August 22, 2011
Each year thousands of Palestinians residing in the Gaza Strip are referred by their physicians to hospitals outside of Gaza in order to access necessary, often life-saving, medical services that are unavailable locally. A recent WHO report analyses how the situation in the Gaza Strip affects the Right to Health of the population living there.
It focuses in particular on the issue of the referral of patients:
1) from the point of view of access: are people who cannot find the specialized treatment they need in the Gaza Strip able to access it elsewhere?
2) from the perspective of the deficiencies of the health system in Gaza: what are the shortcomings of the health system such that people cannot be treated in the Gaza Strip?
The majority of these referrals are for diagnosis and treatment services in five common specialties – cardiovascular diseases, oncology, orthopaedics, neurosurgery and ophthalmology. In 2010, the Palestinian Ministry of Health (MoH) referred 12,483 patients from Gaza to outside hospitals in order to access specialty services not available in Gaza. Of these, 4,843 patients were referred to Egypt – which is accessible through the Rafah border crossing and under Egyptian control, and 7,640 to hospitals in East Jerusalem, the West Bank, Israel or Jordan. In addition, an estimated 1,500 patients from Gaza also left Gaza to access health services funded through NGO charitable donations or were self-funded.
Waiting for approval
In the case of referrals to East Jerusalem, the West Bank, Israel or Jordan, the patient needs to submit an application to Israeli authorities for permission to exit the Gaza Strip via Erez at least 10 days in advance of their appointment. According to the WHO, this is far too long: “Patients waiting for health care require an efficient, timely, dignified and transparent process for applying for referrals and permits for themselves and their caretakers to exit from the Erez checkpoint”, the report states. “The health of critically ill patients is likely to deteriorate while they wait for approval for travel permits, which can take weeks and is always uncertain.”
WHO’s monitoring of the process over 2010 showed that patients often suffer protracted delays in receiving permits to access medical services; can face interrogation by the Israeli security services as an application condition; experience difficulties during the arduous travel procedures to destinations; and, in worst cases, can be denied access. Six persons with known serious medical conditions, including four children, died after submitting applications for travel permits but before being able to access referral hospitals.
Of the 11,200 requests submitted to the Israeli authorities at Erez checkpoint on behalf of patients for permits to access hospitals in other areas of the Occupied Territories, Israel or Jordan; 9,112 requests (82%) were approved, 8,647 people actually crossed the border, 646 crossings were denied and 1,418 were delayed. The rate of timely approvals of permits varied considerably depending on the age and sex of applicants: 52% of male applicants aged 18-40 did not receive approvals on time and had to forfeit their scheduled hospital appointment, compared with just 5% of young patients aged 0-17. Six percent of applicants were denied permits, all without explanation (up from 2 percent in 2009).
In 2010, the Rafah crossing into Egypt, which does not require Israeli travel permits, became an increasingly reliable route for access to Egyptian medical centers for referred patients, especially for males aged 18-60. The border was closed from January to May 2010, except for a few days per months, however, in the last seven months of the year when the crossing had scheduled weekday openings, the percentage of patients accessing Rafah increased from 29% of all referrals to 45%.
The WHO report concludes: “All of these factors hindering referrals compromise patient access to health services, which is an essential element of the fundamental right to health and, as such, protected by international human rights law and international humanitarian law. Israel is a state party to the International Covenant for Economic, Social and Cultural Rights and is therefore obligated to observe its provisions protecting the Right to Health. Every effort should be made to address the factors that undermine the delivery of health care, and to ensure that patients who need to access hospitals outside of Gaza can do so quickly, easily and in as dignified a manner as possible.”
Download report: Referral of Patients from Gaza. Data and Commentary for 2010. World Health Organization Occupied Palestinian Territory, 2011