Siege, a process of political domination aimed at isolating an entire population, represents a unique threat to healthcare provision. This study is a qualitative examination of the impacts of siege on the practices and systems that underlie health in Gaza. The siege has significant and deliberate deleterious effects on the provision of medical care, and exacerbates problems present in Gaza’s overtaxed medical services. Methods Data are from participant observation conducted over a period of eight years (2009-2017), along over 20 interviews with doctors and health administrators in the Non-Governmental Organization (NGO), Governmental, and United Nations sectors. These data were analyzed using a critical political economic framework, based largely on the concepts of primitive accumulation, accumulation by dispossession, surplus populations, and de-development. These analytical frames are developed to interpret neoliberal trends in healthcare systems organizing and financing as they apply in the distorted social and economic context of siege. Findings The elimination of political sovereignty through the twin processes of occupation and siege are the primary impediments to the successful promotion of public health in Gaza. Findings indicate that siege impinges on effective healthcare provision through two central, intertwined processes: withholding materials and resources and undermining healthcare at a systems level. These strains pose considerable threats to healthcare. Gazan society is continually divested of any of the underpinnings necessary for a well-functioning sovereign health care infrastructure. Instead of a self-governing, independent system, this analysis of health care structures in Gaza reveals a system that is comprised of captive clients who are entirely dependent on Israel, international bodies, and the aid industry for goods and services, with no means of independent development. Interpretation This study points to the importance of foregrounding the geopolitical context for analysis of medical service delivery within conflict settings. While the siege creates a seemingly unique economic context for analysis of health care provision, critical analyses that deconstruct the depredations of neoliberalism in the health care setting provide a useful framework for analysis of the failings of the Gazan health care sector. Indeed, health care providers are in an impossible position of attempting to provide quality care without the ability to coordinate with their colleagues in other sectors, in the face of an occupying force that refuses to abide by its obligations under international law. The final analysis also highlights the importance of advocating for sovereignty and self-determination as related to health systems.