health and Environmental Engineering
a. Sewage
Sewage collection systems have been extended and re-equipped in
urban areas in Judea-Samaria. Before 1967 there were no sewage
treatment plants in the area. Since 1967, sewage treatment plants
have been built in Jenin (1971), Tul-Karem (1972), Ramallah (1979)
and Kalkilya (1986). For the present time the projects under
construction are the sewage projects of Hebron, Beit Lehem, Beit
Jala, Beit Sahour and Al Birah. In Gaza dealing with sewage
projects was also only begun after 1967. Sewage collection systems
are being expanded in Gaza City, Jabaliya and Khan Yunis.
b. Water
Central supply of water to the areas was developed after 1967.
Routine water tests are carried out throughout the public water
supply system.
c. Garbage Disposal
Garbage disposal is now organized on a municipal basis and has been
vastly expanded and modernized. Improved facilities for solid waste
collection and disposal have contributed to improved sanitation in
Judea-Samaria & Gaza.
A master-plan for garbage disposal for Judea-Samaria was finalized
and approved.
d. Sanitary Supervision
Supervision of food and sanitary conditions has been improved and
intensified throughout the years. The activities include licensing,
education, building licensure and dealing with public complaints.
CHAPTER B: FIELDS OF INTERACTION BETWEEN THE HEALTH SERVICES
IN JUDEA-SAMARIA & GAZA AND THE HEALTH SERVICES IN ISRAEL
a. Water and food testing -
Done in the public health laboratories in Israel.
b. Epidemics and outbreak of diseases -
Coordination with the epidemiology unit of the Israel Ministry of
Health.
c. Immunization -
Coordination with the advisory committee for immunizations in the
Israel Ministry of Health.
d. Environmental health -
Coordination and consultation with the professional unit in the
Israel Ministry of Health.
e. Quality control of medicines produced in the areas -
Coordination with the professional institute of the Israel Ministry
of Health.
f. 'Clinical medicine department/units lacking in the areas -
Radiotherapy, Hematology, Oncology, Ped. Card., Pediatric-
Nephrology, Pediatric-Urology, Pediatric-Neurology, Neonatal and
Pediatric Intensive Care, Respiratory Intensive Care, Plastic
surgery burns, sophisticated Ophthalmology, Maxillofacial surgery,
Rheumatology, Endocrinology, Immunology, (Dermatology and Venereal
diseases) physical medicine and rehabilitation, Card. Cath.; all
kinds of operations for transplantation of organs.
Specialties which deserve cooperation to a certain extent:
Neurosurgery (severe cases), Cardiac Surgery (children and
complicated cases), Pulmonary Cardiology, Gastroenterology,
Neurology.
g. Sophisticated laboratory tests -
i.e. endocrinological, immunological, etc.
h. Special diagnostic procedures -
Cardiac catheterization, angiographies, imaging by MRI, etc.
i. Genetic tests and evaluations -
j. Any examinations or diagnostic procedures that must be performed by
a specialist or with special medical equipment.
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