4. Health DataUNRWA's Department of Health provides health services free of charge to registered refugees. The Agency's medical care services comprise out-patient and in-patient18 medical care, dental care, rehabilitation of physically disabled persons, essential diagnostic and support services such as laboratory and radiological services, specialist and special care services and provision of medical supplies. UNRWA's health programme concentrates on provision of primary health care delivered through Health Centres, Health Points, or Mother and Child Health (MCH) clinics.19 Registered refugees have no obligation to use UNRWA's health services, nor are they obliged to notify the Agency of health-related events such as births, deaths or diseases.
What possibilities do UNRWA's health data offer for research on the health of Palestine refugees? First, it should be noted that UNRWA's health statistics primarily deal with information on UNRWA's own system, and does therefore not provide an exhaustive picture of the health situation for Palestine refugees. This is due to self-selection mechanisms with regard to utilization of health services in general, which results in a limitation of the data's coverage.
Health information collected from health institutions only covers those individuals who choose to visit such places. The 1993 FAFO report Palestinian Society found that 90% of the population in the Occupied Territories consulted a doctor during illness.20 Information recorded at any (not only UNRWA) health clinic in this area is hence representative for 90% of those persons who perceive themselves as ill, and choose to consult a doctor.
Measures of morbidity are determined both by the underlying diseases and by perceptions of illness. Because types of diseases and perceptions of illness vary between individuals and socio-economic groups, a systematic bias between the self-perceived and the "true" morbidity in the (refugee) population is likely to occur. Rates of self-perceived illness may even be inversely correlated to clinically diagnosed morbidity. This has been found in several studies where poor people with high prevalence of clinically diagnosed diseases report less illness than rich people, who may tend to categorize a wider range of conditions as illnesses (Feachem et. al. 1992).
The second type of bias due to self-selection has to do with utilization of health services and the mechanisms that determine where a person (refugee) seek health services. Such mechanisms may include the type and quality of the health services being offered by various clinics, their physical proximity to the person (refugee), and the fees charged for various services.
In the Occupied Territories the FAFO living conditions survey (Heiberg and Øvensen 1993) found a much higher use of UNRWA's health institutions among camp refugees than among refugees outside camps. Because most refugee camps are small in size, and most of them have their own health clinic, this observation may in part be due to the physical proximity of UNRWA clinics to camp dwellers.
A related and perhaps more plausible reason is economic deprivation. Because households in refugee camps are on the average economically worse off than those outside the camps21, the fact that UNRWA's services are free of charge may compensate for the long hours that must sometimes be spent in the waiting room. Due to limited budgets, UNRWA health personnel must often operate in overcrowded clinics, and doctors have short time for consultation with each patient.
Use of UNRWA health clinics may also vary among individuals in the same household. The household's willingness to pay for private or governmental health services may vary between adult men, adult women and children. Many male refugees may further have special access to non-UNRWA health services through their employers22.
Finally, regardless of socio-economic status and gender, the fact that UNRWA's health clinics do not offer adequate treatment (such as hospitalization) for particular types of illnesses may lead to a general under-reporting of such illnesses within the UNRWA disease registration system.
UNRWA's data on refugees and health are therefore representative of those refugees who chose to use UNRWA's health services, and not for the group of UNRWA refugees as such23. To be recorded in UNRWA's health statistics a person must: 1) Perceive him (her) self as ill. 2) Choose to visit a physician; 3) Choose to visit a physician at an UNRWA clinic.
This generalization problem could to some extent be solved if information could be obtained about how the group using UNRWA's health services differs from the refugee population as a whole with regard to other socio-economic factors.
Due to the incompleteness of demographic data, it is at present difficult to estimate crude birth rates, child mortality rates, vaccination coverage, etc. in the refugee population. In spite of these limitations UNRWA health data offer extensive statistical information about those who visit their clinics (see list of health data in Appendix 3). The Health Department has conducted several evaluative and research studies based on clinic records and statistics either independently or in collaboration with World Health Organization (WHO).
UNRWA's health data provide an epidemiological basis for comparative trend-analysis
of health status of the population, disease prevalence, as well as assessment
of the effectiveness of services, etc. Before proceeding we will present
a brief overview of UNRWA's system of collecting health data.
18.) UNRWA itself operates only one hospital (in the West Bank). In additon, UNRWA
helps refugees cover hospital expenses.