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 StripTo 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.

Cessation of IMR decline In Gaza: Infant Mortality Rates (IMR) in Gaza Strip 1970-2005

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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.

The effects of victimizing Gaza: 1- Change in the diseases’ burden: - The conflict related mortalities became the 2nd or

3rd cause 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

De-development. 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

servicesNo Health planning. But, the future is uncertain.

The causes of Health System Resilience : its capability to respond to emergency situations and to deal with high level of 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