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Shortages of medicines and medical supplies in the Gaza Strip, June 2011
Of the 480 medications on the essential drug list, 178 (37%) were reported at zero stock levels in the Ministry of Health’s Gaza Central Drug Store (CDS) at end of May 2011. The CDS supplies the Ministry’s 13 hospitals and 54 primary health care clinics in Gaza.
While the shortage of essential drugs has been a chronic problem and zero stock levels have increased steadily since 2007 (2007: 14%; 2008: 16%; 2009: 18%; 2010: 24%), the protracted period of low stocks is now deemed critical for the continued delivery of health care.
Essential Supplies:
Of the 700 medical disposables on the essential list, 190 (27%) were reported at zero stock levels in the CDS-Gaza.
Impact of Shortages:
On patients: The inability to benefit from proper medications and supplies puts patients at substantial risk of medical complications and deterioration in health status. The shortages force patients to cope by trying to procure medications from other health providers or from the local market at greater cost, using inappropriate substitute medications, and by seeking treatment abroad. Cancer patients requiring on-going chemotherapy have also been referred outside for treatment. Patients with kidney diseases, transplants, hypertension, blood conditions and chronic illnesses who require a regular regime of medications, some of which are unavailable, are exposed to special risk.
On the Ministry of Health: Due to the need for vital drugs and supplies that are out-of-stock, surgeries in all major specialties have been either curtailed or stopped altogether, and the most serious cases have been referred to hospitals outside the Gaza Strip. The Ministry has coped with supply shortages by reusing some disposable items which compromises infection control, and by rescheduling dialysis patients to maximize use of existing functioning machines. Overall, referrals to hospitals outside of Gaza for conditions that heretofore could be treated within Gaza have increased.
Expected Deliveries:
150 drugs are currently out of stock in the West Bank because suppliers have not been making deliveries. Despite this, some shipments to Gaza are currently in process from the MoH-Ramallah as well as from the ICRC and NGOs. However, shortages in Gaza have remained at critical levels since January 2011 and the situation will require close monitoring and possible contingency measures.
Shortages of drugs and disposables at the CDS- Gaza, June 2011 2
Background
There are 480 drugs on the essential drugs list and 700 items on the essential medical disposables list considered by the Palestinian Ministry of Health as necessary for the provision of essential health care. Disposables include a wide variety of essential items such as syringes, line tubes, filters for dialysis and dressing materials. "Zero level stock" designates critical supplies that will be totally depleted in less than one month at the Central Drug Store (CDS-Gaza), which supplies all 13 MoH hospitals (1937 beds) and 54 MoH clinics in Gaza.
The Palestinian Ministry of Health in Ramallah is responsible for providing drugs and medical disposables to MoH facilities in both the West Bank and Gaza and for sending regular shipments according to the requests of the CDS-Gaza. A "zero level" designation prompts an urgent re-supply request to the Palestinian MoH in Ramallah. In practice, drug deliveries have not made regularly or in sufficient quantities: the last supply of medications occurred in early April, and the last shipment of disposables in February 2011. Moreover, the CDS-Gaza reports that items sent generally cover 70% of those requested for the 2 months period, which results in the steady deterioration of stocks.
While the shortage of essential drugs has been a chronic problem and zero stock levels have been depleted steadily in Gaza since 2007 (2007: 14%; 2008: 16%; 2009: 18%; 2010: 24%), addressing the protracted period of low stocks is now deemed critical for the continued delivery of health care.
Current Drugs and Disposables Crisis in Gaza
The MoH-Gaza has reported 178 drug items at zero stock level, in addition to another 69 items at low stock which means sufficient for less than 3 months consumption. 190 medical disposable items were reported at zero stock level, in addition to another 70 items at low stock sufficient for less than 3 months consumption. (See Annex1 and 2.)
Essential drugs and disposables at zero stock level, 2011.
1. Zero Stock Drugs:
The categories of drugs at zero stock are: 17% antibiotics for acute infections, 10% for chronic diseases (diabetes, hypertension, cardiac conditions, osteoarthritis, etc.), 9% chemotherapy, 8% analgesics, narcotics and anti inflammatory drugs, 8% psychotherapeutics and anticonvulsants, 7% for blood disorders 6% for ophthalmological disorders, 5% for immunity disorders, 4% antidotes, and others including special milk formulas (5 items), vitamins, solutions and formulas for external application (ointments, creams, etc).
Shortages of drugs and disposables at the CDS- Gaza, June 2011 3
2. Zero Stock Medical Disposables:
The shortages of the 190 medical disposable items include some basic and very critical items such as: syringes, Central Venous Pressure devices, ECG and CTG paper, X-Ray film, gauze, disposables used in laparoscopies, and filtration cartridges used in haemodialysis for patients with kidney failure.
The shortages in Gaza are compounded by shortages faced by the MoH in the West Bank where 150 drugs were reported to be out of stock. This is because suppliers have held back deliveries to the MoH due to uncertainty about receiving payment in the aftermath of the political reconciliation between Fatah and Hamas in late April. The suppliers’ issue was reported to have been resolved in mid June and suppliers began starting to supply back orders. The MoH-Ramallah prepared 170 pallets of 80 types of drugs and 130 pallets of disposables for immediate shipment to Gaza. The ICRC was assisting with logistics of transferring 5 types of essential supplies, while NGOs also sent in emergency supplies: the Physicians Association of Egypt sent 3 trucks of 19 types of essential medications to the Rafah border, MAP-UK was releasing some of its buffer stock in Gaza, and Islamic Relief was also shipping drug items.
Examples of Impact of Shortages on Health Services
1. The relatively big shortages in drugs and medical disposables have forced hospitals to curtail or stop the following kinds of surgeries:
Elective surgeries stopped
Laparoscopic surgeries stopped
Vascular surgeries stopped (shortage of embelectomy catheter)
Neurosurgeries stopped (shortage of Gellfoam, and other supplies)
Spinal vertebrae and joint surgeries stopped (shortage of transpendicular screw, rods, artificial joints)
Pediatric surgeries (curtailed due to lack of sutures)
ENT, burns and plastic surgeries stopped at the main Shifa Hospital
2. Referrals to outside hospitals for treatments previously done within Gaza:
Cancer treatments, and cardiovascular, orthopedic and neurosurgeries.
3. Improvised methods for coping with shortages of medical disposables:
Re-sterilizing disposable tubes
Reusing gloves and other disposable items (increasing risk of cross-infections and hospital-acquired infections.
4. Patients at special risk:
Kidney disease patients:
Rescheduling of 200 patients for haemodialysis at Shifa hospital to machines not requiring filters which are currently unavailable (increasing risk of infections)
Insulin shortages for insulin-dependent patients
Calcium shortages for the 450 patients on haemodialysis in Gaza (shortage for 2 months).
Cellcept (immuno-suppressant) shortages for 100 kidney transplant patients
Patients requiring adenoviral, an antiviral used to treat hepatitis
Patients with hypertension (out of stock at primary health care level for past 3 months)
Patients with blood disorders requiring Factor VIII medication (increases risk of complications)
Essential medicine procurement in the Gaza Strip, August 2011
This week the WHO oPt completed a $2 million project, funded by the Gulf Cooperation Council, administered by the Islamic Development Bank and approved by the Ministry of Health (MoH) in Ramallah, for the procurement of life-saving essential medications to help meet the needs of patients at MoH facilities in Gaza. Through the three-phased project, the WHO oPt procured 48 essential medications and 3 special infant formulas for the Ministry’s Central Drug Store (CDS) in Gaza, where there is a chronic shortage of drugs. The majority of the medications procured were for cancer therapy, ophthalmologic problems, cardiovascular disease, anticonvulsants, blood disorders and psychotherapy. Three special milk formulas were also provided for infants with allergies or digestive deficiencies. The medications were delivered to the CDS for disbursement to the 13 hospitals and 54 primary health clinics operated by the Ministry of Health in Gaza.
The public health facilities in Gaza depend on regular shipments of drugs and supplies from the Ministry of Health in Ramallah, but 14% to 37% of medications on the essential drug list have been out of stock since 2007. In July, 30% of essential medications, as well as 20% of essential medical disposables, such as dialysis machine filters and IV tubing, were reported at zero stock. Donors and charities contribute medications and supplies on an ad hoc basis to reduce the gap, but shortages have remained at critical levels in 2011.
The shortages affect the delivery of health services and have resulted in: a curtailing of the number of surgeries, necessitating referrals abroad for serious cases; reusing of medical disposables which pose potential risks for patient safety; rescheduling of procedures, such as kidney dialysis, due to reduced number of functioning machines; and patients seeking medications from other health providers, purchasing cheaper and often inappropriate substitute medications.
Referral patients vulnerable to delay, denial and conditions in accessing right to health
"Patients often suffer protracted delays in receiving permits to access medical services; can face interrogation by the Israeli security services as an application condition; experience difficulties during the arduous travel procedures to destination; and, in worst cases, can be denied access. Patients waiting for health care require an efficient, timely, dignified and transparent process for applying for referrals and permits for themselves and their caretakers to exit from Erez checkpoint."
Referral of Gaza Patients: Commentary and Data 2010, WHO oPt (July 2011),
http://www.emro.who.int/palestine/
Barriers to access:
The Palestinian Authority Ministry of Health sponsors referral treatment for Palestinians for services that are not available in Gaza. Patient access to services, either in the oPt or in neighbouring countries, is a complicated process which is neither transparent nor timely, and presents barriers for Palestinian patients.
Permits required at Erez:
Patients are required to apply for Israeli-issued permits if they need to cross Erez checkpoint for treatment in the West Bank, East Jerusalem, Jordan or Israel. Patients needing multiple sessions of chemotherapy or radiation must apply for a new permit for each appointment. The Palestinian Liaison Office submitted 11,176 applications to the Israel Liaison Office for permits in 2010. MoH referrals accounted for 85% while 15% were for patients supported by NGOs or charities, or were self-funded.
63% of MoH outside referrals through Erez checkpoint are to Palestinian facilities within the oPt (West Bank and East Jerusalem).
Permits can be denied:
The overall approval rate of permit applications in 2010 was 82%, highest for children (94%) and lowest for
adults aged 18-40 (57%).18% of applications were denied or delayed: 646 permit applications were denied, and 1,418 applications were not answered in time for patients to meet their medical appointments.
Permits are conditioned:
One in 25 patients is called for questioning by Israeli security services as a condition for access though Erez checkpoint, after applying for a permit.
No direct access for ambulances:
Critically ill patients traveling by ambulance must be transferred at Erez checkpoint by being carried 100 meters from Palestinian ambulances to Israeli ambulances for travel through Israel. Ambulatory patients must travel by taxis at their own expense.
Delays for critically ill:
35 patients died before reaching referral hospital in 2009 (29) and 2010 (6).
Referrals reflect gaps in health care:
inadequate infrastructure
lack of professional training for staff
shortages in supply of medicines and disposables and fuel
delayed equipment maintenance due in part to the tight restrictions on
2/2
movement of people.
delayed equipment and good into and out of Gaza
Delays at Rafah:
In 2010, about 30% of patient referrals were to Nasser Institute Facility in Cairo, which requires coordination with Egyptian authorities to access through Rafah crossing. Patients faced long delays in access due to border closures and daily quotas on passenger exit. In the last half of 2010, the percentage of patients referred through Rafah increased from 29% to 45% of MoH referrals, indicating its importance as a medical access route for Gaza patients.
International law:
The Government of Israel is obligated under the International Covenant on Economic, Social and Cultural Rights, and General Comment 14 to respect the Right to Health, including to not deny or limit equal access to health services. WHO calls on all parties concerned, Israel and Egypt, as well as the Palestinian Authority in Ramallah and the de facto
authorities in Gaza, to fulfill their respective responsibilities to ensure that the Right to Health of patients is protected, including access for medical treatment, and that health services are efficiently managed and ensured the means for continued development, in the best interests of patients.
Health Facts Gaza
| Fertility rate | 5.4 |
|---|---|
| Infant mortality | 21.5 |
| Anaemia among pregnant women | 14.1% increase |
| Anaemia among infants | 5.3% increase |
| Food insecurity | 54% |
| Living in poverty | 38% |
