Determinants of and changes in catastrophic health expenditure in the occupied Palestinian territory: an analysis of ten rounds of the Palestinian Households Expenditure and Consumptions Survey (1996–2011)

Abstract

BackgroundCatastrophic health expenditure (CHE) is measured to assess the financial protection from the risk of health-related conditions, which is considered a principle performance goal of any health system. The incidence and intensity of CHE in the occupied Palestinian territory between 1998 and 2007 was assessed in previous research; however, no research has assessed the occurrence of CHE in different population groups in the occupied Palestinian territory. The objective of this study was to examine the changes in the occurrence of CHE in different groups of Palestinians from 1996 to 2011, which was a period of increasing political turmoil, transformation of the national health system, and economic hardship faced by the population. MethodsThe repeated cross-sectional series of the Palestinian Expenditure and Consumption Survey was conducted by the Palestinian Central Bureau of Statistics ten times between 1996 and 2011. Each survey asks detailed questions about a household's expenditure, including spending on health, using a diary approach. CHE was measured using a threshold of spending of 10% or more of the household's resources on health care. Total household expenditure was used as a proxy of a household's resources. The occurrence of CHE was traced from 1996 to 2011 and compared across different expenditure quantiles, dwellers of urban areas, rural areas, or refugee camps, and the characteristics of head of households within the West Bank and the Gaza Strip were compared. FindingsCHE in the occupied Palestinian territory increased from 7·3% of households in 1996 to 8·2% of households in 2011. This increase was observed in the West Bank and Gaza Strip. However, the occurrence of CHE in the Gaza Strip was consistently and significantly lower than in the West Bank. CHE was consistently higher in the worse-off expenditure quantiles in the occupied Palestinian territory and in the West Bank compared with affluent households. The change in the occurrence of CHE in different expenditure quantiles in the Gaza Strip was statistically insignificant from 1997 to 2004. From 2005 onward, the economically vulnerable groups of the households have become less exposed to CHE than affluent households. The occurrence of CHE in households in rural areas of the West Bank was consistently higher than elsewhere. Households in the West Bank with illiterate heads of family were consistently more exposed to CHE than other households, whereas the opposite was observed in the Gaza Strip. InterpretationThe findings should be interpreted within the context of the unique Palestinian situation. For example, the overburdened rural populations in the West Bank could have greater difficulty in accessing health services. The lower occurrence of CHE in the Gaza Strip and the trend towards reducing inequalities between the more vulnerable households, especially in a period of socioeconomic adversity, points to an emerging paradox of resilience in the Gaza Strip, which should be investigated carefully from the perspectives of both the health system and social lives. FundingNone.