Relying on others: provision of water and health care

Izzat Abdul-Hadi; Thomas White
Bisan Center for Research and Development

Palestinian dependence on Israel for water and on the international community for healthcare services underscores the crippled state of Palestinian welfare and its subjugation to Israeli military decisions. This is not the result of shortcomings of the traditional development approaches (in particular the differing incentive and sanction structures behind state and market approaches to basic service provision) but of Israeli military and government policy towards the West Bank and Gaza.

Thecurrent failures in service provision should not be seen within the context ofthe past two years alone. Israeli policies since 1967, especially in the WestBank, have sought to promote Jewish over non-Jewish development. The consequenceof these policies is Israeli cooption of the potential of both the PalestinianNational Authority (PNA) and private organisations to provide basic services toPalestinians.

Thisassessment will look at two basic services[1]:water and health care. The Israeli government has sought to control waterresources in PNA areas. The impact of this control confounds normalstate-vs.-market development theory, leading to questions about itsapplicability in Palestine. In the case of health care, the unique context ofthe Palestinian territories and the current crisis of Israeli invasion favourservice provision by foreign NGOs, as opposed to traditional state or marketapproaches.

Thewater supply: dependent on a private Israeli monopoly

Watersupply is dependent upon Mekorot, an Israeli private contracting company thatsupplies Israeli settlements in the West Bank and Gaza. Mekorot controls over90% of all water resources in the Palestinian territories. (Private Palestiniandug or rainfall wells provide the additional 10%.) Mekorot is an outgrowth ofIsraeli military orders concerning the licensing of Palestinian wells and watersupply that were put into place after the occupation of the Palestinianterritory during the 1967 war. These orders placed the control of water sourcesin the hands of regional commanding officers, and eventually under control ofthe Israeli 1959 Water Law, in which all water is declared Israeli stateproperty. Since 1967, Israel has worked to incorporate the occupied territoriesinto the Israeli water system. After 1967, water was distributed from theIsraeli system in the occupied territories by the Israeli Army’s civiladministration at the district level. Distribution was handed to the PNA uponits establishment, although the occupied territories are still linked to theIsraeli settlement water network. Currently, the Palestinian Water Authority isresponsible for purchasing water from Mekorot and providing it to thePalestinian districts that are responsible for final distribution.

Israelisuse 85% to 90% of the water resources of the West Bank, either inside Israelthrough laterally drilled wells, or in Jewish settlements in the West Bank andGaza Strip.[2]The drilling of Palestinian wells is forbidden without permission from theIsraeli military authorities even in Palestinian ruled areas, as water issuesare a part of final status talks to be negotiated in the future. Agriculturalwater use by the Palestinians has stayed at 1967 levels, and domestic use hasonly increased by 20% since 1967, despite a 300% increase in population duringthe same period.[3] Palestinians must cope with serious shortages and theIsraeli monopoly’s high prices. Water consumption prior to the Israeliinvasions was rationed by Mekorot to provide 110 million cubic metres (MCM) ofwater to more than one million Palestinians and 50 MCM to 125,000 Israelisettlers, a ratio of 4:1 in favour of settlers. In Gaza this ratio was 12:1 infavour of settlers prior to the second Intifada. Prices for water forPalestinians were seven times those charged to settlers, a fact that theIsraelis blame on the cost of distribution. Other sources claim “the issue isnot the absolute price that Palestinians pay for water, which may indeed reflectreal costs. The issue is one of blatant and formalised discrimination on thepart of the Israelis.”[4]Mekorot essentially subsidises water provision for Jewish settlement of the WestBank, and taxes Palestinians to pay for the costs incurred.

TheIsraeli invasions of PNA areas since September 2000 damaged Palestinian waterdistribution systems and affected the safety of the supply. Direct attacks bythe Israeli army to the Palestinian water infrastructure have amounted to USD774,405 in damages since March 2002. Prices for drinking water have increased,especially in the private-sector trucking of water to non-networked villages,where prices are as much as 40% higher than pre-Intifada PNA rates. In responseto Israeli water needs, Mekorot reduced water pressure in the West Bank in May2002; the entire city of Hebron received less than 2000 cubic metres of waterdaily.[5]In April 2002, Israeli military forces tore up water pipelines entering thecities of Nablus and Jenin, leading to extreme shortages in some areas. Theoverall consumption per person in Jenin has been reduced to 20 litres per month,a rate 80% below World Health Organization estimates for reasonable health.[6]Israeli closures and curfews have reduced Palestinian access to safe waterresources. The Union of Palestinian Health Work Committees (UPMRC) reported 95cases of hepatitis A in Nablus during August 2002, and according to a USAIDstudy, 30% of Palestinian homes currently have at least one case of diarrhoea asa result of contaminated water sources.

Fromthe perspective of the policy debate over public or private provision of water,the Palestinian case does not fit simply into the established discourse.Currently the PNA, a state-like entity, purchases most Palestinian water from anIsraeli contracting company. Whether this is public or private provision isdebatable. Also, given the current crisis, answering questions about thebenefits of public or private water provision for Palestinians depends heavilyon short-term considerations, leaving long-term discussions for a time whenPalestinians again control their lives through the PNA. Israel’s invasion hascrippled the PNA’s efforts to provide most basic services.

Thehealthcare sector: outside dependence for funding and supply

Afterthe 1967 war Israel moved to incorporate the health care of Palestinians intothe Israeli healthcare system by linking military control of hospitals in theWest Bank and Gaza to its national healthcare system. Military orders from thelate 1960s and 1970s banned Palestinians from opening new health clinics orhospitals, and the Israeli army took over the operation of most Palestinianhospitals. The situation in the occupied territories remained stable until theoutbreak of the first Intifada in 1987, after which charitable societies andNGOs defied Israeli orders and opened healthcare clinics to care for thethousands of injured Palestinians. NGOs formed the basis of health care duringthe 1980s and early 1990s. In 1994, the Israeli military’s civiladministration of the West Bank and Gaza transferred authority for health careto the Palestinian Authority’s Ministry of Health (MOH), which in turn hasundertaken a process of integrating PNA, NGO and private healthcare provision. Amajor trend since the establishment of the PNA is the transfer of internationalfunding from the non-governmental sector to PNA institutions, reducing thenumber of NGO clinics by 65% since 1993.

Beforethe start of the second Intifada in September 2000, an integrated strategy wasbeing employed, recognising the importance of developing a national plan thatincluded public, private and NGO sources. In 1999, there were 52 hospitals inthe West Bank and Gaza, 14 run by the MOH, 24 run by NGOs and 14 run as privatecompanies. Of primary healthcare centres, 60% were run by the MOH, 31% by NGOsand nine percent by the United Nations Relief and Works Agency for PalestinianRefugees (UNRWA). Ninety-four percent of hospital beds in the West Bank and Gazaare publicly provided either through the MOH, NGOs or UNRWA; only six percentare provided privately. In 1998, recognising the importance of the NGOs, the MOHbegan a system of outsourcing health care by funding services provided by NGOs.This parallel service provision approach includes either partial or full fundingfrom MOH for NGO health services.

ThePalestinian health sector depends on international support for funding andsupply of healthcare services. Funding is given to the MOH through the PNA–funded through international sources– health insurance payments, andco-payments and fees. UNRWA is funded through donor countries. Palestinian NGOsdepend on international donors either directly from governments or throughinternational NGOs, and private clinics depend on outsourcing from the MOH, feesand charity. In 1999, the last period for which sector-wide statistics areavailable, the foreign funding distributed was nearly USD 175 million. To give asense of the scale of this contribution to the Palestinian healthcare system,this figure may be compared with the overall budget for the MOH in 2000, whichwas USD 50 million not including salaries and approximately USD 95 millionincluding salaries. In 1997, Japan provided the greatest proportion ofinternational funding to the Palestinian healthcare system (39%).

Israeliactions since September 2000 have seriously damaged the Palestinian healthsector –and indeed health itself–, mostly as a result of reducedexpenditures on the part of public providers, and lack of access to services bythe Palestinian population. The health of Palestinians has also suffered as aresult of increased poverty, and a consequent decrease in ability to pay forhealth insurance. PNA losses in income due to Israeli seizure of tax income haveaveraged USD 20 million per month since April 2001. The Authority faced a 76%decline in revenues between the end of 2000 and the beginning of 2001.[7]The MOH reports that because of decreased income its hospitals and otherfacilities are now functioning at only 30% of capacity.[8]In2001, 62.5% ofhouseholds in Gaza reported difficulty in accessing health care because “theyhave faced problems…due to Israeli [road] closure.”[9]

Inthe face of the Israeli siege, the MOH implemented a strategy of“decentralisation” whereby local NGO and private health clinics were givenadditional authority. Strategies employed by the MOH to confront the healthcrisis included the purchasing of drugs on credit from local suppliers,coordination of medical efforts with national and international NGOs, thepromotion of home care, and the development of mobile health teams. In manycases, increasing international aid efforts given to NGOs has propped up thehealthcare sector. The Union of Palestinian Medical Relief Committees (UPMRC)reports that the total number of treated people in its clinics increased from32,000 in 2000 to 308,000 in 2001, as a result of external funding increases,the fact that services are provided without charge, and the establishment ofclinics throughout the West Bank and Gaza.[10]Anecdotal evidence shows that private healthcare companies are suffering. Theinability of individuals to pay insurance, and the reduction in MOH funding,means that private suppliers have had to cut costs or go out of business. Insome cases, private hospitals and clinics are being purchased by NGOs that arebenefiting from increased international aid.


Developmentalmodels of public versus private service provision do not apply to water andhealthcare provision in Palestine. As a result of the current structure of waterprovision, Palestinians depend entirely upon Israeli price and supply controlsfor the provision of water. Palestinians cannot sanction these Israeli controlsthrough either market or state mechanisms. Palestinians do not have the choiceto purchase water through secondary sources –the market option– or voiceopposition to Israeli water provision policy –the state provision option.

Theoverall dependence of the Palestinian healthcare system on international funding–especially important with the Israeli withholding of Palestinian taxrevenues– leads to a structure that favours NGO provision of services overgovernment or private healthcare provision. NGOs are more flexible given thechanging circumstances and do not depend upon taxation for their funding.Neither do they depend on private wealth and insurance to cover the costs oftheir operations, as do private service providers.

Underthe current circumstances, dependence on Israel for water will continue todominate public and semi-public distribution networks in PNA areas regardless ofPalestinian choices about public and private provision. In the health sector,circumstances dictate a return to the pre-PNA days of NGO service provision.


[1] The usual debates over the different incentives and the effectiveness of public or private service provision do not apply well to a situation of foreign military occupation. For a strong analysis of Palestine and development theory under occupation see "Theories of Development and Underdevelopment: the Particularity of Palestinian Dependence" in S. Roy, The Gaza Strip: the Political Economy of De-Development, Washington DC: Institute of Palestine Studies, 1995.

[2] The West Bank has three main water basins that are consumed by the Israelis as follows: of the Western Basin, 91.4% Israel proper and 2.69% settlers; Northern Basin, 68.67% Israel proper, 3.33% settlers; and Eastern Basin, 29.41% Israel proper and 30.88% settlers.

[3] The Palestinian population increased from 1,013,000 in 1967 to over 3.3 million in 2002. Cf. population statistics in

[4] D. Brookes and S. Lonergan, The Economic, Ecological and Geopolitical Dimensions of Water in Israel. Centre for Sustainable Regional Development, Victoria, Canada, 1993.

[5] K. Kamphoefner, “Water Inequalities,” CPTnet, 9 September 2002, p. 1. See

[6] Interview with Taher Nasser El-Dein, District Deputy of the Ramallah Water District, 28 October 2002.

[7] World Bank Draft Report, “One Year of Intifada - The Palestinian Economy in Crisis,” World Bank, November 2001, p. 25.

[8] Cited in The Palestinian Initiative for the Promotion of Global Dialogue & Democracy: Miftah, “Palestinian Humanitarian Disaster,” 10 July 2002. See

[9] Palestinian Central Bureau of Statistics, “Impact of the Israeli Measures on the Economic Conditions of Palestinian Households (3rd Round: July-August, 2001)” PCBS, 2001, p. 5. Available at

[10] Interview with Dr. Jihad Mashal, general director of UPMRC, 20 October 2002.