Saddled with seemingly insurmountable debt and lacking a long-term solution, Tawfiq Nasser doesn't mince words. "People will die," he said, solemnly, from his office at Augusta Victoria hospital in East Jerusalem.
"The bottom line is that people will not be able to access healthcare, especially the most disadvantaged: the poor, women, children, and people from Gaza," Nasser, CEO of Augusta Victoria hospital, and Director of the East Jerusalem hospital network (EJHN), said.
East Jerusalem hospitals are currently facing the most severe financial crisis in their history. As a result of unpaid debt accrued from the Palestinian Authority (PA), the six specialised healthcare centres that comprise the EJHN are currently operating with a financial shortfall of more than 57 million NIS ($14.9m).
Many hospitals are now considering cutting down on staff, or limiting the amount of patients they admit. Some are running out of medicines, while others haven't paid surgeons their full salaries in months. Most don't have the cash flow needed to purchase expensive equipment and tools.
"When the Palestinian Authority is in trouble, we have no means of sustenance. Of course, then it's the people who suffer," said Nasser, explaining that at Augusta Victoria hospital alone, the PA is behind on about 42 million NIS ($11m) in debt payments. "We could be looking at a complete collapse scenario."
The EJHN encompasses six separate healthcare institutions: Augusta Victoria hospital, St-John's eye hospital, St-Joseph's hospital, Princess Basma rehabilitation centre, Makassed Islamic charitable hospital, and the Palestine Red Crescent maternity hospital.
|Dr Abdeen says the Ministry of Health has come to agreements with some hospitals [Jillian Kestler-D’Amours/Al Jazeera]
These hospitals serve Palestinians from East Jerusalem while at the same time acting as referral hospitals for the Palestinian population of the West Bank and Gaza Strip. Since the hospitals provide specialised services - including chemotherapy, neurosurgery and urology, among others - they provide Palestinians with treatments that are unavailable elsewhere.
"There are limited services within the West Bank. They have an infrastructure but at the moment it's very, very small," said Rod Bull, Director of St-John's Eye Hospital in East Jerusalem.
Bull said the PA is currently indebted to St-John's by approximately 850,000 British Pounds ($1.4m). "Last year we treated 117,000 patients. If we pushed those [patients] back to the PA, there is no way in a million years would they ever cope with it. It's impossible," he said.
Since the late 1990s, the PA has referred patients to the six EJHN hospitals. According to PA Minister of Health Dr Hani Abdeen, the PA refers patients if government-run hospitals in the West Bank cannot meet the demand or cannot provide the best quality care.
"We have a number of hospitals in East Jerusalem that we are keen, as a matter of policy, to strengthen, to augment and to consolidate their operations," Dr Abdeen explained.
"We had really some financial difficulties in the PA, where we were not able to meet all our debts owed to the East Jerusalem hospitals. These debts accumulated over the months or years, and unfortunately, there was really this kind of gap where the Ministry was referring patients [while] not being able to cover their expenses in the interim," he said.
According to a statement released by the World Health Organisation (WHO), over 22,000 patients from the West Bank and Gaza Strip were referred to the East Jerusalem hospital network in 2011, accounting for more than half of the hospitals' total patients. The WHO also stated that 20 per cent of patients receiving care at East Jerusalem hospitals are without insurance or the necessary resources to pay for their own treatments.
Following Hamas's election victory in 2006, international donors stopped transferring funds to the Occupied Palestinian Territories, resulting in a similar difficult situation throughout the EJHN. Recently, however, the number of referrals from the West Bank and Gaza has been growing, necessitating a larger investment from the PA and further compounding the problem.
Dr Abdeen said that the Ministry of Health has come to agreements with some hospitals, including, for instance, a payment scheme whereby the Ministry will transfer 3 million NIS ($780,000) to Makassed hospital each month. The Ministry also aims to pay half of its total debt to the hospitals within the next two weeks, he said.
"We are not going to deny any of them the money that we owe them, of course, but they have to be a little bit more patient with us until we settle all these debts."
Reliance on donor aid
The PA's current financial crisis has impacted virtually all aspects of Palestinian life.
"It's very difficult for us to send back the patients of Gaza because it wasn't easy for them to leave from the beginning. So I'm stuck."
- Jamil Koussa, St-Joseph's Executive Director
In September, Palestinians took to the streets in major cities across the West Bank in protest of rising costs, especially for basic foods and diesel fuel, and high unemployment. The protesters' ire was largely directed at the PA government in Ramallah, and the restrictions placed upon the Palestinian economy by agreements signed with Israel.
Earlier this year, the PA announced it was facing a severe economic crisis and was unable to pay the salaries of many of its public sector employees. The PA government is now relying on donor aid to cover a budget deficit of over $1bn.
A report released by the World Bank on September 23 found that, in order to ease the current crisis, financial support from international donors must be maintained, and that the PA must raise local revenues and control expenditures.
In turn, Israel must ease restrictions placed on the Palestinian private sector, including access to water and land, and removing physical barriers. This step, the World Bank report stated, is "the only medium term solution to exit from protracted fiscal crisis."
According to Samia Al-Botmeh, an economist at Birzeit University, the PA and the international community have taken on the financial burden of Israel's colonial policies by relying on foreign donors.
"Israel actually shifted the burden of its occupation onto the shoulders of both the PA and the international community, with the international community shouldering a significant part of the cost of everyday life," she said.
Suha Al-Umri lay propped up on her left side, a crocheted blanket covering her legs, in a bed at East Jerusalem's St-Joseph's hospital earlier this month. From the northern Gaza town of Beit Lahia, the 27-year-old had been waiting for one week to be transferred to the nearby Augusta Victoria hospital.
|Koussa says St-Joseph's cannot afford essential medicines and supplies [Jillian Kestler-D'Amours - Al Jazeera]
There, she was expected to begin chemotherapy treatments for cancer in her leg and upper abdomen; she has already sought treatment at hospitals in Jordan, Egypt, Gaza and Israel.
"They want me to come home," Al-Umri said, muffling tears, about being separated from her husband, and two young children, aged eight and three, who stayed behind in Gaza. Only her mother, sitting at her bedside, was able to secure an exit permit to travel with her to Jerusalem.
Al-Umri isn't the only resident of Gaza who must seek medical care outside the Occupied Palestinian Territory. According to St-Joseph's Hospital Executive Director Jamil Koussa, almost 40 per cent of the hospital's patients come from the Gaza Strip.
Now saddled with a debt of approximately 7 million NIS ($1.8m), which the PA has yet been able to pay, Koussa said that St-Joseph's is experiencing a severe cash flow problem and is struggling to buy essential medicines and prosthesis' needed for specialised care and operations.
"I have patients from Gaza waiting for operations and I don't have prosthesis to do the operations," he said. "It's very difficult for us to send back the patients of Gaza because it wasn't easy for them to leave from the beginning. So I'm stuck. I don't know what to do with them."
According to Koussa, if the problem persists past October, the hospital might be forced to lay off up to 40 of its 140 staff members, and stop admitting patients from the West Bank and Gaza.
"Other than that, I close down the hospital," he said. "The only solution is that one of the donors will take the responsibility of settling the bill. That's the only solution."