Abstract
Gaza's health system has been devastated by a confluence of political determinants that long predated the 2023-25 Israeli military assault and were dramatically intensified during it. Using historical, political economy, ethical, and health systems lenses, this article argues that settler colonialism, military occupation, and a protracted blockade created chronic shortages, workforce erosion, and institutional fragility, leaving services acutely vulnerable to targeted destruction of facilities and personnel. We examine the role and limitations of international medical deployments and field hospitals, which provided lifesaving care but operated under stringent access controls, supply interdictions, and security risks. Short rotations, poor continuity of care, and donor restrictions that discourage engagement with local authorities contributed to parallel systems, fragmentation, and dependency. We then identify four intersecting barriers to reconstruction: ongoing blockade and humanitarian access denials; lack of protection and accountability for attacks on health; governance fragmentation and the sidelining of Palestinian leadership; and donor fatigue amid politicised aid. The article proposes a justice-centred pathway for recovery that prioritises accountability and reparations, an end to the blockade and occupation, inclusive Palestinian-led governance, alignment of aid with national plans, avoidance of parallel structures through early transition to local ownership, workforce stabilisation, and long-term partnerships. Without these political preconditions, reconstruction efforts will remain fragile and inequitable.