The Palestinian Economy. Theoretical and Practical Challenges

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Abu-Zaineh – Mataria
5. Discussion
In this study we sought to extend the analysis of inequality in health care utilisation
beyond the standard methods that have dominated the literature. A more elaborated
decomposition approach that allows rectifying the commonly used standard
decomposition methods has been attempted. The microsimulation-based decomposition
was applied to various levels of health care proper to health care delivery in the two
Palestinian regions: the WB and GS. Results presented in the paper shed lights on the
degree of inequality associated with each level, as well as the factors underlying
horizontal inequity.
Results revealed that socioeconomic inequalities were responsible for the majority of
inequity in the utilisation of all levels of health care. Using microsimulation, the
decomposition approach was able to identify the contribution of each socioeconomic
variable integrated in the model. On the whole, income itself was found to be invariably
the most important contributor to the pro-rich inequity. We know that income is more
likely to have an impact on utilisation in countries where either financial or non-financial
access costs differ by income levels (van Doorslaer, Wagstaff et al. 2000). In addition,
the more unequally the income is distributed, the stronger its contribution to inequality in
utilisation would be – as we also know from the results of international comparisons of
equity in health (van Doorslaer, Masseria et al. 2006). The degree of income inequality in
the two Palestinian regions were found in (Abu-Zaineh, Mataria et al. 2008) to be quite
high. Perhaps equally noteworthy, is the variation in the contribution of income by levels
of care, which was found to be large enough to counterbalance the pro-poor distribution
of need for the costly care – secondary and tertiary-levels – compared to primary-level.
The decomposition analysis clearly confirmed the importance of heterogeneity in
behaviour in generating inequity in health care utilisation. In effect, by estimating
separately the model for each SES group, the microsimulation exercise was able to detect
potential differences in utilisation behaviour amongst different subgroups of population.
By so doing, we have shown that about 30% of horizontal inequity was due to
heterogeneity in behaviours with respect to the rank in income distribution. As noted
earlier, this feature of inequity could not be explicitly elucidated in previous research
where the standard methods were applied. Interestingly, the breakdown of behaviour by
participation and conditional usage demonstrated that, without exception, the probability