Two-year-old Rafiq lays his head peacefully on his mother’s shoulder, sticks a thumb in his mouth and buries his face in her black veil. Up until a short while ago Rafiq, whose family lives in Gaza, was at death’s door with a deadly kidney condition. But last September he was given a new lease of life when he was admitted to Barzilai hospital in Israel and nursed back to health.

“When I went back to Gaza everyone asked me how it went,” his mother tells The Media Line. “I told them the staff at the hospital treated him well. They could see for themselves how his condition improved dramatically.”

On the face of it, Rafiq is a success story. Where the health facilities in the Gaza Strip were incapable of helping the now perky toddler, Israeli doctors were able to save his life.

For Israel, Rafiq provides an opportunity to show the world a humanitarian face, and counter the warmongering image it often gets in the international media.

But ideally, Palestinian health officials would have preferred Rafiq not have to go to Israel at all. They would rather he be treated in a Palestinian hospital without being dependent on their Jewish neighbors.

This is one of the reasons the Palestinians are currently initiating sweeping reforms in the health sector, in an effort to make the industry a stable pillar in the future Palestinian state.

Plenty needs to be done, and the political divisions between the West Bank and the Gaza Strip, coupled with the ongoing conflict and unsteady peace talks with Israel, do not make this an easy task.

‘Faltering’ Health System

Health in the Palestinian territories is faltering where other modern Western countries are progressing, said a recent comprehensive report on the subject published in The Lancet, a respected medical journal.

According to the report, infant mortality among Palestinians stood at 27 per 1,000 live births during the period between 2000 and 2006, the same level as that reported in the 1990s. In comparison, the rate in Israel is 3.9 per 1,000 live births.

In addition, several diseases and conditions have become more common, with a rise in the rate of stunted growth among children, tuberculosis, meningococcal meningitis and mental disorders.

There are currently four main health providers in the Palestinian territories – the Palestinian Ministry of Health, the United Nations Relief and Works Agency (UNRWA), non-governmental organizations and the private medical sector.

The health services are financed through a mixture of taxes, health insurance premiums and co-payments, out-of-pocket payments, local community donations and finances and loans or aid from the international community.

The proportion of expenditure contributed by donors has ranged in recent years from 40 percent to 60 percent, with the rest coming from direct payments from the population and revenue raised by the Ministry of Health.

The total estimated health expenditure of the Ministry of Health in 2007 was 613 million shekels, which amounts to roughly $150 million.

But The Lancet report points out that a lack of development under Israel’s military rule, poor governance and mismanagement by the Palestinian Authority (P.A.) have rendered the Palestinian health services inadequate.

In many cases, patients have to be referred elsewhere, usually to Israel, Egypt or Jordan.

Over the course of 2008, around 14,000 Palestinians from the West Bank and 7,000 Gazans were treated in Israeli hospitals

Israel’s 22-day military offensive in Gaza, which began in December 2008, also caused a setback in health facilities in Gaza, as well as resulting in a shortage of food, medicine and other essentials.

The poorest sections of society are the most deprived of healthcare, the report said. A recent survey suggested that a third of the Palestinian population could not access health services because of high costs.

There are currently 76 hospitals in the Palestinian territories. Twenty-four of them are governmental and are divided equally between the West Bank and the Gaza Strip, and the remaining are non-governmental, with 40 in the West Bank and 12 in Gaza.

A new planned compulsory health insurance law expected to be approved within the coming months will cover the costs of health services provided to vulnerable groups that are unable to pay for health insurance.

Under the new law, those who are unemployed or poor will be covered through the relevant cabinet ministry, with the Ministry of Labor providing payments on behalf of the unemployed and the Ministry of Social Affairs caring for the poor.

Also, under the overhaul, there will be efforts to increase the number of beds in Palestinian hospitals.

A case in point is the Palestine Medical Complex in the West Bank, which currently comprises five medical facilities with a total of 188 beds. But a planned restructure of the facilities will increase the number of beds to 259.

The Lancet report concluded that the best way to improve the ailing Palestinian health system included the creation of a sovereign Palestinian state.

This fact is not lost on Fathi Abu Mughli, the Palestinian health minister in Ramallah.

“We have set two main objectives,” he tells The Media Line. “The first is to secure quality healthcare services for our patients. The second is to make sure these services will be sustainable. Accordingly, we have developed a three-year plan to reform the existing system, taking into consideration the available health facilities that need to be expanded and redistributed, or reinforced with additional staff.”

The current health insurance system does not secure income to the Palestinian Authority, Abu Mughli says.

A new health insurance law in the works will be compulsory and will be financially and administratively independent from the Ministry of Health and there will be more competition between the governmental and non-governmental health sectors.

The new law, which awaits the approval of P.A. Chairman Mahmoud ‘Abbas, will ensure the system is sustainable by increasing revenues and funding services that are being purchased from health providers locally and internationally.

One of the results of this will be reduced dependence on healthcare from outside the Palestinian territories.

According to the Ministry of Health, the P.A. is currently spending $70 million a year on purchasing healthcare from abroad.

Abu Mughli believes that with a new policy, Palestinians can minimize referrals abroad, improve local capacities and cut the costs of outside referrals by as much as 80%.

“Nowadays we’re revising this policy. We discovered that most of these cases can be managed locally if we can just secure the drugs. Instead of sending patients to Jordan, Israel and Egypt, we can secure expensive drugs locally.”

The ministry says it already cut the cost of buying health services abroad by $17 million throughout 2008, and hopes this dependency will continue to decline.

This will not only require a structural change, but also a change in the Palestinian mindset that has become accustomed to relying on its neighbors for healthcare. Even teaching Palestinians to trust their local doctors will require effort.

Medical Brain Drain

A lack of skilled medical professional is another problem the ministry has to tackle.

The Palestinian Authority has three medical schools – one each in eastern Jerusalem, Nablus in the West Bank and in the Gaza Strip – and four nursing schools that provide graduates with B.A. degrees, in addition to several community colleges that provide diplomas in nursing.

Up to 120 Palestinians graduate from the medical schools every year, says Prof. Muhammad Al-Subu, head of the Education Ministry’s Accreditation and Quality Assurance Commission. However, most of them will proceed to pursue a career abroad, leaving only about a quarter of them in the Palestinian territories to shoulder the burden of healthcare.

The situation is stable, he says, due to a large number of Palestinians who pursue medical studies abroad, usually in the former Soviet Union, Arab states, Europe or the United States, and nearly all come back to the territories to practice the profession.

However, expanding the current medicine studies locally is not a viable option, because of political and bureaucratic obstacles which impede the universities’ ability to accommodate more students.

“Because not everyone can come to the West Bank and Gaza – you need special permission if you don’t hold a Palestinian ID – we have a shortage of qualified professors and teachers in the field of medicine,” Al-Subu says.

As a rule of thumb, up to 80% of the health expenditure is always spent on human resources, says Dr. Alex Leventhal, director of Public Health Services at the Israeli Ministry of Health.

“The quality of the people in the system is very important,” he says. “The Palestinians are losing excellent people to other countries.”

At the moment there are roughly 4,000 doctors and 4,300 nurses in the West Bank and the Gaza Strip, according to MoH data. Around two thirds of them work for the Ministry of Health.

Dr. Tony Lawrence, the acting head of office for the World Health Organization (WHO) in the West Bank and Gaza, says the situation is not as bad it is may seem.

“Over the years, a lot of doctors have been trained in a wide number of countries. They go to medical schools abroad, sometimes finish their postgraduate studies there and then they come back to practice,” he says. “If you look at the number of professionals, it’s not bad in comparison with neighboring countries. It’s not nearly as good as Israel but it’s roughly on par with Jordan and Syria.”

The Gaza Impasse

But one of the main challenges facing the ministry is the fact that many of its beneficiaries are out of direct reach, and under the thumb of a competing government.

This unusual and complicated situation emerged when the Hamas movement, a rival of the Palestinian Authority-backed Fatah, took over the Gaza Strip in a violent coup in 2007.

The takeover resulted in a de facto rift between the West Bank, which is currently controlled by a government recognized by the international community, and an ousted and internationally isolated government headed by Hamas in Gaza.

The governmental element of Gaza’s health system is still partly funded by the government in the West Bank, with additional funding reportedly provided by Hamas from money smuggled through underground tunnels from Egypt.

The situation means the two competing governments are in some way cooperating on an unofficial level, but it creates a lot of problems.

“We’re responsible for the health of Palestinians everywhere,” Abu Mughli says. “We’re paying the salaries of health professionals working in the government sector there and we’re supplying them with the necessary drugs. We can’t control the system efficiently because of the political situation but we’re supporting our facilities and our professionals.”

“You can’t plan for people when you have two competing governments,” a Palestinian doctor familiar with the system says. “You’re duplicating everything and wasting resources.”

He says there were thousands employees in the Gazan-based Ministry of Health who were aligned with Fatah and not with Hamas and did not wish to cooperate with a Hamas government.

Lawrence, from the WHO, says that at a technical level, hospitals and clinics in Gaza continue to function and in practice come under the day-to-day direction of Hamas’s Ministry of Health in Gaza.

“But the salaries and other administrative procedures are still controlled by Ramallah. To that extent there is collaboration but in practice there are de facto two ministries,” he says.

“It certainly doesn’t make life easier,” Lawrence says. “We can’t do any development work in Gaza because that requires a formal relationship to be established with the relevant authorities.”

A Gaza-based doctor says donors were hearing different plans and requests from each ministry. It is unfortunate, yet not surprising, that donors are reluctant to open their pockets in such a divisive situation, he says.

Though the Ramallah-based government calls the shots and has its hands on the money tap, the strength of the competing Gazan-based ministry is apparent even in cyber-space.

Typing the words “Palestinian health ministry” in Arabic into Google takes the surfer straight to the website of the Gaza ministry, without much mention of its counterpart-cum-rival.

As a result of this rivalry, those bearing the brunt are Palestinians in need of medical care and who rely on Hamas for this purpose.

Dr. Mofeed Mokhallalati, dean of the faculty of medicine at the Islamic University in Gaza, and a consultant surgeon at the Ahli Arab Hospital in Gaza, says NGOs are suffering as well as the government sector, because both require basic needs such as medicine, disposables, maintenance for the equipment and experts.

These are difficult to come by in the Gaza Strip, because of the closure imposed by Israel.

But the presence of two governments is only half of the problem, he says.

For some diseases and conditions there is only one expert or one treatment facility to cover both the West Bank and Gaza, and not everyone will have access to it. Gazans traveling to the West Bank or Israel usually need to obtain permits from Israel, and these are not always granted.

“NGOs have to do more to help the poor people and compensate for the deficiency in governmental health services, but government and non-governmental services are both suffering,” Mokhallalati says.

Israel Encourages Reforms

Israel plays a crucial part in the Palestinian health system.

The Palestinian health ministry gives Israel around $7 million a month for medical care, money that is deducted from taxes and revenues that Israel collects on behalf of the Palestinian Authority and transfers to the P.A.

Under the reforms, the Palestinians hope to reduce this dependency, which on the surface would mean a loss of profit for Israel.

However, Leventhal, from the Israeli Ministry of Health, says the loss of profit is negligible and unimportant.

Israel is not directly involved in the Palestinian health reforms, but it welcomes these changes, he says.

“Our system generally encourages the Palestinians to have all the things they need in-house,” he says. “Any attempt to upgrade the Palestinian health system is good and is a win-win situation.”

With an annual national health expenditure amounting to some $10 billion, the $7 million or so that Israel gets from the Palestinian every month barely makes a dent, he says.

“It’s a monetary loss, but I don’t think the state is trying to make a profit here and I don’t think they’re calculating that the income should cover the expenses.”

In many cases, Palestinians approach Israeli hospitals seeking healthcare, but fail to come up with the necessary documents to cover the expenses. In these cases, Leventhal says, Israeli hospitals provide them with the healthcare, fully aware that they will sustain a loss.

Israel is not an active part of the reforms currently being undertaken in the Palestinian health system, but it is indirectly encouraging this, mainly by providing training to Palestinian doctors and making them more self-sufficient.

When looking at the bigger picture the reforms could, in a way, benefit Israel.

“A physically healthy neighbor is also a politically healthy neighbor,” Leventhal says. “The healthier your neighbor, the healthier the whole region will be, so it’s a win-win situation for everyone.”