Healthcare in the State of Palestine

Between 1993 and 1995, the State of Israel and the Palestine Liberation Organization (PLO) reached a series of pacts collectively known as the Oslo Accords.[9] The accords were facilitated by the international community, led by the United States and the Russian Federation. The accords established an autonomous Palestinian National Authority (PNA) that could administer the occupied territories.[10] The accords transferred jurisdiction over Palestinians living in the Gaza Strip and the West Bank from Israel to the PNA, whose charter calls for the creation of a democratically elected Legislative Council that could write laws pertaining to the economic, security, educational and health care needs of Gaza and West Bank Palestinians.

Since 1967, a division of the Israeli Military known as the Health Department of the Civil Administration (HDCA) had been responsible for overseeing health care in the occupied territories.[11] During this time, HDCA’s work was greatly supported by three other major sources of health care: Non-governmental organizations, the UN, and the private sector.

Shortly after Oslo I and the corresponding transfer of jurisdiction, the PNA established a Ministry of Health (MOH) to administrate healthcare in Gaza and the West Bank.

Until 2007, PNA healthcare policy was fully exercisable in both the West Bank and the Gaza Strip. However, in the 2007 Battle of Gaza, Hamas militias forcibly expelled all rivals from Gaza, bringing Gaza firmly under Hamas control.[12] Hence, as of 2007, the PNA’s control does not extend to Gaza de facto. Despite its lack of de facto control, the PNA still contributes financially to health care in Gaza by assisting with salaries of some health officials and sending medical supplies.[13][14]

Through its Ministry of Health (MOH), the PNA provides health services to Palestinians under its jurisdiction in accordance with the Constitution and the Public Health Law. Additionally, the PNA government insurance plan is the principal insurance provider in the PNA run territories. Since the ascendancy of the Hamas government in Gaza, the PNA’s MOH no longer serves a governmental function in Gaza healthcare, having been replaced by Hamas. The majority of funding for MOH services emanates from foreign aid and taxes. Public sector spending represents about 32% of health care expenditure in the Palestinian territories.[17]

Since its inception in 1948, UNRWA has had jurisdiction over the social services of Palestinian refugees . The organization has money in its budget (which is determined by the UN) to provide free health services to eligible Palestinians living in the West Bank and in Gaza provided that they are registered as refugees. As of 2012, the UNRWA provides health services to 727,471 people in the West Bank through some 42 primary health centers and to 1,167,572 Gazans through 21 Primary Health centers.[18][19] The UNRWA finances about 24% of all health care spending in Palestine.

PHR-IL Mobile Clinic Medical day for women In Azbat Jarrad village, near Tul Karem, April 2010

Palestinian Non-Governmental Organizations (NGOs) bankrolled by private benefactors encompass a sizable portion of the health care economy in the PNA. A World Bank survey found that 11.7% of Palestinians used NGOs most frequently for their health needs. 13.3% of households in the West Bank relied on NGOs compared to 8.1% of households in Gaza. The World Bank report explained that fewer NGOs operate in Gaza than in the West Bank and that Gaza residents are more likely to be classified as refugees and therefore to have access to services provided by UNRWA. Palestinians are most likely to visit NGOs when they require mental health counseling, physical therapy and rehabilitation, and medical training and they are least likely to use NGOs for emergency care, routine check-ups, and maternity and pediatric needs. The Department for International Development, a British government agency, found that a visit to an NGO-run primary health clinic cost twice as much as a visit to a government clinic and four times as much as a visit to a UNRWA facility. In 2004, DFID reported that NGOs employed 33% of workers in the Palestinian health sector, while the Palestinian Central Bureau of Statistics put the figure at 26% in 2005. In 2003, Palestinian NGOs received $54 million from donors, out of about $240 million donated for healthcare in the Palestinian territories.[20]

The private health care space has grown in recent years with the advent of privately held hospitals, pharmacies, laboratories, and rehabilitation centers. A nascent pharmaceutical industry has also developed, which is able to supply about one half of total Palestinian demand for prescription medicine. Some private health insurance programs have been established, though with limited popularity. Many Palestinians with means self-pay for health services not available to them through other avenues and private expenditure comprises roughly 37% of all spending on health care in Gaza and the West Bank.

A 2012 article in The Lancet says the Israeli Military's blockade of the Gaza Strip as a major health challenge.[28] Hospitals in the West Bank and in Gaza are sometimes not equipped to deal with more advanced medical problems and procedures. In such cases, doctors will refer their patients to more sophisticated treatment centers in Israel. Such treatment is often delayed by the Israeli bureaucratic process which has to approve requests. Ambulances traveling from the Palestinian territories to hospitals in east Jerusalem are often delayed or denied at security checkpoints.[29] Moreover, within the West Bank, mobility is limited as residents must pass through Israeli checkpoints in order to travel in between various West Bank cities. This means that West Bank residents have trouble accessing health care providers located in other nearby West Bank towns. The limited mobility has even more serious ramifications in emergency situations wherein ambulances traveling in between West Bank towns experience delays.[30]

According to the WHO, the residents of Gaza are in a particularly precarious position given Israeli tensions with the de facto Hamas government. Hamas claims that Israel has severely obstructed the flow of goods to that region since 2007, preventing the importation of essential medical equipment and prescription drugs. In recent years, periodic battles between Hamas militants and the Israeli Military have resulted in much damage to the medical infrastructure in Gaza which cannot be readily repaired due to limitations on the amounts of construction material being imported to the region. According to the Israeli government, it has imposed no restrictions whatever on medical supplies and equipment since 2010. In any case, supplies could be imported through Gaza's border with Egypt.[31] Additionally, Palestinian officials maintain that the quality of health care professionals in Gaza has been hampered as they are often not permitted to travel abroad to conventions and training sessions where they can advance their skills and knowledge.[32]

Besides the problems posed by the conflict with Israel, a major challenge to health care in the PNA territories is the fact that the PNA is currently not at liberty to physically implement policy in Gaza. Currently, the extent of its involvement in Gaza health care is limited to the financial contributions it makes there.

The PNA has identified government expenditure on health care to be unsustainable in the long term absent alterations in financing mechanisms. Approximately 30.5% of those enjoying health care provisions from the government do not currently pay into the system, causing the PNA to incur debt or rely on donations to cover the difference. Moreover, in recent years, participation in the government’s health plan has been on the decline, leaving the MOH with fewer revenues. In response, the PNA is currently considering adopting a single-payer health care system whereby all Palestinian residents under its de facto jurisdiction will be mandated to purchase insurance from the government. Currently, mandates to purchase the PNA's insurance extend only to civil servants and retirees. The PNA hopes that a universal scheme will stabilize revenues and reduce inefficiencies. To meet the new demands that universal coverage would place on the system, the PNA will first have to make substantial investments in the MOH’s administrative capabilities.[34]

The WHO has described the PNA’s Health Information System (HIS) as "incomplete, fragmented, unreliable, and outdated".[35] With $86 Million in assistance from the United States Agency for International Development (USAID), the PNA plans to upgrade its HIS from paper based to electronic, the first such system in the Arab Middle East.[36] A central database is to provide computerized and up to date information on matters such as medical professionals, patient medical records, and prescription drug use. In addition to streamlining information on individual patients across all medical facilities, the data gathered will be used for research, enabling the medical community to pinpoint health trends and incidence of disease more accurately than ever before.[37]