A NAHḌA OF CHARITABLE ORGANIZATIONS? HEALTH SERVICE PROVISION AND THE POLITICS OF AID IN PALESTINE

Int. J. Middle East Stud. 40 (2008), 227–247. Printed in the United States of AmericaDOI: 10.1017/S0020743808080525

Benoıt Challand

A N A H D. A O F C H A R I TA B L E O R G A N I Z AT I O N S ?

H E A LT H S E RV I C E P R O V I S I O N A N D T H E

P O L I T I C S O F A I D I N PA L E S T I N E

Until recently, the topic of charitable organizations seemed to have fallen in disgrace.Social scientists have given little attention to this sector of associational life. Instead,a great deal has been written on the issues of democratization through pressure groupsor on the transformation of social movements into professional organizations whileassessing the overall impact of development promoted by donors. Yet three signs pointto the need for a better understanding of charitable organizations. First, new researchstudying Islamic activism through the lens of social-movement literature has offeredinnovative results.1 Second, studies on the impact of aid during the second intifadahave revealed that charitable organizations as well as Islamic organizations offereda significant amount of emergency support, sometimes competing with professionalnongovernmental organizations (NGOs).2 Finally, the fact that Hamas, also known forrunning a vast network of charitable organizations,3 achieved such a significant politicalsuccess in the 2005 municipal and 2006 legislative elections should invite social scientiststo consider whether and how political momentum can also be obtained through activismin the charitable sector.

This article argues that in the last years there has been a nahd. a, or reawakening, ofcharitable organizations, the origins and meanings of which need to be investigated. To doso, we hypothesize that the rebirth of the charitable sector is linked in part to a discoursethat is in opposition to the parlance advanced by large Western donors and relayedby professional NGOs. Such contrasting discourses reflect profound changes and riftswithin Palestinian social movements. In the past few years, conservative and religiousdiscourses have gained the upper hand at the expense of the mobilization historicallyproposed by the secular left, whose leadership of late has been pushed to the marginsof Palestinian politics.4 This article discusses the modalities through which charitableorganizations and socioreligious movements in the occupied Palestinian territories(OPTs) have gained social and political ground in the last decade—a process assisted byprolonged military confrontation and political stalemate in the region and acceleratedby the discrediting of mainstream secular factions. We focus on health NGOs and assessthe ways in which they frame their work, how they relate to their constituencies, andhow their discourses can be read in relation to the massive aid disbursed for the OPTs.

Benoıt Challand is Marie Curie Post-Doctoral Fellow in the History Department of the European UniversityInstitute, Via Boccaccio 121, 50133 Firenze, Italy; e-mail: [email protected]

© 2008 Cambridge University Press 0020-7438/08 $15.00

228 Benoıt Challand

To understand how the political economy of aid impacts the framing of socioreligiousmovements, we focus on the health organizations stemming from the mixed matrix ofcharitable organizations (which include some Islamic institutions and zakat [almsgiving]committees). We contrast their representation with that of another set of medical NGOs,namely those that arose as popular movements from the secular-left factions and thathave developed into professional organizations. Although some health NGOs of thesecular block have been successful in establishing large professional organizations,5

have managed at times to check autocratic tendencies within the Palestinian NationalAuthority (PNA), and have offered key ideas for the development of a national healthplan,6 they have become increasingly active only in central urban zones and ensnaredwith the priorities and modalities of intervention of large international donors.7 Asa result, some of these large NGOs (and some of their leaders) gradually lost touchwith the aspirations of the population, and a rift emerged between the lay people andlocal elites.8 In contrast, charitable organizations have played an important role inproviding health services to peripheral zones and to underserviced populations,9 albeit ina lower-key manner and generally unnoticed to the international donor community. If theIslamic NGOs, particularly active in the charitable sector, have gained so much influencepolitically in the last few years and if the charitable sector is expanding, it is becausethey have remained more faithful and closer to the poor. (Study of their discourse10 willshed light on to what the links ought to be, from the population’s perspective.)

If contemporary socioreligious movements (as embodied in the present case of re-ligiously inspired health NGOs) promote successful discourses of common good thatattract more popular support (and that eventually garner the organizations more popularsupport and legitimacy),11 it is also because such discourses are in open (at timesconscious) tension with modern liberal conceptions, such as civil-society promotion,good governance, and democracy, that are generally relayed by secular and more pro-fessionalized NGOs. Therefore, to understand the success of socioreligious movementsin the OPTs and the nahd. a of charitable organizations (success defined by number ofactive organizations, type and quality of service provided, and political support for thesponsoring factions in the latest elections), we must grasp the political economy thatalters and favors the work of these organizations, both secular and religious.

After a presentation of the methodology and the motives behind the Hebron casestudy selected here, a third section briefly outlines the evolution of the health sectorand the changing context of international aid for Palestinian NGOs over the past fifteenyears. A fourth section analyzes the discourses of various health organizations, with afocus on the Hebron district, a region with a high density of charitable organizations.The goal is to explore how health organizations discursively frame their work and tostudy their links to the local populations they serve. We present three models of socialmobilization explained as a function of the relationship between health organizationsand international donors.

M E T H O D O L O G Y A N D T H E H E B R O N C A S E S T U D Y

Studying civil society and the impact of aid is all too often done with a focus onprofessional or well-institutionalized NGOs, leaving aside smaller organizations such ascharitable institutions. The material presented here is part of a larger research project to

A Nahd. a of Charitable Organizations? 229

understand the perception of external aid by a wide variety of local civil-society actors inadvocacy and health-service provision.12 This paper covers health organizations only. Ashealth is a very broad sector, we limit our focus to providers of primary health care (i.e.,basic medical treatment that can be done at the community level without hospitalization),allowing us to include charitable and religious organizations. The interplay of healthand activism is possible because health does not limit itself to mere physical well-being:health is multifaceted, providing an entry point into political activism and social workand revealing deeper moral codes of a community’s functioning.13 Studying how healthactors frame their work is therefore an interesting way to divulge different politicalvisions and unearth profound changes within a given society.

Two criteria guided our sampling. For a selection representative of the whole OPTs, wefirst identified which NGOs to interview from the northern half of the Gaza Strip (fromBeit Hanoun to Gaza City) and from the southern half of the West Bank (from Hebronto Ramallah). Within this geography, we chose organizations by quota in order to havea nearly equal number of large, professional NGOs (eleven) active on the national leveland smaller organizations (twelve) active only locally, with charitable organizations ourtarget. Overall, we conducted interviews with twenty-three Palestinian health NGOs,between January 2003 and March 2004, using a semistructured questionnaire withopen-ended questions. We gathered additional information about NGO activities fromthe organizations’ annual reports and printed material in English and Arabic.14

We illustrate our findings through a case study of health organizations operating inHebron, the most populated district of the West Bank (530,000 inhabitants). The cityof Hebron (160,000), at the heart of one of the most vital industrial regions of theWest Bank, is known for its political and social conservatism. Its rural hinterland isalso heavily populated, with more than two-thirds of the district population (370,000)living outside the city. A key feature of the district is its very vibrant charitable sector:forty-eight of a total of 175 organizations based in Hebron are charities15 (i.e., 28 percentof the region’s NGOs, as opposed to 20 percent on average for the West Bank).16

Its peripheral situation makes it an interesting case study to assess the differentiatedimpact of external aid, because donors tend to work mostly in and through urban centers,such as Ramallah and Jerusalem. There are actually very few health providers: to servethe population, the large, secular health NGOs operate only three permanent primaryhealth-care centers, two in Hebron city and one in the rural zone of Idhna, to the west.The rest of the rural area is covered by small, charitable organizations based in villagesor smaller cities. We adjusted our sample to target such charitable organizations offeringbasic medical treatment to a local constituency.

Ten organizations active in the Hebron district were interviewed for this study (sixcharitable and four professional). We made an effort to reach village-based organizationsas well as a mix of charitable organizations and religious NGOs in addition to one localzakat committee. According to the most recent NGO directory (2006), new organiza-tions have been created in the last four years, including charitable organizations. Fromthirty-three charitable organizations registered with the Union of Charitable Societies ofHebron in 1990, the number grew to forty-two in 2003 and forty-eight in 2006.17 Thisincrease offers the first evidence of a nahd. a in charitable organizations. The creation ofnew organizations indicates that the local population perceives their work as a necessityand supports them.


A B R IE F P O L IT IC A L E C O N O M Y O F H E A LT H N G O S

Over the past fifty years, there have been three main types of health providers in theOPTs. The first (and oldest) is the United Nations Relief and Works Agency for PalestineRefugees in the Near East, which has provided health and education to registeredPalestinian refugees since its creation in the aftermath of the 1948 war. The second typeof health actor is embodied by governmental services run by the PNA since 1994. Thethird type of health service comes from the nongovernmental sector, be it nonprofit orfor profit (private treatment centers, labs, or hospitals). As our paper concerns competingmodels of social mobilization, we limit our study to the third sector.18 Within it we lookat two subsectors of health NGOs, namely, the professional and secular as opposed tothe charitable and religious.

Health NGOs developed from competition among nationalist secular parties. Startingin the early 1970s, the main PLO factions created popular committees in the territoriesto promote political participation, to fight against Israeli policies of de-development,and to provide basic services to the population.19 Israel did little to develop healthinfrastructures. In fact, under Israeli rule the number of government hospitals droppedfrom twenty in 1968 to fourteen by 1992, limiting the scope of services offered. Threeof the six hospitals closed down were converted into a police station, a military base,and a prison.20 In the late 1980s, while Israel was investing $306 per capita on thehealth of its citizens inside the 1949 Green Line, it was spending $30 per capita in theWest Bank, an outlay that decreased to a mere $20 per person by 1991.21 As a result,the so-called popular committees, divided by political party and professional activities,spread throughout the OPTs to organize basic health services for the local population.22

With the advent of the PNA, many organizations closed down clinics, either becausethe PNA set up new infrastructure or diverted funding. Thus, the Union of PalestinianMedical Relief Committees, the health NGO linked until a few years ago to the Commu-nist Party, had thirty-one primary health-care clinics in 1992, twenty-eight in 1995, andonly twenty-five by the end of the decade.23 The Union of Health Work Committees,originally linked to the Popular Front for the Liberation of Palestine, also shut downsome of its clinics. The Union of Health Care Committees, originally affiliated withthe Democratic Front for the Liberation of Palestine, cut back most drastically, closingfifteen clinics at the beginning of the Oslo years; their health operations shrank fromthirty-two in 1992 to three in 1999.24 Health organizations closely affiliated with Fatahmerged with the nascent PNA, and many staff gained a job in the PNA administrationor in the Palestinian Red Crescent Society, another health NGO that maintained strongties with Fatah.25 The scarcity of funding meant that the remaining secular NGOs hadto scramble for money to survive, increasing both competition and the trend towardprofessionalization.26

The other subsector of nongovernmental health under the lens here is charitable andreligious organizations. Most charitable organizations tend to be affiliated with oneof the four regional Unions of Charitable Societies (Nablus, Jerusalem, Hebron, andGaza). They differ from the larger secular NGOs in that they are led by local notables(and therefore have a tendency toward paternalism). Many (and this is true only for theWest Bank) were established under specific legislation, such as the Jordanian Law ofCharitable Organizations Number 22 of 1955 (when Jordan was administering the WestBank).


Although most Islamic health organizations are charitable organizations (al-jam–ıyatal-khayriyya), not all charitable associations are Islamic. Some are Christian and otherssecular (close to the Fatah movement). In all cases, however, they function conservativelyand often work at the crossroads of various activities, offering health services alongsidecultural events, for instance, or help for orphans or elderly people. Their approach isrooted in local needs and means. A last commonality between charitable and Islamicorganizations is the rejection of Western discourse, to be discussed later.

For what distinguishes charitable from Islamic organizations, we look at the degree ofinclusion of religious principles in their work ethos. Islamic organizations have their ownsubfields of organizations: some have a clear political project based on religious values,and some do not. The former can be described as “Islamist” organizations, whereas thelatter correspond to the more neutral “Islamic” denomination.27 Islamist NGOs do notaim only at gaining “political support, but [they are] also the result of a conscious policyto build up Islam as the basis for a sense of community to replace the sense of a nationshattered by the occupation.”28

Another way to distinguish the charitable from Islamist NGOs is funding: IslamistNGOs apparently did not have serious financial difficulties during the early years of thesecond intifada and managed even to increase their work. On the contrary, charitableNGOs have suffered during the Oslo years from diminishing locally generated incomeand international support,29 whether from the Gulf region, which might have preferredsupporting Islamists, or from Western donors fearful of funding Islamists. Whereas theWest tends30 to blur the lines between Islamic and Islamist, some within the internationalArab donor community make the distinction and precisely orient funding on this basis.31

The Islamist movement started creating its own service-provision organizations fol-lowing the model of the Muslim Brothers in neighboring countries. This is the casewith al-Mujamma–al-Islami (the Islamic Assembly), created in Gaza in 1973 under theleadership of Shaykh Ahmed Yassin,32 who later founded Hamas in 1988. The modelof service provision through voluntary popular participation (which originally emergedin the secular left) was emulated on a broader basis only later, from the end of the 1980sonward. Roy notes how Islamic NGOs providing services around health, education, ororphan care have contributed to the further rise of the Islamic movement because of thequality of their work—despite the crackdown on Hamas structures during the 1990s.33

To return to the distinction between charitable and professional organizations, ourdatabase suggests that 21 percent of health organizations active in the OPTs (27 of 129)are charitable ones. They are rather small entities, dispersed throughout communities andin villages. They are less clearly structured: a recent study reports that most charitableNGOs are headed by a general assembly, whereas professional NGOs are managedby boards of trustees or administrative boards.34 The study highlights that rural-basedcharitable organizations are “generally weaker in structure” than NGOs based in urbancommunities.35

Charitable organizations also differ from the larger, professional NGOs in their rolesand activities. Table 1 indicates the main field of activity, as reported by NGOs; the lastcolumn reports the percentage of funding dedicated to this main activity.36

Note the contrast between the variety of activities and the main purpose of each NGO.Table 1 shows that although many NGOs work in certain areas (culture, education,charities, and youth), fewer define these fields as their main activities. By contrast, few


TABLE 1. Field of activities and proportion of funding, as describedby nongovernmental organizations (NGOs) in 2000

NGOFunding

Main for MainActivities Activities Activity

Type of Activity (%) (%) (%)

Children 40.2 20.4 16.6Charity and relief 39.2 13.3 13.3Elderly people 4.8 1.6 1.2Family organization 5.8 0.5 0.1Culture, science, and humanity 56.2 10.2 2.4Rural development 11.8 2.8 6.9Environmental and water 3.9 0.9 0.3Health services 25.7 4.9 32.3Human rights 8.6 2.6 2.5Handicapped 10.7 4.4 5.5Rehabilitation 26.4 3.5 1.7Women 17 1.8 1.3Education and teaching 35.4 3.4 6.4Religious activities 12.5 1.5 1Research centers 9.2 2 4.1Proselytism (Da–wa) 5.7 0.6 —Youth 30 22.7 1.3Other 6.7 3 3Totals 100 100

organizations identify health as a main activity (4.9 percent), rural development (i.e.,agriculture, 2.8 percent), education (3.4 percent), and research (2 percent), but these foursectors, host of most professional NGOs, absorb much more funding per NGO than therest (almost half of the funding, respectively 32.3 percent, 6.9 percent, 6.4 percent and4.1 percent).

Table 2 identifies which sector employs most NGO workers, giving us an idea of therelative importance of each sector.37 Again, the charitable sector stands out, not only inmere numbers of NGOs, but also because it employs more than half of those paid byNGOs. Table 1 highlights that youth activities are very popular but require little funding.This is also confirmed here, with only 3.4 percent of all employees being in this sector.Finally, the NGOs describing themselves as “developmental” (what we call “professionalNGOs”) employ 25.1 percent of all employees, although they represent only 4.9 percentof all NGOs. This suggests that certain activities cost more than others; they are notonly professionalized, but also have become an important source of employment for anew and rising middle class.38 A rival hypothesis posits that developmental NGOs aresimply much better at fund-raising from large foreign donors and therefore can pay more(and better) salaries. This theory goes hand in hand with the view that a thin layer ofNGOs in the OPTs has become truly professionalized. By contrast, other sectors (suchas charitable organizations) employ many volunteers, even if they have very little moneydedicated for their activities. Therefore, charitable organizations occupy a different nichethan the larger, more professionalized NGOs.


TABLE 2. Number and percentage of employees by type of nongovernmentalorganization (NGO) activity in 2000

Employees Volunteers

NGOs Female FemaleType of Activity (%) Number % (%) Number (%)

Charitable 40.4 5,894 56.8 58.6 22,883 44.0Relief 4.8 397 3.8 52.1 979 31.8Youth clubs 30.4 348 3.4 23.6 21,740 7.5Research 3.5 265 2.6 51.7 318 30.1Development 4.9 2,605 25.1 50.4 4,510 39.8Human rights 2.6 237 2.3 43.9 234 24.0Culture 10.2 271 2.6 50.9 12,415 38.4Rehabilitation 2.7 301 2.9 51.2 1,789 95.0Other 0.5 57 0.5 57.9 68 34.6Totals 100 10,375 100 54 64,936 31.5

Let us now look at how reforms affected the work of health actors during the secondintifada. The PNA, under intense political and economic pressure exerted by large donorsin the wake of the Oslo Accords, profoundly reformed the health field.39 One conse-quence was increased privatization, the approach favored by the majority of internationaldonors. It aimed at improving “the efficiency and the quality of [health] services, the sus-tainability of present financial arrangements and equity and accessibility to services.”40

However, for some, such outside-driven health-sector reforms “missed the forest for thetrees” by often offering only “quick fixes” and technical assistance that did not respondto the population’s real needs. In short, the reform failed to apply a broader systemicanalysis and was divorced from the OPTs’s sociopolitical context.41

The divorce was even more acutely perceived with the outbreak of the second intifada.The emergency situation after 2000 increased centrifugal forces because of closures andcurfews imposed by Israel. The occupied territories rapidly became a chaplet of smallislands, with little possibility for mobility, even for medical staff. Therefore, the quality ofthe medical response offered by governmental and nongovernmental health institutionsdepended on their capacity to decentralize services or on their presence (or absence)in peripheral zones. Interviews with health professionals highlighted the differentiatedlack of health structures during the second intifada. Even if good infrastructures hadbeen developed in urban centers during the Oslo years, patients simply could not reachthem because of the hundreds of checkpoints scattered throughout the territories. Larger,secular NGOs as well as religious and charitable health organizations had to play a moreimportant role, in different manners, to compensate for the unavailability of governmentservices.

Professional health NGOs received a clear mandate from international donors toprovide the services that the collapsing PNA could no longer offer. This message wassent in a financial envelope: according to estimates, whereas all Palestinian NGOs (notjust health) received about $100 million each year during the Oslo period (1994–2000),donations to civil society increased to an annual average of $300 to $500 million forthe years from 2001 to 2005, which actually represents the overall yearly average of


international aid to the OPTs (aid to the PNA included) during the Oslo years.42 Thisfinancial trend probably increased after Hamas came to power and the donor communitycut its funding to the PNA.43

NGOs (particularly professionalized ones) have again become major actors in provid-ing vital resources to the Palestinian population. The role of international donors (whoshould not be hastily treated as a homogenous category)44 has also massively expandeddue to the difficulty for the PNA to function. This in turn may have hindered someof these large, secular NGOs because local perceptions may have linked their reliefefforts to the unclear political intentions of international donors. Indeed, a few monthsafter the outbreak of the second intifada, criticism mounted against large, professionalNGOs. Some inhabitants spoke of an exaggerated “NGO-ization” of Palestinian sociallife, regretting the insistence on formal structures rather than mutual and voluntary as-sistance for the population in need.45 Others contrasted the dynamic role of civil societyduring the first intifada with its absence and its incapacity “of organizing at the masslevel” during the second uprising.46 Still others denounced certain NGOs for seekingprivileges for themselves and abandoning the common interest, which contributed toa growing “confidence gap between the leadership and the masses from the start” ofthe Oslo process.47 Adding to this catalogue of grievance was the location of mostdonors in central zones (i.e., in Jerusalem, Ramallah, or in some cases Gaza City), solocal organizations seeking funding were limited by their (in)ability to travel to thesezones.48 A small, village-based NGO trapped in the periphery (such as the Hebrondistrict) was far less likely than a larger organization to reach potential donors for itsprojects.

The contrast here with charitable organizations is stark. Charitable organizations, andin particular Islamic health NGOs, have concentrated mostly on local help and sometimesat a lower scale of intervention, with redistribution of locally collected alms and funding.In a period when the local has become the most important resource, because of thesignificance of local economic network provided, for example, by the h. amula or extendedfamily,49 this form of community self-help has been highly appreciated and used bycharitable organizations. We argue that its different rhetoric resonates much more withthe local population than grand schemes about empowerment, good governance, civil-society promotion, and reforms—all buzzwords promoted by the majority of Westerndonors.50

Despite this resistance to Western principles and institutional arrangements, manyobservers are keen to underline the importance of charitable organizations and, withinthat group, the professionalism of the Islamic sector. An International Crisis Groupreport attributes some of their success to maintaining “very organic links with theirconstituencies.”51 With PNA infrastructures increasingly targeted and initially incapableof delivering aid, and with larger, secular NGOs having difficulties transitioning fromadvocacy-oriented activities (such as reform and democratization) developed during theOslo years and from 2003 onward, Palestinians in dire economic situations turned tothe charitable sector because it delivered services more quickly (particularly Islamistorganizations).

According to a wide survey done in 2002, this type of NGO enjoys high credibil-ity among locals.52 As mentioned in the methodology section, the emergence of newcharitable organizations in the last three years suggests popular endorsement. In this


line of community self-help, we must underline the work of another Islamic institution,zakat. Locally organized zakat committees redistribute to the needy the mandatory tithethat they collect throughout the year. Such committees can give financial help, organizeeducational activities, and provide health services. The Hebron Zakat Committee, forexample, covers insurance fees and certain hospitalization expenses for the needy andruns its own small medical laboratory.53 Zakat provides vital resources at the heart oflocal communities—a role recently acknowledged in an international report on foodsecurity in the West Bank.54

H E A LT H N G O S A N D T H E U S E S O F “C IV IL S O C IE T Y ”

Let us now analyze the discourses produced by health actors about their role and theirrelationship to the local population. As we have since the outset spelled out the necessityof contrasting these models according to political economy criteria (external fundingavailable, institutional development, access to central decision zones), we divide healthorganizations into three categories (large, medium, and small health NGOs) as a proxyfor the institutional capacity to reach out for international aid.

The larger NGOs include such institutions as the Palestinian Red Crescent Society,which has twenty branches and twenty-six primary health-care centers. Other big NGOsinclude the Union of Health Work Committees, the Union of Palestinian Medical ReliefCommittees, and the Union of Health Care Committees. They were originally popu-lar committees affiliated with political parties; although all three organizations insistthat they are formally independent, they have remained in a very close orbit.55 Otherorganizations fit this category because of their large number of employees. The GazaCommunity Mental Health Project and the Health Development Information and PolicyInstitute are good examples. Neither is formally working in the whole of the OPTs, buttheir fully professionalized programs are meant to exert a national influence (throughreport publications and/or training).

A survey of staffing indicates that these big NGOs (founded on average in 1976)employ an average of 175 persons, in addition to a few hundred volunteers.56 Allare urban based in their administration (although they have some branches in ruralareas and provide mobile clinics to the periphery)57 and benefit from highly structuredorganizations (including public-relations work). Some even produce high-quality booksand publications and offer information management as services to other organizations,thus becoming “meta-NGOs” or “multiplicator NGOs,” with a new type of constituency,namely, small NGOs. All these organizations receive very large amounts of money fromabroad.58 Almost exclusively dependent on external funding, they have a team withinthe staff specializing in fund-raising and in external relations with key donors.

Medium-sized health NGOs employ on average about eighty workers—large institu-tions with a reach that is nonetheless only regional. They are older and were founded, onaverage, in 1970. Some prominent examples are the Red Crescent Society for the GazaStrip (headed by Dr. Haydar Abdel-Shafi until his death; it is not affiliated with thePalestinian Red Crescent Society), Ard al-Itfal (Gaza City), Ard al-Insan (Hebron), theBethlehem Arab Society for Rehabilitation, and some of the Patient’s Friends societies.The last are not part of a unified movement; totally independent, they share no commonresources except their name. Finally, we include some hospitals registered as NGOs


because they are draining from a basin bigger than a single locality. This is also the casefor the al-Ihsan Charitable Society (in Hebron) because it does some training for otherrehabilitation NGOs from the West Bank.59

Some medium-sized health NGOs have a refined administrative apparatus, but it isless developed than that of their larger counterparts. For example, they do not have thesame visibility (i.e., the capacity to attract donors’ attention). Their funding capacitiesare less developed too. Although they rely on external aid for a large share of theirbudgets, they also tap local sources for income.

We describe the rest of health NGOs as “smaller NGOs,” although this can be slightlymisleading because some employ up to fifty staff. However, their vocation is only local.Examples of such organizations are the Al-Mahaba Charitable Clinic (Nablus), theQalandiya Health Centre, the Al-Aqsa Society for the Handicapped (Samu–), and theRafah Refugee Camp Medical Center. The average year of foundation is more recent:1986. They represent more than 78 percent of all health organizations.60 Proportionallymore diffused in Gaza (forty-five NGOs) than in the West Bank (fifty-five), they aremuch more active than larger organizations in the nonurban setting. All thirty-sevenhealth NGOs based in refugee camps or villages are actually “smaller NGOs.”61 Theirprofile of activities is also different: of the thirty NGOs based in refugee camps, 77percent have rehabilitation/handicap as a main priority. Their financial resources mighton rare occasions originate from Western donors but in small sums (ranging from $5,000to $25,000). Therefore, such organizations survive principally on local contributions(membership fees, in-kind payments, or cash) and on volunteer work.

We analyze how these health NGOs frame their work and how this might be influencedby international donors, before exploring the possibility that these various framings maycontribute to maintaining or losing social and political touch with the local population.How do these NGOs describe their relations with local constituencies? How do theyspeak of themselves and of their roles? The three models proposed here use as a dividingline the notion of civil society, a concept heavily sustained by international donors,which allows us to take political economy factors into consideration.

The first message underlines the explicit alliance of civil society within the healthagenda. According to one of the most vocal supporters of such an alliance, healthorganizations can be an “entry point into society for those sectors of society that weremost oppressed and disadvantaged.”62 This model stresses the usefulness of the healthagenda in promoting changes beyond physical well-being. The spirit of the Declarationof Alma-Ata (a U.N. conference held in 1978 that consecrated primary health care asa fundamental human right) explains in part the popularity of mingling civil-societydiscourse with health-service provision.63 It is not just about curative medicine butabout an alternative vision of primary health care that takes the sociopolitical context ofoccupation into account, as already framed in a 1990 text.64

The following excerpt from an interview gives a better understanding of what wemean by the “marriage” of civil society with the health agenda. This NGO, specializingin mental health and particularly psychotraumas as a result of torture, runs a programfor Palestinian police forces:

We have a training and education department. It covers all the short-term training courses. Wealso offer training courses to police and intelligence officers (on human rights and mental health:


namely, the impact of torture on prisoners). . . . I think civil society has two roles to play: toprovide needed professional services to the community, and [it has a] role in the democratizationof the society. By democratization, I mean also the political level.65

Here, the idea is one of spillover: by raising awareness about health issues amongpolice forces (accused of torturing prisoners), this health NGO hopes to contribute to astronger dedication by all parts of the Palestinian polity to human rights and democracy.Although some NGOs make use of the hegemonic discourse around “civil society” forpolitical purposes, others make only general reference to sociopolitical change and donot imply a political agenda. In the first case, we find very large professional NGOshistorically linked to left-wing political parties whose frequent and overt use of theinternational leitmotiv around “civil society” has helped render “civil society” almostvoid of sociopolitical significance. It has become simply a political identity marker (seefollowing). In the second case, we find mostly medium-sized organizations without clearpolitical agendas, but these NGOs follow the trend of professionalized organizationsthat arose during the Oslo years. Their use of the phrase “civil society” reflects a silentconditionality set by donors, namely, that beneficiaries need to follow the dominant andhegemonic parlance in order to receive aid.

The second vision of “civil society” in the parlance of Palestinian NGOs separates“civil society” from professional health work or mentions it only as a general motivation.This is the case for the Palestinian Red Crescent Society for the Gaza Strip.66 Dr. HaydarAbdel-Shafi sees civil society as civic engagement for the welfare of the community.When questioned whether “civil society” was used too much in a top–down manner tocontrol, he responded:

It should be a bottom-up process. Civil society is concerned with civil affairs pertaining [to] thewelfare of the community. This is civil society. In essence it is political because its objectiveis safeguarding the interest of the population. But there is no active and direct involvement inpolitics. In its activity, towards welfare, it can really become political. But it does not engage itselfin political activities.67

More interesting for this category is the case of small NGOs we call “family associa-tions” because they represent refugees from the same town organized so as preserve thesense of the original community. In this line, the Family Association of Majdal (Jami–iyaAhaliyya Majdal) started in 1976 as a cultural center, and in 1994 it began offering avariety of education activities as well as basic medical care through volunteers. Whenasked about the association’s philosophy, the director responded:

[This] reformed alliance was founded in order to reform civil society. It is not just about politics,but also to develop social life and recuperate the loss of education during the Israeli direct occu-pation. . . . We must concentrate on the social dimension of education, on how to watch TV, onthe relations with groups, how to speak with one another, how to be open to others, to be loyalto the society at large, how to be positive with one another. All in all, it is about teaching how tobe positive social beings. It is like Pavlov: it is a kind of reflex to become calmly positive people,shakhs. [individual], and muwat.in [citizen].68

Beyond the paternalist assumption that the association has to teach its members howto behave socially, the definition of the overarching role of the association is close to thedefinition of civil society put forward by certain left-wing secular activists (who stress


social change and the leading role assumed by NGOs). The previous quote reinforcesthe idea that “civil society” (as narrowly understood by the largest donors) does not needto be explicitly stated, but in some cases, it is only the expression or the phrase itselfthat is missing, not the substance behind it.

This Family Association model is widespread in the OPTs. Such organizations per-form important mediation between the community and the PNA.69 The two familyorganizations we interviewed each gather at least 10,000 members, so they serve asimportant relayers of local interests. Although they might not be professional in struc-ture, they have a strong membership base. Moreover, they usually operate in peripheralzones much less covered by international aid—although one interviewee suggested thatinternational support for such organizations could undercut militant religious groups.

A leader of the charitable sector also addressed this thorny question of the rivalry ofcertain smaller NGOs with those belonging to militant Islamist groups. For her, manycharitable organizations became lethargic after the disengagement of the Jordanians in1988 and the sudden drop in financial assistance from Amman.70 The second intifadahas forced NGOs to respond to all sorts of challenges. On the one hand, the work ofsome charitable organizations stopped after 1988 and even more after the arrival of thePNA. On the other hand, the dynamic involvement of both large, secular NGOs andIslamic (in some cases Islamist) NGOs forced charitable organizations to react. This ledto what she describes as an “awakening” of the charitable sector.71 She regrets that alarge majority of international donors overlook charitable organizations—despite theirlonger historical involvement among civil-society organizations and their attention tooverlooked areas, such as elder care. Yet she also keenly criticizes Palestinian NGOsthat merely follow fashion:

It looks like the global terminology [such as civil society, democracy, or empowerment] is im-pacting even the local organizations and local scene. People always try to follow and jump onthe bandwagon, as they say. . . . I know many organizations that came to existence because [ofthe themes] of democracy and civil society. . . . If you look at the numbers of these organizationsdoing conflict resolutions, civil society, and this and that, it is not out of conviction only: it isbecause donors have money. It is opportunity! People are opportunists! People want to make haywhile the sun shines!

Without negating vices of the charitable sector (e.g., clientelism and political patron-age), she notices that some charitable organizations are renewing their activities and theirways of working, which often means specializing in a specific field of intervention andprofessionalizing part of the staff. They remain very active and important in rural settingsand could serve as a cordon sanitaire vis-a-vis the Islamist organizations recruiting onthe same turf in marginalized areas. Some small health organizations also frame theirsocial work this way. They rely in part on external aid but enlist volunteers among peoplehaving access to their services.

Finally, the third approach to civil society in the health sector conveys a very differenttype of message. We find a variety of health actors, mostly religious, ranging from theHebron Zakat Committee to the al-Ihsan charitable organization to the tiny, village-basedTarqumya Charitable Society as well as to Maqassed Hospital (indirectly sponsored bythe PNA). To assess the impact of external aid, we divide these small organizations into


two subgroups, one with resources that are mostly locally generated and the other withresources that come from international donors.

Established in 1983 with a staff of sixty, the Al-Ihsan Charitable Society typifiesoganizations with externally generated income. Specializing in care for the disabled,this Hebron NGO belongs to the International Cerebral Palsy Society and trains healthprofessionals for the rest of the West Bank. It also runs an emergency primary health-care center with four doctors and five nurses. When asked how the organization viewsits role vis-a-vis the population, Ihsan’s PR officer responded that:

We can give the value of an institution; we give rules and help them form a society. We are thelighthouse that guides the people according to our proper model [nah. nu manara yuhtadı binabi-l-nas wafq al-niz. am al-khas. bina]. We are the candle lighting the path for the people [sham–atadhı–al-t.arıq li-l-nas]72

Behind this colorful phrase lies a totally different philosophy: no more secular dis-course about people’s empowerment through pluralism or civil society but very piousinvitations to follow religious models of activism. Far from being a militant Islamistassociation, this NGO (like others in the Hebron region) insists on generic religiousobligations. Thus, the annual reports of al-Ihsan and of al-Ahli Hospital (run by thePatient’s Friends Society of Hebron) both start with the fatih. a and three pages ofIslamic references with many hadiths, excerpts from the Qur»an, and pictures of thelocal Ibrahimi Mosque. Most of their international donors are Arab or Muslim orga-nizations, the target audience for their bilingual reports. On rare occasions, however,they also collect funding from nonreligious Western organizations (such as AmericanNear East Refugee Aid, CARE, or the Red Cross) because of the good quality of theirwork.73

This second subgroup of organizations, which have an income that is internallygenerated, insists on involving local residents, whose voluntary contributions fund themajor part of the NGO work. Zakat committees organize obligatory almsgiving on alocal basis. In Hebron, the zakat committee made special financial contributions duringthe second intifada to people without health insurance. It also ran a small clinic near adowntown mosque.

The Tarqumya Charitable Society is a small NGO in a town west of Hebron thatalso relies on local financial contributions. Its catchment area encompasses 70,000people caught between Hebron and the Green Line. Receiving only rare and smallcontributions from international organizations, it extended its primary health-care centeron land donated by a local resident.74 Another organization in this category, the Unionof Charitable Societies of Jerusalem, stresses local resources and the necessity forPalestinians to do their own development work.75

In all three cases, these organizations put forth very little or no discourse about civilsociety, democracy, or other key concepts usually mouthed by international donors.Rather, interviewees insist on Palestinian capacity to organize themselves, workingdirectly with the people, thanks to local contributions. To this group, local involvementbest guarantees social work in the best interests of all and at minimum cost.

What do these different framings imply? We notice a twofold strategy by health actors.Some make frequent and conscious use of key concepts that most international donors arekeen to support (“civil society,” “empowerment,” or “democracy promotion”). Others


use less complex strategies and less fashionable rhetoric, even laced with religiousovertones. However, they refrain from the kind of orthodoxy replicated by those whopursue funding from donors. We hypothesize that framing tends to be polarized by thepresence, or more precisely by the frequency, of interaction with Western donors.76

Notions of civil society are not the unique resource of a few larger, professional, secularNGOs. On the contrary, many organizations that do not have an extensive public-relationsstaff also speak the language of “civil society” (even if not explicitly, as in the case of theinterview with the leader of the Family Association of Majdal), nor is the use of “civilsociety” the exclusive domain of people trained and educated abroad. Many physicianswho studied outside the OPTs and were interviewed did not automatically use the conceptof civil society as an overarching justification for their work. In summary, there is nomonopoly on “civil society” by a given type of organizations or by a certain sociologicalprofile of individuals running NGOs. To the contrary, the concept is widespread eventhought the exact phrase might be absent. Although many observers would not considercertain religious NGOs as part of “civil society,”77 they use its content in one form oranother.

In addition to the service provided by health NGOs, what also matters therefore isthe message transmitted through it.78 Some organizations link a strong message aboutsociopolitical change or the need to enhance the rule of law; others entertain a paternalistmodel of relations between NGO and communities. Others prefer to imbue their workwith conservative religious values.

Which message is more popular and successful among Palestinians? As argued previ-ously, large, secular NGOs (active in any field and not just health) faced harsh criticismat the beginning of the second intifada for their incapacity to relate and respond topopular needs and for their tendency to follow priorities set by donors. Moreover, thephrase “civil society” has been so widely linked to left-wing political parties and theways in which leftist NGOs frame their work that it has become an identity markerwithin Palestinian politics. The PNA and intellectuals close to Fatah (as long as it wasthe dominant PNA faction) have on many occasions attacked the concept of civil societyand the physical entity “hiding” behind it, namely, NGOs. PNA officials have led manycampaigns against the “dakakın,” boutiques, denoting the businesslike approach of someNGOs that represent themselves as watchdogs of the corrupt PNA.79

Islamist groups have not been keen to promote the substance or the term “civil society”because they rely on another type of ready-made discourse—one sanctioned by religiousrhetoric that is also greatly constrained by nationalist rhetoric and in open opposition toforeign, or “Western,” discourses. When speaking about NGO work, Islamic movementsprefer the phrase “al-–amal al-ahlı” (civic work), a phrase more common in daily Arabicthan the phrase “al-mujtama– al-madanı” (civil society).80 An article by a declaredIslamist went further in this open tension with international orthodoxy, by proposingthe new phrase of “al-jihad al-madanı” (civil struggle).81 Such an expression is highlyinteresting for our argument, because it marries the concept of “jihad” (understood asa spiritual or physical struggle) with madanı. “Jihad” is a very popular concept amongreligious conservatives, and the phrase evokes political struggle within the sphere ofsocial mobilization. This rebuke of “al-mujtama–madanı” further demonstrates how thecivil-society concept is loaded with internal political connotations, a gathering bannerfor a variety of political forces.


Another, more down-to-earth reason may account for Islamic socioreligious move-ments’ success (measured in popular support for their organizations) in the OPTs andeven the rest of the Arab world. They work in more remote and underserved zones.Here the example of the Hebron Zakat Committee is useful. By offering services free ofcharge to people in dire need, the organization contributes to the widespread circulationof religious messages. Between 1992 and 2000, the committee disbursed on average$1.05 million per year, peaking in 2000 at $1.3 million.82 It outspent the larger healthNGOs in the Hebron district, and its small clinic provided 10,000 treatments.

Based in disadvantaged areas, these religious organizations are also flexible, adaptingto local needs. This, too, bolsters their message. They can tap into local knowledge,networks, and resources to tailor assistance, often more efficiently and quickly. TheHebron Zakat Committee has no need for grand developmental schemes or costlyscreening programs: it suffices to know who exactly needs 200 shekels for urgentmedical care.

Local organizations can also function as exempla for the rest of the society theyserve. The transparency and flexibility of a locally and socially anchored institutionhave an important consequence: people know each other, and everyone is part of theeffort through voluntary contributions. Therefore, people return to this institution. Trustbecomes visible in the form of increasing numbers of charitable organizations, theirbroadening role during the second intifada, and even election outcomes. The fact thatHamas won all nine territorial seats attributed to Hebron for the Palestinian LegislativeCouncil in the 2006 elections is further proof of the strong link between the activismof certain charitable organizations and political support. The Hamas victory certainlycannot be reduced to this factor: elections are a complex process. Yet the profiles of manyHamas ministers point to solid experience and involvement in the charitable sector, withnine (of twenty) ministers of the tenth cabinet rooted in the charitable and civil-societysector.83

C O N C L U S IO N

As accurately pointed out by Levine and Salvatore, “socio-religious movements basetheir public actions primarily on practical reason sanctified by religious traditions.”84

These traditions can be interpreted in a multiplicity of ways by socioreligious move-ments. Their rewording and reframing capacity is very important and may changeaccording to the context and interlocutor. We must add to the two aforementionedelements (practical reason and religious sanction/tradition) two more factors: proximityof organizations to their populations and the model (or example) that socioreligiousmovements represent (explicitly or not) for the constituencies they serve.

Put another way, if religious health organizations succeed in their mission and garnermore popular support, it is because they function as tangible and concrete examples forthe population. Service provision for the marginal and disadvantaged, more transparenteconomic redistribution of aid and behavior (their image is clean and free of corruptioncharges—true or not—unlike many of the larger, professional NGOs),85 and a rhetoricto frame their action (or “ideological wrapping”) that speaks to the local populationmore than the sophisticated, secular prose overused by larger health NGOs—all are keyelements to explain the importance of religious organizations in the OPTs today.


It is vital to look at the political economy of aid given to civil-society organizationsbecause the vocabulary and discourse consciously selected by Islamic and charitablehealth NGOs is not only the product of traditions or culture but also reflects a reactionto the massive imposition by external donors of a vulgate, catch phrases about “devel-opment,” “civil society,” and “empowerment,” which have become totally emptied ofmeaning because of cynical overuse by a large number of self-proclaimed civil-societychampions. A thorough analysis of the language used by charitable and Islamic healthNGOs demonstrates that the content of civil society is also part of the organizationalculture of charitable organizations. They compensate for their institutional weaknessesthrough a closer relationship with deprived segments of the population, volunteer work,and discourses that strike the popular imagination in a time of hardship.

The international context and political economy that motivate socioreligious move-ments might offer windows of opportunities but also counter-opportunities (i.e., a re-action to dominant ideologies, praxes, or discourses) to social movements in general,not only socioreligious ones. This is especially important in the OPTs, where everyyear donors pour hundreds of millions of dollars into various organizations and whereexternal involvement is paramount in solving the “Palestinian question” from above,regardless of the situation on the ground.

By studying the international context and the political economy of civil-society or-ganizations, we avoid classifying social movements as religious per se and forever.Charitable and Islamic NGOs might now frame their actions in terms of religioustraditions in order to speak to broader layers of Middle Eastern or Muslim majoritypopulations or to resist the imposition of dominant values such as secularism, liberaldemocracy, civil society, and so forth. However, this framing might evolve differentlyin a different context. Socioreligious movements might significantly alter their behaviorand framing if they were to have different access to resources, financial or symbolic.With Hamas coming to power and the violent confrontations it sparked, local perceptionsof Islamic and charitable organizations may shift dramatically. As the political economyevolves, we can even imagine a future in which religious sanctions and references toreligious traditions might become a handicap for socioreligious movements. However,this remains to be discussed in the future.

N O T E S

Author’s note: I thank Armando Salvatore and Caroline Abu-Sada for their comments on earlier draftsof this paper, as well as the editors and anonymous reviewers of IJMES for their enriching and stimulatingsuggestions.

1To name a few, see Quintan Wiktorowicz, ed., Islamist Activism: A Social Movement Theory Approach(Bloomington, Ind.: Indiana University Press, 2003); Jillian Schwedler, “Who Opened the Window? Women’sActivism within Islamist Parties,” Comparative Politics 35 (2003): 293–312.

2See in particular the ten reports produced by Riccardo Bocco et al., Palestinian Public Perceptions ontheir Living Conditions (Geneva: University of Geneva, 2001–2006). The role of Islamic NGOs is discussedthematically from the fifth report onward. All reports are available at https://www.iuedpolls.org (accessed 14December 2007).

3See, for example, Sara Roy, “The Transformation of Islamic NGOs in Palestine,” Middle East Report 214(2000): 24–26.

4Dyala Hamzah and Penelope Larzilliere, “Entre lutte nationale et fondation etatique, les intellectuelspalestiniens d’Oslo I a Intifada II,” in Les nouveaux intellectuels islamistes, ed. Farhad Khosrokhavar andMalika Zeghal (Paris: Balland, 2006).


5Mustafa al-Barghouthi and Rita Giacaman, “The Emergence of an Infrastructure of Resistance. The Caseof Health,” in Intifada: Palestine at the Crossroads, ed. Jamal R. Nassar and Roger Heacock (New York:Praeger, 1990), 73–87; Alean Al-Krenawi, John R. Graham, and Mahmud R. Sehwail, “Mental Health andViolence/Trauma in Palestine: Implications for helping Professional Practice,” Journal of Comparative FamilyStudies 35 (2004): 185–209.

6Rita Giacaman, Hanan Abdul-Rahim, and Laura Wick, “Health Sector Reform in the Occupied Pales-tinian Territories (OPT): Targeting the Forest or the Trees?” Health Policy and Planning 18 (2003): 59–67.

7Karma Nabulsi,“The Peace Process and the Palestinians: A Road Map to Mars’” International Affairs 80(2004): 221–31.

8Helena Lindholm-Schulz, “The ‘Al-Aqsa Intifada’ as a Result of Politics of Transition,” Arab StudiesQuarterly 24 (2002): 21–46; Salah Abdel-Shafi, Civil Society and Political Elites in Palestine and the Role ofInternational Donors: A Palestinian View, EuroMeSCo Paper No. 33 (2004).

9Ibid., 9; Roy, “The Transformation of Islamic NGOs”: 24–26.10The focus on discourse throughout the text does not mean we should neglect health-care practice; it is the

consequence of our focus on the importance of different framings of social movements.11Mark LeVine and Armando Salvatore, ed., Religion, Social Practice, and Contested Hegemonies.

Reconstructing the Public Sphere in Muslim Majority Societies (New York: Palgrave Macmillan, 2005),18.

12Benoıt Challand, Palestinian Civil Society: Foreign Donors and the Power to Promote and to Exclude(London: Routledge, 2008).

13Alean Al-Krenawi and John R. Graham, “Principles of Social Work Practice in the Muslim Arab World,”Arab Studies Quarterly 25 (2003): 75–91. See also Barghouthi and Giacaman, “The Emergence of an Infras-tructure of Resistance.”

14The interviews were conducted in English for the most part, with four in Arabic. The eleven health NGOsinterviewed (four in Hebron) were the Union of Health Care Committees, Gaza; the Union of Health WorkCommittees, Gaza; the Health Work Committees, West Bank; Bethlehem, Medical Relief and Development,Gaza; the Union of Palestinian Medical Relief Committees, Ramallah; the Gaza Community Mental HealthProgramme, Gaza; the Red Crescent Society for the Gaza Strip, Gaza; the Health Development Informationand Policy Institute, Ramallah; the Ardh al-Itfal, Hebron; the Palestinian Red Crescent Society, Hebron; andJUZOUR, Jerusalem. We also conducted twelve interviews with charitable organizations (six in Hebron): theFamily Association of Majdal, Beit Lahyia; the Family Association of Yafa, Jabaliya; the Union of CharitableSocieties-Central Section, Jerusalem; the Palestinian General Union of Charitable Societies (National Board),Jerusalem; the Patient’s Friends Society, Jerusalem; the Maqassed Charitable Hospital, Jerusalem; the Unionof Charitable Societies (Hebron District), Hebron; the Patient’s Friends Society, Hebron; the TarqumyahCharitable Society, Tarqumya; the Ihsan Charitable Society, Hebron; the Islamic Charitable Society, Hebron;and the Hebron Zakat Committee.

15We counted as charitable the organizations that describe themselves as charitable (khayriyya) or that aremembers of the Palestinian General Union of Charitable Societies.

16As there are no exhaustive lists of NGOs, I have created my own database of Palestinian NGOs. Ihave merged into one database partial lists and have counted about 900 NGOs active by 2004, a figure thatcorresponds to the number proposed by a Palestinian research center: Palestine Economic Policy ResearchInstitute, Ta–dad al-Munazamat Ghayr al-Hukumiyya al-Filastiniyya fi-l-Dhifa al-Gharbiyya wa Qitta’ Ghaz-zah (Mapping of Palestinian NGOs in the West Bank and Gaza Strip) (Ramallah: Palestine Economic PolicyResearch Institute, 2001). This figure is likely to be lower than the actual figure. Nonetheless, the database islarge enough to offer general insights into the whole NGO sector, including the relative weight of the char-itable sector. Other lists compiled include the following: Office of the United Nations Special Coordinator,Directory of Non-Governmental Organisations in the Gaza Strip, 2nd ed. (Jerusalem: Office of the UnitedNations Special Coordinator, 1998, 2003); Office of the United Nations Special Coordinator, Directory of Non-Governmental Organisations in the West Bank (Jerusalem: Office of the United Nations Special Coordinator,1999); Palestine Economic Policy Research Institute, Ta–dad al-Munazamat Ghayr al-Hukumiyya; Union ofCharitable Societies–Jerusalem, Activities and Services of the Societies (Jerusalem: mimeo, 2003); Union ofCharitable Societies, Hebron District, Provoke and Aspiration. 1990 (n.p. [Khalil]: [1990]); Nader Said andAyman Abdul-Majeed, Institutional Structures in Palestinian Refugee Camps in the West Bank and the GazaStrip: An Evaluative Study for the PLO Department of Refugee Affairs (Birzeit, Palestine: Birzeit University,2000).


17Figures for 1990 taken from Union of Charitable Societies, Hebron, Provoke and Aspiration, 3. The 2003figures were communicated to the author by the vice-president of the union; interview with Sameh Hashemabu Aysheh, Union of Charitable Societies, Hebron, 12 February 2004. The 2006 figures are taken from theOffice of the United Nations Special Coordinator, Directory of Non-Governmental Organisations in the WestBank, 2nd ed. (Jerusalem: Office of the United Nations Special Coordinator, 2006).

18This does not mean that the PNA and United Nations Relief and Works Agency for Palestine Refugees inthe Near East are not important health actors. On the PNA, see Brigitte Curmi, “Relations intra-palestiniennes,persistance du conflit et surenchere des bailleurs de fonds internationaux: le cas de la sante dans les Terri-toires palestiniens,” in Etats et ONG: vers une internationalisation des politiques de sante dans les pays endeveloppement? ed. Sylvia Chiffoleau (Paris: IFEAD, 2003). On the role played by the United Nations Reliefand Works Agency in the field of health (especially during the second intifada), see Bocco, Palestinian PublicPerceptions, Report X (2006), 84–89.

19Sara Roy, The Gaza Strip. The Political Economy of De-Development, 2nd ed. (Washington: Institute ofPalestine Studies, 2001), 108.

20Al-Haq, An Ailing System: Israeli Military Government Health Insurance in the Occupied PalestinianTerritories (Ramallah: al-Haq, 1993), 12.

21Jihad Mash–al, “Palestine,” in The Concept of Health Under National Democratic Struggle, ed. In-ternational People’s Health Council (Jerusalem: Union of Palestinian Medical Relief Committees, 1995),90.

22Glenn Robinson, Building a Palestinian State. The Incomplete Revolution (Bloomington, Ind.: IndianaUniversity Press, 1997).

23Olle Jeppson and Claes Lindhal, Health Services in Transition. An Evaluation of the Union of PalestinianMedical Relief Committees. Unpublished assessment report for SIDA. mimeo (s.l.: SIDA 1995), 2; Unionof Palestinian Medical Relief Committees, Annual Report [2000] (s.l.: Union of Palestinian Medical ReliefCommittees Publications, 2001), 6.

24Hans-Joachim Rabe, “Palestinian Elites after the Oslo Agreements (1993–1998)” (PhD diss., Universityof London, School of Oriental and African Studies, 2000), 277.

25Ibid., 85, 265.26Rema Hammami, “NGOs: The Professionalisation of Politics,” Race & Class 37 (1995): 51–63. By no

means should the number of clinics serve to measure the quality of health provision. They merely indicatestructural changes that affected the health sector in various historical moments. See also Dina Craissati,“Social Movements and Democracy in Palestine: Politicization of Society or Civilization Of Politics?” Orient,Zeitschrift des Deutschen Orient-Instituts 37 (1996): 111–36.

27For a further elaboration of distinctions between charitable and Islamic organizations and between Islamicand Islamist NGOs, see International Crisis Group, Islamic Social Welfare Activism in the Occupied Pales-tinian Territories: A Legitimate Target? (Bruxelles and Amman: International Crisis Group, 2003): 3 fn. 14,7–9.

28Jonathan Benthall and Jerome Bellion-Jourdan, The Charitable Crescent. Politics of Aid in the MuslimWorld (London: I. B. Tauris, 2003), 105.

29Amaney A. Jamal, “From Active Resistance to Democratic Missionaries?” Palestine Report (Jerusalem:Jerusalem Media and Communication Centre, 2000). Yet the charitable organizations had benefited fromArafat’s support for Saddam Hussein in 1990 because part of what the PLO lost in financial support fromArab countries was redirected to the charitable sectors.

30This is not true for all international donors. Islamic Relief (based in the United Kingdom and fundedin part by the European Union) is very keen to check on the recipient’s record to ensure money will notgo to Islamist groups. The International Committee of the Red Cross’s program of “smart aid” (throughvouchers) seemed also “to be deliberately aimed at providing an alternative source of effective support” tothat of Islamist circles. See Benthall and Bellion-Jourdan, The Charitable Crescent, 106. See also the dossieron Muslim NGOs, ISIM Review 20 (2007): 6–19.

31As suggested in Abdel-Rahman Ghandour, Jihad humanitaire: enquete sur les ONG islamiques (Paris:Flammarion, 2002).

32Jean-Francois Legrain, “HAMAS: Legitimate Heir of Palestinian Nationalism,” in Political Islam. Revo-lution, Radicalism or Reform? ed. John L. Esposito (Boulder, Co.: Lynne Rienner, 1997), 163.

33Roy, “The Transformation of Islamic NGOs.”34Palestine Economic Policy Research Institute, Ta–dad al-Munazamat Ghayr al-Hukumiyya, 1.


35Ibid., 2. Let us note such a study does not distinguish between charitable and Islamic or even IslamistNGOs; instead it relies on the self-description provided by the NGOs. Therefore, most of the religiousorganizations are included in the charitable sector.

36Ibid., 112 (Statistics 4-2). The two tables are based on the responses of 881 NGOs for a total expense of$112 million for the year 2000.

37Ibid., 120 (Statistic 8-3).38Jamil Hilal, “Problematizing Democracy in Palestine,” Comparative Studies of South Asia, Africa and

the Middle East 23 (2003): 169.39On reform pressure, see Michael Keating, Anne Le More, and Robert Lower, ed., Aid, Diplomacy and

Facts on the Ground: The Case of Palestine (London: Chatham House, 2005). On health reforms, see WorldBank, West Bank and Gaza: Medium-Term Development Strategy for the Health Sector (Washington, D.C.:World Bank, 1998).

40Ibid., 1.41Giacaman et al., “Health Sector Reform”: 60, 66.42Benoıt Challand, “The Evolution of Western Aid for Palestinian Civil Society: The Bypassing of Local

Knowledge and Resources,” Middle Eastern Studies 44 (forthcoming). For figures on the Oslo years, see RexBrynen, A Very Political Economy. Peacebuilding and Foreign Aid in the West Bank and Gaza (Washington,D.C.: United States Institute of Peace Press, 2000).

43There are only partial figures on disbursement to the health sector after the boycott of the PNA and theintroduction of the so-called temporary international mechanism in June 2006. The European Union alone in-creased its envelope for health activities from €270 million in 2005 to €340 million in 2006. See their operationand financial report for June-December 2006, 4. Available at www.delwbg.ec.europa.eu/en/tim/tim_in.htm(accessed 14 December 2007).

44I have argued elsewhere that there are important differences according to the size of the donors, the originsof their own funding (governmental vs. solidarity based), or their geographic origins (north vs. south Europe,Europe vs. the United States), and so forth. See Challand, “The Evolution of Western Aid.” For a bleak pictureon the role of donors during the stand-off between Hamas and Fatah in 2006 and 2007, see Yezid Sayigh,“Inducing a Failed State in Palestine,” Survival 49 (2007): 7–39.

45Eilen Kuttab, “Women and the Current Intifada,” Between the Lines 2 (2001): 4–6.46Rema Hammami and Salim Tamari, “The Second Uprising: End or Beginning?” Journal of Palestine

Studies 30 (2001): 6, 18.47Roger Heacock, “Seizing the Initiative, Regaining a Voice: The Palestinian Al-Aqsa Intifada as a Struggle

of the Marginalized” (unpublished paper, 5th Mediterranean Social and Political Research Meeting, IUE,Montecatini, Italy, 2004): 15.

48On overcentralization, see Mudar Kassis, “Civil Society Organisations and Transition to Democracy inPalestine,” Voluntas 12 (2001): 35–48.

49Majdi al-Malki, “Entraide sociale et clientelisme en Palestine,” Etudes rurales 173–74 (2005): 201–18.Majdi al-Malki, “Le systeme de soutien social informel et les relations de neo-patrimonialisme en Palestine,”Les Annales de l’Autre Islam 8 (2001): 171–87. See also Heacock, “Seizing the Initiative.” These two workshighlight how the h. amula structure has been used for political purposes mostly by Fatah and the Islamistsectors. Caroline Abu-Sada suggests that some professional NGOs (in the field of agriculture) have also usedthe repertoire and networks of the h. amula (and of notable families) in the last years. See Caroline Abu-Sada,“ONG et construction etatique, l’experience de PARC [Palestinian Agricultural Relief Committees] dans lesTerritoires Palestiniens, 1983–2005” (PhD diss., Institut d’Etudes Politiques, 2005), Part III. On the manytransformations of the Palestinian h. amula, see the classic work of Abner Cohen, Arab Border-Villages inIsrael: A Study of Continuity and Change in Social Organisation (Manchester: Manchester University Press,1972).

50A similar argument is made about the Arab Muslim world in general by Krenawi and Graham, “Principlesof Social Work.”

51Despite the level of professionalization of secular NGOs, they may not compete successfully against theIslamist social network, precisely because these secular NGOs rely “primarily on foreign funding rather thangrassroots participation.” See International Crisis Group, Islamic Social Welfare Activism, 26, fn. 183, 3, and12.

52Quoted in Heacock, “Seizing the Initiative,” 26. The survey is the Participatory Poverty Assessment,Relationship between the Poor and the Different Institutions: Learning from the Poor (Ramallah: Ministry of


Planning and UNDP, 2004). See also Jean-Francois Legrain, “La dynamique de la ‘guerre civile’ en Palestine,”Critique Internationale 36 (2007): 148.

53Interview with Majeed Nasser ed-Din, board member, Hebron Zakat Committee, Hebron, 12 February2004.

54Caroline Abu-Sada, Amer Madi, and Ahmad Uweidat, Food and Agriculture Organization, StrengtheningResilience: Food Insecurity and Local Responses to Fragmentation of the West Bank (Jerusalem: U. N. Foodand Agriculture Organization, 2007): 44–47.

55Formally, they are detached from the parties, and the board of directors is multipartisan. Yet the networkof organizations with which they work and the public positions these NGO leaders take clearly demonstrate acontinuation of links (even if not formally institutionalized) with the party.

56Source from author’s database.57Despite these renewed efforts, many interviews conveyed the sense that these urban-based NGOs are

actually perceived by people in the periphery as urban organizations active mostly in central zones of theOPTs.

58The issue of “meta-NGOs” that redirect funding to smaller NGOs can best be exemplified by the NGOproject run by the Welfare Association since the mid-1990s. It is now in its third phase. For an overview,see http://www.pngo-project.org (accessed 10 December 2007). See also Challand, Palestinian Civil Society,chaps. 6, 7.

59Interview with Iyaad Surour, public relations officer, Ihsan Charitable Society, Hebron, 11 February 2004.60Source from author’s database.61We are speaking here of the locations where the organizations were registered. Some large or medium-

sized NGOs are active in villages or refugee camps but are registered elsewhere. Source from author’sdatabase.

62Mustafa al-Barghouthi, “Popular/Mass Movement in the Community,” Journal of Refugee Studies 2(1989): 128.

63See www.who.int/hpr/NPH/docs/declaration_almaata.pdf (accessed 14 December 2007); SocratesLitsios, “The Long and Difficult Road to Alma-Ata: A Personal Reflection,” International Journal of HealthServices 32 (2002): 709–32.

64Barghouthi and Giacaman, “The Emergence of an Infrastructure,” 80, fn. 27, 84.65Interview with Salah Abdel Shafi, director, Gaza Community Mental Health Programme, Gaza City,

2 February 2003.66Dr. Haydar Abdel Shafi headed the Palestinian delegation to the Madrid conference in 1991 and was later

elected to the PLC in 1996.67Interview with Dr. Haydar Abdel Shafi, president, Red Crescent Society for the Gaza Strip, Gaza City,

2 February 2003.68Interview with Zakaria al-Ba–lousha, secretary general, Family Association of Majdal, Beit Lahiya,

1 February 2003.69Interview with Khamees al-Battran, chairman of the north Gaza branch, Family Association of Yafa,

Jabaliya Refugee Camp, 1 February 2003.70Yezid Sayigh, Armed Struggle and the Search for State. The Palestinian National Movement, 1949–1993

(Oxford: Oxford University Press, 1997), chap. 4.71Interview with Nora Qort, board member, Palestinian General Union of Charitable Societies, Beit Hanina,

23 January 2004. Following quotes from the same interview.72Interview with Iyaad Surour, public relations officer, Ihsan Charitable Society, Hebron, 11 February 2004.73Ibid. See also the interview with Baasem Natsheh, public relations officer, Patient’s Friends Society

(running al-Ahli Hospital), Hebron, 11 February 2004.74Interview with Izzo Ghrayb, board member, Tarqumya Charitable Society, Tarqumya, 10 February

2004.75Interview with Maajed –Aloush, board member, Union of Charitable Societies of Jerusalem, 28 January

2003.76Western donors, however, should not be treated homogenously, because they have variegated ways of

working with local organizations. See Challand, “The Evolution of Western Aid.”77See Jeffrey C. Alexander, “The Paradoxes of Civil Society,” International Sociology 12 (1997): 115–33.

For a counterview, see Iliya Harik, Democracy and the Paradoxes of Cultural Diversity. Beyond the Veil ofDifference (Byblos: UNESCO, 2003).


78See Abdel-Shafi, Civil Society and Political Elites.79Rema Hammami, “Palestinian NGOs since Oslo. From NGO Politics to Social Movements?” Middle

East Report 214 (2000): 18. The multiplication of dakakın was also engineered by USAID, which preferredcreation of new NGOs to funding NGOs with credentials that could be difficult to verify.

80On this tension, see Sheila Carapico, Civil Society in Yemen. The Political Economy of Activism in ModernArabia (Cambridge: Cambridge University Press, 1998): 4–8.

81Mohammad I. al-Madhoun, “Hal al-Qawi al-Islamiyya –Ajiza –an al-Musharaka al-Mujtama–iyya al-Fa–ila?” (Are Islamic Forces Incapable of Having an Effective Social Participation?) Al-Quds al-Arabi, 27July 2004.

82Interview with Majeed Nasser ed-Din, board member, Zakat Committee Hebron, Hebron, 12 February2004. See also Abu-Sada et al., Strengthening Resilience, 46.

83On the 10th cabinet, see http://www.jmcc.org/politics/pna/pagovmar06.htm (accesssed 14 December2007). For a sociological analysis of the Palestinian cabinets and of the proportion of civil society actors, seeBenoıt Challand, “Palestinesi contro. Una storia lunga quarant’anni,” LIMES—Rivista Italiana di Geopolitica5 (2007): 57–77.

84LeVine and Salvatore, Religion, Social Practice, and Contested Hegemonies, 18.85See Roy, “The Transformation of Islamic NGOs”; International Crisis Group, Islamic Social

Welfare, 12.

Documents

A NAHḌA OF CHARITABLE ORGANIZATIONS? HEALTH SERVICE PROVISION AND THE POLITICS OF AID IN PALESTINE