Utilization of Health Services

Table 4.8 During your illness, did you consult a physician: Per cent (cases)

	Per cent (cases)	Acute illness and/or injuries	Consulted physician
All	2441	25	23
Age
15-19	373	17	13
20-39	1244	22	19
40-59	526	29	26
60+	297	45	42
Sex
Men	1214	25	22
Women	1226	26	23
Main region
Gaza	959	17	16
West Bank	1004	31	27
Arab Jerusalem	477	23	15
Region
Greater Gaza City	313	17	17
Gaza town/village	332	12	12
Gaza Camp	313	21	19
WB town	399	31	28
WB villages	517	28	24
WB camp	87	50	46
Arab Jerusalem	478	23	15
Refugee status
Non-refugee	1359)	26	23
Urban camp	319	27	24
Rural camp	77	36	34
Refugee, not camp	644	23	19
Camp status
Gaza, ex. camps	646	14	14
WB ex camps	916	29	25
Arab Jerusalem	478	23	15
Camps	400	29	26
Wealth
0-30%	740	31	27
31-66%	872	25	23
67-100%	827	21	18

The results show a very close connection between what people perceive as illness and injury and the actual use of medical services. Academic medicine - doctors, nurses, etc - dominates, just as it generally does in industrialized countries. Traditional healers are only contacted by about 1 in 10 (12%) of those who perceive themselves as being ill, and most of these people also contact a physician.

Table 4.9 During your illness - have you consulted somebody? Answers are not exclusive. Per cent.

Physician	89
Nurse/pharmacist	22
Traditional healer	12
Treated yourself	14
Other	1
N= 623

Israeli Jews normally have very high rates of utilization of primary health care services (Schuval, 1992). According to data from the Israeli Central Bureau of Statistics (Israel, Central Bureau of Statistics, 1988), an average member of the Jewish population in Israel visits a physician about 10 times per year, while amongst the non-Jewish population each person goes to see a physician about 3 times per year on average. In the occupied territories, the rate of visits to physicians is 6 per adult per year, according to the FAFO survey. Because of differences in demographic composition and health care systems, one should be wary of direct comparisons between countries. It is still interesting to note that data from the United States (US Department of Health and Human Services, 1989) shows rates for selected western countries varying between 2.4 in Portugal and 2.7 in Sweden, and 7.4 in Belgium and 10.7 in Italy. In other words, the rates found in the occupied territories seem well within the range normally found in European countries.

Utilization rates do not necessarily reflect health conditions in a population, and may not say much about the quality, the appropriateness and the effectiveness of the health care services that are offered. A major determinant of the utilization of primary health care services is, simply, availability. The present data indicates that the availability is satisfactory for most of the population, although there is, of course, some variation between groups and areas.

Women and men alike tend to utilize health services once they have defined themselves as ill or injured. Internationally it is often found that women utilize health services more than men do, but this is not the case in the present survey, when excluding visits connected with pregnancy and childbirth (table 4.10). Women are more inclined to seek help at private clinics than men are (50% vs 40%), while men are treated at government clinics and hospitals more often than women are (17% vs 10%). This probably owes to the fact that many men work in Israel. The tendency to utilize health services is strong in all age groups, but it also increases with age.

Table 4.10 Where did the consultation take place? Per cent (cases)

- = less than 10 persons	Respon- dents	Private clinic	UNRWA clinic	Government clinic or hospital	Charitable clinic or hospital	Popular committee clinic,	Consultant came to my home	Other
All	567	45	16	14	10	3	4	8
Age
15-19	57	36	19	19	-	-	-	16
20-39	246	49	12	9	13	4	5	6
40-59	137	40	19	16	11	-	-	10
60+	127	49	16	18	-	-	-	-
Sex
Men	251	40	15	17	10	2	4	10
Women	316	50	16	10	10	-	3	6
Main region
Gaza	153	29	36	25	-	-	-	-
West Bank	296	52	9	9	11	4	5	9
Arab Jerusalem	118	29	-	27	-	-	-	-
Refugee status
Non-refugee	322	53	-	15	13	4	5	8
Urban camp	72	22	56	14	-	-	0	-
Rural camp	23	44	44	-	0	-	0	-
Refugee, not camp	148	41	21	11	9	-	-	12
Camp status
Gaza ex camps	92	42	19	28	-	-	-	-
WB ex camps	261	53	4	9	13	5	5	10
Arab Jerusalem	118	29	-	27	-	-	-	-
Camps	96	28	54	12	-	-	-	-
Wealth
0-30%	197	34	28	14	7	-	-	12
31-66%	206	53	12	14	7	5	-	-
67-100%	164	49	-	12	17	-	-	8

Refugees both inside and outside camps seem to consult health personnel and institutions as frequently as others do. The difference is that they utilize UNRWA services to a greater extent. UNRWA services are particularly important to those living in camps and to refugees in Gaza. However, private clinics and government clinics are used also by refugees, although less so by camp dwellers.

Charitable clinics play a certain role for some groups, while popular committee clinics and home visits play only a minor role. Pharmacies are without importance as places to go for consultation. The category labelled 'other' is quite large, but it is not clear what this signifies.
Recent descriptions and assessments of the health care services in the occupied territories are provided in both Israeli (Schuval, 1992, Israel Ministry of Health 1992) and Palestinian reports (Barghouti and Daibes, 1990, 1991a, 1991b, 1991c). To a certain extent, these documents evaluate the quality of health care services, although their conclusions are conflicting.

As a conclusion, the availability of health care services seems good and quite fairly distributed both socially and geographically. This may be an indication of a social welfare system which serves to counteract inequality and a skewed distribution of other resources. UNRWA seems to play an important role in this process, being an organization that serves many of those who have the least resources - i.e. the many refugees and poor in Gaza, and refugees in camps.

Maternal and Child Health Care Services
It is generally assumed that the provision of maternal and child health care services can have an impact on fertility behaviour by reducing infant mortality, and by providing family planning and counselling services to couples. However, only a small share of health services provide family planning assistance. In addition, it should be noted that most of the health care resources are found in the urban areas and the centre of the West Bank, leaving especially the north and south of the West Bank with a shortage of basic health services (Barghouti and Daibes 1990, 1991a, 1991b, 1991c). For instance, 64% of the communities in the Jerusalem and 53% in the Ramallah districts have access to prenatal care services, whereas numbers are but 30% in the Jenin, 38% in the Tulkarm and 20% in the Hebron districts. This information has been obtained from the Health Development Information Project Data Base for 1992. Note that the Gaza Strip is generally well served by UNRWA-operated clinics and has a good system of pre- and post-natal care, with the exception of family planning services.

This section is based on the reports of women under the age of 50 years who have one or more children under the age of five. These women represent 56% of the total number of married women that are studied. Of these, 32% have one, 36% have two and 32% have three or more children under the age of five. When asked about their pre- and post-natal history in relation to the last child, 69% report having had pre-natal care, making 3 or more visits during the pregnancy, whereas 22% made 1-2 visits and the rest made but a referral visit or had no care at all (9%).

No correlation has been found between age or family wealth status and regular pre-natal care. The women's educational level, however, is a relevant factor. 59% of those with 0-6 years of schooling have made 3 visits or more, the number increasing to 71% among those with 7-19 years of schooling. This finding has not been corrected for age or number of children.

Geographical residence also appears to be of importance. 67% of the urban women, 63% of the village women and a high 79% of the camp women, report receiving adequate care, reinforcing the notion that when services are accessible, as in the case of UNRWA services, women tend to use them. What adds further weight to this argument is the finding that 87% of the women from the central West Bank area and 70% of the Gaza Strip women report receiving adequate care, as opposed to 59% of the women from the north and a low 54% of the women from the south of the West Bank. This is in line with the previously noted distribution of health services, reconfirming the lack of basic services in the northern and the southern parts of the West Bank.

A surprising 64% of those who have received pre-natal care report having been examined by a gynaecologist/obstetrician, followed by 38% by certified midwives, 15% by a general practitioner and 1% by a traditional birth attendant. This indicates the end of the era when traditional birth attendants figured prominently in local communities. 33% of these women have made use of UNRWA clinics. We note that a high per centage (46%) were given assistance in private clinics, and a low, but not surprising per centage (18%) by governmental health services - the majority of primary health care services in 1992 were provided by the Palestinian non-governmental and private sector -, and that 5% were given assistance at charitable societies, 13% in hospital (probably referral), 1% through committee services and the rest at home.

An attempt to identify those who seek pre-natal care in private practice reveals no correlation to age, education or wealth status. However, 51% of the women in urban areas, 48% in villages and 32% in camps seek private services for pre-natal care. Likewise, 27% of the women in the Gaza Strip, 43% of the women from the central area of the West Bank, 71% of the women from the north and a very high 88% of the women from the south of the West Bank seek private practice for pre-natal care. Those who seek private care differ little from those who do not as to regularity - three visits or more.

This analysis does suggest that financial considerations do not actually determine where care is sought. The primary determinant of where to seek care appears to be accessibility related to distance from domicile.

To summarize: First, the use of regular pre-natal care is influenced by education. The more educated the woman, the more likely that she will receive regular care. Second, regular pre-natal care is in part contingent upon area of residence. Village women and women from the south of the West Bank have a drawback, reflecting the overall skewed distribution of health services in the occupied territories. Geographical distance clearly affects women's willingness to seek regular care during pregnancy. Third, and supporting this argument, pre-natal care in private practice is not associated with age, education or family wealth status, but rather with residence. Urban women seek private care to a greater extent than other women, as most of the private practitioners are found in urban areas. Gaza Strip women use private care less than others, reflecting the readily accessible and regular services provided by UNRWA.

These results combined thus support the notion that when a system of adequate pre-natal care is available, women are in fact likely to utilize such services. Otherwise, they may skip medical follow-up.

al@mashriq                       960715