Physicians for Human Rights-Israel: Israel´s Step Children – Position Paper about the lack of pediatrics in the Unrecognized Villages in the Negev and its Ramifications - ENG

8/8/2019 Physicians for Human Rights-Israel: Israels Step Children Position Paper about the lack of pediatrics in the Unrec

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Israels Step Children

About the lack of pediatrics in the Unrecognized Villages in

the Negev and its Ramifications

A Position Paper by the Women Promote Health Group and Physicians for Human

Rights

November 2008

Author: Heijer Abu Sharb


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Brief

In the South of Israel there are forty five villages which include about

83,000 residents, out of whom 60% are children. Most of the villages are

unrecognized by the state thus, their right to health services and necessary

health conditions is violated. Since 1999, eleven of the villages were

recognized by the state, yet despite that recognition they do not receive the

full services each resident is entitled to.

There are twelve clinics in the unrecognized villages and only in eight

villages are there family health centers. There are no pediatricians,

gynecologists and pharmacies in the clinics; in most cases the staff does not

speak Arabic, reception hours are very limited etc.

According to data from the Soroka Medical Center, compared to Jewish children,

more Bedouin children arrive at the emergency units; more Bedouin children

need hospitalization in the pediatric ward and the emergency units; and more

Bedouin children die due to their illness. Moreover, Bedouin children who

arrive at the emergency department arrive at critical stages of the illness,

due to a late diagnosis deriving from the lack of health services,

infrastructure, roads, transportation and access routes for the community.

Despite the high morbidity and mortality among the Bedouin children in the

Negev, none of the clinics existing in the villages (all clinics except for

one are run by Clalit), employ a pediatrician. On the other hand, in

adjacent, rich Jewish communities such as Meitar, Omer and Lehavim the

residents insured in Clalit, have pediatricians, gynecologists and family physicians, many and more flexible reception hours and accompanying services

that do not exist in the clinics in the unrecognized villages. For instance,

in Omer there are 5.18 physician hours per 100 patients compared to 1.86 in

Algrain. The Jewish residents have the option of being insured in other health

funds (Maccabi, Meuhedet and Leumit), which operate in the Jewish communities

and do not operate in the unrecognized villages.


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A survey conducted by the Women Promote Health group and PHR-Israel among 70

residents of the villages show that due to the long distance of the clinicsfrom the village center and due to the lack of basic services such as

medications, professional medicine (especially pediatricians), limited

reception hours and so on, many residents prefer to receive the service in

townships or in private clinics. Thus, for instance:

Only 55% of the women visit the village clinic most of the time, while 45%

dont visit the clinic at all or visit it sometimes.

48% of the women reported that after receiving treatment in the village

clinic, they had to go to an additional clinic in order to complete the

treatment; 77% of the women who reported visiting a different clinic had been

forced to visit a private pediatrician, and 13% visited the pediatricemergency unit.

32% of the women reported they visited the emergency unit with their children

in the past year: 24% due to high fever, 16% due to an unsuccessful treatment

by the clinic physician, and 12% due to dehydration.

50% of the women reported that they go to the clinic on foot, with their

child, and that they do not have another way to get there. 51% of the women

claimed that its a 5-15 minute walking distance, 35% indicated a walking

distance of between 20-40 minutes and 14% indicated a 60-120 minute walking

distance.

As you can see, the establishment of the clinics in the villages, most of

which were built only after a Supreme Court petition1, is only a partial move

in the realization of the villages residents right to health. A full

realization requires electricity and water connection and additional necessary

health conditions. Moreover, the right to health is bound with the right to

equality and therefore, the existence of clinics that offer a low range of

services compared to the services available for residents in clinics outside

the unrecognized villages in the Negev, violates the equal right of the

residents of the villages to unified health services. Furthermore, the core

principles of the National Health Insurance Law are not only equality but also

the value of justice which means a bigger investment in resource development

1High Court Petition 4540/00.

The Number of Reception Hours Physicians in Clalit Clinics according to Settlement

38

0

81.5

031

0

109

55

214

36

83

36.5

0

50

100

150

200

250

MeitarBir Hadaj

OmerAlgrainLehavimUmmMatnan

Weekly reception hoursPediatrician

Weekly reception hours

All physicians


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especially where it is most needed. Since the residents of the unrecognized

villages suffer from higher morbidity and mortality, the state should initiate

a differential investment when establishing health services within the

villages.

With regards to pediatrics, in many places in the world the family physician

is the main caregiver of the child and the pediatrician serves as his advisor

(in England, for instance). This method has many advantages; among others itis a comprehensive understanding of the familys needs. However, the fact that

there is no pediatrician in the village clinics, where there are numerous

children, with high morbidity and mortality rates and given the harsh living

conditions, raises questions and calls for action.

PHR-Israel and the Women Promote Health group demand from the state:

To act for the recognition of the unrecognized villages in the Negev; to

connect them to all national infrastructures, especially water, and to connect

the clinics to the electricity network in order to allow, among other things,

refrigeration of medications;To act so that the scope, variety, and quality of the services provided in the

villages' clinics are equal to available services in most primary clinics in

other communities, and that pediatricians and gynecologists are employed in

the existing clinics;

To differentially invest in developing the volume and variety of health

services in the unrecognized villages in the Negev;

To act for the planning and implementation of programs designed to reduce

morbidity and mortality rates among the residents of the unrecognized villages

in the Negev in general, and their children in particular, so that it will be

culturally fitting;

To make sure that the health services are adapted to the cultural and labial

needs.

The "Women Promote Health" Group Background about the

Authors of the Position Paper

We are a group of Arab-Bedouin women, residents of the unrecognized villages

in the Negev that formed in the framework of a course called "Women Promote

Health" initiated by Physicians for Human Rights. We are residents of tenunrecognized villages - Tel Arad, Qasar Alsir, Wadi Alna'am, Al-Zarnug, Khashm

Zinna, Um Bateen, Wadi Ghwain-Tela Rashid and Albatel- Karkur.

During the course, we were exposed to a lot of information regarding health

and the right to health. When the course ended, we decided to take action

while focusing on two issues: (1) Raising the awareness of women to the right

to health, by means of workshops dealing with the subject and (2) taking

advocacy steps demanding from The "Clalit" health fund and the Ministry of

Health to employ pediatricians in the existing clinics.

This position paper presents our findings as for the second cause: to make

sure that the existing clinics in the villages will provide basic services pediatrics that are provided in our surrounding communities.


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General Background about Underlying Determinants of Health

and Services in the Unrecognized Villages in the Negev

In the south of Israel there are forty five villages which include about

83,000 residents, 60% out of whom are under 19 years old. Most villages are

not recognized by the state, thus their right to health and Underlying

determinants of Health, such as water, electricity, sewage, garbage disposal,

adequate housing, paved roads, road signs etc, are violated. The eleven

villages that were recognized by the state since 1999 still do not receive the

full services every resident is entitled to.

The Lack of Underlying Determinants of Health

Naturally, children are more prone than adults to dehydration and intestine

illnesses, due to the lack of accessibility to clean water, adequate for

drinking. A "Diarrhea epidemic" erupts every August, during which 16,000

Bedouin children are admitted to hospital, compared to 5,000 Jewish children;

that is to say that while the Bedouin children constitute only 15% of the

entire population of the Negev, they constitute 80% of the entire children

population admitted to hospitals2.

Another danger lurking for the children in the summer time is caused by the

living conditions in the tin shacks. These shacks double the heat level and

many babies need medical care due to a rise in their body temperature and

dehydration. In the winter, the condition worsens even more since the extreme

cold in the house and the inability to provide safe heating facilities (due to

the lack of electricity connection), causes the hospital admissions (due tocold and burns) and even the death of children.

3

The poor sanitary conditions, such as garbage accumulation, due to the lack

of a disposal solution constitute a good base for mice which have bitten

children more than once. Burning the garbage is not safe either. It causes the

release of toxins that harm the children playing in the surroundings.4

The Lack of Adequate Health Services

Due to the lack of necessary health conditions and the poor health results,

the residents of the unrecognized villages in the Negev should have highaccessibility to health services. Yet, the situation is far from it. Today,

there are twelve clinics in the unrecognized villages and only eight villages

have family care units. These clinics serve only 20% of the residents of the

unrecognized villages. Moreover, the services provided in the existing clinics

are lacking and are not accessible to the residents:

Physical accessibility: The lack of public transportation and paved roads make

it hard to reach the clinics situated far from the village center. It is

especially difficult for women, who are in charge of child care and also

2O. Almi (May 2006). Physicians for Human Rights. Water Discipline: Water, the Stateand the Unrecognized Villages in the Negev.3Ibid.4Ibid.


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suffer social mobility limitations. This fact goes to show that when locating

the clinics far away and in setting the reception hours (they do not operate

in the afternoon and on Fridays), there is no proper adjustment to the needs

of the population it is supposed to serve.

A Lack of Medications and Lab Services: Since the clinics are not connected to

the electricity network and operate using generators, they are only able toprovide medications that do not need refrigeration. There are no pharmacists

in the clinics thus the nurse has two duties. Residents, who need medications

that cannot be supplied by the clinics, are forced to reach the clinics

located in townships5, the cost of which causes some not to take their

medications.

Language: The medical staff in the clinics usually speaks only Hebrew, a fact

that does not enable the mothers to communicate with the doctors. They have

troubles explaining the problem as well as understanding the orders given to

them by the medical staff.

Primary Mother-Child-Health care clinics: Even though there are clinics in

twelve villages, only eight also have Primary Mother-Child-Health care

clinics. These operate twice a week in the mornings, a fact that causes a

heavy burden.

The Lack of Services to Un-Documented Children:

Thousands of Un-documented (status-less) children live in Israel and

especially in the unrecognized villages in the Negev.6Since the entitlement to

health services under the National Health Insurance law is stipulated to

residency, a large number of children have no health insurance and are not

entitled to medical care, except in a state of emergency. A settlement

providing health services in return for payment, to un-documented children,

was validated in February 2001 by the "Meuhedet" health fund. The services

included in the basket are equal to those included in the national health

basket provided to Israeli residents. Yet, one of the limitations of the

settlement is that if one of the parents is Palestinian, the child is not

entitled.7

This limitation practically prevents the only alternative for

receiving medical care from most of the un-documented children in the villages

(except for private medicine). Despite the limitation, the children in the

villages that are entitled for the settlement suffer from accessibility

problems, since there is no "Meuhedet" health fund in the villages.

5 Between 1968 to the 1980's, the state established 7 townships: Rahat, Tel-Sheva, Hura,Laqye, Segev-Shalom, Kuseife and Ar'ara. The townships, as opposed to the villages,have been recognized by the state, and are connected to the infrastructures and haveclinics.6In a survey conducted by PHR-Israel and the "Women Promote Health" group discussedlater in this paper - 5 out of 70 women reported that their children have no healthinsurance since they have no legal status.7Ran Cohen, coordinator immigrants and non residents project, PHR-Israel. Thesettlement suffers from additional, problematic limitations: the settlement is

voluntary and based on the parents responsibility to sign their children and pay forthe service, and not on every child's right to health, as opposed to Israeli childrenwho are entitled to health services, without registration and payment; there is a sixmonth waiting period for entitlement for children who were not born in Israel; theinsurance does not cover health care for a condition that existed prior to the entranceto Israel; the treatment is expensive; etc.


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Children's Right to Health in the Unrecognized Villages in

the Negev: Situation Report

The children in the unrecognized villages in the Negev suffer from a threefold

discrimination: being residents of the south they suffer from higher morbidity

and mortality rates and lower availability of medical services compared to the

rest of the country; being a part of the Arab minority in Israel they suffer

from higher morbidity and mortality percentages and lower availability of

medical services compared to the Jewish majority; being Arab-Bedouin, the

residents of the unrecognized villages in the Negev suffer from higher

morbidity and mortality percentages and lower availability of medical services

compared even with the Arab minority.

Since the villages in the Negev are not recognized by the state, they remain

invisible to the different authorities. Thus, for instance, they are notregistered in the Central Bureau of Statistics, the Ministry of Health and the

Soroka Medical center; therefore there is no available information about their

medical condition. The little information we found about the unrecognized

villages in the Negev, had been classified according to the residents' tribal

origin and not according to the village in which they reside. As a result, it

was difficult to receive exact data about the medical condition of the village

children. For instance, when we wanted to check the percentage of child

emergency admissions of children from the villages compared to those from

townships and Jewish children, we faced a problem: The Soroka Medical Center

had information about children according to their tribal origin and notaccording to their village so that we were unable to ascribe the children to a

specific village or township since members of one tribe can reside both in a

township and in an unrecognized village.

Data collection constitutes a necessary basis for dealing with inequality in

health. The lack of a data base specific for the population of the

unrecognized villages does not allow dealing with the problem and helps in its

perpetuation8.

Children's Health Condition in the Unrecognized Villages in the NegevThe childhood years are critical. Poor health might influence the child's

general functioning throughout his entire life. Not treating health problems

might cause an untreatable health condition later on. The poor housing, living

and hygienic conditions, the lack of infrastructures, electricity, water,

sewage, roads, public transportation and health services, along with the

socio-economic status and the demographic-social characteristics of the Arab-

Bedouin population in the Negev, have a crucial effect on the residents'

health conditions in general, and that of their children in particular.

8Avni, s. (April, 2007). PHR-Israel. "The Right to Health among Arab-Palestinians inIsrael: A Comparative Look." A Report for the International Health Day.


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Injury, high morbidity, many emergency admissions and high mortality among

Bedouin children, are extremely common phenomena9:

Infant Mortality:

The rate of infant mortality in the Arab-Bedouin population in the Negev is

one of the highest in Israel: in 2005 the rate of infant mortality was 4.72

out of 1,000 live births among the Jewish population compared to 15.45 out of1,000 live births among the Arab population.

10

In 2006, the rate of infant mortality in the general population was 5.5 out of

1,000 live births. The rate within the Jewish population was 3.1 out of 1,000

live births and 13.7 out of 1,000 live births within the Arab population in

the Negev. It should be mentioned that even if congenital deficiencies are the

leading death factor among Arab children, it does not serve as an explanation

for the gap.

Morbidity:

The lack of infrastructures running water, sewage and the lack of

electricity leads to poor hygienic conditions which cause contagion of

infective illnesses among children; A "diarrhea epidemic" erupts every August,

during which 16,000 Bedouin children are admitted to hospital every year,

compared to 5,000 Jewish children; that is to say that while the Bedouin

children constitute only 15% of the entire population of the Negev, they

constitute 80% of the entire children population admitted to hospitals11; the

lack of adequate physical and environmental conditions lead to domestic

accidents, road accidents, burns, poisoning, inhalation of foreign bodies and

drowning; the environmental conditions expose the village children to numerous

dangers such as snakes, scorpions, frostbites and sun burns; and living close

to Ramat Hovav results in respiratory illnesses, oncological illnesses and a

higher risk of general morbidity.

The poor economic state of the residents along with the loss of the

traditional way of life, leads, among others, to malnutrition among their

children a study showed that Bedouin children residing in the unrecognized

villages have a 2.4 times higher chance of suffering from malnutrition,

compared to those residing in townships (such as Rahat).12

In addition, the small number of Family Care Units in the villages makes the

pregnancy supervision, necessary for the early diagnosis of congenital

deficiencies13, growth supervision and proper development of infants - hard.

9Weisblai, A. (November 20, 2006). "Situation Report Bedouin Children in the Negev."Submitted to the 'committee on the Rights of the child'.10National data on infant and child mortality until the age of 5 in Israel December20, 2005, the Ministry of Health.11O. Almi (May 2006). PHR-Israel. Water Discipline: Water, the State and theUnrecognized Villages in the Negev.

12Ofer Meir, Ynet. "A New Study Reveals: Malnutrition among First Graders in theSouth." 6.2.2005.13Sofer, S. (2006) in: "Environmental (in) Justice Report: Health, Environment andSocial Justice." Environmental Justice Committee.


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The rate of vaccine coverage among Arab-Bedouin in the Negev is 5% lower than

the rate in the Jewish sector.14

A larger number of Bedouin infants are hospitalized compared to Jewish

children: in 2003 the rate of Bedouin children admitted was 32% compared to

about 8% among the Jewish population. The high rate of admissions among

Bedouin infants is attributed to the high rate of congenital deficiencies,accidents and illnesses. Since 2000, we can see a decrease in the admission

rates of infants among both populations, especially among the Bedouin

population.15

According to Prof. Shaul Sofer16, based on data from the Soroka Medical Center,

compared to Jewish children: more Bedouin children go to emergency units; more

Bedouin children need to be admitted to pediatric wards; more Bedouin children

need to be admitted to emergency units and a growing number die due to their

illness. In addition, Bedouin children that reach the emergency units arrive

at a critical stage of the illness, due to a delayed diagnosis deriving fromthe lack of medical services, infrastructures, roads and community access

routes.

9.1% 0f the Bedouin children in the Negev are children with special needs

(suffering from physical, cognitive and different mental disabilities)

compared to 7.7% out of the entire Israeli population. This rate is higher

even in comparison with the parallel rates among the Arab and Jewish

populations in Israel (8.3% and 7.6% respectively). 7.9% of the Bedouin

children suffer from learning disabilities or behavioral and emotional

problems.17

Health Services Availability for the Children of the Unrecognized

Villages in the Negev

"Clalit" is the health fund operating all primary clinics (except for one run

by "Leumit" in Algrain/said village) in the unrecognized villages in the

Negev.

Only about 60% of the residents of the villages in which clinics are located,

are registered in their clinics (Graph number 1)18. Conversations of the "Women

Promote Health" group with residents, show that due to the long distance of

the clinics from the village center and due to the lack of basic services such

as medications, professional medicine (especially pediatrics), limited

14The Health System in the Negev Description of the existing conditions and needs

during the development of the area according to the national plan. September 2005.15Weisblai, A. (November 20, 2006). "Situation Report Bedouin Children in the Negev."Submitted to the 'committee on the Rights of the child'.

16Sofer, S. (2006) in: "Environmental (in) Justice Report: Health, Environment andSocial Justice." Environmental Justice Committee.17Strosberg, N., Naon, D., Ziv, A. (July 2008). Shatil and the Regional Council for theUnrecognized Villages in the Negev. "Special-needs Children in the Bedouin Populationof the Negev: Characteristics, Patterns of Service Use, and the Impact of Caring forthe Children on the Mothers."18

The datum regarding the number of insured residents was submitted by the RegionalCouncil for the Unrecognized Villages. It was submitted following a freedom ofinformation appeal to the supervisor from the "Clalit" health fund Mrs. Noa Denai.There are more insured patients In the Al-Zarnoog clinic than residents. According tothe Regional Council for the Unrecognized Villages, the reason is that residents fromadjacent villages -Khashm Zanna and Beer Al-Hamam, go to that clinic.


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reception hours etc., many residents prefer to receive the treatment in the

townships. The residents told the women that those who are registered to the

village clinics belong to the most weakened populations families with many

children, living on income support benefit, families that do not own a car,

widows, second wives and elderly people.

The Number of "Clalit" Patients in Villages with a "Clalit" Clinic

0500

1,0001,5002,0002,5003,0003,5004,0004,5005,000

BirHadaj

UmmMa

tnan

QasarAlsi

r

UmBate

enDa

rijat

WadiGh

wain

Algrain

AbuT

alul

Al-Za

rnug

Number of residents

Number of clalit patients

In order to examine the medical services available to the residents of the

unrecognized villages in the Negev, compared to the Jewish residents living in

adjacent settlements in the Negev, we conducted a comparison between three

unrecognized villages (Bir-Hadaj, Algrain and Umm-Matnan the three villages

with the highest number of residents) and three Jewish adjacent settlements

(Meitar, Omer and Lehavim)19:

The clinics in Meitar, Omer and Lehavim offer a wider range and variety of

medical services. All of them have pediatricians and gynecologists, an

expertise that is not available for the residents of the unrecognized villages

in the Negev. The reception hours of the clinics situated in the Jewish

settlements are spread out throughout the day, they are more accessible and

offer services such as a pharmacy, dietitian and so on, which are not

available in the village clinics.

19The data are taken from the "Clalit" health fund website.

Graph Number 1


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See appendix for additional comparative data between the clinics)(

These gaps are especially pungent considering the data regarding the high

morbidity and mortality of the children in the unrecognized villages, compared

to Jewish children and considering the data regarding the social-economic

conditions of the residents of the unrecognized villages compared to those in

adjacent settlements: Meitar, Lehavim and Omer head the social-economic

stratification made by the Central Bureau of Statistics (clusters 9,9 and 10

respectively) compared to the unrecognized villages in the Negev which stand

at the bottom (they are actually not graded but the townships such as Ar'ara

in the Negev, Segev Shalom, Laqye and Rahat, are graded at the bottom of the

table cluster number 1).

The Accessibility of Health Services to the Children in the

Unrecognized Villages in the Negev

Seventy women, mothers to children, were interviewed by the "Women Promote

Health" group, accompanied by PHR-Israel, in order to examine the children's

accessibility of health services in the unrecognized villages in the Negev.

The survey focused on the extent and manner of use of health services in the

village clinics and on the limitations in receiving the service, while

focusing on the medical needs of the children and the existing solutions to

these needs.The interviews were conducted face to face, using a structured questionnaire

in Arabic, in their homes or in the clinics (in four villages Wadi Alna'am,

Um Bateen, Alsurra, and Al-Zarnug).

The ages of the interviewed women: 51% are 20-30 years old, 32% are 30-40

years old, and 17% are over 40 years old.

Education level of the interviewed women: 22.8% havent studied at all, 34.2%

haven't finished high school, and 38.5% finished high school. The rest (3

women) acquired higher education.

Average Number of Children: 6. The answer to the question - "Does any of your

children suffer from a chronic illness": 20% of the women responded that they

38

0

81.5

0

31

0

109

55

214

36

83

36.5

0

50

100

150

200

250

MeitarBir Hadaj

OmerAlgrainLehavim

UmmMatnan


pediatrician


All physicians


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have a child suffering from a chronic illness and needs monthly supervision,

medications and treatment on a regular basis.

The Findings of the Interviews:20

Medical Services Usage:

In response to the question: "Were most of the visits to the clinic aimed for

your children or for you or your husband?" 90% of the women answered that most

of the times they visit the clinic due to their children's needs.

In response to the question: "Who do you usually turn to when your child is

ill21?" they gave the following answers:

55% of the women said that they visit the village clinic "most of the

time"; the rest said that they "never" visit the clinic or only

"sometimes".

20% of the women said that they visit a private physician "most of the

time"; 55% "sometimes" visit a private physician.22

Few women visit the emergency unit "most of the time"; 53% visit it"sometimes".

31% of the women visit a clinic in another village "most of the time";

32% visit it "sometimes".

In response to the question "Have you ever visited the village clinic and

later on had to visit another clinic in order to complete the treatment of

your children?": 48% of the women said they had to visit another clinic. Out

of them, 77% reported visiting a private physician, 13% reported visiting the

emergency unit and the rest visited a clinic in another village or the same

clinic again:

20The interviews were conducted in Arabic. The answers refer to the percentage amongthe women who answered the specific question.21

When answering this question we asked them to refer to 5 categories village clinic,private physician, emergency unit, traditional care and a clinic in another village. Ineach of the categories, they were able to tick "most of the time", "sometimes" or"Never".22 Regarding the reasons for visiting a private physician, read further in this sub-chapter.


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Graph Number 2

In response to the question "why did you need another visit?" 87.5% said that

the treatment at the clinic "did not help".

In response to the question "In the past year, have you visited the emergency

unit with your children?" 32% said that they visited the emergency unit with

their child in the past year.

In response to the question "In case you visited the emergency unit, what was

the reason for visiting it?" the women said:

24% due to diarrhea20% due to a high fever

16% due to an unsuccessful treatment by the clinic physician

12% due to dehydration

The rest visited the emergency unit due to a fracture/shortness of breath/

loss of consciousness/burn/swallowing of a foreign body.

051015202530

Diarrhea

The treatment didn't work

High fever

A fracture

Lack of oxygen

loss of consciousness

Swallowing of a foreign body

Dehydration

A burn

Graph Number 3

Accessibility to Medical Health:

In response to the question "How do you get to the clinic?" 50% of the women

said that they reach the clinic with the child, on foot, and that they have no

If you ever visited an additional health care provider who did you visit?

010203040506070

8090

Private physicianClinic inother village

Same clinic

Emergency care

%


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other way of reaching the clinic. The women described the difficulty in

reaching the clinic, especially when the child is ill and they are forced to

walk a long distance in adverse weather the terrible heat in the summer and

the rain and harsh cold in winter. They emphasized that it is especially hard

for pregnant women who are forced to carry their children. The lack of a paved

road, suitable for walking and/or driving, adds to the poor accessibility to

the clinic.

In response to the question "What is the walking distance from your home to

the village clinic?" 51% of the women replied that it takes between 5-15

minutes, 35% indicated that it takes between 20-40 minutes and 14% indicated

that it takes between 60-120 minutes.

Among the women that reach the clinic by car, 65% mentioned that it takes

between 10-20 minutes and 35% mentioned a 25-30 minute ride. Due to the lack

of public transportation in the villages, the women arrive with their husband

or a relative. One might assume that a large proportion of the women will notreach the village clinic unless their husband or a relative drives them and

their children, due to the distance between their home and the clinic.

Cultural Accessibility (Language):

In response to the question "Do you need help with the Hebrew language?" 56%

of the women replied that they did. In response to the question "If so, who

helps you translate?" 53% of the women replied they were helped by their

husbands or relatives while 24% of the women were helped by the medical staff

or by passers-by.

Turning to Private Medicine :

Turning to private pediatric medicine is a common, increasing phenomenon among

the residents of the unrecognized villages in the Negev. The major reason is

the lack of pediatricians and the limited reception hours in the village

clinics. The private physicians receive patients at more convenient hours when

the village clinics are closed in the afternoons, in the evenings and on

Fridays, thus serving as an alternative solution for visiting the "Moked"

service center when needed. In addition, the private physicians offer their

service in Arabic, showing cultural understanding since they belong to the

same culture. Turning to private medicine is not common only among the

residents of the villages. Many insured patients turn to it also when the

services are offered by the public health system. However, pediatrics is a

trivial service provided in clinics throughout Israel, an alternative that is

not provided to the residents of the unrecognized villages in the existing

clinics. Therefore, turning to private medicine is almost an inevitable

default and many pay for private medicine instead of receiving the service in

the existing clinics.

Taken from an interview with A' a pediatrician owning a private clinic:

I opened a private clinic since I could not accept the current state of

affairs. People are looking for me at home; if I were to receive patients in

the village clinic people would not come to my home. I did not intend to open


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a clinic but people know me and they know where I live. If a woman comes to me

with her child who suffers from a high fever I cannot send her home or for

treatment elsewhere when I know how difficult it is for her to come at such

hours to the village clinic or to the emergency unit. The emergency unit is

not the solution for her child's condition and it is a shame that she go there

when it is not needed. In the beginning, people came to my home and I could

not refuse to provide their children with the treatment; "this one" knows meand "this one" I have treated in the past. Sometimes, mothers expect me to

treat their children the same way I treated their neighbor's son. In the end,

I was forced to open a private clinic. People come to me because they know I

am a pediatrician and they want to receive the best treatment for their

children. I feel bad when people pay double to the health fund and to the

private physician. I thought that the minute I started charging for the

treatment people would stop coming but that was not the case they come and

pay".

H', from Assir:

My son had medical problems. When I approached the family physician in the

village clinic, he gave him a medication and said: "it will pass." The problem

was not solved, I came back many times and in the end, the child was admitted

to the hospital, suffering from severe kidney problems. This was caused due to

a negligent treatment by the clinic doctor. I do not visit the clinic anymore,

and go straight to a private pediatrician."

In conclusion, the above mentioned findings show a lack of accessibility of

the village clinic to their residents a lack in specialist physicians, a

long distance from the village center, limited reception hours and an

inability to communicate. Therefore, the women turn to alternative solutions

private pediatricians, clinics in townships where pediatricians receive

patients and even to the emergency unit.

Half of the women who visit the village clinic report that they are anyway

forced to turn to another solution with the same problem. About three quarter

of them, turn to a private physician, a time consuming and expensive solution.

The main reason for turning to another solution is the feeling that the family

physician did not solve the problem. Even though this problem exists outside

the unrecognized villages in the Negev, the high percentage of those looking

for other solutions, such as visiting the emergency units (a third of the

women), might indicate problems in communication between the physician and the

mother (language), a sense of disbelief caused by the fact that the physician

is not a pediatrician, and a sense that no medical answer to the patient's

needs is supplied.

This duplication causes not only a waste of time and resources by the

individual but also a more costly service emergency units and an economic

burden on the health system in general, due to lacking available primary

medicine.


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The State's Duty to Realize the Right to Health23

The right to health was anchored in international conventions signed by the

state of Israel and in local rules: The National Health Insurance Law and The

Patients Rights Act. According to these, the state is obligated to make sure

every person residing within its borders has access to medical services and to

the Underlying Determinants of Health.

Non discrimination and equality constitute repetitive central motives

throughout the International Covenant on Economic, Social and Cultural Rights,

ratified by the State of Israel in 1991, as well as in the general comment 14

of the monitoring committee, concerning article 12 of this covenant which

deals with health. According to these, the state must ensure, among others,

non discrimination in accessibility to health services and to "necessary

conditions" for health.

One of the state's core obligations24

is to ensure that accessibility to health

services will be fulfilled in an in discriminatory fashion to all, and

especially to vulnerable or marginalized groups. The covenant outlines the

need to take measures to reduce infant mortality and promote the healthy

development of infants and children, to prevent infectious diseases and treat

them, to create health services infrastructure.

The UN Convention on the Rights of the Child (1989) acknowledged "the right

of the child to the enjoyment of the highest attainable standard of health"

and stresses that the state should pursue full implementation of this right

and, in particular, shall take appropriate measures."25

The National Insurance Law came into force in 1995, and set the rights of the

individual to health services and the state's obligation to fund these

services. The law's major principles "Justice, Equality and Mutual Help"

helped in reducing, to some extent, the inequality between different residents

in Israel.

The Patients Rights Act came into force in 1996, and anchored the patient's

rights toward the medical factor the physician and the medical institute.

One of the articles of the law stresses that "a care giver or a medical

institute shall not discriminate one patient from another based on religion,

race, sex, nationality, state of origin, sexual tendency or other."26

Yet, The National Insurance Law and The Patients Rights Act did not offer a

sufficient response to reducing the inequality between different residents in

general and between Jews and Arabs in particular. Although every resident is

entitled, by law, to equal services, in fact there are gaps in availability

and quality of the services provided in different settlements; the residents

23This chapter was written by Shlomit Avni-Ouaknine, based on: Avni, S. (April 2008).PHR-Israel. "The Right to Health among Arab-Palestinians in Israel: A Comparative

Look."A Report for the International Health Day.24An obligation the state must endure according to the International Covenant onEconomic, Social and Cultural Rights, regardless of its condition.25Convention on the Rights of the Child, 1989, article 24.26High Court Petition 4540/00.


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17

of the unrecognized villages in the Negev suffer from the poorest health data

in Israel and poor availability and accessibility to health services

clinics, family care units, specialist medicine, equipment, pharmacy services

etc.

It is the state's obligation to reduce the gaps mentioned in this position

paper health level, availability and accessibility of medical services and"necessary conditions" for health derived from international conventions and

local laws. The state's obligation to initiate an active action to reducing

these gaps also has a medical logic (since it will improve the health

condition of the Arab-Bedouins in the Negev) and an economic logic (since an

ill population needs more medical services, more expensive and complicated

services and "costs" working days, pensions etc.); it is its human and moral

right.

Summary and Recommendations

The state of Israel, committed to the health of its entire population does not

provide equal medical services to the residents of the unrecognized villages

in the Negev in general and to their children in particular. The existing

services in the few clinics established in the villages, lack basic services

such as pediatrics and gynecology. This lack is especially visible due to the

inequality in the range and variety of the services in the unrecognized

villages compared to adjacent Jewish settlements.

The establishment of the clinics, most of which were built only after a high

court petition27, is but a partial step towards the realization of the

residents' right to health. A full realization requires connecting the

villages to water and electricity and additional necessary conditions for

health. Yet, this is not enough: the right to health is connected with the

right to equality, therefore, clinics offering a poorer scope and variety of

services compared to the services available for residents in clinics outside

the unrecognized villages, violates the equal right of the residents of the

unrecognized villages for unified health services. Moreover, The National

Insurance Law emphasized not only equality but also the value of justice whichmeans bigger investment in service development especially where it is most

needed. Since the residents of the unrecognized villages suffer higher

morbidity and mortality rates, the state must initiate differential investment

in the building of health services especially among them.

With regards to pediatrics, in many places in the world, the family physician

is the main caregiver of the child and the pediatrician serves as his advisor

(in England, for instance). This method has many advantages: one of which is a

comprehensive understanding of the familys needs. However, the fact that

there is no pediatrician in the village clinics, where there are numerous

27High Court Petition 4540/00.


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18

children, with high morbidity and mortality rates and given the harsh living

conditions, raises questions and calls for action.

Recommendations for Policy Change28

1) The state must recognize the villages while including them in the

process.

2) The state must connect the unrecognized villages to all nationalinfrastructures, especially to the water network. The clinics must be

connected to the electricity network in order to allow, among other

things, the refrigeration of medications.

3) The state must act so that the scope, variety and quality of services

provided in the village clinics are equal to those available in most

primary clinics in other settlements. Therefore, the state must provide

the existing clinics with pediatricians and gynecologists and broaden

the existing services available in the family care units.

4) The state must initiate differential investments especially in

developing the scope and variety of medical services in the unrecognized

villages, due to the health data of the village residents.

5) The state must initiate and implement planning programs aimed for

reducing the morbidity and mortality rates among the residents of the

unrecognized villages in general and their children in particular, in a

culturally adapted manner.

6) The medical services must be adapted to the residents' cultural and

labial needs.

Author: Heijer Abu Sharb Translation from Hebrew: Noga Almi

Research: Heijer Abu Sharb, the "Women Promote Health" group:Najah Abu-Nadi,

Maliha Al-Nasasarah, Nasra Al-Walidi and Amira Al-Hawashla

Author of the summary and the chapter: "The State's Duty to Realize the Right

to Health": Shlomit Avni-Ouaknine

Questionnaire writing and analysis of results: Dr. Nadav Davidovich, Gila

Zelikovich

Data collecting for the survey (interviews using questionnaires): Amira Abu-

Kuydar, Hana Abu-Kuydar, Asma Abu-Kuydar, Amira Al-Hawashla, Nasra Al-Walidi,

Sawsan Abu-Kaff, Sabrin Abu-Kaff, Zuhara Abu-Gharbi, Ismahan Abu-Kuydar

Content editor: Shlomit Avni-Ouaknine

Lingual Editor: Hadas Ziv

This publication was produced with funding from the European

Commission through Oxfam GB. The contents of this document are the sole

responsibility of Physicians for Human Rights-Israel and can under no

circumstances be regarded as reflecting the position of the European

Commission.

28Based on the recommendations submitted to the Goldberg Committee: Abas, w.Regularization of the Bedouin settlement in the Negev PHR-Israel's position.


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Appendix: Comparison of the Services Provided in Meitar,

Omer and Lehavim to the Services Provided in Bir Hadaj,

Algrain and Umm-Matnan29

A comparison of the services provided in the Meitar "Clalit" clinic and the

Bir Hadaj "Clalit" clinic:

Bir Hadaj ClinicNumber of residents 5106 Number of "Clalit" patients242960% of the residents are under 19

Meitar ClinicNumber of residents 6900 Number of "Clalit" patients426336.1% of the residents are under 19

RemarksReceptiondays and

hours

Number ofreceptionHours per

Week

Number ofphysician

s

SpecialtyRemarksReceptiondays andHours

Number ofreceptionHours per

Week

Number ofphysician

s

Specialty

Number ofinsuredchildren301564

Number ofchildrenwithchronicillnesses108

000Pediatrics


Sun-Fri7:30-12:00,17:00-20:00

382Pediatrics

WednesdayThursday8:00-15:30

Sun-Thu8:30-16:00

552Familyphysician

Sun-Fri6:30-12:00,

17:00-20:00

677Familyphysician

0Gynecologist

Once aweek7:30-11:30

41Gynecologist

55Totalnumber ofhours

109 hoursTotalnumber ofhours

The clinic operates 5 daysa week between 8:00-15:30Lab servicesTwice a week: Monday,Wednesday 8:30-9:30Family care unit: twice a

week 8:30-15:30

Additional ServicesThe clinic operates 6 daysa week between 6:30-12:00and 16:30-20:00Lab services 5 days aweek: 7:00-9:30Dietitian twice a week

7:30-11:30 and 16:30-19:30Pharmacy 6 days a weekFamily care 5 times aweek 8:00-11:00, oneevening16:30-19:00

Additional Services

A Comparison of the two clinics reveals gaps in the scope and the variety of medical

services:

1. The Meitar clinic has two pediatricians with a total of 38 weekly hours while

the Bir Hadaj clinic has no pediatrician at all, despite the fact that there are

more children in Bir Hadaj according to the "Clalit" health fund, 64.3% of the

patients are children between the ages of 0-18 (compared to 36.1% in Meitar

between the ages of 0-19. We assume that the percentage of the children between

the ages of 0-18 insured in the "Clalit" health fund is not different from their

percentage in the population).

2. The Meitar clinic has seven family physicians with a total of 67 weekly hours

1.57 weekly hours per 100 patients; the Bir Hadaj clinic has two family

physicians with a total of 55 weekly hours 2.26 weekly hours per 100 patients.

3. Apart from family physicians and pediatricians, the Meitar clinic has a

gynecologist 4 hours a week. The Bir Hadaj clinic does not have any at all.

29The number of the residents was calculated on the basis of the number of residents in2004 (according to data from the Regional Council for the Unrecognized Villages) whilecalculating the Muslim population growth in the south in 2004-2006 (according to datafrom the Central Bureau of Statistics). The number of residents in the Jewishsettlements is also taken from data from the Central Bureau of Statistics, referring to

2006.30Calculated according to ratio of residents between the ages of 0-19 in Meitar (CBS,2006): 36.1% out of 4263 "Clalit" patients.31The number of patients in the "Clalit" health fund between the ages of 0-18,according to data received on January 6, 2008, following a correspondence conductedwith Clalit by the group and PHR-Israel.


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4. The total number of reception hours in the Meitar clinic 109 hours, which are

2.55 weekly hours per 100 patients compared to 2.26 per 100 patients in Bir

Hadaj. It should be noted once more that apart from the larger number of

physicians' reception hours per capita, the Meitar clinic provides specialized

physicians in three different fields while in Bir Hadaj the family physician

receives all the patients, regardless of their medical needs.

5. The clinic in Meitar is open 6 days a week while the Bir Hadaj clinic is open 5

days a week.

6. The Meitar clinic gives services all day round both in the morning and in the

afternoon while the Bir Hadaj clinic is open only until 16:00.

7. The Meitar clinic provides pharmacy and dietitian services, which are not

provided in the Bir Hadaj clinic.

8. The lab services in Meitar operate 5 days a week for two and a half hours daily,

while in Bir Hadaj they operate only twice a week for an hour daily.

9. The family care unit in Meitar operates every morning and once a week in the

afternoon, while in Bir Hadaj the same service operates only two mornings a

week.

It should be mentioned that the Meitar clinic is more accessible to its patients due to

proper infrastructures and public transportation while in Bir Hadaj the roads to the

clinic are not paved and there is no public transportation.

In addition, it is important to mention that in Meitar the residents have another

independent "Clalit" clinic (which according to the internet website of the health fund

"receives patients from Meitar and the South Mount Hebron area only") as well as a

"Meuhedet", a "Leumit" and a "Maccabi" clinic.


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A comparison of the services provided in the Omer "Clalit" clinic and the

Algrain "Clalit" clinic:

Algrain ClinicNumber of residents 4267 Number of "Clalit" patients193160% of the residents are under 19

Omer ClinicNumber of residents 6924 Number of "Clalit" patients412928% of the residents are under 19


hours

Number ofreception

hours perweek

Number ofphysician

s

SpecialtyRemarksReceptiondays and

hours

Number ofreception

hours perweek

Number ofphysician

s

Specialty

Number ofinsuredchildren1311Number ofchildrenwithchronicillnesses121

000Pediatrics


Sun-Fri6:30-12:00,17:00-19:30

81.54Pediatrics

Sun, mon,wed 8:00-16:00,Tue-8:00-14:00,thu-8:00-

13:00

361FamilyPhysician

Sun-Fri6:30-12:00,

17:00-20:00

129.56FamilyPhysician

000Gynecologist

Once aweek-16:30-19:30

31Gynecologist



The clinic operates 5 daysa week between 8:00-16:00Lab services - twice aweek: Monday, Wednesday8:30-9:30Family care unit: twice aweek 8:30-15:45

Additional ServicesThe clinic operates 6 daysa week between 6:30-12:00and 16:30-20:00Lab services 5 days aweek: 7:00-9:30Pharmacy 6 days a week 7:00-11:00 and 16:30-20:00The clinic providesfetoprotein test on a daily

basis

Additional Services


services:

1. The Omer clinic employs 5 pediatricians and provides 81.5 weekly hours while in

Algrain there is no pediatrician at all, despite the fact that there are more

children in Algrain according to the "Clalit" health fund 67.8% of the

patients are children between the ages of 0-18 (compared to 28% of the entire

Omer population who are between the ages of 0-19. We assume that the percentage

of children between the ages of 0-18 is not different from its percentage in the

general population).

2. The Omer clinic employs 6 family physicians and provides 129.5 weekly hours

3.13 weekly hours per 100 patients in Omer; the Algrain clinic employs one

family physician providing a total of 36 hours 1.86 weekly hours per 100

clinic patients.

3. Apart from the pediatricians and the family physicians, the Omer clinic provides

a 3-hour weekly service of a gynecologist while the Algrain clinic has no

gynecologist.

4. The total reception hours in the Omer clinic are 214, which are 5.18 hours per

100 patients, compared to 1.86 per 100 patients in Algrain. It should be noted

once more that apart from the larger number of physicians' reception hours per

capita, the Omer clinic provides specialized physicians in three different

fields while in Algrain the family physician receives all the patients,

regardless of their medical needs.

32Calculated according to the ratio of residents between the ages of 0-19 in Omer (CBS,2006): 28% out of 4129 "clalit" patients.


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5. The Omer clinic operates 6 days a week while the Algrain clinic operates 5 days

a week.

6. The Omer clinic gives services all day round both in the morning and in the

afternoon while the Algrain clinic is open only until 16:00.

7. The Omer clinic provides pharmacy services, which is not provided in the Algrain

clinic.

8. The lab services in Omer operate 5 days a week for two and a half hours daily,

while in Algrain they operate only twice a week for an hour daily.

9. The Omer clinic provides fetoprotein test 5 days a week, a service not provided

at all at the Algrain clinic.

It should be mentioned that the Omer clinic is more accessible to its patients due to

proper infrastructures and public transportation while in Algrain the roads to the

clinic are not paved and there is no public transportation.

In addition, it is important to mention that there is also a "Meuhedet", a "Leumit" and

a "Maccabi" clinic.

A comparison of the services provided in the Lehavim "Clalit" clinic and the

Umm-Matnan "Clalit" clinic:

Umm-Matnan ClinicNumber of Residents 4467 Number of "Clalit" Patients151960% of the residents are under 19

Lehavim ClinicNumber of residents 5600 Number of "Clalit" patients351736.5% of the residents are under 19


hours

Number ofreceptionhours per

week

Number ofphysician

s

SpecialtyRemarksReceptiondays andhours

Number ofreceptionhours per

week

Number ofphysician

s

Specialty

Number ofinsuredchildren979Number ofchildrenwithchronicillnesses65

000Pediatrics


Sun-Fri7:00-12:00,17:00-20:00

314Pediatrics

Sun-thu8:00-15:30,

36.51FamilyPhysician

Sun-Fri7:00-12:00,

17:00-20:00

494FamilyPhysician

000Gynecologist

Once aweek-17:00-20:00

31Gynecologist

36.5Totalnumber ofhours


The clinic operates 5 daysa week between 8:00-15:30

Lab services - twice aweek: Monday, Wednesday8:00-10:00Family care unit: twice aweek tue, thu 9:00-15:30

Additional ServicesThe clinic operates 6 daysa week between 6:30-12:00

and 16:30-20:00Lab services 5 days aweek: 7:00-9:30Dietitian 3 days a week 7:00-12:00 Pharmacy 6days a week 8:00-12:00and 17:00-20:00Family care unit 3 days aweek, mon-tue8:30-12:00, thu 16:00-19:30

Additional Services


services:

1. The Lehavim clinic employs 4 pediatricians who provide 31 weekly hours while in

Umm-Matnan there is no pediatrician at all, despite the fact that there are 979

"Clalit" patients between the ages of 0-18.


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2. The Lehavim clinic employs 4 family physicians who provide 49 weekly hours 1.3

weekly hours per 100 patients; the Umm-Matnan clinic employs one family

physician providing a total of 36.5 hours 2.4 weekly hours per 100 patients.

3. Apart from the pediatricians and the family physicians, the Lehavim clinic

provides a 3-hour weekly service of a gynecologist while in Umm-Matnan there is

no gynecologist at all.

4. The total reception hours in the Lehavim clinic is 83 hours, which constitute

2.35 weekly hours per 100 patients, compared to 2.4 per 100 patients in Umm-

Matnan. It should be noted once more that apart from the larger number of

physicians' reception hours per capita, the Lehavim clinic provides specialized

physicians in three different fields while in Umm-Matnan the family physician

receives all the patients, regardless of their medical needs.

5. The Lehavim clinic operates 6 days a week while the Umm-Matnan clinic operates 5

days a week.

6. The Lehavim clinic gives services all day round both in the morning and in the

afternoon while the Umm-Matnan clinic is open only until 15:30.

7. The Lehavim clinic provides pharmacy and dietitian services, which are not

provided in the Umm-Matnan clinic.

8. The lab services in Lehavim operate 5 days a week for two and a half hours

daily, while in Umm-Matnan they operate only twice a week for two daily hours.

9. The Lehavim clinic provides family care unit services operating every day while

in Umm-Matnan the services are provided only twice a week.

The accessibility to the Lehavim clinic is also easier than that in Umm-Matnan due to

proper infrastructures in Lehavim.

It should be mentioned that there are additional clinics serving the Lehavim community:

"Meuhedet", "Leumit" and "Maccabi".

Documents

Physicians for Human Rights-Israel: Israel´s Step Children – Position Paper about the lack of pediatrics in the Unrecognized Villages in the Negev and its Ramifications - ENG