Israel’s Step Children

About the lack of pediatrics in the Unrecognized Villages in

the Negev and its Ramifications
A Position Paper by the “Women Promote Health” Group and Physicians for Human
Rights

November 2008

Author: Heijer Abu Sharb

Brief

In the South of Israel there are forty five villages which include about
83,000 residents, out of whom 60% are children. Most of the villages are
unrecognized by the state thus, their right to health services and necessary
health conditions is violated. Since 1999, eleven of the villages were
recognized by the state, yet despite that recognition they do not receive the
full services each resident is entitled to.

There are twelve clinics in the unrecognized villages and only in eight
villages are there family health centers. There are no pediatricians,
gynecologists and pharmacies in the clinics; in most cases the staff does not
speak Arabic, reception hours are very limited etc.

According to data from the Soroka Medical Center, compared to Jewish children,
more Bedouin children arrive at the emergency units; more Bedouin children
need hospitalization in the pediatric ward and the emergency units; and more
Bedouin children die due to their illness. Moreover, Bedouin children who
arrive at the emergency department arrive at critical stages of the illness,
due to a late diagnosis deriving from the lack of health services,
infrastructure, roads, transportation and access routes for the community.
Despite the high morbidity and mortality among the Bedouin children in the
Negev, none of the clinics existing in the villages (all clinics except for
one are run by “Clalit”), employ a pediatrician. On the other hand, in
adjacent, rich Jewish communities – such as Meitar, Omer and Lehavim the
residents insured in “Clalit”, have pediatricians, gynecologists and family
physicians, many and more flexible reception hours and accompanying services
that do not exist in the clinics in the unrecognized villages. For instance,
in Omer there are 5.18 physician hours per 100 patients compared to 1.86 in
Algrain. The Jewish residents have the option of being insured in other health
funds (Maccabi, Meuhedet and Leumit), which operate in the Jewish communities
and do not operate in the unrecognized villages.

2
 The Number of Reception Hours – Physicians in “Clalit” Clinics according to Settlement

250
214
200
Weekly reception hours
Pediatrician 150
109
Weekly reception hours 83 81. 5 100
All physicians 55
36. 5 31 36 38 50
0 0 0
0
Umm Lehavim Algrain Omer Bir Hadaj Meitar
Matnan

A survey conducted by the “Women Promote Health” group and PHR-Israel among 70
residents of the villages show that due to the long distance of the clinics
from the village center and due to the lack of basic services such as
medications, professional medicine (especially pediatricians), limited
reception hours and so on, many residents prefer to receive the service in
townships or in private clinics. Thus, for instance:
Only 55% of the women visit the village clinic “most of the time”, while 45%
don’t visit the clinic at all or visit it sometimes.
48% of the women reported that after receiving treatment in the village
clinic, they had to go to an additional clinic in order to complete the
treatment; 77% of the women who reported visiting a different clinic had been
forced to visit a private pediatrician, and 13% visited the pediatric
emergency unit.
32% of the women reported they visited the emergency unit with their children
in the past year: 24% due to high fever, 16% due to an unsuccessful treatment
by the clinic physician, and 12% due to dehydration.
50% of the women reported that they go to the clinic on foot, with their
child, and that they do not have another way to get there. 51% of the women
claimed that it’s a 5-15 minute walking distance, 35% indicated a walking
distance of between 20-40 minutes and 14% indicated a 60-120 minute walking
distance.

As you can see, the establishment of the clinics in the villages, most of
1
which were built only after a Supreme Court petition , is only a partial move
in the realization of the villages residents’ right to health. A full
realization requires electricity and water connection and additional necessary
health conditions. Moreover, the right to health is bound with the right to
equality and therefore, the existence of clinics that offer a low range of
services compared to the services available for residents in clinics outside
the unrecognized villages in the Negev, violates the equal right of the
residents of the villages to unified health services. Furthermore, the core
principles of the National Health Insurance Law are not only equality but also
the value of justice which means a bigger investment in resource development

1
High Court Petition 4540/00.

3
especially where it is most needed. Since the residents of the unrecognized
villages suffer from higher morbidity and mortality, the state should initiate
a differential investment when establishing health services within the
villages.
With regards to pediatrics, in many places in the world the family physician
is the main caregiver of the child and the pediatrician serves as his advisor
(in England, for instance). This method has many advantages; among others it
is a comprehensive understanding of the family’s needs. However, the fact that
there is no pediatrician in the village clinics, where there are numerous
children, with high morbidity and mortality rates and given the harsh living
conditions, raises questions and calls for action.

PHR-Israel and the “Women Promote Health” group demand from the state:
To act for the recognition of the unrecognized villages in the Negev; to
connect them to all national infrastructures, especially water, and to connect
the clinics to the electricity network in order to allow, among other things,
refrigeration of medications;
To act so that the scope, variety, and quality of the services provided in the
villages' clinics are equal to available services in most primary clinics in
other communities, and that pediatricians and gynecologists are employed in
the existing clinics;
To differentially invest in developing the volume and variety of health
services in the unrecognized villages in the Negev;
To act for the planning and implementation of programs designed to reduce
morbidity and mortality rates among the residents of the unrecognized villages
in the Negev in general, and their children in particular, so that it will be
culturally fitting;
To make sure that the health services are adapted to the cultural and labial
needs.

The "Women Promote Health" Group – Background about the

Authors of the Position Paper

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

in the Negev that formed in the framework of a course called "Women Promote
Health" initiated by Physicians for Human Rights. We are residents of ten
unrecognized villages - Tel Arad, Qasar Alsir, Wadi Alna'am, Al-Zarnug, Khashm
Zinna, Um Bateen, Wadi Ghwain-Tela Rashid and Albatel- Karkur.
During the course, we were exposed to a lot of information regarding health
and the right to health. When the course ended, we decided to take action
while focusing on two issues: (1) Raising the awareness of women to the right
to health, by means of workshops dealing with the subject and (2) taking
advocacy steps demanding from The "Clalit" health fund and the Ministry of
Health to employ pediatricians in the existing clinics.
This position paper presents our findings as for the second cause: to make
sure that the existing clinics in the villages will provide basic services –
pediatrics – that are provided in our surrounding communities.

4
General Background about Underlying Determinants of Health
and Services in the Unrecognized Villages in the Negev

In the south of Israel there are forty five villages which include about
83,000 residents, 60% out of whom are under 19 years old. Most villages are
not recognized by the state, thus their right to health and Underlying
determinants of Health, such as water, electricity, sewage, garbage disposal,
adequate housing, paved roads, road signs etc, are violated. The eleven
villages that were recognized by the state since 1999 still do not receive the
full services every resident is entitled to.

The Lack of Underlying Determinants of Health

Naturally, children are more prone than adults to dehydration and intestine
illnesses, due to the lack of accessibility to clean water, adequate for
drinking. A "Diarrhea epidemic" erupts every August, during which 16,000
Bedouin children are admitted to hospital, compared to 5,000 Jewish children;
that is to say that while the Bedouin children constitute only 15% of the
entire population of the Negev, they constitute 80% of the entire children
2
population admitted to hospitals .

Another danger lurking for the children in the summer time is caused by the
living conditions in the tin shacks. These shacks double the heat level and
many babies need medical care due to a rise in their body temperature and
dehydration. In the winter, the condition worsens even more since the extreme
cold in the house and the inability to provide safe heating facilities (due to
the lack of electricity connection), causes the hospital admissions (due to
3
cold and burns) and even the death of children.

The poor sanitary conditions, such as – garbage accumulation, due to the lack
of a disposal solution – constitute a good base for mice which have bitten
children more than once. Burning the garbage is not safe either. It causes the
4
release of toxins that harm the children playing in the surroundings.

The Lack of Adequate Health Services

Due to the lack of necessary health conditions and the poor health results,
the residents of the unrecognized villages in the Negev should have high
accessibility to health services. Yet, the situation is far from it. Today,
there are twelve clinics in the unrecognized villages and only eight villages
have family care units. These clinics serve only 20% of the residents of the
unrecognized villages. Moreover, the services provided in the existing clinics
are lacking and are not accessible to the residents:

Physical accessibility: The lack of public transportation and paved roads make
it hard to reach the clinics situated far from the village center. It is
especially difficult for women, who are in charge of child care and also

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

5
suffer social mobility limitations. This fact goes to show that when locating
the clinics far away and in setting the reception hours (they do not operate
in the afternoon and on Fridays), there is no proper adjustment to the needs
of the population it is supposed to serve.

A Lack of Medications and Lab Services: Since the clinics are not connected to
the electricity network and operate using generators, they are only able to
provide medications that do not need refrigeration. There are no pharmacists
in the clinics thus the nurse has two duties. Residents, who need medications
that cannot be supplied by the clinics, are forced to reach the clinics
5
located in townships , the cost of which causes some not to take their
medications.

Language: The medical staff in the clinics usually speaks only Hebrew, a fact
that does not enable the mothers to communicate with the doctors. They have
troubles explaining the problem as well as understanding the orders given to
them by the medical staff.

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

twelve villages, only eight also have Primary Mother-Child-Health care
clinics. These operate twice a week in the mornings, a fact that causes a
heavy burden.

The Lack of Services to Un-Documented Children:

Thousands of Un-documented (status-less) children live in Israel and
6
especially in the unrecognized villages in the Negev. Since the entitlement to
health services under the National Health Insurance law is stipulated to
residency, a large number of children have no health insurance and are not
entitled to medical care, except in a state of emergency. A settlement
providing health services in return for payment, to un-documented children,
was validated in February 2001 by the "Meuhedet" health fund. The services
included in the basket are equal to those included in the national health
basket provided to Israeli residents. Yet, one of the limitations of the
settlement is that if one of the parents is Palestinian, the child is not
7
entitled. This limitation practically prevents the only alternative for
receiving medical care from most of the un-documented children in the villages
(except for private medicine). Despite the limitation, the children in the
villages that are entitled for the settlement suffer from accessibility
problems, since there is no "Meuhedet" health fund in the villages.

5
Between 1968 to the 1980's, the state established 7 townships: Rahat, Tel-Sheva, Hura,
Laqye, Segev-Shalom, Kuseife and Ar'ara. The townships, as opposed to the villages,
have been recognized by the state, and are connected to the infrastructures and have
clinics.
6
In a survey conducted by PHR-Israel and the "Women Promote Health" group – discussed
later in this paper - 5 out of 70 women reported that their children have no health
insurance
7
since they have no legal status.
Ran Cohen, coordinator immigrants and non residents project, PHR-Israel. The
settlement suffers from additional, problematic limitations: the settlement is
voluntary and based on the parents’ responsibility to sign their children and pay for
the service, and not on every child's right to health, as opposed to Israeli children
who are entitled to health services, without registration and payment; there is a six
month waiting period for entitlement for children who were not born in Israel; the
insurance does not cover health care for a condition that existed prior to the entrance
to Israel; the treatment is expensive; etc.

6
Children's Right to Health in the Unrecognized Villages in
the Negev: Situation Report

The children in the unrecognized villages in the Negev suffer from a threefold
discrimination: being residents of the south they suffer from higher morbidity
and mortality rates and lower availability of medical services compared to the
rest of the country; being a part of the Arab minority in Israel they suffer
from higher morbidity and mortality percentages and lower availability of
medical services compared to the Jewish majority; being Arab-Bedouin, the
residents of the unrecognized villages in the Negev suffer from higher
morbidity and mortality percentages and lower availability of medical services
compared even with the Arab minority.

Since the villages in the Negev are not recognized by the state, they remain
invisible to the different authorities. Thus, for instance, they are not
registered in the Central Bureau of Statistics, the Ministry of Health and the
Soroka Medical center; therefore there is no available information about their
medical condition. The little information we found about the unrecognized
villages in the Negev, had been classified according to the residents' tribal
origin and not according to the village in which they reside. As a result, it
was difficult to receive exact data about the medical condition of the village
children. For instance, when we wanted to check the percentage of child
emergency admissions of children from the villages compared to those from
townships and Jewish children, we faced a problem: The Soroka Medical Center
had information about children according to their tribal origin and not
according to their village so that we were unable to ascribe the children to a
specific village or township since members of one tribe can reside both in a
township and in an unrecognized village.

Data collection constitutes a necessary basis for dealing with inequality in

health. The lack of a data base specific for the population of the
unrecognized villages does not allow dealing with the problem and helps in its
8
perpetuation .

Children's Health Condition in the Unrecognized Villages in the Negev

The childhood years are critical. Poor health might influence the child's
general functioning throughout his entire life. Not treating health problems
might cause an untreatable health condition later on. The poor housing, living
and hygienic conditions, the lack of infrastructures, electricity, water,
sewage, roads, public transportation and health services, along with the
socio-economic status and the demographic-social characteristics of the Arab-
Bedouin population in the Negev, have a crucial effect on the residents'
health conditions in general, and that of their children in particular.

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

7
Injury, high morbidity, many emergency admissions and high mortality among
9
Bedouin children, are extremely common phenomena :

Infant Mortality:
The rate of infant mortality in the Arab-Bedouin population in the Negev is
one of the highest in Israel: in 2005 the rate of infant mortality was 4.72
out of 1,000 live births among the Jewish population compared to 15.45 out of
10
1,000 live births among the Arab population.

In 2006, the rate of infant mortality in the general population was 5.5 out of
1,000 live births. The rate within the Jewish population was 3.1 out of 1,000
live births and 13.7 out of 1,000 live births within the Arab population in
the Negev. It should be mentioned that even if congenital deficiencies are the
leading death factor among Arab children, it does not serve as an explanation
for the gap.

Morbidity:
The lack of infrastructures – running water, sewage and the lack of
electricity – leads to poor hygienic conditions which cause contagion of
infective illnesses among children; A "diarrhea epidemic" erupts every August,
during which 16,000 Bedouin children are admitted to hospital every year,
compared to 5,000 Jewish children; that is to say that while the Bedouin
children constitute only 15% of the entire population of the Negev, they
11
constitute 80% of the entire children population admitted to hospitals ; the
lack of adequate physical and environmental conditions lead to domestic
accidents, road accidents, burns, poisoning, inhalation of foreign bodies and
drowning; the environmental conditions expose the village children to numerous
dangers such as snakes, scorpions, frostbites and sun burns; and living close
to Ramat Hovav results in respiratory illnesses, oncological illnesses and a
higher risk of general morbidity.

The poor economic state of the residents along with the loss of the
traditional way of life, leads, among others, to malnutrition among their
children – a study showed that Bedouin children residing in the unrecognized
villages have a 2.4 times higher chance of suffering from malnutrition,
12
compared to those residing in townships (such as Rahat).

In addition, the small number of Family Care Units in the villages makes the
pregnancy supervision, necessary for the early diagnosis of congenital
13
deficiencies , growth supervision and proper development of infants - hard.

9
Weisblai, A. (November 20, 2006). "Situation Report – Bedouin Children in the Negev."
Submitted to the 'committee on the Rights of the child'.
10
National data on infant and child mortality until the age of 5 in Israel – December
20, 2005, the Ministry of Health.
11
O. Almi (May 2006). PHR-Israel. Water Discipline: Water, the State and the
Unrecognized Villages in the Negev.
12
Ofer Meir, Ynet. "A New Study Reveals: Malnutrition among First Graders in the
South." 6.2.2005.
13 Sofer, S. (2006) in: "Environmental (in) Justice Report: Health, Environment and
Social Justice." Environmental Justice Committee.

8
The rate of vaccine coverage among Arab-Bedouin in the Negev is 5% lower than
14
the rate in the Jewish sector.

A larger number of Bedouin infants are hospitalized compared to Jewish

children: in 2003 the rate of Bedouin children admitted was 32% compared to
about 8% among the Jewish population. The high rate of admissions among
Bedouin infants is attributed to the high rate of congenital deficiencies,
accidents and illnesses. Since 2000, we can see a decrease in the admission
rates of infants among both populations, especially among the Bedouin
15
population.

16
According to Prof. Shaul Sofer , based on data from the Soroka Medical Center,
compared to Jewish children: more Bedouin children go to emergency units; more
Bedouin children need to be admitted to pediatric wards; more Bedouin children
need to be admitted to emergency units and a growing number die due to their
illness. In addition, Bedouin children that reach the emergency units arrive
at a critical stage of the illness, due to a delayed diagnosis deriving from
the lack of medical services, infrastructures, roads and community access
routes.

9.1% 0f the Bedouin children in the Negev are children with special needs
(suffering from physical, cognitive and different mental disabilities)
compared to 7.7% out of the entire Israeli population. This rate is higher
even in comparison with the parallel rates among the Arab and Jewish
populations in Israel (8.3% and 7.6% respectively). 7.9% of the Bedouin
children suffer from learning disabilities or behavioral and emotional
17
problems.

Health Services Availability for the Children of the Unrecognized

Villages in the Negev
"Clalit" is the health fund operating all primary clinics (except for one run
by "Leumit" in Algrain/said village) in the unrecognized villages in the
Negev.
Only about 60% of the residents of the villages in which clinics are located,
18
are registered in their clinics (Graph number 1) . Conversations of the "Women
Promote Health" group with residents, show that due to the long distance of
the clinics from the village center and due to the lack of basic services such
as medications, professional medicine (especially pediatrics), limited
14
The Health System in the Negev – Description of the existing conditions and needs
during the development of the area according to the national plan. September 2005.
15
Weisblai, A. (November 20, 2006). "Situation Report – Bedouin Children in the Negev."
Submitted to the 'committee on the Rights of the child'.
16
Sofer, S. (2006) in: "Environmental (in) Justice Report: Health, Environment and
Social Justice." Environmental Justice Committee.
17
Strosberg, N., Naon, D., Ziv, A. (July 2008). Shatil and the Regional Council for the
Unrecognized Villages in the Negev. "Special-needs Children in the Bedouin Population
of the Negev: Characteristics, Patterns of Service Use, and the Impact of Caring for
the
18
Children on the Mothers."
The datum regarding the number of insured residents was submitted by the Regional
Council for the Unrecognized Villages. It was submitted following a freedom of
information appeal to the supervisor from the "Clalit" health fund – Mrs. Noa Denai.
There are more insured patients In the Al-Zarnoog clinic than residents. According to
the Regional Council for the Unrecognized Villages, the reason is that residents from
adjacent villages - Khashm Zanna and Beer Al-Hamam, go to that clinic.

9
reception hours etc., many residents prefer to receive the treatment in the
townships. The residents told the women that those who are registered to the
village clinics belong to the most weakened populations – families with many
children, living on income support benefit, families that do not own a car,
widows, second wives and elderly people.

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

5,000
4,500
4,000
3,500
Number of residents 3,000
2,500
Number of clalit patients 2,000
1,500
1,000
500
0
t
g

aj
ir
in

en
l

n
lu

ija
nu

na
ls
ai
ra

ad
Ta

te
ar

rA
hw

at
ar

H
Ba
D
Al
u

M
-Z

a
iG

r
Ab

as

Bi
m
Al

m
ad

Q
U

m
W

Graph Number 1

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

unrecognized villages in the Negev, compared to the Jewish residents living in
adjacent settlements in the Negev, we conducted a comparison between three
unrecognized villages (Bir-Hadaj, Algrain and Umm-Matnan – the three villages
with the highest number of residents) and three Jewish adjacent settlements
19
(Meitar, Omer and Lehavim) :

The clinics in Meitar, Omer and Lehavim offer a wider range and variety of
medical services. All of them have pediatricians and gynecologists, an
expertise that is not available for the residents of the unrecognized villages
in the Negev. The reception hours of the clinics situated in the Jewish
settlements are spread out throughout the day, they are more accessible and
offer services such as a pharmacy, dietitian and so on, which are not
available in the village clinics.

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

10
 250
214
200
Weekly reception hours
pediatrician 150
109
Weekly reception hours
83 81.5 100
All physicians
55
36.5 31 36 38 50
0 0 0
0
Umm Lehavim Algrain Omer Bir Hadaj Meitar
Matnan

(See appendix for additional comparative data between the clinics)

These gaps are especially pungent considering the data regarding the high
morbidity and mortality of the children in the unrecognized villages, compared
to Jewish children and considering the data regarding the social-economic
conditions of the residents of the unrecognized villages compared to those in
adjacent settlements: Meitar, Lehavim and Omer head the social-economic
stratification made by the Central Bureau of Statistics (clusters 9,9 and 10
respectively) compared to the unrecognized villages in the Negev which stand
at the bottom (they are actually not graded but the townships – such as Ar'ara
in the Negev, Segev Shalom, Laqye and Rahat, are graded at the bottom of the
table – cluster number 1).

The Accessibility of Health Services to the Children in the

Unrecognized Villages in the Negev
Seventy women, mothers to children, were interviewed by the "Women Promote
Health" group, accompanied by PHR-Israel, in order to examine the children's
accessibility of health services in the unrecognized villages in the Negev.
The survey focused on the extent and manner of use of health services in the
village clinics and on the limitations in receiving the service, while
focusing on the medical needs of the children and the existing solutions to
these needs.
The interviews were conducted face to face, using a structured questionnaire
in Arabic, in their homes or in the clinics (in four villages – Wadi Alna'am,
Um Bateen, Alsurra, and Al-Zarnug).

The ages of the interviewed women: 51% are 20-30 years old, 32% are 30-40
years old, and 17% are over 40 years old.
Education level of the interviewed women: 22.8% haven’t studied at all, 34.2%
haven't finished high school, and 38.5% finished high school. The rest (3
women) acquired higher education.
Average Number of Children: 6. The answer to the question - "Does any of your
children suffer from a chronic illness": 20% of the women responded that they

11
have a child suffering from a chronic illness and needs monthly supervision,
medications and treatment on a regular basis.
20
The Findings of the Interviews:

Medical Services Usage:

In response to the question: "Were most of the visits to the clinic aimed for
your children or for you or your husband?" 90% of the women answered that most
of the times they visit the clinic due to their children's needs.
In response to the question: "Who do you usually turn to when your child is
21
ill ?" they gave the following answers:
• 55% of the women said that they visit the village clinic "most of the
time"; the rest said that they "never" visit the clinic or only
"sometimes".
• 20% of the women said that they visit a private physician "most of the
22
time"; 55% "sometimes" visit a private physician.
• Few women visit the emergency unit "most of the time"; 53% visit it
"sometimes".
• 31% of the women visit a clinic in another village "most of the time";
32% visit it "sometimes".
In response to the question "Have you ever visited the village clinic and
later on had to visit another clinic in order to complete the treatment of
your children?": 48% of the women said they had to visit another clinic. Out
of them, 77% reported visiting a private physician, 13% reported visiting the
emergency unit and the rest visited a clinic in another village or the same
clinic again:

20
The interviews were conducted in Arabic. The answers refer to the percentage among
the women who answered the specific question.
21
When answering this question we asked them to refer to 5 categories – village clinic,
private physician, emergency unit, traditional care and a clinic in another village. In
each of the categories, they were able to tick "most of the time", "sometimes" or
"Never".
22
Regarding the reasons for visiting a private physician, read further in this sub-
chapter.

12
 If you ever visited an additional health care provider – who did you visit?

90
80
70
%
60
50
40
30
20
10
0
Emergency care Same clinic Clinic in Private physician
other village

Graph Number 2
In response to the question "why did you need another visit?" 87.5% said that
the treatment at the clinic "did not help".

In response to the question "In the past year, have you visited the emergency
unit with your children?" 32% said that they visited the emergency unit with
their child in the past year.

In response to the question "In case you visited the emergency unit, what was
the reason for visiting it?" the women said:
24% due to diarrhea
20% due to a high fever
16% due to an unsuccessful treatment by the clinic physician
12% due to dehydration
The rest visited the emergency unit due to a fracture/shortness of breath/
loss of consciousness/burn/swallowing of a foreign body.

A burn
Dehydration
Swallowing of a foreign body
loss of consciousness
Lack of oxygen
A fracture
High fever
The treatment didn't work
Diarrhea

30 25 20 15 10 5 0

Graph Number 3
Accessibility to Medical Health:
In response to the question "How do you get to the clinic?" 50% of the women
said that they reach the clinic with the child, on foot, and that they have no

13
other way of reaching the clinic. The women described the difficulty in
reaching the clinic, especially when the child is ill and they are forced to
walk a long distance in adverse weather – the terrible heat in the summer and
the rain and harsh cold in winter. They emphasized that it is especially hard
for pregnant women who are forced to carry their children. The lack of a paved
road, suitable for walking and/or driving, adds to the poor accessibility to
the clinic.

In response to the question "What is the walking distance from your home to
the village clinic?" 51% of the women replied that it takes between 5-15
minutes, 35% indicated that it takes between 20-40 minutes and 14% indicated
that it takes between 60-120 minutes.

Among the women that reach the clinic by car, 65% mentioned that it takes
between 10-20 minutes and 35% mentioned a 25-30 minute ride. Due to the lack
of public transportation in the villages, the women arrive with their husband
or a relative. One might assume that a large proportion of the women will not
reach the village clinic unless their husband or a relative drives them and
their children, due to the distance between their home and the clinic.

Cultural Accessibility (Language):

In response to the question "Do you need help with the Hebrew language?" 56%
of the women replied that they did. In response to the question "If so, who
helps you translate?" 53% of the women replied they were helped by their
husbands or relatives while 24% of the women were helped by the medical staff
or by passers-by.

Turning to Private Medicine :

Turning to private pediatric medicine is a common, increasing phenomenon among
the residents of the unrecognized villages in the Negev. The major reason is
the lack of pediatricians and the limited reception hours in the village
clinics. The private physicians receive patients at more convenient hours when
the village clinics are closed – in the afternoons, in the evenings and on
Fridays, thus serving as an alternative solution for visiting the "Moked"
service center when needed. In addition, the private physicians offer their
service in Arabic, showing cultural understanding since they belong to the
same culture. Turning to private medicine is not common only among the
residents of the villages. Many insured patients turn to it also when the
services are offered by the public health system. However, pediatrics is a
trivial service provided in clinics throughout Israel, an alternative that is
not provided to the residents of the unrecognized villages in the existing
clinics. Therefore, turning to private medicine is almost an inevitable
default and many pay for private medicine instead of receiving the service in
the existing clinics.

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

I opened a private clinic since I could not accept the current state of
affairs. People are looking for me at home; if I were to receive patients in
the village clinic people would not come to my home. I did not intend to open

14
a clinic but people know me and they know where I live. If a woman comes to me
with her child who suffers from a high fever – I cannot send her home or for
treatment elsewhere when I know how difficult it is for her to come at such
hours to the village clinic or to the emergency unit. The emergency unit is
not the solution for her child's condition and it is a shame that she go there
when it is not needed. In the beginning, people came to my home and I could
not refuse to provide their children with the treatment; "this one" knows me
and "this one" – I have treated in the past. Sometimes, mothers expect me to
treat their children the same way I treated their neighbor's son. In the end,
I was forced to open a private clinic. People come to me because they know I
am a pediatrician and they want to receive the best treatment for their
children. I feel bad when people pay double – to the health fund and to the
private physician. I thought that the minute I started charging for the
treatment people would stop coming but that was not the case – they come and
pay".

H', from Assir:

My son had medical problems. When I approached the family physician in the
village clinic, he gave him a medication and said: "it will pass." The problem
was not solved, I came back many times and in the end, the child was admitted
to the hospital, suffering from severe kidney problems. This was caused due to
a negligent treatment by the clinic doctor. I do not visit the clinic anymore,
and go straight to a private pediatrician."

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

the village clinic to their residents – a lack in specialist physicians, a
long distance from the village center, limited reception hours and an
inability to communicate. Therefore, the women turn to alternative solutions –
private pediatricians, clinics in townships where pediatricians receive
patients and even to the emergency unit.
Half of the women who visit the village clinic report that they are anyway
forced to turn to another solution with the same problem. About three quarter
of them, turn to a private physician, a time consuming and expensive solution.
The main reason for turning to another solution is the feeling that the family
physician did not solve the problem. Even though this problem exists outside
the unrecognized villages in the Negev, the high percentage of those looking
for other solutions, such as visiting the emergency units (a third of the
women), might indicate problems in communication between the physician and the
mother (language), a sense of disbelief caused by the fact that the physician
is not a pediatrician, and a sense that no medical answer to the patient's
needs is supplied.
This duplication causes not only a waste of time and resources by the
individual but also a more costly service – emergency units – and an economic
burden on the health system in general, due to lacking available primary
medicine.

15
 23
The State's Duty to Realize the Right to Health

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

state of Israel and in local rules: The National Health Insurance Law and The
Patients Rights Act. According to these, the state is obligated to make sure
every person residing within its borders has access to medical services and to
the Underlying Determinants of Health.
Non discrimination and equality constitute repetitive central motives
throughout the International Covenant on Economic, Social and Cultural Rights,
ratified by the State of Israel in 1991, as well as in the general comment 14
of the monitoring committee, concerning article 12 of this covenant which
deals with health. According to these, the state must ensure, among others,
non discrimination in accessibility to health services and to "necessary
conditions" for health.
24
One of the state's core obligations is to ensure that accessibility to health
services will be fulfilled in an in discriminatory fashion to all, and
especially to vulnerable or marginalized groups. The covenant outlines the
need to take measures to reduce infant mortality and promote the healthy
development of infants and children, to prevent infectious diseases and treat
them, to create health services infrastructure.

The UN Convention on the Rights of the Child (1989) acknowledged "…the right
of the child to the enjoyment of the highest attainable standard of health…"
and stresses that the state should pursue full implementation of this right
25
and, in particular, shall take appropriate measures."

The National Insurance Law came into force in 1995, and set the rights of the
individual to health services and the state's obligation to fund these
services. The law's major principles – "Justice, Equality and Mutual Help" –
helped in reducing, to some extent, the inequality between different residents
in Israel.

The Patients Rights Act came into force in 1996, and anchored the patient's
rights toward the medical factor – the physician and the medical institute.
One of the articles of the law stresses that "a care giver or a medical
institute shall not discriminate one patient from another based on religion,
26
race, sex, nationality, state of origin, sexual tendency or other."

Yet, The National Insurance Law and The Patients Rights Act did not offer a
sufficient response to reducing the inequality between different residents in
general and between Jews and Arabs in particular. Although every resident is
entitled, by law, to equal services, in fact there are gaps in availability
and quality of the services provided in different settlements; the residents

23
This chapter was written by Shlomit Avni-Ouaknine, based on: Avni, S. (April 2008).
PHR-Israel. "The Right to Health among Arab-Palestinians in Israel: A Comparative
Look."
A
24
Report for the International Health Day.
An obligation the state must endure according to the International Covenant on
Economic, Social and Cultural Rights, regardless of its condition.
25
Convention on the Rights of the Child, 1989, article 24.
26
High Court Petition 4540/00.

16
of the unrecognized villages in the Negev suffer from the poorest health data
in Israel and poor availability and accessibility to health services –
clinics, family care units, specialist medicine, equipment, pharmacy services
etc.

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

paper – health level, availability and accessibility of medical services and
"necessary conditions" for health derived from international conventions and
local laws. The state's obligation to initiate an active action to reducing
these gaps also has a medical logic (since it will improve the health
condition of the Arab-Bedouins in the Negev) and an economic logic (since an
ill population needs more medical services, more expensive and complicated
services and "costs" working days, pensions etc.); it is its human and moral
right.

Summary and Recommendations

The state of Israel, committed to the health of its entire population does not
provide equal medical services to the residents of the unrecognized villages
in the Negev in general and to their children in particular. The existing
services in the few clinics established in the villages, lack basic services
such as pediatrics and gynecology. This lack is especially visible due to the
inequality in the range and variety of the services in the unrecognized
villages compared to adjacent Jewish settlements.

The establishment of the clinics, most of which were built only after a high
27
court petition , is but a partial step towards the realization of the
residents' right to health. A full realization requires connecting the
villages to water and electricity and additional necessary conditions for
health. Yet, this is not enough: the right to health is connected with the
right to equality, therefore, clinics offering a poorer scope and variety of
services compared to the services available for residents in clinics outside
the unrecognized villages, violates the equal right of the residents of the
unrecognized villages for unified health services. Moreover, The National
Insurance Law emphasized not only equality but also the value of justice which
means bigger investment in service development especially where it is most
needed. Since the residents of the unrecognized villages suffer higher
morbidity and mortality rates, the state must initiate differential investment
in the building of health services especially among them.

With regards to pediatrics, in many places in the world, the family physician
is the main caregiver of the child and the pediatrician serves as his advisor
(in England, for instance). This method has many advantages: one of which is a
comprehensive understanding of the family’s needs. However, the fact that
there is no pediatrician in the village clinics, where there are numerous

27
High Court Petition 4540/00.

17
children, with high morbidity and mortality rates and given the harsh living
conditions, raises questions and calls for action.

28
Recommendations for Policy Change
1) The state must recognize the villages while including them in the
process.
2) The state must connect the unrecognized villages to all national
infrastructures, especially to the water network. The clinics must be
connected to the electricity network in order to allow, among other
things, the refrigeration of medications.
3) The state must act so that the scope, variety and quality of services
provided in the village clinics are equal to those available in most
primary clinics in other settlements. Therefore, the state must provide
the existing clinics with pediatricians and gynecologists and broaden
the existing services available in the family care units.
4) The state must initiate differential investments especially in
developing the scope and variety of medical services in the unrecognized
villages, due to the health data of the village residents.
5) The state must initiate and implement planning programs aimed for
reducing the morbidity and mortality rates among the residents of the
unrecognized villages in general and their children in particular, in a
culturally adapted manner.
6) The medical services must be adapted to the residents' cultural and
labial needs.

Author: Heijer Abu Sharb Translation from Hebrew: Noga Almi

Research: Heijer Abu Sharb, the "Women Promote Health" group: Najah Abu-Nadi,
Maliha Al-Nasasarah, Nasra Al-Walidi and Amira Al-Hawashla
Author of the summary and the chapter: "The State's Duty to Realize the Right
to Health": Shlomit Avni-Ouaknine
Questionnaire writing and analysis of results: Dr. Nadav Davidovich, Gila
Zelikovich
Data collecting for the survey (interviews using questionnaires): Amira Abu-
Kuydar, Hana Abu-Kuydar, Asma Abu-Kuydar, Amira Al-Hawashla, Nasra Al-Walidi,
Sawsan Abu-Kaff, Sabrin Abu-Kaff, Zuhara Abu-Gharbi, Ismahan Abu-Kuydar
Content editor: Shlomit Avni-Ouaknine
Lingual Editor: Hadas Ziv

This publication was produced with funding from the European

Commission through Oxfam GB. The contents of this document are the sole
responsibility of Physicians for Human Rights-Israel and can under no
circumstances be regarded as reflecting the position of the European
Commission.

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

18
 Appendix: Comparison of the Services Provided in Meitar,
Omer and Lehavim to the Services Provided in Bir Hadaj,
29
Algrain and Umm-Matnan
A comparison of the services provided in the Meitar "Clalit" clinic and the
Bir Hadaj "Clalit" clinic:

Meitar Clinic Bir Hadaj Clinic

Number of residents 6900 Number of "Clalit" patients Number of residents 5106 Number of "Clalit" patients
4263 2429
36.1% of the residents are under 19 60% of the residents are under 19
Specialty Number of Number of Reception Remarks Specialty Number of Number of Reception Remarks
physician reception days and physician reception days and
s Hours per Hours s Hours per hours
Week Week
Pediatric 2 38 Sun-Fri Number of Pediatric 0 0 0 Number of
s 7:30- insured s insured
12:00, children
31
children
30
17:00- 1538 1564
20:00 Number of
children
with
chronic
illnesses
108
Family 7 67 Sun-Fri Family 2 55 Sun-Thu Wednesday
physician 6:30- physician 8:30- Thursday
12:00, 16:00 8:00-
17:00- 15:30
20:00
Gynecolog 1 4 Once a Gynecolog 0
ist week ist
7:30-
11:30
Total 109 hours Total 55
number of number of
hours hours
Additional Services The clinic operates 6 days Additional Services The clinic operates 5 days
a week between 6:30-12:00 a week between 8:00-15:30
and 16:30-20:00 Lab services
Lab services – 5 days a Twice a week: Monday,
week: 7:00-9:30 Wednesday 8:30-9:30
Dietitian – twice a week Family care unit: twice a
7:30-11:30 and 16:30-19:30 week – 8:30-15:30
Pharmacy – 6 days a week
Family care – 5 times a
week – 8:00-11:00, one
evening
16:30-19:00
A Comparison of the two clinics reveals gaps in the scope and the variety of medical
services:
1. The Meitar clinic has two pediatricians with a total of 38 weekly hours while
the Bir Hadaj clinic has no pediatrician at all, despite the fact that there are
more children in Bir Hadaj – according to the "Clalit" health fund, 64.3% of the
patients are children between the ages of 0-18 (compared to 36.1% in Meitar
between the ages of 0-19. We assume that the percentage of the children between
the ages of 0-18 insured in the "Clalit" health fund is not different from their
percentage in the population).
2. The Meitar clinic has seven family physicians with a total of 67 weekly hours –
1.57 weekly hours per 100 patients; the Bir Hadaj clinic has two family
physicians with a total of 55 weekly hours – 2.26 weekly hours per 100 patients.
3. Apart from family physicians and pediatricians, the Meitar clinic has a
gynecologist 4 hours a week. The Bir Hadaj clinic does not have any at all.

29
The number of the residents was calculated on the basis of the number of residents in
2004 (according to data from the Regional Council for the Unrecognized Villages) while
calculating the Muslim population growth in the south in 2004-2006 (according to data
from the Central Bureau of Statistics). The number of residents in the Jewish
settlements is also taken from data from the Central Bureau of Statistics, referring to
2006.
30
Calculated according to ratio of residents between the ages of 0-19 in Meitar (CBS,
2006):
31
36.1% out of 4263 "Clalit" patients.
The number of patients in the "Clalit" health fund between the ages of 0-18,
according to data received on January 6, 2008, following a correspondence conducted
with “Clalit” by the group and PHR-Israel.

19
 4. The total number of reception hours in the Meitar clinic – 109 hours, which are
2.55 weekly hours per 100 patients compared to 2.26 per 100 patients in Bir
Hadaj. It should be noted once more that apart from the larger number of
physicians' reception hours per capita, the Meitar clinic provides specialized
physicians in three different fields while in Bir Hadaj the family physician
receives all the patients, regardless of their medical needs.
5. The clinic in Meitar is open 6 days a week while the Bir Hadaj clinic is open 5
days a week.
6. The Meitar clinic gives services all day round – both in the morning and in the
afternoon while the Bir Hadaj clinic is open only until 16:00.
7. The Meitar clinic provides pharmacy and dietitian services, which are not
provided in the Bir Hadaj clinic.
8. The lab services in Meitar operate 5 days a week for two and a half hours daily,
while in Bir Hadaj they operate only twice a week for an hour daily.
9. The family care unit in Meitar operates every morning and once a week in the
afternoon, while in Bir Hadaj the same service operates only two mornings a
week.
It should be mentioned that the Meitar clinic is more accessible to its patients due to
proper infrastructures and public transportation while in Bir Hadaj the roads to the
clinic are not paved and there is no public transportation.
In addition, it is important to mention that in Meitar the residents have another
independent "Clalit" clinic (which according to the internet website of the health fund
"receives patients from Meitar and the South Mount Hebron area only") as well as a
"Meuhedet", a "Leumit" and a "Maccabi" clinic.

20
 A comparison of the services provided in the Omer "Clalit" clinic and the
Algrain "Clalit" clinic:

Omer Clinic Algrain Clinic

Number of residents 6924 Number of "Clalit" patients Number of residents 4267 Number of "Clalit" patients
4129 1931
28% of the residents are under 19 60% of the residents are under 19
Specialty Number of Number of Reception Remarks Specialty Number of Number of Reception Remarks
physician reception days and physician reception days and
s hours per hours s hours per hours
week week
Pediatric 4 81.5 Sun-Fri Number of Pediatric 0 0 0 Number of
s 6:30- insured s insured
12:00, children children
32
17:00- 1156 1311
19:30 Number of
children
with
chronic
illnesses
121
Family 6 129.5 Sun-Fri Family 1 36 Sun, mon,
Physician 6:30- Physician wed 8:00-
12:00, 16:00,
17:00- Tue-
20:00 8:00-
14:00,
thu-8:00-
13:00
Gynecolog 1 3 Once a Gynecolog 0 0 0
ist week- ist
16:30-
19:30

Total 214 Total 36

number of number of
hours hours
Additional Services The clinic operates 6 days Additional Services The clinic operates 5 days
a week between 6:30-12:00 a week between 8:00-16:00
and 16:30-20:00 Lab services - twice a
Lab services – 5 days a week: Monday, Wednesday
week: 7:00-9:30 8:30-9:30
Pharmacy – 6 days a week – Family care unit: twice a
7:00-11:00 and 16:30-20:00 week – 8:30-15:45
The clinic provides
fetoprotein test on a daily
basis

A Comparison of the two clinics reveals gaps in the scope and the variety of medical
services:
1. The Omer clinic employs 5 pediatricians and provides 81.5 weekly hours while in
Algrain there is no pediatrician at all, despite the fact that there are more
children in Algrain – according to the "Clalit" health fund 67.8% of the
patients are children between the ages of 0-18 (compared to 28% of the entire
Omer population who are between the ages of 0-19. We assume that the percentage
of children between the ages of 0-18 is not different from its percentage in the
general population).
2. The Omer clinic employs 6 family physicians and provides 129.5 weekly hours –
3.13 weekly hours per 100 patients in Omer; the Algrain clinic employs one
family physician providing a total of 36 hours – 1.86 weekly hours per 100
clinic patients.
3. Apart from the pediatricians and the family physicians, the Omer clinic provides
a 3-hour weekly service of a gynecologist while the Algrain clinic has no
gynecologist.
4. The total reception hours in the Omer clinic are 214, which are 5.18 hours per
100 patients, compared to 1.86 per 100 patients in Algrain. It should be noted
once more that apart from the larger number of physicians' reception hours per
capita, the Omer clinic provides specialized physicians in three different
fields while in Algrain the family physician receives all the patients,
regardless of their medical needs.

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

21
 5. The Omer clinic operates 6 days a week while the Algrain clinic operates 5 days
a week.
6. The Omer clinic gives services all day round – both in the morning and in the
afternoon while the Algrain clinic is open only until 16:00.
7. The Omer clinic provides pharmacy services, which is not provided in the Algrain
clinic.
8. The lab services in Omer operate 5 days a week for two and a half hours daily,
while in Algrain they operate only twice a week for an hour daily.
9. The Omer clinic provides fetoprotein test 5 days a week, a service not provided
at all at the Algrain clinic.

It should be mentioned that the Omer clinic is more accessible to its patients due to
proper infrastructures and public transportation while in Algrain the roads to the
clinic are not paved and there is no public transportation.
In addition, it is important to mention that there is also a "Meuhedet", a "Leumit" and
a "Maccabi" clinic.

A comparison of the services provided in the Lehavim "Clalit" clinic and the
Umm-Matnan "Clalit" clinic:

Lehavim Clinic Umm-Matnan Clinic

Number of residents 5600 Number of "Clalit" patients Number of Residents 4467 Number of "Clalit" Patients
3517 1519
36.5% of the residents are under 19 60% of the residents are under 19
Specialty Number of Number of Reception Remarks Specialty Number of Number of Reception Remarks
physician reception days and physician reception days and
s hours per hours s hours per hours
week week
Pediatric 4 31 Sun-Fri Number of Pediatric 0 0 0 Number of
s 7:00- insured s insured
12:00, children children
17:00- 1283 979
20:00 Number of
children
with
chronic
illnesses
65
Family 4 49 Sun-Fri Family 1 36.5 Sun-thu
Physician 7:00- Physician 8:00-
12:00, 15:30,
17:00-
20:00
Gynecolog 1 3 Once a Gynecolog 0 0 0
ist week- ist
17:00-
20:00

Total 83 Total 36.5

number of number of
hours hours
Additional Services The clinic operates 6 days Additional Services The clinic operates 5 days
a week between 6:30-12:00 a week between 8:00-15:30
and 16:30-20:00 Lab services - twice a
Lab services – 5 days a week: Monday, Wednesday
week: 7:00-9:30 8:00-10:00
Dietitian – 3 days a week – Family care unit: twice a
7:00-12:00 Pharmacy – 6 week – tue, thu 9:00-15:30
days a week – 8:00-12:00
and 17:00-20:00
Family care unit – 3 days a
week, mon-tue
8:30-12:00, thu – 16:00-
19:30

A Comparison of the two clinics reveals gaps in the scope and the variety of medical
services:
1. The Lehavim clinic employs 4 pediatricians who provide 31 weekly hours while in
Umm-Matnan there is no pediatrician at all, despite the fact that there are 979
"Clalit" patients between the ages of 0-18.

22
 2. The Lehavim clinic employs 4 family physicians who provide 49 weekly hours – 1.3
weekly hours per 100 patients; the Umm-Matnan clinic employs one family
physician providing a total of 36.5 hours – 2.4 weekly hours per 100 patients.
3. Apart from the pediatricians and the family physicians, the Lehavim clinic
provides a 3-hour weekly service of a gynecologist while in Umm-Matnan there is
no gynecologist at all.
4. The total reception hours in the Lehavim clinic is 83 hours, which constitute
2.35 weekly hours per 100 patients, compared to 2.4 per 100 patients in Umm-
Matnan. It should be noted once more that apart from the larger number of
physicians' reception hours per capita, the Lehavim clinic provides specialized
physicians in three different fields while in Umm-Matnan the family physician
receives all the patients, regardless of their medical needs.
5. The Lehavim clinic operates 6 days a week while the Umm-Matnan clinic operates 5
days a week.
6. The Lehavim clinic gives services all day round – both in the morning and in the
afternoon while the Umm-Matnan clinic is open only until 15:30.
7. The Lehavim clinic provides pharmacy and dietitian services, which are not
provided in the Umm-Matnan clinic.
8. The lab services in Lehavim operate 5 days a week for two and a half hours
daily, while in Umm-Matnan they operate only twice a week for two daily hours.
9. The Lehavim clinic provides family care unit services operating every day while
in Umm-Matnan the services are provided only twice a week.

The accessibility to the Lehavim clinic is also easier than that in Umm-Matnan due to
proper infrastructures in Lehavim.
It should be mentioned that there are additional clinics serving the Lehavim community:
"Meuhedet", "Leumit" and "Maccabi".

23