Majdi Ashour, MD, MPH

Health in the Gaza Strip: Siege, Fire and Internal Division

Abstract:

Gaza Strip is going through an acute political turmoil and socioeconomic adversity in the context of a protracted political conflict; this situation, which is exacerbated by the Israeli policies and practices and the internal Palestinian division, has tremendous influences on the performance and the outcomes of the health care system.

The effects of Israeli siege are manifested by restricting the access of patients to health services out side it, increasing the economic recession and its impacts on the population's health and the health services delivery system, and limiting the import of supplies necessary for the regular performance and the future development of the health care system. The effects of recurrent military operations and incursions are manifested by the increased burden of conflict related health conditions; and the disruption of the regular performance of health care facilities.
The effects of the internal Palestinian division on the health care system are manifested by the semi-collapse of some health services' delivery institutions, duplicated administrative orders in the governmental health care facilities which disrupt the delivery and the quality of their provided services, shifting the population to seek care outside the Ministry of Health (MoH) facilities, increasing the burden of internal conflict related health conditions, limiting the stewardship function of the national health authorities, and hindering the planning and priority sitting for the health care system.

There will not be a normal performance of the health care system without a solution of the Palestinian question; meanwhile, neutralizing the health issues from the political motives, respecting the right to health, and increasing the involvement of international health organizations in the health affairs could give a window of opportunities to prevent further deterioration of the health care system in the Gaza Strip.

Introduction:

Every time when the humanitarian situation in the Gaza Strip reaches its peak of misery, the media and the Nongovernmental Organizations (NGOs) working in the fields of health and human rights, both local and international, center their attention on health affairs to exemplify the despair situation in the strip. The media coverage and reports produced by NGOs about the deteriorated health system performance and health conditions in Gaza are true, but they ignore the complexity of realities around health issues and are almost always driven from their context, making it difficult for the reader who is not aware enough about the Palestinian affairs to thoroughly understand the issues around health here. The reports of different NGOs, which are prepared mainly for advocacy and fund-raising purposes, and the sensational nature of media may make them questionable for readers who pretend to be neutral. Furthermore, the nature and the scope of the reports which are produced by some international organizations, such as the World Health Organization (WHO) and the United Nations' Office of Coordination of Humanitarian Affairs in the occupied Palestinian territories (OCHA), in order to monitor the humanitarian and health conditions in the Gaza Strip, are limited to deliver merely a day-to-day operational information about these conditions, in order to early detect the indicators of emergency situations, failing to draw a comprehensive picture of the health affairs in the strip ; and they do not intend to suggest medium and long terms solutions for the dilemmas around the health issues in the context of politically unstable and unpredictable environment.

This paper will attempt to document and to describe the manifestations of main influencing political factors on the current health affairs, amalgamating the information of various reports, putting them in their context, and will try to draw a picture about the future of the health care system and to suggest some possible actions that might prevent a further deterioration in the health affairs in the Gaza Strip.

This paper will document and discus issues around the performance and the outcome of the health care system in the Gaza Strip, through personal observations , reviewing various documents including mainly the reports of the WHO, the reports of OCHA, the Palestinian MoH, the Palestinian Central Bureau of Statistics (PCBS), United Nations Relief and Work Agency for Palestine Refugees in the Near East ( UNRWA), various documents of local and International NGOs, and other resources of data including grey literature, such as newspaper, internet based information and press releases.

The paper will be divided into three parts after this introduction: a background, a description of the manifestation of the main political determinants of health affairs in the Gaza Strip, and a discussion about the consequences of the current realities on the performance and the outcomes of the health care system in the Gaza Strip and about possible remedies for the current and the possible future problems.

The background will attempt to provide an evidence about the interrelationship between socioeconomic and political determinants and health affairs and their outcomes, then it will try to draw an overall concise picture of the demographic and health status of the population, and the organization and the functioning of the health care system in the Gaza Strip.

The following part of the paper will describe the nature of Israeli policy toward the Gaza Strip, the socioeconomic and health results of Israeli practices of sealing it and the recurrent military operations in it; further, it will document the effects of the internal Palestinian division, especially after Hamas military takeover of it, on its health care system organization, delivery, financing, and future development.

The third concluding part summarizes the impacts of the current status on health affairs, describes the nature and the scope of these impacts, attempts to predict the future of the health care system in the light of continuing current realities, suggests alternatives to the current way of the management of the health care system, proposes some remedies to deal with the status quo in case of its continuation, and finally calls for a more proactive approach in dealing with health issues in the Gaza Strip.

Background:

Prior to describing political factors that influence the current health affairs in Gaza, it is worthy to admit that the health conditions in the Strip, like in any other area of the world are strongly associated with the socioeconomic and political situation. The case of Infant Mortality Rate (IMR), which is widely considered as an indicator of health status of the population as well as of the overall level of development, could give a strong evidence about this tight association between health indicators and the political and the socioeconomic situation in the Gaza Strip.

Thanks to the efforts exerted by thousands of health professionals and different health delivery institutions, IMR has seen a considerable decline in the Gaza Strip during the four decades following the Palestinian Nakba in 1948 ; however, this decline appears to have been tapering since the late 1980s¹ ², and showed reversing trends after the eruption of the second Intifada in 2000 ³ ⁴ ⁵ (See figure 1). The cessation of the steady and significant historical decline in the IMR was paralleled with the eruption of the first Intifada in 1987, which was followed by sharp economic decline, the infertile political and socioeconomic outcomes of the Oslo process, and the questionable performance of the Palestinian Authority (PA), which has led it to be a failed political entity even before its conversion into a state.

Figure 1: Infant Mortality Rates in the Gaza Strip (1970-2005)

Sources of Data:

1970- 1988: Official reported Infant Mortality Rates reported by the Israeli Authorities⁶.
1990-2005: Official reported Infant Mortality Rates presented in the Annual Reports of the Palestinian Ministry of Health⁷.

It is important before describing the manifestations of the main political factors influencing the health care system performance and outcomes, to draw a picture about the demographic and health status of the population and about the organization and the structure of the health care system, the delivery of health care services, and the nature of health policy development in the Gaza Strip.

The society in the Gaza Strip is characterized by being young, with a relatively high fertility and low-to-moderate mortality, living in a small area of 362 square kilometers which is densely populated by 1.5 million Palestinians . More than 49.1 percent of the population is below the age of 15⁸, the Total Fertility Rate (TFR) is 5.4⁹, the crude mortality rate is 3.1 per 1000 of the population in 2005¹⁰, the IMR stands between 20.8¹¹ and 30.7¹² deaths per 1000 live births, and the estimates of maternal deaths are significantly uncertain.

The disease pattern in the Gaza Strip, which is characterized by the manifestations of an ongoing epidemiological transition with an increased burden of Non-Communicable Diseases (NCDs) and conflict related health conditions, poses serious challenges for the health care system delivery and financing. Increased life expectancy, which stands at 72.5 years¹³, progressive urbanization and changes in nutritional habits and life-styles, all contribute to increasing the burden of NCDs. As a result of the ongoing Palestinian-Israeli conflict, accident, being responsible for 12.5 percent of the overall mortality, became the second cause of deaths in the OPT in 2002¹⁴. Vaccine-preventable diseases are well under control. Communicable diseases, which still dominate the global health agenda, have been eradicated - such as malaria- or are of low endemicity- such as tuberculosis and HIV/AIDS-; however, other communicable diseases especially those associated with poor environmental health conditions are still highly prevalent such as viral hepatitis, enteric fevers and intestinal infestations. Micronutrient deficiencies especially iron deficiency anemia among preschool children, women of reproductive age and school children as well as vitamin-A deficiency, represent major problems. Post-traumatic stress disorders (PTSD) and other psychological and behavioral problems are widely spread among the population, especially children and youth.

The health care system in the Gaza Strip is a mosaic of four subsystems: the governmental health services, the UNRWA health program, the dozens of health NGOs, and the private for profit health sector.

The governmental health services in the Gaza Strip resemble the services of the MoH and the services of the Directorate of Police Medical Services (PMS). The MoH in Gaza employs more than two thirds (67 %) of health human resources, owns and manages about 75% of hospital beds, where 64 percent of births were delivered¹⁵, and provides primary health care (PHC) services through 56 PHC centers, where 39 percent of physician consultations outside the private sector were taken place¹⁶, about 35 percent of the Expanded Program of Immunizations' (EPI) vaccinations are provided, and where 17 percent of family planning users receive this service¹⁷. The services of the MoH are mainly financed from the budget of the PA, which are derived from its tax and non-tax revenues and external international support to it , and from the user fees paid for its services and the fees paid for participation in the Governmental Health Insurance (GHI) scheme managed by the MoH¹⁸. About 70 percent of the budget of the MoH was traditionally spent on hospital services while the reminder on the PHC services. The second component of the governmental health subsystem is the PMS, which was responsible for providing health services to few dozens of thousands of police personnel and their families. In 2004, the PMS was responsible for managing 2 small size hospitals and for delivering 5 percent of the PHC physicians' consultations outside the private sector, and for employing 9 percent of health professionals in the Gaza Strip¹⁹. The PMS is funded from the budget of the PA.

The following major component of the health care system in the Gaza Strip is the UNRWA health program, which is mandated by the United Nations (UN) to provide health services to more than 1 million Palestinian refugees, who compromises about 70 percent of the population, through 7 percent of available health human resources in the Gaza Strip²⁰ employed in its 19 PHC centers²¹, where more than one half (51%) of all physician consultations out side the private sector are taken place²², 65 percent of EPI vaccinations are provided, and more than 60 percent of family planning services in Gaza Strip are utilized²³. UNRWA health program is not involved directly in the provision of hospital services; however, it partially subsidizes the costs of some hospital services utilized by the refugee population. UNRWA is exclusively funded from external donors. A comparison between the role of UNRWA in health services delivery and resources available to it indicates its operation above its optimal capacity.

The third component of the health care system in Gaza Strip is a scattering of dozens of health NGOs, which are the main provider of the physical and mental health rehabilitation programs, health education activities, and ambulance services, and a complementary provider of PHC and hospital services, through 17 percent of the available health human resources²⁴. The dozens of PHC centers belonging to different health NGOs in the Gaza Strip provides about 6 percent of physician consultations outside the private for profit sector²⁵ and 3.2 percent of the provided family planning services²⁶. NGOs hospitals own 23 percent of hospital beds, where 15 percent of all births are delivered²⁷. A comparison between the NGOs' role in health services provision and resources available to them indicates the underutilization of their capacities. NGOs receive main bulk of their funding from international donors; other sources of funding include fees for services paid from households and reimbursement for secondary and tertiary health services purchased by the MoH, PMS and UNRWA²⁸.

The last component of the health care system is the private for profit health care sector. The services of the private for profit health sector are minimally regulated and are still provided by a plethora of individual professionals who run their own practices on a fees-for-services basis, while working simultaneously at other health care facilities. Data of a conducted survey shows that more than one half of private sector human resources (56%) are employed at the MOH facilities²⁹.

It is worthy to notice that following occupying Gaza Strip- and the West Bank- in 1967, the Israelis took over the governmental health care services and proceeded to administer them in a manner that kept them stunted and underdeveloped, with high reliance on the referrals to Israeli hospitals for tertiary care, thus creating a total dependence on the Israeli health system³⁰. After Oslo Accords and the establishment of the PA in 1994, the MoH had managed to reduce the costs of patients referred to Israeli hospitals by referring patients to Jordan, Egypt, and Palestinian hospitals in Eastern Jerusalem, alongside with the referral to Israeli hospitals. Data of the MoH indicates that 11,987 patients from the Gaza Strip were referred through its referral system in 2005 for the tertiary and specialized care outside it^31.

The Palestinian health care system is complex, lacking of basic coordination between its components at both operational and policy-making levels, and is characterized by a merely symbolic nature of the stewardship of a central health authority, dependence on external sources of funding, existence of clear health inequalities, and questionable quality of provided care. The heterogeneity of health care services provision has led the population to utilize the services of different health care system components simultaneously. A study which was conducted and published ten years ago showed that a high proportion of GHI scheme enrollees utilized the health services of private for profit and health NGOs on the basis of fees for services, and that the refugee population utilized the free of charges services of UNRWA health program simultaneously with their utilization of governmental, private for profit, and NGOs health services³². Some Palestinians have double or triple health insurance overages, while a portion of them doesn’t have any coverage at all³³. This indicates both the inefficiency of the available system's arrangements and the absence of universal health insurance coverage.

3- The Determinants of Health in the Gaza Strip:

Social factors have great influence on the performance of national health care systems; those social factors could be categorized into economic, political, and cultural³⁴. This part of the paper will be concerned about the influence of political factor on the health care system in Gaza. The performance and the outcomes of the health care system in the Gaza Strip are currently influenced by the political situation in the Strip and their impacts on the socio-economic landscape. Those political determinants of health in the Gaza Strip include: the Israeli policies and practices toward it, including mainly the policy of sealing the strip and the recurrent Israeli military operations in it, and the ongoing internal Palestinian administrative and political division.

3-1- The Israeli policies and practices:

The Israeli policy toward the Gaza Strip was characterized during the last two decades by maximizing control over it with minimal -or without any- direct military presence on the ground and with minimal-or without any-responsibilities. This policy was finally manifested by the Israeli unilateral disengagement from it. By the 12th of September 2005, Israel evacuated all settlements from the Gaza Strip and the withdrawal of Israeli forces from it was completed without any arrangements with the PA. Apart from the restoration of internal mobility within the Strip, evacuating about 7000 Israeli settlers and freeing up about 20 percent of the Gazan land, in which the Israeli settlements in it were built, and the short lived joy of seeing the Israeli soldiers leave, the 1.5 million Gazans were not, in reality, offered a positive change in their conditions and the status of Gaza Strip as an occupied territory was not changed. Instead, Israel has continued supervising and guarding its external envelope of land, maintaining exclusive control in the air space and the territorial water of it, conducting military activities, controlling the crossing points with Israel and Egypt , and controlling telecommunications network, the population registry, and the customs and tax revenues.

3-1-1- The Israeli Policy of Closure:

Perhaps, it is important before describing the effects of Israeli policy of closure on the health affairs in the Gaza Strip, to give an account about the context and the historical development leading to the current sealing of the Gaza Strip by declaring it as a "hostile entity", citing firing the home-made rockets from inside it into the southern part of Israel, which was homes to hundreds of thousands of Palestinian refugees who were displaced into the strip in 1948 in the aftermath of the establishment of the State of Israel.

Israel, over time beginning from 1967, fostered its political inseparability with Gaza through economic integration which was predicated on the structural containment of the Palestinian domestic economy and the deliberate and consistent dismemberment of that economy over time³⁵. In the years of occupation, Israel had neither developed nor allowed the development of an independent economical infrastructure in Gaza -and the West Bank-, making employment in Israel the only real economic resource available to the people of Gaza. Between 1970 and 1987, the number of Gazans crossing the green line-the border between Israel and the occupied territories-grow from 10 to at least 60 percent of the total labor force. By 1987, the number of Gazans working in Israel exceeded 70,000, leading to the reorientation of its labor force away from the local indigenous labor market³⁶.

In order to foster the implementation of its policies for integrating the Palestinian socio-economic sphere into the Israeli market, Israel allowed the residents of the Gaza Strip -and the West Bank-, since 1972, to leave it freely, enter Israel and East Jerusalem, and pass between it and the West Bank.

In June 1989, Israel introduced the magnetic-card system, as a method of collective punishment, responding to the eruption of the first intifada in 1987, whereby only those with such card were allowed to leave the strip. The magnetic card system signaled the beginning of the current Israeli policy of closure. In January 1991, during the Gulf War, every resident of the Occupied Palestinian Territories (OPT) wanting to enter Israel or pass through it had to have a personal exit permit. With time, Israel's personal exit permit policy has gradually become stricter. This new policy created a situation in which the OPT were divided into three areas, with passage between them requiring a permit from Israeli authorities: the Gaza Strip, the West Bank, and the East Jerusalem. The personal exit permit policy which was started in 1991 marked the beginning of the permanent closure policy, which was exacerbated over time. The closure policy remained in effect and even was intensified after the Oslo Accords and the geopolitical changes that followed it³⁷.

In September 2000, following the failed Palestinian –Israeli final status negotiations in Camp David, a provocative visit of Ariel Sharon to the Muslem holy places in Jerusalem had triggered the eruption of the second Palestinian Intifada, during which the closure policies were further intensified and the Israeli use of military force was described to be excessive.

The Israeli policy of closure was strictly tightened after the Unilateral Israeli Disengagement from Gaza in September 2005, especially after the victory of Hamas in the election of the Palestinian Legislative Council (PLC)- the parliament of the PA- in January 2006, capturing an Israeli soldier by Hamas militants in June 2006, the Hamas military takeover of it in June 2007, and the subsequent declaration of it as a "hostile entity" by Israel in September 2007.

The current manifestations of Israeli policies of closing the Gaza Strip, after declaring it as a hostile entity in September 2007, has converted Gaza into "The biggest open air prison in the World", and this has grave effects on the health situation and on the performance of the health care system in the Strip. Rafah boarder crossing into Egypt was almost totally closed since the 25^th of June 2006³⁸, making Erez crossing point the only way for patients to access health care services outside it. Physician for Human Rights- Israel have noticed that the Israeli General Security Services (GSS ) at Erez are taking advantage of the vulnerability of patients who have no other means of accessing medical care and that rejection or approval of a patient’s request to leave Gaza for treatment is almost entirely dependant on undisclosed security reasons³⁹. Physicians for Human Rights- Israel and Amnesty International have reported separately that some patients from Gaza testified that they were openly told in interviews with GSS at the Erez that they would not receive treatment in Israel unless they become informants for the GSS⁴⁰ ⁴¹.

After the Israeli declaration of the Gaza Strip as a "hostile entity" in September 2007, the number of patients who were permitted to leave it for medical care outside the Strip was sharply dropped. The data of the WHO indicates that out of 8,803 patients who applied for permits to cross Erez check point for medical reasons in 2007, only 7,176 patients (81.5 %) were permitted to access health care services out side the Strip; and that about 31% patients who applied for permits to cross it during three months after declaring it as a hostile entity were not permitted to leave⁴². The situation regarding access of patients from Gaza Strip to health services in Israel was further deteriorated in 2008. Amnesty International reported that " According to the UN Office for the Coordination of Humanitarian Affairs, since the beginning of 2008 only 58 per cent of the applications for permits submitted by patients have been approved, compared to an average of 90 per cent in the first half of 2007. In July 2008 approximately two thirds of patients received permits, 2.5 per cent of patients were refused and 300 patients, nearly a third of the total, were given no response. A patient who receives no response is left in limbo, unable even to appeal against the response.⁴³"

The effects of Israeli policy and practices of closing the Gaza Strip is not limited to the referral of patients for tertiary and specialized medical care outside it. Sealing the strip prevents medical students and health professionals from medical and postgraduate training which is not available in it.

The sharp drop of imported commodities, after declaring Gaza as a "Hostile entity" by Israel in September 2007, disrupted the daily life and the performance of health care system. The very restricted supplies of fuels and the decreased supplies of electricity from Israel has led during the last year to frequent and prolonged electricity cuts and to limit power available to run health facilities' generators, interrupting the performance of intensive care units, operating theatres, and emergency rooms and disturbing the refrigeration of perishable medical supplies, including vaccines in the Central Drug Store (CDS)^44, Beside the effects of power shortage on the performance of health services facilities, it has negatively disrupted the quality of water supplies and sewage disposals, which are of vital public health importance. In the first two weeks of November 2007, following Israeli restriction on fuel supplies, some water wells in Gaza city have been out of action or only partially working due to a lack of sufficient fuel supply^45.

The very restricted import of commodities has made the CDS of the MoH short of many dozens of essential drugs and medical supplies⁴⁶, including the MMR vaccine which was not available at the Gaza Strip PHC centers from the end of June 2007 till March 2008, and has made the local pharmaceutical market, which is dependent on importing drugs from outside the strip, short of many drugs and other medical consumables leading to increasing their prices for a population who is heavily stricken by unprecedented economic decline. The global and the local rise of prices of foods are similar to the case of pharmaceuticals. Furthermore, the Israeli authorities refused the entry of critical spare parts for water wells and sewage pumping stations. The stoppage of importing the construction materials, equipments and spare parts has lead to stoppage of the construction and maintenance projects in the health facilities and the maintenance of biomedical equipment; hence, this will certainly hinder the possibility of health system development in the Gaza Strip.

3-1-2- Impoverishing Gaza:

Even before the Hamas take over of the Gaza Strip and the Israeli declaration of it as a hostile entity, as a cumulative result of the Israeli policy of closing it over time, the socioeconomic situation was bleak, where 70 percent of the Gazan households were living under the poverty line, and 42 percent of them in extreme poverty⁴⁷ . This economic situation has its clear effects on the health situation of the population in the Gaza Strip exacerbating the diseases of poverty and bad nutrition and influencing the pattern of utilization the health care services among different health services providers in the Strip. A survey which was conducted among Palestinian refugees utilizing health care services in Gaza showed that the prevalence of anemia was 57.5 percent among 6-36 months children, and 44.9 percent among pregnant women⁴⁸.

An other manifestation of the effects of poverty on health issues in the Gaza is the ability of the Palestinian households to access and to pay for health services; people who live under the poverty line and who live in extreme poverty are not, most probably, able to pay for private health services, which is a principal component of the Palestinian health care system in the context of the absence of universal health insurance coverage and the questionable quality of publicly provided health care services in the MoH and UNRWA health care facilities. It was reported that there was a decline in utilizing the NGOs and private –for-profit and a rise in utilizing the MoH maternity services; this may be attributed to the relatively high charge of these services in the private and NGOs facilities and the nominal user fees in the MoH health services. The poor people in the Gaza strip may avoid the utilization of MoH PHC facilities especially when the utilization of these services requires a prior payment and participation in the governmental health insurance scheme and payment the user fees for the utilization of those services, shifting them toward using the PHC services of UNRWA.

3-1-3- Living in a War-like situation:

Additionally, the recurrent military operations of the Israeli army have resulted in changing the nature of morbidity, disability and mortality in the strip and in disrupting the performance of health care services. Since the eruption of the second Palestinian Intifada in September 2000 till the end of 2005, 3844 Palestinians were killed by the Israeli Forces in the OPT, among them 2081 from the Gaza Strip, and 54, 548 were injured, among them 14,397 from the Gaza Strip⁴⁹, of whom few thousands became permanently disabled. During the two years followed the Israeli disengagement from Gaza 572 and 289 gazans were killed by the Israeli army in 2006 and 2007 respectively⁵⁰. During the first eight months of 2008, the number of fatalities due Israeli attacks was 410⁵¹. An analysis of the mortality due to Israel operations and the overall mortality in Gaza Strip reveals that 9.6 percent of the overall mortality during the last 8 years was attributed to the Israeli military operations inside it. This proportion of deaths attributable to Israeli operations inside the Gaza Strip is close to the proportion of deaths attributable to malignant neoplasm(10.3%), which is the third cause of deaths in the OPT after heart diseases (21%) and cerebrovascular diseases(11%)⁵².

The Israeli recurrent military operations in the Gaza Strip are also associated with disrupting the performance of health care services facilities, changing the pattern of morbidity, and increasing the burden of psychological and psychosocial disorders. Due to the excess of injured patients received by the hospitals and admitted to them during the Israeli military operations, hospitals become oversaturated by injured forcing them to postpone regular admissions and prematurely discharge patients.

3-2-The Internal Palestinian Division:

The current affairs of the health system in the Gaza Strip are also attributable to the internal political, geographic and administrative division and conflict between the Hamas de facto government in Gaza and the PA Ramallah based government.

Two months after its victory in the elections of the PLC in late January 2006, Hamas had formed its own government. Directly after the announcement of the Hamas led government in late March 2006, the international donors have suspended funding to the PA. The effects of donors reaction was manifested by the suspension of direct financial and technical support to MoH, and withholding payment of salaries of the governmental health services employees till the August 2006 when the MoH employees began receiving a lump sum of 1500 New Israeli Shekels (NIS), which represented only a proportion of one month salary for most health professionals. The donor suspension of direct funding to the PA had continued till the internal Palestinian division was institutionalized by hamas takeover of the Gaza Strip. Donors have directed their funding to the PA Ramallah based government. Full salary was paid by the Ramallah government to the majority of the MoH employees in Gaza at the beginning of July 2007⁵³.

After the Hamas takeover of Gaza in June 2007, the health sector in the Strip has become disrupted by the internal Palestinian schism. Directly after this takeover, the PMS has become nearly paralyzed. Most of the staff of the PMS, similar to their colleagues at the Palestinian Police and Security Forces, has not reported to their work since Hamas takeover of the Strip in June 2007. Hamas health officials had declared that the PMS beneficiaries were eligible to the services of MoH; however, practices on the ground have shown that this eligibility is highly questionable. As a result of the semi-collapse of the PMS and the questionable eligibility of its beneficiaries to the services of MoH, those beneficiaries may shift their utilization of health care services toward using the services of UNRWA health program, health NGOs, and/or private health providers.

In addition to the effects of the internal division on the PMS, the eligibility of some groups of GHI beneficiaries, the pattern of the burden of conflict related health conditions, and the existence and the performance of some health NGOs were affected. Beginning from 2000, the PA has included "the what called the victims of Intifada" in its GHI coverage for nominal fees or free of charges for enrolment in it. The enrollees of this category have amounted to 83,128 Gazan families in 2005⁵⁴, one year before Hamas victory of the election for the PLC. While some enrollees of this category, which includes families of injured and those workers who used to work in Israel or in Gaza before the start of Intifada becoming unemployed after its eruption, was not required to pay for their participation in the GHI , some others have to pay nominal fees for their participation to some institutions, such as trade unions, which are affiliated with Fatah. After Hamas military takeover of the Strip in June 2006, the de facto MoH in Gaza shifted payment for participation in this category to its treasury; hence, shifting and fostering the politicization of an already politicized enrolment in this category of GHI coverage.

Moreover, the existence and the performance of some NGOs were affected by the internal Palestinian division. Directly after its June 2007 seizure of power, Hamas has captured some health care facilities belonging to some NGOs, including a rehabilitation hospital⁵⁵, and transferred them into its control . Capturing NGOs by Hamas has continued during the Hamas exclusive internal control over the strip and reached its peak directly after an explosion that targeted Hamas activists on the 25^th of July near the beach of Gaza, where five of the movement’s military leaders in addition to a young girl were killed. In the weeks following the beach explosion, a broad campaign targeted 205 organizations , approximately 140 of them were NGOs, which Hamas believed were tied to Fatah, where those organizations were raided, sealed, and/ or confiscated⁵⁶.

The health effects of the internal division are also manifested by increasing the burden of internal conflict related mortalities, morbidities and disabilities. During the period of internal fighting in June 2007, mainly in the Gaza city, 161 deaths were reported⁵⁷. Deaths due to internal fighting are not limited to the June 2007 round of massive internal fighting; a human right organization has reported that at least 110 people were killed in Gaza Strip during the first 8 months of 2008⁵⁸.

The consequences of the internal Palestinian division is not limited to the PMS existence, eligibility of some groups of beneficiaries to the GHI, increasing the burden of conflict related health conditions and the existence and the performance of some health NGOs, but it mainly interrupted the performance of the MoH, which is a major health services provider and the supposed steward for the entire performance of the health care system in the Gaza Strip.

3-2-1- Duplicated power in the MoH:

During the Fatah exclusive control over the PA form May 1994- when the PA was established - till March 2006-when Hamas formed its own led government- managerial appointments in governmental apparatus were subject to patronage and political influence. During the one year of Hamas governance, from March 2006- when it formed its own government- till March 2007- when a national unity government was formed after Mecca agreement- , its appetite for power was apparent and it succeeded in shifting the influence in the MoH, especially in the Gaza Strip, gradually from the pro-Fatah previously appointed administrators to the trusted managers of the Islamic movement; but its ability to shift the influence, during that period, was hindered by the fact that appointments of high ranking managers were subject to the approval of the PA president. After its seizure of power in Gaza in June 2007, Hamas de facto government in the Strip has augmented its control over the governmental health services.

After the hamas military takeover of the Gaza Strip, confusion was noticeable among the employees in health facilities. This confusion was attributed to various measures taken by both Fatah and Hamas . On one hand, the Hamas de facto MoH in Gaza had transformed staff to and from positions, and the security forces of Hamas had interrogated and investigated health professionals. On the other hand, the pro-Fatah Rammallah based PA government had withheld payment of the salaries of hundreds of MoH employees. As a result of those practices imposed by both conflicting sides, the ability of the MoH health care facilities to provide quality health care services had been challenged. Staff absence in some of the PHC district offices was noticeable during the working hours, and some employees were not reporting to work as a result of being transferred to different positions/ facilities by Hamas Authority⁵⁹.

In response to the Hamas dismissal of manager of the health care facilities, interrogating and beating some of them by its security forces which maintain heavy presence in hospitals, three syndicates of health professionals declared a strike in August 2007 at the MoH facilities for several weeks⁶⁰. Most of members of the local health unions went on strike, including nurses although the nursing union was not originally involved. Hamas de facto MoH in Gaza responded to the strike by closing the private clinics of physicians who were on the strike and by replacing the permanent health staff by volunteers⁶¹. The syndicates of health professionals have suspended their strike during September 2007 as a "good well initiative" during the Ramadan month. However, many of the health workers were not reporting to work after the end of the strike as an act of protest against reallocation of them or of their managers by Hamas. The WHO Health Sector Surveillance Indicators indicated that 169 health staff out of 323 at Abou Yousef Elnajar Hospital in Rafah did not report to work during the December 2007; a lower level of non-attendance was noticed at other hospitals, 109 employees out of 890 at Shifa hospital, 47 out of 168 at Tal el Elsultan, 40 out of 405 at Alaqsa Martyr hospital, and 47 out of 333 at Kamal Edwan hospital did report to work during the same month⁶².

Even after the end of the health sector strike, organized by the Gaza based syndicates of health professionals, both conflicting sides has continued their practices toward the governmental health services. In February 2008, the de facto MoH led by Hamas has dismissed the General Directors of Maintenance, hospitals, the directorate of PHC and Human Resources Development. Since then, as a protesting measure, a noticeable proportion of the MoH employees, including the majority of the maintenance staff⁶³, is not reporting to wok. This situation in managing and controlling the MoH, has led the employees not knowing to whom reporting, listening, responding, and what to do; and the political loyalty replaced competency and productivity even in posts which require high technical knowledge and skills. De-motivation, absenteeism and non disciplinary performance have become common among the MoH employees. In addition to the collective absenteeism which observed at many health care facilities in response to Hamas measures against health employees who are not loyal to it, low commitment to work of many health workers were observed⁶⁴.

Furthermore, there is a duplicated administrative orders in the governmental health services in the Gaza Strip regarding eligibility for the health services provided by the MoH; the PA President Mahmoud Abbas' had issued a decree to exempt Gaza's 1.5 million residents from paying taxes and governmental fees; however, this decree was not implemented as Hamas parliamentary has assigned staff in the governmental facilities, including health facilities to collect the co-payments from the beneficiaries⁶⁵. These contradicting practices lead to unclear eligibility for the services of the MoH, hindering the patients' rights to receive health care. Licensing health professionals and accreditation of private health institutions is also subject to the conflict over power between the two sides.

While the Hamas de facto MoH in Gaza did not proposed any explicit future plans for health system development in Gaza, the Rammallah based MoH has proposed only 21 percent of the budget of its two years medium term development plan for the Gaza Strip⁶⁶, where 37 percent of the OPT population are living.

3-2-2- An end to Duplicated power in the MoH:

The last days of August 2008 may become a turning point in the performance of the governmental health services and in the overall performance of the health care system in the Gaza Strip.

On 29 August, the Health Workers' Union , which is based in Ramallah, called for an unlimited strike in the Gaza Strip in protest of the decision taken by the de facto MoH in Gaza to dismiss approximately forty employees⁶⁷. While, the Ramallah based PA denies any involvement in the strikes, several human rights groups, including Al Mezan and the Palestinian Centre for Human Rights (PCHR), have argued that it supported the strike⁶⁸ ⁶⁹; and the WHO has reported that local pharmaceuticals’ suppliers have been instructed by the MoH in Ramallah to deliver pharmaceuticals’ shipments for Gaza to the Central Drug Stores (CDS) in the West Bank instead of the CDS in Gaza⁷⁰.

In response to the strike, the de facto MoH in Gaza, which was caught off-guard by the number of striking employees during the first days of its start, has threatened striking staff with the closure of their private practices, revocation of their licenses, and replacing them permanently by other health workers ⁷¹ ⁷² ⁷³. During the first days of the strike, 48 percent of health staff in governmental hospitals and 68 percent of the PHC employees was committed to it⁷⁴ ⁷⁵. Although the strike continues, the proportion of health professionals committed to it, six weeks after its start, was significantly declined to 25 percent in hospitals and to 40 in the PHC centers⁷⁶ . The reduction of the proportion of health workers committed to the strike may attributed to many factors, including inappropriate reporting of the personnel committed to the strike, especially when the data was mainly obtained from the de facto MoH in Gaza, the dissatisfaction of health workforce with the purpose and/ or the nature of the strike, the harsh administrative and security measures taken by Hamas de facto government in Gaza against striking health professionals and the violence against them by Hamas members and supporters. It was reported that the security forces of the Hamas Ministry of Interior has forced essential staff to report back to duty⁷⁷, interrogated hundreds, and arrested dozens of health professionals⁷⁸, and the de facto MoH in Gaza has taken various administrative measures against them including closing their private practices, redeploying of staff, demotion of heads of departments, and replacing striking staff. Moreover, Hamas has organized a series of public actions against health professionals participating in the strike; Hamas members and supporters have organized demonstrations of women and children in front of the houses of striking doctors, some doctors have claimed that they found signs posted on their private clinics, such as " Murder" and " Mercenary child-killer", a group of Hamas clerics prepared a "black list" of striking doctors as shaming device⁷⁹.

Regardless the harsh measures taken by Hamas against the health professionals committed to the strike and the decline of commitment to it by health professionals, the impact of this strike on the health care services facilities was a manifest, though declining. Some of MoH hospitals declared emergency status and suspended all non-emergency health service, twelve of 56 PHC facilities were reportedly closed due to the strike, and the remaining open facilities have limited their activities to essential services⁸⁰. Few weeks after its start, despite the strikes and measures taken by the Rammallah based PA, Gaza hospitals and all but two PHC clinics continued to provide health services, though the quality and timely provision of services remains a concern⁸¹.

The referral abroad department and the Health Coordination Office, which are responsible for issuing and processing referrals for medical management outside the Gaza Strip, do not open their doors during the strike and the directors of the two departments work from their houses to process only the life threatening cases and limited categories of cases, resulting in a decline of cases that actually crossed Erez Crossing during the first three weeks of the strike by 40 percent as compared to the number of patients that crossed Erez during the first three weeks of the previous month⁸² ⁸³.In response, Hamas police has raided the building of the referral abroad department in the Gaza Strip and prevented the employees of the department from accessing its building⁸⁴.

The effects of the last strike on the health delivery system are serious, including diminishing the capacity and the quality of the MoH services, strengthening the grip of Hamas de facto government over the health care system , augmenting the utilization shift of PHC services from the MoH to UNRWA and some NGOs, and may lead the Ramallah based PA to withhold responsibilities for financing the MoH.

4-Discussion:

The negative impacts of the current situation in the Gaza Strip on its health care system are evident. The effects of the Israeli policies and practices toward the strip on its health care system during the last two years are manifested by restricting the movement of patients from the strip to access health care services not available in it, increasing the economic adversity of the population and its effects on their health status and their pattern of health care services utilization, the shortage of fuel and energy supply and their effects on the functioning of the health care facilities, the limited import of construction materials and equipment which hinders the physical expansion and the construction of health care facilities and their maintenance, and the effects of Israeli military operation in the strip on the diseases pattern and on the functioning of the health care facilities. On the other hand, the impacts of the internal Palestinian division is manifested by the semi-collapse of the PMS and transforming the health care facilities of some NGOs into Hamas charities , dismissal and reallocation of Fatah loyalists and replacing them by Hamas loyalists resulting in recurrent strikes , frequent absenteeism and low commitment to work among health professionals in the governmental health services, interrogating and arresting health professionals by Hamas security forces and stopping the salaries of hundreds of health professionals by the Ramallah based PA, unclear chain of command in the governmental health services, unmatched proposed funding for the governmental health services development by the Ramallah based PA to the population proportion in the Gaza Strip, unclear financing mechanisms of the governmental health services, and weakening the already weak capabilities of national health authorities in developing health policy and in regulating and standardizing the health care system.

4-1- Health Care System resilience:

Although the current realities in the Strip have clear negative impacts on the performance of the health care system, it is true that the health care system was able to survive despite the deteriorated quality of health care services. This resilience of the health care system is attributed to several factors including among others the following:

The health care system is characterized by its capability to respond to emergency situations and to deal with high level of uncertainity; the last 8 years after the eruption of the second intifada witnessed high level of experience in dealing with and responding to the recurrent Israeli military operations in the strip, and their impacts on the pattern of the burden of diseases and the health services provision.
The availability and the development of a network of PHC facilities belonging mainly to the MOH and UNRWA.
The geographic characteristics of the Gaza Strip as a small piece of land which is densely populated, making it mostly a big catchment area, made the health care services geographically accessible to the most of the population in the Gaza Strip.
Low enforcement of regulations allows population who are not eligible for some health services to access them regardless of their eligibility.
UNRWA provides free of charge PHC services to about 70 percent of the population, and it traditionally provides more than half of all health care visits to physicians outside the private sector and deliver more than 65 percent of vaccinations and 60 percent of family planning services.
Availability of health professionals in the Gaza Strip. Although, the quality of available health professionals is questionable, their high quantity may partially compensate the low quality.
The scope of Israeli Policy toward the Strip, which is manifested by three vetoes :

" No humanitarian Disasters, No normal life, No Development.", may prevent catastrophic impacts on the health sector, but it jeopardizes its optimal functioning and further development of the health care system.

Heavy involvement of International organizations in financing health care system and in delivering various health projects.
Silent coordination between the de facto MoH and Rammallah based PA health authorities prior to the current health sector strike; The Crisis Group estimated that half of the governmental health services activities during the last year were coordinated between both sides⁸⁵.
Financing the health care system in Gaza was almost stable and sustainable during the last year, where 90 percent of salaries, which represent about 60 percent of the health costs, were paid from the PA Rammallah based payroll, and almost all the expenditure on referral outside the strip was paid from the same source. The WHO, CARE, Islamic Relief, and other international organizations have financed the procurement of drugs and other medical consumables.
Involvement of the United Nation Organization ( mainly the WHO and the OCHA ) in monitoring the humanitarian situation and issues pertaining to the health care system performance, making the early identification of crisis indicators possible.

4-2- The Future of the Health Care System:

The resilience and the survival of the health care system in the Gaza Strip during the last two years despite the harsh realities encountered are not infinite in the context of politically complex and unpredictable environment. The current status quo with continuing the Israeli policy of sealing the strip and possible recurrent military operation in it, and the deepening rift in the internal Palestinian landscape with strengthening the security and the bureaucratic grip of the Hamas de facto government in Gaza will certainly pose additional challenges on the daily life and health issues in it in both the short and the medium terms.

The sustainability of financing the governmental health services and the nature of health care system are areas of concern. On one hand, the ability of de facto government in Gaza to secure sustainable financing of the governmental health services is questionable; on the other hand, the recent health sector strike may question whether the Rammallah based PA will continue financing governmental health services that are getting out from its control. Furthermore, the attitude and the behavior of the de facto MoH in Gaza may encourage any observer to predict a health system management with an authoritarian nature.

The development of the health care system and sustaining the existing levels of health services delivery are other areas of concern. Any health care system in an area with a relatively high population growth will certainly need regular expansion of the available health care services and addition of new resources to existing ones; it was estimated that Gaza Strip requires 425 additional physicians, 520 new nurses, 465 new hospital beds, and 24 new PHC centers by 2010 in order to keep the health care delivery system in track with the previously existing one⁸⁶. The current situation on the ground, where Israel does not permit the free movement of health human resources and goods necessary for both health human resources and physical infrastructure development and where the capabilities of the existing national health authorities to develop coherent plans and to secure funds are decreasing , makes it difficult, if not impossible, to respond to the health system development needs.

It should be recognized that there will not be a normal performance of the Palestinian health care system without a radical solution for the Palestinian question by ending the Israeli Occupation, it is very important, now, to neutralize the health issues in the Gaza Strip from the political motives, driving it away from the Israeli-Palestinian conflict and from the internal Palestinian political and administrative division. Meanwhile, taking the health care system in the Gaza Strip away from its politization is extremely difficult; therefore, looking for innovative alternatives to secure acceptable levels of funding the health care system and to sustain the current levels of health services provision.

4-3-Looking for Alternatives:

Suggesting a Transitional Neutral Health Authority (TNHA), in order to supervise and to mange the governmental health services and to steward the overall health care system in the Gaza Strip might be an alternative to the current status quo in the internal management of the health care system, and might decrease the negative impacts of Israeli policies and practices of siege on the health affairs in the Gaza strip. However, converting this suggestion into practice could not be achieved without its acceptance by the concerned parties, including mainly Hamas, the Rammalah based PA, and the suggested governing body of the TNHA.

Some suggested governing bodies of the proposed TNHA could include: Palestinian health NGOs, the UNRWA Gaza Program, neutral national health experts, or the direct involvement of the WHO in managing the governmental health services and shepherding the health care system in the Gaza Strip.

Proposing local health NGOs in leading the TNHA should be put in mind; however, the capacity, the neutrality, and the acceptance of their role by both Hamas de facto MOH in Gaza and the Rammallah based PA are highly questionable. Moreover, Palestinian health NGOs has repeatedly declined willingness to provide health services which are currently delivered by the governmental health facilities.

Suggesting UNRWA Gaza health program to lead TNHA could be a good alternative, especially when UNRWA is a major provider of PHC services in the Gaza Strip, is highly neutral UN organization, and is respected by both the Hamas de facto MoH in Gaza and the Rammallah based PA; however the UNRWA has no experience in the direct provision of secondary health services, hindering its ability to manage the governmental health services, where about 70 percent of health expenditure are spent on secondary health services. Furthermore, the willingness of UNRWA health program in managing the delivery of governmental health services and supervising the national health care system is highly questionable.

Mandating a body, consisting of national neutral local and expatriate national health technocrats, could be suggested. But even the availability of neutral national technocrats may be questionable in the context of highly politicized internal Palestinian environment. Moreover, the nature of the existing regime in Gaza may exert pressure on any neutral national individuals or groups shifting them from their supposed neutrality; moreover, the local technocrats may not be able to recruit funds to finance the national health system without the support from the international community.

Alternatively, the WHO could lead the governing body of the TNHA with coordination with other UN organizations active the health sector in the Gaza Strip, recruiting both national health technocrats, local and expatriates, and international health experts, and using the organizational structure of the MoH in Gaza prior to Hamas takeover of the Strip in June 2007. The idea of proposing the WHO as a steward of the health care system and as a shepherd of the governmental health services in the Gaza Strip may offer a window of opportunities; this may improve the possibility of patients to access health services outside the strip, especially when Israel is a member state in the WHO; could ensure good recruitment of funds to finance the health care system; could directly bring the technical expertise of the WHO into the governmental health services; could foster coordination between the governmental health services and UNRWA health program in Gaza toward avoiding duplicated eligibility, services provision and utilization, and efforts by the two main services providers in the Gaza Strip; and may offer an opportunity for the governmental health services to benefit from the technical assistance projects to the health sector offered by international developmental agencies, especially when some developmental agencies, such as the USAID, have suspended their support to the MoH after Hamas victory in the election of PLC in January 2008.

4-4-Living with the Status Quo:

Any suggestion to propose a neutral governing body, or authority, to lead the health care system in Gaza could be put into practice -or hindered- by its acceptance - or rejection-by concerned parties, especially by Hamas de facto MOH in Gaza, the willingness- or unwillingness- of the state of Israel to cooperate with it, and the willingness- or unwillingness- of the supposed elements of the neutral governing body to have this function. Hence, this idea may be an illusive one representing a wishful thinking; therefore, it is wise to suggest some day-to- day remedies to overcome or to minimize the effects of the current realities, which may last for years or even decades, on the Gaza's health affairs.

Some of those remedies could include, among others, sustaining the role of the governmental health services by attempting shifting them from the internal Palestinian division and attempting to manage and to operate them on merely professional standards avoiding the militarization of governmental health care facilities, sustaining the funding of the health care system by creating mechanisms that ensure that no party will exploit its power as a sponsor of the health care to cut salaries or to give them on the background of political loyalty; sustaining and strengthening the role of UNRWA health program as a major PHC services provider for 70 percent of the population; strengthening the role of some health NGOs in the provision of some services and functions, such as ambulance and emergency services, physical and mental rehabilitation, advocacy for health rights, and health education and promotion; continuing and strengthening the role of some UN organizations, such as the WHO and OCHA, in monitoring the health care system and the humanitarian situation, in order to early detect any further deterioration of the performance of the health care system and to minimize and to prevent possible deteriorations in its outcomes; and advocating for a better access of patients to receive health care services not available in the strip and exerting pressure on the state of Israel to allow entry of spare parts, medical consumables, equipment, construction materials, and energy necessary for the regular performance and the future development of the health care system in the Gaza Strip.

The future of Gaza is uncertain, and only a miracle could convert Gaza into a normal place for the lives of human beings. If the current affairs in the health care system in the Gaza Strip will continue, it will not only has short term negative effects on the daily operational level , but it will certainly have a non desirable implications on the medium and the long term on the health situation in the Gaza and may threat reversing the achievements of the health care system in the Strip which was gained during many decades through continuous effort of many thousands of dedicated and industrious health professionals. Therefore, a proactive approach is required in dealing with the health affairs in Gaza regardless of their bleak prospective, reminding of the Antonio Gramsci paradoxical and lovely phrase: "Pessimism of the intellect, optimism of the will."

Could the common sense prevail?

(please see document for footnotes)

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