Health care policy in Palestine: challenges and opportunities Motasem Hamdan, Ph.D. School of Public Health, Al-Quds University, Jerusalem [email protected]

Health care policy in Palestine: Health care policy in Palestine: challenges and opportunitieschallenges and opportunities

Motasem Hamdan, Ph.D.Motasem Hamdan, Ph.D.School of Public Health, School of Public Health,

Al-Quds University, JerusalemAl-Quds University, Jerusalem

[email protected]@med.alquds.edu

Health care policy in PalestineHealth care policy in Palestine 22

Outline Outline Introduction Introduction

Overview about the Palestinian health care systemOverview about the Palestinian health care system

Recent policy changes: Recent policy changes:

– financing financing

– provision of servicesprovision of services

Public policies on private for-profit health sectorPublic policies on private for-profit health sector

– Characteristics Characteristics

– Factors affecting emergence and growthFactors affecting emergence and growth

– Role in provision of health careRole in provision of health care

– Impact on availability and accessibility Impact on availability and accessibility

Conclusions Conclusions


Introduction: historical backgroundIntroduction: historical background

1993 the Oslo peace agreement and the 1993 the Oslo peace agreement and the

transitional context.transitional context.

1994 the establishment of the Palestinian 1994 the establishment of the Palestinian

Ministry of Health (MOH) and the changeover of Ministry of Health (MOH) and the changeover of

authority on the health sector.authority on the health sector.

Earlier a division of the Israeli Ministry of Defense Earlier a division of the Israeli Ministry of Defense

administered the public PHC clinics and hospitals.administered the public PHC clinics and hospitals.

Reform in the health care system has focused on Reform in the health care system has focused on

financing and provision of health care.financing and provision of health care.

44

PROVISION*

The public sector: the MOH and the security forces medical services.

United Nation Relief and Working Agency (UNRWA)

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 /PATIENTS38.6% 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, premiums, and services revenues.

The Palestinian health care triangle

(Hamdan et al, 2002)


Major public policy change: Major public policy change: financing health carefinancing health care

1. Increasing the governmental

or public spending on

healthcare.

2. Shift in the sources of public

financing from Governmental Governmental

Health Insurance (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.

Governmental (MoH) spending (1000 US$), 1993-2003

61976

8761398420

0

20000

40000

60000

80000

100000

120000

1993 1999 2003


Major public policy change: financing health Major public policy change: financing health carecare

3. Expanding the coverage of of

Governmental Health Governmental Health

Insurance scheme, by opening Insurance scheme, by opening

the scheme for voluntary the scheme for voluntary

enrolment by those who were enrolment by those who were

not required to participate and not required to participate and

reducing premiums. reducing premiums.

Palestinian families covered by the governmental health insurance scheme, 1993-2003

0

10

20

30

40

50

60

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

(Source of data: MoH, 2000; MoH 2003)


PROVISION*

The public sector: the MOH and the security forces medical services.

United Nation Relief and Working Agency (UNRWA)

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 /PATIENTS38.6% 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, e.g. remuneration of providers, user fees/ patient contributions, premiums, and services revenues.

The Palestinian health care triangle

(Hamdan et al, 2002)


Public policy: strengthening provision of Public policy: strengthening provision of health carehealth care

– Strengthening the public sector capacity in the Strengthening the public sector capacity in the

health care deliveryhealth care delivery

– Promoting the private sector role in health Promoting the private sector role in health

care deliverycare delivery


PHC clinic/centre by sector, Palestine 1994-2003

41 51 51

208170 177

205

341

391

0

50

100

150

200

250

300

350

400

450

1994 1999 2003

UNRWANGOMOH

Hospital beds by sector, Palestine 1994-2003

129294

518

12211408 1489

18112005

2614

0

500

1000

1500

2000

2500

3000

1994 1999 2003

UNRWAPrivateNGOMoH

Consistent public policy toward enhancing the public provision of health care since 1994


Provision of health care: the role of the private Provision of health care: the role of the private health sectorhealth sector

Private health sector is all individuals and organisations Private health sector is all individuals and organisations working outside the direct control of the government, working outside the direct control of the government, including for-profit and not-for-profit initiatives e.g. NGOs.including for-profit and not-for-profit initiatives e.g. NGOs.

Private for-profit practices, accessibility to is determined by Private for-profit practices, accessibility to is determined by the ability and willingness to pay. the ability and willingness to pay.

The focus here is on the for-profit private sector.The focus here is on the for-profit private sector.


Provision of health care: Characteristics of Provision of health care: Characteristics of the private for-profit practicesthe private for-profit practices

Important role in providing ambulatory medical care.Important role in providing ambulatory medical care.

Significant growth in private for profit practices after Significant growth in private for profit practices after

1994.1994.

Prevalence of private practices in the West Bank more Prevalence of private practices in the West Bank more

than in Gaza Strip due to economic reasons. than in Gaza Strip due to economic reasons.

Concentration in the urban areas.Concentration in the urban areas.

Mainly focus on curative medical care.Mainly focus on curative medical care.

1212

Ambulatory health clinics/centres by sector, Palestine 1994-2003

0

200

400

600

800

1000

1200

1400

1994 1999 2003

MOHNGOUNRWAPrivate

•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

Role of the private for profit sector in the provision of health Role of the private for profit sector in the provision of health care in Palestinecare in Palestine


Number of private (for profit) health facilities by type of service, the West Bank 1998- 2003

385

346

258

352

103

236

23 21

400

309

569

664

183

31 19 21 30

0

100

200

300

400

500

600

700

1998

2003

Role of the private for profit sector in provision of health Role of the private for profit sector in provision of health care in Palestine: recent growthcare in Palestine: recent growth


Distribution of hospital beds by sector, 1994-2003

1,852

2,217

2,614

1,1961,322

1,489

151288

518

0

500

1000

1500

2000

2500

3000

1994 1998 2003 1994 1998 2003 1994 1998 2003

Governmental beds NGO beds Private beds

Gaza West BankPalestine

Role of private sector in the provision of hospital services


Hospital beds by sector, 1994-2003

2614

1196

1489

151288

518

38 38 58

1852

2217

1322

0

500

1000

1500

2000

2500

3000

1994 1998 2003

MoH

NGOs

Private

UNRWA

Role of private sector in the provision of hospital services: recent growth


Reasons behind the growth of the private Reasons behind the growth of the private sectorsector

A public policy towards promoting private health provision seems A public policy towards promoting private health provision seems

evidentevident..

– Lack of proper regulating processes e.g. accreditation and Lack of proper regulating processes e.g. accreditation and

licensing of private facilities is very weak.licensing of private facilities is very weak.

– Shortages of the governmental capacity in providing health care Shortages of the governmental capacity in providing health care

e.g. contracting out the private sector for providing tertiary health e.g. contracting out the private sector for providing tertiary health

care.care.

Other factorsOther factors

– Prospects of political stability and economic security in the post-Prospects of political stability and economic security in the post-

Oslo periodOslo period

– Donor driven policies towards promoting the private sector, Donor driven policies towards promoting the private sector,

decrease state involvement in health care provisiondecrease state involvement in health care provision..

Health care policy in PalestineHealth care policy in Palestine 1717(Source: MoH)

Impact on the availability of health services

Private for-profit practices by type and region, 2003

0

100

200

300

400

500

600

700

General clinic Specializedclinic

Dental clinic Pharmacies Labs X-RayCentres

SurgicalCentres

Hospitals

West Bank

Gaza


Private for-profit practices: Impact on the Private for-profit practices: Impact on the accessibilityaccessibility

Accessibility to private for-profit practices is Accessibility to private for-profit practices is

determined by the ability and willingness to pay for determined by the ability and willingness to pay for

services.services.

However, 65% of population are living below the However, 65% of population are living below the

poverty line (2US$ per day) as of 2003.poverty line (2US$ per day) as of 2003.


Private for-profit practices: Impact on the Private for-profit practices: Impact on the accessibilityaccessibility

Health insurance schemes and coverage of private services:Health insurance schemes and coverage of private services:

1.1. Governmental Health Scheme (GHI) about 38% of the Palestinian households Governmental Health Scheme (GHI) about 38% of the Palestinian households

enrolled, but covers only public providers unless they referred for care not enrolled, but covers only public providers unless they referred for care not

available by the MoH.available by the MoH.

2.2. UNRWA system serve registered refugees, about 15% of the Palestinian UNRWA system serve registered refugees, about 15% of the Palestinian

households. UNRWA also covers services available at its clinics, yet outsource households. UNRWA also covers services available at its clinics, yet outsource

some limited services from private providers. Patients have to contribute to the some limited services from private providers. Patients have to contribute to the

cost.cost.

3.3. Private insurance schemes, covers about Private insurance schemes, covers about 7. 8% of the households and covers 7. 8% of the households and covers

specific packages of services.specific packages of services.

4.4. About 40% without About 40% without any health insurance coverageany health insurance coverage..


ConclusionsConclusions

Weakness of the public capacity to provide health care has Weakness of the public capacity to provide health care has

contributed to the flourishing of the private health sector.contributed to the flourishing of the private health sector.

Policies of promoting the private sector have had positive impact on Policies of promoting the private sector have had positive impact on

the availability of services, but created inequitable patterns of the availability of services, but created inequitable patterns of

accessibility between different socio-economic groups.accessibility between different socio-economic groups.

Integration and complementarity policies accompanied with Integration and complementarity policies accompanied with

appropriate regulation and monitoring by the government (the Ministry appropriate regulation and monitoring by the government (the Ministry

of Health) are necessary. of Health) are necessary.

2121

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%

2222

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%


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%


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%


Growth of hospital beds by sector, Palestine 1994-2003

20

11

91

1813

80

0

10

20

30

40

50

60

70

80

90

100

MoH NGOs Private

Sector

% 1994-1998

1998-2003

Documents

Health care policy in Palestine: challenges and opportunities Motasem Hamdan, Ph.D. School of Public Health, Al-Quds University, Jerusalem [email protected]