Changes in out-of-pocket payments and health-seeking behaviours in the Gaza Strip

Abstract

BackgroundPeople living in the Gaza Strip have experienced a protracted political conflict and extreme socioeconomic adversity since 1948. Economic conditions have deteriorated markedly since the onset of the Palestinian Intifada in 1987 and have been exacerbated by the economic siege after 2006. The health system in the Gaza Strip has faced additional challenges. The aim of this study was to assess how Palestinian households in the Gaza Strip experienced health care services during this period of political turmoil, socioeconomic adversity, and challenges to health services. MethodsMixed methods research (MMR) was used. The quantitative part of the MMR involved the analysis of data from ten rounds of the Palestinian Expenditure and Consumption Survey from 1996 to 2011. This survey enabled the components of out-of-pocket health expenditures and their catastrophic and impoverishing effects across the years to be measured and traced in different groups of households. The occurrence of catastrophic out-of-pocket spending was calculated at thresholds of spending 10% or more of the households' resources and 40% of their capacity to pay (non-food expenditure) for health care. The qualitative component of MMR consisted of life histories reported via semi-structured in-depth interviews with heads of households aged 46 years or older to capture changes over time in their experience with health services. The interviews were analysed using thematic narrative analysis and timeline analysis. The results of the Palestinian Expenditure and Consumption Survey and the interviews were triangulated. FindingsThe occurrence of catastrophic out-of-pocket spending was stable, with no changes between 1996 and 2011. However, vulnerable groups tended to become less exposed to catastrophic out-of-pocket spending, especially after the major deterioration of the economic situation in the Gaza Strip after 2006. The ability to pay for health care, the nature of health conditions of the households, and the accessibility and entitlement to certain health services determined their choice of health providers and influenced their health-seeking behaviours. Additionally, households had used a wide range of coping mechanisms, including self-medications, decreasing the use of private health services, and relying on social capital. Interview respondents noticed the expansion of both public and private health services, but expressed their dissatisfaction with public services. The low financial cost of using public services is coupled with other costs such as increased waiting times, perceptions of indignity, and perceived low quality of services. InterpretationsThe findings are interpreted within the political history of the Gaza Strip and its health-care system during the last three decades. The reduced occurrence of health-care-related financial catastrophe and impoverishment in the more vulnerable groups in the Gaza Strip could point to an emerging paradox of resilience and high level of household and health-system adaptation, which should be investigated carefully. FundingNone.