^^ WORLD HEALTH ORGANIZATION A44/INF.D0C./8 ORGANISATION MONDIALE DE LA SANTE 6 May 1991
FORTY-FOURTH WORLD HEALTH ASSEMBLY
Provisional 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-fourth World Health Assembly, for its information, a report by the Ministry of Health of Israel.
1 See Annex. A44/INF.D0C
ANNEX
STATE OF ISRAEL MINISTRY OF HEALTH
HEALTH IN JUDEA/SAMARIA AND GAZA
1990-1991
APRIL, 1991 JERUSALEM TABLE OF CONTENTS
Table of Contents i
Tables and Figures ii
Foreword V
1. Highlights 1
2. Demography and vital statistics 6
3. Socio-economic conditions 8
4. Primary health care 12
5. Hospital services 38
6. Manpower and training 4 7
7. Environmental protection 56
8. Administration and finance 58
9. Research 61
10. International cooperation 63
11. Planning 65
12. Summary 67
13. Bibliography 68
14. Index 73 TABLES
Table 1: Population in Judea/Samaria and Gaza 1970-1990 . 6
Table 2: Percentage Annual Growth, Judea/Samaria and
Gaza, 1970-1990 7
Table 3: Births and Birth Rates, Judea/Samaria, 1970-1990 7
Table 4: Births and Birth Rates, Gaza, 1970-1990 7
Table 5: Gross Domestic Product, Judea/Samaria and Gaza, 1972-1987 8 Table 6: Home Facilities in Judea/Samaria and Gaza, 1972, 1981 and 1985 11
Table 7: Calories Per Capita in Food Supplies, Judea/ Samaria and Gaza, 1970-1986 12
Table 8: Homes with Less Than Three Persons Per Room, Judea/Samaria and Gaza, 1975-1989 ... 12
Table 9: Primary Care Facilities Operated by the Government Health Services in Judea/Samaria and Gaza, 1970-1990 14
Table 10: Infectious Disease Rates Reported in Judea/Samaria Gaza, 1970-1990 15
Table 11: Immunization Program for Infants, Judea/Samaria, 1991 18
Table 12: Immunization Program for Infants,Gaza, 1991 . 18
Table 13: School-Age Immunization Program, Judea/Samaria and Gaza, 1991 19 Table 14: Circulating Antibody Levels Determined in Sero-surveys in School-Children aged 6-7 Years in Judea/Samaria 20 Table 15: Tuberculosis Incidence Rates in Judea/Samaria and Gaza, 1972-1990 22
Table 16: % of Total Births Occurring in Hospital or Medical Centers, Judea/Samaria and Gaza, 1970-1990 . . 22
Table 17: % of Low Birth Weight of Newborns in Government Hospitals/Medical Facilities, 1983-1990 ... 23
Table 18: Reported Infant Mortality Rates, Judea/Samaria and Gaza 1970-1990 25
Table 19: Child Mortality Rates by Cause, Ages 1-4, Judea/Samaria, 1988-1990 27
Table 20: Mortality from Selected and All Causes of Death, Judea/Samaria, 1988-1990 27
Table 21: Brucellosis: Reported Cases and Incidence Rates, Judea/Samaria, 1981-1990 34
Table 22: Ambulance Service in Judea/Samaria and Gaza, 1990 36
Table 23: Present and Projected Hospital Beds,
Judea/Samaria, 1990 39
Table 24: Hospital Utilization, Judea/Samaria, 1977-1990 40
Table 25: Hospital Beds in Gaza, 1977-2000 Projected . . 40
Table 26: Present and Projected Acute Care Hospitals and
Beds, Gaza, 1990-2000 41
Table 27: Hospital Utilization, Gaza, 1977-1990 .... 41
Table 28: Manpower in the Government Health Service,
Judea/Saroaria 54
Table 29 : Manpower in the Government Health Service, Gaza 54
Table 30： Health Manpower in Government Hospitals, Judea/Samaria 1990 55 FIGURES
Figure 1: Distribution of Government Health Services by District, Judea and Samaria, 1990 9
Figure 2: Distribution of Government Health Services
by District, Gaza, 1990 10
Figure 3: Pertussis, Judea/Samaria and Gaza, 1970-1990 • 16
Figure 4: Measles: Judea/Samaria, Gaza 5 year annual average rates, 1968-1987 17
Figure 5: Polio： Judea/Samaria, Gaza, 5 year annual average rates, 1968-1988 17
Figure 6: Gaza Infant Growth Patterns : Weight-for-Age, 1987-1989, Under the 10th Percentile 24
Figure 7: Reported Infant Mortality Rates, Judea/Samaria, Gaza, 1970-1990 26
Figure 8: Brucellosis, Judea/Samaria, 1980-1990 .... 34 FOREWORD
A number of important steps forward occurred during 1990. This was highlighted by the opening of the fully modern new surgical building at Shifa Hospital in Gaza. New projects were also completed in several government hospitals in Judea/Samaria, including the new physiotherapy, emergency and other service building in Rafidia Hospital in Nablus, and the new operating wing at Hebron Hospital.
The Israel Government Health Services (IGHS) in Judea/Samaria and in Gaza have continued to develop their own services, and to encourage the development of non-government health services fostered by charitable organizations• New hospitals have been approved for construction and operation by non-governmental agencies in both areas. The new Hebron Hospital is under construction and will become operational in stages over the coming years.
Emphasis continues to be placed on developing primary health care, especially in prevention of infectious diseases, pregnancy care, hygiene, and nutrition, in keeping with recommendations of the international health community. Great success has been achieved in control of dreaded infectious diseases including polio, and more recently measles, contributing to the improvement in infant and child health. Studies also show very great improvement in nutrition of infants.
The year 1990-91 has been a difficult one in Israel, Judea/ Samaria and Gaza. Nevertheless, the health services have continued to provide needed health care, including preventive services and curative care. The following report documents this progress. 1. HIGHLIGHTS OF 1990/1991
!•! JUDEA/SAMARIA
1.1.1 Emergency Health Services
** Preparation for management in the event of chemical attacks;
Staff training for 605 medical, nursing, administrative and ambulance personnel in the principles and practices of chemical injury management;
** Designation and preparation of б hospitals for chemical injuries - evacuation, reception, decontamination, triage, and treatment of chemical injuries；
** Equipping hospitals for potential emergency treatment of chemical warfare injuries with showers for removal of chemical contact agents, as well as treatment, antidotes and drug therapy, positive pressure respirators, as well as other equipment and supplies for other types of war injuries；
1.1.2 Hospital Development
1 Hebron Hospital s new East Wing, including an out-patient department, cardiac assessment unit, laboratories and new surgical wing is under construction with the financial support of the Government of Italy;
** Hebron Hospital's new operating theater suite was completed and put into operation, including 3 modern operating rooms, a recovery room, and a central sterile supply department;
** Rafidia Hospital in Nablus has completed construction of
the emergencf y department, administration, physiotherapy, physicians residence and pharmacy wing which is now being equipped and prepared for operation；
1 ** Ramallah Hospital s new surgical wing was expanded to 4 modern operating rooms, and a recovery room, which are now being equipped for operation；
** Ramallah Hospital has completed construction of the new building for the Computerized Tomography and Cardio/Pulmonary Assessment units; 1 Ramallah Rehabilitation Center operated by the Patient s Friends Society of Ramallah саше into operation with a large out-patient department, staffed by highly professional medical, nursing, physiotherapy and occupational therapy staff from Sweden and Norway, with a training program for local staff;
Beit Jallah Rehabilitation Center has commenced operation of its outpatient service, along with its Occupational Rehabilitation Service for cerebral palsy, post-polio, congenital malformation, and other medical rehabilitation cases;
Holy Family Maternity Hospital was opened in Bethlehem with 31 beds, sponsored by the Knights of Malta Order.
3 Primary Health Care
The immunization program has been further expanded by adding the third dose of IPV at age 12 months to the 4 feedings of OPV and adding a second dose of measles vaccine for school age children in grade 1. The measles immunization program has been expanded with a special campaign in 1990 for grades 1 to 3, and addition of booster doses of TOPV for pupils in grades 1 and 9;
Mid-term Evaluation of the Expanded Primary Health Care Project serving 49 villages in Hebron District was carried out measuring Knowledge, Attitudes and Practices of pregnant women. Process and outcome measures of pregnancy and child care in the Village Health Rooms showed a major impact of the Village Health Room program;
Opening of 2 new Maternal and Child Health Centers•
4 Staff Professional Development
Nurse training in a neonatal and pediatric intensive care course of 7 months commenced at Assaf Harofe Hospital;
The health services administration course conducted by Haifa University over a 2 year period was completed by 23 Arab and Israeli senior physicians, administrators and
A 2-month course in biostatistics, research methods and computers for 14 medical and statistical staff of the Israel Government Health Service (IGHS) in Judea/Samaria, and 3 from Gaza is being given at the School of Public Health and Community Medicine of Hadassah-Hebrew University in Jerusalem; Training of ambulance drivers from government and non- government health services, including Red Crescent, UNRWA and others, continued during 1990, with 102 completing the 12 day course operated by Magen David Adorn of Israel, with Arabic speaking staff;
Training in first-aid for Village Health Workers from the Hebron program in primary health care in small villages was carried out in Jerusalem by Magen David Adorn staff in 3 day courses in Arabic, to be followed by continuing education in this field during 1991.
5 Environmental Protection
The first stage of the Hebron City sewage treatment plant was completed and construction of the second stage, funded by the Israeli Civil Administration, will begin in the summer of 1991;
Planning for new garbage disposal facilities for the municipalities of Ramallah, Jenin and Kalkilia is under way.
6 Others
A visiting surgical team of the American Physicians for Peace carried out a number of complex plastic-urological surgical procedures on patients from Judea/Samaria and Gaza in 1990;
19 new pharmacies received licenses during 1990;
A hospital discharge information system for all hospitals in the area is now in advanced stages of preparation•
GAZA
1 Emergency Health Services
The Ophthalmic Hospital was designated and prepared to receive cleanse, triage and treat potential victims of gas warfare attacks; this included equipping with antidotes, other medications, respirators and other support services. During the emergency situation, staff from other hospitals and primary health care were seconded for this service which has been operating 24 hours a day. Other hospitals served as backup for trauma cases;
420 medical, nursing, ambulance drivers and administrative staff of government and non-government hospitals in Gaza were trained in management of persons injured in chemical warfare. 1.2.2 Hospital Development
*• Building 8 in Shifa Medical Center was completed and put into operation in 1990. The new building includes 157 beds, a completely modern surgical suite, recovery and intensive care units, orthopedics and surgical departments as well as emergency room, out-patient department and radiology department;
*• Bureij Hospital operated jointly by the IGHS and UNRWA for many years for ТВ patients was by mutual consent closed, due to the low incidence of tuberculosis in the area, and the staff was transferred to the new Shifa Hospital Chest Department.
1.2.3 Primary Health Care
• • The immunization program in Gaza continued to have over 90% coverage of infants and full cooperation between the IGHS and UNRWA.
A joint measles campaign was carried out by the IGHS and UNRWA to immunize all school and pre-school children with a second dose of measles vaccine in order to prevent the measles in Ramallah and Beersheva from entering the area;
A study of growth patterns among infants attending five government community health centers showed a major improvement in weight and height for age according to international growth standards as compared to data from 1987;
A WHO study of growth patterns among UNRWA populations also showed very substantial improvement over a 1984 study, and Gaza children appeared to have better growth patterns than all other fields of service of UNRWA；
High risk pregnancy identification and care has been improved over the past year by having obstetricians from Shifa and Khan Younis Hospitals provide prenatal care in 20 of 28 IGHS community health centers.
1.2.4 Staff Professional Development
•• A course for 19 Gaza public health nurses is being conducted both in Gaza and at Wolfson Hospital in Tel Aviv, using the curriculum of the Israeli public health nursing course； Training in intensive care nursing for infants and adults at Ashkelon Hospital for 10 Gaza nurses has helped in preparation for the opening of the intensive care facilities in Building 8 at Shifa Hospital;
The two year course in basic and clinical sciences for 35 family physicians at Beer Sheba Medical School continues;
A two year full-time course for 40 radiological technicians for Gaza health services at Sheba Medical Center in Tel Hashomer and in Gaza is to begin in the spring of 1991;
A course in anesthesia of 2 1/2 year duration for 13 Gaza physicians will commence in several hospitals in Israel in the spring of 1991.
A 3 day seminar on health administration was held in 1990 for 30 senior physicians, nurses and administrators;
Individual training continued in Israeli teaching hospitals for physicians in gynecology orthopedics, / hematology oncology, psychiatry, gastroenterology, oral- # maxillary surgery, and radiology.
1.2.5 Environmental Protection
Sewage projects funded through the UNDP have neared completion, linking Jabaliya refugee settlements to the northern central sewage system；
The sewage treatment plant serving Gaza City and adjacent areas is now functional. 2. DEMOGRAPHY AND VITAL STATISTICS
2.1 Population Density
Gaza, with an area of 362 square kilometers, has a population density of some 1,758 persons per square kilometer, with 52% of the population living in the five main urban centers. The area is divided into five districts: the northern district (Jabaliya, Bet Lahia, Bet Hanoun) with a 1990 population of 93,000; Gaza City with 239,000; Dir el Balah and middle camps with 95,000; Khan Younis with 129,000; and Rafah with 81,000. There are 7 refugee settlements located near the main urban centers in the Gaza Strip.
Judea/Samaria includes an area of 5,500 square kilometers, so that the population density is 168 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.
2.2 Population Growth
The population of Judea/Samaria and Gaza continues to grow at high rates due to the high birth rates, and reduced infant, child and crude mortality rates. Growth is also affected by changing migration patterns in the area. The population is young, with some 47% of the total population between the ages of 0-14 years.
Data is from the Central Bureau of Statistics, except that for 1990 which are preliminary from the Civil Administration in each area.
Population data for Judea/Samaria and Gaza, along with rate of annual growth are shown in the following Tables (1 and 2).
Table 1: Population in Judea/Samaria. and Gaza, 1970-1990
Population/ Year 1970 1975 1980 1985 1990*
Judea/Samaria 607.8 675.2 724.3 815.5 925.0
Gaza 370.0 425.5 456.5 527.0 636.5
Note: * 1990 data are preliminary estimates of the Israeli Civil Administration. The population for 1990 in Gaza is an estimate based on a recent registry of population, and excludes those with residential status but who are currently living abroad. Table 2： Percentage Annual Growth. Judea/Samaria and Gaza. 1970-1990
% annual growth/ Year 1970 1975 1980 1985 1990*
Judea/Samaria 1.7 0.8 0.8 2.8 3.1
Gaza 1.7 2.8 2.7 3.4 3.5 Note: * 1990 data are preliminary estimates of the Civil Administration.
2.3 Fertility
The total number of births in Judea/Samaria has increased steadily over the years, but the birth rate has declined, from 45.4/1,000 population in 1975 to 37.8 in 1990. There was a slight rise in the birth rate per 1,000 population, from 1988 (37.2) to 1989 (40.6), declining in 1990 to 37.8. Births in Gaza increased from 32,500 in 1989 to 33,100 in 1990, with a birth rate of 52 per 1,000 population.
Table 3: Births (000's). and Birth Rates. Judea/Samaria. 1970-1990
Year 1970 1975 1980 1985 1990*
Total births 26.4 30.5 30.4 33.2 35.0 (000's)
Birth rate* 43.9 45.4 42.1 41.3 37.8
Note: Births per 1,000 population. * 1990 data preliminary.
Table 4: Births, and Birth Rates. Gaza. 1970-1990
1970 1975 1980 1985 1990
Total births 16.0 21.6 21.4 23.5 33.1 (000's)
Birth rate/1,000 population - 49.5 47.6 47.3 52.1
Note: 1990 preliminary estimates. 3. SOCIOECONOMIC CONDITIONS
3.1 GNP per Capita
Economic conditions have been characterized by increases in gross national product per capita from 1968 to 1987. Data for the period 1982-1987 are shown in Table 5 (in US $)• Economic indicators for the years 1988-1990 show adverse economic effects of the political situation, with effects on family disposable income and economic activity in general.
Table 5: Gross Domestic Product, Judea/Samaria and Gaza, 1972-1987, in US $
Years 1972 1975 1980 1987
Judea/Samaria $410 836 1,334 2,090
Gaza 268 605 878 1. 486
Judea/Samaria have reached per capital GNP levels within the "middle level of development" i.e. over $1,500 GNP per capita; Gaza is close to that category. Data in tables 5-7 are the most recent data available from the Central Bureau of Statistics periodic surveys in Judea/Samaria and Gaza.
3.2 Economic Development
Economic development has been based on full employment, improved agricultural productivity, business and service industries and small scale industrial development.
During the 1988-90 period recurrent general and commercial strikes and disturbances have adversely affected the local economic situation, including business activity and family incomes.
3.3 Education
Education has been compulsory to the age of 14 for both sexes for the past 15 years. This 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. FIGURE 1： Distribution of Government Health Services, Judea/Samaria, 1990
.?. II • д JFNIM
_LUS UISI • A h Mtfüíffsf：!?： ,t 5丨：丨，80i:i 'тии<лпм ,NAP. I из • •赛
ITULKARM DIST. 145, lOtiV о —
ПЛМЛИЛН HIST 144,300V
•IFRICIIO ÜISr. 參* 14,70i:iV/ плмлилн EL UIHEII M • Д JFRICIIO
96, irinV • IM ••少 • - HFTIIIflirM
223,21:丨丨:丨、 H I lospilal IIEBnoN DIST General clinic MA•汆A•水 MCH HEBRON о Mobile Clinic Т.В. Contre Specialized Clinic
•population oetlmatee by government hnnlth services. FIGURE 2： Distribution of Government Health Services, Gaza, 1990 In Judea/Samaria over 60% of the total population aged 18-24, and over 42% of those in the age group 25-34 have 9 or more years of education. Educational levels are higher in Gaza; 63% of those in the 18-24 age group and 61% of those in the 25-34 group have 9 or more years of education.
During 1988-1990 the education system in Judea/Samaria was disrupted by strikes, disorders and administrative closures. The education system in Gaza continued to function during this period almost without interruption.
3.4 Home Facilities
Changes in living conditions are shown in the Table 6 regarding percentage of homes with specific facilities.
3.5 Living Standards
Living standards for most residents of Judea/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 Judea/Samaria and Gaza in terms of food value in calories per capita.
Table 6: Home Facilities in Judea/Samaria and Gaza. 1972. 1981 and 1985
Area/ Years 1974 1981 1985
Judea/Samaria 50.6 63.1 Electricity 24 hours/day 45.8 31.0 28. 1 Electricity part time - 44.9 61.6 Running water in dwelling 23.5 60.7 66.1 TV set 10.0 75.3 84.6 Gas/electric cooking range 32.7
Gaza 88.5 92.8
Electricity 24 hours/day 34.5 51.4
Running water in dwelling 13.9 69.6 76.5
TGas/electriV set c cooking range 12.7.75 70.9 8。1 Table 7: Calories per Capita in Food Supply, Judea/Samaria and Gaza. 1970—1986
Calories/capita/Years 1970 1975 1980 1986
Judea/Samaria 2661 2761 2808 2931
Gaza 2309 2384 2500 2612
3.6 Housing
The following table (Table 8) indicates changes in living standard for the population of Judea/Samaria and Gaza, as indicated by percentages of home s with less than three persons per room.
Table 8: Homes with Less Than Three Persons Per Room. Judea/Samaria and Gaza. 1975-1989
Area 1975 1980 1985 1989
Judea/Samaria 47.4 52. 8 63 .6 70.1
Gaza 52.5 56 . 6 59 .9 66 . 5
4. PRIMARY HEALTH CARE
4.1 Program Priorities
Emphasis in the IGHS in Judea/Samaria and Gaza over the years has been placed on developing primary health care with the following priorities :
4.1.1 Expanded program of immunization (EPI);
4.1.2 Sanitation - garbage disposal, -safe water supply and chlorination, -sewage collection, -food safety;
4.1.3 Control of infectious diseases；
4.1.4 Oral rehydration (ORS) for diarrhoeal diseases;
4.1.5 Primary health care located close to the population; 4.1.6 Hospital or medical center deliveries;
4.1.7 Supervision and training of traditional birth attendants (Dayas);
4.1.8 Growth monitoring and nutrition education;
4.1.9 High risk pregnancy identification, referral• follow-up; 4.1•10 Expanded primary health care in small villages - the Hebron project;
4.1.11 Screening for congenital diseases (PKU and hypothyroidism) and treatment;
4.1.12 Health education/community involvement;
4.1.13 School health;
4.1.14 Control of infectious and non-infectious diseases.
4.2 Primary Health Care Services
Primary health care facilities established and operated by the IGHS of the Israeli administration in Judea/Samaria and Gaza are shown in Table 9.
In Judea/Samaria there is a total of 176 IGHS primary care units, including 136 combined general and MCH clinics, 6 separate MCH centers in urban areas and 34 general clinics without MCH services. MCH Centers operated by the IGHS in Judea/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.
In Gaza, the IGHS operates 28 Community Health Centers which provide immunization and well child care services, as well as treatment services. Services are free for children up to age 3, and for pregnancy care. Twenty-two of the centers now provide pre and post-natal care with an obstetrician in attendance. UNRWA operates 9 Health Centers, providing MCH and some other primary health care services. Table 9: Primary Care Facilities Operated bv the Government Health Services in Judea/Samaria and Gaza. 1970- 1990
Area 1970 1975 1980 1985 1990
Judea/Samaria General Clinics 105 126 140 156 168
MCH Centers 25 29 71 115 141
Village Health - 49 Rooms
High Risk Pregnancy Clinics -
Specialized NA Clinics
Mobile Clinics -
Gaza Community Clinics 3 12 22 24 28
Three of the Community Health Centers operated by the IGHS in Gaza operate delivery units on a 24 hour a 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 IGHS 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. During emergency situations, 12 of the Community Health Centers in Gaza operate from 7 a.m. until 7 p.m. continuously, while the remainder operate according to their regular hours•
Planning for primary health care in Gaza calls for 32 IGHS 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. 4.3 Control of Childhood Infectious Diseases
Immunization for the major childhood diseases has resulted in increasing control and elimination of these diseases, as shown in the attack rates for these diseases in the following tables (in case rates per 100,000 population).
Diphtheria, pertussis, tetanus and polio have been largely controlled or have virtually disappeared. Measles still occurs in outbreaks, but with a steep overall decline. Major outbreaks of measles occurred in 1975, 1979, 1982, and 1985- 86. As a measles outbreak was anticipated during 1990-91, a mass immunization campaign among preschool and school aged children was carried out in the fall of 1990.
In late 1990/early 1991 an outbreak of measles occurred in Ramallah district which was controlled by mass vaccination of all school children up to age 18 and case contacts in affected areas. Outbreak prevention in Gaza, in addition to the routine immunization program, was required because of a 1990/91 outbreak of measles in Beersheva. Gaza school children age 6-12 and preschoolers age 2-6 were immunized in a special campaign, in addition to the routine program, in full cooperation between the IGHS and UNRWA.
Table 10: Infectious Diseases Rates fper 100.000 Population) Reported in Judea/Samaria and Gaza. 1970-1990
Rates 1990 Disease/Year 1970 1975 1980 1985 No. Rate
Judea/Samaria
3 о о о Diphtheria 0 о 0.8 2.7 о о о о Pertussis 8 3 2 2 о 3 о 1 Tetanus 53 7 0 о о о Polio о 3 0 2 б 9 о 1 7 1 Measles 16 52 2 10 76 1
Gaza
о Diphtheria 1 0 2 0 0 0 0 0 Pertussis 30 6 11 0 0 0 0 Tetanus 3 10 8 6.3 2.2 7 1 0 Polio 1 31 3 0 о 0 Measles 137 2 18 5
Note: * 5 neonatorum, 2 adults. Gastroenteric and parasitic disease are still prevalent, particularly in the refugee settlements in Gaza primarily due to the less than ideal sanitary conditions. Morbidity, hospitalization and mortality resulting from these diseases however, is much less now than it has been in previous years.
FIGURE 3:
Pertussis Judea/Samar ia, Gaza 1970-1990
1ШЩ1 Jud«a/Smnazla
Rates pez lOO,ООО population FIGURE 4:
Measles : Judea/Samaria, Gaza 5 Year Average Annual Rates
111 U-72L 197Э-77
ш/Зш шпш<
per 100,ООО population
FIGURE 5:
Polio: Judea/Samaria, Gaza 5 Year Annual Average Rabes
^шш •lili -72 1»7Э-77
ЛлЛля/Лтятх1л ШЛИ <
Incidence ratee 100,000 population 4.4 Immunization Program
The routine immunization schedules used in Judea/Samaria and Gaza have recently been modified following extensive discussions and consultations with Israeli Ministry of Health and international experts in this field. The Israeli program of immunization was adopted, with modifications in keeping with the local epidemiologic situation.
Table 11: Immunization Program for Infants Judea/Samaria. 1991
Aae (Months) 2 4 6 12 15
DPT DPT DPT DPT MMR
elPV ElPV - elPV -
- TOPV TOPV TOPV -
Table 12: Immunization Program for Infants, Gaza. 1991
Acre (Months) 1 2.5 4 5.5 9 12 15
BCG OPV(I) TOPV TOPV TOPV - TOPV - elPV elPV DPT DPT DPT - DPT - M - MMR Table 13: School Age Immunization Program, Judea/Saroaria and Gaza. 1991
Acre fvears) 6^7 8^9 12fGirls) 15-16
Vaccine DT Measles* Rubella** TT
TOPV TOPV
MMR/Measles*
BCG Note： See measles campaign 1990/91 below• Rubella = German Measles; An extensive program of immunization against Rubella among school age girls and women in the age of fertility has been carried out over the past several years. RT о PG V и D T II Triple Oral Polio Vaccine (Sabin) с в II Diphtheria Tetanus и TMT ]i l Bacillus Calmette-Guerin (ТВ) M Tetanus Toxoid Measles, Mumps, Rubella
4.6 Special Immunization Programs
4.6.1 Hepatitis В Vaccine for Newborn Carriers
This was introduced in Judea/Samaria IGHS in 1989• 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 is 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.
4.6.2 Hepatitis В Vaccination of Health Workers
Hospital employees in Judea/Samaria, particularly those working with blood products in laboratories, blood banks, operating rooms, dialysis and intensive care units, emergency rooms and delivery rooms, are given prophylactic immunization with Hepatitis В vaccine. In Gaza, during 1990, health workers in hospitals, including Ahli Hospital and blood bank staff, were immunized with Hepatitis В vaccine.
4.6.3 Meningococcal A Vaccine
This vaccine is given to pilgrims making the pilgrimage to Saudi Arabia 10 days prior to departure. 4.6.4 Measles
An epidemic of measles was anticipated in the area during the 1990-1992 period, following the 3-4 year cycle and the experience of 1982 and 1985/86 epidemics. A second dose measles campaign was conducted in all Gaza health services during 1990-1991 in order to fully cover children between 2 to 12 years of age, and to move toward maximum control and elimination of measles in the area.
In Judea/Samaria primary school students in grades 1-3 have been given the second dose of measles and grades 4一6 will be given the second dose in the coming school year. A catchup campaign of unvaccinated children age 2-6 years was also carried out in 1990. The epidemic began in Ramallah district in late 1990 and spread to Beersheva district in early 1991.
4.7 Antibody Serosurveys
Serosurvey results of two separate random sample studies of school children aged 7-9 years in Judea/Samaria are seen in Table 14, showing the percentage of persons in the samples with protective antibody levels.
In a 1987 serosurvey among a representative sample of 14 year old school girls in Judea/Samaria, rubella antibodies were found at a protective level in 100%, and hepatitis A antibodies in 100%.
Table 14: Circulating Antibody Levels Determined in Serosurveys in School children Aged 6-7 Years in Judea/Samaria
Polio Year (I, II, III、 Measles Rubella Tetanus
1983 97 91 49 98
1987 96-99 82 - 72 (types I,II and III)
Following the serosurveys, a number of changes have been made in the immunization schedule. In 1990, a serosurvey of polio antibody levels was carried out in Gaza children in government and UNRWA health services, and high levels of protective antibody were shown. Antibodies to type III polio were however, lower for children who had received OPV only as compared to those who had received the combined OPV/IPV program. This reinforces the need to continue with the combined OPV/IPV program using the enhanced strength IPV. A similar serosurvey in Judea/Samaria is in process.
4.8 Poliomyelitis
An outbreak of poliomyelitis occurred in Israel in 1988, mainly in one subdistrict where enhanced IPV was used exclusively for 6 years; a total of 15 cases occurred among persons with only OPV as their previous immunization.
A mass immunization campaign with OPV was carried out in October 1988 for everyone aged 0 to 40 in Israel, as well as in Judea/Samaria and Gaza. In this campaign, 798,000 persons were immunized in Judea/Samaria in a large number of immunization centers. The success of these campaigns organized by the IGHS involved the participation of all health and many other agencies, as well as the general public.
No cases of polio have been reported in Judea/Samaria and Gaza since 1988. The combined OPV/IPV polio immunization program carried out over the past ten years was recently reported in a leading journal of public health. Figure 5 (page 17) shows polio incidence in 5 year annual average rates since 1968.
4.9 Tuberculosis
Tuberculosis has generally declined as seen in the following Table (15), with a more significant decline in Gaza. A review of preventive and diagnostic services for ТВ is currently under discussion, with regard to the role of BCG in ТВ control. Gaza has had no cases of miliary or meningeal ТВ in children over the past 15 years. BCG is used at one month of age in Gaza, and at school entry following tuberculin testing in Judea/Samaria. Positive tuberculin testing in grade one is followed by full diagnostic work-up on the child and his/her family. Table 15: Tuberculosis Incidence Rates. Judea/Samaria and Gaza. 1972-1990
Year 1972 1975 1980 1985 1987 1989 1990
Judea/Samaria Cases 108 119 191 113 110 145 88 Rates NA 17.5 27.1 14.0 12.8 15.8 9.0
Gaza Cases 199 164 59 57 18 11 19 Rates 49.7 38.2 12.9 10.7 2.9 1.6 2.7 Note: Rates per 100,000 population Data since 1979 for Gaza does not include population from the Sinai.
4.10 Deliveries in Medical Institutions
Hospital and medical center deliveries as a percentage of total deliveries in Judea/Samaria and Gaza has increased steadily over the years, from 15% to 68% in Judea/Samaria, and from 10% to 80% in Gaza from 1970 to 1990 (see section 2).
Births in Gaza also increased in 1989, and the birth rate remains over 45/1000 population. Births in medical facilities have increased over the years, from 10% in 1970 to over 63% in 1989. In 1990, a study of place of birth showed that 65% of all deliveries took place in government medical facilities, with another 15% in private medical facilities, and the remaining 20% occurring at home, indicating that some 80% of all births took place under medical supervision.
Table 16: Percentage of Total Births Occurring in Hospital or Medical Centers. Judea/Samaria and Gaza. 1970—1990
1970 1975 1980 1985 1990
Judea/Samaria 15.0 30.1 40.4 55.9 68.0
Gaza 10.0 45.2 65.0 78.0 80.0
Note: Data for 1970 includes hospital deliveries only; data from 1975 includes hospital and medically supervised delivery units; data for 1990 includes hospital and medical center deliveries including private medical centers. 4.11 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 17: % of Low Birth Weights of Newborns in Government Hospitals/Medical Facilities
Years 1983 1985 1988 1989 1990
Judea/Samaria б.8 б.1 8.1 9.5 9.8
Gaza 5^2 5.9 7.5 4 .1 =
The higher rates of LBW in Judea/Samaria may be related to the program of referral and follow-up of high risk pregnancies and primipare cases who are encouraged to have their deliveries in medical facilities.
4.12 Growth of Infants
Studies of growth patterns of infants and school children carried out in Judea/Samaria showed some differences to the standard patterns of the United States National Center for Health Statistics (NCHS) infants sample. These variances were 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 Judea/Samaria and Gaza. Breast fed children had growth advantage over non-breast fed children 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 IGHS in Judea/Samaria and Gaza as an essential part of routine well child care, accompanied by nutritional education of mothers.
New well child care records have been adop.ted in the IGHS in both Judea/Samaria and Gaza for use in community clinics, MCH centers and Village Health Rooms. Emphasis has been placed on the subject of infant nutrition in staff training and maternal health educational programs• A study of growth patterns of infants attending 5 IGHS community health centers in Gaza for routine immunization in 1987 and in 1989, was recently completed. During 1986-87 stress was placed by the Gaza Child Health Committee and in the IGHS on nutrition monitoring and education, as well as routine provision of iron and vitamin A and D. The growth patterns in weight-for-age and length-for-age showed marked improvement, and have come close to the accepted international standard NCHS growth curves. The study included analysis of feeding patterns, which showed longer duration of breastfeeding.
FIGURE 6: Gaza Infant Growth Patterns
Gaza Infant Growth. Patterns Weight - for - Age, 1987 - 1989 Under 10th %
Age in Months
Ш 87/ee _ аэ In 1990, a study was carried out by WHO on nutrition status of the population in refugee settlements 'under care of ÉJNRWA in Judea/Samaria and Gaza and in adjacent countries. The study showed a marked improvement over the previous 1984 study. A time trend study of growth patterns of children attending 10 sentinel MCH centers in Judea/Samaria will be completed by the Ramallah WHO Collaborating Center for Health Services Research during 1991/92.
4.13 Infant Mortality
Infant mortality has declined rapidly in the Gaza area as the childhood infectious and diarrhoeal diseases were brought under control through successful immunization and ORS programs• Increased hospital and medical center deliveries, as well as rising educational and socioeconomic standards, have also contributed to this improvement•
Gaza infant mortality has declined from 86/1000 in 1970 to 25/1000 in 1990 (see table 18 and figure 7). Studies are continuing concerning causes of infant mortality as part of research into primary health care in the area.
In Judea/Samaria infant mortality rates have declined, but the rates1 are difficult to determine particularly during the 1970 s, 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 1 increased the reliability of infant mortality data in the 1980 s. It is currently estimated that neonatal deaths are under-reported by between 25-35%
In 1988, a visiting WHO consultant in perinatal epidemiology suggested methods of improving reporting and data analysis in infant mortality. Table 18 shows reported infant mortality trends in rates per 1000 live births based on reported cases.
Table 18: Reported Infant Mortality Rates. Judea/Samaria and Gaza, 1970-1990
Area/Year 1970 1975 1980 1985 1990
Judea/Samaria - 38.1 28.3 25.1 22.0
Gaza 86.0 69,3 43 . 0 33 . 4 26 .1
Note: Reported infant deaths (0 to 12 months) per 1,000 live births• A 1989 study of infant mortality in the refugee camp population in Judea/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 1988. In the 1990 evaluation of the primary health care project in 49 small villages in Hebron district, the infant mortality rate was reduced from 80 to 33 per 1000 live births among the women attending the VHR's, comparing their previous IMR to their current IMR.
Reported. Infant Mortality Rates Judea/Samaria, Gaza 1970 -1990
Yi JiKUm/Svtutcia ШШШ
per 1,000 liv© 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.
4.14 Child and Adult Mortality
Mortality for children aged 1-4 in Judea/Samaria for the years 1988-1990 are seen in table 19. Table 19: Child Mortality Rates by Cause. Ages 1-4. Judea/Samaria. 1988-1990 fper 10.000 population)
Diseases 1988 1989 1990 n r n r n r
Respiratory 38 2.7 36 2.0 36 2.1
Diarrheal 0 0 0 0 9 0.5
Other infectious 2 0.1 5 0.3 1 0.1
Congenital anomalies 19 1.3 15 0.8 28 1.6
Accidents 27 1.9 24 1.3 20 1.2
Total All Causes 139 9.9 149 8.4 180 10.5
Changing patterns of morbidity and mortality over the years 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 a greater stress on reduced smoking, reduced use of fatty foods, and other self care features that are being introduced into school and health education programs.
Table 20: Mortality from Selected and All Causes of Death (per 100,000 population), Judea/Samaria, 1988-1990
Cause/Disease 1988 1989 1990
Infectious 5.2 3.8 7.1 Malignant 39.1 36.5 35.1 Ischemic heart 60.2 64.9 63.2 Cerebrovascular 36.2 32.2 31.2 Transport accident 7.0 3.6 6.4 Obstetrical causes 0.6 0.2 0.3 Respiratory 35.7 32.3 36 . 0
Total N 4,237 4,391 4,125 Population(000s) 887 919 92 Rate 4.15 Diabetes Mellitus
Over the past two years, three Diabetic Clinics have been established in Tulkarem, the Nablus Public Health Offices, and in Kalkilya. 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 who 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 卢lso being prepared. An epidemiologic survey of diabetes is in preparation.
Rimal Clinic in Gaza operates a diabetic clinic three days per week. It is attended by a specialist in endocrinology who was sent by WHO to London for studies in diabetes. Patients are referred from primary care clinics through out the area. During 1990 the clinic attended to 24,318 visits.
4« 16 Rehabilitation Services, Judea/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 in 1990. The center is planned for 100 bed capacity. It is funded jointly by the Government of Italy, the CDF, and the UNDP.
A 30 bed rehabilitation center is being funded by the Government of Sweden for operation by the Swedish organization, Diakonia. A building in Ramallah has been renovated for this purpose, and the center became operational for out-patient care during 1990.
In Gaza, a rehabilitation service is operated in Shifa Hospital.
4,17 Expanded Primary Health Care (EPHC)
In 1985, the Hebron Project Expansion of Primary Health Care (EPHC) in Judea/Samaria was undertaken as a special project by the IGHS, in conjunction with UNICEF. This project was designed to provide on-site preventive health care in small villages lacking MCH services in Hebron District. It was intended to provide better access to and utilization of well child and pregnancy care for the residents of these small villages, identification and care of high risk groups, thus reducing infant mortality especially associated with diarrheal and respiratory diseases, as well as improving nutrition and self care at '. ( a family level. It established Village Health Rooms (VHR'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)•
Primary health care in these small villages was previously 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.
During 1985, a pilot phase was carried out in 4 villages. This included a 6 month training program for local village high school graduates, preparation of health records and carrying a household health survey in all the homes in the villages. In 1986, a further 20 VHR* s were opened following the six months training program of VHW's, and in 1987 a further 25 VHR*s were opened.
1 Currently 49 VHR 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； * coordinating with Mukhtars re: sanitation, emergency transportation； * visiting all newborns at home； * visiting the sick - environmental health, 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• Proposals for expansion of this project to other areas have been submitted to various funding agencies¿
Evaluation of the project is being carried out by the Hebron Public Health Office, and the Ramallah Health Services Research Center (RHSRC). A study of Knowledge, Attitudes and Practices of mothers attending the Village Health Rooms has been completed by the RHSRC, showing a substantial impact of the VHR's 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's are operational, a high percentage 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 studied to date.
A study of pregnancy and child care in the Village Health Rooms was carried out by the Hebron Public Health Office. Pregnant women attending the VHR's made extensive use of prenatal care, had high percentages of hospital deliveries and much lower infant mortality, compared to their previous experience (from 80 per 1000 to 33 per 1000 live births). Growth patterns of children attending the VHR's showed considerable improvement over previous studies of rural Hebron child growth patterns. Referrals of malnourished children from Hebron villages to the Terre des Hommes Center in Bethlehem have declined substantially.
4.18 Traditional Birth Attendants
There are some 400 traditional birth attendants (TBAs or Dayas) in Judea/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 IGHS in Judea/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 Judea/Samaria and Gaza. With the assistance of UNICEF, new kits were provided for Dayas who successfully completed a program of study days. Continuing education for Dayas was expanded both in Judea/Samaria and in Gaza during 1988• In Judea/Samaria, a further program of Dayas training was carried out in 1990. This involved 1QÍ0 senior publié health nurses, Daya supervisors, qualified midwives and Dayas. The program was sponsored by the IGHS with UNICEF support and assistance.
In Gaza during 1990, all practicing midwives attended a UNICEF sponsored course and were provided with equipment for home deliveries. In each district within Gaza, the chief public health nurse supervises the local Dayas by checking instruments birth records, attendance at teaching sessions # and other meetings for annual licensure. Home deliveries still constitute 20% of all births in Gaza•
4.19 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 Judea/Samaria. School health services are being reviewed as part of a study of primary care services, and improved procedures for public health supervision of school hygiene and student health are being developed.
In Judea/Samaria, school health services are provided to some 280,000 students, and include 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 6th year elementary class girls (until 1995, as MMR has been given since 1987)； * Tetanus Toxoid (2 doses) to third preparatory class (age 15); 丄 • Measles vaccine is now given routinely to grade one pupils； * Measles booster campaign to cover school age children was carried out in 1990； * OPV to primary school entry pupils； • surveillance of infectious disease among students； • supervision of hygiene in schools.
In Gaza, a new emphasis on school health is being implemented during 1991. This emphasizes health education regarding nutrition, home safety and hygiene. It also includes early detection for parasitic diseases. The program covers all school children from 6-18 years in the government schools. 4.20 Oral Rehydration Salts
ORS is now used throughout the IGHS primary care centers in Judea/Samaria and Gaza. This, in conjunction with improving standards of sanitation, hygiene and nutrition, has resulted in a dramatic decline in mortality, hospitalization and serious morbidity from diarrhoeal 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.
Gastroenteritis deaths have declined in Gaza with use of ORS, but a recent increase has been noted and is under review.
4.21 PKU and Hypothyroidism Screening
Screening of newborns for Phenylketonuria (PKU) and Hypothyroidism was started in Judea/Samaria IGHS in 1987 in cooperation with Sheba Medical Center, Tel Hashomer. In this project, infants born in hospitals 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 IGHS.
During 1989, 9,078 newborns in Judea/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.
4.22 Vitamins and Iron
Vitamins A and D and iron are provided routinely to all infants attending government health centers in Judea/Samaria and Gaza. Vitamin К injections are given routinely to all newborns in government facilities for prevention of hemorrhagic disease of the newborn. Iron and folate are given routinely to pregnant women attending IGHS 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 risk factors of anemia in infants in the first two years of life. Preliminary data show anemia rates well below those found in a similar study six years ago.
4.23 High Risk Pregnancy Care
High risk pregnancy screening, referral, and follow-up systems were developed in the IGHS in Judea/Samaria during 1987. 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 Judea/Samaria, eight High Risk Pregnancy Clinics were opened in 1988, and systematic referral, investigation and follow-up began. This program is monitored by the High Risk Pregnancy Committee. Seven high risk pregnancy clinics were transferred to district hospitals during 1990 for greater patient convenience and a wider range of diagnostic modalities.
In Gaza, a High Risk Pregnancy program is also being implemented in the IGHS with the establishment of two High Risk Pregnancy Clinics, and development of referral systems. Of 28 community health centers, 20 provide prenatal care, including high risk referral and follow-up. 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.
The director of the Center for Perinatal Epidemiology at the Center for Disease Control, Atlanta, a WHO Collaborating Center, visited the area in 1988 to review the high risk pregnancy programs, and the role of the Gaza and Ramallah WHO Collaborating Centers in Primary Health Care Research. His visit provided encouragement and stimulation of the staff and policy level personnel in developing these programs as essential, integral parts of the IGHS, including family planning. He also provided valuable technical and professional advice to the programs, including use of computers for program analysis. 4.24 AIDS
‘. { Two cases of AIDS were diagnosed in Judea/Samaria in 1988, both imported. All blood donations are routinely tested for AIDS in the Nablus, Ramallah, Beit Jallah, Hebron and Gaza hospital blood banks.
Screening of donated blood in Gaza has revealed a number of false positive samples which were negative on confirmatory testing in cooperation with Israel's Central Blood Bank operated by Magen David Adorn, the Red Star of David, at Sheba Medical Center, Tel Hashomer.
4.25 Brucellosis
Brucellosis has again become a major public health problem in Judea/Samaria, with the number of reported cases peaking in 1988, and a small decline in 1989 and 1990. The incidence of cases of Brucellosis among humans in the Judea/Samaria is seen in Table 21.
The Veterinary Service of the Department of Agriculture, in cooperation with the IGHS, is expanding its immunization and surveying of flocks for infected animals. A four year program for control and eradication of Brucellosis is now in progress. The first stage of this project was a pilot project in two villages in Hebron District. An estimated 5,000 sheep and goats were marked and bloods taken for laboratory testing to identify those infected with Brucellosis. Infected animals were slaughtered at municipal slaughterhouses and the owners / compensated for between 80-100% of current market value of the animal.
Four laboratory technicians underwent training for this project in Bet Dagan Veterinary Research Institute in Israel, 2-3 days per week. The program will be expanded to all villages in Hebron, Bethlehem and Jericho Districts. The veterinarian/ sanitarian teams visiting the villages will be developed on the basis of the experience of the pilot phase.
A Brucellosis education program is being carried out by the public health services with a focus on medical staff, and the general public. Random samples of milk products are continuously tested for Brucella.
Table 21: Brucellosis; Reported Cases and Incidence Rates. Judea/Samaria. 1981-1990
Years 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 No. 194 176 141 186 250 299 225 718 321 295
Rate 27 24 18 24 31 36 26 81 35 32 Note: Reported cases and rates per 100,000 population FIGURE 8:
Brucellosis Judea/Samaria : 1980-1990 I rI
:0: П 1 1 1 1 1 1 1 1 1 ±9韋 0 1»«2 Iff) 丨扈 19 尊 S 1»«C 1»$« 1» 尊» »iso Years Rates per 100,000 population
Gaza has also experienced a recent increase in cases of Brucellosis, from 115 cases in 1988 to 367 in 1989 and a subsequent decline to 95 cases in 1990 (14 per 100,000 population). Family members and contacts of reported cases are investigated by public health nurses, in conjunction with the Veterinary Department of Gaza. 4,26 Supervision of Drug Manufacture
‘ ’. { There are seven local pharmaceutical manufacturers in Judea/Samaria. The IGHS 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 IGHS purchases local products very extensively.
A proposal by local entrepreneurs to establish local manufacturing and packaging of pharmaceuticals in Gaza is now under review by the Institute for Standardization and Control of Pharmaceuticals, Ministry of Health.
4.27 Ambulance Services
Ambulance services have developed substantially over the past several years in Judea/Samaria and Gaza. Table 22 shows the ambulance services currently operating, not including vehicles used for administrative and non-urgent patient transportation.
The Benevolent Society of Gaza in 1989 opened its well equipped ambulance center in Gaza City with 10 fully modern ambulances and a cadre of drivers trained by Magen David Adorn. The number of ambulances increased to 15 in 1990. The first MDA course for Gaza ambulance drivers produced 25 qualified drivers in 1989, and a second course for 25 was held in 1990. Additional ambulance stations are opening in the northern, mid-zone and southern districts of Gaza. These are to increase their complement of ambulances as follows : in Jabalyah (5 units)； the Eastern Villages (3 units)； Khan Younis (5 units)； in Rafah (5 units). Five new ambulances of # which four are for UNRWA, are being introduced of the spring of 1991. Driver training will be continued with Magen David Adorn in Ashkelon, including classroom and practical experience.
Table 22: Ambulance Services Judea/Samaria and Gaza. 1990/91
Aqencv/Area Judea/Samaria Gaza
Gov't hospitals 9 Non-Gov't hospitals 3 Red Crescent Society 19
Cities/municipalitie1 s 9 Patient s Friends Societies 5 Benevolent Society of Gaza - 15 UNRWA 4.
TQtal 49 47 Five courses for ambulance drivers have been held in Jerusalem by Magen David Adorn for all agencies dperating ambulances in Judea/Samaria over the past 2 years. A total of 102 graduates have completed the training. Drivers participating in these courses have come from many health care organizations, including UNRWA, the Red Crescent, Patients Friends Societies, as well as from the IGHS,
4.28 Epidemiology
The health department in Judea/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, at Beersheva University and the Center for Disease Control in Atlanta, USA.
The Gaza Health Services Research Center began publishing a Weekly Epidemiologic Record during 1991. The statistics department of the Health Services epidemiology department in Judea/Samaria, continues to publish its monthly record.
4.29 Public Health Laboratories
A public health laboratory was opened in Nablus to serve the north and a new one recently opened in Ramallah for the south. These provide an improvement in service of water and food bacteriologic testing in the area. 5. HOSPITAL SERVICES
5.1 Introduction
The hospital services in both areas are primarily operated by the IGHS. Non-government hospitals also serve the population. The hospitals in both sectors have advanced in terms of facilities, professional and support services over the years by adding new departments and diagnostic equipment, as well as improved professional training.
5.2 Hospital Discharge Information Systems
In 1988 a trial hospital discharge information system (HDIS) was carried out in two government hospitals in Judea/Samaria. In Gaza, HDIS has begun on a trial basis in Khan Younis Hospital with a computer based program including ICD9 and all discharges recorded from January 1, 1991. After 6 months, all hospitals in Gaza will implement HDIS. Data transmitted on paper to Health Services Research Center for analysis will result in regular reports on utilization of hospital facilities and morbidity rates.
A HDIS is now being introduced in Judea/Samaria hospitals as well.
5,3 Hospital Facilities in Judea/Saraaria
Judea/Samaria government hospital service facilities are outlined in Table 23, for the year 1990, and as projected in current master plans for government hospitals.
Projecte 1 d beds are based on current planning for the mid- 1990 s• The number of hospital beds in the non-government sector rose from 400 beds in 1989 to 469 in 1990, an increase of 17% over one year.
5.4 Utilization of Hospital Care in Judea/Saraaria
Utilization of acute hospital care in local hospitals (both government and non-government) is shown in Table 24. Occupancy rates have remained under 65%, while average length of stay has gone down, and the number of surgical procedures has increased. The total number of admissions and days of care per 1,000 population have decreased reflecting both improved levels of health in lesser morbidity from childhood and infectious diseases, as well as lack of universal health insurance coverage. Table 23: Present and Projected Hospital Beds. Judea/Samaria 1990
Government 1990 Projected Hospitals Beds Beds* 568236583626400 3 Jenin 140 Tulkarem 136 Nablus-Watanee 124 11 Nablus-Rafidia 181 Ramallah 1 207 Beit Jallah 91 Jericho 50 Hebron 141 Total 682 1,070
Bethlehem Mental Hospital 320 120
Grand Total 1,002 1,373
Non-Government Hospitals 1990 Beds
Shifa, Jenin 10 UNRWA», Kalkilia 36 Al Ittihad, Nablus 104 Evangelical Mission, Nablus 53 Mt. David Orthopedic, Bethlehem 67 Caritas Children's Hospital, Bethlehem 79 Holy Family, Bethlehem 31 Red Crescent Pediatric Hospital. Hebron 30
Total 410
Private Maternity 59
Grand Total 469
Total Acute Care Hospital Beds. Judea/Samaria 1990
Government Acute Care Beds 682
Non-Government Acute Care Beds 469
Grand Total 1,151 Table 24: Hospital Utilization. Judea/Samaria. 1977-1990
Utilization/Years 1977 1982 1989 1990 Admissions per 1000 population 75.8 86. 6 76.3 86.8 Days of care per 1000 380 347 268 289 Average Length of Stay 5.0 3. 8 3.5 3.4 Surgical procedures per 1000 15.7 19. 1 23.5 24.3 Occupancy rate (%) 58 65 64 63.7
5.5 Hospital Facilities in Gaza
Hospital services in Gaza have increased from 896 beds in 1989 to 914 beds in 1990. While occupancy rates have remained stable, (65% and 64% respectively), as have total days of care, surgical procedures increased and deaths declined. Out- patient and day care increased (from 13.5 to 17.4 thousand) # and average length of stay declined slightly (from 3.7 to 3.6 days).
Gaza hospital facilities are outlined in the following tables based on current master plans :
Table 25：Hospital Beds in Gaza. 1977-2000 Projected
1977 1982 1989 1990 2000
Government Hospitals 745 800 771 789 1,580
El Ahli (private) 75 54 67 75 70
El Bureij Tuberculosis 210 70 50 0 0 (government and UNRWA)
Total 1.030 924 888 864 1.650
Government hospitals include Shifa Hospital, the Nasser Children's Hospital, the Ophthalmic and the Psychiatric Hospitals in Gaza City, and the Khan Younis Hospital serving the southern portion of the Gaza Strip. Bureij Hospital was transferred to the chest department in Shifa Hospital.
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 26. Table 26: Present and Proiected Acute Care HosDitals and Beds. Gaza. 1990 and 2000' {
HosDital Location Present Proiected Shifa Gaza City 380 660
Pediatric Gaza City 115 - Ophthalmic Gaza City 35 一 Psychiatry Gaza City 34 一 North Hospital Jabalyah — 220 Central Hospital Central area 200 一 Khan Younis Southern area 225 400 Ahli Gaza City 75 100
Total 864 1. 580
In addition, 44 day care beds are operated in government hospitals； Shifa 14, Khan Younis 7, Pediatric 20, Psychiatric 3•
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, non-profit agencies, but as part of the overall health program for the area.
5.6 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 27: Hospital Utilization. Gaza. 1977-1990
Utilization/Years 1977 1982 1989 1990
Admissions per 1000 population 93.6 94.5 84.8 82.5
Days of care per 1000 547 425 319 297
Average Length of Stay 5•9 4.9 3.7 3.6
Surgical procedures per 1000 - 31.3 29.6 40.2
Occupancy rate z 58 65 65 5.7 Referral to Hospitals in Israel
Hospitalization of patients referred 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, pediatric nephrology, pediatric urology, complicated neurosurgery, pediatric, infant and respiratory intensive care, burn cases and others. The IGHS referrals to Israeli hospitals in 1988 involved 649 cases, 625 in 1989 and 597 in 1990.
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.
5.8 Hospital Development in Judea/Samaria
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 Judea/Samaria during the period 1985-1990 include the following：
5.8.1 Rafidiah Hospital, Nablus
Radiology Center, 1987 •• Out-patient Department, 1988 ** New Wing — completed and operational in 1990 includes: Emergency Room Physiotherapy Pharmacy Administration Doctor•s residence ** New Section - plans ready for construction phases, include： Laboratories Kitchen Dining Room Medical Records Hospital admission section
5.8.2 Wattanee Hospital• Nablus
•• Intensive care unit, 1987 5.8.3 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, 1990/91 •• Emergency room - equipped and operational in 1988 ** Neurosurgery department - operational, 1988 •• CT scan - operational - 1989 ** Digital Fluoroscopy - operational, 1988 ** Peritoneal dialysis (CAPD) - operational, 1988 ** New operating theater and recovery room, completed 1990/91 *• New sewage system - completed, 1988 ** New electrical system 一 in construction ** New Outpatient Department 一 completed 1989 ** New CT/X-ray/Heart Institute Building 一 to be completed 1991 •• Hospital entrance, bridge connectors and elevator tower - construction during 1990/91.
5.8.4 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 1991 will include the following： 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.
5.8.5 Hebron Hospital
•• Central Sterile Supply Department - equipped and operational, 1988 •• Surgical suite/operating theaters, 1987/88 ** Service elevator, 1987 •* Radiology Department - completed and operational, 1988 ** Outpatient and Laboratory Wing - equipped and operational, 1988 ** Recovery room, 1988 •* New North Wing 一 planning completed； this wing will include: Emergency Room Delivery Suite and OB/GYN department Physiotherapy Kitchen Dining Room Storerooms.
*• New East Wing - to be built with the assistance of the Government of Italy 一 now under construction； this wing will include s New out-patient department Cardiac Assessment lab New surgical department Laboratories Blood Bank.
5.8.6 Bethlehem Mental Hospital
*• Chronic care department (male) - completed and operational, 1986 •• New Chronic and Acute Departments (for males), planning completed.
5.8.7 Open Heart Surgery Ramallah Hospital # Ramallah Hospital opened this department in early 1987. The department has now performed 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. The Cardiac Surgery Department has carried out between 40-50 open heart procedures each year since 1987.
5.8.8 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 1,927 in 1988 to 3,356 in 1989, 5.8.9 Government of Italy Hospital Development Projects
The Government of Italy is working with the IGHS in Judea/Samaria on hospital development and projects in both government and non-government hospitals• This includes major construction and equipment projects in Beit Jallah, and Hebron government hospitals, as well as Ittihad non-government hospital. The cost of these projects will be a total of $7.5 million. A further one million dollars was spent on providing modern equipment for hospital laboratories in Judea/Samaria.
The government of Italy sends specialists in various branches of medicine and nursing for consultative and training activities both in Judea/Samaria and Gaza.
5.8.10 Private Voluntary Organization Hospital Projects
The Red Crescent has recently opened a 30 bed children'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, commencing with the Emergency Room, delivery suite and out- patient department, in 1991.
The Patients Friends Society in Ramallah is developing a Rehabilitation Center. The first stage of the project, the Out-patient Department, staffed by a specialized team from Sweden, including medical, physiotherapy, and occupational health personnel, was opened in 1990. The second stage, a 30 bed rehabilitation department for in-patients, is planned for 1991.
The Friends of the Handicapped Society in Bethlehem have recently opened a new medical and occupational health center in Beit Jallah. The occupational health unit is now in operation. This center is planned to reach a capacity of 100 beds.
5.9 Hospital Development in Gaza Hospitals
Projects completed or in implementation in Gaza during, 1985-1990 period include the following： 5.9.1 Shifa Hospital Gaza City # •• Obstetrical Department (100 beds), 1986 Radiology center, 1987 •• Neonatal Intensive Care Unit, 1987 ** Dialysis department - completely renovated in 1989 Building 8 was opened in 1990, including orthopedic department (46 beds), general surgery (101 beds), operating suite of 5 theaters, intensive care unit (7 beds) a recovery unit (6 beds), and an emergency # room (11 beds)
5.9.2 Khan Younis Hospital
Refurbished surgical suite, 1987 ** Emergency room - to be refurbished during 1991, or a new ER unit to be built by the Society of Friends of Khan Younis Hospital during 1991/92•
5.9.3 Ophthalmic Hospital, Gaza City
•• Extensive renovation and reequipping of this hospital was carried out in 1989.
10 New Hospital Specialty Departments, Gaza
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.
5.10.1 Specialty Departments Shifa Hospital, Gaza # In Gaza, medical and nursing staff have completed training in Israeli hospitals for the 1990 opening of pediatric surgery, neurosurgery, pediatric oncology and adult oncology services at Shifa Hospital. Building 8 at Shifa Hospital opened in 1990, providing ultra modern operating theaters, surgical, ENT and orthopedic wards, preparatory and recovery units, emergency room and oüt-patient department.
This excellent facility, and the staff training that has been associated with it, will make a major contribution to raising the standards of hospital care in Gaza, and will permit taking obsolescent facilities (Building 1) out of operation. Manpower additions to the IGHS provided 180 new staff positions to operate the new Building 8. 6. MANPOWER AND TRAINING
6.1 Introduction
Manpower and training has received great emphasis, particularly since 1985• This was achieved through cooperation between the IGHS, local health personnel and Israeli institutions. There is a strong and sustained interest on the part of local health personnel to take part in full-time and part-time post-graduate training in Israeli teaching institutions, and a matching interest by these facilities to provide training.
In recent years large budgetary allocations were provided for this purpose by the IGHS, as well as by the United Nations Development Program and the World Health Organization. The success of a number of manpower projects spurred on new activities in this area which have had an immediate, demonstrable effect on improving the quality of care for the population.
6.2 Joint Specialty Training, Judea/Samaria, and Gaza
Specialty training in two-three year programs for local health personnel from Judea/Samaria and Gaza have been carried out in a number of areas, including the following：
6.2.1 Anesthesia
In 1987, 25 physicians of the IGHS in Judea/Samaria (11) and Gaza (14) successfully completed two-and-a-half years of full- time training in 10 different Israeli teaching hospitals, and are now responsible for real improvement in surgical care standards in their hospitals.
New equipment and organization of anesthesia services in these hospitals have raised the level of this vital service. Continuing education through monthly study days for this group of physicians is ongoing. This project was funded by the UNDP and the IGHS. 〜
This program has had a major beneficial effect in raising the standards of surgical care available throughout Judea/Samaria and Gaza. 6.2.2 Various Specialties
Seven physicians from Judea/Samaria and Gaza specializing in internal medicine, gynecology, pediatrics, pathology or orthopedics completed two years of training at Beilinson Hospital. Some remained for a further year, and the pathology resident remained for a fourth year.
6.2.3 Public Health Physicians
Nine physicians and one statistician from Judea/Samaria and Gaza have completed a one year, full time Master of Public Health (MPH) degree program at the School of Public Health, Hebrew University 一 Hadassah, Ein Karem, Jerusalem. Seven of these MPH graduates completed their studies during the past 4 years.
All of these graduates are engaged in public health work and research in primary health care, working in the respective IGHS. One physician from Judea/Samaria, and one senior health administrator from Gaza, participated in the MPH program in the 1988/89 academic year. One physician from Judea/Samaria participated in the course in the 1989/90 school year.
In 1989/90 one physician from Gaza attended the Kennedy School of Public Administration at Harvard University for studies in public health. In 1990/91, two physicians from the IGHS of Judea/Samaria and one physician from Gaza went to the same program.
In 1990, the director of the Gaza HSRC completed requirements for a doctorate in public health at Johns Hopkins University School of Public Health, and is now carrying out the required thesis study on anemia among children in Gaza.
6.3 Specialty Training and Continuing Education, Judea/Samaria
б.3•1 Intensive Care Nursing
18 nurses from government hospitals throughout Judea/Samaria completed six months full time training at Beilinson Hospital in 1987.
6.3.2 Public Health Laboratory Technicians
Three laboratory technicians from Judea/Samaria completed three months full time training at the Jerusalem Central Public Health Laboratory in 1987. 6.3.3 Various Medical Specialties
/ . i. Fifteen doctors from Judea/Samaria government hospitals began two years full-time training in various Israeli hospitals in 1987. Thirteen of these physicians completed their 2 year programs in 1988, and continued for a third year. The specialties include neurology, hematology, pediatrics, orthopedics, pediatric surgery, neurosurgery, cardiology (at Hadassah); internal medicine and urology (at Shaarei Zedek); pathology (at Beilinson)• and psychiatry (Kfar Shaul Hospital).
Five of these physicians finished three years of training in March 1990 in hematology, radiology, neurology, neurosurgery, and psychiatry. One physician completed two-and-a-half years of orthopedics training, and two have finished two years at Hadassah Mt Scopus in cardiology and pediatric surgery； one finished two years in pediatrics, and two had two years in cardiology and urology at Shaarei Zedek in Jerusalem,
Three other physicians recently started training at Hadassah Ein Karem in urology, dermatology, and orthopedics.
6.3.4 Traumatology
Specialty training for three physicians from Judea/Samaria began in 1988 in traumatology (Hadassah), ENT Surgery (Bikur Holim) and Pediatrics (Hillel Yaffe, Hadera Hospital) for periods of one to one and a half years.
6.3.5 Midwifery
A midwifery postgraduate training course for nine registered nurses from Judea/Samaria was carried out in Assaf Harofe Medical Center, This ten month program carried out in English, was conducted according to the standard training program for Israeli midwives, and was completed in late 1988. These midwives have now returned to the government hospitals.
6.3.6 Neurosurgical Nursing
Two registered nurses from Ramallah Hospital spent three days per week over a one month period in the Neurosurgical
Department at Hadassah 1Hospital, Ein Karem, and have returned to help set up Ramallah s Neurosurgical Department. 6.3•7 Various Medical Specialties, Plans
'• ( Plans have been made to send a number of physicians abroad during 1991 for periods of training in the following fields: Oncology (2), Intensive Care (3) and Burns (2). This will help to complete their specialty training and to operate new facilities, already in place or soon to be developed. Funding for this training is being considered by the WHO.
6.3.8 Courses in Public Health and Administration
Twenty health workers including doctors, nurses, sanitarians and a statistician participated in a one year Public Health course in the School of Public Health, Hebrew University at Hadassah and received a diploma in Public Health in 1988.
Senior medical, nursing and administrative personnel recently completed a two year Medical Administration course conducted by Haifa University.
14 medical paramedical and administrative personnel / participated in a two month course in Biostatistics and Computers given by the School of Public Health, Hebrew University at Hadassah Medical Center.
6.3.9 Intensive Care Nursing
Eight graduate student nurses from Judea/Samaria participated in a seven month post-graduate course dealing with premature, neonatal and pediatric intensive care. The course began in Assaf Harofeh Hospital in late 1990.
6•3.10 Continuing Medical Education
Continuing education programs have been developed extensively over the past three-four years for Judea/Samaria government health personnel. Training programs have continued, and new ones began during 1988/89• The following is a list of these continuing education programs :
•• Internal Medicine for 52 physicians, one full day per week over one year at the University of Tel Aviv, Faculty of Medicine, 1985-86.
•• Safe Home Delivery for 250 Dayas (Traditional Birth Attendants) 1 day per week for ten months, since 1987, with assistance of UNICEF;
** First Aid/CPR for 102 Ambulance drivers in 6 courses since 1987, each consisting of 120 teaching hours, conducted in Arabic by Magen David Adorn at the Holyland Hotel in Jerusalem, along with 40 hours field experience; this included drivers from the IGHS, the Red Crescent and UNRWA; ‘. 、
** Family Medicine course for 15 General practitioners from Nablus, Jenin, Tulkarem was conducted one full day per week in Afula Hospital over a 2 year period, starting in 1987;
•• Refresher course for various medical specialties for 48 physicians. One full day per month started 1988 over one year at Beilinson Hospital;
•• Basic medical sciences for 30 Physicians conducted at Hadassah Hospital, Ein Karem, started in 1987, carried on one day per week over a one year period；
Continuing education in general surgery for 11 Surgeons conducted at Hadassah Hospital, Mount Scopus, commenced in 1988, one day per week over one year；
** Gynecology continuing education for 9 gynecologists at Hadassah, Ein Karem, started in 1987, and continued for one year；
Refresher course in Open Heart Surgery for 2 surgeons from Ramallah, once per week at Tel Hashomer Hospital during 1986/87 over 9 months in preparation for opening the open heart surgery unit in Ramallah Hospital;
•• Training for 2 surgical nurses in open heart surgery, once per week over six months at Tel Hashomer Hospital during 1986/87;
Training for 2 open heart machine technicians six days per week for 6 months at Tel Hashomer Hospital during 1986/87;
•• Training courses in CT, ECHO, EEG and Ultrasound for 5 MDs at Hadassah, Ein Karem during 1988;
*• Child Development for 2 RNs at Terre des Hommes in Jerusalem for six months, during 1989.
6.4 Gaza
6.4.1 Midwives
Twelve senior local nurses completed a nine month training program at Assaf Harofe Hospital in 1987 and have returned to the IGHS. These midwives have returned to work in the new obstetrical department in Shifa Hospital and in Khan Younis Hospital, as well as in the community delivery centers. 6.4.2 Sanitarians
Twenty five Gazans completed a year's training program for qualified sanitarians at Assaf Harofe training center in 1987. They completed the examination for licensure as qualified sanitarians at the standard required by the Israel Ministry of Health for its sanitarians.
6.4.3 Clinical Nursing Specialties
Eight nurses from Gaza completed four months of training in March 1989 in pediatric surgery, pediatric oncology, adult oncology and neurosurgery at Hadassah Hospital, Ein Karem, in preparation for the new departments opened in Shifa Hospital in 1990.
A nine month course in ICU nursing with 11 participants from the Shifa and Khan Younis Hospitals in Gaza was completed in 1990 to prepare staff for the opening of Building 8, as well as for the proposed new Emergency Room at Khan Younis Hospital.
6.4.4 Anesthesia Course for Gaza Physicians
During 1991, 13 physicians from Gaza will begin a two-and-a- half year training program in anesthesia based at Beilinson Hospital in Petah Tikvah, and four other teaching hospitals in central Israel. This course includes weekly study days of didactic classroom work and 5 days per week of working as part of the anesthesia department teams in the training hospitals.
The trainees will be from Shifa and Khan Younis Hospitals, and three spaces will be available for Ahli Hospital staff. The training program will be similar to the program operated successfully in 1985-1988, and it will also contribute to raising standards of surgical care in the area.
6.4.5 Public Health Nursing Course
During 1990 a course in Public Health Nursing began for nineteen Gaza nurses from the government and private health services. The course is the full Ministry of Health certificate course in this field, and successful graduates will receive the Ministry certificate.
The course is underway in Wolfson Hospital in Holon, with field work in Ashkelon and Gaza. Some graduates of the course will be selected for extra training to become the trainers of future public health nurse courses. 6.4.6 Continuing Medical Education in Gaza t. Recent programs for health personnel from Gaza include the following：
•• Senior Nurses refresher course for 25 nurses, two full days over one year - completed；
General Physicians course for 30 Physicians, 1 full day over one year, one day per week at Beer Sheva Faculty of Medicine, in basic and clinical sciences, during 1988/89;
Health information and policy analysis course for 33 doctors, nurses administrators in 15 study days in Ashkelon, conducted by the School of Public Health, Hadassah-Hebrew University, over a three month period in 1989, with a follow-up study day in 1990;
•• Continuing education in anesthesia continues for 15 Gaza anesthetists at Beilinson Hospital.
6.4.7 Neurosurgical Training
2 Gaza physicians trained at Tel Hashomer and Beilinson Hospitals have returned to Gaza and opened the Neurosurgical Service at Shifa Hospital.
6.5 Nursing Education - Judea/Samaria
Nursing education is being increased in Judea/Samaria by expansion of the nursing school Ibn Sinna, in Ramallah. The intake class was increased from 24 to 40 in 1987 by opening a second course in Nablus and a third one for male nurses in Bethlehem.
Graduates of the non-government BA academic schools of nursing at El Bireh Arab College of Nursing and Bethlehem University School of Nursing are recruited to government and non-government health services.
Several private hospitals have schools for Licensed Practical Nurses.
6.6 Health Manpower - Judea/Samaria
6.6.1 The number of physicians in Judea/Samaria in 1987 totalled 856, or 9.93 per 10,000 population, or 1 physician per 1,007 persons•
6.6.2 Health manpower employed in the IGHS of Judea/Samaria have increased steadily over the years, as shown in the following Table (number of establishments and rates per 10,000 population): Table 28: Manpower in the Government Health Service. Judea/Samaria
1974 1980 1988 1990 Profession No. Rate No. Rate No. Rate NO. Rate Physicians 119 1.8 174 2.4 277 3. 0 289 3.1 Nurses 308 4.6 620 8.6 763 8. 6 798 8.6 Technical, paramed. 147 2.2 169 2.3 199 2. 2 209 2.3 Admin, sup. 493 7.4 440 6.1 494 5. 6 512 5.5 Total 1067 16.0 1403 19.4 1723 19. 4 1807 19.5
Manpower in the IGHS increased from 1988 to 1990 from 1,723 staff positions to 1,807, or by 4.9% in one year. This includes an increase in medical personnel from 3.0 to 3.2 per 10,000 population.
6.7 Health Manpower - Gaza
Health manpower employed in the IGHS in Gaza increased since 1974, as shown in Table 29 (numbers and rates per 10,000).
Table 29: Manpower in the Government Health Service, Gaza
Profession 1974 1980 1988 1990 No. Rate No. Rate No. Rate No. Rate Physicians 119 2.9 224 4. 9 280 4.2 342 5. 4 Nurses 308 7.4 485 10. 6 610 9.1 687 10. 8 Technical, paramedical 147 3.6 169 3. 7 158 2.4 176 2. 8 Admin. sup. 394 9.5 491 10. 8 581 8.7 633 9. 9 Total 968 23.4 1.369 30. 0 1. 629 24 . 4 1,838 28. 9
The number of staff positions i the Israeli Government Health Service was increased from 1700 in 1989 to 1838 in 1990, with 132 positions allocated for the operation of Building 8 in Shifa Hospital, and 6 positions for the new Community Health Center in Jabaliya Camp.
6.8 Hospital Manpower - Judea/Saraaria
Health manpower in government hospitals in Judea/Samaria at the end of 1990 are shown in Table 30 including rated positions, rated beds and staff-to-bed ratios.
The total staff-to-bed ratio increased from 0.97 in 1989 to 1.03 in 1990. The nurse-to-bed ratio in government hospitals increased in recent years from 0.5 to 0.6 per bed. The physician-to-bed ratio is 0.26, an increase from 0.25 per bed in 1988. Table 30: Health Manpower in Government Hospitals. Judea/Samaria. 1990
Total Staff/ Profession MDs Nurses Paramed Staff Beds BQd 906548323929212 5 603568243683625 0 llloool4028790o4049958 51 50 • Beit Jallah 25.0 11 11 Hebron 25.0 64 4 ••••••參 Ramallah 42.5 97 29.5 1 1 Jenin 14.0 7 5 Tulkarem 15.0 26 8.5 5 Wattenee Nablus 20.0 50.5 1.5 5 Rafidia Nablus 30.5 83 8 Jericho 6.0 14
Total 178 0 415.5 T 704, -Ml.
Bethlehem Mental HOSP, 91 320 0.28
6.9 Specialty Qualification in Gaza
During 1988, 23 Gaza physicians from the IGHS or 8.2% of the total number of physicians working in the service are currently in full time training in Israeli teaching hospitals. This included specialty training in various -specialties for periods of 1-3 years.
Six physicians have just completed periods of specialized training, and five in 1989 had begun 2 full years of training in Intensive Care (2 in pediatric and 3 in adult 1С). Most of those entering specialty training in Israeli hospitals had previously been working in related fields in Gaza, and already had some training in the field.
The Medical Scientific Council in Gaza has now completed criteria and classification of medical specialization. Since 1 January 1989 all new candidates for specialty recognition are required to have specific periods of experience in Gaza hospitals, as well as additional training.- Approximately 100 of the physicians in the area are recognized as specialists.
Family medicine is also recognized as a specialty with specific requirements such as those now being fulfilled in / the Beer Sheva course for 30 doctors. The first semester was in basic medical sciences and the 2nd semester was in clinical family medicine, including diabetes and other clinical subjects, as well as clinic administration and medical records. A second course began in 1990 for 30 other family physicians from the IGHS. 7. ENVIRONMENTAL PROTECTION
7.1 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), Tulkarem (1972), Ramallah (1979)and Kalkiliya (1986).
The first stage of the Hebron City sewage treatment plant has been completed and construction on the second stage, as budgeted by the Israeli Civil Administration, will start in the summer of 1991. Expansion of the northern area sewage collection system of El Bireh is currently under construction. An integrated sewage treatment system planned for Bethlehem/Beit Jallah/Bet Sahur is now in the implementation stages, with financial assistance from the governments of Italy, Germany and the Israeli Civil Administration. A master plan for sewage collection and disposal systems has been prepared.
Before 1967, sewage was managed through local septic tanks only. Since 1967, extensive sewage projects have been carried out by the local authorities. Sewage collection systems are being expanded in Gaza City, Jabalya and Khan Younis with funding from UNDP and Community Development Fund (CDF) in conjunction with the municipalities and the Civil Administration. In Jabaliya, a special pond for collection of spring runoff and open sewer flow was in operation in 1990. Some 50% of Jabaliya camp sewage pipe infrastructure has now been completed.
Expanding water supplies to most homes in the area, as well as the increasing population has put great stress on the sewage systems in Judea/Samaria and Gaza. Projects underway during 1991 will result in a major improvement in sanitation in Gaza, Khan Younis and Rafah. The existing treatment plants in Gaza and Khan Younis are being upgraded to cope with the increased sewage collection and will produce recycled waste-water for use in local agriculture (citrus orchards). The improved sewage collection systems will also benefit the Beach, Jabalia and Rafa refugee camps.
7.2 Community Water Supplies Judea/Samaria #
Community water supplies have been expanded in Judea/Samaria by increased development of local wells and by supplementation from the Israeli national water distribution system. Water consumption for domestic purposes has increased from 5 cubic meters per capita to 25 cubic meters in rural areas, and to 75 cubic meters in urban areas. Routine water tests are carried out throughout the public water supply system. Samples are takdn•by IGHS sanitarians and tested in the Nablus Public Health Laboratory and in the Ministry of Health Laboratory in Jerusalem.
The number of villages connected to central water supply systems has increased from 50 in 1969 to 220 in 1986 with another 10 in advanced stages of implementation. This provides direct provision of safe supervised chlorinated water to the homes in place of previous reliance on cisterns or container water. Running water reached 61.6% of homes in the area in 1985, as compared to 23.5% in 1974; this has contributed to improved hygiene and health standards.
7.3 Water Supplies - Gaza
In Gaza, all cities, towns and villages are now provided with safe, supervised domestic water since the area 1 was linked to the Israeli National Water Carrier in the 1970 s. As a result, running water now reaches 75% of homes in the Gaza area, as compared to 13.9% in 1974•
7.4 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 and Gaza. Disposal sites have been increased in number with improved management practices• Sites for Jenin and Kalkilia are currently in the planning stages while planning for a site in Ramallah has been completed and is ready for execution. A master plan for garbage disposal for Judea/ Samaria was finalized and approved in 1987.
7.5 Sanitary Supervision, Judea/Samaria
The IGHS employs 43 environmental inspectors who are actively engaged in supervision of food and sanitary conditions. This includes licensing, education, building licensure and legal action as needed, as well as dealing with public complaints. 7.6 Anti-Malaria Control, Judea/Samaria
After four years of preparation and intensive control activities, Judea/Samaria was recognized in 1971 as a malaria free area. Continuous surveillance is, however, required in this area because of the prevalence of the Anopheles mosquitoes and movement of people who may have acquired malaria abroad.
Following the spring rains intensive spraying activities are carried out in Anopheles breeding areas throughout Judea/Samaria by special malaria control teams.
7.7 Leishrainiasis Control, Judea/Saraaria
The Jericho area is endemic for Leishminiasis. Control activities are carried out continuously, involving spraying areas where Phlebotomus is endemic.
7.8 Pesticide Usage, Surveillance and Control, Judea/Samaria
Since 1967, insecticides for agricultural purposes have become common and widely used in Judea/Samaria. In order to reduce toxic exposure of workers and food consumers to these materials, surveys of pesticide utilization and educational programs regarding safe and effective use of pesticides for farmers and retailers have been carried out since 1979.
8. ADMINISTRATION AND FINANCE
8.1 Government Health Services
The IGHS continue to provide the bulk of services in Judea/Samaria, and Gaza. These are funded from the Israeli Civil Administration in each area from the general budget which is based on local taxes and revenues, including funds from health insurance. 8.2 Non-Government Health Services
Non-government services are funded from private sources both locally and from international agencies, along with charges to the user of services. Community, voluntary and charitable societies provide important services in Judea/Samaria in particular.
8.3 International Voluntary Agencies
International voluntary agencies provide major assistance to the development and operation of vital facilities in Judea/Samaria and Gaza. These include:
Caritas Pediatric Hospital in Bethlehem - operated by a Swiss-German charitable society;
Mt. David Orthopedic Hospital in Bethlehem - operated by the Christian Holyland Mission, USA；
Terres des Hommes Child Nutrition Center in Bethlehem, and Nutrition Center, Gaza - operated by a Swiss charitable society;
•• Child Development Centers in Ramallah, Hebron, Gaza and Jenin, originally funded by UNICEF, and then transferred to local charitable societies.
8.4 United Nations and Other Agencies
Cooperation between the Israeli Administration, the IGHS and other agencies associated with the United Nations has also provided important development funding and initiative. The most important of these agencies is the United Nations Development Program (UNDP)• followed by the World Health Organization (WHO). Various Agencies funded by the United States Agency for International Development (AID) have also fostered many development projects in the area.
The following lists recent projects of these agencies:
UNRWA - Provides sanitation, health and education programs for the refugee population； immunization policy is coordinated with the IGHS, which provide some of the vaccines for UNRWA； UNDP - Undertakes development of projects on behalf of various UN affiliated agencies, including in recent years the anesthetist training program, the sewage project in Jabaliya, the sewage treatment plant for Gaza City; radiology equipment for Ramallah and Shifa Hospitals, the surgical suite for Ramallah and equipment for Shifa Hospital;
WHO/UNDP 一 has funded the Ramallah Health Services Research Center, the Gaza Health Services Research Center, Ramallah Center for Health Manpower Development; these centers were initiated in 1986 in response to WHO resolutions, and in agreement with the Government of Israel. These centers are operated in cooperation with the IGHS which provide most of the staff;
AID - funded sewage projects through agencies such as ANERA, CDF, CRS, MCC, NECC, and A-MidEast in El Bireh, Jabaliya, and Gaza, coordinated with municipal and government projects； AID has also funded health education, medical equipment and other projects；
UNICEF - funded Child Development Centers in Ramallah, Hebron, Gaza, and Jenin； these were later transferred to local voluntary agencies； UNICEF also played a key role in launching and funding from 1985-1988 the Hebron Expanded Primary Health Care Project in 49 small villages in the Hebron District, implemented by the Hebron public health office; UNICEF also funded and initiated Dayas training projects in Gaza and in Judea/Samaria;
UNFPA - has funded some support for High Risk Pregnancy services being developed in the IGHS systems in Gaza and in Judea/Samaria；
The Government of Italy - has funded hospital projects in both IGHS and non-government hospitals, as well as supplying hospital laboratories with modern electronic equipment;
WHO - has undertaken to provide funding for a variety of hospital and community health projects in Judea/Samaria and Gaza, including manpower training, a new emergency room at Khan Younis Hospital, Burns Units at three hospitals in Nablus, Hebron and Ramallah, development of a Primary Health Care project in the Jordan Valley, as well as other projects in non-government hospitals• 9. RESEARCH
9.1 Introduction
Research in relation to health needs in Judea/Samaria and Gaza has become an important element of the health service systems, particularly over the past three years, as a result of several factors: the establishment of Health Services Research Centers in Ramallah and Gaza; the availability of more local graduates of the School of Public Health at the Hebrew University; WHO/UNDP support and encouragement of research activities through agreements reached between the Government of Israel and WHO; and a general realization of the need for operational research in the planning of health services.
9.2 Ramallah WHO Collaborating Center for Health Services Research in Primary Health Care
The Ramallah Health Services Research Center (RHSRC) was established in 1985 as a unit of the IGHS of Judea/Samaria to carry out operational research in primary health care in the area. The RHSRC was recognized as a WHO Collaborating Center with funding by WHO through UNDP to expand its staff facilities and projects.
The center initiated and carried out several studies: a serosurvey of immune status of school children; studies of growth patterns of infants； evaluation studies of the Expanded Primary Health Care project in Hebron； an IMR study.
Recommendations for changes in immunization policy arising from the serosurvey results have been adopted by the IGHS. A review of infant deaths was incorporated into the routine of the Public Health District offices of the Health Service. The growth study is being followed up by an intensive analysis of growth patterns in 10 sentinel MCH centers in the area.
The Ramallah HSRC has carried out Knowledge Attitudes and Practices (КАР) studies for evaluation of the process and impact of the Hebron Project in Expanded Primary Health Care now operating in 49 villages in the Hebron area.
9.3 Gaza Health Services Research Center
The Gaza Health Services Research Center was initially established in 1981 as the IGHS epidemiology and medical information center. The center's main role was development of vital statistics of the area, but it also carried out various studies in polio, cholera, rotaviruses and measles in conjunction with Israeli academic research centers. In 1986, this center was recognized as a WHO Collaborating Center in Primary Health Care and provided with funding for important additional resources and staff to expand its area of activity. Since 1985, the Center has initiated studies in factors relating to infant mortality, growth patterns of infants沁 and a serosurvey of antibodies in school children to the childhood immunized diseases. Computerization of the basic vital statistics system for Gaza has been completed by the Center. Computerization of basic child health records including birth weight, immunization and growth patterns, has been established in 10 government community health centers•
The Gaza HSRC now has four major roles. Firstly, gathering vital statistics and epidemiologic data, their computerization, analysis and continuous reporting, provides a strengthened basis for vital statistics. Secondly, the Center carries out research in primary health care with current emphasis on a retrospective analysis of infant mortality, and growth of children studies. Thirdly, the HSRC serves as an educational center with a library and courses in scientific English and computers for Center staff and associated health workers. Finally, the Center is closely involved in policy formulation, playing an active role in development of primary health care, the Child Health Committee, the High Risk Pregnancy Committee and other policy groups in the IGHS.
9.4 Ramallah Center for Health Manpower Development
The Ramallah Center for Health Manpower Development was established in 1987 as part of the IGHS and as a WHO Collaborating Center. It focussed initially on collating data regarding health manpower in the public and private sectors of health care in the area.
The Director of Hospital Services of the IGHS serves as the director of the Center, and othe1 r senior persons from the IGHS serve as members of the Center s steering committee. There is close coordination with the many manpower training projects initiated and carried out by the IGHS in the past several years.
9.5 Workshop on Research Methods
A Workshop on Research Methods was carried out by WHO in collaboration with UNDP, the IGHS and the three WHO Collaborating Centers between December 1986 and June 1987. Twenty-five persons associated with the three WHO Collaborating Centers participated in 'the workshop. They conducted projects which included： surveys of risk factors for heart disease among school teachers； knowledge attitudes and practices (КАР) of women related to childbirth； КАР studies of Dayas; smoking patterns among high school students； school health practices and health of primary school students； cold injury prevalence and others.
Graduates of the workshop constitute a cadre of people oriented to health care research and to planning of health services based on needs-assessment• Some have gone on with further training in public health and many serve as staff persons or on important committees active in health assessment and planning.
9.6 Workshop on Health Information and Health Policy
During February-May 1989, the IGHS in Gaza, in conjunction with the Israel Ministry of Health, carried out a 15 day workshop on health information and health policy with 33 senior doctors, nurses and administrators participating.
The course utilized the case study method of problem identification and analysis by the participants. Emphasis was on management objectives with critical analysis in policy formulation. Workshop topics selected by the participants included continuity of care, dental health, growth patterns of school children, attitudes of care providers and utilization of prescription drugs.
The workshop participants had a 2 day follow-up session in 1990, in which health projects undertaken over the past 10 years were critically reviewed based on the concepts of the workshop. Most members of the workshop serve in day to day planning and supervisory functions in the IGHS and on committees involved in monitoring and planning health services for the area.
10. INTERNATIONAL COOPERATION
10.1 Introduction
International cooperation in the development of health in Judea/Samaria and Gaza has evolved over the years. Direct provision of services for the refugee population by UNRWA has continued. More recently a variety of international agencies have provided important resources and initiatives to assist in development of key areas of health services - including sanitation, medical equipment, health education and health services research. 10.2 WHO Consultants
WHO consultants in a number of arpas of expertise have visited Judea/Samaria and Gaza, working closely with the IGHS and the WHO Collaborating Centers. Most recently a group of WHO consultants carried out mid-term review of the activities of the WHO Collaborating Centers in conjunction with two professors from the School of Public Health in Jerusalem, Hadassah-Hebrew University. In 1988, a WHO consultant from CDC Atlanta visited in regard to the High Risk Pregnancy program. During 1990 and 1991, WHO staff visitors have met with public and non-government sector health services to promote financial assistance for needed health care projects in the area from donors abroad•
10.3 Other Consultants
The American Public Health Association provided a team of experts in primary health care and hospital administration at the request of the Arab Medical Welfare Association to consult on health planning in Judea/Samaria during 1986.
10.4 UNICEF
UNICEF consultants in primary health care have visited the area frequently since 1985 in connection with the four Child Development Centers and the Hebron Expanded Primary Health Care project. Funds for these projects were provided by the government of the Federal Republic of Germany. This funding terminated at the end of 1988.
10.5 Plastic Surgery Volunteer Group
A team of 12 including plastic surgeons, an anesthetist and operating room nurses from Virginia and other parts of the United States and Canada came for an intensive work and teaching session lasting two weeks in January 1988. The team carried out 75 general plastic surgery and urologie plastic surgery procedures at Ramallah Hospital and hand surgery at the Mt. David Orthopedic Hospital of Bethlehem on selected cases from Judea/Samaria and Gaza, in conjunction with local staff and plastic surgeons from Hadassah Hospital.
This team was under the direction of Prof. Charles Horton of Norfolk, Virginia. Three physicians from Judea/Samaria are now in training in variou1s medical specialties in West Virginia with Dr, Horton s group.
The same group had another visit to Israel in 1990 for one week. They conducted fifteen plastic urologie operations on patients from Judea/Samaria and Gaza in Ashkelon Medical Center. PLANNING
11.1 Introduction
Emphasis has been placed on primary health care, sanitation, hospitals and health manpower development of health services in Judea/Samaria and Gaza. Improved local research capacity contributes to the planning process.
11.2 Health Planning, Judea/Samaria
The Joint Planning Committee on Health Services in Judea/Samaria and Gaza report of 1985 provided a basic program for further development to the year 1990 which is in the stages of implementation. In this report, emphasis was placed on new stages in primary health care, environmental health/ hospital specialized department developments, emergency health services, and manpower development.
11.3 Hospital Development Plans, Judea/Samaria
Master plans have now been completed for all the nine government hospitals in Judea/Samaria. These plans include both program and physical development for Judea/Samaria hospitals to be implemented over the next 5-8 years.
11.4 Primary Health Care, Judea/Samaria
Primary care services are being expanded in Judea/Samaria by a number of important new initiatives. The Hebron Expanded Primary Health Care has now linked 49 small villages to the PHC system, providing on-site services in villages previously served by visiting immunization teams. This project is now planned for 10 villages in the Jordan Valley. Further expansion to small villages in the northern districts is also being planned.
11.5 High Risk Pregnancy Care, Judea/Samaria
The High Risk Pregnancy Committee established by the IGHS in Judea/Samaria is now implementing High Risk Pregnancy centers in all seven districts of the area with improved referral and diagnostic services.
All 141 MCH centers and 49 Village Health Rooms are using new pregnancy care records and high risk referral forms developed by this Committee as well as new child care records. Nursing and medical staff study days on high risk pregnancy identification and care are being carried out to implement this new program. 11.6 Hospital Planning, Gaza
In Gaza, a new master plan for development of hospital services has been completed based on consultation with senior local health personnel and Israeli consultants. This provides for development of the hospital services to the year 2000..
The master plan for health service development in Gaza includes transfer of the Children's and Ophthalmic Hospital to the Shifa Medical Center, conversion of the Bureij Tuberculosis Hospital to a chronic care facility, as well as substantial expansion of the Shifa Medical Center bed and outpatient service capacities. A new hospital is to be built to replace the obsolescent Khan Younis Hospital to serve the southern part of the Gaza district. A new 200 bed hospital is planned to serve the middle area of the Gaza district as well.
11.7 Child Care Committee Gaza # The Child Care Committee established in Gaza in 1986 includes senior child health personnel from the IGHS of Gaza, from ÜNRWA, the Ministry of Health of Israel, and from Terres des Hommes. This Committee meets regularly to review and develop plans for dealing with child health issues such as nutrition, immunization policy, parasitosis, anemia of infancy, cold injury, thalassemia, diarrhoeal disease control, child health records, child development services, phenylketonuria and hypothyroidism screening and related issues. Operational decisions are taken in this committee which become part of the program development of government and UNRWA health services.
11.8 High Risk Pregnancy, Gaza
The High Risk Pregnancy Committee, established by the IGHS with participation of UNRWA, has developed a program for high risk pregnancy identification and care• This includes improved records and referral forms, district high risk pregnancy clinics and regional birth centers. Three birth centers are located in community health centers (CHC) of the IGHS in Gaza, and a further two are to be opened in the next several years. The objective of this program is to increase hospital and medical center births providing for all deliveries in the area over the next several years. 12. SUMMARY
Improved quality of health care is a vital element in raising the quality of life of the residents of Judea/Samaria and Gaza. Rising standards of living have contributed substantively to improved nutrition, community infrastructure and education levels. For a population in which 50% is under the age of 15, emphasis has been placed on primary health care and sanitation, as well as health education. Improving medical and hospital care has also been emphasized.
The health services operated by the Israeli Civil Administration IGHS in Judea/Samaria and Gaza, together with voluntary health services, continue to provide regular and emergency health care. During 1990-91, the health services have continued to function, to improve facilities, to introduce new services, and to carry out staff training and educational programs. 13. BIBLIOGRAPHY
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A-HidEatt ....60 Endocrinology Accident ....27 Environmental health 29, Envi ronmental Protection • • • i 3, 5, Acut* Care Hospitals • . • .iii, 41 # Admissions 38. 40. 41 Epidemiology 25, 33, 37, 61, 70, 71 Agricultural product ivi ty • Family income 11 Ahli Hospital 19, 52 Family Medicine 51, 55 Ambulance iii. 1, 3, 14, 36, 37. 50 Family physicians 5, 55 American Physicians for Peace 3 Fertility . . . 1. 19 American Public Health Association 64, 68 Fir»t Aid 50 Anemia 33, 48, 66, 68 Folate 33 ANERA 60 Food Supplies i i Anesthesia 5, 47, 52. 53 Garbage disposal 3, 12, 57 Anesthetists • 53 Gas/electric 11 Annual Growth ii, ó, 7 Gastroenteric and parasitic disease 16 Antibody Levels И, 20, 21 Gastroenteric and parasitic disease .... 5 Gaza Health Services Research Center . 33, 37, 60 61, Antibody Levels 64 # Assaf Harofe Hospital 2, 51 68, 69. 72 Beersheva 4, 15. 20. 37 General Physi ci ans 53 Beersheva University 37 Germany 56, 64 Beilinson Hospital 51-53 GNP 8 Beit Jallah Rehabilitation Center 2 Good manufacturing practice 36 Benevolent Society of Gaza 36 Gross Domestic Product i i, 8 Bet Hanoun 6 Gynecology 5, 48, 51 Bet Labia 6 Gynecology 2, 37, 48-53, 64, 68, 69, 71 Bethlehem . г. 9, 30 34, 39. 44, 45, 53. 55, 56, 59, 64 Haifa University 2, 50 # Bikur Holiro 49 Haifa University 5 Blood bank 19, 34, “ Health education . . 13, 27-29, 31, 32, 60. 63. 67. 71 Health for All 71. 72 29 Health services . ii iv, v, 1-3, 5. 9, 10, U, 20, 21, •lf-«xamination # Breastfeeding 24 25. 26. 30-34, 37. 38, 52. 53, 58-61. 63-72 Brucellosis iii, iv, 34, 35 Health Services Research Canters 26, 61 Bureij ..k, 40, 66 Hebron . v, 1-3. 9, 13, 26, 28. 30. 34, 39, 43, 45, 55, Burn cases • 42 56, 59, 60, 61, 64, 65, 68 Burns ....50, 60 Hematology 5, 49 Calories Per Capita • • ..ii, 11, 12 Hepatitis 19, 20 ....27, 69 High risk pregnancies 23 Caritas Pediatric Hospital 59 Hillel Yaffe, Hadora Hospital 49 Causes of Death iii, 27, 68 Holy Family Maternity Hospital 2 CDF 28, 56, 60 Home Fací И ties i i, 11 Center for Disease Control 33, 37 Hospital Beds . iii. 38-40 Hospital services i, 38 40, 62 66 Central Bureau of Statistics 6, 8. 69 f f Chi Id Development Center 32 Housing conditions 11 Cholera 61 Hygiene v, 28, 29, 31, 32, 57 Christian Holyland Mission, USA 59 Hypothyroidism 13, 32, 66 Hypothyroidism . . v, 2, 4, 12-15, 19, 21, 23, 24 28, Civil Administration • • • 3, 6, 7, 28, 56, 58, 67, 69 # Community Health Center 54 30-34. 36-38, 42, 45, 46-48, 51, 53-55. 57-67 Computerization 62 Immunization . ii. 2, 4, 12. 13, 15. 18-21, 24, 25, 29, Congenital 2, 13, 27, 32, 44 31, 34, 59. 61. 62. 65. 66 Construction v, 1, 3, 42-45, 56 Incidence Rates iii, 22, 34 Continuing education • . • • 3, 30, 47, 48 50, 51. 53 Industrial development 8 # CRS 60 Infant Hi. iv. v, 6, 23-26, 28, 30. 42. 61. 62, 70. 71 CT scan Infant Growth Patterns iv, 24 Dayas 13, 30-32, 50, 60, 63 Insecticides 58 Decontamination 1 Insecticides 36 Intensive care . . 2, 4, 5, 19, 42, 43, 46, 48 50, 55 Demography î, 6 f Diabetes HelUtus 28 Internal Medicine 48-50 Diakonia 28 International voluntary agencies 59 Dialysis 19, 43, 46 IPV 2, 21 Diphtheria 15, 19 I ron deficiency 33 Dir «I Balah 6 Italy 1, 28, 43-45, 56, 60 Disorders 11, 32 Jabaliya 5, 6. 54, 56, 60 Disorders 8 Jenin 3. 9. 39, 51. 55-57. 59. 60 ECHO 51 Jericho 9, 34. 39, 55, 58 Economic activity 8 Jerusalem Central Public Health Laboratory 48 Edinburgh University 37 Kalkilia 3, 39, 57 Khan Younis . 4. 6 10, 36, 38, 40, 41. 46, 51. 52, 56, EEG 51 # Electricity 11 60, 66 Electrification 11 Knights of Malta Order 2 Emergency Health Services 1, 3, 65 Leishminiasis 58 Emergency situation 3 Length of Stay 38, 40, 41 Licensed Practical Nurses 53 Public health nursing 4, 52 Living standards ” Public health servi ces 34 Magen David Adorn 3 34, 36, 37, 50 Rafah 6. 36, 56 f 58 Rafidia v 1 39. 55 Malaria f # Manpowe r i. iH, 46, 47, 53-55. 60, 62, 6605 Ramallah . 1-4. 9, 15, 20, 25, 28, 30. 33. 34, 37, 39, MCC 42-45, 49, 51, 53. 55-57, 59-62. 6A, 71 Measles iv. v, 2, 4, 15, 19, 20. 31. 61, 71 Ramallah Health Services Research Center (RHSRC) 30, 61 Medical education 50, 53 Red Crescent 3, 36, 37, 39, 45, 51 Medical Scientific Council in Gaza 55 Red Crescent Society 36 Referral to Hospitals in Israel 42 Meningococcal A 19 Refugee settlements 5 6, 16, 25 Mental retardation 32 # Midwives 31, 49. 51 Rehabilitation 2, 28, 45 Migration 6 Rimal Clinic 28 Morbidity 16. 27, 32, 38, 41 Roads 11 Mortality . • iii. iv, 6. 16, 25-28, 30, 32. 62, 69, 71 Rotaviruses 61 29 Hukhtars Rubella 19, 20, 31 Nablus 1, 9, 28. 34, 37. 39. 42, 51, 53, 55, 57, 60 Safe water supplies 11 Samaria ... 1, i i iii, iv, v 1-3, 6-9, 11-15, 18-23, National Water Carrier 57 # # NECC 60 25-28, 30-34, 36-40, 42, 45, 47-50, Neurosurgery 41-43, 46, 49, 52 53-61. 63-65, 67. 69-71 Neurosurgical “》53 Sanitary Supervision 57 Newborns iii. 23, 29, 30, 32, 43 Saudi Arabia 19 Norway 2 Screening . . . 13, 29, 32-34, 66 Number of births 7 Serosurvey 20, 21, 61, 62, 71 Nurse training 2 Sewage 3, 5, 12, 43. 56, 60 Nursing education 53 Sbeba Medical Center, Tel Hashomer 32, 34 Nutrition • v, 11, 13. 23-25, 29, 31, 32, 59, 66, 67, 72 Shifa Hospital ... v, 4. 5, 28, 40, 41, 46, 51-54, 60 Shi fa Medical Center 4 66 Obstetricians “ # Occupancy rates 38, 40 Showers 1 Occupational health 45 Smoking 27, 63 Oncology 5. 42, 46, 50, 52. 69 Specialty Qualification 55 Open Heart Surgery ^2-44, 51 Strikes 8, 11 Ophthalmic 3, 40, 41 46, 66 Sweden 2, 28, 45 # OPV 2, 18. 21, 31 Swedish-Jerusalem Society 43 Oral rehydration 12, 32, 70 ТВ 19, 21 Oral-maxillary 5 Terre des Hommes 30, 51 Orthopedics 4, 5, 48, 49 Tetanus 15, 19, 20, 31, 71 Paramedical 50, 54 Tomography 1 Parasitic 16, 31 TOPV 2, 18, 19 Parasitosis 60 Traditional birth attendants (Dayas) 13, 30 raining program 2 29, 49, 51 52 Patient's Friends Society of Ramallah 2 了 f # Pediatric nephrology 42 Transportation 11, 29, 36 Pediatric urology Trauma 3 Pertussis iv, 15 Traumatology 49 Pesticide 58 Tuberculosis iii. 4, 21. 22, 40. 66 Pharmacy 1, U, 42 Tulkarem 9, 28, 39, 51, 55. 56 Phenylketonuria 32, 66 TV 11 Phlebotomus 58 Ultrasound 51 UNDP 5, 28, 47, 56 59-62 Physical Therapy • • • 28 # Physiotherapy v, 1, 2, 42, 44. 45 UNFPA 60 Planning • 3, H. 33, 38, 40, U2, 44, 57, 61, 63-66 UNICEF 28, 30, 3、50, 59, 60. 64 Plastic surgery Uni ted Nations Development Program 47, 59 Polio iv. v. 2. 15, 19-21, 61, 70 Uni ted States Agency for International Political situation 8 Development (AID) 59 Population \\. 6, 7, 11, 12, U. 15, 22, 25-27, 32. 34, University in Jerusalem 2 35, 38, 40, 41, 47 53. 54, 56, 59, 63, UNRWA 3, 4, 13, 15, 21, 25, 32, 36. 37, 39, 40, 51, 59, # 63 66, 72 67, 71, 72 ( Population growth 6 Urology 42, 49 Utilization iii, 28, 38, 40. 41 58, 63 Positive pressure respirators 1 # Pregnancy ... v, 2. 4. 13. U, 19. 28-30. 33, 60. 62. VHR 26, 29. 30 64-66, 70 Village Health Uorkers 3 Prenatal 4, 14. 19. 30 33 Vitamins 32 # Primary Care W. 13. 14, 28, 31, 32. 65 Uattenee 55 Professional Development 2. A Uolfson Hospital in Tel Aviv 4 Projects v, 5. 42. 45. K7. 56. 59-64 World Health Organization 47, 59. 68, 71, 72 X-ray H 43 Psychiatric Hospitals 40, 41 # Psychiatry 5, 41 49 f