An Unhealthy Accord: 20 years of Oslo and preventable Palestinian aid dependency

There is widespread scepticism amongst Palestinians as to whether the current talks – continuing with the framework for negotiation established by Oslo – could ever succeed.

New Statesman
The Palestinian flag flutters in front of the Church of the Nativity. Image: Getty

Twenty years ago, on 13 September 1993, Israeli Prime Minister Yitzhak Rabin and PLO chair Yasser Arafat shook hands on the White House lawn and signed the Oslo Accords – launching a transitional process towards a permanent peace settlement that was not supposed to exceed five years. Today this ‘interim’ agreement has ossified into an interminable situation in which Palestine remains occupied, while Palestinians face enduring insecurity, uncertain access to essential services and the downward spiral of aid dependency.

Although much has been said about the failure of the Accords to settle the key issues – including Jerusalem, the Palestinian right of return, the status of Israeli settlements in occupied Palestinian territory, and the issue of borders – the fate of healthcare in the West Bank and Gaza under the framework of the agreement has garnered little attention.

Yet, Palestinian healthcare provides a prime example of the way in which the initial optimism surrounding Oslo has failed to translate into reality over the past two decades. Indeed, as negotiations resume once again, it sheds crucial light on some of the lessons to be learned from Oslo if there is to be any chance of a just settlement.

Following the June war of 1967, Israel was required by international law to assume responsibility for health services in the newly occupied West Bank and Gaza. Between then and 1993, health services in the occupied Palestinian territory were starved of funds and there were shortages of staff, hospital beds, medication and essential specialised services, while responsibility for healthcare passed from the Israeli Ministry of Health to the military government and then to the Israeli Civil Administration, under the Ministry of Defence. During that time, Israel aimed only to maintain standards of public health and did not attempt to build services beyond primary care. As a result, many Palestinians had to seek specialised treatment in Israel and they were often unaware of their entitlements under the Israeli Civil Administration’s health insurance programme.

Following Oslo, no sovereign Palestinian state was established so, as the occupying power, Israel remained responsible under international law for ensuring the health and well-being of Palestinians. Yet, under the framework of the agreement, Israel was able to release itself from this responsibility – and its costs.

As a result, the Palestinian Ministry of Health – part of the newly established Palestinian Authority – inherited the neglected health services of the West Bank and Gaza. Over the next 20 years, with the support of massive funding from international donors, the PA has managed to develop a health system with a reasonable spread of primary care clinics and hospitals across the West Bank and Gaza. However, healthcare services today remain fragmented and of very variable quality, while restrictions on access to care, particularly for patient referrals outside the West Bank and Gaza, have become entrenched. The PA’s dependence on foreign aid also raises troubling questions about long term sustainability. Aid from the international community currently makes up 40 per cent of the PA’s annual budget.

From the very outset, the ability of the PA to provide healthcare to Palestinians was hampered by the division of the West Bank under the agreement into three zones: Areas A, B and C. Twenty years later it remains the case that only 18% of the West Bank falls under PA civil and security control (Area A),  20% is under PA control with responsibility for security jointly held by Israel and the PA (Area B), while the remaining 62% of the West Bank is under full Israeli civil and security control (Area C).

Unequal access to healthcare in the Jordan Valley in Area C – which is home to around 60,000 Palestinians – provides one of the starkest examples of the extent to which the Accords have cemented the divide between Palestinian and Israeli services. Israelis living in illegal settlements there enjoy government subsidies and much greater access to services and local resources than Palestinian residents. While the Israeli Ministry of Health is able to freely construct and administer health clinics for the settlements in the area, the Palestinian Ministry of Health is not able to build health facilities in 87% of the Jordan Valley without obtaining a building permit from the Israeli authorities – which are rarely granted. The network of checkpoints and barriers in Area C, together with the proximity of settlements, also makes it difficult for staff and patients to reach clinics or hospitals.

The closest hospitals for Palestinians in the Jordan Valley are in Jericho and Nablus cities. The hospital in Jericho is far from many Palestinian villages and those seeking treatment in Nablus face potential delays at checkpoints. Last month, for example, a young boy who suffered a snake bite was reported to have been denied permission to pass through a checkpoint for an hour and a half by Israeli soldiers, who refused to call an ambulance. Eventually an ambulance from the Palestinian Red Crescent managed to access the area and transfer to the boy to Rafidiya hospital in Nablus, where he was said to be in a critical condition.

Restrictions on movement are also preventing or impeding referrals to medical centres in East Jerusalem and Israel. The main specialised Palestinian hospitals are, and always have been, located in East Jerusalem. Last year alone, 39,280 patients, companions and visitors from the West Bank and Gaza did not make it to the hospitals they were referred to because their permits were denied by the Israeli authorities. Even in extreme emergencies, ambulances from the rest of the West Bank are only permitted to enter East Jerusalem in exceptional circumstances, when prior approval has been given by the Israeli Civil Administration and checkpoint personnel agree. In 2012, only 9% of requests for ambulances to enter East Jerusalem were approved.

The status of occupied East Jerusalem – which was illegally annexed by Israel in 1967 – was left out of the Oslo agreement. As a result, it remains under de facto Israeli control today. While the political, economic, social and religious significance of East Jerusalem for Palestinians gets some attention, its additional importance as the location of Palestine’s six specialist hospitals tends to go unacknowledged.

Gaza is also of particular concern. Although the Accords declared that Gaza and the West Bank would be one territorial unit, this has proved far from the reality - not least because of the political divisions between Fatah and Hamas.  Gaza has experienced some of the most severe restrictions on healthcare in occupied Palestine, with healthcare services deteriorating steadily in recent years. The political split between the West Bank and Gaza has certainly contributed to this. But the major factor has been the land, air and sea blockade on Gaza since 2007, which has eroded healthcare infrastructure, exacerbated shortages of medicine, rendered some medical equipment useless due to a lack of spare parts and impeded patient transfers.  Constant power cuts and the degradation of water supplies and sewage disposal are seriously affecting the safe and efficient operation of hospitals and clinics. In 2012, important infrastructure such as waste disposal systems and utilities to provide essential healthcare services were lacking in as many as 63% of primary healthcare facilities and 50% of hospitals. Unless immediate action is taken, a recent UN report has stated, water, electricity and health problems will have become so bad in the coming years that Gaza is set to be unliveable by 2020.

The justification always provided for Israel’s occupation policies – such as the blockade of Gaza, the separation wall, checkpoints and the permit regime – is their need for security. Both sides, of course, have a right to security. But too often this has become an excuse for practices that have nothing to do with security, such as the ongoing building of illegal settlements, and for avoiding their responsibilities under international law, including Israel’s obligation to safeguard the health of the civilian population in the territory it continues to occupy.

Against this background, there is widespread scepticism amongst Palestinians as to whether the current talks – continuing with the framework for negotiation established by Oslo – could ever succeed. The persistence of Israeli violations of international law during peace talks raises serious questions about the basis of the current negotiations, the role of the international community and the different forms of leverage available to ensure that international law is upheld. The international community has a clear responsibility to ensure that peace negotiations do not continue to provide Israel with the cover to pursue with impunity its illegal colonisation of Palestinian land, which is not only a major obstacle to the health and dignity of Palestinians but is also deepening aid dependency.