Overview
Overall, the health system in Palestine is not as well established as in developed countries, with clear roles for the primary, secondary and tertiary tiers of a healthcare system. The Palestinian Ministry of Health (MoH) is the main provider of health services. Other organizations also take part in providing healthcare services. These include the United Nations Relief and Works Agency (UNRWA), local and international NGO’s, and private entities. There are around 732 primary care centers in Palestine, 147 of them are in Gaza strip, and there are around 82 hospitals, 15 of them are in Gaza strip; only two of the Gaza hospitals are major one equipped with subspecialties personnel and could be classified as tertiary referral centers. The governmental hospitals and health care centers that give the best possible services, not the ideal, due to lack of manpower, supplies and resources. Patients are frequently referred abroad, mainly to the West Bank and Israel, due to unavailable investigations, e.g. PET Scan, or treatment. The UNRWA plays a major role in the primary health care section in the country. In fact, around 70% of diabetic patients get their meds from UNRWA.

The main challenges facing all healthcare providers in Palestine include problems related to accessibility, equity, poor coordination among major providers, unregulated private sector, high utilization rates in the private sector, limited quality improvement programs, inefficient use of available resources, poor management, lack of equipment, low payment to healthcare workers, overloaded system and inappropriate health information systems. Governmental insurance, as well as other types, cover the costs of healthcare services. Services provided by UNRWA and other NGO’s are usually free of charge or charged at a lower-than-normal rate. In simple words, we could say it’s available almost all the time, but it’s not 100% reliable.

What happens if you need to see a doctor?
Due to the diversity of health care providers, there is a personal freedom of choice when seeking care according to the patient’s needs and ability to pay. In general, the role of family doctor is not so clear and patients can go directly to the secondary or tertiary healthcare center, or they can visit any specialist or consultant in his or her private clinic without a referral. However, the patient will have to pay out of pocket if they chose the private clinic.

The governmental health services are normally available, but with long waiting lines and schedules. In case of private sector, getting a doctor’s appointment is quite easy and you can access one within the same day, but only if you can pay the fees (around $20 depending on the doctor). Private patients go to private based clinics where they register, follow up, and get prescription from the doctor, paying cash for prescriptions.

Who decides what doctors can prescribe?
Theoretically, it is the Ministry of Health, which controls everything related to practicing medicine in Palestine and gives licenses for the medical and pharmaceutical industry. The MoH approves which drugs can be sold in the pharmacies, and they impose strict control measures on drugs that may cause addiction, such as opioids. Moreover, hospitals and departments usually follow specific guidelines and protocols, but doctors’ adherence to the guidelines and protocols is almost always suboptimal. In cases of reported mistakes by doctors, there is an ethical committee that takes over the investigations with the doctor and decides the appropriate discipline.

Pharmaceutical companies are very active in the marketing field. They sponsor almost all scientific events and gatherings, and sometimes they are even present in the morning meetings. As a result, many doctors prescribe based on their individual preference and their affiliation with a certain pharmaceutical company.

Practically, what is it like to live with type 1 diabetes in Palestine?
Living with type 1 diabetes in Palestine is affected by two main factors: the social and the financial level of people living with diabetes. Insulin is available in almost all the primary health care centers and pharmacies in Palestine and it is one of the ‘‘Over the Counter’’ drugs like most of the drugs in the market.

In primary health care governmental centers, the prices are mostly nominal. However, in UNRWA centers everything is free. When going out to the market, some types of mixed insulin are of low price and more affordable for low-income people. However, the other types of insulin are expensive to afford related to the income per capita scale, but as mentioned most of the diabetic patients seek their care from the UNRWA centers, which is free.

Just after the WHO updated their Essential drug list in June 2021, insulin analogue pens were added to the Palestinian government's list and were provided in all MoH hospitals and primary health clinics for nominal prices (approximately 0.5$ for a pen).

The social level plays an important role in patient access to health care and also affects their whole lives. People living with diabetes face a lot of discrimination, and society’s habits are rude when it comes to treating people with special conditions. As for the financial level, it is a major determinant of people’s access to health care as the salaries of most of the employees in Palestine are not enough to afford their monthly diabetes supplies. There is a high percentage of unemployment (46.7% among youth) and a scary percentage of poverty (about 29.2% with the highest percentage in the Gaza strip of 53%).

No glucometer is given to newly diagnosed patients in the MoH health care centers, so patients seek the NGOs to get a glucometer and monthly strips when available. That means that patients have to pay out of pocket if they run out of test strips when NGOs cannot afford the strips for them. Insulin pumps are neither present nor covered by the health insurance in Palestine.

What about getting admitted to hospital?
Admission to the hospital takes place either through the Emergency Room (ER) in the case of emergency or accident, or through a referral from a consultant or a specialist from an outpatient clinic.

It runs smoothly, and it does not take time to finish paper work. Despite the low number of beds in the ICU in the hospitals, they can usually accommodate any diabetic emergency, especially in pediatric hospitals where they have more capacity, as they don’t have to care for all specialties.

How does diabetes care vary throughout Palestine?
The density of doctors and specialists in rural areas is not as big as in cities. But in general, it’s acceptable. The huge gap is actually between the private and governmental sections as mentioned before.

A very special thank you to Mohammed Seyam for providing this information.