Johns Hopkins University
Al Quds University
In this issue we will highlight health issues of the Hebron district as this area has been exceptionally vulnerable and immunization access for the West Bank and Gaza Strip as this is a popular focus of humanitarian assistance.
This is the seventh Health Sector Bi-weekly Report which describes data that is collected every two weeks in an effort to monitor the impact of the emergency on various aspects of the health sector. CARE/Johns Hopkins University/ANERA, under the Emergency Medical Assistance Project, has partnered with Al Quds University to design and implement a sentinel surveillance system for Palestinian households. The Maram Project has designed and implements a monitoring system for all health service delivery facilities operated by the Palestinian Ministry of Health, UNRWA and Palestinian non-government organizations (NGOs). Both EMAP and Maram are funded through USAID.
The Sentinel Surveillance System (SSS) is an ongoing survey of 320 randomly sampled households of urban and non-urban clusters every two weeks in all 16 districts of the West Bank and Gaza. Findings presented in this report refer to data reflecting a period between 2 November and 16 November (Round 13) and 17 November through 1 December 2002 (Round 14), as well as cumulative data and trends representing 4,480 households since 17 May 2002
The Monitoring of Health Service Delivery study is linked to the SSS, simultaneously collecting data from all clinics (levels 1-4) and hospitals located in the same clusters as the SSS households. Findings presented here represent cumulative data from 294 health facilities surveyed over the course of rounds of data collection. The number of clinics in a given round varies depending on the number of clinics within a chosen cluster and the density of health facilities within that cluster.
Graph 1 presents the cumulative percentage of households with a decrease in food consumed. Ninety percent of Hebron and Bethlehem households report decreases.
During November, 183 of 320 (57.2%) households reported that the amount of food eaten by household members had decreased for more than one day during the previous two weeks; percentage of households reporting a decrease in the amount of food consumed since the onset of data collection is presented in Graph 2.
Since July, lack of money is increasingly becoming the primary reason cited for the decrease in food consumption in the West Bank (Graph 3). The effect of closure during the month of November is increasingly affecting the amount of food consumed. In Gaza lack of money alone has been the sole major factor.
Graph 1: Percentage of households with a decrease in the amount of food in the two weeks prior to the survey, May 17 to 1 December, 2002, by district
Graph 2: Percentage of households with a decrease in the amount of food over the two week interval in each two week round.
n= 220 households in west bank and 100 household in Gaza in each round.
Graph 3: Reasons for decreased food consumption, by territory
n= 320 households in each round
Hebron district continues to be the most vulnerable district for households needing to sell assets for food (Graph 4).
Graph 4: Percentage of households reporting selling assets in the two weeks prior to the survey since May 17 to 1 December, 2002, by district.
n= 280 households in each district.
- In round 13, 56.3% (54.5% WB, 60%GS) and in round 14, 49.7% (50% WB, 49% GS) of households were forced to borrow money to purchase food during the two week sampling interval;
- In round 13, 25.6% (25% WB, 27% GS) and in round 14, 18.4% (16.4% WB, 23% GS) of households were forced to sell assets to buy food.
Households may have borrowed more money or sold more possessions in preparation for Ramadan during the first half of November (Round 13) as opposed to the latter half of November (Round 14). In addition, during Ramadan, wealthier Muslims tend to give more either to needy people or to their relatives.
Since May, Hebron is the most vulnerable district for household water availability (Graph 5).
Graph 5: Percentage of households with water interruption since 17 May, 2002, by district.
- During November, water interruption, adequate water for drinking, and adequate water for bathing for both the West Bank and Gaza Strip showed some improvement (Graph 6);
- Household water interruption continues to be more problematic in Gaza compared to the West Bank: 26.4% WB versus 33% GS households in Round 13; 17.3% WB versus 27% GS households in Round 14 reported water interruption.
Graph 6: Percentage of households with water interruption and decreased water for drinking and bathing since 17 May, 2002.
n= 320 households in each round.
- Household watery diarrhea prevalence has decreased since the end of October which marks the end of the dry season and beginning of the wet season (Graph 7).
Graph 7: Percentage of households having a family member with three watery stools for at least one day in the two weeks interval by round.
n= 320 households in each round.
Health Services: Access
Table 1 presents data highlighting household access to care. With the exception of antenatal/ postnatal care, the ratio of the numbers of households that had at least one member that required specific health services but was unable to access them to the total number of households with at least one member who required that service improved during November.
- In November, access was only a problem in the Northern West Bank districts.
- In November, 39 of 46 Northern West Bank households who required antenatal care were unable to access services due to non-functioning clinics
Table 1: Rounds 13, 14 and cumulative frequencies and percentages of households (HH) in which at least one member required specific health services and was unable to access them
Round 13 HH N* (%)
Round 14 HH N* (%)
Cumulative HH** N* (%)
|Antenatal and post natal care||
*Number of households with at least one member requiring health service but unable to access/total number of households with at least one member requiring services
**Due to technical difficulties, the cumulative numbers do not include Rafah district in the first 13 rounds; total HH = 4240
- The ratio of households whose members required emergency care but were unable to access them to the total number of households requiring emergency care improved since October (Graph 8) even though the number of households requiring emergency care has remained consistent.
Graph 8: Ratio of households unable to access emergency care to all households requiring emergency care, since 17 May, 2002
- Since May, in the Hebron district, 19 out of 20 patients who required specialized care services (diabetes clinics, chemotherapy, and dialysis) had no access to those services, citing curfew as the main reason for their inability to access these services.
Since May, 159 out of 1064 (14.9%) children needed immunization but had no access;
Access to immunization showed some improvement in the last few rounds (Graph 9);
Household access problems have been particularly worse in Bethlehem, Gaza City, and Nablus (Graph 10)
Reasons: Curfew was cited by 84% of the households.
Graph 9: Percentage of households having a child scheduled for immunization and had no access to immunization services in the two weeks interval by round.
n= 320 households in each round, this percentage is out of those children needing the services.
Graph 10: Percentage of households having a child scheduled for immunization and had no access to immunization services, by district, since 17 May 2002.
Immunization service delivery, critical to maternal and child health, is continuing in the West Bank and Gaza but under a number of direct and indirect constraints.
- 217(77.6%) of the 294 health facilities surveyed from June through November offer immunization services as specialty services or through pediatric primary care services;
- 9 facilities reported having suspended immunization clinics for two or more days during the two weeks prior to the survey interview
- 37 (17.5%) of the 214 facilities offering pediatric primary care suspended those services for two or more days during the two week reporting interval;
A key to quality immunization services is the integrity of the cold chain. Electricity shortages can disrupt refrigeration systems and negatively impact vaccine efficacy.
- 64(24.9%) of the 217 facilities offering immunization services reported electrical supply disruptions during the two week reporting interval;
- 45 (70.3%) of the 64 have back-up generators
More investigation is required to assess the steps facilities may be taking to protect their cold chain and to identify measures that can be taken to protect immunization services, particularly in the Central and Southern Districts of the West Bank, and in the Gaza Strip (Graph 11),where many facilities do not have access to generators.
Graph 11: Generator availability in surveyed facilities that offer immunization services, since 17 May, 2002, by District.
Health Facilities: Hebron
The health service delivery system in Hebron has been particularly challenged since the escalation of the emergency in May of 2002. Since then a total of 37 facilities scattered throughout the District have been surveyed. No facility level data for Hebron is available for mid-August because of the lack of facilities in the geographic area where households were being sampled during the 7th round of data collection. The number of facilities surveyed in each round in Hebron is shown in Graph 12, which also indicates the numbers of facilities experiencing disruptions in:
- Staff access to facilities (improving as of September),
- Availability of essential equipment and supplies, and
- Provision of referral services.
Although each of these constraints threatens health service delivery, facilities have managed to avoid suspending services since the end of June (Round 3).
Graph 12: Service delivery challenges and constraints, Hebron District, since 17 May, 2002
n = 37 (cumulatively)
Cumulatively since 17 May 2002:
17 facilities (45.9%) reported staff access problems; all indicated curfews/closures posed the primary constraint, 2 also listed funding for transportation as a factor;
30 facilities (81.1%) reported equipment/supply problems, primarily due to the constraints listed below, in that order. Note that 14 (46.7%) of these experienced all 3 constraints (Graph 13):
- impassable roads,
- curfews and closures, and
- lack of funds.
n = 37
Relative to referral service disruptions, in addition to the negative impact of curfews/closures and impassable roads, ambulance problems and lack of trained staff required for referral service delivery were also listed as constraints, as shown in Graph 14 below (facilities are allowed to mention more than one constraint):
- 29 (78.4%) of 37 facilities reported referral service disruptions
- 24 (82.8%) of the 29 indicated both curfews/closures and impassable roads were negatively impacting referral services
- 2 facilities (6.9%) also experienced problems with ambulance and essential staff
n = 37
Another challenge to health service delivery in Hebron is lack of water, which has impacted 7 (21.6%) of the facilities surveyed thus far, although no facilities reported water problems in the last 4 reporting periods included in this report (early October through the end of November). The facilities that did report problems from mid-May to mid-June, mid-July through early August, and early September to early October indicated that the interruptions in water supply were due primarily to non-delivery of purchased water, and damage to public water supplies. The impact of the water shortages on the seven facilities affect all four key concerns - provision of clinical services, drinking water for patients and for staff, and the housekeeping and sanitation activities that are critical for infection prevention. The number of facilities experiencing each of these problems is shown in Graph 15 below.
Graph 15: Effects of water shortages in 7 health facilities in Hebron, since 17 May 2002
n = 7
It is also interesting to note that data from Hebron-based facilities consistently suggests an increased incidence of diarrheal dehydration, relative to the norm for the time of year.
Bdour Dandies, email@example.com
Ellen Coates, firstname.lastname@example.org
Bassam Abu Hammad, email@example.com
Fuad Ewissat, firstname.lastname@example.org
Johns Hopkins University/CARE
Derek Ehrhardt, email@example.com
Gregg Greenough, firstname.lastname@example.org
Al Quds University
Ziad Abdeen, email@example.com
Mohammad Shahin, firstname.lastname@example.org
With appreciation to Radwan Qasrawi and the Operations Research Laboratory staff, and data collectors.