The effects of the Israeli siege on health provision in the Gaza Strip: a qualitative and theoretical analysis.

Abstract Background Siege, a process of political domination aimed at isolating an entire population, is a unique threat to health-care provision. The aim of this study was to qualitatively examine the effects of the Israeli siege on the practices and systems that underlie health in the Gaza Strip. Methods Data were from participant observation between 2009 and 2017, including 20 interviews with doctors and health administrators in non-governmental organisations (NGO), government, and UN sectors. All participants were provided with a description of the study and provided written consent to participate. The study was approved through the Human Subjects Review process at Bucknell University and the University of Washington. The data were analysed using a critical political economic framework, based on the concepts of primitive accumulation, accumulation by dispossession, surplus populations, and de-development. These analytical frames are further developed to interpret neoliberal trends in health-care systems organising and financing as they apply in the distorted social and economic context of siege. Findings The elimination of political sovereignty through the twin processes of occupation and siege are the primary impediments to the successful promotion of public health in the Gaza Strip. Findings indicate that siege impinges on effective health-care provision by withholding materials and resources and undermining the health care at a systems level. These strains pose considerable threats to health care, within the ministry of health and among other entities in the Gaza Strip that deliver care. Gazan society is divested of the underpinnings necessary for a well functioning sovereign health-care infrastructure. Instead of a self-governing, independent system, this analysis reveals a system that is comprised of captive clients who are entirely dependent on Israel, international bodies, and the aid industry for goods and services, with no means of independent development. Interpretation The siege represents a totalising social determinant of public health in the Gaza Strip, and it has significant and deliberate deleterious effects on the provision of medical care and exacerbates problems in overstretched medical services. These findings point to the importance of foregrounding the geopolitical context for analysis of medical service delivery within conflict settings. The data indicate formative trends in health-care provision in the Gaza Strip. Although the siege creates a seemingly unique economic context for analysis of health-care provision, critical analyses that deconstruct the depredations of neoliberalism in the health-care setting provide a useful framework for analysis of the failings of the health-care sector. Indeed, health-care providers are in an impossible position of attempting to provide quality care without the ability to coordinate with their colleagues in other sectors, and without substantial support from the international community. The final analysis also highlights the importance of advocating for sovereignty and self-determination as related to health systems, and it suggests that successful health-care provision is impossible without a strong analysis of the political and economic context. Funding Bucknell University.