Individual and socioeconomic disparities in health-seeking behaviours and out-of-pocket payments in the Gaza Strip in 2013: results from a household survey

Abstract

BackgroundDifferent population groups in the Gaza Strip, occupied Palestinian territory, use the services of a pluralistic health system and spend part of their income on health. Nonetheless, little is known about disparities between different populations in seeking and paying for health care. MethodsA random sample of 760 households with 5192 people in July, 2013, in the Gaza Strip, occupied Palestinian territory, were interviewed using a structured questionnaire to inquire about health-seeking behaviour and the out-of-pocket payments. The data were collected over 1 week, and respondents were asked about their use of services with different recall periods. Expenditure was annualised to calculate catastrophic health expenditure as a proportion of income (defined as spending 20% or more of household income on health). χ2 tests were done to compare differences between grouped variables. Statistical Package for Social Sciences (SPSS) version 20.0 was used for statistical analyses. FindingsCatastrophic health expenditure occurred less in households with refugee status (132 [25·1%] of 526) than in those without refugee status (77 [32·9%] of 234); this yielded to a relative risk (RR) of 0·76 (95% CI 0·60–0·96, p=0·026). The occurrence of catastrophic health expenditure in households which live inside refugee camps was less than households which live outside the refugee camps (43 [20·4%] of 209 living inside vs 168 [30·2%] of 551 living outside; RR 0·67, 95% CI 0·50–0·91, p=0·006]). Catastrophic health expenditure occurred in 138 (33·2%) of 416 households that have at least one person with a chronic non-communicable disease, and in 71 (20·6%) of 344 households with no individual with a chronic non-communicable disease (RR 1·61, 95% CI 1·25–2·06). The occurrence of catastrophic health expenditure in the households with the lowest two income quintiles was greater than households with higher income; 129 (35·5%) of 363 households in the lowest-income quintiles compared with 80 (20·15%) of 397 households in other income quintiles (RR 1·76, 95% CI 1·39–2·24; both p=0·0001). People reported having good access to health services, and preferred free-of-charge services and those offered at nominal users fees for medicines and diagnostic tests. 15 (12·3%) of 122 consultations of people who were acutely ill and from the lowest-income quintile were provided by private for profit providers, compared with 72 (28·9%) of 249 consultations from other income quintiles; relative risk of using private providers for the lowest-income quantile was 0·43 (95% CI 0·25–0·71, p=0·0088. However, a proportion of health services users sought the care of second health providers, mostly private, in addition to initially chosen ones, although this proportion did not differ among income quintiles. InterpretationRefugees who were offered free of charge primary health care services were had reduced health expenditures. People in poor households avoided using costly health services; however, they spent a higher proportion of their income on health than those wealthier households. The findings suggest that maintaining health services offered free of charge or on a low-cost basis and improving their quality and responsiveness might decrease financial burden of ill health on the poor in the Gaza Strip. FundingWorld Health Organization.