Amman, Jordan

1
PRELIMINARY
WORKING SESSION
Jordan National Agenda Social Welfare
Theme Health Care
Amman, Jordan June, 2005
2
Table of Content

• Introduction
• Health Care
• Social Security
• Poverty Alleviation

Focus of This Session
3

• Introduction
• Health Care
• Social Security
• Poverty Alleviation

4
Social Welfare contributes to the achievement of
key constituents of every modern society, namely
democracy, solidarity, social organization and
economic effectiveness
Social Welfare
Social Welfare Contribution to a Modern Society
Healthy Citizens
Safe and Secure Citizens
Economically Active Citizens
Educated Citizens
Modern Society
Social Organization
Economic Effectiveness
Democracy
Solidarity
5
Social welfare covers a broad set of social
services
Social Services
All social interventions intended to enhance or
maintain the social functioning of human beings
Social Services
Health Care
Education
Welfare Assistance
Unemployment Assistance
Personal Social Services

• Providing adequate access to health care

• Providing education

• Ensuring a minimum level of income and decent
  life conditions for the vulnerable segment of the
  population

• Ensuring a safety net is put in place for the
  unemployed
• Providing vocational training and job placement
  assistance

• Providing support services for vulnerable
  segments
• Mentally ill people
• Disabled
• People with learning disabilities
• Elderly
• Abused Children

Covered in Education Theme
Covered in Employment Support Vocational
Training Theme
Source GPD Team analysis
6
Most developed countries adopt an Institutional
stance while developing countries adopt a
Residual stance towards social welfare, with
Jordan adopting a fairly balanced stance
Governments Attitude Towards Social Welfare
Sweden
Brazil
South Africa
Egypt
France
Canada
Malaysia
USA
Mexico
Jordan
Peru
UK
Germany
Developed Countries
Developing Countries
Residual
Institutional

• Government positions Social Welfare as a
  temporary necessity when the normal channels for
  meeting needs of the most vulnerable segments of
  the population fail to perform adequately
• Welfare provision is often positioned as targeted
  to the poor

• Government positions Social Welfare as a normal
  on-going function of society
• Welfare is provided for the population as a
  whole, in the same way as public services like
  roads or water might be

Source GPD Team analysis
7
Coverage of social services varies by country,
with developing countries being generally mostly
selective in their provision of social services
Social Welfare Programs by Type
Selective
Universal
Selective benefits and services are made
available on the basis of individual need,
usually determined by a test of income
Universal benefits and services are made
available to everyone as a right, or at least
to whole categories of people (like 'old people'
or 'children)
Coverage
Health Care
France
Germany
Canada
UK
Sweden
USA
Jordan
S. Africa
Mexico
Education
France
Canada
Germany
UK
Sweden
Mexico
USA
S. Africa
Jordan
Welfare Assistance
Social Services
Jordan
France
Canada
Germany
UK
Sweden
Mexico
USA
S. Africa
Unemployment Assistance
France
Canada
Germany
UK
Sweden
Mexico
USA
S. Africa
Jordan
Personal Social Services
France
Canada
Germany
UK
Sweden
Mexico
USA
S. Africa
Jordan
Source GPD Team analysis
8
Jordans social services spend, as percent of
GDP, is among the highest in developing countries
Public Social Expenditure in Selected Countries
(as of GDP) (2001)
Comments

• The Ministry of Social Development is the main
  government body responsible for the social work
  in Jordan
• Several public sector entities take part in
  social welfare activities NAF, SSC, MoH, MoPIC
  and the Family Protection Directorate (FPD)
• Government programs are designed to target the
  following vulnerable segment of the population
• Orphans
• Disabled
• Drug addicts
• Victims of domestic violence
• Elderly
• Etc.
• The main tools used to alleviate poverty are
• Cash transfer through the NAF
• Health care subsidies
• Food coupons
• Employment through income-generating projects
  (mainly though MoPICs ESPP programs)

Note () Public social expenditure in Jordan is
estimated by adding up the budgets for the
following government entities MoH, MoL, MoE,
MoHE, MoSD, RMS, NAF as well as the government
contributions to social insurance schemes (Social
Security, Pensions) Source OECD 2004 Jordan
Budget Law MoSD GPD Team analysis
9
In Jordan, social welfare costs and benefits to
society need to be balanced to ensure the right
trade-offs are made
Coverage
Public Finance

• Pressure on Government Budget
• Level of Taxation as to not Deter Economic Growth
  (i.e., corporate and individual)
• Amount of citizens financial contribution

• High Service Quality and Wide Availability
• Fair Eligibility (Universality vs. Selectivity)
• Type of Benefit (In-kind vs. In-cash)

Source GPD Team analysis
10

• Introduction
• Health Care
• Social Security
• Poverty Alleviation

11
This session is dedicated to discussing Jordans
challenges in the Health Care sector and
potential initiatives to address these challenges

• Profile the current health care providers and
  services and identify gaps in population reach
  and service provision
• Assess strength and weaknesses of the health care
  system in terms of accessibility, coverage and
  financial sustainability
• Illustrate successful health care system through
  international case study and derive lessons
  learned for Jordan
• Assess current trends in the health care sector
  and benchmark key indicators against other
  countries
• Illustrate successful programs through
  international case studies and derive lessons
  learned for Jordan
• Propose initiatives to address the challenges
  faced by the health care sector
• Propose Strategic Sector Development National
  Agenda Targets over a 10-year period

12
Jordans healthcare system ranks higher than most
countries in the region
Healthcare System Ratings (2002)
Basis of Ratings

• A-High quality care, good average health status
• Overwhelming majority of the population has
  access to a high standard care
• Health system is well balanced between primary,
  secondary and tertiary care
• B- Good quality care, good average health status
• Overwhelming majority of the population has
  access to good care, although services are
  stretched
• Healthcare expenditure is high, but insufficient
  to be close to meeting demand
• C- Mixed quality of care, mixed average health
  status
• Most of the population has access to some form of
  care, although the quality of that care is mixed
• Services often very stretched and a lack of
  doctors and facilities, particularly in rural
  areas
• D-Struggling health service, poor average health
  status
• Lack of doctors and health facilities
• Significant variations in access to healthcare
• E-Dysfunctional health system, extremely poor
  average health status
• Short supply of doctors and health facilities,
  especially outside urban conglomerations
• Significant variations in access to care, with a
  large proportion of the population lacking easy
  access

Worst
Best
Source World Markets Health of Nations 2002
13
Health care indicators are among the best in the
region and are in line with international
benchmarks
DPT Immunization for Selected Regional and OECD
Countries (As of Children Ages 12-23
Months) (2003)
Measles Immunization for Selected Regional and
OECD Countries (As of Children Ages 12-23
Months) (2003)
Births Attended by Skilled Health Staff for
Selected Regional and OECD Countries(As of
Total Births) (2002)
Malnutrition Prevalence - Weight for Age for
Selected Regional and OECD Countries(As of
Children Under 5) (2002)
Source World Development Indicators, World Bank
14
Health care is provided by three publicly-run
entities and the private sector
Health Care Providers in Jordan
Description and Eligibility
Hospital Beds and Inpatients - by Healthcare
Provider (2003)
Ministry of Health

• Provides comprehensive healthcare services at
  public hospitals and primary healthcare centers
• Administers the Civil Insurance Program

9,743
600,000
8
6
Royal Medical Services

• Primary, secondary and tertiary care provider
• Provides healthcare services to military
  personnel and their dependents, as well as
  referrals from the other public providers

19
18
University Hospitals

• Jordan University Hospital and King Abdullah
  University Hospital are teaching hospitals that
  operate primary, secondary and tertiary care
  facilities
• Serve as fee-for-service referral centers for
  other public programs and private payers

University Hospitals
32
36
Royal Medical Services
Private Sector
Ministry of Health
Private Sector

• Owns and operates both hospitals and clinics for
  primary, secondary and tertiary care
• Ranges from expensive, luxury clinics to
  independent hospitals
• Serves beneficiaries of private health plans and
  citizens willing to pay

43
37
Public Sector Entities
Source Annual Statistical Book, Ministry of
Health (2003) Jordan National Health Accounts,
PHR Health Taskforce, MOH (2003) GPD Team
Analysis
15
All Jordanians and foreigners present in Jordan
benefit from subsidized health care coverage
provided by the MoH facilities

• The whole population, i.e., foreigners and
  Jordanians, has access to MOH facilities at
  subsidized charges- Patients pay a fee, which
  consists of a symbolic fraction of the service
  cost (i.e., up to 15 of cost), with the
  remainder financed through the MOH budget
• MoH waives healthcare fees to civil servants and
  their dependents, as well as a segment of the
  population that is pre-certified as poor by the
  Ministry of Social Development
• In addition, MoH provides some of the most
  expensive treatments free of charge to patients
  who suffer from certain medical conditions (e.g.,
  cancer, dialysis, AIDS, Alcoholism and drug
  addiction, anemia) irrespective of their ability
  to pay
• The Ministry of Health has also managed to secure
  significant funds for expanding health insurance
  coverage at no cost for the beneficiary, to the
  following population categories
• Children under the age of six (310,000 children
  insured in 2004)
• One member of the families of each organ donor
  (for a period of five years), blood donors (for a
  period of 6 months)
• Certain citizens that categorized poor by the
  ministry of social development

Ministry of Health Services
Source Al Bashir Hospital- Survey of 390
patients Jordan National Health Accounts, PHR
GPD Team Analysis
16
While over 45 of the population in Jordan is
covered by insurance schemes provided by the
government to civil servant and their dependents
Covered Workforce vs. Covered Population (In
Thousand) (2003)
Public Insurance Schemes
Civil Insurance Program (CIP)

• The monthly premium for civil service employees
  is 3 of their monthly salaries, up to a cap of
  30 JD
• Features of the CIP include
• Coverage of dependents, whether the beneficiary
  is a male or a female
• No limits on coverage
• Comprehensive coverage of all medical services,
  including dental
• Patients with medical conditions not treatable
  within the MoH facilities (e.g., complicated
  heart surgery) are transferred to other
  facilities (e.g., private sector) free of charge
• Insured individuals have to pay 5 of the price
  of their medications, with a price ceiling of JD
  10
• Beneficiaries of the MoH health insurance scheme
  can seek treatment at private sector hospitals,
  but need to contribute 10-30 of treatment fee

1,110
5,200
Civil Servants Covered by the CIP
Covered by the CIP
(17)
(20)
Military Covered by the RMS Insurance
(19)
Covered by the RMS Insurance
(25)
Private Sector and Self-Employed
Other Insured or Uninsured
(64)
(55)
Royal Medical Services (RMS)

• Military personnel pay a monthly flat fee ranging
  from 2-4 JD, depending on their rank
• RMS facilities services are viewed as
  best-in-class in Jordan

Source Employment and Unemployment Survey 2003,
Department of Statistics GPD Team analysis
17
A large portion Jordanians remain not covered
by any medical insurance, which is largely driven
by the lack of incentives and loopholes in
mandatory insurance law enforcement
Comments
Distribution of Health Insurance by Type (2003)

• Private sector firms with more than five
  employees are required by law to provide health
  insurance coverage to their employees
• This law, however, is not being enforced as
  provision of health insurance to employees is
  left up to the employer
• Given the current coverage offering of the
  Ministry of Health, the uninsured people have no
  incentives to contract a health insurance
• All population has access to MoH facilities at
  highly subsidized charges, making the MoH the
  insurer of last resort
• In reality, the MoH provides subsidized
  healthcare services up to 80 coverage to the
  non-insured
• The MoH coverage may result in a disproportionate
  share of subsidies being inequitably targeted to
  higher income groups that can afford to contract
  a health insurance scheme

Urban
Royal Medical Services
Uninsured
Ministry of Health
University Hospitals
UNRWA
Private
Rural
Uninsured
University Hospitals
Royal Medical Services
UNRWA
Private
Ministry of Health
Source Ministry of Health
18
As such, in addition to financing the whole cost
of civil servant care, the public budget funds
most of the cost incurred by MoH facilities with
little contribution from the insured
MoH Budget By Source of Financing (2003)
Comments

• Public health expenditure amounts to 9 of the
  total public budget
• The MoF covers the operating deficits of
  hospitals as well as the operating costs of the
  Primary Health Care centers
• Primary Health Care Centers are accessible to all
  civil servants free-of-charge
• MoH is expanding the number of primary health
  care centers, at a cost completely borne by the
  public budget
• Those that do not have medical coverage, use MoH
  facilities at a highly subsidized price (i.e.,
  10-15 of cost)

Donors
Ministry of Finance
Contributions and User Fees
Total JD 205 Million
RMS Budget By Source of Financing (2003)
Private Firms
Donors
Other Govt Entities
Ministry of Finance
Households
Total JD 93 Million
Source Jordan National Health Accounts, PHR
19
The public sector appears to spend too much on
secondary health care, potentially due to
insufficient primary health care management and
facilities
Public Health Expenditure by Category in
Jordan (In JD Million) (1999-2003)
CAGR (1999-2003)
6.6
Total
9.1
302
G A
282
Human Resources Development
9.1
271
2
1
2
2
1
246.4
20
Primary Health Care
1
234
5.4
2
18
2
1
20
1
21
21
6.8
Hospitals (Secondary Health Care)
76
78
77
76
76
Source Ministry of Health
20
Overall, public sector expenditure is growing
fast, driven mainly by operating expenses
Government Health Care Expenditure in Selected
Countries (As of GDP) (2002)
Breakdown of Public Expenditure on Health In
Jordan (JD Million) (1999-2003)
CAGR (1999-2003)
6.6
302
282
271
Capital
4.1
18
246
19
234
Transferable Expenses
19
4
35.4
6
19
3
20
2
2
Operating Expenses
41
6.6
37
40
40
41
37
Wages Salaries
6.1
38
38
38
38
Note Transferable expenses include Social
Security expenses, various contributions and
donations, compensations to non employees,
interests and pensions Source Ministry of
Health, WHO
21
Going forward, the increasingly aging Jordan
population is expected to further strain
government budget over the next decade
Population Breakdown by Age (In Million) (2005 /
2020)
Government Health Care Expenditure (In JD
Million) (2004 / 2020)
CAGR (2005-2020)
100
100
65
5
4
5
16
40-64
6
26
x 2.6
36
35
20-39
2
45
0-19
0
33
Elderly Dependency Ratio
6
8
Note () Elderly dependency ratio is the
population over 65 divided by those between ages
15 and 64 Source US Census Bureau GPD Team
analysis
22
Recognizing the issue, the government is
increasing the number of primary health care
facilities throughout Jordan
Health Sector Initiatives and Projects (2004-2006
plans)
Project
Beneficiaries
Execution
Cost (MM JD)
Funding (MM JD)
Funding Source

• Laboratory equipment for Primary Care

Citizens / Low Income
Ministry of Health
8.01
1.346
Public Budget

• PHCI/ROC rehabilitation of HC

Citizens using centres
USAID Local firms
8
8
USAID Grant

• Build 73 Primary Health Care Centers

Citizens in rural areas
Ministry of Health
7.68
7.68
SETP

• Equipment for Royal Medical Services

Military Insurance Beneficiaries
Royal Medical Services
6.745
6.745
Public Budget

• Building for Food Drug Administration

All citizens
Ministry of PWH
6.5
1.5
SETP

• Equipment for Royal Medical Services

Military Insurance Beneficiaries
Royal Medical Services
6.473
0
Awaiting SETP

• Modernize public hospitals equipment

Citizens / Low Income
Ministry of Health
6.2
0
Awaiting SETP

• Develop Health Sector (Al Bashir)

MoH insured citizens
Ministry of Health
5.5
5.3
World Bank Budget

• Import of equipment for public hospitals

Citizens / Low Income
Ministry of Health
4.3
4.3
French and Swiss Loans

• Expand Queen Alia Center for Heart

Military Insurance Beneficiaries
Royal Medical Services
4.24
2.76
Islamic Development Fund

• Various infrastructure works for RMS

Military Insurance Beneficiaries
Royal Medical Services
3.65
3.65
Public Budget

• Furniture for public hospitals

Citizens / Low Income
Ministry of Health
3.293
3.293
Public Budget

• External Clinics

Citizens / Low Income
Ministry of Health
3.293
0.45
Korean Government
TOTAL
70.592
44.574
Source Ministry of Planning and International
Cooperation- Ministry of Health
23
As such, over 85 primary health care centers have
either been built or expanded in 2004

• Primary Health Care projects funded by SETP are
  finally underway, after several re-tendering
  iterations due to increase in budgeted
  construction costs (primarily construction
  materials)
• A total of 55 health care centers are currently
  under construction (out of the 73 planned) -
  Shortage of funds have prevented tendering the
  remaining 18 health care centers for construction
• Expansion projects for 22 existing health care
  centers have all been tendered (to be completed
  by Q2 2005)
• Renovated all publicly owned health centers with
  a plan to move out of currently rented facilities
  to publicly owned real estate
• Annual funding has also been secured by MoH (JD
  350k in 2004) for the maintenance of the 650
  existing primary and comprehensive health care
  centers
• Primary Health Care projects funded by the
  Government budget have all been progressing as
  planned
• Primary health care centers in Mafraq, Irbid,
  Karak, Balqa, Amman, Wadi Sir, completed in 2004
• Expansion of 6 existing health care centers in
  Maan, Tafila, Amman, Irbid, Mafraq and hospital
  wards in Irbid and Karak
• Remaining infrastructure projects are on hold
  until further funding has been secured

24
Other hospital projects remain mostly on hold,
due to funding shortages
Health Sector Initiatives and Projects (2004-2006
plans)
Project
Beneficiaries
Execution
Cost (MM JD)
Funding (MM JD)
Funding Source

• New Zarqa hospital

Citizens / Low Income
Ministry of PWH
35
0
-

• Rehabilitation of Al-Bashir (Ph II III)

Citizens / Low Income
Ministry of PWH
25
21.25
Awaiting funding (Saudi Fund / Islamic Bank)

• New Baqaa hospital

Liwa citizens / Low Inc.
Ministry of PWH
12.5
0
Chinese Government

• New Aqaba hospital

Citizens / Low Income
Ministry of PWH
12
0.1
Awaiting funding (Islamic Bank)

• New Al- Salt hospital / Replacement

Citizens / Low Income
Ministry of PWH
20
0
-

• Al Salt- clinics rehabilitation

Citizens / Low Income
Ministry of PWH
0.25
0
-

• Al- Quwayra hospital- Construction

Citizens / Low Income
Ministry of PWH
5
0
-

• Al Karak hospital- Construction

Citizens / Low Income
Ministry of PWH
2
0
-

• Al Amir Ben Al Hussein hospital- Constr.

Citizens / Low Income
Ministry of PWH
0.6
0
-

• Ajloun hospital

Citizens / Low Income
Ministry of PWH
0.6
0
-

• Al Nadim Hospital- Extension

Citizens / Low Income
Ministry of PWH
0.3
0
-

• Jerash hospital- Expansion and rehabilitation

Citizens / Low Income
Ministry of PWH
3
0
Jordanian Government

• Al amira Raya center- Extension

Citizens / Low Income
Ministry of PWH
0.4
0
Jordanian Government

• Abi Obeyda hospital- Extension

Citizens / Low Income
Ministry of PWH
0.1
0.1
Swiss Government

• Al Shouna al Jounoubiya hospital- Extension

Citizens / Low Income
Ministry of PWH
0.1
0.1
Swiss Government

• Ghawr al Safi hospital- Extension

Citizens / Low Income
Ministry of PWH
0.1
0.1
Swiss Government

• Amir Hamza hospital

Citizens / Low Income
Ministry of PWH
40
4.5
Arab Development Fund

• Childrens hospital

Children insured by Military
Royal Medical Services
4.5
3.775
Abu Dhabi Development Fund
TOTAL
152.45
21.65
Source Ministry of Planning and International
Cooperation- Ministry of Health
25
As a result, geographical access to public
hospitals remains uneven across governorates
Bed Penetration by Governorate (Number of Beds
per 10,000 Population) (2003)
25.5
18.1
Private Hospitals
51
17.9
Jordan Average 18
17.1
15.6
26
13.2
40
22
10.9
10.8
10.3
University Hospitals
10
21
9.1
19
8.6
19
8.4
28
Royal Medical Services
18
17
100
20
22
100
60
100
53
100
100
81
82
43
Ministry of Health
20
50
Source Ministry of Health
26
The Higher Council for Health is not operating
effectively under its current structure

• The Ministry of Health has overseen a law for the
  establishment of the Higher Council for Health
• The General Secretariat for the Higher Council
  for Health has been created and has contributed
  to a number of important activities at the
  policy-making and strategic planning levels
• Participated in a number of committees, such as
  the National Health Accounts (NHA), the Public
  Expenditure Review (PER), health information
  databases, the national plan for reproductive
  health
• Created an action plan for the Higher Council for
  Health
• Supported achievement of the first phase for the
  WHO Macroeconomics Health initiative, and the
  ongoing development a National Health Investment
  Plan targeted at poorer strata of the population
• Leading implementation of the hospital
  accreditation program
• Completed studies on the medical nursing
  situation in Jordan and dental services in Jordan
• However, the Higher Council for Health is
  currently facing a number of legislative and
  organizational challenges which are preventing it
  from operating effectively
• The Council has rarely met, due to other
  competing priorities of its members
• The law forming the council is general and vague
  on responsibilities and modus operandi
• Lack of a common understanding of the Higher
  Councils goals
• These impediments need to be swiftly addressed
  potentially involving an amendment of the law and
  organizational restructuring in order for the
  Council to effectively assume its policy-making
  and supervisory role
• Development of a National Health Care strategy
• Adoption of cost-effective practices
• Enforcement of accreditation of medical
  institutions and monitoring of service quality

27
As a result, the absence of collaborative
governance of the sector, combined with the lack
of a systematic cost evaluation framework, have
limited public-private partnerships in medical
care

• Decentralization of hospital administration is
  gradually taking place at only two hospitals to
  date The process has been slow due to the
  unavailability of a decentralization strategy for
  Government and public institutions
• Delegation of proper authority to hospital
  administrators for financial and administrative
  matters
• Programs for financial administration and
  pharmacy administration (cost accounting)
• A limited number of agreements with private
  sector hospitals, aiming at managing capacity and
  containing costs, have been concluded
• Treatment of patients covered by the MoH health
  insurance
• Pilot agreement with private sector hospitals to
  handle most obstetrics treatment cases, with the
  aim of increasing public sector competencies and
  controlling costs
• Capacity of the Ministry of Health to enter into
  a larger number of agreements is limited by the
  absence of a systematic framework to evaluate
  costs and determine controlled private sector
  involvement opportunities
• A clear strategy and action plan for creating
  further partnerships with the private sector are
  required, prior to securing the necessary funds
  for implementation
• Delegation to the private sector certain medical
  treatment services
• Partnership / Outsourcing opportunities to reduce
  public health care costs- e.g. hospital
  management, insurance management, etc.

28
And have led to a number of inefficiencies in
public hospitals

• Weak IT automation, systems standardization and
  electronic networking for the sector as a whole
• Automation of MoH hospitals is lacking well
  behind
• No specific process restructuring and automation
  initiatives have been taken to date to improve
  efficiency of operations at public hospitals
• There has been some cases of developing specific
  software for certain processes in the Ministry of
  Health, however, required funding has not been
  secured

Automation
Procurement

• A combination of efforts to benefit from a
  centralized procurement organization serving the
  Ministry of Health, University hospitals and
  Royal Medical Services is facing resistance from
  the public entities themselves
• No pooling of public tenders, preventing further
  price reduction from larger procurement volumes
• Unification of all administrative and accounting
  systems has encountered high resistance from
  concerned public health institutions and has
  therefore been cancelled from the World Bank
  Project (JO 4449)
• Implementation of a national health information
  system has started, but is only focused on very
  specific health data gathering such as death and
  morbidity statistics. Data collection and
  reporting protocols need to be agreed upon among
  all sector stakeholders

Planning

• Lack of coordination between various stakeholders
  has impeded an efficient planning of heath
  services across the Kingdom
• Heath centers construction and characteristics
  (size, services, etc,) is often decided on a
  sporadic basis
• The lack of planning is leading to
  cost-inefficiencies

29
Furthermore, MoH hospitals in-patient services
remain below citizens expectations
Al Bashir Hospital Survey (August 2004)
General Level of Satisfaction on Cleanliness
General Level of Satisfaction on Support Services
50
50
MoH facilities lack some modern medical equipment
(e.g., laser surgery equipments)
Source Al Bashir Hospital- Survey of 390
patients GPD Team Analysis
30
Emergency Medical Services suffer from poor Human
Resources and Equipments and need to redefine
its modus operandi to better service the
population
Challenges Of EMS in Jordan
What We Heard

• EMS services are provided by the First Aid Units
  of the Jordan Civil Defense
• The EMS services in Jordan are faced by a number
  of challenges
• Limited human resources skills and equipments
• Limited geographical coverage EMS are provided
  by 119 Civil Defense Centers scattered across the
  Kingdom
• Poor communication system between rescuers and
  hospitals
• Legislative barriers legislation limits the
  intervention of rescuers to basic medical
  services and fails in defining authorized areas
  of intervention and legal rescuers rights

• Human resources skills need upgrading by
  importing international expertise and using local
  skills from private sector
• Ambulances are not well equipped
• In order to improve access to EMS services, it
  is recommended to increase the number of Civil
  Defense Centers to 168
• Communication system need to be enhanced to
  ensure better liaison between hospitals and
  rescuers
• A modern legislation need to be adopted,
  protecting rescuers and defining nature of
  first-aid, specifications of medical personnel
  and ambulances, training characteristics, as well
  as minimum technical and human requirements to
  launch and operate first aid units

Source Jordan Civil Defense GPD Team interviews
31
The SAMU coordinates all EMS in France through a
highly centralized network
Emergency Response Units
Description of EMS Services

• In case of non-emergency, medical advice is given
  over the phone

Medical Advice
Private Ambulance

• In non-severe cases, a general practitioner is
  sent to check-up on the patient

General Pract.
General Practitioner
Fire Department
8

• A private ambulance is sent in case of non-lethal
  emergencies requiring transportation to the
  hospital

Private Ambul.
22
24
Less Severe
Severe
SAMU
Medical Advice
SMUR
28
18

• Fire Department ambulances are sent in
  emergencies requiring rapid transportation to a
  hospital

Fire Dept
Emergency Call
SMUR

• Service Mobile d'Urgence et de Réanimation
  (Mobile Emergency and Intensive Care Units)
• Composed of a physician, paramedic and nurse, as
  well as extensive medical equipment
• SMUR are sent in extreme cases where patients
  require immediate medical life support services
• Operate in close collaboration with hospital
  emergency departments

• Service d'Aide Médicale d'Urgence
• (Emergency Medical Assistance Service)
• Fixed central coordination system
• Call center receives all calls for medical
  emergencies
• Physicians at SAMU determine best response for
  the emergency taking into account available
  resources
• Coordination between emergency units and area
  hospitals and monitoring of the rescue operation
• There are currently 96 SAMU call centers in
  France receiving over 10 million calls a year

Source SAMU, France GPD Team Analysis
32
Addressing the quality issue, the Ministry of
Health has taken the lead in establishing an
independent accreditation body, with the capacity
to accredit all hospitals in the country
National Accreditation of Hospitals in Jordan
Vision
Mission

• Establish the National Hospital Accreditation
  Council, define a clear accreditation program and
  enable its infrastructure and culture
• Prepare Jordan hospital facilities for
  accreditation by assisting the Ministry in
  supervision and implementation

• Establishment of a fully functioning independent
  National Hospital Accreditation Council that will
  have the capacity to assist and supervise
  improvement in quality of hospitals and aim to
  accredit all MoH hospitals at first, and then
  private hospitals

Achievements

• National Accreditation Committee formed in
  November 2003, including decision-makers from all
  stakeholders, presided by the Minister of Health
• Funding secured from the Partnership for Health
  Reform (PHR) (A partnership between USAID and ABT
  Association) for the implementation of hospital
  accreditation
• A detailed shared activity plan is currently
  being prepared by the National Accreditation
  Committee, PHR and the accreditation specialists,
  outlining the steps to be taken until 2006 to
  reach the desired goals

Source Five Year Umbrella Strategy and
Milestone for Hospital Accreditation in Jordan
33
In 1992, the health care sector in Colombia was
faced with similar challenges to that of what
Jordan is facing today
Similarities Between Colombia and Jordan
Source WHO Colombian Ministry of Health WDI
GPD Team analysis
34
Prior to 1993, all population in Colombia had
access to free public health care, thus resulting
in very low insurance coverage
Health Care System Prior to 1993
Insured Colombians out of Total Population (1992)

• All population had access to public health care
  services
• The health care system supported a large public
  network of hospitals and clinics
• A large share of the Colombian health care system
  was financed by public funds
• Yet, the public service quality was very poor
• Public hospitals were stretched on capacity
• Service delivery was low

Insured
Uninsured
Source World Bank Escobar 2005
35
The applied universal coverage regime resulted in
an inequitable distribution of health services
across income groups
Use of Public Hospitalizations and Surgeries By
Income Group (1992)
Use of Free Care in Public Facilities (1992)
100
100
100
100
9
31
Free Care
88
80
Other
91
Out-of-pocket expenses
69
20
Richest Quintile
12
Source World Bank Escobar 2005
36
In 1993, Colombia adopted a two-tier health
insurance coverage scheme as part of health care
reform to help achieve more equitable system
Description of 1993 Health Sector Reform in
Colombia
Population
Contribution / Coverage
Benefits
Insurer / Services

• Private insurer of choice within contributory
  network
• Basic benefit package
• of medical services at
• all levels of care

• Contribution collected by insurer
• 12 of monthly salary
• 33 of the contribution is usually paid by the
  employee and 66 by the employer
• Coverage mandatory to all worker

• Access to higher quality private hospitals
• Increase in use of preventive care services
• Decreased pressure on public institutions

Contributory Regime CR

• Formally Employed
• Independent Workers

• No Contributions
• Annual extension of coverage depends on the
  availability of financial resources
• Access priority is given to children, single
  mothers, the elderly, the handicapped and the
  chronically ill

• Access to higher quality private hospitals
• Increase in use of preventive care services for
  poor insured
• Effective targeting of the poor population

• Private insurer of choice within contributory
  network
• Basic benefit package of medical services
  complemented with services provided by public
  hospitals

Subsidized Regime SR

• Poor
• Indigent

Source Escobar, World Bank 2005
37
As a result, health expenditures decreased
Total expenditure on health as of GDP in
Colombia (1998-2002)
Perception of Quality of Service Provided to
Patient in Public Institution in Colombia ( of
Total Respondents) (2003)
Bad Quality
Regular Quality
Jordans Total Expenditure on Health (GDP)
Total Expenditure on Health per Capita in
Colombia (Constant 2002 US) (1998-2002)
CAGR (1998-2002)
-4.3
Jordans Expenditure on Health per Capita (In US)
Good Quality
345
360
385
410
418
Source WHO Colombian Ministry of Health
38
and health care access to the poor population
improved significantly
Share of Total Population Covered by
Reform (1993-2003)
Insurance Coverage among Poorest and Richest
Quintiles (Percentage of Total Quintile) (1993-200
3)
Poorest Quintile
Richest Quintile
Share of Insured and Uninsured with at least One
Preventive Care Consultation (2003)
Main improvements between 1986 and 2000

• 66 increase on child delivery assisted by a
  physician
• 18 increase on institutional delivery
• 49 increase in prenatal care use among rural
  women

Source World Bank Escobar 2005
39
Similarly to Colombia, Jordan should re-consider
the current universal coverage scheme and
outsource the provision of some medical services
to the private sector
Lessons Learned from Colombias Healthcare Reform
Lessons Learned
Consideration for Jordan

• In the absence of a wide insurance scheme, high
  income population abused free government health
  services on the expense of poor people
• Misuse of free public healthcare affected quality
  of services and increased healthcare expenditure
• The Colombian government succeeded in achieving
  health care access equality across the income
  groups by
• Directing public finances towards insurance
  provision for the needy
• Outsourcing the medical services provision to the
  private sector
• Enforcing mandatory insurance to employed persons
• Combining public finance with private provision
  allows resource allocation decisions to be made
  by the public sector, while encouraging
  efficiency in service provision

• The public sector should re-consider the current
  universal coverage scheme and re-design it to
  ensure public finances serve the needy people in
  priority
• Outsourcing of some medical services to the
  private sector would
• Save on heavy capital expenditure in new medical
  equipments
• Allow the beneficiaries to take advantage of the
  high private sector quality services

Source World Bank Escobar 2005
40
Ensuring equitable universal coverage while
minimizing public spending are strategic thrusts
for the Jordanian health care sector
Proposed Jordan Health Sector Strategic Objectives

• Achieve sustainable financing of the health care
  sector while minimizing burden on the public
  financing
• Ensure everyone in Jordan has insurance or health
  care coverage (public or private)
• Eliminate open-door policy (at subsidized cost)
  at all MoH facilities and ensure only qualified
  individuals can obtain access to subsidized cost
• Ensure all employees and their dependents are
  covered under a fee-based health insurance scheme
• Provide health care access to primary and
  secondary facilities to urban and rural
  population alike
• Ensure health care facilities are efficiently run
  without compromising on quality of service
• Increase private sector participation in
  providing health care service and gradually
  reduce the number of inefficiently/costly
  publicly run-entities

41
The health sector in Jordan is faced with a
number of challenges
Health Challenges
Governance

• Lack of effective policy coordination among
  various stakeholders
• Limited public-private partnerships

Efficiency

• Inefficient administrative and IT systems
• Sub-optimal procurement processes
• Un-coordinated of planning for health care
  facilities geographical expansion and services

Coverage

• Absence of an education policy targeted to the
  health sector
• Access to health services is uneven across
  Governorates
• Low income population is not getting all the
  benefits of the MoH coverage scheme
• Mandatory requirement the employed population to
  obtain coverage is not properly enforced
• Public funds are subsidizing some wealthy
  households as the government pays for numerous
  expensive medical treatments regardless of a
  persons income

Funding

• The health system is costly to the government,
  given the size of the Jordanian economy
• Public expenditure on health care (as percent of
  GDP) is as high as some developed countries,
  potentially diverting government funds from other
  pressing issues and further straining the budget
• Around 30 of the population does not have any
  sort of insurance coverage, as any person present
  in Jordan could benefit from subsidized MoH
  treatment without having to contribute/subscribe
  to a program or coverage in advance
• Public health expenditure is likely to further
  increase over the next decades in light of an
  aging population

Source GPD Team analysis
42
Strategic Objectives
Proposed Jordan Health Sector Strategic Objectives

• Achieve sustainable financing of the health care
  sector while minimizing burden on the public
  financing
• Assure quality health care
• Provide health care access to primary and
  secondary facilities to urban and rural
  population alike
• Ensure everyone in Jordan has insurance or health
  care coverage (public or private)
• Increase the level of awareness of healthy life
  style behaviors
• Assure a healthy and safe environment

43
A number of initiatives are required to develop a
comprehensive health care strategy to provide
quality in service in a sustainable manner
Proposed National Agenda Initiatives

• Improve the health sector institutional framework
  
• Define a higher reference for all health sectors
  in order to achieve accountability and revisit
  the role of the higher council for health
• Develop a comprehensive strategy for the public
  health sector addressing all the sector
  challenges
• Define a single reference for public hospitals
  management
• Plan and execute decentralization in the
  management of public health institutions
• Studied geographic allocation of health care
  centers and hospitals
• Primary health care service
• - Improve the quality of the primary
  health care service provided
• - Implement an efficient referral system
• - Broaden programs related to training
  family medicine physicians

Health Care Sector
44
A number of initiatives are required to develop a
comprehensive health care strategy to provide
quality in service in a sustainable manner
Proposed National Agenda Initiatives

• Achieve quality assurance
• - Establish an independent commission for
  the accreditation of
• Credentialing and Accreditation of
  Health centers
• Credentialing of health professionals
  
• - To identify a mechanism that prevent
  from the malpractice and its litigation
• Improve and develop health information systems
• - Establish a national centre for medical
  data
• - Computerization of hospitals and
  install data application systems
• - Develop information systems on
  mortality and morbidity and international
  classification of diseases
• Utilization of financial resources
• - Fair distribution of funds allocated to
  primary, secondary and tertiary health care
  systems
• - Adopt a unified procurement system
• - Avoid duplication in the delivery of
  service and multiple insurance and exemption
• - Coordinate the purchase of medical
  equipment (strategic Purchasing)
• - Promote partnership with the private
  sector in order to save on future capital
  expenditure while taking advantage of the private
  sectors low occupancy rates

Health Care Sector
45
A number of initiatives are required to develop a
comprehensive health care strategy to provide
quality in service in a sustainable manner
Proposed National Agenda Initiatives

• HR supply shall meet the market demand in respect
  to quality maintained
• - Modify financial and managerial
  regulations to employ and retain highly qualified
  health personnel
• - Fairness in salary and incentive
  distributions among health personnel
• - Develop the policy for educating health
  personnel according to market demand
• - Institutionalize continuous education
  and training process for health professions
• - Increase the number of nurses and
  raise their professional capabilities
• - Develop Management Qualifications in
  the area of planning and managing health care
  services

Health Care Sector
46
A number of initiatives are required to develop a
comprehensive health care strategy to provide
quality in service in a sustainable manner
Proposed National Agenda Initiatives

• Ensure the financial sustainability of the Higher
  Council on Population to promote the national
  strategy on population (e.g. population and
  development, reproductive health, gender,
  advocacy and introducing change ..etc)
• Ensure the implementation of preventive care
  programs
• - Reproductive health
• - Health education in schools
• - develop a national strategy for the
  elderly
• - Early diagnosis of diseases (e.g.
  cancer, diabetes, high blood pressure,
  cholesterol,.. Etc) and early detection of
  hereditary disease
• - Healthy life styles
• - Awareness and health education
• - Community programs to increase
  awareness on how to prevent from common disease
• - Coordination between administrations
  that are in charge of monitoring food and drugs
• - Family health protection programs
• - activate anti-smoking regulations
• - Environmental-health (e.g. Medical
  Waste Management)
• Launch awareness campaigns to raise the above
  mentioned activities on preventive care in media,
  shcools, and universities

Health Care Sector
47
A number of initiatives are required to develop a
comprehensive health care strategy to provide
quality in service in a sustainable manner
Proposed National Agenda Initiatives
Health Care Sector

• Develop a comprehensive medical insurance system
  which responds to Jordans welfare agenda in a
  cost-effective manner
• - Assure the fairness in benefiting the
  poor and those with limited income
• - Enforce the law requiring firms to
  provide health insurance coverage for their
  employees and their dependents by covering a
  minimum portion of the insurance premium
• - Establish an independent financially
  and administratively- health insurance
  organization to monitor and supervise the health
  insurance sector
• Develop and improve the EMS
• - Establish an independent committee on
  the national level for EMS
• - HR skills upgrade
• - Improve geographic coverage of EMS
  centers
• - Obligate the accreditation of EMS
  centers in both the public and private sectors
• - Amend EMS regulations to protect
  rescuers and to define authorized areas of
  intervention and legal rescuers rights
• Promote and develop centers of excellence (heart
  centers, cancer centers, and genetic labs)
• Institutionalize RD to ensure coordination
  between entities that carry out scientific
  research and health policy making.

48
A number of objectives were suggested within the
National agenda framework to measure the
development within the health care sector
Health Care Sector
49
A number of objectives were suggested within the
National agenda framework to measure the
development within the health care sector
Health Care Sector