(^Ш/ World Health Organization ^^^^ Organisation mondiale de la Santé

FORTY-SEVENTH WORLD HEALTH ASSEMBLY

Provisional agenda item 32 A47/INF.DOC./3 2 May 1994

Health conditions of the Arab population in the occupied Arab territories, including Palestine

The Director-General has the honour to bring to the attention of the Health Assembly the attached annual report of the Director of Health of the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) for the year 1993. HEALTH CONDITIONS OF THE ARAB POPULATION IN THE OCCUPIED ARAB TERRITORIES, INCLUDING PALESTINE

Report of the UNRWA Department of Health, 1993

CONTENTS

Page

I. INTRODUCTION 2

II. UNRWA'S HEALTH PROGRAMME 2

III. HEALTH STATUS OF PALESTINE REFUGEES 3

IV. PROGRAMME ACTIVITIES DURING 1993 5

Medical Care Services 5 Maternal and Child Health Care 5 Mental Health 6 Environmental Health 6

V. SITUATION IN THE OCCUPIED TERRITORY 8

VI. UNRWA'S CONTRIBUTION TO HEALTH SECTOR DEVELOPMENT 8

VII. UNRWA'S ROLE DURING THE TRANSITION PERIOD 10

STATISTICAL ANNEX 13 I. INTRODUCTION

1. The Annual Report of the Department of Health of UNRWA for 1993 covers a year in which historic events have taken place that will create a radically different situation in the Agency's area of operations.

2. The Palestine Liberation Organization and the Government of have recognized each other and signed a Declaration of Principles, which is guiding their negotiations for an interim self-government period in the and .

3. There is no doubt that these momentous developments have already had a great impact on the perceptions of all parties concerned as well as on UNRWA's role under the new conditions.

4. UNRWA, which is one of the major health care providers in the occupied territories, will make every possible effort to contribute to the process of sustaining and developing the existing health care system and harmonization of the services of the various health care providers. In addition to its Peace Implementation Programme which aims at, inter alia, upgrading the basic infrastructure of primary health care facilities and improving environmental health conditions, the UNRWA Department of Health and the Palestine Red Crescent Society/the Palestine Council of Health have already started a process of ongoing consultations in an effort to further co-operation between the two parties in the health sector including reinforcing and expanding existing programmes, co-ordination of new programmes, exchange of information, harmonization of the standards of service, development of a universal health insurance scheme, development of human resources for health, and material support in fund-raising and health development projects.

5. UNRWA can continue its activities within any framework that would be considered appropriate by the emerging Palestinian health authority and supported by the international community. UNRWA's major contribution towards building a coherent, unified and affordable health care system in the Gaza Strip and West Bank will be focused on the transfer of appropriate technology with special emphasis on primary health care. In the meantime it is needless to emphasize that the Agency will also continue to seek funding and implement projects for meeting essential health needs of the Palestine refugees in , the Syrian Arab Republic and .

II. UNRWA'S HEALTH PROGRAMME

6. As at 31 December 1993 UNRWA cared for a total of approximately 2.9 million registered refugees, of whom one-third live in camps and the rest in cities, towns or villages. The registered refugee population is distributed in the five fields as follows: Gaza Strip 625 000, Jordan 1 140 000, Lebanon 335 000, Syrian Arab Republic 321 000, and the West Bank 492 000.

7. UNRWA provides primary health care services to the registered refugee population, including medical care (both preventive and curative), environmental health services in camps, and nutrition and supplementary feeding to vulnerable population groups. Medical care at the primary level is complemented by secondary services, including hospitalization and other referral services.

8. UNRWA's policy is to provide essential health services to registered Palestine refugees consistent with the humanitarian policies of the United Nations and the basic principles and concepts of WHO. The prime objective of the Agency's health programme is to protect and promote the health of the refugee population by meeting their basic health needs.

9. Since 1950, under the terms of an agreement with UNRWA, WHO has provided technical supervision of the Agency's health care programme by assigning personnel to UNRWA headquarters, currently six WHO staff members, including the Agency's Director of Health.

10. More than 3200 professional and other support staff, most of whom are locally recruited Palestinians, provided essential primary health care services to the refugee population throu^i UNRWA's expanded íacilities of health centres/points and mother and child care clinics. (For details on UNRWA's health personnel, see Annex, Table 1.) 11. During the reporting period UNRWA received contributions and incurred expenditure in the Health Programme under the following main headings: regular programme, Extraordinary Measures in Lebanon and the Occupied Territory (EMLOT), Expanded Programme of Assistance (EPA), Gaza General Hospital project and the Peace Implementation Programme (PIP).

TABLE 1. REGULAR HEALTH PROGRAMME BUDGET

(thousands of United States dollars)

Syrian Gaza Jordan Lebanon Arab West Bank HQ Total Republic

1990-91 19 849 14 972 14 498 12 948 20 897 3 072 86 236 Expenditure

1992-93 Approved 24 809 18 697 14 925 12 895 23 668 7 804 102 798 budget

1994-95 Proposed 29 586 22 578 16 188 10 615 29 016 10 024 118 007 budget

III. HEALTH STATUS OF PALESTINE REFUGEES

12. The health status of the Palestine refugees today resembles that of many populations whose countries are evolving from a developing to a developed state. As such, it has much in common with both.

13. Communicable diseases preventable by immunization and malnutrition are problems of the past. Morbidity from non-communicable diseases, often associated with life-style, such as diabetes mellitus, cardiovascular diseases, and cancer are on the increase. However, birth rates among the refugee population are still high and birth intervals are short. Communicable diseases transmitted through the environment, such as diarrhoea and intestinal parasites, are highly prevalent, and more than 50 per cent of pre-school children and women of reproductive age are anaemic. Services for fertility regulation and mental health are very limited and as such are largely ineffective. The provision of hospital beds, especially in the Gaza Strip, is totally inadequate and the environmental health conditions in refugee camps, especially in the Gaza Strip, Lebanon and the West Bank, are very poor.

14. In the absence of a reliable source of information for obtaining demographic data on the refugee population, and because of the incomplete registration of births and deaths, there are no means of calculating crude birth rates and infant and child mortality rates with accuracy. However, according to the best available estimates, the crude birth rate is estimated at 35 per thousand population and could be as high as 50 per thousand in the Gaza Strip. Infant mortality rates are well below the WHO target of 50 deaths per thousand live births for developing countries by the year 2000.

15. In a recent study conducted by UNICEF in the Gaza Strip and the West Bank, infant mortality rates and child mortality rates were estimated at 41 per thousand and 51 per thousand live births respectively, with significant differences in mortality patterns between camp and non-camp populations. Whereas infant and child mortality rates in refugee camps were 32 per thousand and 39 per thousand respectively, they were 40 per thousand and 50 per thousand in towns, and as high as 48 per thousand and 62 per thousand respectively in villages. ORGANIZATION OF THE DEPARTMENT

FIELD OFFICES

О POSTS LOCATED AT HQ-VIENNA П POSTS LOCATED AT UHB-AMMAN П POST LOCATED IN GAZA 16. These significant differences in rates can be mainly attributed to the easy access of camp population to the Agency's highly effective primary health care services, and its impact on reduction of infant/child morbidity and mortality.

IV. PROGRAMME ACTIVITIES DURING 1993

Medical care services

17. The Agency's efforts to improve the quality of care continued unabated in spite of the limited financial and human resources available to the programme. Several measures were taken to reduce overcrowding ât general clinics, including extension of appointment systems, redeployment of staff to improve patient-flow, expansion of the afternoon-shift clinics in the Gaza Strip, and expansion and upgrading of the Agency's infrastructure of primary health care facilities and basic support services such as clinical laboratories, specialist and special care clinics and dental clinics.

18. In recognition of the changing morbidity pattern of the refugee population, the Agency continued to reinforce its strategy of integrating special programmes for control of non-communicable diseases within its primary health care activities.

19. Analysis of statistical data on diabetes care revealed satisfactory progress. Over 3500 patients were added during the year, i.e., more than 15 per cent. The highest rate of increase was in the Jordan Field, namely 26 per cent. During 1993 more emphasis was placed on prevention, early detection and management of diabetic complications, including the issue of educational material and provision of in- service training for medical officers engaged in the delivery of diabetes care. UNRWA's diabetes control programme was evaluated by a WHO team in December 1993 in order to assess progress in implementation of the current strategy and the need for possible adjustments or improvements in the programme. The Manual on Diabetes Mellitus for UNRWA Staff which was prepared jointly by UNRWA and the WHO Collaborating Centre for Development of Appropriate Technology in the Control of Diabetes Mellitus, Zagreb (1991) is being translated into by the WHO Regional Office for the Eastern Mediterranean.

Maternal and child health care

20. During 1993 there was an overall increase of more than 5 per cent in the number of pregnant women using the services. The highest rates of increase were in Jordan (10 per cent), Syrian Arab Republic (9 per cent) and the Gaza Strip (7 per cent). It is worth mentioning that more than 42 per cent of all pregnant women who received ante-natal care at UNRWA clinics Agency-wide were from the Gaza Strip.

21. Although improvement of coverage was an important achievement, the Agency also exerted special efforts to enhance the quality and efficiency of services.

22. Ante-natal care was strengthened with the introduction of a new strategy aimed at improving identification of risk factors and complications. During 1994 a practical risk assessment approach will be put in practice, women with single or cumulative risk factors will receive special care and assistance throughout the ante-natal, natal and post-natal periods.

23. The combination of risk factors will help to identify pregnant women needing special attention. The new strategy stresses the importance of clinical judgement and proper management of complications as essential elements to reduce the negative outcome of pregnancies. Progress was achieved in improving staffs capability for timely identification and management of women with complications. Clinical guidelines on these tasks are being prepared for medical and nursing staff, who will receive intensive in-service training in their proper implementation.

24. Great efforts were exerted in 1993 to expand family planning services, which were established in 1992. The services emphasize fertility regulation and child spacing for the welfare of the mother, the newborn and the family. Adequate provisions were Plotted to all the Fields in order to procure necessary equipment and supplies. Training of medical officers, midwives and nurses was accelerated in co-ordination with the International Planned Parenthood Federation and local family planning associations. As of 1994 the programme will be supported by additional gynaecologists/obstetricians and trained midwives. Specific studies on the subject were designed and conducted in collaboration with consultants from the WHO Collaborating Center, Centers for Disease Control, Atlanta, United States of America.

25. The number of children cared for by the services in the five Fields rose considerably during 1993. A total of 210 500 children below three years of age received regular care and monitoring at UNRWA clinics, representing an 8 per cent increase compared with 1992, with the highest rates of increase reported from the Syrian Arab Republic (15 per cent), Jordan (14 per cent) and the Gaza Strip (about 9 per cent). It was particularly noticeable that infants below 12 months of age were being taken regularly to the clinics.

Merita丨 health

26. The need to tackle the ever-growing mental and psychological problems of the refugee population was increasingly recognized and planning improved. At the end of 1993 five UNRWA medical officers, one from each Field, completed the post-graduate training course in community mental health at the University of Manchester, United Kingdom, and a subsequent practical internship in India and Pakistan. The scholars will serve as focal points for the establishment of mental health programmes in all the Fields and will co- ordinate UNRWA services with those provided by governments and nongovernmental organizations. An operational workshop is scheduled for February 1994 to define a policy and formulate a practical strategy for the mental health services to be established in the five Fields.

Environmental health

27. Environmental health services are provided by UNRWA to about one million refugees residing in 58 camps in the five Fields. The services include provision of safe water supply to meet domestic needs, collection and disposal of refuse, disposal of sewage, management of storm water run-off, and control of insects and rodents that present a public health risk. However, conditions vary widely from one Field to another, and the environmental health programme in each Field reflects these differences. Where possible, these are integrated within UNRWA，s health programme, or are provided in eo-operation with host governments, municipalities, or other local authorities. (For details see Annex, Table 9.)

28. There are major differences between environmental health programmes in the occupied territory and the other Fields. In the occupied territory, the lack of central authority and local resources limit the capacity for development and management of the sector. Environmental health problems are most severe in Gaza, where extensive pollution of the environment not only creates a high environmental risk, but also contributes to pollution of the groundwater; where heavy use in the domestic water supply and agricultural sectors greatly exceeds recharge, resulting in salt water intrusion from the sea and forcing abandonment of wells; and where insects and rodents must be controlled together.

29. As a result, UNRWA started to assume a growing role in development within the environmental health sector in the Gaza Strip and the West Bank. It looks forward to playing an active role in Lebanon, where environmental health conditions in most of the camps are poor and, for some refugees displaced from camps destroyed in the civil wars, extraordinarily bad.

30. UNRWA could play a substantial role in the development process by providing a base for planning, and, through its special programme of environmental health, a sectoral focus and technical competence. UNRWA is in a unique position to do this in view of its existing quasi-governmental role, its experience in managing programmes and projects with and for the Palestinians, its role as a major employer of Palestinians, and its capacity for attracting funding for programmes and projects.

Gaza Strip

31. In Gaza, where the future of the Strip is seriously at risk from environmental degradation which already affects the health of its population and its potential for economic development, the Agency took the planning initiatives described below:

(a) It established a Special Programme for Environmental Health, designed to co-ordinate action among all concerned in the sector. The programme maintains an information system in order to prepare terms of reference for feasibility studies and camp-by-camp assessments, which will lead ultimately to preparation of a provisional master plan for improving environmental health infrastructure in the Gaza Strip, comprising water supply, sewerage and solid waste disposal.

(b) It concluded special service agreement with international consultants in order to identify strategic actions for development of the environmental health sector in the Gaza Strip, including water supply, sewerage, drainage and related works in the eight camps and adjacent municipal areas in the Gaza Strip. The terms of reference comprise: baseline study of the status of the sector, analysis of needs, preparation of a strategic plan, identification and evaluation of options and priorities, and project identification with rough costings and draft terms of reference for feasibility studies/project designs. The consultants started their work on 27 October 1992, completed then- assignment before the end of the year, and submitted a draft report early in January 1993 that focused on immediate and medium-term solutions. The draft report was reviewed and the final report submitted in June 1993, which generated great interest on the part of major donors, as evidenced by the achievements outlined below:

(i) Sewerage and drainage. The Agency was able to secure funds and started a series of appraisal missions and feasibility studies on sewerage and drainage in refugee camps and adjacent municipalities. Progress so far involves:

- Beach camp. A feasibility study and conceptual plans for sewerage and drainage in the Beach camp and for upgrading of pumping stations and the Gaza waste treatment plant were completed by international consultants. The tender was awarded for construction of the Beach camp sewer pressure line. Contracts were issued for soil testing for the sites of sewage pumping stations and the treatment of effluent, and the technical aspects of the project were co-ordinated with the Gaza municipality;

_ camp. In October 1993 the international consultants started their feasibility study and conceptional desi^i for storm water drainage works in the . The study in October 1993, which was later extended to include Jabalia/ village;

- camp. The draft feasibility study, conceptual designs and project document for sewerage and drainage in the and municipality were completed in October 1993;

- Middle camps. The tender was awarded for aerial photogrammetry of the Middle camps, and offers were received from international firms to carry out a feasibility stucfy for sewerage and drainage in the , Nuseirat and camps.

(ii) Solid waste management. Donors have shown strong interest in the solid wastes sector in the Gaza Strip. UNRWA assisted a team from the German Agency for Technical Co-operation (GTZ) in conducting a pre-appraisal mission on waste management in the Gaza Strip during March 1993. This resulted in funding for a number of projects, including two financed by the European Union in Rafah and Gaza municipalities, and one funded by GTZ to serve the middle area, covering five camps. Two projects were also financed by the Government of Japan. A third project which could potentially be funded by the Government of Denmark through UNRWA would target part of the middle area also covered by the GTZ- funded project.

(c) UNRWA has co-ordinated its work with all three projects financed outside the Agency. The resources received through the Japanese-funded projects and those potentially available from the Government of Denmark provide an opportunity to accomplish much more than was expected. It is imperative however that activities carried out under these projects complement each other and that they be co-ordinated in order to assure commonality of purpose and strategies, in order to make optimal use of resources available and to avoid duplication. (d) In order to set-up a database for project planning, design and implementation in the environmental health sector, the Agency developed an appropriate information system in co-ordination with WHO Headquarters.

West Bank

32. The following progress was made in the West Bank in 1993:

(a) Sewerage systems. UNRWA continued its initiative to construct internal sewerage systems in refugee camps with the ultimate objective of connecting camp infrastructure to municipal systems:

(i) by year end, 90 per cent of the work for construction of sewerage systems in the and camps was completed;

(ii) construction of a sewerage system in the Tulkarem camp will start in early 1994 after completion of the tendering procedures;

(iii) with regard to the five refugee camps (Kalandia, , Fawwar, Arroub and Far，a) located where they can not be connected to nearby sewerage facilities and in urgent need of proper sewerage disposal systems, the Agency drew up terms of reference and secured funding for conducting a feasibility study for sewerage and drainage;

(iv) possible development of the Jericho area prompted the Agency to plan for improvement of the camp infrastructure. Terms of reference for a feasibility study on sewerage and drainage for the entire Jericho area were drawn up and funding was secured.

(b) Water supply. In spite of the extensive development of water supply systems in the West Bank, the situation remained unsatisfactory in the Jericho area. The Agency constructed a water reservoir for the Aqabat Jabr camp to help improve the water supply system.

(c) Solid waste management. The efforts to improve solid waste management in camps by providing appropriate garbage disposal equipment continued. A compactor truck was purchased to serve the , Aida and Beit Jibrin camps and was put into operation in March 1993.

V. SITUATION IN THE OCCUPIED TERRITORY

33. Contrary to expectations, the situation in the occupied territory of the Gaza Strip and the West Bank was anything but normal during 1993. The state of violence, unrest and economic hardship remained largely unchanged and was further aggravated by closure of the two Fields at the end of March 1993. The following table shows the figures for fatalities and casualties since the beginning of the intifada in early December 1987 until 31 December 1993. It can clearly be noticed from these statistics that the number of fatalities in 1993, especially in the Gaza Strip, was higher than in any other previous year.

VI. UNRWA'S CONTRIBUTION TO HEALTH SECTOR DEVELOPMENT

34. Thanks to its forward-looking approach, the UNRWA Department of Health realized, well ahead of the signing of the Declaration of Principles that a major challenge facing the future Palestinian health authority will be to create a coherent, unified and affordable programme of health care out of the radically different health care services currently provided by the Civil Administration of the Government of Israel, UNRWA, nongovernmental organizations and the private sector. TABLE 2. CASUALTIES IN THE OCCUPIED TERRITORY

Year Injuries Fatalities1 Total Gaza Strip 19882 12 730 106 12 836 1989 20 873 128 21 001 1990 16 214 51 16 265 1991 6 331 26 6 357 1992 3 762 59 3 821 1993 3 894 133 4 027 West Bank 19882 4 719 292 5 011 1989 6 021 217 6 238 1990 3 515 127 3 642 1991 1 754 90 1 844 1992 721 88 809 1993 357 64 421 Note: Figures given are those reported or made known to UNRWA and should not be treated as exhaustive.

1 Excludes killings of alleged collaborators. 2 Includes casualties reported during December 1987.

35. In order to facilitate the process of change, the Agency made considerable contributions to health sector development. These include:

(a) strengthening its primary health care programme by introducing new activities and strategies that could be easily adopted and generalized by all health care providers during the period of transfer of the government health services, currently run by the Israeli Civil Administration, to the future Palestinian authority;

(b) developing, maintaining and upgrading its network of primary health care facilities, launching a project for construction, equipment and commissioning of a 232-bed general hospital in the Gaza Strip, remodelling of its 43-bed hospital in Qalqilia，and establishing of a Nursing College in Gaza in order to raise nurses' training to acceptable standards.

(c) providing the services of two WHO consultants, who worked closely with the Planning and Research Centre, Jerusalem, to prepare a comprehensive study on approaches to a universal health insurance scheme for the Gaza Strip and West Bank, with various options for consideration by the Palestine Council of Health. The study was completed in July 1993 and could serve as a guide in planning and decision-making for a future national health insurance plan;

(d) Making major improvements in camp infrastructure, including the construction of internal sewerage systems in eight refugee camps in the West Bank; establishing a special programme of environmental health for comprehensive planning, co-ordination and project implementation in the environmental health sector, including commissioning of a series of feasibility studies to assess needs and identify technical options; and preparing detailed designs with relevant cost estimates for immediate and long-term improvement in the subsectors of water, sewerage, drainage and solid waste management, both in camps and adjacent municipalities;

(e) contributing to the work of the Palestine Council of Health, which was established in 1992 to plan, administer and co-ordinate health care delivery systems and services in the Gaza Strip and the West Bank in the interim period, and to develop a comprehensive Palestinian National Health Plan. VII. UNRWA S ROLE DURING THE TRANSITION PERIOD

36. After signature of the Declaration of Principles the Agency actively participated in the World Bank's mission to the occupied territory from 11 October to 22 November 1993. This mission was fielded to support the work of the Multilateral Working Group on Economic Development and Regional Co-operation, to provide an effective framework for channelling donor assistance to meet the immediate needs of the occupied territory, to assist the Palestinians in identifying technical assistance required for building up Palestinian capacity for policy formulation and programme management, and to lay the groundwork for more effective use of donor assistance beyond the immediate term by identifying the technical studies needed on high priority policies, programmes and projects.

37. The World Bank's mission report recommended an emergency assistance programme for the occupied territory which stresses the need for "maintenance of existing facilities，support for recurrent e^enditures and preparation for the eventual assumption of responsibility for a fully integrated national health care system built from the programmes now being operated by UNRWA and the Civil Administration."

38. In consultation with the Palestinian leadership, UNRWA has developed a Peace Implementation Programme to replace the Expanded Programme of Assistance begun in 1988. Under this programme UNRWA has identified nearly 100 short-term projects which, if financed, could be implemented within six to nine months. These short-term projects are worth in total some US$ 100 million, about half are in the Gaza Strip (some US$ 60 million) and the other half are in the West Bank (some US$ 40 million). These activities aim to improve and enhance services, improve basic physical and social services infrastructure, and create new employment opportunities for the estimated 40 per cent of the work force which has been idle since the closure of the occupied territory in late March 1993. Clinics will undergo comprehensive maintenance, and projects will be launched to tackle the complex and extensive environmental health problems, particularly with regard to sewerage, water supply and solid waste disposal.

39. Within the context of this programme efforts exerted in order to prepare and review project proposals for financing immediate and medium-term health-related needs received wide support from the international community. During the short period between the signature of the Declaration of Principles and the end of 1993, not only were pledges received for funding almost all health-related projects included in the programme for the Gaza Strip and the West Bank, but also donors expressed interest in financing major development projects in environmental health. The total pledges received for funding of short and medium-term health-related projects amounted to US$ 8 166 920 for the Gaza Strip and US$ 936 678 for the West Bank. The pledges covered projects for renovation and upgrading of health premises, construction of new health centres, up-grading of medical equipment, feasibility studies on sewerage and drainage, and immediate improvements of environmental health conditions in refugee camps and adjacent municipalities of the Gaza Strip. (List in Table 3 below.)

40. In the meantime, a similar initiative was taken to identify urgent needs of Palestine refugees in Jordan, Lebanon and the Syrian Arab Republic, and to draw up relevant project proposals for possible funding. By the end of December 1993 all such projects were identified and relevant proposals were prepared by the Fields and cleared by the Department of Health.

41. UNRWA has infrastructure, trained human resources, institutional capacity, and experience in health care delivery and project implementation. It also has the flexibility to adapt to changing situations and can contribute to the future development of the health sector within any framework that would be considered appropriate by the international community and the Palestinian health authorities.

42. Responding to the urgent need to advance the process of harmonization of services between the various health care providers, the Agency's Department of Health reinforced dialogue and consultations with the Palestine Red Crescent Society and the Palestine Council of Health, and is actively participating in the work of the Technical Committees of the Council in the Gaza Strip and West Bank on all practical aspects of health policy and technical co-operation.

43. UNRWA remains in close consultation with all parties concerned, including donor countries, United Nations organizations and nongovernmental organizations. Co-ordination with WHO, UNICEF and UNDP

-10- was enhanced in order to facilitate implementation of the special programme of assistance based on health needs identified by the Palestine Council of Health in its interim action plan (1994-1995) and to co-ordinate technical assistance and define the specific roles of each body in sustaining and developing the health care system during the period of transition.

TABLE 3. HEALTH PROJECTS FUNDED UNDER THE PEACE IMPLEMENTATION PROGRAMME IN THE GAZA STRIP AND THE WEST BANK

DETAILS OF PROJECT DONOR AMOUNT us$ Gaza Strip Comprehensive maintenance of nursing school USAID 100 000 Upgrading of medical equipment Switzerland 275 310 Reconstruction of maternal and child health in Switzerland and Fakhoura and maintenance at Bani Shueila 180 000 Renovation of the Khan Younis and Rafah health centres and The Netherlands painting of the Rimal Health Centre 250 000 Environmental health projects: waste disposal, clean-up Denmark campaign, water control, water tanks 2 960 000 Co-funding of solid waste disposal, Beach Camp Finland 340 000 Upgrading of garbage depository sites Japan 550 000 Upgrading of municipal refuse collection and disposal system Japan 2 600 000 Sewerage/drainage improvements at Deir el-Balah Australia 250 000 Dental clinic at Maghazi Australia 89 600 Upgrading of medical equipment at the Khan Younis and Australia 252 032 Rafah health centres West Bank Construction and equipping of the Biddo Health Centre Finland 285 000 Additional trucks for refuse collection Japan 236 000 Feasibility study on sewerage/storm water drainage Germany 150 000 Camp No. 1 Health Centre Australia 204 100 Feasibility study of sewerage and drainage in five camps Japan 313 700 Clinical supervisors' course Australian NGO 27 300

STATISTICAL ANNEX

CONTENTS

Table 1. Health personnel

Table 2. Outpatient services

Table 3. Diabetes care

Table 4. Inpatient (hospital) services

Table 5. Maternal and child health care

Table 6. Prevalence of growth-retarded children below three years

Table 7. Communicable diseases

Table 8. Expanded programme on immunization

Table 9. Environmental health services

-13- TABLE 1. HEALTH PERSONNEL As at 31 December 1993

A - Posts Under Regular Programme

Syrian West Field HQ Jordan Gaza Lebanon Arab Total Bank Republic

(I) Area Staff

(i) Medical Care Services

Doctors 3 55 43 47 35 33 216 Dentists 0 15 9 10 11 10 55 Pharmacists 1 2 2 2 2 2 11 Nurses 0 186 156 152 104 97 695 Paramedical staff 1 70 56 52 42 46 267 Admin./clerical/secretarial 9 41 31 33 33 32 179 Health education 1 7 5 7 5 6 31 Other categories 0 70 61 95 58 57 341

Subtotal 15 446 363 398 290 283 1795 Environmental Health Services

Supervisory category 1 29 21 34 22 14 121 Labour category 0 298 175 295 192 98 1058 Admin./clerical/secretarial 1 1 1 6 2 1 12 Other categories 0 0 1 4 3 1 9

Subtotal 2 328 198 339 219 114 1200

(Ш) Nutrition & Supplementary Feeding

Nutritionists 0 2 2 2 2 2 10 Other categories 0 8 3 9 11 1 32

Subtotal 0 10 5 11 13 3 42

Total Area Staff 17 784 566 748 522 400 3 037

(П) International Staff 6 0 0 2 0 0 8 TABLE 1. HEALTH PERSONNEL (continued)

В - Posts Under Extraordinary Measures (EMLOT) and Expanded Programme of Assistance (EPA)

Field West Bank Gaza Total

(I) Area Staff

(i) Emergency Medical Care Services

Doctors 13 17 30 Nurses 22 53 75 Paramedical staff 11 16 27 Admin./ clerical/secretarial 3 8 11 Labour category 2 19 21

Subtotal 51 113 164

(И) Environmental Health

Labour category 15 1 16

Subtotal 15 1 16

Total Area Staff 66 114 180

(П) International Staff 3 1 4

С - Summary of Area and International Posts

Syrian West Field HQ Jordan Gaza Lebanon Arab Total Bank Republic

(I) Area Staff

Regular programme 17 784 566 748 522 400 3 037 EMLOT and EPA 0 0 66 114 0 0 180 Gaza Hospital project 2 0 0 3 0 0 5

Subtotal 19 784 632 865 522 400 3 222

(П) International Staff

Regular programme 6 0 0 2 0 0 8 EMLOT and EPA 0 0 3 1 0 0 4 Gaza Hospital project 0 0 0 2 0 0 2 Peace Implementation Programme 0 0 0 2 0 0 2

Subtotal 6 0 3 7 0 0 16

Total 25 784 635 872 522 400 3 238 TABLE 2. OUT-PATIENT SERVICES

1. Health Care Facilities

Health Dental Specialist Special Care Clinics Field Laboratories Units* Clinics** Clinics Diabetes Hypertension т Ч \ o r H Jordan 22 l o 20 12 17 17 r H West Bank 34 О 17 4 34 34 r- I Gaza 17 С Ч 8 5 9 9

Lebanon 26 i H 13 18 24 Syrian Arab 24 Republic 21 17 3 21 21 Total 120 68 75 42 105 105

2. Services Provided

Syrian Arab Field Jordan West Bank Gaza Lebanon All Fields Republic

Registered refugees 1 140 000 492 000 625 000 335 000 329 000 2 921 000

(a) Medical Consultations First visits 378 675 135 058 249 432 104 172 141 722 1009 059 Repeat visits 791 074 573 491 941 267 390 489 513 820 3 210 141

Ratio repeat to first visits 2.1 4.3 3.8 3.8 3.6 3.2

Subtotal 1 169 749 708 549 1 190 699 494 661 655 542 4 219 200 (b) Other Services Injections 53 849 60 301 550 181 37 664 38 742 740 737 Dressings 136 986 99 845 248 855 57 866 60 770 604 322

Subtotal 190 835 160 146 799 036 95 530 99 512 1 345 059

(c) Dental Consultations 154 962 48 670 73 586 62 737 52 197 392 152 3. Average Number of Attendances/1000 Registered Population

Medical Syrian Arab Jordan West Bank Gaza Lebanon All Fields Consultations Republic

First visits 274 399 310 430 345 Repeat visits 1165 1506 1165 1561 1098 Injections 122 880 112 117 253 Dressings 202 398 172 184 206 Dental iíil ^

consultations S 98 117 187 158 134

* Health units comprise: (a) Health centres: providing full range of preventive, curative and community health care; (b) Health points: providing same services on part-time basis; and (c) Mother and child health (MCH) clinics: providing preventive care only.

** Including mobile dental units. TABLE 3. DIABETES CARE

Syrian Arab Field Jordan West Bank Gaza Lebanon All Fields Republic

Diabetes Clinics 17 34 9 24 21 105

1. Population as at 31.12.93 1 140 000 492 000 625 000 335 000 329 000 2 921 000 2. Patients Registered

As at 1.1.93 7 341 3 708 6 429 2 373 2 419 22 270 Added during 1993 3 075 855 1277 633 587 6 427 Withdrawn as: dead 108 111 149 69 81 518 non attendance > 6 months 1066 542 263 308 205 2 384 As at 31.12.93 9 242 3 910 7 294 2 629 2 720 25 795 Prevalence rate per 100 000 population 811 795 1 167 785 827 883 Percentage increase during 1993 25.9 5.4 13.4 10.8 12.4 15.8

3. Type of Diabetes and Age ID* NID** ID NID ID NID ID NID Ш NID ID NID

0-19 years 144 'ч о 33 60 318 寸名 O N т н W m

20-39 years 344 4 D 225 72 284 522 148 84 1009 1 242 寸 v o 0

40-59 years 487 O N 266 1550 52 3 617 1 069 1 322 918 12 221 W 0

60 years and over 249 123 1 641 2 2 757 1 160 h- > ^ 1 129 461 9 626

Total 1 224 8 018 647 3 263 398 6 896 252 2 377 185 2 535 2 706 23 089

Percentage 13.2 86.8 16.5 83.5 5.5 94.5 9.6 90.4 6.8 93.2 10.5 89.5 4. Type of Treatment ю Й 0 \ Œ 卜 寸 о

Diet only (%) Д ë V O Й Й о 0 \ о o s I n

Insulin therapy (%) Й 0 К w i- i о ^ S \ o \

Oral therapy (%) — i j î- » '- J Й è 1 л 0 S > ( л N > 0 Oral and insulin therapy (%) 1 л w b o

Total % 100.00 100.00 100.00 100.00 100.00 100.00 Syrian Arab Field Jordan West Bank Gaza Lebanon All Fields Republic

5. Risk Factors о 寸 —

Blood relatives (%) 51.4 w 46.5 O s Й Obesity*** (%) 56.3 Й о 55.1 s < 1 í k ё N > 0

Vascular disease (%) 9.7 h i

^ 11.1 ( О L ^ o — 0 O t o H » Obstetric history**** (%) 3.4 O í Î O К » O 2.8 6. Complications g о u S

Retinopathy (%) 11.0 ^ н 15.7

S 13.8 О Nephropathy (%) 7.7 а \

g 7.4 г п 7.1 ы о r j

Neuropathy (%) 24.1 p 20.0 23.6 0 С U w- j Cardiovascular (%) 18.9 с о 23.7 19.4 & 0 м О v o Cerebrovascular (%) 3.6 ( S 3.7 3.7 Ы i- > O S Lf l Peripheral vascular (%) 5.5 1.9 U i 0 4.9

Percentage 70.7 55.9 91.3 72.5 53.4 72.6

* ID = Insulin-dependent diabetes mellitus.

** NID = Non-insulin-dependent diabetes mellitus.

…>20% of standard body weight.

**** Large babies, stillbirths or miscarriages.

Note: Figures under items 5 and 6 relate only to patients who have risk factors and/or complications. Percentages include patients with more than one risk factor/complication. TABLE 4. IN-PATIENT (HOSPITAL) SERVICES

Syrian West Field Jordan Gaza Lebanon Arab Total Bank Republic Registered refugees 1 140 000 492 000 625 000 335 000 329 000 2 921 000

(A) Contracted Hospitals 0* 5** 1 14 8 28

General Hospital Beds 0 210 50 104 45 409

Patients admitted 0 16 387 4 094 10 171 4 428 35 080 Patient days 0 69 696 18 174 37 987 13 746 139 603 Average daily bed occupancy (%) 0 90.9 99.6 103.8 83.7 95.1 Average stay in days 0 4.3 4.4 3.7 3.1 4.0 (B) UNRWA Maternity Units 0 1 6 0 0 7

Number of beds 0 3 60 0 0 63

Women admitted 0 97 7 705 0 0 7 802 Bed days utilized 0 97 14 783 0 0 14 880 Average daily bed occupancy (%) 0 8.9 67.5 0 0 64.7 Average stay in days 0 1.0 1.9 0 0 1.9

(C) Patients Assisted “» Through Reimbursement Schemes*** 6 986 493 2 748 0 0 10 227

* In the Jordan field，the Agency terminated all contractual agreements with private hospitals and resorted to one improved reimbursement scheme of costs incurred by refugees in treatment at government and private hospitals.

** Including one UNRWA 43-bed hospital in Qalqilia.

*** In addition to the substantial funds allotted to cover the cost of contractual agreements with NGO hospitals, additional funds are allotted for reimbursement of costs incurred by refugees on treatment at government or NGO hospitals in Gaza and the West Bank. TABLE 5. MATERNAL AND CHILD HEALTH CARE

Syrian West Field Jordan Gaza Lebanon Arab АД Fields Bank Republic Registered refugees 1 140 000 492 000 625 000 335 000 329 000 2 921 000 A. Maternal Health Care

(i) Antenatal Care

Pregnant women under supervision 17 265 11384 29 568 4 927 6 542 69 686

(ii) Natal care

Total deliveries reported 13 973 10 691 24 815 4 235 5 501 59 215

Proportion of deliveries according to place: — 卜 — — о < N о At home (%) 卜 8 28.5 36 15 rt

At camp maternity (%) 寸 31 0 0 13 0 - 1 ‘ In hospital (%) О 30 67.5 63 56 At private clinics (%) 31 4 1 16 B. Child health care

Infants below 1 year

Under supervision 24 142 11 928 27 584 4 910 7 171 75 735 % regular attendance 73 83 68 81 78 73

Children l-<2 years

Under supervision 21 235 10 851 25 078 4 896 7 242 69 302 % regular attendance 79 78 55 85 81 71

Children 2-3 years

Under supervision 18 432 10 511 25 108 4 719 6 668 65 438 % regular attendance 68 53 26 84 77 52 Note: Monitoring of children is carried out on a monthly basis for those below 1 year, bimonthly for age group 1 - below 2 years and trimonthly for age group 2-3 years. TABLE 6. PREVALENCE OF GROWTH-RETARDED CHILDREN BELOW THREE YEARS

(Measured by percentage of children with sub-standard weight for age)

1. Infants Below One Year Field 1st degree (%) 2nd degree (%) 3rd degree (%) All Fields (%)

Jordan 1.1 0.2 0.1 1.4 West Bank 1.3 0.3 0.1 1.7 Gaza 1.1 0.4 0.1 1.6 Lebanon 1.5 0.3 0.1 1.9 Syrian Arab Republic 1.1 0.3 0.1 1.5 All Fields (%) 1.2 0.3 0.1 1.6 2. Children l-<2 Years Field 1st degree (%) 2nd degree (%) 3rd degree (%) All Fields (%)

Jordan 1.8 0.2 0.1 2.1 West Bank 0.9 0.2 0.0 1.1 Gaza 2.9 0.7 0.1 3.7 Lebanon 1.8 0.2 0.0 2.0 Syrian Arab Republic 2.0 0.3 0.0 2.3 All Fields (%) 1.8 0.3 0.1 2.2 3. Children 2-3 Years Field 1st degree (%) 2nd degree (%) 3rd degree (%) АИ Fields (%)

Jordan 1.2 0.1 0.0 1.3 West Bank 0.4 0.1 0.0 0.5 Gaza 1.4 0.2 0.0 1.6 Lebanon 0.8 0.1 0.1 1.0 Syrian Arab Republic 2.5 0.4 0.1 3.0 All Fields (%) 1.2 0.2 0.0 1.4 Note: 1. Percentage of 1st, 2nd and 3rd degrees under-weight are calculated against the number of infants and children registered in maternal and child health clinics.

2. Degrees of under-weight are based on the following standard deviations from the international standard-weight for age: 1st degree more than 2 standard but less than 3 standard below the mean. 2nd degree more than 3 standard but less than 4 standard below the mean. 3rd degree more than 4 standard below the mean. TABLE 7. COMMUNICABLE DISEASES

Incidence Rates among Registered Refugees in 1993 per 100 000 Population

Syrian West Field Jordan Gaza Lebanon Arab All Fields Bank Republic Registered refugees as at 31.12.1993 1 140 000 492 000 625 000 335 000 329 000 2 921 000 Acute flaccid paralysis 0.1 0 0 0 0 0.03 HIV/AIDS 0.1 0 0 0.6 0 0.1 Brucellosis 6.4 45 0.8 0.6 69 18 Chickenpox 405 899 1 131 497 1 035 725 Conjunctivitis 1 114 1 822 2 147 876 3 904 1 741 Diarrhoea below 3 years (10% of population) 10 818 17 844 25 544 14 478 36 796 18 498 Diarrhoea above 3 years (90% of population) 488 895 1 966 1 339 1 764 1 114 Dysentery (amoebic and ЬасШагу) 338 291 1 401 129 2 794 810 Gonorrhoea 0 0 0 0.3 0 0.03 Infectious hepatitis 23 35 16 4.8 172 38 Influenza 106 4 888 3 691 0 2 782 1 968 Leishmaniasis (cutaneous) 0 0 0 0 12.2 1.4 Measles 19 0 2.1 16.7 28 12.7 Meningitis 0.1 0.2 0.2 0 0 0.1 Mumps 253 155 150 550 506 277 Paratyphoid fever 0.2 0.2 0 0 36.8 4.2 Pertussis 0 0 0 0 0 0 Poliomyelitis 0.2 0 0 0 0 0.06 Rubella 0.3 11.6 8 1.2 0 6.4 Scarlet fever 6.3 0 0.2 0 12.5 3.9 Tuberculosis (respiratory) 0.2 1.2 0 2.7 6.1 1.3 Typhoid fever 1.1 0 0 0 44 5.4 Note: No cases of ankylostomiasis, schistosomiasis, cholera, leprosy, diphtheria, plague, rabies, tetanus (adult/neonatorum), trachoma, relapsing fever (endemic/louse borne), malaria or syphilis were reported. TABLE 8. EXPANDED PROGRAMME ON IMMUNIZATION

Vaccination at Maternal and Child Health Clinics

Syrian West Field Jordan Gaza Lebanon Arab All Fields Bank Republic (A) Infants who completed full primary series Infants registered 24 142 11 928 27 584 4 910 7 171 75 735

1. Poliomyelitis (TOPV) vaccine

Vaccinated 21 549 12 107 25 166 4 937 7 304 71 063 Coverage rate (%) 89 102 91 101 102 94

2. Triple (DPT) vaccine

Vaccinated 21 610 11 957 25 606 4 955 7 322 71 450 Coverage rate (%) 90 100 93 101 102 94

3. BCG vaccine

Vaccinated 23 454 11 779 25 611 4 932 6 574 72 350 Coverage rate (%) 97 99 93 100 92 96

4. Measles vaccine

Vaccinated 20 560 11 440 24 912 5 226 7 064 69 202 Coverage rate (%) 85 96 90 106 99 91 (B) Tetanus immunization of pregnant women Tetanus toxoid

Under supervision 17 265 11 384 29 568 4 927 6 542 69 686 Vaccinated 5 049 3 981 11 234 1 597 4 520 26 381 Note: 1. Coverage rates were calculated on the basis of infants, children and pregnant women registered at UNRWA maternal and child health clinics.

2. Coverage rates in excess of 100 per cent include vaccinations provided to infants of non- registered refugees who have access to UNRWA clinics for immunization.

3. Because of the high coverage of tetanus vaccination during infancy on school entry and in preparatory school, only primigrávida and pregnant women who had not received a booster dose of tetanus immunization within five years from the present pregnancy are given a booster dose of tetanus toxoid. The number of women vaccinated does not, therefore, match the number of pregnant women under supervision. TABLE 9. ENVIRONMENTAL HEALTH SERVICES

Syrian West Field Jordan Gaza Lebanon Arab All Fields Bank Republic A. Population served

Registered refugees as at 31.12.1993 1 140 000 492 000 625 000 335 000 329 000 2 921 000 Camps 10 19 8 12 9 58 Camp population 161 000 Percentage of camps to 296 000 124 000 330 000 90 000 1 001 000 total registered refugees 48 26 25 52 27 34 B. Water Supply

Percentage of shelters served by indoor connections 92 98 100 96 75 93 C. Liquid Waste Disposal

Camps partially or fully connected to sewerage systems 6 6 3 10 8 33 Percentage of shelters connected to sewerage systems 66 37 27 60 85 57 D. Refuse Disposal

Camps served by UNRWA mechanized equipment 0 10 8 10 2 30 Contractual agreements: With municipalities 6 5 0 2 3 16 With private contractors 4 2 0 0 4 10 Local disposal 0 2 0 0 0 2 Total 10 19 8 12 9 58 Note: 1. In all these services it is not uncommon that camp population are served by more than one source/system.

2. All camp shelters Agency-wide are served by private latrines connected to local cesspits or proper sewerage schemes.