The past decade has seen a continued decline in the quality and capacity of health service providers in the Gaza Strip. The decline has prompted hospitals to refer tens of thousands of patients who cannot be treated in Gaza to hospitals in the West Bank, including East Jerusalem, and Israel. In order to access these hospitals, patients—with Palestinian Authority (PA) approved hospital referrals and appointments—must obtain exit permits from the Israeli security authorities. The permit system that referred-patients must navigate is a rigorous maze of opaque rules and policies, which around half of the time result in denied or excessively delayed medical treatment.

While the vast majority of obstacles that patients and their families face—including exacerbated health conditions and in the gravest cases, death—are the result of the Israeli government’s restrictions on patients’ access to medical care,[1] the PA’s engagement in this system has served to inflame the conditions. In 2017, the PA took administrative measures that resulted in hampered patient access to medical care outside of Gaza and reduced flow of medicine and equipment into Gaza.

Since the establishment of the PA, all patients approved by the Palestinian Ministry of Health (MoH) for medical referral automatically received financial coverage for their hospital and treatment costs. In line with the measures adopted by the PA in 2017, patients are now either delayed or flat out denied financial coverage for their care. The World Health Organization (WHO) reported in July 2017 that 64% of patients were only granted financial coverage from the PA after more than seven days of the application being submitted.[2] According to Al Mezan’s documentation, 16 patients, including two women and 11 children, died between mid-2017 and mid-2018 after such delays by the PA. This is not to say that the deaths are due directly to the delays, but that the deaths are viewed as associated with the delays.

The PA measures were implemented at the height of a public health crisis in Gaza that continues to be marked by a crippled healthcare system and insufficient access to electricity, clean water, and safe food—a crisis prompted by the policy of closure and blockade that Israel has imposed on Gaza for over 11 years. Compounding the effects of this crisis is the Palestinian political divide, which has resulted in a political and geographic split. Within the context of division and rivalry between the governments, the PA’s measures regarding patients are seen as a tool to extract political gains, which could only be pursued at the cost of the vulnerable patient community.

As the statistics show, there has been a diminishing number of referrals being successfully processed by the MoH.[3] In addition, gaps in medical supplies entering Gaza have increased.[4] In August 2018, health service providers announced that chemotherapy would no longer be available to cancer patients in the Gaza Strip due to dwindling supplies from the PA. The shortage of these medicines had peaked at 75 percent out of stock—with 45 types out of the necessary 60 being at zero stock in Gaza.[5] Meanwhile, the rhetoric around the Palestinian political split remained charged.

The PA implemented restrictive measures against Gaza from the beginning of 2017, including cutting the salaries of public sector employees and limiting the expenditure on electricity supplies purchased from Israel. Thousands of PA employees were driven into early retirement and poverty levels increased. Further pressure was also placed on Gaza’s electricity infrastructure. 

As a signatory to the International Covenant on Economic, Social and Cultural Rights, which stipulates in article 12 that every human being is entitled to the enjoyment of the highest attainable standard of health, the PA, by implementing the restrictive measures against patients, is in breach of international human rights law. The practical implication of the measures is a system in which patients’ access to medical care is increasingly precarious and expensive, and in many cases ultimately out of reach. In this paradigm, life and wellbeing are unnecessarily threatened for Gaza’s patient community.

At the beginning of 2018, Al Mezan published, “Medical Care Under Siege”, a report that focused on the implications of the Israeli closure policy on Gaza patients’ access to medical care.[6] This current report focuses on the restrictive—and broadly considered punitive—measures taken by the PA since 2017, and their implications on a patient’s effective access to medical care. It does not address the role of the Israeli authorities in the situation faced by Gaza’s patients.

This report provides information on the following:

1. 1:  The consequences of the PA’s restrictive measures for Gaza’s patients;
2. 2:  The procedures and conditions regulating the process of obtaining medical referrals within the PA health system;
3. 3:  The barriers in patients’ effective access to medical referrals; and
4. 4:  Recommendations to improve the medical referral system in support of patients’ smooth and timely access to urgent treatment.

[1] World Health Organization, Monthly Report on Health Access for Referral Patients from the Gaza Strip, December 2017, available at: http://www.emro.who.int/images/stories/palestine/documents/WHO_monthly_Gaza_access_report_Dec_2017-final.pdf

See also, Joint Press Release on Record-Low in Gaza Medical Permits, available at http://mezan.org/en/post/22378

[2] World Health Organization, Monthly Report on Health Access for Referral Patients from the Gaza Strip, August 2017, available at: https://goo.gl/E5p71A

[3] Al Mezan, “Gaza Healthcare Update: Conditions Worsen”. 8 August 2017, available at: http://www.mezan.org/en/post/22018

[4] Al Mezan, “Zero Stock Medicine in Gaza Threatens Cancer Patients’ Lives”. 14 August 2018, available at: http://mezan.org/en/post/23181.

[5] Ibid, footnote 1  

[6] Al Mezan, “Medical Care Under Siege”. 1 February 2018, available at: http://mezan.org/en/post/22333