Palestine: A Health-Care System in Transition

By Louisa S. Nye

The Hebron Nursing College doesn't look like much from the outside, with its dilapidated entrance off a dusty potholed street. Inside, the floors are bare but the whitewashed walls are covered with cheerful watercolors of smiling people and gentle landscapes. The art and graffiti on the wall opposite the library is dedicated to student "free speech" which the director, Abdul Rahman Abu Ajamieh, says is absolutely essential to learning.

Passing through the colorful corridor, he ushered me into a small, austere corner room for a discussion with the men and women students of the college. There on the floor was a bird cage, home for one tiny grey bird. Every day at this time one of the students hangs the cage on a hook at the window. When the sunlight is just right, they say, the bird sings.

Sublime moments like these are hard to come by in Hebron and throughout Palestine, where every issue seems to be at crisis level. My day in Hebron was part of my second visit to Palestine as a member of the medical team of Physicians For Peace, which began working in the West Bank during the years of the intifada. While the early missions straddled extreme violence and repression, this team witnessed something new: growing pains of a health-care system in crisis and transition.

With the PFP team members sprinkled among Hebron, Nablus, Ramallah, Gaza and East Jerusalem, opinions on health care issues varied among our Palestinian hosts, but the concern was universal. In the short term, the fact that authority gradually is being transferred to the Palestinians serves as a motivator to get things working. However, they are faced with the painfully slow progress of changing from an uneven health-care system run by the so-called civil administration, a branch of the Israeli army.

Last year in the town of Ramallah, the government hospital performed 2,200 operations. This year, the hospital's director and chief of surgery, Dr. Shawki Harb, explained that his staff has been overwhelmed with more than 4,000 cases.

"Ramallah struggles with double the work load, and low pay...it's very demoralizing," he said. Morale, however, is only one issue on a platter full of problems including patient overcrowding, unsanitary conditions, poor staff training, and lack of supplies and pharmaceuticals.

The goal is to create a health-care system from the years of occupation that will segue to the future. Currently, the Palestinians are dependent upon an Israeli system that funnels seriously ill patients back to more specialized Israeli institutions. Israeli patients have their medical costs paid for by the government. But West Bank Palestinians must pay their own costs, and this referral practice is the most expensive type of health care available. Such fragmented patient care also divides doctors and hospitals along boundary lines. The patients are isolated from their doctors and, with border restrictions, anyone can be cut off from the hospital to which he or she has been referred.

Another such problem was illustrated in Hebron where, to reach Al-Ahli hospital, I had to follow a lengthy detour around the small, obdurate tract of Jewish settlers who have bolted themselves to the center of the city. Nevertheless, in the words of urologist Mamdouh Al-Aker, "The main challenge is to build on what we have inherited, even though it is flawed...do not let it collapse!"

As the pledges promised from donor countries either have not been fulfilled or have been stalled, and taxation is not fully operational, most physicians agree funding is a major concern for a health-care plan. The immediate focus should be on modest short-term development with a newly created infrastructure; opening the lines of communication through middle management. "There is a large gap between administration and employees," says Dr. Harb. "We must bring everyone together, they must feel they are part of the decision-making process."

Ideally, the need for communication could stretch to include a central committee of health care professionals, with the Ministry of Health presiding over representatives from all areas of Palestine. This would be the forum for discussing future projects, priorities and problems, as well as distribution of funds. Ultimately it would short-circuit destructive competition between doctors and hospitals, exacerbated by poor communication.

The next step for health care is to encourage the rapidly developing private sector to integrate with the government system, guaranteeing access and quality for all patients, without stifling free enterprise. Dr. Al-Aker sees joint ventures for hospitals and diagnostic centers as the wave of the future. "What we are looking for is a mixed model between national health and privatization," he explains.

Health-care issues are politically sensitive because they touch most people's lives one way or another. Competition for funding and professional status will create jockeying for position inside and outside the system. ANERA president Peter Gubser believes Palestinian health-care facilities can succeed by networking with larger facilities such as those in Hebron and Nablus, providing a training and referral resource for technical expertise. Also, there exists a great opportunity to establish regular cooperative training seminars using different clinics throughout Palestine. This innovation would encourage professional camaraderie and a free flow of people and ideas for all levels of health-care workers.

For Palestinians, the wobbly status of health care mirrors the unsteady transition in all areas of life to a Palestinian state.

Yet in all our visits to West Bank medical facilities I kept thinking back to my day at the Hebron Nursing College. As the class of 1997 sat around me firing off questions about nursing professionalism, ethics, career rewards, and planning for the future, I realized the importance of their concerns. The seeds are being planted for a new generation of professionals. They are bright, ambitious, and very curious. Their energy is precisely what a budding country needs. Nourishing ideals concerned with work ethics, responsibility, and professionalism must be high on the new national agenda.

As I drove away from the college on that chilly day, I felt very reassured by those students who were so full of questions. I did not hear the bird sing in the window of that austere little room—perhaps the shadows were too strong and the sun did not come out. One day, however, the sunlight will drench that dreary square of glass, a small grey bird will puff to twice its normal size, and the world will stop to listen as it sings.

Louisa S. Nye is a trustee for Physicians For Peace, based in Norfolk, VA. As a free-lance writer, she travels frequently throughout the Middle East.