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Statement by UNRWA Commissioner-General: The challenge of providing primary health care in conflict situations - The example of Palestine refugees

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Primary Health Care Conference, Doha, 3 November 2008

Distinguished delegates:

I thank the Government of Qatar for hosting this important conference. We are also grateful to WHO for inviting UNRWA to contribute a perspective from its sixty years of service to Palestine refugees.

As many of you will know, UNRWA was established in 1949 to provide relief and emergency assistance for Palestine refugees in the Near East. Since commencing operations in May 1950, our programmes have considerably evolved in response to the changing needs of refugees over the decades. At present, we maintain services in education, health, social welfare, infrastructure, camp improvement, microfinance, and emergency assistance in Jordan, Syria, Lebanon, West Bank and Gaza (the occupied Palestinian territory).

UNRWA is the main provider of comprehensive primary health care services to Palestine refugees in its areas of operation. Our network of 134 clinics, located both inside and outside the refugee camps, are serviced by 2,911 health care workers, including 484 doctors. In 2007 alone, 9.5 million medical consultations were managed by UNRWA's primary health care system.

My remarks today, which go beyond UNRWA's experience in conflict situations, will take us quickly through the evolution of UNRWA's health programme, drawing attention to some of our current concerns in this sector. I will conclude with a few broad reflections on the challenge of health care provision as seen through the lens of UNRWA's experience.

UNRWA began its operations in the immediate aftermath of the 1948 Arab-Israeli war at a time when some 800,000 Palestinians were traumatised by the violence of the conflict and the loss of their ancestral homes. This was a classic post-conflict situation, in which the living conditions and health status of the refugees was extremely poor. Malnutrition was rife and morbidity and mortality rates from air, food and water-borne infections and communicable diseases such as malaria, gastroenteritis, tuberculosis and trachoma were very high.

In these early years, UNRWA's focus was by necessity on emergency response and on improving environmental health conditions in the refugee camps. Septic-tanks as well as water, sanitation and sewerage systems were installed in refugee dwellings. Of note is UNRWA's introduction of a special oral rehydration formula (Najjar salts) for treating mildly dehydrated diarrheic infants. The success of this method cemented the widespread use of oral rehydration therapy by international agencies and globally.

To reduce malnutrition and under-nourishment amongst infants and children, a supplementary feeding programme was launched which included the provision of fresh midday meals to children, as well as monthly dry rations, milk and cod liver oil. These provisions were also supplied to pregnant and nursing women and tuberculosis patients.

The fight against communicable diseases was particularly challenging. A highly effective malaria eradication programme in the Jordan Valley was complemented by an expanded programme of immunization in mother-and-child health clinics and mass immunization campaigns for school-age and pre-school-age children. UNRWA counts among its successes the high level of immunization coverage it has maintained to the present. This has kept communicable diseases effectively in check, with no serious outbreaks among the Palestine refugee population to date.

The establishment of UNRWA's school health service was another landmark in the evolution of our programme. We deployed school health teams to conduct medical checks and manage immunization programmes, sanitary inspections and morbidity surveys. This service coincided with the expansion of health facilities. Our Mother and Child Health Preventive Care (MCH) Programme was extended to pre-school children and more rehydration and nutrition centres were established to address the high incidence of diarrhoeal diseases, iron-deficiency anaemia and deficiencies in protein and micronutrients such as vitamin A and D in children.

This summary provides a sketch of how UNRWA's health service has taken shape to this present time. I will now turn to a brief outline of the health programme's current preoccupations, many of which, as in the past, are dictated by the changing needs of the population we serve.

At present, non-communicable diseases have emerged as a major health concern. The diagnosis and treatment of cancers and the rising demand for physical rehabilitation are related challenges for which the Agency should be better prepared. UNRWA's response so far has included the establishment of a Disease Prevention and Control Programme for prevention, early detection and management of hypertension, diabetes and cardiovascular diseases. We have also expanded our reimbursement scheme to facilitate access for Palestine refugees to advanced diagnostic and treatment facilities in contracted hospitals. It has become increasingly clear that addressing non-communicable diseases has sustainability implications for the Agency because of the higher cost and duration of treatments.

Even as non-communicable diseases emerge, old enemies such as communicable diseases and micronutrient deficiencies have not been entirely defeated in some refugee communities. Surveillance systems for communicable disease have to be constantly updated and efficiently maintained, while the nutritional status of vulnerable groups must be monitored, and supplementary feeding programmes implemented in vulnerable groups.

Owing to serious funding difficulties, UNRWA is struggling to maintain a level of personnel, facilities and resources that will ensure high quality health care for refugees. With utilization of out-patient services at approximately 9 million medical consultations per year and an average of 95 visits a day per doctor, we need to do much more to secure for refugees the standards of care they need and deserve.

UNRWA is also aware of the need to reinforce and broaden its existing response to mental health problems and psychological well-being. These are expected to continue to be major issues in the coming years in view of the trauma and poverty many refugees experience in their lives.

I shall now speak briefly about the occupied Palestinian territory, a major preoccupation for UNRWA. In the eight years since the second intifada began, UNRWA and the refugees it serves have faced an array of extraordinary challenges in Gaza and the West Bank. The net result has been a situation in which all aspects of Palestinian life continue to be afflicted by progressive deterioration.

The closure of borders and rigid control of Palestinian movement means that Palestinians in Gaza who are at risk medically are frequently prevented from seeking health care elsewhere. The informal ceasefire of June this year has brought a welcome lull in the recurrent conflict and bloodshed that was a constant feature of Palestinian lives. Unfortunately, this period of calm has not reversed abysmal socio-economic conditions or relaxed in any significant degree the blockade to which Gaza has been subjected for the past 17 months.

The public health infrastructure is crumbling as a result of many months of poor maintenance due to a lack of equipment, spare-parts, materials and supplies. The sad state of the public health care system has been documented comprehensively by UNRWA, WHO, the Red Crescent Society and other national and international agencies. A week ago, the International Committee of the Red Cross (ICRC) issued a statement drawing attention to the grave state of affairs, highlighting in particular how an already critical health situation has been aggravated by an impasse in cooperation between Ramallah and Gaza.

In the West Bank, rigid control of Palestinian movement continues alongside sporadic incidents of armed conflict. The illegal separation barrier and its associated regime of over 600 physical obstacles are reinforced by a harsh administrative system of permits and prohibitions. These measures seriously affect Palestinian access to health and other facilities. They also impede the ability of UNRWA staff and other humanitarian workers to reach those in need, particularly the sick, wounded and vulnerable that are less able to negotiate the multiple obstacles to free movement.

Conditions in the occupied Palestinian territory present unique problems to the delivery of health services. In times of armed conflict, the Agency has strained to sustain existing services while simultaneously responding to emergency needs. Medical personnel and health staff, along with the communities in which they live, have been exposed to serious risks of injury or even death in the course of their work. Almost as worrying are the massive pressures imposed on our staff in terms of physical stress and psychosomatic symptoms.

In the face of these concerns and challenges, what thoughts might I share by way of the lessons UNRWA has learned?

Given the public character of health issues, the health sector is one where close coordination with local and national authorities, as well as with WHO and other international agencies is indispensable. The Agency's experience clearly points to partnership as a key prerequisite for addressing health needs in emergency situations and through regular programmes. Sharing of information and expertise, pooling of human resources, complementary advocacy strategies and apportioning tasks on the basis of the comparative operational advantage are examples of areas of coordination where inter-agency partnership could be enhanced.

A further lesson from UNRWA's experience is the advantages of utilizing cross-sectoral methods to promote the well-being of refugees and other beneficiaries. The one example I mentioned earlier was the use of UNRWA schools as channels for achieving high immunization rates and improving child health generally. Our experience suggests that other possibilities are worth exploring. Could we, for example, use schools and social workers as vehicles for delivering psycho-social support? Or could health, education and social workers cooperate more systematically to address such issues as domestic violence and violence in schools? In UNRWA, we believe that integrated strategies that harness skills and expertise across sectors can be an effective way to meet complex refugee needs.

Yet another lesson from UNRWA's experience is the need to ensure that resource mobilization strategies keep pace with planning and innovation in health interventions.

I take this opportunity to express UNRWA's gratitude to the countries and authorities that have made - and continue to make - sacrifices to host Palestine refugees. The hospitality and cooperation of the Palestinian Authority and the governments and people of Jordan, Syria, Lebanon, have been the mainstay of UNRWA's work. We are also thankful to the donor community whose generosity over the years has made possible the success story I have outlined in my statement.

We trust that even higher levels of contributions will be forthcoming as donors come to appreciate the urgency of the need to raise the quality of healthcare and to attend to the more sophisticated morbidity profile of refugees today. I include in this appeal a special and urgent call to Arab donors who have been exemplary in contributing to large scale projects, but have yet to respond to our Nahr El Bared appeal, or to provide the level of support we need in our health, education and other regular programmes. This is the time for that to change. This is the time for Arab donors to cement their commitment to the Palestinian cause through significant contributions to UNRWA.

Distinguished delegates:

Thus far, I have offered an overview of how UNRWA's health services grew over the years in response to changing refugee needs. I have outlined from the standpoint of UNRWA's experience a few areas on which we must focus our attention if health care for refugees and other vulnerable groups is to be maintained at an adequate standard and level of coverage. In this connection, I have mentioned the urgent need for increased funding, particularly from the Arab world; the importance of enhanced partnerships both locally and internationally; and the benefits of exploring the potential for integrated programming.

I shall conclude by referring to one more set of requirements which we consider the most pressing and the t imperative, particularly as regards the conditions faced by refugees in the occupied Palestinian territory. I refer to the need for action by the international community to ease the closure of Gaza's borders, to relax the restrictions on access and movement in the West Bank, to bring an end the occupation and to move closer to realizating a negotiated settlement that delivers for Palestinians and Palestine refugees a just and lasting solution to their plight. Concerted and effective action in these areas is essential if our work in health care and all other sectors is to make a meaningful and durable difference in the lives of those we serve.

Distinguished delegates:

There are intricate links between the health challenges Palestinians in the occupied Palestinian territory and the grave violations of Palestinian rights and freedoms over many decades. We cannot - and should not - fail to acknowledge these links any more than we can afford to ignore the doctrine of "do no harm". My call to you as members of the international community is to do whatever you can to encourage relevant actors to act on the underlying causes of the situation of Palestine refugees. This is an international obligation drawing its authority from the UN Charter and human rights instruments.

More fundamentally, it also rests on universal precepts regarding the need to safeguard human dignity wherever - as in the Palestinian case - it is threatened, denied or disregarded. I trust that as we leave this conference we will continue to seek, in our respective roles, ways to ensure for Palestinians and Palestine refugees the safeguards of humanity which have for so long proved elusive.