A ‘transitional’ context for health policy development: the Palestinian case

Health Policy 59 (2002) 193– 207 www.elsevier.com/locate/healthpol

A ‘transitional’ context for health policy development: the Palestinian case Motasem Hamdan a,b,*, Mia Defever a a

Centre for Health Ser6ices and Nursing Research, School of Public Health, Katholieke Uni6ersiteit Leu6en, Kapucijnen6oer 35, 3000 Leu6en, Belgium b Faculty of Public Health, Al-Quds Uni6ersity, Jerusalem Received 16 January 2001; accepted 19 June 2001

Abstract The objective of this article is to focus on the challenges and opportunities the Palestinian health care system is currently facing in a ‘transitional period’, which started subsequent to the Oslo Agreement in 1993. The characteristics of ‘transition’ have to be highlighted in order to understand the context and peculiarities in which the Palestinian health care system is operating. A descriptive analysis is provided of the historical, political, economic and socio-demographic elements to gain an insight into the complex context of the Occupied Palestinian Territories, a country in ‘transition’. © 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Health care system; Health policy context; Conflict; Transition; The Occupied Palestinian Territories

1. Introduction A health care system cannot be understood without understanding the context in which it operates. Especially a health care system does not operate in a vacuum. It is influenced by the political, socio-economic, and cultural context within which it is enacting [1]. Health policy development is a dialectic process between the policy process itself and the environment in which it takes place. An understanding of the policy context is a critical element in the policy analysis and contributes to policy-making in different ways [2]. * Corresponding author. Tel.: +32-16-33-6974; fax: +32-16-33-6970. E-mail address: [email protected] (M. Hamdan). 0168-8510/02/$ - see front matter © 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 8 - 8 5 1 0 ( 0 1 ) 0 0 1 7 4 - 9

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The Palestinian health care system is a mixture of several health care providers: namely government, UNRWA (The United Nations Relief and Working Agency for Palestinian Refugees in the Near East), not-for profit NGOs, and private for-profit groups. In addition, health care is financed by different sources including a significant contribution of external resources. The responsibility of clinics and hospitals run by the Ministry of Health section of the Israel Civil Administration during the period of Israeli occupation 1967–1994 was transferred to the Ministry of Health of the Palestinian National Authority1 (PNA) in 1994. The UNRWA clinics and the Non-governmental Organisations (NGOs) continued as they had been before. One of the world’s most arduous conflicts is going on in the Occupied Palestinian Territories. This conflict is the factor underlying the complex context of this area and influencing all aspects of people’s lives. The direct effect of the conflict on health and the health care system is manifest [3–11]. Thousands of deaths, injuries, disabilities, and mental health disorders are emerging. Operating the health care system has been directly influenced by the conflict. Diminished health care delivery and health programmes, jeopardized accessibility to health services are due to the closure and separation policies. However, all these are not unique to the Palestinian case. The effects of violent political conflicts have been experienced in many countries, for example in Uganda, Lebanon, Cambodia, Tigray-Eritrea, Bosnia, and many others, as amply documented in the literature [12–17]. Health care systems, especially in those particular circumstances can only be understood from the characteristics of the political and socio-economic environment in which they are embedded. This article focuses on the contextual challenges and opportunities the Palestinian health care system is currently facing in a ‘transitional period’. It serves as a background for further analysis of the health care system and health policy development. A variety of frameworks, which have been proposed or adapted in the analysis of the context of health policy reforms in different settings are cited in the literature ([1,2,18,19], and others). Most of these frameworks have incorporated political, economic and social factors as critical elements influencing health policy change. This analysis of the context of the Palestinian health care system is taking advantage of these frameworks and considers the political, economic, socio-demographic, international donor community, and health status of the population as contextual factors of crucial impact on health policy development in the country. Special emphasis is put on the historical context of the conflict, and the consequences of the ambiguity of the peace-making process. The analysis focuses on the ‘transitional period’ from 1993 up to the Al-Aqsa Intifada at the end of 2000. It has been based on: (1) intensive review, synthesis, and interpretation of formal and informal literature; empirical research and statistics available about the related period; (2) consultation with key informants. 1 The Palestinian National Authority (PNA) is the governing body in the areas of the West Bank and Gaza Strip for the ‘interim period’ specified by the Oslo Agreement in 1993.

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2. Background The West Bank and Gaza Strip (WBGS) are geographically separated areas (see map). In 1950, the West Bank including East Jerusalem and Gaza Strip were administratively attached to Jordan and Egypt respectively, then occupied by Israel in 1967 [20]. The whole area of the WBGS is 6170 km2 (excluding the water areas), of which the West Bank is 5800 km2, and Gaza Strip area 365 km2 [20]. In comparison Norway is 4000 km2, Belgium 30 510 km2 [21].

3. The historical background Palestine was incorporated into the Ottoman Empire between 1514 and 1918. It is assumed by some that the roots of the conflict go back to the end of this period with the beginning of immigrations and settlements of the Jews in Palestine. The British Mandate on Palestine started after the First World War and continued until 1948. In 1947 the United Nations approved the ‘Partition Resolution’ (number 181), splitting Palestine into an Arab and a Jewish state. Following the end of the British Mandate the State of Israel was established in 1948 [20,22]. The Arab-Israeli wars (the 1948, 1967 and 1973) resulted in the displacement of many Palestinians inside and outside the country. Currently, UNRWA counts the officially registered Palestinian refugees to about 3.8 million; about 1.4 million of them in the WBGS, and the rest living scattered all over the world [23].

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The peace process effectively started at the Middle East peace conference convened in Madrid in 1991. The Declaration of Principles Agreement on Interim Self-Government Arrangements, also called the Oslo Agreement I, was signed by Israel and the Palestinian Liberation Organisation (PLO) on 13th September 1993. By signing this agreement both groups made a first step together on the way toward ending a long-lasting and complex conflict [59]. The first important outcome of this process was the establishment of the PNA with the Agreement on Gaza Strip and Jericho Area on 5 May 1994, through which a limited Palestinian self-rule was established in these areas. That agreement was followed on 28 September 1995, by the Israeli– Palestinian Interim Agreement on the WBGS, which set the stage for the extension of the PNA’s authority over additional areas (including major cities of the West Bank), and stipulated that there would be an ‘interim period’ lasting for at most 5 years. By the end of this ‘interim period’, May 1999, the final status negotiations to solve the major disputed issues would be started; namely the status of Jerusalem, the Jewish ‘settlements’, the return of the Palestinian refugees, the control over borders and water, the security arrangements, and the foreign relations. These issues have always been, and still, the main obstructions to reaching a final status agreement [20,59].

4. The political context The Palestinian political system is an evolving democratic system. It is based upon a multi-party system and has an elected legislative council. However, it is difficult to talk about a clear Palestinian political system because Palestinians lack sovereignty [24]. The PNA is still not a ‘state’. It assumes its responsibilities under conditions of particular adversity and complexity for a governing institution [25]. Now it is directly responsible for the civil affairs of the Palestinians living in the WBGS, other than those living in East Jerusalem. In accordance with the Palestinian Israeli agreements, the ‘interim period’ should have ended by May 1999, and the withdrawal from and redeployment in the WBGS should have occurred in several steps and have been completed by July 1997. Israel remains in exclusive control of 61% of the West Bank despite its commitment to redeploy its forces from 88% of the West Bank by July 1997 [59]. So far, the permanent status negotiations are in state of flux and they are facing many obstacles. Moreover, uncertainty is dominant regarding the outcome of this process.

5. The economic situation Prior to 1993, the Palestinian economy was mainly dependent on the economy of Israel for trade and employment opportunities [26]. Currently the PNA still lacks control over the borders and the natural resources, in particular the scarce water resources; two major prerequisites for giving impetus to economic development.

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Figures from the national accounts show that the Gross National Product (GNP) in 1997 was $4.173 billion. The per capita share of the GNP was about $1763 [27]. Figures of the World Bank Development Report 1999 show that the average GNP per capita in the low-income countries was about $520, in the middle-income countries $2952, and in the high-income countries $25 510. Compared with these figures, the Palestinian economy is situated between the low and the middle-income countries [28]. The Palestinian economy has continued to deteriorate since the signing of the Oslo Agreement [29]. The unemployment rate in the WBGS was around 14% in 2000 [30]. The rise in unemployment is mainly a result of the sharp drop in the number of Palestinian workers in Israel due to the closure policies as well as to the substitution of Palestinians by workers from foreign countries. The closure policies refer to the banning or the restrictions on the movement of people, goods and services within the Palestinian localities in the West Bank, between the West Bank and Gaza Strip, and between the West Bank/Gaza Strip and Israel. These measures also include restrictions on the movement of people to foreign countries. Given the heavy dependence of the Palestinian economy on Israel in the areas of trade and labour, the impact of the closure policies on the economy is highly destructive [29,31]. The closure policies, besides the decline in the productivity of the various local economic sectors, the sharp drop in the PNA’s revenues and the destruction of some of the basic physical and social infrastructure and private properties, are leading to significant losses in the Palestinian economy [32]. A decrease in the income of the Palestinian households parallel to the increase in the level of unemployment has led to an increase in the number of households living below the poverty line; 28% in 1998 [33]. In Morocco 13.1%, in Indonesia 15%, in Nigeria 34.1%, and in India 35% of the population are living below the poverty line [28].

6. The Social and demographic characteristics According to the population census conducted in December 1997, the size of the Palestinian population in the WBGS amounted to 2 895 683 persons, not including 328 601 Palestinians living in East Jerusalem [34,35]. The total Palestinian population in the West Bank is 1 873 476 and 1 022 207 persons in Gaza Strip. 54% of the population reside in urban, and 46% in rural areas and refugee camps [36]. A considerable part of the WBGS population is refugee; 26.5% of the population of the West Bank, and 65% of the population of Gaza Strip are refugees [37]. The population density in Gaza Strip (2978 persons per km2) is considered very high compared with the West Bank (324 persons per km2) and to other areas in the world; the world’s average is 45 persons per km2, being 335 persons per km2 in Japan [28]. The majority of the population is Moslem (about 97%). Christians constitute 3% of the total population. In addition, there are also two very small Jewish communi-

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ties who consider themselves Palestinian Jews; namely the Jewish Orthodox community Neturei Karta in Jerusalem and the Samaritan community living on Mountain Gerizim in Nablus [20]. The population growth rate is considered one of the highest in the world. It was 4.18% in 1999 [38], when the world’s population annual growth rate was around 1.6%, and in the developing countries 2.0% [28]. This rate has been predicted to increase gradually in the years to come [39]. If the prediction turns out to be true, the population will have doubled by the year 2016 due to the high fertility rate as well as the anticipated positive migration [39]. High crude birth and fertility rates are striking attributes of the Palestinian Society; respectively 32.8 per 1000 in 1999 [37], and about six births in 1999 [40]. These are mainly due to the early marriage of women, and to the cultural values and beliefs leading to the under-utilisation of family planning programmes among women in the Society [33,39,41]. It was indicated that 98% of women are aware of family planning methods [33]. However, among married women aged between 15 and 49 (or their partners) only 51.5% of women (or their partners) are using contraceptive methods; 36.7% are using modern methods while 14.8% are still utilising traditional methods [40]. The largest part of the population (80%) is under the age of 35 and the median age of the population is about 16 years. Hence, the dependency ratio was estimated at about 101.1 in 1999. However, it is expected to fall in the next years [39]. Families are mainly nuclear (73.2%); the average household size was estimated at approximately 6.1 person in the West Bank and 6.9 in Gaza Strip [36]. Although a relatively good literacy rate has been achieved, recorded at 85.6% in 1997 for the population aged 15 and above, a gender gap in education still persists [42]. Women in the Palestinian Society tend to marry at earlier ages than men do. The median age of the first marriage during the year 1997 was estimated at 18 and 23 for females and males, respectively [40]. The high percentage of marriages between relatives is a salient aspect of the Palestinian Society that is related to the prevailing traditions and cultural values. In the year 1995 more than 49% of marriages were between cousins and relatives from the same clan, which is called ‘hamula’ [40]. It is evident that marriage between relatives, early marriages, and high fertility rates request special attention in addressing the health of women and children.

7. The health status of the population The overall health status of the population is better than in other countries of the same level of socio-economic development. Box 1 demonstrates the main health and socio-economic indicators. Long established successful immunisation programmes with high coverage (ranging from 92 to 98.28% for immunisation types) have significantly contributed to the improvements in the mortality rates and the life expectancy of the population [43].

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The disease patterns of the Palestinians resemble a mix of developing and developed characteristics [37,38,43]. Although it is not a huge problem, infectious diseases such as Meningitis (incidence rate 2.9/100 000), Poliomyelitis (1/100 000), Viral Hepatitis A and B (87 and 3.2/100 000 respectively), Brucellosis (26.9/ 100 000), Measles (5/100 000), Leishmaniasis (1.9/100 000), Tetanus (0.14/100 000), and AIDS/HIV (a total of 33 cases) are prevalent [37]. Acute respiratory infections, namely Pneumonia is one of the main causes of reported infant mortality, and child (less than 5 years) mortality [43,37,38]. At the same time the main causes of adult mortality are cerebrovascular diseases, cancer, cardiovascular diseases and diabetes mellitus [44,43].

Source of data: *[37],

c

[45], x[40], 8[27],

"

[46].

A prominent aspect of the Palestinian population is that the high fertility rate is equalled by comparatively a low mortality rate [47]. A progressive decline has been witnessed in recent years in both the crude birth and death rates and this decline is anticipated to continue in the years to come [39]. Projections of the Palestinian Central Bureau of Statistics according to the medium series hypothesis estimated

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the crude death rate is to fall from 3.35 per 1000 in 1999 to 3.26 per 1000 in the year 2025. Similarly, the crude birth rate is anticipated to decrease from its 1999 level of 32.8 per 1000 to 25.32 per 1000 in the year 2025 [37,39]. There is a significant discrepancy of health status between the West Bank and Gaza Strip (see Table 1). Based on UNRWA’s estimations, more than 20% of the refugee population lives in overcrowded camps with substandard housing and sanitation conditions [23]. The provision of basic health cover to the refugee population is the responsibility of UNRWA. It is a fact that 65.1% of Gaza’s population are refugees [37], hence an issue requesting special attention. Bearing in mind the given socio-economic and political situation of the country, sustaining and promoting the overall health status of the Palestinians becomes a real struggle.

8. The role of the International donor community The Palestinian Territories is an example by excellence of the growing interest of the international donor community in supporting rehabilitation and peace building in ‘post’-conflict countries. It is considered one of the largest recipients of aid undertaken by the international aid community [25]. The primary objective of international aid is to support the peace building process, and it subsequently intends to promote social and economic development [48]. Following the Oslo Agreement in October 1993 more than 42 donor countries and multilateral agencies provided economic reinforcement to develop the institutional capacity of the PNA [49,50]. The total amount of donor commitments, in the period between June 1994 and October 2000, has reached about $4601 million of which $3070 million have been spent [51].

Table 1 Selected health and socio-economic indicators of the West Bank and Gaza Strip

Crude birth rate per 1000 in 1999* Crude death rate per 1000 in 1999* c Population growth rate (%) 1999a Infant mortality rate per 1000 between 1995 and 1999x Child (B5 years) mortality rate per 1000 between 1995 and 1999x Total fertility rate 1999x Annual Household Health Expenditure 1996 (US$)" GNP per capita (US$) 19978 Refugee population (%) 1999* Population is living under poverty (%) 1997V Average unemployment rate (%) 1998u Sources of data: * [37],

c

[38],

a

[39],

u

[30],

x

[40],

8

[27],

V

[42],

"

West Bank

Gaza Strip

32.2 3.3 3.98 24.4 27.2 5.52 66 1,915 26.5 16 12.1

33.8 3.4 4.53 27.3 31.2 6.81 39 1,388 65.1 38 18.7

[46].

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The share to the health sector of the total amount of aid was about $251 million2, which constituted about 8% of the total disbursements to the Palestinian Territories [51]. This is an example of the special attention that has been given to the reconstruction of the health care system. The international assistance has a crucial impact on the social and economic development, as well as on the development of the Palestinian public (the PNA) institutions, that were totally rebuilt after 1993. Nevertheless, international assistance has been criticised, as Sayigh and Shikaki have argued [25], for the discrepancy between the commitments and the disbursements, the very limited scale of technical capacity and know-how that have been transferred to the Palestinian Territories, and for promoting goods and services from the home country. One of the recent assessments of the effectiveness of aid to the Palestinian Territories is that of the Ad Hoc Liaison Committee for aid co-ordination, produced by Japan and the World Bank [48]. On the one hand, the report underlined the positive impacts of international aid on the institutional development and policy reforms; on the other hand, it did not ignore the peculiar implications of international aid on national policy-making. Whereas, money, ‘conditionality’3, technical assistance, and ‘policy dialogue’, are policy instruments of donors to influence policy reforms and institutional development in developing countries, the report argued that ‘conditionality’ was not likely to be an effective measure in the Palestinian case, since support to the peace process was the prevailing objective.

9. Discussion So far, an effort has been made to explore the major political, economic, and socio-demographic characteristics, being the context of the Palestinian health care system. Table 2 illustrates these elements in a framework, highlighting the contextual challenges and opportunities. Semantically4, ‘transition’ refers to ‘the change from a condition or a form to another’. All countries are facing transitional de6elopments. A country in transition refers to shifts in the major institutions of that country due to internal and/or external pressure. This means that the political, economic and social-cultural

2 This amount does not include the annual international contributions to the operation budget of UNRWA’s health programme. 3 Conditionality refers to donors’ explicit tying disbursement for achievement of specific policy objectives ([48]; 107). ([60]; 1), conditionality is the policy series that the World Bank and the IMF impose on developing countries with their structural adjustment programmes loans to these nations. Examples of these measures are: adjustment/devaluation of local currencies, promoting the private sector, elimination of state enterprises and monopolies, cutting the state budget, including removal of all consumer subsidies and social expenditures, pausing general public sector wage and salary, etc ([60]; 1). 4 The Webster’s Dictionary.

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systems are in jeopardy with a possible spiralling effect on all subsystems. However, a system in transition is different from a country in transition. Systems, like education and healthcare can be in transition in a relatively stable national environment. For example, most European countries have issued healthcare reforms in recent years to face a shrinking of health care resources and an increase in health care demands. Shifts and reforms were necessary to reach a balance between the costs and quality of health care services. In periods of political transition of a country, stability is substituted by uncertainty, risks and threats become greater, and no scenarios can reliably predict the future. Usually political transition coincides with economic and social changes. For instance, the transition of the Central and Eastern European countries has been coupled with economic alterations from planned to market economy, with changes regarding social stratification, and distribution of wealth and income exemplified by a growing number of people living in poverty [52]. Jamison amd Mosley [53] argued that a profound political and economic transformation is likely to have an impact on health as well as on the epidemiological profiles of the population in such countries. A variety of factors contribute to the transitional character of a country and transition can be expressed in terms of a continuum ranging from indicators of transition to radical turnover. Transitional episodes of a country can be witnessed as a result of shifts in its structural and cultural cornerstones, such as the collapse of the Soviet regime and the resurgence of Russia. In other countries, transition emerges as a result of violent conflict whereby either conflict among population groups and/or external conflict with external groups lead to turmoil within the pivotal institutional arrangements. Such is the case for Uganda, Cambodia, and the Occupied Palestinian Territories. Instability, uncertainty, risks and threats are clearly witnessed in most sectors in the Occupied Palestinian Territories. A violent conflict is prevailing, and without a permanent solution to the conflict it is difficult to talk about peace and stability in this region. The peace talks are ongoing. However, the results of the process, including the future status of the Palestinian Territories are ambiguous. Nonetheless, Palestinians are moving into a new and imperative period of their national history, which is a ‘transition’ from ‘war’ to ‘peace’, from occupation toward self-determination. In this ‘transitional’ phase and under circumstances of political instability, Palestinians are building the institutions of their future state. This political shift in turn has consequences for the economic and socio-cultural systems of the Territories. The current Palestinian economy is below its capacity and capabilities [29]. The general political uncertainty tends to undermine economic confidence. Due to this situation the international investments in the Occupied Palestinian Territories after the Oslo Agreement are below the expected level. This situation is exacerbated by the closure policies, which are frequently applied. The economic drawbacks might have adverse effects on the amount of national resources currently allocated to the health sector, about 8.6% of the GNP [46]. Moreover, the escalation of unemployment and the increase in poverty are seriously decreasing the ability to pay for

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Table 2 Challenges and opportunities of the political, economic, social, and demographic characteristics of the Occupied Palestinian Territories Challenges

Opportunities and possibilities

Political General characteristic: uncertainty in the political situation, and lack of so6ereignty Political uncertainty as corollary of peace negotiations regarding the final stage results Unclear political system

Democratic political system characteristics Well-organised civil society, potential for pluralistic system

Geographical separation of West Bank and Gaza Strip The absence of a sovereign Palestinian state Economic General characteristic: deteriorating economic conditions High unemployment rate about 14% in 2000 Uncertainty about the fulfilment of the international aid commitments Imposed closure and separation policies Lack of control over natural resources, especially water Absence of open boarders; barriers on the free movement of people, goods, and services between WBGS Lack of international investment due to the political uncertainty Pressure of the international aid agencies

Potential of qualified labour force Good tax collection system, taxes constitute about 60% of public revenues in 1996 Substantial contribution of the international donor community in the reconstruction Prospect of support and investments by the wealthy Palestinian elite in exile

Demographic General characteristic: high demographic growth and fertility Very high population growth rate; 4.18% in 1999 High crude birth rate, 32.8 per 1000 in 1999

Low percent of aged population, 65+ age group is 3% of the total population in 1997 Expected decrease in the crude birth rate, to 25.32 per 1000 in 2025

High fertility rate, about six births in 1999 Forty seven percent of the population under the age of 18 (children) in 1997 Social General characteristic: 6alues and beliefs as important social control mechanisms High poverty level, 28% of the households living below the poverty line in 1998 A gender gap in education, female illiteracy rate 20.1% compared with 7.7% among males High percentage of marriages between relatives 49% in 1995 Trend of early marriage of women, median marriage age of women 18 years Relatively low utilisation of family planning methods; mainly due to social and cultural control mechanisms, 51.5% in 2000 Tremendous social control by the ‘family’ The power of the tribe ‘hamula’ concept in society Tangible social-cultural, and economic differences between the West Bank and Gaza Strip Sources of data used: [20,24–29,32–43,46,49–51,55–59].

Nuclear families are prevalent, 73.2% in 1997 Relatively good literacy rate of aged 15 and above 85.6% in 1997 Continuously improving education system Co-existence of different religious and cultural groups, treated equally, and living in peace, freedom, and respect for each other without the dominance of any group Strong informal social solidarity system Substantial Contributions of the NGOs to the society

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Fig. 1. The context of the Palestinian health care system.

services in general and health care in particular. Unemployment has a spiralling effect on those already living below the poverty line. International aid has been provided to contribute to the rehabilitation efforts and peace building process in interim periods of transition. However, in phases of ‘post’-conflict transition, the weakness of the state with regard to the lack of political authority and technical capacity, and at times the lack of regime legitimacy is recognised as an easy environment for international actors to influence national policy making. For example, in the political turmoil of ‘post’-conflict in Uganda and Cambodia, a considerable leverage of international agencies on health policy was witnessed through ‘conditionality’ of rehabilitation aid [13,54]. In the Palestinian case, the international assistance is profoundly political, and its continuity will largely depend on the peace progress. Noticeably, the external aid is mainly in the area of capital investments, capacity building, and technical assistance. The positive impact of the assistance to the health sector can explicitly be observed in terms of increased health services capacity using external resources such as rehabilitation and expanding of the infrastructure of services, capacity building as well as installation of medical technologies. However, the impact of external factors on the national policy process has to be understood through the proliferation of bilateral and multilateral technical assistance projects.

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10. Conclusions Eliminating the detrimental effects of the conflict and rebuilding the institutions, including developing the health care system is a major task for the Palestinian community. The Palestinian health care system is functioning in a complex context (see Fig. 1). The ambiguous political and economic environment, the unique geographical separation of the West Bank and Gaza Strip, and the socio-demographic and cultural characteristics of the Palestinian population, as well as the international pressure of the aiding agencies are critical elements. The interaction of these factors as well as the fragile context of the Palestinian health care system makes the organisation of health care and health policy development a very complicated process. As a consequence, appropriate health policy-making and priority setting in the Palestinian health care system is more than challenging. Acknowledgements Motasem Hamdan is a Palestinian. He is an academic member of the Faculty of Public Health, at Al-Quds University in Jerusalem. Currently he is preparing a PhD dissertation at K.U. Leuven, in Leuven, Belgium. The authors would like to thank all those supported in the data collection, and especially key the informants willing to provide an interview. The opinions expressed in this article are the sole responsibility of the authors. References [1] Saltman RB. The context for health reform in the United Kingdom, Sweden, Germany, and United States. Health Policy 1997;41 (Suppl.):S9 – S26. [2] Collins C, Green A, Hunter D. Health sector reform and the interpretation of policy context. Health Policy 1999;47:69 –83. [3] Baker AM. The psychological impact of the ‘Intifada’ on Palestinian children in the Occupied West Bank and Gaza: an exploratory study. American Journal of Orthopsychiatry 1990;60(4):496 – 505. [4] The conditions of health services in Gaza Strip. Medicine and War, 1990; 6(2): 140 – 51. [5] Punamaki RL. Impact of political change on the psychological stress process among West Bank Palestinian women. Medicine and War 1999;6(3):169 – 81. [6] Schnitzer JJ, Roy SM. Health services in Gaza under the autonomy plan. Lancet 1994;343(8913):1614–7. [7] el Sarraj E, et al. Experience of torture and ill-treatment and posttraumatic stress disorders symptoms among Palestinian political prisoners. Journal of Traumatic Stress 1996;9(3):595 – 606. [8] Husseini AS. Palestinian refugee in the West Bank and Gaza Strip: health = development. Medicine Conflict and Survival 1996;12(2):131 – 7. [9] Jaouni ZM, O’Shea JG. Surgical management of ophthalmic trauma due to the Palestinian Intifada. Eye 1997;Pt 3:329 –37. [10] Thabit AA, Vostanis P. Post traumatic stress reaction in children of war. Journal of Child Psychology and Psychiatry 1999;40(3):385 – 91. [11] Pourgourides C. Palestinian health care under siege. Lancet 1999;354(9176):420 – 5. [12] Zwi A, Ugalde A. Towards an epidemiology of political violence in the Third World. Social Science and Medicine 1989;28(7):633 –42. [13] Lanjouw S, Macrae J, Zwi AB. Rehabilitating health services in Cambodia: the challenge of coordination in chronic political emergencies. Health Policy and Planning 1999;14(3):229 – 42.

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