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 [19,20,21,22,23], 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].
Policy implications
The research conducted has a number of important implications. Findings indicate a need for improvement in the level of access and satisfaction in the region studied because of its distinctive characteristics, especially its isolated location and limited resources, and the barriers to optimal health care that flow from them.
It is likely that health services and other resources in the area need to be increased. An increase in clinical staff could decrease wait times and allow longer hours, both issues identified by respondents. There were variations in access by location, with inadequate access to care especially identified by some smaller localities. As a result, these areas may need special attention, including improved transportation and/or enhanced telemedicine alternatives.
It is not merely access to the health care system that appears to be inadequate, but also the satisfaction with health care services that was found to be problematic. Additional research is needed to fully understand the reasons for this, but the staff in the region may need additional training to better inculcate an ethos of focusing on the patient and/or health services provision may need to be reorganized in the region.
The study also has implications for groups other than Israelis living in the Jewish communities of Judea and Samaria. The health of populations living in proximity to each other can affect each other not only in obvious ways such as increased exposure to infectious diseases, but in less direct ways as well. For example, lessons learned for improving the access and satisfaction in smaller isolated areas can also benefit other populations, both in the same region as well as in Israel generally and in other countries.
Limitations and additional research
The study is cross-sectional and based on self-reports, with the usual potential limitations to validity and reliability related of subjective responses at a single point in time. Although steps were taken to increase representativeness of the sample, selection was not fully random, with potential for some selection bias resulting. In addition, the proportion reached by landline, cellphone, or in-person was not tracked, so whether or not the method of contact influenced and biased results could not be determined. Further, the direct connection between access and satisfaction to improved health outcomes could not be studied for the target population, although there is evidence linking patient satisfaction with positive health outcomes in general [5].
Although location was the main demographic factor associated with our outcomes during bivariate analyses, performing multivariable analyses when comparing results to national data would be useful to more accurately determine the association of living on Judea and Samaria with these outcomes, independent of other demographic factors.
Additional research in the future should examine this issue, as well as possible causes for the disparities in access and satisfaction. Replication of the study in other communities in the region would also be of value in understanding the generalizability of findings.
