Health care access and satisfaction in Judean and Samarian communities: opportunities for improving care

Access to health care is a key factor that can affect health system effectiveness and health inequity [1, 2]. Inadequate access can affect health care quality for the individual and raise the burden of disease for society [3]. The term “access” can involve more than just availability of care, but also other elements of receiving health care such as a feeling of connection with providers or language concordance [1, 4].

These latter measures overlap with patient satisfaction, which can affect both clinical outcomes for patients as well as economic outcomes such as patient retention and malpractice claims [5]. Level of satisfaction with health care services can vary among populations within a country, leading to health inequity [2].

Patient satisfaction and access can be considered important elements of patient centered care with a relationship existing between them [2, 6], and with each potentially influencing the other [5, 7, 8]. This approach to care is a topic growing in interest and importance, and has been shown to be related to better quality of care, although its impact can vary [9, 10].

In addition, patient satisfaction and access can be related to each other in both directions. Accessibility affects the satisfaction of the patient with his treatment [6], and studies have found a positive correlation between patient satisfaction and greater health care continuity and accessibility [11, 12].

OECD countries, in general, are increasingly concerned with access and patient satisfaction, and Israel is no different [13]. Since 2009, the Israeli Ministry of Health has undertaken initiatives to reduce health inequity [14, 15]. Among the program’s goals is removing obstacles to appropriate access to health services, yet it has not focused on Judea and Samaria, commonly known as the West Bank.

Judea and Samaria is a large region, with about 5% of the population of the State of Israel living there – almost 400,000 residents [16]. Israel has four health plans, called “kupot”, equivalent in many ways to Health Maintenance Organizations (HMOs) that cover and coordinate patient care for residents of Israel, although non-citizens may need to pay additional fees to obtain coverage [17]. However, there may be inadequate access to care for residents of Judea and Samaria despite Israeli universal health care. There are distinctive challenges to adequate health care service provision in this region that are important to understand and try to overcome. Most of the Jewish communities in Judea and Samaria are relatively small cities and villages, which are dispersed over a wide area, and typically have limited transportation access [16]. There is also evidence of a clinician shortage in the region [18, 19].

While there have been a number of studies investigating access to care and satisfaction for the Arab population in this area [20–23], to our knowledge none have focused on the Jewish communities of Judea and Samaria. There have been studies on health care access and patient satisfaction of Israelis in general, but they have either omitted Judea and Samaria or had limited success in recruiting respondents from this area [13, 24, 25]. This study aims to contribute towards filling that gap, with important implications for improving population health.

We hypothesize that there are distinctive barriers to health care access and satisfaction in these communities, with important implications for achieving appropriate health service use patterns and potentially improving health in this region.

The study population was randomly sampled based on a phone list within each community where possible, supplemented by a face-to-face convenience sample. A maximum of one person per household was selected. Both landline and cellphone numbers were used. About 90% of respondents were reached by telephone, with the remainder interviewed face to face. They were initially attempted to be reached by landline and if not successful an attempt made to reach them by cellphone. The proportion of landline reached by landline, cellphone, or in-person was not tracked.

Surveys were administered by trained students at Ariel University in Samaria. Interviews were conducted in Hebrew. Of the 322 households that were approached, the final sample included 246 residents over the age of 20 living in the six target communities responded, 76.4% of the households. Data were collected from October 2015 through January 2016. No identifying information was collected. The study was approved by the Ariel University ethics board.

The questionnaire was based on a survey instrument developed and used by the Myers-JDC Brookdale Institute (MJBI) for a national satisfaction survey typically conducted every 2–3 years [24]. It consisted of about 70 questions with sections that focused on access to health care, patient satisfaction, health services utilization, branch and staff hours, health status, and demographics. Respondents were asked to rate their level of satisfaction for a variety of services: very satisfied, satisfied, not so satisfied or not satisfied.

Descriptive analyses were performed for all variables. Bivariate analyses for key access and satisfaction measures were performed for the six target locations as well as for other demographic variables; chi-square statistics were produced to test for significance of differences. Comparisons were also made with results, where available, for Israelis in general, using data from the 2016 MJBI survey; Z-ratios were produced to test for significance of the differences between proportions in two samples.

Although Israeli residents of Judea and Samaria were found to regularly utilize the health care system, their level of satisfaction with health services was both suboptimal in itself as well as lower than Israel’s general population, especially in terms of wait times and doctors’ attitudes, an important element of patient-centered care [9]. In addition, there were significant differences among communities for most access and satisfaction measures.

While there have been a number of articles related to the health care access of Arab residents in the region studied [19–23], there have been almost none focusing on the primarily Jewish areas that we researched. One reason for the paucity of literature on this topic may be because it involves a politically sensitive and often controversial geographic area.

The authors believe that the topic is one that warrants attention for a number of reasons. Health is a human right and all of the area’s residents should receive appropriate access to and quality of health care [26]. In addition, findings that improve the health of one group of residents in a region can also benefit other groups in the area. The authors believe the research questions addressed in this study are important ones, regardless of one’s geopolitical opinions, and that the findings make a valuable contribution, with important implications, discussed further below.

Israel has universal health insurance and all the health plans provide a basic and uniform basket of services to all citizens [17]. However, access to care is more than just coverage, often a primary focus of initiatives in some other countries. Given the issues with wait times, referrals, and distance as a barrier, it is likely that health care resources in the area need to be increased. Not all Israeli health plans operate branches in all localities in the region. Moreover, even for branches and clinics that are operating in the region, not all health services are always provided.

There is also a shortage of providers. For example, there are only 3 doctors and 1.5 nurses per 1000 people in Judea and Samaria, both far less than other regions in which Israelis reside [18, 19]. This gap can affect satisfaction level with health services, as patients wait longer to see a doctor, and forego medical care because of wait times.

A review of opening hours for clinics for the four health funds in the region found a diversity of practices. While some clinics had regular evening hours, many either did not have evening hours or when they did, it was for a limited number of days and only until early evening. Although respondents were not asked which specific clinic they used, the limited hours indicate adequate availability of doctors and nurses may be a problem for certain population segments for whom it is difficult to visit providers during working hours. This is consistent with findings, indicating substantial dissatisfaction with doctor hours, especially specialists. Expanded hours of clinics in Judea and Samaria should be considered.

Our findings indicated that problems include not just quantity of services but quality and satisfaction with services offered, indicating a potential need to improve some elements of patient-centered care in the region. Within plans, patients can choose their community-based physicians, both primary and specialist, from physicians affiliated with the plan [17]. Despite this, the majority of respondents are less than very satisfied in almost every category and at levels generally lower than those of Israelis in general, especially attitudes of the clinical staff as well as ease of getting referrals.

A recent study found variations in selected hospital-based procedures by region in Israel including several categories in which utilization for Judea and Samaria [27] was below the Israeli average. The study hypothesized that access to care issues could be a factor in the variations. Our study provides support for this hypothesis, but also that satisfaction may be related to variations.

Interestingly, despite the percentage of respondents who reported low satisfaction with health care services, many reported greater confidence in receiving optimal care and ability to pay for treatment compared to the general population. It is not clear why this is so, although the percentages are still relatively low so this seeming paradox may be an artifact of the percentages for Israelis in general being unexpectedly low.

The issues found in our research appear to be system wide, with virtually no significant differences in outcomes by health plan. However, there were important variations by locality, with the worst results generally found among the regional councils, which contain many small villages. This is consistent with respondent reports of distance being a barrier, as well as literature showing that small and isolated rural villages may have especially limited health care access [28].

The study’s findings make important contributions to a topic where research is lacking and results suggest initiatives that can be taken to improve access and satisfaction among Israelis living in Judea and Samaria. In addition, future research can build upon this study to help understand how to improve health care for diverse populations in the region. Taking steps to improve access and patient satisfaction can affect the timely and efficient delivery of health care as well as potentially reducing health inequity, compared to Israelis in general.