Physicians for Human Rights-Israel: The Bare Minimum - Health Services in the Unrecognized Villages...

8/8/2019 Physicians for Human Rights-Israel: The Bare Minimum - Health Services in the Unrecognized Villages in the Negev, July 2007

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The Bare Minimum

Health Services in the

Unrecognized Villages in the Negev

Apri l 2009


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Physicians for Human Rights-Israel (PHR-Israel) believes that every person has

the right to health in its widest possible sense, as defined by the principles of human

rights, social justice and medical ethics. It is the responsibility of the State of Israelto ensure the fulfillment of this right in an egalitarian manner for all populations

under its legal or effective control: residents of Israel who are eligible for National

Health Insurance, Bedouin residents of unrecognized villages in the Negev desert,

prisoners and detainees, migrant workers, refugees and asylum seekers, and

Palestinian residents of the occupied Palestinian territory.

Tel: 972-3-6873718 | Fax: 972-3-6873029

Address: 9 Dror St., Tel Aviv-Jaffa 68135, Israel

Mail: [email protected] | Site: www.phr.org.il

ISSN # 0793-6222


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The Bare Minimum

Health Services in the Unrecognized Villages in the Negev

April 2009


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Physicians for Human Rights Israel (Registered Association)

The Regional Council for the Unrecognized Villages in the Negev

The Bare Minimum Health Services in the Unrecognized Villages in the Negev

Written by: Wasim Abbas

Research: Yaela Raanan Regional Council for the Unrecognized

Villages in the Negev

Wasim Abbas Physicians for Human Rights Israel

Fadi Al-Ubra Physicians for Human Rights Israel

English editing: Libby Friedlander

English translation: Shaul Vardi

Photography: Daniella Cheslow

Design: David Moscowitz

Printing: Gil Dafdefet

Acknowledgments:

The publication of this report was made possible thanks to the support of the

European Union. Physicians for Human Rights Israel bears sole responsibility for

the content of this report, which in no way reflects the position of the European

Union.


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Contents

Introduction

Primary Health Services: Clinics

The Organizational Structure and Profile of the Clinics

Availability of Services

Connection of the Clinics to InfrastructuresAccessibility of Services

Language and Communication Problems

The Family Health Clinics

Availability and Accessibility of Services

Health Outcomes in the Unrecognized Villages: Infant Mortality and Child

Development

Conclusion, Ramifications, and Recommendations: Ensuring Early

Identification and Treatment


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Introduction

This report focuses on the violation of the right to receive health services among the

Bedouin Arab residents of the unrecognized villages in the Negev. The residents of

these villages suffer discrimination due to the grave lack of clinics and family health

centers, and due to problems of supply, accessibility, availability, and suitability in the

sparse medical services that exist in these communities.

The right to receive medical care constitutes one of the most important components ofthe right to health. The International Covenant on Economic, Social and Cultural

Rights clarifies that signatory countries (of which Israel is one) must ensure the

creation of conditions which would assure to all medical service and medical attention

in the event of sickness.1

As with other human rights, the realization of the right to health depends on the

implementation of four basic components: availability, accessibility, suitability, and

quality.

Availability is defined as the presence of health facilities, services, and programs in

sufficient quantity given the needs of the population.

Accessibility requires egalitarian and non-discriminatory access to health facilities,

services, and programs, including the removal of physical, economic, and

information-based obstacles.

Suitability means that the services provided must be adapted to the sociocultural

context of different populations; attention must be paid to the principles of medical

ethics and to the cultural adaptation of services.

Quality requires the maintenance of a standard of medical and scientific services of

sufficient quality.2

The principle of non-discrimination is one of the core obligations incumbent on the

state in realizing the above components.

Israeli law also emphasizes the value of equality in realizing the different components

of the right to health. The National Health Insurance Law, 1994, which regulates the

commitment of the HMOs to provide health services for all residents of Israel,

establishes that national health insurance shall be based on the principles of

j ti lit d t l li bilit d th t th h lth i i l d d i th


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professional standard and medical quality and in terms of human relations,3

and that

a medical care worker or institution shall not discriminate between patients on the

grounds of religion, race, sex, nationality, country of origin, or on any such grounds.

4

The principle of non-discrimination is not implemented in the context of the provision

of medical services in the unrecognized villages in the Negev. The situation in these

villages is far removed from the spirit of the international conventions and domestic

laws. In terms of the states obligations, the availability of medical facilities and

centers in the villages is limited (just twelve clinics for a population of over 83,000

residents). Moreover, the quality of these services is very poor by comparison tosimilar services provided in other parts of Israel. The gulf between the services

actually provided in these villages and the needs of this society prove the depth of the

discrimination against the residents of the unrecognized villages of the Negev in terms

of their equal right to enjoy health services by comparison to their Jewish neighbors.

There can be no doubt that this situation constitutes a substantive violation of the

principle of equality.

Improving the availability and accessibility of these services, and improving the poor

health results of this population, require differential investments in the development

of services in these communities. In practice, however, the situation is the reverse. As

the bodies responsible for providing these services, the HMOs deliver health services

at an inadequate standard in terms of accessibility, availability, and suitability.

Moreover, the state prevents the supply of vital infrastructures and services and uses

the withholding of additional health services as a means of pressure in order to coerce

the residents to move to the permanent towns and to abandon their ownership of land.

These conclusions are based on a field study undertaken by Physicians for Human

Rights Israel and the Regional Council for the Unrecognized Villages in the Negev.

A mapping was undertaken between March and August 2008 examining all the

existing medical services in the unrecognized villages in the Negev. The mapping

included eleven clinics of Clalit HMO; the single clinic of Leumit HMO in the village

of Al-Sayid; and eight family health centers. A comparison was undertaken betweenthese services and those provided in peripheral Jewish communities in the Negev

region5

that share key demographic and geographical features with the unrecognized

villages: Rural clinics at a similar distance from the city and which provide services

for a similar-sized population. The results of this mapping will be presented in detail

i th f ll i ti


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Primary Health Services: Clinics

The population of the unrecognized villages in the Negev has suffered for many years

as the result of the policy of successive Israeli governments to deny recognition to

these communities. This policy has ramifications in terms of the health of the

residents. A report published in February 2009 by the Southern District of the

Ministry of Health The State of Health of Bedouin Babies and Children up to the

Age of Six in the Permanent Communities and in the Unrecognized Villages in the

Negev6

highlights the poor health results among the Bedouin Arab population in

the Negev in general, and in the unrecognized villages in particular. The infant

mortality rate is particularly high; a large proportion of children suffer from

malnutrition; babies have a lower weight at birth relative to the national average; a

high percentage of children suffer from anemia and growth problems, and so forth.

The report recommends the introduction of preventative programs and the

improvement of health-supporting infrastructures (regular supply of water and

electricity, the construction of access roads, removal of sewage, and garbage

disposal). The report also calls for the improvement and expansion of the existing

health services in the villages, i.e. the family health centers and the primary clinics.

Although primary health centers are considered a crucial factor in treating,

diagnosing, and preventing diseases, there were no clinics in the unrecognized

villages until 1994. Prior to the enactment of the National Health Insurance Law,those of the residents who were able to do so (approximately 60 percent) purchased

health insurance and were forced to travel to the clinics in Bedouin or Jewish

communities in their immediate or more distant vicinity. The clinics of Clalit HMO in

the kibbutzim, moshavim, and community villages close to the Bedouin villages did

not accept patients from the unrecognized villages. Services were provided only at

clinics in such cities as Yeruham, Dimona, and Arad7

that were defined as minority

clinics. This situation continues to the present day. A document on this subjectpublished by the Negev Development Authority in 1994 noted that: the population of

the Negev is denied an appropriate health service, and added: On the basis of the

law, the Bedouin population will be eligible to demand health services that are

currently partially or completely absent.8

After the enactment of the law, the vast

j it f th i d l ti i t d ith Cl lit HMO


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The first clinic in the unrecognized villages was established in the village of Al-Grain

in 1994. Since then, a total of twelve clinics have been opened in the unrecognizedvillages; eleven are operated by Clalit HMO and one by Leumit HMO (an additional

clinic operated by the Clalit HMO has also been opened in the new village established

for the Tarabin Al-Sana tribe).

Most of the clinics and family health centers were only opened after petitions were

submitted to the Supreme Court. In June 2000, the Association for Civil Rights in

Israel, Physicians for Human Rights Israel, and the Regional Council for the

Unrecognized Villages in the Negev submitted a petition (HCJ 4540/00) demanding

the establishment of clinics in the villages. The petition asked the state to establish

clinics in three villages9

and to determine criteria for the future establishment of

clinics in Arab communities in the Negev that do not have community clinics. The

states response ignored the demand to determine criteria, but the state undertook to

establish clinics in the villages of Darijat, Wadi Al-Naam, and Al-Zarnug (Abu

Kweidar). In its response dated 11 September 2001, the Ministry of Health noted that

its professional opinion was that clinics should also be established in the villages of

Al-Fura, Abda, Tel Al-Maleh, and Bir Hadaj. In a ruling granted on 14 May 2006,

the judges refrained from instructing the Ministry of Health to determine clear criteria

for the establishment of clinics. However, they ruled that the establishment of clinics

in the Bedouin communities is a vital need that must be met by the state.10

It is

important to note that this undertaking by the state to establish additional clinics has

not been fully implemented. The recommendations by the Ministry of Health to

establish clinics in Al-Fura and Tel Al-Maleh were rejected by the District Planning

and Building Committee and the Ministry of the Interior on the grounds that the

planning status of these villages does not permit the establishment of clinics.

Over the period March-August 2008, Physicians for Human Rights Israel and the

Regional Council for the Unrecognized Villages in the Negev prepared a study

mapping the existing services at all the clinics and the family stations in the

unrecognized villages in the Negev.11

The survey included a visit to each clinic, adiscussion, and completion of questionnaires by the staff. The questionnaires were

based on previous studies undertaken in 2003 by Physicians for Human Rights

Israel and Ben Gurion University of the Negev. The questions were formulated with

the assistance of public health experts and related to diverse issues, including: the

ti f th li i t i f t t ( t l t i it d ) ti


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In addition, on 25 December 2007 we wrote to Clalit HMO under the terms of the

Freedom of Information Law (after sending two requests for information to Mr.Shmuel Lapid, director of the Southern District in Clalit HMO). We verified the

information provided by Clalit HMO with our findings in the field. The information

received on 21 February 2008 was late and incomplete; Clalit HMO claimed that it

did not have additional information beyond that provided.12

It is important to note that

a similar mapping study undertaken in 200313

revealed grave defects in the standard,

availability, and accessibility of services. It is hardly surprising that five years later we

found the same standard of services and similar outcomes. Once again, the study

paints a depressing picture in terms of the standard of services provided at the clinics

in the unrecognized villages. The main problems identified relate to the availability

and accessibility of clinics; opening hours and days; and language and communication

problems. In addition, the standard of services is poor and there is a shortage of

medicines and specialists. These findings will be discussed in detail below.

The Organizational Structure and Profile of the ClinicsMost of the clinics operate in temporary buildings (trailers) placed alongside schools.

They are connected to the national water grid, but electricity is provided by

generators. Most of the clinics have a similar organizational structure: A maintenance

worker, an administrative director, a nurse, and a family specialist and/or general

practitioner. The administrative director is responsible for routine contacts with

insureds, including scheduling appointments.14

Most of the clinics book appointments

for tests and specialists that are not available at the clinic itself, recognizing thedifficulties faced by those who do not speak fluent Hebrew. In addition to the usual

functions, the nurses are also responsible for laboratory tests, which are performed

twice a week in most of the clinics, and for the sale of medicines in the medicine

room. All the physicians who serve in the Clalit clinics in the villages are specialists

or interns in family medicine or general practitioners without a specialization; there is

not a single specialist pediatrician or gynecologist. At the Leumit HMO clinic in the

village of Al-Sayad, a gynecologist sees patients once every two weeks.

12


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Availability of Services

Availability is defined as the presence of a sufficient quantity of facilities meeting the

needs of the population.

At present, 34 villages do not have any medical services. These include Al-Fura, with

a population of 3885; Al-Za'arura, with a population of 2894; and Tel Al-Maleh, with

a population of 1250.15

By way of comparison, Jewish communities with fewer

residents have a primary clinic; examples include Kibbutz Sde Boker, with a

population of 360; Sde Boker College, with a population of 650; and Kibbutz

Revivim, with a population of 900. Lehavim, which had a population of 5569 in 2006,has three clinics staffed by a family physician and pediatrician, as well as regular

visits by specialists. Lehavim also has a pharmacy, whereas there is not a single

pharmacy in all the unrecognized villages. By contrast to Lehavim, Wadi Al-Naam,

with a population of over 6000, has just a single clinic with a family physician and a

nurse.

One of the indicators of the availability of services is the ratio of physicians to

residents. The acceptable ratio in Israel is one physician per 1200-1400 members of

the community (in a healthy and stable community). The figures we collected show

that in the unrecognized villages the physician-population ratio is one physician to

every 3116.7 residents. The physician-insuree ratio (i.e. relating only to those

residents who are registered as insureds in the village clinics) is also high 1531

insureds to each physician.16

For the purpose of comparison we examined the

physician-population ratio in five Jewish communities of similar size (Sde Boker

College, Kibbutz Sde Boker, Srigim, Revivim, and Maagalim). The examination

shows that the average physician-population ratio in these communities is one

physician to every 892 residents.


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Table 1: Average Number of Residents for Each Physician in the Clinics in the

Bedouin Villages and in Jewish Communities

Average residents for Each Physician

511050004430

4100

35003000

2600256025002400

1200100013001250

900650

360

W

adiG

hwain

WadiAl-

Na'a

m

Al-Zarnu

g

Umm

Matn

an

U

mmBatee

n

Qasa

rAlsir

Khirbe

tAl-W

atan

AbuT

alul

BirHad

aAlg

rain

Abda

Darija

t

Srigi

m

Maag

alim

Reviv

im

SdeBo

kerC

olleg

e

Kibbutz

Sde

Boker

Average in the villages: 3116.7 / Average in the Jewish communities: 892

The situation regarding nurses is even worse. Figures we received from Clalit HMO

show that just nine nurses work in Clalits clinics in the unrecognized villages in the

Negev. A tenth nurse is employed in the Leumit clinic in A-Sayad. A calculation of

the nurse-population ratio shows that in the villages there is an average of one nurse to

every 3751 residents, compared to one nurse to every 657 residents in the Jewish

communities examined. The nurse-insuree ratio in the villages is also high one nurse

to every 1769 insureds.


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Table 2: Average Number of Residents to Each Nurse in the Clinics in the

Villages and in the Jewish Communities

The enormous gaps reflected in the figures presented above can only be explained by

profound and ingrained discrimination in the attitude of the State toward its Bedouin

Arab citizens. A policy of narrowing gaps by means of differential investment in a

population whose health profile is significantly poorer than that of any other

population group would require the allocation of at least 60 positions for physicians

serving this population.17

In practice, however, not only is there no such differential

investment, but the number of physicians and nurses is not even close to accepted

levels, and the ratio of health professionals to residents is three times the usual level inIsrael.

The average number of weekly reception hours by physicians per 1000 residents in

the clinics in the villages is also lower than in Jewish communities: 13 reception hours

a week per 1000 residents in the villages, compared to 21 hours in the Jewish

communities.

Average Number of Residents to Each Nurse

3751

657

0

500

1000

15002000

2500

3000

3500

4000

Unrecognized villages

Jewish communities


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Table 3: Average Weekly Reception Hours in Clinics, per 1000 Residents

This grave shortage of physicians, nurses, and reception hours obviously places an

undue burden on the staff in the clinics. The result is that the physicians devotelimited time to each patient. Waiting times are very long over 45 minutes for a

physicians inspection, and several weeks to see a specialist.18

Connection of the Clinics to Infrastructures

In terms of water and sewage infrastructures, all the clinics in the unrecognized

villages are connected to the national water grid. Sanitation levels are adequate most

of the clinics have toilets connected to underground pits for the absorption of waste.

Connection to electricity is considered a vital infrastructure for improving the quality

and availability of medical services. None of the clinics in the villages are connected

to the electricity grid. The clinics rely on generators, most of which are operated only

during the opening hours of the clinic. A small number of clinics are connected to

generators operated automatically at night, enabling the use of a refrigerator to store

medicines requiring refrigeration. In the remaining clinics the lack of an electricityconnection prevents the storage of many medicines, including those used for treating a

wide range of chronic illnesses. Moreover, inoculation doses requiring refrigeration

are brought by the nurses from the parent clinic each morning and returned at the

end of the day. While the nurses willingness to perform this function is admirable,

this method cannot ensure the regular availability of inoculations throughout the

Average Physicians Reception Hours per 100 Residents

13

21

0

5

10

15

20

25


Jewish communities


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due to faults or the lack of diesel. For example, the clinic in Kasr a-Sar (Al-

Hawashleh) was closed several times during 2008 after the diesel container was

stolen.

The subject of the connection of the clinics in the unrecognized villages to the

national electricity grid was discussed in HCJ 6602/07, submitted in 2007 by

Physicians for Human Rights - Israel, The Association for Civil Rights in Israel, and

the Regional Council for the Unrecognized Villages in the Negev. The petition is still

pending.

Specialist Medicine (Pediatrics and Gynecology) and Pharmaceutical Services

Numerous international conventions define women and children as vulnerable

populations and require the State to pay particular attention to ensuring their access to

medical services and the adaptation of these services to meet the needs of these

groups.19

Despite Israels moral and legal commitment to the conventions it has

ratified, our mapping of the clinics revealed that in all the eleven clinics of Clalit

HMO there is not a single specialist pediatrician or gynecologist.20

A gynecologist

comes once every two weeks to the Leumit clinic in Al-Sayad.

The lack of specialist medical services in the village clinics reflects an

incomprehensible policy. Regarding the lack of pediatricians in a population in which

children under the age of seventeen constitute 61 percent of the total (approximately

50,000 individuals), we were informed that pediatric medicine in the community is

considered primary medicine the family doctors in the Clalit clinics in general are

qualified to examine adults and children on the basis of professional training.21

A previous study by Physicians for Human Rights - Israel22

found that

disproportionate numbers of Bedouin children are evacuated to emergency rooms;

require hospitalization in pediatric wards and intensive care units; and die as the result

19See: The International Convention on the Rights of the Child:

http://www2.ohchr.org/english/law/crc.htmThe International Convention on the Elimination of All Forms of Discrimination against

Women:http://www2.ohchr.org/english/law/cedaw.htm

20Our examination of the small rural clinics of Clalit HMO in Srigim, Sde Boker College,and Kibbutz Sde Boker, Maagalim, and Revivim show these clinics also do not have


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of disease. Moreover, Bedouin children arrive at the emergency room in a critical

stage of the disease. These failings are due to late diagnosis as the result of inadequate

medical services, as well as to the lack of infrastructures and facilities, including

roads, transportation, and access to the community. A survey prepared by the Women

Leading Health group as part of a report on the ramifications of the lack of pediatric

care in the villages found that the absence of pediatricians in the village clinics leads

48 percent of women to take their children to alternative clinics. Of this group, 77

percent turn to private pediatricians,23

since these physicians are more accessible than

any other medical source.

The population of the villages is characterized by a young average age and high

pregnancy rates. Accordingly, it would be reasonable to assume that the clinics would

have staff positions for gynecologists. In fact, there are no gynecologists in the clinics,

and an examination by Physicians for Human Rights - Israel24

found that this leads

some 80 percent of women in the villages to go without medical care due to their

remoteness from clinics outside the villages providing gynecological care.25

In addition to the lack of specialist medicine, the clinics also lack pharmacists and

pharmacies (with the exception of the medicine rooms). The absence of a pharmacist

severely limits the stock of medicines due to Ministry of Health instructions stating

that many medicines may only be issued by a qualified pharmacist and not by a nurse.

A further factor limiting the supply of medicines, as already noted, is the fact that the

clinics are not connected to the national electricity grid, and are therefore unable to

store medicines requiring protracted refrigeration. Making pharmaceutical services

accessible to the residents of the villages would significantly alleviate the suffering ofpatients and prevent the considerable expenses and discomfort involved in traveling to

pharmacies in adjacent communities. The low availability of medicines in the village

clinics is particularly problematic for chronic patients requiring constant medication

and can endanger their health. Our conversations with residents and nurses in the

villages suggest that many elderly people and particularly elderly women cannot

travel to a pharmacy to purchase medicine. The unavailability of medicines for some

chronic diseases in the villages effectively denies the patients access to life-savingmedications.

Accessibility of Services

Equal access to medical facilities, services, and information is an essential condition


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conditions, including infrastructures, access roads, and affordable public transport.

The economic condition of individuals also influences their mobility.

During the course of our field study and the collection of data on the health services in

the unrecognized villages in the Negev, we encountered many types of obstacles that

hamper access to medical services. The main problems in the field of accessibility

identified by the results of the mapping study are: The opening days and hours of the

clinics; the location of laboratory services; and communication difficulties between

the medical staff and patients due to the language barrier.

Opening Days and Hours

The official (but partial) statistics received from Clalit HMO claim that the clinics in

the unrecognized villages in the Negev are open five days a week and for

approximately eight hours a day (it was claimed that most of the clinics are open from

8:00 am through 3:30 or 4:00 pm). In the course of our field work, we discovered

discrepancies that cast doubt on the reliability of this information. For example, Clalit

HMO claims that the opening hours at the clinic in Al-Asam are 7:30 am 3:30 pm.

However, our field study showed that the clinic is actually open from 8:30 am through3:00 pm. In some cases the clinics were closed before the stated time; in others, the

clinic remained open but the only physician on duty left several hours earlier.

Testimonies from residents of the village of Al-Zarnug (Abu Kweidar) suggest that

the clinic sometimes closes shortly after 1:00 pm, rather than at 4:00 pm as Clalit

HMO claims.

A physician employed in one of the clinics (who asked to remain anonymous) drewour attention to an additional and serious problem concerning opening and reception

hours. He states that in some clinics the HMO does not send substitute physicians in

cases when the only physician staffing the clinic is absent due to illness or even

planned vacation leave. In some cases, the result is that the clinic is left for a week or

more without a physician, and many residents are obliged to wait for days without

treatment, or to travel to Beersheva in order to receive services.


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Table 4: Average Total Weekly Opening Hours at Clinics in the Villages and in

Jewish Communities

It must be noted that some of the staff in the clinics are aware of the problem

concerning the opening days and hours not only because they are alerted to thisproblem by local residents and committees, but also because they themselves face

similar delays in reaching the clinics. In the absence of public transport, staff are

dependent on transportation organized by the HMO. Each vehicle takes employees to

several clinics, and the result is that staff arrive late or leave early, thus shortening the

official reception hours. Moreover, these logistical problems and the resulting

financial costs are presumably behind the decision not to split the working day and to

provide morning and afternoon reception hours. Whatever the reasons, the fact is thatthe clinics do not provide services in the late afternoon and evening. The exception to

this is the Leumit clinic, which operates a split working day with morning and

evening reception hours.

The clinic in the Jewish community of Nevatim which is defined as a rural clinic,

as are all the clinics in the unrecognized villages is open five days a week. One day

a week the clinic provides services in the afternoon, closing at 7:30 pm.

26

The clinic in the village of Abda, which is situated close to Mitzpe Ramon, opened in

2004 following the petition filed on the subject of the clinics in the unrecognized

villages (HCJ 4540/00), and following a protracted struggle by the residents of the

village to secure recognition and receive basic education and health services The

Average Total Weekly Operating Hours at Clinics

36.8

39.4

35.5

36

36.5

3737.5

38

38.5

39

39.5

40


Jewish communities


19/41

residents secured recognition for their community, including the establishment of a

primary school and the opening of a clinic.

The opening of the clinic following the Supreme Court petition raised hopes that a

proper response would be provided to the health needs of the village, which has a

population of over 1000. These hopes have not materialized. The standard of services

at the clinic is very poor. There are no regular opening hours, and the clinic is

operated by a single physician who in addition to providing medical treatment is

also responsible for administrative management, scheduling appointments, and

opening and closing the clinic. The physician is not present in the clinic most of the

time. Residents requiring a medical examination must call the physician on his mobile

phone. The physician then schedules an appointment according to his ability to reach

the clinic. The physician comes to the clinic, opens it, and treats the patient. If there

are no other patients waiting which is likely, since most of the residents are unaware

that the physician is coming at that particular time he closes the clinic. In some

cases the physician arrives approximately one hour after the patient calls him, while at

other times patients may have to wait for several hours or days.

Due to the poor availability of services, most of the residents of the village choose not

to register with this clinic. Instead, they prefer to travel to the clinic in Mitzpe Ramon

where they can rely on the availability of services and enjoy a much higher standard

of care, including specialist medicine.

The fact that the clinics are not open in the afternoon or on Fridays (the Muslim day

of rest) causes particular hardship for residents who are employed and are obliged tolose work time. The problem is exacerbated by the fact that in most cases women will

not attend the clinic unless they are accompanied by a male relative.

Laboratory Services and Tests

Laboratory tests performed in primary clinics such as blood, urine, and diabetic

tests, blood pressure, pulse, and weight and height monitoring play an important

role in identifying, monitoring, and preventing diseases in their early stages. Ourcomparison shows that the average number of weekly laboratory hours per 1000

residents is one hour in the unrecognized villages, compared to three hours in the

clinics in the Jewish communities. The clinics in the unrecognized villages offer

limited laboratory services basic blood tests, urine, diabetes, pulse, height and

weight Not all of the clinics can undertake ECG tests and blood counts Special tests


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Table 5: Average Weekly Laboratory Hours per 1000 Residents in the Villages

and in the Jewish Communities

Physical Inaccessibility

Many of the clinics are situated on the edge of the village. In most cases the location

was determined by the planning authorities without due attention to residents needs.

A survey of 70 women residents of the villages undertaken by Physicians for Human

Rights - Israel and the Women Leading Health group28

found that due to the

considerable distance of the clinics from the center of the villages, and the lack of

basic services such as medicine, specialist services (particularly pediatrics), limited

opening hours, and so forth, many residents prefer to receive services in the official

Bedouin towns or from private physicians. For example, only 55 percent of the

women usually turn to the clinic in their village, while 45 percent do not visit the

village clinic at all, or do so only occasionally.

In many cases, residents who require services that are not available at the clinic are

obliged to travel long distances. In the absence of public transport, the need to travel

presents a real obstacle that is particularly problematic for the elderly, sick, pregnant

women, and children, all of whom depend on relatives to drive them to the clinic. In

other cases patients are obliged to walk to the nearest road and wait in the open for

busses that take them to the entrance of one of the towns in the area. They must then

board a second bus in order to reach the clinic. It is hardly surprising, therefore, that

Average Weekly Laboratory Hours per 1000 Residents

1

3

0

0.5

1

1.52

2.5

3

3.5

Unrecognized villagesJewish communities


21/41

kilometers away. In the absence of proper public transport or basic transport

infrastructures, the average time required to reach the clinic in Keseifa from Tel Al-

Maleh is approximately two and a half hours in each direction. Accordingly, it is

hardly surprising that most of the residents prefer not to visit the clinic and do not

receive vital services. During the proceedings in the clinics Supreme Court petition

(HCJ 4540/00), the Ministry of Health recommended that a clinic be established in the

village, but the recommendation was not implemented due to objections from the

planning authorities. After correspondence with the Ministry of Health, the Ministry

of the Interior, and the planning authorities over a period of more than three years, a

petition was submitted to the Supreme Court (HCJ 8211/08) by the Association for

Civil Rights in Israel, Physicians for Human Rights - Israel, the Village Committee of

Tel Al-Maleh, and the Regional Council for the Unrecognized Villages in the Negev.

The petition demanded that a clinic be opened in the village. During the first hearing

in the petition on 26 February 2009, the judges decided to postpone the hearings for a

period of six months pending developments in the implementation of the

recommendations of the Goldberg Committee.29

Economic InaccessibilityThe physical inaccessibility described above is exacerbated by socioeconomic factors.

Most of the residents of the villages are unemployed and poor. As a result, it is

difficult for them to afford even subsidized public transport, let alone renting a car or

paying for private transport in the absence of public services. As a result, a population

that is considered the poorest section of the Israeli public is required to spend a

considerable proportion of its income merely in order to reach medical centers. The

result is that the residents are sometimes obliged to choose between food and clothingand medical treatment.

Cultural Inaccessibility

In Bedouin Arab culture in the Negev, women are the main consumers of health

services. This is due to the prevalence of chronic disease (as high as 30 percent30

);

multiple pregnancies; and the social function of women as the main caretakers of

children. However, most of the women residents do not drive and do not leave thevillage unaccompanied, factors that impede their access to medical services. The lack

of cultural sensitivity is also reflected in symbolic aspects. Many of the clinics are

named after specific tribes, rather than using the historical name of the village. This

creates tension within the community and even prevents residents from coming to the

clinics due to their identification with a different tribe


22/41

Language and Communication Problems

Good communication between medical staff and patients is a precondition for apositive relationship that helps promote efficient and high-quality care. Medical

workers need to communicate with patients not only in order to understand the words

they say, but also in order to understand the patients socio-cultural background in

order to determine the most appropriate course of treatment.

A previous study by Physicians for Human Rights - Israel31

found that communication

problems create an extremely substantial barrier for Bedouin Arab women. Thesurvey revealed that linguistic, cultural, and educational gaps contribute significantly

to the defective use of health services. The survey found that 62 percent of women

consider themselves illiterate in Hebrew and 59 percent lack oral skills in the

language. As a result, women find it difficult to understand the explanations given by

medical staff at the clinic and are forced to rely on assistance from other patients or

workers.

Approximately half the physicians in the clinics in the unrecognized villages do not

speak Arabic or have only a basic command of the language. The same is true of

many of the administrative staff, most of whom have only a basic knowledge of

Arabic. The signs in the clinics detailing the opening hours and days are written in

Hebrew in most of the clinics, despite the fact that these clinics do not serve even a

single patient whose mother tongue is Hebrew.

As for informational leaflets and materials, many of the materials are only available in

Hebrew. Special leaflets in Arabic about specific diseases or preventative medicine

issues (such as diabetes, high blood pressure, or smoking) are given to patients on an

individual basis by the physician at his own discretion.

The Leumit clinic in the village of Al-Grain (Al-Sayad) is the only clinic in the

unrecognized villages that is not affiliated with Clalit HMO. There is also a Clalit

clinic in the village. However, Leumit HMO was careful to position its clinic

(established in 2006) in a convenient location for residents, in the center of the

village. The clinic meets a real need and, as a result, has attracted many residents. The

main reason for the clinics success is the significant improvement it makes in the

accessibility of primary medical services, as well the higher standard of services and


23/41

quality and accessibility of the services has met with satisfaction among a growing

number of residents, and the clinic has managed to attract almost 800 insureds to date.

Table 6: Number of Files to Number of Residents, Clalit HMO Clinics in the

Unrecognized Villages

1,050

4,800

1,200

4,400

1,935 1,875 1,7111,490 1,575

800

2,460

586 512

2,036

3,9004,0003,500

2,9003,200

4,050

4,700

1,377

0

1,000

2,000

3,000

4,000

5,000

6,000

Al-G

rin

AbuT

alul

UmBati

n

Kasa

ra-S

ar

Wad

iGwe

in

UmMatn

an

Darija

t

BirH

adaj

Wad

ia-N

a'am

Abda

Al-Z

arnu

g

No. of residents

No. of files

As the table above shows, there is a substantial shortfall between the number of

residents in the villages and the number of insureds registered at the clinics. The gap

is particularly large in the villages of Wadi Al-Naam (only 586 residents are insured

through the clinic, out of a total of 6800 in the village), Bir Hadaj, Um Matnan, and

Al-Grain. These figures show that most of the residents of the unrecognized villages

still feel that the clinics do not meet their needs and prefer to travel to Segev Shalom,

Beersheva, Hura, Keseifa, Mitzpe Ramon, or Yeruham in order to receive appropriateservices. It is worth emphasizing that improving the services in the clinics should be a

supreme interest of the HMOs themselves if they seek to attract more insureds.

The Family Health Clinics


24/41

Covenant on the Rights of the Child and the International Covenant to Eliminate All

Forms of Discrimination against Women also require a full commitment from the

state to ensure the health and physical wellbeing of children by providing health-

defining services and conditions and by removing various obstacles that impede

access to services.

Until 1997 there was not a single family health clinic in the unrecognized villages in

the Negev, despite the fact that this population has the highest fertility rate in Israel

(the fertility rate is defined as the average number of children to whom a woman can

be expected to give birth over the course of her life),33

and despite the fact that this is

a very young population (61 percent of the population is aged 0-17 years, and 41

percent is aged 0-9).

In 1997 residents of the unrecognized villages and social change organizations

submitted a petition to the Supreme Court (HCJ 7115/97).34

The main demand in the

petition was to establish twelve family health clinics in the unrecognized villages.

During the period before the petition, residents of the villages were forced to travel to

other Bedouin or Jewish communities in order to receive care for their children,including inoculation. As a result, inoculation rates among Bedouin children were

very low by comparison to the national average. As in the case of the clinics, the state

was reluctant to meet the demand. In March 1999, after over a year of hearings, the

court ordered the Ministry of Health to establish six family health centers and to

provide proper public transport to the existing centers in the villages. After no action

was taken on this matter during 1999, the Ministry of Health was accused of contempt

of court at the beginning of 2000. By the end of 2001, six clinics were built. As in thecase of the primary clinics, the family health centers in the villages also suffer from

various problems impairing the accessibility, availability, and quality of services.

Availability and Accessibility of Services

There are currently eight family health centers affiliated with the Ministry of Health in

the villages of Abu Talul, Um Batin, Um Matnan, Bir Hadaj, Darijat, Wadi Gwain,

Wadi al-Naam, and Kasr al-Sar. In addition, a family health truck operates as a

mobile center. The truck is maintained jointly by the Galilee Society and the Ministry

of Health. The driver and the director receive their salaries from the Galilee Society,

while the nurse and physician are Ministry of Health employees. The permanent crew

of the mobile center includes a driver, a nurse, and a physician. Two physicians a


25/41

pediatrician and a gynecologist take turns staffing the truck according to the needs

in the field. The truck travels twice a week to the vicinity of two unrecognized

villages, Wadi al-Naam and Al-Bat. It functions as a full-fledged family health

center, although it cannot provide urine tests or height measurement. The truck is

small and overcrowded and the physician and nurse work in a single, small room.

This slows down their rate of work and also impairs the privacy of patients. The

number of patients seen each day is considerable (approximately 20) and the

workload creates pressure on the staff.

In the absence of additional family health centers in the unrecognized villages, the

residents travel to the centers in the permanent Bedouin towns, as well as to family

health centers intended for the population of the unrecognized villages and situated in

Beersheva, Dimona, Yeruham, Mitzpe Ramon, and Arad. The absence of additional

centers in the villages is harmful to a population that has limited mobility and consists

mainly of women and children. As already noted, many women do not attempt to

travel to centers elsewhere due to the lack of roads and public transport, restrictions

on independence and movement, the cost of travel, and the unavailability of others to

help look after their children.

All the family health centers were opened alongside clinics and solely in villages

where there are also clinics. Like the clinics, the family health centers are connected

to the water grid but receive electricity from generators. As a result, the centers do not

store inoculations. The nurses bring the inoculations with them at the beginning of the

day and take back the remainder to the main branch at the end of their working day.

In the past the family health centers operated twice a week, usually in the morning

(from 8 am to 2 pm). Recently, however, the operating hours of some of the centers

were reduced, as for example at the centers in Darijat and Kasr al-Sar Al-

Hawashleh. These centers now operate just once a week. The reduction of the opening

hours has led to the accumulation of long lines at the centers. Mothers are forced to

wait for hours in order to inoculate their children, monitor their development and

growth, receive guidance from the nurse, or monitor their pregnancy. In many cases

women return home after waiting for hours without seeing the nurse or physician.

While mapping the services in the field, we heard complaints from residents about the

operating hours of the family health centers in the villages of Darijat and Kasr al-Sar

(Al Hawashleh) The complaints related mainly to the availability and quality of the


26/41

day, without prior notice. There was not even any notice on the door of the center.

Over the course of the day more than twenty women from the village who had made

appointments came to the center and waited for hours in the hope that it would open.

We sent a letter to the Ministry of Health on this matter on 23 February 2009; no reply

has been received to date.

By definition, one of the functions of the family health centers is to provide guidance

and advice concerning child development and care and to raise awareness among

mothers to issues relating to family health and pregnancy. In an opinion given in 1997

as part of the petition on the subject of the family health centers (HCJ 7115/97), Dr.

Hatim Kananeh noted, regarding the mobile center: Its structure does not enable theprovision of services for mothers and children, apart from one-time inoculation

Inoculation is just part of the medical and hygienic services provided by the family

health centers35

Due to the small number of centers in the villages, the limited

operating hours, and the shortage of staff, the family health centers usually confine

themselves to providing inoculations and monitoring pregnancies. Little emphasis is

placed on guidance and on raising the awareness of the population of various aspects

of family health. The result is that the centers play only a marginal role in helpingresidents raise and care for their children, particularly since many of the staff have a

limited command of Arabic.

The District Health Office is well aware of the shortage of centers, positions, and

staff. It has admitted that at present, the service provided for mothers and children in

the Negev faces a grave crisis due to the lack of medical and nursing personnel.36

According to a directors circular issued by the head of the Mother and Child Servicein the Ministry of Health, the desirable nurse-child ratio in the family health centers is

one nurse to every 350-400 children. Given the size of the population of children in

the villages, it thus follows that dozens of additional staff positions are required. In

the Ministry of Health report quoted above, the Southern District Health Office

painted a depressing picture regarding the shortage of personnel: There may be an

increase in the proportion of pregnant Bedouin women who do not obtain services

from the family health centers and antenatal monitoring, as well as a decline in theproportion of Bedouin babies registered with the family health centers.

In HCJ 711/97 (which focused on the demand to open family health centers in the

villages), the Ministry of Health declared that in order to implement the ruling and run


27/41

effective intervention programs, and given the size and living conditions of the

population, necessary resources include fourteen positions for nurses, 3.5 positions for

physicians, ten staff positions in a Bedouin womens bridging project, two positions

for a childrens play scheme, and one position for an engineer to inspect and promote

sanitation and sewage facilities. The Southern District Health Office emphasized that:

For years there has been a plan to reduce the gaps between the Jewish population and

the Bedouin population that is not reflected in any sphere in terms of staff

positions in the Southern District (emphasis added). In an article on the subject,

District Physician Dr. Ilana Belmaker stated that the plan to reduce gaps is raised

every year during the proposed budget, but the Ministry of Health does not take it

up.37 At a conference organized in 2008 by the organization Community Advocacy

and Ben Gurion University on the subject of the right to health in the unrecognized

villages in the Negev, Dr. Belmaker again emphasized that the District Health Office

is aware of the needs of the population and is taking action on this matter, though

without the necessary budgetary support.

Apart from problems in terms of the physical accessibility of the centers, there is also

an economic obstacle. A payment of NIS 300 is required for treatment at the familyhealth centers (provided the woman registers in time). In addition, various tests

provided during pregnancy are not included in the health service basket (these include

genetic tests and, until recently occipital translucency screening and the second

systemic review) and thus depends on the ability of the family to pay for these

services. Since the Bedouin population is poor and has a high birthrate, the economic

burden constitutes a real obstacle to securing treatment.

Health Outcomes in the Unrecognized Villages: Infant Mortality and

Child Development

Infant mortality rate is an accepted international index for the standard of health of

children and the population in general. Numerous factors influence infant mortality

rates, including the mothers educational level, poverty, the availability and quality ofservices, health-defining conditions (safe water, a clean environment, sewage and

sanitation), as well as marriage between relatives.

The infant mortality rate among the Bedouin Arab population is amongst the highest


28/41

Health attributes the high mortality rate to various factors, including genetic defects

and hereditary diseases (the most prevalent factor, accounting for 42.7 percent of

infant mortality); premature births (22 percent); and infectious diseases and other or

unknown factors (35 percent).38

Although infant mortality rates have fallen in recent years, the gap remains and the

rate among Bedouin Arabs is still almost three times the national average. The

Ministry of Health generally attributes this gap to the high prevalence of marriage

between relatives, which leads to elevated incidence of congenital defects. The infant

mortality rate due to congenital defects is indeed high, at approximately 5 per 1000

live births (compared to 0.8 among Jews in the Beersheva district). However, an

additional explanatory factor is the poor availability of health services in general, and

family health centers in particular, in the unrecognized villages.

Dr. Kananehs opinion submitted as part of HCJ 7115/97 states that Bedouin women

face particularly grave health and socioeconomic distress the use of preventative

services by pregnant women at as early a stage as possible and at the recommended

frequency has a positive impact on the outcomes of pregnancy, the health of themother and neonate, and infant mortality (emphasis added).

39

Another important health index is weight at birth, which is influenced by the mothers

state of health, nutrition, and antenatal monitoring of pregnancy at the family health

centers. Statistics published in a report by the Southern District Health Office of the

Ministry of Health show that in 2006 the percentage of children in the unrecognized

villages who had a low birth weight (less than 2500 grams) was higher than theaverage for the Israeli population as a whole (ten percent compared to 8.2 percent).

Figures published in a study prepared by Physicians for Human Rights - Israel40

show

a significant improvement in the proportion of women receiving antenatal treatment

and monitoring in the villages in which family care centers have been established.41

A

Ministry of Health report also observed an increase of 12.1 percent in the number of

babies receiving treatment at the family health centers over the period 2000-2006, andan increase of 28.6 percent in the number of toddlers registered at the centers over the

same period.

38See: State of Health of Babies and Children up to the Age of 6 in the Permanent


29/41

The Ministry of Health allocates an annual budget for a special program intended to

reduce infant mortality rates among the Bedouin Arab population in the Negev. The

project is run jointly by the Ministry of Health, Ben Gurion University of the Negev,

Soroka Medical Center, and Clalit HMO, and in cooperation with local leaders,

representatives of the Bedouin community, and NPOs.42

Despite the importance of the

program, its outcomes are inevitably limited in the absence of policy promoting the

establishment of primary clinics, additional family health centers, and the provision of

health-defining conditions for the residents of the unrecognized villages of the Negev

recommendations that the Southern District of the Ministry of Health itself adopted

in a recently-published report.43

Conclusion, Ramifications, and Recommendations: Ensuring Early

Identification and Treatment

According to figures from Soroka Hospital relating to the health condition of Bedouin

Arab society in the Negev, 60 percent of in-patients at the hospital are Bedouin

residents, who account for approximately 26 percent of the population as a whole.

Among other factors, this figure reflects problems relating to preventative and

primary medicine in these communities, as described in this report. Many residents

fail to obtain primary treatment due to the lack of clinics and family health centers, or

due to problems resulting from physical, economic, and cultural inaccessibility. This

situation also exacerbates the residents sense of alienation from medical services and

prevents the effective and high-quality use of these services. The outcome of thissituation has far-reaching ramifications for the health of these residents, but it also has

broader implications. In the long term the savings secured due to the failure to provide

accessible preventative and primary services are offset by considerable costs. As

noted, many residents forego treatment that could prevent the development of

conditions and complications requiring protracted hospitalization. The cost of more

complex treatments such as hospitalization is high not only in terms of the patients

health and the state of the family, but also in terms of the public treasury.

Numerous public health studies support an approach based on expanding preventative

and primary services and on the development of additional services with the goal of

preventing or reducing morbidity. The greater the investment in broad primary and


30/41

Regional Council for the Unrecognized Villages in the Negev demand that the

Ministry of Health, the HMOs, and the other authorities take the following immediate

steps:

- To expand the health services in the unrecognized villages in the Negev:

Establishment of primary clinics and family health centers in all villages where

they do not already exist or are not available in the immediate vicinity at a

reasonable distance.

- To improve access to clinics established at a distance from the villages by

relocating these to the centers of the villages.

- To pave access roads to the clinics and connect them to the national electricity

grid.- To expand the services provided by the clinics, including the provision of

advanced medical instruments; extension of laboratory services and tests; and

addition of new staff positions for specialists, dieticians, pediatricians, and

gynecologists.

- To provide pharmaceutical services and open pharmacies at the existing clinics

in the villages.

- To ensure the cultural adaptation of services including appropriate use of theArabic language in the clinics; the employment of Arabic-speaking physicians

and nurses; the translation and preparation of informational materials for

distribution to the general population; and the use of signs in Arabic.

- To extend the opening hours of the clinics and family health centers and to

introduce a split working day, at least on some days.

- To change the names of existing clinics based on the names of tribes and to

prefer the historical names of the villages in order to prevent a situation whereresidents decline to attend a clinic identified with a different tribe.


31/41

Appendices

Appendix 1 Letter from Dr. Taleb Abu Hamed, Director of theSouthern Negev Administration, Clalit HMO, Dated 22 December

2008 in Response to a Letter from Physicians for Human Rights

Israel.

Appendix 2 Response of Clalit HMO Dated 21 February 2008.


32/41

Community Division ClalitChief Executive

28 Kislev 5769

25 Dec. 2008

Our ref: 35658

Ms. Shlomit Avni Vaknin

Director, Residents Department

Physicians for Human Rights - Israel

Re: Employment of Pediatricians in the Clinics of Clalit Health Services in the

Unrecognized Villages in the Negev

Your letter dated 8 Dec. 2008

Dear Ms. Avni Vaknin,

Your letter to the director-general of Clalit was forwarded for my attention.

I attach a letter from Dr. Taleb Abu Hamed accurately reflecting the actions of Clalit

in the unrecognized villages in the Negev.

Sincerely,

Dr. Orit Yaacobson Deputy Director-GeneralHead of the Community Division

CC:

Mr. Eli Depes Director-General

Dr. Giora Werber Deputy Head, Medicine Division

Dr. Taleb Abu Hamed Director, Southern Negev Administration


33/41

Southern Negev Administration

Southern District

Tel: 08-6651689, Fax: 08-6651688 Clalit

22 December 2008

To:


Re: The Employment of Pediatricians in the Clalit Clinics in the Unrecognized

Villages in the Negev

1. Clalit provides primary medical services in the unrecognized villages (the

Bedouin diaspora) through the following clinics: Al-Sayad, Al-Amal, Al-

Atrash, Darijat, Abu Kaf, Abu Kweidar, Al-Asam, Abu Karinat, Al-Hawashleh,

Bir Hadaj, Wadi Al-Naam.

Some of the unrecognized villages are within the boundaries of the Abu Basma

Regional Council.

2. Clalit is the only HMO that submitted a bid in the Ministry of Health tenders for

the establishment of primary clinics in the unrecognized villages in the Negev.

3. Clalits clinics in the unrecognized villages provide medical services for the

Bedouin population despite the absence of health-promoting infrastructure such

as electricity, roads, flowing water, and refuse disposal.

4. The primary clinics in the unrecognized villages are staffed by a physician, a

nurse, and an administrative worker. Each clinic has a medicine room and

computerized records similar to the rural clinics in the Jewish communities.

5. The clinics in the unrecognized villages receive secondary medical services

from the large health centers in geographical proximity to the unrecognized

villages.

6. In addition, Clalit operates a special mobile unit (at all hours of the day) for the

benefit of the Bedouin residents of the unrecognized villages. The mobile unit

helps locate patients with special needs and assists the medical staff in attending

house calls for housebound and seriously ill patients


34/41

diploma in family medicine at Ben Gurion University (in February 2009 they

are due to complete their training, which lasted three years).

9. Pediatrics in the community is considered as primary medicine rather than

medicine (advisory). The family physicians in Clalits clinics, in general, have

the professional training to examine adults and children.

10. Approximately 50 percent of all the physicians in Clalits clinics in the

unrecognized villages are Arabic speakers; this rate is higher than that among

the physicians in the permanent communities and in the city of Rahat.

11. Most of the Arab physicians from the Bedouin sector are employed by Clalit;

two physicians are employed by other HMOs.

12. All the specialists and interns have been trained as part of their specialization to

examine children. As part of their specialization they have participated in

periods of work in childrens wards in accordance with the criteria of the

Science Council in the State of Israel.

13. Clalit is well aware of the high rate of infant mortality among the Bedouin

population, both in the permanent communities and in the unrecognized villages

a rate that was 11.5 per 1000 live births in 2007. Accordingly to the statistics

of the Ministry of Health, the main reason for the mortality is congenital defects

and hereditary diseases. Out of awareness of this problem, Clalit has since 2005

operated a pre-pregnancy genetic information service, including the provision of

genetic information to the entire Bedouin population. The service is provided

free of charge on request.

14. In Clalits clinics in the unrecognized villages in the Negev, all the workers are

employed on a salaried basis and work from 8:00 am through 4:00 pm without a

split day. In the communities of Omer, Meitar, and Lehavim, only self-

employed physicians are employed, and these work in the early morning and in

the evening. Between midday and 4:00 pm the clinics are closed. During some

of these hours, the clinics are staffed only by general physicians, such as the

clinic in Meitar between 8:00 am and midday every day.

15 Clalit is aware of the constraints facing the Bedouin population of the


35/41

implement a special project to prevent anemia among babies at the clinics in the

Bedouin sector.

16. Clalit is well aware of the poor socioeconomic conditions of the Bedouins in the

unrecognized villages and of the difficulties presented by harsh environmental

conditions that influence access to the service, such as the lack of public

transport. Naturally, the living conditions of the Bedouin residents in the

unrecognized villages have ramifications in terms of their state of health. Clalit

works constantly to improve the medical service by adapting the medical

service to meet the needs and culture of the Bedouin residents of the Negev.

However, the response cannot be confined solely to solving medical problems.In terms of the socioeconomic and environmental conditions of the Bedouin

population in the unrecognized villages (which has a direct impact on their state

of health), the issue cannot be resolved solely by the public health system. This

subject requires intervention on the national level in order to secure a

comprehensive solution for the range of problems, leading to an improvement in

the situation and with positive ramifications in terms of the state of health of the

Bedouins in the Negev.

Sincerely,

Dr. Taleb Abu Hamad

Director, Southern Negev Administration


36/41

Planning and Health Policy Clalit Health Services21 February 2008


52 Golomb St., Tel Aviv

66171

75266

Re: Your Request to Receive Information Concerning the Number of Insureds at Clinics

Further to your request, the following is our response to the requested information.

A. Number of insureds in each clinic, number of children , and number of children suffering from chronic diseases

Insureds

Age 0-18Clinic No. of insureds 0-18 Patients with chronic diseases

Abu-Kweider 2036 1366 116

Abu-Kaf 1697 1084 125

Abu-Kreinat 1519 979 65

Al- Atrash 2147 1423 96

Al- Said 1931 1311 121

Al- Aa'sam 1862 1131 130Bir Hadaj 2429 1564 108

Darijat 795 489 37

Al- Hawashli 1505 918 89


37/41


38/41

Planning and Health Policy Clalit Health Services21 February 2008


52 Golomb St., Tel Aviv

66171

75266

Re: Your Request to Receive Information Concerning the Number of Insureds at Clinics

Further to your request, the following is our response to the requested information.

A. Number of medical staff and their profession

Family

physicians Nurses Admin.

Additional

service 1

Additional

service 2

Al- Amal- Al-

Khurum tribe 1 0 1 Laboratory

Wadi Al- Na'am 1 1 1 Laboratory Family

Darijat 1 1 1 LaboratoryTarabin Al- Sania' 1 0 0 Laboratory

Abu-Kaf 1 1 1 Laboratory

Al- Said 1 1 1 Laboratory

Bir Hadaj 2 1 1 Laboratory

Al- Aa'sam 2 1 1

Al- Hawashli 1 1 1 Laboratory

Al- Atrash 1 1 1 Laboratory

Abu-Kreinat 1 1 1 Laboratory Family


39/41

B. Specializations in the clinic and medicine rooms

There are no specializations in the clinic.

There are no medicine rooms.

C. Opening days and weekly reception hours

Clinic Sun. Mon. Tue. Wed. Thu.

IntermediateDay of

festivals

Eve of

festivals

Al- Amal- Al-

Khurum tribe 8.00-16.00 8.00-12.00 8.00-16.00 8.00-13.00 8.00-16.00

Wadi Al- Na'am 8.00-16.00 8.00-16.00 8.00-16.00 8.00-12.00 8.00-16.00 8.00-13.00 8.00-12.00

Darijat 8.30-15.45 8.30-18.45 8.30-18.45 8.30-12.45 8.30-15.45 8.30-13.00 8.00-12.00

Tarabin Al- Sania' 13.30-15.30 16.15-19.15 8.00-11.00 16.15-19.15

Abu-Kaf 8.00-15.45 8.00-15.45 8.00-15.45 8.00-15.45 8.00-12.30 8.00-11.45Al- Said 8.00-16.00 8.00-16.00 8.00-16.00 8.00-14.00 8.00-16.00 8.00-13.00 8.00-12.00

Bir Hadaj 8.00-16.00 8.00-16.00 8.00-16.00 8.00-16.00 8.00-16.00 8.00-13.00 8.00-12.00

Al- Aa'sam 7.30-15.30 7.30-15.30 7.30-15.30 7.30-15.30 7.30-15.30 7.30-12.30 7.30-11.30

Al- Hawashli 8.00-16.00 8.00-16.00 8.00-16.00 8.00-16.00 8.00-16.00 8.00-13.00 8.00-12.00

Al- Atrash 8.30-16.00 8.30-16.00 8.30-16.00 8.30-16.00 8.30-16.00 8.30-13.00 8.30-12.00

Abu-Kreinat 8.00-15.30 8.00-15.30 8.00-15.30 8.00-15.30 8.00-15.30 8.00-12.30 8.00-12.00


40/41

D. Average monthly number of patients

Insureds

Patients per

month in clinic

Visits per

month in

clinic

Al- Amal- Al-

Khurum tribe 512 33.4 149.5Wadi Al- Na'am 586 16.6 34.2

Darijat 800 58.9 504.7Tarabin Al- Sania' No data

Abu-Kaf 1,711 118.9 942.3

Al- Said 1,935 149.8 1178.8

Bir Hadaj 2,460 155.3 796.1

Al- Aa'sam 1,875 136.7 1100.9

Al- Hawashli 1,490 43.2 91.8

Al- Atrash 2,180 125.9 571.6

Abu-Kreinat 1,575 111.1 686.3

Sincerely

Noa Dannai

Director, Procedures, Coordination, and Knowledge Management Department

Planning and Health Policy Division, Clalit Health Services


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