As Israel blocks PA funding, the West Bank’s healthcare system is failing

Beit Jala, occupied West Bank – Khaldoun Atwan starts each day in the oncology ward at Beit Jala Government Hospital, not knowing what barriers will come his way.

The Nabi Yunis checkpoint in Halhul seems to be “always closed”, so the head of the daytime oncology unit at the hospital leaves his car and finishes the commute from Hebron by taxi.

“More than once, by God, I found the mirror broken. I found the wiper broken,” he said about his journey through an area where settlers are now active.

Traversing a dizzying array of gates and checkpoints opening or closing at will, he does not know whether he will reach the hospital, whether his patients will, or whether the drugs they need will be on the shelf when they do.

Beit Jala is the only government hospital in Bethlehem governorate, home to some 320,000 people. Inside his tiny, spartan office, Atwan is struggling to keep up with his cancer patients who have regressed because they missed crucial appointments or essential drugs needed for their chemotherapy treatment.

Not even during the second Intifada, he recalls, was drug supply an issue. Now, it’s inescapable.

“Everything’s short … whatever’s available we give,” he said. “It’s a disaster.”

The Palestinian Authority (PA)’s finances have collapsed over the last three years due to a reduction in international aid and disruptions in Israel’s transfers of tax receipts. Israel’s actions in the occupied West Bank since October 2023, including widespread road closures, checkpoints and a series of settler pogroms against Palestinian communities, have also impacted the economy.

As a result, the occupied West Bank’s healthcare system is rapidly deteriorating, with staff receiving just half their salaries, while the PA can’t pay for essential medications.

‘Emergency cases only’

Alongside others nervously pacing in the courtyard, an older cancer patient from a village in Bethlehem governorate stood at the entrance of the hospital, weighing with his son what to do. “Every month they do their best, the doctors and the cleaning staff, but they aren’t provided with anything,” he said.

Ministry clinics are now operating part-time, with doctors seeing well more than 100 patients a day when they are. Now, even a doctor’s visit is rushed and unaffordable: “If we want to go to the doctor for a checkup, we need 200 shekels [$65],” said an older cancer patient.

“It’s not a story of there being no staff,” said Iyad Dari, the attending physician at the dialysis unit at Beit Jala. Getting paid only half their salaries, “the government employee is working just two or three days a week, because he hasn’t got enough to come in for his full hours,” he added. As a result, the hospital ends up covering emergency cases only.

“At first, [patients] were [angry]. But now everyone understands: Everyone’s suffering,” Dari said.

The medical supplies crisis in Beit Jala and across the West Bank is the result of Israel’s withholding of tax revenues earmarked for the PA, an action spearheaded by Israeli Finance Minister Bezalel Smotrich.

“This crisis is very predictable, and we saw it coming 100 percent,” said Milena Ansari of Physicians for Human Rights Israel. Even before the genocidal war on Gaza began in October 2023, Israel was periodically withholding tax revenues, endangering the Ministry of Health’s coffers, Milena said.

According to Yosef Ojra, an internal medicine specialist at Beit Jala, the withheld revenues have depleted the Health Ministry’s funds to pay medical suppliers, who are now withholding their services. The ongoing borrowing of supplies between the public and private arms of healthcare has greatly strained private clinics, pharmacies and hospitals.

Hisham Amle, an oncologist at the hospital, said shortages are “an old problem, not a new one”, but that about 90 percent of important items – for chemotherapy, above all – used to be there. Now, even immunotherapies and biologics are missing, and cancer treatment runs on an unbroken chain. “If the patient misses a session or two, he’s lost all the treatment before it,” he said.

“When I first took over the department, the drugs were available,” said Atwan, the lead oncology nurse. He then began to list all the crucial drugs he was now missing for his patients. “There’s not one single complete protocol I’ve got.”

Khuloud Dweib, the hospital’s director of pharmacy, said the ministry recently managed to obtain eight previously missing oncology drugs and four biologics. This should be enough for between a month and a half and two months. But many other drugs are still out of stock, she said.

Unlike in Gaza, Israel is not blocking medicines from entering the West Bank, Ansari noted. The problem is “strictly” that the PA has no money to buy them. But “Israel has the primary legal obligation as an occupying power,” she notes, to ensure adequate medical care and access to occupied populations.

Denied movement, denied care

For all of the southern West Bank, Beit Jala’s hospital is the only public option available for cancer and dialysis treatment, with patients coming from Bethlehem and Hebron governorates, parts of occupied East Jerusalem and sometimes Jericho.

But as Israeli checkpoints and gates multiply, reaching the hospital has become a nightmare. Dari described a dialysis patient from Nahalin, with an appointment at seven or eight in the morning, whose village was sealed. “He sat about four, five hours at the checkpoint,” Dari said. Then he took the long way round, through Jaba, Surif, Halhul and Hebron, and reached the unit at four in the afternoon. A normal journey costs about 10 shekels. “A detour like this costs more than 100 shekels,” Dari said, and some patients need dialysis four times a week.

The ministry’s central supply warehouse, meanwhile, is in Nablus, Dweib said – and an hour-and-a-half drive can now take six to 10 hours when closures hit.

Often, Atwan’s patients require treatments split between his unit and the Augusta Victoria Hospital in occupied East Jerusalem. Before the war, cancer patients from the West Bank routinely received medical permits to enter Jerusalem. Some treatments are in Beit Jala, while others are only available in East Jerusalem. But there are no guarantees any more that patients can reach Jerusalem. “I’ve got a cancer patient … He waited on a referral, and there’s no treatment, and after all the running around it comes back he’s security-rejected, too,” Atwan said. “I mean, he doesn’t get a permit to go to [Augusta Victoria]? Where’s he supposed to go?”

Atwan recalled patients who became neutropenic due to missed treatment sessions, and one was lucky not to end up with sepsis. “These are disasters.”

He’s not sure exactly how many cancer patients he’s lost due to missed and incomplete treatments; many of the poorer patients, he said, simply go home and die there.

‘I’ve started cutting back, not taking much’

As crowds swell at front desks and people wait at the hospital’s entrance, a nervous exhaustion percolates through the hospital’s aged halls. “People are really tense. Everyone’s scared,” Dari said.

Atwan, who receives half his salary, struggles to cover his commute from Hebron and help support his daughters at university.

“Let’s not talk about our state of mind – we’ll start crying, for God’s sake,” said Atwan. “Our morale is at rock bottom … We smile in spite of ourselves.”

Amid mass unemployment with labour permits systematically revoked, more sick Palestinians are pushed towards public hospitals just as those hospitals have less to give. Hospitals “will prioritise someone who will actually pay them”, Ansari added.

Ahmed, a Palestinian from Bethlehem with a medical degree, would check every couple of days with the pharmacist to see if they had Humira, an injection every two weeks that his sister with Crohn’s disease needs. For three months, the pharmacists were out of stock. Buying directly from the pharmaceutical company would cost about 2,000 shekels ($650) for one or two injections. “We couldn’t afford that,” he said. “So we just struggled until it became available again.”

The elderly cancer patient from a village facing settler pogroms has cut back on his own medication. “It’s not supplied regularly,” he said. A course of it costs 20,000 shekels ($6,500). “I’ve started cutting back, not taking much,” he added.

Amid supply and staffing shortages, surgery backlogs have piled up. Sayed Ayyad, 22, from al-Eizariya, fell during an accident, fracturing his ankle badly last month. With serious operations taking priority, he waited three weeks for a slot.

“They told me there’s 60 people waiting for an operation,” he said. “One day we couldn’t do the surgery because there were no medicines, no painkillers, no anaesthetic, nothing.”

Fates left to chance

Khuloud Dweib, who heads the pharmacy department at Beit Jala, has to manage the worsening crisis as patients struggle with their health and finances. “There’s no security. We don’t have political, or health, or even financial security,” she said.

She’s left thinking of cases like a young man with multiple sclerosis studying medicine in Egypt. The Health Ministry used to provide his medicine through private purchase until the company stopped supplying without payment. His mother came to see her. “I want to sell my house so I can get the injection for my son,” the mother told her. “Because he’s in Egypt, away from home, studying, and … he’s stopped seeing, stopped walking.”

“So, what can I tell you,” Dweib said, fighting back the tears. “God help people.”

The medical staff fear that with their supplies being hollowed out, they could face a similar fate to their colleagues in Gaza who have been kidnapped or killed.

“We know that at any moment we could be targeted as medical staff, just because we’re medical personnel providing services to people,” Dweib said. “We’re a father and a mother in this society.”

Nobody in the ageing hospital wards sees an end in sight. “The longer we stay, the worse the situation gets,” said Dari.

At three o’clock each afternoon, Atwan has to leave in the hope that he can reach Bab az-Zawiya in Hebron, where he waits for a shared taxi.

“Maybe there’ll be a checkpoint for me, maybe there won’t be,” he said. It’s not so different from the conundrums his patients face. “When a patient gets sick, it’s his luck if the medicine’s there,” he said. “We’ve got no future. I swear: We’ve got no future.”