1. Health care policy in Palestine: challenges and opportunities
Motasem Hamdan, Ph.D.
School of Public Health,
Al-Quds University, Jerusalem
First of all I would to thank the organisers for providing me the opportunity to give a presentation in this important conference, in fact this is my second time. In Stockholm conference I talked about human resources for health policy development in Palestine after Here, in this presentation I will focus on the recent policy changes with regard to financing and providing health care in Palestine and especially those concerning the role of private health sector and its impact on the availability and accessibility to health care.

2. Health care policy in Palestine
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
The outline of my presentation. In the beginning, my be it is useful to start with the a historical background and general overview of the current Palestinian health care system, then the recent health policy changes with regard to financing and provision of healthcare and within that the public policy on private for-profit health sector, the characteristics of this sector, its role in providing health care, factors affecting its emergence and growth, and its impact on the availability and accessibility to health care. I will finish with some conclusions.
Health care policy in Palestine

3. 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.
Since the Oslo Peace agreement in 1993, the context is characterized by political and economic destabilization.
The authority over the Palestinian health care system was transferred to the Palestinian in Earlier a division of the Israeli Ministry of Defence administered the public clinics and hospitals. Since the changeover, fundamental changes in the system have taken place; the most discernible of these have been in the governmental health services. Reforms included expanding and enhancing health care provision capacity, improving the management, developing of human resources, and adjusting of public financing and health insurance scheme. The aim of these reform initiatives was to reconstruct the system and to assure the provision of appropriate services for the entire Palestinian population. I will come back to these issues later in my presentation.
Health care policy in Palestine

4. The Palestinian health care triangle
PROVISION*
The public sector: the MOH and the security forces medical services.
United Nation Relief and Working Agency (UNRWA)
NGOs
Private for-profit
The Palestinian health care triangle
(Hamdan et al, 2002)
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).
This model provides a summary of the structure of the Palestinian health care, where the system is characterised by heterogeneity of public and private provision and funding arrangements.
As shown in the figure health care is financed by a mixture of resources, the main source is private out of pocket spending, then public spending through taxation and revenues of the Governmental Health Insurance, third international sources and finally by non-governmental sources.
The only available data about the sources of financing is from This data show that private out of pocket spending were about 37%, public spending, were about 32%, external resources including UNRWA’s fund were 24%, and NGOs spending were about 7% of total health funding. However current estimations suggests that private spending is much higher than this figures, and might reach up to 80% of the total spending (PCBS, 2005).
* 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.

5. Major public policy change: financing health care
1. Increasing the governmental or public spending on healthcare.
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.
Now major policy changes concerning health care financing after the changeover can be summarized in three areas:
first Increasing the public spending on healthcare as shown in the figure public spending increase from around 62 million US$ in 1993 to about 99 million in 2003.
Secondly, shift in the sources of public spending with reliance on general tax revenues in stead of the revenues of the GHI; for example the percentage of GHI revenues decreased from 19% in 1991 to only 8% in 1997.
1993
1999
2003
Health care policy in Palestine

6. 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.
The third major policy change with regard to financing has been 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. This public policy has impacted positively on the number of households enrolled in the public insurance scheme where the number rose from 20% in 1993 to reach 53% in 1999, but then regressed to 39% in 2003 after eruption of Palestinian Intifada due to decrease in the number of voluntary insurance because of the economic crisis.
(Source of data: MoH, 2000; MoH 2003)
Health care policy in Palestine

7. The Palestinian health care triangle
PROVISION*
The public sector: the MOH and the security forces medical services.
United Nation Relief and Working Agency (UNRWA)
NGOs
Private for-profit
The Palestinian health care triangle
(Hamdan et al, 2002)
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).
As for the provision, health care is provided by four sectors:
The public sector represented mainly by the MOH, provides all kinds services for free to those covered by the GHI. Some other services such as immunization, prevention, and mother and child care are provided for free and to every body.
The United Nations Relief and Working Agency, UNRWA, established in to serve registered Palestinian refugees.
An important non-governmental not-for profit sector focusing on the marginalized groups.
A gradually growing private for profit health sector, providing services for those able and willing to pay.
* 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.
Health care policy in Palestine

8. 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
In the area of health care provision there has been a consistent policy towards strengthening health care provision in order to assuring appropriate services for the entire Palestinian population. This has been witnessed both in the public as well as in the private health sectors.
Health care policy in Palestine

9. Health care policy in Palestine
Consistent public policy toward enhancing the public provision of health care since 1994
In the public sector, the number of governmental health facilities increased significantly since For example the number of governmental PHC clinics increased from 205 in 1994 to 391 clinics in 2003 with an increase of 97.3%, and the public hospital beds increased from 1852 in 1994 to reach 2614 in 2003 with an increase of 41%.
Health care policy in Palestine

10. 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.
The other important sector in providing health care is the private health sector, which includes all those working outside the direct state control both the for and not-for profit practices e.g. NGOs.
But within this sector our focus is on the private for-profit practices, those accessibility to is determined by the ability and willingness of the people to pay for services.
Health care policy in Palestine

11. Health care policy in Palestine
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.
These are the general characteristics of the private for-profit health sector in Palestine which is similar to those in other countries:
It has an important role in providing ambulatory medical care services, and mainly focuses on curative medical care.
It is prevalent where the well-off population is concentrated for example in Palestine in the urban areas and in the West Bank more than in Gaza Strip due to economic reasons.
It has significant grown after 1994 with the prospects of peace and stability.
I will go deeper into these issues.
Health care policy in Palestine

12. Role of the private for profit sector in the provision of health care in Palestine
Based on the available data this figure provides a comparable data about ambulatory care clinics and centres in Palestine and their recent growth in comparison with services provided by other sectors between this shows that the private for-profit health sector constitutes an important source for ambulatory health care services in comparison with other sectors.
Yet, it is important to indicate that those facilities owned by the Ministry of Health, UNRWA and NGOs are PHC clinics and centres from different levels, and those owned by the private for profit sector consists of the practices of self employed dentists and GP’s as well as specialised physicians.
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

13. Health care policy in Palestine
Role of the private for profit sector in provision of health care in Palestine: recent growth
This figures shows more detailed data about the types of services mainly provided by the private for-profit sector in the West Bank, where the private practices are more prevalent than in Gaza Strip.
These services are: dental clinics, GP and specialists practices, pharmacies, medical laboratories, radiology and imaging centres, physiotherapy clinics, and maternity and obstetrics hospitals.
The figure also shows the recent considerable growth in the number of these practices between 1998 and 2003, where the most important increase have been in the number of dental clinics and private pharmacies, which were doubled over the same period. This increase is due to graduation of many pharmacist and dentists from local universities which started these programmes after 1994.
Health care policy in Palestine

14. Health care policy in Palestine
Role of private sector in the provision of hospital services
If we Look at the role of for-profit private sector in provision of hospital care, we can see that private for-profit beds form a small percentage of the total available beds in Palestine, only about 11% in It worth mentioning that 13 out of the available 21 private hospitals in the West Bank are very small maternity and obstetrics hospitals (about 47% of the private beds in Palestine (MoH, 2003)). This is due to the high fertility rates among Palestinians and the shortness of length of stay at these hospitals.
Health care policy in Palestine

15. Health care policy in Palestine
Role of private sector in the provision of hospital services: recent growth
Similar to public and non-governmental sectors, there has been a significant increase in the number of for-profit beds since For example the total number of private beds in 1998 was twice of 1994 level, and in 2003 it was more than three times of 1994 level.
Health care policy in Palestine

16. 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.
Given the considerable growth of the private for-profit health care supply that has been witnessed lately, it seems evident that there has been a public policy trend towards promoting private health care provision based on the conviction that the private sector can positively contribute to the provision of health care services. Many factors have affected the growth of the sector:
the a lack of proper regulating processes of the private sector for example the accreditation and licensing of private facilities is very weak.
The shortages of the governmental capacity in providing health care e.g. the MoH is contracting out tertiary health care from private providers.
However, we believe that there are other factors which have also played an important role in the increase in private sector such as:
The prospects of political stability and economic security in the post-Oslo period,
And finally , the donor driven policies and there influence towards promoting the private health sector.
Health care policy in Palestine

17. Impact on the availability of health services
Regarding the impact of private for-profit health sector on the availability of services, this figure presents the numbers and types of the licensed for-profit private practices by regions. Based on these and earlier comparable figures two main conclusions can be made:
1. There are many services that are considerably made available by the for-profit private sector such as:
Specialized medical services
Day care surgery services
Hi-tech radiology and imaging services
Specialized dental care services
Advanced medical laboratories
And from hospital care basically maternity and obstetrics services.
However, these services are less prevalent in Gaza than in West Bank, where the socio-economic conditions is better. And even in the West Bank, these services are mainly available in urban areas, lesser in rural and almost not available in the refugees camps where poverty is widespread.
(Source: MoH)
Health care policy in Palestine

18. 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.
As for the impact of the private for-profit practices on the accessibility to health services, we say in principle the accessibility to the private for-profit services is determined by the ability and willingness to pay. Given that currently about 65% of the population are living under the poverty line which means less than 2 US$ per day, and also due to the fact that private for profit services are not cheep we can conclude that the accessibility is very limited.
Health care policy in Palestine

19. Private for-profit practices: Impact on the accessibility
Health insurance schemes and coverage of private services:
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.
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.
Private insurance schemes, covers about 7. 8% of the households and covers specific packages of services.
About 40% without any health insurance coverage.
But, there is another important factor in determining the accessibility to private for-profit practices which is the health insurance. Therefore in order to examine the accessibility to private for profit services it necessary also to look at the available health insurance schemes and their coverage packages.
In Palestine people can be can be divided into four groups according to health insurance coverage:
1. The Governmental Health Scheme (GHI) covers about 38% of the Palestinian households, but this insurance covers only public providers unless they referred to private sector for care not available by the MoH. Most of these cases are limited to tertiary care.
2. UNRWA system serve registered Palestinian refugees, about 15% of the households. UNRWA also mainly covers services available at its clinics, yet it outsource limited services from private providers, but patients have to contribute significantly to the cost of services.
3. Private insurance schemes, covers about 7. 8% of the households and covers specific packages of services.
4. And lastly, about 40% without any health insurance coverage, among them the well off who prefer to purchase their own health services.
In conclusion, given the available insurance schemes in Palestine and their coverage we can say that the utilisation of private for-profit services is largely dependent on the out of pocket spending, and that creates inequity in accessibility between different socio-economic groups.
Health care policy in Palestine

20. Health care policy in Palestine
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.
To conclude In Palestine, weakness of the governmental capacity to provide health care and lack of proper regulating mechanisms have contributed to the flourishing of the private health sector, both the for-profit and not-for profit sectors.
Although, policies of promoting the private health sector have had positive impact on the availability of medical health services, however, it has created inequitable patterns of accessibility between different socio-economic groups.
Therefore, adequate integration and complementarity policies accompanied with appropriate monitoring and regulation by the government (the Ministry of Health) are necessary to improve the efficient use of limited resources, improve the quality of care and can at the same time offer choice alternatives to patients.
Health care policy in Palestine

21. 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 births
12.7
Population covered by the GHI scheme
38%
Population is living under poverty line (less than US$2 per day) (%)
65%

22. 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 births
12.7
Population covered by the GHI scheme
38%
Resources
Hospital beds per 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%

23. Health care policy in Palestine
Main causes of death all age groups, 2003
Heart disease 20.1%
Cardiovascular disease 11%
Conditions in prenatal period 9.7%
Malignant neoplasm 9%
Transport accidents 7.5%
Other accidents 7.5%
Senility 5.7%
Pneumonia 4.8%
Diabetes mellitus 4%
Renal failure 3.4 %
Infectious diseases 2.9%
Health care policy in Palestine

24. Health care policy in Palestine
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

25. Health care policy in Palestine