By: Dr.Basam Abu Hamad

Health Consultant

Al-Quds University

Macro context:

Historically, the Palestinian people's right to control their lives and build their state was denied and hindered by being successively and continuously under tutelage, mandates and occupations. The consequences of this reality affected the social, cultural, as well as the mental composition of the Palestinian people and created a unique case of complex combination of challenges due to the burden of the occupation, oppressions, economic disadvantages and socio-cultural limitations. Unlike politically stable areas, occupied Palestinian territory (oPt) in general and Gaza governorates in particular are witnessing an enormous wide range of life challenges and suppressors. Palestinians didn’t enjoy minimum level of viable stability required to establish coherent and concrete system at which polices, regulations and services are consistent and coordinated. This is true for the health system which spent most of time and efforts as a fire fighter and seldom possessed the vision combined with ability to act on a wider scope of protecting and promoting people's health and wellbeing. 

        In the last few years, the situation for more than 1.6 million Palestinians in the GS became worse than it has ever been since the start of the Israeli occupation in 1967. Occupation, conflict, siege, closures and the frequent wars have left the high densely populated the GS in a state of severe vulnerability.  The current isolation has taken the humanitarian situation to an unprecedented level, with coping mechanisms exhausted, widespread absolute poverty and an inability of civil society organizations and formal authorities to meet even the basic needs of the population.  The collapse of the economy has left little money to buy food, and little food in the local market to buy.  The ability of local communities to purchase required medicaments, contribute to medical fees and pay for transport to reach health facilities is dramatically decreasing (PNGO, 2009).  

        The siege that “Israel” has intensified on the GS since June 2007 which continues in a way or another till now have greatly harmed Gaza’s health system, which had struggled even before these events. The severity of the situation has increased exponentially since Israel imposed extreme restrictions on the movement of goods and people in and out of Gaza in June 2007. Since then, healthcare for people in Gaza has dramatically deteriorated at two levels; the provision of health services inside Gaza and access to treatment outside Gaza.

          Geographically:

        The GS is a narrow band of land; it is 45 kilometres long and 6-12 kilometres wide with an area of 378 square kilometres which has suffered a lot from recurrent occupations.  After the end of the First World War, Palestine was placed under the British Mandate.  The GS was under the Egyptian Administration from 1948 to 1967, then it was occupied by the Israeli Army in June 1967.  The Israelis officially handed the GS to the PA in 1994 according to the Oslo Agreement which was signed between Israel and Palestinian Liberation Organization, in what was known as "Declaration of Principles on Interim Self-Government Arrangements", a document also known as the "Oslo Accords".  The implementation of the partial autonomy in 1994 and the establishment of the PA have had its impacts on the society after the many devastating wars and the long years of occupation and dispersion over the globe.  However, still, Israel holds overall sovereignty over the GS.  It controls borders, movement of goods and travellers, particularly the Gazans themselves.  It also controls trade, the commercial market, water, food, energy sources (fuel, gas and electricity), the means of communications and the overall security.  Hence, it still has a hold over the local Palestinian economy.

        The first turning point of the political and socioeconomic situation started to deteriorate after the second uprising which sprang off in 2000 in the GS and WB.  A historical turning point occurred in June 2007 following the "Hamas" takeover of the GS.  Since then, a tight siege has been imposed on the GS and the Israeli policy sought to ensure ‘no development, no prosperity and no humanitarian crisis' (Oxfam, 2007; World Food Program et al, 2008; PNGO, 2009).  The siege that Israel has intensified on the GS since June 2007 has greatly harmed the health status and the health system, which had struggled even before these events.  However, signs of humanitarian crisis are clearly obvious.  The already insecure, impoverished and imprisoned, Gazans have continued to live under dire conditions.  The Israeli government has stopped virtually everything (except occasionally allowing some basic foodstuff and some medicines to enter Gaza), as well as almost all citizens, from entering and leaving the GS.  Late in 2007, Israeli declared the GS a ‘hostile entity’.  The Israeli government subsequently reduced the supply of fuel and electricity to the GS resulting in further destruction of the already exhausted economy and distortion of basic services including health and sanitary services.

        The internal political division between the two main political parties “Fateh and Hamas” in 2007 is also affecting the social and work values and systems, with frequent disruptions of work and diminished productivity. Distortion of work accountability system, disintegration of the social fabrics and work values and the increase in the political partisan trend, are all among the negative consequences of the division that have become the common norm in the organizational environment. The loyalty then generally became to the ruling party and not necessarily to the organizational objectives. An example of the state of organizational lawlessness is the catastrophic behaviour of thousands of MOH employees (still more than 2000 employees since 2008) have refrained from their work, of those, many engage important technical and managerial positions in the organization; they guaranteed that their salaries will be continuously effused from the slush politicized funds, while they stay home. Meanwhile, those who were committed to their jobs and kept covering their on duty time, had their salaries cut.

        In 22 days, December 27th 2008 through January 17th 2009, Israel launched a large scale Israeli aggression on Gaza which resulted in thousands of deaths and injuries among people and uncharitable damage of thousands of houses, manufacture compounds, agricultural resources, drinking water and sewage systems, government buildings, health facilities, electricity plant and its networks.  Most injuries were serious and strange in nature; often multiple injuries, with head, thorax, abdominal and multi-limb injuries (Ministry of Justice, 2009).  Israel’s three-week military aggression resulted in deaths of 1,455 people, of them, 553 (38%) were children and women; and 5,380 people injured, of them, 2671 (49.6%) children and women, and massive damage to dozens of thousands of homes, businesses, and infrastructure (Ministry of Justice, 2009). In addition, during the period between November 14th through November 21st 2012, “Israel” launched another military aggression on Gaza.  During the course of the operation, Israel struck more than 1,500 sites in the GS, including government buildings, houses and apartment blocks and institutions.  MOH health information system database illustrates that 186 Palestinians died in the operation, with between 47 children and 13 women. An additional 1,399 Palestinians were injured, and between hundreds of thousands were displaced.  Israeli strikes by air, land, and sea resulted in civilian casualties, including those of children, in schools, soccer fields and civilian residences. 

Demographically:

        Recent reports indicate that the GS is among the most densely populated areas on earth.  According to the Palestinian Central Bureau of Statistics (PCBS), the total number of the Palestinian population residing in the GS in mid-2012 is around 1.64 million (PCBS, 2012); the projected 2018 figure is around 2 million (PCBS 2012a; UN, 2012).  The estimated number of annual deliveries has increased from 50,000 deliveries in 2008, 53,000 in 2009, 60,000 in 2010 (MOH Field Statistics). However, it dropped in 2012 to around 56,000. Assuming that the fertility rates will continue in the same trend, it is anticipated that around 75,000 deliveries will be recorded in 2018 with more than 200 deliveries daily.  The Palestinian population in Gaza has one of the highest fertility rates in the region (around 5), compared to 3.8 in the WB, 3.5 in Egypt, 3 in Lebanon, 2.4 in Israel and 3.2 in Turkey (PCBS, 2012).  The crude birth rate in the GS in 2010 was 37.1 (PCBS, 2012) and the population growth rate was 3.37% in 2011.  Demographic trends anticipate that it will slightly decline to 3% in 2018. Nevertheless, the crude death rate in the GS is 3.9 per 1000 population (MOH, 2012a).

        The inevitable increase in the population will pose further strains on access to livelihood conditions of the Palestinians including housing, employment and health services. Population growth and the high number of adolescents who will enter the labour force in the coming years also mean that the health services will have to grow in line, just to keep pace with the expanding.

        Age structure in the GS is similar to that in many developing countries, where nearly half of the total population is under 14 years old (20% in UK).  Children under 5 years old represent around 18% (MOH, 2012a).  In addition to overall population growth, the fact that the GS has one of the youngest populations worldwide will pose particular challenges. Some 51% of the inhabitants are younger than 18 years, projected to decrease slightly to 48% by 2018 (UN, 2012).  The GS has the second-highest share of people aged 0 to 14 years worldwide. Moreover, the ‘youth bulge’–the ratio of youth (15-29) to the total over-15 population–is exceptionally high, at 53% (projected to decrease to 52% in 2018). The life expectancy for males in Gaza is around 70 years and for females is 72.5 (PCBS, 2012).  With the increase in the expected life span, from 65 years in 1994 to 73 years in 2012 (according to MOH reports), the elderly population aged 65 years and over constituted 2.4% of the total population which has increased by five times in comparison to 10 years ago (it is around 21% in Europe). It is anticipated that the proportion of elderly people will increase with additional burden on the health system as they are exposed to chronic diseases and require rehabilitation services. 

          The majority of households of the Palestinian population in the GS are nuclear families (81%) with an increasing trend (PCBS, 2012).  The reported average family size is around 6.3 persons according to PCBS (2012a) with higher rates at the North (6.7) and Rafah (6.5).   Regarding housing density, it was 1.8 per room in 2010, in 53.8% of households, 1 to 2 persons were living per each room, in 32.9% of households, more than 2 persons were living in each room and in 13% of households more than three persons were living in each room (PCBS, 2012). More than 71,000 housing units are currently needed in Gaza (UN, 2012). The population density in the GS is more than 4500 inhabitants per one square kilometre in 2012 (PCBS, 2012) which is expected to rise to 5500 in 2017. If we exclude the safety buffer zones near the green line (accessibility is not allowed to Palestinians in these areas), the actual population density will be much higher. Dependence ratio is estimated at more than 80.5 for WB/G with higher ratio in Gaza (PCBS, 2012). According to PCBS (2012), the literacy rate among Palestinians including females is high (above 95%).  Traditionally, Palestinians place a high value on education and regard it as a durable and movable asset “contrary to land and houses that can be and were lost”; therefore, this value is instilled in their children. According to the PCBS (2012), the majority of the GS population are refugees (66.1%) who receive basic primary health care services and some secondary care services through UNRWA.  

Households’ conditions:

          The recently released PCBS Report (2012) indicates that 40% of the households in the GS were living in houses, 60% in apartments; with increasing trends.  The same source indicates that 93.6% of the households surveyed own their residency place and 3.7% were living in rented houses.  The survey conducted by the Institute of Community and Public Health, Birzeit University (ICPH-BU) in 2009 showed that 30.1% of households were using the public network for obtaining drinking water, almost all households surveyed (99.8%) were connected to the public electricity network and have had the basic household assets such as refrigerators (93.7%), TVs (98.7%), Gaz for cooking (95%), washing machines (96.2%) and basic furniture.  Only 52% of houses in Gaza have had computers at the household and 12% owned a car (PCBS, 2012). Around 23 areas in the GS are connected to the public sewage system and 29 are using alternative methods such as septic tanks (PCBS, 2012). 

          In ordinary situation, 60% of households suffer from food insecurity or potential for suffering from food insecurity.  During the Israeli aggression in 2008/2009, according to ICPH-BU, 2009 survey, food shortage were reported by 80.9% of families during the war as a result of lack of food in the market, lack of resources, restricted movement of goods and people (Israeli’s shot on sight policy).  According to the same source, shortage in drinking water were reported by 69% of the households surveyed during the Israeli aggression as a result of lack of electricity to pump water to households, destruction of infrastructure and movement restriction of municipality. Currently, 70% reported receiving food aid mainly through UNRWA and international organizations. MOSA provides regular assistance to around 57,000 families; UNRWA supports 21,000 families and other organizations financially support large number of families (MOSA field statistics).  It could be concluded that the livelihood safety network was not effective during the war and people were starving. The availability of safety valve during emergency situation is essential to ensure that basic livelihood conditions are maintained. Emergency plans should be prepared to ensure that people have access to essential items such as food and water during crises.

Environmental status:

        Of the 2000 water wells in the GS, 800 have stopped from work, of which many need maintenance and rehabilitation to resume pumping water again (Addameer Association for Human Rights, 2009).  According to UN (2012) only 5-10% of the 150 water wells that cover the domestic water needs of the population meet the international specification of safe drinking water in the GS, while 40% meet the acceptable specifications of safe drinking water according to the local standards. In 2010, the total water samples that were chemically tested by the MOH laboratories, 73.5% did not comply with the local accepted standards' specifications of safety of the drinking water (MAP and Save the Children, 2012). A study conducted by the WHO showed that 30 of the examined samples taken from the Gaza sea were contaminated with animal and human faeces and an additional 25% are contaminated with animal faeces only (WHO, 2008). 

        Electricity outage is prominent for many years in Gaza especially during Israeli aggressions. In June 2006, Israel destroyed the main power plant in Gaza after the kidnapping of “Gilat Shalet”.  Since then, mass punishment measures have been enforced on the inhabitants living in Gaza till now. Currently, at least, there is electricity cut for 8 hrs a day which could increase to 12 hrs in ordinary situation. The current capacity for electricity supply is 242 MW.  The demand in 2011 was 350 which is expected to rise to around 550 in MW 2018 (UN, 2012).  Other environmental challenges include air and soil pollution, desertification, scarcity andsalination of fresh water, sewage treatment, water-borne diseases, soil degradation, poor solid waste management and depletion and contamination of underground water.

Economical context :

        The Gross Domestic Product (GDP) in the GS could not be traced reliably from local sources because of the chaos political situation as described above, however, it was estimated at $ USA 1.3 billion in 2003, and declined to 1.1 billion in 2008 although the population has increased by around 30% during that period (PCBS, 2010).  The annual GDP for Gaza per capita in 2008 was $ 774.5 which is less than 40% of that of the WB figure (1,718.4) (PCBS, 2010).   It seems that it has increased to $ 1156 in 2011 and is expected to reach $ 1273 in 2015 (UN, 2012).  The average monthly household expenditure and consumption in Dinar (JD) in GS Governorates, in 2010 is around 670 (PCBS, 2012).  The main sources of livelihood in Gaza are employment at the services sector (mainly at government, UNRWA and NGOs), rain-fed agriculture, livestock rearing and fishing (PCBS, 2012). 

        According to the PCBS Report (2012), the percentage of those who are older than 15 years in labour force is 40.2% and 59.8% were outside the labour force.  The same source indicates that among those in labour force, 56.3% were employed and the rest 43.7% were unemployed. 

        To conclude, this combination of economic and social deterioration, and the inability of health services to respond to the consequences, has exacerbated the already dire health status of the population of Gaza. Any kind of economic recovery in Gaza is impossible while the blockade of Gaza remains in place. Even if it is lifted, it will take years to repair the damage and to recover the economy. More aid is going to the Palestinians than before and yet the humanitarian situation continues to decline. Continued aid is vital to respond to the growing humanitarian crisis in Gaza but it cannot provide a solution in itself. Consequences of the above situations imply that urgent measures need to be taken to support the delivery of health services and to meet the increasing demands for health services particularly for mothers, children, elderly, PWD and sick who are more vulnerable than other groups. The demographic characters of the Gaza population imply that there is an increasing load on the health sector, particularly Mother Child Health (MCH) services and NCD which affect older population.  The health system should respond not only to the current contextual challenges, but also to the increasing demands for services resulted from increased population size. Therefore, planners, policy makers and donors need to consider these factors in a manner that meets current and future needs of the Gaza population.  

General health status of the population:

        Compared to other countries at a similar level of economic development, the Palestinian population’s overall health status outcomes are relatively good partially due to the strong performance on most basic public health and PHC functions (PNGO, 2009). Women education, family commitment and cultural values are also important factors in this regard.  Also political commitment to health is obvious as manifested in high spending on health around 9-12% of the GDP which has recently increased and reached more than 15% (PCBS and MOH, 2011); OECD (2012) figure is (9.5%) of the GDP.  Spending on health per capita has increased from $ 120 (1994) to $ 165 in 2008 (OECD figure in 2012 was $ 2377; Jordan $ 238; Syria, $ 100; Egypt $ 38).

        Given the prevailing complexity health sector in general face; lack of resources, blockade, siege, uncertainty, the heavy consequences of political division among the Palestinian parties, and expanding needs of people, maintaining service provision to citizens is a credit recorded to the Palestinian health sector. It is worth mentioning that the health sector exerted significant efforts not only to maintain health services but also to improve and present some new services such as opening of a new specialized services at MOH premises such as cardiac surgery and cardiac catheterization, introducing new schemes for health services such as Family Medicine by UNRWA, maintaining adequate coverage of rehabilitation services by the NGO sector and maintaining most of the achievements made by the health sector.  Among the issues that the health sector should be acknowledged for is the heavy investment in IT, HIS, training and developing human resources in some sub-specialties.

        Generally speaking, healthcare services were effective especially when comparing health outcomes in Gaza to those in the region.  This is typically true regarding mortality indicators, Infant Mortality Rate (IMR), Maternal Mortality Rate (MMR), immunization coverage, causes of adults’ deaths and so on. Physical access to services is generally acceptable in ordinary situation but it is usually impaired during emergency situations.  Most basic services are satisfactory in terms of coverage and physical accessibility while the quality of care is questionable due to lack of appropriate standards and weak implementation of the already available ones. Also, access to advanced tertiary services remains a real challenge facing the health care system in Gaza.

        Although the control of infectious diseases has been maintained with no reports of fatal vaccine controllable diseases; still meningitis, hepatitis, diarrhoea and others are common with high morbidity rates.  Gaza is going through what is called “epidemiological transition” with a shift from communicable diseases to no-communicable ones with higher rates of heart diseases, hypertension, diabetes and cancer. Non-communicable diseases including heart diseases, cancer, hypertension and cardiovascular diseases and diabetes mellitus, are gradually replacing the traditional enemies of infectious diseases as the leading causes of death. Recent health reports (MOH, 2012a) indicate that only 4.7% of all deaths were reported due to infectious diseases/septicaemia. Instead, the leading causes of death are chronic conditions, namely heart diseases (23.5%), cancer (11.8%), perinatal conditions (10.8%), and cerebro-vascular conditions (7.5%). In addition, all kinds of accidents (intentional and un-intentional) accounted for 9.4% of deaths. Despite the limitations in documenting root causes of death, this list constitutes a guiding frame for strategic intervention.

Life expectancy at birth level has reached to 70-71 years (79.8 in OECD) in oPt (PCBS, 2012).  Crude death rate remains constant at around 3.1 per 1000 population.  Mortality indicators including IMR and MMR are within the acceptable level, however, it didn’t improve as reported in most countries.  Almost all deliveries are institutionalized and attended by skilful birth attendants.  Anaemia and chronic malnutrition still constitute public health problems especially among children and pregnant women.  Around 40% of males' youth in Gaza are smoking according to PCBS report (2012a) (25.9% in OECD).

What complicates the situation more is that the Palestinian community is suffering from poverty-related diseases and illnesses, such as malnutrition, anaemia and sanitary related diseases which have been aggravated due to conditions associated with the current closure resulted in the deterioration of the sanitary conditions. Nutrition problems are chronic in Gaza and cultural norms are a contributing factor to this problem. Nutritional problems can be partially alleviated by strengthening the ability of communities to advocate and support appropriate nutrition practices. The knowledge of what healthy foods constitute, appropriate eating habits, cooking practices, food storage and possible food alternatives, are all important areas for nutritional awareness. Anaemia preventive practices, such as drinking tea, consuming iron rich food and consuming food rich in vitamin C constitute priority areas.