Mid Sweden University

Background: The epidemics of non-communicable diseases (NCDs) and war-related injuries are a significant health concerns, and are rapidly emerging as major causes of mortality and disability globally, particularly in low and middle-income countries (LMICs) such as Palestine. Health research on the epidemiology and management of NCDs and war injuries is scarce and largely neglected. Therefore, this research responds to epidemiologic and public health concerns due to the increasing incidences of NCDs and war-injuries. The objective of this thesis was to describe, characterize and analyze the burden, incidence and management of NCDs and war-related injuries in the Palestinian health system (PHS).

Methods: A combination of methods was employed in the research, including quantitative (study I and II), and qualitative approaches (study III and IV) in order to achieve the study aims and to gain a better understanding of NCDs and war injuries related issues in the PHS. For study I, the Disability-Adjusted Life Years (DALYs) framework was employed using available registry data of NCDs from 2010 to quantify the burden of NCDs, whereas, for study II a registry injuries data of the 2014 Gaza war was used to analyze the incidence and patterns of war injuries in the PHS. For study III, a qualitative focus group strategy was used to explore healthcare providers’ perspectives on NCDs and war injuries management and for study IV, a qualitative interview strategy was applied, using study topic guides to explore patients and policy makers’ perspectives of barriers to managing and delivering of care to war injured survivors or patients with NCDs. The participants were purposely selected and invited to be involved in the focus group discussions and interviews. The qualitative data were transcribed verbatim and analyzed using manifest content and thematic analysis in study III and IV respectively.

Results: The research concludes that the total burden of reported NCDs was estimated at 57/1000 and 60/1000 DALYs in the Gaza Strip and the West Bank in 2010 respectively, with each DALY being thought of as one lost year of optimal healthy life. Heart diseases were found to be the leading causes of NCDs related burden among the population (study I). Study II showed that males experienced more war injury than females with a male: female ratio of 3.1:1. Almost half of victims were of age 20-39, followed by children and individuals younger than 20 years (31.4%). The overall incidence of war injuries was 6.4/1000 of the population, but it varied among regions. Explosion or blast injuries were the major causes of war-related injuries (72.9%) in the Gaza Strip. The largest percentage of injuries were reported to be in the upper body (study II). In study III, the qualitative analysis resulted in four main themes, resulting from the accounts of the key healthcare providers. The informants frequently expressed feeling that despite some positive aspects in the health system, there were, however, fundamental changes and significant improvements are necessary to make care work better than they do now. Some expressed serious concerns about the healthcare system, suggesting that it needs complete rebuilding in order to make it work better. In study IV, important barriers were explored by patients and key-policy makers, relating to managing and delivery care to war injured survivors or patients with NCDs, including organizational/structural, availability, communication, personal/shortage of staff, and financial and political barriers. Patients had similar experiences of barriers to those of the policy makers. In addition, patients experienced socioeconomic, physical, and psychological barriers.

Conclusion: The epidemic of NCDs, especially heart disease, and the high influx of war-associated injuries, impose a substantial and heavy burden on the PHS. The health system has many deficiencies and public hospitals do not work as they should, because of many challenges and the burden of diseases in the health system. Given this evidence, immediate actions and effective interventions should be initiated to tackle the burden of NCDs and war injuries in Palestine. A clear cost-effective health policy with a focus on preventive measures should be implemented. Further research using recent data on large scale populations are important to provide further insights on the magnitude and trend of NCDs and war injuries in this problematic context. Using research evidence to develop health policy-making is vital.