Mona Jebril
The current health system in Gaza today is a fragmented front, an amalgam of political entities and wills in place, so often adversarial, shaping health experiences for Palestinians under conditions of occupation, violence and deteriorating economy. The necessity of the situation requires that the health sector be de-politicized so as it can come together to support those who are most in need. Nonetheless, in such conflict-affected areas, politics remain a key factor on the ground, underpinning health care in Gaza.
A legacy of fragmentation and politicization
An overwhelming refugee majority area, the Gaza Strip suffers from the consequences of decades of occupation. Despite its small geographical size, Gaza was ruled consecutively by the Ottomans (1516-1917), the British Mandate (1917-1948), Egypt Administration (1948-1967), and since then by the Israeli occupation. Reviewing the existing literature it is clear that, the foreign regimes and outsider funders’ agendas have shaped the health system, in ways that were not in the best interest of the Palestinian people. Consequently, it was necessary that health became intertwined with political activism, through establishing a network of Palestinian non-governmental organizations (PNGOs) that were motivated by the aim of supporting the Palestinian community for better health services. Nonetheless, in a politically charged context, such organizations were not only professional they also carried their ideologies, sometimes competing with each other for factional gains or over funder money; hence these Palestinian NGOs are themselves fragmented.
Currently, there are four main providers of health in Gaza, UNRWA (since 1948); NGOs (since 1970s); the private sector, and the Palestinian Ministry of Health. In effect of the Palestinian schism in 2007, there becomes two Ministries of Health (MoH); Palestinian National Authority (PNA) –run MoH in Ramallah, and Hamas-run MoH in Gaza. Nonetheless, decision making in the health sector in Gaza does not seem to be under the control of any of these actors. In fact, Israel’s siege on Gaza, and the imposed ‘dual list’ restrictions on drug imports to Gaza have significantly incapacitated the health sector. Also, referrals to Israeli hospitals are reported to be a traumatizing experience in which patients and their carers’ permits are so often delayed or rejected, and they are also exposed to investigations on the borders. On top of all this comes at least three devastating offensives launched on the Gaza Strip since 2008, which resulted in many deaths, injuries and disabilities among the Palestinian people. But, the Palestinian schism since 2007 has also fragmented health services further, as well as increasing pressure for adaptation to funder’s agendas. This is in addition to acts of political clientelism of Hamas and the PNA in health institutions in Gaza which reflected negatively on the sector, causing a lack of unified management, funding and implementation strategy for Palestinians. All in all, currently the health system in Gaza, if it is even right to call it a system, is on the ‘verge of implosion’.[1]
De-politicising Gaza health sector as a necessity
As part of R4HC-MENA project, I interviewed policy makers, health officials and carers of patients in Gaza, via telephone, mobile and Skype. All seemed to agree about how important it was for Palestinian health system to come together in cooperation despite any political divisions that may be in place. The interviewees also all emphasized the responsibility of Israel towards the deteriorating condition of health care for people in Gaza, especially as the sector currently suffers from a dire lack of facilities, drugs, training and the migration of health expertise. Under siege, people in Gaza lack alternatives and thus rely heavily on the services in Gaza, in addition to referrals to West Bank, Israel and Arab countries which is described in the literature as an ‘extensive[ly] bureaucratic’ process.[2]
As mentioned above, the relationship between Hamas government in Gaza, and the Palestinian National Authority in the West Bank is fraught with tension, it is also definitely so with Israel. But, the Palestinian schism has a destructive and bitter impact, as it is a suffering that Palestinians inflect on other Palestinians.[3] The repercussions of Israel and Palestinian governments politicizing health care in Gaza cannot be ignored. Patients with NCDs suffer most because of the prolonged time of the disease and possible deteriorating progression that requires advanced health care, which is largely unavailable in Gaza (see for example here). As well as limiting access to health care politics are affecting the sector in that it is undermining both quality and the equity of service distribution for the besieged population.
Is de-politicization possible in Gaza?
So, it is clear that, like every other aspect of Palestinians life, the health sector in Gaza is largely shaped by politics. This is not exclusive to Gaza per se, as to some degree, we can also see similar trends in countries such as Lebanon, Jordan, and Turkey and others. However, the majority of the interviewees seemed convinced that de-politicizing the health sector in Gaza should be a top priority. When I asked them whether achieving this on the ground could be possible, they were optimistic. However, it became critical when I followed this by a ‘how’ query. They thought a unified health system in Gaza would require a collaborative strategy from all actors, and an end to the Israeli occupation including the siege on Gaza. But, as a researcher, I know from the data that these pre-conditions are in themselves too difficult to realise; from their own first-hand experience, they also know that and still clung to it as a policy solution. The fragmentation of the health sector lies deep and its roots are historical. Taking this into consideration, reaching a collaborative strategy for the sector is a real challenge in itself, coupled with the difficulty of actually taking such a strategy to successful implementation on the ground, and of course, let alone the issue of Palestinian liberation which has been a case for more than 72 years now. Thus, there is a complexity in the situation that should be accounted for in terms of time and scale of action when a de-politicization project is considered on the ground.
Although, as seen from the interviews in Gaza, Palestinian doctors and policy makers increasingly attempt to be health care focused and make efforts to denounce divisions within their work domain in order to support Gaza patients, the current institutional and sector context in Gaza remains larger than them, absorbing them, knowingly or unknowingly, into competing political realities and streams. UNRWA (and possibly WHO?) seems an exception in this regard as it is clinging to neutrality, but one wonders whether neutrality in itself requires a form of separation from, or elevation above, other actors of the same system in which case, total integration cannot be maintained for true partnership within the sector. For example, UNRWA has its own sources of funding, research agenda, and decision-making process that is not within the reach of the Ministry of Health in Gaza or Ramallah. To say this, does not negate that UNRWA work is seriously affected by the political context in which it operates, but it is relatively less affected to the core compared to that of other actors. Until a de-politicization of the health sector in Gaza become possible, individual and group efforts to achieve professionalism and put health care in the centre are highly commended. Their ethical struggle and advocacy for it should definitely continue, hoping that in time, it may lead to large scale collective action, and pave the way forward towards a better health experience in Gaza under occupation.
Notes:
[1] Roy, S. (1993). Gaza: New dynamics of civic disintegration. Journal of Palestine Studies, 22(4), 20–31.
[2] WHO. (2017b). Right to Health: Crossing Barriers to Access Health in the Occupied Palestinian Territory 2016. World Health Organization.
[3] Jebril, M. (2018). Academic Life Under Occupation: The Impact on Educationalists at Gaza’s Universities (PhD Thesis). University of Cambridge.
Mona Jebril is a Research Fellow at the University of Cambridge. This research is funded through the UK Research and Innovation GCRF Research for Health in Conflict (R4HC-MENA); developing capability, partnerships and research in the Middle and North Africa ES/P010962/1. Watch a video introduction to Mona’s current research on health in Gaza.