While the movement to reform health care is not new, the understanding of the health of a population, its determinants and ways to improve it has become far more sophisticated in recent times. Approaches to reform efforts have had to take into account the broader definition of health as a social construct as well as the economic, political and social contexts in which health services are provided.
For decades now, and in response to various pressures, developed and developing countries alike have been taking steps to change the policies and practices of their health systems (Sen and Koivusal 1998
). In its modern sense, health sector reform (HSR) has featured prominently on the international health policy agenda since the late 1980s. What characterizes this contemporary version of HSR – and perhaps sets it apart from previous types of reform – is its association with ‘a particular set of policy prescriptions’ aiming at institutional and financial reform, principally introducing increasing market mechanisms in health care provision (Standing 1999
). In the developing world, such reform has been largely, though not solely, donor-sponsored, with the World Bank assuming a leading role.
To date, there have been numerous examples of World Bank-supported HSR initiatives worldwide, driven by similar initial definitions and conceptual tenets. However, reform remains a highly context-dependent process. Even when dealing with the same political and financial driving forces, reform options and the realities of implementation diverge. This is partly due to conditions, which vary from country to country, such as the relative presence of political interest, will and capacity to implement reform (Standing 1999
). Existing models seem to take as given certain pre-conditions, such as the presence of at least a general consensus regarding the ways in which society should proceed on its path to development, strong state institutions and structures, a relatively open and active economy, a vibrant civil society, rational action in policy-making, and the availability of minimum household and national resources. In fact these pre-conditions may not all be present in a particular setting. The structural conditions within which health systems develop and the constraints imposed by a particular setting must have an impact on the way in which reform can or cannot proceed. Such realities call for flexibility in approaching reform in differing contexts and for the exercise of great care regarding universal policies adopted by international aid agencies for implementation in sometimes very differing settings.
In the Occupied Palestinian Territories (OPT), as in other contexts, the structure, function and capacity of the health system has been shaped largely by the country’s complex political history. Since the signing of the Oslo Peace Accords and the establishment of the Palestinian Authority (PA) in 1994, reform activities have been taking place in the health sector with the involvement of several international aid and United Nations (UN) agencies as well as local and international non-governmental organizations (NGOs). This paper will take a critical look at recent developments in the health sector in the OPT, with the aim of contributing to the debate on whether the current approach to reforming the health care system can be effective in fulfilling people’s health needs. Specifically, the paper attempts to analyze the defects of the current approaches to reform by showing that, in the Palestinian case, the assumptions of the pre-conditions described above are simply and fundamentally flawed. Indeed, the Palestinian case of HSR demonstrates the inter-relatedness of health and politics and the importance of an analysis of health needs within a systemic context. Basing that analysis solely on biological and medical indicators, divorced from the social and environmental determinants, may lead investors in reform to the illusion that narrow technical and administrative solutions can solve complex health problems. In the Palestinian case, this microcosmic rather than systemic focus has led to investments in unworkable strategies. In this article, we will attempt to unravel where HSR, intended to engender a sustainable process (Berman 1995
), has missed the forest for the trees, thus resulting in wasted resources and frustrated expectations. A description is necessary first of the geopolitical context and historical evolution of the Palestinian health system, in order to understand the root causes of its current difficulties. The paper will then analyze what have been, in our assessment, the major obstacles undermining reform approaches.
Perhaps it is important to point out that this paper does not attempt to evaluate the impact of reform initiatives implemented so far. In our opinion, such an evaluation is not possible at this time, both because of the ongoing state of conflict and destabilization of Palestinian Authority systems, including the health system, and because of the relatively short amount of time that has elapsed since the beginning of the reform initiatives (in this case, since the signing of the Oslo Peace Accords and the establishment of the Palestinian Ministry of Health). However, with evidence of systemic collapse even before the renewal of the second Palestinian Uprising (Intifada), it seemed important to reflect on and question the approach to reform that has been taken so far.
While it is recognized that the situation of this developing country is a complex one, where rapid changes and political instability make it difficult to plan for the future, it is a key moment to take a critical look at health sector reform, as governmental systems are being established and policies are being formulated. Investigating the context in which changes in the health sector have taken place might contribute to a clearer vision of what is needed and what might be realizable in the future. Furthermore, in its broader framework, the Palestinian experience may also assist in improving our understanding of reform efforts in other countries of the world that endure endemic conflict and instability.