physicians for human rights-israel: the bare minimum - health services in the unrecognized villages...
TRANSCRIPT
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The Bare Minimum
Health Services in the
Unrecognized Villages in the Negev
Apri l 2009
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Physicians for Human Rights-Israel (PHR-Israel) believes that every person has
the right to health in its widest possible sense, as defined by the principles of human
rights, social justice and medical ethics. It is the responsibility of the State of Israelto ensure the fulfillment of this right in an egalitarian manner for all populations
under its legal or effective control: residents of Israel who are eligible for National
Health Insurance, Bedouin residents of unrecognized villages in the Negev desert,
prisoners and detainees, migrant workers, refugees and asylum seekers, and
Palestinian residents of the occupied Palestinian territory.
Tel: 972-3-6873718 | Fax: 972-3-6873029
Address: 9 Dror St., Tel Aviv-Jaffa 68135, Israel
Mail: [email protected] | Site: www.phr.org.il
ISSN # 0793-6222
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The Bare Minimum
Health Services in the Unrecognized Villages in the Negev
April 2009
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Physicians for Human Rights Israel (Registered Association)
The Regional Council for the Unrecognized Villages in the Negev
The Bare Minimum Health Services in the Unrecognized Villages in the Negev
Written by: Wasim Abbas
Research: Yaela Raanan Regional Council for the Unrecognized
Villages in the Negev
Wasim Abbas Physicians for Human Rights Israel
Fadi Al-Ubra Physicians for Human Rights Israel
English editing: Libby Friedlander
English translation: Shaul Vardi
Photography: Daniella Cheslow
Design: David Moscowitz
Printing: Gil Dafdefet
Acknowledgments:
The publication of this report was made possible thanks to the support of the
European Union. Physicians for Human Rights Israel bears sole responsibility for
the content of this report, which in no way reflects the position of the European
Union.
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Contents
Introduction
Primary Health Services: Clinics
The Organizational Structure and Profile of the Clinics
Availability of Services
Connection of the Clinics to InfrastructuresAccessibility of Services
Language and Communication Problems
The Family Health Clinics
Availability and Accessibility of Services
Health Outcomes in the Unrecognized Villages: Infant Mortality and Child
Development
Conclusion, Ramifications, and Recommendations: Ensuring Early
Identification and Treatment
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Introduction
This report focuses on the violation of the right to receive health services among the
Bedouin Arab residents of the unrecognized villages in the Negev. The residents of
these villages suffer discrimination due to the grave lack of clinics and family health
centers, and due to problems of supply, accessibility, availability, and suitability in the
sparse medical services that exist in these communities.
The right to receive medical care constitutes one of the most important components ofthe right to health. The International Covenant on Economic, Social and Cultural
Rights clarifies that signatory countries (of which Israel is one) must ensure the
creation of conditions which would assure to all medical service and medical attention
in the event of sickness.1
As with other human rights, the realization of the right to health depends on the
implementation of four basic components: availability, accessibility, suitability, and
quality.
Availability is defined as the presence of health facilities, services, and programs in
sufficient quantity given the needs of the population.
Accessibility requires egalitarian and non-discriminatory access to health facilities,
services, and programs, including the removal of physical, economic, and
information-based obstacles.
Suitability means that the services provided must be adapted to the sociocultural
context of different populations; attention must be paid to the principles of medical
ethics and to the cultural adaptation of services.
Quality requires the maintenance of a standard of medical and scientific services of
sufficient quality.2
The principle of non-discrimination is one of the core obligations incumbent on the
state in realizing the above components.
Israeli law also emphasizes the value of equality in realizing the different components
of the right to health. The National Health Insurance Law, 1994, which regulates the
commitment of the HMOs to provide health services for all residents of Israel,
establishes that national health insurance shall be based on the principles of
j ti lit d t l li bilit d th t th h lth i i l d d i th
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professional standard and medical quality and in terms of human relations,3
and that
a medical care worker or institution shall not discriminate between patients on the
grounds of religion, race, sex, nationality, country of origin, or on any such grounds.
4
The principle of non-discrimination is not implemented in the context of the provision
of medical services in the unrecognized villages in the Negev. The situation in these
villages is far removed from the spirit of the international conventions and domestic
laws. In terms of the states obligations, the availability of medical facilities and
centers in the villages is limited (just twelve clinics for a population of over 83,000
residents). Moreover, the quality of these services is very poor by comparison tosimilar services provided in other parts of Israel. The gulf between the services
actually provided in these villages and the needs of this society prove the depth of the
discrimination against the residents of the unrecognized villages of the Negev in terms
of their equal right to enjoy health services by comparison to their Jewish neighbors.
There can be no doubt that this situation constitutes a substantive violation of the
principle of equality.
Improving the availability and accessibility of these services, and improving the poor
health results of this population, require differential investments in the development
of services in these communities. In practice, however, the situation is the reverse. As
the bodies responsible for providing these services, the HMOs deliver health services
at an inadequate standard in terms of accessibility, availability, and suitability.
Moreover, the state prevents the supply of vital infrastructures and services and uses
the withholding of additional health services as a means of pressure in order to coerce
the residents to move to the permanent towns and to abandon their ownership of land.
These conclusions are based on a field study undertaken by Physicians for Human
Rights Israel and the Regional Council for the Unrecognized Villages in the Negev.
A mapping was undertaken between March and August 2008 examining all the
existing medical services in the unrecognized villages in the Negev. The mapping
included eleven clinics of Clalit HMO; the single clinic of Leumit HMO in the village
of Al-Sayid; and eight family health centers. A comparison was undertaken betweenthese services and those provided in peripheral Jewish communities in the Negev
region5
that share key demographic and geographical features with the unrecognized
villages: Rural clinics at a similar distance from the city and which provide services
for a similar-sized population. The results of this mapping will be presented in detail
i th f ll i ti
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Primary Health Services: Clinics
The population of the unrecognized villages in the Negev has suffered for many years
as the result of the policy of successive Israeli governments to deny recognition to
these communities. This policy has ramifications in terms of the health of the
residents. A report published in February 2009 by the Southern District of the
Ministry of Health The State of Health of Bedouin Babies and Children up to the
Age of Six in the Permanent Communities and in the Unrecognized Villages in the
Negev6
highlights the poor health results among the Bedouin Arab population in
the Negev in general, and in the unrecognized villages in particular. The infant
mortality rate is particularly high; a large proportion of children suffer from
malnutrition; babies have a lower weight at birth relative to the national average; a
high percentage of children suffer from anemia and growth problems, and so forth.
The report recommends the introduction of preventative programs and the
improvement of health-supporting infrastructures (regular supply of water and
electricity, the construction of access roads, removal of sewage, and garbage
disposal). The report also calls for the improvement and expansion of the existing
health services in the villages, i.e. the family health centers and the primary clinics.
Although primary health centers are considered a crucial factor in treating,
diagnosing, and preventing diseases, there were no clinics in the unrecognized
villages until 1994. Prior to the enactment of the National Health Insurance Law,those of the residents who were able to do so (approximately 60 percent) purchased
health insurance and were forced to travel to the clinics in Bedouin or Jewish
communities in their immediate or more distant vicinity. The clinics of Clalit HMO in
the kibbutzim, moshavim, and community villages close to the Bedouin villages did
not accept patients from the unrecognized villages. Services were provided only at
clinics in such cities as Yeruham, Dimona, and Arad7
that were defined as minority
clinics. This situation continues to the present day. A document on this subjectpublished by the Negev Development Authority in 1994 noted that: the population of
the Negev is denied an appropriate health service, and added: On the basis of the
law, the Bedouin population will be eligible to demand health services that are
currently partially or completely absent.8
After the enactment of the law, the vast
j it f th i d l ti i t d ith Cl lit HMO
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The first clinic in the unrecognized villages was established in the village of Al-Grain
in 1994. Since then, a total of twelve clinics have been opened in the unrecognizedvillages; eleven are operated by Clalit HMO and one by Leumit HMO (an additional
clinic operated by the Clalit HMO has also been opened in the new village established
for the Tarabin Al-Sana tribe).
Most of the clinics and family health centers were only opened after petitions were
submitted to the Supreme Court. In June 2000, the Association for Civil Rights in
Israel, Physicians for Human Rights Israel, and the Regional Council for the
Unrecognized Villages in the Negev submitted a petition (HCJ 4540/00) demanding
the establishment of clinics in the villages. The petition asked the state to establish
clinics in three villages9
and to determine criteria for the future establishment of
clinics in Arab communities in the Negev that do not have community clinics. The
states response ignored the demand to determine criteria, but the state undertook to
establish clinics in the villages of Darijat, Wadi Al-Naam, and Al-Zarnug (Abu
Kweidar). In its response dated 11 September 2001, the Ministry of Health noted that
its professional opinion was that clinics should also be established in the villages of
Al-Fura, Abda, Tel Al-Maleh, and Bir Hadaj. In a ruling granted on 14 May 2006,
the judges refrained from instructing the Ministry of Health to determine clear criteria
for the establishment of clinics. However, they ruled that the establishment of clinics
in the Bedouin communities is a vital need that must be met by the state.10
It is
important to note that this undertaking by the state to establish additional clinics has
not been fully implemented. The recommendations by the Ministry of Health to
establish clinics in Al-Fura and Tel Al-Maleh were rejected by the District Planning
and Building Committee and the Ministry of the Interior on the grounds that the
planning status of these villages does not permit the establishment of clinics.
Over the period March-August 2008, Physicians for Human Rights Israel and the
Regional Council for the Unrecognized Villages in the Negev prepared a study
mapping the existing services at all the clinics and the family stations in the
unrecognized villages in the Negev.11
The survey included a visit to each clinic, adiscussion, and completion of questionnaires by the staff. The questionnaires were
based on previous studies undertaken in 2003 by Physicians for Human Rights
Israel and Ben Gurion University of the Negev. The questions were formulated with
the assistance of public health experts and related to diverse issues, including: the
ti f th li i t i f t t ( t l t i it d ) ti
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In addition, on 25 December 2007 we wrote to Clalit HMO under the terms of the
Freedom of Information Law (after sending two requests for information to Mr.Shmuel Lapid, director of the Southern District in Clalit HMO). We verified the
information provided by Clalit HMO with our findings in the field. The information
received on 21 February 2008 was late and incomplete; Clalit HMO claimed that it
did not have additional information beyond that provided.12
It is important to note that
a similar mapping study undertaken in 200313
revealed grave defects in the standard,
availability, and accessibility of services. It is hardly surprising that five years later we
found the same standard of services and similar outcomes. Once again, the study
paints a depressing picture in terms of the standard of services provided at the clinics
in the unrecognized villages. The main problems identified relate to the availability
and accessibility of clinics; opening hours and days; and language and communication
problems. In addition, the standard of services is poor and there is a shortage of
medicines and specialists. These findings will be discussed in detail below.
The Organizational Structure and Profile of the ClinicsMost of the clinics operate in temporary buildings (trailers) placed alongside schools.
They are connected to the national water grid, but electricity is provided by
generators. Most of the clinics have a similar organizational structure: A maintenance
worker, an administrative director, a nurse, and a family specialist and/or general
practitioner. The administrative director is responsible for routine contacts with
insureds, including scheduling appointments.14
Most of the clinics book appointments
for tests and specialists that are not available at the clinic itself, recognizing thedifficulties faced by those who do not speak fluent Hebrew. In addition to the usual
functions, the nurses are also responsible for laboratory tests, which are performed
twice a week in most of the clinics, and for the sale of medicines in the medicine
room. All the physicians who serve in the Clalit clinics in the villages are specialists
or interns in family medicine or general practitioners without a specialization; there is
not a single specialist pediatrician or gynecologist. At the Leumit HMO clinic in the
village of Al-Sayad, a gynecologist sees patients once every two weeks.
12
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Availability of Services
Availability is defined as the presence of a sufficient quantity of facilities meeting the
needs of the population.
At present, 34 villages do not have any medical services. These include Al-Fura, with
a population of 3885; Al-Za'arura, with a population of 2894; and Tel Al-Maleh, with
a population of 1250.15
By way of comparison, Jewish communities with fewer
residents have a primary clinic; examples include Kibbutz Sde Boker, with a
population of 360; Sde Boker College, with a population of 650; and Kibbutz
Revivim, with a population of 900. Lehavim, which had a population of 5569 in 2006,has three clinics staffed by a family physician and pediatrician, as well as regular
visits by specialists. Lehavim also has a pharmacy, whereas there is not a single
pharmacy in all the unrecognized villages. By contrast to Lehavim, Wadi Al-Naam,
with a population of over 6000, has just a single clinic with a family physician and a
nurse.
One of the indicators of the availability of services is the ratio of physicians to
residents. The acceptable ratio in Israel is one physician per 1200-1400 members of
the community (in a healthy and stable community). The figures we collected show
that in the unrecognized villages the physician-population ratio is one physician to
every 3116.7 residents. The physician-insuree ratio (i.e. relating only to those
residents who are registered as insureds in the village clinics) is also high 1531
insureds to each physician.16
For the purpose of comparison we examined the
physician-population ratio in five Jewish communities of similar size (Sde Boker
College, Kibbutz Sde Boker, Srigim, Revivim, and Maagalim). The examination
shows that the average physician-population ratio in these communities is one
physician to every 892 residents.
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Table 1: Average Number of Residents for Each Physician in the Clinics in the
Bedouin Villages and in Jewish Communities
Average residents for Each Physician
511050004430
4100
35003000
2600256025002400
1200100013001250
900650
360
W
adiG
hwain
WadiAl-
Na'a
m
Al-Zarnu
g
Umm
Matn
an
U
mmBatee
n
Qasa
rAlsir
Khirbe
tAl-W
atan
AbuT
alul
BirHad
aAlg
rain
Abda
Darija
t
Srigi
m
Maag
alim
Reviv
im
SdeBo
kerC
olleg
e
Kibbutz
Sde
Boker
Average in the villages: 3116.7 / Average in the Jewish communities: 892
The situation regarding nurses is even worse. Figures we received from Clalit HMO
show that just nine nurses work in Clalits clinics in the unrecognized villages in the
Negev. A tenth nurse is employed in the Leumit clinic in A-Sayad. A calculation of
the nurse-population ratio shows that in the villages there is an average of one nurse to
every 3751 residents, compared to one nurse to every 657 residents in the Jewish
communities examined. The nurse-insuree ratio in the villages is also high one nurse
to every 1769 insureds.
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Table 2: Average Number of Residents to Each Nurse in the Clinics in the
Villages and in the Jewish Communities
The enormous gaps reflected in the figures presented above can only be explained by
profound and ingrained discrimination in the attitude of the State toward its Bedouin
Arab citizens. A policy of narrowing gaps by means of differential investment in a
population whose health profile is significantly poorer than that of any other
population group would require the allocation of at least 60 positions for physicians
serving this population.17
In practice, however, not only is there no such differential
investment, but the number of physicians and nurses is not even close to accepted
levels, and the ratio of health professionals to residents is three times the usual level inIsrael.
The average number of weekly reception hours by physicians per 1000 residents in
the clinics in the villages is also lower than in Jewish communities: 13 reception hours
a week per 1000 residents in the villages, compared to 21 hours in the Jewish
communities.
Average Number of Residents to Each Nurse
3751
657
0
500
1000
15002000
2500
3000
3500
4000
Unrecognized villages
Jewish communities
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Table 3: Average Weekly Reception Hours in Clinics, per 1000 Residents
This grave shortage of physicians, nurses, and reception hours obviously places an
undue burden on the staff in the clinics. The result is that the physicians devotelimited time to each patient. Waiting times are very long over 45 minutes for a
physicians inspection, and several weeks to see a specialist.18
Connection of the Clinics to Infrastructures
In terms of water and sewage infrastructures, all the clinics in the unrecognized
villages are connected to the national water grid. Sanitation levels are adequate most
of the clinics have toilets connected to underground pits for the absorption of waste.
Connection to electricity is considered a vital infrastructure for improving the quality
and availability of medical services. None of the clinics in the villages are connected
to the electricity grid. The clinics rely on generators, most of which are operated only
during the opening hours of the clinic. A small number of clinics are connected to
generators operated automatically at night, enabling the use of a refrigerator to store
medicines requiring refrigeration. In the remaining clinics the lack of an electricityconnection prevents the storage of many medicines, including those used for treating a
wide range of chronic illnesses. Moreover, inoculation doses requiring refrigeration
are brought by the nurses from the parent clinic each morning and returned at the
end of the day. While the nurses willingness to perform this function is admirable,
this method cannot ensure the regular availability of inoculations throughout the
Average Physicians Reception Hours per 100 Residents
13
21
0
5
10
15
20
25
Unrecognized villages
Jewish communities
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due to faults or the lack of diesel. For example, the clinic in Kasr a-Sar (Al-
Hawashleh) was closed several times during 2008 after the diesel container was
stolen.
The subject of the connection of the clinics in the unrecognized villages to the
national electricity grid was discussed in HCJ 6602/07, submitted in 2007 by
Physicians for Human Rights - Israel, The Association for Civil Rights in Israel, and
the Regional Council for the Unrecognized Villages in the Negev. The petition is still
pending.
Specialist Medicine (Pediatrics and Gynecology) and Pharmaceutical Services
Numerous international conventions define women and children as vulnerable
populations and require the State to pay particular attention to ensuring their access to
medical services and the adaptation of these services to meet the needs of these
groups.19
Despite Israels moral and legal commitment to the conventions it has
ratified, our mapping of the clinics revealed that in all the eleven clinics of Clalit
HMO there is not a single specialist pediatrician or gynecologist.20
A gynecologist
comes once every two weeks to the Leumit clinic in Al-Sayad.
The lack of specialist medical services in the village clinics reflects an
incomprehensible policy. Regarding the lack of pediatricians in a population in which
children under the age of seventeen constitute 61 percent of the total (approximately
50,000 individuals), we were informed that pediatric medicine in the community is
considered primary medicine the family doctors in the Clalit clinics in general are
qualified to examine adults and children on the basis of professional training.21
A previous study by Physicians for Human Rights - Israel22
found that
disproportionate numbers of Bedouin children are evacuated to emergency rooms;
require hospitalization in pediatric wards and intensive care units; and die as the result
19See: The International Convention on the Rights of the Child:
http://www2.ohchr.org/english/law/crc.htmThe International Convention on the Elimination of All Forms of Discrimination against
Women:http://www2.ohchr.org/english/law/cedaw.htm
20Our examination of the small rural clinics of Clalit HMO in Srigim, Sde Boker College,and Kibbutz Sde Boker, Maagalim, and Revivim show these clinics also do not have
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of disease. Moreover, Bedouin children arrive at the emergency room in a critical
stage of the disease. These failings are due to late diagnosis as the result of inadequate
medical services, as well as to the lack of infrastructures and facilities, including
roads, transportation, and access to the community. A survey prepared by the Women
Leading Health group as part of a report on the ramifications of the lack of pediatric
care in the villages found that the absence of pediatricians in the village clinics leads
48 percent of women to take their children to alternative clinics. Of this group, 77
percent turn to private pediatricians,23
since these physicians are more accessible than
any other medical source.
The population of the villages is characterized by a young average age and high
pregnancy rates. Accordingly, it would be reasonable to assume that the clinics would
have staff positions for gynecologists. In fact, there are no gynecologists in the clinics,
and an examination by Physicians for Human Rights - Israel24
found that this leads
some 80 percent of women in the villages to go without medical care due to their
remoteness from clinics outside the villages providing gynecological care.25
In addition to the lack of specialist medicine, the clinics also lack pharmacists and
pharmacies (with the exception of the medicine rooms). The absence of a pharmacist
severely limits the stock of medicines due to Ministry of Health instructions stating
that many medicines may only be issued by a qualified pharmacist and not by a nurse.
A further factor limiting the supply of medicines, as already noted, is the fact that the
clinics are not connected to the national electricity grid, and are therefore unable to
store medicines requiring protracted refrigeration. Making pharmaceutical services
accessible to the residents of the villages would significantly alleviate the suffering ofpatients and prevent the considerable expenses and discomfort involved in traveling to
pharmacies in adjacent communities. The low availability of medicines in the village
clinics is particularly problematic for chronic patients requiring constant medication
and can endanger their health. Our conversations with residents and nurses in the
villages suggest that many elderly people and particularly elderly women cannot
travel to a pharmacy to purchase medicine. The unavailability of medicines for some
chronic diseases in the villages effectively denies the patients access to life-savingmedications.
Accessibility of Services
Equal access to medical facilities, services, and information is an essential condition
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conditions, including infrastructures, access roads, and affordable public transport.
The economic condition of individuals also influences their mobility.
During the course of our field study and the collection of data on the health services in
the unrecognized villages in the Negev, we encountered many types of obstacles that
hamper access to medical services. The main problems in the field of accessibility
identified by the results of the mapping study are: The opening days and hours of the
clinics; the location of laboratory services; and communication difficulties between
the medical staff and patients due to the language barrier.
Opening Days and Hours
The official (but partial) statistics received from Clalit HMO claim that the clinics in
the unrecognized villages in the Negev are open five days a week and for
approximately eight hours a day (it was claimed that most of the clinics are open from
8:00 am through 3:30 or 4:00 pm). In the course of our field work, we discovered
discrepancies that cast doubt on the reliability of this information. For example, Clalit
HMO claims that the opening hours at the clinic in Al-Asam are 7:30 am 3:30 pm.
However, our field study showed that the clinic is actually open from 8:30 am through3:00 pm. In some cases the clinics were closed before the stated time; in others, the
clinic remained open but the only physician on duty left several hours earlier.
Testimonies from residents of the village of Al-Zarnug (Abu Kweidar) suggest that
the clinic sometimes closes shortly after 1:00 pm, rather than at 4:00 pm as Clalit
HMO claims.
A physician employed in one of the clinics (who asked to remain anonymous) drewour attention to an additional and serious problem concerning opening and reception
hours. He states that in some clinics the HMO does not send substitute physicians in
cases when the only physician staffing the clinic is absent due to illness or even
planned vacation leave. In some cases, the result is that the clinic is left for a week or
more without a physician, and many residents are obliged to wait for days without
treatment, or to travel to Beersheva in order to receive services.
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Table 4: Average Total Weekly Opening Hours at Clinics in the Villages and in
Jewish Communities
It must be noted that some of the staff in the clinics are aware of the problem
concerning the opening days and hours not only because they are alerted to thisproblem by local residents and committees, but also because they themselves face
similar delays in reaching the clinics. In the absence of public transport, staff are
dependent on transportation organized by the HMO. Each vehicle takes employees to
several clinics, and the result is that staff arrive late or leave early, thus shortening the
official reception hours. Moreover, these logistical problems and the resulting
financial costs are presumably behind the decision not to split the working day and to
provide morning and afternoon reception hours. Whatever the reasons, the fact is thatthe clinics do not provide services in the late afternoon and evening. The exception to
this is the Leumit clinic, which operates a split working day with morning and
evening reception hours.
The clinic in the Jewish community of Nevatim which is defined as a rural clinic,
as are all the clinics in the unrecognized villages is open five days a week. One day
a week the clinic provides services in the afternoon, closing at 7:30 pm.
26
The clinic in the village of Abda, which is situated close to Mitzpe Ramon, opened in
2004 following the petition filed on the subject of the clinics in the unrecognized
villages (HCJ 4540/00), and following a protracted struggle by the residents of the
village to secure recognition and receive basic education and health services The
Average Total Weekly Operating Hours at Clinics
36.8
39.4
35.5
36
36.5
3737.5
38
38.5
39
39.5
40
Unrecognized villages
Jewish communities
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residents secured recognition for their community, including the establishment of a
primary school and the opening of a clinic.
The opening of the clinic following the Supreme Court petition raised hopes that a
proper response would be provided to the health needs of the village, which has a
population of over 1000. These hopes have not materialized. The standard of services
at the clinic is very poor. There are no regular opening hours, and the clinic is
operated by a single physician who in addition to providing medical treatment is
also responsible for administrative management, scheduling appointments, and
opening and closing the clinic. The physician is not present in the clinic most of the
time. Residents requiring a medical examination must call the physician on his mobile
phone. The physician then schedules an appointment according to his ability to reach
the clinic. The physician comes to the clinic, opens it, and treats the patient. If there
are no other patients waiting which is likely, since most of the residents are unaware
that the physician is coming at that particular time he closes the clinic. In some
cases the physician arrives approximately one hour after the patient calls him, while at
other times patients may have to wait for several hours or days.
Due to the poor availability of services, most of the residents of the village choose not
to register with this clinic. Instead, they prefer to travel to the clinic in Mitzpe Ramon
where they can rely on the availability of services and enjoy a much higher standard
of care, including specialist medicine.
The fact that the clinics are not open in the afternoon or on Fridays (the Muslim day
of rest) causes particular hardship for residents who are employed and are obliged tolose work time. The problem is exacerbated by the fact that in most cases women will
not attend the clinic unless they are accompanied by a male relative.
Laboratory Services and Tests
Laboratory tests performed in primary clinics such as blood, urine, and diabetic
tests, blood pressure, pulse, and weight and height monitoring play an important
role in identifying, monitoring, and preventing diseases in their early stages. Ourcomparison shows that the average number of weekly laboratory hours per 1000
residents is one hour in the unrecognized villages, compared to three hours in the
clinics in the Jewish communities. The clinics in the unrecognized villages offer
limited laboratory services basic blood tests, urine, diabetes, pulse, height and
weight Not all of the clinics can undertake ECG tests and blood counts Special tests
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Table 5: Average Weekly Laboratory Hours per 1000 Residents in the Villages
and in the Jewish Communities
Physical Inaccessibility
Many of the clinics are situated on the edge of the village. In most cases the location
was determined by the planning authorities without due attention to residents needs.
A survey of 70 women residents of the villages undertaken by Physicians for Human
Rights - Israel and the Women Leading Health group28
found that due to the
considerable distance of the clinics from the center of the villages, and the lack of
basic services such as medicine, specialist services (particularly pediatrics), limited
opening hours, and so forth, many residents prefer to receive services in the official
Bedouin towns or from private physicians. For example, only 55 percent of the
women usually turn to the clinic in their village, while 45 percent do not visit the
village clinic at all, or do so only occasionally.
In many cases, residents who require services that are not available at the clinic are
obliged to travel long distances. In the absence of public transport, the need to travel
presents a real obstacle that is particularly problematic for the elderly, sick, pregnant
women, and children, all of whom depend on relatives to drive them to the clinic. In
other cases patients are obliged to walk to the nearest road and wait in the open for
busses that take them to the entrance of one of the towns in the area. They must then
board a second bus in order to reach the clinic. It is hardly surprising, therefore, that
Average Weekly Laboratory Hours per 1000 Residents
1
3
0
0.5
1
1.52
2.5
3
3.5
Unrecognized villagesJewish communities
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kilometers away. In the absence of proper public transport or basic transport
infrastructures, the average time required to reach the clinic in Keseifa from Tel Al-
Maleh is approximately two and a half hours in each direction. Accordingly, it is
hardly surprising that most of the residents prefer not to visit the clinic and do not
receive vital services. During the proceedings in the clinics Supreme Court petition
(HCJ 4540/00), the Ministry of Health recommended that a clinic be established in the
village, but the recommendation was not implemented due to objections from the
planning authorities. After correspondence with the Ministry of Health, the Ministry
of the Interior, and the planning authorities over a period of more than three years, a
petition was submitted to the Supreme Court (HCJ 8211/08) by the Association for
Civil Rights in Israel, Physicians for Human Rights - Israel, the Village Committee of
Tel Al-Maleh, and the Regional Council for the Unrecognized Villages in the Negev.
The petition demanded that a clinic be opened in the village. During the first hearing
in the petition on 26 February 2009, the judges decided to postpone the hearings for a
period of six months pending developments in the implementation of the
recommendations of the Goldberg Committee.29
Economic InaccessibilityThe physical inaccessibility described above is exacerbated by socioeconomic factors.
Most of the residents of the villages are unemployed and poor. As a result, it is
difficult for them to afford even subsidized public transport, let alone renting a car or
paying for private transport in the absence of public services. As a result, a population
that is considered the poorest section of the Israeli public is required to spend a
considerable proportion of its income merely in order to reach medical centers. The
result is that the residents are sometimes obliged to choose between food and clothingand medical treatment.
Cultural Inaccessibility
In Bedouin Arab culture in the Negev, women are the main consumers of health
services. This is due to the prevalence of chronic disease (as high as 30 percent30
);
multiple pregnancies; and the social function of women as the main caretakers of
children. However, most of the women residents do not drive and do not leave thevillage unaccompanied, factors that impede their access to medical services. The lack
of cultural sensitivity is also reflected in symbolic aspects. Many of the clinics are
named after specific tribes, rather than using the historical name of the village. This
creates tension within the community and even prevents residents from coming to the
clinics due to their identification with a different tribe
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Language and Communication Problems
Good communication between medical staff and patients is a precondition for apositive relationship that helps promote efficient and high-quality care. Medical
workers need to communicate with patients not only in order to understand the words
they say, but also in order to understand the patients socio-cultural background in
order to determine the most appropriate course of treatment.
A previous study by Physicians for Human Rights - Israel31
found that communication
problems create an extremely substantial barrier for Bedouin Arab women. Thesurvey revealed that linguistic, cultural, and educational gaps contribute significantly
to the defective use of health services. The survey found that 62 percent of women
consider themselves illiterate in Hebrew and 59 percent lack oral skills in the
language. As a result, women find it difficult to understand the explanations given by
medical staff at the clinic and are forced to rely on assistance from other patients or
workers.
Approximately half the physicians in the clinics in the unrecognized villages do not
speak Arabic or have only a basic command of the language. The same is true of
many of the administrative staff, most of whom have only a basic knowledge of
Arabic. The signs in the clinics detailing the opening hours and days are written in
Hebrew in most of the clinics, despite the fact that these clinics do not serve even a
single patient whose mother tongue is Hebrew.
As for informational leaflets and materials, many of the materials are only available in
Hebrew. Special leaflets in Arabic about specific diseases or preventative medicine
issues (such as diabetes, high blood pressure, or smoking) are given to patients on an
individual basis by the physician at his own discretion.
The Leumit clinic in the village of Al-Grain (Al-Sayad) is the only clinic in the
unrecognized villages that is not affiliated with Clalit HMO. There is also a Clalit
clinic in the village. However, Leumit HMO was careful to position its clinic
(established in 2006) in a convenient location for residents, in the center of the
village. The clinic meets a real need and, as a result, has attracted many residents. The
main reason for the clinics success is the significant improvement it makes in the
accessibility of primary medical services, as well the higher standard of services and
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quality and accessibility of the services has met with satisfaction among a growing
number of residents, and the clinic has managed to attract almost 800 insureds to date.
Table 6: Number of Files to Number of Residents, Clalit HMO Clinics in the
Unrecognized Villages
1,050
4,800
1,200
4,400
1,935 1,875 1,7111,490 1,575
800
2,460
586 512
2,036
3,9004,0003,500
2,9003,200
4,050
4,700
1,377
0
1,000
2,000
3,000
4,000
5,000
6,000
Al-G
rin
AbuT
alul
UmBati
n
Kasa
ra-S
ar
Wad
iGwe
in
UmMatn
an
Darija
t
BirH
adaj
Wad
ia-N
a'am
Abda
Al-Z
arnu
g
No. of residents
No. of files
As the table above shows, there is a substantial shortfall between the number of
residents in the villages and the number of insureds registered at the clinics. The gap
is particularly large in the villages of Wadi Al-Naam (only 586 residents are insured
through the clinic, out of a total of 6800 in the village), Bir Hadaj, Um Matnan, and
Al-Grain. These figures show that most of the residents of the unrecognized villages
still feel that the clinics do not meet their needs and prefer to travel to Segev Shalom,
Beersheva, Hura, Keseifa, Mitzpe Ramon, or Yeruham in order to receive appropriateservices. It is worth emphasizing that improving the services in the clinics should be a
supreme interest of the HMOs themselves if they seek to attract more insureds.
The Family Health Clinics
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Covenant on the Rights of the Child and the International Covenant to Eliminate All
Forms of Discrimination against Women also require a full commitment from the
state to ensure the health and physical wellbeing of children by providing health-
defining services and conditions and by removing various obstacles that impede
access to services.
Until 1997 there was not a single family health clinic in the unrecognized villages in
the Negev, despite the fact that this population has the highest fertility rate in Israel
(the fertility rate is defined as the average number of children to whom a woman can
be expected to give birth over the course of her life),33
and despite the fact that this is
a very young population (61 percent of the population is aged 0-17 years, and 41
percent is aged 0-9).
In 1997 residents of the unrecognized villages and social change organizations
submitted a petition to the Supreme Court (HCJ 7115/97).34
The main demand in the
petition was to establish twelve family health clinics in the unrecognized villages.
During the period before the petition, residents of the villages were forced to travel to
other Bedouin or Jewish communities in order to receive care for their children,including inoculation. As a result, inoculation rates among Bedouin children were
very low by comparison to the national average. As in the case of the clinics, the state
was reluctant to meet the demand. In March 1999, after over a year of hearings, the
court ordered the Ministry of Health to establish six family health centers and to
provide proper public transport to the existing centers in the villages. After no action
was taken on this matter during 1999, the Ministry of Health was accused of contempt
of court at the beginning of 2000. By the end of 2001, six clinics were built. As in thecase of the primary clinics, the family health centers in the villages also suffer from
various problems impairing the accessibility, availability, and quality of services.
Availability and Accessibility of Services
There are currently eight family health centers affiliated with the Ministry of Health in
the villages of Abu Talul, Um Batin, Um Matnan, Bir Hadaj, Darijat, Wadi Gwain,
Wadi al-Naam, and Kasr al-Sar. In addition, a family health truck operates as a
mobile center. The truck is maintained jointly by the Galilee Society and the Ministry
of Health. The driver and the director receive their salaries from the Galilee Society,
while the nurse and physician are Ministry of Health employees. The permanent crew
of the mobile center includes a driver, a nurse, and a physician. Two physicians a
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pediatrician and a gynecologist take turns staffing the truck according to the needs
in the field. The truck travels twice a week to the vicinity of two unrecognized
villages, Wadi al-Naam and Al-Bat. It functions as a full-fledged family health
center, although it cannot provide urine tests or height measurement. The truck is
small and overcrowded and the physician and nurse work in a single, small room.
This slows down their rate of work and also impairs the privacy of patients. The
number of patients seen each day is considerable (approximately 20) and the
workload creates pressure on the staff.
In the absence of additional family health centers in the unrecognized villages, the
residents travel to the centers in the permanent Bedouin towns, as well as to family
health centers intended for the population of the unrecognized villages and situated in
Beersheva, Dimona, Yeruham, Mitzpe Ramon, and Arad. The absence of additional
centers in the villages is harmful to a population that has limited mobility and consists
mainly of women and children. As already noted, many women do not attempt to
travel to centers elsewhere due to the lack of roads and public transport, restrictions
on independence and movement, the cost of travel, and the unavailability of others to
help look after their children.
All the family health centers were opened alongside clinics and solely in villages
where there are also clinics. Like the clinics, the family health centers are connected
to the water grid but receive electricity from generators. As a result, the centers do not
store inoculations. The nurses bring the inoculations with them at the beginning of the
day and take back the remainder to the main branch at the end of their working day.
In the past the family health centers operated twice a week, usually in the morning
(from 8 am to 2 pm). Recently, however, the operating hours of some of the centers
were reduced, as for example at the centers in Darijat and Kasr al-Sar Al-
Hawashleh. These centers now operate just once a week. The reduction of the opening
hours has led to the accumulation of long lines at the centers. Mothers are forced to
wait for hours in order to inoculate their children, monitor their development and
growth, receive guidance from the nurse, or monitor their pregnancy. In many cases
women return home after waiting for hours without seeing the nurse or physician.
While mapping the services in the field, we heard complaints from residents about the
operating hours of the family health centers in the villages of Darijat and Kasr al-Sar
(Al Hawashleh) The complaints related mainly to the availability and quality of the
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day, without prior notice. There was not even any notice on the door of the center.
Over the course of the day more than twenty women from the village who had made
appointments came to the center and waited for hours in the hope that it would open.
We sent a letter to the Ministry of Health on this matter on 23 February 2009; no reply
has been received to date.
By definition, one of the functions of the family health centers is to provide guidance
and advice concerning child development and care and to raise awareness among
mothers to issues relating to family health and pregnancy. In an opinion given in 1997
as part of the petition on the subject of the family health centers (HCJ 7115/97), Dr.
Hatim Kananeh noted, regarding the mobile center: Its structure does not enable theprovision of services for mothers and children, apart from one-time inoculation
Inoculation is just part of the medical and hygienic services provided by the family
health centers35
Due to the small number of centers in the villages, the limited
operating hours, and the shortage of staff, the family health centers usually confine
themselves to providing inoculations and monitoring pregnancies. Little emphasis is
placed on guidance and on raising the awareness of the population of various aspects
of family health. The result is that the centers play only a marginal role in helpingresidents raise and care for their children, particularly since many of the staff have a
limited command of Arabic.
The District Health Office is well aware of the shortage of centers, positions, and
staff. It has admitted that at present, the service provided for mothers and children in
the Negev faces a grave crisis due to the lack of medical and nursing personnel.36
According to a directors circular issued by the head of the Mother and Child Servicein the Ministry of Health, the desirable nurse-child ratio in the family health centers is
one nurse to every 350-400 children. Given the size of the population of children in
the villages, it thus follows that dozens of additional staff positions are required. In
the Ministry of Health report quoted above, the Southern District Health Office
painted a depressing picture regarding the shortage of personnel: There may be an
increase in the proportion of pregnant Bedouin women who do not obtain services
from the family health centers and antenatal monitoring, as well as a decline in theproportion of Bedouin babies registered with the family health centers.
In HCJ 711/97 (which focused on the demand to open family health centers in the
villages), the Ministry of Health declared that in order to implement the ruling and run
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effective intervention programs, and given the size and living conditions of the
population, necessary resources include fourteen positions for nurses, 3.5 positions for
physicians, ten staff positions in a Bedouin womens bridging project, two positions
for a childrens play scheme, and one position for an engineer to inspect and promote
sanitation and sewage facilities. The Southern District Health Office emphasized that:
For years there has been a plan to reduce the gaps between the Jewish population and
the Bedouin population that is not reflected in any sphere in terms of staff
positions in the Southern District (emphasis added). In an article on the subject,
District Physician Dr. Ilana Belmaker stated that the plan to reduce gaps is raised
every year during the proposed budget, but the Ministry of Health does not take it
up.37 At a conference organized in 2008 by the organization Community Advocacy
and Ben Gurion University on the subject of the right to health in the unrecognized
villages in the Negev, Dr. Belmaker again emphasized that the District Health Office
is aware of the needs of the population and is taking action on this matter, though
without the necessary budgetary support.
Apart from problems in terms of the physical accessibility of the centers, there is also
an economic obstacle. A payment of NIS 300 is required for treatment at the familyhealth centers (provided the woman registers in time). In addition, various tests
provided during pregnancy are not included in the health service basket (these include
genetic tests and, until recently occipital translucency screening and the second
systemic review) and thus depends on the ability of the family to pay for these
services. Since the Bedouin population is poor and has a high birthrate, the economic
burden constitutes a real obstacle to securing treatment.
Health Outcomes in the Unrecognized Villages: Infant Mortality and
Child Development
Infant mortality rate is an accepted international index for the standard of health of
children and the population in general. Numerous factors influence infant mortality
rates, including the mothers educational level, poverty, the availability and quality ofservices, health-defining conditions (safe water, a clean environment, sewage and
sanitation), as well as marriage between relatives.
The infant mortality rate among the Bedouin Arab population is amongst the highest
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Health attributes the high mortality rate to various factors, including genetic defects
and hereditary diseases (the most prevalent factor, accounting for 42.7 percent of
infant mortality); premature births (22 percent); and infectious diseases and other or
unknown factors (35 percent).38
Although infant mortality rates have fallen in recent years, the gap remains and the
rate among Bedouin Arabs is still almost three times the national average. The
Ministry of Health generally attributes this gap to the high prevalence of marriage
between relatives, which leads to elevated incidence of congenital defects. The infant
mortality rate due to congenital defects is indeed high, at approximately 5 per 1000
live births (compared to 0.8 among Jews in the Beersheva district). However, an
additional explanatory factor is the poor availability of health services in general, and
family health centers in particular, in the unrecognized villages.
Dr. Kananehs opinion submitted as part of HCJ 7115/97 states that Bedouin women
face particularly grave health and socioeconomic distress the use of preventative
services by pregnant women at as early a stage as possible and at the recommended
frequency has a positive impact on the outcomes of pregnancy, the health of themother and neonate, and infant mortality (emphasis added).
39
Another important health index is weight at birth, which is influenced by the mothers
state of health, nutrition, and antenatal monitoring of pregnancy at the family health
centers. Statistics published in a report by the Southern District Health Office of the
Ministry of Health show that in 2006 the percentage of children in the unrecognized
villages who had a low birth weight (less than 2500 grams) was higher than theaverage for the Israeli population as a whole (ten percent compared to 8.2 percent).
Figures published in a study prepared by Physicians for Human Rights - Israel40
show
a significant improvement in the proportion of women receiving antenatal treatment
and monitoring in the villages in which family care centers have been established.41
A
Ministry of Health report also observed an increase of 12.1 percent in the number of
babies receiving treatment at the family health centers over the period 2000-2006, andan increase of 28.6 percent in the number of toddlers registered at the centers over the
same period.
38See: State of Health of Babies and Children up to the Age of 6 in the Permanent
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The Ministry of Health allocates an annual budget for a special program intended to
reduce infant mortality rates among the Bedouin Arab population in the Negev. The
project is run jointly by the Ministry of Health, Ben Gurion University of the Negev,
Soroka Medical Center, and Clalit HMO, and in cooperation with local leaders,
representatives of the Bedouin community, and NPOs.42
Despite the importance of the
program, its outcomes are inevitably limited in the absence of policy promoting the
establishment of primary clinics, additional family health centers, and the provision of
health-defining conditions for the residents of the unrecognized villages of the Negev
recommendations that the Southern District of the Ministry of Health itself adopted
in a recently-published report.43
Conclusion, Ramifications, and Recommendations: Ensuring Early
Identification and Treatment
According to figures from Soroka Hospital relating to the health condition of Bedouin
Arab society in the Negev, 60 percent of in-patients at the hospital are Bedouin
residents, who account for approximately 26 percent of the population as a whole.
Among other factors, this figure reflects problems relating to preventative and
primary medicine in these communities, as described in this report. Many residents
fail to obtain primary treatment due to the lack of clinics and family health centers, or
due to problems resulting from physical, economic, and cultural inaccessibility. This
situation also exacerbates the residents sense of alienation from medical services and
prevents the effective and high-quality use of these services. The outcome of thissituation has far-reaching ramifications for the health of these residents, but it also has
broader implications. In the long term the savings secured due to the failure to provide
accessible preventative and primary services are offset by considerable costs. As
noted, many residents forego treatment that could prevent the development of
conditions and complications requiring protracted hospitalization. The cost of more
complex treatments such as hospitalization is high not only in terms of the patients
health and the state of the family, but also in terms of the public treasury.
Numerous public health studies support an approach based on expanding preventative
and primary services and on the development of additional services with the goal of
preventing or reducing morbidity. The greater the investment in broad primary and
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Regional Council for the Unrecognized Villages in the Negev demand that the
Ministry of Health, the HMOs, and the other authorities take the following immediate
steps:
- To expand the health services in the unrecognized villages in the Negev:
Establishment of primary clinics and family health centers in all villages where
they do not already exist or are not available in the immediate vicinity at a
reasonable distance.
- To improve access to clinics established at a distance from the villages by
relocating these to the centers of the villages.
- To pave access roads to the clinics and connect them to the national electricity
grid.- To expand the services provided by the clinics, including the provision of
advanced medical instruments; extension of laboratory services and tests; and
addition of new staff positions for specialists, dieticians, pediatricians, and
gynecologists.
- To provide pharmaceutical services and open pharmacies at the existing clinics
in the villages.
- To ensure the cultural adaptation of services including appropriate use of theArabic language in the clinics; the employment of Arabic-speaking physicians
and nurses; the translation and preparation of informational materials for
distribution to the general population; and the use of signs in Arabic.
- To extend the opening hours of the clinics and family health centers and to
introduce a split working day, at least on some days.
- To change the names of existing clinics based on the names of tribes and to
prefer the historical names of the villages in order to prevent a situation whereresidents decline to attend a clinic identified with a different tribe.
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Appendices
Appendix 1 Letter from Dr. Taleb Abu Hamed, Director of theSouthern Negev Administration, Clalit HMO, Dated 22 December
2008 in Response to a Letter from Physicians for Human Rights
Israel.
Appendix 2 Response of Clalit HMO Dated 21 February 2008.
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Community Division ClalitChief Executive
28 Kislev 5769
25 Dec. 2008
Our ref: 35658
Ms. Shlomit Avni Vaknin
Director, Residents Department
Physicians for Human Rights - Israel
Re: Employment of Pediatricians in the Clinics of Clalit Health Services in the
Unrecognized Villages in the Negev
Your letter dated 8 Dec. 2008
Dear Ms. Avni Vaknin,
Your letter to the director-general of Clalit was forwarded for my attention.
I attach a letter from Dr. Taleb Abu Hamed accurately reflecting the actions of Clalit
in the unrecognized villages in the Negev.
Sincerely,
Dr. Orit Yaacobson Deputy Director-GeneralHead of the Community Division
CC:
Mr. Eli Depes Director-General
Dr. Giora Werber Deputy Head, Medicine Division
Dr. Taleb Abu Hamed Director, Southern Negev Administration
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Southern Negev Administration
Southern District
Tel: 08-6651689, Fax: 08-6651688 Clalit
22 December 2008
To:
Physicians for Human Rights - Israel
Re: The Employment of Pediatricians in the Clalit Clinics in the Unrecognized
Villages in the Negev
1. Clalit provides primary medical services in the unrecognized villages (the
Bedouin diaspora) through the following clinics: Al-Sayad, Al-Amal, Al-
Atrash, Darijat, Abu Kaf, Abu Kweidar, Al-Asam, Abu Karinat, Al-Hawashleh,
Bir Hadaj, Wadi Al-Naam.
Some of the unrecognized villages are within the boundaries of the Abu Basma
Regional Council.
2. Clalit is the only HMO that submitted a bid in the Ministry of Health tenders for
the establishment of primary clinics in the unrecognized villages in the Negev.
3. Clalits clinics in the unrecognized villages provide medical services for the
Bedouin population despite the absence of health-promoting infrastructure such
as electricity, roads, flowing water, and refuse disposal.
4. The primary clinics in the unrecognized villages are staffed by a physician, a
nurse, and an administrative worker. Each clinic has a medicine room and
computerized records similar to the rural clinics in the Jewish communities.
5. The clinics in the unrecognized villages receive secondary medical services
from the large health centers in geographical proximity to the unrecognized
villages.
6. In addition, Clalit operates a special mobile unit (at all hours of the day) for the
benefit of the Bedouin residents of the unrecognized villages. The mobile unit
helps locate patients with special needs and assists the medical staff in attending
house calls for housebound and seriously ill patients
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diploma in family medicine at Ben Gurion University (in February 2009 they
are due to complete their training, which lasted three years).
9. Pediatrics in the community is considered as primary medicine rather than
medicine (advisory). The family physicians in Clalits clinics, in general, have
the professional training to examine adults and children.
10. Approximately 50 percent of all the physicians in Clalits clinics in the
unrecognized villages are Arabic speakers; this rate is higher than that among
the physicians in the permanent communities and in the city of Rahat.
11. Most of the Arab physicians from the Bedouin sector are employed by Clalit;
two physicians are employed by other HMOs.
12. All the specialists and interns have been trained as part of their specialization to
examine children. As part of their specialization they have participated in
periods of work in childrens wards in accordance with the criteria of the
Science Council in the State of Israel.
13. Clalit is well aware of the high rate of infant mortality among the Bedouin
population, both in the permanent communities and in the unrecognized villages
a rate that was 11.5 per 1000 live births in 2007. Accordingly to the statistics
of the Ministry of Health, the main reason for the mortality is congenital defects
and hereditary diseases. Out of awareness of this problem, Clalit has since 2005
operated a pre-pregnancy genetic information service, including the provision of
genetic information to the entire Bedouin population. The service is provided
free of charge on request.
14. In Clalits clinics in the unrecognized villages in the Negev, all the workers are
employed on a salaried basis and work from 8:00 am through 4:00 pm without a
split day. In the communities of Omer, Meitar, and Lehavim, only self-
employed physicians are employed, and these work in the early morning and in
the evening. Between midday and 4:00 pm the clinics are closed. During some
of these hours, the clinics are staffed only by general physicians, such as the
clinic in Meitar between 8:00 am and midday every day.
15 Clalit is aware of the constraints facing the Bedouin population of the
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implement a special project to prevent anemia among babies at the clinics in the
Bedouin sector.
16. Clalit is well aware of the poor socioeconomic conditions of the Bedouins in the
unrecognized villages and of the difficulties presented by harsh environmental
conditions that influence access to the service, such as the lack of public
transport. Naturally, the living conditions of the Bedouin residents in the
unrecognized villages have ramifications in terms of their state of health. Clalit
works constantly to improve the medical service by adapting the medical
service to meet the needs and culture of the Bedouin residents of the Negev.
However, the response cannot be confined solely to solving medical problems.In terms of the socioeconomic and environmental conditions of the Bedouin
population in the unrecognized villages (which has a direct impact on their state
of health), the issue cannot be resolved solely by the public health system. This
subject requires intervention on the national level in order to secure a
comprehensive solution for the range of problems, leading to an improvement in
the situation and with positive ramifications in terms of the state of health of the
Bedouins in the Negev.
Sincerely,
Dr. Taleb Abu Hamad
Director, Southern Negev Administration
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Planning and Health Policy Clalit Health Services21 February 2008
Physicians for Human Rights - Israel
52 Golomb St., Tel Aviv
66171
75266
Re: Your Request to Receive Information Concerning the Number of Insureds at Clinics
Further to your request, the following is our response to the requested information.
A. Number of insureds in each clinic, number of children , and number of children suffering from chronic diseases
Insureds
Age 0-18Clinic No. of insureds 0-18 Patients with chronic diseases
Abu-Kweider 2036 1366 116
Abu-Kaf 1697 1084 125
Abu-Kreinat 1519 979 65
Al- Atrash 2147 1423 96
Al- Said 1931 1311 121
Al- Aa'sam 1862 1131 130Bir Hadaj 2429 1564 108
Darijat 795 489 37
Al- Hawashli 1505 918 89
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Planning and Health Policy Clalit Health Services21 February 2008
Physicians for Human Rights - Israel
52 Golomb St., Tel Aviv
66171
75266
Re: Your Request to Receive Information Concerning the Number of Insureds at Clinics
Further to your request, the following is our response to the requested information.
A. Number of medical staff and their profession
Family
physicians Nurses Admin.
Additional
service 1
Additional
service 2
Al- Amal- Al-
Khurum tribe 1 0 1 Laboratory
Wadi Al- Na'am 1 1 1 Laboratory Family
Darijat 1 1 1 LaboratoryTarabin Al- Sania' 1 0 0 Laboratory
Abu-Kaf 1 1 1 Laboratory
Al- Said 1 1 1 Laboratory
Bir Hadaj 2 1 1 Laboratory
Al- Aa'sam 2 1 1
Al- Hawashli 1 1 1 Laboratory
Al- Atrash 1 1 1 Laboratory
Abu-Kreinat 1 1 1 Laboratory Family
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B. Specializations in the clinic and medicine rooms
There are no specializations in the clinic.
There are no medicine rooms.
C. Opening days and weekly reception hours
Clinic Sun. Mon. Tue. Wed. Thu.
IntermediateDay of
festivals
Eve of
festivals
Al- Amal- Al-
Khurum tribe 8.00-16.00 8.00-12.00 8.00-16.00 8.00-13.00 8.00-16.00
Wadi Al- Na'am 8.00-16.00 8.00-16.00 8.00-16.00 8.00-12.00 8.00-16.00 8.00-13.00 8.00-12.00
Darijat 8.30-15.45 8.30-18.45 8.30-18.45 8.30-12.45 8.30-15.45 8.30-13.00 8.00-12.00
Tarabin Al- Sania' 13.30-15.30 16.15-19.15 8.00-11.00 16.15-19.15
Abu-Kaf 8.00-15.45 8.00-15.45 8.00-15.45 8.00-15.45 8.00-12.30 8.00-11.45Al- Said 8.00-16.00 8.00-16.00 8.00-16.00 8.00-14.00 8.00-16.00 8.00-13.00 8.00-12.00
Bir Hadaj 8.00-16.00 8.00-16.00 8.00-16.00 8.00-16.00 8.00-16.00 8.00-13.00 8.00-12.00
Al- Aa'sam 7.30-15.30 7.30-15.30 7.30-15.30 7.30-15.30 7.30-15.30 7.30-12.30 7.30-11.30
Al- Hawashli 8.00-16.00 8.00-16.00 8.00-16.00 8.00-16.00 8.00-16.00 8.00-13.00 8.00-12.00
Al- Atrash 8.30-16.00 8.30-16.00 8.30-16.00 8.30-16.00 8.30-16.00 8.30-13.00 8.30-12.00
Abu-Kreinat 8.00-15.30 8.00-15.30 8.00-15.30 8.00-15.30 8.00-15.30 8.00-12.30 8.00-12.00
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D. Average monthly number of patients
Insureds
Patients per
month in clinic
Visits per
month in
clinic
Al- Amal- Al-
Khurum tribe 512 33.4 149.5Wadi Al- Na'am 586 16.6 34.2
Darijat 800 58.9 504.7Tarabin Al- Sania' No data
Abu-Kaf 1,711 118.9 942.3
Al- Said 1,935 149.8 1178.8
Bir Hadaj 2,460 155.3 796.1
Al- Aa'sam 1,875 136.7 1100.9
Al- Hawashli 1,490 43.2 91.8
Al- Atrash 2,180 125.9 571.6
Abu-Kreinat 1,575 111.1 686.3
Sincerely
Noa Dannai
Director, Procedures, Coordination, and Knowledge Management Department
Planning and Health Policy Division, Clalit Health Services
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