Realizing Potential:

Prospects for the development of the Palestinian health system and economy in the Gaza Strip
Fe bru a ry 20 1 2

Realizing Potential:
Prospects for the development of the Palestinian health system and economy in the Gaza Strip
Fe b ru a ry 20 1 2

Writing and research: Hila Amit Writing (second chapter): Gisha - Legal Center for Freedom of Movement Design: David Moscowitz Infographics: Yael Katzeer Printed by: Total Graphics Special thanks to Dr. Angelo Stefanini, Dr. Danny Filc, Dr. Alam Jarar, Prof. Ephraim Kleiman and Dr. Tomer Broude. The writing of this report was made possible thanks to the generous support of the following foundations and contributors: Diakonia, Eper/Heks, EED, UNDP Christian Aid, The European , Union, The Royal Norwegian Embassy, Medico International. This publication has been produced with the assistance of the European Union. The contents of this publication are the sole responsibility of Physicians for Human Rights-Israel and Gisha, and can in no way be taken to reflect the views of the European Union.

Table of Contents
Introduction Summary 4 6

Chapter One: Humanitarian discourse in the service of preventing sustainable development: The Gaza Strip as a test case 10 Chapter Two: Towards an independent Palestinian economy in the Gaza Strip Obstacles and options Chapter Three: Towards an independent Palestinian health system in the Gaza Strip Obstacles and options Conclusion and recommendations

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31 49

Introduction
Most people in Israel obtain information about what is going on in the Gaza Strip mainly from reports in Israeli and international media. When there is an outbreak of violence, as in Operation Cast Lead, or unusual events such as the Turkish Flotilla incident or the release of Gilad Shalit, the headlines take note of the blockade of Gaza and the effect on its residents. In general, however, the discourse in the media remains at surface level and does not focus on complex questions or provide detailed, in-depth treatment of the reality in which Gazas residents are living. Ignoring what is happening behind the walls that surround Gaza - how its people manage to make a living under these circumstances, what factors dictate this situation and, especially, how the infrastructure of Gaza and its residents quality of life could be improved and who has the responsibility to lead such a process - all these questions have led us to write this report. The idea was to examine the conduct of daily life in Gaza so as to identify ways in which it can be improved. This report addresses the centrality of Israel's role in preventing sustainable development in all aspects of life, in general for the residents of the occupied territories and in particular for civil society in Gaza, notably in two realms: Preventing sustainable development of the Palestinian health system in Gaza. Preventing sustainable development of the Palestinian economy in Gaza. Various parties, including governmental parties, international organizations and local human rights organizations, frequently utilize concepts from the field of humanitarian aid. Yet the very act of focusing on specific crisis situations and humanitarian reactions shifts the public discourse away from Israeli policies that prevent development in the occupied territories. By stressing the humanitarian aid that Israel allows into Gaza, the discussion actually distracts public attention away from the ramifications of successive Israeli government policies on some four million residents of the occupied territories overall, and on more than a million and a half residents of Gaza in particular. This report seeks to move from discussion in a humanitarian mode, which focuses on specific incidents drained of political context, to a discussion about the core development of the various sectors in Palestinian society1; from a humanitarian discourse examining how to preserve a minimal quality of life for residents of Gaza to a discourse based on economic development that addresses how to move forward toward a maximum quality of life. The report seeks to examine
1 Examples of the humanitarian discourse addressed here appear in many articles from the IDF Spokesperson about Palestinian families permitted exit for medical treatment, study, work, etc. See, e.g., these articles emphasizing the humanitarian aid given by Israel and Magen David Adom (Israels Red Cross) to residents of Gaza: Palestinians injured in Beit Hanoun transferred to Ichilov, Ynet, 8.11.2006, retrieved from: http://www.ynet.co.il/articles/0,7340,L-3325842,00.html (Hebrew); Palestinian infant from Gaza transferred for surgery to Tel Hashomer Hospital, Ynet, 27.5.2007, retrieved from: http://www.ynet.co.il/articles/1,7340,L-3405166,00.html (Hebrew); Palestinian woman at Tel Hashomer: Not all Israelis are bad, Ynet, 9.1.2009, retrieved from: http://www.ynet.co.il/articles/0,7340,L-3653001,00.html (Hebrew)

head-on the policies that so profoundly influence the lives of some 1.5 million residents of the Gaza Strip, the discussion of which is often shunted aside in favor of particular individual cases that enjoy the media spotlight. The report will enumerate and examine the political, diplomatic and security-related circumstances influencing the economy and the health system in the occupied territories, particularly in Gaza, and will present data portraying the changes that have occurred in these realms. The first chapter provides a brief overview of how the use of the humanitarian discourse actually facilitates the continuing deferral of development in the Gaza Strip, from the standpoint of civil infrastructure. The second chapter presents the changes that have taken place in the restrictions on movement into and out of Gaza, and surveys the impact of policy on the economics of the Strip over the years, along with a look at the potential for economic development bound up with freedom of movement for people and goods. The third chapter deals with the Palestinian health system and the obstacles preventing its development, as well as the potential to transform the Palestinian health system into one that properly serves the health needs of the population. The central recommendations presented in this report address Israeli responsibility for what happens in Gaza and the initiatives and actions that the Palestinian Authority must undertake in order to improve the civil systems in its domain. Our perspective is that Israel remains bound by its obligations vis- -vis the occupied territories until such time as they are completely free of reliance on Israel and there is full Palestinian independence.

Summary
Since 2000, greater use has been made of terms drawn from international humanitarian discourse in describing the Palestinian situation in the occupied Palestinian territories (oPt). This orientation is evident in the activities of the government, the army, and non-governmental organizations, as well as in media reports. One sees its influence in the way Israeli military authorities respond to requests that involve quality-of-life or health services for residents of Gaza; in the establishment of a humanitarian center in the District Coordination Office in Gaza; and in the humanitarian medical emergency room set up at the end of Operation Cast Lead. The use of humanitarian terminology deflects the discourse away from the status of the Palestinian health system and the Palestinian economy and ignores the absence of health determinants such as suitable water, electricity, nutrition and other infrastructure. The humanitarian activities of the government and human rights organizations render residents of Gaza dependent on charity, and diminish their capacity to help themselves and to manage their own lives independently in very diverse realms - including, as will be illustrated in this report, aspects of the economy and human health.

The Palestinian economy in the Gaza Strip

Between 1967 and 1991, the Palestinian economy gradually became very dependent on the Israeli economy. Following the First Intifada in the early 1990s, however, Israeli policy shifted toward cutting off the Palestinian economy from the Israeli economy. During that same period, Israel began implementing restrictions on freedom of movement for people and for the transfer of goods. With the failure of the Camp David Summit and the outbreak of the Second Intifada, the discourse of diplomacy and economics gave way to a discourse of security. With the 2007 Hamas declaration that the Gaza Strip would have its own government, independent of the Palestinian Authority, there was a change in the attitude of international and Israeli actors toward the Palestinian Authority. This change was manifest in the principle of separation between the Gaza Strip and the West Bank. In 2008, Benjamin Netanyahu (at the time, head of the opposition in the Knesset) declared the need for an economic peace2. The development policy included mainly the removal of restrictions on movement across the West Bank, a step that was largely implemented in June of 2009. In contrast, Israel and the international community adopted a different strategy vis--vis the Gaza Strip. International donors withdrew a large portion of their support for developing Gaza, and instead adopted a policy of humanitarian aid in order to prevent a severe humanitarian crisis featuring
2 See Netanyahus speech to the Herzliya Conference, January 2008.

malnourishment or the outbreak of serious disease. Israel, for its part, adopted a policy toward Gaza that it termed economic warfare, which reduced very broad portions of the population to living at subsistence level3. The intention was to generate civilian pressure on Hamas4. In June 2007, immediately following the Hamas takeover of Gaza, a closure on the Strip was declared and the 2005 Agreement on Movement and Access collapsed once and for all. The siege policy turned out to be ineffective - or so held various commentators and experts. Putting pressure on the population as a way of moderating the stance of Hamas toward Israel neither prevented Hamas increased militarization nor hastened the release of Gilad Shalit. Actually, one could argue that the closure actually helped Hamas to consolidate its control over important sectors: the economy in general, the import of basic goods and the job market, as well as education. The tunnel economy, with its network of tunnels dug underneath the border with Egypt, played a central role in this process mainly thanks to private funding and the blessings of the regime. After the closure, imports increasingly came through the tunnels. In June of 2010, after the Gaza flotilla incident, the government of Israel announced a series of steps to ease the closure5; the discourse of economic warfare gave way to a discourse of development, and during that year there were periodic announcements by civilian and military spokespersons on the need to encourage the development of Gazas economy (see Chapter Two). In practice a few easing measures were implemented, but without effecting any significant improvement in the situation. Experts in economics and in international law delivered, at our request, several recommendations for steps that would contribute to the economic development of the Gaza Strip: Enabling the export of goods from Gaza, including to the West Bank. Allowing workers and businesspeople to cross to the West Bank and to Israel. Allowing students from Gaza to study in the West Bank. Developing a judicial system that would provide an atmosphere of commercial certainty for goods and for investors. Encouraging entrepreneurship and technological development. According to Dr. Tomer Broude, one of the experts consulted, Israel and its commercial sector can contribute to all of the above domains, not just by removing obstacles to development but also by actively initiating positive changes.

The Palestinian health system

Eighteen years after the Oslo Accords and the transfer of power to the Palestinian Authority, the Palestinian health system has fallen into complete disarray. Patients, medical professionals and
3 4 5 From A Guide to the Gaza Closure: In Israels Own Words September 2011, which may be downloaded from Gisha's website at www.gisha.org From a joint report by PHR-Israel and Gisha, Rafah Crossing: Who holds the keys? March 2009, which may be downloaded from Gisha's website at www.gisha.org See Israel's government announsment, June 2010: http://www.pmo.gov.il/PMOEng/Archive/Press+Releases/2010/06/spokemediniyut170610.htm

health service institutions are cut off from each other, preventing the system from operating as an independent, integrated whole. The health system in Gaza is dependent, among other things, on Israel for its ongoing day-to-day functioning. The main factor burdening Gazas health system is the continued blockade and the closure of the crossings, which make development impossible. The requirements for development of an independent health system fall into five main categories: Exit of ill Gaza Strip residents outside the Strip to receive health services. Free movement of medical teams to and from the Gaza Strip. Transport of medical equipment and medicines into Gaza. The strengthening and repairing of medical infrastructure in Gaza - building new clinics and hospitals, and rehabilitating infrastructure damaged during attacks on the Strip or as a result of isolation. Partial Israeli control of passage through the Rafah crossing. The obstacles and problems confronting the Palestinian health system arise from three main sources: Ongoing political turmoil and instability grounded in the Israeli military occupation and leading, inter alia, to isolation and separation between various social units. High dependence on international agencies with various agendas. Intra-Palestinian problems involving a lack of control, internal rifts, a dearth of responsibility and an absence of transparency. Recommended steps in order to develop the Palestinian health system: Basic determinants of health must be assured, such as the freedom to earn a living and the option for decent employment at a living wage, a sufficient quantity of high-quality running water, proper nutrition and adequate housing. Medical services and their delivery must be developed both vertically and horizontally, encompassing preventive medicine, primary care and hospitals, along with secondary care in the community and in the hospitals themselves. Real ownership must be transferred to the Palestinian Authority so that it can create an effective and just health system. Knowledge must be developed and sufficient quantities of professional personnel must be properly trained.

Conclusions and recommendations

In order to rehabilitate civilian infrastructure in the Gaza Strip, promote an independent progressive health system, and enable long term economic development that will benefit the population as a whole, Physicians for Human Rights-Israel and Gisha recommend taking the following actions: Israel must permit medical professionals, medical students, patients and those who accompany them to travel into and out of the Gaza Strip, and must allow passage for medical equipment, medicines, and the construction materials needed to rehabilitate existing medical facilities and build new ones. Israel must remove across-the-board restrictions on the movement of people and goods into and out of Gaza in order to enable comprehensive civilian rehabilitation, with an emphasis on health determinants such as the sanitation system, good quality drinking water, nutrition, housing and employment. Israel, the Palestinian Authority, Egypt and international agencies must arrange and coordinate the activity at the crossings; and any arrangements made must fully respect the rights of the Palestinian residents to freedom of movement, including between Gaza and the West Bank (in both directions). In the process, arrangements for inspections must be made compatible with international law. The Palestinian Authority and the Hamas regime must make it their highest priority to guard the human rights of Gazas residents, and must act transparently and responsibly to advance the Palestinian civilian systems and promote long-term economic development for Gaza. International organizations working in the Gaza Strip must not only address the humanitarian sphere, but also promote sustainable development and independent civil systems that can function without reliance on international involvement.

Chapter One: Humanitarian discourse in the service of preventing sustainable development: The Gaza Strip as a test case
The emphasis on humanitarian discourse contributes to an approach whereby Israel, despite being the ruling power, is not obligated to provide for civil development for residents of the occupied territories because they are not Israeli residents and because they are perceived as a perpetual security threat to the State of Israel. This injury to the residents of the territories is sometimes perceived as a minor wrong and as a necessity arising from the effort to preserve the security of the states citizens. Hence any particular privilege this population may enjoy is perceived as a humanitarian gesture, and not as the actualization of a basic right.

The discourse of international humanitarian law

With its occupation in 1967 of the West Bank and the Gaza Strip, Israel saw itself as responsible, if only partially, for the Palestinian population in the occupied territories, and in a variety of spheres. Between 1967 and 1980, the military administration for the territories bore responsibility for military and security-related missions and for civilian matters as well. Since 1967 Gaza has been held by Israel as an occupied area under the relevant international laws, including the Hague Convention of 1907 and the Fourth Geneva Convention of 1949, to which Israel is a signatory and which it has ratified. Nonetheless, Israel does not acknowledge de jure application of the Fourth Geneva Convention to the territories under its control; apart from the Hague Convention, Israel willingly accepts only the humanitarian provisions of the Fourth Geneva Convention6.

Israels responsibility in the Gaza Strip

The First Intifada, which broke out in December 1987, signaled a process of diminished Israeli commitment toward the residents of the occupied territories, while the peace process and the Oslo Accords instituted autonomous Palestinian authority in various spheres, including full civil autonomy in health, for which the Palestinian Authority was to be responsible. Nonetheless, a regime of permits and restrictions began operating in the West Bank and Gaza which became more sophisticated over the years. The Second Intifada, the continuation of violent conflict, the process of disengagement from the Gaza Strip in 2005, the imposition of a closure policy on Gaza, and Operation Cast Lead in the beginning of 2009 left open questions concerning Israels responsibility toward the Palestinians in general, and toward residents of Gaza in particular. After Hamas came to power, in March 2006, Israel promulgated a policy of restrictions at the
6 Claude Bruderlein, Legal Aspects of Israel's Disengagement Plan under International Humanitarian Law, Program on Humanitarian Policy and Conflict Research at Harvard University 4-5, November 2004.

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crossings and on the entry of humanitarian aid, an act that had severe consequences for the movement of goods and people into and out of Gaza. These restrictions became even more stringent after the kidnapping of the soldier Gilad Shalit in June 2006, when Israel ended crossings transit except for periodic openings in cases of exceptional humanitarian need7. A year later, Hamas took control in the Gaza Strip and Israel further tightened its restrictions, until the state of siege was nearly absolute. In September 2007 Israel declared the Gaza Strip a hostile entity. The restrictions included inter alia a prohibition on exports, restrictions on the exit of persons, and restrictions on the entry of goods beyond the humanitarian minimum, including diesel fuel and cooking gas. This brought about a severe crisis in the supply of electricity to Gaza. Since September 2007, following a Cabinet announcement, we have seen a growing inflexibility in the crossings policy involving the movement of people and goods, as well as a decline in the functioning of the health system in Gaza. Even following the Flotilla incident, in whose wake some of the restrictions were eased, restrictions remained in place regarding the crossing of people and the export of goods to market outside Gaza. Even the release of Gilad Shalit on October 18, 2011 did not bring about meaningful change in Israels policies regarding the crossings.

The humanitarian discourse and Israeli policies in the territories

Since the year 2000, we have seen a growing use of terms taken from the international humanitarian discourse regarding the Palestinian situation in the occupied territories. This use of humanitarian terminology emphasized action taken in exceptional cases and thereby dampened public criticism of the stringent restrictions placed on Palestinians freedom of movement. The declared goal was to provide solutions to the most outrageous and urgent human situations. Human rights organizations also have a broad share in this discourse. Thus, at the end of Operation Cast Lead, a clinic was opened outside the Strip itself to treat wounded Palestinians from Gaza. Then-Minister of Welfare Yitzhak Herzog, at the time Coordinator of Humanitarian Matters for the government of Israel, spoke of the opening of this clinic thus: Our conscience is clear. Israel knows how to fight terror but also knows how to be humane and remediate suffering8. The IDF Spokesperson also makes sure to present, every few months, humanitarian initiatives benefiting the Palestinian population, such as the inauguration of a health center for urgent cases that would be open 24 hours a day to coordinate various medical and humanitarian cases for the Civil Administration in 20119. This adherence to the term humanitarian case placed the emphasis on local solutions to particular problems, and thereby prevented or delayed thinking about complex and comprehensive solutions.
7 8 9 From a joint report by PHR-Israel and Gisha, Rafah Crossing: Who holds the keys? March 2009. "The fighting is over and in Israel they are moving toward taking care of Palestinians", Haaretz, 18.1.2009: http://www.haaretz.co.il/news/health/1.1241794 (Hebrew). On the opening of a 24-hour center for urgent cases, operated by the Civil Administration in 2011, although the Civil Administration was always required to be prepared to deal with urgent cases 24 hours a day, see IDF Press Release:http://dover.idf.il/IDF/News_Channels/today/2011/05/1703.htm/ (Hebrew).

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The political philosopher Giorgio Agamben argued that the humanitarian involvement conceals the rather covert division of labor that exists between the humanitarian organizations and the authorities, whose policies are the cause of the disaster10. Human rights organizations are also liable to find themselves partners to this focus on urgent humanitarian cases, so that the desire to raise awareness via the media about the infringements of peoples rights sometimes leads to highlighting one shocking, individual story; prospects are good that a story of this type will tend to obscure rather than reveal the reality in which rights are denied to an entire population without reaching the point of endangering its existence. With Hamas rise to power in Gaza in 2007, for example, stricter criteria were instituted regarding the awarding of exit permits via the Erez crossing to patients leaving Gaza for medical treatment in the West Bank and in Israel, emphasizing that only life-saving humanitarian cases would be granted permits11. Thus the loss of an arm or loss of eyesight, neither of which is considered life-endangering, would not be counted as humanitarian cases12. Another example of the use of this kind of dialogue was the creation of a situation room for humanitarian affairs, located outside the Gaza Strip during Operation Cast Lead, where NGOs and the media were updated regarding the humanitarian situation of Gaza residents during the assault. Likewise, when Israel permits transit at a crossing for trucks carrying basic goods for the residents of Gaza, an action Israel is obligated to allow under international law13, this action is not perceived as Israels obligation but as a voluntary humanitarian act on its part14. The use of the humanitarian discourse is also very conspicuous in the Israeli media and among various Israeli groups, and humanitarian concepts are used repeatedly. Below are several examples: Humanitarian gesture The term humanitarian gesture relates to an act portrayed as extraordinary and performed out of humane considerations. The term is commonly used to describe acts such as granting a permit to a patient and permitting hospitalization in an Israeli hospital (although the Palestinian Authority provides the funding to cover the treatment costs), permitting the entry of various food products into Gaza despite the closure, and allowing pregnant women to cross internal checkpoints within the West Bank.

10 11 12 13 14

Agamben, Giorgio, 1998. Homo Sacer. Stanford: Stanford University Press, p. 133. Israeli policy at the Erez Crossing: a medical-ethical manifesto, August 2007, at: http://www.phr.org.il/default.asp?PageID=111&ItemID=314. See the PHR-Israel position paper on Unacceptable policy of discrimination by Israel regarding patients from Gaza requiring medical care outside the Gaza Strip, ethical and legal aspects, June 2010, at: http://www.phr.org.il/default.asp?PageID=111&ItemID=558. See the discussion at the beginning of the chapter in Notes 7, 8, and 9. Among the dozens of examples, see e.g. this article: Israel allows humanitarian aid entry via the Sufa Crossing, at http://www.ynet.co.il/articles/0,7340,L-3513726,00.html (Hebrew)

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Red lines15 Red lines are those that Israel has determined as the minimum requirements for human survival, and whose crossing (downward) is liable to lead to irreversible damage to the health of the residents of Gaza. The red lines apply to, inter alia, the quantities of food transferred into Gaza, the number of patients permitted to leave Gaza, and the supply of gas that Israel transfers to Gaza for generating electricity. An example of a red line may be found in the statement by General Amos Gilad, who argued in an interview that there is no hunger in Gaza: Hunger is a lack of basic foodstuffs and when people are walking around with swollen bellies and collapsing and dying. There is no hunger now16. In practice Israel imposes a policy of subsistence, yet the continuation of this policy is described as a positive one that prevents a humanitarian crisis. Humanitarian crisis A humanitarian crisis is a code name for a severe crisis. For example, an outrageous absence of electricity due to Israels refusal to allow fuel into Gaza was termed a 'humanitarian crisis'.17 A severe shortage of medicines and medical supplies is also called a 'humanitarian crisis'. The discussion of possible ways to resolve the crisis (such as allowing limited additional quantities of food or medicines into Gaza) creates a picture of positive acts preventing hardship, and ignores the political reasons that created the crisis in the first place. Continued use of the humanitarian discourse deflects attention from an in-depth examination of the situation facing residents of the occupied territories in terms of the economy, the health system, and health determinants such as water, nutrition and infrastructure. Humanitarian actions by the Israeli government or by human rights organizations leave the residents of Gaza dependent on charity and damage their ability to help themselves and to improve their situation independently in broad civic areas. Apparently the Government of Israel is now also beginning to abandon the humanitarian discourse for a discourse of development, and emphasizes in its reports and press releases elements that relate to economic, health-related or social development18; this transition is not yet substantially evident, nor are there significant results thus far seen in the field.

15 16 17 18

See the verdict obliging the State in a document of that name dealing with Israeli policy on the entry of goods into the Gaza Strip. The document has not yet been released because the State is appealing the verdict, and a decision is pending: http:// www.gisha.org/UserFiles/File/HiddenMessages/VerdictFOIA230311.pdf (Hebrew). Hunger is a lack of basic foodstuffs and when people are walking around with swollen bellies and collapsing and dying. There is no hunger now, General Amos Gilad, at the Haaretz web site, 7.8.02, in an article by Gideon Alon (Hebrew). See "ynet" report on the "humanitarian crises" due to the lack of electricity: http://www.ynet.co.il/articles/0,7340,L-3269334.00.html (Hebrew). Also, see the UN fact sheet at: http://www.ochaopt.org/ documents/ocha_opt_gaza_electricity_crisis_2010_05_17_hebrew.pdf See for example the monthly report from COGAT (the Coordinator of Government Activities in the Territories) which addresses, inter alia, exit for goods, merchants, meetings of businesspeople, and projects, at: http://www.cogat.idf.il/Sip_Storage/FILES/6/2796.pdf (Hebrew)

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Chapter Two: Towards an independent Palestinian economy in the Gaza Strip Obstacles and options
If one turns to the media to try to understand what life is like in the Gaza Strip today, how its residents make a living and what the economic situation is there, two different and opposing pictures emerge, especially in the past year. In one image Gaza is a giant prison, and its residents, malnourished and helpless, face a severe humanitarian crisis. In the second image, Gaza is portrayed as experiencing economic growth, even a construction boom, following Israel's removal of the closure. The truth, as usual, does not lie in either of these extreme versions of the story. While it is true that there is no shortage of food in Gaza, poverty has intensified due to years of closure and restrictions on movement. More than 70 percent of Gaza residents receive humanitarian aid today19, and the official unemployment rate is at 28 percent and rising20. In this chapter we will attempt to show what led to this situation. We will survey the political, diplomatic and security-related circumstances that influenced the economy in the Palestinian territory, looking in particular at the economy of the Gaza Strip from 1967 to the present day and offering data to illustrate the changes that took place. This overview will encompass five periods, which we have defined on the basis of events that are generally considered milestones in Israels policy toward the Palestinian territory. A truly comprehensive and in-depth analysis would require a much broader scope than is afforded by a single chapter in a report such as this one. We will concentrate here on restrictions on movement into and out of the Gaza Strip, their influence on Gazas economy and on potential for economic development should restrictions be lifted. Our central argument in this chapter is that the ability to engage in long-term economic development has been denied to Gazas residents for the entire period of Israels rule over the area. At the end of the chapter, we will present a series of recommendations we have compiled from experts concerning the ways in which Israel could act to remove the remaining obstacles to Gazas economic development, thus allowing creative and productive forces in Gaza to usher in a new horizon of prosperity and well-being for its residents.

19 20

Analysis and cross-checking from the World Food Programme (WFP) and from the United Nations Relief and Works Agency (UNRWA). As of the third quarter of 2011; source: Palestinian Central Bureau of Statistics (PCBS).

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Restrictions on movement 1991 2011 vs. GDP per capita in US dollars

1991 Revocation of the general exit permit from the occupied Palestinian territory. Palestinian residents are required to obtain individual permits in order to enter Israel. 1993 The Oslo Accords. Agreement on arrangements for securing freedom of movement. In practice: a wave of terrorist attacks and full closure on the occupied Palestinian territory. 1995 Electric fence built around the Gaza Strip. Full closure is periodically imposed on the Gaza Strip (until 2000). 2000 The Second Intifada. Cancellation of all existing exit permits. New permits are issued only for laborers, merchants and patients undergoing treatment in Israeli hospitals. Increased restrictions on transport of goods. 2001 Gazas international airport is bombed. 2005 The Gaza Disengagement Plan is implemented. Control over land crossings, airspace and territorial waters continues. GDP (Gross Domestic Product) in Gaza | 2006 Hamas wins elections. Increased restrictions imposed on movement of people: Residents of the Gaza Strip are to be denied entry other than for exceptional humanitarian reasons. June 2007 Following Hamas takeover of Gaza. Closure as part of an economic warfare policy which includes severe restrictions on the transport of goods into and out of the Gaza Strip. December 2008 Cast Lead. Widespread destruction of infrastructure in the Strip. June 2010 Following the Gaza flotilla. The security cabinet announces a number of measures easing the closure. December 2011 Restrictions continue on marketing goods to the West Bank and Israel, on movement of people between Gaza and the West Bank and entrance of building materials into the Gaza Strip. GDP in the West Bank

1,875

1,730

1,579

1,692

1,483

1,443

1,327

1,336

1,224

1,307

1,258

1,203

1,257

1,294

1,098

1,043

1,103

1,104

1,290

902

997

1,460

1,472

1,457

1,475

1,451

886

1,581

1,724 807 2008

1,838 2009 787

1996

1998

1999

1994

1995

1997

2002

2006

2001

2004

2000

2005

Source: Palestinian Central Bureau of Statistics (PCBS)

1967-1991 - Fostering dependence between Gaza's economy and that of Israel The occupation of the West Bank and the Gaza Strip in 1967 sparked a debate in Israel over the economic policy Israel ought to pursue vis--vis the Palestinian territory. The approach taken by
15

2003

2007

2010

877

1,925

then-Minister of Defense Moshe Dayan envisioned interaction between the two economies, whereas the approach preferred by then-Finance Minister Pinchas Sapir supported segregation between them. Dayans approach won out eventually and the connections between the two economies deepened. Israel, via its Civil Administration, collected taxes and provided basic services, but the level of investment in infrastructure remained relatively low. A key characteristic of that period was the freedom of movement enjoyed by people and vehicles throughout the area under Israels control. This reality led to tens of thousands of Palestinians working within the Green Line (i.e., in Israel within its pre-1967 borders), mainly in the construction industry. Nonetheless, commercial freedom was not total. Pressure from various sectors in Israel led to a policy of protectionism and defending Israeli products from Palestinian competition. The absence of restrictions on the labor force had a positive influence on the Palestinian economy - Palestinian laborers returned home from jobs in Israel with cash in hand. This income, for various reasons, was invested mainly in building homes. Over the years, the Palestinian economy became increasingly dependent on Israel and also highly vulnerable to economic fluctuations in Israel and to security-related and other restrictions that Israel imposed. 1991-2000 - First steps to separate the economies In the early 1990s, Israel's policy underwent a change with respect to the Palestinian territory. Following the start of the First Intifada in 1987, Israel began placing restrictions on the freedom of movement of people and on the transfer of goods. In 1991, Israel canceled the general exit permit and began demanding that Palestinian residents acquire individual permits in order to leave Gaza21. Under the Oslo Accords signed in 1994, it was decided that there would be a phased transfer of power to the Palestinian Authority, including concerning decisions about financial policy in the territory. In addition, it was decided that the area within 20 nautical miles of the Gaza coast would be open to Palestinian use for fishing, recreation and economic activity22. Since it was agreed by both sides that determination of the border between Israel and the Palestinian Authority would be postponed until final status talks, it was not possible to create separate customs regions23. Hence it was decided that the two regions would share a joint "customs envelope" and that Israel would collect customs duties and value-added tax on imports to the Authoritys territory on behalf of the PA, monies which until then had been added to Israels treasury24. According to Prof. Ephraim Kleiman, who was a member of the Israeli negotiating team, the agreement was signed because both sides had an interest in the economic development of the Palestinian territory.
21 22 23 24 From a joint report by PHR-Israel and Gisha, Rafah Crossing: Who holds the keys? March 2009, which may be downloaded from Gisha's website at www.gisha.org, (hereinafter: Rafah Crossing). From a report by the United Nations' Office for Coordination of Humanitarian Affairs, "Between the Fence and a Hard Place" August 2010: http://www.ochaopt.org/documents/ocha_opt_special_focus_2010_08_19_english.pdf (hereinafter: Between the Fence and a Hard Place). From an interview with Prof. Ephraim Kleiman by Gisha representatives, 14.9.2011. The tax monies that the Civil Administration collected and the VAT on sales by Palestinians to Israelis were added to the treasury of the Civil Administration; the tax monies that Israel collected on imports via Israeli ports and the VAT on sales by Israelis to Palestinians were added to the Israeli treasury.

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It was in this atmosphere of optimism, sometime later, that began a wave of suicide bombings and a closure of the Palestinian territory was declared. The closure on Gaza was enforced with particular effectiveness beginning in 1995, with the construction of an electronic fence around the Strip. Passage was also prevented from time to time even for permit holders, during the imposition of absolute closures on Gaza. Restrictions on movement during the Oslo period were determined against the backdrop of two opposing trends in Israel. On the one hand, the political process aimed to partition the territory, while creating a zone relatively free of restrictions on the movement of goods and people. On the other hand, the volatile security situation put pressure on decision-makers and the security establishment to make increasing use of movement restrictions as a means of defense, deterrence and punishment. 2000-2006 - From an economic discourse to a security discourse In 2000, with the failure of the Camp David talks and the outbreak of the Second Intifada, the peace process had reached an impasse and the economic discourse of the 1990s was replaced entirely with a security discourse. Existing exit permits held by Palestinians were cancelled, and new ones were issued only to workers, merchants and patients being treated in Israeli hospitals25. More severe restrictions were also imposed on the passage of goods into and out of Gaza. Restrictions on movement were imposed not only on the land-based crossings. In 2001, Israel shelled the Gaza airport, which had begun operating only in 1998, and since that time it has not resumed operations26. Nor did Israel permit entry to or exit from Gaza via the sea27, and fishing was restricted to a limit of 12 nautical miles from the coast. Finally, between 2003 and 2005, the wharf at Khan Yunis was closed for long periods and access to other coastal areas was frequently disrupted28. These restrictions took their toll on economic activity in Gaza. In 2001, the average daily number of workers leaving Gaza to work in Israel dropped to about a quarter of the average number prior to the Intifada, the number of trucks entering and leaving Gaza also dropped after 200029 and the unemployment rate meanwhile rose to 18.7 percent30.

25 26 27

28 29

30

See Rafah Crossing. The airport was inaugurated in 1998. Its operations were very restricted, and in 2001 stopped altogether. After it was shelled, negotiations were not renewed on its resumption of operations, contravening a stipulation in the Agreement on Movement and Access. This prohibition has been in force since the occupation of the Gaza Strip in 1967. The Agreement on Movement and Access signed at the end of 2005 stated that construction of a Gaza seaport could begin and obligated Israel to assure donors funding its construction that it would not interfere with its operation. Israel did not provide such guarantees to donors, and the construction of the port never began (See Rafah Crossing). See Between the Fence and a Hard Place. The average daily number of workers in 2001 was 619, compared with 26,500 during the three months prior to the Second Intifada in 2000 (UNSCO). The average number of trucks entering and leaving daily dropped after 2000 (600-700 trucks compared with 450 trucks after 2000) (from Gaza Strip Crossings: Israeli Policies in a Broader Perspective, Peres Center for Peace, 2011 (hereinafter: Gaza Strip Crossings). Palestinian Central Bureau of Statistics (PCBS).

17

In September 2005, Israel implemented its "Disengagement Plan" for Gaza31. Even after that, however, Israel maintained sole control over Gazas air space and territorial waters and sole control over transit between Gaza and the West Bank32. 2006-2010 - Development of the separation policy During elections held in the Palestinian Authority in January 2006, Hamas won a majority of votes and control of the parliament. In the months following the Hamas victory, the United States and the European Union heavily pressured the Palestinian Authority and cut off the flow of direct donor funding to it. Furthermore, hostilities between Hamas and Israel intensified - Hamas fired rockets at Israeli communities and captured Gilad Shalit, and Israel conducted a military campaign in Gaza that lasted five months. At the end of the year, confrontations began between Hamas and Fatah, and it was against this backdrop in March 2007 that a unity government was set up in the Palestinian Authority, lasting three months. In June of that same year, Hamas took control of the internal governance apparatus in Gaza. Palestinian Authority President Mahmoud Abbas announced the dismantling of the unity government, and Hamas for its part declared an independent government in Gaza, free of the PAs control, the latter now reduced to ruling the West Bank. These dramatic events led to changes in the strategic discourse of international actors and of Israel vis--vis Palestinian rule in Gaza in the West Bank - changes that were then manifest in the principle of separation between Gaza and the West Bank. The foundation for this principle is the distinction made between the two Palestinian governments - the one in the West Bank, which forswore violence in favor of negotiations, versus that in Gaza, which refused to recognize Israel or prior agreements with Israel, and remained committed to the armed struggle. Accordingly, the principle of separation as a policy adopted by Israel is expressed differently toward the respective leaderships - continued security coordination and the development of political and economic ties with the PA, while refusing any direct connection with the government in Gaza. Among decisions-makers in Israel, the principle of separating Gaza from the West Bank was given a far-reaching interpretation, the significance of which was the complete isolation of the Gaza Strip from the rest of the world. The policy of separation vis--vis the West Bank was manifest in the adoption of a discourse of economic development. At the beginning of 2008, Benjamin Netanyahu, as head of the opposition, began to talk about the interest in economic peace33 with the West Bank and the need to develop its economy. The idea was rejected by then-Prime Minister, Ehud Olmert, but became government

31 32 33

This refers to Israel's removal of settlers from the Gush Katif settlements and withdrawal of its permanent military presence in Gaza. See: http://www.mfa.gov.il/MFA/Peace+Process/Guide+to+the+Peace+Process/Israeli+Disengagement+Plan+20-Jan-2005.htm See the position paper Scale of Control; Israel's Continued Responsibility in the Gaza Strip," November 2011, which may be downloaded at www.gisha.org Netanyahus speech to the Herzliya Conference, January 2008.

18

policy when Netanyahu took over as prime minister in 200934. The development policy included mainly the removal of restrictions on movement across the West Bank, a step that was largely implemented in June of 200935. But economic peace had more than one emissary. In 2010, Regional Development Minister Silvan Shalom argued that this was a policy that would restore hope to young people and give them a reason to follow the right path, a humane and rational path36. Last year, the Governor of the Bank of Israel said that trade with the Palestinian Authority has great political importance and that the Palestinian economy is very far from realizing the potential it could achieve under conditions of peace37. Some figures in the defense establishment also expressed the opinion that a reduction in poverty and unemployment among Palestinians is in Israels interest from a security standpoint: A turn to radical Islam, arising from the high unemployment rates and from poverty, enhances the ability of the various terrorist organizations to operate within the civilian population and enhances the number of individuals willing and ready to participate in hostile activity38. Pronouncements about economic development for the West Bank were actualized in part. The West Bank economy grew and Netanyahu was quick to take pride in that39. But according to a recent study, the growth was short-lived, and based on external aid rather than on activity or investment in the private sector40. As agreed in the Oslo Accords, Israel collects taxes on behalf of the Palestinian Authority and transfers the money to it, but in recent years Israel delayed the transfer of monies to the PA several times as a means of exerting pressure on it41. Regarding Gaza, as noted, Israel and the international community made use of a completely different policy. International donors withdrew a large portion of their support for the development of Gaza and adopted, instead, a policy of humanitarian aid, intended to prevent a severe humanitarian crisis due to malnourishment or the outbreak of disease42. A further freeze on development was buttressed by the policy Israel opted to use and which it called economic warfare43. This policy
34 See PM Ehud Olmerts speech at the Institute for National Security Studies (INSS) Annual International Conference, December 2008, at: http://www.mfa.gov.il/MFA/Government/Speeches+by+Israeli+leaders/2008/ Address_PM_Olmert_TAU_INSS_Annual_Conference_18-Dec-2008 See OCHA's movement and access update, June 2010 at: http://unispal.un.org/UNISPAL.NSF/0/4694C27BF640414685257744004ACE17 Silvan Shaloms speech to the Herzliya Conference, 2010. Ynet, September 2011: http://www.ynet.co.il/articles/0,7340,L-4118019,00.html (Hebrew). See a report on Palestinian labor written by Deputy Governor of the Bank of Israel, Dr. Zvi Eckstein, submitted in July 2011 to the Prime Minister. See also, The Marker, June 2011: http://www.themarker.com/realestate/1.654815 (Hebrew). See Netanyahus speech to the US Congress, May 2011: http://www.mfa.gov.il/MFA/Government/Speeches+by+Israeli+leaders/2011/Speech_PM_Netanyahu_US_Congress_24May-2011.htm See article in MEMRI, December 2011: http://www.memri.org/report/en/0/0/0/0/239/0/5888.htm See "Palestinian fury at Israeli refusal to unblock funds," Khaleej Times, February 2006: http://www.khaleejtimes.com/ DisplayArticle.asp?xfile=data/business/2006/February/business_February58.xml&section=business&col=; and May and November 2011: "UN chief presses Israel to release funds," Guardian, May 2011: http://www.guardian.co.uk/world/2011/ may/08/israel-palestinian-authority-funds-un and "Israel releases PA tax funds," Jerusalem Post, November 2011 at: http:// www.jpost.com/DiplomacyAndPolitics/Article.aspx?id=247629 See Gaza Strip Crossings. See the fact sheet Guide to the Gaza closure in Israel's own words, September 2011, on Gisha's website at www.gisha.org (hereinafter: Guide to the Gaza Closure).

35 36 37 38 39 40 41

42 43

19

included lowering the standard of living of the population to a humanitarian minimum, with the intention of pressuring Hamas44. In June 2007, immediately after Hamas took control of Gaza, a closure was imposed on the Gaza Strip, and the Agreement on Movement and Access signed in 2005 collapsed once and for all. The closure included, inter alia, a prohibition on fishing at a distance greater than six nautical miles from the coast, imposed in June 200645; severe restrictions on the transfer of goods into and out of Gaza; and restrictions on access for people, already intensified in March 2006, such that entrance shall not be permitted [to Israel or the West Bank] for residents of Gaza except for extraordinary humanitarian reasons46. The closure almost completely shut down commerce between Gaza and the West Bank and Israel. Entry to Gaza was permitted to only a few dozen items, mainly for humanitarian needs47, so that the average number of trucks entering monthly dropped by 95 percent48. In addition, export from Gaza was prohibited altogether by Israel, apart from a negligible quantity of agricultural produce bound for Europe, although the West Bank and Israel are the traditional markets for goods from Gaza49. The failure of the closure policy The economic warfare policy was implemented in contravention to international law, which forbids collective punishment of a civilian population as a means of warfare50. But apart from being unlawful and unethical, the policy turned out to be ineffective as well, to put it mildly. Most of the Israeli commentators and experts who have spoken on the subject have held that pressure placed on the civilian population did not lead to any greater flexibility in Hamas positions vis--vis Israel, did not prevent the organization from acquiring weapons, and did not contribute to furthering negotiations on the release of Shalit51. In fact, there is broad agreement that the closure actually helped Hamas consolidate its control over the economy, over the import of basic necessities and other goods, over the job market and over education in the Gaza Strip. A central role in this process was played by the tunnel economy - a network of tunnels dug underneath the border with Egypt, mainly via private funding and under the auspices of the regime, and through which goods were imported into Gaza52. The Hamas government collected import duties and various other taxes on the incoming goods.

44 45 46 47 48 49 50 51 52

The official demand made of Hamas was that it accepts the three conditions of the Quartet, and an additional demand was the release of Gilad Shalit. See Between the Fence and a Hard Place. See Rafah Crossing. A list of 40 approved items was expanded to 70 items during the latter half of 2009, and to some 108 items at the beginning of 2010. See Partial list of products whose import into the Gaza Strip is prohibited or permitted, from June 2010 on Gisha's website, www.gisha.org See Gaza Strip Crossings. Between 2000 and 2005, 85 percent of the exports from Gaza were destined for Israel. See Guide to the Gaza Closure. See post entitled More mainstream than mainstream on the Gisha blog at www.gazagateway.org (hereinafter: More mainstream than mainstream). Per the Office of Economics of the Palestinian Authority, during the first half of 2010, the number of tunnels operating was over 1,300, and more than 4,300 types of products were imported through them.

20

Hamas budget in millions of dollars

2006 2010
total

500

million dollars

40

foreign contributions taxes 50 localfees and

150

The goal of the closure: to weaken Hamas financially*

4,300 types of products have been imported through 1,300 active tunnels. These account for 80% of the total import 300
As of 2009-2010, more than into the Gaza Strip

the tunnel economy

* Testimony of Israels military advocate general to the Turkel commission, August 2010
Source: Ministry of National Economy, Gaza Economic Strategy, March 2011; Gaza Strip Crossings: Israeli Policies in a Broader Perspective, Peres Center for Peace, 2011.

While Hamas was counting its profits from imports from the tunnels, the private sector in Gaza was shrinking. The number of active industrial enterprises dropped in 2007 by 95 percent in comparison with 2005, and the number of industrial workers dropped from 350,000 to 2,00053. In July 2007, Director Ali Al Hayek of the Palestinian Businessmen Association described things this way: The situation in which there is no possibility of importing raw materials into Gaza is paralyzing Palestinian industry. Israel is not punishing the government, but rather the people. We as the private sector are paying the price There are a lot of people who have been harmed by this closure, who have lost their jobs, their livelihood54. The collapse of the agreed-on "lull" in fighting - the tahadiya - between Israel and Hamas in November 2008 led to the military operation on Gaza known as Cast Lead, which continued for about a month, and destroyed a broad swath of infrastructure55. Then in March 2009, Netanyahu was named prime minister and began easing restrictions on the import of goods into Gaza, leading to an increase in the types of goods permitted to enter Gaza as well as their quantity56.
53 54 55 56 See Gaza Strip Crossings. See the report Commercial closure: Deleting Gaza's economy from the map, July 2007, on Gisha's website at www.gisha.org See the report Red Lines Crossed: Destruction of Gaza's Infrastructure, August 2009, on Gisha's website at www.gisha.org See graphs on Gisha's website: http://www.gisha.org/graph.asp?lang_id=he&p_id=901

21

The ineffectiveness of the closure policy also manifested itself in damage to Israels image worldwide. The flotilla incident in May 2010 only reinforced that damage57. Overall, the outcomes of the policy led Netanyahu and other key policy-shapers to admit that the civilian closure wasn't working, and moreover damaged Israel's ability to enforce a security blockade58. 2010 - The transition to the discourse of economic development for Gaza In June 2010, after the flotilla to Gaza, the government of Israel announced a series of steps to ease the closure59. The discourse of economic warfare was replaced by one of development, and over the course of that year, military and civilian actors made several declarations concerning the need to stimulate the economy of Gaza as well as Israels commitment to doing so.

57 58 59

A flotilla that sailed from Turkey to Gaza was stopped by armed forces. A violent struggle ensued, culminating in the deaths of nine Turkish citizens and the injury of several Israeli soldiers. The incident sparked severe criticism of Israel around the world. See More mainstream than mainstream. See Security Cabinet decision: http://www.mfa.gov.il/MFA/Government/Communiques/2010/Prime_Minister_Office_statement_20-Jun-2010.htm

22

On Israels interest in economic growth in the Gaza Strip

The Cabinets decision removes the civilian closure on Gaza and tightens the security closure.
PM Netanyahu at the Foreign Affairs and Defense Committee, June 21, 2010

We must distinguish between the civilian population and the terrorists.

COGAT, April 10, 2011

I thought... we wouldnt be able to bring Hamas down through the siege this is why I thought it couldnt work and Im sad to say it hasnt worked.
Minister Dan Meridor, Meet the Press, April 30, 2011

One way to increase stability is to continue the policy we have been implementing for the past two years promoting Palestinian economic growth and development. Its good for them. Its good for us. There are a number of measures here that advance this objective.
PM Netanyahu, February 4, 2011

Expand operations at the existing operating land crossings, thereby enabling the processing of a significantly greater volume of goods through the crossings and the expansion of economic activity.
Security Cabinet statement, June 20, 2010

The Security Cabinet approved additional measures this morning to increase export from the Gaza Strip.
Government decision, December 8, 2010

According to the declarations quoted in the chart, members of the government and security officials believe that economic development for Gaza is clearly in Israels interest. Just last September (2011), Foreign Minister Avigdor Lieberman announced that when the Palestinian GDP reaches $15,000 per capita, a resolution of the conflict will be attainable60. Likewise, Dr. Tomer Broude, senior lecturer on the law faculty and in the international relations department at Hebrew University, argued in an interview conducted for the purpose of writing this report that it would certainly be easier to reach an agreement and ensure its sustainability were there a more developed and flourishing Palestinian economy. In such a case, the Palestinian public would have a stronger
60 See article in the National Post, September 2011: http://fullcomment.nationalpost.com/2011/09/20/avigdor-lieberman-palestinian-statehood-would-set-a-dangerous-precedent/

23

interest in preserving its own prosperity. Broude adds that more balance between the Israeli and the Palestinian economies would lessen Palestinians feeling of dependence vis--vis the sense of Israeli economic hegemony. An examination of what has been done in practice, in light of the declarations by these government and military figures, reveals that so far, several steps have been taken to ease the closure. Israel removed obstacles on the entry of all goods, except for goods that it defines as dual-use (i.e. having both civilian and military purposes) and on construction materials61. The transfer of construction materials is permitted only in cases in which the materials are intended for projects being carried out by an international organization and under the supervision of the Palestinian Authority. Export of agricultural produce (strawberries, flowers, peppers and cherry tomatoes), to Europe only, continues in larger quantities than in recent years62, and at present Israel claims that it, in principle, would also allow export to Europe of textiles and furniture. Nonetheless, Gaza merchants face difficulties in developing far-off European markets, a less natural destination for their products, and in practice, the quantity of export that Israel permits is only about 2 percent of the quantity that it obligated itself to allow in the framework of the 2005 Agreement on Movement and Access. The number of exits permitted for businesspeople from Gaza traveling to the West Bank or Israel rose to 70 a day63 according to the Coordinator of Government Activities in the Territories (COGAT). In a report published to mark the one-year anniversary of the announcement that conditions would be eased, COGAT proudly noted that nearly 30,000 permits were given since June 2010, but this number pales in comparison with the average of half a million exits a month for Palestinian workers in 200064. In addition, the permits granted today are intended for senior merchants only, defined as those whose exit will contribute to improving Gazas economy. The few businesswomen in Gaza, and those few young merchants seeking to make commercial connections with Israel and the West Bank, do not receive permits65. The data portrays a disregard for the commonly accepted notion that small businesses are a critically important sector driving the development and progress of an economy. Over the last decade, Israel closed three of the five crossings between Gaza and Israel one by one, which had become the target of attacks by Palestinian militant organizations. They have not been reopened66. In addition, since 2008, along most of Gaza's coast, access has been restricted
61 62 63 64 65 66 This list of products includes and even expands on the inspection list promulgated by the Wassenaar Arrangement on Export Controls for Conventional Arms and Dual-Use Goods and Technologies: http://www.wassenaar.org/controllists/index.html Between November 2010 and May 2011, 290 trucks exited, while during the entire three years of the closure (June 2007 through June 2010), 255 trucks exited Gaza. See Policy on the movement of people between the State of Israel and the Gaza Strip, Coordinator of Government Activities in the Territories, http://www.cogat.idf.il/Sip_Storage/FILES/3/2533.pdf See at: http://www.mfa.gov.il/NR/rdonlyres/EDD50D8A-E136-4C82-B7FC-9AB3CB463122/0/ GazaImplementationCivilPolicy1year2.pdf See footnote 63 herein. The Rafah crossing was closed to the movement of goods in 2005 and, at this writing, that closure is still in force; the Karni crossing was mostly closed in 2007 (although the conveyer belt at Karni was finally closed only in 2011); the Sufa crossing was closed in 2008; and the fuel terminal at Nahal Oz was closed in 2010. Remaining is the Kerem Shalom crossing which is located within Israel, next to the three-way border with Gaza and Egypt.

24

to three nautical miles. In the north, access for Palestinians has been restricted altogether along a section of coastline 1.5 nautical miles wide at the border with Israel, and in the southern Gaza Strip for one nautical mile along the border with Egypt67. During the years 2009-2011, average fishing hauls were the lowest in the last decade68. In fact, despite the minor economic improvements which took place in the wake of the eased restrictions, there remains a large disparity between current economic activity and that recorded in the years before the closure was instituted, and also in comparison with other measures of Gaza's economic potential (about which we expand further below).

Gazas economy | Entry and exit of trucks carrying goods

Incoming trucks Outgoing trucks

124,800

104,536

98,653

77,500

39,610

29,916

23,234

72,352

97,241

104,487 17,814 2001

11,957

214

20

2010

2009

33

2008

2007

4,535

2006

9,964

2005

11,566

2004

13,494

2003

13,317

2002

Source: PalTrade and Israel Airports Authority

The path to economic recovery and development in Gaza is a long one yet, and though the easing measures to the closure policy can't be overlooked, the growth indicators of the last year do not point to long-term economic development for Gaza. The improvements recorded are the result of a combination of international aid, the continued transfer of monies from the Palestinian Authority to Gaza, and the growth of the public sector. Meanwhile, the components of an engine of economic development have been rendered virtually inactive. Among these we note the ability to market goods from Gaza to both the West Bank and Israel, the opportunity for workers and businesspeople to travel to the West Bank and Israel, the opportunity for students from Gaza to study in the West Bank, the strengthening of the rule of law to provide financial security for merchants and investors, and education for entrepreneurship and technological development.
67 68 See Between the Fence and a Hard Place. See OCHA's monthly report from December 2011: http://www.ochaopt.org/documents/ocha_opt_the_humanitarian_monitor_2011_12_15_english.pdf

22,357 2000
25

112,450

As argued by Dr. Broude, in all these respects, the Israeli government and the private sector can contribute, not just from the standpoint of removing obstacles to development but also from a positive standpoint, by renewing commercial initiatives. The release of Gilad Shalit is a development that should signal a turning point in the governments actions vis--vis Gaza - and spur the actualization of its declared intentions to create a suitable infrastructure for the economic development of Gaza. The potential for growth in Gazas economy It is difficult to assess the precise growth potential of an economy; many factors are at play and cannot be considered simultaneously. This challenge is even more acute in the case of the Gaza Strip, given all the existing obstacles to development. To try to assess growth potential under these circumstances, we chose to present a number of possible approaches. It is important to note that in each assessment, restrictions on movement are not the only hindrances to development, but they are certainly considered to be among the principal obstacles. The intuitive approach, and hence69 the first, is to examine the scope of economic activity during the period before the closure, treating it as representing potential. This assessment is perhaps modest in comparison with projected growth under optimal circumstances, but it is reliable in that it is based on past experience. The chart showing GDP per capita before and after the closure best presents this assessment. Another approach addresses the parallel growth that took place in the West Bank and in Gaza during the period prior to the closure, and in these terms, Gaza could have relative growth resembling that of the West Bank since 2007. The next chart demonstrates this approach.

69

See the IMF report from April 2011: http://www.imf.org/external/country/WBG/RR/2011/041311.pdf

26

The economic costs of the Israeli occupation for the occupied Palestinian territory, the Palestinian Ministry of National Economy, Sept. 2011. According to the International Monetary Fund, between 1968 and 1987 the growth in per capita income in the West Bank and the Gaza Strip stood at 4.4 percent per year, and between 1994 and 2010 it dropped to 0.6 percent per year. Had the rate remained, over the years, at 4.4 percent, the per capita GDP in 2010 would have been 88 percent greater than it is today.
27

Finally, the degree to which various sectors are positioned for increased economic activity is noteworthy. In a survey conducted among 188 manufacturing companies, 60 percent of them claimed that they were prepared to begin exporting within one month from receipt of the relevant permit. Manufacturers in Gaza estimate that opening the crossings for sale to Israel and the West Bank would generate an increase of 63 percent in sales, 51 percent in employment and 39 percent in investments70. Company Al-Amir Ice Cream Industries Prior to 2007 Output of 85 percent, sale to West Bank represents 50 percent of all production June 2007 - July 2010 Ceased operating June 2007. Resumed production 2009 at 30 percent of work capacity Since July 2010 Working at approximately 30 percent capacity, without being able to sell to the West Bank Potential Factory manager estimates that plant could return to the standard pre-2007 production volume if restrictions on export to the WB were removed Factory manager estimates that plant could return to the standard pre-2007 production capacity

Palestine Juice Concentrates Company

Sold 95 percent of production (equivalent to 3,500 tons annually) in Israel

Completely shut down in June 2007. Resumed working in 2008 at about 5 percent of typical pre-2007 production level Completely shut down

Scope of work 30 percent of typical pre-2007 level

Al-Radisi Factory: production of plastic bottles

Sale to Israel and the West Bank 50 percent of production

Working at only 40 percent of capacity

Factor manager estimates that removal of restrictions would enable expanded production and additional production lines Factory owner estimates that removal of restrictions would enable high production capacity and additional production lines

Ajour Furniture Co.

Sale to Israel of 80 percent of production and to West Bank 20 percent

Completely shut down June 2007, resumed work with raw materials smuggled via the tunnels 2009, at lower than pre-2007 levels

Production capacity approximately 30 percent

70

Per a joint report by the Quartet and PalTrade, March 2011: http://www.paltrade.org/cms/images/enpublications/Tracking%20Changes%20in%20Major%20Industrial%20Sectors%20 in%20Gaza.pdf

28

Export potential | Industry and agriculture

are ready to market their goods to the West Bank

furniture manufacturers

40

At least

sewing workshops
are ready to produce for sale to Israel and the West Bank

550

are ready to market their goods to the West Bank

food manufacturers

13

Of them, 280 are ready to produce for sale to the West Bank

Export potential per season

Actual export during the 2010-2011 season

strawberries

carnations

cherry tomatoes

2300 389

tons

tons

55 11

million

million

904 6.7

tons

tons

Palestinian Federation of Industries; PalTrade

Recommendations
In the framework of the writing of this report, we consulted with experts in economics and in international law, and asked them to recommend steps towards the realization of Gazas development potential; below are their recommendations. Prof. Ephraim Kleiman, a professor of economics at Hebrew University, notes that there is need for construction projects and for projects to rehabilitate infrastructure and repair damage caused by Operation Cast Lead in the short-term. Beyond that, the first thing that governments can do for development is, in his words, to enable businesses to reach their markets. If Israel is interested in development for Gaza, it must remove restrictions, because people will not invest in Gaza if they are not certain that goods can reach the market and arrive on time; that raw materials can get to manufacturing facilities and that workers can get to work on time. Removing restrictions

29

that prevent investment means, first and foremost, allowing free movement of people and goods into and out of the area. Prof. Kleiman also notes the option to market agricultural products from Gaza in Israel, and says that while the need for phytosanitary inspection designed to prevent the entry of agricultural pests to Israeli territory presents logistical challenges, solutions can be found to meet them. These recommendations coincide with those in a report published this year (2011) by the Peres Center for Peace71. Dr. Tomer Broude, senior lecturer in law and in international relations at the Hebrew University, argues that the notion of absolute economic separation between the Israeli economy and the Palestinian economy is not optimal or even realistic, since the two economies are interwoven in practice and are in many respects complementary. Israel, he says, must develop sensitivity to Palestinian reservations concerning Israeli economic hegemony. For the Palestinians to accept that hegemony would simply emphasize their dependence on Israel, a dependence they seek to avoid. Thus, says Broude, in order to promote Israeli-Palestinian cooperation following a political agreement and maybe even before, the conditions required for economic development must be ensured. In order for this cooperation to take place, Palestinians must feel a greater sense of economic independence and Israel will need to feel a sense of security that will permit it to provide those conditions. Dr. Broude adds that in order to achieve better economic integration between the Israeli and the Palestinian economies, there is a need to work for the amalgamation of standards regarding public health, the environment, and so on. Relative integration may be attained via a third party (other countries or international organizations). Dr. Broude notes that one way to encourage Israel-Palestinian cooperation is by obtaining favorable import duties in external markets (such as the United States and the European Union) for goods produced in the framework of that cooperation72.

71 72

See Gaza Strip Crossings. As in the Qualified Industrial Zones agreements (QIZ) signed with Jordan and the USA, and with Egypt and the USA: http:// www.moit.gov.il/NR/exeres/FB0AA59D-BA77-4C8A-ACC1-D3A19663BBBE.htm

30

Chapter Three: Towards an independent Palestinian health system in the Gaza Strip Obstacles and options
In this chapter we will survey the Palestinian health system that developed alongside Israel, and the challenges it faces in terms of becoming an independent health system that is able to provide for the needs of the Palestinian population in the occupied territories. We will show how the system functions, the obstacles faced by a patient from Gaza seeking to receive treatment in a hospital elsewhere, and the possibilities for training and advancement for both younger and more senior Palestinian doctors.

The Palestinian health system and Israel

From 1967 until the outbreak of the First Intifada in 1987, Israel looked after the medical needs of Palestinian residents to a limited extent, at first via the Military Administration and later via the Civil Administration. Nonetheless, the Palestinian health system was operated as a closed enterprise, and in a manner different than the way the Israeli health system was operated, creating a permanent disparity between the two systems. This disparity was notable, inter alia, in the allocation of budgets, in the creation and development of medical services, and in the training of medical professionals. In general, Israeli policy worked to develop only basic services, while all further development was considered less important and dependent on separate funding73. When the First Intifada began there was a serious impact on the accessibility of health services, limited as they were, for Palestinian residents. The budget for treatment referrals in Israel was reduced to nearly nothing, while anyone seeking to enter an Israeli hospital required a permit from an Israeli army financial officer74. Only thanks to a campaign by PHR-Israel and others, the level of referrals for Palestinian patients to hospitals in Israel was restored to about 70 percent of the levels prior to the Intifada75. This period signaled the start of a process typified by patients whose requests for medical treatment in Israel were rejected, even when the treatments appropriate to their medical condition did not exist in their area of residency76.
73 Inter alia, the budgets approved for referring patients for treatment in Israel were reduced; very few medical personnel were allowed to attend professional training in Israel; very few new medical facilities were built in the territories and only in specific medical fields. For more on the Palestinian health system during the first years of the occupation, see a PHR-Israel report entitled Organized Injustice, November 2002, and the book by Tamara Barnea and Rafiq Husseini (eds.), Separate and Cooperate, Cooperate and Separate: The Disengagement of the Palestine Health Care System from Israel and Its Emergence as an Independent System [Hebrew], Am Oved: Tel Aviv, 2002. Report by PHR-Israel: Organized Injustice, November 2002, p.20 Ibid. Cancer and kidney patients, for example, for whom prevention of treatment in Israel was a death sentence. Haaretz, 12.1.89 reported that the director of Shaarey Tzedek Hospital accepted a child for dialysis despite his having arrived without financial coverage.

74 75 76

31

Under the Oslo Accords, health was among the first areas to be transferred to the aegis of the Palestinian Authority. In 1992, Dr. Haidar Abdel Shafi, chief of the Palestinian delegation to the Madrid talks, refused autonomy in health matters only because it was impossible unless accompanied by autonomy in all other spheres and the end of Israeli occupation in practice. Nevertheless, in 1993, chief of the Palestinian delegation Nabil Shaath signed the Interim Accords (Oslo B) which included transfer of authority in five civil spheres: health, education, welfare, tourism and taxation77. These agreements also stated that both sides see the West Bank and Gaza as a single territorial unit with an understanding that territorial wholeness would enable continuous free movement, a necessary condition for the existence of a functioning, balanced health system78. Following this agreement, Palestinians who for years had paid National Insurance fees to the Civil Administration lost their health rights, and the Palestinian health system became responsible for purchasing services from Israeli hospitals. At the end of the 1990s, and before the Second Intifada, there were broad differences between the Israeli and the Palestinian health systems79: Govt. Infant mortality per 1,000 population 6.3 Maternal mortality per 1,000 population 6 70 Adult mortality per 1,000 population 110 male 68 fem. 149 male 125 fem. Life Fertility expectancy rate 76 male 80 fem. 70 male 74 fem. 2.4 6.9 Doctors Nurses Hospital per 10,000 per 10,000 beds per population population 10,000 population 37 66 59 9 13.7 12

Israel

Occupied 29 Palestinian Territories

The infrastructure and the existing Palestinian government services today, at the beginning of 2012, serving a population of some four million people, are divided between partial territories separated from one another; access for residents of one partial territory to services in other, separated areas are limited. In Gaza today there are twelve government hospitals, four CT machines serving the public, and four MRI machines in private clinics, which means that a patient referred for an MRI costs the Palestinian Authority a lot of money and must endure a long waiting time. There is also an MRI machine in the Shifaa Hospital in Gaza, but the machine has been out of order for two years and cannot be repaired because Israel prohibits the radioactive materials necessary to repair it from entering Gaza. For the same security reasons, an additional MRI machine donated by the government of Norway has been sitting at the port of Ashdod for more than a year.

77 78 79

Separate and Cooperate, op. cit., p.74. For the full document, see at: http://www.knesset.gov.il/process/asp/event_frame.asp?id=42 The data in the chart are taken from a general chart of health services in the Middle East, which appears in: Separate and Cooperate, op. cit., p.389.

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In the West Bank today there are twelve government hospitals and another hospital under construction in Tubas. In the West Bank there are seven CT machines. MRI machines, as with the situation in Gaza, exist only in private clinics. Four hundred of the 1,400 beds in the West Bank have been added in the last four years. In East Jerusalem there is a Palestinian medical campus that also serves the Palestinian population in the occupied territories at a relatively high level relative to the services provided in the Gaza hospitals80. At this campus there are seven hospitals, including the St. John's Eye Hospital, St. Joseph Hospital, Augusta-Victoria, Al Makassed and the Red Crescent Hospital. The health system in Gaza is dependent on Israel in order to operate continuously, and this is directly linked with Israels control of the crossings. This control is evident in five main areas: Exit for ill residents of Gaza seeking to receive health services outside the Strip. Transit for medical teams into and out of the Gaza Strip. Transport of medical equipment and medicines into Gaza. Strengthening and repairing the medical infrastructure in Gaza - building new clinics and hospitals and rehabilitating infrastructure damaged during Israeli attacks on the Strip. Partial Israeli control of those passing through the Rafah crossing. There is no doubt that the division between the Gaza regime and the Ramallah regime also has significant implications for the functioning of the Palestinian health system in general, and in particular for the health situation in Gaza. With the Hamas takeover in 2006, the Palestinian Ministry of Health was divided such that Ramallah had a Fatah Minister of Health, while Gaza had a Hamas Minister of Health. The political differences between Gaza and Ramallah had an impact on Gaza patients access to health services, whether through growing referrals to Egyptian hospitals where quality of care is relatively lower, or by diminishing referrals to Israeli hospitals due to high cost. Currently, nearly twenty years after the signing of the Oslo Accords and the transfer of authorities, the Palestinian health system is divided and in disarray, with its budget, patients, medical professionals and medical institutions separated from each other, preventing the system from functioning as an autonomous whole. Despite all the problems arising from political disagreements between Fatah and Hamas, clearly the main factor in the problems afflicting the health system in Gaza today is Israels policy of continued blockade and closure of the crossings, which prevents any possibility of sustainable development.

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In this passage we are addressing Jerusalem as a territory separate from the West Bank, solely because from a territorial contiguity standpoint (and concerning all aspects of access to health services), East Jerusalem has been separated from the West Bank by checkpoints and the separation barrier, and Palestinian patients residing in the West Bank require transit permits in order to get to hospitals located in the city.

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A. Obstacles to developing an independent Palestinian health system

In order to understand the grave implications of Israeli policy on the ability of the Palestinian Authority to develop an independent health system, one must understand how Israels policy of movement restrictions in the territories, and in Gaza in particular, functions. Below are some typical ways in which the policy influences the health system in Gaza.

Obstacles to the free movement of Palestinian patients residing in Gaza

With the outbreak of the First Intifada, and even more so during the 1990s, the Erez crossing was closed to civilian traffic (including patients), and from year to year the policy of permits became more sophisticated. Today, a resident of Gaza seeking to leave the Strip for medical treatment must navigate a series of obstacles81. To begin with, he must pass an initial screening in one of the Palestinian hospitals in Gaza, and if the medical procedure or treatment he needs does not exist in Gaza, the doctor will refer him to a hospital that provides the required treatment. This referral document is faxed to the Palestinian Ministry of Health in Ramallah, which determines whether the patient is entitled to financial coverage and to which hospital he will be referred. The next stage is that the patient, assisted by his doctor and the Palestinian office of referrals, requests an appointment at the designated hospital. Only after the patient has these three documents in hand - a referral form, a financial coverage form, and an appointment at a hospital (another long process which does not involve the Israeli authorities) - only then can he submit an application to the Israeli military authorities for a permit to enter Israel via the Erez crossing. These requests are submitted to the Matak (the Coordination and Communication Authority) in Gaza via the Palestinian Coordination Office. In the best case scenario, it takes between a week and ten days to receive a response. Cases have been documented in which patients were not afforded any reply, even after a month or more. If the date set for a patients hospital appointment passes, he must repeat the process. Sometimes financial coverage that has been committed for a given period simply runs out, and the patient must reapply for financial coverage. From the moment the application is submitted to the Israeli authorities, the patient has no knowledge of his applications progress nor of whom to contact for clarification; there no live voice at the other end to explain. In fact, the patient can be in touch only with the Palestinian Office of Referrals, headed by the chief of the Coordination Office, who alone handles communication and coordination with the Israeli Coordination Office. Since the disengagement in 2005, there has been significant change in the standard delay. Given that Israeli soldiers are no longer stationed inside Gaza, Shabak (Israels General Security
81 For more on the exit process for Gaza patients seeking medical treatment, see the PHR-Israel web site exhibit entitled Bumpy Road, at http://www.phr.org.il/default.asp?PageID=60&ItemID=664

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Service) investigators are useing patients to try obtaining information and intelligence on Gaza. Today, on average each month some 3 percent of patients submitting permit requests to exit Gaza for medical care are summoned to the Erez crossing for a security interrogation by Shabak. The interrogation creates another substantial delay before medical treatment can be obtained. In addition, majority of these patients report that they are pressured to collaborate, on order to obtain a permit to exit for medical care82. Until June 2007, before Hamas came to power in Gaza, about 10 percent of those submitting requests were denied permits on security grounds and were unable to receive medical care outside Gaza. Between the Hamas takeover and the Turkish Flotilla affair in May 2010, the number of refusals jumped to 32 percent; this represents a huge number of patients who could not access the critical treatment for which they had been referred. After the Flotilla affair and the Israeli cabinet decision easing certain aspects of the closure on Gaza, there was a drop in the number of refusals. In 2010, about 52 percent of requests from men aged 18-40 did not receive timely responses and lost their hospital appointments. Among all requests submitted, 6 percent were refused exit permits with no explanation whatsoever, representing 646 ill men and women83. These fluctuations show the impact of political decisions on the ability of patients to exit Gaza for medical care, especially how patients are refused out of Israels desire to counter Hamas through pressuring the civilian population, rather than out of strict security concerns.

Obstacles concerning the free movement of Palestinian medical professionals

The movement of medical personnel is influenced by the fluctuating political climate between Israel and Hamas, as described above, and by international pressure in the wake of Operation Cast Lead and the Flotilla affair. In general, between the suicide bombings period during the Oslo Accords and the disengagement from Gaza, there were permanent restrictions on people moving from Gaza into Israel, with minor fluctuations in either direction. With the closure on Gaza that followed the abduction of Gilad Shalit and Hamass rise to power, the apparatus of restrictions and delays became more complicated. Palestinian doctors who live in Gaza are not permitted to travel freely from Gaza into Israel or the West Bank in order to study, train or attend conferences. Like the patients, they must submit special applications and wait a long time to receive permits to exit Gaza. In order to receive a permit for employment or training purposes, there is a very complicated bureaucratic procedure which involves submitting an application (including letters of reference and confirmation from the university or the hospital where the doctor is employed), followed by a wait of between a week
82 83 For the whole question of Shabak interrogations of Gaza patients, see the PHR-Israel report on Conditional healthcare: Extortion of Palestinian patients by the Shabak in interrogations at the Erez crossing, August 2008. All the data are taken from the WHO annual report published at the end of 2010: Referral of Patients from Gaza - Data and Commentary for 2010

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and ten days for a reply. The petitioners security record must be unblemished. Israeli authorities also demand that petitioners families have clean security records. The doctors, like the patients, are subject to Shabak interrogation and in many cases threatened and even blackmailed to become collaborators. Only a small proportion of medical personnel are allowed to leave for training in Israeli hospitals or abroad; the others maintain static professional medical skills without the opportunity for further learning and development. Beyond Israeli restrictions, the Hamas government also sometimes imposes travel restrictions on doctors wishing to attend conferences in Israel, and on students wishing to study outside Gaza. Medical professionals in the West Bank suffer under similar restrictions; travel to Gaza is nearly impossible, while movement between various cities in the West Bank and through Israeli checkpoints demands current travel permits. Sometimes travel permits or employment documents are disallowed for no clear reason, and without prior notification.

Obstacles to training medical students

Over the years, medical students from Gaza have studied at West Bank universities and completed their internships abroad because Gaza lacks university teaching hospitals. When the Second Intifada began, an across-the-board ban was instituted on student exits for study outside Gaza84. Students from Gaza who had been studying in the West Bank without a residence permit thereafter have faced the daily risk of immediate expulsion, and cannot visit their families back home during the years of their studies85. Medical students in the West Bank cannot complete their studies without spending time in Palestinian hospitals in East Jerusalem or abroad, because West Bank hospitals and universities lack the complete series of training rotations in all the required specialties. Hospitals in the West Bank do not have all the necessary departments, clinics and experts in the various fields. Likewise, the equipment is not sufficiently advanced, and the complicated medical cases important for learning experiences are referred to hospitals outside the West Bank. These young people must have permanent travel permits for East Jerusalem, which are harder to obtain from a bureaucratic standpoint, and which can be taken away without reason at any time. Medical students have reported to PHR-Israel that they are blackmailed by the Shabak, and that their study permits are conditioned on collaborating with Israel - a practice that endangers the lives of these young students.

84

85

As far back as November 25, 2004, PHR-Israel received a written reply from Avi Biton, then Lt. Colonel in the Public Inquiries branch of COGAT, that travel for students between Gaza and the West Bank is prohibited. An appeal in principle regarding students by Gisha was submitted to the High Court in 2007, after imposition of closure on Gaza and the decision on a permanent policy regarding the exit of students from Gaza to the West Bank: http://www.humanrights.org.il/articles/aviv6.doc See FAQ: Students confined to Gaza, November 2008 on the Gisha web site at: http://www.gisha.org/

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Obstacles to the entry of foreign Israeli and Palestinian medical professionals into Gaza, in order to provide training to local doctors
As noted, after the imposition of the Gaza closure in 2007, Israel intensified its restrictions on Gaza medical personnel. Because Palestinian medical students are not permitted to leave Gaza, there were many and varied attempts to bring instruction and continuing education to them. Although there are medical professionals from Israel and abroad who are prepared to go to Gaza, they increasingly encounter obstacles grounded in Israeli policy. The problems are mainly bureaucratic, from long periods awaiting response to entry applications (two months or more for delegations from abroad), to permits allowing entry to only half the delegation, or permits allowing the entire delegation entry but without their medical equipment. Israeli Jewish doctors are not permitted to enter Gaza due to security concerns, so volunteer doctors in an organization like PHR-Israel are prohibited from entering Gaza. For over two years now - since early 2009, following Operation Cast Lead - the entry of medical teams under the aegis of PHR-Israel has almost never been permitted. In the past, these delegations were able to enter, carry out complicated operations and train Gaza doctors. In one exceptional case in 2011, two delegations of three or four members each were given permits to enter Gaza for periods of up to 48 hours. The permits arrived at the offices of PHR-Israel only two days prior to the scheduled departure date for the group, which prevented adequate organization in advance. Apart from these two applications, all other PHR-Israel applications for doctors wishing to enter Gaza during this period were rejected. Delegation of Icelandic physicians delayed, their equipment seized September 2010 In September 2010 a delegation of physicians from Iceland applied to the Israeli authorities for a permit to enter Gaza and for the medical equipment they would be bringing with them. The physicians had been sent by the Icelandic organization OK Prosthetics to conduct training for medical teams in the use of prostheses designed for amputees in low-income countries and conflict areas86. The delegation waited for over a month to receive entry permits from the relevant Israeli security figures. A permit to enter Gaza at the Erez crossing was issued, but on the scheduled date, the crossing was closed due to the Succoth holiday and it was impossible to utilize the permit. The members of the delegation were not informed by the security officials and were obliged to find lodging in Israel for four days, thus forfeiting four days of work out of the short period they had been allotted in Gaza in the first place.

86

See on the organizations web site: http://www.okprosthetics.com/

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After the delegation reached Erez crossing on the Sunday after the holiday, they discovered that the medical equipment they had brought with them, including material for the preparation of dozens of prostheses, was denied entry. Appeals by PHRIsrael did not succeed in changing the security decision, and the medical delegation subsequently left without having affixed a single prosthetic device for a resident of Gaza, and without having trained local medical teams. Today, too, entry permits for foreign delegations depend on decisions by security figures and on temporary political considerations. In Gaza at this time there is not a single clinic qualified to fit prosthetic devices for amputees. Patients needing a prosthesis fitting are referred, assuming a security permit is forthcoming, to the "Reut" Medical Center in Israel, or to hospitals in Jordan or Egypt.

Obstacles concerning medicines, medical supplies and equipment

The imposition of the closure on Gaza in 2007 created a continuous threat to the health of its residents. The closure, together with the economic hardships on the Palestinian Authority in Ramallah and the lack of cooperation between the respective governments in Ramallah and in Gaza, has led to a severe shortage of medical supplies and medicines. In 2011, several pharmaceutical companies stopped operating in Palestinian Authority areas due to its economic problems. In September 2011 there was a grave shortage of 36 percent of critical supplies for routine operations at hospitals and clinics in Gaza, comprising 164 different critical medicines. A visit by a PHR-Israel delegation in the winter of 2011 revealed that there were no more analgesic medicines for children. Also noteworthy is the shortage of needles, gauze and bandages, the dearth of which could thwart simple procedures as well as complicated surgical operations87. Medical equipment, like all other civilian goods and products, enters Gaza under many security restrictions and only with required management. Every shipment destined for Gaza is inspected, tested and authorized by Israel, even if the supplies have been donated by external agencies. Donated shipments often turn out to be inappropriate to the needs in the field. Likewise, often the sell-by date of the donated materials has passed, and they cannot be used.

87

See report by Doctors without Borders on the shortage of medical equipment and medicine in Gaza, November 2011: http:// www.msf.org/msf/articles/2011/11/gaza-residents-deprived-of-critical-medications-and-medical-care.cfm#.Tsk_aAcDThh. facebook

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Dr. Abed Agbarya, senior oncologist at the Rambam Hospital Oncology Institute and Chief of the Community Oncology Unit in the Nazareth branch of Clalit Health Services: In my volunteer work with PHR-Israel I have visited Gaza several times during 2007 and 2008. During these visits I have established a connection with several oncologists from Gaza from two hospitals - Shifaa Hospital and the European Hospital, and there have been medical seminars conducted together with the local oncologists during which dozens of oncology patients were examined and many medical decisions made. During my visits I have been exposed to the tremendous shortage both in medical and paramedical personnel, and in medical supplies and the new medical technologies that are an inseparable part of modern medicine. There is a tremendous shortage of chemotherapy and biological drugs, both low-cost and expensive, along with a shortage of auxiliary medicines used in chemotherapy treatment, such as those to prevent nausea and vomiting and drugs to manage pain. There is also a shortage of medical supplies that are basic to treating an oncology patient whose situations are mostly very complicated and difficult. Some of the missing supplies are nuclear medicine supplies such as those used in PET CT and MRI scanners. In addition there is currently no radiation equipment in all of Gaza, a fact which impedes the routine and optimal treatment of patients. In my opinion, if the opportunity were given for some of the doctors there to undergo advanced training for short periods in oncology wards in Israel, the matter could serve to enhance the level of the doctors and in the last analysis provide a reasonable solution for a serious and chronic problem in this regard.

The prevention of the development of new medical centers and the expansion and repair of existing medical centers
Security considerations and political decisions are what prevent the movement of doctors, patients and medical supplies. In addition, they dictate whether or not new medical centers will be built in the territories, and whether existing ones that are outdated or that have been destroyed can be renovated and repaired. Rehabilitation of hospitals and clinics in Gaza after Operation Cast Lead During Operation Cast Lead, 34 Palestinian medical structures were damaged by Israeli military bombardment or shelling, among them eight hospitals and 26 first-aid clinics88. After the Turkish flotilla incident at the end of May 2010, the Israeli government announced its intention to expand the quantity of dual-use construction materials entering Gaza, and to restrict only the entry of war materiel in order to enable the rehabilitation of Gaza and the expansion of its
88 From: Health Situation in the Gaza Strip, World Health Organization, 19-20 February 2009.

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economic activity. Despite the cabinet decision, Israel continues to prohibit the entry of iron, gravel and cement - materials that are not considered dual-use according to international standards89. Between October 2010 and February 2011, Israel permitted the entry to Gaza of c. 20,000 tons of different construction materials, only 7.6 percent of the average monthly quantity brought into Gaza prior to the closure90. The importance of construction materials is great because, without them, Gaza cannot rehabilitate destroyed public and residential buildings, hospitals and clinics (some of which have been unfit for use since Operation Cast Lead). Only recently, in November 2011 after the release of abducted soldier Gilad Shalit, did the government of Israel announce that it would permit the entry of construction materials for the private sector in Gaza91. But it will take time for the release of Gilad Shalit to impact restrictions on the Gaza crossings. Dr. Alam Jarar, Chief of Rehabilitation Medicine in the Palestinian Medical Relief Society, which has operated for many years in the territories, provided written details concerning the problems and obstacles confronting the Palestinian health system. As a representative of Palestinian civil society, Dr. Jarar addresses the failure of the Palestinian Authority and its health system to cope with the health needs of the Palestinian population. Nonetheless, he emphasizes that the central obstacle facing the health system is the problem of access, the restrictions on movement that Israel imposes along with the Israeli occupation of the territories. In his opinion, the closure on Gaza and the separation barrier in the West Bank are the central obstacles affecting the basic needs of the population: Health conditions in Palestine - Realities and Myths Alam Jarar, Palestinian Medical Relief Society (PMRS) Since the establishment of the PA in 1994, Palestinians have invested a lot of effort and resources in order to improve the situation of the health sector, one of the main pillars of social development in the Palestinian territories. All Palestinian efforts to develop the sector and lessen the dependency on Israel and on neighboring Arab countries in this respect, however, have achieved only very limited success. Currently, after almost twenty years of multidimensional work, the sector is still unable to meet the health needs of Palestinian citizens in providing them with adequate health services and in contributing to a substantial improvement in their health conditions.

89 90 91

For a list of the supervised items on the web site of the Israeli Foreign Ministry: http://www.mfa.gov.il/MFAHeb/Israel_Policy/Gaza_Lists_of_Controlled_Entry+_Items_050710.htm From A matter of construction materials, April 2011, Gisha, at www.gazagateway.org; and for more on this, see the December 2010 Gisha position paper, Easing the closure: dont count on it [literally, in Hebrew: dont build on it]: www.gisha.org/UserFiles/File/HiddenMessages/hakalotbasegerb19_12_10.doc Reported on ynet, November 2011, For first time since Hamas takeover Israel permits entry of construction materials to Gaza: http://www.ynet.co.il/articles/0,7340,L-4149386,00.html

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According to some indicators, the Palestinian health sector is unable to render comprehensive and appropriate services for cancer patients, many of whom are referred to Israel, Jordan or Egypt. Management and control of chronic illnesses, mainly heart and vascular diseases, lack adequate infrastructure and competent human resources. At the level of PHC provision, although there have been substantial improvements in coverage and utilization at this level, the main issue remains ACCESS due to restriction of movement and closure of areas, especially in the Wall area, by the Israeli occupation forces. [] One of the most striking facts facing the health sector in Palestine is its ability to continue to render needed services for almost one and a half million population in Gaza at a time when Gaza is completely sealed off by Israel, and where the imposed siege is denying Palestinians not only access for advanced health care provision but sometimes for basic medical supplies and services. The eruption of the Second Intifada, which was mainly fueled by the populations disappointment with the peace process, combined with severe unemployment, spiraling poverty, closures, siege, curfews, invasions, and the building of the Separation Wall separating families from each other, from the land they till, and from work opportunities, are all leading to an observed rise in mental health complaints among the population. The international response to what has come to be known as a humanitarian crisis was mainly directed towards a biomedical or narrow individual medical intervention rather than dealing with the underlying causes of ill health in Palestine, and instead of addressing how to assist communities in positively coping with arising crises at all levels. Mental health problems related to exposure to violence, injustice and the severe distress of ongoing conflict affect the majority of the Palestinian population. These are the people who live between the ease/dis-ease continuums but suffer mental health symptoms in reaction to violation and injustice, yet are not sick and do not have a diagnosable mental illness. In conclusion, health conditions in Palestine have been deteriorating during the last decade due to mainly outside factors brought upon them by all kinds of violence which led to devastating impact on health indicators at all levels. Free and even development of the health sector in Palestine cannot be achieved without addressing the underlying causes behind the inability of the sector to cope with needs of the Palestinian society, foremost among which is the long-lasting Israeli military occupation.

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In general, the laws, restrictions and regulations described above have created a situation in which the Palestinian health system overall, and the health system in Gaza especially, are prevented from functioning autonomously, and even more so from developing and advancing. Medical professionals cannot adequately acquire specialties and remain highly dependent on Israeli or international teams. The level of medicine in the local centers remains low and insufficient, access for patients to medical treatment is prevented or delayed, and critical medical supplies do not manage to arrive routinely and continuously to Gaza hospitals. The development of the health system in Gaza, so as to be capable of functioning and ending its dependence on Israel and international agencies, demands the removal of Israeli restrictions on all movement of medical professionals, patients and medical supplies and equipment.

B. The potential and possibilities for developing an independent Palestinian health system
This section will focus on cases in which nothing is required of Israel except to remove basic obstacles and to permit free movement for medical teams, patients, medical supplies and equipment. This emphasizes that the obstacles confronting development of an independent health system are political and bureaucratic; if Israel were to remove all its restrictions, the Palestinian health system would be able to advance toward independence. This section will thus present examples of models and projects demonstrating how it would be possible for the Palestinian health system to move ahead; what has been done and what remains to be done in order to train medical professionals, develop clinics and hospitals, and instill the knowledge required for the system, so that one day the Palestinian health sector can wean itself from international assistance and support and end its structural dependence on Israel and its health sector. One of the central problems exemplifying the deep dependence of the Palestinian health system on Israels system is the need for charity, like allowing patients to cross into Israel for treatments that are not available in the occupied territories in general and in Gaza in particular. In our view, Palestinian-Israeli medical cooperation creates a foundation for developing and advancing the Palestinian health system. Such cooperation is manifested in local initiatives by medical professionals from both sides of the barricade, and by NGOs which work together to train, advise, and mentor local medical teams. Such cooperation can also come in the form of government initiatives, between Israel and the Palestinian Authority in the West Bank and in Gaza, whose goal is to prepare the groundwork for turning the Palestinian health system into an independent system that will provide medical services at a high level, and that will not be influenced by political conflicts liable to harm the systems ability to provide four million residents with basic and advanced health services.

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Cooperation between PHRIsrael and the Palestinian medical community: Practical and theoretical training courses at the Center for Medical Simulation, Tel Hashomer
As part of the cooperation between PHR-Israel and the Palestinian medical community, there are training courses at the Center for Medical Simulation (Masar) at Tel Hashomer Hospital. The aim of these seminars is to expose Palestinian medical professionals and paraprofessionals to new developments in various medical fields and to progressive practices for preserving patients safety and health, while teaching new and complex skills. Among the wealth of training seminars, we have chosen a few examples: Training in intensive care, October 26-28, 2009: The aim of the training was to provide updated information and hands-on practice in new medical technologies, and to train physicians who address the daily needs of the Palestinian Health Service. The training was designed to address emergency care and intensive care, and dealt with diverse subjects including triage, cardiac intensive care, burn treatment, trauma, poisoning, and intubation. The course integrated theoretical training with practicum, using the latest tools and equipment at the disposal of the Masar Center and including computerized demonstration dolls, top-quality audiovisual equipment, and rooms for guidance and observation that permit all the doctors to have close-up, high-level training. Sixteen paramedics from government hospitals throughout the West Bank participated in the training. Training course in trauma care, January 21-24, 2006 Sixteen doctors from the West Bank and Gaza participated in a seminar aiming to provide tools and techniques for treatment in trauma cases. The program included comprehensive theoretical training in trauma to the head, spine, chest and abdomen, and treatment of burns, pregnant women and children. In addition, the program included hands-on training using equipment belonging to the Masar Center. To ensure that the training would have the broadest impact on the Palestinian health system, participants were invited from various medical centers in the territories - Tulkarm, Qalqilya, Hebron, Ramallah, Jenin, Nablus, Gaza and Rafah. The aim was to make sure that every Palestinian medical center has at least one expert in trauma medicine. Paramedics training course, October 19-20, 2006 Twenty paramedics from the West Bank and Gaza were invited to the Center for two days devoted to carrying the burden of their critical role in both daily life and crisis situations in conflict areas. As the first to arrive at an incident, the paramedics must be well-versed in a great many areas and have diverse skills in order to care for the injured and reduce the need for urgent care by a physician. The training was constructed with the aim of preparing Palestinian paramedics to cope with cases they are exposed to in their work: patients with cardiac problems, gunfire
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injuries, traffic accident injuries, and childbirth. The main role of the paramedics is to stabilize the situation of the injured, to provide life-saving intensive care and cope with medical trauma until arrival at a hospital. This unique training course focused on being a paramedic in situations of violent conflict and crisis, when it is often necessary to care for patients and evacuate them under live fire and mortal risk. The participating paramedics were chosen from a broad range of organizations, including the Palestinian Medical Relief Society, the Red Cross, and governmental and non-governmental organizations.

Cooperation between PHRIsrael and the Palestinian medical community medical conferences, oneday surgical clinics in the West Bank, and medical delegations to Gaza
Palestinian doctors who are prevented from leaving the West Bank and Gaza, due to the siege and restrictions on movement in the territories, have limited exposure to innovations and advances in the various medical fields. In the current reality of bureaucracy and permits, there is a need to improvise and find ways to train doctors within West Bank cities, and thereby outflank the difficulties inherent in obtaining permits for Palestinian doctors. Events like conferences and intensive surgical clinic days allow the training of a large number of medical professionals from the West Bank, in ways that cannot be done in Israeli cities. The lectures at these conferences are given on a volunteer basis by Israeli doctors who come to West Bank cities. Apart from intensive conferences, every year several intensive surgical clinics are organized, to which expert surgical teams and specialists from Israeli hospitals come to perform a series of operations in hospitals throughout the West Bank. The aim is to care for patients who have trouble getting to an Israeli hospital for surgery, thereby providing demonstrations to train local doctors and promote further professionalism in handling surgical cases. We should note that, despite attempts to organize them, similar training days in Gaza are not currently possible, due both to the permanent prohibition on Jewish medical professionals entry into Gaza and the bureaucratic aspects controlled by the Shabak and the army. Answers concerning permits are given at the last moment and do not allow advance planning. Likewise, exit permits are rarely granted for Gaza doctors wishing to attend such conferences outside Gaza.

C. Recommendations
Clearly the Palestinian health system could develop rapidly were there no further direct or indirect occupation by Israel. Even if we lay aside the basic demand for Israeli responsibility for the fate of the residents of the territories occupied by Israel (a demand that would require the transfer of funds and the training of doctors by state institutions), the central obstacle confronting the development of the Palestinian health system is not the economy but rather the policy promulgated by the government of Israel over the years preventing development.

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Moreover, the Palestinian Authority should take the initiative and attempt additional steps in furtherance of an improved health system while doing its utmost toward ending dependence on Israel. The Palestinian Ministry of Health has recently formulated a new plan to improve the operation of the Palestinian health system. At a meeting of representatives of PHR-Israel with Nizar Masalma, Director-General of Health Insurance for the Palestinian Authority, and Dr. Naim Saeb, DirectorGeneral of Hospital and Clinic Services for the Authority, it was reported that the plan is multi-system and designed to progress in several fields simultaneously: Logistics: Increasing the number of hospital beds, improving the medical equipment, and opening new clinics and hospitals. Professionalism and skills: Approving the entry of young doctors to internships in Palestinian hospitals, provision of training for professional staff in diverse fields (endoscopy, protoscopy, etc.), and training for doctors in pediatric subspecialties. Building trust between Palestinian patients and the health system: improving services at the highest level so that residents of the territories may have confidence in the health services offered. The Palestinian Ministry of Health aspires to reduce to a minimum the referrals of Palestinian patients to hospitals outside the territories. Dr. Angelo Stefanini, the World Health Organizations Coordinator in the oPt, wrote his own expert opinion and detailed his recommendations in this regard, based on the obstacles he identify in the field. According to Dr. Stefanini, the problems and obstacles confronting the Palestinian health system are in three main areas: Ongoing political interference and continuing instability, arising from the Israeli occupation of the territories, which imposes inter alia isolation and segregation between social units. The high dependence on international agencies with differing agendas. Internal Palestinian problems: lack of control, internal rifts, lack of responsibility and lack of transparency. He argues that international agencies must set their sights on developing an improved Palestinian health system while ensuring, on the one hand, that Israel operates according to international law and, on the other, that they themselves are not providing aid that is liable only to preserve the situation created by the occupation.

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Expert opinion of Dr. Angelo Stefanini on the health situation in the occupied Palestinian territory My knowledge and field experience of the health situation in the oPt derives, besides a longtime professional and personal interest in the Palestinian predicament, from nearly three years (2008-2011) as Coordinator of the Italian-funded Health Program in the oPt, with a base in East Jerusalem. In that capacity, I was also in charge of representing the international community in the main coordinating body of the Palestinian health sector, the Health Sector Working Group. During the year 2002, at the peak of the Israeli offensive in the West Bank, I was Head of Office of the World Health Organization for the oPt. The main obstacles to the Palestinian health sector development result from (a) the ongoing political disorder, and the consequent system instability, due to the Israeli military occupation policies of isolation and segregation; (b) the high dependence of the health sector on foreign aid from a multitude of donors, each with its own agenda, who dislike harmonization and favor bilateral deals with the Palestinian counterpart; (c) internal difficulties of the Palestinian leadership, due to both lack of control over the basic resources necessary to run a would-be country (such as borders jurisdiction, free movement of people and goods, social determinants of health, economic autonomy), and domestic divisions, corruption, lack of accountability and transparency92. A crucial health determinant in the oPt is human security93, i.e. protection from the severe and widespread threats to Palestinian lives brought by military occupation in the form of direct violence (deaths, injuries, homes destroyed) and indirect/structural violence. The latter is embodied in the lack of freedom of movement, due to an interlocking network of checkpoints, the separation barrier, and a dreadful permit system that causes pervasive poverty, social exclusion and extensive suffering. As Palestinians do not have a full-fledged state to protect them, this role should fall on the international community.

92 93

Mataria A, Khatib R, Donaldson C, Bossert T, Hunter D, Alsayed F & Moatti J-P (2009). "The health care system: assessment . and reform agenda". The Lancet, 373(9670), 1207-1217. Batniji R, Rabaia Y, Nguyen-Gillham V, Giacaman R, Sarraj E, Punamaki R-L, Saab H & Boyce W. (2009). "Health as human security in the occupied Palestinian territory". The Lancet, 373(9669), 1133-1143.

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The main objective of international partners ostensibly committed to develop the Palestinian health system and improve population's health should be, firstly, to do no harm, an outcome more frequent than commonly thought. Indeed, according to the International Court of Justice donors are under the obligation not to render aid that might maintain the situation created by the occupying power, ensure Israels respect for international humanitarian law, and not substitute for the responsibility of the occupying power. Examples of actions contravening this requirement are plenty94. As it is abundantly evident that Israeli military occupation is the main obstacle to the development of Palestinian society95 and that aid to the oPt without freedom of movement is largely squandered, donors' efforts to improve the health of Palestinian people should reconcile solid technical assistance with a coherent political commitment - one that maintains relationships between contending partners within a framework based on international laws. Recommendations by Dr. Dani Filc, senior lecturer and chairman of the Department of Politics and Government at Ben-Gurion University of the Negev, a member of the board of PHR-Israel and a member of the board of the Adva Center, addresses the external opinions set forth above. Dr. Filc states that in order to develop an independent Palestinian health system, one must proceed according to the following principles: Promotion of health indicator conditions: freedom to earn a living, running water of adequate quality and quantity, proper nourishment, and decent housing. A good health system must be integrated vertically (preventive medicine/primary care/hospitals) and horizontally (between hospitals specializing in various fields, and between secondary medicine in the community and secondary medicine in hospitals). Building such a system is impossible without control in the field, without the ability to plan for the future and without freedom of movement. The inability to plan for the future due to the possibility that Israel will adopt some new decision (for example by stopping the transfer of funds) is a central point. In addition, it is further recommended that emphasis be placed on the following points: Sovereignty and concentration of responsibility: one of the outstanding characteristics of the Palestinian health system today is the fragmentation of responsibility (between the Palestinian authority, Medical Relief, the Hamas clinics, the UNRWA institutions, and private clinics). A better and more efficient system, and hence a more just system, is one that relies on comprehensive health insurance for the general population, with stronger emphasis on primary medicine and thereafter hospital medicine. To that end, there is a need to transfer real sovereignty to the
94 95 Stefanini A, Pavignani E. (2010). The unhealthy aid provided for the health of Palestinians. The Lancet, published on line http:// www.thelancet.com/ health-in-the-occupied- palestinian-territory-2010 The World Bank. Investing in Palestinian economic reform and development: report for the pledging conference: www.prospectsforpeace.com/Resources/Statements/World_BankPalestinian_Economic_Reform_and_Development.pdf

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Authority. Likewise, universal insurance demands sources of employment for the majority of the population, because such a system is based on taxing the employed. The current conditions of occupation do not allow this. Human Resources: There is a need to develop and train an adequate, appropriate personal (doctors, nursing, paramedics). During the years of the occupation, Israel did not permit the Palestinian health system to train expert physicians and hence the system has a dearth of professionals in various specialties. Development of independent medical specialization: After emphasizing primary care, there is a need to develop the fields in which the Palestinian Authority today is almost entirely dependent on Israel and Jordan - services in disciplines like oncology, neurosurgery and vascular surgery.

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Conclusion and recommendations

Physicians for Human Rights-Israel and Gisha recommend taking the following actions in order to rehabilitate the civil systems and infrastructure in the Gaza Strip, promote an independent progressive health system and enable long-term economic development that will benefit the population as a whole: Israel must permit medical professionals, medical students, patients, and those who accompany them to move into and out of the Gaza Strip, and allow the transit of medical equipment and medicines as well as the construction materials needed to rehabilitate existing medical facilities and build new ones. Israel must remove across-the-board restrictions on the movement of people and goods into and out of Gaza, in order to enable comprehensive civilian rehabilitation, with an emphasis on health determinants such as the sanitation system, good quality drinking water, nutrition, housing and employment. Israel, the Palestinian Authority, Egypt and international agencies must arrange and coordinate activity at the crossings; any arrangements made must fully respect the rights of the Palestinian residents to freedom of movement, including between Gaza and the West Bank (in both directions). In the process, inspection arrangements must be made compatible with international law. The Palestinian Authority and the Hamas regime must make it their highest priority to guard the human rights of Gazas residents, and must act transparently and responsibly to further Palestinian civilian systems and promote long-term economic development for Gaza. International organizations working in the Gaza Strip must not only address the humanitarian sphere, but must also promote sustainable development and independent civil systems that can function without reliance on international involvement.

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