Far from home: Medical referrals abroad from Gaza

Heart disease, cerebrovascular disease, diabetes mellitus and cancer account for approximately half the total of deaths  in the occupied Palestinian territories.  The Israeli blockade, the Hamas takeover in 2007 and the recent Israeli military operation in Gaza throughout December and January 2009, has led to an almost complete bureaucratisation and politicisation of the health care system in Gaza meaning patients requiring specialised health care are forced to seek treatment outside, namely in Egypt, Jordan, Israel or East Jerusalem.

Although healthcare resources are adequate ( 1.4 beds per person, 0.9 health care centers per 10, 000 people, and 2.6 physicians per 1,000 people),  hospitals face a chronic lack of spare parts for medical equipment and Tertiary health care (such as cardiac catheterisation and open heart surgery, radiotherapy, and some chemotherapy) are not available. Many patients have had to undertake a lengthy and unpredictable referral process, which has delayed treatment and in some cases, cost lives.

Referral Abroad Department – A Past Overview

Since 2006, the Referral Abroad Department (RAD) within the Gazan Ministry of Health (MoH) has been directly responsible for dealing with patients needing health care outside of Gaza namely in East Jerusalem, Jordan and Egypt. In 2006, 90% of patients who applied were given permission to leave through the Erez check point; in 2007, RAD approved  81.5% of referral applications.

However since 2007, strict border controls and unexpected border closures through Erez and Rafah (the main exit point into Egypt) have prevented many patients with permits from leaving Gaza. In the first six months of 2008, on the 6.232 patients (WHO) who have applied for permission to leave the Strip for medical treatment abroad, 3.520 patients were given permits (WHO), while 3,250 patients (OCHA) effectively exited through Erez (541 a month on average).

The amount dropped from July 2008 to June 2009, during which 4,038 exited (336 on average per month). Between October 2007 and March 2008, 32 patients died after being denied access to specialised treatment outside the Gaza Strip.

Hamas’ Takeover of the Referral Abroad Department

Complicating the situation further was the 18 January 2009 decision by the MoH in Ramallah to stop referrals of Gazan patients to Israeli hospitals, followed which was exasperated by the Hamas takeover of RAD in March. Hamas justified the takeover referring to allegations of corruption and inefficiency by Fatah personnel.  The liaison officer, key to getting patients referred out of Gaza, was suspended and replaced by a Hamas-affiliated official. Israel subsequently refused to recognise the new system effectively putting a stop to referrals abroad.

Within this ‘black hole’ many informal initiatives were undertaken to ensure at least a minimum flow of patients exiting Gaza. Most patients attempted to leave through local human rights organisations while others were able to exit using permits obtained prior to the takeover of the RAD.

The Resolution and Current Situation

After negotiations and strong pressure from local organisations within the Palestinian Network for NGOs (PNGO), Hamas and Fatah finally agreed on 27 April 2009 to form a joint referrals committee under the guidance of an independent Palestinian body. All new referrals would bear the Palestinian Authority stamp (to which Hamas is not a party), allowing Israel to maintain its strict policy of not engaging with Hamas.  The agreement would also allow Fatah and Hamas to work together without compromising their own political agendas.

Since the resolution, the numbers of referrals have increased significantly.  Nearly 58% of applications were granted in May and 68% in June. However, bureaucratic delays in the application process at local level or at the Israeli level, where the final permission is granted, are still unacceptably high. Delays of up to two weeks are not uncommon. Also while most cases are covered by medical insurance, the referral process can place financial pressures on families already struggling in Gaza.

The increasing politicisation of the health care system in Gaza will undoubtedly have an impact on the quality of care provided to patients.  With no end in sight to the internal political problems between Hamas and Fatah, and no real progress regarding the ongoing Israeli blockade, the health care system in Gaza will continue to suffer. It remains to be seen if the Referral Abroad Department (RAD) will enable the many patients in need of urgent medical treatment outside of Gaza.