Health in Gaza

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

• Majdi Ashour, MD, MPH
• Public Health and Health Policy Specialist

2
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.

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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.

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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.

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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.

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Cessation of IMR decline In Gaza
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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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 services
• No Health planning.
• But, the future is uncertain.

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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

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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.

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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.

22
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.

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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.

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The despair and the hope

• "Pessimism of the intellect optimism of the
  will."
• Antonio Gramsci
  

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Endnote

• ??
• Some of my points of view could be political
  incorrect, but realities are very complex.

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• Thank you