Non-Governmental Health Organizations in Palestine from Israeli Occupation to Palestinian Authority

The paper examined the Palestinian Non-Governmental Organisations (PNGOs) from a historical perspective with focus on their roles, the challenges they faced, and their current status after the establishment of the Palestinian National Authority (PNA) in 1994. It also examined their driving motives, their contributions to the advancement and development of the Palestinian society, and the challenges they faced. The role of health in development is highlighted and an introduction to NGOs in general is offered, with emphasis on their characteristics in comparison to the public and private sectors after the establishment of the PNA in parts of the West Bank and Gaza Strip (WBG). It is clear that PNGOs in general and health NGOs in particular played an instrumental role in providing much needed health services, but also in paving the road for the establishment of a Palestinian state. The paper showed that there are three main challenges that faced NGOs, namely, political challenges, financial challenges and the unclear role of the PNA. The first two challenges faced NGOs during the Israeli occupation and continue to do so after the establishment of the PNA. The third challenge became relevant only after the establishment of the PNA in parts of the WBG.


Introduction
Palestinian non-governmental organisations (PNGOs) have traditionally played a critical role in affecting most aspects of Palestinians' lives.Not only did PNGOs provide desperately needed services to the marginalised and disadvantaged during the Israeli occupation of the West Bank and Gaza Strip (WBG) after 1967, but they also provided an invaluable forum for mobilising and organising the national liberation movement that led to the establishment of the Palestinian National Authority (PNA) in 1994.In the absence of a Palestinian government in charge of the WBG, PNGOs provided almost 60 percent of the primary health care services, 100 percent of kindergartens, as well as a substantial portion of services in agriculture, informal and university education, welfare, and housing in WBG (Clark & Balaj, 1996;Claudet, 1996).
When the Palestinian Authority took over a weak, underdeveloped and fragmented public health sector from the Israeli authorities in 1994, it faced the task of health sector reform.In its effort to reform the health sector, the PA sought to impose its own vision of health care.The PA initially seemed successful in establishing its vision of health care.However, its attempt to marginalise and control health organisations in this effort has been challenged.
The Palestinian NGOs, their driving motives, their contributions to the advancement and development of the Palestinian society, and the challenges they faced will be addressed, the role of health in development will be highlighted and an introduction to NGOs in general will be offered, with emphasis on their characteristics in comparison to the public and private sectors.The Palestinian NGOs from a historical perspective will be examined, with focus on their roles, the challenges they faced, and their current status after the establishment of the PNA.

Health and Development
It has long been recognised that the health of individuals and groups is influenced by interaction with their environment (Bracht et al., 1990).It is increasingly recognised that behaviour and condition of life are important determinants of health and illness (Bracht et al., 1990).Accumulated evidence suggests that there is a mutually influencing relationship between health and development.The health status of the labour force is an important determinant of the economic potential of a country (Cornia et al., 1987).Several studies have suggested that poor levels of health are associated with poor worker productivity (Cornia et al., 1987).Life expectancy is relatively shorter in underdeveloped communities, and morbidity and mortality are higher compared to more affluent communities.
Global solidarity and concern grew during the twentieth century, as well as the belief that every world citizen has the right to a minimal, basic level of health and well-being.Over the years this has been expressed in several international agreements such as the Alma Ata Declaration "Health for All by the Year 2000" (World Health Organisation & UNICEF, 1978) and the Declaration of Rights of the Child (United Nations, 1959).An increasing amount of international action is allocated to health enhancement in developing countries.Parties involved in this area include local governments, international agencies like the World Health Organisation (WHO), and increasingly, national and local NGOs.In recent years, national and local NGOs have grown significantly in number and influence (Ball and Dunn, 1996).Prominent reasons for the expanding role of national and local NGOs are the failing collaboration between international agencies and local governments, and the increased emphasis on community organisation and empowerment as strategies for health promotion and social development.The NGO explosion of recent years can in part also be seen as a response to regionalisation and globalisation.According to Ball and Dunn, "Between the global trends towards powerful institutions and individualism, NGOs thus represent a third force, for collectivism…NGOs are an expression of the people's belief that through their own initiative they can better fulfil their potential by working together, and in so doing reduce the opportunity gap which exists between the advantaged and disadvantaged in society" (Ball & Dunn, 1996, p. 9).

Non-governmental Organisations (NGOs): An Overview
NGOs, in general terms, are defined as private, voluntary agencies which fund, implement or actively support development assistance programmes (Frantz, 1987).NGOs emerge when a group of people organise themselves into a social unit that is established with the explicit objective of achieving certain ends, and formulate rules to govern the relations among the members of organisation and the duties of such members (Ball & Dunn, 1996).
It is becoming more widely recognised that NGOs constitute a large and growing sector, not only in developing countries, but also in more industrialised and developed ones (Sheldon, 1987).Needless to say, although the specific focus of NGOs differs among countries, their fundamental role of championing the disadvantaged and marginalised segments of the population is common to all NGOs.It is the ubiquitous, complex, and multi-faced nature of NGOs that makes it difficult to give them a precise or unified definition.This is particularly true in the light of the instrumental role that NGOs have played at the grass-roots, local, regional, national, and international levels.The World Bank, for example, defines an NGO as "any group or institution that is independent from government, and that has humanitarian or co-operative rather than commercial objectives" (World Bank, 1996, p. 4).Accordingly, there are two main criteria for classifying an organisation as an NGO.The first is independence from government; otherwise it is no longer an NGO but a public organisation.Second, the entity must not be commercially based and, hence, it cannot operate for the sole purpose of making profit.
NGOs are also different in terms of objectives, which differ according to each group's conception of development.Some NGOs direct their action towards clearly defined problems of society, while others act with much broader agendas.Some have objectives which are more charitable, while others shape their efforts in a more political fashion, working with other groups in the pursuit of a common goal (Clark, 1995).
The international structure of NGOs also varies; some NGOs are complex and hierarchical and others are simple and informal.Some have salaried staff while others only exist because of their members' militant devotion to a cause (World Bank, 1996).
In seeking a definition of these NGOs, Uphoff (1993) classified NGOs as elements of the "third sector" as distinct from the first or "public" sector which is governed by bureaucratic regulations and binding policies, and from the second or "private" sector, which is regulated by market mechanisms and the desire to maximise profit.The "grassroots" or third sector, in comparison, typically relies on volunteer services and community efforts associated with the desire to make social changes.

History of the Non-Governmental Organisation Sector in Palestine
Throughout the years of the Mandate, Jordanian rule over the West Bank and the Israeli Occupation, Palestinians were governed by others.These regimes and occupying powers had their own agenda, and served interests other than those of Palestinians.(Palestinian Human Rights Information Centre, 1997).
In this period the only representative system for Palestinians was through the NGOs.It was the sole outlet for Palestinians to express themselves and serve their own needs.This was a matter of preservation of national identity, especially during the Israeli occupation.NGOs provided services for the most marginalised groups and provided essential services that the Israelis failed to make available to the Palestinians (PASSIA, 1998).
Starting early in the twentieth century, a number of charitable and relief organisations were established on a family, tribal, or religious basis to provide services to marginalised groups in the various locations within Palestinian society (Claudet, 1996).Successive rulers over Palestine, including the Ottomans, British, Jordanians, Egyptians and Israelis, played a limited and often destructive role in the provision of social services and investment in human capital in Palestine.It is under these regimes that the civil society organisations, including NGOs, the private sector, the media, professional and labour unions, were mobilised to fill parts of the gap resulting from such systematic destructive practices of civil society (Nakhleh, 1990;Sullivan, 1996).These organisations were particularly active during the 1948 Israeli-Arab war and the post-war era to provide assistance to oppressed and displaced Palestinians (Nakhleh, 1990).
In essence, the absence of an official Palestinian government in the WBG that necessitated, and in many cases facilitated, the establishment of NGOs to fill the void and provide basic community services to rural and needy urban areas and refugee camps (Samara, 1990;Abdulhadi, 1996).Retrospectively, one can identify at least two major roles that Palestinian NGOs (PNGOs) played during the Israeli occupation period.They contributed to resisting Israeli occupation, and also provided support to Palestinian society to alleviate the impact of occupation (Abdulhadi, 1996).
The Israeli policy towards the Palestinian Territories was to limit its social and political development and to maintain dependence on the Israeli economy.Part of that policy was the limitation, restriction and control of the Palestinian NGOs.The Israeli authority followed several procedures that allowed it to control the activities of the NGOs; the approval of elected boards, the control of registration of new NGOs; and control of the funding for these NGOs (Palestinian Network for NGOs, Newsletter, 1996).In the case of international bodies who offer funds to the local NGOs, such as UNDP, the Israelis controlled the projects to be funded (Palestinian NGOs Network, 1995c).
The Israeli authorities approved no more than half of the economic development projects submitted by these agencies.As a result, co-ordinating committees were established by international third sector organisations working in the Occupied Territories such as the Association of International Development Agencies (AIDA) and the Network of European Non-Governmental Organisations in the Occupied Territories (NENGOOT).The main role of these networks was to co-ordinate development efforts, which increased during the uprising, Intifada, (Palestinian NGOs Network, 1995c).Despite these limitations, during the long years of the occupation, it was the NGO sector that provided services to the Palestinian communities, mainly in health, education, and agriculture.The NGOs were the only institutions that were able to function successfully during a time where a national authority did not exist.They accumulated long and valuable detailed experience during those years (PASSIA, 1997).
Palestinian NGOs' experience is recognised as one of the richest world-wide with regards to the ability of these organisations to preserve the Palestinian social system and to provide services that government did not provide (Sullivan, 1996;Brynen, 1996).This was particularly true during the Israeli occupation period.It is worth nothing that the richness of NGOs' experiences is closely related to the types of challenges and adverse conditions that these NGOs had to endure during the Israeli occupation period, especially during the Intifada, with all the uncertainties arising during that period.That the instability that Palestinian NGOs faced during the Intifada included a whole set of political, financial, legal, and internal factors.Their activities were distinguished by a high level of community involvement due to the political nature of these programmes.Palestinian local initiatives led to the formation of organised structures in the form of charitable societies, co-operatives, professional associations, youth clubs, women's groups, unions, syndicates and popular movements and committees, which played a vital role in the resistance during the Intifada.
To assist them in their role as the de facto body responsible for all development-related activities, PNGOs received substantial financial support from local charities, the Palestinian Liberation Organisation (PLO), Arab governments and NGOs, as well as foreign donor states and NGOs (Nakhleh, 1990).This financial and moral support was political in nature.But the local NGOs were alone working on the ground, and they were directly involved in allocating resources and delivering the services (Bird & Lister, 1997).
The NGOs in the WBG were among the most affected by externally-oriented planning process, due to their great dependence on external sources of funding, which limited the NGOs' role in this process very significantly (Hamami, 1998;Samara, 1998).

Palestinian NGOs under the Palestinian Authority
Since the Oslo accord in 1993, the Palestinian arena has witnessed major changes that have left their mark on all aspects of Palestinian society.The NGO sector is not an exception in this sense (Hamami, 1998).
Before the Oslo agreement and the emergence of the Palestinian Authority, the NGO sector was tied with the PLO political factions, particularly in the case of the grassroots organisations which represented an extension of the communist party.Funding was mainly secured from the Palestinian National Fund which used to get donations from Arab governments and levies of 5% of the Palestinian wages in the Gulf countries (Jarbawi, 1995).
Due to the several Israeli restrictions on community and development activities and censorship of NGOs and the public, the personal and political agendas of NGOs were frequently masked by the need for security.The need for transparency was ignored on the pretext of security (Abu Sitta, 1998).
The transfer of some power to authority institutions has been followed by attempts to control and regulate the NGOs through registration procedures and by delegating discretionary authority to government employees to control and even close down NGOs (Al-Barghouthi & Lennock, 1997).This was in the absence of a clear distribution of responsibilities between NGOs and the PNA.PNA ministries' relationship with NGOs depended on the people in charge rather than clear policies (Al-Barghouthi & Lennock, 1997).
NGOs have taken two initiatives to work towards a coordinated strategy.The first was an NGO coordinating committee for the annual UN conferences on the question of Palestine in 1995.This was a purely political body, to which the political parties appointed their representatives.The second initiative was a network started by a group of NGOs dominated mainly by the political left and by non-Fateh NGOs (Palestinian NGOs Network, 1996).

Classification of the Non-Governmental Organisations in Palestine
As discussed earlier, the term NGOs is broad and encompasses a whole set of institutions, associations and organisations that constitute the so-called third sector (Uphoff, 1993).The Palestinian definition, however, is slightly different from the typical international one.During the Israeli occupation, the term NGO was given to every organisation or institution that was not controlled by the Israeli occupation and did not seek to make profit while fulfilling one or more of its roles.Many of these organisations were not officially registered, due to the "secretive" nature of many of these NGOs during the Israeli occupation, which meant that the real number of existing organisations was higher than the official number (Hamami, 1998).
With the establishment of the PNA, however, this definition started to be changed.From its earliest days, the nascent PNA tried to contain or at least regulate the NGO sector operating under its authority.Thus, while Fatah-affiliated NGOs were completely absorbed by the PNA structure, the leftist secular and religious-oriented NGOs, which are mainly affiliated with the opposition, have taken an opposite path.Many of these "opposition" NGOs tried to remain independent from the potential domination of the PNA.Consequently, tension between the PNA and many of these NGOs has escalated to the extent that both sides have exchanged accusations of misuse of public funds and abuse of power (Al-Barghouthi & Lennock, 1997).
Palestinian NGOs may be divided into three main types of organisations, based on Korten's typology namely (1) welfare NGOs, which represent the oldest and simplest type of organisations and are typically apolitical in nature; (2) development NGOs, which represent the second generation of Palestinian NGOs that started to appear in the late 1970s with the intention of building the nucleus of the Palestinian institutions while reversing the "de-development" efforts of the Israeli authority in the WBG and lastly ; (3) empowerment organisations, which emerged after the establishment of the PNA in 1994 in order to build the foundation for a democratic government in PNA-controlled areas (Korten, 1987b).In the following subsections, more details will be given to define these types of NGOs.

Welfare Organisations
Welfare organisations are the oldest and most established type of NGOs in Palestine.Historically, welfare and charitable organisations were established in response to unmet basic needs at the community level.Traditionally, such organisations were largely supported by wealthy families, as well as by internationally based religious organisations, to further their own interests (Korten, 1987b).In the Palestinian context, welfare organisations can be defined as those NGOs for which the ultimate purpose is to help poor and marginalised individuals at the grassroots level.Welfare organisations do not interfere, in or aim at alleviating any of the causes of poverty.Instead, their efforts are focused on providing basic food items and services to meet the needs of poor people.Another distinguishing feature of welfare NGOs is that their scale of operation is typically small and often does not exceed the municipal or village council level (Hilal, 1995).
Welfare organisations continued their work during the Jordanian and Egyptian rule over the West Bank andthe Gaza Strip, respectively, between 1948 and1967.During that time, no significant changes in the size or importance of these organisations took place.The turning point for Palestinian welfare organisations was the Israeli occupation of the West Bank and Gaza Strip in 1967.During the early years of the occupation, the Israeli authorities focused on tightening their control over the newly occupied areas and setting the stage for containing the territories politically, economically, and even socially, whenever possible.Thus, they did not put much effort into countering charitable and politically non-threatening initiatives by welfare NGOs (Hilal & Al-Malki, 1998).
Furthermore, because of the perceived apolitical nature of the welfare organisations, especially in comparison with the more nationalist groups under the patronage of the PLO, the Israeli authorities felt less threatened by welfare organisations.The Israeli authorities wanted to give the impression that they were targeting only radical and "terrorist" organisations and that if an organisation did not interfere in politics and focused on delivery of basic services, it would not be touched.In addition, with the establishment of the PNA in 1994, charitable organisations, unlike other types of NGOs, continued to operate as normal with no noticeable problems, due to their perceived welfare-orientation and apolitical, non-threatening nature (Hilal, 1995).
The Community Rehabilitation Centre for Children (CRCDC) is an example of a welfare organisation.CRCDC was established in 1991 by a group of community activists in Jabalia refugee camp in the Gaza Strip.It is dedicated to providing specialised services and enhancing the acceptance of disabled children in the society through a rehabilitation and community education and awareness programme (PHC, 1995).

Development Organisations
Development organisations in Palestine are relatively new with the majority established in the last twenty years (Claudet, 1996;Abdulhadi, 1996).The establishment of these organisations was a response to systematic Israeli policies and practices aimed at "de-developing" Palestine and eventually making it an integral part of the Israeli economic structure (Roy, 1995) The Union of Health Work Committees (UHWC) is a good example of a Palestinian development organisation in the health sector.UHWC was established in 1984 by a team of medical paramedical volunteers who started working in outreach clinics, camps and villages under the slogan "the health service is a right for whoever needs it".UHWC focused its work on helping the marginalized groups in the society, not only by providing them with needed services, but also by working with their constituency to develop their skills to become more active citizens (Al-Barghouthi, 1993b).
To understand the nature of the functions of these organisations, we should first briefly examine the "de-development" process that sparked their establishment.Israeli plans for de-developing the West Bank and Gaza were based on three interrelated strategies-(1) expropriation and dispossession, (2) integration and externalisation, and (3) de-institutionalisation (Roy, 1994).
Expropriation and dispossession aimed at destroying the potential comparative advantage of the West Bank and Gaza through the expropriation of large areas of strategically located parcels of land throughout the WBG under various excuses and pretexts.For a traditionally rural society that relied heavily on agriculture, the negative impacts of these Israeli policies were severe.These conditions deteriorated with Israeli blocking of direct export of Palestinian agricultural products to outside markets, as well as obstacles place d in the way of Palestinian efforts to dig water wells on their lands (Ma'an Development Centre, 2003).
The second approach that Israel utilised to de-develop the Palestinian economy focused on increasing Palestinian dependency on Israel through integration and externalisation.Furthermore, Israeli policies supported the integration of the Palestinian economy and its large, youthful, unskilled labour force into the Israeli economy by opening Israel's doors and paying high daily wages to unskilled and semi-skilled Palestinian workers in Israeli factories, farms and the then booming construction industry (Feiler, 1993).
Moreover, integration and externalisation were eased by de-linking the Palestinian areas from each other and creating three separate Palestinian entities in Jerusalem, the West Bank and the Gaza Strip after outbreak of the Intifada in 1987.Consequently, it became extremely difficult for people, goods and services to move between these areas without prior permission from the Israeli authority (Latendresse, 1995).The forced physical separation between these three areas encouraged duplication of efforts, lack of co-ordination, and economic inefficiency (Coon, 1992).
As for the third part of the Israeli plans to de-develop the WBG, it was focused on de-institutionalisation of the Palestinian organisations.That is, Israel tried to destroy and prevent the establishment of institutions that could threaten or even challenge the legitimacy of Israeli occupations and control over the WBG.Israel restricted the establishment of new associations, as well as professional, labour and student unions, and certainly, professional and development-oriented NGOs, which were politically affiliated for most part (Birzeit University, 1997).

Empowerment Organisations
Empowerment, power sharing, lobbying, and advocacy were not well -developed concepts during the Israeli occupation.Understandably, the Israeli authorities that occupied the West Bank and Gaza were never considered by Palestinians in the WBG as their representative organisation or as a legitimate authority that they could lobby.On the contrary, the public's perception was that dealing with Israelis was national and moral treason.This was true for individuals and organisations alike.For most Palestinians, this was justifiable, given the great injustice and inequalities inflicted against the Palestinian people by the Israelis (Al- Barghouthi & Daibes, 1993).
The Israeli government never permitted the formation of democratic structures for Palestinians in West Bank and Gaza.On the contrary, the Israeli government and its occupation army tried to suppress and crush Palestinian attempts to exercise any democratic principles such as freedom of speech and assembly (Palestinian Human Rights Information Centre, 1994).
For these and other reasons, empowerment NGOs, as part of the democratic evolution of civil society, did not develop until the peace negotiations between Israel and the PLO started in Madrid in late 1991, and the Palestinian state started to materialise.
With the establishment of the PNA in 1994 and the subsequent elections for the President and the Legislative Council in 1996, a transitional form of national government was formed.To ensure transparency, good governance and pluralism, empowerment and advocacy NGOs were established (Bishara, 1999).The Women's Affairs Technical Committee (WATC) is an example of the empowerment NGOs.WATC was founded by a group of women activists to ensure greater participation of women in the decision-making process at the local and national levels of government within the PNA (Holt, 1996).
As a result, PNA has waged a crusade against these NGOs and has placed them under tight control.Two main reasons may have caused this; the first is that these NGOs are playing the role of marginalised political opposition, which is making the PNA's position weaker than it would have been otherwise.The second cause of tension between the PNA and the PNGOs is financial, as the NGOs are receiving foreign funding for their activities.

Health Organisations: Actors and Contributors
Planning in Palestine has traditionally been a complex process, typically undertaken by outsiders, and health planning is no exception (Bird & Lister, 1997).To illustrate this complexity, after the Israeli occupation of the WBG in 1967, four main actors started to provide health services, with little if any co-ordination between them.In addition to Israeli government run hospitals and health centres, the United Nations Relief and Workers Agency (UNRWA), the private sector, and NGOs operated their own clinics and health centres (Al- Barghouthi & Giacaman, 1990).
Because each of the four health providers had its own agenda, competition and hostility among them were keen.Health planning was not co-ordinated for the benefits of the Palestinians.Instead, as in most other sectors, health services were used to promote the provider's own agenda and not the recipients' interests.Consequently, despite the apparent improvement in health condition since 1967, the level of improvement was not as high as it could have been if planning efforts were co-ordinated.This was one reason why a World Bank report emphasised that "the root causes of these problems are to be found in a lack of coherent policy and an absence of sector planning" (World Bank, 1993, p. 32).
Unfortunately, due to the existing political circumstances, lack of co-ordination, and unproductive competition, duplication of resources and activities continued even after the establishment of the Ministry of Health of the PNA, which was tasked with providing these services (Al-Barghouthi & Lennock, 1997).Given the obstacles faced by the NGO health sector, however, one should be impressed with the overall primary level health conditions in WBG, which compare favourably with other countries in the region, perhaps with the exception of Israel, which enjoys remarkable health care (UNDP, 1997;World Bank, 1998).In the following sections, a brief introduction to the main four health providers will be presented, with emphasis on the overall contribution of each provider.When Israel took control over the Palestinian public health sector in 1967, the Israeli authorities placed health care under the Israeli's Civil Administration.Health care was run by a coordinator at the Israeli Ministry of Health and by the Ministry of Defence.Prior to the Israeli occupation of the West Bank and the Gaza Strip in 1967, the share in health provision by the public health sector constituted 75 percent.The decline of the public sector is the result of Israeli's policy of 'de-institutionalisation'. Israeli authorities spared no effort to exploit their military power to enforce their control over the Palestinians, their resources, and their development, as discussed in the previous sections (Al-Barghouthi & Giacaman, 1990).
All public offices and institutions were run by Israeli officials, either from the military or from the civil administration departments, which were in charge of the day-to-day operation of the West Bank and Gaza (Coon, 1992;Roy, 1994).
The Israeli administration neither expanded the public health sector under its control nor did it encourage the development of a Palestinian health sector.Thus the number of hospitals was not increased in accordance to the natural population growth.While new clinics were established by the Israeli government, the number of hospital beds remained unchanged, although the population had more than doubled since the beginning of the occupation (Al-Barghouthi & Lennock, 1997).At the same time the development of the Palestinian health sector was discouraged.The main mechanism employed by the Israeli authorities was denying licenses for the establishment of health institutions or imposing high taxes on them (Al-Barghouthi & Giacman, 1990).
The Israeli authorities also restricted access of Palestinians to public health care by introducing a government health insurance scheme.As a result only insured Palestinians could benefit free of charge from government health services (Al-Barghouthi & Lennock, 1997).
Health policy in the Occupied Territories remained Israel's responsibility.Although the majority of the employees in the public health sector in the Occupied Territories were Palestinians decision-making was confined to a small number of Israeli army officers responsible for public health (USAID, 1993).
The result of Israel's attempt to keep the health sector underdeveloped is reflected in the health indicators.These indicators are especially reflected in the high infant mortality rate (Heiberg & Ovensen, 1994).The high levels of expenditure on health compared to the low outcomes point to a distortion or imbalance in the health sector.These are predominantly related to the effects of the Israeli occupation on the social, economic and political development in the Occupied Territories but also to the inefficiency in health care delivery (Lennock, 1998).

Public Health Sector under Palestinian Rule
When the PA took over the public health sector in May 1994, it inherited a health care system that suffered from weaknesses in both structural and infrastructural underdevelopment.Furthermore, the health care system was fragmented and health care was provided by four different health care providers, the UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), the private sector, the non-governmental sector and the government sector, previously controlled by Israel, without, however coordinating their services.Plans to reform the health care system were initiated in the early 1990s (World Development Report, 1993quoted in Hecht & Musgrove, 1993).
The vision on reform of the health sector reform is reflected in the National Health Plan and the Internal Action Plan.Both were developed by the Palestinian Red Crescent Society (PRCS).
Criticism of the plans by health committees has centred around several issues.It has been claimed that the plans fail to design an overall strategy for the rehabilitation of the health-care system (PHC, 1995).The plans have also been criticised for emphasising the rehabilitation of infrastructure without paying sufficient attention to structural problems such as the absence of protocols and standards and the coordination between different health providers (PHC, 1995).Furthermore, the plans' rationale that secondary and tertiary health care form the foundation for a comprehensive primary care system has been challenged (Palestinian Health Council, 1995;Schnitzer & Roy, 1994;Daibes & Al-Barghouthi, 1996).Moreover, studies on the rehabilitation of health care systems in post-conflict situations have indicated the risk associated with strategies focusing on infrastructural development without considering long-term development objectives (Macrae et al., 1996).
The establishment of the PNA in 1994 brought about some, albeit modest, improvement as far as the government contribution to health is concerned.The main increase in the government's health contribution came through additional donor support for building new hospitals and clinics on the one hand, and transferring the ownership of the many clinics and hospitals from NGOs to the Ministry of Health due to the complete integration of these NGOs in the PNA system (Al-Barghouthi & Lennock, 1997).
But because of the lack of co-ordination and competition among the various PNA ministries and institutions, together with increasing reluctance of donors to pay for the operating expenses of these activities, many of the ministries, and especially the MOH began to face crises (Al-Bargouthi & Lennock, 1997).In addition, many of the NGOs recognised that donors were slowly starting to shift their funds to the PNA and realised the importance of forging strong relations with the increasingly powerful PNA (World Bank, 1996).

United Nations Relief and Work Agency (UNRWA)
UNRWA was established in 1949 to provide relief and social services, basic education and health care to Palestinians who were displaced as a result of the 1948 war.Its ultimate purpose was to improve living conditions of Palestinian refugees in and outside the West Bank and Gaza, particularly in Jordan, Lebanon and Syria, until a permanent solution is achieved to the Palestinian refugee problem.UNRWA provides basic health services without charge to almost one million refugees in the West Bank and Gaza through a single hospital and through contracts with governmental, and privately -owned and run hospitals (Al-Barghouthi & Lennock, 1997).
Unlike other health providers in the private-and NGO-sectors, however, UNRWA has established a formal working relationship with all health providers, including these in the public sector, which was run by the Israeli until 1994 (State of Israel, 1994).Moreover, UNRWA has co-ordinated its efforts with other donors, not only in the health sector, but also in the education and welfare sectors.UNRWA's network of offices and its large staff in the West Bank and Gaza have given it a comparative advantage over other health providers.Based on this, UNRWA has become a natural co-ordinating body for many donors with no offices on the ground, as well as for other donors who did not want to be identified due to the sensitive nature of assistance.

Private-, For-Profit-Sector
Private health care providers in the WBG remain under-developed compared to their counterparts in the region.By and large, Al-Barghouthi (1993a) argued that Israeli policies were the main causes of such under-development in the private health sector.Other reasons for the under-development of this sector were the availability of cheaper primary health-care alternatives offered by NGOs and by UNRWA for registered refugees.Furthermore, as the economic conditions in the WBG started to worsen in real terms during the Israeli occupation period, fewer people were able to afford private health services.Consequently, demand for more expensive health-care decreased, which made it even more difficult for private health providers to continue operation without major financial losses (Clark & Balaj, 1996;Claudet, 1996).
In addition, because private health providers were, for the most part, small clinics, they could not benefit from the economy-of-scale, or agglomeration, which a larger and planned system would enjoy (Al-Barghouthi & Daibes, 1993).This situation started to change gradually in 1994, however, as more specialised health centres started to open, and as existing ones expanded into various areas of the WBG.At least two interrelated factors contributed to the sudden expansion of private health-care providers in Palestine after 1994.The first factor is the sizeable need for high quality specialised, secondary, and tertiary medical treatment in certain areas of Palestine, which was not adequately met by the public, UNRWA or NGO sectors.The second factor is the PNA's efforts to reduce dependency on Israeli and other foreign health centres (Al-Barghouthi & Lennock, 1997).
Many health professionals left their jobs in the public and NGO sectors and joined private companies to obtain the highly competitive financial packages offered by the private sectors.Consequently, governmental and NGO sectors faced a real "brain drain" to the private sector, which left the public sector professionally weaker than before.Ultimately, the poor and marginalised segments and regions were the biggest losers, because their access to high quality health care, which is increasingly monopolised by the private sector, is declining, especially in the light of deteriorating economic conditions in the area (Clark & Balaj, 1996).

Non-Governmental, Not-for-Profit Health Sector
In the past, the Israeli occupation and the fluctuation in donors' agendas were the main causes of instability facing the Palestinians and their institutions in the WBG.Until 1994, every person and every institution was forced to be on high alert and to be prepared for dealing with whatever action or policy might be taken by Israeli occupation forces to create new facts on the ground before final status negotiations began (Birzeit University, 1997).In addition, because foreign aid to Palestine has traditionally been politically rather than developmentally oriented, Palestinians had to pay close attention to donors' agenda and to remain able to deal with sudden and unpredictable changes in those agendas (Palestinian Authority, 1997).
Unlike health NGOs in the other parts of the world, PNGOs have had a busier and more complex agenda that could not be adequately realised solely by providing health services (Abdulhadi, 1996).In addition to providing desperately needed health services, PNGOs had to become involved in national struggles in their own ways.These factors contributed to the uniqueness of Palestinian NGOs (Claudet, 1996).

Major Challenges for Health Planning in Palestine
The challenges that face health NGOs include both external and internal forces.As explained below, these challenges are closely related to the unstable, uncertain and evolving political conditions in Palestine (Hamami, 1998).During full Israeli occupation of the WBG, many NGOs were not permitted to register due to alleged illegal political affiliations, thus forcing many to operate without a licence or registration (Mohana, 1996).
In dealing with the PNA, which has little government experience, Palestinian health NGOs were forced to face additional challenges.The following sub-sections will examine three of the main challenges that faced NGOs, namely, political challenges, financial challenges and the unclear role of the PNA.The first two challenges faced NGOs during the Israeli occupation and continue to do so after the establishment of the PNA.The third challenge, by definition, became relevant only after the establishment of the PNA in parts of the WBG (Clark & Balaj, 1996).

Political Factors
More than three decades after the fact, it is becoming widely agreed that the Israeli occupation of the WBG in 1967 and the annexation of Jerusalem in 1980 were the most important factors that prevented the Palestinians from living normal lives and establishing their own civil society and public institutions.Israeli policies and military orders were especially tailored to legitimise and normalise the restrictions imposed on the Palestinian people and their nascent institutions.Non-governmental organisations were put in an awkward position (Craissati, 1997).This dilemma forced NGOs to be creative enough to circumvent all obstacles they faced, and to continue their quest to achieve their missions.In response to this pressure, most of the PNGOs were forced to operate underground, all the while taking on the risk of closure, torture, or jail and were forced to 'plan' as a way to deal with the surrounding challenges and to meet the unexpected (Al-Barghouthi, 1993b).
Although these challenges were relevant during Israeli occupation, a similar trend continues even after the establishment of the PNA in 1994, albeit to a lesser extent.Because most successful PNGOs were affiliated with leftist political parties, such as the Palestinian Communist Party (now known as the Palestinian People's Party), or with religious parties such as the Islamic Resistance Movement (known as Hamas), tension between these NGOs and the PNA grew significantly (Abu-Amr, 1997).
Two main reasons may be identified for the escalation of the tension between the PNA and the NGOs.The first reason is that the NGOs continued to play a political role that was not in harmony with the PNA's agenda (Claudet, 1996).The second reason for the tension is the competition among the NGOs themselves on the one hand, and between the NGO and the PNA on the other, over donors' assistance.Competition became particularly keen in light of the strong relationship that leaders of various NGO have forged with donors and the stronger capacities of NGOs to attract donors' assistance.A second area where donors could weaken ties among NGOs was in giving funds only to established NGOs or strong NGOs which further widened the gap between established NGOs and disadvantaged one (Sourani, 1996;Silsby, 1996).
Despite the fact that the signing of the Oslo accords allowed the Palestinian leadership to impose its authority on certain aspects of people's lives, the nature of the accords prevented any improvement in the economic or social conditions of Palestinian residents of the WBG.On the contrary, statistics show that there was a general decline in most economic and social indicators after 1992 (UNSCOT, 1998, p. 19).With the establishment of the PNA, most donors started to shift a large percentage of their funding from the traditional NGOs to PNA ministries and institutions.The changing situation forced many NGOs to close their operations or reduce their size to cope with the financial problems.
By mid-1997, the date of publication of the first report on PNA performance by the State Comptroller's Office, which made headlines worldwide, exposed substantial incompetence, mismanagement and misuse of funds by members of the PNA (Sayigh & Shikaki, 1999).As a result, many donors started to re-think their positions, and some began to re-channel funding to NGOs, at least for specific projects.Due to political pressure from the PNA and the donors' own interests in having a stable PNA, however, few such changes were made.Therefore, NGOs still suffer from these politically motivated factors, and more of them are closing operations.As an official of one donor agency said, "Only the strong, the slick and well-connected organisations will survive under such a competitive environment" (personal communication from a major grant donor, interview with author, Gaza).

Limitation of Funding and the Donors' Perspective
During the Israeli occupation of the West Bank and Gaza, assistance to Palestinians came from a variety of sources, including from local donations and fees, from the PLO, from Palestinian expatriates, from Arab governmental and non-governmental sources, from American and European sources mainly through foreign NGOs based in the respective countries, and, finally, multilateral agencies such as UNRWA and its subsidiary organisations.The peak years for PNGOs were during the years between 1990-1992, during which time they received from 170-240 million U.S. dollars per year.It has been estimated that 70-80 percent of the total funding was received by only 30-40 NGOs (Clark & Balaj, 1996).Although the Intifada did not directly influence the work of health NGOs, it had a positive impact on the environment surrounding the organisations and consequently on the organisation, as Arab funding sources were available even to smaller organisations.
The transfer of authority was accompanied by an increase in engagement of the international community and its support to the PNA since the peace process was possible only with the help of this community.The goal of large international donors both bilateral and multilateral, was to strengthen the PNA, so a large amounts of funding were pledged to support it.Some of these donors, such as the European Union, in the past channelled support to the Palestinians through NGOs because they had networks and links in their communities.The transfer of authority meant a shift in funding from NGOs to the PNA was thought to be the appropriate structure for carrying out the vital services for the Palestinian population (Abu-Sitta, 1998).
As discussed earlier, assistance to PNGOs suffered a sharp decline after 1994 because most assistance was channelled to the PNA and its institutions.It is for this reason that a World Bank report examined the 'financial crisis' faced by PNGOs and decided to establish an NGO trust fund to support PNGOs in overcoming the crisis (Claudet, 1996).Another way of dealing with this crisis came from the PNGOs themselves, as many of them started to establish profit making operations within their organisations to cover part of their costs and potentially to reduce dependency on external sources of funding over the long term (Al-Barghouthi & Lennock, 1997).
In spite of the important role played by these NGOs, it is worth noting that most assistance was political in nature, and it is only in the last decade that developmental thinking started to influence PNGOs' actions.For example, before the Iraqi invasion of Kuwait in 1991, Kuwait was one of the largest sources of assistance to Palestinians in the West Bank and Gaza.After the Iraqi invasion, Kuwait stopped its financial support of the Palestinians and immediately terminated work contracts with the vast majority of Palestinians working there (Al-Barghouthi & Gene, 1997).
As the Palestinian Ministry of Health becomes stronger and more structured, it is able to start new activities to cover most needs.In addition to, and perhaps because of, shifting financial resources from NGOs to the PNA, NGOs are increasingly forced to lay off workers and to close certain branches.This has created a high staff turnover at these NGOs, due to their inability to pay salaries for their staff and overall uncertainty of their future (Palestine, Ministry of Health, 1998).In addition, another requirement of NGOs by the PNA was to acknowledge the right of the PNA to monitor their income.

Ambiguity of the Palestinian Authority's Vision
Since its establishment in 1994, the nascent PNA has had to deal with a whole set of fundamental and challenging issues that have direct impacts on Palestinian's present and future.The PNA has undertaken a lengthy and pains taking negotiation process with the Israelis on issues ranging from withdrawal of Israeli soldiers from certain areas to determining the exact type of beans that Palestinians are permitted to export.In addition, the PNA, as the acting government in the WBG, has had to establish a police force to ensure the safety and security of its citizens and to address the PNA's security commitments with the Israelis.Furthermore, the PNA has had to deal with a deteriorating services infrastructure and attempt to improve it in preparation for Palestinian statehood in the near future (Bird & Lister, 1997).
The experience of the PNA, combined with the politically motivated growth of work force in the PNA-created public sector, have all contributed to the lack of focus and to the narrowness of the PNA's vision.It has become hard, if not impossible, for anyone, including well-connected leaders, to anticipate the PNA's position in any matter of interest (Sayigh & Shikaki, 1999).
In addition, the absence of a legal framework to govern and regulate the NGO sector has made it more difficult for these NGOs to operate and plan.Under these ambiguous circumstances, many NGOs have had to work without licences, as they did during the Israeli occupation, and to reduce or even close down their operations completely (Al-Barghouthi & Lennock, 1997).
Several officials highlighted the importance of legal codes for the regulating the relationship between NGOs and the PNA.Given the current social and political circumstances, it is unknown, if and when these circumstances will change.

Summary
This paper has presented information on the role of health NGOs, in general and in Palestine in particular.
Health is widely recognised to be related to development and, for this reason, NGOs are increasingly stepping in to fill gaps in government provision, as well as to empower local communities.NGOs have varying affiliations and objectives, but they have in common an independence from government, and a non-profit orientation.With their advantages of practical, relevant grassroots experience and greater flexibility than governments, they play a valuable role which attracts a large proportion of international aid and, increasingly, they are seen by governments as cooperative partners in service provision.
In Palestine, NGOs are an important focus of local representation, in a context where most social service provision has been governed by the agendas and interests of successive occupying powers.Nevertheless, they are constrained by the political and legal environment.They receive financial and moral support from a variety of sources, local, regional and international, but this often has political strings attached.They also have a limited role in playing because of their political affiliations.This situation has extended into the recent period under the PNA, who first saw the NGOs as competitors and tried to regulate and control them, although policies have often been unclear or inconsistently applied.Empowerment-oriented NGOs, in particular, have had a difficult relationship with the authority.
Health care provision in Palestine has been seriously disrupted by the occupation, both by policies linking the NGOs scope of action, and by the destruction of infrastructure.The PNA, in the areas where it assumed control, inherited a weak public health system.Its response was to focus on infrastructure rehabilitation; however, primary health care was comparatively neglected, and serious distortions remain in service provision, for example, in the disparity between urban and rural areas.Moreover, the public health sector was left with the less successful and experienced doctors, when their more successful counterparts opened private clinics.In this context, a major role of the NGOs has been to fill unmet needs in the health sector, for example, providing services for marginalised population groups and regions.Other roles include implementing the political agenda of the PNA and the affiliated bodies, and establishing the foundation for Palestinian statehood by building basic health infrastructure and preparing a cadre of professionals.
Palestinian health NGOs have faced a variety of challenges: political pressure from Israel, the PNA, and donor countries and organisations; financial, due to heavy reliance on fluctuating outside aid; and organisational, related to the ambiguity of the PNA's vision and the changing priorities of influential bodies, making organisational objectives difficult to establish and sustain.

7. 1
Public Health Sector Care 7.1.1Public Health Sector under Israeli Occupation Before the Israeli occupation in 1967, health care in the West Bank and the Gaza Strip was provided by the UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), the private sector, charitable organisations and the government health sector, i.e. the Egyptian government the Gaza Strip and the Jordanian one in the West Bank (Al-Barghouthi & Giacaman, 1990).