Healthcare in the times of increased adversity: changes in out-of-pocket payments, treatment seeking behaviours, and public-private mix in the Gaza Strip

Abstract

AIMS AND OBJECTIVES OF THE RESEARCH: This thesis aims to increase understanding of changes in access to and affordability of healthcare in the Gaza Strip, especially after socioeconomic conditions began to deteriorate in the territory with the start of the first intifada in1987. This aim is addressed by studying changes in three key areas: (i) the extent and distribution of out-of-pocket payments for health-related products and services; (ii) household experiences of care-seeking in the mixed health system; and (iii) the nature of the mixed (public / private sector) health system in the Gaza Strip.

DATA AND METHODS: Investigation of these phenomena, and changes in them, have been pursued through quantitative and qualitative methods. In relation to area (i), a secondary quantitative analysis of 11 repeated rounds of the Palestinian Expenditure and Consumption Survey (PECS) between 1996 and 2017 was conducted. In relation to area (ii), 29 qualitative interviews with 33 householders were completed. In relation to area (iii), review of academic and grey literature, complemented by 17 key informant interviews in the Gaza Strip, was undertaken.

RESULTS: Out-of-pocket payments were broadly stable between 1996 and 2017. The incidence of catastrophic health expenditures increased in 2017, driven by a significant decrease in household budgets. However, the socioeconomic distribution of out-of-pocket payments, and of catastrophic expenditures, have changed over time after 2007, with the burden shifting to richer population groups. Although out-of-pocket payments and their catastrophic burden were not high by international standards, their impact on poverty were consistently very high, indicating that paying out of pocket was able to push the near-poor into extreme poverty.

The consistent relatively low levels of out-pocket payments reflect the continuous reliance on publicly-provided healthcare among most people, which is complemented by incidental use of private sector among those who can afford. The change in the socioeconomic distribution of out-of-pocket payments after 2007 has occurred in parallel to the emergence of an environment conducive to the growth of private sector.

There has been a rise in the number of private hospitals and their activities in the context of overstretched and underfunded government hospitals. This suggests that the change in the socioeconomic distribution of out-of-pocket payments resulted from a re-configuration of the health system into more social stratification.

CONCLUSION: This research provides new understanding of the changes in the scale, share, composition, burdens, and socioeconomic distribution of out-of-pocket payments, and connects the results of this analysis to the changes in healthcare-seeking experiences and to the incipience of a socially stratified mixed healthcare system in the Gaza Strip.