The health care system in the occupied Palestinian territory: assessment and agenda for reform

Presenter: Awad Mataria, Birzeit University

Abstract

Rationale:

Since the establishment of the Palestinian National Authority in 1994, substantial donor assistance was intended to improve a health care system for the occupied Palestinian territory. In 2003 alone, this amounted to US$ 240 million (US$ 65 per capita), covering 87 per cent of the budgeted non-salary operating costs of the Ministry of Health. However, attempts to establish the basis for an efficient and equitable health care ‘system’ have been so far unsuccessful.

Objectives:

The paper assesses the performance of the Palestinian health care ‘system’ in fulfilling its goals of: improving health, responding to the needs of the population, and enhancing risk protection. It identifies obstacles to system building and suggests ways in which developmental approaches could be integrated with responses to emergencies to create a more effective, efficient and equitable health system, while acknowledging different potential political developments.

Methodology:

The paper applies the WHO-suggested framework for analyzing health care systems, using its six “building blocks”: (a) service delivery; (b) workforce; (c) information; (d) medical products and technologies; (e) financing; and (f) leadership/governance – stewardship, to assess performance and identify systemic gaps. A holistic view of the system was possible by completing an extensive review of all available policy and planning documents, including published and grey literature.

Results:

The failure in system building reflects (i) the arrangements for health care established by the Israeli military government between 1967 and 1994; (ii) the nature of the Palestinian National Authority, which has little ‘authority’ in practice, and has been burdened by malpractices (e.g., inefficiency, cronyism and corruption); and (iii) the inappropriate nature of much foreign aid, with priorities being repeatedly set to satisfy preferences of the respective donors. Although similar problems exist elsewhere, these are exaggerated and perpetuated under conditions of military occupation.

Conclusions:

Should a Palestinian “governing body” continue to exist, the key feature of any successful initiative toward building an effective, efficient and equitable health care system will depend on there being effective stewardship, through which the Palestinian Ministry of Health becomes empowered and has the capacity needed to oversee and steer the entire health system. A clear policy for human resources for health is needed, with a focus on strengthening monitoring and supervision and integrating a system of rewards and sanctions. Efforts should be also made to remedy the current malfunctioning of health care financing schemes, with gradual institutionalization of a genuine social insurance scheme. But health systems do not evolve in a vacuum. For their structure to progress, social determinants have to be addressed. In the case of the occupied Palestinian territory, this means that the occupation must end.