Health Insurance for Persons with Disabilities: Real Practices or Pure Wishes?
By Rima Canawati
The Palestinian law on the rights of persons with disabilities No. 4/99 stipulates that “the state shall guarantee health services that are included in the government health insurance free of charge both to the individual with disability and to his/her family.”
Unfortunately, the law has not yet been implemented. However, an agreement was reached between the General Union of Disabled Palestinians (GUDP) and the Palestinian Ministry of Social Affairs during the second Intifada that allows persons with disabilities to access government health insurance and enable them to receive health care services for 60 shekels to be paid once. A few years ago, this fee was cancelled and persons with disabilities became entitled to free government health insurance. Nevertheless, children and adults with disabilities are entitled to health insurance for themselves and not their families, unless the head of the household himself/herself has a disability.
Before obtaining health insurance, persons with disabilities should first be referred to a district level medical committee to determine their disability percentage, since only those with a disability percentage of 60 percent or more can be entitled to health insurance under the current regulations; although the Palestinian Law No. 4/99 on the rights of persons with disabilities asserts that all persons with disabilities are entitled to health services covered by the government health insurance free-of-charge regardless of the disability percentage.
The health service providers in Palestine are the Palestinian Ministry of Health, non-governmental organisations, the private sector, and UNRWA. NGOs are still the main service providers in the rehabilitation sector, providing national, intermediate, and grassroots-level rehabilitation services as well as assistive devices.
Health services are restricted to health centres, general hospitals, and private clinics in addition to rehabilitation centres, whereas many specialised health services are still lacking, particularly in the public sector. The majority of patients seek these specialised services within the NGO and private sectors, if available; otherwise, they seek those services abroad being self-referred or, when entitled to public health insurance, referred by the Palestinian Ministry of Health, which covers approximately 70 to 90 percent of the cost of treatment incurred depending on the period during which the person has been insured (i.e., 70 percent for those newly insured, 80 percent for those insured for the past three months, and 90 percent for those insured for at least one year.
Treatment expenses for civil servants, public workers, and persons with disabilities are 95 percent covered, while those for the staff of the Ministry of Health and the Intifada injured are fully covered. The referral decision has to be made by the National Referral Committee situated in Ramallah, which might take a long time before a decision is acted on unless the patient has personal contacts with top government officials. Those who have these personal relations can also get referrals to NGOs, the private sector, or abroad, even if the same services are made available by the public sector.
The continuous movement restrictions, especially with the construction of the separation Wall that has divided the Palestinian territories into isolated cantons, has led to the establishment of specialised health services at the district level by NGOs and actors in the private sector to meet the emerging needs of the Palestinian population. Nevertheless, patients with public health insurance still need to access the health services they are entitled to from public hospitals in other districts, rather than being referred to NGOs despite difficulties encountered in access and expenses given the deteriorating conditions in the country, not to mention the quality differences between the health services rendered by the public sector on one hand and those rendered by the NGO sector on the other.
Patients entitled to public health insurance may avail themselves of primary level health services at primary health clinics in rural areas and secondary level health services at general public hospitals in cities whenever needed; patients without disabilities have to pay fees for public health insurance (around 960 shekels per year).
It is important to note that the health system in Palestine has been overburdened due to increased emergency demands as a result of the rising number of conflict-related injuries, the tight siege imposed on the Palestinian territories, and the continuous decline of the Palestinian economy. The country is currently experiencing severe constraints: an apparent lack of specialists and qualified medical and paramedical human resources, a considerable shortage of medical supplies and technical resources, which in turn has adverse effects on the quality of the health services rendered.
Not all persons with disabilities have equal access to health care services in Palestine; particularly those who come from poor families and live in remote rural areas. A significant number of them face problems accessing the needed specialised health services that are unavailable in the public sector because the referral system is quite bureaucratic, centralised, and ineffective.
In general, there are no conditions for obtaining health insurance as long as end users pay the required fees that the majority of the population cannot afford due to the sluggish economy stifled by continued Israeli restrictions on trade and movement. Thus, everyone is entitled to public health insurance; public workers are usually insured by the Palestinian Authority but the Palestinian health system remains inefficient.
As for persons with disabilities, they can access public health services, made available to them when their disability percentage exceeds 60 percent, as per the Jordanian law of 1951. This does not correspond to the Palestinian law on the rights of persons with disabilities No. 4/99, which has not yet been implemented due to severe financial constraints on the part of the Palestinian Authority. The disability percentage is decided by a designated medical committee at the district level appointed by the Ministry of Health. Unfortunately, the disability issue was overlooked by the Palestinian government in its last health development plan, which indicates that it is not a priority on the political agenda under the prevailing conditions.
Government health insurance fees amount to 960 shekels per family per year. However, the person, whether with or without disability, should also cover five to thirty percent of his/her treatment expenses when referred to NGOs, the private sector, or abroad, depending on the period during which he/she has been insured, as explained earlier. Public workers are automatically covered by the Palestinian Authority.
According to World Bank reports, more than 66 percent of the Palestinian population live below the poverty line. Almost all persons with disabilities in Palestine also subsist below the poverty line. Persons with disability are among the most disadvantaged persons in the world and are often over-represented among the poorest of the poor. The situation is more complicated for persons with disabilities in Palestine due to the deteriorating conditions that make it very difficult to break the vicious cycle of disability and poverty.
At any rate, there are no official disability and poverty related statistics available in Palestine; nor are there official statistics regarding the number of persons with disabilities who do not have adequate health insurance in Palestine; but in principle, all persons with disabilities are entitled to public health insurance. However, even persons with disabilities who do use their health insurance do not receive adequate, quality health services since the health system and infrastructure in Palestine have been damaged under the deteriorating conditions; public health services often lack human and technical resources and even medical supplies.
It is important to point out that the lack of health care coverage for persons with disabilities in Palestine has negative implications for the early detection, identification and proper diagnosis of disability as well as for early intervention. In addition, it causes further complications in the person’s health condition as well as increased disability and mortality rates among persons with disabilities.
Rima Canawati is a self advocate with visual impairment who has a master’s degree in special educational needs from Lancaster University, UK, and 16 years of work experience in the disability field. She is head of Special Education and Community Programs at the Bethlehem Arab Society for Rehabilitation. Rima is keen on promoting the human rights of persons with disability.