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

Majdi Ashour, MD, MPH
Public Health and Health Policy Specialist
Acknowledgement
1-This analysis merely reflects my own views about the
effects of current realities in Gaza on its health care
system, its future , and possible actions that might
prevent a further deterioration in the health affairs ;
and does not represent any organization where I am
working or where I volunteered for.
Acknowledgement
2-This description and analysis of the benefited from several
sources of information and data, including:
1- Various reports of the Palestinian Ministry of Health
( 1994-2005)
2- Reports of the WHO : especially the “Health Sector
Surveillance Indicators: Monitoring the Health Sector in the oPt”
3- Data of the PCBS (1997-2008)
4- Reports of Crisis Group on the Gaza affairs.
5- UNRWA, OCHA, UNDP, and other UN organizations.
6-Books, reviews, and peer reviewed published articles about
the Palestinian Health Care System.
7-Reports of local and International health and HR NGOs.
8- Others.
Social Determinants of Health:
*Social factors have great influence on the performance
of national health care systems; those social factors
could be categorized into economic, political, and
cultural.
*This paper will be concerned about the influences of
political and economic factors on the Health Care
System.
Economic and Political Factors: The Case of
Infant Mortality Rates (IMR) in the Gaza Strip
To demonstrate the influence of political factors, it
is wise to mention that 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.
20
0
20 5
0
20 4
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20 3
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20 2
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20 1
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19 0
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70
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70
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10
0
year
Infant Mortality rate
Cessation of IMR decline In Gaza:
Infant Mortality Rates (IMR) in Gaza Strip 1970-2005
Current realities in the Gaza Strip (GS):
Acute political turmoil and socioeconomic adversity in
the context of a protracted political conflict. (Acute on
top of Chronic).
The main factors influencing the GS realities are:
1- Israeli Policies and Practices.
2- The Internal Palestinian Division.
Israeli Policies and Practices:
The Israeli policy toward the G S 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 has lead to:
1-Sealing Gaza.
2-impoverishing Gaza.
3-victimizing Gaza.
The effects of Sealing Gaza on its Health
Care System :
1- restricting the movement of patients and health
Human resources from the strip to access health
care services and training opportunities not
available in it .
2- Restricting the import of fuels, energy,
construction materials, equipments and spare
parts hindering the regular performance and the
future development of health care facilities .
3- Sealing Gaza has led to its impoverishment.
The effects of Impoverishing Gaza:
1- exacerbating the diseases of poverty and bad
nutrition.
2- Shifting the utilization of health care services toward
free of charge Health Care Services.
1- Change
in the diseases’
burden:
The
effects
of
victimizing
Gaza:
- The conflict related mortalities became the 2 or 3 cause
nd
rd
of death during the last years.
- Increasing the burden of physical disabilities and
psychosocial conditions.
2- disrupting the performance of health care services
facilities:
Due to the excess of injured patients received by the hospitals
and admitted to them during the Israeli military
operations, hospitals were oversaturated by injured forcing
them to postpone regular admissions and prematurely
discharge patients.
Internal Palestinian Division:
1- Aftermath of June 2007 military takeover.
2- The period of coexisting duplicated power in the
Ministry of Health (MoH).
3- The current Health Sector Strike and its possible
results.
1- Aftermath of June 2007 military takeover.
-Increasing the burden of conflict related health
conditions. ( Deaths, Disabilities, and PTSD)
-The semi-collapse of Police Medical Services.
-The questionable eligibility of some groups of GHI
beneficiaries to the MoH services.
- Reversing administrative orders for MoH financing.
- The takeover of some NGOs health facilities and
transferring it into Hamas charities ( Fita Hospital).
- The heavy presence of security forces in health care
facilities.
The Aftermath-Cont.
- Cutting salaries of hundreds of MoH employees by
Ramallah based PA.
- Redeployment of staff and appointments of
Hamas loyalists in managerial positions.
- Absenteeism, de-motivation, and low
commitment to work among MoH workforce
- Beating, interrogating, and investigating MoH
workforce.
- Health sector strike: (August 2007)
- questionable quality of services and utilization
shift.
2- coexisting duplicated power in the MoH.
- Continuing the same practices at various levels and
intensity, while halve of MoH were silently
coordinated.
- Contineous waves of cutting salaries by PA.
- Replacing PA managers by Hamas loyalists.
- Gaza De facto MoH did not declare any explicit
health plans.
- The PA has proposed only 21 percent of the budget
of its two years medium term development plan
for the Gaza Strip, where 37% of OPT population
are living.
Health Sector Strike:
*Although the scope of the strike is diminishing, its
consequences on the performance of the MoH is
evident.
* It may become a turning point in the future of the
Health Care system in Gaza, especially when
aggressive measures were taken by both conflicting
parties during the strike.
The current MoH strike:
- 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.
The scope of health system performance or
deterioration.
No Health System collapse, No quality, and Dedevelopment.
No diseases outbreaks.
No nutritional emergencies or catastrophes.
No catastrophic health expenditure crisis.
Access to health services is secured.
No Normal performance of health care services
No Health planning.
But, the future is uncertain.
 its capability
to respond
to emergency
situations and
to deal with high level
of
The
causes
of
Health
System
Resilience
:
uncertainity.
 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, making it mostly a big
catchment area, made the health care services geographically accessible to the
most of the population.
 Low enforcement of regulations allows population who are not eligible for
some health services to access them regardless of their eligibility. ( Decreasing
the possibility of Catastrophic health expenditure)
 UNRWA role in health services provision.
 Availability of health professionals in the Gaza Strip.
 The scope of Israeli Policy toward the Strip, which is manifested by three vetoes
:
 " No humanitarian Disasters, No normal life, No Development
 Heavy involvement of International organizations .
 Silent coordination between the de facto MoH and Rammallah based PA health
authorities prior to the current health sector strike.
 Financing the health care system in Gaza was almost stable.
 Involvement of the United Nation Organization in monitoring the
humanitarian situation and issues pertaining to the health care system
performance
The Future of the Health Care System:
A need for health system
development in an area with high
population growth.
No one can predict future in a
unstable political environment; but
if the current situation continues,
the future will be bleak.
Looking for Alternatives:
Neutralization of the health care
system from politicization and its
operation in a professional
manner is the key point for any
alternative.
Could the WHO become a steward in Gaza
HCS?
Suggesting
a transitional neutral
administration of the national
health system under technical
and managerial supervision of
the WHO to derive it from
politicization.
How to live better with the Status Quo :
1-Sustaining the role of the governmental health services by
attempting shifting them from the internal Palestinian
division
2-Sustaining the funding of the health care system
3- Sustaining and strengthening the role of UNRWA health
program strengthening the role of some health NGOs in
the provision of some services and functions.
4-Continuing and strengthening the role of some UN
organizations in monitoring the health care system and the
humanitarian situation
5-Advocating for a better access of patients to receive health
care services not available in the strip
6-Exerting pressure on the state of Israel.
The despair and the hope
"Pessimism of the intellect:
optimism of the will."
Antonio Gramsci
Endnote:
ٍٍ
Some of my points of view could be political incorrect,
but realities are very complex.
Thank you