The incidents around the perimeters of the Gaza fence, which separates the area from Israel, have led to more than 12,000 Palestinians being injured, and a further 110 unarmed people dying. Reactions have ranged from outrage to blaming the Palestinians for their victimhood, echoing the old and well-known statement of the late Israeli Prime Minister Golda Meir: “we will perhaps forgive them for killing our children, but it will be harder for us to forgive them for forcing us to kill their children”.
I have been following the news from Gaza from a distance, and two observations have attracted my attention. The first is the nature of the gunshot injuries inflicted by the professional snipers, who most probably attended lessons in human anatomy; pictures have shown victims with extensive bullet exit wounds. Other pictures have shown that the bullets that were used had the ability to explode inside the body, severely damaging the soft tissues and pulverizing the bones into dust. This may indicate that the military industry was testing new weaponry in hunting fields.
The second is the condition of the public hospitals of the MoH, where the vast majority (88.7%) of those who were wounded and treated in hospitals were managed. The number of injured exceeded those of the Israeli war on Gaza in the summer of 2014, and the wounded were treated on the floors of emergency rooms and corridors of surgical sections and operating theatres. Reports and pictures showed that two or even three patients were operated on, in one theatre, at the same time. In fact, the hospitals’ absorptive capacity was much lower than the huge number of people that were injured during the shootings; this is consistent with what happened in Winter 2008-2009 and Summer 2014, when Israel attacked Gaza.
Each time the Gaza Strip is subjected either to a military attack or to exacerbation of its harsh humanitarian realities, media outlets and reporters inform us about the collapsing health system or in the best case scenario, that the health system is on the verge of collapse. It is true that the health system in Gaza has been severely challenged by the effects of the Israeli blockade which has made the strip a hermetic enclave, but it is also true that the first casualty when war comes is the truth. Contrary to the image conveyed by media outlets and many healthcare actors, who are lobbying for funds, the healthcare system in Gaza is far from collapsing. However, it is in a state of constant turmoil and unceasing effervescent, and subject to external pressures and internal dynamics that influence both its disruption and its survival.
I understand that the last sentence challenges the convenient thinking adopted by solidarity activists who advocate for Palestinian rights and by academic scholars and health systems researchers who look at the Jungle without feeling the touch of the trees.
Health services in the Gaza strip: a long history
The history of conflict and dispossession has made publicly provided healthcare the backbone of health services in the Gaza Strip. The exodus of more than one quarter of dispossessed Palestinians from their villages and townships, which became part of Israel, in the aftermath of the 1948 war into the Gaza Strip, which constituted only 1.4% of Palestine, has created a humanitarian crisis. This forced the UN to intervene, offering free of charge primary healthcare through UNRWA to refugees, who constitute two thirds of Gaza Strip’s population. Under Egyptian administration, for two decades, governmental healthcare was expanded and offered on a free of charge basis, and private provision of healthcare was limited to one Christian missionary hospital that existed in Gaza during the British mandate and to dual practicing private practitioners, who moonlighted after the end of their working hours in the public healthcare facilities.
Confronted by the free of charge healthcare, the Israelis introduced co-payments on drugs dispensed and diagnostic tests performed at governmental healthcare facilities that they controlled in Gaza, instituted a Government Health Insurance scheme to collect revenues and kept hospital services stagnant, ensuring dependence on the Israeli healthcare system for the 27 year period of their control. Notwithstanding, the Israelis expanded the network of primary healthcare services and strengthened the disease control programs, since germs and viruses do not stop at the checkpoints. Inspired by both nationalist and ideological agendas, in the 1970s and 1980s, popular health committees were set up by leftwing activists. These have, in time, become, particularly during the Intifada of stones, the backbone of Palestinian health NGOs, which were kept minuscule or at best filled niches uncovered by the publicly provided services.
The post-Oslo period brought new developments. The first Palestinian health authority, thanks to the generous support from international donors, was able to rehabilitate hospital services and expand the network of primary healthcare. The global tendency to promote private provision of social and health service found a place in Palestine, but while the MoH gave the green line for healthcare entrepreneurs to operate in the West Bank, the poverty stricken Gaza Strip made such business a mission impossible. To counter this, the MoH encouraged private not for profit NGOs to expand. The increasing financial adversity of the population, coupled with violence, which resulted from the failure of the Oslo process, has prevented the implementation of Bretton Woods institutions’ prescriptions.
The Second Intifada (in 2000) generated a situation in which Israelis divided the tiny Gaza Strip into four separate enclaves and severely restricted the passage of people and goods from and to the strip, rendering those who used to work inside Israel jobless and harming the local market. Responses to this situation included the expansion of MoH hospital services to make them geographically accessible for people who were living in the shuttered areas, and the extension of enrolment in the Government Health Insurance scheme to make MoH services financially affordable for the impoverished population, resulting in a situation of semi-universal health coverage. The health services provided by NGOs expanded further during the second Intifada, and the so called “Hamas Civil Society” activity in the health sector became stronger and more visible.
The last decade, when Hamas became internally in charge of the Gaza prison facility, has produced new dynamics that have affected the healthcare system. Israel restricted passage of the supplies of materials necessary for the operation of healthcare facilities, isolated health cadres from around the world, and restricted the passage of patients trying to receive treatment unavailable in Gaza. International donors adopted no contact policies with Hamas and ceased, or at best decreased, their direct support to the services of MOH controlled by Hamas Gaza Health authorities. Additionally, the Ramallah based Palestinian Authority has repeatedly interrupted its supply of material resources to the MoH facilities in Gaza. All of these, in addition to Hamas practices, have disrupted and destabilized MoH services, which are considered alongside the free of charge UNRWA primary healthcare, the major public options for healthcare .
MoH hospitals have not been dormant and have maintained their role as the main providers of secondary healthcare services, however, the average number of MoH hospital beds, admissions to them, and surgeries performed there has been declining. MoH Primary healthcare centres are fewer, because four of them were destroyed during the Israeli onslaught of 2014, although the decline in the number of primary healthcare centres and utilized services can not only be attributed to this.
On the other hand, private healthcare is thriving. Local and outside training institutions have oversupplied the healthcare market with health human resources that are not absorbed by the local health system. Disabled by the lack of financial resources, the Gaza Health Authorities have encouraged the private provision of healthcare and consciously or unconsciously started to implement advice that was given by the World Bank in the past, which was not implemented during the immediate post-Oslo period. It has increased co-payments, strengthened its revenue generating abilities, introduced private healthcare at MoH hospitals and increasingly contracted NGO hospitals to provide healthcare for patients who co-pay for these services. While western donors and international NGOs have stayed present in this conflict affected area with symbolic connotations, Islamic donors have also become increasingly more visible.
NGO hospitals, which are staffed mainly by dual practicing physicians and which provide services on a fee for services basis, have been thriving thanks to external funding which has shifted away from supporting the MoH services towards them. Additionally, Gaza health authorities, which reportedly treated Islamic NGOs preferentially, have encouraged their growth. The number and bed capacities of NGO hospitals and surgeries performed in them have more than doubled in the last decade. Similarly, NGO curative out-patients and primary healthcare services have grown remarkably.
An emerging two-tier health care delivery system
The challenges faced by MoH facilities, and the growth of the private health sector in the last decade have created new developments. A two-tier healthcare delivery system is emerging, whereby MoH hospitals alongside with its and UNRWA primary healthcare, serve those who cannot afford to pay for private healthcare and those people whose health conditions are not manageable within the private sector. Meanwhile, those who can afford payments or who seek practitioners courtesy, swift clinical pathway and additional attention use the services of private health sector.
As with previous post-conflict periods, it is expected that donors and the international aid industry will increase their presence in the Gaza Strip and funnel additional technical and financial support to the health sector. Will they ever learn that supporting healthcare by bypassing the Ministry of Health in Gaza under the pretext of it being under the Gaza Health Authorities controlled by Hamas, will only contribute to weakening the backbone of the entire health care system and harming the already harmed population, the majority of whom are unemployed and below the poverty line??
You probably know the answer.