At the Al-Najah Hospital in Nablus, they are hoping to hear soon that Israeli authorities will approve the purchase of a PET-CT scan machine – a medical imaging device which is an important tool in diagnosing cancer and malignant growths.
PET-CT scanners have been in common use in Israeli hospitals for years. But if the Israeli authorities respond positively to the request by the Nablus hospital, it will be considered a real coup, because it would be the first such machine anywhere in the territories.
Until they get a PET-CT device, West Bank doctors will continue to refer their patients to hospitals in Israel for diagnostic scans. The convoluted process involves a referral from a Palestinian specialist physician, a wait for approval by the Palestinian Authority Health Ministry and a request to the Israel Defense Forces’ Coordination of Government Activities in the Territories for permission to enter Israel, which is not always granted.
Even if the efforts are successful, the problem represented by the absence of PET-CT scanners in the territories is overshadowed by a wider crisis that the Palestinian medical system has been facing for years.
The system suffers from a regular shortage of medications, medical equipment, specialist physicians, and medical personnel in general. During certain periods, Palestinian hospitals are on a strike footing, working just three days a week. Occasionally, patients are sent to pharmacies to buy injections themselves, while medical staff sometimes find themselves lacking even basic equipment such as syringes and rubber gloves.
One upshot of the current situation is that, increasingly, patients are referred for medical treatment outside of the Palestinian Authority – to Israel, Egypt or Jordan – and various medical treatments and procedures are becoming less available to Palestinians. Not only is the Palestinian health-care system in a sorry state, but it looks even worse when compared to the situation in Israel. The disparities are dramatic by almost every possible measure.
The facts of life expectancy
It begins with government expenditure on health, which is $248 per capita (16 percent of the gross domestic product) in the Palestinian Authority, compared to $2,046 per person in Israel (7.7 percent of GDP). And the comparisons become even starker the more one delves into the situation for Palestinian residents in the territories.
Their situation was analyzed in a report entitled “Divide & Conquer: Inequality in Health,” just released by the NGO Physicians for Human Rights. It presents medical and socioeconomic data, and shows how these factors affect the ability of Palestinians to gain access to health care.
The report provides comparable data from Israel as well, and also deals with Israel’s role in the situation in which the Palestinian health-care system finds itself.
The compilation of the data and report writing took two years and are based on information that was assembled from a variety of official sources, including Israel’s Central Bureau of Statistics, the Palestinian statistics bureau, the World Health Organization and the United Nations.
One of the most common measures for quality of health care is average life expectancy. The life expectancy, on average, of Israeli men and women is about 10 years higher than their Palestinian counterparts, the report states. For Palestinian men, it is 71 years (compared to 79.9 for Israeli men); for Palestinian women, it’s 73.9 years, on average, compared to 83.6 for Israeli women.
Another gauge of health-care quality is infant mortality, as measured by the number of baby deaths per 1,000 births. By this measure also, the disparity is significant. The figure in the territories is 18.8 deaths per 1,000 births for those under 1-year-old. In Israel, by contrast, it is 3.7, a figure thought to be among the lowest infant mortality rates in the world. In comparison, the average for countries in the developed world is 4.3.
About two-thirds of Palestinian infant deaths occur in the first months after an infant is born, which is similar to the situation in Israel. However, about 55 percent of Palestinian infant deaths are caused by preventable infections. This is the primary reason for the disparity in the two infant mortality rates.
The difference in rate of deaths of mothers as a result of complications during pregnancy or labor is also highlighted in the report. The figure for Israeli mothers is 7 per 100,000 births, while in the territories it is four times that, at 28 per 100,000 births.
In evaluating the Palestinian health-care system, at least part of the explanation for the disparities with Israel can be found both at the level of physical infrastructure and the human resources. For example, the report states that there are 1.76 specialist physicians in Israel per 1,000 people, compared to 0.22 specialists per 1,000 people in the territories. The number of nurses per 1,000 inhabitants in Israel is 4.8, compared to 1.9 among the Palestinians.
The disparity is also apparent in the number of hospital beds, which is a measure of the system’s capacity to provide care. There are 3.27 beds per 1,000 people in Israel, and 1.23 beds per 1,000 Palestinians.
The occupancy rate of hospital beds in Israel is actually higher than in the Palestinian Authority, where it is only about 76 percent, although many of the Palestinian hospital beds are at private facilities rather than public hospitals. In general, the limited investment by the Palestinian Authority in public services has spurred the development of private medical services at the expense of the public health-care system.
So, to what extent is Israel responsible for the condition of the Palestinian medical system and health of the Palestinians? In 1994, as part of the Oslo Accords, responsibility for the Palestinian health-care system was transferred from Israeli authorities to the Palestinian Health Ministry. Although the transfer did occur officially, in practice, even 20 years later, the Palestinian medical system is dependent to a great extent upon Israeli authorities both indirectly – with respect to the transfer of taxes and influence over the Palestinian Authority budget – as well as some policies that directly affect the medical system.
This includes limitations on the freedom of movement of patients, medical personnel, ambulances and medicine between the Gaza Strip and the West Bank and East Jerusalem, as well as within the West Bank itself. (East Jerusalem was annexed to Israel following the 1967 Six-Day War and is not under the jurisdiction of the Palestinian Authority, and Palestinian residents of East Jerusalem receive health coverage from the Israeli public health system.)
About 200,000 Palestinians a year request permission for travel between the Gaza Strip and the West Bank and East Jerusalem for medical treatment. This involves cumbersome bureaucracy and about 40,000 of the requests are denied. Hundreds of Gaza residents looking to leave the Strip for medical treatment in Israel or the West Bank are called in for questioning by the Shin Bet security service as part of the process. As a result, some patients forgo treatment out of fear that Hamas will accuse them of collaborating with Israel.
Israel also exerts its influence on medical personnel, from initial medical education to continuing professional training to actual employment. For example, Israel controls the number of Palestinian medical personnel from the West Bank who are authorized to work in East Jerusalem, where six Palestinian hospitals are located.
Arab markets out of bounds
When it comes to the purchase of medicine, the Palestinian health system is also subject to limitations and subject to economic agreements with Israel. The import of medicines into the territories is limited to drugs that are also registered in Israel, which in practice blocks access to drugs from neighboring Arab markets that can supply medicine at a lower price. There are also limitations on the import of raw materials for the production of medications, as well as on drug exports.
Nonetheless, Israeli limitations on Palestinian medical services are not the only explanation for the circumstances in which the Palestinian health-care system finds itself, and clearly does not absolve the Palestinian leadership and bureaucrats of responsibility for their citizenry. Twenty years is arguably sufficient time for the Palestinians to have developed a proper health-care system.
This also prompts the question of where on its scale of priorities the Palestinian leadership has placed the medical system. The question becomes particularly relevant in light of corruption scandals and the alleged flow of sizeable amounts of money over the years to senior Palestinian officials, as well as the large sums that have found their way into the development of underground terrorist infrastructure rather than above-ground medical facilities.
Officials at Physicians for Human Rights express the belief that disparities between the Israeli and Palestinian health-care systems will only widen in the future. As long as Israel continues to exert influence on the ground, they claim, it must take full responsibility for the health of the Palestinians and provide them with health care that is equal to what the residents of Israel receive.
“It is among the obligations of the Palestinian Health Ministry to provide health-care services to the population to the extent of its capacity,” said Mor Efrat, who is the coordinator of the PHR department that deals with the territories and headed the team that produced the report. “But it is Israel’s obligation to provide all the services beyond the [Palestinians’] capacity, so that a Palestinian child and an Israeli child, who sometimes live just hundreds of meters from one another, receive equal medical care.”