United Nations System
Standing Committee on Nutrition



 

Nutrition Information in Crisis Situations - Occupied Palestinian Territories
 


NICS 13, May 2007

Since the start of the second Intafada in 2000, Palestinians have suffered a deterioration in their livelihoods, food security, and access to basic services (see RNIS 43 and NICS 4).

A food security analysis released early 2007 concluded that 34% of the population of West Bank and the Gaza Strip was considered food secure in 2006, while 20% was marginally food secure, 12% was vulnerable to becoming food insecure and 34% was food insecure (FAO/WFP, 21/02/07). Although not directly comparable with the FAO/WFP food security assessment in 2003, which used a different methodology, the findings were similar.

Refugees were most likely to be food insecure with 39.7% of the refugees categorised as food insecure, and 29.1% as food secure, compared to 30.2% and 38.5% for non-refugees. Moreover, refugees living in camps, who represent only 34% of the refugees, were more vulnerable with 44.7% of them food insecure and only 23.3% food secure. The urban population was more likely to be food secure than rural population: 39.4% vs. 30.4%. The Gaza Strip was more affected by food insecurity with 58% of the food insecure non-refugees located in the Gaza Strip and 24% in the West Bank.

New population groups such as families supported by the Palestinian Authority government employees have become food insecure since the beginning of 2006. This is explained by the fact that following the victory of Hamas at the parliamentary elections at the beginning of 2006, key donors suspended international aid to the Palestinian Authority government (PA), leading to a drop of 60% in its income (OXFAM, 04/07). This is reported to have had an adverse effect on the livelihoods of Palestinians , the PA being a major employer, employing about 161,000 people who support about 1 m dependents. The decrease in income has meant that salary payments have been irregular and services, such as health care, schools and provision of welfare payments have been curtailed. OXFAM reported a 30% increase in poverty in 2006. To mitigate this situation, a temporary international mechanism was established by the European Commission in the last semester of 2006 with the aim of channelling aid directly to Palestinians. This has included social allowances to health workers, provision of fuel to hospitals and water systems. A new unity government was formed in March 2007, following an agreement between Fatah and Hamas. However, direct aid to the Palestinian Authority had not resumed as of April 2007.

Economic access to food was still the most significant concern in terms of food security, with increases in food prices, especially in the Gaza Strip amidst the drastic reduction in livelihoods. Food aid was found as having recently become a more prominent source of food. Factors leading to food insecurity are described in figure 10.

The results of the Palestinian Family Health Survey conducted at the end of 2006/beginning of 2007 showed that the level of wasting has remained under control with 1.4% of the children wasted, including 1.7% in West Bank and 1.2% in the Gaza Strip (PCBS/joint, 04/07). About 13% of the children were stunted in the Gaza Strip and 7.9% in the West Bank, or an average 10.2% in the Palestinian Territories. Compared with the same type of surveys conducted in 2000 and 2004, it seemed that stunting showed a slight increase from 7.5% in 2000 to 9.9% in 2004 and 10.2% in 2006. This was especially marked in the Gaza Strip with an increase from 8.3% in 2000 to 13.2% in 2006. As the confidence intervals or a statistical comparison were not provided in the report, it is difficult to know the significa

Figure X Factors leading to food insecurity as depicted in qualitative feedback sessions (FAO/WFP, 21/02/07)


NICS 4, November 2004

The second Intifada, which began in September 2000, is still on-going. The recent death of the president of the Palestinian Authority, Yasser Arafat has meant that there will be elections in January 2005 (AFP, 14/11/04). Restrictions on the movement of Palestinians have particularly affected food security as many have lost their former employment in Israel. Moreover, the blockade paralyses the economy of the territories and hampers access to health care (see RNIS 43).

It had seemed there was a slight improvement in the situation in 2003, with a relaxation of closures and a modest economic recovery due to an increase in the amount of employment within the territories (WB, 11/04). The Palestinian Authority budget recovered somewhat in 2003 with an increase in the transfers of clearance revenue from Israel and collection efforts by the Palestinian authorities (WB, 03/04). On the other hand, budget support from donors declined to US$ 230 million in 2003 from US$ 467 million and US$ 530 million in 2002 and 2001, respectively (WB, 03/04).

The construction of the Separation Barrier, which aims to separate the West Bank from Israel intensified in 2003. However, the construction of the barrier has had a limited impact on the economy compared to the impact of closures, although agricultural lands, infrastructure and water resources have been destroyed and access to land has been further restricted (WB, 11/04). Moreover, thousands of Palestinians have had less access to basic services.

The situation suffered a further setback in 2004, especially in the Gaza Strip where an estimated 20,000 people lost their jobs (WB, 11/04). Restrictions of movement have intensified as well as incursions by the Israeli army which have led to an unprecedented destruction of houses and infrastructure (UNRWA, 11/04). Only an average of 1,900 workers crossed daily from the Gaza Strip to Israel this year, compared to about 10,000 in 2003 (OCHA, 10/04). Humanitarian access to the Gaza Strip has also seen the worst restrictions since the beginning of the Intifada (UNRWA, 11/04).

Coping mechanisms developed by the Palestinians to deal with the economic crisis have tended to become overstretched. While in 2001, 70% of the poorest families drew down their savings, only 13% were able to do so in 2003 (WB, 11/04). Support from relatives is also a significant way of coping, but it seems that the value of assistance from relatives has sharply decreased since the beginning of the Intifada, especially in the Gaza Strip (IUED, 10/03).

However, it seems that basic needs services are still provided thanks to donors' commitment, although support from donors declined slightly in 2003 compared to 2002 (WB, 11/04). The proportion of the population who received assistance was consistent between 2001 and 2003 and was 48% in July 2003 (IUED, 10/03). Coverage of the needy population seemed to have increased in 2003 compared to 2002, maybe due to better targeting (IUED, 10/03). However, 24% of the hardship cases reported that they did not receive assistance. The proportion was especially high outside the camps: 38% in the West Bank and 19% in the Gaza Strip.

Food was the main type of assistance received (69% of families), followed by financial aid (17%) (IUED, 10/03).

WFP has estimated that in 2004, 752,000 people are food insecure among the non refugee population, among whom WFP aims at targeting 457,000 for whom food aid is considered an appropriate intervention (WFP, 06/04): the "chronic poor", "new poor farmers" (farmers whose land is confiscated or who have lost access to markets) and "new poor unskilled waged workers" (waged workers who have lost jobs due to closure).

In addition, UNRWA, the agency caring for the refugees in the Occupied Palestinian Territories (estimated at about 1.5 m) has made an appeal to distribute a 60% food ration to 226,000 families, besides other programmes such as employment creation, health care and house reconstruction (UNRWA, 11/04).

Nutrition situation

A nutrition survey, which was conducted in mid-2003 and recently released, showed an acceptable situation: the prevalence of acute malnutrition was 3.9% in the Gaza Strip and 3.1% in the West bank, while stunting rates were 12.7% and 9.2% in the Gaza Strip and the West Bank, respectively (AQU/JHU/Care, 08/03). Stunting was significantly higher in the Gaza Strip than in the West Bank and significantly higher in refugee children than in non-refugees. However, there was no difference in wasting or stunting between camps, rural areas or urban areas, which is not contradictory to the fact that refugee children are more affected by stunting, because more than half of the refugees live outside the camps. The nutrition situation has been stable over the previous two years (see RNIS 43).

A survey on micro-nutrient deficiencies was carried out in June 2004 among children 6-59 months old (MARAM, 06/04). The survey revealed a high prevalence of vitamin A, vitamin E and iron deficiencies (table 12). Low plasma level of vitamin A may be caused or compounded by infection. When adjusted for infectious status, a significant proportion of the children remained vitamin A deficient (table 12). Prevalence of all micro-nutrient deficiencies was significantly higher in the Gaza Strip than in the West Bank.

The results of this survey are in line with the food consumption survey done by AQU/JHU/Care, which found that a significant proportion of children had an intake of vitamin A, vitamin E, folic acid and iron lower than the Recommended Dietary Allowance, and for vitamin A and iron in particular in the Gaza Strip (AQU/JHU/Care, 08/03).

The MARAM survey also assessed use of iodized salt in the households. According to the survey, 80% of the families were using iodized salt, although about half of the women didn't know they were using it or thought they were not.

Table 12 Vitamin A, vitamin E deficiencies and anaemia among 12-59 month olds, The Gaza strip and West Bank, June 2004 (MARAM, 06/04)

Population group Vitamin A
deficiency
(< 200 µg/L)
Vitamin A
deficiency among
non infected children
Vitamin E
deficiency
(< 5 mg/L)
Anaemia
(Hb < 11 g/dl)
West Bank & Gaza Strip 22.0% 11.6% 18.6% 23%
West Bank 18.9% 8.9% 15.6% 17.4%
Gaza Strip 26.5% 15.6% 23.1% 31.2%


Overall

The economic situation is still dire in the Palestinian territories. The resilience of the population, as well as the external assistance, has helped to keep the nutrition situation acceptable, although there are significant levels of micro-nutrient deficiencies. Only a political solution may see the situation improving.


RNIS 43, November 2003

1917   The British capture Palestine from the Ottomans. The Balfour declaration, issued by the British Government, expresses support for "the establishment in Palestine of a national home for the Jewish people", and the safeguard of the civil and religious rights of the existing "non-Jewish" communities in Palestine.
1922   Palestine is placed under a British Mandate, by the League of Nations with the objective of the implementation of the Balfour declaration.
1922-1947   Large-scale Jewish emigration. Violent clashes between the Palestinian Arabs and the Jewish population, and between the British and the two parties.
1947   The British Government appeals to the United Nations to take over the problem and indicates its intention to give up the mandate. The United Nations' General Assembly approved a partition plan of the territory between an Arab state (52% of the land) and a Jewish state (48% of the land), with Jerusalem as an international zone. The plan is accepted by the Jews, but rejected by the Arab League.
1947   End of the British Mandate in Palestine and proclamation of the independent State of Israel on the 14th of May. Arab states (Egypt, Iraq, Jordan, Lebanon, Syria and Palestinian guerrillas) attack Israel on the 15th of May. War ends in December 1948, with Israel controlling 77% of the territory of Palestine, Egypt controlling the Gaza strip and Jordan controlling the West Bank, including East-Jerusalem. About half (700,000) of the Palestinians flee their homes or are expelled.
1947   Israel becomes a member of the UN.
1948   Creation of the Palestinian Liberation Organisation (PLO)
1949   Six-Day War, between Israel and Egypt, Jordan and Syria. Israel occupies several territories, including the West Bank and Gaza Strip. New exodus of about 500,000 Palestinians. The UN Security Council calls on Israel to withdraw from territories it has occupied during the 1967 conflict.
1974   The General Assembly reaffirmed the rights of the Palestinians to self-determination, national independence and sovereignty and to return. PLO obtains the status of observer in the General Assembly.
1987   First "Intifada", an uprising against the Israel occupation in the occupied territories, which will end in 1993.
1988   The Palestine National Council (parliament in exile) recognises the right of Israel to exist and declares an independent State of Palestine.
1989 Beginning of negotiations between Israel, Syria, Jordan and Palestinian representatives in Madrid.
1993-1995   Series of negotiations, coming to mutual recognition of Israel and PLO, establishment of Palestinian Authority, withdrawal of Israel from most of the Gaza Strip and Jericho, division of the West Bank into three areas with different levels of control by the Palestinian Authority and Israel, treaties on security and economic relations.
1996-2000   Stalemate in the peace negotiations and escalating violence.
2000-2003   Second Intifada begins in September 2000. Increasing violence including bomb attacks in Israel, closure of the territories, curfews and destruction of houses in Gaza and West Bank, have so far resulted in 862 deaths and 5,868 injured among Israelis (IDF, 17/09/03), and 2,307 deaths and 22,705 injured among Palestinians (PRCS, 08/03). Further increase in restrictions in March/April 2002: Operation Defensive Shield. June 2002: Beginning of the construction of a "security barrier" by the Government of Israel, to physically separate the West Bank from Israel, which has raised a lot of concerns (UNRWA, 15/07/03). The UN Security Council publishes the "road map" in April 2003, a performance based roadmap to a permanent two-state solution to the Israeli-Palestinian conflict within two years (MEQ, 07/05/03). Despite some improvements, violence still continues.

Since the beginning of the second Intifada, in September 2000, the Government of Israel has imposed a series of sanctions, including internal restrictions on movement of Palestinians and goods within the West Bank and the Gaza strip, reinforced by curfews; external closure of the border between Israel and Palestinian territories and limitation on access by Palestinian workers to work in Israeli settlements. The government of Israel has also withheld taxes collected on the Palestinian Authority's behalf.

These sanctions have had a major impact on the Palestinian economy. In 2002, gross national income decreased by 38% from 1999 level and real per capita income was 46% lower than in 1999 (WB, 05/03). Imports and exports decreased by one third between September 2000 and December 2002 and total investment declined by about 90% (WB, 05/03).

The monthly Palestinian Authority revenue fell from a monthly average of US$ 82 million in late 2000 to US$ 33 million by the end of 2002. This sharp drop may be attributed to rising unemployment, the reduced demand and the withholding by the Government of Israel of taxes collected on the Palestinian Authority's behalf (WB, 05/03). The municipalities have also seen their revenues and expenditures diminished by about 40% since the Intifada (WB, 05/03).

Population of the Palestinian territories and refugees

The total population of the Palestinian Territory (including refugees) is estimated at 3,634,495 in 2003 (PCBS).

As of June 2003, it has been estimated that there are more than four million registered Palestinian refugees in host countries and in Gaza Strip and the West Bank (see table). Palestinian refugees are defined as persons whose normal place of residence was Palestine between June 1946 and May 1948, who lost both their homes and means of livelihood as a result of the 1948 Arab-Israeli conflict, and their descendants (UNRWA).

About one third of the registered refugees live in 59 refugee camps in Jordan, Lebanon, the Syrian Arab Republic, the West Bank and Gaza Strip. The others live in and around the towns.

About one and a half million refugees live in Gaza Strip and the West Bank, of whom 42% (636,578 persons) are settled in 8 refugee camps in Gaza Strip and 19 refugee camps in the West Bank (see map).

Number of registered Palestinian refugees as of June 2003, (UNRWA)

  West Bank Gaza Strip Lebanon Syria Jordan Total
Number of
registered refugees
654,971 907,221 391,679 409,662 1,718,767 4,082,300
Number of registered
refugees in camps
176,514 478,854 222,125 119,766 304,430 1,301,689
Number of
official camps
19 8 12 10 10 59

The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) was established by a United Nations General Assembly resolution in 1949, and became operational the first of May 1950. UNRWA activities are essentially directed to the provision of relief services, and include a development component (UNSGB, 17/02/00). UNRWA has, however, no mandate to guarantee the safety, security or legal and human rights of the refugees (SCF).

Nutritional status

Several nutrition surveys were carried out in the Occupied Palestinian Territories in 2002 and 2003 (AEI/ACH, 03/03; AQU/JHU/Care, 09/02; PCBS, 2002) (see table). All the surveys used random sampling methodologies but the results were not consistent; one of the surveys reported much higher rates of malnutrition in Gaza Strip. At the request of the John Hopkins University and the Palestinian Central Bureau of Statistics (PCBS), the World Bank was to provide a neutral expert to assess the survey methodologies and findings (WB, 05/03). RNIS does not know about the status of this intended assessment.

If the PCBS and AEI/ACH nutrition surveys are taken into account, the nutrition status of the children was satisfactory (AEI/ACH, 03/03; PCBS, 2002). Moreover, the distribution curve of the weight-height index for the children surveyed in Gaza Strip was similar to the distribution curve of the population used as a reference (healthy American children, National Center of Health Statistics) (AEI/ACH, 03/03).

On the other hand, the AQU/JHU/Care survey showed a worrying situation in the Gaza Strip (AQU/JHU/Care, 09/02).

According to the PCBS surveys, it seems that wasting and stunting have remained within the same range since 1996. Wasting was 2.8% in 1996, 1.4% in 2000 and 2.5% in 2002; stunting was 7.7% in 1996, 8% in 2000 and 9% in 2002 (PCBS).

The nutrition status of non-pregnant women aged 15-49 years was evaluated in the AQU/JHU/Care nutrition survey (AQU/JHU/Care, 09/02). The results showed that a very low percentage of women had a BMI < 18.5. On the other hand, a significant proportion of women had a BMI >= 30, which is considered as obesity (see table). However, the proportion of obesity among women of reproductive age seems to have significantly decreased, compared to 1998 when 25% of women were obese (AQU/JHU/Care, 09/02).

Prevalence of acute malnutrition, Occupied Palestinian Territories, 2002-2003

Date Agency West Bank Gaza Strip OPT
    Acute
malnutrition
Severe acute
malnutrition
Acute
malnutrition
Severe acute
malnutrition
Acute
malnutrition
Severe acute
malnutrition
June-August 2002 Al Quds
University/John
Hopkins University,
Care
4.3* 0.2* 13.3* 3.8* 7.8* 2.2*
May-June
2002
PCBS 2.9* 0.8* 2.0* 0.7* 2.5* 0.7*
March
2003
Ard El Insan/
Action contra el Hambre
- - 1.7**(1.1-2.6) 0.2**(0.0-0.6) - -
    Stunting Severe stunting Stunting Severe stunting Stunting Severe stunting
June-August 2002 Al Quds
University/John
Hopkins University,
Care
7.9 2.9 17.5 7.9 11.7 5.7
May-June
2002
PCBS 8.0 2.1 10.5 2.8 9.0 2.4
March
2003
Ard El Insan/
Action contra el Hambre
- - 6.7 (5.4-8.4) 1.8 (1.1-2.8) - -

* Oedema not assessed
** No nutritional oedema

BMI distribution, Palestinian Territories, 2002 (AQU/JHU/Care, 09/02)

  West Bank Gaza Strip OPT
BMI< 18.5 1.6 2.1 1.8
BMI>= 30 10.4 11.9 10.9

Food security

Decrease in food consumption

Several sources reported a decrease in food consumption since the beginning of the Intifada in September 2000. The World Bank estimated that the real per capita food consumption has decreased by 25% compared to 1998 (WB, 05/03).

According to the AEI/ACH survey in Gaza Strip, 69% of the 1251 families interviewed were eating 3 meals a day, whilst 22% were eating two meals a day and 9% were eating only one meal a day, in March 2003 (AEI/ACH, 03/03).

The AQU/JHU/Care survey reported a 13% decrease in protein consumption and a 15-20% decrease in carbohydrate and fat consumption for women (AQU/JHU/Care, 09/02). According to the same survey, a Sentinel Surveillance System, which consisted of seven rounds of 320 interviews between mid-May and mid August 2002, revealed that 55% of the families interviewed experienced a decrease in the amount of food eaten for more than one day during the two weeks prior to the interviews. There was no difference between the West Bank and Gaza Strip. In the same way, a MOH/WHO/AQU survey showed that 53% of the 1897 households interviewed had experienced a food shortage between March 2002 and January 2003 (MOH/WHO/AQU, 08/03).

Consumption of meat, fish and chicken as well as fruits was the most affected (AEI/ACH, 03/03; AQU/JHU/Care, 09/02; FAFO, 2003). According to the Sentinel Surveillance System of AQU/JHU/Care, between 60 and 70% of the households experienced a decline in meat, fish and chicken consumption, whilst 50-70% of the households experienced a decrease in fruit consumption. The decline in milk consumption was somewhat less, with a 40-50% decline. Bread, rice and potato consumption decreased by 26-42%. According to FAFO, fresh meat, fish, chicken and fruits were the first dropped from the consumer basket, then frozen meat and fish.

Availability of food but decrease in access to food

Availability of food

According to a AQU/JHU/Care market survey, food shortages have been largely experienced at wholesale and retail levels (AQU/JHU/Care, 09/02). During the month of June 2003, disruptions in the market place were especially high for meat, fish, chicken and dairy products, whilst fruits, vegetables, grains, frozen and canned goods were more available. The most commonly given reason for the shortage was the border closure in Gaza Strip and road closures and curfews in the West Bank.

On the other hand, food prices have not significantly increased (AQU/JHU/Care, 09/02; WB, 05/03), probably because of a reduction in demand. The WB estimates that there was no general problem of food shortage (WB, 05/03).

Decrease in access to food

Access to food has decreased as described above (see decrease in food consumption). According to the AQU/JHU/Care survey and the PCBS survey, the main reasons explaining the drop in access to food were a lack of money and restrictions of movement (AQU/JHU/Care, 09/02; PCBS, 2002). According to the PCBS survey, 63% of the people faced difficulties in obtaining food during the Intifada, because of combined factors: loss of income (57%), curfew (41%) and siege (87%) (PCBS, 2002).

Sources of food

According to a survey carried out by the IUED (Graduate Institute of Development Studies) in November 2002, 13% of the 1370 Palestinians interviewed were relying on food assistance, 17% were relying on their extended family and 70% were relying on their own incomes (IUED, 12/02). According to a PCBS survey, undertaken in August 2003, 82% of the 886 households interviewed were primarily relying on their own income for food, whilst 10% were depending primarily on food assistance and 7% were depending on relatives (PCBS, 09/03). Although the surveys are probably not directly comparable, it seems that the number of households depending on relatives decreased between November 2002 and August 2003, which may reflect the increasing difficulties for the better-off households in supporting relatives.

Decrease in incomes and increase in poverty

Loss of employment and wages

Unemployment has risen constantly since the beginning of the Intifada, from 10% in September 2000 to 26% in December 2001 and 37% by the end of 2002 (WB, 05/03).

Some of the main reasons for the decrease in employment were the restriction of access to Israel where many Palestinians used to work, and the collapse of the Palestinian private sector. Although the Palestinian Authority has developed a strategy to create new jobs, the 17,000 new jobs created between September 2000 and December 2002 (WB, 05/03) did not compensate for the overall lost of jobs.

According to the World Bank, in September 2000, 128,000 people were working in Israel and Israeli settlements; this represented 21% of employment and 21% of Palestinian incomes. In 2001, only 51,000 people were still working in Israel and Israeli territories, with a further drop in March 2002. The number of work permits increased again slightly at the end of 2002 (32,000 permits were given but only half were used) and in 2003 (WB, 05/03). In Palestine, more than 25% (43,000 employment) of the private sector workforce has been laid off since the beginning of the Intifada (WB, 05/03).

The type of employment has also changed since the beginning of the Intifada; there has been a switch from stable employment to temporary work and self-employment. According to the World Bank, self-employment has increased by 26,000 since the beginning of the Intifada (WB, 05/03). According to the IUED survey, in addition to the increase in unemployment between November 2001 and November 2002, full-time employment has decreased (see table) (IUED, 12/02).

Employment in Occupied Palestinian Territories (IUED, 12/02 )

  November 2001 November 2002
Unemployed 27% 33%
Part-time 18% 8%
Full-time 55% 44%
Few hours/day - 15%

In March 2003, 19% of the households interviewed in Gaza Strip had no resources, whilst 32% had official work, 25% had temporary earnings and 18% had private work (AEI/ACH, 03/03).

Moreover, wages have decreased for the employed. The World Bank stated that real wages have decreased by 5%, since the beginning of the Intifada (WB, 05/03). According to the IUED survey, 55% of the employed respondents have experienced a decrease in wages, whilst 44% earned the same salaries, and 1% experienced an increase in income (IUED, 12/02).

According to the people interviewed during the IUED survey, 20% of the respondents did not have enough to cope financially, 38% could barely manage now, 12% might be able to manage for a few months to one year, and 31% could manage as long as it takes (IUED, 12/02).

Olive oil is also a significant source of income, but 48% of the families reported that cultivating land was difficult and 16% had been prevented from cultivating land, in the first semester of 2003 (PCBS, 09/03).

Damage to properties

Since the beginning of the Intifada, 24% of the people interviewed in the IUED survey had experienced damage to houses, 33% have experienced damage to equipment and 22% have had their orchards ravaged (IUED, 12/02). The West Bank was more affected than Gaza Strip. Damage to the Infrastructure and public buildings represented 37% of all damage (WB, 05/03).

Increased poverty

Poverty has increased steadily. The IUED survey showed that the proportion of households below the poverty line increased from 40% in November 2001 to 56% in November 2002 and reached 70% of the households in Gaza Strip (IUED, 12/02). According to the World Bank, 21% of the families were considered as poor before the Intifada, rising to 46% in 2001 and 60% in December 2002 for the whole Palestinian territories and 75% in Gaza Strip (WB, 05/03).

Coping mechanisms and mitigation

Families have had different ways of coping but coping mechanisms tend to become scarce over the Intifada.

Safety net

There is great cohesion and resilience in the society, which acts as a safety net. Inter-household redistribution may concern food, cash or help to set up income- generating activities (FAFO, 2003). However, as the crisis continues, there are more and more people in need and fewer and fewer people who can help.

Debts and credits

Another coping mechanism is the non-payment of water and electricity bills and to ask for credit in shops. Shop-keepers are, however, less and less keen according to give credit to people who have lost their source of income (FAFO, 2003).

According to the AQU/JHU/Care survey, 52% of the people were borrowing money to buy food, 18% of the people were selling assets (AQU/JHU/Care, 09/02). According to the AEI/ACH survey, about 40% of the families were borrowing from relatives, 27% from shops and 15% from the bank (AEI/ACH, 03/03). 38% of the families used the loan for food.

Asset selling

The extent of the sale of assets is not clear but it does not seem to play a major role; this may also be due to a lack of demand because of the low purchasing power of the population.

Increase in work by women and children

It seems that the number of women and children under 18 years who are working has increased. Women's employment increased from 23% in November 2001 to 31% in November 2002 (IUED, 12/02). The percentage of children under 18 years who were employed also increased from 10% in November 2001 to 20% in November 2002; the increase was especially marked in low-income families (IUED, 12/02).

Huge assistance to the Palestinian Authority

Although the Palestinian Authority has lost 80% of its revenue since the Intifada, assistance from external donors has mitigated the situation. Since the beginning of the Intifada, donor support to the Palestinian authority has doubled from pre-Intifada level; on average US$ 39 million/month (more than half of the whole budget) was provided to the Palestinian Authority between November 2000 and December 2002 (WB, 05/03). Support came essentially from the Arab states and the European Union. However, the amount of aid has declined since mid-2002.

Despite this assistance, the Palestinian Authority's monthly expenditure has declined regularly since the beginning of the Intifada. The strategy that has been adopted by the Palestinian Authorities has been to ensure the payment of salaries and to create new jobs; 17,000 new jobs were created between September 2000 and December 2002. In December 2002, the Palestinian Authority was employing 125,000 people, which represented 26% of overall employment and 40% of domestic wages (WB, 05/03). On the other hand, non-salary recurrent expenditures, such as on infrastructure or operating budgets for health, have been reduced.

Increased assistance to families

Direct assistance to families has also risen since the beginning of the Intifada. UNRWA has increased by a multiple of nine the number of refugees, who were assisted (Bertini report, 19/08/02). Similarly, WFP was assisting 500,000 beneficiaries in 2002, compared to 150,000 before September 2000 (Bertini report, 19/08/02). However, UNRWA is experiencing a budget shortfall and its June 2003 appeal was only 30% funded as of September 2003 (UNRWA, 24/09/03): the number of food distributions had to be cut by one-quarter in Gaza Strip and the content of the food parcel has been reduced to only 30% of nutritional needs. ICRC has also implemented a voucher programme, which permits 120,000 people in urban centres in the West Bank to buy essential items (Bertini report, 19/08/02).

Although the structural assistance of the Ministry of Social Affairs to the hardship cases has been delayed or interrupted since the beginning of the Intifada, and especially in 2001, it seems that households have been able to compensate by obtaining assistance from other sources, such as NGOs (FAFO, 2003).

According to interviews with Palestinians, the overall level of assistance seems to have remained within the same range between February 2001 and November 2002 (IUED, 12/02); in November 2002, 49% of the families were receiving assistance. Assistance seemed to have increased in rural areas (from 23% in November 2001 to 43% in November 2002). The level of assistance has not varied much in towns and camps since November 2001 and was 45% in towns and 78% in refugee camps, in November 2002. It seems that poor refugees were more covered by assistance than poor non-refugees. Food assistance was the main type of assistance received, followed by financial assistance. Food aid donations mainly consisted of wheat flour/cereals (AEI/ACH, 03/03; IUED, 12/02).

According to the AEI/ACH survey, 56% of the families interviewed in Gaza Strip had received food aid, from international NGOs (83%) or national NGOs (16%) (AEI/ACH, 03/03).

The first needs according to the population were employment and then food, health, housing and financial assistance (PCBS, 09/03; IUED, 12/02).

Public health

According to the AEI/ACH survey in Gaza Strip, 57.3% of the children included in the survey had a disease within the month prior to the survey; the majority presented respiratory infections (55.8%), whilst 11% had respiratory allergic conditions and 7.5% suffered from diarrhoea (AEI/ACH, 03/03).

Regarding vaccination coverage in children aged 12-23 months, it seems that there has been a slight decrease in polio and DPT vaccination in 2002, compared to 2000 (polio: 98.3% coverage in 2000 vs 92.2% in 2002; DPT 98.7% coverage in 2000 vs 92.8% in 2002). On the over hand, measles vaccination coverage remains stable: 94.5% coverage in 2002, compared to 92.7% coverage in 2000 (PCBS; MOH/WHO/AQU, 08/03). The vaccination coverage has remained high overall.

Decrease in access to medical care

Decrease in capacity of the health structures

In 2002, the MOH reported that because of curfews and closures, facilities operated at 30% of their capacity and that there was a 60% decline in implementation of school health programmes (WHO, 27/09/02). There has also been a severe shortage of operating budgets and an increase in emergencies, following the beginning of the Intifada, which has led to a reduction in health service capacity, especially in 2001; the situation improved in 2002 (WB, 05/03).

Restriction of access to medical facilities

Restrictions of access to medical care have been widely reported. According to PCBS in 2002, the main reasons people cited for having difficulties in accessing medical care were: siege, cost, curfew, distance, and non -availability of services.

According to the IUED survey, 17% of the households were denied access to health facilities, whilst 45% experienced a delay and 13% were not restricted (25% did not seek medical treatment) (IUED, 12/02).

According to a MOH/WHO/AQU survey, at the end of 2002, most of those individuals seeking assistance during the month prior to the survey received care (more than 95%), although with delay; 4% of patients needing emergency care did not receive any treatment (MOH/WHO/AQU, 08/03).

Delays in access have increased since March 2002. The proportion of people who needed more than an hour to reach health facilities doubled (22% vs 10%) after March 2002, and the proportion of people seeking hospital care, who needed more than one hour to access the facility tripled (36.5% vs 12%). Moreover, 51% of people changed health facilities after March 2002 because of restriction of movement or breakdowns in service (MOH/WHO/AQU, 08/03).

According to the PCBS, in the first semester of 2003, 39.5% of the households did not have any problems getting medical care, whilst 17.6% had a few problems and 41.3% found it difficult ; access to health care was impossible for 1.4% of the households (PCBS, 09/03). Although the MOH adopted a strategy of decentralisation including the implementation of mobile clinics, with the aim of facilitating access to health services, this strategy has not compensated for the sharp drop in access. Moreover, after March 2002, mobile clinics were often prevented from moving (Bertini report, 19/08/02).

The Palestinian Authority also introduced free health insurance at the beginning of the Intifada, for the unemployed and their families (FAFO, 2003). According to MOH/WHO/AQU, 55% of the households who had health insurance did not pay for it (MOH/WHO/AQU, 08/03).

Nutrition care

Sixty-eight clinics were surveyed by the AQU/JHU/Care survey, of which, 45 were MOH facilities and 23 were UNRWA clinics (AQU/JHU/Care, 09/02). All of the clinics had a weighing scale and 97.1% of the weighing scales worked properly. Tools to measure height were not available in all of the clinics. Half of the clinics did not have protocols to standardize diagnosis and treatment of malnutrition. 60% of children's records in the clinics had weight measurements: 95% of the children 6-12 months, 71% of the children 13-24 months and only 18% of the children 25-36 months; the youngest were more likely to be measured than the oldest. The clinics diagnosed 60% of the malnourished children, according to the clinics' criteria.

Water and sanitation

There has been a deterioration in the water supply and waste disposal, especially due to the decrease of PA revenues. However, according to PCBS, 93.8% of households had access to safe drinking water in 2002. MOH/WHO/AQU reported that 72% of the households were using a public water supply and that 64% of the households reported interruption of three days or more in the water supply in the second semester of 2002, and interruption of water chlorination (MOH/WHO/AQU, 08/03). According to the World Bank, water services have deteriorated. In urban areas, the deterioration was primarily due to physical damage and inadequate maintenance. Problems were more crucial in rural areas which were not served by piped water networks and relied on water transported by tanker. The price of water has increased by up to 80% since September 2000, and the water supply may represent one third of the household income; some families sought alternative, dirty water (WB, 05/03).

In August 2003, the average water supply in 31 communities was 39.5 litres but was far less in some rural communities: 11 to 18 litres/person/day (OCHA, 15/08/03).

Collection and disposal of solid waste have also been reported to be problematic (WHO, 27/09/02).

Overall

The Palestinian Territories have been under hard military and economic pressure since the beginning of the second Intifada in September 2000. The economy has suffered badly and unemployment and poverty have risen. There has been a decrease in access to food and the public health system has deteriorated. However, good structures were in place before the Intifada, donors’ support to the Palestinian Authority or through relief assistance has risen considerably during the Intifada and families have had good coping mechanisms. This may explain the mitigation of the effects of the crisis. However, coping mechanisms tend to become exhausted during the Intifada and donors’ support to decrease. The longer the current crisis lasts, the more difficult will be the ability of Palestinian Society to cope.