Developing the Occupied Territories: An Investment in Peace Volume 6 Human Resources and Social Policy

Public Disclosure Authorized

Public Disclosure Authorized

Public Disclosure Authorized

Public Disclosure Authorized

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An

Investment In Peace

A World Bank Publication

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DEVELOPING THE OCCUPIED TERRITORIES AN INVESTMENT IN PEACE Volume 6: Human Resourcesand Social Policy

The World Bank Washington, D.C.

September 1993

Copyright (C 1993 The International Bank for Reconstruction and Development/THE WORLD BANK 1818 H Street, N.W. Washington, D.C. 20433, U.S.A. All rights reserved Manufactured in the United States of America First printing September 1993 Second printing October 1993

The six-volume series, Developingthe OccupiedTerritories:An Investment in Peace,is published to communicate the results of the Bank's work to the development community with the least possible delay. The typescript of this paper therefore has not been prepared in accordance with the procedures appropriate to formal printed texts, and the World Bank accepts no responsibility for errors. This paper has been prepared by staff of the World Bank and should not be attributed in any manner to its affiliated organizations, or to members of its Board of Executive Directors or the countries they represent. The World Bank does not guarantee the accuracy of the data included in this publication and accepts no responsibility whatsoever for any consequence of their use. Any maps that accompany the text have been prepared solely for the convenience of readers; the designations and presentation of material in them do not imply the expression of any opinion whatsoever on the part of the World Bank, its affiliates, or its Board or member countries concerning the legal status of any country, territory, city, or area or of the authorities thereof or concerning the delimitation of its boundaries or its national affiliation. The material in this publication is copyrighted. Requests for permission to reproduce portions of it should be sent to the Office of the Publisher at the address shown in the copyright notice above. The World Bank encourages dissemination of its work and will normally give permission promptly and, when the reproduction is for noncommercial purposes, without asking a fee. Permission to copy portions for classroom use is granted through the Copyright Clearance Center, 27 Congress Street, Salem, Massachusetts 01970, U.S.A. The complete backlist of publications from the World Bank is shown in the annual Index of Publications, which contains an alphabetical title list (with full ordering information) and indexes of subjects, authors, and countries and regions. The latest edition is available free of charge from the Distribution Unit, Office of the Publisher, The World Bank, 1818 H Street, N.W., Washington, D.C. 20433, U.S.A., or from Publications, The World Bank, 66, avenue d'Iena, 75116 Paris, France.

ISBN 0-8213-2693-7 ISBN 0-8213-2694-5 (6-vol. set)

CURRENCYEOUIVALENTS (As of January 1, 1993) CurrencyUnits in Use = New Israeli Sheqal (NIS) and JordanianDinar (JD) NIS 1.00 US$ 1.00 JD 1.00 US$ 1.00

= = = =

US$ 0.361 NIS 2.764 US$ 1.453 JD 0.688

GLOSSARYOF ABBREVIATIONS CBS GDP GHS GNP IBRD ILO

= = = = =

Central Bureauof Statistics Gross DomesticProduct GovernmentHealth Service Gross National Product InternationalBank for Reconstructionand Development InternationalLabour Organization

JD

=

Jordanian Dinar

NGO

=

Non GovernmentalOrganization

NIS

=

New Israeli Sheqal

UNDP = UNICEF = UNRWA =

United Nations DevelopmentProgram United Nations InternationalChildren's EmergencyFund United Nations Relief and Works Agency

WB

=

West Bank

WHO

=

World Health Organization

CONTENTS PREFACE EXECUTIVE SUMMARY ............................................ A. Historical Background ............. ....................... B. Human Resources . ...................................... C. Health ............................................. D. Education and Training .......... ........................ E. Social Welfare and Relief Programs .......................... F. Financial Requirements ...................................

xviii xx

I. INTRODUCTION AND BACKGROUND ............................... A. Organization of the Report ......... ....................... B. Historical Background ............ ....................... C. The Present Situation ............. .......................

1 3 3 4

II. OVERVIEW OF THE STOCK OF HUMAN RESOURCES ..... A. Population Estimates . ................................... B. Participation in the Labor Force ............................. C. Unemployment . ....................................... D. Population Prospects ............. .......................

vii

x x xi xii xv

..............

5 5 12 12 15

III. HEALTH CARE .............................................. A. Introduction .......................................... B. Health Status .......................................... C. Health Care Institutions and Finances .......................... D. Uses and Sources of Funds ................................. E. Health Care Facilities and Staff ............................. F. Special Initiatives . ..................................... G. Sector Problems . ....................................... ..................................... H. Recommendations .

17 17 17 22 25 27 30 31 33

IV.

34 34 34 37 37 40 42 44

V.

EDUCATION AND TRAINING ..................................... A. Introduction .......................................... B. The Institutions of the Education Sector ......................... C. Education Finance ....................................... D. Education Resources . ................................... E. Education Processes . ................................... F. Sector Problems ........................................ G. Recommendations . ..................................... SOCIAL WELFARE AND RELIEF PROGRAMS ......................... A. Introduction .......................................... B. Institutions and Programs .................................. C. Deficiencies in the Social Insurance System ...................... D. Recommendations . .....................................

VI. CONCLUSIONS AND RECOMMENDATIONS .......................... V.

REFERENCES .53

46 46 46 49 49 51

PREFACE 1. At the request of the sponsorsand organizersof the MiddleEast Peace Talks, the World Bank has been supportingthe workof the MultilateralWorkingGroupon EconomicDevelopmentand Regional Cooperationby providinganalysesof the key economicissues and developmentalchallengesfacing the Middle East region. At its second meetingin Paris in October 1992, the WorkingGrouprequestedthe Bank to expand its contributionto include, inter alia, an assessmentof the developmentneeds and prospectsof the economiesof the West Bank and the GazaStrip (commonlyreferred to as the Occupied Territories). In response to this request, a Bank mission visited the OccupiedTerritories during the period January 21-February 24, 1993. The mission comprised five teams focusing on the following areas: PrivateSectorDevelopment,Agriculture,HumanResources,Infrastructureand Macroeconomics. Each team was in the field for about two weeks. The missionwas led by Prem Garg who, together with SamirEl-Khouri,stayed in the field throughoutto providecontinuityand guidanceto the five teams. The staffingof the five teams was as follows: Macroeconomics:

MichaelWalton (TeamLeader) Samir El-Khouri(FiscalAnalyst) Ishac Diwan (Macroeconomist)

Private Sector Development:

Albert Martinez (Team Leader)

Robert Mertz (FinancialSectorSpecialist) Joseph Saba (Legal Specialist) Dileep Hurry' (RegulatoryEnvironment and TourismSpecialist) Agriculture:

Gert van Santen(Team Leader) Ulrich Kuffner(Water ResourceEngineer) Merle Jensen' (HorticultureSpecialist)

Infrastructure:

AlastairMcKechnie(Team Leader) UlrichKuffner (Water ResourceEngineer) LawrenceHannah (Urban Specialist) Nail Cengiz Yucel (TransportSector Specialist) Ted Moore' (Power Engineer)

Human Resources:

Fredrick Golladay(Team Leader) MaureenField' (EducationSpecialist) Radwan Ali Shaban' (HumanResourceEconomist)

2. Missionmemberstravelledextensivelyin the West Bankand Gaza, visitingmunicipalities,farms, businesses,industries,academic institutions,refugee camps and NGO-run facilities. Mission members also travelled in Israel, as needed, and paid several visits to Amman. The representativesof the key bilateral and multilateral donors in Jerusalem, Tel Aviv and Amman responsible for the Occupied Territorieswere kept briefed aboutthe work of the mission. Close contactwas also maintainedwith the field staff of UN agencies.

1/

Bank consultant.

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Preface

3. The Bank mission was receivedwarmlyby all sides, who took keen interest in the work of the missionand providedsuperblogisticaland counterpartsupportfor the field work. The main counterparts on the Israeli side were the Bank of Israel and the Civil Administrationin charge of the Occupied Territories. On the Palestinianside, the main counterparts were the Technical Committees of the PalestinianTeam to the Peace Conference, consistingmainly of Palestinians who are members of the bilateral or multilateralpeace teams. The Ministry of Planningwas the main contacton the Jordanian side. The Bank wouldlike to thankall concernedparties, especiallythe Israeli, Jordanianand Palestinian hosts, for the excellent support and cooperationthat the Bank mission receivedfor this field work. 4.

This report is based on the findings of the abovemission. The report is in six volumes: o

VolumeI provides a summaryoverviewof the key findings and recommendationsof the study. After commentingselectivelyon the current socioeconomicsituation in the OT and its evolutionover time, it discussesprospects for sustainable developmentin the future and outlinesthe priority agendaof policies and programs neededto promote such development.

o

VolumeII exploresthe strategicchoicesat the macro level that will be faced by the OT in the future and the implicationsfor economicrelations betweenthe OT and the rest of the region. The study looks at the current situation and its evolution over the past 25 years. The study then examines several policy choices for the future affecting the structure of developmentin the OT. Finally, it outlinessome illustrativescenariosfor the future, focussingon the consequencesof current developmentsin the region.

o

Volumem reviews the performance of the private sector (including, in particular, the industry and tourism sectors) in the OT. The study assessesthe environmentin which the private sector operates and its future prospects and makes recommendationsfor acceleratingprivate sector developmentin the future.

o

VolumeIV reviews the evolution and structure of the agriculturalsector in the OT; analyzes its current characteristics;assesses OT competitivenessin the immediateand longer term; outlines the main policy options and their implications;and provides a preliminaryassessmentof sectoral financialand technicalassistance(TA) needs.

o

VolumeV assessesthe current situation in the infrastructuresectors (electricity, water supply and sanitation,transport, housing and solid waste services) in the OT; identifies the major issues confrontingthese sectors; and outlinespriorities for TA and investment needs. As local authoritiesare major institutionsin the delivery of public services in these sectors, the study also includes a review of their current situation and makes recommendationsfor improvingthe functioningof municipalities.

o

VolumeVI reviewsthe current status as regards human resourcedevelopment;analyzes options for enhancingindividualwelfareand labor productivityin the OT; and outlines investmentand TA priorities for strengtheningexisting programs and for laying the foundationfor later reforms.

Preface

Lx

5. It is worth highlightingtwo limitationsof this study right at the outset. First, a number of key issues bearing upon the future developmentof the OT (e.g., the allocationof land and water resources, the dispositionof Israeli settlementsin the OT, the future status of expatriatePalestinians,the territorial issues surrounding Jerusalem and, most importantly, the nature of the proposed "self-governing' arrangementsfor the OT) are the subject of ongoing bilateral negotiationsbetween the Israelis and the Palestinians. The resolution of these issues is likely to be based primarily on political and security considerations. As the Bank missionto the OT was a technicalmission, with neither the mandatenor the expertiseto deal with politicalor security aspects,this studydoes not take any positionson issuesthat are on the agendafor bilateralnegotiations.The focusinsteadis on policies, institutionsand investments-where optimal choices are largely invariantto the eventualpolitical arrangementsto be agreed at the bilateral negotiations. Thus, for example, while analysing, where appropriate, the economic links betweenEastJerusalemand the West Bankand Gaza,the reportavoids makingany judgementsregarding the future status of East Jerusalem. 6. Second,the study has had to cope with very seriousdata gaps and inconsistencies. Muchof the data on the OT are, directlyor indirectly,from officialIsraeli sources. There are, however, seriousgaps in the OT data base. A populationcensus has not been carried out in the OT for more than 25 years. As a result, most of the demographicand labor force data are based on extrapolationsand on sample surveys, the reliabilityof which are underminedby problemsof nonresponse,especiallysince the onset of the Intifada (popularuprising)in 1987. Data on East Jerusalemand on Israeli settlementsin the OT, both of which are treated as part of Israel by the officialIsraeli sources, are mostly unavailable. Data available on trade between the OT and Israel and on the profitability and competitivenessof the agricultural, industrialand service enterprisesare also very limited. Data on the OT from Palestinian and Israeli nonofficialsourcesare sparse and selective. Also, Palestiniandata, when they exist, are often based on ad hoc surveysthat do not lendthemselveseasilyto cross-sectionalor longitudinalcomparisons. In many instances,data differ betweensources, and, even when the same source is used, there are gaps and apparent inconsistencies. Given these data problems, the report uses estimates that appear most plausiblein light of the mission's field observations. In cases where the data differencesamongvarious sourcesare particularlysharp (e.g., population,unemploymentand socialindicators),the report attempts, where possible,to examinethe reasonsfor thesedifferencesand to indicatethe implicationsof alternative estimatesfor the results of the analysis. 7. In view of the limitationson the missionmandate,the data difficultiesand the time and resource constraints,this study can only be considereda beginning. The analysisin the study, especiallyfor the longerterm, is necessarilyincomplete;as, and when, progress is made in the bilateral negotiations,the study will need to be updated and expanded to take account of the agreements reached. Also, notwithstandingthe care exercised in locating and interpreting the data from various sources, the empirical underpinningsof this study leave somethingto be desired, and, therefore, the conclusionsof the study should be treated only as indicativeof broad trends and priorities. Further, in-depthstudies and project feasibilitywork will be required before the findings of this report could be used to make operationaldecisions. 8. An earlierdraft of this report wasdiscussedwith the Israeli, Jordanianand Palestinianauthorities by a Bankmissionto the region duringJuly 12-26,1993. Whereappropriate,the reporthas been revised to incorporatethe commentsreceivedby the mission during the July discussions.

EXECUTIVESUMMARY 1. The broad purposesof this report are, first, to help definethe options for enhancingindividual welfareand labor productivityin the OccupiedTerritories and, second, to contributeto the development of a strategic plan for pursuing these goals in the future. The report focuses on three sectors: health, educationand social welfare. It concludesthat the developmentof a coherentpolicy frameworkand the creationof effectivepublic sector institutionsare prerequisitesfor improvementsin the contributionsof these sectors. The report also suggests investmentsthat should be undertakenover the next decade in order to strengthen existing programs and to lay the foundationsfor the implementationof sectoral reforms. 2. The publishedliterature on social conditions and needs in the Occupied Territories is very large, but many of the data are highly controversial. Hence, the empirical basis for assessingpolicy alternativesis unsatisfactory. Nonetheless,the broad outlinesof a sound policy are clear. In the case of health, improvingaccessto basic services should be assigned greater priority than either increasing the supplyof hospitalservicesor increasingthe technicalsophisticationof care. In contrast, in the education sector, improvementsin fundamentalareas, such as curriculumdevelopmentand teachertraining, are needed to enable the system to offer quality instruction and, thus, to expand employabilityand productivity. A comprehensive,but simple, system of social protection is needed to replace the patchworkof categoricalprogramsthat now serve some, but not all, members of the community. In all three areas, the creationof unified, coherent programs is an urgent priority. A. HistoricalBackground 3. The weaknessesof programs in the social sectors are due primarily to a pervasive lack of coherencein policies and programs. The variety of systemsof health, educationand social policy that coexist in the OccupiedTerritories grows out of a remarkablycomplexhistory. Following the war of 1948, and the creationof the state of Israel, the West Bank becamea part of Jordan and the Gaza Strip came under the controlof Egypt. The health and educationpoliciesof the two governingcountrieswere then introducedinto the territories by Egypt and Jordan. In 1950,the United Nations Relief and Works Agencyfor PalestinianRefugeesin the Near East (UNRWA)was createdby the United Nationsin order to providehumanitarianassistanceand employmentopportunitiesto displacedPalestinians. UNRWAwas also assigned the task of providingsocial services to refugees. Its educationprograms were made to follow the outlinesof the governmenteducationsystems, but its health programs were allowedto follow different paths. Israel occupiedthe Gaza Strip and the West Bank in 1967,but retainedthe policiesand structuresthat were introducedearlier by Egypt and Jordan. Israel has made only minor modifications to sector policies and institutionssince that time. The most important of these reforms has been to replace a policy of free government health services with one in which care was to be financed by a government-sponsoredhealth insuranceschemeand user fees. Charitableand profit --seekinginstitutions quickly emerged to competewith the governmentservice. Small changeshave also been made in the operationof governmenthealth care institutions. The educationalpolicies and practicesthat Israeltook over in 1967have been left largely unchanged. 4. Expenditureson health, education and social welfare programs are now controlledby five clusters of institutions, none of which is either responsive, or accountable,to the entire community.

Executive Summary

xi

Accessto their services often dependupon the recipient's status, past or current. About 30 percent of the population of the Gaza Strip and the West Bank benefit from the Israeli Government's health insuranceplan, and slightlymore than 60 percentof school children in the OccupiedTerritories attended governmentschools in 1991. Half of the residents of the OccupiedTerritories are registered refugees and, thus, entitledto the free primary and secondaryeducation,health care and relief servicesprovided by UNRWA. Residentsof the larger towns have accessto sophisticatedhealth and educationservices suppliedby charitableorganizations. People living in poorly served areas have begun to receivebasic health and social servicesfrom networksof grass roots voluntaryorganizationsthat have expandedvery rapidlysince 1987. Those who can afford to pay haveaccessto high qualityprivate health and education services.

5. Three primary sources of financialsupport may be identifiedfor these various activities. In 1991, the Civil Administrationspent US$125 millionon health and educationservices in the Occupied Territories, with 90 percent of this total allocatedto recurrent expenditures. UNRWA spent a total of US$85 million in order to provide health, educationand relief services in 1991. Nongovernmental organizations,both charitable and for-profit, added approximatelyUS$185 million. B. Human Resources

6. The de facto Palestinianpopulationof the OccupiedTerritories was 1,769,000 at the end of 1992, according to the Israeli Central Bureau of Statistics (CBS). However, independentresearch suggeststhat there may be a downwardbias in the CBS estimatesof 10-15percent. This suggeststhat the resident population may have been as much as 2 million people at the end of 1992. The rate of natural population increase has been rising over the period 1968-91, from a low rate of 2.2 percent in 1968 to 4.1 percent in the West Bank and 5.0 percent in Gaza Strip in 1991. A decline in mortality drove the accelerationof populationgrowth initially, but starting in the mid-1980's, the increase seems to have been due to a rise in birth rates. About half of the population is now less than 15 years of age. The share of the populationover 35 years of age has declinedcontinuouslyfrom 25 percent in 1967, to 18 percent in 1990. 7. About 308,000persons --34 percent of the adult population--are membersof the labor force. If age cohort-specificparticipationrates were to remain unchanged,the labor force participationrate for the male population 15 or older years would increase from 72 percent over the period 1986-1991to 75 percent in the year 2000; the total numberof workers would then be about 470,000. 8. The emigrationrate from the OccupiedTerritorieshas beenquite high since 1967. There was a large wave of politically motivatedmigrationimmediatelyfollowingthe Israeli occupation,but high rates of migrationhave continuedsince, as well. In 1985, about 40 percent of familiesin the Occupied Territorieshad one or more family membersresiding abroad. It is estimatedthat currently 3,000,000 to 3,500,000 Palestinianslive outsideof the OccupiedTerritories. How many of these might return to the OccupiedTerritories would dependupon a variety of factors including the agreementsreached in bilateral negotiations and the perceptions of expatriate Palestinians concerning future economic opportunitiesin the OccupiedTerritories.

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Executive Summary C. Health

Health Status 9. Health conditions in the Occupied Territories are fairly typical of lower-middle income, developing countries. The infant mortality rate is about 45 infant deaths per thousand live births, and life expectancy is about 66 years. The communicable diseases of childhood have largely been overcome, and gastrointestinal and respiratory infections remain major problems only in the Gaza Strip. High rates of respiratory and skin infections continue to be reported by residents of refugee camps due to residential crowding and poor environmental sanitation. Food supplies are adequate in quantity and fairly well distributed. The customary diet is rich in proteins and fiber and low in animal products, but it is deficient in some micronutrient, most notably iron. Moderate and severe malnutrition are virtually unknown. The West Bank reports rates of cardiovascular disease, hypertension, diabetes and cancer characteristic of industrialized countries. Nonetheless, many residents of the Occupied Territories are dissatisfied with the quality and accessibility of health services. This dissatisfaction is based primarily on observations of very large differences between the range and quality of services available in the Occupied Territories and in Israel. Institutions and Finances 10. Health services are provided in the Occupied Territories by clusters of institutions operated by the Civil Administration, UNRWA, private voluntary organizations and private, for-profit providers. Each cluster focuses on the needs of a distinct segment of the population. In 1991 the Civil Administration managed about 37 percent of all expenditures on modern health care. UNRWA's share was about 10 percent. The voluntary and for-profit sectors together controlled more than half of all spending on health care. 11. Civil Administration. The institutions operated by the Civil Administrations in the Gaza Strip and the West Bank are still recognizable as descendants of the Egyptian and Jordanian systems. Until 1974, when a government health insurance scheme was introduced, residents of the Gaza Strip and the West Bank were entitled to free health care from these facilities. Now only members of the government health insurance scheme may receive comprehensive care at government facilities without charge. (They may also obtain services that are not available within the Occupied Territories from Israeli hospitals; 597 patients were referred to Israeli hospitals in 1990). Prenatal care and preventive services are provided by the Civil Administration, without charge, to all children under the age of three years. In addition, those injured by the Israeli Defense Force and those infected with highly contagious diseases are treated free of charge. 12. All Palestinian employees of the Civil Administration, and of municipal authorities in the Occupied Territories, are required to join the government insurance scheme. Palestinians who are employed by Israeli firms also are required to participate. Reports of the numbers of families enrolled in the government scheme vary enormously. The budget of the Civil Administration estimates the revenues for 1992 from health fees to be US$25 million, implying that about 75,800 households (a fifth of the total population) were covered. Persons who are not enrolled in the government health insurance scheme may purchase services from government clinics and hospitals; revenues from patient charges may represent as much as 20 percent of the total resources available to the public sector.

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13. About 61 percent of the government health budget is devoted to the operation of acute care hospitals, and only about 28 percent is spent on primary care and public health services. The remaining 11 percent is committed to other public health functions, including the inspection of sanitary conditions and disease surveillance. This pattern of resource allocation has resulted in the underprovision of basic outreach services, especially in relatively isolated areas. 14. UNRWA. UNRWA offers basic health care without charge to 940,000 registered refugees. It also contracts with private and government hospitals for the provision of secondary care to refugees. In addition, UNRWA reimburses refugees for sixty percent of the cost of hospital care obtained from outside the UNRWA system; however, the funds budgeted for this purpose typically are exhausted by the end of the eighth month of the fiscal year. 15. In 1991 UNRWA spent about US$20 million on health programs in the Occupied Territories. Nearly US$12 million of this was allocated to activities in the Gaza Strip. Approximately 58 percent of the total budget was devoted to primary prevention and health promotion activities, while hospital care consumed the remaining 42 percent. The UNRWA budget is supported by some 60 governments and a dozen charitable organizations. 16. The Voluntary Sector. Private voluntary organizations are responsible for about a fifth of spending on health care. Most private medical charities were established after the introduction of the government health insurance scheme in 1974 and were provided with generous external assistance during the 1980s by Middle Eastern countries and private donors. These institutions offer modern curative care from very well-equipped clinics and charge patients for their services. Since the onset of the Intifada, a group of grass-roots non-governmental organizations have expanded dramatically. They provide very basic preventive and promotive care, emphasizing health education, maternal and child health care and outpatient-management of chronic conditions. The activities of the voluntary sector are not closely supervised or regulated and, as a consequence, reflect a very wide range of aims and policies. 17. Private Health Care. About US$25 million was spent in 1991 on health care produced by private for-profit organizations; this represents nearly 12 percent of total health care expenditures. In addition, more than twice that amount was spent by households on pharmaceuticals; about half of private spending on drugs was for over-the-counter pain killers. Most private expenditure is financed from user fees, but a private insurance company does offer health insurance to about 10,000 households. Insurance benefits may be used to pay for care from approved sources in either the public or private sector. 18. Largely because of a proliferation of health care providers, the cost in 1991 of providing health care to the residents of the Gaza Strip and West Bank represented about 7 percent of Gross National Product (GNP) or about 9 percent of Gross Domestic Product (GDP). Health Care Facilities 19. Government health care services are produced at 14 hospitals and 165 primary health care clinics. The 14 hospitals had a total of 1,546 beds in 1990. Most government clinics are fully staffed for only one or two days a week. The Civil Administration has not increased the number of beds in government hospitals since 1967. Even so, the bed occupancy rate is 62 percent; this low rate of utilization of government hospitals is due in part to economic barriers.

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Executive Summary

20. UNRWAprovides its servicesthrough a networkof 42 health centers, 9 of which are located in the GazaStrip. Most facilities in the GazaStrip have well equippeddiagnostic laboratories. A staff of 82 physiciansserve the more than a half million refugees in the Gaza Strip. Facilities in the West Bank are generally less extensive but, nonetheless,include 13 diagnostic laboratories. A staff of 61 physicianscare for about 400,000 registered refugees. UNRWA also operatesfeeding centers, dental clinics, maternitycenters and a 34-bed hospital. Five private, voluntaryhospitalsin the West Bank and two governmenthospitals in the GazaStrip are used to deliver secondarycare. 21. About half of all primary health care facilitiesare owned and managed by private, voluntary organizations. Between720 and 750 physicians(approximatelya third of all physicianspracticingin the OccupiedTerritories)work at clinics in the voluntary and for-profitsectors. About200 physiciansand about800 nursesare employedby non-governmentalhospitals. Thirty percent of acute care hospitalbeds and half of all hospitalsare operatedby the NGO sector. For-profit, private providers are also important sourcesof care, but little is knownabouttheir activities. Mostare public employeesworkingafter hours. Special Initiatives 22. The Civil Administrationhas workedwith severalexternalagenciesto improvehealth care and environmentalconditions in the OccupiedTerritories. It has cooperatedwith UNICEF since 1985 in developinga program to provideprenatal and child care to high-risk groups in small, isolated villages. Other initiativeshave includedprograms to identify and managehigh risk pregnancies,provide training and continuingeducationto traditionalmidwives,andproviderehabilitationservicesand physicaltherapy. 23. The Palestinianmedicalcharitieshave also made significantcontributionsto health care. The subsidiesdeliveredthrough these initiativeshave been financed mainly with private donationsfrom the Gulf and grants from officialbilateral sources. In addition,grass-rootsnon-governmentalorganizations (knownamongPalestiniansas "national"voluntaryorganizations)have grownrapidlysincethe beginning of the Intifada in 1987. These groups have promoted initiatives aimed at the care of mothers and children, treatment of minor illnesses, control of infectious diseases and health education. These programs have grown at an explosiverate; more than a hundred clinics were constructedbetween 1988 and 1990. The impactsof these initiativesare not yet reflected in health statistics and indicators. Sector Problems 24. The OccupiedTerritoriesdevotean unusuallylarge share of their resourcesto the health sector and do not obtain the health impact from this expenditurethat they should. Several reasons for poor performanceare apparent. First, most socialresourcesare beingused to providecostly,high technology, hospital-basedcare for the benefit of the relativelywell to do. Second, very small, inefficienthospitals have been allowed to proliferate (68 percent of all hospitalshave fewer than 100 beds). Third, highly specializedproceduresare being carried out by units that are too small either to exploit economiesof scale or to provide physiciansand staff with enough practice to maintain skills. Finally, too little attention is being given to reaching out to underservedgroups, especiallywomen. Recommendations 25. The developmentof a sound policy environmentwill be required in order to address these problems. Present inefficienciesare rooted in the fragmentationof responsibility, not only for the delivery of health care, but also for the managementof subsidies to the sector from the government

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Executive Summary

budget and externaldonors. This problems is intensifiedby the lack of a broad sense of accountability to the public. A responsiblebody must be createdto developa coherenthealth policy and to coordinate activitiesin the sector. Sincea large numberof highly diverse and effectiveorganizationsnow populate the sector, such a body should not seek to control sector activities directly, but rather should seek to achievegreater coordination. 26. Policies should, at the same time, seek to interrupt the link betweenrefugee or employment status and entitlementto subsidizedhealth care. In assemblinga set of policies, issues of health care finance, servicestandards, investmentin technologyand qualityassuranceshouldbe addressed. In view of the large fraction of GDP alreadybeing committedto the sector, policies shouldalso stress increasing the internal efficiencyof the health sector and controllingthe overall costs of health care, rather than expandingthe system, particularly at the hospital level. Sanitationshould be further improved, and a larger fractionof cases of acute diarrheashouldbe treatedwith oral rehydrationfluids. Acuterespiratory infectionsshould be diagnosedearlierand treatedwith appropriatedrugs. The onset of chronic diseases due to suchconditionsas hypertensionand diabetesshouldbe controlledat primary health care level with appropriatediet and drug therapy. D. Education and Training

A strong commitmentto educationis reflectedin the formal attainmentsof the populationsof 27. the OccupiedTerritories: Palestiniansare amongthe most highly educatedof any Arab group. Muchof the higher educationhas been acquired from Europeanand North Americaninstitutions. Nonetheless, basic and secondaryeducationprovidedin the OccupiedTerritories is generallyof poor quality. Institutions of the Education Sector

28. The institutionsfoundin the educationsectorin the OccupiedTerritoriesare muchlesscomplex than those found in the health sector. The OccupiedTerritories are served by two distinct systems of education:the Egyptiansystem in the GazaStrip and the Jordaniansystem in the West Bank. Thesetwo system are organized differently, pursue distinct objectivesand employ separate examinationsystems. The Civil Administrationsupervises all primary and secondary educationalinstitutions. Services are providedby the Civil Administration,UNRWA and a small number of private (principallycharitable) organizations. Schoolsoperatedby the Civil Administrationenroll about62 percent of all primary and secondary school students; UNRWA provides schoolingto about 31 percent of the students; and the voluntary and private, for-profit institutionsserve less than 8 percent. In 1991 enrollment in primary schools was equivalent to about 102 percent of the estimated population aged 6-12. (The excess enrollmentis due to either underestimationof the schoolage populationand/orthe enrollmentof overage students.) Becauseof frequentstrikes and curfews,manyschoolshave beenclosedfrom half to a quarter of the time since 1987. 29. Vocationaleducationand technicaltraining are offered by both the Civil Administrationand UNRWA. Vocationaland technical educationhave a very poor public image and have never been a seriouspart of the educationprogram. Israel establishedadditionalvocationaltraining centersin the main cities of the West Bank and the Gaza Strip, after 1967, in order to prepare semi-skilledlaborers for employmentin the Israeli economy. Most courses are only a few days in length and are designedto

xvi

Executive Summary

enablePalestiniansto meetthe formal requirementsof the Israelilabor market. The most commoncourse prepares studentsto take the written examinationfor a license to drive a truck in Israel. 30. Insufficienteffort has been made to assess the training needs or evaluate the outcomes of training courses. The Civil AdministrationLabour Staff Officer, responsiblefor Civil Administration vocationaltraining activityhas met with local employersregularly, to identify vocationaltraining needs in the Territories. Furthermore,the Civil Administrationhas run an employmentfollow-upof some of the vocational training graduates in order to evaluate how effective the programs are in practice. Teachingsubjectssuch as communications,has been prohibited becausethe equipmentcould easily be used for military purposes. Courses have focused on the mastery of crafts and have provided little instruction in organization and management; training for self-employmenthas been almost totally neglected. Both public and private vocationalschools are seriouslyunderfunded,and, hence, facilities are inadequateand equipmentis often obsolete. 31. All university and most communitycollege instruction is supplied by private, voluntary organizations. Higher educationinstitutionsare supervisedby the Higher EducationCouncil, which is composedof representativesof the collegesand universitiesand electedleadersfrom the educationsector. There are 20 communityand teachers' training colleges in the West Bank and one in the Gaza Strip. Four of these are administeredby the Civil Administration,three by UNRWA, nine by the Council for Higher Educationand five by private entities. The communitycolleges offer technical training (e.g., engineering), agricultural, commercial (business administration), paramedical, social services and teachers' training programs. 32. There are eight universitiesin the OccupiedTerritories: six in the West Bank --including an open university--and two in Gaza. Accordingto the Council for Higher Education, there were a total of 16,368 students and 1010 faculty in Palestinian universities during the 1991-92 academic year. Universitiesare too small to be able to provideeconomicallythe laboratoryand library facilitiesrequired for advancedstudy, particularlyin the sciences. Approximately40 percent of universitystudents in the West Bank are women. The universities have played a major role in the political activities of the Territories. Becauseof this, they were closedfrom the beginning of the Intifada until 1992 when the Civil Administrationbegan to alloweddesignatedfacultiesto reopen. 33. Efforts are being made, in the main by charitableinstitutions,to combata significantproblem of illiteracy among Palestinian adults. Some 170 centers in the West Bank are run by voluntary organizations,but there is a growingneed for more and better equippedcenters. In the Gaza Strip there are 27 centers; the PalestinianRed CrescentSocietyplays a major role in supportingthese centers. The Civil Administrationprovides literacy training at about ten vocational training centers. The Higher Committeefor Literacy and Adult Educationcoordinatesliteracy training activities. Education Finance

The total expenditurefor all levels of academiceducationis about US$170 to 175 million a 34. year. This representsa per capitaexpenditureof US$90-100per residentof the OccupiedTerritoriesand correspondsto approximatelytwo-thirdsof the amount being spent per capita on health care. 35. Total expenditureon education for grades 1-12 in 1991 for the Occupied Territories was between US$140 and US$150 million. The Civil Administrationspent US$58 million in 1991and has budgetedUS$80 millionfor 1992. The UNRWA1991educationbudgetfor the OccupiedTerritorieswas

Executive Swwnary

XVii

US$52 million: two-thirdsfor the Gaza Strip and one-thirdfor the West Bank. Per student expenditures were about US$153 in governmentschools: US$334per student in UNRWA schools in the Gaza Strip and about US$425 at UNRWA schools in the West Bank. These per student expendituresrepresent between 15 and 25 percent of per capita GDP. NeighboringArab countries are spending on average between 11 (Iraq) and 22 (Morocco)percentof per capitaGDP, per student. Differencesin unit costs are due to variations in salaries and to greater expenditureson teachingmaterials and the maintenanceof facilities in UNRWAschools. Private primary and secondaryschools are financed largely or entirely with student fees; they attract paying students because they are perceived to offer a better education. Private spending on primary and secondaryeducationtotaledabout US$13 million in 1991. 36. Per studentcosts for collegeand universityeducationrangefrom US$1,500-2,000. The total cost of universitylevel educationis about US$27 milliona year. Studentsare charged fees of US$400500 per year. The universitiesare financiallyautonomous. They haveobtainedabouttwo thirds of their funds from private and foreign donors in the past. Becauseof sharp drop in foreign donations and significant decrease in fee income due to lengthy closures since the onset of the Intifada, many universities now face financialcrises. Most are now depletingstaff retirementfunds in order to meet essentialexpenses. Severalhave beenunableto pay faculty salariesfor months at a time and, as a result, have experiencedfaculty strikes. Libraries, laboratories,textbooksand other educationalmaterialsand computer facilities are deteriorating. Education Resources 37. About 18,600 teachers were employedduring the 1991-92school year. Two-thirdsof these teachers (a total of 12,496) were working for the Civil Administration,and about 22 percent were employedby UNRWA. The private sector employedslightlyfewer than 10 percentof all teachers. The lowest student-teacherratio was found in the private sectorin the Gaza Strip wherethere were only 16.9 students per teacher; the highest student-teacherratio was found in UNRWAschools in the Gaza Strip where the ratio was 36.1 students per teacher. The average school enrolls about 400 students. Many schools are housed in convertedresidencesand many others are operated on doubleshifts. 38. At present, most teachers have a two-year diploma from a communityor teachers' college. Under Jordanian Law, all West Bank teachers must have a minimumqualificationof Bachelorof Arts degree by 1997. Some efforts have already been made to provide in-servicetraining at teachertraining institutesand universities. Problems 39. The school curriculahave beenborrowed from Egypt (for the Gaza Strip) and Jordan (for the West Bank). The contents of the two curricula and methods of instruction have not been revised significantlysincethe beginningof the Occupationin 1967,but textbookshavebeen updatedperiodically. The present curricula emphasizethe recall of facts rather than higher level cognitive skills, including analysis and synthesis. Present materials afford students few opportunitiesto participate actively in learning;to develop and apply skills in formulatingresearchableor solvableproblems; or to draw on a wide range of knowledge,skills and analytic methodsto illuminatereal-world problems. Curriculum reforms are beingpursued by both Jordan and Egypt, but classroomactivitieshave not yet been affected. 40. The qualificationsof educationalpersonnelin almostall positions needto be strengthened. A reformof both pre-serviceand in-serviceteachereducationis urgentlyneeded. Presentteachingmethods

xviii

Executive Summary

do not take advantageof recent advancesin educationaltheories, practice and technologies. There is a need to strengthenthe skills of administratorsand planners, as well. 41. Schoolbuildingsare generallyin a poor state of repair. Libraries, laboratoriesand recreational facilities are generally inadequate,as are supplies of textbooks and teaching materials. Libraries and laboratoriesare inadequatethroughoutthe universitysystem. 42. The frequent closingof schools since the beginningof the Intifada is reported to have led to an increase in dropout rates, a breakdown in disciplineand deteriorationof student achievement. The needs of those school children who should have been attending school during this period are poorly documentedbut clearly require urgent attention. Widespreadviolencehas also produced an alarming growth in the populationthat is physicallyor mentallydisabled. Some 37 training institutionshave been createdto addressthe needs of thesegroups. About2,900 personsare enrolled in theseinstitutions, most of which are privatelyoperated. Recommendations 43. An extensiveeducationplanningprocessshouldbe initiatedto considerthe goals, possibilities and resourcesfor a unified educationsystemfor the GazaStrip and WestBank. Planners, administrators and curriculumexpertsshouldbe giventraining in carryingout these tasks. Personnel exchangesacross institutionscould prove useful. A program to replace inadequateand insufficienteducationalfacilities should also be developed. 44. A revisedcurriculumshould be developedthat can be adoptedon both the West Bank the and GazaStrip. It should not only give attentionto the modernizationof content and teachingmethods,but should also link curricula to broad economic,social and cultural objectives. As the developmentof curricula is time-consumingand costly, considerationshould be given in the short term, to adapting materialsfrom abroad, especiallyin the sciencesand mathematics. E. Social Welfare and Relief Programs 45. The legal environmentand the programsthat protectthe welfareof workers and provide relief to the needydraw upon elementsof manyseparateand uncoordinatedsystems. The partitionof Palestine in 1948led to the introductionof Egyptianand Jordanianlabor laws and socialprograms in the Occupied Territories. The creation of UNRWA ensured that registered refugees were entitled to an alternative collectionof protectionsand benefits;a large numberof internationalvoluntaryorganizationshavebeen created since 1950to provide humanitarianaid to refugees. The adoptionby the Governmentof Israel of an open borderspolicy followingthe 1967war extendedthe benefitsof manyof Israel's social welfare programs to Palestiniansworking in Israel. These developmentshave yielded a patchworkof relief programs that ensure that some, though not all, the residents of the Occupied Territories receive assistancein meetingtheir basic needs. Institutions and Programs 46. The core of the social welfare system for the residents of the Occupied Territories is the collectionof programs operatedby UNRWA. Abouthalf the populationof the OccupiedTerritories are registered refugees. Of the US$98 million UNRWA spent in the Gaza Strip and in the West Bank in

Executive Sunmary

xix

1991, aboutUS$12.6 millionwas allocatedto relief and social programs. Ninety percent of the budget for relief and social services programs was used to provide direct assistance to needy refugees. In addition, UNRWA administereda number of projects serving especially vulnerable groups such as widows, the aged and the physically disabled; these programs continue to be funded from special contributions. Relief and social service programs focus on "special hardship cases" to whom food, shelter, clothingand othersurvivalneeds are offered. UNRWAalso operatesa modest loanprogramfor special hardship cases. 47. Palestinianswho work for Israeli employersare required to participatein the Governmentof Israel's national social securityscheme. All taxes that are applied to Israeli workers were imposedon foreign(Palestinian)workersto ensure that the latter do not cost employersless than Israeli workersand, thus, have a competitiveadvantagein labor markets. Thesedeductionsfinance a wide rangeof benefits to Israeli workers but only a very limitedset of benefitsto Palestinians. The taxescontributedon behalf of Palestiniansthat are not used to pay for benefits to them are transferred to the budget of the Civil Administration.The amountdepositedrepresents11.8percent of wagespaid. The Governmentof Israel reports that the total amounttransferredwas about US$23 million in 1992; this amount is equivalentto what should have been collectedfrom 36,100 full time workers employedat the minimumwage. This suggests that Israeli firms substantiallyunderreportthe employmentof Palestinianworkers. 48. Collectivebargaining agreementsrepresentthe principalsource of social securitybenefits in Israel. The agreementsdefine the benefitsto be providedto workers and the contributionsto be made by workers and employers in order to finance these benefits. Palestinian workers are required to participate in these programs. The combinedcontributionsof employersand employeesin the private constructionsector represent37 percent of wages. The benefitsunder the collectiveagreementare supposed to be availableto all workers, but residencyin Israel is required to benefit from most programs. The dispositionof the unusedfundscollectedfrom Palestiniansis not clear. Palestinianstaff of the Civil Administrationand municipalauthoritieslocatedin the OccupiedTerritoriesparticipatein socialinsurance schemesthat provide them pensions and health care. The Civil Administrationalso operates a Social Welfare Departmentthat provides indigent familieswith food, medical insurance, educationassistance and cash stipends. 49. Residentsof the GazaStrip are employedunder the provisionsof Egyptianlabor law. The law regulatesconditionsof employment,includingthe minimumagefor workersand the maximumhours of work; however, they do not provide for compensationin the event of work-relatedinjuries or accidents nor provide for pension benefits, health insurancecoverage, maternity benefitsor severancepay. 50. The Jordanianlabor law appliesto workers in the WestBank. It regulatesthe employmentof women and children and prescribesthe maximumhours of work per day and week. It requires that employersprovide annualleave, severancepay and compensationfor workplaceinjuries. The Jordanian law does not provide for pension rights, old age insurance, survivor benefits, compensationfor work related disabilities,health insuranceor family benefits. The most important sources of financial security and social protection for residents of the 51. OccupiedTerritorieshave been individualsavings and private, intra-familytransfers. Palestinianshave, for many years, successfullysought employmentabroad and have saved a very large fraction of their earnings. Reliable informationon the managementand use of worker remittancesis not available, but anecdotal informationsuggests that many householdsare able to retire very early and to live on the incomeobtainedfrom these savings. The collapseof employmentopportunitiesin the Gulf in 1991, and

xx

Executive Suwmnary

the losses of savings that occurred with the freezing of accounts in Gulf banks in 1991, may have seriously impactedthis approachto achievingincomesecurity. Deficienciesin the Social InsuranceSystem 52. The provisions for social security for the residents of the OccupiedTerritories are patchy, inequitableand inadequate. The Palestiniansliving in the Gaza Strip and the West Bank participatein programs reflecting their refugee and employmentstatus. About half of the total population of the OccupiedTerritoriesqualifyfor assistancefrom UNRWA. Its programs of relief and social services are targetedon "specialhardship cases" in whichthe headof householdis female. Approximately8 percent of the refugee populationbenefitsfrom these programs. However,UNRWA supplementsthese benefits with a quite extensiveprogram of health benefits and with shelter servicesin the camps. Many refugee familiesalso qualify for benefitsfrom other sources and do not employthe services of UNRWA. Recommendations 53. Resourcesto support a comprehensivesocialwelfareprogram areunlikely to becomeavailable to a self-governingPalestinianauthorityover the next few years. Moreover, over the longer term such an authority will be calledupon to replace those benefitsthat have been provided to the very needy by UNRWA and the Civil Administration. It will be faced with demandsfor the maintenanceof in-kind transfersto registered refugees,includingfree health care, subsidizedhousingservices and assistancein the educationof children. These in-kind subsidies constitutea significantsafety net for persons with refugeestatus; large numbers of people maintaintheir refugeestatus simply in order to remain qualified for these programs in the event of a personal economiccrisis. 54. The public sector will have to develop a basic program of social protections and ensure that the resulting list of services receives broad political endorsement. The list should provide for the handicapped,elderly, orphaned and widowed, but it should not seek to replace reliance on private transfers and personalsavings. The public sectorshould facilitatethe operationof benefit programsthat are self-financingfrom employeeand employer contributionsbut should, in the near term, avoid the developmentof programs that draw heavily on general public revenuesfor their financing. 55. The public sector should also encouragethe developmentof private institutions that supply financial services, including health and life insurance companiesand pension schemes. A very small insurance industry already exists in the West Bank; with the creation of an appropriateregulatory and legal environment, that industry could contributesignificantlyto meeting the community's need for economicsecurity. F. Financial Requirements 56. Investmentsof US$475to US$550millionwill be requiredover a period of ten years in order to address the needs that have been identifiedin this report and to replace depreciatedequipmentand facilities. About US$12 millionwould be requiredfor technicalassistanceand the remainder wouldbe neededfor capitalinvestments(includingdesign, constructionsupervisionand the like). RoughlyUS$35 million could be investedimmediatelyin the rehabilitationof social facilities and urgent expansionof services. These estimates are very approximatebecause the underlying analyseshave been based on

Executive Swnmary

xri

sketchydata. Beforefinal decisionsare taken, a morethorough investigationof the health, educationand social welfare sectors should be undertaken. Such a study shouldbe carried out by a team of local and internationalexpertsand should allowsufficienttime to thoroughlyexaminethe facts and institutionsin these sectors.

1. INTRODUCTIONAND BACKGROUND 1.1 The broad purposes of this report are, first, to help define the public policy options for enhancingindividualwelfareand laborproductivityin the OccupiedTerritoriesand, second, to contribute to the developmentof a strategic plan for introducingthese policies in an environmentin which the bureaucracyis directlyaccountableto its clients. The report focuseson three sectors:health, education and social welfare. 1.2 Social conditions in the Occupied Territories are fairly typical of lower middle-income countries. Life expectancyat birth is about 66 years, and the infant mortalityrate is about 40-45 deaths per thousand live births. The pattern of diseaseand the burden of morbidity are also characteristicof this group of countries: Infectionsof the gastrointestinaland respiratorysystemsare the leading causes of death amonginfants and children, and high fertilityis a further importantthreat to child health. Adult onset diseases play a modest role at present in determiningthe health of the population, but they are becomingmore common. 1.3 All children are being offeredthe opportunityfor a basic education. However,the quality of this educationand the contributionsit is makingto the productivityof the labor force are not as great as one might reasonablyhope or expect. The deficienciesin the educationprogram are due primarily to weaknessesin the school curriculumand to antiquatedteachingmethods. In addition, frequent school closures due to strikes and curfewshave played an importantrole in underminingeducationalachievements since the beginningof the "popular uprising" (Intifada)in December 1987. 1.4 The patchwork of programs intended to enable families to deal with emergencies and extraordinaryhealth care costs are adequatefor some segmentsof the society, but they are entirely inadequatefor many others. Access to basic health care is assured for perhaps 60 percent of the population,and old age pensionsare availableto no more than a quarter of households. Unemployment benefits and compensationfor work-related injuries and illnesses are available to a minority of Palestinians.

1.5 The publishedliteratureon social conditionsand needs in the OccupiedTerritoriesis vast but, at the same time, highly controversial. Hence, the empirical basis for identifyingpolicy problems or evaluatingpolicy alternativesis weak. Nonetheless,it is clear that substantialadvancescouldbe achieved in all three of these areas --health care, educationand social welfare-- without significantlyincreasing public sector spending. The developmentof a coherentpolicy frameworkand the creation of effective public sector institutionsare the keys to increasingprogram effectivenessand ensuring equitableaccess to benefits. In the case of health, improvingaccessto basic services should be assigned priority, and, at the sametime, expandingthe productionof hospitalservicesand increasingthe technicalsophistication of care should be delayed. In the education sector, fundamental improvementsin areas such as curriculumand teachertraining are neededto enablethe system to offer quality instructionand, thus, to contributefully to employabilityand labor productivity. The impactof social welfareprograms could be increasedby reducingthe range of benefitsbeing providedand, instead,focusingon the provision of a very basic level supportto the most needy membersof the community. The criteria for eligibilityfor social benefitsshould be redraftedto removethe anomaliescreatedby categoricalprograms for refugees, civil servants and foreign workers. In all three areas, the creationof unified, coherentprograms is an

2

Chapter I

urgent priority. The report identifiesinvestmentsthat should be undertakenin the near term in order to strengthen existing programs and to lay the foundationsfor later reforms, and it lays out, in general terms, a program of capital expendituresthat will be requiredover the longer term.

Box 1.1: The Issue of Jerusalem The city of Jerusalem has occupied a central place in the history of three great religions Judaism, Christianity and Islam. It has also played a major role in shaping the economic, social and political lives of the Middle East Region for over three thousand years. Therefore, an important aspect of the current conflict in the Region centers on the control of Jerusalem. The 1948 war led to partition of Jerusalem into the Eastern and Western parts. At the end of the 1967 War, East Jerusalem was occupied by Israeli forces. Following the occupation, the Jerusalem cily limits were expanded by Israel to include some surrounding areas from the West Bank. The expanded city was annexed by Israel on July 30, 1980. Arab residents of Jerusalem have been given the option of obtaining Israeli citizenship although very few have chosen to do so. Israel views Jerusalem as its historic capital and maintains that Jerusalem must never again be a divided city. Actions taken by Israel were considered invalid by the United Nations, which called upon Israel to refrain from taking any action that would alter the status of Jerusalem. Although the international community has not recognized the Israeli annexation of East Jerusalem, Israel continues to exercise authority over the area and considers it an integral part of Israel and not subject to further negotiations. The Palestinians insist that East Jerusalem is part of the West Bank as per the pre-1967 borders and that Israel should withdraw from all areas occupied during the 1967 war as per the United Nations resolutions. There are important economic links between the West Bank and Gaza Strip and Jerusalem. Decisions concerning Jerusalem would, therefore, have important implications for future economic prospects and priorities for the Occupied Terrotories. The following are among the most important of these links: o o o o o o

The tourist potential of the West Bank is critically dependent on the ancient religious sites of Jerusalem. Major north-south transportation links in the West Bank pass through Jerusalem. The only tertiary care hospital and some of the best secondary care hospitals available to the West Bank population are located in East Jerusalem. East Jerusalem houses much of the Palestinian financial services, marketing facilities, and social and cultural infrastructure. Qalandia airport, a potential outlet for linking the West Bank with regional airports, is within annexed Jerusalem. Parts of East Jerusalem are an integral part of the power network covering the area from Rama'dah to Bethlehem.

Considering that the question of Jerusalem is essentially a political matter, this report should not be construed as tacing any position on this issue. Therefore, while analyzing the links where appropriate, this report has endeavored to avoid making any recommendations that might imply prejudging the status of Jerusalem.

Chapter 1

3

A. Organizationof the Report 1.6 The report is organized into five chapters. The remainderof this chapter reviews the history of social developmentin the Gaza Strip and the West Bank since 1948. Chapter 2 describes the human resources of the OccupiedTerritories. Chapters3, 4 and 5 examinein turn the health, educationand social welfare sectors in the OccupiedTerritories. These three chapters review the current status of efforts in each sector, describethe programs and institutionsthat are now addressing needs, summarize the financialand real resourcecommitmentsbeing made to the area and identifythe principalproblems of the sector. Finally, these chapters suggest initiativesthat would help to overcome these problems. Chapter 6 summarizesthe findings of the report, and outlines investmentpriorities. B. HistoricalBackground 1.7 The weaknessesof programs in the social sectorsare due more to a lack of coherence in policies and initiatives,rather than to a lack of resources or to the mismanagementof particular programs. This incoherence is the result of the duplicationand competition introduced into the system through the creation,over the past 45 years, of several largely independentauthoritiesin each sector. This complex organizationalenvironmenthas grown out of an extraordinaryset of historical developments. With improvementof the policy environment,it will be possible to address, efficiently, additionalneeds, but this will require that more funds are found. 1.8 When Israel was createdin 1948, the Gaza Strip came under the controlof Egypt and the West Bank becamea part of Jordan. In 1950the UnitedNations introduceda third major player into the area by establishingthe United Nations Relief and Works Agency for PalestinianRefugees in the Near East (UNRWA). UNRWAwas intendedto providedirect internationalassistanceand essentialsocial services to Palestinians displaced as a result of the 1948 war. Persons whose means of livelihood had been destroyedas a result of the settlement,and who could prove residencyin Palestinefor at least two years prior to the settlement,were registered as refugees. The refugeeswere provided with education,health care and relief services, as well as temporary shelter (tents and campinggear), food and clothing. The UNRWArefugee campshave sincebecome permanentsettlements. All Palestinianswho can trace their ancestry(alongthe male line) to refugeescontinueto be entitledto benefitfrom these programs. Because the demandson its budget exceed its resources, UNRWAhas recentlybeen forced to introducenominal charges for health care servicesprovidedby private hospitals. 1.9 Since the end of the 1967 Middle East War, the Governmentof Israel has occupied the two territories. A military governmentwas establishedto maintainorder and to safeguardthe welfare of the citizens of the OccupiedTerritories. The occupyingmilitary government continued the policies and programs that had been introduced in the OccupiedTerritories by the Egyptian administrationand the Governmentof Jordan. In addition, civil servants working in the West Bank, including health workers and teachers, were kept membersof the Jordaniancivil service and continued to be paid in part from funds provided by the Government of Jordan. In November 1981 the functions of the military governmentwere reorganizedinto two branches. The Israeli Defense Force was assignedthe task of maintaininglaw and order, and the Civil Administrationwas given the responsibilityfor advancingthe welfareof the Palestinianpopulation. 1.10 Over the past 25 years, the military governmenthas made several modificationsto the social programs that had been operated by the Governmentsof Egypt and Jordan for the benefit of the

4

Chapter 1

Palestiniansprior to 1967. These changeshave been introducedprimarily in order to reduce costs, but, in some instances, they were institutedin order to improve efficiency. The most important of these changeswas to halt the free provision of medicalcare to everyonefrom governmenthealth facilities. In 1974, the military governmentbegan to imposeuser charges on those who did not enroll in the newly created government health insurancescheme. Both charitable and profit-seekinginstitutions quickly emerged to provide health care in competitionwith the fee-for-servicehealth care system. Several of these institutionswere highlysuccessfulin attractingfundingfor the constructionand operationof health centersand polyclinicsfrom Arab countries. This fundingenabledthemboth to purchasemodernmedical equipmentnot availablein governmenthealth facilitiesand to chargefees that were substantiallyless than the cost of producingthe services. Since the beginningof the popular uprising in 1987, several groups of grass-rootsvoluntaryorganizationsexpandedvery rapidlyin order to providebasichealth care. These groups have sought both to increasethe supply of primary health care and to reduce the dependencyof the Palestinianpeople on the Israeli Civil Administration. Since 1974, when charges for the use of governmenthealth care facilities were first introduced,the proportionof the populationrelying on the governmenthealth care systemhas fallen from nearly 90 percent to less than a third. 1.11 The Palestiniangraduatesof both governmentand privateschoolsin the WestBank are examined by local officials under the supervisionof the Civil Administrationand representativesof the Ministry of Educationof Jordan. Graduatesin the GazaStrip are examinedby Egyptianofficials. Therefore, all schools, to the maximum extent possible, pursue the curriculum and instructional methods of the examiningcountries. Presumablybecauseof the difficultiesthat have been encounteredin obtainingthe latest teachingmaterials,the performanceof Palestinianstudents has generallynot been as good as that of Egyptian and Jordanian students. Private schools have sprung up that provide better teaching materials, smaller classes and richer course offerings than either the governmentor UNRWAoffers. C. The Present Situation

1.12 Health, educationand socialwelfareprograms are now controlledby five clustersof institutions. These institutions are not accountableto the entire Palestinian community even though they have responsibilityfor the allocation of subsidies providedfrom domestic taxes and internationalaid. The costs of theseprograms are met from a poorly understoodcombinationof user fees, local taxes, private donationsand internationalcontributions. Accessto theseservicesis allocatedamongpeopleon the basis of their membership in predefined groups rather than on their individual need for services or their financialcircumstances. About 30 percentof the populationof the GazaStrip and the WestBank benefit from the Israeli Government'shealth insuranceplan, and slightlymore than 60 percent of schoolchildren in the OccupiedTerritories attendedgovernmentschools in 1991. Half of the residentsof the Occupied Territories are registered refugees and, thus, entitled to free primary and secondaryeducation, basic health care and relief servicesprovidedby UNRWA. High technologyhealth care is provided in Israeli hospitals to insured persons. Residents of the larger towns have access to sophisticatedhealth and educationservicesproducedby charitableorganizations. The subsidiesfrom officialdonors and private benefactorsare distributed in nontransparentways. Peopleliving in poorly served areas have begun to receivebasic health and socialservicesfrom a fast-growingnetworkof voluntaryorganizations. Those who can afford to pay have accessto high qualityprivate health and educationservices.

II. OVERVIEW OF THE STOCK OF HUMAN RESOURCES A. PopulationEstimates 2.1 The Israeli Central Bureau of Statistics (CBS)estimatedthe de facto' Palestinianpopulation of the West Bank to have been 1,052,000and the populationof the Gaza Strip to have been 717,000 at the end of 1992. Thus, the total populationof the OccupiedTerritories wouldbe roughly 1,769,000persons at the end of 1992. The CBS estimateswere obtained by updatingthe censusof population conducted in September 1967;cumulativereported births were addedto the census figure and cumulativeestimates of deaths were subtracted. Further adjustmentswere made for net emigration in order to obtain an estimateof the resident(de facto)population. Table 2.1 presents CBSpopulationestimatesfor the period 1967-1993,along with the estimatesfor each year of natural increase and net emigration employedin updatingthe census. Alternative Population Estimates 2.2 Independentresearchershavetestedthe CBSestimatesof populationusing a variety of techniques. These studies have fairly consistentlyconcludedthat the officialestimatesof populationundercountthe true population. This findinghas been attributedto two principal causes. First, the 1967Census may have undercountedthe population in 1967. It was conductedonly three months after the occupation, under a military curfew, using Arabic-speakingIsraelis. Therefore, respondentsare suspectedof not cooperatingfully with interviewers. On the other hand the curfew significantlyreducedthe likelihood that individualswould not have been countedbecausethey were absent from their homes. Second, the estimatesof the numberof births maybe underestimatedas well. Infantsborn at home and who die early in life are often not reportedto the authorities. While CBS statisticianscorrect for the under-recording of infant mortality by using appropriate estimates of infant mortality, they do not make a similar correctionfor the under-reportingof the births of these infants. 2.3 Several alternativeestimatesof the populationof the OccupiedTerritories have been prepared. The Arab Thought Forum conducted a survey in the Spring of 1992 in which village and community 2 The study estimated that the leaders were asked to estimate the population of their communities. population of the West Bank was 1,281,000and that of the GazaStrip was 758,000. A second study conductedby Benvinistiand Khayatand based on a survey carried out in the mid-1980sin more than 100 villages in the West Bank, concludedthat the numberof West Bank residents was approximately14

' The 'de facto' estimnatecounts those who are in the territoryat the time of the census, and excludes those who are outside the territory for whatever reason. The official estimates exclude the Palestiniansof East Jerusalem and the Jewish settlers in the Occupied Territories. 2

Arab Thought Forum,Final Report on Populadon Agglomerations Survey in the West Bank and Gaza Stip. Jerusalem, vol. 1, No. 2,

1992.

6

Chapter 2 Table 2.1: The De Facto Palestinian Population of the West Bank and Gaza Strip: 1967-1992

Date

W

_est

Initial Population

Nov 1961

806

May 12967

846

Sen 1967

596

1968

1969

Natural Increase Rate

|

Gaza Strip

Net Emnigration Rate

Total

Initial Population

Natural Increase Rate

Net Emigration Rate

Total Population

Population Growth Rate

3.13

986

-1.92

2.18

390

0.85

5X6

0.50 24955A-2,22

2.70

381

2.18

8.48

967

-2.77

583

2.32

-0,22

357

?2.80

0.81

940

2 .33

1470_

598

2 49

0L84

364

2.58

0 91

962

1971

608

2-85

0.41

370

3.03

0.65

978

2.41

19272

623

2,91

1.17

379

3.22

1.06

1001

I .90

122

634

2.95

-0.05

387

3.31

-0.44

1021

3.28

1974

652

3.08

0.43

402

3.56

0.45

1054

2.83

1975

670

3.08

?.25

414

3,62

0.85

1084

1.57

22 1977 1297-

675

3.33

2.13

4;26

3.78

099

1101

1.82

683

3.32

I1.49

437

3.73

.66

1121

2.31

696

3.10

135

451

3.75

1.04

1147

2.13

1979

708

3.29

1.78

463

3.56

1.04

1171

1.91

1980 1928

719

3,19

2.41

445

3.80

1.15

1163

I .50

724

3 20

2I7

457

3.88

1.16

1181

1.69

1202

2.60

L2uQ

W2B

Bank

.12

-2

-

_

1.66

733

3.34

1.08

470

3.79

0.66

1983

749

3.36

0.36

477

3.81

0.21

1984

772

3.55

0.7.S

495

4.08

0.9'7

12^66

2,92

19X5

793

19H16

1'727

3.24

3.42

0.63

510

3.90

0.57

1303

3,00

3.37

0.63

527

4.10

0.68

1343

3.01

1997

838

3.55

-0.08

545

4.33

0.61

1383

3.67-

1998

868x

3.55

0.40

566

4.53

0.48

1434

3.50

1989

895

3.-76

1.46

589

4.88

1.16

14X4

2.86

1990

916

4.20

-02.'7

610

5.05

-0,25

1526

4.80

1991-

957

4.16

-0.98

-0.06

1600

_ 5.13

19222

1006

4.90

-051_

676

5.03

-1.01

1682

5.17

1993

1052

n.a.

n.a.

717

n.a.

n.a

1769

1

643

1

5.12

.

Sources: Data for Nov. 1961 are based on Census of Population in Jordan. Population estimates for 1966 and May 1966 are taken from Fawzi A. Gharaibeh, TheEconomies of the West Bank and Gaza Strip, Westview Press, 1985, p. 29. Data from Sep. 1967 (time of Census) onward are taken from Central Bureau of Statistics, Statistical Abstract of Israel 1992, No. 43, Table 27.1.

Remark: Natural increase and net emigration rates are presented relative to the initial population.

Chapter2

7

percent higher than estimated by the CBS while the permanent West Bank population was roughly 24 percent higher than reported by the CBS.3 A survey of the Gaza Strip carried out in 1990 found 750,000 people living there at the beginning of 1990 --about 23 percent more than the number reported by the CBS.4 A census of the population of the Hebron district (except Hebron city) carried out in 1985 found the population to be 12.5 percent greater than the corresponding CBS estimate.5 2.4 An alternative estimate of the population of the Gaza Strip has been obtained from an examination of the numbers of individuals registered with the Israeli Ministry of Interior. This source of data has been expected to overestimate the population because the death and migration subsequent to the registration may not have been accurately recorded. However, based on a fairly accurate and recently updated registration of the identity cards of all Gaza residents, the Israeli Economics Officer for the Gaza Strip reports that the "registered" population of Gaza Strip in 1992 was 831,000 people, while the "resident" population was 740,000.6 The estimate of the resident population is 10 percent higher than the corresponding CBS estimates, while the estimate of the registered population is approximately 24 percent higher than the CBS estimate of the de facto population. 2.5 These studies, while in no instance able to claim a high degree of statistical rigor, nonetheless as a group strongly suggest that a downward bias in the CBS estimates of the resident population of roughly 10-15 percent. The CBS readily concedes the possibility of an undercount but disputes the magnitude suggested by these studies. It argues instead that the magnitude at the undercount is likely to be on the order of 3-4 percent. The CBS notes that the 1967 census was conducted during a curfew; thus, since people were confined to their homes the census was likely to have obtained an exceptionally complete count of the number of residents. In addition, the CBS points to the high degree of consistency between its estimates of population and the numbers of children reported to be entering school, or being immunized. Finally, the CBS cites the similarity between the number of new identity cards issued to residents of the Gaza Strip and its estimate of the population of the Strip. An adjustment of 12 percent provides for the largest plausible estimate of the undercount. This adjustment would imply that the resident populations of the West Bank and Gaza Strip in the end of 1992 were no more than 1,200,000 and 800,000 people, respectively, with a combined total population of no more than 2 million people. The Permanent Population 2.6 The permanent (de jura) population is defined as everyone who has a legal right to reside in the territory. The number of Palestinians from the Occupied Territories living abroad appears to be about 350,000. This figure has been obtained from data on the net annual migration flow since the beginning of 1969,7 and the assumption that migrant Palestinians have had the same rate of natural increase as those who remained behind. These assumptions imply that 227,000 from the West Bank and 120,000 people Meron Benvinisti and Shlomo Khayat, The West Bank and GazaAtlas, The West Bank Data Project, 1988. 'Mahmoud M. Okasha, Population and Labor Force in Gaza Strip: A Statistical Survey, October 1990, Publishedby the Arab Thought Forum, Jerusalem. University Association of Hebron, Population of theHebron District: A Demographic Study, May 1987, in Arabic, pp. 228-231. 'Interview with the World Bank mission, 3 February 1993. We startthe analysis from 1969 as earlier migrants are assumed to have respondedto the political shock of occupation and are thus treated as 'displaced' Palestinians.

8

Chapter2

from GazaStrip were living abroad in 1992. However, manyhave lost their right to return becausethey have failed to renew their exit visas. (One must renew the exit visa after three years by appearing annually at any Israeli consulateabroad; alternatively,a relative of the person living abroad may apply on his or her behalfat the officesof the Civil Administration. At the end of six years the applicantmust reapply in person at the Civil Administrationoffices). In addition, childrenborn abroad to nonresidents sometimeshave been unable to acquirethe right to enter to the OccupiedTerritories, particularlywhere one of the parents was not a Palestinianfrom the OccupiedTerritories. A household survey conducted in 1985foundthat 76.3 percent and 62.4 percent of the WestBank and Gazamigrants, respectively,held valid Israeli-issuedvisas. Thus about 173,200people from the West Bank and 74,900 people from the Gaza Strip were legally entitled to return to the OccupiedTerritories. These numbers imply that the permanentPalestinianpopulationof the West Bank and GazaStrip may have been as great as 2.2 million people at the end of 1992. Recent Trends 2.7 Table 2.2 presentscrudebirth rates, crudedeathrates, and the naturalrates of populationincrease for the West Bank and Gaza Strip preparedby the CBS for the period 1968-1992.a 2.8 Rate of Natural Increase. The rate of naturalpopulationincreasehas been rising over the period 1968-91,from a low rate of 2.2 percent in 1968to 4.2 percent in the WestBank and 5.1 percent in Gaza Strip in 1991. A decline in mortality drove the increase in the natural population growth in the early period, but starting from the mid-1980s, the natural rate of population increase seems to have been increasingprimarily in responseto changesin the birth rate. 2.9 Crude Death Rates. Crude death rates have declinedover the period of the occupation,from roughly 20 deaths a year per thousandpopulationin the late 1960sto roughly 5 deaths per thousand in the early 1990s. The declinehas beendue in large part to the shiftingage compositionof the population: a population that is, on average, younger is expectedto have a lower death rate. The trend for the OccupiedTerritories is similar to that for Jordan;9 this is not surprising since standards of living in Jordan are comparableto those in the OccupiedTerritories. 2.10 A survey conducted recently by UNICEF and the Jerusalem Family Planning and Protection Associationprovides independentestimatesof death rates. The studyconcludedthat the estimatedinfant mortality rates for the West Bank and Gaza Strip both were 42 per thousand in 1988. This figure is consistentwith the infantmortalityrate estimatedby CBS demographers,but nearly twice as high as the 10 rates reported by the Israeli Ministry of Health and UNRWA.

' See Statistical Abstract of Israel 1993, and U. 0. Schmelz, et. al., Multiplicity Study of Births and Deaths in Judea-Samaria and Gaza Strip - North Sinai, Technical PublicationSeries No. 44, Central Bureau of Statistica. See previous note. '° See A Survey of Infant and Child Mortality in the West Bank and Gaza Strip, UNICEF and Jerusalem Family Planning and Protection Association, Interim Report, December 1992.

Chapter 2

9 Table 2.2: Indicators of Population Natural Increase - Crude Birth Rates and Estimated Crude Death Rates, 1968-1992

l_______)

lWEST

[

BANK

GAZA STRIP

Year

Births Per Thousand

Estirnated Deaths Per Thousand

Rate of Natural Increase

Births Per Thousand

Estimated Deaths Per Thousand

Rate of Natural Increase

1968

43.90

21.70

2.22

42.00

19.50

2.25

1969

43.30

20.40

2.29

46.70

18.90

2.78

1970

43.90

18.70

2.51

43.60

18.00

2.56

1971

45.90

17.80

2.81

46.80

16.90

2.99

1972

45.90

17.10

2.88

47.90

16.00

3.19

1973

45.50

15.70

2.98

49.60

17.10

3.25

1974

46.10

15.70

3.04

49.90

14.80

3.51

1975

45.40

14.80

3.06

51.50

15.80

3.57

1976

46.80

13.70

3.31

51.90

14.60

3.73

1977

45.40

12.50

3.29

49.50

12.80

3.67

1978

43.40

12.60

3.08

49.90

12.90

3.70

1979

44.10

11.40

3.27

49.80

13.40

3.64

1980

42.10

10.40

3.17

47.60

10.10

3.75

1981

41.80

9.90

3.19

47.50

9.20

3.83

1982

42.20

9.10

3.31

46.20

8.60

3.76

1983

42.10

9.00

3.31

45.80

8.30

3.75

1984

43.20

8.20

3.50

48.80

8.60

3.99

1985

41.30

7.60

3.37

45.40

7.00

3.84

1986

40.00

6.70

3.33

48.60

6.90

4.17

1987

41.30

6.50

3.48

47.70

5.20

4.25

1988

40.60

5.70

3.49

50.20

5.80

4.44

1989

43.10

5.90

3.72

53.80

5.90

4.79

1990

46.90

5.80

4.11

54.70

5.50

4.92

1991

47.30

6.80

4.05

56.10

6.20

4.99

1992

44.70

5.60

3.91

54.60

5.80

4.88

Sources:Birth rates were obtainedfrom various statisticalabstractsof the CBS. The CBScomputedthese figuresas reported births dividedby the de facto populationfor that year. Estimateddeath rates were estimatedby the CBS basedon modelsand comparisonswith neighboringcountries. Remark: Ratesare measured relativeto mid-yearpopulations.

10

Chapter 2

2.11 Crude Birth Rates. Between 1968 and 1974, birth rates increasedby 2.1 per thousand in the West Bank and 8.0 per thousand in the Gaza Strip. These increases have been explained by the normalization in the marriage market and the re-unificationof families after the 1967 War.'" In addition, there may have been greater under-reporting of births in the early years of occupation.12 Between1975and 1985birth rates declinedby approximately5 per thousand in both the WestBank and Gaza Strip. However, birth rates began increasingagain in the mid-1980s, rising from 45 to 56 per thousand between 1985and 1991in the Gaza Strip, and later in the West Bank-froma low point of 40 per thousand in 1986,to 47 per thousandin 1991. Analysisof the sudden surge in birth rates is beyond the scope of this report but is cruciallyimportant,particularlyto the extent that the underlyingreasons are related to "temporary" causes that would disappear with political normalizationor "permanent" changes that reflect a structural shift in attitudes, cost-benefitcalculus, and practices. It has been suggested to the mission that the age at marriage has declined since the Intifada, reflecting a general decline in the cost of marriageceremonies. 2.12 Net Migration. The emigrationrate from the OccupiedTerritories has been quite high since 1967. There was a large waveof politicallymotivatedmigrationin the period immediatelyfollowingthe Israeli occupation,but high rates of migrationhave continuedsince, as well. The peak occurredduring the oil-boomof 1974-1982,suggestingthat much of it was economicallymotivated.The emigrationrate began to decline in 1982becauseof the reduceddemandfor Palestinianlabor that accompaniedthe oilinducedrecessionin the regionand the introductionby Jordanof administrativecontrolson the movement of Palestinians from the Occupied Territories, starting in 1982.'3 During the Gulf War, many Palestinians returned from working in Kuwait, and many others were no longer welcome in the Gulf countries. 2.13 In 1985, about 40 percent of families in the Occupied Territories had one or more family membersresiding abroad. Table 2.3 illustratesthe migrant selectivity:migrants were overwhelmingly males, in the age group 21-35, and highlyskilled. Migrantsfrom the West Bank and Gaza canbe found throughoutthe World, but the largestgroup has migratedto the oil-exportingArabcountries, with Jordan a close second. Age Compositionof the Population 2.14 About half of the population of the Occupied Territories is less than 15 years of age; the population in Gaza Strip is slightly younger due to higher fertility. The Palestinianpopulation has become youngerduring the 1980s,due mainlyto the high and increasingfertility and to decliningchild mortality. The share of the populationover 35 years of age has declinedsteadilyfrom 25 percent in 1967 to 18 percent in 1990.

" See p.51 in U. 0. Schmekz, et. al., Muliplicity Study of Births and Deaths in Judea-Samaria and Gaza Strip-NorthSinai, Technical Publication Series No. 44, Central Bureau of Statistics. See p. 8 in Housing Requiremenus in the Future Independent Palestinian State 1987-2007, A Study for thc U.N. Center for Hunan Settlements (HABITAT), Commissioned from Birzeit University, August 1989. 12

13see Hussein Yousef, 7he Demography of the Arab Villages of Lhe WestBank, Unpublished Ph. Thesis, University of Durham, July 1989, p. 377.

Chapter 2

11

Table 2.3: Characteristics of Palestinian Migrants in 1985 Indicator

West Bank

Gaza Strip

Percent of Families with a Member Abroad

40.3

39.4

Males as Percent of Migrants

66.9

80.0

Age Distribution of Migrants (Percentages in 1985)

|

Less than 21 Years of Age

4.62

4.24

21-35 Years of Age

69.23

58.18

36-50 Years of Age

23.08

33.64

3.08

3.94

Percent Single

29.9

22.1

Percent Married

68.9

77.9

52.68

55.79

76.3

62.4

30.15

7.27

42.77

67.88

2.92

13.33

America

11.69

1.82

Europe

8.92

6.67

All Others

3.54

3.03

Percent Seeking Work

48.62

55.45

Percent Seeking Education

18.92

13.33

PercenL Joining a Spouse

29.54

16.97

2.92

9.40

More Than 50 Years of Age Marital Status

Percent of Migrants Employed as Supervisors, Managers or Technicians Percent with Valid I.D. for Return to Occupied Territories Percent of Migrants by Country of Destination Jordan Arab Oil-exporting Countries Other Arab Countries

| |

Reasons for Migrating

Percent Politically Motivated

Source: Assembledfrom varioustabkein Abdel-FatLhAbu Shokor.ErtenalMigrU4onfroim dhe WestBank and GazaStripandAsEconomic and Socidal Impact. lerualem: ArabThoughtForum, 1990, inArabic.

12

Chapter2 B. Participation in the Labor Force

2.15 Out of the 834,000 persons estimatedby the CBS to be 15 years of age or older in 1991, 37 percent were in the labor force. The labor force participationrates for femaleswere very low; in 1991 only 8.8 percent and 1.7 percent of the femalepopulationaged 15 years or older in the West Bank and GazaStrip, respectively,were economicallyactive. (See table 2.4) These femaleparticipationrates are much lower than those found in nearbyArab countries. The crudelabor force participationrate was the lowest reported by any economy in the world; approximately 19 percent of the population was economicallyactivein 1991. In comparison,the crudeparticipationrate for selectedcountries were 39 percent for Israel, 24 percent for Syria, 27 percent for Egypt, 27 percent for Iran, 29 percent for Bangladesh and 49 percent for the USA. This unusually low rate was due in large part to the youthfulnessof the population. 2.16 The male labor forceparticipationrate averaged72.6 percent and 68.8 percent of the population 15 years and older, over the years 1987-1991in the West Bank and the Gaza Strip, respectively. Male labor force participationrates were at their highest levels in the late 1980sand early 1990s, due in part to fairly low emigrationrates since 1982. Approximately92 percent of males aged 25-44 years old were in the laborforce in 1991. The participationrate for males aged 18-44years old has generallyrisen over the period 1986-1991in both the West Bank and Gaza Strip, with the most impressive increase in the group 25-34years old. The 1986participationrates of the age group 15-17was 30.4 percent in the West Bank and 29.4 percent in Gaza Strip. By 1991,these rates dropped to 25 percent in the West Bank but fell to 14.6 percent in the GazaStrip. Education and Participation 2.17 The relation between years of schoolingand labor force participationis mixed. For females, higher educationattainmentsare associatedwith higher participationrates. However, the relationship between male participationrates and educationis not as consistent. In 1991, the participationrate was highest for males with 5-6 years of schooling followed by those with 7-8 years of schooling and university graduates (16 or more years of schooling). However, over the period 1987-1991,the only groupsthat increasedtheir participationratessignificantlywere universitygraduatesand those with 13-15 years of schooling;the participationrate for all other educationalgroupshas either stagnatedor declined. C. Unemployment 2.18 The estimates of unemploymentrates prepared by the CBS rely on the ILO definition of unemployment,wherebythose whoactivelysoughtwork during the week prior to the interviewand who had worked less than one hour during that week were regardedas unemployed."' During the early years of 1969-1973,unemploymentratesdeclinedfrom the double-digitregionto roughly I percentof the labor

" The 1992 unemnploymentrate is for only the first 3 quarters of the year; it waa provided by CBS officials. The unemploymnentrates refer to the labor force aged15 or older years from 1986 onward, and to the age group 14 or older years prior to 1986. The implication of this change is insignificant for rates of unemployment because the participation rate of the 14-year old group is less than 30 percent and their unemployment rates are not likely to be sizably different from the rest of the labor force. Therefore, the difference between the two definitions is likely to fall within 0.1 percent of the measured unemployment rate.

Chapter2

13 Table 2.4: Labor Force ParticipationRate in OT for Adult Population: 1968-1991

Year

Size of Labor Force

ParticipationRate

ParticipationRate

(In Thousands)

West Bank

Gaza Strip

(Percent)

(Percent)

[

._________

-

West Bank

Gaza strip

Total

Male

Femalc

Total

Malb

Female

1968

92.9

53.5

30.1

56.0

8.2

29.3

58.8

6.3

1969

114.5

58.2

36.5

62.2

13.4

30.8

61.9

4.9

1970

118.5

62.4

36.7

61.4

14.3

31.7

63.1

5.0

1971

119.8

61.8

36.3

62.0

12.8

30.8

61.8

4.4

1972

126.6

64.6

37.6

66.5

11.0

31.5

64.0

3.9

1973

127.8

68.6

37.4

66.6

10.8

32.6

65.7

4.0

1974

138.9

73.4

39.1

66.1

14.3

33.6

66.7

4.5

1975

133.9

72.7

36.5

61.9

12.8

32.3

64.6

4.1

1976

131.3

76.4

35.4

59.7

12.8

33.0

65.6

4.3

1977

128.6

77.4

33.9

57.4

11.9

32.3

64.0

4.1

1978

132.9

80.7

34.1

56.8

12.8

32.3

64.1

3.6

1979

133.9

79.7

33.6

56.9

11.7

32.8

65.1

3.5

1980

137.2

81.3

34.2

57.7

12.4

33.5

65.5

4.3

1981

135.4

82.8

33.6

57.8

11.2

33.5

66.0

3.7

1982

142.9

82.3

35.2

60.0

12.5

33.4

66.0

3.2

1983

150.2

85.8

35.7

62.1

11.0

32.8

64.2

3.8

1984

160.0

87.9

36.7

63.7

11.1

33.2

65.5

3.3

1985

159.2

92.0

35.9

63.9

9.5

33.0

65.4

2.9

1986

173.6

95.6

37.8

66.7

10.5

33.4

65.7

3.0

1986

172.2

95.1

39.0

69.1

10.8

34.4

67.6

3.1

1987

182.2

101.7

40.0

72.2

9.5

36.0

71.1

3.0

1988

188.1

101.2

41.0

73.3

10.4

34.7

68.9

2.4

1989

189.1

101.2

40.3

73.6

8.5

33.6

66.8

2.0

1990

199.7

108.0

40.8

72.6

9.8

34.4

68.6

1.9

1991

200.3

111.8

39.4

71.3

8.8

34.3

68.4

1.7

1

Source: Various issues of S:adisucal Abstract of Israel, published by the Israeli CBS. Remark: (a) Data in this table prior to 1986 refers to adults who were 14 years or older, but data from 1986 onward refers to those who were 15 years and older. Two sets of data are given for 1986, the first using the earlier definition while the second uses the newer.

14

Chapter 2

force. This declineresultedfrom migrationof Palestiniansfrom the OccupiedTerritoriesto Jordan and other Arab countries,and from an expansionofjob opportunitiesin Israel. During the period 1974-1982 the average unemploymentrate was 1.2 percent and 0.4 percent in the West Bank and Gaza Strip, respectively. Since 1982,unemploymentrateshave been increasing,as the demandfor Palestinianlabor in both the Israeli and Arab labor markets stagnated. The unemploymentrates for the West Bank and Gaza Strip in the first 3 quartersof 1992were 5.6 percent and 3.2 percent in the West Bank and Gaza Strip, respectively. Younger workers tend to be over-represented among the unemployed. Unemploymentincreaseswith education,with the highestrate of unemploymentfound amonguniversity graduates. 2.19 The labor market of the OccupiedTerritoriesis characterizedby a high turnover and a large (and rising) fraction of workers employed part-time. The proportion of employees from the West Bank working full time was greater than 93 percent in every year between 1984 and 1987, but this ratio dropped to 66 percent, 74 percent, 83 percent, and 83 percent in the years 1988, 1989, 1990, and 1991, respectively. A similar pattern wasobservedfor GazaStrip. High turnoverresults from the participation of roughly a third of the OccupiedTerritories labor force in the market for day laborers in Israel. 2.20 Several Palestinianeconomistshave challengedCBSestimatesof unemployment. For example, using a sample survey, Abu-Shokorestimatedthe unemploymentrate in 1985to be 9.1 percent in the West Bank and 2.7 percent in Gaza Strip; CBS estimatesfor the same year were 5.0 percent and 1.2 5 percent." These differences reflect the small sample (approximately 1,000 potential labor force participants in the West Bank and Gaza Strip) and adoption by Abu-Shokor of a definition of "unemployed"that did not conform to that of the ILO. A sample survey of 700 households in Gaza suggestedthat the 1989unemploymentrate in Gaza was 20.8 percent for the labor force over 16 years of age.'6 The definitionof the unemployedused in this study conformedto that of the ILO. Recently, a reanalysisof CBS data producedan unemploymentrate in the West Bank and the Gaza Strip of 27.2 percent; however, this study adopted a definitionof the unemployedthat included "part-timers", those "temporarilyabsent from work" and the roughly 15,000prisoners in Israelijails."7 Wages and Labor Markets 2.21 During the Intifada, the number of Palestiniansworking in Israel initially declined. However, by the end of 1992 employmentin Israel had returned to its pre-Intifada level --about 115 thousand people. Palestinians working in Israel earn wages at, or somewhatbelow the Israeli minimumwage (aboutNIS1,400 a month, in early 1993). Nonetheless,these wages are substantiallyhigherthan wages earned in the OccupiedTerritories; a school teacher earns about NIS900 a month, for example. The Israeli labor market places upward pressures on wages in the Territories. In 1990, the wage premium

See pp. 90-102 in Abdel-Fattah Abu-Shokor, LaborMarket in the West BaRnk and GazaStrip, Nablus: An-Najah National Univcrsity, 1987, in Arabic. "

16 See p. 4 and 32 in Mahmoud K. Okasha, Population and Labor Force in Gaza Strip, A Statistical Survey, Jerusalem:Arab Thought Forum, October 1990.

" See p. 17 in A. Abu-Shokor Unemploymeiu in the Occupied Palestinian Terrilories: 1968-1991,a paper presented at a seminarheld at the U.N. ESCWA in Amman, November 30, 1992.

Chapter 2

15

for working in Israel was about 22 percent.' Palestinianuniversity graduatesdo not command a wage premium over non-graduatesbecausethe jobs open to graduatesrarely utilize their education. D. Population Prospects

2.22 Table 2.5 presents population projections through the year 2002. These projections were prepared in 1982 by the CBS relying on several assumptionsabout fertility and net migration."9 The lowest populationprojection assumeda net emigrationrate of 1.0 percent annually and a sharp decline in the total fertility rate --from 6.5 in 1982, to 3.8 by the year 2002 in the West Bank, and from 7.2 to 4.5 in the Gaza Strip. The high growth scenario assumedno change in the total fertility rate and zero net migration in both the West Bank and Gaza. The estimatedgrowth of population in the Occupied Territories since 1982 has been closer to the assumptionsunderlyingthe highest growth scenario. It seems reasonableto assume that net migration will be zero, on average, over the next decade and that fertility will stabilize. Under these assumptions,the CBS high growth projectionswould continueto be the most appealing. The end-of-yearpopulationestimatefor 2002 wouldthen be 1,071,000for Gazaand 1,550,000for the West Bank. The total populationwould then equal 2,621,000 people. 2.23 On the other hand, if the analysiswere based on 1992populationestimatesof 800,000for Gaza and 1,178,000for the WestBank, and the assumptionthat the rate of natural increasesfor the GazaStrip were 4.0 and 3.5 percent for the West Bank, then the populationof the Gaza Strip would be 1,184,000 and of the West Bank 1,661,000in the year 2002. Labor Force Prospects

2.24 The male labor force may reach 265,300 in the West Bank and 166,100in the GazaStrip by the year 2000. If age cohort-specificparticipationrates were to remain unchanged,the overall male labor force participationrate for the population 15 or older years would increase from 72 percent over the period 1986-1991to 75 percent in the year 2000 in the West Bank, and from 69 percent to 71 percent in the GazaStrip. This increasearises becauseof changesin the age-compositionof the population. The projected size of the female labor force at the end of year 2000 is 33,800 in the West Bank and 4,700 in the Gaza Strip. Therefore, the projectedsize of the total labor force in the year 2000 is 299,100 in the West Bank and 170,800 in the Gaza Strip. This representsan average annualgrowth of 4.1 percent in the West Bank and 4.7 percent in GazaStrip over the period 1990-2000.

SeeJoshua D. Angrist, Wages and Employntent in the West Bank and Gaza Strip: 1981-1990, July 1992, Falk Institute Discussion Paper No. 92.02, The Hebrew University, Jerusalem. "

19 See Central Bureau of StaListics, Projections of Population in Judea, Samaria and Gaza Area up to 2002, Based on the Population In

1982, Special Series No. 802, 1987.

16

Chapter 2

Table 2.5: Population Projection for 2002 Year-end Resident Population (In Thousands)

_

Gaza Strip

|_West Bank

Total

1991: CBS Year-endEstimate

676

1006

1682

1992: CBS 1991 Estimate Projected to End 1992

717

1052

1769

1992: CBS Estimate Adjusted for Possible Under-Reporting

800

1178

1978

1992 Scenario TV

702

1042

1742

1992 Scenario V

712

1057

1769

2002 Scenario IV

992

1429

2421

2002 Scenario V

1071

1550

2621

CBS Forecasts

Projections for 2002 Based on CBS Estimates of Population and Projections of the Rate of Natural Increase

Gaza: 3.5%; WestBank: 3.0%

1003

1407

2410

Gaza: 4.0%; West Bank: 3.5%

1052

1476

2528

1147

1535

2682

Gaza: 4.9%; West Bank: 3.9%

T

Projectionsfor 2002 Based on Adjusted CBS Estimatesof Population and Projectionsof the Rate of Natural Increase

Gaza:3.5%; WestBank:3.0%

1128

1583

2711

Gaza:4.0%; WestBank:3.5%

1184

1661

2845

Gaza: 4.9%; West Bank: 3.9%

1290

1727

3017

III.

HEALTH CARE

A. Introduction

3.1 This chapter describesthe efforts that are being madeto protect the health of the residentsof the OccupiedTerritories, assesses the weakness in these efforts and outlines the initiatives that would be requiredto address theseshortcomings. The remainderof chapter is divided into six sections. The first section offers an overviewof the current status of health in the Territories. The secondsection describes the institutionsthat provide preventiveand curativeservicesin the Gaza Strip and the West Bank. The third section presents the informationthat can be found on the financial and real resources that these institutionsare committingto the sector. The fourth sectiondiscussesthe programs that are being carried out and assessestheir impact on health. The fifth section examinesthe deficienciesin these programs and identifies measures that promise to overcome these problems. The final section sets forth recommendations. B. Health Status An Overview 3.2 In spite of formidable data problems, a fairly broad consensus exists regarding the general outlines of health conditionsin the Gaza Strip and in the West Bank. Life expectancy,infant mortality and patterns of morbidity in the OccupiedTerritoriesare believedto be fairly similar to those typically found in lower-middleincomecountries. Palestinianand Israeli expertsagree that life expectancyat birth is 65 to 66 years. The infant mortality rate is 40-45 infant deaths per thousand live births. Gastrointestinaland respiratoryinfectionsare reportedas major problemsin the GazaStrip but not in the West Bank. High rates of respiratoryand skin infectionscontinueto be reported by residentsof refugee camps due to crowded housing and poor envirornental sanitation. The communicablediseases of childhood--mumps, whoopingcough, tetanus,measlesand polio- have been largely controlledthrough a successful child immunizationprogram. Moderate and severe malnutritionare virtually unknown. Food suppliesare adequatein quantity and fairly welldistributed. The customarydiet is rich in proteins and fiber and low in animalproducts but provides too little of some micronutrient--particularly iron. Weaningpracticesgenerallyare also sound. The WestBank reports high prevalencerates for cardiovascular diseases, hypertension,diabetes and cancer-- diseases usually associated with highly developed countries. However, these findingsmay reflect the selectivityof the sampleproducedby well-equipped clinics and by the aggressivenessof diagnosticefforts at these facilities. 3.3 The pattern of disease is expectedto be somewhatdifferent in the Gaza Strip than in the West Bank. The two areas are distinct in terms of environmentalconditions,economiccircumstances,social situationsand social services. Nonetheless,the reports that are availabledo not reveal major differences, except in the area of chronic, adult-onsetdiseases.

18

Chapter3

Conditions In the Gaza Strip 3.4 The Governmentof Israel reported an infant mortalityrate for the Gaza Strip for 1990 of 26.1 infant deaths per thousand live births. It had estimatedthe infant mortalityrate for 1980 to have been 43 and for 1970to have been 86. These reports suggestthat dramaticimprovementsin infanthealth have been achievedsince the occupationbegan. However, these figures are disputedby Palestinianleaders. Some of the controversycanbe attributedto definitionsand methodsof measurement. The Israeli figure is based on the estimatednumberof births and the infantdeaths reportedto the Civil Administrationby health care providers and households. The reportingof deathsby the governmenthealth serviceand by UNRWA is probablyquite complete,but about35 to 40 percent of all births occur at home and are not supervisedby a physicianor qualifiedmidwife. Some births are not reported as well. The infant death rate is likely to be much higher amongthose who give birth at home, not only because the quality of medical care is lower, but also because this group is more likely to be economicallyand socially disadvantaged. Those householdsthat do report births and deaths typicallydelay reporting; thus, births that lead to death in the early months of life are unlikely to be reported at all. The number of infant deaths is believed to be substantiallyunderestimatedand, therefore, the official estimate of the infant mortality rate is thought to biased downward. Studies of infant deaths among disadvantagedgroups suggest that the mortalityrates may be in the range of 70 to 120for this group. If one assumesthat the Government's estimatesof infantdeaths are correct for the 60 percent of children deliveredat official health care facilities and that the remaining 40 percent of births suffers a mortality rate of 70 per thousand, then the overall infant mortality rate in Gaza in the 1990s would be about 45 deaths per thousand live births. 3.5 Table 3.1 reproducesestimatesof the principalcauses of infant deaths in 1991 by age at death. Nearly40 percent of infant deathsoccurredduring the first week of life. Slightly less than half of these deaths were causedby birth trauma or prematurity;the secondand third leadingcauses were respiratory conditionsand hypothermia. Slightlymore than half of infant deathsoccurred betweenthe ages of one month and one year. The causes of death in this group are distributed uniformly over the 15 classificationsof the WHO InternationalClassificationof Diseases,Revision 12. Table 3.1: Leading Causesof Infant Mortality Causes of Death

% of Deaths

Certain ConditionsOriginatingin the PerinatalPeriod (ICD9 code 760-779)

25.7

Other Diseasesof the RespiratorySystem (ICD9 code 446, 480-519)

22.6

CongenitalAnomalies(ICD9740-759)

15.1

Diseases of the DigestiveSystem (ICD9530-579)

13.3

Signs, Symptomsand Ill-definedConditions (ICD9 780-799)

8.1

Other

15.2

Source: StatisticalReport of HealthServicesin Judea and Samaria1988, Table 13.

Chapter 3

19

3.6 The number of children born live to the average woman over her reproductivelife (the "total fertility rate") for the GazaStrip is reportedto be amongthe highest in the world. The Governmentof Israel estimatedthe total fertility rate to be 7.2 births per woman in 1987. The crude birth rate is reportedto have risen sharply since the beginningof the Intifada;accordingto the Israeli Central Bureau of Statistics, in 1985 there were 45.4 births per thousandpopulationand in 1991there were 56.1. The reasons for this 25 percent increase in the crude birth rate have not been analyzedrigorously, but part of the explanationis thought to be that the age at marriage for females dropped considerably after 1987.1 Despitethe significantdifferencesbetweenthe Gaza Strip and the West Bank in environmental conditions,health care provision, economiccircumstancesand reportedpatterns of disease, estimatesof life expectancyare the same. 3.7 A rough indication of the contributionof specific diseases to death and to temporary and permanentdisabilitycan be obtained from analysesof presentingcomplaintsand diagnoses reported by health facilities. Table 3.2 presents results for the GazaStrip. Observersof the GazaStrip report seeing a remarkably high incidenceof trauma; this is presumably due both to a neglect of occupationaland highway safety, and to the violencethat has accompaniedthe Intifada. 3.8 The per capita availabilityof calories in the Gaza Strip was approximately2,612 kcal a day in 1987, which is adequatebut certainlynot generous. Incomesare distributedquite equitablyin the area, implying that access to food is quite equitable as well. Moreover, the customary diet is relatively inexpensiveand nutritionallysound. Traditionalweaningpracticesentail the early introductionof whole grain breads and highly nutritious pastes made from legumes and oil seeds. The unimportanceof malnutritionis suggestedby the Palestinianliterature, which has noted that the extent of malnutritionis so slight that the problem is not easily recognized. 3.9 Living conditionsin the Gaza Strip are much worse than per capita incomeswould lead one to 2 expect." Nearlythree-quartersof the populationare registeredrefugees,and 55 percent of these people live in refugeecampsoperatedby UNRWA. Environmentalconditionsin the campsare generallypoor. Most of the camps have no organizedsy;tem of sewage collection, and none has an adequatesystem of sewage treatment for collected wastes. All of the camps are provided with solid waste collection facilities, but none is served by a proper disposalsite. 3.10 Outside the camps, solid wastesare collectedat neighborhoodcollectionbins, and abouta third of the populationis served by the system. Large containersare placed at central placesin communities. The containersare collectedat intervalsand dumpedat surfacedisposal sites, where the organicwastes are allowedto decomposeand combustiblematerialsareburnt. Properlydesignedsanitary landfills have not been constructed anywhere in the Gaza Strip; wastes often leach into the aquifer, thereby contaminatingdrinking water supplies.

I

Palestinian observers argue that the violence and uncertainty that has accompanied strikes and curfews during the intifada has led parents to seek the security of early marriages for their daughters, and that the emergency has also resulted in a reduction in social demnandsfor expensive ceremonies. For a fuller discussion of living conditions in the Gaza Strip and West Bank, please see Developing the Occupied Tenitories: An Invesanentin Peace, Volume V: Infras:nicture, The Wodd Bank, August 1993. 2

20

Chapter 3 Table 3.2: PrincipalDiagnosesfor Patients Visiting the GovernmentHealth Service, 1989 Disease

ICD9 Codes

Number of Visits

Percent of Visits

460-465, 470-478

139,642

24

466, 480-519

74,360

13

Diseasesof the Skin and SubcutaneousTissue

680-709

52,549

9

Diseasesof the MusculoskeletalSystem and ConnectiveTissue

710-739

51,429

9

Diseasesof Other Parts of the

530-579

48,871

8

240-259,270-279

26,682

5

HypertensiveDisease

401-405

26,241

4

Diseasesof the Urinary System

580-599

18,118

3

Disordersof the Eye and

360-379

16,875

3

IschemicHeart Disease

410-414

15,475

3

Diseasesof the Ear and

380-389

14,012

2

Diseases of the Upper Respiratory Tract

Other Diseases of the Respiratory System

Digestive System

Endocrine and Metabolic Diseases, ImmuneDisorders

Adnexa

Mastoid

l

Diseasesof the Blood and

280-289

11,534

2

Blood-Forming Organs

IntestinalInfectiousDiseases Other

TOTAL

ll

001-009

8,963

2

69,784

12

591,206

100

3.11 More than half of householdsin camps are served by a piped water supply in the dwelling, and two-thirdshave good accessto some source of piped water. In more than 90 percent of cases, the water is disinfectedat the source. Inadequatesuppliesof water, poor water quality and unsanitarydisposalof

Chapter 3

21

liquid and solid wastes nonetheless contribute to a high incidence of gastrointestinal and parasitic infections. In addition,the fluoridecontentof the groundwaterin the area north of GazaCity is reported to be high enough to lead to the mottlingof teeth and bone disease. 3.12 Crowdingis a problem throughoutthe GazaStrip, but it is especiallyacute in the refugeecamps. The average householdin the Gaza Strip has 2.7 personsper room; half of Gazanslive in householdsin which the number of persons per room is greater than 2. Crowding facilitatesthe spread of diseases transmittedthroughpersonalcontactand airbornerespiratorysecretions. The very high rates of dermatological and respiratoryinfectionscan be traced to crowding. 3.13 The use of governmenthealth care services has been inhibitedby the strikes and curfews that have accompaniedthe Intifada. The incidence of personal injuries has risen sharply due to related violence; however, the magnitudeof this problem is difficultto assess. Woundedpersons have been reportedto be reluctantto presenttheir injuriesto governmenthospitalsfor fear of beingarrested. Health workers have encountereddifficultiesin getting to clinics and hospitalsbecause of border closures and road blocks. These problemshave compoundedthe effectsof the Intifada on health in the Territories. Conditions in the West Bank 3.14 The natural environmentin the West Bank is generally healthier than that in the Gaza Strip. Populationdensitiesare muchlower, drinkingwater suppliesare both generallysafer and more abundant, housing is less crowded and incomesare --on average--substantiallyhigher. In addition, only about 9 percent of the populationlives in refugeecamps, and the campsare much smaller. These advantageslead one to expect substantiallybetter health conditionsin the area. 3.15 The informationon health conditionsis even more sketchyfor the West Bank than for the Gaza Strip. The Governmentof Israel reports that in 199022 infant deathsoccurredper thousand live births in the West Bank. As in the case of the Gaza Strip, this figure representsthe numberof infant deaths reported by health care providers and individualhouseholdsdivided by the estimatednumberof births. The Governmentof Israel reports that two-thirdsof births in the Gaza Strip and West Bank occurred at a hospital or medicalcenter in 1992. UNRWAalso reports that the patients at its clinics experiencean infant mortality rate of about 22 deathsper thousand live births. Palestinianleaders disputethese estimatesof the infant mortalityrate; they notethat studiesof isolatedcommunitieshaveproducedestimates in the range of 80 to 100 deathsper thousand live births, suggestingthat the true infant mortalityrate is somewherebetween40 and 45 deathsper thousandlive births. The failure of a healthier environment to lead to better health may be due to poorer accessto health care. 3.16 The total fertility rate for the West Bank is reported by the Governmentof Israel to be 6.5.Y Like the estimatefor the Gaza Strip this figure is based on very limited, and statisticallysuspect data. Both Governmentof Israel and Palestiniansourcesestimatelife expectancyat birth for those born in the West Bank to be about65 years. Estimatesof life expectancyare highly sensitiveto estimatesof infant and child mortality; because the latter are in dispute, the estimatesof life expectancymust be regarded with some suspicion as well.

I

Yaqub Lama and Mario Ferraro, GeneralSurveyof HealthServces in theOccupiedTerntories,Ministry of Foreign Affairs, Government of Italy, Jerusalem, 1989.

22

Chapter 3

Recent Trends in Health Conditions 3.17 Knowledgeableexperts agree that considerable improvement in health conditions has been achievedduring the 25 years of military occupation. Over this period, life expectancyhas increasedby about 10 years; the infant mortality rate has been reduced from about 80 to about 40 to 45; and the childhoodcommunicablediseases, includingpolio and measles, have been brought under control. The paceof improvementsince 1967appearsto have beensomewhatslower in the Gaza Strip and in the West Bank than in Jordan and Syria. 3.18 While significantprogresshas been achievedover the past 25 years, additionalgains are clearly technicallyfeasible. The infant mortality rate could be reduced further if adequateprenatal care were provided to a larger proportion of pregnant women. Both the incidenceof diarrheal disease and the severityof diarrhealepisodescouldbe dramaticallyreducedif sanitaryfacilitieswere improved,and the treatment of acute diarrhea with oral rehydration fluids were extended to a larger fraction of the population. The toll attributableto acute respiratory diseases could be cut back sharply with better clinical managementof these conditions. The onset of chronic diseases due to such conditions as hypertensionand diabetes could be slowed substantiallywith appropriatediet and drug therapy. C. Health Care Institutions and Finances 3.19 Health servicesare providedin the OccupiedTerritories by four clustersof institutionsoperated by the Civil Administration,UNRWA,private voluntaryorganizationsand private, for-profitproviders. Each cluster focuses on the needs of a distinct segment of the population. In 1991 the Government producedabout 37 percent of all modernhealth care. The voluntary and for-profitsectors now provide more than half of all health care, with UNRWAcontributingabout 10 percent. Together these institutions spend about US$200 million a year (US$110 per capita). These funds are used to provide public health services,such as the inspectionof restaurantsand food processingplants, and diseasesurveillance, as well as preventive,promotiveand curativehealth care services. Each clusterof health care institutions responds to the needs of a distinct segment of the Palestinianhealth care market, but their clientele overlap considerably. Civil Administration 3.20 The institutionsoperated by the Civil Administrationsin the GazaStrip and in the West Bank are still recognizableas descendantsof the Egyptianand Jordaniansystems. Until 1974whena government health insuranceschemewas introduced,all residentsof the Gaza Strip and West Bank were entitledto free health care from these facilities. After the introductionof the insurance scheme, the share of the populationable to use these facilitiesdropped sharply. 3.21 Membersof the governmenthealthinsuranceschemeare eligiblefor care at governmentfacilities without charge; they may be referred to an Israeli hospital for servicesthat are not availablewithin the OccupiedTerritories, but this care must be financed by the Civil Administration. Prenatal care and preventive services rendered to children under the age of three years are provided by the Civil Administrationwithoutcharge. In addition,those injuredby the Israeli DefenseForce and those infected with serious, highly contagiousdiseases, such as cerebrospinalmeningitis,typhoid fever, tuberculosis, and sexuallytransmitteddiseases, are treated free of charge.

Chapter 3

23

3.22 All Palestinianemployeesof the Civil Administrationandof municipalauthoritiesin the Occupied Territories are required to join the governmenthealth insurance scheme. Palestinianswho are legally registered employeesof Israeli firms are required to participateas well. The rate for health insurance is US$24 a month for a worker employedby the Civil Administrationand all of his dependentsunder the age of 16 years. Persons employedby private Israeli firms pay US$29 a month. Individualfamilies may enroll in the scheme as well, but the premium is then US$34 a month. The numberof individuals enrolled voluntarily dropped sharply in the late 1980s primarily as a result of large increases in premiums. The Civil Administrationreports a sharp increasein enrollmentin Gaza in 1992-from 22 to 45 percent of the population. 3.23 Estimatesof the total numbers of familiesenrolled in the governmenthealth insurancescheme vary enormously.Z'The budget of the Civil Administrationestimatesthe revenuesfor 1992from health fees to be US$25 million, implying that about 75,800 households(a fifth of the total population)were expectedto be covered. In addition, persons who are not enrolled in the governmenthealth insurance schememaypurchaseservicesfrom governmentclinics and hospitals;total revenuesfrom patientcharges may represent as much as 20 percent of the revenuesavailableto the public sector. 3.24 Persons who are not enrolled in the governmenthealth insuranceschememay purchaseservices from governmentclinics and hospitalson a fee-for-servicebasis. In 1992, an outpatientconsultationcost US$17, and hospital care cost US$150a night. Other representativechargesinclude US$22 for a chest X-ray, US$70 for a normal delivery and US$160 for a CT scan with contrast media. Laboratory examinationsare biiled at a flat fee regardlessof the numberof tests conducted;in 1992, the chargewas US$23. Total revenues from charges levied on uninsured patients are not reported by the Civil Administrationbut several researchers have produced indirect estimates; these range from US$5-8 million. If the fee receipts projected by the Civil Administrationincluded these charges, then the estimatednumberof insurees would be reducedby betweena quarter to a third. UNRWA 3.25 UNRWA offers basic health care without charge to 940,000 registered refugees living in the OccupiedTerritories. Some 540,000 of these refugees(nearlythree-fifthsof the total) live in the Gaza Strip where they form about 72 percent of the total population. In contrast, about 400,000 registered refugees live in the West Bank where they represent about a third of the total population. 3.26 UNRWA provides secondary medical care through one hospital operated by the agency, five voluntary sectorhospitalsand two governmenthospitals. The sole UNRWAhospital is a 34 bed facility located in the West Bank in the city of Qalqiliah. The cooperatingprivate, voluntary hospitalsare all in the West Bank and Jerusalem. They provide a total of 236 acute-care beds for use by refugees. UNRWA also contractswith the Civil Administrationfor the use of 75 of its psychiatricbeds and 75 of Consultants engaged by WHO and UNRWA to study health insurance options report that at the beginning of 1992 about 119.600 families were enrolled; that 48,000 of these families were living on the Gaza Strip; and that the remaining 71,600 were residents of the West Bank. Slightly more than half of the enrollees were Palestiniansworking in lsrael. An additional 18 percent (21,500 families) were Palestinians employed by the Civil Administration who are required to join thc scheme. About 18,300 indigent families were reported to have been enrolled by the government using general tax revenues to pay their insurance premiums. Only 14,300 families were reported to have enrolled voluntarily. A study conducted in 1989 by the Italian Ministry of Foreign Affairs concluded that only 46,000 households were enrolled at that time. The principal differences between the two estimates appear in the categories 'employees of Israeli firms' and 'social cases'. Many Palestinian workers employed in Israel are not properly registered and thus are not enrolled in the health insurance scheme and nmanyothers are employed on a daily basis and hence not entitled to the benefits devised for regular 'monthly' employees. 23

24

chapter3

its tuberculosisbeds. In addition, UNRWAreimbursesrefugeesfor 60 percent of the cost of hospital care obtained outside the UNRWA system. Many refugees are unable to advance the costs of using government or voluntary sector services and, thus, are unable to take advantage of this assistance. Nonetheless,the fundsbudgetedfor this purposetypicallyare exhaustedby the end of the eighth month of the year. In March 1993, UNRWA introduceda modest charge for the use of hospital servicesand for care at hospital outpatientclinics. The Voluntary Sector Private voluntary organizationsare responsiblefor about a fifth of spending on health care. 3.27 Most private medicalcharitieswere establishedafter the introductionof the governmenthealth insurance scheme in 1974 and many were providedwith generous externalassistanceduring the 1980sby Middle Eastern countriesand private donors. Since the Gulf war in 1991, many of these sources of fundshave dried up; thus, many of these groups have turned increasinglyto donors in North Americaand Europe for support. Most voluntary organizationscharge for their services. Fees depend on the financial capacity of the patient's family. The basic fees for physician services range from US$1.50 for an outpatient consultation with a general practitioner to US$4-7 for consultation with a specialist. Hospitalizationcosts rangefrom US$8to US$55a night. Routinedeliveriescost US$60-US$120.These organizationsoffer modern curativecare, often from very well-equippedclinics. Sincethe onset of the Intifada, several "grass-roots"non-governmentalorganizations(NGOs)have flourished. They provide very basic preventiveand promotivecare, emphasizinghealth education,maternaland child health care and outpatient-managementof chronic conditions. The activitiesof the voluntary sector are not closely supervisedor regulatedand, as a consequence,reflect a very wide range of aims and policies. 3.28 The most prominent NGOs providing health care are now the Red Crescent Societies, the Patients' Friends Societies and the Women's Union Societies. A number of other smaller charitable organizationswere also activein the sectorprior to the partition, includinglocal IslamicZakat Charitable Funds. These groups are organizedas local NGOsbut are most affiliatedwith local and international organizationsas well. The Women's Union Societieswere formed during the 1920sunder the British mandateand were intendedto deal with a variety of social concerns. 3.29 The grass-rootsNGOs include the Health Services Council, the Health Care Committees,the Union of Health Work Committeesand the Union of PalestinianMedical Relief Committees. These organizationswere formedin order to provide an institutionalframeworkfor securinggreater Palestinian independencein meetingthe need for basic health services. Each of these groups has a close tie to one of the leading Palestinianpolitical factions. Theseorganizationshave succeededin more than doubling the numberof primary health care facilitiesserving the OccupiedTerritoriesover the six years sincethe beginningof the Intifada. 3.30 Many of the more establishedNGOshave pursued the aim of providingPalestinianswith access to the best and most moderndiagnostictechnology. The Red CrescentSocietiesand the Patient's Friend Societies have been especially fervent advocates of making high quality, high technology medicine available in the OccupiedTerritories. Not surprisingly, the leadership of many of these organizations is composedof medicalspecialists,manyof whompracticedabroadfor years. As a result, the Occupied Territories have a much larger stock of high-costequipmentthan one would expect for an economyable to spend perhaps US$100 a year per capita for health services. For example, the West Bank has five privately owned CT scanners.

Chapter3

25

Private Health Care 3.31 Little is knownabout private medicalpractice. Mostprivate clinics are operatedfor only a few hours a day, usuallyby well known specialists. The typicalprivate clinic is believedto serve only three to five patients a day. A total of about US$25 million was spent in 1991on private care, accordingto a UNRWA/WHOstudy of health care financing. In addition, householdsspent aboutUS$55 millionon pharmaceuticals.In order to put thesenumbers in perspective,one shouldnote that the same study found that total spending by the Civil Administrationfor health care was about US$45 million. Most of the expenditureon private health care is believed to go to noted specialists who work full time in the government or private voluntary sector. Many of the clinics operated by private practitioners are provided with equipmentnot availableat public or voluntaryclinics. Privatehealth care is financedfrom user fees or by private health insurance. D. Uses and Sources of Funds 3.32 Total expenditureson health care from all sourceshave been estimatedat about US$200million for 1991. This correspondsto about 7 percent of GNP or about 9 percent of GDP and represents an expenditureof approximatelyUS$110 per capita. Civil Administration 3.33 The Civil Administrationreports that it spent about US$45 million on health programs in the Occupied Territories in 1990/91 and that it expectsto have spent US$52 million in 1992. About 55 percent of this current account expenditurewent to the West Bank and the remainderwent to the Gaza Strip. The principalsource of funds was the government-operatedhealth insurancescheme, but some funds were obtained from patientfees; the Civil Administrationdoes not provide a detailed accounting of sourcesof funds, but knowledgeableobserverssuggestthat fee incomemay have representedas much as 20 percent of the total funds availableto the public sector for health programs. About61 percent of the health budget is devotedto the operationof acute care hospitals,and only about 28 percent is spent on primary care and public health services. The remaining 11 percent is committedto public health functions, includingthe inspectionof sanitaryconditionsand disease surveillance. UNRWA 3.34 In 1991 UNRWA spent about US$20 millionon health prograns in the OccupiedTerritories. Nearly US$12 millionof this was allocatedto activities in the Gaza Strip. Approximately58 percent of the total budget was devotedto primary prevention and health promotion activities, while hospitalcare consumedthe remaining42 percent. The UNRWAbudget is supported by some 60 governmentsand a dozen charitableorganizations. The VoluntarySector 3.35 The Palestinian NGO sector is financed from a very broad group of donors, including both charitable groups and bilateral agencies. For example,the Union of Health Work Committeeslists 12 institutionaldonors in its 1991annual report. This group of donors includesAmericanMedical Relief for Palestine, The Jerusalem Fund/USA, the MennoniteCentral Committee, the Pontifical Mission, Medical Aid to Palestine/UKand Medical Aid to Palestine/Canada. The NGO sector also depends on

26

Chapter3

donationsfrom individuals. Until the Gulf war many of the NGOsreceivedsubstantialsupport from the Gulf countries and Saudi Arabia. Private Health Insurance 3.36 A private insurance companyoffers health insuranceto about 10,000 households; most of the enrolleesare employeesof Palestinianmanufacturingenterprises. The annualpremium is US$131. The benefits may be used to purchasecare from approvedsourcesin either the public or private sector. The rates are agreed with the approvedsources; in 1993, US$4.35 is being paid for an office visit with a general practitionerand US$8.70 for visit to a specialist. The maximumbenefit per year is US$2900. 3.37 Tables 3.3 and 3.4 summarizethe financingof the health care system. These tables are based on surveys of health facilities and health spending undertakenby consultantsto UNRWA and WHO. (Thetwo surveysprovideindependentand inconsistentestimates.) One shouldrecall that this study found substantiallyhigher spendingon health care than earlier studies. The UNRWAIWHOconsultantsreport much greater enrollmentin the Government'shealth insuranceschemethan Palestinianshave estimated in the past. The enrollmentfigures are based on the numberof valid insurancecards held at the time of the study, as reportedby the Governmentof Israel. The estimatesof donationsmay be overstated. Table 3.3: Uses of Funds by the Health Care Sector, 1991 (Millionsof US$) =

.~-

Object of Expenditure

Civil Administration

UNRWA

NGOs

25.2

5.5

29.3

60.0

MentalHospitals

1.6

7.8

8.6

18.0

Primary Care

12.0

Pharmaceutical

5.0

Acute Hospitals

Private

Total

25.0

38.0

55.0

60.0

Eye care

5.0

5.0

Dental care

9.3

9.3

Ambulances

0.8

0.8

Community Mental Health

0.7

0.7 _

1.0

_

___

Medical Services IT OTAL

43.8

13.3

38.9

5.0

5.0

100.8

196.8

Source:UNRWA/WHO,"UniversalHealthInsurancefor the West Bank and GazaStrip," (Draft Report, 1992).

Chapter 3

27

Table 3.4: Sources of Funds for Health Care, 1991 (Millions of US$)

________________________________J |Millions Health Insurance

of US$

[

Per Cent

43.6

18

42.0

18

1.6

01

Private Expenditures

89.5

38

Purchase of Drugs

56.2

24

Private Health Care

21.0

09

Private Dental Care

9.3

04

Eye Care

5.0

02

Medical Devices

2.0

01

UNRWA Budget

13.3

06

International and Private Donations

18.4

08

Donations from Arab Funds

59.0

25

236.9

1.00

GHS Plan Private Insurance

TOTAL

Source: UNRWA/WHO, "Universal Health Insurance for the West Bank and Gaza Strip," (Draft Report, 1992).

3.38 These estimates of health care expenditures suggest that per capita spending is about US$110 a year. (The population figures on which estimates of per capita spending must be based are themselves subject to a wide range of error.) If these estimates are roughly correct, then the Occupied Territories would be spending an amount equal to about 7 percent of GDP, or approximately 9 percent of GNP, on health care.

E. Healtlh Care Facilities and Staff 3.39 Government health care services employ about 685 physicians and about 1,556 nurses. About 170 of the physicians and 450 of the nurses are assigned to hospitals. The Civil Administration operates 14 hospitals and 165 primary health care clinics. The 14 hospitals had a total of 1,477 beds in 1992. Twenty-five years earlier, at the onset of military occupation, the number of beds in government hospitals was about the same. Since the population of the Occupied Territories has more than doubled over the

Chapter3

28

period of occupation,this impliesthat the number of residentsper hospital bed has more than doubled as well. 3.40 In its report for 1991 to the World Health Organizationon the health of the Palestiniansin the Occupied Territories, the Government of Israel reported its intention to increase the number of governmentbeds in the OccupiedTerritoriesto 2,650 by the year 2000 - an increaseof 70 percent. The numberof beds currently in operation and the projectednumbers in the year 2000 are reported in Table 3.5. Table 3.5: Actual Number of GovernmentHospitalBeds in 1990and Projected Number for 2000 Number of BOds 1990

Projected Number of Beds 2000

Jenin

55

140

Tulkarem

64

136

Nablus-Watance

86

124

Nablus-Rafidia

122

181

Ramallah

136

207

Beit Jaflah

64

91

Jericho

50

50

Hebron

103

141

Shifa (Gaza City)

380

660

Nassar Pedtric

115

0

City)

35

0

Psychiatric (GazaCity)

34

0

Central Hospital

0

200

Khan Younia

225

400

Ahli (Gaza City)

75

100

1477

2650

Hospital WEST BANK

GAZA STRIP

Ophthalmic (Ga

TOTAL

(Gan City)

3.41 The Civil Administrationalsoprovidesprimaryhealthcare from a networkof basichealth clinics. The primary health care system has a total staff of about 500 persons, of whom 95 are physicians,300 are nurses and about 100 are sanitariansand medicaltechnologists. The term 'clinic" is used by Israeli authoritiesto refer to a specifichealth care activityrather than to a physical facility. This practicehas causedconsiderableconfusionaboutthe actuallevel of effort. A single facility may offer a prenatal

Chapter 3

29

clinic, a post-natal clinic, a well-babyclinic and a diabetes clinic and, thus, be reported by the Civil Administrationas four clinics. Outside observers suggest that the number of government facilities offeringprimary health care is probablyabouthalf the numberof clinics officiallyreported. Moreover, most clinics operate on a part-timebasis. For example,in 90 percent of the governmentclinics in the West Bank, a physicianwas presentfor two or fewer days a week. UNRWA

3.42 UNRWAprovides most of its servicesthrough a network of 42 health centers providingbasic health care. Eight of the nine health centers located in the Gaza Strip have well-equippeddiagnostic laboratories;all nineUNRWAhealthcentersin the GazaStrip providematernaland child healthservices. UNRWAemploys82 physicians(of whom 37 are generalpractitioners)to serve more than a half million refugees in the Gaza Strip. Thirty-threehealth centers are located in the West Bank; only thirteen of thesehave a diagnosticlaboratory. UNRWAemploys61 physiciansto care for about400,000 registered refugeesin the West Bank. UNRWAalso operates46 supplementaryfeedingcenters, 15 dental clinics, 8 birthingcenters and 15free-standinglaboratoryfacilities. UNRWAruns a 34 bed hospital in Qalqiliah. In addition, UNRWA contracts with private, voluntaryhospitalsto supply secondarycare to refugees. UNRWAcontractedfor the use of 350 hospitalbeds in voluntaryand governmenthospitalsin 1992.(See Table 3.6.) A capitaldrive is under way to raise US$25millionto constructa 232 bed hospital in Gaza; the Gaza hospital is scheduledto be openedin 1995. Table 3.6: Hospital Beds Contractedby UNRWA Name of Hospital

Number of Beds Contracted

AugustaVictoria, Jerusalem

104

St. John's OphthalmicHospital,Jerusalem

14

Caritas Baby Hospital, Bethlehem

12

Al-IttihadHospital, Nablus

30

Al-Ahli (Evangelical)Hospital, Gaza City

40

BethlehemGovernmentPsychiatricHospital

75

Bureij GovernmentTuberculosisHospital, Gaza

75

3.43 UNRWAreports that it providesabout 3.7 millionpatientcontactswith the primary care system a year. This implies an average of about 3.7 encountersper capita with the health care system a year. This averagelies nearthe upper end of what mightbe expected;middle incomecountriestypicallyreport an average of 2.5 to 4.0 encountersper capita per year.

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Chapter 3

Non GovernmentalOrganizations 3.44 About half of all primary health care facilities are owned and managed by private, voluntary organizations. Between720 and 750 physicians(approximatelya third of all physicianspracticingin the OccupiedTerritories)work at clinics in the voluntaryand for-profitsectors. About 200 physiciansand about800 nursesare employedby non-governmentalhospitals. Thirty percentof acute care hospitalbeds and half of all hospitalsare operated by the NGO sector. F. Special Initiatives

3.45 The Civil Administrationis working with several external agenciesto improvehealth care and environmentalconditions in the OccupiedTerritories. It has cooperatedwith UNICEF since 1985 in increasingaccessto primary health care in the Hebrondistrict. This program aimsat providingprenatal and child care to high risk groups in isolated, small villages. It focuses especiallyon the management of diarrhealdiseases, the preventionof childhoodcommunicablediseases, the treatment of respiratory infectionsand the improvementof self-care. The program provides six months of full-time training to a communitymember with a high school certificate. The trained villagehealth worker then identifies high-risk pregnancies,follows up on well-childcare (includingimmunization),monitors the nutritional status of small children and works with local leaders to improve environmentalsanitation. The village health worker also coordinatesperiodicvisits from a publichealth team and facilitatesreferrals to urban health care facilitieswhen that is needed. The UNICEF/CivilAdministrationExtendedPrimary Health Care Project operated in 49 villages at the end of 1987. 3.46 A programto identifyhigh-riskpregnancieswas launchedby the GovernmentHealth Servicein 1988. It includesthe introductionof a set of guidelinesand a referral form for the processingof pregnant women, the orientationof all staff posted at maternaland child health centers and village health rooms, and the creationof high-risk pregnancyclinics. Eight of these clinics have been developed in the West Bank, sevenof which nowoperate from district hospitals;two clinicshave been createdin the GazaStrip. UNICEF has assisted in the training and continuing educationof traditional midwives. In 1990 all practicingmidwivesin the GazaStrip attendeda UNICEF sponsoredcourse and receivedequipmentfor home deliveries. 3.47 The Civil Administrationhas also workedwith several groupsproviding rehabilitationservices to persons with serious injuries. A 30-bedrehabilitationcenterhas been constructedin Ramallahby the Swedishorganization,Diakonia. The Friends of the Sick (Patients' Friends Society)has constructeda rehabilitationand physicaltherapycenter in Bet Jallah with financialassistancefrom the Governmentof Italy, the CDF and UNDP. 3.48 The Civil Administrationhas also launcheda numberof initiativesto improvehospitalservices. It introduceda new, computerized,hospitaldischarge informationsystem in 1991;this system classifies patients under the International Classificationof Diseases, Revision 9. The records are analyzed periodicallyto evaluateutilizationand outcomes. Improvementshave been made in radiology services in several hospitals. Intensivecare units have been addedin Nablus, Ramallahand Gaza City, and open heart surgery and neurosurgerydepartmentswere added to Ramallahhospital in 1987. 3.49 The lack of government investmentin hospitalbed capacity remains a particularly contentious issue. In addition, the Civil Administrationhas been very slow in grantingpermits to nongovernmental

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institutionsto construct additionalprivate hospitals. These public policies have had the largely positive effects of encouraginggreater reliance on outpatientcare, includingprimary prevention of disease and self-care, and of forcing more efficientuse of hospitalfacilities and resources. Since 1967, the average length of stay in hospitals has declined from 6.8 to 3.2 days. The present length of stay compares favorably with that of many Western countries. The occupancy rate for government hospitals has continuedto decline as well. In 1991hospitalsoperatedby the Civil Administrationoperated with only 62 percent of beds occupiedon average. The low occupancyrate is due in part to economicbarriers to hospital utilization. Private SectorInitiatives 3.50 The Palestinianmedicalcharitieshavemadesignificantimprovementsin healthprograms in recent years. The Patient's Friends Societyof Hebronhas undertakenthe constructionof a 300-bedhospital, the 40-bed obstetricswing of which is expectedto open in 1993. Smaller bedded polyclinicsare being developedby charitableorganizationsin Gaza City, Tulkaremand Hebron. These initiatives are being financed from private donations, as well as aid from the Gulf and officialbilateral sources. 3.51 The grass-roots voluntary organizationshave developedvery impressiveprograms of primary health care. These groups have prepared detailedplans for the provisionof mother and child care, the treatment of minor illnesses,the control of infectiousdiseases and health education. These servicesare typically rendered from converted residences. The growth of these programs has been explosivewith more than a hundred clinics constructedbetween 1988and 1991. The facilities that have been created and the staff that has been employedare very impressive. 3.52 Most of these initiativesrepresent reasonableresponsesto the health needs of the Palestinians. The impacts of improvements in primary health care are not yet reflected in health statistics and indicators, but one must bear in mind that these data are of limited value because they are poorly collectedand unrepresentative. The aggressiveefforts being made by the voluntarysector to strengthen primary health care should pay off quickly in terms of reduced infant and child mortality, as well as improvedmaternalhealth. The efforts of the Civil Administrationto improvematernaland child health are likelyto have a more modesteffect, primarilybecauseof the growingreluctanceto utilizegovernment services. Some efforts by the Civil Administrationand voluntary organizationsto upgrade hospital servicesmay be inappropriate,especiallyin areasof diagnosticimagingand sub-specialtycare. Proposals to provide additional capacity for heart surgery, organ transplantationand oncology care should be carefullyevaluated,particularly in view of the small populationbase and the uneconomicsize of many hospitalsin the OccupiedTerritories. G. SectorProblems 3.53 The health outcomesthat are being reported suggestthat significantgains have been made over the period since 1967. Over the past quarter century, the infant mortality rate has declinedby roughly half. Life expectancyhas increasedby morethan a decadeover the sameperiod. At issueis not whether the health of the Palestinianshas improvedover the period but rather whetherthe pace of improvement has been as great as it could have been. The more rapid pace of progress in Jordan than in the Gaza Strip and the WestBank is cited by Palestiniansas evidencethat inadequateefforts havebeen made under rule by the Israeli Civil Administration. Muchof the credit for improvementsin health can be traced to the prevention of diseases transmittedunder poor sanitary conditionsand hence must be attributed to

32

Chapter 3

improvementsin educationalstatus and general living conditionsrather than to the expansionat health servicesas such. Still, the health servicesdeliveredby the CivilAdministration,UNRWA,the charitable and voluntaryorganizationsand privateprovidersof health care haveplayeda substantialrole. The work of the nongovernmentalsector has been especiallysignificant. In 1967 over 85 percent of all health servicesdeliveredin what are nowthe OccupiedTerritorieswere producedby the public sector; by 1991 the Government'sshare had shrunkto about37 percent. Over the same interval,private voluntary and for-profithealth care grew from a negligibleshare to representabout a third of health care expenditures and more than half of patient contacts. 3.54 However,the OccupiedTerritorieshave devotedan unusuallylarge share of availableresources to the health sector, and the health impacthas been more modest than should have been obtained from this expenditure. Several reasons for this disappointingperformance are apparent. First, most social resources are being used to provide costly, high technology, hospital-basedcare for the benefit of the relatively well-to-do. Second, very small, inefficient hospitals have been allowed to proliferate (68 percent of all hospitals have fewer than 100 beds). Third, highly specializedprocedures have been carried out by units that are too small to either exploit economiesof scale or providephysiciansand staff with enough practiceto maintainskills. Fourth, accessto many services has been blocked for specific groups of people because of the segmentationof the health care market introduced by the insurance schemeand the provision of free care to refugees. Finally, too little attentionhas been givento reaching out to underservedgroups, especially women; more than a third of all deliveries continue to occur without supervisionby a trained health worker, for example. 3.55 The root causes of these problemsare to be found in a lack of coherent policy and an absence of sectorplanning. Severalunrelatedinstitutionsare providingservicesto distinctgroupswithinthe area. Moreover, the GovernmentHealth Servicecould not charge current premiums and provide the level of servicenominallyavailableto those with governmenthealth insurance,let alone all residentsof the Gaza Strip and the West Bank. At the sametime, UNRWAappearsto be achievingroughly comparablehealth outcomes with much smaller per capita outlays of funds. Part of the explanationfor this apparently superior performance is that UNRWA is extracting subsidies from the hospitals that provide it with contract beds for refugees, but the more importantexplanationappearsto be that UNRWA is focusing more sharply on the primary preventionof disease. The voluntarysector presents a remarkablydiversified picture. The older and more establishedprivate voluntary organizationshave in several instances clearlyoverinvestedin expensivemedicaltechnology;this phenomenaappearsto be a legacyof theperiod when private and official donors from the Gulf were generous supporters of these institutions. The voluntaryorganizationsfoundedsince 1987haveobviouslyoperatedwith more modestbudgets and have made much more careful choicesabout both the servicesthat they wishedto offer and the technologies that they wishedto adopt. 3.56 The fragmentationof decision-makingin the health sector is also revealedin the proliferationof small hospitals and beddedmedical clinics. In order to exploit the most important economiesof scale in the operation of a communityhospital, it is necessaryto build a minimumof about 150 beds. The ideal sizeof a hospitalin the OccupiedTerritoriesmay be somewhatsmallerbecauseof the relativelylow cost of qualifiedmanpowerin the area. However, 68 percent of all hospitalshave fewer than 100beds, and 20 percent have fewer than 50 beds. In addition, 11private maternityhospitalsexist, none of which has more than 35 beds (the average has only 16). Rationalizationof the hospital sector would entail a considerablereduction in the numberof institutionsand would lead to a significantreduction in costs. In addition, rationalizationof the hospitalsectorwould contributeto improvementsin the qualityof care. The numbers of procedures being carried out by specializedunits are not large enough to provide

Chapter3

33

physicians and nurses with enough practice to operate at peak skill and efficiency. For example, Ramallahhospital is reported to be doing 40 to 50 open heart operationsa year --roughly one a week. This is no more than a third of the minimumnumberthat a hospitalteam should seek to perform in order to maintain its skills and proficiency. H. Recommendations 3.57 The development of a sound policy environmentwill be required in order to address these problems. As noted above, present inefficienciesare rooted in the fragmentationof responsibility,not only for the delivery of health care but also for the managementof subsidies to the sector from the governmentbudgetand externaldonors. Thus, a responsiblebody must be createdto developa coherent health policy and to coordinate activities in the sector. Since a large number of highly diverse organizationsnow populate the sector, and a newly formed self-governingauthority will initially have limited administrativecapacity,the bureaucracyshould not seek to control sector activitiesdirectly but rather should seek to facilitategreater coordination. Policiesshould, at the same time, seek to interrupt the link betweenrefugeeor employmentstatus, and entitlementto subsidizedhealth care. In assembling a set of policies, issues of health care finance, service standards, investmentin technologyand quality assuranceshould also be addressed. 3.58 In view of the large fraction of GDP already being committed to the sector, policies should increasinglystress increasing the internal efficiencyof the health sector and should try to control the overallcosts of health care, ratherthan to expandthe system, particularlyat the hospital level. Sanitation should be further improved, and a larger fraction of cases of acute diarrhea should be treated with oral rehydrationfluids. Acute respiratorydiseases shouldbe better managed. The onset of chronic diseases due to such conditionsas hypertensionand diabetesshould be controlledwith appropriatediet and drug therapy. 3.59 The total cost of the investmentsrequired to address the needs identified in this chapter and to continue to replace worn out and obsoleteequipmentand facilitiesover the next decade is likely to be US$175to 200 million. The greatest priority withinthis programof investmentsis the expansionof the basic health care system. The second highest priority ought to be given to the rehabilitation and renovationof existinghealth facilities, includinghospitals. Gapsin the current health care infrastructure should be filled through the developmentof a burns unit, a cancer care programand a laboratoryfor the control of communicablediseasesshould also be given high priority.

IV. EDUCATION AND TRAINING A. Introduction 4.1 The Palestinianshave demonstrateda strong commitmentto education. Enrollment in basic education(grades 1-6)is equalto about 102percent at the age group 6-12. Palestiniansare creditedwith havingone of the highestproportionsof their populationcompletinghigher educationof any Arab group. 4.2 This chapter describesthe efforts that are now being made to educateand train the children of the Gaza Strip and the West Bank; it outlines the steps that would have to be taken in order to rectify deficienciesin these programs. The rest of the chapter is divided into five sections. The first section describesthe institutionsthat provide educationand training services. The second section presents the informationavailable on the financial and real resources that have been committedto the sector. The third sectiondiscussesthe programsthat are beingcarried out and assessestheir effectiveness. The fourth sectiondescribesthe weaknessesin programsthat the chapterhas identifiedand suggests initiativesthat ought to be considered in order to rectify these problems. The final section summarizesthe chapter's recommendations. B. The Institutions of the Education Sector 4.3 The institutionsof the educationsector are much less complex than those found in the health sector. The OccupiedTerritories are served by only two distinct systems of education: the Egyptian system in the Gaza Strip and the Jordanian system in the West Bank. However, these two systems pursue distinctobjectives,are organizeddifferently,and employseparateexaminationsystems. The Civil Administrationsupervisesall primary and secondaryeducationalinstitutions. Schools are operated by the Civil Administration,UNRWAand a small numberof private (principallycharitable)organizations. The Civil Administrationenrolls about 62 percent of all primary and secondaryschool students in its institutions. UNRWA provides schoolingto about 31 percent of the students, and the voluntary and private, for-profitinstitutionsserve less than 8 percent. Preschooland higher educationis dominatedby nongovernmentalorganizations. Becauseof frequentstrikes and curfews,schoolshave been closedoften since the onset of the Intifada. Kindergartens 4.4 About 10percent of five-year-oldslivingin the GazaStrip, and about 15 percentof the same age group living in the West Bank, attend preschools. In both the Gaza Strip and the West Bank preschool education is offered primarily by the private sector, usually by charitable institutions, women's associations, religious groups or individualsbut also, in a few instances, by for-profit organizations. UNRWA and the Civil Administrationprovide preschooleducationto a very small numberof children living in the West Bank. Preschool teachers are not required to possess any formal qualifications,but most have passed the examinationfor graduation from secondaryschool, and a few have obtained a Bachelors degree. Very few teachers have taken any courses in pre-school education. Most kindergartensdo not have a formal curriculumwith clear objectivesand goals. Educationalmaterialsand equipmentare limited due to the scarcity of funds.

Chapter4

35

The Schools 4.5 Following the partition of Palestinein 1948, the Governmentsof Egypt and Jordan introduced their education systems into the Gaza Strip and the West Bank, respectively. The Israeli military governmenthas retained these arrangementssince 1967. The structure and content of the curriculum, teaching materials and examinationsare obtained from Egypt and Jordan. Israeli officials censor the contentsof books andjournals in order to ensurethat politicallyprovocativematerialsare not disseminated through the schools. Educationofficials from the two countriescontinueto assist in the examination of graduatesof schools in the GazaStrip and in the West Bank. The Civil Administrationsupervisesall educational institutions and continues to review the content of the curricula of public, private and UNRWAschools and to regulatethe constructionand extensionof school facilities. Vocational Education 4.6 Vocationaleducationand technicaltrainingare offeredby the Civil Administration,UNRWAand private institutions. Vocational and technical educationhas never been viewed by the Palestinian communityas a serious part of the educationprogram. Israel establishedadditionalvocationaltraining centers in the main cities of the Gaza Strip and the West Bank, after 1967, to prepare semi-skilled laborers for employmentin the Israeli economy. Most courses were only a few days in length and were designedto enable Palestiniansto meet the formal requirementsof the Israeli labor market. The most common course has prepared students to take the written examinationfor a license to drive a truck in Israel. 4.7 The Civil Administrationdeterminesthe curriculumof vocationaland technicalschools (public, UNRWAand private). Its Labour Staff Officermeets with employersin Territoriesto identify training needs. The Civil Administrationalso followsup on selectedgraduatesof training programs in order to evaluatetheir effectiveness. The Governmentof Israel prohibits the teachingof some subjectssuch as maintenanceof conmmunications equipment,becausethe equipmentrequired might be used for military purposes. Employersare not involvedin settingtraining policy. Coursesfocus on the masteryof craft skills and provide little instruction in areas such as organization and management. Training for self-employmenthas been almost totally neglected. Both public and private vocational schools are seriously underfunded. The problemscreatedby a scarcityof funds are compoundedby restrictionson the importation of equipmentfor educationaland training purposes. As a consequence,facilities are inadequate,and equipmentis often obsolete. Community and Teachers' Training Colleges 4.8 There are 20 communityand teachers' training colleges in the West Bank and one in the Gaza Strip. Four of these are administeredby the Civil Administration,three by UNRWA, nine by the Councilfor Higher Educationand fiveby private entities. The communitycollegesoffer technical(e.g., engineering),agricultural,commercial(businessadministration),paramedical,socialserviceandteachers' training programs. All communitycolleges in the West Bank require the Jordaniansecondary school leavers examination(the Tawjihi)for admissionto two-yeardiplomacourses. In the past, graduatesof the communitycollegeshave not been allowed to transferto West Bank universities.

36

Chapter 4

Universities 4.9 There are 8 universitiesin the OccupiedTerritories: 6 in the West Bank --including an Open University--and two in the GazaStrip. All are under the supervisionof the Council for Higher Education, and all were establishedwith private Palestinianfunds. The objectivesof Palestinianuniversities are: to meet society's needs by providing experts, techniciansand specialists in all fields; to prepare scientists and researchers, inventorsand innovators;and to conductscientificresearch, both theoretical and applied. The universitieshave played a major role in political activitiesin the Territories. Because of this, they were closedby the Israeli authoritiesat the beginningof the Intifada, and were allowedto reopenpartially, beginningin 1990. By 1992,theuniversitieshad resumedoperations. However,access to the universitieshas continuedto be restrictedbecauseof difficultieswith passesand travel permits for both faculty and students. Considerableduplicationof courses and departmentsamonguniversitieshas emerged in responseto this problem. During the 1991/92academicyear, there were a total of 16,368 studentsand 1,010faculty in Palestinianuniversities. Approximately40 percentof the universitystudents in the West Bank were women. Literacy Education 4.10 Illiteracy remainsa significantproblem amongPalestinianadults. Within the group 35-44 years of age, 28.5 percent of women are illiteratecomparedto 7.4 percent of men.4 Efforts are being made, in the main by charitable institutions,to combat this problem. The Higher Committeefor Literacyand Adult Educationcoordinatesliteracy training activities. There are some 170 centers in the West Bank run by the various associations,but there is a needfor more, and better equipped,centers. In the Gaza Strip there are 27 centers; the PalestinianRed CrescentSocietyis playing a major role in supportingthe program. TheHigher Committeefor Literacyand AdultEducationcoordinatesliteracytraining activities. The Civil Administrationprovides literacy classes at ten vocationaltraining schools. Services to the Handicapped 4.11 About 30,000 handicappedpersons lived in the Occupied Territories in 1990, according to UNESCO. This number is believedto have increasedconsiderablyover the past two years because of violenceassociated with the Intifada; Palestiniansources report that over 43,000 people were injured between 1987and 1993in connectionwith the uprising. These reports claimthat about 11,000 persons have suffered significant,permanentphysicaldisabilities. 4.12 In 1990there were 37 institutionsin the GazaStrip and the WestBank for educatingstudentswith handicaps. Oneof these institutionswas run by the Civil Administration;9 were administeredby foreign missions, and 27 were privately operated. The total enrollmentin these institutionswas 2,907. They deal with problems of deafness, blindness, mental retardation, physical impairment and multiple handicaps. Thesecentersare understaffedand underfinanced,and their staffsneed additional,specialized training. Despitethe tremendousgrowth in the prevalenceof mentalhealth problems since 1987, little has been done to addressthis issue. The Gaza CommunityMentalHealth Program was established in 1990to begin to confrontthe problem.

'

Statisf cal Abstct

of bral 1992, No. 42.

Chapter 4

37

C. EducationFinance 4.13 The total expenditurefor all levels of academiceducationis about US$170to US$175milliona year. This representsa per capitaexpenditureof about US$90 per resident of the OccupiedTerritories and correspondsto approximatelythree-quartersof the amountbeing spent per capita on health care. 4.14 The Civil Administrationspent US$58millionin 1991and has budgetedUS$80 millionfor 1992. Over 70 percent of its recurrent expenditureswere devotedto the WestBank and the remainingroughly 30 percent were committedto the Gaza Strip. The UNRWA 1991educationbudget for the Occupied Territories was US$52 million --two-thirds for the Gaza Strip and one-third for the West Bank. Per studentexpendituresin 1991were aboutUS$153in governmentschools,US$334per studentin UNRWA schools in the Gaza Strip and aboutUS$425 in UNRWAschoolsin the West Bank. Differencesin unit costs were due to differences in salaries and to greater expenditureson teaching materials and the maintenanceof facilities in UNRWAschools. 4.15 Theprivate sectoreducatesabout8 percentof studentsenrolledin primary and secondaryschools. Most of these institutionsare financedlargely or entirelywith studentfees and are able to attract paying studentsbecausethey are perceivedto offer a richer curriculumor better education. A commonrationale for sending children to a private primary or secondaryschool is to gain accessto special programs in music, art and foreign languages. Figures on per studentexpendituresare not availablefor the private sector, but it appears reasonable to assume that costs are roughly the same as those experiencedby UNRWA. If one accepts this assumption,then private spending on primary and secondaryeducation totaled aboutUS$13 million in 1991. 4.16 The total cost of university educationis about US$27 million a year. Per student costs for college and universityeducationrange from US$1500-2000. Studentsare charged fees of US$400-500 per year. The universitiesare financiallyautonomous. They have receivedsubstantialassistancefrom private and foreign donors in the past. Becauseof a sharp drop in foreign donationsand a significant decrease in fee income due to the lengthy closures of universitiessince the onset of the Intifada, the universitiesnow face financial crises. Most are now depletingstaff retirement funds in order to meet essentialexpenses. Severalhave been unableto pay facultysalariesfor months at a time and, as a result, have experiencedfaculty strikes. Libraries, laboratories,textbooksand other educationalmaterialsand computerfacilities are deteriorating,as well. D. Education Resources InstructionalStaff 4.17 The Councilfor Higher Educationreports that 18,594teachers were engagedin teachingschool in 1991/92. Table 4.1 presents the numbers of students and teachers, and the student-teacherratio for the two regions and for government,UNRWAand private schools. Two-thirdsof theseteachers (a total of 12,496)were employedby the governmentsector, and about22 percent were employedby UNRWA. Theprivate sectoremployedslightlyless than 10 percentof all teachers. The ratio of studentsto teachers varied among regions and sectors by a factor of 2.2. The lowest student-teacherratio was found in the private sector in the Gaza Strip where there were only 16.9 students per teacher; the highest studentteacherratio was foundin UNRWAschoolsin the GazaStrip where there were 36.1 studentsper teacher.

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Chapter4

Obviously,the averagesfor a regionobscure variationswithin the area. At present, roughly two-thirds of teachershave only a two-yeardiplomafrom a communityor teachers' college. UnderJordanianLaw, all West Bank teachers must have a minimumqualificationof a Bachelordegree by 1997. Some efforts have already been made to providein-servicetraining at teachertraining institutesand universities. EducationalFacilities 4.18 The averageschool is reportedto enroll about400 students. The largest schoolsare found in the Gaza Strip (703 studentsper school);this figure no doubt reflects both the high populationdensitiesthat prevail there and widespreaddouble-shiftoperation of schools. The lowest average is found in the Ramallah district where the average school size is 273 students. Table 4.2 presents the numbers of schools in each district for each level of education. Table 4.1: Total Numbersof Studentsand Teachers by SupervisingAuthorityand Region 1991/92School Year | Total Number of Total Number of | Student/Teacher Ratio l |__ ___Students Teachers

Authority

Region

Government

West Bank

280,682

9,720

29

Gaza

97,689

2,776

35

Total

378,371

12,496

30

West Bank

43,593

1,456

30

Gaza

100,863

2,800

36

Total

144,456

4,256

34

West Bank

40,208

1,696

24

Gaza

2,463

146

17

Total

42,671

1,842

23

West Bank

364,483

12,872

36

Gaza

201,015

5,722

35

565,498

18,594

30

UNRWA

Private

Total

Total

1

Source: Council for Higher Education 4.19 The Civil Administrationconstructedabout200 school rooms in 1991. At that time, 317 rooms were beingrented. With a growingpopulationand large numbers of classroomsoperatingdouble shifts, the need to add classrooms, especiallyfor public schools, is clear. In view of the rapid rate of growth in the school age population (more than 4 percent a year), a program for replacingthe current school

Chapter4

39

structures and adding not only classrooms, but also libraries, laboratoriesand recreational facilities, is required over the medium- and long-term. 4.20 The quality of the teachingstaff does not appear to be adequate. This judgement is based on the level of training that is being provided (and required) and the methods of training observed in teacher training institutions. Too much emphasisis given to the recall of fact and masteringof terminology. In the medium-andlong-term, a concertedprogramof upgradingteachereducationand retrainingteachers is required. This is particularlyurgent in basic educationbut is also necessaryat the technical college and universitylevels. Teachersrequire accessto new educationaltechnologiesand training in their use. In addition, teachersneed to become familiar with recent developmentsin cognitivetheory. Exchanges with overseas institutions through scholarships and fellowships should be pursued. Twinning arrangementswith educationalinstitutionsin the region, in Europe and other parts of the world should be encouraged.

Table 4.2: Numberof Schoolsby Location 1991/92 School Year Location

BasicLevel

Academic

Vocational

Secondary

Secondary

Total

Jenin

118

38

1

157

Tulkarem and

120

51

1

172

Nablus

126

44

1

171

Ramallah

156

51

3

210

Bethlehemand Jericho

91

29

3

123

Hebron

169

37

1

207

Gaza

245

39

0

286

1025

289

10

1326

Qulqilia

TOTAL

Source: Council for Higher Education 4.21 Schoolbuildingsare generallyin a poor state of repair. Broken windowsand doors, leakyroofs and faulty sanitaryfacilities are common. Some of these problemscan be traced to the violencethat has plaguedthe OccupiedTerritories, especiallysince 1987. However,a significantpart of the problemmust be attributed to inadequate preventive maintenance and delays in executing minor repairs. The rehabilitationof decayingfacilitiesis clearlyone of the leadingpriorities in the educationsector. In addition, many schoolsoccupy buildingsthat were constructedas private residencesand, thus, do not have adequateprovisionfor sanitationor sufficientplay areas. While thesedeficienciesdo not seriously affect

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the effectivenessof schools, they should be kept in mind when the developmentof the sector is being discussed. Educational Materials and Equipment

4.22 Data on the availability of teaching materials, library books and laboratory equipment, regrettably,are not available. Anecdotalaccountsand the mission's observationssuggest that supplies of these inputsare highlyinadequatein both qualityand quantity. Modern educationalmaterials,teaching aids and equipment are required from preschoolthrough university level. Donors have contributed hardwareto some institutions,but training is required in the use and maintenanceof the equipmentand materials. In the medium- and long-term, considerableresources will be required to update equipment and educationalmaterialsto ensure the relevancyof studies at all levels. E. Education Processes The Curriculum

4.23 Schools in the OccupiedTerritories rely on curricula that were developed during the 1960sby the governmentsof Egypt (for the GazaStrip) and Jordan (for the WestBank). Teachingmaterialshave been updated periodically,but significantchangeshave not been made in either objectivesor teaching methods. Egypt and Jordan are both now revisingtheir curricula. Severalmore years will be required before this process affectsclassroomteaching. The present curriculumemphasizesthe masteryof facts rather than higher-levelcognitiveskills, includinganalysisand synthesis. The teachingmethodsthat are typically used to impart this knowledgestress the one-waytransmissionof knowledgefrom the teacher to the student. In order to prepare studentsfor roles in an expandingand rapidly changingeconomy,the curriculum needs to be updated to prepare students to deal successfullywith novel problems. This implies that the school curriculumshould be strengthenedto develop capacityto mobilize information, evaluate both evidence and argumentation, and apply general knowledgeto the solution of specific, unfamiliarproblems. 4.24 Representativesof the Palestinianshave not participated formally in the ongoing efforts to modernizeand strengthenprogramsof primaryand secondaryeducationin Egyptand Jordan. Palestinian leadersshould be participatingin discussionsof the relevanceof both or either system to the needs in the OccupiedTerritories, or should be working to prepare a curriculumand instructionalprogram of their own. Pedagogy

4.25 The systems of primary and secondary education now being implementedin the Occupied territories rely heavily on educationpracticesestablishedin the 1950sand early 1960s. While most of these practices remain valid, the major advancesin cognitivetheory, teachingpracticesand educational technologiesachievedover the past four decades needs to be brought to bear on classroomteaching. In particular, the present system of educationaffords children few opportunitiesto participateactively in learning;to applytheir skills in formulatingresearchableor solvableproblems;or in drawing on a wide range of knowledge,skills and analyticmethodsto illuminatereal-worldproblems.

Chapter 4

41

Educational Quality 4.26 The educationnow being providedto childrenliving in the OccupiedTerritories does not meet reasonablequality standards. The evidenceon school quality is of two kinds. First, the resourcesbeing suppliedare inadequatein both quantityand quality, and second, the performanceof Palestinianchildren on standardizedtests falls far below internationalnorms and expectations. 4.27 As previouslynoted, the Civil Administrationhas attemptedto maintaina systemsof education in the Occupied Territories that is as much like those of Egypt and Jordan as possible. It has been successfulin providing reasonablenumbers of teachers, and through the use of many school buildings for two shifts a day, it has kept averageclass size reasonable. However, the quality of the instructional staff, though similar to what has been mandatedin the past by Egypt and Jordan, leaves a great deal to be desired. Both Egypt and Jordan have launchedeffortsto raise the minimumqualificationsof primary school teachers from a two-yearpost secondarycertificategranted by a two year communitycollegeor teachertraining institute,to a bachelorsdegree from a four year college. The governmentof Jordan has decreed that all teachers shouldhave attainedthe higher qualification,by 1997. As of 1992, only about a third of the primary school teachingstaff met the new standard.' 4.28 Evidenceon the outcomesof educationhas recentlybecome available. The testing program of the InternationalAssessmentof EducationalProgress --a twentycountryinternationalcomparativestudy of student achievementin science and mathematics--was administeredin June 1992 to children in the West Bank by the Jordanian National Center for Educational Research and Development. The investigationwas financedby UNICEF and carried out under the supervisionof the EducationalTesting Service. The average score for students in the West Bank was 52.2 on the sciencetest. This compares with a score of 57.6 in Jordan and 69.7 in Israel. The highest average score --77.5-- was achievedby South Korea. The West Bank placed twentiethin a field made up of twenty countriesand the Occupied Territories;Jordanplaced eighteenthand Israelplacedeighth. Onthe mathematicsexamination,the West Bank achievedan averagescore of 33.6 comparedwith 40.4 for Jordan and 63.1 for Israel. The West Bank ranked nineteenthamong the twenty-oneparticipants;Jordan placed seventeenthand Israel placed ninth. Most alarmingly,Palestinianstudentsperformedespeciallypoorly on test itemsthat requiredthem to use several skills to deal with novel tasks --preciselythe sort of capacitythat the economyis expected to require in the future. 4.29 Analyses of the comparativeperformance of students enrolled in government, UNRWA and private schoolsreveal that the worst outcomeshave beenachievedby the UNRWAschools, eventhough they are more generouslysuppliedwith teachersand teachingmaterials. The underlyingexplanationfor this findinghas not beenestablished,but the hypothesisthat the social conditionsthatprevail in the camps may play a major role cannot be ruled out. 4.30 The quality of educationis believedto have fallen sharply since 1987. The principal reason for this presumeddeteriorationhas been the dramatic reduction in the length of the school year, resulting from the numerous curfews and strikes that have accompaniedthe Intifada. For expample,during the 1990/91 school year, children enrolled in UNRWAschools in the West Bank lost 40 percent of school days due to officialclosures;by 1991-92,losseshad declinedto 17 percent of all scheduledschool days.

25 Attaining a higher qualification does not necesurily guaranteea bctter teacher, but it doca help to insure that teachers havc masered the subject matuerthat they are expected to teach.

42

Chapter 4

It shouldbe notedthat time-on-task(theamountof time actuallyspent in schoolon school work)has been found to be the single most powerful determinantof student achievement. The Intifadahas also been associatedwith an increasein disciplineproblems,decliningacademicstandards, and increasedrepeater rates. F. Sector Problems Curriculum 4.31 The schoolcurriculashould be examined,at all levelsof educationand by all providers in order to developand implementa medium-and long-termframeworkfor curriculumdevelopment. Someinitial discussions have already taken place between UNRWA and the Council for Higher Education. Representativesof private schoolsshouldbe includedin the deliberationsalso. In the medium-,and even long-term, a program for curriculumdevelopmentshould be established. Ideally, a unified curriculum should be establishedfor both the West Bank and Gaza in order to minimizethe cost of developingand producingteaching materials. A unified curriculumwould also facilitatethe mobilityof teachingstaff betweenthe two areas of the OccupiedTerritories. As the process of developingcurricula is costly in time and resources,it maybe advisable,in the medium-term,to purchaseexistingrelevantcurriculafrom abroad and modify in order to reflectlocal concernsand interests. Teacher Qualifications 4.32 The qualificationsof educationalpersonnel in almost all positions need to be upgraded. In addition, the teaching staff needs to be reoriented to the expectationsof the revised curriculum; the introductionof more participativelearning methodswill require particular attention. Thus, reform of both pre-serviceand in-serviceteachereducationis urgentlyneeded. Teachersin the governmentschools appearto havethe greatest needof upgradingtheir qualificationsand extendingtheir experiences. Some efforts have alreadybeen madeto run in-serviceteachertraining coursesin some of the teachertraining institutesand universities. A continuationand expansionof this training is necessary,especiallyin the areas of cognitivetheory and practice. Facilities 4.33 Schoolbuildingsare generallyin a poor state of repair. Libraries, laboratoriesand recreational facilities are generallyinadequate,as are suppliesof textbooksand teachingmaterials. Deficienciesin libraries and laboratoriesare especiallycritical in the university system. A study of the inventoryof school facilities is neededto form the basis for planningtheir rehabilitationand upgrading. Bureaucratic Regulation and Restriction 4.34 The currentofficialpracticeof limitingaccessto librarymaterialsand censoringtextbooksshould be reviewed. In private institutionsand some UNRWAcenters,the presentpolicyof not grantingpermits to build, extend and update school premises should be relaxed. These practices have, in some cases, forced voluntary agencies to return funds to donors because of lengthy delays in gaining permits or outright refusals to grant them. Much more cooperationbetweenthe Civil Administration,private and UNRWA educationproviders, and donors shouldbe sought. If the major problems are to be resolved,

Chapter4

43

easier accessto one another's institutions,facilitiesand expertisemust be granted. Seminarsand workshops, where the experiencesof educationistsmay be shared, should be developed. Vocational Education 4.35 Economicdevelopmentwill require a labor force skilled in acquiringnew technologiesin order to meet changing conditions. In the short term, in order to make training courses more relevant to economicneeds, program and course design couldbe addressedby local committeescomposedof those responsiblefor vocationaland technical education, educationaland subject area specialists, and local businesspeople. Areas of particular relevanceinclude agriculture,food processingand manufacturing. 4.36 In the medium- and long-term, community colleges should be encouraged to upgrade their faculties and recruit staff to provide more specialized,technicallyadvanced education. Greater stress should be place on the developmentof mid-leveltechniciansto bridge the gap between craftsmenand highlyspecializedengineers. Programsbasedon those availablein polytechnicswould appearto be more appropriate to the future employmentand economicneeds of the OccupiedTerritories. Community collegescould focus future attentionon polytechnictype curricula. A detailed review of the curricula provided by the communitycolleges might help to avoid duplication of educationalprograms. The universities should be encouraged to review their policy of not admitting graduates of community colleges. Special Education 4.37 The frequent closingof schoolssince the beginningof the Intifadahas led to a deterioration in the quality of educationand an escalationof behavioralproblems. The needs of children who should havebeen attendingschoolduring this period are poorly documentedbut clearlyrequire urgent attention, nonetheless. Widespread violence has also produced an alarming growth in the population that is physically or mentally disabled. The needs of these sections of the community, while largely unquantified,require urgent attention.In the short-term,more facilitiesand centers are required, staffed by professionalpeople. In the medium- and long-term, special training is required in these areas. Counselors, literacy teachers, career counselors and vocational guidance experts are required as a necessarypart of a modern educationalsystem. Education Administration 4.38 Reference has already been made to the need to upgrade teachers' qualificationsat all levels of education. There is also need to professionalizeplannersand administratorsto enable them to carry out the planning and managementfunctionsthat have been neglected in the past. Training is needed in administration,fiscalmanagementand educationplanning. Personnelexchangesacrossinstitutionscould prove useful. In the medium- and long-term, professionalqualificationsin educationadministration should be required of heads of schools, collegesand universities. Higher Education Infrastructure 4.39 University libraries and laboratoriesare woefullyinadequate. Becauseenrollmentsare small, these institutionscannotjustify investmentsin serious research libraries and laboratories. The mission of each institution,and the resourcesrequiredto enable it to fulfill its mission shouldbe decidedthrough a systematicand formal mechanismfor inter-institutionalcooperation. A system of shared library (and

44

Chapter 4

perhaps laboratory)facilitiesshould be explored. The use of electronictechnologyto provide accessto journals and scholarly books should also be supported. The possibilities of developing specialized universities and of encouragingcross registrationto allow institutions to achieve economiesof scale should be investigated. G. Recommendations 4.40 The quality of educationoffered to children in the OccupiedTerritories urgently needs to be improved. As a first step, an educationreform processshould be launchedin order to initiatedebate on the aims and objectivesof the educationprogram. This processshouldlead to the adoptionof new course contents that provide students with greater skills in the manipulationof ideas and the applicationof conceptsand disciplinesto the solutionof novelproblems. In order to acceleratethe reformprocess, the possibilityof borrowing curriculumand teachingmaterialsfrom Arab countriesshould be explored. In the longerterm, the contentsof educationprograms in the GazaStrip and West Bank should be unified. The quality of teachingshould also be given attention. Teachersshould be trained in the use of forms of teaching/learningthat provide students with greater opportunitiesto practice their newly acquired skills. Both pre-serviceand in-servicetrainingprograms for teachers shouldbe established. Additional training shouldbe offeredto policy analysts,planners,and administrators,as well. The educationsystem shouldseek to strengthenthe participationof parentsand communitiesin the running of schoolsin order to strengthenboth governanceand accountability. 4.41 Efforts should also be made to strengthenpost secondaryeducation. The vocationaleducation systems should be redirected to enable it to developmentgeneric skills rather specific craft skills. It should aim at make its graduateshighlytrainableand thus responsiveto the opportunitiesthat are likely to becomeavailablein what promisesto be a rapidlychangingeconomicenvironment. Higher education shouldfocus its attentionon providingvery high quality trainingat communitycollegesand universities. The communitycollegesystem shoulddirect its resourcesparticularlyto the developmentof welltrained mid-leveltechnicalworkers such as medical technologists,electronic repairmenand accountants. The universitysystem should seek to consolidateits programsand to develop mechanismsfor the sharing of expensivelaboratories,libraries and other specializedteachingresources. The possibilityof creating a cooperativeagreementfor the enrollmentof studentsfrom other institutionsat each universityshould be explored. Thedevelopmentof new, specializedfacultiesshouldbe a pursued only after carefulevaluation of the financialfeasibilityof providinga high qualityprogram and the probable demandfor instruction. 4.42 The total cost of the investmentsnecessaryto implementtheserecommendationsis approximately US$375400 million. The highest priority should be attachedto ensuring that the quality of the basic educationbeing provided is brought up to a high standard. The second highest priority should be assigned to protecting investmentsin the universitysystem by consolidatingand rationalizingprograms 26 Third priority should be given to the rehabilitationand modernizationof facilitiesthat and facilities. havefallen into disrepairin recentyears. A modestprogramof improvementsto the vocationaleducation system would form the fourth priority. In additionabout US$34 milliona year should be spent on the

financialcrisisnow facestheuniversitysystm becauseof a sharpdrop in foreigndonationsto the ector; temporarysuistanceis requiredto retore the financialviabilityof the universities. This crisisnmwt be resolvedultinmtelythroughthe creationof local funding mechanisms.In the meanwhile,the sctor requiresasistance of aboutUS$20milliona year in orderto continueto operate. XA

Chapter4

45

routine replacementof worn out and obsolete facilitiesand equipment. The timing for implementation of these priorities should reflect the constraints imposedby the Peace Process and the scheduling of activities, as well as sector priorities.

V. SOCIALWELFAREAND RELIEFPROGRAMS A. Introduction 5.1 The partition of Palestine in 1948 led to the creation of extraordinary social and economic problems. The internationalcommunity's first step in responding to these problems was to found UNRWAin 1950in order to provideassistanceto dislocatedfamilies. UNRWArespondedinitially with a variety of emergency relief measures aimed at meeting the basic human needs of the Palestinian refugees. Since 1950, a numberof internationalvoluntaryorganizationshave been created in order to provide further humanitarianaid to the refugees. 5.2 This chapter attemptsto describethe welfareprogramsthat are now availableto the Palestinians living in the Gaza Strip and the West Bank, to identifythe deficienciesin the resulting safety net and to suggestmeasuresthat mightbe takento strengthenand improvethese provisions. The chapter is divided into four sections. The next sectiondescribesthe institutionsand programs that protect and benefit the residents of the Occupied Territories. The third section presents information on the funds being committedto these programs and their current effects. The fourth section examines the weaknessesin these programs and suggestsareas in which modificationshould be made. B. Institutions and Programs 5.3 The legal environmentand programsthat protect the welfareof workers and provide relief to the needy draw upon elementsof many separate and uncoordinatedsystems. The partition of Palestine in 1948 led to the introductionof Egyptian and Jordanian bureaucraciesand programs in the Occupied Territories. The creation of UNRWA ensured that registered refugeeswere entitled to an alternative collectionof protectionsand benefits. In addition,a largenumberof internationalvoluntaryorganizations have been createdsince 1950to providehumanitarianaid to refugees. The adoptionby the Government of Israel of an open borders policy followingthe 1967 war extendedthe benefits of many of Israel's socialwelfareprograms to Palestiniansworkingin Israel. These developmentshaveyielded a patchwork of relief programs and social protections that ensure some, though not all, residents of the Occupied Territories receiveassistancein meetingtheir basic needs. UNRWA 5.4 The core of the social welfare system serving the residents of the OccupiedTerritories is the collectionof programs operatedby UNRWA. UNRWAwas createdto aid personswho lost their means of livelihoodas a result of the partitionof Palestine in 1948and who in addition could demonstratethat they had resided in Palestine for at least two years prior to the partition. About 900,000 persons were designatedas refugeesat that time. Refugeestatus is passed along the male line to successors;in 1992 about3.5 millionpersonsworldwidewere registeredas refugees. Abouttwo-thirdsof registeredrefugees live outside the OccupiedTerritories. Of the nearly I millionliving in the OccupiedTerritories, about 540,000 live in the Gaza Strip and about 400,000 live in the West Bank.

Chapter S

47

5.5 In 1991, UNRWA had a budget of about US$255 million; of that amount US$98 million was spent directly on programs in the Gaza Strip and the West Bank. UNRWA spent US$12.6 million for relief and social programs in the OccupiedTerritoriesin 1991. About 90 percentof the budgetfor relief and social servicesprograms is spent on providingdirect assistanceto needyrefugees. Relief and social service programs focus on "special hardship cases" to whom food, shelter, clothing and other survival needs are offered. UNRWAreports havingprovided assistanceto about 58,000 special hardship cases in the OccupiedTerritories in 1991. About 17 percent of householdsare headed by women; a special programfor these womenassists in copingwith familyproblemsand in developingjob skills. UNRWA also operatesa modestloan program for special hardship cases. In addition, a number of governments provide special contributionsto support projects serving especiallyvulnerablegroups such as widows, the aged and the physicallydisabled. Many of the specialcontributionsare in-kindrather than in cash. In 1991, 305 staff, includingwelfareworkers, instructorsand distributionteam members,were assigned by UNRWA to administer programs of assistanceto the Gaza Strip and the West Bank. These staff membersoperatedfood distributioncenters, women'sprogram centers,youth activitiescenters and community rehabilitationcenters. The case load for UNRWA welfareworkers is 257 clients each. Government of Israel 5.6 Palestinians who work for employers located within Israel are required to participate in the Governmentof Israel's nationalsocial securityscheme. This scheme is financed from contributionsby employees(5.35 percent of wages), and contributionsby employers(7.35 percentof wages). For Israeli workersthese deductionsfinance old ageand survivorsinsurance,maternitybenefits, family allowances, workman's compensationinsurance, insurancefor accidentsoutside the work place, disabilitybenefits, income replacementduring reserve military service, nursing home care, severance pay in the event of the bankruptcyof the employerand unemploymentcompensation. In several instances,these programs provide only nominal benefits; for example, the old age and survivor's insuranceprogram pays only about US$90 a monthto beneficiaries. Palestinianworkersare not entitledto any of thesebenefitsother than maternity pay, workman's compensationand severance pay in the event of bankruptcy of the employer. 5.7 Since 1970,all Israeli employershave been requiredto pay employmenttaxes, regardlessof the nationalityof the worker. The taxes for Palestinianworkers are assessedand collectedby the Payments Section of the Employment Department of the Israeli Ministry of Labor. All Palestinian workers employedin Israel are supposedto be registeredwith the EmploymentDepartmentand assigned by it to an employer. Wagesare paidto the EmploymentDepartment,whichassessesand collectsrelevanttaxes and issuesa check to the worker for his net pay. All taxes applicableto Israeli workers were imposed on foreign (Palestinian)workersso that the latter wouldnot cost employersless than Israeli workersand, thus, have a competitiveadvantagein the labor market. The amount of social security taxes collected for programsthat are not providedto Palestinianworkersare transferredby the Governmentof Israel to the Civil Administration. These transfers are deposited to an "equalizationfund" (also called the "deductionfund") and are used to financeprograms benefitingthe residentsof the OccupiedTerritories. The taxesthat are depositedto the fund represent 11.8 percent of wagespaid. The Governmentof Israel estimatedthe contributionto the fund to be aboutUS$25 million in 1991. This correspondsto earnings of about US$195 million; at the minimum wage, these earnings would have been obtained by about 36,000 Palestiniansworking full time. This is a substantiallysmaller number than commonlybelieved to be employedin Israeland probablyreflects widespreadfailure to complywith labor laws. In addition, many Palestinianswork only part time. Israeli sourcesestimatethat only about30 percentof Palestinians working in Israel in 1987-1990were properly registeredwith the Israeli EmploymentService.

48

Chapter 5

SocialBenefits underIsraeliLabor Agreements 5.8 Collective bargaining agreementsrepresent the principal source of social security benefits in Israel. Histadrut,the umbrellalabor organization,representsabout 95 percent of all workers employed in Israel and concludeslabor agreementswith all major industry groups. The union sets the minimum wage and agreeswith industry representativeson the benefitsto be providedto workers and the contributionsto be madeby workersand employersin order to financethese benefits. These schemespay for supplementaryold agepensions,unemploymentcompensation,health insuranceand other agreedbenefits. The worker's contributionvaries from 5.5 to 6.0 percent of wages. The employer agrees to rates dependingon the branch of activity, but ranging from 12.5 percent (industry and services) to 37.33 percent (private construction). The contributionsare collectedfrom employerson behalf of Palestinian workersby the Israeli EmploymentService, which, as noted earlier, serves as the payroll section for all Palestiniansworking legally in Israel. The benefitsunder the collectiveagreementare supposedto be availableto all workers, but residencyin Israel is required to benefit from some of the programs. The extent to which Israeli employershave been willingto hire Palestinianworkers illegallyis clearlyin part due to the high employmenttaxes chargedfor those registeredwith the EmploymentService. Civil Administration 5.9 Palestinianstaff of the Civil Administrationand of Palestinianmunicipalauthoritiesparticipate in a specialsocial insurancescheme. This schemeprovides old age pensions, paid vacation,sick leave, maternityleave, workman's compensation,survivorsbenefitsand disabilityinsurance. Civil servantsare also required to participatein the governmenthealth insurancescheme. The SocialWelfare Department of the Civil Administrationprovides cash benefits, food, health care and social servicesto the needy. Five officesserve the Gaza Strip and six provide assistancein the West Bank. Each office is headedby an Arab manager. At mid-year 1993, about 36,800 members of 9,300 families were benefitingfrom some form of social assistanceprovidedby the Civil Administration. About 13 percent were receiving a comprehensivepackageof aid that includesfood, medicalinsurance,exemptionfrom school fees and a cash stipend. The vast majority were receiving a smaller package of aid that excluded education benefits. About 17 percent were being given only food. The remaining9 percent were receivingeither a cash allowanceor free health insurance. In addition to its programof aid to dependentfamilies, the Social Welfare Departmentoffers counselling and vocational training to delinquent youth, provides rehabilitation services to the handicappedand supports youth clubs for children from "distressed" families. Finally, the Departmentoversees the activitiesof about 200 private, charitableorganizations in the West Bank; this practice follows that establishedby the Governmentof Jordan. Labor Law in the Gaza Strip 5.10 Residentsof the GazaStrip are employedunder the provisionsof the Egyptian labor law. These laws regulatethe conditionsof employment,includingthe minimumage for workers and the maximum hours of work; however, they do not provide for compensationin the event of work-relatedinjuries or accidentsnor provide for pension benefits, health insurancecoverage, maternity benefits or severance pay.

Chapter 5

49

Labor Law in the West Bank 5.11 The Jordanian labor law applies to workers in the West Bank. It regulates the employmentof women and children and prescribes the maximumhours of work per day and week. It requires that employersprovide annualleave, severancepay and compensationfor job-relatedinjuries. The Jordanian law does not provide for pension rights, old age insurance,survivor benefits, compensationfor workrelated disabilities,health insuranceor family benefits. Private Transfers 5.12 The most important sources of financial security and social protection for residents of the OccupiedTerritories have been individualsavings and private transfers. Palestinianshave, for many years, successfullyfound employmentabroad and have saved a very large fraction of their earnings. Reliable informationon the managementand use of worker remittancesis not available,but anecdotal informationsuggests that many householdsare able to retire very early and to live from the income obtained from these savings. The collapse of employmentopportunitiesin the Gulf in 1991, and the losses of savings that occurred with the freezing of accountsheld in Gulf banks in 1991, may have seriously impactedthis approachto achievingincome security. C. Deficienciesin the Social InsuranceSystem 5.13 The provisions for the social security of the residentsof the OccupiedTerritories are patchy, inequitableand inadequate. The Palestiniansliving in the Gaza Strip and the West Bank participatein programs reflecting their refugee and employmentstatus. About half of the total population of the OccupiedTerritories qualifies for assistancefrom UNRWA. Its programs of relief and social services are targeted on "special hardship cases" in which the head of household is female; approximately8 percent of the refugee population benefits from the programs so targeted. However, UNRWA supplementsthese benefitswith a quite extensiveprogram of health benefits and with shelter servicesin the camps. Nearlyhalf (about49 percent)of the populationof the OccupiedTerritoriesis entitledto such assistance; many of these familiesalso qualify for benefits from other sources and do not employthe services of UNRWA. D. Recommendations 5.14 The resources needed to operate a comprehensivesocial welfare program certainly will not be availableto the OccupiedTerritories withinthe interimperiod. Nonetheless,good governancedemands the replacementof the current patchworkof benefits provided to the very needy by UNRWA and the Civil Administrationwith a moreequitable,unifiedsystemof protections. The benefitsof these programs should be targetedon the most vulnerable--the elderly withoutfamilies and female-headedhouseholds, particularlythose without significantassets. In addition, the system of in-kindtransfers and subsidies shouldbe analyzedand rationalized. Accessto free or highly subsidizedservices(includinghealth care, subsidizedhousing servicesand assistancein the educationof children), nowavailable only to registered refugees, should be extendedto others on the basis of relevant criteria, rather than refugee status. At presentlarge numbersof people maintaintheir refugeestatus simplyin order to remain qualifiedfor these programs in the event of a personaleconomiccrisis. A social survey is needed in order to assess the effectivenessof the social insurancesystem in alleviatingpoverty.

50

Chapter S

5.15 Over the longerterm, a basic program of socialprotectionthat has broad political endorsement needsto be developed. The list shouldprovidefor the handicapped,elderly, orphanedand widowedbut not seek to replacerelianceon private transfers and personalsavings. The public sector should facilitate a benefits program that is self-financingfrom employeeand employer contributionsbut should, in the near term, avoidthe developmentof programsthat draw heavilyon general revenuesfor their financing. 5.16 The public sector should also encourage the developmentof private institutions that supply financial services, including health and life insurancecompaniesand pension schemes. A very small insuranceindustry already exists in the West Bank. With the creation of an appropriateregulatory and legal environment,that industry could contribute significantlyto meeting the community's need for economicsecurity.

VI. CONCLUSIONSAND RECOMMENDATIONS

6.1 The central finding of this report has been that the programs that now serve the people of the OccupiedTerritories are inadequate,but that their deficienciesare rootedprimarily in poor governance and defectivepolicy rather than a scarcityof resources alone. Becauseof the exceptionalhistory of the area, the institutionsthat supplyhealth care, educationand social welfareserviceshavebeen accountable not to the communitybut rather to segmentsof the population. These institutions have obtained funds from conventionaldomesticsources, includinggeneral revenues,specialtaxes and user charges,but they have also relied extensivelyon foreign grants and private donations.This pattern of funding has led to uncoordinatedefforts; overspendingon capitalequipmentin some sectors and underspendingin others. Moreover, the implicit subsidiesprovidedwith these grants and donationshave been allocated in such a way that many needypeople have been deniedservices, or at least services of reasonablequality. 6.2 An accelerationof social developmentin the Gaza Strip and the West Bank will require the creationof institutionsthat are more accountableto their clients,governedand operatedunder transparent rules, and equitablein their treatmentof all residentsof the area. These changeswill have to be erected around institutionsthat providefor participationby the affectedpublic and that are seriouslyaccountable, either through the market or through a political mechanism. In view of the political complexityof the area, many political mechanismsare not likely to be workable;hence, markets and competitionshould be givengreater attentionthan is customary. This impliesthat theusefulnessof such devicesas education vouchersand "portable"health insurancebenefits, togetherwith the broad regulationof the market environment, shouldbe the major focii of public policy debate. 6.3 Investmentsof betweenUS$475to US$550millionwillbe requiredto respondfullyover the next ten years to the needs that have been identifiedin this report and to needs to replace worn out and obsoletefacilitiesand equipment. This estimateis very rough becausethe underlyinganalyseshave been based on insufficientdata. A thorough investigationof the health, educationand social welfare sectors should be undertakenbefore investmentdecisionsare made. Such a study should be carried out by a team of local and internationalexpertsand should allow sufficienttime to thoroughlyexaminethe facts and institutionsin these sectors. 6.4 The following table offers very rough estimates of the technical assistance and investment requirementsof the program.

S2

Chapter 6

Table 6.1: Summaryof FinancialNeeds

Category

_

Short Term

Studiesand TechnicalAssistance

| |

1

Medium Term |

Long Term

(US$ M)

Studies of Strategic Choices for Social and Human Resource Development Feasibility Studies for Rehabilitation and Expansion of Schools Feasibility Studies for Rehabilitation and Expansion of Health Facilities Studies for the Modernization of Vocational Education Socioeconomic Surveys Feasibility Studies for Construction of Facilities for the Care of Burn Victims and Cancer Patients, and of a Public Health Laboratory Provide Training and Travel Fellowships for Education Planners and Administrators Prepare Program for Upgrading Pre-Service and In-Service Teacher Training

1.0 1.0 0.5 1.0 1.0 0.5

1.5 1.0 2.5

0.5 1.5

Total

7.0

5.0

In|estment Projects Provide In-Service Training to Teacher. Rehabilitate Primary and Secondary Schools Renovate and Upgrade Health Facilities Construct and Equip Facilities for Care of Burns Victims and Cancer Patients, and Public Health Laboratory Upgrade School Libraries and Laboratories Upgrade Pre-Service Teacher Training Modemize and Expand Vocational Education Create Programs of Post-Graduate and Public Health Education Develop Networks and Strengthen Univenities Mount Emergency Progrm for Supplementing the Education of Post-Intifada Students Replace Depreciated and Obsolete Education Infratructure Replace Depreciated and Obsolete Health Infrastructure Develop and Produce a Basic Education Curriculum Increase Capacity of the Education System Increase Capacity of the Health Care System

Total

15.0

50.0 30.0 10.0 15.0 25.0 15.0 10.0 20.0 10.0

r

15.0

30.0 20.0

35.0 30.0 40.0 80.0 50 0

2500

250.0

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1992. UN Economicand Social Council. IsraeliLand and Water Practicesand PoliciesIn the Occupied Palestinianand Other Arab Territories. June 19, 1991. UN Economicand Social Commissionfor Westernand Asia (ESCWA). Land and Water Resources in the OccupiedPalestinianTerritory,The Centerfor Engineeringand Planning. 1992. United Nations. DevelopmentProgramme,IntersectoralNeeds, AssessmentReport, 1992. United Nations, National Health InsuranceProject - West Bank and Gaza, (1991). United NationsChildren's Fund in Jerusalem, and JerusalemFamily Planningand Protection Association. A Survey of Infant and ChildMortalityin the West Bank and Gaza Strip, December 1992. USAID Policy ResearchInc. DevelopmentOpportunitiesin the OccupiedTerritories(West Bank and Gaza Strip) - Health. October, 1992.

Welfare Association,GenevaSwitzerlandFeasibilityStudy (Draft Report). Dev. Finance and Leasing Companyand IndustrialDev. Fundfor the OccupiedTerritoriesin Palestine. February 12, 1992. World Health Organization. Proposalsfor WHO Programmeof Cooperationin the OccupiedArab Territories,1993-1994. World Health Organization.Health Conditionsof the Arab Populationin the OccupiedArab Territories,including Palestine,April 1991.

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World Health Organization. Planningfor the Transitionof the HealthServices In the OccupiedArab Territoriesand the Promotionof Regional Cooperationin Health, 1991.

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