The health-care system: an assessment and reform agenda

Summary

Attempts to establish a health plan for the occupied Palestinian territory were made before the 1993 Oslo Accords. However, the first official national health plan was published in 1994 and aimed to regulate the health sector and integrate the activities of the four main health-care providers: the Palestinian Ministry of Health, Palestinian non-governmental organisations, the UN Relief and Works Agency, and a cautiously developing private sector. However, a decade and a half later, attempts to create an effective, efficient, and equitable system remain unsuccessful. This failure results from arrangements for health care established by the Israeli military government between 1967 and 1994, the nature of the Palestinian National Authority, which has little authority in practice and has been burdened by inefficiency, cronyism, corruption, and the inappropriate priorities repeatedly set to satisfy the preferences of foreign aid donors. Although similar problems exist elsewhere, in the occupied Palestinian territory they are exacerbated and perpetuated under conditions of military occupation. Developmental approaches integrated with responses to emergencies should be advanced to create a more effective, efficient, and equitable health system, but this process would be difficult under military occupation.

Introduction

Achievement of the human right to the highest attainable standard of physical and mental health¹ entails equitable access to effective health-care systems² and calls for health professionals to promote necessary change.³ To strengthen the health systems of low-income and middle-income countries, the WHO Commission for Macroeconomics and Health calls for greater resources for health care.⁴ Since the signing of the Declaration of Principles on Interim Self-Government Arrangements by the Palestinian Liberation Organisation and the State of Israel, also known as the Oslo Accords,⁵ substantial donor assistance was meant to improve a health-care system for the occupied Palestinian territory (the West Bank, including the Palestinian Arab East Jerusalem, and the Gaza Strip). In 2003 alone, donations amounted to US$240 million ($65 per person), covering 87% of budgeted non-salary operating costs of the Ministry of Health.⁶

Health-care systems have three main goals: improving health, responding to the non-medical expectations of the population, and enhancing financial risk protection.7, 8 The first and second reports in this Series9, 10 on health and health services in the occupied Palestinian territory trace the steady improvement in the health status of the population until the mid-1990s when improvements slowed, and, in some cases, reversed. Reports two and three10, 11 show how planning and coordination of health care are inadequate, the use of resources is ineffective, and services are below acceptable standards, leading to public dissatisfaction with health services.¹² Current financial arrangements are associated with high risks and unequal burdens,13, 14 with substantial out-of-pocket payments that favour rich people and place a high burden on poor people.¹⁵ Other reports in this Series9, 10, 11, 16 elucidate the role of Israeli military occupation in producing and maintaining inefficiencies and inequities and the relative powerlessness of the Palestinian National Authority to counteract them.

In this report, we use reviews of published work and interviews to identify ways to integrate developmental approaches with responses to emergencies to create a more effective, efficient, and equitable health system. We provide a profile of the Palestinian health-care system and analyse the system with respect to the six building blocks of the WHO framework⁸ for health systems: service delivery; workforce; information; medical products and technologies; financing; and leadership, governance, and stewardship. We emphasise the complexity of health-system building under conditions of military occupation, review future political scenarios, and suggests ways to improve performance and equity.