Establishment of a birth-to-education cohort of 1 million Palestinian refugees using electronic medical records and electronic education records.

Introduction: By linking datasets, electronic records can be used to build large birth-cohorts, enabling researchers to cost-effectively answer questions relevant to populations over the life-course. Currently, around 5.8 million Palestinian refugees live in five settings: Jordan, Lebanon, Syria, West Bank, and Gaza Strip. The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) provides them with free primary health and elementary-school services. It maintains electronic records to do so.We aimed to establish a birth cohort of Palestinian refugees born between 1st January 2010 and 31st December 2020 living in five settings by linking mother obstetric records with child health and education records and to describe some of the cohort characteristics. In future, we plan to assess effects of size-at-birth on growth, health and educational attainment, among other questions. Methods: We extracted all available data from 140 health centres and 702 schools across five settings, i.e. all UNRWA service users. Creating the cohort involved examining IDs and other data, preparing data, de-duplicating records, and identifying live-births, linking the mothers' and children's data using different deterministic linking algorithms, and understanding reasons for non-linkage. Results: We established a birth cohort of Palestinian refugees using electronic records of 972,743 live births. We found high levels of linkage to health records overall (83%), which improved over time (from 73% to 86%), and variations in linkage rates by setting: these averaged 93% in Gaza, 89% in Lebanon, 75% in Jordan, 73% in West Bank and 68% in Syria. Of the 423,580 children age-eligible to go to school, 47% went to UNRWA schools and comprised of 197,479 children with both health and education records, and 2,447 children with only education records. In addition to year and setting, other factors associated with non-linkage included mortality and having a non-refugee mother. Misclassification errors were minimal. Conclusion: This linked open birth-cohort is unique for refugees and the Arab region and forms the basis for many future studies, including to elucidate pathways for improved health and education in this vulnerable, understudied population. Our characterization of the cohort leads us to recommend using different sub-sets of the cohort depending on the research question and analytic purposes.

Classifying caesarean section to understand rising rates among Palestinian refugees: results from 290,047 electronic medical records across five settings.

BACKGROUND: Rising caesarean-section rates worldwide are driven by non-medically indicated caesarean-sections. A systematic review concluded that the ten-group classification system (Robson) is the most appropriate for assessing drivers of caesarean deliveries. Evidence on the drivers of caesarean-section rates from conflict-affected settings is scarce. This study examines caesareans-section rates among Palestinian refugees by seven-group classification, compares to WHO guidelines, and to rates in the host settings, and estimates the costs of high rates. METHODS: Electronic medical records of 290,047 Palestinian refugee women using UNRWA's (United Nations Relief and Works Agency for Palestine Refugees in the Near East) antenatal service from 2017-2020 in five settings (Jordan, Lebanon, Syria, West Bank, Gaza) were used. We modified Robson criteria to compare rates within each group with WHO guidelines. The host setting data were extracted from publicly available reports. Data on costs came from UNRWA's accounts. FINDINGS: Palestinian refugees in Gaza had the lowest caesarean-section rates (22%), followed by those residing in Jordan (28%), West Bank (30%), Lebanon (50%) and Syria (64%). The seven groups caesarean section classification showed women with previous caesarean-sections contributed the most to overall rates. Caesarean-section rates were substantially higher than the WHO guidelines, and excess caesarean-sections (2017-2020) were modelled to cost up to 6.8 million USD. We documented a steady increase in caesarean-section rates in all five settings for refugee and host communities; refugee rates paralleled or were below those in their host country. INTERPRETATION: Caesarean-section rates exceed recommended guidance within most groups. The high rates in the nulliparous groups will drive future increases as they become multiparous women with a previous caesarean-section and in turn, face high caesarean rates. Our analysis helps suggest targeted and tailored strategies to reduce caesarean-section rates in priority groups (among low-risk women) organized by those aimed at national governments, and UNRWA, and those aimed at health-care providers.

Co-payments and equity in care: enhancing hospitalisation policy for Palestine refugees in Lebanon.

BACKGROUND: This paper measures the impact of introducing a 10% co-payment on secondary care hospitalization costs for Palestine refugees living in Lebanon (PRL) in all UNRWA contracted hospitals, except for the Red Crescent Society. This ex-post analysis provides a detailed insight on the direction and magnitude of the policy impact in terms of demand by hospital type, average length of stay and treatment costs. METHODS: With a complete population episode level dataset, we use multinomial logit, negative binomial, and linear models to estimate impacts on the different dependent variables, controlling for disease, patient and hospital characteristics. RESULTS: After the implementation patients were at least 4 pp (p <0.01) more likely to choose a Red Crescent Society hospital for secondary care, instead of one with co-payment. Average length of stay was not affected in general, despite the increase in control at all UNRWA contracted hospitals. Except for the decrease in UNRWA contribution, did not find a statistically significant impact of the co-payment on costs, nor for the provider or for the patient. Findings suggest that introducing a 10% co-payment for secondary hospital care had an impact on patients' health care budget, leading to demand shifts towards cheaper options - i.e., patients had to chose care based on financial constraints rather than on their treatment preferences. CONCLUSION: Before changing healthcare payment schemes in different types of hospitals, facilities offering free of charge treatment should be assessed and prepared for potential demand shifts to avoid overcapacity and the collapse of health care services for such a fragile population. In addition, exemptions from co-payments should be considered for patients with severe health conditions and financial constraints, who, according to our results, are the most likely to change their pattern of care due to an increase in treatment costs.

Effects of change in hospital treatment payment policy for Palestinian refugees in Lebanon: a health economics analysis.

BACKGROUND: In 2016, the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) changed from covering the full cost of secondary care in contracted public and private hospitals in Lebanon, Jordan, to requesting that these hospitals pay 10% of the costs. Meanwhile, services at UNWRA-contracted Palestine Red Crescent Society (PRCS) hospitals remained fully covered. We did a health economics analysis to assess the effects this policy change on the demand for secondary care in UNRWA hospitals. METHODS: We assessed the difference in use of different types of hospital (demand) from January to May, 2016, and June, 2016, to October, 2017, before and after the payment policy change. Data were collected by UNWRA from each hospital's database, including individual-level inpatient information for 22 193 Palestinian refugees in Lebanon who were admitted to secondary care at UNRWA-contracted hospitals (public, private, and PRCS). We used regression analyses to estimate the effects on demand for the different hospital types, length of stay, and total costs of treatment to UNWRA and patients. FINDINGS: Around 64% of patients attended PRCS, 26% private, and 9% public hospitals. According to our econometric estimations, after June, 2016, patients were 16% more likely to choose a PRCS hospital over the other types of hospital. Mean length of stay in PRCS hospitals increased, leading to a 20% chance of patients staying 1 day longer in PRCS hospitals than in public or private hospitals. However, the length of stay in public and private hospitals decreased (by an average of 22% at public and 28% at private hospitals), giving an overall decrease in length of stay of 13%. In terms of bill value (ie, total costs to UNRWA and to patients), we found no difference between before and after the policy change. INTERPRETATION: The introduction of the UNWRA cost-sharing component for secondary care led patients to attend PRCS hospitals more often and for longer periods of time. The finding that no effect was seen on costs for UNRWA or patients suggests that the 10% cut in cover at public and private hospitals did not save any money for UNWRA because patients managed to accommodate the increase by changing their hospital preference The study is limited in that it cannot argue causality between the policy and the results found because there is no control group. Nevertheless, robustness testing, including assessing the year 2017, supports our results. This study contributes to the literature on the impacts of co-payments in health care in a very specific context of poverty and conflict that has rarely been subject to scrutiny and provides feedback to UNRWA on a health-care system measure, relevant for future policy designs. FUNDING: None.

Morbidity patterns among hospitalised Palestine refugees from Syria in Jordan: a population-based study.

BACKGROUND: Palestine refugees from Syria (PRS) are among the most vulnerable refugee groups for adverse health outcomes and require assistance from humanitarian agencies. As the armed conflict in Syria has continued, most Palestinians have been displaced from that country to neighbouring countries, where they have experienced difficulties in accessing essential services. More than 17 000 PRS are in Jordan as of 2018 and have received assistance from the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), including free primary care and subsidised secondary and tertiary care through contracted governmental hospitals. In this study, we investigated the morbidity patterns among PRS in Jordan receiving UNRWA-supported hospital care. METHODS: We assessed cross-sectional data extracted from the UNRWA Hospitalization Database in Jordan on Oct 18, 2018, for PRS who used UNRWA hospitalisation support between May 31, 2012, and Dec 9, 2017. The database records demographic and medical characteristics of patients and financial information for the care sought. We used descriptive statistics to reveal morbidity patterns. Analyses were done with Microsoft Excel 2016 and Stata/IC (version 15). No ethics approval was required for this study as it was conducted as a part of routine internal monitoring by UNRWA. FINDINGS: 889 PRS were included in analysis, among whom 637 (72%) were girls or women and 252 (28%) were boys or men. The age range was 1-78 years, with girls and women being younger than boys and men (28·1 years [SD 15·1] vs 31·0 years [SD 21·3], p=0·02). The most common reasons for seeking care were pregnancy, childbirth, and the puerperium (381 [60%] of 637 girls and women). Diseases of the circulatory system, digestive system, and musculoskeletal system and connective tissue were the most common diagnoses among boys and men (34 cases [14%] of 252 for each diagnosis). The mean length of stay for women (1·8 days [SD 2·0]) was slightly shorter than that for men (2·0 days [SD 2·2]) but the difference was not significant. The cost was significantly higher for boys and men (mean US$729·7 [SD 557·4] per person) than for girls and women ($326·0 [SD 1190·4], p<0·001). Of all, 886 (>99%) patients were discharged from hospital, two died, and one was transferred to another hospital. INTERPRETATION: More girls and women than boys and men sought care through the UNRWA support programme during the study period, mostly for pregnancy, childbirth, and the puerperium. However, the conditions seen in boys and men led to longer stays in hospitals and significantly higher costs. Diagnoses based on International Classification of Diseases standards should be investigated further, but this study highlights the demand for health-care services and types of care required by the PRS population. Future research should focus on identifying similarities and differences in hospital admissions for PRS compared with other Palestine refugees to inform future preventive public health efforts by UNRWA. The study examined PRS who accessed to UNRWA services only, thus the findings are not representative of PRS in general. However, this is to our knowledge the first study to present morbidity patters and differences in female and male PRS patients receiving care at UNRWA in Jordan. FUNDING: None.

Health and dignity of Palestine refugees at stake: a need for international response to sustain crucial life services at UNRWA.

The UN Sustainable Development Goals affirm equality and dignity as essential to the enjoyment of basic human rights, including the right to the highest attainable standard of physical and mental health, which promotes global solidarity among all people, including refugees. The UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) has provided support to Palestine refugees in Jordan, Lebanon, Syria, the Gaza Strip, and the West Bank since the 1950s. Today, however, conflict and violence, occupation, high levels of poverty, and other social determinants of health jeopardize the wellbeing of Palestine refugees. Health concerns include non-communicable diseases, mental health conditions, and access to hospital care. Additionally, UNRWA is continuing to face a severe funding crisis. Using a historical and health policy perspective, this Health Policy examines UNRWA strategies that facilitate continuous provision of health-care services for Palestine refugees. Given the increasingly volatile environment faced by this population, a multifaceted international response is needed to enable UNRWA to deliver sustainable services to Palestine refugees and avert further loss of life, dignity, and hope, pending a just and lasting solution to their plight in accordance with applicable international law and UN General Assembly resolutions.