A mixed methods study of using Wasta in healthcare services in Palestine: predictors, consequences and proposed solutions

Wasta, an Arabic term loosely translated to ‘clout’ is frequently used in the Arab world, utilizing social/family connections, political affiliations, and economic means. Authors El Jabari, Carol and Takruri, Adel
Published in Business & Management
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BioMed Central
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A mixed methods study of using wasta in healthcare services in Palestine: predictors, consequences and proposed solutions - BMC Health Services Research

Background Equity in access to quality healthcare is a fundamental human right. Yet studies demonstrate that some people receive preferential treatment while others are discriminated against. Wasta is a prevalent strategy whereby personal connections are used for influence and may result in gaining unfair advantages over others. This study aims to investigate wasta use in healthcare, the factors associated with its use, and the impact of wasta use on the equity and quality of healthcare services. Methods A mixed-methods study utilizing a quantitative survey and qualitative interviews was conducted in Palestine (West Bank and Gaza) between October 2021 and February 2022. Quantitative analysis was performed using Stata version 14. Bivariate and multivariate logistic regressions assessed the relationship between wasta use and individual-level variables such as gender, residence, age, employment status, and financial situation. Content analyses of qualitative transcripts were performed using Dedoose version 9. Textual quotes were grouped into major and minor themes. Results Multivariate regressions revealed that wasta use is more prevalent among refugee camp dwellers and more frequent in Gaza compared to the West Bank. Wasta was also employed to a greater degree among government employees. Qualitative interviews complemented the quantitative results and added further insights into the consequences of Wasta use in healthcare settings such as negatively impacting quality and equity in healthcare services. Conclusion Wasta use in healthcare can have an adverse effect on equity and quality. Ensuring efficient processes, reduced financial burdens, stringent accountability measures, transparency, and training programs can contribute to diminishing the need for using wasta in healthcare. By addressing both systemic and cultural factors that perpetuate wasta, societies can move closer to healthcare systems characterized by fairness, accessibility, and ethical integrity.

This unique study conducted in 2021-22 in the occupied Palestinian territories and Gaza examined the use of wasta. Examining the use of wasta in healthcare in Palestine, we employed qualitative (ten health professionals and eighteen patients from Gaza and the West Bank) and quantitative research methods, surveying more than 700 individuals. Where the official processes to reach a goal are corrupt, bureaucratic, or inefficient persons often turn to using wasta to overcome barriers. 

Participants included refugees living in camps, urban, and rural dwellers from the age of 18.  Approximately one-third (34%) stated they used wasta to get a health service in the last year, 39.3% from Gaza and 31.6% from the West Bank. Wasta is reportedly also used within healthcare institutions by some employees to gain unfair advantages over others. Our interviews also highlighted social and organizational-level predictors and consequences of wasta. The potential predictors include scarcity of resources (material, human, and financial), cultural factors, and inefficient administration. The consequences of wasta include inequities in healthcare, decreased healthcare professionals’ motivation and morale, and lower service quality.

This study considerably enriched the conceptual definition of wasta use in healthcare settings by elucidating the multifaceted mechanisms through which it manifests, its predictors, and its consequences. Wasta can be employed by utilizing social connections, political affiliations, family ties, and economic means. This study confirmed previous research about the role of organizational, social, and economic factors in causing wasta.

The utilization of wasta in healthcare leads to outcomes such as disparities, reduced staff motivation, and compromised service quality. Through wasta and social connections, some patients may gain unfair advantages over others. Our interviews revealed that when staff are promoted and rewarded through wasta or social connections rather than for hard work, dedication, or performance, inequities become manifest. These unfair practices cast a negative shadow on the institution and its services by eroding the morale and motivation of its personnel.

Predictors and consequences of wasta in countries where official processes to reach a goal are corrupt, bureaucratic, or inefficient, individuals resort to wasta to overcome oppressive processes [1]. Patriarchy, tribalism, religious and political strife, inequities, discrimination, and lack of trust in public institutions are contextual vices within which wasta proliferates [2, 3].

The higher prevalence of wasta in refugee camps and in Gaza is probably because these communities have faced disadvantages for generations, enduring various difficulties and injustices. It is possible that their perception, based on personal experiences or hearsay, is that utilizing wasta can help improve their situation. In the camps, residents are bound by a common history of forced displacements and are living in crowded conditions. Political activism is stronger in camps.

Wasta results in inequalities by depriving women and those with lower social networks from accessing opportunities [4, 5]. Wasta encourages people to invest more in social networks rather than other more useful forms of social capital [6]. Wasta could decrease the utilization of healthcare services via a lack of trust in the system. Additionally, wasta may lower healthcare providers’ motivation, satisfaction, and morale. Our interviews highlighted social and organizational-level predictors and consequences of wasta.   The consequences of wasta include inequities in healthcare, decreased healthcare professionals’ motivation and morale, and lower service quality.   

It is essential to optimize processes for efficiency, alleviate financial strains, and implement accountability measures in the healthcare domains.

  1. Horak S, Afiouni F, Bian Y, Ledeneva A, Muratbekova-Touron M, Fey CF. Informal networks: Dark sides, bright sides, and unexplored dimensions. Manag Organ Rev. 2020;16:511–42.
  2. Hutchings K, Weir D. Guanxi and Wasta: A comparison. Thunderbird Int Bus Rev. 2006;48:141–56.
  3. Alsarhan F, Ali S, Weir D, Valax M. Impact of gender on use of wasta among human resources management practitioners. Thunderbird Int Bus Rev. 2021;63:131–43.
  4. Abalkhail JM, Allan B. “Wasta” and women’s careers in the Arab Gulf States. Gend Manag Int J. 2016;31:162–80.
  5. Banihani M. Empowering Jordanian women through entrepreneurship. J Res Mark Entrep. 2020;22:133–44.
  6. Baranik L, Gorman B, Wright N. Wasta and its relationship to employment status and income in the Arab Middle East. Curr Sociol. 2021;:00113921211024705.

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