Exercer la Médecine générale en Palestine : influence des contraintes en Territoires occupés

The occupation and fragmentation context of the Palestinian territory questions the health system organization, especially first line care. Does the geopolitical context is the source of specific and / or exercise changes? We studied the practice of general practitioners (GPs) in the West Bank by identifying external factors which influence this practice. A field survey (from 3 to 16 March and from 01 July until 31 August 2014) was based on a qualitative approach by conducting semi-structured interviews with GPs. Physicians had to have obtained the Bachelor Degree of Medicine Doctor to practice medicine in Palestine (no family medicine speciality is required). They had to work in primary health care and the four main health providers should be represented: Ministry of Health, UNRWA, NGOs and the private sector. Various health actors were also interviewed. Data analysis was based on the method described by MILES and HUBERMAN (2003). Palestinian GPs integrate the psychological and environmental factors of their patients. They provide joint missions: community-based and first line care, resolution of all undifferentiated health problems, prevention, health education. The occupation of the territory isolates populations and prevents any territorial continuity. The governorates are fragmented and the health care system cannot develop homogeneously on the territory since institutions can be implanted only in area A or B according to the Oslo Accords (urban hubs and their close suburbs). The geopolitical, economic and structural context of Palestine impacts their professional practice: physicians are isolated on the territory and in the health system. Health resources are difficult to access: they are not available in all governorates and the coordination between health providers is insufficient to promote community-based care. Limited in the use of common and complementary examinations and missing link with the secondary sector, primary care physicians answer with difficulty the health problems of Palestinians. The permanence and continuity of care are unpredictable as they depend on physicians and patients travelling facilities; often forced by the checkpoints regime and other obstruction means on Palestinian roads. The comings and goings of patients from one health care provider to another on the territory also complicate their aftercare in the long term and the care continuity. The instability of the situation, at the root of armed conflicts or altercations, also brings GPs to heal wounds "of war". Our study shows that the GPs practice is strongly constrained by the Palestinian geopolitical context and the health care access is inseparable from the territorial issue. Since 2014, family medicine is growing in Palestine with the support of WHO and other foreign institutions. A homogeneous discipline in primary care, would promote a fair access to quality health care for Palestinians. The development of the discipline should take into account the practice conditions of GPs in order to settle in primary care. The occupation of the territory, the instability of the situation and the absence of a Palestinian state are as many factors behind a specific practice of family medicine in this part of the world.