The best solution for health in the occupied Palestinian territory is a sovereign Palestinian state

March 04, 2009

Developing the ailing health system in the occupied Palestinian territory (OPT) will be near-impossible under military occupation. The best-case scenario to improve the health system would include the creation of a sovereign Palestinian state. These issues are discussed in the fifth and final paper in The Lancet Series on Health in the Occupied Palestinian Territory, written by Dr Awad Mataria, Birzeit University, OPT, and colleagues.

Four main providers are responsible for primary, secondary, and tertiary health care: the Palestinian Ministry of Health (PMoH), Palestinian non-governmental organisations, the UN Relief and Works Agency, and the private sector. Health services are financed through a mixture of taxes, health insurance premiums and co-payments, out-of-pocket payments, local community financial and in-kind donations, and loans and grants from the international community. Reviews of the health sector estimated that total health expenditure in 2002 was 8•6% of gross domestic product (GDP) and per-person expenditure was $135 in 2005.

While some indicators for the OPT are good (most women receiving some form of antenatal care and 95% immunisation coverage), inequalities persist and mental-health problems are rising. The authors say: "In view of the turbulent situation, the chances of the occupied Palestinian territory achieving most Millennium Development Goals by 2015 are low."

Movement restrictions cause serious problems for the health sector. In July, 2007, alone, there were 40 recorded cases of ambulances being denied access to patients in the West Bank. A survey at the end of 2003 found that the number of people needing 1 h or more to reach an appropriate health facility had increased by ten times in 3 years.

Financial accessibility to health services, especially for the most deprived sections of the population, has been compromised since 2000. Results of recent surveys show that a third of a representative sample of the population could not access health services because of high costs and that people living with financial hardship or in poverty are twice as likely as rich people to be unsuccessful in accessing hospital care.

Health services in the Gaza strip have deteriorated rapidly since the political impasse between Fatah and Hamas, and the Israeli and international boycott of Hamas. In June, 2007, Israel refused to allow travel outside the Gaza Strip for all patients referred to health-care services abroad through Israel (282 cases), a policy indicative of Israel's decision to impose collective restrictive measures against civilians in the Gaza Strip. A recent WHO report documents patients who died between October, 2007, and March, 2008, after being denied access to specialised treatment from outside the Gaza Strip.

Whereas Israel has 6•3 nurses for every 1000 people, the OPT has only 1•7. Health-care services remain highly physician oriented, with doctors running many activities that could be done by nurses and community health workers at much lower costs. Insufficient monitoring and lack of supervision have allowed cronyism and corruption, a lack of commitment and interest, and erosion of public trust and satisfaction.

The authors say: "The factors that hinder health system development are not unique to the occupied Palestinian territory, but they are exaggerated and perpetuated under the oppressive conditions of the Israeli military occupation. Furthermore, occupation creates some of the difficulties. Occupation policies of separation, isolation, and segregation have created uncertainty, raised transaction costs, and shrunk markets, resulting in critical constraints on the survival of the Palestinian economy as a whole."

The authors go on to say: "Under the best-case scenario, the Palestinian Ministry of Health can choose to limit its role to being the steward of the system, while providing a basket of core services--including public-health activities--and the funding needed to cater for the needs of specific categories of the population, for example vulnerable groups...Under the worst-case scenario, the focus has to remain on emergency relief, with attempts made to pursue human capacity development. Finally, the scenario of the continuing status quo means consideration should be given to coordinating and harmonising the efforts of donors and providers to avoid wastage of scarce resources."
Dr Awad Mataria, Birzeit University, OPT. T) +972 2298 8654/5 E)

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