Health care policy in Palestine:
challenges and opportunities
Motasem Hamdan, Ph.D.
School of Public Health,
Al-Quds University, Jerusalem
mhamdan@med.alquds.edu
Outline
Introduction
Overview about the Palestinian health care system
Recent policy changes:
– financing
– provision of services
Public policies on private for-profit health sector
– Characteristics
– Factors affecting emergence and growth
– Role in provision of health care
– Impact on availability and accessibility
Conclusions
Health care policy in Palestine
2
Introduction: historical background
 1993 the Oslo peace agreement and the transitional
context.
 1994 the establishment of the Palestinian Ministry of
Health (MOH) and the changeover of authority on the
health sector.
 Earlier a division of the Israeli Ministry of Defense
administered the public PHC clinics and hospitals.
 Reform in the health care system has focused on
financing and provision of health care.
Health care policy in Palestine
3
PROVISION*
 The public sector: the MOH and the
The Palestinian health
care triangle
security forces medical services.
 United Nation Relief and Working Agency
(UNRWA)
(Hamdan et al, 2002)
 NGOs
 Private for-profit
FINANCING
• Private: out of pocket spending (37%).
• Public: general taxation, GHI
premiums, services charges (32%).
• External funds: including UNRWA’s
financing (24%).
• NGOs (7%).
[World Bank, 1997]
SOCIETY /PATIENTS
 38.6% covered by the Governmental
Health Insurance scheme, (MoH, 2003)
 14.8% covered by UNRWA , registered
refugees (PCBS, 2004)
 7. 8% covered by private insurance
schemes, and (PCBS, 2004)
 About 40% without any insurance
coverage (PCBS, 2004).
* Some overseas providers are contracted for tertiary care.
Health care services relationship e.g. supplies, coverage and entitlement.
Monetary relationships, e.g. remuneration of providers, user fees/ patient contributions,
4
premiums, and services revenues.
Major public policy change:
financing health care
Governmental (MoH) spending (1000 US$), 19932003
1. Increasing the governmental
or public spending on
healthcare.
120000
98420
100000
2. Shift in the sources of public
financing from Governmental
Health Insurance (GHI)
revenues to more based on
general tax revenues; GHI
premiums were 19% of
public spending in 1991 to
be 8% in 1997.
87613
80000
61976
60000
40000
20000
0
1993
Health care policy in Palestine
1999
2003
5
Major public policy change: financing health
care
3. Expanding the coverage of
Governmental Health
Insurance scheme, by opening
the scheme for voluntary
enrolment by those who were
not required to participate and
reducing premiums.
Palestinian families covered by the governmental health
insurance scheme, 1993-2003
60
50
40
30
20
10
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
(Source of data: MoH, 2000; MoH 2003)
Health care policy in Palestine
6
PROVISION*
 The public sector: the MOH and the
The Palestinian health
care triangle
security forces medical services.
 United Nation Relief and Working Agency
(UNRWA)
(Hamdan et al, 2002)
 NGOs
 Private for-profit
FINANCING
• Private: out of pocket spending (37%).
• Public: general taxation, GHI
premiums, services charges (32%).
• External funds: including UNRWA’s
financing (24%).
• NGOs (7%).
[World Bank, 1997]
SOCIETY /PATIENTS
 38.6% covered by the Governmental
Health Insurance scheme, (MoH, 2003)
 14.8% covered by UNRWA , registered
refugees (PCBS, 2004)
 7. 8% covered by private insurance
schemes, (PCBS, 2004)
 About 40% without any insurance
coverage (PCBS, 2004).
* Some overseas providers are contracted for tertiary care.
Health care services relationship e.g. supplies, coverage and entitlement.
Monetary relationships, Health
e.g. remuneration
of providers, user fees/ patient contributions,
7
care policy in Palestine
premiums, and services revenues.
Public policy: strengthening provision of
health care
– Strengthening the public sector capacity in the
health care delivery
– Promoting the private sector role in health
care delivery
Health care policy in Palestine
8
Consistent public policy toward enhancing the public provision of health
care since 1994
PHC clinic/centre by sector, Palestine 1994-2003
450
3000
391
400
2614
2500
341
350
2005
300
250
208 205
200
177
170
150
UNRWA 2000
NGO
1500
MOH
UNRWA
Private
NGO
MoH
1811
1408
1489
1221
1000
100
50
Hospital beds by sector, Palestine 1994-2003
51
41
518
51
500
294
129
0
0
1994
1999
2003
1994
Health care policy in Palestine
1999
2003
9
Provision of health care: the role of the private
health sector
Private health sector is all individuals and organisations
working outside the direct control of the government,
including for-profit and not-for-profit initiatives e.g. NGOs.
Private for-profit practices, accessibility to is determined by
the ability and willingness to pay.
The focus here is on the for-profit private sector.
Health care policy in Palestine
10
Provision of health care: Characteristics of
the private for-profit practices
Important role in providing ambulatory medical care.
Significant growth in private for profit practices after
1994.
Prevalence of private practices in the West Bank more
than in Gaza Strip due to economic reasons.
Concentration in the urban areas.
Mainly focus on curative medical care.
Health care policy in Palestine
11
Role of the private for profit sector in the provision of health
care in Palestine
Ambulatory health clinics/centres by sector, Palestine 19942003
1400
1200
1000
MOH
NGO
UNRWA
Private
800
600
400
200
0
1994
1999
2003
•MoH, NGOs and UNRWA’s sector consists of PHC clinics of different level.
•Private for-profit sector consists of self-employed GP, specialists physicians and dental clinics
12
Role of the private for profit sector in provision of health
care in Palestine: recent growth
Number of private (for profit) health facilities by type of service, the West
Bank 1998- 2003
700
664
600
569
1998
500
2003
385
400
400
352
346
309
300
258
183
200
103
100
23 31
6
23 21
19
21 30
Health care policy in Palestine
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Role of private sector in the provision of hospital services
Distribution of hospital beds by sector, 1994-2003
3000
2,614
2500
2,217
2000
1,852
Gaza
West Bank
Palestine
1,489
1500
1,196
1,322
1000
518
500
288
151
0
1994
1998
2003
Governmental beds
1994
1998
2003
NGO beds
Health care policy in Palestine
1994
1998
2003
Private beds
14
Role of private sector in the provision of hospital
services: recent growth
Hospital beds by sector, 1994-2003
3000
2614
2500
2217
MoH
2000
1852
NGOs
Private
1500
1322
1489
UNRWA
1196
1000
518
500
288
151
0
38
38
58
1994
1998
2003
Health care policy in Palestine
15
Reasons behind the growth of the private
sector
A public policy towards promoting private health provision seems
evident.
– Lack of proper regulating processes e.g. accreditation and
licensing of private facilities is very weak.
– Shortages of the governmental capacity in providing health care
e.g. contracting out the private sector for providing tertiary health
care.
Other factors
– Prospects of political stability and economic security in the post-
Oslo period
– Donor driven policies towards promoting the private sector,
decrease state involvement in health care provision.
Health care policy in Palestine
16
Impact on the availability of health services
Private for-profit practices by type and region, 2003
700
600
500
400
West Bank
Gaza
300
200
100
0
General clinic
Specialized
clinic
(Source: MoH)
Dental clinic
Pharmacies
Labs
X-Ray
Centres
Health care policy in Palestine
Surgical
Centres
Hospitals
17
Private for-profit practices: Impact on the
accessibility
Accessibility to private for-profit practices is
determined by the ability and willingness to pay for
services.
However, 65% of population are living below the
poverty line (2US$ per day) as of 2003.
Health care policy in Palestine
18
Private for-profit practices: Impact on the
accessibility
Health insurance schemes and coverage of private services:
1. Governmental Health Scheme (GHI) about 38% of the Palestinian households
enrolled, but covers only public providers unless they referred for care not
available by the MoH.
2.
UNRWA system serve registered refugees, about 15% of the Palestinian
households. UNRWA also covers services available at its clinics, yet outsource
some limited services from private providers. Patients have to contribute to the
cost.
3. Private insurance schemes, covers about 7. 8% of the households and covers
specific packages of services.
4. About 40% without any health insurance coverage.
Health care policy in Palestine
19
Conclusions
Weakness of the public capacity to provide health care has
contributed to the flourishing of the private health sector.
Policies of promoting the private sector have had positive impact on
the availability of services, but created inequitable patterns of
accessibility between different socio-economic groups.
Integration and complementarity policies accompanied with
appropriate regulation and monitoring by the government (the Ministry
of Health) are necessary.
Health care policy in Palestine
20
Demographic
Population (million)
3.73
Population growth rate
2.4%
Population under 15 years
46%
Dependency ratio
97
Median age
16.7
Life expectancy at birth
72.3
Literacy rate is among individuals aged 15+
91%
Health
Crude birth rate per 1000 population
27.2
Crude death rate per 1000 population
2.7
Infant mortality rate per 1000 live births
24
Neonatal mortality rate per 1000 live births
11
Child < 5 mortality rate 1000 live births
21
Deliveries at health institutions
95%
Maternal mortality ration 100 000 births
12.7
Population covered by the GHI scheme
38%
Population is living under poverty line (less than
US$2 per day) (%)
65%
21
Health
Crude birth rate per 1000 population
27.2
Crude death rate per 1000 population
2.7
Infant mortality rate per 1000 live births
24
Neonatal mortality rate per 1000 live births
11
Child < 5 mortality rate 1000 live births
21
Deliveries at health institutions
95%
Maternal mortality ration 100 000 births
12.7
Population covered by the GHI scheme
38%
Resources
Hospital beds per 10 000 population
12.5
Population per physicians
1200
Population per dentists
12750
Population per nurse
762
Percent of GDP spent on health
7.4%
Economic
GDP per capita US$
895
Unemployment rated
31%
Population is living under poverty line (less than
US$2 per day) (%)
65%
22
Main causes of death all age
groups, 2003
1. Heart disease 20.1%
2. Cardiovascular disease
11%
3. Conditions in prenatal
period 9.7%
4. Malignant neoplasm 9%
5. Transport accidents 7.5%
6. Other accidents 7.5%
7. Senility 5.7%
8. Pneumonia 4.8%
9. Diabetes mellitus 4%
10. Renal failure 3.4 %
11. Infectious diseases 2.9%
Health care policy in Palestine
23
Main cases of child
(0-4 age) death:
• Conditions in
prenatal period
48.4%
• Congenital
malformations 14.4%
• Septicaemia 5.4%
• Peunomia 5.1%
• Accidents 4.6%
• Sudden infant death
syndrome 4.8%
• Malformation
metabolic disorders
2%
• Heart disorders 1.7%
• Cerebral Palasy 1.6%
• Malignant neoplasm
1.1%
Health care policy in Palestine
24
Growth of hospital beds by sector, Palestine 1994-2003
100
91
90
80
80
70
%
60
1994-1998
1998-2003
50
40
30
20
20
18
11
13
10
0
MoH
NGOs
Private
Sector
Health care policy in Palestine
25