29 health staff in Ramallah received WHO training on Mental Health Gap Action Programme. Photo:WHO February, oPt - The World Health Organization supports the Palestinian Ministry of Health (MoH) in integrating mental health services into primary health care to ensure that people in the West Bank and Gaza get better access to the mental healthcare they need.

In February 2019, 29 health staff working in the MoH primary healthcare clinics in Ramallah received WHO training on Mental Health Gap Action Programme (mhGAP) that will help them to identify and manage priority mental, neurological, and substance use conditions. The training was conducted using the mhGAP Intervention Guide (2.0), a tool designed to build the capacity of non-specialist on detecting, treating and referring mental health cases with common mental health problems.

According to the WHO survey conducted in 2013, one-third of people using MoH primary health care services in the West Bank and Gaza have common mental health problems. Provision of mental health services at primary health care is part of WHO recommendation in developing comprehensive mental health services at the three levels of health care (primary, secondary and tertiary) to enhance detection, treatment and referral for common mental health problems.

The mhGAP enables health workers to provide essential mental health care to people with depression, psychosis, bipolar disorders, epilepsy, developmental and behavioural disorders in children and adolescents, dementia, alcohol use disorders, drug use disorders, self-harm/suicide and other significant emotional or medically unexplained complaints.

With continuous support from the European Union, WHO’s mental health project ‘Building Palestinian resilience: improving psychosocial and mental health responses to emergency situations’, aims to significantly enhance the capacity of mental health services in both Ministry of Health and UNRWA health facilities. The project promotes comprehensive national mental health services, supports integrating mental health services into primary health care, enhancing the emergency response and scaling up community mental health services.

WHO Regional Director Dr Al-Mandhari visiting Palestinian Public Health Laboratory in Ramallah. Photo: WHO 27 February 2019, oPt - Concluding a three-day visit to the occupied Palestinian territory (oPt), Dr Ahmed Al-Mandhari, WHO Regional Director for the Eastern Mediterranean, called for ensuring regular and reliable access to health for all Palestinians and respect for the sanctity of health care.

During his visit, the Regional Director met with Prime Minister Dr Rami Hamdallah for a discussion on the importance of achieving universal health coverage, and reiterated WHO’s support to ongoing efforts to improve the health and well-being of all Palestinians.

In his meeting with Minister of Health Dr Jawad Awad, the Regional Director commended the progress made to improve health services that best meet people’s needs, noting that WHO will continue to work closely with the Ministry of Health to strengthen the Palestinian health system and respond to humanitarian health needs.

The Regional Director underlined that the recently enforced restrictions on vaccine imports to the oPt might, if not resolved, jeopardize sustainability of the highly successful immunization programme and pose a serious health security threat, not only to the West Bank and Gaza, but also to neighbouring countries.

At the Palestinian National Institute of Public Health, a WHO-led project, Dr Al-Mandhari praised the close collaboration between WHO, Palestinian health authorities and partners to produce evidence for informed health policy decisions and improved health outcomes.

In Gaza, Dr Al-Mandhari voiced concerns over the growing access restrictions for patients. In 2018, only 61% of the Palestinians who required health services outside the Gaza Strip obtained an Israeli permit to travel, posing a substantial impediment to accessing health care, particularly for vulnerable patients.

Visiting Gaza’s largest hospital, Shifa, the Regional Director witnessed firsthand the fragility of an overburdened health system. The influx of trauma patients is putting extra strain on hospitals that have to discharge patients prematurely to make room for newly injured. Chronic shortages of medicines and medical supplies is a significant challenge, with almost half of essential medicines and over a quarter of essential medical disposables at less than a month’s supply over the last year.

With attacks on health care in the Gaza Strip continuing with disturbing regularity, Dr Al-Mandhari also reiterated a call to all parties to respect the sanctity of health staff and medical facilities. In 2018, oPt saw the highest number of reported attacks on health care globally, and the highest number of injuries to health workers: 363 attacks on health care were reported, leading to the tragic deaths of three health workers and leaving 565 more injured. 

“Health is a fundamental human right, and attacks on health care are a violation of that right,” Dr Al-Mandhari said. “I call on all parties to abide by their legal obligations under international humanitarian law and respect the sanctity and safety of health facilities and health workers. Health care is not a target.”

Women waiting at a cross point to exit Gaza for treatment. Photo: WHO 4 February 2019 – After being diagnosed with cancer, patients in Gaza may often have to wait for months before being able to receive treatment. Getting a permit to access the health care needed outside can be a stressful and unpredictable process, and many apply multiple times before being able to exit. Even then, some patients are never able to secure the permits they need to access care.

The ability of Gaza’s hospitals to provide adequate diagnosis and treatment to cancer patients is severely limited due to chronic shortages of medicines and lack of medical equipment. Nuclear medicine scanning needed for staging cancers, radiotherapy equipment and some specialized surgeries are unavailable. More than half of essential chemotherapy drugs were at less than a month’s supply throughout 2018. 

Many patients need health care elsewhere in the occupied Palestinian territory or abroad. But to leave the Gaza Strip for treatment, they must obtain a permit from Israeli authorities. This process can take up to several months, and even then some patients may be unsuccessful in securing access to travel for health care. In 2018, 39% of patient applications for permits to exit Gaza for health care were unsuccessful.

64-year-old Samira was diagnosed with uterine cancer in 2016. She underwent surgery but then required follow-up treatment unavailable in Gaza. Doctors referred Samira for radiotherapy to East Jerusalem. It took her more than 6 months and 5 permit applications to finally exit Gaza in June 2018. “All this time I was suffering from abnormal bleeding. It was a matter of life and death. Why was I denied a permit?’’ she says.

Proper cancer diagnosis and effective treatment are essential to improve the prognosis of patients and their chance of survival. The 5-year survival rate for breast cancer can exceed 80% if early detection and essential treatment services are available and accessible. In Gaza, however, it is significantly lower - only 65% of women with breast cancer survive 5 years after diagnosis.

Khadijah, a 32-year-old mother of 4, noticed something unusual with her breast in December 2017. Soon doctors confirmed she had breast cancer. In January 2018, Khadijah applied for a permit to go to Augusta Victoria Hospital in East Jerusalem for a specialized investigation – to see whether the cancer had spread and if so, how far. Her permit was denied. She started receiving chemotherapy in Gaza, but for optimal treatment surgery was needed. In July, Khadijah reapplied for a permit, and again was denied. She decided to change her treatment destination to Egypt. Khadijah’s second attempt to leave Gaza to Egypt was finally successful. She had surgery in August 2018, 7 months after diagnosis.  

Every cancer patient has the right to health. This means being able to access quality and acceptable health care and to enjoy the conditions of life that support staying healthy. Restrictions to accessing essential health services are one of the major barriers to the right to health for Palestinians living in the West Bank and Gaza Strip. Restrictions affect cancer patients at a vulnerable point in their lives, when they need specialist care and services for diagnosis and treatment. The World Health Organization calls for the protection and fulfilment of the right to health for all Palestinians.