Department of Health

Annual Report 2022

 Department of Health

Annual Report 2022

© 2023 UNRWA

About UNRWA

UNRWA is a United Nations agency established by the General Assembly in 1949 with a mandate to
provide humanitarian assistance and protection to registered Palestine refugees in the Agency’s area of
operations, namely the West Bank, including East Jerusalem, Gaza, Jordan, Lebanon and Syria, pending a
just and lasting solution to their plight. Thousands of Palestine refugees who lost both their homes and
livelihoods because of the 1948 conflict have remained displaced and in need of significant support for over
seventy years. UNRWA helps them achieve their full potential in human development through the quality
services it provides in education, health care, relief and social services, protection, camp infrastructure and
improvement, microfinance and emergency assistance. UNRWA is funded almost entirely by voluntary
contributions.

This document is a formal publication of the United Nations Relief and Works Agency for Palestine refugees
in the Near East, and the organization reserves all rights. However, the document may be freely reviewed,
abstracted, reproduced and translated, in part or whole, but not for sale or use in conjunction with
commercial purposes.

The views expressed in documents by named authors are solely the responsibility of those authors. The
designations employed and the presentation of the material in this document, including tables and maps,
do not imply the expression of any opinion whatsoever on the part of the Agency concerning the legal
status of any country, territory, city or area or its authorities, or concerning the delimitation of its frontiers
or boundaries.

The mention of specific companies or certain manufacturers' products does not imply that they are
endorsed or recommended by UNRWA in preference to others of a similar nature that are not mentioned.
Errors and omissions accepted; the names of proprietary products are distinguished by initial capital letters.

www.unrwa.org

Cover photo: NCDs-Plaestine refugee with his wife at UNRWA Nuzha Health Centre in Jordan. ©2022
UNRWA Photo by Dima Ismail
 unrwa health department - annual report 2022 1

Table of Contents
Acronyms and abbreviations ........................................................................................................................................................................... 3
Foreword UNRWA commissioner general................................................................................................................................................... 5
Message from the WHO regoinal director for the eastern mediterranean...................................................................................... 6
Executive summary and report overview.....................................................................................................................................................7
Section 1 – Introduction and health strategic approach........................................................................................................................ 8
UNRWA........................................................................................................................................................................................................ 8
Health profile..............................................................................................................................................................................................8

Section 2 – COVID-19 and Beyond – Lessons Learned From The Experience................................................................................12

UNRWA`s health response to COVID-19....................................................................................................................................... 12
Field innovations................................................................................................................................................................................... 17

Section 3: Strategic Outcome 2 : refugees` health is protected and the disease burden is reduced....................................22
Output 2.1: people-centred primary health care system using fht model.......................................................................22
Family health team (fht) approach and the e-health system......................................................................................... 22
Outpatient care................................................................................................................................................................................23
Non-communicable diseases (ncds)....................................................................................................................................... 26
Integrating the mhpss Programme into UNRWA phc and the fht Approach.......................................................... 30
Communicable Diseases..............................................................................................................................................................32
Maternal health services...............................................................................................................................................................33
Child health services..................................................................................................................................................................... 41
School health................................................................................................................................................................................... 44
Oral health........................................................................................................................................................................................ 46
Physical rehabilitation and radiology services.....................................................................................................................48
Disability care.................................................................................................................................................................................. 49
Pharmaceutical services.............................................................................................................................................................. 50

Output 2.2: Efficient hospital support services.......................................................................................................................... 53

In patient-care................................................................................................................................................................................. 53

Cross-cutting services......................................................................................................................................................................... 55
Nutrition.............................................................................................................................................................................................55
Laboratory services........................................................................................................................................................................56
Health communication................................................................................................................................................................ 58
Research and evaluation activities...........................................................................................................................................59
Health Response to GBV in Healthcare Settings................................................................................................................. 60
 2 unrwa health department - annual report 2022

Table of Contents
Human resources for health reform................................................................................................................................................60
Family medicine training.....................................................................................................................................................................61
Finance resources.................................................................................................................................................................................. 62

Section 3 – Data................................................................................................................................................................................................... 65
Part 1 - Agency-wide trends for selected indicators..................................................................................................................65
Part 2- CMM (2016-22) Indicators.....................................................................................................................................................69
Part 3 – 2021 Data tables.....................................................................................................................................................................70
Part 4 - Selected survey indicators...................................................................................................................................................78
Annex 1- Donor support to the unrwa health programme during 2022...........................................................................81
Annex 2 - Strategic outcome 2: refugees’ health is protected and the disease burden is reduced........................ 84
Annex 3 - Health Department research activities and published papers..........................................................................86
Annex 4 – Health Maps........................................................................................................................................................................87
Annex 5 - Department of Health at UNRWA HQ, Amman Organizational Chart............................................................ 89
Annex 6 - Contacts of Senior Staff of the UNRWA Health Programme...............................................................................90
 unrwa health department - annual report 2022 3

acronyms and abbreviations

AIDS Acquired Immunodeficiency Syndrome MKAP-UK Medical Aid for Palistine united Kingdom
ANC Antenatal Care MMS Multiple Micronutrient Supplementation
BC Breast Cancer MMR Maternal Mortality Rate
BSE Breast-Self Examination MOPH Ministry of Public Health
CI Confidence Interval MoH Ministry of Health
CMM Common Monitoring Matrix MOs Medical Officers
COVID-19 Coronavirus Disease 2019 MTS Medium Term Strategy
DM Diabetes Mellitus NCDs Non-communicable Diseases
DMFS Decayed/Missing/Filled Surface NGO Non-governmental Organization
DMFT Decayed/Missing/Filled Teeth OPV Oral Polio Vaccine
DS Decayed Surface PHC Primary Health Care
DTC Damascus Training Centre PIO Public Information Office
DT/Td Tetanus-Diphtheria Power BI Microsoft Power Business Intelligence
e-MCH Maternal and Child Health Mobile Application PCC Pre-conception Care
EMR Electronic Medical Records PEC Primary Eye Care
EMRO Eastern Mediterranean Region of Operations PPE Personal Protective Equipment
e-NCD Non-communicable Disease Mobile Application PR Palestine Refugee
EPI Expanded Programme on Immunization PRCS Palestine Red Crescent Society
FHT Family Health Team PRL Palestine Refugees from Lebanon
FICIP Field Infrastructure and Camp. Improvement PRS Palestine Refugees from Syria
Programme
PHC Primary Health Care
FMDP Family Medicine Diploma Programme
PNC Post-natal Care
EMR Electronic Medical Records
PNs Practical Nurses
FP Family Planning
LFO Lebanon Field Office
FS Filled Surface
RDA Recommended Dietary Allowance
GBV Gender-Based Violence
RDT Rapid Diagnostic Test
GFO Gaza Field Office
RSS Relief and Social Services
GHQ-12 General Health Questionnaire
RSSP Relief and Social Services Programme
GSHS Global School-based Student Health Survey
SHP School Health Programme
GYTS Global Youth Tobacco Survey SFO Syria Field Office
G-SHPPS Global School Health Policies and Practices SJEHG St. John Eye Hospital Group
Survey
SMART Standardized Monitoring and Assessment of
HBA1CHbA1c Hemoglobin A1C survey Relief and Transitions Survey
HCs Health Centres SSNP Social Safety Net Programme
HD Health Department TB Tuberculosis
Hib Haemophilus Influenza Type B UN United Nations
HP Health Programme UNCRPD United Nations Convention on the Rights of
HQ Headquarters Persons with Disabilities
HSP Hospitalization Support Programme UNICEF United Nations International Children’s
Emergency Fund
IFA Iron and Folic Acid
UNIMMAP United Nations International Multiple
IMDT Information Management and Technology Micronutrient Antenatal Preparation
Department
UNFPA United Nations Population Fund
IMR Infant Mortality Rate
UNRWA United Nations Relief and Works Agency for
IPC Infection Prevention Control Palestine Refugees in the Near East
IPV Inactivated Poliovirus Vaccine USD U.S. Dollar
IUD Intrauterine Device USP United States Pharmacopeia
LBW Low Birth Weight WB West Bank
MCH Maternal and Child Health WHO World Health Organization
mhGAP mental health Gap Action Programme WISN Workload Indicators of Staffing Need
MHPSS Mental Health and Psychosocial Support WLUs Workload Units
4
unrwa health department - annual report 2022
 unrwa health department - annual report 2022 5

foreword unrwa Commissioner-General

Health is not only a fundamental human right, but also in Lebanon, our hospitalization programme struggles to
the most essential prerequisite to a productive and keep up with the needs in the wake of skyrocketing costs.
dignified life. This is why I am particularly proud of the Needs for psychosocial support are on the rise across the
Agency’s health programme, whose impact continues to region.
exceed global standards, including in terms of universal
infant vaccinations and reduced maternal mortality. Despite these challenges, the perseverance and
dedication of our health staff has been at the core of
In 2022, UNRWA continued to deliver primary health our success. I want to take this opportunity to express
care services to nearly two million Palestine refugees, my gratitude to all UNRWA health staff, who work
with 7.86 million consultations in 140 health centers tirelessly to provide quality care, often under challenging
across the region. The most vulnerable among them circumstances they themselves face as refugees.
also continued to be supported with much needed
access to hospitalization services. UNRWA operates at This work would also not have been possible without the
the crossroad of the humanitarian- development nexus, support of our generous donors and devoted partners.
quickly adapting to evolving crises to ensure continued Our long-standing partnership with the World Health
access to health care services in times of conflict and Organization represents a model example of excellent
displacement, including through mobile health clinics. cooperation that produces remarkable results.
In Syria, UNRWA strive to rehabilitate its health centers
to support returning refugees in Yarmouk, Ein el Tal and From our side, responding to the health needs of
Neirab refugee camps. Palestine refugees will continue to remain a top priority,
and forms a core pillar of the Agency’s Strategic Plan
UNRWA continued to pioneer digital health care. Our 2023-2028. The key priorities for the next strategic term
e-health system, which keeps the medical records of are improving maternal and child health, as well as
some two million patients, allowed us to spearhead mental health; tackling non-communicable disease as
telemedicine and develop smartphone applications the leading cause of preventable death among refugees;
to support patients, including pregnant women, to strengthening our response to infectious diseases; and
track their health and remind them to go to their continuing to improve refugees’ access to quality health
appointments, and for persons with diabetes to regularly services.
test themselves.
To continue this critical role in the lives of Palestine
These accomplishments did not come without refugees in the region, the Agency needs reliable and
challenges. Chronic underfunding of the core budget sustainable funding and the commitment of donors
of the Agency, recurring conflicts and collapsing public and partners. Together I am confident we will be able
health care systems in some fields of operation have put to uphold our responsibility to ensure that Palestine
severe strains on our health programme. Most notably, refugees have the quality healthcare they deserve.

Mr. Philippe Lazzarini

UNRWA Commissioner-General
 6 unrwa health department - annual report 2022

message from the who regional director for the

eastern mediterranean

On behalf of the World Health Organization Eastern address the health needs of Palestine refugees and to
Mediterranean Regional Office, I would like to extend ensure that they receive the care and support they need
my sincerest congratulations on the release of your to lead healthy and productive lives.
Annual Health Report. This report is a testament to the
tireless efforts of your team in providing the essential In addition to our partnership with UNRWA, at
health services to Palestine refugees. The work you do is the WHO Eastern Mediterranean region office, we
vital to improve health outcomes of vulnerable refugee have a clear vision set for the year 2023: ‘Health for
communities, and I am grateful for your ongoing all by all.’ This vision aims to achieve health for all,
commitment to this important cause. involving stakeholders including government, health
professionals, communities and individuals collectively,
As Director of WHO, I am acutely aware of the challenges to maximize health outcomes and well-being in the
facing health systems in the region. UNRWA’s health region. Through fostering collaboration, sharing
services is critical in ensuring that essential health knowledge and advocating for the rights for health, we
services are accessible to those who need them most. strive to make significant strides towards achieving the
The report underscores the challenges that continue to vision in partnership with UNRWA.
face Palestine refugees, including the ongoing COVID-19
pandemic and the difficult socio-economic conditions in I would like to take this opportunity to commend
which many of them live. UNRWA for its dedication to improving the health
of Palestine refugees and for its ongoing efforts to
At WHO EMRO, we recognize the critical role that promote equity, dignity and the respect for the people
UNRWA plays in providing health services to Palestine UNRWA services. Your work is an inspiration to us all,
refugees, and we are proud to partner with UNRWA in and we look forward to continuing our partnership in
these efforts. We are committed to working together to the years to come.

Dr. Ahmed Al-Mandhari

Regional Director,
WHO/Eastern Mediterranean
Region of Operations (EMRO)

Dr. Ahmed Al Mandhari

WHO Regional Director for the Eastern Mediterranean
 unrwa health department - annual report 2022 7

executive summary and report overview

The year 2022 started with the spread of Omicron variant occupation and acute conflicts, and Health response to
globally and this hit the UNRWA Fields of operation these health situations.
too. UNRWA Health Programme continued to adopt
the service delivery models with the challenges posed Section 2: COVID-19 and beyond- lessons learned
by COVID-19. Despite the protracted challenges, the from the experience.
health programme continued to deliver its essential This section highlights the impact of the past three
work of providing health care services to Palestine years of COVID-19 response and lessons learned from
refugees. In 2022, over 2 million Palestine refugee the experiences. It showcases the transition from acute
utilized the UNRWA health services a round 7.86 million phase of pandemic to post pandemic services deliveries,
consultations. The number of consultations increased as well as health systems that UNRWA continues to
by 12.4 percent compared to the previous year. The implement. Field specific activities and innovations are
patients number returned almost to the pre COVID time also stated in this section.
with resumption of full health services and withdrawal
of COVID-19 restriction in the host countries. In 2022, the Section 3: Strategic outcome 2- refugee’s health is
health programme focused on strengthening its health protected and the disease burden is reduced.
care systems, improving access to essential health The Agency's MTS 2016-2022 sets health goal under
services and enhancing the capacity of health workers in its outcome 2. The activities and achievement under
line with family health team approach. all sub programmes by the health programme are
presented in this section. These includes outpatient
The Health Annual report 2022 highlights the health care, NCD treatment, communicable diseases, maternal
services provided by UNRWA to Palestine refugees and child health, school health, oral health, Physical
between 1 January and 31 December 2022. The report rehabilitation and radiology services, hospitalization
also showcases the relevant health indicators linked to services, as well as cross cutting issues such as disability
the Agency’s MediumTerm Strategy (MTS) 2016-2022 inclusion, health response to GBV and workforce norms
as well as programmatic and resource mobilization for health reform.
achievements.
Section 4: Data
Section 1: Introduction and health strategic This section presents major health indicators, including
approach for Agency wide trends, common monitoring matrix
This section gives you an overview of UNRWA, health (CMM) 2016-2022 indicators, data tables for 2022 and
workforce, and health profile of Palestine refugees served selected survey indicators, donor support to UNRWA
by the Agency. The health profile contains demographic health programmes, research activities and a list of
information, disease trends, the impact of protracted published papers.

UNRWA Medical Officer checking blood pressure of

a Palestine Refugee patient in Beddawi camp HC in
Lebanon. © 2022 UNRWA Photo by Dima Farran
 8 unrwa health department - annual report 2022

section 1 – introduction and health strategic approach

UNRWA
The Agency's primary mission is to assist Palestine
refugees in Jordan, Lebanon, Syria, Gaza and the
West Bank to achieve their full potential in human
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G W E ST BANK Catography UNRWA HQ Amman Health Department
Map produced : April 2023
Base data UNR WA Health Department

staff. Out of the 5.9 million registered Palestine refugees, For comments contact :
w.zeidan2@ unrwa.org

it is estimated that 3.2 million Palestine refugees are Figure 1: No. of medical consultations and distribution of UNRWA
registered at UNRWA HCs and receive health services health facilities
free of charge. UNRWA does not operate its hospitals
(except for one, Qalqilya Hospital, in the West Bank), but Health Profile
instead, the Agency conducts a reimbursement scheme Over the span of seven decades of displacement and
for its beneficiaries. dispossession, the number of Palestine refugees has
increased from 750,000 in 1950 to 5.9 million in 2022.
Throughout these years, UNRWA has been committed
to providing quality health services to address the
needs of Palestine refugees. Through partnerships
3,070 staff throughout the three tiers with host countries and other stakeholders, UNRWA
has realized significant health gains for Palestine
refugees. As the demographic profile of the population
491 34 116 1,020 has changed, the health needs of Palestine refugees
medical specialist dental nurses have also evolved over the past decades. Despite
officers doctors surgeons
this, UNRWA has continued to adapt and improve its
services to meet the changing needs of the population.
Currently, it is estimated that 3.2 million or 53.9
666 738 140 per cent of served Palestine refugees still heavily
paramedical auxiliary HCs
staff staff rely on UNRWA services due to economic hardship,
high unemployment rates, and worsening poverty
5.9 3.2 levels, especially in conflict areas. Around one-third
million million of registered Palestine refugees reside in 58 official
Registered Palestine Refugees are registered Palestine refugee camps, living side-by-side among
Palestine Refugees at UNRWA health centres
host countries' communities.
 unrwa health department - annual report 2022 9

In 2022, the world faced the third year of the COVID-19 Although significantly decreased, maternal mortality
pandemic as the virus continued to claim lives and rates (MMR) and infant mortality rates (IMR) among
overburden health systems and services. During this Palestine refugees remain relatively high. Among
period, UNRWA focused on sustaining the health gains Palestine refugees in Gaza, the MMR decreased from
it had made in previous years, continuing to provide 16.2 per 100,000 live births in 2019 to 9 per 100,000
health services and improving its preparedness live births in 2022 (further assessment is needed to
and response capacity. UNRWA's FHT approach was better understand this decline in MMR in Gaza)1. The
restored, allowing its health services to resume pre- estimated IMR in Gaza increased slightly from 20.2 per
pandemic operations through preventive measures 1,000 live births in 2008 to 22.7 per 1,000 live births in
like triage, COVID-19 rapid diagnostic testing, home 2015. The stagnation of progress on the IMR indicates
delivery of medication, and COVID-19 vaccination that further efforts are needed to investigate the causes
services. This was reflected in the gradual improvement for this stagnation and ways of addressing potentially
in performance indicators. preventable causes among Palestine refugee children
in Gaza.
Increasing life expectancy among Palestine refugees
has resulted in an ageing population. However, high 30

fertility rates have markedly increased in the youth 25

population, with 29.0 per cent of registered Palestine 20
refugees currently below the age of 18 years old. 15
Maternal and child health (MCH) care is a crucial focus
10
of the Agency. Women of reproductive age have
5
universal access to contraceptive (family planning)
care, antenatal care (ANC), safer delivery care with 0
Neonatal Infant <1 year
referrals to and subsidies for hospital delivery, post-
2008 2013 2015
natal care (PNC) and infant and childcare (0-5 years
old). In 2022, UNRWA provided maternal health care Figure 3: Infant mortality rate per 1,000 live births among Palestine
refugees in Gaza (Sources: UNRWA surveys conducted in 2008, 2013
services, and family planning (FP) care for 190,827
and 2015, with reference times of 2006, 2011 and 2013, respectively).
women, 81,166 pregnancies and 425,585 infants
and children (0-5 years old) registered. Although still A reduction in communicable disease incidence,
relatively high, a slight reduction in the overall fertility combined with longer life expectancy and lifestyle
rate has been recorded and stabilized over the past modifications, has led to a change in refugees' morbidity
few decades. profile.

200
180
160
No. of patients (thousand)

140
120
100
80
60
40
20
0
2011 2012* 2013* 2014 2015 2016 2017 2018 2019 2020 2021 2022

Family planning Pregnant Women

Figure 2: Total number of patients registered for FP services and newly registered pregnant women at UNRWA HCs
(*data excludes Syria)

1 Maartje, M. et. al. (2018). Stalled decline in infant mortality among Palestine refugees in Gaza Strip since 2006. PLOS ONE, June 13, 2015.
 10 unrwa health department - annual report 2022

Cardiovascular diseases, chronic respiratory diseases, mobile application for NCD patients to contribute to
diabetes mellitus (DM), hypertension and cancer health promotion efforts, help ensure compliance with
are today's leading NCDs among Palestine refugees, regular appointments, and provide health advice.
representing the highest financial burdens on UNRWA
health services. In 2022, 130,036 patients were treated The long-term provision of health care services
for hypertension only, 46,720 were treated for DM only, to Palestine refugees has effectively controlled
and 129,089 were treated for both DM and hypertension. communicable diseases by ensuring high vaccination
The significant risk factors for NCDs among the Palestine coverage and timely outbreak detection and
refugee population include sedentary lifestyles, obesity, management. Diseases related to poor hygiene and
unhealthy diets and smoking. sanitation have been almost completely eradicated.
However, micronutrient deficiencies and food insecurity
continue to be significant risk factors for diseases

130,036 among Palestine refugees, especially during the

pandemic. Despite the implementation of a mental
Patients
were treated for health and psychosocial support program in all five
hypertension only fields of operation, the prevalence of mental illnesses is
increasing among Palestine refugees due to the ongoing
46,720 conflicts, occupation, and COVID-19.
Patients
were treated for
diabetes mellitus only Ongoing protracted and acute conflicts, occupation,
the lack of a just and durable solution for Palestine
refugees'status and the added burden of COVID-19
129,089 continue to affect the population's physical, social and
Palestine refugees mental health. Assessment, diagnosis and treatment
were treated for DM and hypertension
of mental health and psychosocial-related disorders
show their prevalence is increasing throughout UNRWA
To target NCDs, UNRWA applies a strategy that focuses operation. To address this trend, the Agency introduced
on three dimensions: (i) disease surveillance, that a mental health and psychosocial support (MHPSS)
consists of collecting, analysing and interpreting health- programme in all five fields in 2018 which aims to identify
related data on NCDs and their determinants; (ii) health and address mental illnesses, particularly in Gaza.
promotion and prevention interventions to combat MHPSS services are heavily integrated into UNRWA PHC
NCD major risk factors or determinants among Palestine and work towards ensuring that all Palestine refugees
refugees across their life cycle; and (iii) the provision enjoy the highest attainable mental health level. In 2022,
of cost-effective interventions for the management of all 140 HCs across five fields of operations continued to
NCDs. In 2019, UNRWA HD invested in developing a integrate the MHPSS within its services.

A nurse at Al-Nuzha health centre in Amman, Jordan explaining to a patient with

a non-communicable disease (NCD) about how to use the NCD smart phone
application “Your health with UNRWA” and how it connects to her electronic health
record in UNRWA e-Health system. © 2020 UNRWA Photo by George Awwad
 unrwa health department - annual report 2022 11

UNRWA health care services cover basic medical needs of

Palestine refugees in Syria, UNRWA health centre in Dera’a
camp. © 2022 UNRWA Photo by Taghreed Mohammad
 12 unrwa health department - annual report 2022

section 2 – covid-19 and beyond – Lessons learned

from the experience

UNRWA Health Response to COVID-19 and loss of livelihoods for many refugees. Since the
Although globally COVID-19 is not yet over, UNRWA beginning of COVID-19, a dramatic increase in the
health service provision has transitioned beyond the number of confirmed cases and deaths has been
acute phase of the pandemic and have regained a reported, while new variants continued to emerge.
complete resumption of health services and a complete Despite these challenges, UNRWA continued to provide
package of Family Health Teams are now actively serving primary health care services without disruption, which
the Palestine Refugees. was enabled by the tireless dedication of the health staff
within the Agency.
Since the start of the pandemic, UNRWA has responded
to the issues that surround it. Initially, it was with the goal UNRWA has adapted its health services to the
of containment and later with a strategy of mitigation COVID-19 pandemic by gradually resuming services
to safeguard the Palestine refugee population as with preventive measures and focusing on emergency
efficiently as possible. UNRWA’s main objectives have and high-risk group patients. With the introduction of
been fourfold: preventing the spread of the pandemic COVID-19 vaccinations, the utilization of UNRWA health
among Palestine refugees and UNRWA staff by an services started to return to pre-COVID-19 levels and full
introduction of preventive measures including the PHC services were resumed. UNRWA has also continued
safeguarding of vulnerable groups among Palestine its efforts to maintain infection prevention and control
refugees and UNRWA staff and reinforcing the health (IPC) measures in HCs, providing training for staff and
services to prevent it from collapsing. Ideally this is done supplying cleaning and sterilization tools.
by following a comprehensive approach that not only
addresses COVID-19 but also ensures uninterrupted However, there were challenges that UNRWA faced in
access to broader health care services. Additionally, providing direct PHC services to Palestine refugees. The
supporting host countries has been essential to health workers running the HCs remained exposed to
achieving optimal vaccination coverage which involves the risk of being infected with the COVID-19 virus, as
emphasizing communication as crucial to vaccine were other frontline workers. By the end of 2022, a total
acceptance and building trust in these measures. of 14,000 COVID-19 positive cases and 40 death cases
due to the infection were reported and 5 deaths were
7000 reported among UNRWA health staff. Within the Agency,
health staff had the highest positivity rate and remained
6000 5.726
5.497 at risk for acquiring the infection as frontline workers.
5000 The occurrence of multiple waves of the virus with new
variants has led to a constantly changing epidemiological
4000
situation. UNRWA has nevertheless remained flexible
3000 with service delivery changes depending on the
2.257 epidemiological situation of each host country.
2000

1000

0
14,000
Covid-19 Positive Cases
2020 2021 2022
Figure 4: Number of confirmed COVID-19 cases among Palestine
Refugees 40 Death Cases
were reported
The COVID-19 pandemic has had significant impacts due to the infection
on both Palestine refugee communities and UNRWA
health services over the past three years. The 5 Death Cases
pandemic has compounded existing vulnerabilities were reported
among UNRWA health staff
and poverty, resulting in profound health impacts
 unrwa health department - annual report 2022 13

Despite the increasing vaccination coverage and high Telemedicine:

levels of herd immunity in some fields, the pandemic UNRWA response: Telemedicine consultations were
is expected to remain active within Palestine refugee continued through telephone hotlines, allowing
communities. UNRWA will continue to implement the a remote provision of medical advice and health
necessary measures to minimize the risk of transmission information. The number of telemedicine consultations
of the virus and ensure the safety of UNRWA staff and increased by 160 per cent in 2021, with 844,518
Palestine refugees. During the past three years, UNRWA consultations provided. This number, however, reduced
has introduced the following key measures to tackle to 336,029 (signifying 60 per cent reduction) in 2022
COVID-19 and to ensure continuity of health service pointing towards a resumption of the complete package
provision. of services provided in-person.

Triage System:
UNRWA response: During the past three years, Telemedicine Consultations
the triage system was applied and standardized 60
across all health centres. This new system included 160
screening patients for respiratory symptoms and
high temperature, and minimizing contact between
suspected cases and staff or other patients. The
table below shows the commonly reported signs
and symptoms of the respiratory system among our 844,518 336,029
patients who underwent triage.

Table 1: Major diseases of respiratory system and symptoms & signs

Number of visits
Diseases of respiratory system and symptoms & signs
2020 2021 2022

Acute upper respiratory infection, site unspecified 15,816 248,347 345,663

Acute upper respiratory infections of multiple and unspecified sites 2,363 24,433 21,530

Acute upper respiratory infections of multiple sites 71 284 979

Upper respiratory tract disorders, unspecified 427 2,038 1,019

Other specified upper respiratory tract disorders 1,011 4,489 5,761

Lower respiratory tract disease, unspecified 2,334 13,325 14,293

Respiratory infections, not elsewhere classified 297 1,311 1,015

Fever of other or unknown origin 16,153 83,647 101,421

Future direction: Triage had been one of the Future direction: UNRWA plans to continue using
successful non-pharmaceutical interventions for telemedicine to reduce overcrowding in HCs and enable
tackling the burden of the COVID-19 pandemic. longer patient-doctor consultations in future years.
Implementation of triage was needed to prevent In particular, telemedicine service continues in Gaza
the spread of COVID-19 among both our patients and will be expanding in Syria and potentially other
and health care providers. This intervention allowed fields depending on the feasibility. UNRWA will retain
the agency to streamline the patient flow and to telemedicine as a means of service delivery in similar
separate the high- risk visitors from those who had situations.
no symptoms. A clear case definition, well- trained
staff and pre-defined patient flow helped to render Personal Protective Equipment:
UNRWA health facilities safe, build the trust of UNRWA’s response: Approximately 3,000 health care
Palestine refugees and enforce the safety of health providers were provided with personal protective
service providers. Although the triage may not be equipment (PPE), including masks, gloves, gowns,
sustained in the post-COVID-19 era, it will remain protective eye goggles, and face shields. During
as a key intervention in UNRWA’s readiness and the past three years, UNRWA dedicated financial
response to such a pandemic in the future. resources for procurement of PPE and also secured
 14 unrwa health department - annual report 2022

UNRWA provides laboratory services, oral health, and maternal

and child healthcare to Palestine refugees in its health facilities
across Syria, UNRWA health centre in Khan Dunoun camp in Rif
Damascus. © 2022 UNRWA Photo by Taghreed Mohammad

in-kind donations of PPEs that helped in protecting Future direction: As the COVID-19 pandemic situation
staff and Palestine refugees from avoidable exposure is gradually normalizing, there is still a large number of
to COVID-19. people in the host countries who require vaccination
coverage. UNRWA will continue supporting the
Future direction: PPE is part of UNRWA infection efforts of host countries in reaching the desired level
prevention and control protocols. Thusly, it will of vaccination. UNRWA will continue offering its HCs
continue to be used within the HCs even after the and staff for COVID-19 vaccination where the host
post-COVID-19 pandemic. Additional precaution and country needs such support. UNRWA will also continue
protective measurements will be implemented during encouraging Palestine refugees to comply with host
the active phases of epidemics/pandemics as per the country regulations with regard to COVID-19 vaccination.
UNRWA infection prevention and control protocols.
Rapid Diagnostic Test (RDT):
COVID-19 Vaccination: UNRWA response: Distributed 10,000 RDTs in Jordan,
UNRWA’s response: UNRWA encouraged its staff and Syria and Lebanon whereas Gaza and the West Bank
Palestine refugees to get vaccinated against COVID-19. procured their own tests. RDTs were introduced as a
UNRWA’s continued advocacy and communication quick measure to differentiate at risk and potential
campaigns have helped in reducing misinformation positive staff members and patients from the otherwise
about the COVID-19 vaccination. Health staff were healthy individuals and to reduce the avoidable risk of
encouraged to get vaccinated against COVID-19, spreading COVID-19. In Gaza, RDTs were made part of
resulting in 93.8 per cent of them receiving two doses of triage and had successful results in identifying potential
the vaccine by the end of 2022. positive cases.

60,000

50,000

40,000

30,000

20,000

10,000

0
1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q
2021 2022
No.of tests Positve tests
Figure 5: Number of antigen rapid diagnostic tests (Ag-RDT) in Gaza
 unrwa health department - annual report 2022 15

Future direction: UNRWA will continue to utilize RDTs as department, in collaboration with the HR department,
a tool to protect its health staff from the spread of viral established hotlines in each field to provide staff members
infection. During active future phases of the COVID-19 with access to dedicated psychologists. Furthermore,
pandemic, RDTs may remain a feasible method for specific mental health activities were organized at a HC
COVID-19 testing in our humanitarian settings, especially level, aimed at reducing work stress and encouraging
in Syria, where testing services are not readily available staff members recovering from COVID-19 to share their
and affordable. In the fields where the strong triage experiences. These interventions helped to reduce the
facilities exist such as in the Gaza Strip, UNRWA will use fear of COVID-19 among staff and build their confidence.
RDTs to identify the patients with positive cases during
the phases of COVID-19 pandemics to identify the
patients suffering from the disease.

Staff Care:
During the COVID-19 pandemic, protecting the well- among
being of staff, especially the frontline workers, became 2021 366 UNRWA Staff
one of the priorities for UNRWA. UNRWA implemented
various interventions aimed at ensuring their physical
safety and protection. Mental health support was
98% 28.7%
COVID-19 Symptoms Fully Recovered
identified as a necessary element , as staff members who
contracted COVID-19 infection required counselling.
In addition, mental health support was also needed to
alleviate mental stress and fatigue experienced by health
care providers who were affected by a shortage of staff 39.7% 18.8% 15.8%
during the COVID-19 pandemic. A study was conducted persistent fatigue shortness of breath depressed mood
symptom symptom symptom
in 2021 among 366 UNRWA staff and the results indicated
that the majority of staff suffered from the long-lasting
COVID-19 symptoms. Ninety-eight per cent of staff Future direction: In light of the COVID-19 pandemic and
developed acute COVID-19 symptoms, of which only 28.7 other emergency situations, UNRWA acknowledges the
per cent fully recovered. The majority of staff members crucial importance of prioritizing staff care, particularly
suffered from long COVID symptoms, such as persistent in the realm of psychosocial support. As such, Mental
fatigue (39.7 per cent), shortness of breath (18.8 per cent), Health and Psychosocial Support (MHPSS) remains a
and depressed mood (15.8 per cent). Consequently, a fundamental aspect of UNRWA health services, and
significant proportion of study participants required the organization places significant emphasis on the
mental health and psychosocial support. To address the provision of such services. Going forward, UNRWA
needs for mental health support, the UNRWA health intends to maintain staff care as a central feature of its

UNRWA staff nurse providing vaccination to a Palestine Refugee

baby in Baqa'a Main HC in Jordan. ©2020 UNRWA Photo
 16 unrwa health department - annual report 2022

UNRWA is committed to continue providing primary health care to

Palestine refugees in Syria, UNRWA health centre at the Agency’s
Damascus Training Centre. ©2022 UNRWA Photo by Taghreed Mohammad

preparedness and response strategies, with a specific Digital Platform for Evidence:
focus on anticipated active phases of COVID-19 as well UNRWA response: The UNRWA demonstrated an
as other potential emergencies, such as conflicts or admirable response to the COVID-19 pandemic by
natural disasters. leveraging its valuable electronic medical records
(EMR), also known as e-health, to introduce an ICD-
Health Service re-orientation: 11 module for improved diagnosis and surveillance of
UNRWA response: In response to the COVID-19 COVID-19 cases. Through remote training during the
pandemic, UNRWA undertook a reorganization of pandemic's active phase, UNRWA's health department
its services to prioritize emergency care for high-risk successfully trained its staff in the use of ICD-11
groups, specifically those with uncontrolled NCDs and augmented the existing e-health platform with
and high-risk pregnant women. This reorientation was ICD-11. This achievement has empowered UNRWA
designed to ensure the continuation of positive health to harness the data from e-health and use business
outcomes in priority areas and to reduce unnecessary intelligence and analytics tools to create dashboards
exposure for both patients and health care providers, that facilitate easy uploading, analysis, and access to
with non-emergency services suspended. The COVID-19 caseloads in the fields and headquarters.
limited number of staff available were redirected to The use of these dashboards enabled UNRWA to
provide new services, such as telemedicine, triage, report in a timely and accurate manner and allocate
and home delivery of medication for NCD patients. resources to areas with the greatest need. The use of
This intervention allowed UNRWA health facilities digital technology was a key intervention that helped
to maintain services during the active phase of the UNRWA streamline its COVID-19 response.
pandemic, and with the decline of COVID-19 incidence,
UNRWA health facilities are now returning to their pre- Future direction: In order to monitor services and
pandemic utilization levels. analyse disease trends among Palestine refugees,
UNRWA persistently employs e-health and the ICD-11.
Future direction: Reorganization of health services UNRWA acknowledges the value of technology and
constitutes an integral component of UNRWA's electronic health records for efficient operations and
health department preparedness and response intends to further leverage such systems to advance
planning, serving as a vital mechanism for effectively its mission. To achieve this goal, UNRWA plans to
addressing comparable events in the future. Drawing upgrade its EMR system in the near future to comply
upon the lessons learned from COVID-19 pandemic, with contemporary industry standards and take
UNRWA intends to incorporate these insights into its advantage of advanced functionalities not currently
preparedness and response planning efforts. available in its existing system.
 unrwa health department - annual report 2022 17

Field Innovations SMART survey was conducted on nutrition status of

the children and pregnant/lactating women residing
Jordan in Lebanon. This survey showed alarming results on
Multiple Micronutrient Supplementation (MMS) for the diets that over 80 per cent of children aged 6-23
Pregnant Women: Pilot in Two HCs months did not eat the required variety to grow
Multiple Micronutrient Supplementation (MMS) for healthy. This obliged Lebanon MOPH and UNICEF
pregnant women was introduced as an innovative to lead on a multisectoral group consultation where
program that positively reflected on the UNRWA UNRWA is a member and produced the Lebanon
health services in 2022. MMS is a form of daily prenatal National Nutrition Strategy for the first time in 2022.
supplements that provide 15 vitamins and minerals,
including iron and folic acid, in one tablet. These An immediate intervention and support for pregnant
supplements are intended to address the increased and/or lactating women and children is extended
nutritional needs during pregnancy and to prevent through the UNRWA-MCH. A new tool was added
micronutrient deficiencies that can lead to negative to the regular child and mother monitoring visits
health outcomes for both the mother and the baby, which is a tape measuring the arm circumference. It
such as maternal anaemia, low birth weight, preterm is very effective in early detection of malnutrition and
and small-for-gestational-age births. In 2020, the World hence allows early intervention to prohibit severe
Health Organization updated its antenatal guidelines malnutrition and delayed development. Training on
now recommending MMS for pregnant women in the the proper assessment for the health staff (nurses,
context of rigorous research, where the programs are MWes and doctors) was conducted during September
being considered. In 2021, MMS was added to the WHO’s 2022 to ensure the accuracy of the results to proceed
Essential Medication List. with the management. In addition to the treatment
of anaemia when detected by the iron supplements,
The Jordan Field Office was chosen to pilot MMS. In coordination with UNICEF resulted in enrolling the
September 2022, the MMS was first piloted in two UNRWA HCs in the PHC networks to provide children
HCs (Amman New Camp and Marka HCs) to test with multiple micronutrients supplementations
the acceptability, feasibility of workflow, education (MNS) in June 2022. It is planned to continue this MNS
materials, and data collection tools between September for the coming years whenever they are funded.
and December in 2022.
b. Cholera Outbreak in Lebanon
The UNRWA health programme has a routine
surveillance system for communicable diseases in
place continuing daily reporting in response to the
announcement of Cholera outbreak in North and
Beqaa, and as a lesson learned from the COVID-19
response strategy. A task force, led by the D/ DUAL(P)
composed of the main departments (Health,
Education, RSSP, FICIP, PIO) was established to ensure
the proper response and preventive measures are
in place to maintain clean safe camps and ensure
awareness and comprehension of the hygienic
UNRWA Midwife providing MMS Tablets and instructions to
a Palestine refugee pregnant woman at Amman New Camp practices are well delivered to the community.
HC in Jordan. ©2022 UNRWA Photo by Masako Horino Similar working groups were established at the area
level to follow up on measures in place. In parallel
Lebanon with the decision to continue full coverage of any
a. Training Health Staff on the Proper Assessment admitted case to hospitals, the departments, with
for Monitoring Maternal, Newborn, and Child the support of PIO, worked on producing a series of
Health awareness videos, posters and flyers depicting main
Within the context of a collapsing healthcare system in preventive practices and information about Cholera
Lebanon, UNRWA continues its healthcare provision infection with tailoring of the messages according
through its network of HCs to deliver essential primary to the target group (whether students by age and
health care and supported hospitalization services community). So far, no cholera cases were detected
by contracts with the local institutions. In 2021 the inside any PR camp.
 18 unrwa health department - annual report 2022

The Implementation and Evaluation:

Health Department implemented a queue system in
DTC HC (Piloting):
• The Queue system helped to improve the working
mechanism.
• The screen on which the Queue is presented is clear
and visible to clinic visitors and patients.
UNRWA Medical Officer providing a Cholera related • The technical support provided to the Queue system
awareness sessioPn to Palestine refugees in Lebanon.
©2022 UNRWA photo by Maysoun Mustafa by the IMTD Department meets these needs.
• The Queue system allows beneficiaries to receive the
With the current pandemic and challenging economic service in a fair manner.
situation in Lebanon, it is important to continue the • The sound alert mechanism helped to draw the
coordinated, multi-sectorial and targeted efforts to attention of the clinic visitors.
avoid exacerbation of the negative coping mechanisms • The use of the TV Box is useful and helps display the
that the patients are adopting. They are adopting Queue on the screen clearly.
these mechanisms to avoid health expenditures but
simultaneously jeopardizing their own well-being. Health & IMDT will implement the system in other clinics
While responding to immediate needs is critical, as soon as the needed hardware is provided.
strengthening cooperation and partnership continues
to be a main pillar in bridging the health gaps that are
not covered under the regular health policy schemes.
Hence, working closely with partners is ongoing and is
especially very close with UNICEF, WHO, PRCS, MOPH,
UNFPA, MAP-UK, National MHPSS and AIDS programs,
and indirectly with several NGOs through the National
Joint Health Working Group.

Syria
Queue System in All HCs Starting in Damascus UNRWA delivers basic health services to
Palestine refugees in its health facilities
Training Centre (DTC) Piloting across Syria, queue system at UNRWA
HCs in Syria are crowded with hundreds of patients daily. Damascus Training Centre Clinic. ©2022,
UNRWA Photo by Taghreed Mohammad
Most of the patients are used to gathering early morning
(8 – 11) A.M which creates crowdedness and pressure
on the staff. There was a critical need to organize the Gaza
appointments and the flow of the patients to raise the a. Appointment Initiatives
service quality, but at the same time, HD was not able to In 2022, efforts were made to resume the health
afford the Queue system from the market. HD & IMDT in service provision to the pre-COVID-19 era. As
SFO created a queue system for HCs with the following COVID-19 restrictions and measures subsided in the
added values: host country, the lives of Palestine Refugees gradually
• The system is almost free. returned to normal. One of the issues that have been
• Respond to special Health Department requirements affected is the appointment system. The Gaza field
in SFO. health management realized that resuming the strict
• Provide a good impact on the level of service provided appointment system would eventually result in an
to beneficiaries. automatic improvement of patients’ flow and hence
the quality of care provided.
The Plan:
Finishing the requirement collection stage before Sep To encourage health providers to provide quality
2022 care, a health programme launched an initiative
• Piloting the system in the middle of November 2022, that aims at enhancing the appointment system
including change requests, Chrome Cast, and TV Box at different stations of the HCs. In July 2022, HP
testing). launched the competition between HCs to select
• Evaluation of the system during February 2023 (our the best HC. HCs exerted their utmost efforts to
Sample was DTC HC team). follow up, analyse, review appointments at different
 unrwa health department - annual report 2022 19

stations and correlate the adherence to the given exam on a regular basis, are considered the most
appointment by date and time. At the end of every effective ways.
month health management extracted the reports,
analysed the data, and announced the selected The absence of a national screening programme for
HCs. The health programme organized gatherings breast cancer and the inability of refugee females to
for all HCs to celebrate their achievement of staff pay the cost of mammograms have initiated the idea
outside the HCs. of mammography services. Entirely through GFO-HP
efforts and with the help of project funds, the first
To ensure adherence of the HCs to the initiative, HP mammography started in 2016.
monitored the daily reports on E- health and provided
the HC with regular feedback on their progress. This included reviewing the literature to decide the
HCs have shown a high level of commitment to this criteria, in cooperation with other departments to
initiative to continue improving the quality of care ensure contracting with the specialised centres
provided to the refugees. Sheikh Radwan succeeded across Gaza after passing the technical and financial
in scoring the highest in November and December evaluation.
99.2 per cent and 99.3 per cent respectively.
Between 2016 and the end of 2022, a total of 79,678
b. Screening Mammography women were sent for screening according to a
Within the efforts to promote early detection and well-defined criterion, and 544 were identified as
early management of breast cancer, getting a high- confirmed cases of a breast cancer. A total of 784,732
quality screening mammogram, having a clinical women were examined by health staff and trained on
breast examination, and training on a self-breast breast self-exam by 2022.

2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011

0 20000 40000 60000 80000 100000 120000 140000 160000 180000

BSE referred to Hosp/mamogram Confirmed BC cases

Figure 6: Screening for breast cancer with mammography

Palestine refugees receiving UNRWA Health services at Pink October (Breast Cancer awareness
Deir El Balah UNRWA Health Centre in Deir El Balah, Gaza month) Health Programme activities in
Strip. © 2022 UNRWA Photo by Mohammad Hinnawi Gaza. © 2022 UNRWA Photo
 20 unrwa health department - annual report 2022

During 2022, breast cancer awareness campaigns implementation of the Primary Eye Care (PEC) project.
were under the spotlight mainly when Pink October The PEC project aimed to maximise the UNRWA health
activities were launched with participation of different system and the provision of medical eye care services
stakeholders in Gaza including WHO, UNFPA, MoH, to the most vulnerable population in the West Bank
NGOs, and community leaders. including women and girls, people with disability and
persons living in isolated areas.
These activities included: health awareness sessions,
outreach activities, and enhancing referral of all • 45 primary health doctors received eye care training
female staff members who are above 40 years old to to strengthen their capacity to successfully treat
do mammogram screening. patients with eye diseases.

In addition to health program participation, an • 12 nurses were trained in diabetic retinopathy

oral presentation “UNRWA Effort in Early Detection detection using a fundus camera.
of Breast Cancer” was given at the First Annual
Multidisciplinary Breast Cancer Conference in Gaza. • The referral mechanism was strengthened between
UNRWA HCs and SJEHGs so that PEC patients can be
UNRWA HP managed to have a closing ceremony referred for specialized secondary and tertiary care.
for Pink October with a large gallery exhibition that
presented all the year’s efforts and activities in a very • Several PEC equipment and supplies were provided to
creative and attractive way. UNRWA health facilities (39 direct ophthalmoscopes
44 LCD vision charts and 7 Fundus cameras).
West Bank
Improve Eye Care in West Bank Field and Prevent • During 2022, 30,185 patients received PEC screening.
Blindness. 15,214 patients were screened for Diabetic
During the Year 2022, the health department in Retinopathy, and 3118 patients were referred for
collaboration with St. John Hospital (SJEHG) started the specialized care.

An elderly Palestine refugee woman from Lebanon, in

Beddawi camp at UNRWA health center, Lebanon getting
a check-up. ©2022 UNRWA Photo by Maysoun Mustafa
 unrwa health department - annual report 2022 21

UNRWA Pharmacist delivering medications to

Palestine refugees patients at Amman New Camp HC
in Jordan. ©2022 UNRWA Photo by Amjad Ghosoun
 22 unrwa health department - annual report 2022

section 3: strategic outcome 2 - refugees’ health is

protected and the disease burden is reduced

Output 2.1: People-Centred Primary Health in Syria is expected in 2023, contingent upon
Care System Using the FHT Model security, infrastructure and connectivity. Currently,
Services under Output 2.1 include outpatient health the system is operational across 99.3 per cent of all
care, NCD treatment, communicable (infectious) disease UNRWA HCs.
treatment, maternal health care, child health care, school
health, oral health, mental health and psychosocial Table 2: Number of UNRWA HCs fully implementing the
support, physical rehabilitation, radiology services, e-Health system
disability care and pharmaceutical services.
Field 2018 2019 2020 2021 2022

FHT Approach and the E-Health System Jordan 25 25 25 25 25

The Family Health Team (FHT) approach represents a
system of delivering PHC through a multidisciplinary Lebanon 27 27 27 27 27

team of health professionals who work together to Syria 11 20 22 22 22

serve the Palestine refugees comprehensive health
needs across the client’s life cycle and in a community Gaza 22 22 22 22 22

setting close to the client. FHT approach design aims West Bank 43 43 43 43 43
to improve the quality, efficiency, and effectiveness of
Agency 128 137 139 139 139
health services.

Each FHT is composed of doctor(s), nurses, and other Since its introduction in 2017, the Maternal and Child
health workers[1]. The FHTs work together and are Health Mobile Application (e-MCH) has been used
responsible for providing health services for the families by around 237,714 mothers, allowing registered
who are registered with them. Palestine refugee mothers to view their electronic
health records and those of their children on their
In 2022, the performance of the FHT’s approach was smartphones. The e-MCH application notifies mothers
retained as it was affected during the past two years about their appointments and their children’s
by the precautionary and preventive measures taken appointments, in addition to providing health advice
by the Department of Health to mitigate the spread of according to their health status and the age of their
COVID-19 in most health centres in the fields.. children.

The e-Health system, introduced in 2009, has

streamlined service provision, improved efficiency,
and enabled high-quality data collection. In 2022,
e-Health was upgraded to cope with the new
technical instructions’ requirements. Additional
online training modules were introduced to facilitate
new staff capacity building for different roles. Also, around

the e-health was integrated with the laboratory

machines for the CBC test results. E-Health is
237,714
Mothers using e-MCH
operational in 139 out of 140 HCs; Gaza (22 HCs),
Jordan (25 HCs), Lebanon (27 HCs), West Bank
(43 HCs), and (22 out of 23 HCs) in Syria. E-Health
implementation in Syria is challenged due to the
ongoing conflict and the resulting connectivity
issues in some areas. Further expansion of e-Health

3 Each FHT is composed of medical officer, nurse, midwife and clerk as core team and other health providers such as pharmacist, laboratory technician, dentist and
non-medical staff such as cleaners are shared resource. Number of staff may vary per FHT.
 unrwa health department - annual report 2022 23

Palestine refugees receiving UNRWA Health services at Deir El Balah UNRWA Health
Centre in Deir El Balah, Gaza Strip. © 2022 UNRWA Photo by Mohammad Hinnawi

In 2020, a second mobile application, targeting NCD Utilization

patients was introduced. By the end of 2022, the In 2022, UNRWA provided over 7.8 million medical
e-NCD app was utilized by approximately 137,240 consultations. The utilization of outpatient services
patients, including 3,000 patients not registered Agency-wide increased by 22.4 per cent from 6.2
with the Agency’s HCs. The app provides the users million in 2021 for both face-to-face and specialist
with a self-assessment and monitoring tool for consultations. This increase was due to resumption of all
their health and enables access to electronic health health services, increased demand, and improvement of
records, enables recording of home measurements patient access to health care services.
i.e., BP, BG .. and shows trends, notifies patients about
their appointments and medications in addition to
providing health information and education. 2022
Outpatient Care
UNRWA Provides comprehensive Primary Health Care 22.4
(PHC) services through a network of 140 HCs, 47.1 per over
cent (66) of which are located within Palestine refugee 6.2 million 2021
camps. Furthermore, the Agency manages six mobile
Utilization of outpatient services Agency-wide
HCs in the West Bank to facilitate in accessing health care
for both face-to-face and specialist consultations
in areas impacted by barriers and checkpoints, as well as
two mobile HCs in Syria to provide health coverage in
hard-to-reach areas. Of the outpatient consultations held in 2022, 7,440,030
were face-to-face consultations, an increase of 22.4
Throughout the MTS strategic period (2016-2022), per cent compared to the 6,078,956 consultations held
there was an 8.0 per cent reduction in the utilization in 2021. A reduction in popularity for telemedicine
of the Agency›s outpatient services, with 7.9 million consultations was observed in 2022, with a reduction
consultations held in 2022 as opposed to 8.6 million in of 60.2 percent from 844,518 consultations in 2021
2016. This decrease was evident with a lower average to 336,029 consultations in 2022, this reduction was
daily medical consultations per doctor, dropping from mostly due to an improvement in beneficiary’s physical
85 consultations in 2016 to 75 consultations in 2022. access to UNRWA health services. Some 93,860 specialist
consultations (including those offered by gynecologists/
In 2022, there was a further increase in the utilization obstetricians and cardiologists) were also conducted.
of the Agency's outpatient services, approaching the
levels seen before the COVID-19 pandemic. UNRWA All fields showed an increase in the overall number of
continued to provide all health services in the context of outpatient consultations compared to 2021. However,
the FHT approach, while keeping the implementation of the increase was variable from one field to another which
preventive measures against COVID-19 at the HC level. may be explained by the different level of improvement
This included crowd-control measures such as triage, of patient’s access to UNRWA HCs at UNRWA’s fields of
appointments, and the use of telemedicine. operation.
 24 unrwa health department - annual report 2022

Table 3: Number of Agency-wide medical consultations in 2021and 2022

Year Type of consultation Jordan Lebanon Syria Gaza West Bank Agency
a) Face to Face
Male 448,131 241,117 298,316 1,062,619 329,100 2,379,283
Female 846,700 341,152 456,924 1,497,522 557,375 3,699,673
Total (a) 1,294,831 582,269 755,240 2,560,141 886,475 6,078,956
b) Telemedicine
Male 10,721 - 12,654 339,963 658 363,996
Female 17,490 - 33,725 427,941 1,366 480,522
2021 Total (b) 28,211 0 46,379 767,904 2,024 844,518
Total (a) + (b) 1,323,042 582,269 801,619 3,328,045 888,499 6,923,474
c) Specialist
Male 1,076 1,213 123 4,580 1,985 8,977
Female 23,441 12,295 7,722 20,330 4,467 68,255
Total (C) 24,517 13,508 7,845 24,910 6,452 77,232
Total consultations
1,347,559 595,777 809,464 3,352,955 894,951 7,000,706
(a+b+c)
a) Face to Face
Male 521,046 365,994 348,384 1,325,106 364,866 2,925,396
Female 949,177 518,252 548,754 1,878,160 620,291 4,514,634
Total (a) 1,470,223 884,246 897,138 3,203,266 985,157 7,440,030
b) Telemedicine
Male 4,616 0 2,232 149,390 0 156,238
Female 7,898 0 3,300 168,593 0 179,791
2022 Total (b) 12,514 0 5,532 317,983 0 336,029
Total (a) + (b) 1,482,737 884,246 902,670 3,521,249 985,157 7,776,059
c) Specialist
Male 1,063 2,305 829 5,264 2,761 12,222
Female 24,366 16,577 11,909 22,057 6,729 81,638
Total (c) 25,429 18,882 12,738 27,321 9,490 93,860
Total consultations
1,508,166 903,128 915,408 3,548,570 994,647 7,869,919
(a+b+c)
Face to Face 175,392 301,977 141,898 643,125 98,682 1,361,074
% 14% 52% 19% 25% 11% 22.4%
Telemedicine -15,697 0 -40,847 -449,921 -2,024 -508,489
Variance (no)/(%)
(2021 / 2022) % -56% 0% -88% -59% 0% -60.2%
Face to Face &
176,304 307,351 146,791 645,536 101,720 1,377,702
Specialist
% 13% 52% 19% 25% 11% 22.4%

UNRWA's outpatient medical consultations can be the same field. The interpretation of this ratio may
categorized into two groups: first visits and repeat visits. reflect the fact that some patients in some fields have
First visits indicate the number of persons attending a access to other health care providers. Furthermore,
HC during a calendar year, while repeat visits indicate the ratio of repeat visits to first visits was higher in
the frequency of service utilization. HCs located inside camps where Palestine refugees
can easily access health care services, and in fields
The ratio of repeat visits to first visits experienced a where Palestine refugees have limited or no access to
slight increase from 2.7 in 2021 to 2.9 in 2022, with a other health care providers, such as in Gaza, Syria, and
slight variation among fields and between HCs within Lebanon.
 unrwa health department - annual report 2022 25

Table 4: Agency-wide total number of first and repeat visits to UNRWA HCs and ratio of repeat to first visits in 2022
Jordan Lebanon Syria Gaza West Bank Agency
Total first visits 459,690 180,329 184,304 915,301 278,578 2,018,202
Total repeat visits 1,023,047 703,917 718,366 2,605,948 706,579 5,757,857
Ratio of repeat to first visits 2.2 3.9 3.9 2.8 2.5 2.9

Workload
The average number of medical consultations per Despite the variation across the fields, the overall
doctor per day increased Agency-wide from 66.3 in 2021 workload on MOs and PHC services has been reduced
to 74.5 in 2022, which was observed across all UNRWA’s through the FHT approach. This reduction has been
fields of operation due to the improved physical access achieved by shifting some preventive tasks from MOs
to UNRWA’s health services and the increased demand to nurses, such as providing nurses with the authority
from patients during the third year of the COVID-19 to approve monthly repeat prescription refills for NCD
pandemic. patients. In addition, the introduction of an appointment
system in HCs resulted in a more evenly distributed
The highest workload was observed in Lebanon, with an workload for all health staff. The introduction of
average of 87.5 medical consultations per doctor per day, telemedicine consultations in 2020 has also contributed
while Gaza had the lowest workload, with an average of to this reduction in workload.
62.8 medical consultations per doctor per day.

100
87.5
73.9 77.1 74.5
80 71.3 73.2
69.1 66.3
64.8 63.7 62.8
60.8
60

40

20

0
Jordan* Lebanon** Syria* Gaza* West Bank** Agency
2021 2022
Figure 7: Average daily medical consultations per doctor in 2021 and 2022
(*HCs open for six days per week; **HCs open for five days per week)

Palestine refugees receiving UNRWA Health services. A diabetic focus

group awareness session done for diabetic patients, Burj Barajneh
health center, Lebanon.© 2022 UNRWA Photo by Maysoun Mustafa
 26 unrwa health department - annual report 2022

Non-Communicable Diseases

The Burden of NCDs

In 2022, the number of patients with NCDs registered
Total NCD Patients
at UNRWA HCs continued to increase. By the end of the

2022 305,845
year, a total of 305,845 Palestine refugee patients with
DM, and/or hypertension, are registered at 140 HCs in
the five fields. This is 14,512 higher than the total NCD
patients registered in 2021. The estimated Agency- 2021 291,333
wide prevalence rates of DM and hypertension were
that same as those of 2021; at 15.9 per cent and 23.8
2021 2022
Agency-wide prevalence rates of DM and hypertension
per cent for DM and hypertension among those above
40 years old respectively, while for those above 60 it
reached 22.0 per cent for DM and 32.3 per cent for
hypertension. The prevalence of DM among patients
18 years and older was at 8.0 per cent and 11.9 per
cent for hypertension. Age-wise, 94.0 per cent of NCD 15.9% 23.8% 22% 32.3% 8.0% 11.9%
patients are those aged 40 years and older. Gender-
wise, 60 per cent of the patients were female and 40
94.0% 40% 60%
per cent were male, which most probably reflects
the attendance pattern of refugees, and not the
epidemiological situation.

Table 5: Patients registered with UNRWA HCs with DM, hypertension or both, by field and by type of morbidity
Morbidity type Jordan Lebanon Syria Gaza West Bank Agency

Type I DM 1,152 321 502 1,716 587 4,278

Type II DM 12,870 3,899 3,909 15,498 6,266 42,442

Hypertension 31,738 16,853 18,995 48,765 13,685 130,036

DM and hypertension 40,057 12,959 13,482 40,503 22,088 129,089

Total 85,817 34,032 36,888 106,482 42,626 305,845

30.0%
26.8%
25.7%
24.4% 23.8%
25.0% 22.5%
20.7%
20.0% 17.1% 17.9 %
15.4% 15.9%
13.9% 13.8%
15.0%

10.0%

5.0%

0.0%
Jordan Lebanon Syria Gaza West Bank Agency

Prevalence(%) of DM Prevalence(%) of HTN

Figure 8: Prevalence (per cent) of patients diagnosed with type I and type II DM and hypertension among served population ≥40 years of age
in 2022
 unrwa health department - annual report 2022 27

Risk Scoring Table 6: Per cent of insulin usage among patients with
Every year, UNRWA assesses the risk status of all DM only and with DM and HTN by field
NCD patients to help staff with the management of
Jordan Lebanon Syria Gaza West Bank Agency
the condition of patients. The assessment is on the
presence of modifiable risk factors such as smoking, DM only 24.8% 13.9% 22.8% 29.6% 28.2% 25.9%
hyperlipidemia, physical inactivity, blood pressure and
blood sugar, as well as non-modifiable risk factors such DM+HTN 20.7% 14.5% 21.0% 28.4% 28.4% 23.8%
as age and family history concerning the disease. In
Total 21.7% 14.3% 21.5% 28.8% 28.4% 24.4%
2022, the risk-scoring assessment of all NCD patients
revealed that 39.0 per cent of them were with high-risks
on average, which is less than that of 2021 40.7 per cent. The above differences among fields need further
The percentage of patients at moderate risk was 49.7 per analysis and follow up to understand the reasons for
cent, and those with low risk were only 11.3 per cent. This the differences particularly in Lebanon. Uncontrolled
means the majority 89.7 per cent of patients are either at patients on a maximum dose of oral hypoglycemic drugs
high or moderate risk and in need of further follow up must be enrolled in combination therapy or total insulin
to reduce the modifiable risk factors mentioned above treatment. Close monitoring of management protocols
through different means of health education, increasing need to be strengthened at HC, area, and field levels to
their physical activity and smoke cessation, controlling improve the quality of care provided to patients with
blood sugar and pressure, and reducing the level of DM. MOs need to be more alert and patients properly
hyperlipidemia in line with UNRWA guidelines and best educated as per observation as some are not convinced
practices such as Microclinic and support group sessions. to prescribe and patients are afraid to inject themselves
with insulin.
Treatment
As per UNRWA technical instruction, patients with type Control Status
1 diabetes need to be managed by Insulin only, without Criteria for monitoring the control status of patients
oral hypoglycemic agents. Therefore, 100 per cent of with DM and/or hypertension refer to HbA1c readings
type 1 diabetic patients should be using insulin therapy. and blood pressure measurements as seen in the table
The per cent utilization of insulin among diabetic below.
patients varied among fields, with an average of 25.9 per
cent which is less than that of 2021 26.3 per cent. This Table 7: Criteria of monitoring the control status of DM
proportion ranged from 13.9 per cent in Lebanon to 29.6 and HTN
per cent in Gaza , 28.2 per cent in the West Bank, 24.8 per
Value Reading Controlled Uncontrolled
cent in Jordan and 22.8 per cent in Syria. The proportion
also varied among patients with DM alone and with DM DM: HbA1c <7
and hypertension as shown in the following table. Hypertension:
<140/90
Blood pressure (mmHg)

2022 25.9 Definitions of controlled statuses for diabetic and

hypertensive patients are as follows. For patients with
2021 26.3% DM, the protocol is to conduct two HbA1c tests every
year. The most recent HbA1c test result is considered
Utilization of insulin
the control status assessment. If no HbA1c tests are
among diabetic patients among fields
done in the year, the patient will be considered as not
tested. As for those with hypertension, the protocol is to
Lebanon Jordan
measure blood pressure every three months, resulting
13.9% 24.8% in a total of four blood pressure measurements in one
year. The patients with at least two measurements of
Syria
Gaza blood pressure <140/90 mmHg are considered to be
22.8%
29.6% controlled. For patients living with both conditions,
the control of diabetes and that of hypertension are
measured separately.
West Bank
28.2%
 28 unrwa health department - annual report 2022

Table 8: Percentage of DM and HTN patients under control

Indicator Jordan Lebanon Syria Gaza West Bank Agency

% of DM1 patients under control 7.0% 16.2% 9.2% 9.2% 7.3% 8.8%

% of DM2 patients under control 24.8% 42.1% 30.0% 31.0% 33.3% 30.2%

% of DM&HTN patients under control 29.5% 45.7% 38.0% 36.2% 37.3% 35.2%

% of all DM patients under control 28.0% 44.4% 35.5% 34.0% 35.9% 33.4%

% of HTN patients under control 38.6% 56.9% 54.7% 50.8% 41.7% 47.2%

Late Complications
Late complications of NCDs include cardiovascular
diseases (myocardial infarction, congestive heart failure,
or both), cerebrovascular disease (stroke), end-stage 2022 11.1%
renal failure, above-ankle amputation, and blindness.
The Agency-wide late complications rate in 2022 was
2021 10.3%
11.1 per cent, which was higher than that of 2021 10.3
per cent. This could be either due to the improved
Late Complications Rate
recording and reporting and/or later complications
that appeared among patients in the reported year. The
highest rate was in Gaza 13.3 per cent and the lowest Gaza 7.7
rate was in Lebanon 7.7 per cent which may reflect low
13.3 Lebanon
detection, recording, and reporting.

As expected, patients with both DM and hypertension

had the highest incidence of late complications 14.7
per cent, followed by patients with hypertension
only at 8.6 per cent and patients with DM type 2 only
at 6.5 per cent. There were some differences in the
distribution of late complications of diseases between
the fields. The variations among fields could be due
to different doctors' treatment and possible variation
in recording the complications in patients' files and
subsequently reporting.
14.7% 8.6% 6.5%

A Palestine refugee from Lebanon (PRL), in Nahr elbared camp(NBC) at UNRWA health
center, Lebanon getting a check-up. ©2022 UNRWA Photo by Maysoun Mustafa
 unrwa health department - annual report 2022 29

UNRWA Medical Officer checking diabetic Palestine

refugee foot at Zarqa HC in Jordan. ©2022 UNRWA Photo

Defaulters Case Fatality

The UNRWA defines “Defaulters” as patients who did The mortality rate among NCD patients registered at
not attend the HCs to get NCD care for one calendar UNRWA HCs showed a decrease from 1.8 per cent (or
year, neither for follow-up nor for collecting medicines. 4,791 deaths) in 2021 to 1.5 per cent (or 4,373 deaths),
During 2022, the defaulters who missed follow-up in 2022. One possible reason behind this decline from
appointments was 7.2 per cent, down from 7.5 per 2021 to 2022, or high mortality in 2021, was COVID-19.
cent in 2021. Health staff used many different means, In 2021, many patients with NCDs died with COVID-19,
including home visits, telephone calls and notifications mostly due to the complications related to the chronic
via family members. Field-specific defaulter rates ranged conditions that these patients had. In 2022, less cases
from 5.0 per cent in Lebanon to 9.6 per cent in the West with COVID-19 were reported, and even when they
Bank. Following close follow-up, defaulter’s rate in the contracted COVID-19, the reported cases had mild to
Jordan field dropped from 11.2 per cent to 9.4 per cent. moderate symptoms. The case fatality was the highest in
More work is needed in the West Bank and Jordan on Lebanon at 2.3 per cent (712 deaths). Ageing is a reason
defaulters’ issue that could be due to the availability for death among NCD patients but other factors such as
of more than one health care provider and possible hard living conditions and lack of advanced hospital care
dissatisfaction among some patients and accessibility were another reason.
barriers mainly in the West Bank.

2022 7.2%
2021 7.5% 2022 4,373 Deaths 1.5%
Defaulters 2021 4,791Deaths 1.8%
who missed follow-up appointments Mortality rate among
patients registered at UNRWA's HCs
Field-specific Defaulter Rates
Lebanon West Bank
5.0% 9.6% Reason is COVID-19
Jordan
2022 9.4% Lebanon
2021 11.2% 2.3
 30 unrwa health department - annual report 2022

The Way Forward for NCD Care The third is updating the technical instruction including
There are three priority areas for the future of NCD care treatment guidelines of NCD along with the latest WHO
at UNRWA HCs. and other international guidelines. UNRWA’s current
guidelines are in line with WHO’s recommendations, but
The first is the primary prevention of NCDs. It is there are several new medicines that have been recently
obvious that NCDs including DM, hypertension, and added to the WHO’s Essential Medicine List. UNRWA is
their complications are on the continuous rise among under strong pressure not only from its doctors, but
Palestine Refugees. This is primarily because of the also from the refugee communities to include such new
epidemiological shift of the burden of diseases (from medicines. Still, it is critically important to assess the
communicable to non-communicable diseases) due to current treatment status first, and then identify the need
lifestyle changes, diet changes, and prevailing poverty for new medicine and its anticipated benefit for patients.
and social stresses. This increase of NCDs is happening In the above table, for example, the first operational
in all countries hosting Palestine Refugees. UNRWA priority is to reduce the per cent of HbA1c “not tested”
continues to provide NCD care at its HCs and to improve patients from the current 19 per cent average to as close
its service quality. At the same time, UNRWA realized to zero per cent as possible.
the importance of strengthening its primary prevention
approach through health education and raising UNRWA will continue cooperation with ministries of
awareness of risk factors among Palestine refugees. health in host countries, other UN entities, NGOs and
Within the limited resources, UNRWA will explore diabetes associations for technical support and exchange
possible primary prevention approaches with a special of experiences and seek funding for related projects and
focus on school children in 2023 onwards. activities. This cooperation aims to scale up diabetes and
hypertension care provided to Palestine Refugees. In
The second is the improved data analysis and 2022, all fields completed the project supported by the
interventions. Because of e-health, detailed programme World Diabetes Foundation. In the Jordan field, diabetic
operational information is now available. One example is foot care also was completed in terms of training MOs
the HbA1c tests among DM patients. The following table and nurses and providing related equipment for early
shows the two sets of critical information for diabetes diagnosis and better care of patients' feet. UNRWA will
care: per cent of patients who did not do HbA1c test seek continued cooperation and provisions for a new
in 2022 (not tested), and per cent of patients whose project to support the Lebanon and Syria fields.
HbA1c is higher than 9 per cent. The former is a sort
of “defaulters” from the HbA1c tests, and it is critical to Integrating the MHPSS Programme into UNRWA PHC
reduce such HbA1c test “defaulters” as much as possible and the FHT Approach
(close to zero per cent). The latter represents the highest UNRWA aims to protect and promote the mental
risk groups among diabetes patients, and it is important health of Palestine refugees through its MHPSS services
to prioritize the care for such highest risk groups by that is implemented in all Agency HCs. Reports from
supporting them to reduce their HbA1c to less than 9 fields during the last four years have confirmed a high
per cent at the least. The planned new Electronic Medical occurrence of mental health problems and psychological
Records (EMR) system is expected to strengthen such distress among Palestine Refugees. The COVID-19
data analysis on NCD including incidence, prevalence, pandemic in addition to the challenging social and
treatment compliance, and patient control status. economic situation aggravated these conditions.

Table 9: HbA1c results among diabetes patients by field UNRWA’s MHPSS strategy is based on the WHO’s MhGAP
(including HbA1c not tested) (Mental Health Gap Action Programme) strategy. The
Field <7 7-9 >9 Not tested Total strategy seeks to address and enhance individuals
and their communities' psychological well-being and
Jordan 22.1% 29.3% 27.6% 21.1% 100%
empowering the community and individual resilience,
Lebanon 27.6% 21.2% 13.4% 37.9% 100% implemented in coordination with the FHT approach.
Syria 21.8% 24.2% 15.4% 38.6% 100% MHPSS services were integrated into all HCs, and HC staff
received MHPSS training based on their roles. MOs, senior
Gaza 29.7% 35.4% 22.3% 12.6% 100%
staff nurses, and midwives received a comprehensive
WB 29.1% 30.2% 21.8% 18.9% 100% two-week training course on MHPSS, while PNs received
a one-week MHPSS training, and other support and
Total 26.2% 30.1% 22.3% 21.3% 100%
paramedical staff received at least one day orientation
 unrwa health department - annual report 2022 31

training. Technical instructions based on WHO and other decide whether the person may need MHPSS care or
international standards were developed as reference not. In a case where the presence of GBV has become a
and guidance to staff during the implementation. matter of concern, the health staff may ask questions on
GBV with the consent of the person.
UNRWA’s MHPSS aims at responding to the four mental
health conditions such as depression, epilepsy, stress- In 2022, a total of 182,595 patients at health centres were
related conditions, and unexplained medical conditions. screened for MHPSS. Of which, 35,274, or 19.3 per cent,
It also aims to address the needs of gender-based were found to have GHQ-12 scores higher than 6. The
violence victims. following table shows the data by field.

The first step is to screen the high-risk groups identified The above reflects the immense needs of MHPSS
by using the international screening and scoring tool care as one out of five screened having needs for
known as the 12-Item General Health Questionnaire psychological or mental health assistance. Variation
(GHQ-12). The targeted groups include uncontrolled was observed among fields, with Gaza having the
patients with diabetes and/or hypertension, high-risk highest detection rate at 26.4 per cent followed by
pregnant women, new mothers receiving postnatal Syria at 14.2 per cent, the West Bank by 10.1 per cent,
care, caregivers of children with growth problems and Lebanon by 8.4 per cent and Jordan with 5.8 per cent.
patients with severe anaemia, frequent visitors to the Such variation needs to be followed up closely by the
out-patient clinic (defined as more than one visit per field officers to enhance screening and identify those
month), Gender-based Violence (GBV) survivors and in need of MHPSS services.
other protection cases, clients with relevant symptoms
identified through normal service provision, survivors Of the 35,274 whose GHQ-12 scores were higher than
of other traumatic events (persons directly exposed to 6, a total of 23,262 patients were cared for their mental
trauma or witnessing trauma), and school-aged children health conditions, namely depression (17,089 patients),
with special education needs who are referred by epilepsy (3,471), psychosis (2,437), and dementia (355).
schools' health tutors or teachers. If the GHQ-12 score is In addition, a total of 7,172 GBV survivors were safetly
more than six, HC staff will ask detailed questions and identified through screening tool.

Table 10: Number and percentage of patients screened for MHPSS through GHQ-12 tool
Field Total No. of screened Total No. of those GHQ-12>6 %
Jordan 14,739 873 5.9%
Lebanon 11,320 948 8.4%
Syria 16,164 2,293 14.2%
Gaza 103,898 27,470 26.4%
West Bank 36,474 3,690 10.1%
Total 182,595 35,274 19.3%

Table 11: Number of people screened in 2020, 2021, and 2022

2020 2021 2022
Total No. of screened 50,810 76,477 182,595
Total No. of these with GHQ-12 > 6 10,838 15366 35,274
% 21.3% 20.1% 19.3%

Table 12: Number of people identified with MHPSS conditions in 2022

Depression Epilepsy Psychosis Dementia
Field
Male Female Total Male Female Total Male Female Total Male Female Total
Jordan 115 587 702 20 32 52 20 30 50 2 3 5
Lebanon 103 285 388 122 62 184 65 42 107 3 2 5
Syria 100 548 648 63 58 121 26 31 57 0 0 0
Gaza 4,996 9,454 14,450 1,758 1,204 2,962 530 1,535 2,065 123 218 341
West Bank 99 802 901 70 82 152 20 48 68 1 3 4
Agency 5,413 11,676 17,089 2,033 1,438 3,471 661 1,686 2,347 129 226 355
 32 unrwa health department - annual report 2022

UNRWA introduced a management health information Other Communicable Diseases

system for GBV inclusion within the current MHPSS
reporting. It is planned to include fully computerized Cholera Outbreak in Lebanon and Syria
mental health module in the coming new EMR system. According to WHO, between 25 August 2022, and
21 January 2023, 84,607 suspected cases of cholera
Regarding referral, UNRWA MOs can refer patients with have been reported from all 14 governorates in Syria,
more severe mental health conditions to Psychosocial including 101 attributed deaths. The first case in Lebanon
Counsellors available in some HCs/fields or to external was confirmed on October 5th, 2022, in which over 1,400
specialists (psychiatrists) contracted by the Agency. suspected cases have been reported across the country,
These mental health referral systems should be including 381 laboratory-confirmed cases and 17 deaths.
sustained by increasing availability of specialized care, While the outbreak was initially confined to northern
especially in Lebanon and Syria, in the coming years as districts, it rapidly spread, with laboratory-confirmed
UNRWA continues to seek additional funds. cases now being reported from all eight governorates
and 18 out of 26 districts. Serotype Vibrio cholerae O1
El-Tor Ogawa was identified as the currently circulating
Communicable Diseases cholera strain, similar to the one circulating in Syria.
The COVID-19 pandemic that affected the whole world
since 2020 is still being reported in 2022, even though As for UNRWA, a total of 111 cases were reported among
some hosting authorities stopped the reporting on Palestine refugees (76 from Lebanon and 25 from Syria)
COVID-19 and considered it as part of an influenza-like out of which 10 cases were confirmed (8 in Lebanon and
illness. Conversely, both Lebanon and Syria reported 2 in Syria) and reported with no deaths.
a cholera outbreak which will later be discussed in
further detail. There were no reports on polio cases Cholera Outbreak in Syria
or other emerging diseases among Palestine refugees.
Mumps and measles cases were reported from Gaza in
25 Aug 84,607 21 Jan
2022 2023
2022 (288 and 40 respectively), while the other fields Reported suspected cases
101 Deaths/Syria
reported few cases.

UNRWA continued its cooperation with host authorities over 1,400

1st Case reported suspected cases
with WHO as well and participated in immunization
in Lebanon 381 laboratory-confirmed cases
campaigns across all fields where required. UNRWA’s 17 deaths
5 Oct 2022
focus on strengthening the surveillance of emerging
and re-emerging diseases continued to be active. Close Total of 111 Cases
coordination with the host countries' Ministries of Health reported among Palestine refugees
continued the surveillance of communicable diseases, 10 Cases Confirmed
Syria
outbreak investigation, and supply of vaccines as well as Lebanon 8 Lebanon & 2 Syria
76 Cases 25 Cases with no deaths
an exchange of information.

UNRWA in coordination with relevant stakeholders

Expanded Programme on Immunization (EPI): managed to overcome the outbreak and ensured
Vaccine-Preventable Diseases preventive measures in camps and UNRWA installations
UNRWA's immunization services follow the host as well as immunization for the targeted groups (mainly
countries’ EPIs. In 2022, the immunization coverage in school children) in affected areas.
all fields for 12-month-old and 18-month-old children
registered with UNRWA continued to be above the Viral Hepatitis
WHO's target (95.0 per cent). Factors contributing to The Agency-wide incidence of suspected cases of viral
UNRWA's success in immunization coverage include a hepatitis (mainly hepatitis A) varied among fields; the
consistent supply of vaccines, the enforcement of an reported cases from Gaza were at 157 versus 262 cases
appointment system for vaccinations, and continuous in 2021, while for Syria it increased to 459 cases versus
follow-up of defaulters by HC staff. 362 in 2021. At the same time, Lebanon reported 153
cases versus 60 cases in 2021. Jordan and the West Bank
reported two and seven cases, respectively. Agency-
wide incidence in 2022 remained at a similar range of
 unrwa health department - annual report 2022 33

24.5 versus 23.07 per 100,000 cases in 2021. Causes of Brucellosis

viral hepatitis are most probably related to poor hygienic In 2022, a total of 226 cases of brucellosis were reported,
conditions inside some camps as well personal related compared to 204 in 2021. Out of these cases, most were
issues, and more adherence to cleanliness and personal recorded in Syria (193). Cases were also notified in the
hygiene measures are required. West Bank (13), Gaza (20), and zero in both Jordan and
Lebanon. The relatively high prevalence of the disease
in Syria indicates the need to identify the source of
infection. There is also a need for more awareness-raising
activities for Palestine refugees on the importance of
safe food handling, especially the handling of milk and
dairy products.

2022 157 Cases 2022 459 Cases Maternal Health Services

2021 262 Cases 2021 362 Cases UNRWA maternal health services include family
planning, preconception care (PCC), antenatal care
2022 (ANC), delivery care, and post-natal care (PNC). During
2022 153 Cases Jordan 2 Cases 2022, our staff continued to overcome the effect of the
2021 60 Cases West Bank 7 Cases COVID-19 preventive measures that were taken from
2020 till the beginning of 2022. These measures taken by
2022 24.5 our staff have improved the capacity of women's access
per 100,000 Cases
23.07 to UNRWA health centres, which has led to an increase in
Agency-wide
2021 per 100,000 Cases
the number of women benefiting from maternal health
services. This increase varies between fields as well as
Typhoid Fever between HCs in the same field.
The Agency-wide incidence of suspected typhoid fever
cases decreased further from the previous three years Family Planning
11.6 cases per 100,000 populations in 2019 to 9.4 in 2020 UNRWA HCs provide universal access to family planning
to 8.0 in 2021) to 7.1 per 100,000 populations in 2022. (FP). FP is implemented as a main part of maternal health
The highest and most significant incidence is still being services, in addition to supporting women to access
observed in Syria at 59.9 per 100,000 populations but counselling services and obtain modern contraceptives,
lower than that in 2021 (71.6 per 100,000 populations), male active participation and engagement were also
with a total of 193 out of 226 cases Agency-wide. encouraged. In 2022, utilization of FP services Agency-
This high incidence is also attributable to poor water wide was improved, the total number of new FP users
quality and hygienic conditions and the challenging increased by 12 per cent (22,592 in 2021 versus 25,212
environmental conditions caused by complex economic in 2022), while the total number of continuing users of
status and refugees' displacement. At the same time, contraceptive methods increased by 5 per cent (182,319
Gaza reported 20 cases, 13 cases from the West Bank. in 2021 versus in 190,827 in 2022), and the family
Lebanon and Jordan and fields reported zero cases. planning discontinuation rate increased from 4.8 per
cent in 2021 to 5.1 per cent in 2022.
Tuberculosis (TB)
In 2022 TB remained underreported. During the year, 33 Utilization of Family Planning services
cases were reported. Some 91 per cent of this caseload Agency-wide
(30) was recorded in Syria. The remaining two cases
were registered in Gaza and one from Lebanon. Out of 2022 25,212 New FP Users
2021 22,592 New FP Users 12%
the these reported cases, 10 were smear-positive, 2 were
smear-negative and 21 were extra-pulmonary. Patients 2022 190,827
diagnosed with TB are managed in close coordination 5%
2021 182,319
with national TB programmes, while in Lebanon, UNRWA total number of continuing
users of contraceptive methods
reimburses the costs of anti-TB drugs for Palestine
refugees. It is essential to highlight that the figures 2022 5.1%
above are most likely underreported, and therefore, 2021 4.8%
close follow-up with the Ministries of Health in host family planning
discontinuation rate
countries is required.
 34 unrwa health department - annual report 2022

Table 13 : Utilization of UNRWA FP services in 2021 and 2022

Indicator Year Jordan Lebanon Syria Gaza West Bank Agency

2021 6,295 1,806 2,171 10,013 2,307 22,592
Number of new FP users 2022 5,953 2,082 2,246 11,550 3,381 25,212
Variance % -5% 15% 3% 15% 47% 12%
2021 37,266 17,201 11,385 94,847 21,620 182,319
Total number of continuing users at year end 2022 37,481 16,980 11,843 101,070 23,453 190,827
Variance % 1% -1% 4% 7% 8% 5%
2021 5.2 4.2 5.8 4.5 4.2 4.8
Discontinuation rate (%)*
2022 5.2 5.7 6.2 4.3 4.2 5.1
*(No of discontinuers / total number of remaining FP users x 100)

The distribution of FP users according to contraceptive Palestine refugees, in 2011 the Agency implemented the
method remained stable. In 2022, the intrauterine device preconception care programme. Today, this programme
(IUD) continued to be the most common method 47.3 is an essential element of maternal health care integrated
per cent of users, followed by condoms 27.3 per cent, within the PHC system in UNRWA HCs.
oral contraceptives (pills) 22.4 per cent and injections
3.0 per cent. Preconception care intends to prepare women of
reproductive age for pregnancy with an optimal state
Pills of health. Women are assessed for risk factors, screened
22.4%
Condoms
for hypertension, DM, anaemia, and oral health diseases.
27.3% Women are provided with folic acid supplements to help
prevent congenital malformations (such as neural tube
defects) among their children. At the same time, women
who attended PCC usually have early registration for
ANC which enable pregnant women to be seen more
Injection
3.0% frequently by UNRWA health staff.
IUD
47.3% A total of 42,421 women registered for the preconception
care programme in 2022, and this number increased
Figure 9 : Contraceptive methods use, Agency-wide, in 2022 by 68 per cent compared to 2021 (25,251 registered
women). These achievements were the results of a series
Preconception Care of health awareness sessions on preconception care
Over the past few decades, controlling Infants Mortality targeting women attending UNRWA HCs for medical,
Rate (IMRs) and Maternal Mortality Rate (MMRs) have dental, and NCD consultations. The figure below shows
focused on by providing quality health care at UNRWA. the percentage of newly registered pregnant women
To further control infant and maternal mortality among who attended preconception care in 2022.

50.0%
42.9%
45.0%
40.0%
35.0%
27.7%
30.0% 25.7%
25.0%
20.0% 15.9% 16.9%
15.0%
10.0% 6.3%
5.0%
0.0%
Jordan Lebanon Syria Gaza West Bank Agency
Figure 10: Percentage of newly registered pregnant women who attended PCC in 2022
 unrwa health department - annual report 2022 35

UNRWA provides special health care to meet the needs of newborns, and infants
under five years of age. A nurse weighs a Palestine refugee baby in Lebanon at
UNRWA health Center in Shatila camp. © 2022 UNRWA Photo by Dima Farran
 36 unrwa health department - annual report 2022

Antenatal Care
To promote early detection and management of risk
factors and complications, UNWRA encourages pregnant 2022 81,116 7%
women to access an initial antenatal assessment as early
as possible and attend at least four additional prenatal
2021 87,173
care visits throughout their pregnancy. Pregnant women pregnant women
receive a comprehensive initial physical examination and registered for ANC
regular follow-up care, including screening for pregnancy-
2022 52.0%
related hypertension, gestational diabetes, anaemia, oral
health problems and other risk factors. Women are then
2021 56.2%
classified according to their status of pregnancy risk for Ante-natal coverage among
individualised management. While all pregnant women registered population
are provided with iron and folic acid supplementation,
UNRWA also started piloting Multiple Micronutrient Gaza
Supplementation (MMS) implementation research in the 72.8
Jordan field. UNRWA uses selected indicators for coverage
and quality to monitor the performance of ANC services,
including ANC coverage, percentage of pregnant women Registration for Antenatal Care in the First Trimester
registered for antenatal care in the first trimester, number Early registration will increase the likelihood of positive
of ANC visits during pregnancy, tetanus immunization outcomes for mothers and children and it is considered
coverage, pregnancy risk status assessment and DM and a key element to focus on while providing quality ANC
hypertension in pregnancy. for Palestine refugee women. UNRWA seeks to safeguard
this by ensuring ample time for risk identification,
Antenatal Care Coverage follow-up, and management according to their needs.
The percentage of pregnant women registered for ANC During 2022, the proportion of pregnant women who
decreased by 7 per cent (from 87,173 in 2021 to 81,166 registered for ANC in UNRWA HCs during the first
in 2022). In 2022, the coverage rate of all expected trimester of pregnancy was 78.5 per cent compared to
pregnancies among the registered refugee population 73.0 per cent during 2021. The ratio of pregnant women
decreased to 52.0 per cent compared to 56.2 per cent registered during the second trimester was 17.9 per
in 2021. This calculation is based on the registered cent, and during the third trimester was 3.6 per cent. The
population's expected number of pregnancies. The variation of this rate within the fields reflects the ability
coverage remained the highest in Gaza, which reached of pregnant women to have access to other health care
72.8 per cent. providers.

Table 14: UNRWA Antenatal care coverage in 2022

Jordan Lebanon Syria Gaza West Bank Agency
Registered population 2,542,999 557,342 674,455 1,754,309 1,123,485 6,652,590
*Expected No. of pregnancies 57,421 7,301 15,324 48,542 27,436 156,023
Newly registered pregnancies 20,054 4,627 6,380 35,341 14,764 81,166
)%( ANC Coverage 34.9 63.4 41.6 72.8 53.8 52.0

* Expected number of pregnancies=Total number of registered population (from UNRWA registration system) multiplied by crude birth rate

100 89.7%
90 85.2%
75.8 % 78.5%
80
70 65.6%
60 49.7%
50
40
30
20
10
0
Jordan Lebanon Syria Gaza West Bank Agency
Figure 11: Percentage of pregnant women registered during the first trimester in 2022
 unrwa health department - annual report 2022 37

Number of Antenatal Care Visits Risk Status Assessment

Within efforts to decrease maternal mortality, UNRWA The WHO model of ANC classifies pregnant women into
adopted the WHO new ANC guidelines issued in 2016. two groups: those likely to need only routine antenatal
These new guidelines increased the number of ANC care (50.2 per cent of pregnancy cases), and those with
contacts by health care providers to pregnant women specific health conditions or risk factors that necessitate
from four to eight. The HD continued to gradually special care (49.8 per cent of pregnancy cases). UNRWA
increase the number of ANC contacts among high- classifies pregnant women into three categories based
risk and alert pregnant women. This improved the on risk: low, alert, and high-risk.
percentage of pregnant women who paid 4 visits
throughout pregnancy in 2022. During 2022, Agency-wide, 49.7 per cent were classified
as low-risk, 30.1 per cent were an alert-risk, and 20.2 per
In 2022, the Agency-wide average number of antenatal cent of women were high-risk. The rates varied from one
visits per client was 6.1. The lowest number of visits field to another, with the highest high-risk rate of 27.8
was in Syria, with an average of 3.9 antenatal visits per per cent in Jordan, followed by 18.6 per cent in the West
client, and the highest in Gaza with 7.6 antenatal visits Bank and 17.9 per cent in Gaza. The high-risk and alert-
per client. Agency-wide, some 87.6 per cent of pregnant risk pregnancies received more intensive follow-up than
women attended four or more antenatal visits, with the low-risk pregnancies, including referral to specialists as
highest attendance rate in Gaza, at 98.3 percent, and the needed.
lowest in Syria, at 54.6 percent.

Table 15: Percentage of pregnant women who made ≥ four antenatal visits in 2021 and 2022

Indicator Year Jordan Lebanon Syria Gaza West Bank Agency

Percentage of pregnant women 2021 72 55.1 19.8 94.1 73.8 77.6

who paid ≥ four antenatal visits 2022 80.5 75.2 54.6 98.3 90.1 87.6

Average number of antenatal visits 2021 4.6 3.8 2.2 6.6 4.4 5.2
per pregnant woman 2022 5.2 4.8 3.9 7.6 5.3 6.1

Tetanus Immunization Coverage Diabetes mellitus and hypertension during pregnancy

In 2022, 98.5 per cent of pregnant women received Pregnant women are regularly screened for DM and
adequate immunization against tetanus. As a result of the hypertension throughout their pregnancy. Agency-
optimal immunization coverage, no tetanus cases have wide, in 2022 the prevalence of DM during pregnancy
been reported during the last two decades among mothers (pre-existing and gestational) was 7.0 per cent. Almost
and newborns that attended UNRWA ANC services. 17.5 per cent of women with DM during pregnancy

60.0 53.3 52.2

49.7 49.7
50.0 43.5 43.0
40.3
40.0 36.9
28.8 29.2 30.0
27.8 28.8
30.0
18.6 20.2
16.7 17.9
20.0 13.4

10.0

0.0
Jordan Lebanon Syria Gaza West Bank Agency
High Alert Low

Figure 12: Percentage of ANC cases by risk category in 2022

 38 unrwa health department - annual report 2022

had pre-existing DM; 46.7 per cent had gestational lowest rate was 25.8 per cent in Gaza. This wide variation
DM with recovery after delivery, 5.2 per cent were among the fields is due to several reasons, particularly
diagnosed during pregnancy and had not recovered client preference and prevailing medical practice.
after delivery, and 27.2 per cent were still pregnant by
the end of 2022. Globally, reported rates of gestational Despite a wide variation among regions and countries,
DM range between 2.0 per cent to 10.0 per cent of the worldwide caesarean section rates were estimated
pregnancies (excluding pre-existing DM) depending in 2015 to be around 21.4 per cent, while in the Middle
on the population studied and the diagnostic tests and East and North Africa the estimation is at 29.6 per cent4.
criteria employed.
Table 16: Percentage of caesarean section rate, 2022
The prevalence rate of hypertension during pregnancy Field Total deliveries Caesarean section rate (%)
(pre-existing and pregnancy-induced hypertension) Jordan 19,245 33.9
was 7.5 per cent. Approximately 29.4 per cent of Lebanon 4,326 55.5
hypertension cases had pre-existing hypertension Syria 6,038 64.9
and 45.6 per cent recovered after delivery, 7.7 per cent Gaza 33,219 25.8
were identified during pregnancy with the condition
West Bank 14,532 33.1
persisting after delivery, and 13.8 per cent were still
Agency 77,360 33.9
pregnant by the end of 2022.

12.0
10.0 9.9
10.0 9.0
8.1 7.8
8.0 7.5
7.0

6.0 5.5 5.3

4.7 4.3 4.6
4.0

2.0

0.0
Jordan Lebanon Syria Gaza W.Bank Agency
Diabetes during pregnancy (%) Hypertension during pregnancy (%)
Figure 13: Prevalence of DM and hypertension during pregnancy in 2022

Delivery Care
Place of Delivery Monitoring the Outcome of Pregnancy
UNRWA subsidizes hospital delivery for all pregnant UNRWA has closely monitored and registered births
women. In 2022, Agency-wide, 99.9 per cent of all through a registration system (active surveillance)
reported deliveries took place in hospitals, while home since 2002 (based on the expected delivery date). The
deliveries only represented 0.13 per cent. The vast outcome of each pregnancy, including details of the
majority of these home births were in Syria. newborns, is recorded in each health facility.

Caesarean Sections In 2022, the expected number of pregnant women to

In 2022, the caesarean section rate among pregnant deliver was 83,314. Among these women, 77,360 infants
women assisted through the UNRWA hospitalization were born (92.9 per cent), and 5,891 births resulted in
schemes was 33.9 per cent. The rate varied widely from miscarriages or abortions (7.1 per cent). The outcome
one field to another. These rates, however, relate to women of 63 pregnant women who received ANC at UNRWA
in the high-risk category and not to all reported deliveries. health facilities (0.08 per cent) was unknown.
The highest rate was in Syria at 64.9 per cent, and the

4 The Lancet, «Global epidemiology of use of and disparities in caesarean sections», October 2018
 unrwa health department - annual report 2022 39
33

The percentage of unknown pregnancies' outcomes

continued to decrease from 6.8 per cent in 2002 to 0.08 Maternal Mortality Ratio
per cent in 2022. The Lebanon field reported the highest
prevalence of unknown pregnancy outcomes, with 0.68
per cent of unknown pregnancy outcomes. This can 2022 18.0Deaths
per100,000 live births
be attributed to the worsening of the socio-economic
situation, and difficulty with tracking and ascertaining among women
the outcomes of the pregnancies among registered registered with UNRWA antenatal service.
women by health staff.
Reported Deaths
Monitoring Maternal Deaths
During 2022, a total of fourteen maternal deaths
were reported across the five fields. This is equivalent
to a maternal death ratio of 18.0 deaths per 100,000 3 7 4
live births among pregnant women registered with Gaza Jordan Syria
UNRWA antenatal service. Three deaths were reported
in Gaza, seven deaths in Jordan, four deaths in Syria
and no deaths were reported in the West Bank and 0 0
Lebanon. Following a report on maternal death, West Bank Lebanon
UNRWA health staff conducted a thorough assessment
using a standardized verbal autopsy questionnaire. In one woman died one woman died
during pregnancy during delivery
2022, one woman died during pregnancy, 12 deaths
occurred during the post-natal period and one woman 12 deaths
during the post-natal period
died during delivery. Eleven women died in hospital
during/ after delivery, two women died at home and
one woman died elsewhere. Most maternal deaths Postnatal Care
were of multi-parity. Based on the causes of death, UNRWA encourages all women to attend PNC after
28.6 per cent were due to pulmonary embolism (four delivery as soon as possible. PNC services include a
cases), 21.4 per cent of death cases were due to septic thorough medical examination of the mother and the
shock (three cases), 14.3 per cent were due to post- newborn, either at UNRWA HCs or during home visits,
partum bleeding (two cases), 7.1 per cent were due to and include counselling on family planning, breast
aspiration pneumonitis due to anesthesia (one case), feeding and newborn care.
7.1 per cent were due to eclampsia & disseminated
intravascular coagulation (one case), 7.1 per cent were In 2022, out of the 77,360 pregnant women who
due to Renal Impairment (one case), 7.1 per cent due to delivered live births, 75,978 women received PNC within
Sudden Cardiac Death (one case) and 7.1 per cent were six weeks of delivery, representing a coverage rate of
due to acute liver injury attributed to an overdose of 98.2 per cent compared to 92.9 per cent in 2021. The
antipsychotic medication (Suicide) (one case). highest rate was 100 per cent in Gaza.

Acute liver injury due to overdose of… 7.1%

Sudden cardic arrest 7.1%
Renal Impairment, Thrombotic… 7.1%
Eclampsia & DIC 7.1%
Aspiration pneumonitis due to anaesthesia 7.1%
Postpartum hemorrhage 14.3%
Septic shock 21.4%
Pulmonary Embolism 28.6%

0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0%

Figure 14: Underlying per cent of causes of maternal mortality cases in 2022
 40 unrwa health department - annual report 2022

UNRWA Nurse performing Mental Health screening for a Palestine Refugee

patient at Shatila HC in Lebanon. ©2022 UNRWA Photo by Dima Farran

Multiple Micronutrient Supplementation for Pregnant Dietary Allowance (RDA) of 15 essential vitamins and
Women minerals including iron and folic acid in one tablet, and
Background was added to the WHO’s Essential Medicines List in 20219.
Micronutrient deficiencies are a major public health
burden among pregnant women attending UNRWA Table 17: UNIMMAP Formulation Multiple Micronutrient
HCs health centres as they contribute to increased risks Supplementation
of low, preterm and small-for-gestational-age births5.
Component Amount
Deficiencies of vitamins A, D, E and B-complex, iron,
zinc and iodine likely coexist among pregnant Palestine Vitamin A 800 µm
refugee women throughout the Middle East.6,7, Vitamin D 200 IU
Since the 1990s, UNRWA HD has provided antenatal Vitamin E 10 mg
iron and folic acid (IFA) supplementation to address Niacin 18 mg
maternal anaemia; however, effectiveness of the IFA Folic acid 400 µm
supplementation remained uncertain reflected by a Vitamin B1 1.4 mg
health centre (HC) prevalence of anaemia (haemoglobin Vitamin B2 1.4 mg
<110 g/L) in the 24th week of gestation being 26.3 per Vitamin B6 1.9 mg
cent in 2005 and 37 per cent in 2021. Vitamin B12 2.6 µm
Vitamin C 70 mg
In 2020, World Health Organization (WHO) updated
Zinc 15 mg
the antenatal guideline to recommend antenatal MMS
Iron 30 mg
use where the prevalence of MNDs represents a public
Selenium 65 µm
health burden8, “...in a context of rigorous research.” This
provided the opportunity for UNRWA to replace IFA Copper 2 mg

with MMS accompanied by planned implementation Iodine 150 µm

research, which is a pragmatic, scientific approach that
can help guide programmes and policies to improve MMS Pilot Program in Two HCs
efficiency, coverage, feasibility, fidelity, and adherence Since early 2020, UNRWA HD has had numerous
and thereby attainin the intended antenatal health discussions, reviews of policies, guidelines, technical
services. Accordingly, the United Nations International instructions, assessment of existing health-centre-based
Multiple Micronutrient Antenatal Preparation (UNIMMAP) data to understand the prevalence of maternal anaemia
formulated MMS, which provides one Recommended and received external assurances of safety and efficacy

5 Bourassa et al. Review of the evidence regarding the use of antenatal multiple micronutrient supplementation in low- and middle-income countries. Ann N Y Acad
Sci. 2019;1444(1):6-21.
6 Horino et al. Dietary Inadequacy, Micronutrient Deficiencies, and Approaches to Preventing Poor Nutrition in the Gaza Strip. Food Nutr Bull. 2020;41(4):503-511.
7 MoH, UNICEF, WFP, Jordan Health Aid Society International. Department of Statistics, Biolab, GroundWork. Jordan National Micronutrient and Nutrition Survey 2019.
Amman Jordan; 2021.
8 WHO antenatal care recommendations for a positive pregnancy experience. Nutritional interventions update: Multiple micronutrient supplements during pregnancy.
Geneva: WHO; 2020. Licence: CC BY-NC-SA 3.0 IGO.
9 WHO Model List of Essential Medicines – 22nd List, 2021. Geneva: World Health Organization; 2021 (WHO/MHP/HPS/EML/2021.02). Licence: CC BY-NC-SA 3.0 IGO.
 unrwa health department - annual report 2022 41

of MMS. Over time, these activities built constituencies evaluation elements, detectable cost and effectiveness
within the Agency to start MMS programming of MMS in anaemia prevention compared to IFA. Based
accompanied by rigorous implementation research. on the evaluation results and findings, MMS is planned
The MMS Work Group was organized at UNRWA HD HQ, to scale up in all 25 HCs in Jordan by the end of 2023 and
which was tasked to revise technical instruction, develop in other fields of operation in 2024.
education materials, secure resources, and develop a
protocol for rigorous implementation research. Due to Child Health Services
the proximity to the HQ office and political stability, the The UNRWA Health Department HD continues to provide
Jordan Field Office was chosen to pilot MMS. Through a comprehensive health care services to maintain and
Memorandum of Understanding with Vitamin Angels, improve Palestine refugee children›s health. UNRWA uses
UNRWA received technical assistance from the faculties at multiple approaches to maintain its services and keep
Johns Hopkins University, the Sight and Life Foundation, Palestine refugee children safe while visiting its HCs. The
a donation UNIMMAP-formulated, and USP and halal- FHT approach implementation continues at HCs, as these
certified MMS from the Kirk Humanitarian Foundation. approaches keep our ability to provide health care services
In September 2022, as requested by the Director of for children early during maternal care (preconception
Health, the MMS was first piloted in two HCs (Amman care and ANC) and continue for newborns, infants under
New Camp and Marka HCs) to test the acceptability, one year of age, children from one to five years of age
feasibility of workflow, education materials and data and school-aged children and adolescents. UNRWA child
collection tools. Between September to December health services including newborn medical assessment,
2022, a total of 2315 MMS bottles were distributed to periodic physical examinations, immunization, growth
pregnant women through the two HCs. This MMS pilot monitoring and nutritional surveillance, micronutrient
was highly appreciated by the Jordan Field Office, HC supplementation, preventive oral health, school health
staff, and our beneficiaries and communities as it further services, and referrals for specialised care if needed.
increased the interest and commitment of UNRWA HC
staff to participate in the planned MMS program and its UNRWA child health services are one of the essential
evaluation. investments in health. The impact of the child's health
improvement will decrease their morbidity and mortality
MMS Programme Evaluation/Implementation Research rates in the future and extend to improve their health and
in Jordan wellbeing during later periods of their life cycle. The age of
In 2023, a 10-month comparative evaluation of MMS children covered with child health services was raised from
program is planned, in which 13 HCs will provide MMS 3 to 5 years old in 2010 to enhance child health outcomes.
(2 pilot HCs plus 11 randomly assigned HCs) and 12 This decision enabled filling the gap in child health services
HCs will continue with the traditional IFA regimen. until the child reaches school age and improves growth
The evaluation will focus on acceptability, coverage, monitoring, nutritional surveillances, micronutrients
adherence, feasibility and fidelity of program and supplementation and fluoride varnish coverage.

UNRWA Medical Oficcer checking a Palestine refugee child at

Nuzha HC in Jordan. ©2022 UNRWA Photo by Dima Ismail
 42 unrwa health department - annual report 2022

500
408 425 434 426 422
450 410 410 409
381
400
350 300
Thousands 300 247
250
200
150
100
50
0
*2012 *2013 2014 2015 2016 2017 2018 2019 2020 2021 2022
Figure 15: Children 0-5 years under supervision at UNRWA HCs between 2012 and 2022 (*Data not available for Syria)

Childcare Coverage reminders to the mothers to vaccinate their child

In 2022, UNRWA HCs continued to provide preventative according to each child's vaccination schedule. This
services to 409,329 children up to 5 years old, a coverage tool's use decreased the number of defaulters and the
of 53.6 per cent of the estimated number of Palestine nurse's need to follow up on the mother for bringing
refugee children compared to 54.5 per cent during 2021. their child to the HC for vaccination.
The basis for this estimation was the number of infants
below 12 months of age who have been registered Growth Monitoring and Nutritional Surveillance
and the expected number of surviving infants, which UNRWA health services regularly monitor the growth and
is calculated by multiplying the crude birth rates (as nutritional status of children under five years of age. It is
published by the Host Authorities) by the number of considered the second strategy to improve the health
registered refugees in each country. of Palestine refugee children. In 2022, the HP started to
overcome the effect of the COVID-19 pandemic which
Immunization led to an increase in the number of children benefiting
Due to the importance of child immunization as the from growth monitoring services compared to 2021.
most reliable primary prevention method, UNRWA Available data shows an increase in the percentage of
health services continue to provide immunization malnutrition among children. This increase is mainly due
against Tetanus-Diphtheria (DT/Td), Pertussis, TB, to an improvement in the number of evaluated children
Measles, Rubella, Mumps, Polio, Haemophilus influenza compared with previous years. At the same time, it
type B (Hib), and Hepatitis B. Moreover, the UNRWA continues to show the double burden of malnutrition
HP provides the Rota vaccine in all fields except Syria among monitored children. To prevent malnutrition and
and the Pneumococcal vaccine in the West Bank, promote a healthy lifestyle, we established a nutrition
Gaza and Lebanon. In 2020, the UNRWA HP started guideline for health care staff to counseling mothers
to provide the Hepatitis A vaccine in Jordan as part on their child’s proper nutrition. Accordingly, HC staff
of Jordan's National Vaccination Programme. In 2022, encourage mothers to properly practice breastfeeding
immunization coverages for the above-mentioned and best practices for child weaning and nutrition
infectious diseases were 99.6 per cent for children beyond the age of 6 months. Health education also
aged 12 months and 98.6 per cent for children aged 18 focused on the appropriate use of complementary
months. The use of the e-MCH application by mothers feeding and micronutrient supplements and the
supported this coverage. The e-MCH application sends importance of avoiding fast food and sweetened drinks.

12 11.13
10.02
10 8.56
8.05
8 7.14
6.44
5.79 5.91
6
4
2
0
Under weight Stunting Wasting Overweight/Obesity
2021 2022
Figure 16: Prevalence of malnutrition among children 0-5 years between 2021 and 2022
 unrwa health department - annual report 2022 43

The electronic growth monitoring system is integrated

within e-Health and is based on revised WHO growth
2022 358
monitoring standards. This integration enabled HC staff
to plot the data and interpret growth monitoring results. 2021 258
If the electronic system detects one or more of the
four significant growth and nutrition-related problems Reported deaths among registered infants <1 year
among children under five years (underweight, wasting,
The leading causes of infant death in 2022 included:
stunting, and overweight/obesity), it sends an alarm.
27.1% 26.2%
Table 18: Prevalence of malnutrition among children 0-5
years between 2019 and 2022 Congenital malformations OR Respiratory infections
metabolic disorders & other respiratory conditions
Underweight Wasting Stunting Overweight/
Obese
2019 6.26 6.4 11.0 8.96 16.2 9.8% 5.6
2020 5.12 5.0 8.9 6.92 Low birth weight/ Heart disease Septicaemia
prematurity
2021 5.79 10.02 5.91 8.05
2022 6.44 11.13 7.14 8.56
1.4% 0.3% 0.3%
All children were provided with iron and vitamin A Gastroenteritis Accidents Poisoning
supplementation starting from 6 months of age, and this
supplementation continues until they turn five years old.
Once a child reaches 12 months of age, they are screened Child Mortality
for anaemia. Anaemic children who are unresponsive to In 2022, there was an increase in the number of reported
supplementation are screened for hereditary anaemias, deaths among registered children between 1-5 years
mainly thalassemia and sickle cell anaemia. age across all fields. In 2022, the number of reported
deaths among infants reached 130 as compared to
Surveillance of Infant and Child Mortality 81 in 2021. The leading causes of child death were
Infant Mortality congenital malformations 35.4 per cent, respiratory
In 2022, there was an increase in the number of reported tract infections and other respiratory conditions 20.8 per
deaths among registered infants who were less than cent, heart disease 12.3 per cent, accidents 10.8 per cent,
one year of age across all fields. In 2022, the number of septicaemia 6.2 per cent, gastroenteritis 3.1 per cent,
reported deaths among infants reached 358 as compared birth trauma 0.8 per cent, and poisoning 0.3 per cent.
to 258 in 2021. According to the data, the leading causes
of infant death included: congenital malformations or There is no apparent difference between causes of death
metabolic disorders 27.1 per cent, respiratory infections between infants and children living in or outside of the
and other respiratory conditions 26.2 per cent, low birth camps. Most of them died in hospitals, and only some
weight / prematurity 16.2 per cent, heart disease 9.8 per children died at home and were not hospitalised 16.6
cent, septicaemia 5.6 per cent, gastroenteritis 1.4 per per cent. In terms of the distribution of deaths by gender,
cent, accidents 0.3 per cent, and poisoning 0.3 per cent. there were slight differences between child mortality
This data is comparative to previous years. among males 48.6 per cent than females 51.4 per cent.

UNRWA provides special health care to meet the needs of newborns, and infants
under five years of age. A nurse weighs a Palestine refugee baby in Lebanon at
UNRWA health Center in Beddawi camp. © 2022 UNRWA Photo by Maysoun Mustafa
 44 unrwa health department - annual report 2022

UNRWA students participate in the summer camp games, under the

title ‶Keeping Kids Cool.‶ © 2021 UNRWA Photo By Mohamed Hinnawi

Oral Health services have been provided to these newly registered

Preventive oral health services start as soon as the students, mainly carrying out medical examinations,
child reaches one year of age by conducting awareness immunization services and specialized follow-up of
sessions for parents on preventing oral diseases, mainly students as needed. UNRWA succeeded in conducting a
dental caries and applying fluoride varnish every six medical examination for 99.7 per cent of students during
months. In high community transmission times, the the scholastic year compared to 91.8 per cent during
number of screened children within the two years the previous year. As a result of the screening activities,
increased from 35,729 in 2021 to 52,346 in 2022. different diseases were detected among the newly
enrolled students, including dental caries and gingivitis
School Health 78.0 per cent, speech defects 15.9 per cent, vision
During the 2021/2022 school year, around 555,892 problems and squint 8.7 per cent, heart disease 1.1 per
Palestine refugee students were enrolled in UNRWA cent, bronchial asthma 1.1 per cent, and epilepsy 0.3 per
schools compared with 540,000 during the previous cent. There was a sustainability in decreased percentage
year. The UNRWA HP, in coordination with the Education of students who were diagnosed with health diseases
Department, implemented the School Health Programme related to personal hygiene, including lice 2.3 per cent
(SHP) to improve the health of school's students and scabies 0.3 per cent compared to the 2020/2021
through planned meetings, school health committees, scholastic year. The newly diagnosed students with
training on health awareness materials and ensuring the disabilities or recognized for their needs for assistive
availability of a first-aid kit. SHP offers various services, devices (or both) had assistance in being provided
including medical check-ups for a new school entrance, eyeglasses, hearing aids, and other prosthetic devices
immunizations, hearing and vision screening, dental according to their condition and available resources.
check-ups, and deworming. The SHP provides follow-up
guidelines for children with special health needs, as well Based on the activities of the SHP in 2021, there was
as updated procedures for inspections and improving decrease in the number of students referred for further
the schools' environment and schools' canteens. School care to UNRWA health facilities from 5,763 in 2021 to
health services are provided to UNRWA schools' students 5,277 students in 2022. The number of students referred
through HCs and school health teams (doctors, nurses for special assessment increased from 1,093 in 2021
and dentists) according to scheduled visits during the to 2,847 students in 2022. UNRWA HP helped 13,316
scholastic year. students to cover the costs of eyeglasses, which was
more than the number of students supported in 2021
New School Entrants' Medical Examination (12,538), and 192 students were helped to cover the
UNRWA schools registered 55,173 new students in costs of hearing aids, which was less than the number of
first grade during the 2021/2022 scholastic year. Many students supported in 2021 (284).
 unrwa health department - annual report 2022 45

Table 19: Number of patients who received financial cent received fissure sealant, and for grades second,
support from UNRWA for the cost of eyeglasses. fourth, and seventh the number reached 15,740, in
Field 2019/2020 2020/2021 2021/2022 addition to applying general fluoride mouth rinsing and
teeth brushing campaigns. During the reorientation of
Jordan 1,699 0 3264
the Oral Health Programme towards prevention, oral
Lebanon 6 0 35
health screening for UNRWA students has played a
Syria 794 831 822 significant role in achieving this shift.
Gaza 4,531 10,283 7689
West Bank 1,545 1,424 1506
Oral health screening 2022
Total 8,575 12,538 13316

Screening
Health care screening during the school year 2020/2021 1st Grade 4th & 7th Grade 2nd Grade

targeted students in the fourth and seventh grades in 50,956 56,950 Syria & Lebanon
Students
all fields and included screening for visual and hearing Students Students
impairment and oral health assessments. Usually, in all fields received oral health screening
students’ screening is conducted during the second
semester. In 2022, 96.9 per cent of fourth grade and Oral health screening is coupled
with other dental caries prevention methods
96.5 per cent of seventh grade students were screened
such as pit and fissure sealant
for visual impairments, with only 48.3 per cent of fourth
grade students and 51.0 per cent of seventh grade 1st Grade 2nd & 4th Grade
students conducting hearing screenings as well. The 11,888 28% 15,740
most prevalent morbidity conditions among students in
Received Fissure Sealant
the fourth grade were vision impairment (13.3 per cent)
and hearing impairments 0.2 per cent, while among
students in the seventh grade 15.6 per cent had visual Children with Special Health Needs
impairments and 0.2 per cent had hearing impairment. In the 2021/2022 scholastic year, the HP’s School Health
Teams, in cooperation with school staff, identified
Oral Health Screening 6,926 students with special health needs. Their school
In 2022, 50,956 students in the first grade in addition to registration records are maintained and monitored by
56,950 students in the fourth and seventh grades in all both the HD and the Education Department staff to
fields, and second grade students in Syria and Lebanon ensure close follow-up since the school health team
received oral health screening. in 2022 dentist continued provides the needed specialized medical care. These
screenings for molar eruption for students at the first special health needs cases include 870 students with
and second grade. Oral health screening is coupled with heart disease, 533 students with behavioral problems,
other dental caries prevention methods such as pit and 1,566 students with bronchial asthma, 280 students with
fissure sealant for first graders, 11,888 of which 28 per type 1 DM, and 461 students with epilepsy.

Major deformities
4.9% Heart disease
12.3%

Others
33.7%

Bronchial asthma
22.1%
Growth disorders
9.0%
Diabetes mellitus
Behavioral problems Epilepsy 4.0%
7.5% 6.5%
Figure 17: Children with special health needs 2021/2022
 46 unrwa health department - annual report 2022

Immunization 3. A pilot of a new survey called “the Global School

The UNRWA Immunization programme for school Health Policies and Practices Survey (G-SHPPS) for
students is streamlined and follows the host countries' school administration in all UNRWA schools“.
requirements. During the 2021/2022 school year, 99.8 per
cent of new entrants in all fields received a booster dose Five training workshops were conducted at the fields to
of DT/Td immunization and oral polio vaccine (OPV). train fields’ implementing teams during September and
October 2022, all fields concluded data collection by
De-Worming Programme December 2022, except for Syria field, which is expected
Following WHO recommendations, UNRWA maintains to finish early 2023.
the de-worming programme for children enrolled in
UNRWA schools across all five fields. The programme The first two surveys (GSHS and GYTS) will provide data
targets students from first to sixth grade, and it consists on young people's health behaviour, monitor their
of the application of two rounds of a single dose of an tobacco use and protective factors related to the leading
effective wide-spectrum anti-helminthic medicine. causes of morbidity and mortality among children and
adults worldwide. This will guide the implementation
During 2022, school health teams provided the first dose and evaluation of prevention and control programmes.
of the de-worming drug for the first application rounds
in March and April 2022 for 343,333 students, the de- The third survey (G-SHPPS) assesses school health
worming drug coverage of 98.5 per cent. The second policies and practices to develop priorities, establish
round was conducted during September and October programmes, advocate for school resources and
2022 for 341,749 students (coverage reach 99.3 per cent). establish trends in school health policies and practices.
Usually, health awareness campaigns accompany the
de-worming drug application at schools to emphasise Final results and findings are expected to be available by
the importance of personal hygiene in preventing the the end of 2023.
transmission of these diseases.
Oral Health
UNRWA provides oral health care services to Palestine
refugees Agency-wide. Among the 130 dental clinics
providing these services, 119 are located within the
Agency's primary HCs, while the remaining 11 are mobile
dental clinics. The primary objectives of the oral health
services are (i) to prevent, detect, and manage dental and
De-worming programme
periodontal disorders, with particular attention paid to
at-risk groups; (ii) to promote oral hygiene through active
screening, management of vulnerable populations, and
targeted health education activities promoting the use
1st Dose 2nd Dose of fluoride toothpaste; (iii) to provide an equitable service
and expand public health interventions to address
March & April 2022 Sep. & Oct. 2022
oral health determinants; and (iv) to improve ongoing
343,333 341,749 collection, analysis, and interpretation of health data for
Students Students
drug coverage 98.5% drug coverage 99.3% planning, implementation, monitoring, and evaluation.
Additionally, the Agency conducts operational research
on oral health in line with World Health Organization
Global School Health Surveys (WHO) guidelines and UNRWA's needs to track disease
Supported by WHO’s Eastern Mediterranean regional trends and improve the overall oral health status.
Office (EMRO), CDC, and UNRWA Department of
Education, the Department of Health conducted at UNRWA's health services continue to prioritize
UNRWA schools, three WHO global school health surveys preventive oral health components by raising
in five fields (2022-2023): awareness of the importance of preventative oral
1. Global School-based Student Health Survey (GSHS) for health during routine MCH care and providing
sampled students who are 13-17 years old. preventive dental care for newly registered NCD
2. Global Youth Tobacco Survey (GYTS) for the same patients. This includes dental screenings for women
GSHS sampled schools with different students. during their first preconception care visit and all
 unrwa health department - annual report 2022 47

pregnant women, as well as comprehensive oral During the third year of the COVID-19 pandemic,
health assessments for children at the age of one UNRWA dental clinics continued to provide curative
and two, and application of fluoride varnish starting and preventive oral health services while adhering to
from one year of age and then twice a year until they the updated standard infection prevention procedures
reach five years old. The Oral Health Programme's and measures for COVID-19 transmission in dental clinic
staff conducts regular oral health assessments for settings.
preschool children and dental screenings for new
school entrants, second, fourth, and seventh-grade During 2022, a total of 834,598 curative and preventive
students, and applied pit and fissure sealant for consultations were provided Agency-wide. The greatest
first and seventh-grade students. Additionally, oral number of curative and preventive interventions were
hygiene education continues for all school students provided in Gaza, with 360,949 consultations, while the
across all fields to prevent oral health problems. West Bank had the lowest dental consultations with only
65,478.
An assessment of the Oral Health Programme’s
staff workload, needs, productivity, and efficiency The percentage of preventive dental services provided
is conducted in all five fields annually. The Health Agency-wide was 40.2 per cent. Among the five fields,
Programme uses a standardized counting unit to the West Bank had the highest utilization of preventive
measure the technical workload of the staff, and this oral health care at 50.9 per cent, while Lebanon had the
assessment is conducted periodically as part of the lowest utilization with only 18.5 per cent.
performance evaluation process. This assessment
is also used to identify staffing requirements and The average number of dental consultations per dental
the need for reorganizing oral health services. surgeon per day Agency-wide increased from 29.0 in
Furthermore, UNRWA conducted an additional 2021 to 33.2 in 2022, exceeding the Agency's target of 25
assessment in collaboration with WHO/EMRO to daily consultations per dental surgeon as recommended
evaluate the impact of oral preventive services and to by the WHO. The field with the highest workload was
identify improvement opportunities. Gaza, with an average of 52.4 dental consultations per
dental surgeon per day, while the West Bank field had
Throughout the MTS strategic period (2016-2022), the lowest number of dental consultations at 21.3 per
the total number of dental consultations decreased dental surgeon per day.
by 8.8 per cent, with 834,598 consultations held in
2022 compared to 914,712 in 2016. This reduction was
2022 33.2
particularly evident in curative dental consultations,
which can be attributed to UNRWA's shift in strategy 2021 29.0
to prioritize preventive oral health interventions. This average number of dental consultations
shift was also reflected in the percentage of preventive per dental surgeon per day Agency-wide
services, which increased from 39.0 per cent in 2016 to
exceeding the Agency’s target of
40.2 per cent in 2022. Additionally, the average daily 25 daily consultations per dental surgeon
number of dental consultations per dental surgeon as recommended by the WHO
declined from 42 in 2016 to 33.2 in 2022, exceeding
the Agency's target of 25 daily consultations per dental Gaza 52.4 West Bank 21.3
dental surgeon/day dental surgeon/day
surgeon as recommended by WHO.

A dentist treats a patient at Shu'fat Health Centre, West

Bank. © 2019 UNRWA Photo by Marwan Baghdadi
 48 unrwa health department - annual report 2022

Physical Rehabilitation and Radiology Services Physiotherapists offer a diverse array of treatment
Physiotherapy Services and rehabilitation services, which comprise
Throughout the MTS Strategic Period (2016-2022), the manual treatment, heat therapy, electrotherapy,
utilization of physiotherapy services remained stable, and gymnastic therapy. In addition to this,
although there was a small reduction of 4.2 per cent physiotherapists also provide education and training
in the number of patients who received the service, not only to Palestine Refugees with permanent
which decreased from 16,951 in 2016 to 16,261 in 2022. disabilities, but also for their family members,
This trend was also observed in the total number of enabling them to handle the physical aspects of their
physiotherapy sessions provided. disability in their day-to-day lives. These services aim
to promote independence and self-reliance amongst
UNRWA provided physiotherapy services to 16,261 Palestine refugees with disabilities.
Palestine Refugees in 2022, which is a 37.1 per cent
increase compared to the previous year. These services Radiology Services
were facilitated through 18 physiotherapy units by 46 Throughout the MTS strategic period (2016-2022),
physiotherapists in Gaza, the West Bank, and Jordan, with there was a significant decrease in the utilization
a total of 199,066 physiotherapy sessions conducted, of radiology services. The total number of patients
representing a 34.6 per cent increase from 2021. In Gaza, receiving plain X-rays reduced by 25.3 per cent,
13,547 patients received 172,008 physiotherapy sessions dropping from 89,669 in 2016 to 67,002 in 2022. This
from 11 physiotherapy units by 34 physiotherapists, downward trend was also evident in the total number
while in the West Bank, 2,158 patients received 22,090 of plain X-rays administered during the same period.
physiotherapy sessions from six physiotherapy units by Furthermore, this decline was even more pronounced
11 physiotherapists. In Jordan, 556 patients received in radiology services that were referred to contracted
4,968 physiotherapy sessions from one physiotherapy health facilities, with a 61.6 per cent reduction in both
unit by one physiotherapist. There was an overall rise the number of referred patients and the number of
in the utilization of physiotherapy services in all fields, X-rays conducted in such facilities.
which can be attributed to improved patient access to
UNRWA's health services and the resumption of all health UNRWA runs 21 radiology units across all HCs Agency-
services in the third year of the COVID-19 pandemic. wide (seven in Gaza, nine in the West Bank, four in
Lebanon, and one in Jordan) to offer plain X-ray
services to patients who visit the HCs. In cases where
Utilization of Physiotherapy Services
patients require other X-ray services or specialized
diagnostic radiology services such as mammography,
37.1 4.2
urography, and ultrasounds, they are referred to
contracted services through contractual agreements
between UNRWA HCs and hospitals or private
radiology centres.
16,951Patients 16,261Patients
During 2022, a total of 67,002 patients received 74,227
18 physiotherapy units X-rays. Of these, 62,899 patients (representing a 23.1
46 physiotherapists per cent increase compared to 2021) received 70,111
199,066 plain X-rays within UNRWA radiology units, while
physiotherapy sessions conducted
Gaza, West Bank & Jordan 34.6 4,103 patients (showing a 73.9 per cent decrease
compared to 2021) received 4,116 X-rays and other
radiology services at contracted radiology units
Gaza West Bank located outside of UNRWA HCs. This upswing in service
13,547 patients 2,158 patients utilization aligns with the overall trend of increased
172,008 physiotherapy sessions 22,090 physiotherapy sessions health service utilization observed in the third year of
11 physiotherapy units 6 physiotherapy units the COVID-19 pandemic. The primary factor behind
34 physiotherapists 11 physiotherapists
the decrease in referred patients and the quantity of
Jordan
X-rays performed at contracted health facilities was
556 patients
the improvement in radiology service capabilities at
4,968 physiotherapy sessions
1 physiotherapy units UNRWA, particularly in the Lebanon field.
1 physiotherapists
 unrwa health department - annual report 2022 49

HD continued during 2022 to provide health services

that address or meet the needs of persons with
disabilities or both. The health services focused on

2022 67,002
patients
74,227
plain X-rays
improving the accessibility of persons with disabilities to
health services. Many HCs improved their infrastructure
to be more user-friendly for people with disabilities.
23.1% These improvements included having ramps, elevators,
within UNRWA radiology units and special restrooms for beneficiaries with physical
62,899 70,111 disability and elderly persons, implementing a Q-tag
patients plain X-rays
system and tactile ground surface indicators for the
blind and visually impaired.
73.9% Outside of UNRWA HCs
The second track focuses on disability prevention
4,103 4,116 applied through the FHT approach, the implementation
patients X-rays & other
radiology services of maternal health services (quality FP services, ANC,
peripartum care, and postpartum care), child health
services (child growth monitoring, immunization, and
2021 screening), as well as prevention, early detection and
increased control of patients for NCDs. The Jordan
field continues to implement the new hearing test
for newborns to detect hearing problems as early as
Disability Care possible to benefit the child from cochlear implant
The Agency adopts the definition of disability operations. Gaza field continues to provide support for
presented in the UN Convention on the Rights of students with the need for speech therapy, hearing aids,
Persons with Disabilities (UNCRPD). This definition and visual aids.
states that, “Persons with disabilities include those
who have long-term physical, mental, intellectual, or The HP updated e-Health (EMR) system enables
sensory impairments, which in interaction with various the screening of beneficiaries for disabilities and
attitudinal and environmental barriers hinder their full monitoring the services offered to them. This is done
participation in society on an equal basis with others.” at two levels: one is for children under five years as
One of the Agency’s principles of disability inclusion is a continuous medical evaluation for the children.
non-discrimination, ensuring that all Palestine refugees The second is integrated within the medical file of
with disabilities have equal opportunities to access beneficiaries above five years. This evaluation system
and benefit from UNRWA services and programmes, is based on Washington Group Questions, which is an
including healthcare. assessment tool to identify people with disabilities.
It enables tracking the usual services utilized by
The HD adopted the “twin-track” approach to disability, persons with disabilities and the time needed to get
which requires working on the social environment complete assistance. The data gathered can be used
(ensuring non-discrimination health services and for improving the process of disability inclusion within
accessibility to these services) and strengthening the HCs. Among 651,720 beneficiaries were screened
services-targeted disability prevention and support during 2022, five per cent (32,531 beneficiaries) were
persons disabilities. registered to have a disability.

Table 20: Number and percentage of patients identified with a disability at UNRWA HCs
Female Male Total
Field
Screened With Disability % Screened With Disability % Screened With Disability %
Jordan 42,150 2,509 6.0% 16,678 1,457 8.7% 58,828 3,966 6.7%
Lebanon 41,077 1,759 4.3% 27,350 1,321 4.8% 68,427 3,080 4.5%
Syria 29,952 1,794 6.0% 12,703 1,319 10.4% 42,655 3,113 7.3%
Gaza 223,018 10,083 4.5% 129,884 6,616 5.1% 352,902 16,699 4.7%
West Bank 78,625 3,345 4.3% 37,754 1,944 5.1% 116,379 5,289 4.5%
Total 414,822 19,490 4.7% 224,369 12,657 5.6% 639,191 32,147 5.0%
 50 unrwa health department - annual report 2022

5,694
5,526 (13.0%)
(12.6%)

4,445 3,084
(10.2%) (7.1%)

5,207
(11.9%) 19,749
(45.2%)

See Hear Walk Remember Selfcare Communicate

Figure 18: Number and Percentage of type of disability at UNRWA HCs

In addition to prevention, the HD also supplies other Pharmaceutical Services

essential services to registered refugees whose Total Expenditure
permanent physical, visual and hearing impairments In 2022 the total funds spent on medical supplies
have been identified via screening in UNRWA HCs. and equipment from all the funds (General Fund and
They are eligible for financial support from the HD to projects), was approximately US$ 24.81 million. Of this
cover the costs of assistive devices such as hearing amount, US$16.47 million (66.4 per cent) was from the
aids, eyeglasses, artificial limbs, wheelchairs, etc. General Fund and US$1.83 million (7.4 per cent) was
These services were re-opened after suspension from project funds, and US$ 6.49 million (26.2 per cent)
during 2020 due to COVID-19 preventive measures, was in-kind donation.
mainly due to the opening of schools for in-person
education. Simultaneously, screening at care centres
was resumed. In 2021, we provided 12,538 URNWA
26%
students with eyeglasses compared to only 8,575
students during 2020, and covered the cost of hearing
aids for 284 students compared to 57 students
recieving assistance devices in 2020.
7%
Physiotherapy centres operating in Jordan, Gaza and 67%
the West Bank do not target persons with permanent
disabilities. However, it is recognized that a significant
proportion of beneficiaries treated at these HCs are Programme Budget Project In-kind donation
likely to be considered “persons with disabilities” under Figure 19: Total expenditure on medical supplies and equipment from the
the definition of the UNRWA Disability Policy (2010) programme budget, project funding and in-kind contributions in 2022
and UNCRPD. However, it is essential to note that data
collection regarding physiotherapy services does not Among the fields, the highest expenditure on medical
differentiate between beneficiaries with and without supplies and equipment was observed in Gaza (US$ 11.6
permanent disabilities. million) and the lowest was in Lebanon (US$ 2.3 million).

14
11.6
Expenditure (millions)

12
10
8
6 4.7
4 3.3 2.8
2.3
2
0
Jordan Lebanon Syria Gaza West Bank
Figure 20 : Expenditure on medical supplies by field in 2022 (US$ million)
 unrwa health department - annual report 2022 51

Expenditure on Medical Supplies

In 2022, the average expenditure on medical supplies
per outpatient medical consultation Agency-wide 2022 3.2 US$
was US$ 3.15, which is an increase from the 2021 2021 2.6 US$
with US$ 2.6. The average annual expenditure on
Average expenditure on medical supplies
medical supplies per served person Agency-wide per outpatient medical consultation Agency-wide
was US$ 7.82, which is an increase compared to US$
5.85 in 2021. The increase of annual expenditure on
medical supplies per medical consultation, as well as 2022 7.8 US$
the increase in expenditure for medical supplies per 2021 5.9 US$
served refugees, which is mainly due to receiving
Average annual expenditure on medical supplies
more in-kind donations reflected as an increase in per served person Agency-wide
medical supplies expenditure.

Table 21: Average medical product expenditure (US$) of medical supplies per outpatient medical consultation and
per served person in 2022
Jordan Lebanon Syria Gaza West Bank Agency-wide
Expenditure for medical supplies per
3.1 2.5 3.6 3.3 2.9 3.2
medical consultations (US$)
Expenditure for medical supplies per
5.5 8.9 10.3 8.9 6.6 7.8
served person (US$)

Expenditure on Medicines
The total expenditure on medicines in 2022 was US$ 18.3 During 2022, medical equipment and related supplies
million. Analysis of expenditure on different medicines accounted for 26 per cent (US$ 6.51 million) of the
revealed that 41 per cent of the funds were spent on total expenditure (GF and project) funds of medical
medicines used for the treatment of NCDs, and 12.3 per commodities (US$ 18.30 million).
cent were spent on antimicrobial medicines. Further
analysis on NCD drug expenditure shows that 47.6 per Donations of Medical Supplies
cent of funds were spent on hypoglycaemic medications, In 2022, UNRWA received several in-kind donations of
21.9 per cent on antihypertensive medications, 14.6 per medical supplies (medicines, medical equipment and
cent on cardiovascular medications, 4.7 per cent on others) from key partners and stakeholders including
diuretics, and 11.3 per cent on lipid-lowering agents. the following:

mineral 0.3%
miscellaneous 0.4%
topical 10.5%
mental 5.8%
lipid
hormones,vitamins, 11.3%
minerals 4.9%

GI 2.1% diuretic
4.7%

asthma CVD 14.6% hypoglycemic

7.9% NCD 47.6%
41.1%

analgesics 11.6% Antihypertensive

21.9%

anaemia 3.1%
antimicrobials
Figure 21: Drug expenditure in 2022
12.3%
 52 unrwa health department - annual report 2022

• The MoH of the Palestinian Authority provided Gaza Antibiotic Prescription Rate
and the West Bank fields with vaccines, iron drops In line with the WHO recommendations, the target
and tablets, medical supplies as well as disposable antibiotic prescription rate in UNRWA HCs Agency-
syringes, needles and PPE. wide aims to be not more than 25.0 per cent. In 2022,
• The MoH of Jordan supplied in-kind donations of antibiotic prescription rate Agency-wide was 22.2 per
vaccines and contraceptives. cent and ranged from 18.1 per cent in the West Bank
• The MOPH provided Lebanon with vitamins, to 27.6 per cent in Lebanon. It is worth mentioning
medications, and Covid rapid test devices. that antibiotic prescription rates in all fields except
• UNICEF provided Lebanon with various medical for Jordan and Lebanon had decreased in 2022 as
supplies, medicines and PPE items. compared to 2021, which is the result of returning the
• The MoH of Syria and the WHO provided the Syria field number of medical consultations to pre-COVID-19
with vaccines and modern contraceptives. periods at Fields and having more stable trends.
• Vitamin Angels supported UNRWA with vitamin Antibiotic prescription is a key focus in UNRWA HCs
supplements. in order to ensure the rationalization and control
• St. John Eye Hospital provide Gaza and the West Bank of antibiotics usage among the Palestine refugee
with vision charts, ophthalmoscopes, and portable population.
fundus cameras.
• Novo Nordisk supported UNRWA with insulin vials.
• WHO supported UNRWA with medicines and staff costs.

30 27.3 27.6 26.2 25.7

25 23.3 23 22.2
21.3 21.6 21.2
19.4
20 18.1

15

10

0
Jordan Lebanon Syria Gaza West Bank Agency
2021 2022
Figure 22 : Expenditure on medical supplies by field in 2022 (US$ million)

A Palestine refugee baby receives his vaccination in Sheikh

Radwan Health centre in Gaza. © 2020 UNRWA Photo
 unrwa health department - annual report 2022 53

Output 2.2: Efficient Hospital Support Services

Inpatient care
Every year, the UNRWA Hospitalization Support
Programme (HSP) is becoming more critical for Palestine
refugees in order to grant them access to secondary
77,744 Palestine refugees
Received help from UNRWA
and tertiary health care services without incurring a supported hospitalisation services
catastrophic health expenditure. In 2022, the program
continued to complement the primary health services
offered by UNRWA to ensure that Palestine refugees
have access to hospital services in the hosting country.
29.8 million US$
Hospitalisation support program (HSP)
Outsourced Hospital Services expenditure
UNRWA provides hospitalisation to Palestine
Hospitalisation Cases
refugees contracting services at discounted prices in
governmental, private and NGO hospitals and covering
the expenditure with different percentages according to
the policy in place in each field. UNRWA hospitalisation 29.5% 30% 40.5% 64%

policy is defined by the users' eligibility that depends

on their access to alternative services, their case's
medical urgency, and their economic status. Ensuring Table 22: Patients who received assistance for outsourced
the effectiveness and efficiency of HSP has become hospital services during 2021 and 2022 in the five fields
essential given the Agency's constrained finances in the
Jordan Lebanon Syria Gaza West Bank Agency
protracted fragile context UNRWA is operating, which
exacerbated access problems to hospitals. 2021 2,470 19,729 15,855 14,502 20,708* 73,264*

In 2022, a total of 77,744 Palestine refugees received help 2022 2,310 23,861 16,110 14,743 20,720 * 77,744*
from UNRWA supported hospitalisation services. The
*Exclude patients admitted to Qalqilya Hospital
hospitalization support Programme (HSP) expenditure
was US$ 29.8 million including programme budget, The HSP implementation is closely related to the access
emergency, and projects, with an average length of in- to hospital services for Palestine refugees and the host
patient stay of 1.8 days across the five fields of UNRWA countries' governmental health policy. For this reason,
operations. Of all hospitalisation cases, approximately caseload, targets, utilization rate per served population,
64.3 per cent were women, 40.5 per cent were between unit cost of the services, number and type of contract
15 and 44 years old, 30 per cent were children below the with health service providers and staff involved in
age of 15 years and 29.5 per cent were over 45 years. monitoring are different in each field.

UNRWA operates only one hospital in West Bank,

a Palestinian refugee child admitted to Qaliqilia
Hospital in West Bank. © 2019 UNRWA Photo
 54 unrwa health department - annual report 2022

In 2022, patients were comparable to those served the exporting the Lebanon Hospitalization Management
previous year and pre-COVID-19 time as the situation System to all other fields has been realized with the
stabilized after the pandemic and hospitals went back to collaboration of an IT department in all fields, particularly
their normal routine and schedule. in Lebanon. The structure of the data collection tool was
presented to Jordan, Syria, the West Bank and Gaza Health
In Jordan, the number of hospitalised patients slightly teams involved in the management of hospitalization
decreased this year, but the availability of good public referrals, claims, and follow-up. All the requirements for
services assures that, despite not being supported adapting HMS to the field-specific situations were collected
by UNRWA, Palestine refugees still can have access to and realized as much as possible to respond to user’s needs,
hospitals services without major problems. and the new version was tested and approved. Training was
implemented to instruct MOs, Clerks and Chiefs on the use
In 2022, the number of patients in Lebanon increased by and the system was rolled out to almost all HCs.
21 per cent from 2021. After the COVID-19 pandemic and
restriction in access to hospitals that were still in place Strong collaboration was seen among departments in the
in the first part of 2021, in 2022 the average number of Fields, particularly with Finance for the close monitoring
patients per month returned to be around 2,000 for the of the expenditure, and with HD at HQA which is
whole year. The financial crisis that Lebanon has been ongoing. Continuous project writing to seek support of
facing since 2018 was significantly impacted this sector donors to cover budget shortfalls has continued during
as most of the medicines and medical equipment were the year and has become more and more important
purchased from outside of the country and paid for in to assure the coverage of the hospitalization needs of
the U.S. Dollar (US$). The contract signed with hospitals Palestine refugees.
in 2022 accounted for this complex situation and the
requests to pay part of the bill in US$ continued. Despite Qalqilya Hospital
this, the favourable exchange rate with the local currency In addition to subsidising hospitalisation services in
allowed for a decrease in hospitalization expenditure in contracted hospitals, UNRWA manages a secondary care
2022. The Health Department maintained its monitoring facility in Qalqilya, West Bank. Qalqilya Hospital is the only
efforts, reinforcing UNRWA MOs’ gate-keeper role and hospital operated by the Agency. Of the 58 available beds,
auditing hospital bills regularly. 14 are for surgical, 13 for medical, 15 for paediatric, 14 for
obstetric/gynaecologic, and two are intensive care beds.
In Syria and Gaza, the number of patients in 2022 The hospital has also an emergency room and provides
marginally increased from the previous year (+1.6 per outpatient services. It serves UNRWA refugees and non-
cent), but this is in line with the natural increase in the refugees from the surrounding municipalities in a health
population. In Syria, the caseload is various in response service area of around 100,000 people. In 2022, 5,593
to the needs of a population that rely on UNRWA for the patients were admitted to Qalqilya Hospital, increasing by
access to hospital services. In Gaza, the Hospitalization 13 per cent from the 4,598 patients in 2021. The average
Support Programme continues to protect maternal bed occupancy in Qalqilya Hospital was 53.1 per cent in
health and other non-urgent matters but it is still an 2022, increasing from 42.5 per cent the previous year. The
important life-changing health condition to release the average length of stay in 2021 was almost two days.
pressure on the Ministry of Health hospitals which are
collapsing after years of blockade.
UNRWA Qalqilia Hospital
In the West Bank the number of patients was the same
as last year proving that already in 2021, the situation
was normalized. The caseload is mixed with medical and
surgical cases, but it is skewing towards maternal health patients were admitted

as vaginal deliveries and caesarean sections are more 58 beds available 2022 5,593
than half of the caseload and increasing in the last years. 14 surgical bed 2021 4,598 13
This shows that Palestine refugees are relying on UNRWA 13 medical bed
when it comes to deliveries. 15 paediatric bed
14 obstetric/gynecologic bed Average bed occupancy
53.1
The complexity of the Hospitalization Support Programme 2 intensive care bed
2022
requires a common and harmonized database to
consolidate data reporting. During 2022 the project of
2021 42.5
 unrwa health department - annual report 2022 55

The hospital this year worked with all the departments In 2022, the Health Department had an effective role
that opened for the whole year, and this allowed in managing food commodities quality in Gaza & Syria
all the indicators to be back to pre-COVID time. The fields. Food commodities specifications were reviewed,
new Acting Director Dr. Ramzi Abu Yaman worked and new food specifications were developed. Sampling
throughout the year in close collaboration with the methods, laboratories, inspection companies and
local community to realize several maintenances works food suppliers were evaluated quality-wise, all these
thanks to volunteering donations made to improve the procedures raise the quality for food commodities
hospital setting. UNRWA is also working on a revision provided to Palestinian Refugees.
of the organogram and staff compensation of the
hospital to guarantee a comparable situation with the HD reviewed the nutrition brochures distributed in the
governmental hospital in the country. health centres and updated them in line with the latest
updates from WHO. The new brochures will be designed
Table 23: Inpatient care at the UNRWA Qalqilya Hospital and distributed in 2023.
in 2020 and 2022
Indicators 2021 2022 In 2020, the WHO updated the antenatal guideline
Number of beds 58 58
recommending use of Multiple Micronutrient
Supplementation (MMS), which is a safe and effective
Persons admitted 4,842 5,493
evidence-based intervention to improve fetal and
Bed days utilized 8,990 10,796
maternal health and to reduce risks of adverse pregnancy
)%( Bed occupancy rate 42.5 53.1 outcomes, anaemia, and multiple micronutrient
Average stay in days 1.86 2 deficiencies. Given the chronically high prevalence
of maternal anaemia and micronutrient deficiencies
among our beneficiaries, reported by both our clinic
Cross-cutting Services data and national surveys, UNRWA HD has decided to
Nutrition pilot the antenatal MMS as a standard of ANC, starting
During 2022, the HD continued to promote healthy in Jordan, and then scaled-up to other fields of UNRWA
lifestyle among Palestine refugees, focusing on maternal operation. As per the WHO recommendation, the
nutrition, child nutrition and well-being, patients with UNRWA’s MMS Programme will be rigorously evaluated
NCD, as an essential activities to prevent malnutrition and continuously improved using the Implementation
and NCDs. This including sending electronic messages Research methodology.
through MCH Application and NCD Application, during
Ramadan, a daily tip regarding nutrition were provided There is research related to the nutrition program at
to our beneficiaries by MCH and NCD applications and UNRWA that focus on different aspects of health and
social media. These tips and information supported the wellbeing. Some of this research is being conducted in
health staff counseling regarding healthy life style and the Gaza strip. One title is “Prevalence and Determinants
outreach awareness activities conducted at HCs and of Short Stature (SS) among First Graders in UNRWA
other community institutions specialty schools. Schools in the Gaza Strip“. This research aims to identify
the prevalence and factors contributing to short stature
Our health staff continued to focusing on early detecting in young children attending UNRWA schools. Another
of malnutrition among children under five years old, the research titled “Evaluation of Iron Deficiency Anemia
prevention and treatment of micro-and macro-nutrient Management Among Preschool Children Attending
deficiencies among pregnant women and children, and UNRWA Health Centres in the Gaza Strip: A Mixed-Study
screening and counseling for NCD diseases especially Approach“ focuses on assessing the management of
among HCs attendant over-weight to improve the iron deficiency anaemia among preschool children.
health of Palestine refugees. Another research that is conducted in one of Gaza’s
health centres, titled “Knowledge Attitude and Practice
In 2022, the HD improved staff capacity regarding of Weaning Among Mothers and Impact on Child's
nutrition counselling, supported with electronic Health: A Cross-Sectional Study“ examines the impact of
nutritional guidelines for health staff. These guidelines weaning practices on child health.
focusing on proper nutrition for all beneficiaries,
nutrition during pregnant and nursery, infants & A Research is conducted in Jerusalem titled
toddlers nutrition and proper nutrition for prevention “Determinants of Anemia among Pregnant Women
and management of NCDs. Attending the UNRWA Healthcare Clinics in Jerusalem:
 56 unrwa health department - annual report 2022

A Follow-Up Study“ seeks to understand the underlying and efficiency of laboratory services was conducted
factors contributing to anaemia among pregnant based on 2022 data. The Agency-wide productivity of
women in the West Bank. The research will examine the laboratory services in 2022 was 49.9 WLUs/hour. In the
effectiveness of current anemia management strategies West Bank, the productivity of laboratory services was
and propose recommendations for improvement. 67.9 WLUs/hour, while it was 52.3 WLUs/hour in Jordan,
54.8 WLUs/hour in Gaza, 43.4 WLUs/hour in Lebanon,
Laboratory Services and 31.1 WLUs/hour in Syria.
UNRWA offers comprehensive laboratory services across
127 out of 140 HCs. Among the remaining 13 facilities, Laboratory Costs
11 continue to provide essential laboratory assistance, The total cost of laboratory services provided across
such as blood glucose, blood haemoglobin, and urine the five fields by UNRWA was US$7,972,743, with
dipstick tests. The other two facilities are located in Syria US$7,888,340 (98.9 per cent) secured through the
and are unable to provide laboratory services due to Programme Budget, and approximately US$ 84,000 (1.1
accessibility issues. per cent) obtained through in-kind donations, projects, or
emergency funds. This shows that UNRWA's expenditure
Utilization Trend on laboratory services is lower than the estimated cost
Over the course of the MTS strategic period (2016-2022), of MoH laboratory services in host countries combined,
there was a 14.0 per cent increase in the overall number which is US$21.84 million. Therefore, it can be inferred
of laboratory tests conducted Agency-wide, from that UNRWA HCs offer cost-effective and efficient
4,368,018 tests in 2016 to 4,978,607 tests in 2022. This laboratory services.
increase was primarily attributed to enhanced patient
access and greater demand among beneficiaries.

In 2022, UNRWA provided a total of 4.98 million laboratory

tests across the Agency, representing a 10.3 per cent
increase from the previous year (4.51 million laboratory
tests in 2021). Throughout the reporting period, there was
an 82.7 per cent increase in laboratory services utilization
7,972,743USD
Total cost of laboratory services
in Lebanon, a 14.6 per cent increase in Syria, a 7.6 per cent provided across the five fields
increase in Gaza, a 5.1 per cent increase in Jordan, and a
2.7 per cent increase in the West Bank compared to 2021. 98.9% / 7,888,340US$
This upsurge in the use of laboratory services across all
Programme Budget
fields reflects a general trend of increased utilization of
health services observed in 2022, due to the resumption
of all health services, higher demand, and improved
1.1% / 84,000US$
patient access to health care services. In-Kind Donations
projects, or emergency funds
As part of the Agency's regular self-evaluation of its
UNRWA's HCs offer cost-effective
programs using the WHO approach for workload and efficient laboratory services
measurement, an annual comparison of the workload

Table 24: Expenditure on laboratory services (US$) by field and Agency-wide in 2022
Cost Jordan Lebanon Syria Gaza West Bank Agency
Programme Budget 1,707,575 881,045 562,682 2,442,014 2,295,025 7,888,340
Non-Programme Budget - - 81,472 - 2,931 84,403
Total 1,707,575 881,045 644,153 2,442,014 2,297,956 7,972,743

Table 25: Comparative analysis of the annual cost of laboratory services performed at UNRWA facilities and cost of the
same services if outsourced to host authorities (US$) in 2022
Cost Jordan Lebanon Syria Gaza West Bank Agency
Host authorities 5,568,014 812,884 928,862 7,740,015 6,788,366 21,838,141
UNRWA 1,707,575 881,045 644,153 2,442,014 2,297,956 7,972,743
 unrwa health department - annual report 2022 57

An UNRWA Medical officer examining a Palestine refugee

child from Lebanon in Beddawi camp health center,
Lebanon. ©2022 UNRWA Photo by Maysoun Mustafa
 58 unrwa health department - annual report 2022

Health communication
The scope of health communication covers all the Relevant World Health Days 2022 were observed in
programmes, sub-programmes and activities that cooperation with the fields’ health programmes. Awareness
the HD implements. This includes but is not limited materials were produced and disseminated through
to: disease prevention and control, health protection UNRWA HCs, HP mobile applications (e-NCD and e-MCH),
and promotion, medical care services, health care and through posting infographics, posters, videos, and
policies, as well as enhancement of the quality of life social media cards on UNRWA social media platforms. The
and health of the Palestine refugees. UNRWA’s health most important observed health-related world days were:
communication uses a variety of channels to deliver its a. World Health Day theme was, “Our Planet...Our
messages to varied audiences, including individuals, Health, clean our air, water & food.” Messages during
communities, UNRWA staff and health professionals, the campaign focused on how to save our planets.
and policy makers. b. World No Tobacco Day theme was, “Tobacco: Threat
to our environment.” Messages highlighted the
The persisting COVID-19 situation, new outbreak environmental impact of tobacco from cultivation to
of monkeypox in the world, and cholera becoming waste as additional reasons for people who smoke to
widespread in both Syria and Lebanon fields, revealed quit smoking.
a crucial need for health awareness campaigns. As part c. World Diabetes Day theme was, “Education to protect
of the response, many kinds of awareness materials tomorrow” which is the theme of the second year of
were developed and widely distributed via different the World Diabetes Day 2021-23 campaign “Access to
communication channels (printed materials in addition Diabetes Care.”
to using UNRWA social media channels and the UNRWA d. Mental Health Day theme was, “Make mental health
website). The campaigns focused on ways of prevention for all a global priority.” Messages shared with
and encouraging vaccination for UNRWA staff and Palestine refugees focused on how to look after their
Palestine refugees. own mental health.
e. Breast Cancer Month (Pink October) aimed to raise
During Ramadan, for the third year the HD, in awareness about the importance of early detection
cooperation with the Communications Department, and access to timely, high-quality care and the
launched a special Ramadan campaign on UNRWA social importance of psychosocial and palliative support for
media platforms to educate UNRWA staff and Palestine this disease.
refugees about appropriate health and nutrition
behaviours during Ramadan and on how to continue Overall, the communication role supported successful
protecting themselves and their family members from preparations of the ninth annual participation of the
the COVID-19 pandemic. Director of Health in the 75th World Health Assembly
(WHA) on Palestine Refugees’ health in cooperation
 unrwa health department - annual report 2022 59

with the Lancet and other stakeholders highlighting Despite the ongoing challenges faced by UNRWA due
the situation in Gaza after a year of lasting hostility. It to conflicts, financial crisis, and the long-term impact
supported the preparation, production, and release of of COVID-19, the research activities carried out in
the HD annual report (2021). collaboration with the Health Department have enabled
partnerships with academic and research institutions
It also supported revising HD Technical Instructions, globally. These activities have also supported the sharing
Guidelines, MOUs, and other publications, in addition of critical findings on the health status of Palestine
to updating the interface for the SharePoint–Health refugees with the global audience.
intranet site and uploaded the related health published
materials. Since 2022, the UNRWA Health Program (particularly
the research team) has been actively collaborating
As a part of the HD team, this role also participated in the with researchers to ensure that the proposals meet
planning, implementation, and publication of relevant the research needs and priorities of UNRWA. Looking
research activities, including production and design of forward to 2023, the HD research team plans to work
pamphlets, posters, and labels for the pilot programme closely with academia to foster greater engagement in
of Multiple Micronutrient Supplementation (MMS) for research activities.
Pregnant Women.
Internship at the Health Department
Research and Evaluation Activities UNRWA Health Department offers internships for
In 2022, the Research Review Board (RRB) approved a individuals who are interested in gaining practical
total of fifteen research proposals on diverse topics, experience in the fields. Interns are given the opportunity
including non-communicable diseases (NCDs), to work alongside UNRWA staff and learn about the
telemedicine, e-health, patient safety, oral health, quality health program operations, projects, and activities.
of care, micronutrient deficiencies, maternal and child
health, long-term COVID-19, and health policy. These The internship activities at UNRWA vary depending on
proposals were evaluated by the technical staff in the the department and location where the intern is placed.
health department at the field and headquarter level. Some common activities may include conducting
research, analysing data, preparing reports, drafting
Four articles resulting from these research efforts were proposals, and assisting with project implementation.
published in peer-reviewed journals, with UNRWA Interns may also participate in meetings, workshops,
HD authors serving as co-leads. Additionally, two oral events, and have the opportunity to network with
presentations and three poster presentations were professionals in the agency.
delivered virtually at the Lancet Palestine Health Alliance
Conference held in 2022. One of the HD posters was UNRWA Health Department welcomed students from
awarded the Best Poster prize among more than 40 Columbia University and Stanford University, as well
presented posters. as other graduates from Japan, Kenya, and Jordan in

A French delegation from the French embassy in Jordan visited Baqa'a Elementary school and
Baqa'a health centre run by UNRWA at Baqa'a refugee camp in Amman. The visit was accompanied
by Marta Lorenzo, Director of UNRWA Affairs in Jordan. © 2021 UNRWA Photo by Sally al-Akhras
 60 unrwa health department - annual report 2022

2022 which was a very great opportunity for knowledge help women advance in work and encourage a work-
sharing and collaboration with diverse backgrounds and life balance in their day-to-day work.
expertise the students brought.
UNRWA aims to lead by example and is committed to
Overall, the opportunity for UNRWA Health Department achieving gender parity in its workforce. Culturally,
to welcome students and graduates from a diverse female patients are more likely to disclose and share
range of countries and universities in 2022 is a great way their health concerns with same-sex doctors and
to promote cross-cultural learning, collaboration, and nurses. To respond to patients’ needs, currently, 60
innovation in the field of public health and of course, per cent of the total health staff in all the UNRWA HCs
advocating for UNRWA’s health program and services. are female, including doctors, specialists, pharmacists,
nurses, etc. Nursing and paramedical positions have
Health Response to GBV in Healthcare Settings the highest proportion of female staff, at 86 per cent
Gender-Based Violence (GBV) is a significant public and 60 per cent, respectively. In addition, several
health issue and addressing it in healthcare settings senior posts within the HP are filled with female staff
is critical. GBV programming in primary health care at both field and HQ levels. These steps underscore the
includes a comprehensive approach that focuses on commitment to realizing gender parity and patient-
safe identification, health response and safe referral. In friendly health services.
UNRWA HCs, safe identification is facilitated through
active screening for targeted patient groups who Human Resources for Health Reform
are more likely to be exposed to GBV, followed by The United Nations Relief and Works Agency for
appropriate referrals to provide other non-medical Palestine Refugees (UNRWA) is facing significant
services. In 2022, out of the total who received challenges in its health workforce due to an increase in
screening in the UNRWA HCs, 7 per cent were identified annual patient visits and a long-standing funding crisis
as experiencing GBV. Of those identified, 3 per cent that has limited its ability to hire additional medical
were men and boys and 97 per cent were women and staff. To address this issue, the UNRWA health program
girls. UNRWA’s current data system does not report assessed staffing needs in its health facilities using the
the number of referrals to other services. The UNRWA World Health Organization's (WHO) workload indicators
is in the process of developing a system that records of staffing need (WISN) methodology. The purpose of
referrals, making sure that those who are identified this assessment was to determine the existing staffing
are supported beyond medical needs if they wish to norms, estimate the workload on health workers,
receive them. In the context of the UNRWA healthcare efficiently utilize the existing workforce, and determine
setting, we adopt GBV programming that is culturally staffing requirements at each health facility.
appropriate, gender-sensitive and respectful of the
unique needs of Palestine refugees. The Health Programme used the standardized WISN
methodology to assess the staffing requirements for all 140
Addressing the Gender Gap in the Workforce health facilities in the five fields, covering seven categories
The gender gap in the workforce can be addressed of health staff. Of these categories, three (MOs, clerks, and
through a multi-faceted approach that involves cleaners) were updates of previously set norms, while the
sustained effort over time. The UNRWA HD strives other four (nurses, pharmacists, laboratory technicians,
to increase the number of female health workforce, and dentists) were newly established norms. The nurses
in order to respond to the needs of female patients category included four sub-categories, namely senior staff
who prefer to be seen by the same-sex health care nurse, staff nurse, practical nurse, and midwife. The norms
professionals. Currently, more than 60 per cent of the for MOs, clerks, and cleaners were established in 2019 as
total healthcare providers in UNRWA HCs are female. part of phase 1, while the other health categories were
UNRWA also provides training and development completed in 2021 in phase 2.
opportunities to help doctors and nurses for both sexes
to acquire new skills and to advance in their careers However, due to the negative impacts of the COVID-19
through the nursing and family medicine diploma pandemic on health service utilization patterns,
programme. In the headquarters, one female staff consultation data for 2019 (pre-COVID-19) was utilized
represents the women’s advisory committee that the for the workload assessment. The WISN results showed
Agency leads. Women often face a lack of role models that most of the health cadres across the Agency were
and mentors within their careers. Representation and understaffed, highlighting the urgent need for additional
the committee provide networking opportunities to staffing and resources to address this issue.
 unrwa health department - annual report 2022 61

Table 26: Number and percentage of norms against the staffing policies and the adoption of workload-based
posts under programme budget. norms to address the shortage of health staff in the
Field Norm
Programme- Gap for % PB posts region. To address the staffing shortage, a multi-year
budget posts PB-funded posts against norms
implementation plan was developed in consultation
Gaza 1507 887 621 58.9% with relevant stakeholders. The plan includes several
Jordan 691 613 78 88.7% potential scenarios to ensure that the norms can be
funded within budget constraints.
Lebanon 411 288 124 70.1%

Syria 445 316 129 71.0% Family Medicine Training

UNRWA recognizes the importance of providing
West Bank 560 516 44 92.1%
ongoing training to all staff working in UNRWA HCs,
not only for the professional development of staff
The table provides information about the number of but also for maintaining and improving the quality of
health staff norms required for various fields and the health care provision to Palestine refugees. Therefore,
number of posts available under the current program the Rila Institute of Health Sciences in the United
budget. The Gaza field requires the most significant Kingdom collaborated with UNRWA to tailor a 12-month
number of health staff norms, with 1,507 posts needed, training course on Family Medicine for UNRWA medical
whereas Jordan requires the lowest number of norms physicians. This is called the FMDP.
with 691 posts.
The FMDP is tailored to UNRWA's PHC model and its
When comparing the number of program budget posts adopted FHT approach. The FMDP provides clinicians
against the required health staff norms, it becomes with an in-service training model that they can take
evident that there is a significant shortfall in staff in all without disrupting their daily work. The training is also
fields. The West Bank has the smallest gap, with only designed to help medical doctors at UNRWA HCs meet
44 posts needed to meet the optimal staffing level. the Palestine refugee populations' health needs in the
However, in other fields such as Gaza, Lebanon, and five fields of UNRWA operations.
Syria, the gap between the required number of staff
and the available posts is significant, with 621, 124, The diploma programme included different modalities
and 129 posts needed, respectively. The percentage such as face-to-face workshops held in field offices at the
of program budget posts against norms is lowest for beginning of the course, an e-learning platform, regular
Gaza at 58.9 per cent, indicating a large shortfall in exams after each unit, and interactive webinars. On-the-
staffing levels. job practical training activities were directly provided by
local facilitators who specialise in family medicine.
In summary, the data highlights a significant shortfall in
the number of health staff norms required for various Milestones of FMDP
fields, particularly in Gaza, Lebanon, and Syria. While Since the start of 2015, a total of 125 doctors of UNRWA
the West Bank has a smaller gap, there is still room completed the family medicine diploma courses, as
for improvement. These findings call for a review of shown in the following table.

Table 27: Number of doctors who completed the family medicine diploma course

Year Gaza Jordan West Bank Lebanon Syria Total

2015 – 2016 (First cohort) 15 - - - - 15

2017- 2018 (Second cohort) 15 15 10 - - 40

2018 – 2019 (Third cohort) 12 8 - - - 20

2019 – 2020 (Fourth cohort) 15 6 10 10 9 50
2020 (Fifth cohort –graduation Feb 2022) 15 10 10 5 10 50
2021/2022 (sixth cohort – graduation July 2022) 15 10 10 13 2 50
No. of UNRWA doctors trained by 2022 87 49 40 28 21 225
 62 unrwa health department - annual report 2022

The fifth cohort was started in January 2021 instead of number of registered refugees (5.9 million), the annual
June 2020 as per the annual Family Medicine Diploma per capita expenditure is US$ 39.7 Agency-wide. WHO
schedule due to the postponement caused by the recommends US$ 40.0-50.0 per capita for the provision
COVID-19 pandemic and the delay in signing the contract of basic health services in the public sector.
with the Rila Institute, the fifth cohort included 50 MOs.
In June 2021, health department started the sixth cohort Table 28: Health expenditure per registered Palestine
which was participated by 50 medical doctors, in which refugee, 2021 and 2022 regular budget (US$)
the fifth and sixth cohorts' graduation was on July 2022.
Year Jordan Lebanon Syria Gaza Strip West Bank Agency
Both cohorts' evaluation was carried out based on the
2021 9.5 46.1 15.5 25.3 33.6 21.0
scheduled mini exams, situational judgement tests,
2022 8.7 58.4 19.0 24.5 30.9 21.4
medical case management, and attendance records of
online webinars.
There is a significant expenditure gap per registered
Participants who already graduated with a postgraduate Palestine refugee between Lebanon (US$ 58.4) and
diploma in family medicine provided positive feedback Jordan (US$ 8.7). This gap is due to the heavy investment
on the training that they received. Key points that in secondary and tertiary care made necessary in
they highlighted included the positive impact of their Lebanon, where Palestine refugees are denied access
training on the quality and comprehensiveness of to public health services and cannot afford treatment
their health care services. They believe that they could costs at private facilities. Conversely, in Jordan, UNRWA-
share knowledge and skills with other colleagues and registered Palestine refugees have access to the
become more competent and capable of focusing on government's social and health services.
the prevention of diseases in general and on recognising
psychosocial-physical related health problems. UNRWA provides a comprehensive PHC delivery through
140 HCs Agency-wide with support accessing secondary
Finance Resources and tertiary health care for the most vulnerable Palestine
In 2022 the total HP expenditure amounted to refugees through contracts with hospitals or by
approximately US$ 145.2 million including all funded reimbursing a high proportion of the costs incurred for
portals (programme budget, emergency, projects and inpatient care at public, non-governmental, and private
in-kind), while around US$ 127 million was under the healthcare facilities.
programme budget, corresponding to an estimated
expenditure of US$ 21.4 per registered refugee, a slight In 2022, the allocation for hospital services represented
increase compared to the 2021 total expenditure of only 23.3 per cent of the total HP budget and financial
US$ 122.4 million or US$ 21.0 per registered refugee. constraints represented a significant challenge due
Even if a more conservative approach was used to to the increase in the served population, worsening
estimate the per capita expenditure based on the of living conditions, and rise of NCDs which are often
number of the population served by the HP in the associated with significant complications and long-
Agency (approximately 3 million) rather than the total term care.

Pharmacy-Amman New Camp Health Centre.

© 2022 UNRWA Photo by Amjad Ghosoun
 unrwa health department - annual report 2022 63

A Palestine refugee from Lebanon(PRL) receives medicine at Nahr el bared

camp NBC health center which has been prescribed by UNRWA doctor
after the physical check-up. © 2022 UNRWA Photo by Maysoun Mustafa
Table 29 -Breakdown of health expenditure by sub-programme-2022
64

Sub Programme Sub Sub-Programme description Jordan Lebanon Syria Gaza West Bank HQ Total

Hospital Services 667,811 15,701,094 1,485,374 3,299,928 4,542,385 25,696,592

Hospitalization Services Qalqilya Hospital 3,422,818 3,422,818

Tertiary Health Care 671,637 671,637

Total Hospitalization Services 667,811 16,372,731 1,485,374 3,299,928 7,965,203 29,791,048

Disability Screening and Rehabilitation 76,946 3,940 264,724 1,028,194 462,775 1,836,579

Laboratory Services 1,707,575 881,045 644,153 2,442,014 2,297,956 7,972,743

Oral Health 1,741,181 817,836 500,752 1,385,703 967,452 5,412,923

unrwa health department - annual report 2022

Outpatient Services 17,452,092 9,992,017 8,375,419 33,527,577 15,852,571 - 85,199,675

Primary Health Care Pharmaceutical Services 1,574,786 916,153 419,892 1,817,470 1,942,926 6,671,226

Psychosocial Support Programme 191,016 (0) 164 545,501 736,681

Radiology Services 104,053 442,933 173,106 720,092

School Health Services 262,659 456,526 75,431 794,616

Maternal Health & Child Health Services 96,987 96,987

Total Primary Health Care 22,912,225 12,906,060 10,204,940 41,100,580 22,317,717 - 109,441,523

Programme Management 443,006 650,452 300,717 614,445 704,866 3,187,779 5,901,265

Programme Management Total 443,006 650,452 300,717 614,445 704,866 3,187,779 5,901,265

Health Counsellor 42,630 42,630

Health Counsellor Total 42,630 42,630

Grand Total 24,023,042 29,929,244 11,991,031 45,057,583 30,987,787 3,187,779 145,176,465

 unrwa health department - annual report 2022 65

section 3 – Data
Part 1 - Agency Wide Trends for Selected Indicators

100 10 9.2
86.0 85.0 8.6 8.3 8.5 8.7
82.0 7.8
78.0 78.0 74.5
80 8 7
66.3 5.79
58.8
60 6

40 4

20 2

0 0
2015 2016 2017 2018 2019 2020 2021 2022 2015 1016 2017 2018 2019 2020 2021 2022

Figure 23: Average daily medical consultations per doctor Figure 24: No. of outpatient consultations (million),
included Telemedicine.

120
30 102.7 102.0 103.0 96.5
25 23.2 24.5 24.3 23.5 23 22.3 23 22.2 100 88.1
77.3 78.1 83.2
20 80

15 60

10 40
5 20
0 0
2015 2016 2017 2018 2019 2020 2021 2022 2015 2016 2017 2018 2019 2020 2021 2022

Figure 25: Antibiotics prescription rate Figure 26: No. of hospitalizations, including Qalqilya
hospital (in thousand)

90 78.9 82.5 82 81.9 80.7 78.5

700
605 80 73.1 72.6
600 558 565 554 546
499 70
500 60
400 50
268
300
398 40
30
200
20
100 10
0 0
2015 2016 2017 2018 2019 2020 2021 2022 2015 2016 2017 2018 2019 2020 2021 2022

Figure 27: No. of dental consultations (thousand) Figure 28: % of pregnant women registered during the
1 st trimester
 66 unrwa health department - annual report 2022

100 120
90.2 89.8 92.0 91.4 87.0
90 87.6 97
75.5 77.6 100 91 93 91 88
80 81.2
70 80 75.8
87
60
50 60
40
40
30
20 20
10
0 0
2015 2016 2017 2018 2019 2020 2021 2022 2015 2016 2017 2018 2019 2020 2021 2022

Figure 29: % of pregnant women attending at least 4 ANC visit Figure 30: No. of newly registered pregnant women
(thousand)

0.4 45
40 38
0.32
0.3 35
0.3
0.24 30
25
25 21
0.2 0.17
20
14 14 14
0.17 15
0.08 16
0.1 10 14
0.09
5
0.05
0 0
2015 2016 2017 2018 2019 2020 2021 2022 2015 2016 2017 2018 2019 2020 2021* 2022

Figure 31: % of delivers with unknown outcome Figure 32: No. of maternal deaths.
* Of the 38 maternal deaths, 27 had COVID-19 reported as
the cause of death

100 93.3 93.8 95 93.6 91.1

40 91.9 92.9
87
35 32.7 33.9
28.9 30.4 31.1 80
30 25.4 26.8
25 23.1 60
20
40
15
10
20
5
0 0
2015 2016 2017 2018 2019 2020 2021 2022 2015 2016 2017 2018 2019 2020 2021 2022

Figure 33: % of caesarean section deliveries Figure 34: % of women attending PNC within 6 weeks of
delivery
 unrwa health department - annual report 2022 67

98.1 98.4 98.6 99 98.3 97.8 98.5 98.5

100 100
98.8 99.0 99.0 99.9 99.9 99.9 99.9
99.9
80 80

60 60

40 40

20 20

0 0
2015 2016 2017 2018 2019 2020 2021 2022 2015 2016 2017 2018 2019 2020 2021 2022

Figure 35: % of pregnant women protected against tetanus. Figure 36: % of deliveries in health institutions

98.9 99.3 99 99.2 99.4 99.4 99.3 99.6

200 191 100
177 182
170 173
158 165
153 80
150
60
100
40

50 28 26 25 25 20
21 26 20 23

0 0
2015 2016 2017 2018 2019 2020 2021 2022 2015 2016 2017 2018 2019 2020 2021 2022
Total No. FP No. of new FP

Figure 37: New & total no. of family planning acceptors Figure 38: % of children 18 months old who received all
(thousand) EPI booster

176
500 180 167
425 434 157 160
450 410 410 408 426 422 409 160 148 152
136 142
400 140
350 120
300
T hou sa nds

100
250
80
200
150 60
100 40
10.2 9.9 10.1 10.1 10.7 7.5 11.2 11.9
50 20
0 0
2015 2016 2017 2018 2019 2020 2021 2022 2015 2016 2017 2018 2019 2020 2021 2022
Total No. of DM No. of new DM

Figure 39: No. of children 0-5 years under supervision Figure 40: New & total no. of patients with diabetes
(thousand) (thousand)
 68 unrwa health department - annual report 2022

300 14
246.0 259.1 12.4 11.7 11.9
240.1 11.2 11.1
250 225.3 229.3 234.8 12
216.3
205.6 10 9.1
8.3 9.1
200
8
150 8.2 7.9 8.0
6 7.3 7.3
100 5.4 5.9 5.9
4
50 17.1 18.3 17.8 18.4 18.5 13.1 17.5 21.0 2
0 0
2015 2016 2017 2018 2019 2020 2021 2022 2015 2016 2017 2018 2019 2020 2021 2022
Total No. of HTN Total No. of new HTN DM HTN

Figure 41: New & total no. of patients with hypertension Figure 42: Prevalence of NCD among population served
(thousand) > 18 years

350 10
305.8
271.1 283.6 291.3
300 277.4 7.5 7.5
256.8 264.6 8 7 7.2 7.2
245.7
250 6.3
5.9 5.5
6
200

150 4
100
2
50

0 0
2015 2016 2017 2018 2019 2020 2021 2022 2015 2016 2017 2018 2019 2020 2021 2022

Figure 43: Total No. of all patients with diabetes and/or Figure 44: % of NCD patients’ defaulters
hypertension (Thousand)

60 7
5.79 5.9
6 5.5 5.6 5.7
50 5.2 5.3 5.4
5
40
31 33
4
30 28 27 28 26
24 25
3
20
2
10 1
0 0
2015 2016 2017 2018 2019 2020 2021 2022 2015 2016 2017 2018 2019 2020 2021 2022

Figure 45: No. of new reported TB cases Figure 46: No. of Registered Refugee (millions)
 unrwa health department - annual report 2022 69

Part -2 CMM (22-2016) Indicators

Table 30: Selected CMM indicators 2022
SO2 Indicator Jordan Lebanon Syria Gaza West Bank Agency
Prevalence of diabetes among population served, 18 years
and above
8.2 8.4 7.5 7.4 9.1 8.0

Percentage of DM patients under control per defined criteria 28.0 44.4 35.5 34.0 35.9 33.4

Average daily medical consultation per doctor 71.3 87.5 73.9 62.8 77.1 74.5

Average consultation time per doctor 3.8 2.3 2.5 4.5 3.7 3.5

Number of HCs fully implementing eHealth system 25 27 22 22 43 139

Percentage of NCD patients coming to HC regularly 78.3 71.4 73.7 82.1 84.0 79.8

Percentage of NCD patients with late complications 8.4 7.7 12.2 13.3 11.5 11.1

Number of EPI vaccine preventable disease outbreaks 0 0 0 0 0 0

Percentage of women with live births who received at least
4 ANC visits
80.5 75.2 54.6 98.3 90.1 87.6
Refugees’ health is protected and the disease burden is reduced

Percentage of post-natal women attending PNC within 6

weeks of delivery
87.1 88.5 81.0 100.0 90.8 92.9
Percentage Diphtheria + tetanus coverage among targeted
students
95.7 98.4 98.5 100 100 98.9

Antibiotic prescription rate 21.3 27.6 25.7 21.6 18.1 22.2

Percentage of HCs with no stock out of 12 tracer medicines 100 100 91.3 100 100 98.6
Percentage of preventative dental consultations out of total
dental consultations
37.2 18.5 31.1 47.9 50.9 40.2
Percentage of targeted population 40 years and above
screened for diabetes mellitus
17.3% 23.1% 11.8% 27.4% 21.2% 20.9%

Number of new NCD patients (DM, HT, DM+HT) 8,947 4,449 3,236 9,086 3,286 29,004

Total number of NCD patients (DM, HT, DM+HT) 85,817 34,032 36,888 106,482 42,626 305,845
Percentage of children 18 months old that received all
booster vaccines
98.8 96.8 97.9 98.5 99.8 98.6

Number of new TB cases detected 0 1 30 2 0 33

Percentage of 18 months old children that received 2 doses
of Vitamin A
99.7 96.5 85.0 99.4 99.8 99.4

Number of active/continuing family planning users 37,481 16,980 11,843 101,070 23,453 190,827

Number of new enrolments in pre-conception care

programme
5,271 1,673 788 29,830 4,859 42,421

Percentage of 4th grade school children identified with vision

impairment
19.4 7.8 4.9 13.1 15.6 13.3

Unit cost per capita 10.2 61.4 20.6 29.0 34.4 24.1
Percentage of UNRWA hospitalization accessed by Social
Safety Net Programme (SSNP)
14.8 30.4 46.6 67.3 2.1 30.7

Hospitalization rate per 1000 served population 2.7 92.1 49.7 11.4 61.0 26.2
Hospitalization unit cost 105.1 675.6 227.6 223.8 285.4 370.2
 70 unrwa health department - annual report 2022

Part 3 – 2022 Data Tables

Table 31: Aggregated 2022 Data Tables
Field Jordan Lebanon Syria Gaza Strip West Bank Agency
31.1 – Demographics

Population of host countries in million 10,998,531 5,296,814 21,563,800 1,997,328 3,000,021 42,856,494

Total number of registered refugees 2,366,050 487,662 581,018 1,553,868 901,035 5,889,633

Refugees in host countries (%) 21.5 9.2 2.7 77.8 30.0 13.7
Number of persons (individuals) who used UNRWA health
467,229 180,206 202,912 936,910 265,775 2,053,032
services.
Total persons eligible UNRWA health services (no.) 2,542,999 557,342 674,455 1,754,309 1,123,485 6,652,590

Refugees accessing (served population)

865,562 259,036 324,249 1,295,528 428,950 3,173,325
UNRWA health services

Growth rate of registered refugees (%) 1.7 2.1 2.9 1.4 1.3 2.0

Children below 18 years (%) 24.2 21.6 26.8 40.7 26.5 29.0

Women of reproductive age: 15-49 years (%) 28.6 25.5 27.9 25.1 28.4 27.3

Population 40 years and above (%) 38.6 45.7 37.7 24.1 36.3 34.9

Average family size10 5.2 4.7 4.8 5.6 5.6 5.3

Aging index (%) 61.8 81.9 46.0 19.4 51.8 43.7

Fertility rate 3.2 2.7 2.7 3.6 3.6 3.2

Male/female ratio 1:1 1:1 1:1 1:1 1:1 1:1

Dependency ratio 43.3 47.9 46.5 70.0 48.6 51.2

31.2- Health Infrastructure

PHC facilities (no.):

Inside official camps 11 14 12 11 18 66

Outside official camps 14 13 11 11 25 74

Total health centres 25 27 23 22 43 140

Ratio of PHC facilities per 100,000 population 1.1 5.6 4.0 1.5 4.9 2.4

Services within PHC facilities (no.):

Laboratories 25 17 21 22 42 127

Dental clinics:

- Stationed units 30 19 20 25 25 119

- Mobile units 4 0 2 5 0 11

Total Dental clinics 34 19 22 30 25 130

Radiology facilities 1 4 0 7 9 21

Physiotherapy clinics 1 0 0 11 6 18

Hospitals - - - - 1 1

Health facilities implementing E-health 25 27 22 22 43 139

10 Current contraceptive practices among mothers of children 0-5 years survey conducted in 2015.
 unrwa health department - annual report 2022 71

Field Jordan Lebanon Syria Gaza Strip West Bank Agency

Strategic Objective 1

31.3 - Outpatient Care

Outpatient consultations (no.)

(a) Face to face consultations

Male 521,046 365,994 348,384 1,325,106 364,866 2,925,396

Female 949,177 518,252 548,754 1,878,160 620,291 4,514,634

Total (a) 1,470,223 884,246 897,138 3,203,266 985,157 7,440,030

(b) Outpatient consultations specialist

Male 1,063 2,305 829 5,264 2,761 12,222

Female 24,366 16,577 11,909 22,057 6,729 81,638

Total (b) 25,429 18,882 12,738 27,321 9,490 93,860

Sub-total (face to face & specialist)

Male 522,109 368,299 349,213 1,330,370 367,627 2,937,618

Female 973,543 534,829 560,663 1,900,217 627,020 4,596,272

Total (a+b) 1,495,652 903,128 909,876 3,230,587 994,647 7,533,890

(c) Telemedicine consultations

Male 4,616 0 2,232 149,390 0 156,238

Female 7,898 0 3,300 168,593 0 179,791

Total (c) 12,514 0 5,532 317,983 0 336,029

Grand total (a) + (b) +(c) 1,508,166 903,128 915,408 3,548,570 994,647 7,869,919

Average daily medical consultations / doctor11 71.3 87.5 73.9 62.8 77.1 74.5

31.4 - Inpatient Care

Patients hospitalized -including Qalqilya (no.) 2,310 23,861 16,110 14,743 26,183 83,207

Average length of stay (days) 2.0 2.6 0.9 1.4 1.9 1.8

Age distribution of admissions (%):-

0-4 yrs 0.2 16.7 5.6 7.5 18.2 12.9

5-14 yrs 1.5 7.3 7.8 7.4 38.2 17.0

15-44 yrs 93.7 32.7 39.1 59.8 32.9 40.5

>45 yrs 4.6 43.3 47.5 25.4 10.7 29.6

Sex distribution of admissions (%):

Male 4.8 47.1 40.0 29.6 28.8 35.7

Female 95.2 52.9 60.0 70.4 71.2 64.3

Ward distribution of admissions (%):

Surgery 2.9 26.5 39.0 41.2 18.4 28.3

Internal Medicine 8.5 57.1 21.5 4.5 39.6 34.1

Ear, nose & throat 1.1 2.4 5.2 0.0 0.0 1.7

Ophthalmology 0.0 3.7 15.0 15.6 3.5 7.8

Obstetrics 87.4 10.3 19.3 38.7 38.5 28.1

11 The working days in Jordan and Gaza are six days/week, and in Lebanon, Syria and West Bank Fields are five days/week.
* PRS data is included.
 72 unrwa health department - annual report 2022

Field Jordan Lebanon Syria Gaza Strip West Bank Agency

31.5 - Oral Health Services

Dental curative consultation – Male (no.) 48,498 27,784 34,137 80,042 13,484 203,945

Dental curative consultation – Female (no.) 76,175 35,009 57,372 108,119 18,665 295,340

(a) Total dental curative consultations (no.) 124,673 62,793 91,509 188,161 32,149 499,285

Dental screening consultations – Male (no.) 25,405 5,146 17,263 51,970 9,476 109,260

Dental screening consultations – Females (no) 48,360 9,069 23,953 120,818 23,853 226,053

(b) Total dental screening consultations (no.) 73,765 14,215 41,216 172,788 33,329 335,313

Grand total of Dental consultations/screening (a) & (b) 198,438 77,008 132,725 360,949 65,478 834,598

% preventive of total dental consultations 37.2 18.5 31.1 47.9 50.9 40.2

Average daily dental consultations / dental surgeon 27.8 24.0 27.6 52.4 21.3 33.2

31.6 - Physical Rehabilitation

Trauma patients - - - 3,912 476 4,388

Non-Trauma patients 556 - - 9,635 1,682 11,873

Total 556 - - 13,547 2,158 16,261

Strategic Objective 2

31.7 - Family Planning Services

New family planning users (no.) 5,953 2,082 2,246 11,550 3,381 25,212

Continuing users at end year (no.) 37,481 16,980 11,843 101,070 23,453 190,827

Family planning discontinuation rate (%) 5.2 5.7 6.2 4.3 4.2 5.1

Family planning users according to method (%):

IUD 39.5 37.2 30.8 50.8 60.4 47.3

Pills 29.1 22.2 25.2 21.3 15.1 22.4

Condoms 27.8 39.3 41.6 24.4 22.8 27.3

Injectables 3.6 1.2 2.4 3.5 1.6 3.0

31.8 - Preconception Care

No. of women newly enrolled in preconception care
5,271 1,673 788 29,830 4,859 42,421
programme
31.9 - ANTENATAL CARE

Registered population (no.) 2,542,999 557,342 674,455 1,754,309 1,123,485 6,652,590

Expected pregnancies (no.)12 57,421 7,301 15,324 48,542 27,436 156,023

Newly registered pregnancies (no.) 20,054 4,627 6,380 35,341 14,764 81,166

Antenatal care coverage (%) 34.9 63.4 41.6 72.8 53.8 52.0

Trimester registered for antenatal care (%):

1st trimester 75.8 85.2 49.7 89.7 65.6 78.5

2nd trimester 20.6 11.9 32.3 10.1 28.8 17.9

3rd trimester 3.6 2.9 17.9 0.2 5.6 3.6

Pregnant women with 4 antenatal visits or more (%) 80.5 75.2 54.6 98.3 90.1 87.6

Average no. of antenatal visits 5.2 4.8 3.9 7.6 5.3 6.1

12 Expected no. of pregnancies =population X CBR

 unrwa health department - annual report 2022 73

Field Jordan Lebanon Syria Gaza Strip West Bank Agency

31.10 - Tetanus Immunization

Pregnant women protected against tetanus (%) 97.1 91.5 99.5 99.4 99.8 98.5

31.11 - Risk Status Assessment

Pregnant women by risk status (%):

High 27.8 13.4 16.7 17.9 18.6 20.2

Alert 28.8 36.9 40.3 28.8 29.2 30.0

Low 43.5 49.7 43.0 53.3 52.2 49.7

31.12 Diabetes Mellutes And Hypertenstion During Pregnancy

Diabetes during pregnancy (%) 10.0 4.7 4.3 5.3 9.0 7.0

Hypertension during pregnancy (%) 9.9 8.1 5.5 7.8 4.6 7.5

31.13 - Delivery Care

Expected deliveries (no.) 21,012 4,879 6,304 35,872 15,247 83,314

a - Reported deliveries (no.) 19,245 4,326 6,038 33,219 14,532 77,360

b- Reported abortions (no.) 1,767 520 252 2,643 709 5,891

Unknown delivery outcome (no.) 0 33 14 10 6 63

Unknown delivery outcome (%) 0 0.68 0.22 0.03 0.04 0.08

Place of delivery (%):

Home 0.03 0.09 0.91 0.06 0.08 0.13

Hospital 99.97 99.91 99.09 99.94 99.92 99.87

Deliveries in health institutions (%) 100.0 99.9 99.1 99.9 99.9 99.9

Deliveries assisted by trained personnel (%) 100 100 99.9 100 100 100

31.14 - Maternal Deaths

Maternal deaths by cause (no.)

Pulmonary Embolism 2 1 1 4

Septic shock 1 1 1 3

Postpartum hemorrhage 1 1 2

Aspiration pneumonitis due to anaesthesia 1 1

Eclampsia & DIC 1 1

Renal Impairment, Thrombotic thrombocytopenic
1 1
purpura
Sudden cardiac arrest 1 1
Acute liver injury due to overdose of antipsychotic
1 1
(Suicide)
Total Maternal Mortality 7 0 4 3 0 14

Maternal mortality ratio per 100,000 live births. 36.1 0 66.2 9.0 0 18.0

C-Section among reported deliveries (%) 33.9 55.5 64.9 25.8 33.1 33.9
 74 unrwa health department - annual report 2022

Field Jordan Lebanon Syria Gaza Strip West Bank Agency

31.15 - Postnatal Care
Post natal care coverage (%) 87.1 88.5 81.0 100.0 90.8 92.9
31.16 Care Of Children Under Five Years
Registered population (no.) 2,542,999 557,342 674,455 1,754,309 1,123,485 6,652,590
Registered refugee (no.) 2,366,050 487,662 581,018 1,553,868 901,035 5,889,633
13
Estimated surviving infants (no.) 56,623 7,250 15,080 47,802 27,016 153,771
Children < 1 year registered (no.) 21,605 4,655 5,346 39,612 11,176 82,394
Children < 1 yea r coverage of care (%) 38.2 64.2 35.4 82.9 41.4 53.6
Children 1- < 2 years registered (no.) 22941 4908 5490 37155 10824 81318
Children 2- < 3 years registered (no.) 20988 4698 5972 37155 10361 79174
Children 3- < 4 years registered (no.) 23819 5029 6861 38315 10787 84811
Children 4- < 5 years registered (no.) 25181 5326 7007 40724 10629 88867
Total children 0-5 years registered (no.) 114,534 24,616 30,676 192,961 53,777 416,564
31.17 - Immunization Coverage
Immunization coverage children 12 months old (%):
BCG 100.0 100.0 99.5 99.6 99.4 99.7
IPV 99.9 NA 99.5 99.6 100.0 99.7
Poliomyelitis (OPV) 99.8 99.0 99.0 99.5 100.0 99.6
Triple (DPT) 99.9 99.3 97.0 99.2 100.0 99.4
Hepatitis B 99.9 99.3 99.2 99.2 100.0 99.6
Hib 99.9 99.3 99.2 NA NA 99.5
Measles 99.6 99.3 0.0 NA NA 99.6
All vaccines 99.9 99.4 99 99.4 99.9 99.6
Immunization coverage children 18 months old - boosters (%)
Poliomyelitis (OPV) 98.8 96.7 98.0 98.8 99.8 98.7
Triple (DPT) 98.9 96.7 98.0 98.5 99.8 98.6
MMR 98.8 97.0 97.8 98.3 99.8 98.5
All vaccines 98.8 96.8 97.9 98.5 99.8 98.6
31.18- Growth Monitoring and Nutrional Surveillance
Infants and Children with Growth Problems (0-5) years
of age
Prevalence of underweight among children aged <5
6.05 5.93 9.54 6.8 4.61 6.44
years
Prevalence of stunting among children aged <5 years 12.77 7.8 13.62 10.5 10.00 11.13
Prevalence of wasting among children aged <5 years 5.69 9.11 7.07 8.4 4.99 7.14
Prevalence of overweight/obesity among children aged
11.12 9.88 2.59 6.7 12.48 8.56
<5 years
31.19 - School Health
4th grade students screened for vision (No.)
Boys 5,260 1,417 3,205 16,064 1,882 27,828
Girls 5,146 1,486 2,997 14,734 3,064 27,427
Total 10,406 2,903 6,202 30,798 4,946 55,255
4 grade students with vision impairment (%)
th

Boys 16.0% 6.6% 4.3% 11.6% 15.2% 11.6%

Girls 23.0% 8.9% 5.5% 14.7% 15.8% 15.0%
Total 19.4% 7.8% 4.9% 13.1% 15.6% 13.3%

13 Expected no. of pregnancies =population X CBR

 unrwa health department - annual report 2022 75

Field Jordan Lebanon Syria Gaza Strip West Bank Agency

th
7 grade students screened for vision (No.):

Boys 6,667 1,263 3,135 14,055 2,000 27,120

Girls 6,125 1,241 3,168 14,485 3,187 28,206

Total 12,792 2,504 6,303 28,540 5,187 55,326

7 grade students with vision impairment (%)

th

Boys 17.3% 7.4% 6.4% 13.4% 14.8% 13.4%

Girls 25.5% 13.0% 6.8% 17.7% 16.4% 17.8%

Total 21.2% 10.1% 6.6% 15.6% 15.8% 15.6%

31.20 – Non-Communicable Diseases (NCD) Patients Registered With UNRWA

1,152 321 502 1,716 587 4,278
Diabetes mellitus type I (no/%)
(1.3%) (0.9%) (1.4%) (1.6%) (1.4%) (1.4%)
12,870 3,899 3,909 15,498 6,266 42,442
Diabetes mellitus type II (no/%)
(15.0%) (11.5%) (10.6%) (14.6%) (14.7%) (13.9%)
31,738 16,853 18,995 48,765 13,685 130,036
Hypertension (no/%)
(37.0%) (49.5%) (51.5%) (45.8%) (32.1%) (42.5%)
40,057 12,959 13,482 40,503 22,088 129,089
Diabetes mellitus & hypertension (no/%)
(46.7%) (38.1%) (36.5%) (38.0%) (51.8%) (42.2%)
85,817 34,032 36,888 106,482 42,626 305,845
Total (no. / %)
(100%) (100%) (100%) (100%) (100%) (100%)
31.21 - Prevalence of Hypertension and Diabetes

Served population ≥ 40 years with diabetes mellitus (%) 15.4% 13.9% 13.8% 17.1% 17.9% 15.9%

Served population ≥ 40 years with hypertension (%) 20.7% 24.4% 25.7% 26.8% 22.5% 23.8%

3122 – Management

Hypertensive patients on lifestyle management only (%) 0.6% 3.1% 0.5% 3.3% 0.2% 1.9%

DM I & II patients on lifestyle management only (%) 0.6% 2.6% 0.7% 4.8% 0.2% 2.3%

Diabetes I & II patients on insulin only (%) 8.2% 8.7% 15.6% 13.0% 11.4% 11.2%

31.23 - Risk Scoring

Risk status - patients with diabetes mellitus type 1 (%):

Low 34.0% 54.7% 56.9% 51.1% 16.6% 32.5%

Medium 60.7% 40.1% 39.4% 47.2% 60.6% 54.8%

High 5.4% 5.2% 3.8% 1.6% 22.8% 12.6%

Risk status - patients with diabetes mellitus type 2 (%):

Low 8.9% 18.7% 21.5% 15.2% 13.4% 14.0%

Medium 58.7% 52.4% 57.0% 63.6% 60.9% 60.5%

High 32.4% 29.0% 21.5% 21.1% 25.7% 25.5%

Risk status - patients with hypertension (%):

Low 9.5% 17.0% 23.1% 8.7% 7.7% 11.3%

Medium 28.7% 54.5% 58.1% 50.9% 45.0% 46.2%

High 61.8% 28.5% 18.8% 40.4% 47.3% 42.5%

Risk status - patients with diabetes & hypertension (%):

Low 11.0% 5.7% 5.7% 13.4% 5.2% 9.6%

Medium 45.7% 44.3% 46.1% 55.6% 46.9% 49.3%

High 43.3% 50.0% 48.2% 30.9% 47.9% 41.1%

 76 unrwa health department - annual report 2022

Field Jordan Lebanon Syria Gaza Strip West Bank Agency

Risk factors among NCD patients (%):

Smoking 14.1 29.9 26.5 9.5 13.9 15.0

Physical inactivity 75.2 37.8 27.0 56.7 36.2 53.8

Obesity 46.6 46.7 32.5 53.1 55.7 49.0

Raised cholesterol 61.0 37.7 42.9 46.1 59.0 51.7

31.24 - Late Complications Among NCD Patients (%)

Diabetes mellitus type I 1.2 1.6 2.2 2.1 2.9 2.0

Diabetes mellitus type II 5.2 3.8 5.8 7.9 6.6 6.5

Hypertension 6.7 6.7 10.9 9.5 8.3 8.6

Diabetes mellitus & hypertension 10.5 9.8 15.6 19.6 14.6 14.7

All NCD patients 8.4 7.7 12.2 13.3 11.5 11.1

31.25 – Defaulters

NCD patients defaulting during (no.) 7,619 1,527 2,405 5,426 4,064 21,041

NCD patients defaulting during 2022 (%) 9.4% 5.0% 6.7% 5.4% 9.6% 7.2%

31.26 - Fatality

Reported deaths among registered NCD patients (%) 1.1% 2.3% 1.3% 1.7% 1.4% 1.5%

Reported deaths among registered NCD patients by morbidity (no):

Diabetes mellitus 78 53 27 159 50 367

Hypertension 198 277 211 493 132 1,311

Diabetes mellitus & hypertension 650 382 226 1,039 398 2,695

Total 926 712 464 1,691 580 4,373

31.27 - Communicable Diseases

Registered refugee (no.)

Population served (no.) 865,562 259,036 324,249 1,295,528 428,950 3,173,325

Reported cases (no.):

Acute flaccid paralysis 0 0 0 0 0 0

Poliomyelitis 0 0 0 0 0 0

Cholera-suspected 0 76 25 0 0 101

Cholera- Confirmed 0 8 2 0 0 10

Diphtheria 0 0 0 0 0 0

Meningococcal meningitis 0 0 0 3 0 3

Meningitis - bacterial 0 0 4 16 0 20

Meningitis – viral 0 0 1 39 14 54

Tetanus neonatorum 0 0 0 0 0 0

Brucellosis 2 1 146 12 27 188

Watery diarrhoea (>5years) 4,317 3,276 2,806 2,399 1,143 13,941

Watery diarrhoea (0-5years) 4,320 2,953 2,962 8,673 1,968 20,876

Bloody diarrhoea 12 16 25 297 24 374

Viral Hepatitis 2 153 459 161 7 782

HIV/AIDS 0 0 0 0 0 0

13 No. of surviving infants = Population X crude birth rate X (1-IMR).

 unrwa health department - annual report 2022 77

Field Jordan Lebanon Syria Gaza Strip West Bank Agency

Leishmania 0 0 13 0 1 14

Malaria* 0 0 0 0 0 0

Measles 0 8 8 40 4 60

Gonorrhoea 0 1 0 0 0 1

Mumps 0 12 11 305 19 347

Pertussis 0 0 0 0 1 1

Rubella 0 1 0 0 1 2

Tuberculosis, smear positive 0 0 10 0 0 10

Tuberculosis, smear negative 0 0 2 0 0 2

Tuberculosis, extra pulmonary 0 1 18 2 0 21

Typhoid fever 0 0 193 20 13 226

Crosscutting Services

31.28 - Laboratory Services

Laboratory tests (no.) 1,118,835 385,724 496,150 2,192,917 784,981 4,978,607

Productivity (WLUs / hour) 52.3 43.4 31.1 54.8 67.9 49.9

31.29 - Radiology Services

Plain x-rays inside UNRWA (no.) 0 20,984 0 30,118 19,009 70,111

Plain x-rays outside UNRWA (no.) 569 3,547 0 0 0 4116

Other x-rays outside UNRWA (no.) 0 0 0 0 0 0

Total plain x-ray in and outside UNRWA (no.) 569 24,531 0 30,118 19,009 74,227

31.30- Human Resources Hq Jordan Lebanon Syria Gaza West Bank Agency
Health staff at end of December 2022 (no.)
Medical care services:
Doctors 3 99 33 67 214 75 491
Specialists 0 6 8 8 6 6 34
Pharmacists 1 2 23 16 71 68 181
Dental Surgeons 0 30 15 25 29 17 116
Nurses 1 250 86 115 322 246 1,020
Paramedical 7 128 44 80 151 76 486
Admin./Support Staff 2 70 70 68 116 79 405
Labour category 0 86 24 66 86 71 333
Sub-total 14 671 303 445 995 638 3,066
International Staff 7 7
Grand total 21 671 303 445 995 638 3,073

Health personnel per 100,000 registered refugees:

Doctors 4.2 6.8 11.5 16.5 8.3 8.7 4.2

Dental surgeons 1.3 3.1 4.3 2.2 1.9 2.1 1.3
Nurses 10.6 17.6 19.8 24.9 27.3 18.1 10.6
 78 unrwa health department - annual report 2022

Part 4 - Selected Survey Indicators

Infant and child mortality survey, 2013

Table 32: Infant and child mortality

Indicators Jordan Lebanon Gaza Strip West Bank Agency

Early neonatal (<7 days) 10.8 8.3 10.3 5.9 9.2

Late neonatal (8 - <28 days) 2.5 2.8 10.0 1.8 4.6

Neonatal (< 28 days) 13.3 11.1 20.3 7.8 13.7

Post neonatal (>28 days - 1 year) 6.7 3.9 2.1 4.1 4.3

Infant mortality (< one year) 20.0 15.0 22.4 11.9 18.0

Child mortality (> one year) 1.6 2.2 4.8 0.5 2.4

Infant and child mortality 21.6 17.2 27.2 12.3 20.4

Decayed/Missing/Filled Surface (DMFS) Survey, 2010

Table 33: Descriptive: Total number of decayed surface (DS), filled surface (FS) and DMFS sorted by age group

Age group DS Mean, SE (95%CI) FS Mean, SE (95%CI) DMFS Mean, SE (95%CI)8

3.27, 0.34 0.49, 0.13 3.83, 0.38

11-12 year
(2.61 – 3.94) (0.24 – 0.74) (3.08 – 4.58)
3.20, 0.08 0.58, 0.03 3.92, 0.09
13 years
(3.04 – 3.36) (0.52 – 0.63) (3.74 – 4.10)
3.09, 0.49 0.94, 0.24 4.22, 0.54
> 13 years
(2.11 – 4.06) (0.46 – 1.42) (3.16 – 5.29)

Table 34: DMFS, DS and FS sorted by age group and gender.

Age group gender DS Mean, SE (95%CI) FS Mean, SE (95%CI) DMFS Mean, SE (95%CI) DS/ DMFS % FS/ DMFS %

3.38 0.39 3.90

males 86.5 10.0
0.47 (2.43 – 4.32) 0.12 (0.14 – 0.64) 0.52 (2.86 – 4.94)
11-12 year
3.16 0.59 3.75
females 83.0 14.1
0.48 (2.20 – 4.12) 0.23 (0.14 – 1.05) 0.56 (2.64 – 4.86)
3.23 0.55 3.90
males 77.2 22.8
0.12 (3.00 – 3.47) 0.04 (0.46 – 0.63) 0.13 (3.65 – 4.15)
13 years
3.16 0.60 3.9
females 84.2 15.8
0.12 (2.93 – 3.40) 0.04 (0.52 – 0.68) 0.13 (3.67 – 4.20)
3.75 1.11 4.87
males 80.4 15.3
0.85 (2.03 – 5.48) 0.47(0.16 – 2.06) 0.90 (3.05 – 6.68)
> 13 years
2.57 0.81 3.72
females 69.0 21.8
0.57 (1.43 – 3.70) 0.22 (0.36 – 1.25) 0.65 (2.42 – 5.03)
 unrwa health department - annual report 2022 79

Table 35: DMFS, DS and FS sorted by Field

Field DS Mean, SE (95%CI) FS Mean, SE (95%CI) DMFS Mean, SE (95%CI) DS/DMFS % FS/DMFS %

2.48 0.55 3.23

Jordan 76.9 17.0
0.15 (2.19 – 2.78) 0.05 (0.45 – 0.64) 0.17 (2.89 – 3.56)
2.99 0.77 3.78
Lebanon 79.2 20.3
0.21 (2.57 – 3.41) 0.08 (0.61 – 0.92) 0.23 (3.33 – 4.23)
3.37 0.7 4.22
Syria 80.0 18.0
0.18 (3.02 – 3.72) 0.09 (0.59 – 0.93) 0.20 (3.82 – 4.62)
2.21 0.34 2.66
Gaza 82.9 12.7
0.11 (1.99 – 2.42) 0.04 (0.25 – 0.42) 0.12 (2.38 – 2.87)
5.02 0.54 5.88
West Bank 85.4 9.2
0.21 (4.60 – 5.44) 0.06 (0.42 – 0.66) 0.23 (5.42 – 6.34)

Decayed/missing/filled teeth (DMFT) survey conducted in 2016

Table 36: Prevalence of Dental Caries (DMFT/S>0) in the permanent dentition by Field, 2016

Field No. % CI 95%

Jordan 262 68.4 63.5 – 73.0

Lebanon 287 73.6 68.9 – 77.8

Syria 134 45.9 40.1 – 51.8

Gaza 309 70.7 66.2 – 74.9

West Bank 271 79.7 75.0 – 83.9

Agency 1263 72.8 70.5 – 75.0

Table 37: Prevalence of dental sealants on permanent teeth, by Field, 2016

Indicator Jordan Lebanon Syria Gaza Strip West Bank Agency CI 95%

Prevalence of dental sealants 4.2 431.5 0.0 1.6 1.8 9.8 (CI 95%: 8.4-11.4)

Table 38: Prevalence of Dental Caries (DMFS) results 2011 and 2016

Year Jordan Lebanon Syria Gaza Strip West Bank Agency

2011 71.1 68.5 71.8 68.8 85.1 73.1
2016 68.4 73.6 45.9 70.7 79.7 72.8

Current practices of contraceptive use among mothers of children 0-3 years survey, 2015
Table 39: Selected reproductive health survey indicators

Indicators Jordan Lebanon Syria Gaza Strip West Bank Agency

Mean birth interval (months) 40.4 42.4 42.9 33.7 39.4 39.2
Percentage of women married by the age < 18 years 24.6 16.6 19.0 23.7 23.6 22.0
Percentage of women with birth intervals < 24 months 27.7 30.4 26.2 38.5 30.4 31.3

Mean birth interval (months) 40.4 42.4 42.9 33.7 39.4 39.2

Percentage of women married by the age < 18 years 24.6 16.6 19.0 23.7 23.6 22.0

Percentage of women with birth intervals < 24 months 27.7 30.4 26.2 38.5 30.4 31.3

Prevalence of modern contraceptives among women of

64.0 67.2 59.6 52.8 55.6 59.3
reproductive age utilizing UNRWA MCH services

Mean marital age (women) 20.3 21.4 20.9 19.9 19.9 20.4
 80 unrwa health department - annual report 2022

Table 40: Total fertility rates among mothers of children 0 to 3 years of age who attended the Maternal and Child Health centres

Field 1995 2000 2005 2010 2015

Jordan 4.6 3.6 3.3 3.5 3.2

Lebanon 3.8 2.5 2.3 3.2 2.7

Syria 3.5 2.6 2.4 2.5 2.7

Gaza Strip 5.3 4.4 4.6 4.3 3.6

West Bank 4.6 4.1 3.1 3.9 3.6

Agency 4.7 3.5 3.2 3.5 3.2

Prevalence of anaemia among pregnant women, nursing mothers and children 6-36 months of age survey,
2005

Table 41: Selected anaemia survey indicators

Indicator Jordan Lebanon Syria Gaza West Bank Agency

Percentage of infants breastfed for at least one month 75.9 87.2 78.3 65.0 87.1 78.9

Prevalence of exclusive breast feeding up to 4 months 24.0 30.2 40.3 33.3 34.5 32.7

Prevalence of anaemia among children < 3 years of age 28.4 33.4 17.2 54.7 34.2 33.8

Prevalence of anaemia among pregnant women 22.5 25.5 16.2 35.6 29.5 26.3

Prevalence of anaemia among nursing mothers 22.2 26.6 21.7 45.7 23.0 28.6

Prevalence of anaemia among school children

1st grade 14.4 22.3 9.1 36.4 14.6 19.5

2nd grade 11.6 16.9 6.0 11.4 14.9 12

Annex -1 Donor Support to The UNRWA Health Programme During 2022
Table 42: Donor support to the UNRWA health programme
Funding Portal Donor US$D Amount Title Fund code
Austria 2,708,865 Supporting UNRWA Health Programme in Gaza and West Bank 2022 GF22022
Germany 18,518,519 UNRWA basic services in the context of the Syria crisis in Lebanon and Jordan phase III GF22032
Japan 462,962 Support for education and healthcare to Palestine refugees in Lebanon GF22012
Enhancing the human security of Palestine refugees in the West Bank by delivering health care
Japan 2,250,000 GF22009
services
Jordan 2,996,883 In-kind donation of vaccines and family planning supplies GI00000
Lebanon 16,804 In-kind donation of vitamins, medicine and COVID 19 rapid test devices GI00000
Luxembourg 481,605 Supporting the provision of health care for Palestine refugees in Gaza Strip GF22026
Palestine 2,427,009 In-kind donation of various medical supplies, medicines and PPE items GI00000
Local Government of Andalucia, Spain 369,129 To cover MCHC and GBV in Syria GF22019
Regional Government of Asturias, Spain 63,700 To cover MCHC in Gaza GF22018
Barcelona City Council, Spain 92,502 To cover MCHC program in Sabra HC in Gaza GF22029
Regional Government of Basque, Spain 194,775 Health Points in WB 2022 GF22028

Programme Bilbao Local Council, Spain 23,026 MCHC program in Bureij HC, Gaza GF22005
Budget Local Council of Castello, Spain 56,756 Cover MCHC program in Jabalia HC in Gaza GF22001
Local Council of Castello, Spain 60,207 Support MCHC in Jabalia HC, Gaza GF22027
Castilla La Mancha Regional Government,
67,177 MCHC in West Bank GF22004
Spain
Local Government of Catalonia, Spain 300,557 To support MCHC and GbV prevention at Deir el-Balah Health Centre GF22020
Local Government of Catalonia, Spain 309,204 MCHC and GbV prevention at Askar and Balata Health Centres, West Bank GF22035
Extremadura Regional Government, Spain 193,798 To cover MCHC program in Gaza GF22030
La Rioja Government, Spain 113,895 Support MCHC in West Nuseirat HC, Gaza GF22010
Local Government of Navarra, Spain 136,493 MCHC in Gaza (Shouka Health Centre) GF22002
Local Government of Navarra, Spain 115,494 Health Point in WB GF22003
Local Government of Navarra, Spain 305,527 To Support Health in the West Bank GF22021
Valencia City Council, Spain 65,717 MCHC in Tulkarem HC in WB GF22013

Zaragoza Regional Government, Spain 45,664 Health points intervention in Azzoun and Silat al-Daher in West Bank GF22008
unrwa health department - annual report 2022
81

Syria 82,438 In-kind donation of Hormonal Contraceptive and vaccines GI00000

 Funding Portal Donor US$D Amount Title Fund code
82

UNRWA USA National Committee 638,012 UNRWA USA Support to GFO Health Centre Staff GF22037

Vitamin Angels 23,904 In-kind donation of Vitamins GI00000

UNICEF 495,778 In-kind donation of various medical supplies, medicines and PPE items GI00000
Programme
Budget WHO 307,780 In-kind donation of staff costs and medicine GI00000

Novo Nordisk 4,800 In-kind donation of Insulin Vials GI00000

St. John Eye Hospital 49,362 In-kind donation of Vision chart, Ophthalmoscopes and Portable Fundus Camera GI00000

Private Sector Funding 93,625 In-kind donation of medical supplies and equipment GI00000
unrwa health department - annual report 2022

Support to UNRWA COVID-19 response: ensuring that Palestine refugees are able to meet
Germany 1,116,071 their basic needs, mitigating a further deterioration in their humanitarian and socio-economic PR22002
conditions
Emergency Grant Aid in response to the deterioration of the humanitarian situation in the Gaza
Japan 2,911,752 PR22024
Strip

Bilbao Local Council, Spain 4,372 Support COVID-19 intervention in Gaza PR22008

Responding to the impact of emergency on the psychosocial well-being and mental health of
Emergency Appeal ECHO 3,046,199 Palestine refugee children in the Gaza Strip and strengthening UNRWA’s engagement in inter- PR22044
(oPt) agency planning and coordination, Palestinian Occupied Territory

Muslim Charity Helping the Needy 75,000 Supporting Palestine refugees’ access to health care in the Gaza Strip PR22019

UNRWA USA National Committee 521,956 2022 UNRWA USA Support to Gaza Mental Health and Psychosocial Support (MHPSS) PR22026

Private Sector Funding 40,000 Emergency Appeal 2022: Providing 2,600 women with support to access mammograms PR22058

Sbitany & Sons Co. LTD. 31,230 MHPSS School Activities in Gaza PR22015

Germany 13,531,933 UNRWA Digital Transformation in Health and Education PQ22040

Projects
Japan 1,000,000 Support to the UNRWA Health Program, HQA PQ22011
Funding Portal Donor US$D Amount Title Fund code
A human rights-based approach in UNRWA health services focusing on inclusion of vulnerable
Japan 800,694 PQ22012
groups among Palestine Refugees, HQA
Japan 63,945 Staff costs of Junior Professional Officer, assigned to UNRWA in Health Dept. HQ Amman IQ20A05
Japan 64,883 Staff costs of Junior Professional Officer, assigned to UNRWA in Health Dept. HQ Amman IQ20A06
Luxembourg 515,404 Supporting the provision of health care for Palestine refugees in Gaza Strip PQ22056
Castilla y León Regional Government,
83,907 Laboratory equipment in Syria PQ22003
Spain
Local Government of Navarra, Spain 73,496 MCHC in Gaza (Shouka Health Centre) PQ22004
Zaragoza City Council, Spain 100,196 Support Health Program through providing medical equipment in West Bank PQ22008
UNRWA health systems strengthened to provide integrated health, nutrition and early child- PQ22051 &
UNICEF 125,000
Projects hood interventions and services in UNRWA Health Centres- Jordan Field IQ22051
WHO 10,000 Implementation of Global Young Tobacco Survey - GYTS, (HD/HQA) PQ22044
To design and conduct GSHS and GSHPPQ surveys among 13–17-year-olds in the schools man-
WHO 15,000 PQ22058
aged by UNRWA
To cover specifically the cancer medication for kids under 18 years old in Palestine refugee (PRS
Palestine Children’s Relief Fund (PCRF) 300,000 PQ22H01
& PRL) camps, Lebanon
Evaluation of Multiple Micronutrient Supplementation (MMS) program in UNRWA health clinics
Vitamin Angels 129,016 PQ22027
in Jordan
Strengthening existing health systems in the Gaza Strip through sustainable Inclusive Eye
St. John Eye Hospital 45,827 PQ22006
Health services, Gaza Strip
Strengthening existing health systems in the Gaza Strip through sustainable Inclusive Eye
St. John Eye Hospital 34,980 IQ21071
Health services, PEC training “Direct Ophthalmoscope Unit with LED Heine”
Germany 653,136 Supporting UNRWA COVID-19 Response to the most vulnerable Palestine refugees in Jordan PQ22S21
Supporting UNRWA for provision of Comprehensive Health Care Services to Palestine Refugees
Italy 1,495,513 PQ22S31
from Syria and in Jordan-Phase II
Japan 2,850,000 Emergency Grant Aid in response to the humanitarian crisis in Syria, Lebanon and Jordan PQ22S03
Palestine 52,324 Covering 10% of COVID-19 hospitalization expenses in Lebanon PQ21S27
Pharmaceutical supplies to UNRWA Lebanon Field Office for donation to the Palestinian Red
Syria Appeal Palestine 217,145 IQ22S15
Crescent in Lebanon (in-kind donation)
Local Government of Andalucia, Spain 52,733 To cover MCHC and GBV in Syria PQ22S22
Regional Government of Basque, Spain 834,339 Humanitarian Strategy to support the second phase of Gender project in LFO PQ22S04
OCHA 500,000 Provision of life-saving health care services to Palestine Refugees in Syria PQ22S33
unrwa health department - annual report 2022

UNICEF 211,455 Pregnant women have access to proper maternal health and nutrition care, Syria PQ22S30
83

UNHCR 77,664 Health assistance for Palestinian persons arriving from Syria to Egypt PQ22S12
 84
Annex 2 - Strategic Outcome 2: Refugees’ health is protected and the disease
burden is reduced
Table 43: Agency-wide CMM 2016-22

Output 2.1
Activities
people-centred primary health care system using FHT model

Outpatient Outpatient
2.1.a Average daily medical consultation per doctor 2.1.1.b Number of staff trained on comprehensive MHPSS
2.1.b Average consultation time per doctor response
2.1.c Number of HCs fully implementing eHealth system oral health
2.1.f Number of health centres integrating the MHPSS technical 2.1.1.d Percentage of preventative dental consultations out of
instructions into the Family Health Team approach total dental consultations
2.1.g Percentage of positive MHPSS cases assisted non-communicable diseases
non-communicable diseases 2.1.1.e Percentage of targeted population 40 years and above
unrwa health department - annual report 2022

2.1.h Percentage of NCD patients coming to HC regularly screened for diabetes mellitus
2.1.i Percentage of NCD patients with late complications 2.1.1.f Number of new NCD patients (DM, HT, DH+HT)
2.0.a Prevalence of diabetes among population served 18 years and
communicable diseases 2.1.1.g Total number of NCD patients (DM, HT, DH+HT)
above (Health)
2.1.j Number of EPI vaccine preventable disease outbreaks communicable diseases
Maternal health and child services 2.1.1.h Percentage of children 18 months old that received all
2.0.b Percentage of DM patients under control per defined criteria
2.1.k Percentage of women with live births who received at booster vaccines
(Health)
least 4 ANC visits 2.1.1.i Number of new TB cases detected
2.1.l Percentage of post-natal women attending PNC within 6 Maternal health and child services
2.0.c Maternal mortality ratio (per 100,000 live births) (Health)
weeks of delivery 2.1.1.j Percentage of 18 months old children that received 2
school health services doses of Vitamin A
2.0.d Degree of alignment with UNRWA protection standards of
2.1.m Percentage Diphtheria + tetanus coverage among 2.1.1.k Number of active/continuing family planning users
health services (Health/Protection)
targeted students 2.1.1.l Number of new enrolments in pre-conception care
pharmaceutical services programme
2.1.n Antibiotic prescription rate school health services
2.1.o Percentage of HCs with no stock out of 12 tracer medicines 2.1.1.m Percentage of 4th grade school children identified with
2.1.t Percentage of protection mainstreaming recommendations vision impairment
from internal protection audits implemented (Health/ 2.1.1.n Unit cost per capita
Protection)
Output 2.2
Activities
efficient hospital support services

2.2.a Percentage of UNRWA hospitalization accessed by SSNP 2.2.1.a Hospitalization unit cost
 unrwa health department - annual report 2022 85

Table 44: Agency-wide Common Indicators

Indicator Calculation

Number of medical consultations seen by doctor during given quarter / Number of

Average daily medical consultations per doctor
working days for the same doctor during the same quarter

No. of patients receiving antibiotics prescription / All patients attending curative

Antimicrobial prescription rate services (general outpatient at health centres+ sick babies + sick women + sick
NCD) X100

% Preventive dental consultations of total No. of preventive dental consultations / Total no. of preventive & curative dental
dental consultations consultations X100

% 4th-grade school children identified with No. of 4th-grade school children identified with vision impairments / No. of 4th-
vision defect grade school children screened by UNRWA school health programme X100

% Health centres implementing at least one

No. of HCs implementing at least one ehealth module / Total No. of HCs X100
ehealth module

% Health centres with no stock-outs of 12 tracer

No. of HCs with no stock-outs of 12 tracer items / Total no. of HCs X100
items

% Pregnant women attending at least 4 ANC No. of pregnant women attending at least 4 ANC visits / No. of women with live
visits births X100

% 18-month-old children that received two No. of children 18 months old that received two doses of Vitamin A / Total no. of
doses of Vitamin A children 18 months old X100

No. of women newly enrolled in Pre-Conception

No. of women newly enrolled in Pre-Conception Care programme
Care programme

% Women attending PNC within six weeks of No. of women attending postnatal care within 6 weeks of delivery / No. of women
delivery with live births X100

No. of continuing family planning acceptors No. of continuing family planning acceptors

Diphtheria and tetanus (dT) coverage among

No. of school children that received dT / Total no. of school children targeted X100
targeted students

No. of patients 40 years and above screened for diabetes / (Total no. of served
% Targeted population 40 years and above
population 40 years and above) – (total no. of diabetes patients currently registered
screened for diabetes mellitus
in NCD programme) X100

% Patients with diabetes under control No. of DM patients defined as controlled according to HbA1C or postprandial
according to defined criteria glucose criteria / Total no. of DM patients X100

No. of new NCD patients in the programme (Diabetes mellitus; Hypertension;

No. of new NCD patients in the programme
Diabetes mellitus & hypertension)

Total No. of NCD patients in the programme (Diabetes mellitus; Hypertension;

Total No. of NCD patients in the programme
Diabetes mellitus & hypertension)

No. of EPI vaccine-preventable diseases

No. of EPI vaccine-preventable diseases outbreaks
outbreaks

% 18-month-old children that have received

No. of children 18 months old that received all doses for all required vaccines / Total
all EPI vaccinations according to host country
no. of children 18 months old X100
requirements

No. of new TB cases detected No. of new TB cases detected (smear-positive + smear-negative + extra pulmonary)
Annex3 - Health Department Research Activities and Published papers
86

Table 45: Health department published papers/Abstracts

Month/year Type of
S. N UNRWA author(s) Title Citation Language Web site (if applicable)
of publication publication
Diabetes Research https://www.ncbi.nlm.
Diabetes care to Palestine Refugees during
1 April,2022 Shahin, yousef and Clinical Practice Journal abstract English nih.gov/pmc/articles/
COVID 19 pandemic
(2022). PMC9164763/pdf/main.pdf

Risk factors for hearing impairment in infants https://www.thelancet.com/

Zaqqout, Randa F., and Bassam Abu
2 June,2022 and toddlers in the Gaza governorates: a The Lancet, 399, S41. Journal Abstract English action/showPdf?pii=S0140-
Hamad
case-control study 6736%2822%2901176-X

Oral health problems among patients with https://www.thelancet.

type 2 diabetes attending UNRWA health com/pdfs/journals/lancet/
3 June,2022 Alqedra, Emad, and Yousef Aljeesh The Lancet, 399, S20. Journal Abstract English
centres in Gaza governorates: a cross- PIIS0140-6736(22)01155-2.
sectional study pdf

Albeik, Shatha, Suha Saleh, Yassir Barriers and solutions to implementing a https://www.thelancet.
unrwa health department - annual report 2022

Turki, Ayoub Mousa, Nada Abu Kishk, multisectoral action plan to prevent and com/journals/lancet/article/
4 June,2022 The Lancet, 399, S28. Journal Abstract English
Mengxin Tan, Yousef Shahin, and control non-communicable diseases within PIIS0140-6736(22)01163-1/
Akihiro Seita. UNRWA settings: a mixed-methods study fulltext

Orubu, Ebiowei SF, Shatha Albeik,

Carly Ching, Rana Hussein, Ayoub A Survey Assessing Antimicrobial Prescribing The American journal https://www.ajtmh.org/
5 July,2022 Mousa, Masako Horino, Rabie Naqa, at United Nations Relief and Works Agency of tropical medicine Journal article English view/journals/tpmd/107/2/
Mohammad Elayyan, Rawan Saadeh, Primary Health Care Centers in Jordan and hygiene article-p474.xml
and Muhammad H. Zaman

Rimawi, Asmaa, Adarsh Shah, Henry

Community Health Worker Program https://www.ncbi.nlm.
Louis, David Scales, Jawad Abu
Outcomes for Diabetes and Hypertension Global Health: nih.gov/pmc/articles/
6 October, 2022 Kheiran, Nashat Jawabreh, Sofia Journal abstract English
Control in West Bank Refugee Camps: A Science and Practice PMC9622278/pdf/GH-
Yunez, Masako Horino, Akihiro Seita,
Retrospective Matched Cohort Study GHSP220115.pdf
and Bram Wispelwey.

Jamal, Zeina, Zoheir ElKhatib, Shatha

Social determinants and mental health https://bmcpublichealth.
AlBaik, Masako Horino, Mohammed
needs of Palestine refugees and UNRWA Journal biomedcentral.com/
7 Dec,2022 Waleed, Farah Fawaz, Giulia Loffreda, BMC public health English
responses in Gaza during the COVID-19 Article articles/10.1186/s12889-
Akihiro Seita, Sophie Witter, and Karin
pandemic: a qualitative assessment 022-14771-9
Diaconu
https://
Jamaluddine, Zeina, Gloria Paolucci, Classifying caesarean section to understand
bmcpregnancychildbirth.
Ghada Ballout, Hussam Al-Fudoli, rising rates among Palestinian refugees: BMC Pregnancy and
8 Dec,2022 Journal Article English biomedcentral.com/
Louise T. Day, Akihiro Seita, and Oona results from 290,047 electronic medical Childbirth 22, no. 1
articles/10.1186/s12884-
MR Campbell. records across five settings
022-05264-z
Making Health Chapter 24
Katherine Rouleuo, Shatha Albeik,
Systems Work in Low- Textbook for
9 Dec,2022 Sayed shah, Kenneth yakubu , Integrated People-Centered Health Care. English
and Middle-Income Public Health
Akihirio Seita
Countries: Practitioners
 unrwa health department - annual report 2022 87

Annex 4 – Health Maps

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Map produced : April 2023
Base data UNR WA Health Department
F or comments contact :
w.zeidan2@ unrwa.org
88 unrwa health department - annual report 2022

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! G W E ST BANK Catography UNRWA HQ Amman Health Department
Map produced : April 2023
Base data UNR WA Health Department
For comments contact :
w.zeidan2@ unrwa.org
Annex 5 - Depatrtment of Health at UNRWA HQ, Amman Organizational Chart

Director of Health

Deputy Director of Health &

Chief Medical Care Services

Chief Health Chief Disease Head Health Policy

Protection & Promotion Prevention & Control & Planning

Hospitalization E-health Project

Head Nursing Medical Care Health Communication
Officer Coordinator
& Midwifery Services Services Officer & CBI Officer

E-health Quality
Associate Programme Head Pharmaceutical Visual Design &
Health Nutrition Control Officer
Support Officer Services Infographics Officer
Officer

E-health Quality
Administrative Senior Programme Medical Supply
Control Officer
Support Assistant Support Assistant Chain Coordinator Public Health Specialist/
Epidemiologist

Associate Programme Public Health Administrative

Support Officer Coordinator Assistant A

Health Information
& System Officer
unrwa health department - annual report 2022
89
 90 unrwa health department - annual report 2022 85

Annex 5 - Contacts of Senior Staff of the UNRWA

Health Programme

Technical staff in the Health Department, HQ, A

Post Title Incumbent Telephone E-mail address

WHO Special Representative & Director of Health Dr. Akihiro Seita 5808300 a.seita@unrwa.org

Deputy Director of Health Vacant

Health Policy & Planning Officer Dr. Sayed Shah 5808309 s.shah@unrwa.org

E-Health Project Coordinator Ms. Ghada Ballout 5808359 g.ballout@unrwa.org

Health Communication & Community Based Initiative Officer Ms. Amal Arafeh 5808395 a.arahehi@unrwa.org

Public Health Specialist /Epidemiologist Ms. Mai Ogawa 5808357 m.aogawa@unrwa.org

Hospitalization Consultant Ms. Gloria Paolucci 5808357 g.paolucciqunrwa.org

Hospitalization Officer Dr. Rami Habash 5808167 r.habash@unrwa.org

Health Information & Systems Officer Ms. Wafa Zeidan 5808311 w.zeidan2@unrwa.org

Division of Health Protection & Promotion

Chief, Health Protection & Promotion Vacant

Health Nutrition Officer Vacant

Head Nursing and Midwifery Services Ms.Tamara Hani 5808167 t.rahahleh@unrwa.org

Division of Disease Prevention & Control

Chief, Disease Prevention & Control Dr. Yousef Shahin 5808315 y.shahin2@unrwa.org

Division of Medical Care Services

Medical Care Services Officer Dr. Saed Atallah 5808567 s.atallah@unrwa.org

Head Pharmaceutical Services Ms. Rawan Saadeh 5808306 r.saadeh@unrwa.org

unrwa health department - annual report 2022