Aid shortfall causes agencies to rethink approach in Gaza

Abstract

UN agencies are being forced to consider their health and development priorities in Gaza after shortfalls in donor funding for the occupied territory. Sharmila Devi reports.Since the last big flare-up of violence between Israel and the Palestinians late last year, other conflicts such as that in Syria have grabbed headlines and overshadowed the long-standing and persistent health needs in the Occupied Palestinian Territory (OPT).Health-care professionals and aid agencies say the need for humanitarian assistance remains acute. The blockade on the Gaza Strip, severe restrictions on movement in the West Bank, and periodic bouts of hostilities with Israeli forces all prevent long-term planning and implementation of a sustainable economy and health sector, they say.In the latest crisis, food distribution centres in the Gaza Strip were briefly closed last month following violent protests over aid cutbacks. The UN Relief and Works Agency (UNRWA), which provides aid for an estimated 800 000 people in Gaza, warned the centres could shut again if there was further unrest.UNRWA is facing a budget deficit of more than US$67 million as refugee population growth has risen by 3·5% in Gaza, meaning up to 8000 new children to school and care for each year amid an unemployment rate of 32%. “The budget is not increasing as much as the numbers and the needs of the population. The deficit in the UNRWA budget affects the cash assistance for poor people. The agency was forced to cut assistance because the main goal now is to develop education and health services”, says Adnan Abu Hasna, an UNRWA spokesman.UNRWA cares for 5 million refugees in Jordan, Lebanon, Syria, the West Bank, and Gaza. This year's estimated budget is $662 million, of which the Arab League was supposed to provide 7·5% but it had only donated 1·5%, said Abu Hasna.The Palestinian health-care system has been in acute difficulty since 2000 when the second intifada started, says Mahmoud Daher, the head of WHO's Gaza office.The list of restricted goods allowed into Gaza still goes beyond “dual-use” items that can have both military and civilian use. Aid workers have reported delays of between 6 and 8 weeks in getting medicines through the crossings from Israel into Gaza.WHO figures for shortages in Gaza are stark. A couple of months after the 8 days of Israeli air strikes on Gaza last November, the number of medicines out of stock was 160 of 478 essential medicines and 199 of 659 disposables and consumables. Medical staff still lack necessary equipment because they are missing spare parts or the devices are outmoded.“The occupation and political situation contributes to a lack of development in health. We have 60 000 newborns every year and the increased demand for health services is not matched by our resources”, says Daher. “We have shortages of antibiotics, chemotherapy drugs, and preoperative care drugs. Many chemotherapy courses require two or three drugs in combination but we often lack at least one of them so treatment can't continue.”“Palestine is in an epidemiological transition. It's not Africa or southeast Asia with the infections and diseases found there. The Palestinian population has gone into a new era with non-communicable diseases, such as diabetes, that are prevalent in the West. The mortality rate is not like that found in less developed countries while the fertility rate is still high. We have the profile of a country in the middle between developed and less-developed countries”, he adds.Earlier this year, the UN Office for the Co-ordination of Humanitarian Affairs (OCHA) launched the Consolidated Appeal Process (CAP) for 2013, asking for $401·6 million for OPT. This is a slight decrease on last year's $416·7 million, only 68% of which was financed and distributed for projects implemented by UN agencies and non-governmental agencies.“This is the tenth time we've come together to do this consolidated appeal”, says Maria Jose Torres, OCHA's deputy head of office in the OPT. “We don't know whether we'll stay at the 68% level of funding or not. Other issues around the region are attracting the attention of the international community, such as Syria. But even if the money is decreasing, we have to make sure priority needs are addressed.”The appeal is to fund 157 projects aimed at addressing a variety of humanitarian needs, including education, nutrition, and health. Growing numbers of Palestinians are facing food insecurity because of border restrictions, poverty, and fluctuating prices. “The CAP encapsulates the situation of food insecurity, particularly that faced by 1·3 million people in Gaza. This all has an impact on health and the situation is not improving”, said Torres. “But it's just as important to work on the political front and the root causes of the conflict in order for these communities to see a future, and not only to provide humanitarian assistance.”The Palestinian Authority (PA) is split between the Fatah-dominated government in the West Bank that is supported by the West and the Hamas administration in Gaza, subjected to harsh international sanctions since it took over in 2007.The situation was exacerbated in February by a public sector strike including health workers, who provided only emergency care as they demanded better conditions and payment of salaries.Hani Abdeen, Palestinian health minister, told The Lancet that the PA was being kept “under siege” by the periodic withholding of tax revenues by Israel, which collects the funds on their behalf. Abdeen said donors such the USA and Arab Gulf states that failed to pay pledged funds meant the Ministry of Health was unable to pay for items such as pacemakers, diabetes and chronic hypertension drugs, and anaesthetics. “It is very difficult and we are facing lots of shortages in drugs and in our primary care clinics”, he said.In view of the lack of specialised treatment in the territories, doctors often have to refer patients to hospitals in Israel, Egypt, and Jordan for treatment in fields such as cancer, neurology, and cardiology. Not only was it extremely difficult to gain travel permits from the Israeli authorities, the lack of funds meant the PA was unable to pay those hospitals, with Jordan at one point refusing to accept Palestinian patients, says Abdeen.Non-communicable diseases accounted for 70% of Palestinian deaths and addressing the economic and social determinants of health was a big challenge, Akihiro Seita, UNRWA's health programme director, tells The Lancet. “We should be providing statins to treat high cholesterol but they're too expensive as is haemoglobin. All the new technologies are too expensive”, he said. “People are poorly nourished, malnourished, and the core reason isn't just cultural, it's economic. If people can't get balanced food and eat only bread, bread, bread, then they become obese.”A host of other organisations are also working on the ground to try to alleviate the situation. Salah Haj Yahya of Physicians for Human Rights Israel said he had seen a sharp increase in patients at its mobile clinic, which operates one day a week across the West Bank with the help of volunteer Israeli medics. “We have 2800 members and volunteers but if we had a bigger budget we could do more than one medical day in more villages”, he said.“In the West Bank, there are only 1600 public hospital beds, which is equivalent to just one Israeli hospital. Our demand is that as long as Israel is the occupying power, it must provide services equivalent to that in Israel.”Aimee Shalan, director of advocacy and communications for Medical Aid for Palestinians, said damage to the sewage system and electricity supply in Gaza caused by Israeli air strikes in the winter of 2008–09 was still not repaired. “There are high incidences of water-borne diseases, such as diarrhoea”, she said. “Meanwhile, there are more burn injuries because power cuts force people to use alternative fuels.”Her colleague in Ramallah, Majed Nassar, director of programmes, said because all non-governmental work was so sensitive to financial changes in richer countries, it was a challenge to ensure its services on a long-term basis. “We used to get much assistance from Spain, for example, but now Spain needs financial injections itself.”A rare good news story came from Gaza in January when a team of British surgeons did the first organ transplants there. Abdul Hammad and three colleagues from the Royal Liverpool Hospital undertook kidney transplants on two patients at Gaza's Shifa Hospital as a pilot for a long-term plan to train local medical staff to do the operations. “Power cuts and the lack of spare parts make dialysis difficult and transplants a more urgent priority”, said Hammad. “This is the start of the hard work to bring staff to be trained by the Royal Liverpool, which is volunteering and won't charge. We just need to raise the funds to pay for travel, accommodation and so on.”He planned to return to Gaza in May to do five more operations. “We're just trying to solve a small problem in a big conflict”, he says. “If everyone does something small, they will help the whole situation.” UN agencies are being forced to consider their health and development priorities in Gaza after shortfalls in donor funding for the occupied territory. Sharmila Devi reports. Since the last big flare-up of violence between Israel and the Palestinians late last year, other conflicts such as that in Syria have grabbed headlines and overshadowed the long-standing and persistent health needs in the Occupied Palestinian Territory (OPT). Health-care professionals and aid agencies say the need for humanitarian assistance remains acute. The blockade on the Gaza Strip, severe restrictions on movement in the West Bank, and periodic bouts of hostilities with Israeli forces all prevent long-term planning and implementation of a sustainable economy and health sector, they say. In the latest crisis, food distribution centres in the Gaza Strip were briefly closed last month following violent protests over aid cutbacks. The UN Relief and Works Agency (UNRWA), which provides aid for an estimated 800 000 people in Gaza, warned the centres could shut again if there was further unrest. UNRWA is facing a budget deficit of more than US$67 million as refugee population growth has risen by 3·5% in Gaza, meaning up to 8000 new children to school and care for each year amid an unemployment rate of 32%. “The budget is not increasing as much as the numbers and the needs of the population. The deficit in the UNRWA budget affects the cash assistance for poor people. The agency was forced to cut assistance because the main goal now is to develop education and health services”, says Adnan Abu Hasna, an UNRWA spokesman. UNRWA cares for 5 million refugees in Jordan, Lebanon, Syria, the West Bank, and Gaza. This year's estimated budget is $662 million, of which the Arab League was supposed to provide 7·5% but it had only donated 1·5%, said Abu Hasna. The Palestinian health-care system has been in acute difficulty since 2000 when the second intifada started, says Mahmoud Daher, the head of WHO's Gaza office. The list of restricted goods allowed into Gaza still goes beyond “dual-use” items that can have both military and civilian use. Aid workers have reported delays of between 6 and 8 weeks in getting medicines through the crossings from Israel into Gaza. WHO figures for shortages in Gaza are stark. A couple of months after the 8 days of Israeli air strikes on Gaza last November, the number of medicines out of stock was 160 of 478 essential medicines and 199 of 659 disposables and consumables. Medical staff still lack necessary equipment because they are missing spare parts or the devices are outmoded. “The occupation and political situation contributes to a lack of development in health. We have 60 000 newborns every year and the increased demand for health services is not matched by our resources”, says Daher. “We have shortages of antibiotics, chemotherapy drugs, and preoperative care drugs. Many chemotherapy courses require two or three drugs in combination but we often lack at least one of them so treatment can't continue.” “Palestine is in an epidemiological transition. It's not Africa or southeast Asia with the infections and diseases found there. The Palestinian population has gone into a new era with non-communicable diseases, such as diabetes, that are prevalent in the West. The mortality rate is not like that found in less developed countries while the fertility rate is still high. We have the profile of a country in the middle between developed and less-developed countries”, he adds. Earlier this year, the UN Office for the Co-ordination of Humanitarian Affairs (OCHA) launched the Consolidated Appeal Process (CAP) for 2013, asking for $401·6 million for OPT. This is a slight decrease on last year's $416·7 million, only 68% of which was financed and distributed for projects implemented by UN agencies and non-governmental agencies. “This is the tenth time we've come together to do this consolidated appeal”, says Maria Jose Torres, OCHA's deputy head of office in the OPT. “We don't know whether we'll stay at the 68% level of funding or not. Other issues around the region are attracting the attention of the international community, such as Syria. But even if the money is decreasing, we have to make sure priority needs are addressed.” The appeal is to fund 157 projects aimed at addressing a variety of humanitarian needs, including education, nutrition, and health. Growing numbers of Palestinians are facing food insecurity because of border restrictions, poverty, and fluctuating prices. “The CAP encapsulates the situation of food insecurity, particularly that faced by 1·3 million people in Gaza. This all has an impact on health and the situation is not improving”, said Torres. “But it's just as important to work on the political front and the root causes of the conflict in order for these communities to see a future, and not only to provide humanitarian assistance.” The Palestinian Authority (PA) is split between the Fatah-dominated government in the West Bank that is supported by the West and the Hamas administration in Gaza, subjected to harsh international sanctions since it took over in 2007. The situation was exacerbated in February by a public sector strike including health workers, who provided only emergency care as they demanded better conditions and payment of salaries. Hani Abdeen, Palestinian health minister, told The Lancet that the PA was being kept “under siege” by the periodic withholding of tax revenues by Israel, which collects the funds on their behalf. Abdeen said donors such the USA and Arab Gulf states that failed to pay pledged funds meant the Ministry of Health was unable to pay for items such as pacemakers, diabetes and chronic hypertension drugs, and anaesthetics. “It is very difficult and we are facing lots of shortages in drugs and in our primary care clinics”, he said. In view of the lack of specialised treatment in the territories, doctors often have to refer patients to hospitals in Israel, Egypt, and Jordan for treatment in fields such as cancer, neurology, and cardiology. Not only was it extremely difficult to gain travel permits from the Israeli authorities, the lack of funds meant the PA was unable to pay those hospitals, with Jordan at one point refusing to accept Palestinian patients, says Abdeen. Non-communicable diseases accounted for 70% of Palestinian deaths and addressing the economic and social determinants of health was a big challenge, Akihiro Seita, UNRWA's health programme director, tells The Lancet. “We should be providing statins to treat high cholesterol but they're too expensive as is haemoglobin. All the new technologies are too expensive”, he said. “People are poorly nourished, malnourished, and the core reason isn't just cultural, it's economic. If people can't get balanced food and eat only bread, bread, bread, then they become obese.” A host of other organisations are also working on the ground to try to alleviate the situation. Salah Haj Yahya of Physicians for Human Rights Israel said he had seen a sharp increase in patients at its mobile clinic, which operates one day a week across the West Bank with the help of volunteer Israeli medics. “We have 2800 members and volunteers but if we had a bigger budget we could do more than one medical day in more villages”, he said. “In the West Bank, there are only 1600 public hospital beds, which is equivalent to just one Israeli hospital. Our demand is that as long as Israel is the occupying power, it must provide services equivalent to that in Israel.” Aimee Shalan, director of advocacy and communications for Medical Aid for Palestinians, said damage to the sewage system and electricity supply in Gaza caused by Israeli air strikes in the winter of 2008–09 was still not repaired. “There are high incidences of water-borne diseases, such as diarrhoea”, she said. “Meanwhile, there are more burn injuries because power cuts force people to use alternative fuels.” Her colleague in Ramallah, Majed Nassar, director of programmes, said because all non-governmental work was so sensitive to financial changes in richer countries, it was a challenge to ensure its services on a long-term basis. “We used to get much assistance from Spain, for example, but now Spain needs financial injections itself.” A rare good news story came from Gaza in January when a team of British surgeons did the first organ transplants there. Abdul Hammad and three colleagues from the Royal Liverpool Hospital undertook kidney transplants on two patients at Gaza's Shifa Hospital as a pilot for a long-term plan to train local medical staff to do the operations. “Power cuts and the lack of spare parts make dialysis difficult and transplants a more urgent priority”, said Hammad. “This is the start of the hard work to bring staff to be trained by the Royal Liverpool, which is volunteering and won't charge. We just need to raise the funds to pay for travel, accommodation and so on.” He planned to return to Gaza in May to do five more operations. “We're just trying to solve a small problem in a big conflict”, he says. “If everyone does something small, they will help the whole situation.”