Jordan - Primary Health Care Project

Document of The World Bank FOR OFCIAL USE ONLY Repor No. P-4024-JO REPORT AND RECOMMENDATION OF THE PRESIDENT OF THE INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT TO THE EXECUTIVE DIRECTORS ON A PROPOSED LOAN IN AN AMOUNT EQUIVALENT TO US$ 13.5 MILLION TO THE HASHEMITE KINGDOM OF JORDAN FOR A PRIMARY HEALTH CARE PROJECT April 12, 1985 This document has a resticted distibudou and may be tsed by recipients ozly in the perfomance of their Official dudes Its contents may not oherwise be dLclosed without World Bank atborizadon.  HASHEMITE KINGDOM. OF JORDAN CURRENCY EQUIVALENTS Calendar 1984 December 1984 Currency Unit = Jordan Dinar (JD) US$1.00 = JD .384 JD .403 JD1.00 = US$2.60 US$2.48 Exchange rate used in the Appraisal Report JDI = US$2.53 GOVERNMENT OF JORDAN FISCAL YEAR January 1 to December 31 ABBREVIATIONS AND ACRONYMS CHC - Comprehensive Health Care IUD - Intrauterine Device JUJ - Jordan University Hospital MCH - Maternal and Child Health MOH - Ministry of Health PHC - Primary Health Care RMS - Royal Medical Services UNRWA - United Nations Relief Works Agency VC - Village Clinic WHO - World Health Organization  FOR OFFICIAL USE ONLY HASHEMITE KINGDOM OF JORDAN PRIMARY HEALTH CARE PROJECT LOAN AND PROJECT SUMMARY Borrower: The Hashemite Kingdom of Jordan. Beneficiary: The Ministry of Health (MOH). Amount: US$13.5 million equivalent. Terms: 15 years, including three years of grace, at the standard variable interest rate. Project Description: The project would support the Government's efforts to reorganize primary health care (PEC) in Jordan and would improve the coverage, quality, and efficiency of PHC, including birth spacing services, and of outpatient referral care in the basic medical specialties. The project would include: (a) the establishment of 25 new PKC centers, the refurbishing of 9 PHC centers, and the establishment of 17 comprehensive health care centers; (b) training for personnel at all levels to work in the new health care facilities; (c) audio-visual equipment, materials and vehicles to improve and expand health, population and nutrition education; and (d) funds for local consultants for evaluation of the project, research on key sector topics, preparation of future projects, and project management. The project is expected to reach over a third of Jordan's population, including a large number of urban and rural poor. It should have a significant impact on health in Jordan and in particular help bring about a reduction in mortality and morbidity of women of childbearing age, infants and children. The main risk of the project is that the demand for MOB services may be less than anticipated. This risk is being addressed by involving communities in the project at an early stage, and by linking improvements in the quality and coverage of health care with an improved referral system. This document has a restricted distribution and may be used by recipients only in the performance of their ofril duties. Its contents may not otherwise be discbsed without World Bank authorization.  - ii - Estimated Cost: 1/ Local Foreign Total - --(US$ million)-- Improving Health Care Services 5.7 9.0 14.7 Health Manpower Development 5.3 1.0 6.3 Expanding Health Education 0.0 0.4 0.4 Strengthening Planning, Management Research and Evaluation 0.3 0.1 0.4 Base Cost 11.3 10.5 21.8 Physical Contingencies 0.6 1.0 1.6 Price Increases 3.6 3.5 7.1 TOTAL COST_ 15.5 15.0 30.5 Financing Plan: Proposed World Bank Loan 0.0 13.5 13.5 Government Contribution 15.5 1.5 17.0 TOTAL 15.5 15.0 30.5 Estimated Disbursements: Bank Fiscal Year (Us$ million) 1986 1987 1988 1989 1990 1991 1992 Annual 0.8 1.0 2.7 4.0 3.2 1.5 0.3 Cumulative 0.8 1.8 4.5 8.5 11.7 13.2 13.5 Staff Appraisal Report: No. 5441-JO, dated April 11, 1985. Map Number: IBRD 18690. 1/ Does not include direct taxes and duties from which the project is exempt.  INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT REPORT AND RECOMMENDATION OF THE PRESIDENT CF THE IBRD TO THE EXECUTIVE DIRECTORS ON A PROPOSED LOAN TO THE HASHEMITE KINGDOM OF JORDAN FOR A PRIMARY HEALTH CARE PROJECT 1. I submit the following report and recommendation on a proposed Bank loan to the Hashemite Kingdom of Jordan of US$13.5 million equivalent to help finance a Primary Health Care Project. The loan would be for 15 years, including three years of grace, at the standard variable interest rate. PART I - THE ECONOMY 1/ 2. A report entitled "Jordan Review of the Five-Year Plan"-(No. 4129-JO, dated May 1983) was distributed to the Executive Directors in June 1983. An economic mission visited the country in May/June 1983; its findings have been included in the present text. Country data sheets are attached as Annex 1. Recent Economic Developments 3. Conscious of the country's limited natural resources, its relatively narrow productive base and the sensitiveness of the economy to changes in its oil-rich regional environment, the Government has pursued liberal, outward-looking policies in trade, labor migration and foreign exchange. This has enabled Jordan to alleviate the effects of a very high natural population growth rate (3.4 percent) through massive emigration stimulated by high salaries in the neighboring countries and through rapid expansion of domestic production fueled by an exceptionally high investment rate and rapidly growing export demand. At present, a large part of Jordan's total workforce is employed abroad. In addition to sizable workers' remittance inflows, Jordan has benefited from large inflows of grant aid from neighboring countries as well as from a rapid increase in regional demand for its exports. During the period 1976-82, the yearly inflow of workers' remittances and grants reached on average close to two-thirds of Jordan's GDP. The abundant supply of these resources and a favorable entrepreneurial climate enabled Jordan to maintain both very high consumption and investment rates. 4. As a result, the Jordanian economy expanded rapidly with an annual average GDP growth rate of over 10 percent in real terms during the 1976-82 period; almost full employment was reached. The overall balance of payments remained strong despite a large chronic deficit in merchandise trade. Although exports of goods and non-factor services (primarily agricultural products, manufactured goods, tourism and exports of the new commodities, fertilizers and potash) grew at a rapid rate of about 16 percent in real terms 1/ This section is substantially the same as Part I of the President's Report for the Greater Amman Water Supply and Sewerage Project (P-3913-JO), dated December 5, 1984. 2/ All references are to the East Bank of Jordan.  during 1976-82, its small base in relation to imports led to a continuous deterioration of the resource gap. These trade deficits, however, were almost fully covered by factor income and transfers from abroad. Government- guaranteed external borrowing remained therefore within reasonable limits and borrowing on commercial terms was reduced to a modest level (para. 14). 5. Beginning in 1982, however, the economic slowdown in the neighboring countries has affected the Jordanian economy in many ways; it led to a slowdown of domestic economic activity and a reduction in the inflow of external transfers. The overall economic growth rate slowed to about 5.5 percent (in real terms) in 1983, still a satisfactory performance considering the present unfavorable economic environment; foreign grant aid was about 25 percent lower, and workers' remittances stagnated while exports of manufactured goods and services to neighboring countries declined. The effect of these factors was exacerbated by a marked decline in exports of raw and processed minerals. Imports also declined, in line with the sizable reduction in public and private investments. As a-result, the current account deficit for 1983 showed only a slight increase to $390 million. It was mainly covered by the proceeds of a $225 million Eurodollar-loan contracted in early 1983. Jordan also drew on its reserves, which remained, however, equal to three months of imports. Preliminary estimates for 1984 show the decline in merchandise imports continuing, which, combined with a modest increase in exports of goods, contributed to an improvement in the balance of trade, from a deficit of nearly $2.4 billion in 1983 to about $2.1 billion in 1984. However, a sharp reduction in official transfers more than offset the decline -n imports, and the current account deficit deteriorated to $500 million. 6. With the decline in Government revenues from grants, public investment has been reduced, and the Government has further intensified its domestic resource mobilization efforts through cuts in subsidies and improved collection of direct and indirect taxes (about 99 percent of recurrent expenditures is covered by domestic revenues). 7. The main concerns of monetary policy have been mobilizing savings and controlling domestic liquidity. Private savings have improved, but public savings have continued to be negative because of the high level of defense expenditures. To promote domestic savings, greater discretion is being allowed the Central Bank in adjusting interest rates and banking commissions. As a result of increases in deposit rates in 1983, savings deposits rose faster than the money supply. A parallel siLuation materialized in 1984 though both savings deposits and the money supply grew at slower rates in that year. Together with a marked decline in inflation to 4.5 percent in 1984, these increases have resulted in interest rates becoming substantially positive again in real terms. Medium-Term Prospects 8. Given the changed situation and outlook in the neighboring oil producing countries, continuing GDP growth in the 9-11 percent range as projected by the 1981-85 Plan would no longer appear feasible in the medium term; a rate in the neighborhood of 5 percent per annum in real terms appears more likely during the next Plan (1986-90). This projection assumes a reduction in the exceptionally high level of investments achieved during the  early 1980s, which was mainly due to implementation of a number of major new projects such as potash, fertilizer and a refinery, now at initial stages of production. While the new, major natural resource-based industries have provided some new employment opportunities in the short term, the economic slowdown is likely to change the manpower situation in Jordan from one of selective shortages to one of general excess supply requiring finding employment for a rapidly increasing domestic workforce (para. 12). 9. The industrial sector (including mining, manufacturing and construction) is expected to continue to lead the growth of GDP and exports. The new industries are expected to contribute more than one third towards incremental GDP during 1984-85. Together with an expansion of phosphate mining and cement production, total industrial output would grow at a brisk annual rate of about 10.8 percent for 1984-85 but slow down to an underlying rate of 7.5 percent per annum for the period 1987-90. Since the rapid expansion of infrastructure and private housing during the boom years of the 1970s and early 1980s has-slowed down substantially, the construction industry is likely to grow at a substantially lower rate (3 percent) during 1986-90. Thus, industrial growth during the next plan period will have to rely increasingly on development of more small and medium-scale higher technology manufacturing, largely for exports. The projected 7.5 percent for industrial growth assumes that adjusL- ent of the industrial sector in this direction will be achieved, inter alia through changes in protection policies and improvements in export incentives. 10. Curtailment in growth of public expenditures and the slowdown in domestic and foreign demand for banking and transportation services are expected to slow down growth of services to an average annual rate of little over 3 percent per annum for 1984-87. In particular, it is expected that the transportation sector and the hotel industry, which at present are facing large surplus capacity, will undergo a period of consolidation. In the trade sector, efficiency gains from modernization would likely be offset by increased pressure from higher unemployment to expand the less efficient informal sector of trade. In contrast to the expected slow growth performance of traditional private services, the prospects are favorable to exploit Jordan's potential in skilled labor and meet the demand for special services in areas such as consulting, contracting, and maintenance. Agriculture is projected to continue to grow by about 5 percent per annum. Overall, the sectoral growth rates would enable Jordan to maintain a comfortable GDP growth rate of about 5 percent per annum for 1984-85, which would seem suscairable throughout the 1980s. 11. On the external balance side, the projections assume that exports of goods and non-factor services would grow by an average rate of about 7 percent per annum in real terms for 1985-90. Exports from the output of previous and new, industrial natural resource based projects to the world market would make the largest contribution to this growth performance. The export projections for the later 1980s assume that adequate measures are taken to develop Jordan's manufacturing exports. The external balance projections assume that imports would increase less rapidly because of the slow overall economic growth rate and the expected sizable reduction in the level of investments after completion of the major industrial projects. Even though me,-chandise exports are projected to approach a high rate of increase while imrorts would  - 4 - grow at a significantly lower rate, the trade deficit could remain large and exceed the $2.1 billion mark in 1985. In relation to GDP, however, the resource gap is expected to show a further decline from about 56 percent in 1984 to about 37 percent in 1987. Unlike the past, net workers' remittances and foreign grants, which are likely to decline, may not be sufficient to meet the growing trade deficit. Jordan therefore would have to rely more on external borrowing (para. 15). In order to maintain its prudent build-up of external debt, Jordan will need to combine external borrowing with increased efforts to mobilize domestic resources, particularly in the public sector. Social Issues 12. Due to the substantial migration of Jordanian workers to neighboring countries and the rapid economic growth, the labor market situation has been characterized until recently by selective manpower shortages. However, according to recent manpower projections, supply of labor in Jordan in the medium term is likely to show selective surpluses, particularly throughout certain categories of skilled professionals. In 1983, it is estimated that 312,000 Jordanians were working abroad compared to a total domestic employment of about 570,000. Domestic employment includes at present a relatively large number of foreign workers currently estimated at about 130,000, half of whom are unskilled. A comprehensive manpower and training plan is needed to help ensure that the education and training system is geared to meet both domestic and external demands for manpower. 13. The Government has emphasized social issues in the current Five-Year Plan (1981-85). AlLhough the social indicators are relatively favorable in most sectors, social services are unevenly distributed across income groups and between urban and rural areas. Housing remains a problem despite the boom in 1978-80, mainly because housing costs have far exceeded the means of the lower income groups. External Assistance 14. With the large, chronic trade deficit offset by inflows of remittances and foreign transfers, the current account of the balance of payments was on average in equilibrium through 1975-81. Net workers' remittances increased from about $160 million in 1975 to about $900 million in 1983 and 1984. Following the Baghdad Arab Summit Conference in November 1978, which pledged assistance of about $1.2 billion per year over a 10-year period, net foreign grant aid rose from $400-500 million in 1977-78 to about $1.3 billion in 1980 and 1981; it declined to some $0.8 billion in 1983 and to $0.4 billion in 1984. This decline was the main reason for the current account deficits of $390 million in 1983, and $500 million in 1984, both of which were financed largely by external borrowing and partly by drawing on reserves. The external public debt outstanding and disbursed reached $2.0 billion at the end of 1984 (about 45 percent of GNP). External debt service payments amounted to $316 million in 1984 or 9.4 percent of total exports of goods and services. 15. Jordan's impressive growth, pragmatic economic and social policies and efficient economic management have helped to attract large amounts of foreign assistance. The grant component of this foreign assistance is  projected to decline gradually in real terms over the next few years. The projections on that basis indicate a need for average gross external borrowing of about $0.7 billion over the 1985-1990 period, mostly in later years. While bilateral and multilateral sources can be expected to provide the bulk of external resources, Jordan is likely to resort increasingly to the financial markets, and this would result in a hardening of loan terms. On these assumptions, the debt service ratio as a percentage of exports of goods and services is projected to reach 11.2 percent by 1987 and some 13.3 percent by 1990. Given this outlook and the country's record of prudent management, Jordan remains creditworthy for Bank lending. PART II - BANK GROUP OPERATIONS 16. Jordan has received 16 Bank loans totalling $410.8 million and 15 IDA credits totalling $86.1 million (net of cancellations), of which all the credits and two loans have been fully disbursed. Project implementation and disbursement performance have been generally satisfactory. In recent years, disbursements have amounted to about 50-60 percent of appraisal estimates. IFC has-made investments in Jordan with total commitments of $94.2 million. Annex II contains a summary statement of Bank loans, IDA credits and IFC investments as of September 30, 1984. 17. Under its last two development plans, Jordan has aimed at restructuring its economy to achieve a wider manufacturing base, reduce its dependence on external grants, and spread the benefits of development among different regions. The Bank's strategy has been tailored to support those objectives and in particular is designed to help the Government: (a) to diversify the country's economic base and promote exports; (b) to alleviate manpower and infrastructure constraints in the productive sectors; and (c) to encourage more balanced growth and distribution of social services among regions and income groups, with particular emphasis on low-income groups. 18. Within this broad framework, past lending has emphasized support for capital infrastructure and manpower development. Since 1962, Bank Group lending has focussed on water supply and sewerage, power and energy development, education and urban and municipal development. The Bank Group has also lent for irrigation, agricultural and industrial credit, transportation, and tourism. In addition, the Bank Group has financed technical assistance for developing and implementing a plan for expanding phosphate rock mining. An engineering credit was made in FY75 to help prepare a large project for potash production from the Dead Sea via solar evaporation, for which a loan was approved in September 1978. These projects have been designed with an emphasis on institution building to assist the agencies involved to develop their capabilities to plan, prepare, and implement projects on their own. In addition to the proposed health project, future lending would include projects for mining, transportation, water supply and sewerage, urban development, power and energy development, and industry. IFC has provided loans and equity contributions for a major fertilizar project and for projects in the construction materials subsector. It has also assisted the capital market and leasing ventures. 19. The Bank has recently helped the Government to review the energy, water supply, health, and urban sectors, and the Bank's economic and sector  work will continue to focus on strengthening the macroeconomuic and sector base for our lending program. The Bank's economic work program aims to deepen and broaden the well-established policy dialogue with the Government in three priority areas: (i) development planning, with a focus on resotrce mobilization and allocation; (ii) industrial and trade policies, including technology transfer and export strategy/promotion and industrial subsector studies; and (iii) regional development and equity and efficiency of government revenues and social expenditures. These subjects are cruci'l because the substantially tighter balance of paymerts situation expected for the rest of the decade calls for increased efforts to step up domestic resource mobilization, to stimulate manufactured exports and to optimize resource aLlocation, while making particular efforts to reduce rural and urban poverty. 20. At the end of 1983, the actual Bank Group share in Jordan's total external p-"'ic debt was estimated at 12 percent, and its share in debt service was 5 percent. In 1985, the Bank Group's slares in debt outstanding and in debt service are expected to be about 13 and 8.5 percent respectively. PART III - THE HEALTH SECTOR Population, Health and Nutritional Status 21. During the last two decades, the population of the East Bank of JordanI' grew at an annual rate of 4.8 percent (including immigration) and more than doubled. The reasons for this rapid growth have been sharply reduced mortality rates, very high fertility, and a very heavy volume of net immigration over the last 20 years. If the current rate of natural increase of 3.4 percent continues, the population would grow from about 2.5 million today to about 4.3 million in the year 2000. Children under 15 comprise about half of the population. and Jordan has a high dependency ratio. About 70 percent of the population lives in urban areas, mostly in the three largest cities of Amman, Zarqa, and Irbid. 22. Health conditions in Jordan have improved dramatically in the last two decades, but there are still critical problems of preventable diseases that need to be addressed as a high priority. As a result of both improved living conditions and better health care, mortality has declined rapidly in the past two decades and life expectancy has risen from 47 years in 1960 and to 64 in 1982. The crude death rate fell from 20 per 1,000 in 1961 to the current 11 per 1,000. Although infant mortality declined by almost half during that period to about 69 per 1,000 live births in 1983, it remains somewhat higher than tile average rite for other upper middle-income countries and is seven times the average for industrialized market economies. Jordan now exhibits a mixed pattern of morbidity and mortality, comprised of the chronic disLase profile of industrialized countries and the infectious disease pattern typical of developing countries. Diarrhea and respiratory diseases are the most important causes of illness and death in children under five; accidents and respiratory disease in those aged five to fourteen. For those 1/ All references that follow are to the East Bank of Jordan.  over 15 years of age, the main causes of death are heart, circulatory and respiratory diseases, accidents and cancer. Jordan's major health problems are preventable communicable diseases and complications of pregnancy and childbirth. Children under five and women in the reproductive age group, who make up 37 percent of the population, are the most vulnerable group, accounting for a disproportionate share of morbidity and mortality. 23. The nutritioxnal status of infants and children has improved significantly during the last two decades, and the prevalence of malnutrition appears to be low. Studies suggest that malnutrition is related to poverty, the young age of new mothers, high fertility, inadequate breastfeeding and diet supplementation, and deficient knowledge of dietary and health practices. The Health Care System 24. The Government has given a high priority to the health sector in the last two decades. During that period, it has made major efforts tc expand facilities and increase the number and quality of health personnel; since 1975, the number of doctors, hospital beds, and health centers has more than doubled. Although many Jordanians enjoy relatively good physical access to health facilities, about 40 percent of the families in Jordan do not get adequate primary health care. The most important gaps in coverage concern women, infants, and children, particularly in the lower socioeconomic groups. 25. There are four major health providers in Jordan. The Ministry of Health (MOH) is the largest, serving about 60 percent of the population through 14 hospitals and 174 health centers. The PIOH: (i) provides care to civil servants and their families; (ii) provides free care to families certified as poor by the Government and free maternal and child health (MCH) care and treatment for some communicable diseases and cancer; and (iii) covers Jordanians not eligible for other services on a fee-for-service basis. The MOH is essentially the only provider of care to civilians outside the large towns and hence the only accessible and affordable source for most of the rural and lower socioeconomic groups in Jordan. MOH services are presently organized in four levels: (i) village clinics (VCs), which offer treatment of simple health problems and referral to physicians; (ii) primary health care (PHC) centers, which offer immunization, first-line treatment of illnesses and referral to specialists; at the same level as the PHC centers, there are also separate maternal and child health (MCH) care centers that offer immunization, well-baby care and pre- and post-natal care; (iii) regional hospitals, which offer outpatient specialty clinics and inpatient services; and (iv) the Al Bashir hospital in Amman, which is the referral hospital for the rest of the MOB system. 26. The Royal Medical Ser,rices (RMS), through 6 hospitals and L4 health centers, cares for members of the armed forces and their dependents, and individuals requiring specialized care not available elsewhere. The United Nations Relief Works Agency (UNRWA) provides primary care to refugees through its 17 health centers and reimburses other providers for the cost of hospital services deLivered to refugees. The Jordan University Hospital (JUH) provides primary care and hospital services to a number of groups including the Jordan University community and serves as a referral hospital for other parts of the  health system on a fee-for-service basis. The private sector delivers a substantial volume of health services in Jordan through about 1,300 private physicians, numerous clinics and 24 hospitals, mostly in large cities and towns; it serves about 40 percent of the population at one time or another and is the sole provider of services to 10-15 percent of the population. 27. Provision of Family Planning Services. ,t is estimated that about 26 percent of women aged 15-49 use some form of contraception. This rate compares with contraceptive prevalence rates of 27 perrent in Morocco, 41 percent in Tunisia and 49 percent in Colombia. The private sector provides the bulk of family planning services in Jordan, including almost three quarters of the pills and intrauterine deviceb (IUD) used. The major private institutional provider is the Jordan Family Planning and Protection Association, which has 15 clinics. The Government makes pills and IUDs available in its MCH centers, but these provide family planning to only about one percent of the total number of eligible couples; the Government has a program, however, to increase this percentage (para. 40). MOH and RMS hospitals also provide some family planning services. 28. Health Manpower. Jordan has one of the highest physician/population ratios among developing countries, and dentists and pharmacists are available in adequate numbers. Nurses and professional midwives, however, are scarce, and about half of the nursing staff are expatriates, working in Jordan on contract. Health technicians are available in adequate numbers in some categories, while shortages exist in others. Jordan is developing an extensive system for training health sector personnel, which with some strengthening should be able to support the training of health professionals in the medium term. 29. Health Expenditure and Financing. Total expenditure on health in 1982 was about 5.2 percent of GDP, which was above the average for middle-income countries. The Government accounted for about 58 percent of total expenditure, the private sector for about 41 percent, and UNRWA for about 1 percent. Public expenditure on health increased in real terms over the past five years, growing from 10 to 11 percent of Government's annual recurrent expenditure, and amounted to $39 per capita. However, recurrent expenditure on health as a proportion of GNP fell from 2.4 to 2.1 percent. The MOH since 1976 has spent annually about 14 percent of its recurrent budget on preventive care and 72 percent on curative care. 30. Each of the major health care providers has its own sources of funding, and the piinciple of recovering at least some costs from patients is well establisl.ed in' Jordan. The MOR operates principally on allocations from the Governm-nt. however, patients' fees and payroll deductions from the civil service insu_ance scna'me comprise l0-15 percent of total MOR funds and are projected to rise to ,0 percent over the next five years. Most RMS funds come from the central bueget, but it also receives patients' fees and fees from MOR referrals. The vT receives direct budgetary allocations and a transfer from the Jordan University budget. In addition, fees from patients and deductions from the university employees' insurance scheme make up about a third of its funds. With regard to expenditure on health care provided by the private  sector, several of the largest private sector employers carry insurance for their staff, although most people pay for private medical services from their own funds. Key Health Sector Issues 31. Despite significant progress made in developing the sector, there remains a considerable amount of illness and death in Jordan that is preventable, particularly among infants, children, and women of reproductive age. This is the main health challenge confronting the Government today. The Bank's Health Sector Review (Report No. 4748-JO, dated May 26, 1984) identified a number of priority issues that need to be addressed in the sector S if the Goverrnment is to meet this challenge. First, the health system needs to expand coverage, in particular, to infants, children and women of child-bearing age. At the moment, many people, particularly pregnant women and children, do not get essential health care services. As a result, pre- and post-natal care, maternity and well-baby care are much less than satisfactory; about two out of five births are not attended by professional personnel, and half of the infants and children do not receive weHl-baby care. The public health system has not provided adequate information and services for birth spacing in the past. About one-quarter of the women who bear children have an average interval between births of only 18 months, which is linked to a threefold increase in child mortality compared with those born more than 24 months apart; and women most in need of family planning services among the poor have the least access to them, since MDH family p:anning services are weak. However, the Government is taking steps to improve the situation by strengthening MCH, including birth spacing, services (para. 40). 32. In order to expand the coverage of the country's primary health care, the ;40 will need to improve the system's efficiency and quality by addressing the following critical weaknesses: (i) the system is passive and outreach is limited; (ii) there are few trained health educators and little health education; (iii) the referral system does not function effectively; (iv) facilities and services are frequently inadequate; and (v) there are critical problems concerning the delivery of MCH services, including family planning services. In particular, the system of operating separate PHC and MCH centers is inefficient and discourages the use of MCH facilities. Centers are also insufficiently staffed with physicians, female nurses, and midwives and there are few dentists or laboratories in the centers. Almost no deliveries outside of hospitals are attended by health professionals. Furthermore, in the absence of midwives, physicians and other health care personnel offer little MCH care. As a result of the above weaknesses, people often use high-cost hospital services rather than lower cost local facilities, because the type and quality of care at the local level are not satisfactory. Thus, the demand for hospital services has frequently been much greater than the hospitals could meet, and quality has suffered as a result. Specialists in hospital outpatient clinics, for example, frequently see 60 to 70 patients per day, and women are often asked to leave hospitals shortly after delivery. 33. There is a mismatch of demand for and supply of certain categories of health manpower in Jordan, which impedes the effective development of PHC services. There is a shortage of midwives, female nurses, qualified laboratory technicians, and professional health care administrators, and  - 10 - imported nurses are not always effective because of language barriers. On the other hand, there is an impending surplus of general practitioners and physicians in some specialties. The MOH also needs to address some questions of training and career development for health sector personnel. For example, public health issues and MCH care have not been sufficiently stressed in the education of most Jordanian health care personnel. 34. Finally, the planning and management of the health sector needs to be improved if Jordan is to make more efficient use of health sector resources. Improvements are required in the MO[ management information system, since the MOH has lacked the statistical information necessary to plan and manage the sector. There are also important gaps in Jordan in the supervision of health care personnel, since the staff available for supervision has not grown with the rest of the system. It will also be important to strengthen the referral system to encourage people to use the most appropriate facilities. The Government's Strategies for Health, Population, and Nutrition 35. It is likely that there will be increasing constraints on the Government's overall resources for recurrent expenditure in the next decade. Since the prospects for significant increases in the recurrent budget for health are not great, it is clear that the Government needs to carefully plan future sector development and maximize the efficiency of existing infrastructure. The most efficient and cost-effective manner to deal with Jordan's main health problems is by improving the access, quality and efficiency of primary health care (PHC). 36. The Government's 1981-85 development plan emphasized the need to extend basic health services, strengthen primary health care and preventive services and increase the quality and supply of health personnel. However, a disproportionate share of resources in the plan was directed toward curative and especially hospital care, which would have required a near-doubling of future MOH budgets for current expenditures on curative care. The Government has now revised its plan targets. It has shelved most of the program for hospital construction and decided to focus its attention on strengthening PHC and referral care in the basic specialties. 37. As a first st. in these directions, the MOB has begun to reorganize its approach to PHC and to referral care in conjunction with a comprehensive series of measures linking improvements in health services, training, health education, management and facilities. These measures include: (i) increasing the effectiveness of MCH care by integrating MCH services into regular PHC centers and focussing on pre- and post-natal care of pregnant women, attendance of deliveries by health care prof2ss:onals and well-baby care; (ii) establishing a net ievel of the health system comprising "comprehensive heialth care (CHC) ce-lters', which will supervise the activities of the PHC ce.iters, serve as pria.ary care centers for adjacent populations and as referral centers in the basic medical specialties for related PHC centers and provide basic maternity, emergen-y. and laboratory services; (iii) increasing the responsibility of PHC centers ror supervising village health clinics and improving outreach activities by increasing the staffing at PHC centers  - 11 - (para. 46) and by establishing mobile outreach teams to identify and treat people who need care; and (iv) upgrading existing centers with inadequate facilities and establishing new centers in order to expand access to PHC and decentralize referral and maternity care. 38. The Government is also taking steps to deal with the problems of health manpower. These include: slowing down the supply of physicians by tightening licensing requirements for foreign-trained physicians and discouraging the continued use of large numbers of foreign fellowships for their training; increasing the number of trained female nurses, midwives, and medical tFechnicians, and registering and upgrading traditional birth attendants; introducing physicians' residency programs in emergency medicine and in family medicine; increasing the public health content of nurses' training programs; and starting a graduate program in health care administration. 39. The GLvernment is also implementing a USAID-financed health education project. Several Jordanians have already been trained in this area, and a health education specialist is working with the MOH. The MOH has prepared a five-year plan for developing health education and plans to strengthen the Health Education Division in the MOH and place a health educator in each governorate to supervise the implementation of health education programs. USAID is also assisting the Government with a project to improve health sector planning. This has led to several useful studies on disease patterns and to the creation of a new management information system for the MOH. In addition, a number of Jordanians will be trained in planning and management under the project. The MOH is also developing a new referral system to prevent people from bypassing the appropriate level of the health care system and is devising measures to improve supervision of its PHC program. 40. The Government has no explicit nutrition policy, but it does monitor the growth of children and the nutritional status of pregnant women as part of its MCH services, which can be expected to increase as the MOK increases the coverage of the PHC system. The Government's policy on family planning is to provide information on family planning as a part of all MCH care and to offer services in public facilities on request as an aid to birth spacing. The Government also allows voluntary associations and private physicians to provide family planning services on request for this purpose as well. The Government has also taken a number of steps that indirectly encourage the adoption of family planning practices. It has, for example, made great strides in the last decade in providing primary education to females; and an increasing share of females are now attending secondary schools and universities. The participation rate of females in the labor force has also risen dramatically in the last ten years. The MOR, however, has not provided adequate birth spacing services, which stemmed largely from its inability, in a sensitive local environment, to formulate a coherent program of birth sEacing services. To remedy this situation, the MOH plans to improve its provision of birth spacing services as part of its efforts to strengthen MCH care. Toward this objective, the MOH is preparing a guide for its staff on the provision of birth spacing services and plans to carry out regular upgrading courses for its staff on MCH care, including birth spacing. MOE personnel will also participate in training courses on birth spacing offered by agencies such as WHO and the International Planned Parenthood Federation.  - 12 - The Bank Role in the Sector 41. The Bank in recent years has helped the Government improve access to basic social services and has financed a series of projects in education, urban development, and water supply. In addition, the Bank is financing three activities that directly relate to the health sector. The Fourth Education Project (Loan No. 2068) is financing the construction in Irbid of a training institute for nurses, midwives, and health technicians; another such institute at Zarqa would be included under the proposed FY86 Manpower Development Project. The First Urban Development Project (Loan No. 1893) financed the construction of two health centers, which the MOH is operating successfully. The Bank is also financing a research project that is examining the impact of this urban project on the health of people in the affected community. The a proposed project would be the first World Bank lending operation in Jordan to focus on the population, health, and nutrition sectors. 42. Bank Strategy. Based on discussions with the Government on the Health Sector Review (para. 31), the Bank's overall strategy in the sector is to assist the Government to expand the coverage, quality, and efficiency of primary health care and referral care in the basic specialties, with a special emphasis on maternal and child health. This will be done by strengthening PHC services, developing health sector personnel, expanding health education, improving sector management, and adding required physical infrastructure. The proposed project was designed by the Government to address the main issues identified in the sector report and would help the MOR implement its new service delivery program for primary health care and basic referral care (paras. 35-40). The project is also in line with the Government's desire to expand the access of its poorer people to social services, and, with its emphasis on improving PHC, would be the most efficient way to improve the health status of the Jordanian people as well as begin to improve the efficiency of the entire system. In addition to health projects, the Bank would also continue its assistance to the sector through projects in education, water supply and sewerage and urban development, all of which have important effects on health. PART IV - THE PROJECT Project History 43. The project was identified in January 1984 in the context of discussions of the sector report with the Government. It was preappraised in June 1984 and appraised in November 1984. Negotiations were held in Washington, D.C. during March 27-29, 1985. The Jordanian delegation was headed by H.E. Dr. Kamel Al-Ajlouni, Minister of Health, and included Mr. Nabil Sweis of the Ministry of Planning. A Staff Appraisal Report (No. 5441-JO), dated April 11, 1985, is being distributed separately. The main features of the proposed loan and project are outlined in the Loan and Project Summary and in Annex III. A map of the project area is attached.  - 13 - Project Obiectives 44. The project would support the Government's efforts to reorganize primary health care and referral care in the basic specialties by expanding coverage and improving quality and efficiency. The project is the first phase of the Government's program to implement a new service delivery model that will be expanded throughout Jordan. Its main goal would be to reduce morbidity and mortality in Jordan that result from preventable causes, with a special focus on the health problems of mothers and children. Specifically, the Government's targets over the life of the project are: (a) to increase the share of pregnant women who receive pre-natal care from the MOH from 20 to 40 percent of all pregnancies; (b) to increase the share of deliveries attended by MOH staff from 30 to 40 percent of total deliveries; (c) to increase the share of couples who get contraceptive services from the MOH from 1 to 6 percent of all eligible couples; and (d) to increase the share of children under six who get MOH well-baby care from 15 to 30 percent. Assuming no increase by other providers, the overall percentages for the system as a whole would increase respectively to 80 percent, 70 percent, 31 percent and 65 percent. The project is expected to reach over a third of Jordan's population, including a large number of rural and urban poor, almost two fifths of whom would be women of childbearing age and young children. Project Description 45. The project includes the following major components: (i) expanding and improving health care services: construction and equipping of 25 new and refurbishing of nine existing primary health care (PHC) centers, construction and equipping of 13 new comprehensive health care (CHC) centers, and refurbishing of four existing PHC centers to turn them into CHC centers; (ii) developing health sector personnel: the training of around 800 staff who will work in project PHC and CHC centers; (iii) expanding health, population and nutrition education: audio-visual equipment, materials and vehicles; and (iv) strengthening health sector planning and management: funds for evaluations of the project, research, preparation of future projects, and project management. 46. Expanding and improving health care services. The new MOH service delivery model would be implemented in the facilities to be established under the component. The new PHC centers would be staffed with two physicians (one to work in the center and one through related village clinics), a midwife for maternal and child health (MCH) services, a dentist and an elementary laboratory. Thus, PHC centers would be able to offer pre- and post-natal care, child spacing information and services, well-baby care, immunization, treatment of chronic and communicable diseases, basic curative and laboratory services, dental care and health and nutrition education. The CHC centers would serve and be staffed as PHC centers for immediately adjacent populations. They would also be referral centers for the PEC centers in the basic medical specialties and staffed with nurses and full-time specialists in internal medicine, pediatrics and obstetrics/gynecology. Other specialists, including general surgeons, would visit as needed. CHC centers would offer basic emergency services and have a maternity section to handle normal deliveries. The demand for services and staffing, equipment and facilities has been based on the present use of services in Jordan and reasonable norms  - 14 - for service delivery. Locations for the proposed facilities were based on a review of facilities nationwide and criteria agreed with the Bank. including the socioeconomic status of the communities, their access to health services and size of population. 47. Developing health care personnel. This component would finance the share of the MOH training program needed to put the new KOH services into effect. It includes: (i) training locally and abroad for 24 managers of the CHC centers in health care administration; (ii) local residency programs for 95 specialists in Eamily medicine, 15 specialists in emergency medicine and 25 specialists in internal medicine, pediatrics, and obstetrics/gynecology; (iii) local training of 60 nurses' trainers, 40 registered nurses, 90 midwives, 195 assistant nurses, and 235 medical technicians; (iv) funds for 40 MOH staff to participate in international short-term training programs related to PHC; and (v) funds for local workshops for physicians and auxiliaries and for training staff of the new facilities. The Government has -agreed to submit to the Bank by July 31 of each year during the project the training program proposed for the following calendar year (Loan Agreement, Section 3.02(a)). 48. Expanding health, population and nutrition education. The project would also finance equipment, audio-visual materials and vehicles for health education outreach and supervision of health education activities. This would complement the USAID health education project and allow the Government to expand health education to the community level. 49. Strengthening health sector planning and management. This component would cover the costs of equipping and furnishing the Project Management Unit (para. 53). It would also cover consultant services and costs to support mid-term and final evaluations of the project and research related to key sector topics and to help the MOR develop future projects. The Bank and the Government have already agreed on a five-year research plan, which would include the following topics: health manpower problems, cost of health services, efficiency of public and private services, nutritional issues, and maternal and child morbidity and mortality. Each year during the project the Government would review with the Bank by September 30 the proposals for project-related research to be carried out during the following year (Loan Agreement, Section 3.02(b)). Terms of reference and qualifications for specialists recruited under the project would be reviewed by the Bank. Project Costs and Financing Plan 50. The total cost of the proposed project, including physical and price contingencies (in March 1985 prices) is about $30.5 million, of which $15.0 million (49 percent) is in foreign exchange. Cost estimates do not include import duties and taxes, from which the project is exempt. Unit costs of civil works and lists of goods are based on similar work and goods carried out and procured recently. The cost of local training takes account of recent experiences in Jordan, and the cost of overseas training, of recent fellowships awarded by bilateral agencies. The project cost includes physical contingencies of 10 percent for civil works, furniture, equipment and vehicles. The price contingencies on civil works, materials and equipment for foreign components have been estimated at 5 percent for 1985, 7.5 percent for  - 15 - 1986, 8 percent for 1987-90, and 5 percent for 1991-92. Price contingencies for local cost components have been estimated at 5 percent for 1985, 7.5 percent for 1986, 8 percent for 1987-90, and 5 percent for 1991-92. The overall allowance for price escalation is about 33 percent of base costs plus physical contingencies. 51. The proposed Bank loan of $13.5 million would cover 44 percent of the total financing requirements and would be used to finance the foreign exchange costs of civil works (including architectural fees), equipment, furniture and vehicles. The balance would be financed by the Government, including foreign exchange costs of overseas training, for which the Government has access to bilateral fellowship funds. The 3ank loan would be made to the Government for 15 years, including three years of grace, at the standard variable interest rate. 52. Project recurrent costs and unit costs. At full operation in 1992, project-assisted programs would add only about $2.8 million per year to the annual recurrent budget of the MOH, or about 5 percent of the 1985 recurrent MOH budget and about 0.3 percent of the 1985 national recurrent budget. The new model could be extended to the .ntire country with only a 1.3 percent per year increase in the recurrent budget of MOH between 1985 and 2000 and would be an affordable basis for providing primary and referral care in the future. The unit costs of services, including pharmaceuticals, to be provided by the new model would be about $5.50 and $5.00 per outpatient visit at a PHC center and a CHC center, respectively. This compares to per visit charges in the private sector of $7.50 by a general practitioner and $15.00 by a specialist for an office visit only. The unit cost is about the same or slightly less than a visit to MOH facilities under the existing modes, although services under the new model should be of a higher quality. Project Execution 53. The MOH has established a Project Management Unit (PMU), which would continue to be satisfactorily staffed (Loan Agreement, Section 3.01(b)). The PMU would coordinate the execution of project-financed activities that will be carried out by regular line units of the MOH. The Ministry of Public Works is responsible for architectural design and supervision and would recruit private consultant architects in accordance with Bank guidelines to assist it in these activities. In addition, a Project Advisory Committee (headed by the MOH undersecretary and composed of all department heads) has been established to advise the PMU on issues that may arise. The MOH Department of Primary Health Care would be responsible for implementing the new service delivery model and the expanded program for health, population and nutrition education. To facilitate project execution, a handbook for project management has been written establishing precise guidelines for all staff involved in the project and timetables for project activities. Final designs for the project have been completed, and the MOH has identified all of the 38 sites for the new centers and has acquired 26 of them, which is more than sufficient to begin the first phase of the project. All sites would be acquired by July 31, 1986 (Loan Agreement, Section 3.04). The Bank has reviewed the lists of equipment, vehicles and furniture as well as project-financed training programs. The  - 16 - MOH is also preparing draft manuals for its staff on specific responsibilities for supervision, general MCH services, maternity services, and birth spacing services and a plan for an improved referral system. The Bank has reviewed much of the information to be contained in the manuals and they should be completed by the end of 1985. The Government has already begun to implement key activities related to the project, including offering MCH services in all health centers, having physicians live in the communities in which they will serve, and putting in place a new management information system. The project is expected to be completed by June 30, 1992. 54. Accounts and Audit. The PMU is establishing accounts for the project in accordance with internationally accepted accounting procedures. Project accounts would be audited by the Auditor General's office, which is satisfactory. The Government has agreed that the audits would be conducted annually in accordance with appropriate auditing principles consistently applied in a form satisfactory to the Bank and that the accounts and audit would be submitted to the-Bank for review within six months of the close of the Government's fiscal year (Loan Agreement, Section 4.01). 55. Proiect Monitoring and Evaluation. The PMU would monitor the day-to-day implementation of the project and would submit progress reports to the Bank every four months. The PMU would also coordinate efforts to carry out mid-term and final evaluations of the project (Loan Agreement, Section 4.02). The Directorate of Planning, Training and Research of the MOH would monitor the impact of the project and in particular examine the extent to which it reaches the targets noted in para. 44. The MOH, in conjunction with the two universities in Jordan, would also carry out studies on the impact of the project and of specific program improvements related to the project. 56. Procurements and Disbursements. Procurement arrangements are summarized below: Project Element ICB LCB Other Total - ----$ Million-- Civil Works 12.31 0.20 12.51 (5.64) (0.09) (5.73) Furniture 1.80 0.25 2.05 (1.24) (0.15) (1.39) Equipment 4.91 0.32 5.23 (4.44) (0.26) (4.70) Vehicles 1.87 - 1.87 (1.68) (1.68) Overseas Fellowships -- - 0.68 0.68 (0.0) (0.0) Local Training and -- - 7.75 7.75 Other Expenses (0-0) (0.0) Consultant Services -- 0.47 0.47 - (0.0) (0.0) TOTAL 20.99 0.77 8.90 30.56 (13.00) (0.50) (0.0) (13.50) Note: Figures in parentheses are the respective amounts to be financed by the Bank.  - 17 - 57. Civil works contracts for new construction, with an estimated value of $12.3 million, would be subject to international competitive bidding (ICB). The remaining civil works contracts, with an estimated aggregate value of $200,000, with no single contract expected to cost over $50,000, are for simple remodeling. They would be awarded by MOH in accordance with local competitive bidding (LCB) procedures, which the Bank has reviewed and found satisfactory. The MOH would group furniture, equipment, and vehicles to the extent possible in large contracts for bulk procurement and award contracts for packages exceeding $100,000 equivalent on the basis of ICB; contracts below this amount up to an aggregate amount of $800,000 would be awarded on the basis of LCB. For material and equipment to be procured under ICB, a domestic preference of 15 percent or the import duty, whichever is lower, would be used for the purpose of bid evaluation. Documents and awards for construction contracts greater than $250,000 and contracts for goods greater than $150,000 (which would constitute 75 percent of the total estimated value of goods and civil works) would be awarded under ICB and subject to prior review by the Bank. 58. The proposed loan would be disbursed over a period of approximately seven years as follows: civil works, 100 percent of foreign and 46 percent of local expenditures; furniture, 100 percent of foreign and 60 percent of local expenditures; equipment and vehicles, 100 percent of foreign and 80 percent of local expenditures. The estimated disbursement schedule in the Loan and Project Sunmary is somewhat shorter than the standard disbursement profile for health projects and reflects the advanced state of project preparation, Jordan's satisfactory record in project execution and the fact that the loan would only finance activities scheduled for the first four years of the project. In order to expedite disbursements, a revolving fund of $0.5 million (equivalent to an average of about three months disbursements) would be opened by the Government and would be replenished on the basis of standard documentation for eligible reimbursable expenditures. Contracts below $10,000 equivalent may be claimed under statements of expenditures (Loan Agreement, Section 2.02(b), Schedule 5). The loan closing date would be December 31, 1992. Project Benefits and Risks 59. The main benefit of the project would be a reduction in mortality and morbidity, particularly of people in lower socioeconomic groups and of women of childbearing age, infants, and children. This reduction should come about as the public health system expands the coverage and improves the quality of primary care, including birth spacing services, maternity care, and referral care in the basic specialties. It is expected that the project would lead to increases in the number of pregnant women receiving pre-natal care, in the share of deliveries attended by a health care professional, in the contraceptive prevalence rate, and in the number of children under six receiving well-baby care. The project would also improve the efficiency of the public health system by providing better quality services at the same or lower unit costs. Finally, MOH is using the project as a basis for developing and implementing comprehensive health planning norms for the first time, which will considerably improve the delivery of health services in Jordan.  - 18 - 60. The main risks of the project are that: (i) demand for services may be less than planned; (ii) people may continue to bypass lower levels of the system; and (iii) health personnel may continue to take a passive approach to health care and not focus sufficiently on outreach, preventive care, and MCH care. The demand for services is always difficult to predict, particularly when there are numerous providers. The risks of overestimating demand have been limited by concentrating services on areas most dependent on the KOH, setting clear and efficient norms for staffing, equipping and designing facilities, and making estimates on the basis of best available data on present patterns of use. A new referral system will be put in place; coupled with improvements in the quality of PHC, it should limit the risk that people will not seek care at lower levels of the system. It will, of course, take time to change the orientations of the public health system. However, the comprehensive approach of the project, the involvement of MOH staff and communities in the project, and the large amount of project-related training should all encourage change in the right direction. PART V - LEGAL INSTRUMENTS AND AUTHORITY 61. The draft Loan Agreement between the Hashemite Kingdom of Jordan and the Bank and the Report of the Committee provided for in Article III, Section 4(iii) of the Articles of Agreement of the Bank are being distributed separately. 62. Special conditions of the project are listed in Section III of Annex III. 63. I am satisfied that the proposed loan would comply with the Articles of Agreement of the Bank. PART VI - RECOMMENDATION 64. I recommend that the Executive Directors approve the proposed loan. A. W. Clausen President Attachments Washington, D.C. April 12, 1985  - 19 - ANNEX I Page 1 of 6 joRDA - SOCTa imnaLM ahrA inun __ su cx QOnmZCmii anauJ)l IIDIT tlT MUC T nonAT) /b ~~~,.e~~~ IulDU 1113i HIlDIAI tS mal tweL =nTDW, or. tnCa N* tO IAT. tEC S CAl AA (SoiSm a. u) TOraL 97.7 97.7 97.7 ACRICULTItAL 12.0 19.0 14.3 - EPR CPITA (0415) - 30.O/c 190.0 le 11".9 2106.9 - 01 wmurn a cor (KILOGAS OF OIL EQUIVALErT) 121.0 ZL2.0 70.0 922.L 995.3 rormaTIn Am VnL gn eec POPULATION.NID-v" (THOUSANDS) 1"S.0 2299.0 3127.0 UtUA POPULATION (Z eO TOrAL) 42.7 30.3 9.9 41.2 66.3 nvunArup mmoazcTIONS POPULATION IN EAR 2000 (HILL) *.2 STATtONARE POPULATION (HILL) 16.2 POPULATION MNi 2.0 ProutArtoll DzEWstTY PEE SQ. M. 17.3 23.5 30.9 39.3 35.7 PER SQ. K. AGRI. LAND 141.4 199.2 203.9 461.7 92.9 POPULATION AGE SRUCTIRE CE) 0-14 US 4.4 45.8 46.1 43.9 39.9 L5-6 I S 31.5 51.0 SL.S 53.1 39.0 bS AND ABO 4.1 3.1 2.9 3.3 4.1 POPULArION GRUOTH RATE CE) rOTAL 3.1 3.0 2.9 2.0 2.4 URBAN 5.2 4.7 4.0 9.5 3.6 GLUM BIRTH RATE (PER THmOS) 47.4 47.9 44.3 40.4 31.3 CRUDE DEATH RATE CPE TNOV5 19.9 15.1 3.1 11.5 3.1 CROSS REPRDUCTCrOI RATE 3.5 3.5 1.2 2.8 2.0 FAMILY. PLAIINING CCErrOS. ANmwAL (TNOUS) USERS (2 OF MAIED S ) .. 22.0 Id ZS.0 1. 22.2 60.3 INDEX lit FOOD PROD. PER CAPITA C1969-71-LD0) 220.0 79.0 70.0 97.2 I4.3 PER CAPITA SOWrT OF CALORIES (2 OF RESQUIRETS) 93.0 93.0 102.0 '10. 110.6 PROTEINS (GRAM PR OAT) 61.0 55.0 94.0 70.1 67.3 UF WHICH ANIMAL AND aLcSE 15.0 15.0 19.0 if 17.8 34.1 CHILD (ACES 1-4) DEATH RATE 26.3 12.5 6.0 14.6 3.7 SALTE LIFE EXPECT. Ar UTH (TEARS) 4.9 34.1 b4.0 57.3 64.7 =W.IT PRT. RATE (PER T3OUS) 135.5 97.5 94.6 101.5 b0.9 ACCESS TO SAFE WM (EPM?) TOTAL 21.3 *- .0.0 lc 59.7 65.4 URBAN 4a.6 *- *- 9.3 78.1 RURAL 2.1 .. .. 38.4 46.2 ACCESS TO EeRETA DISPOSAL (: OF POPULATION) TOTAL *- *- 78.0 IC .. 52.9 UaBN 97.0 RURAL .. .. .. 24.5 POPULATION PER PNTSICIAN 5600.0 3760.0 1700.0 4395.1 1917.7 POP. PER NIURSING PERSON 1930.0Oj 180.0 1llW.0 1831.1 315.8 POP. PER HOSPIrAL BED rOTAL 390.0 1350.0 1060.0 lb 932.9 397.2 UA .. 1120.0 80.o 7F 345.5 411.5 RURAL 540.O .. 2513.5 2936.3 ADOISStONS PER NOSFITAL EO .. 36.5 4.7 f 2b.2 27.3 -IsmH AVERACE SIZE OF HOUSEHOLD TOrAL 5.3 6.1 4.7 -c1 URBA 5.5 .. RURAL 5.1 . AVERAE NO. OF PERSONSIROS7 TOTAL .. -. . /c.1 i URBaN .. .. RURAL * ** ACCESS TO ELECT. (Z OF ODCLLIGS) TOTAL 17.0 - .0 IC 1 4.2 tURA 39.2 .. 90.0 7e T 77.7 RURAL 1.4 30.0 IC-t 16.1 1/ The data in this annex and in the text are not comparable. Data in the annex (unless noted by footnote c/) are for all of Jordan; data in the text for the East Bank only. Data in the text are also based upon more recent information.  -20- ANNEXi Page T2of 6 mmnu_ gm !X,LD ,,,,h,, RIn ItlM PZ a07 NE "a A. AN*I As CAR MM= 1113aM! T7*L 77.0 72.0 102.0 66.23 10.4 k1L3 34.0 79.0 105.0 102. 104.3 1WOIL 53.0 45.0 100.0 73.4 104.5 SscoIC aaa TOTAL 25.0 33.0 7.o 4 43.2 - Nei 24.0 41.0 73.0 52.2 42.3 136*1. 12.0 24.0 74.0 33 2.0 44.5 YOCAXoI*L CSair SICUIAI) 2.7 3.0 6.1j 10.3 33.4 KVwzL*ZKACI RATIO 1311MM! 34.0 39.0 31Oj 0.3 30.1 630011MM! ~~~~ ~~20.0 23.0 2102.11. A30!T LITIMAC!I &M! CZ) 32.4 .. 70.0 42.2 79.5 VAIUIIUX C*ANflUDUUMD Po 3.7 4.1 20.7 17.6 4G.0 MaDio R=IC3VIII0UDAMN 101 37.8 160.9 162.4 126.4 223.4 TV INCRIVIRSITN005AN PM . 20.0 36.5 44.1 L07-4 3636*13 (.0521. 0in*. INhTZSRK) CZXOUAS?IO PER r3005*A1 IOIM&TXOU 18.3 24.4 31.3 3 12 63.3 cIum Amun*j tiu4.eJC 3.2 0.9 5.2 1.72 2.6 usaunLsx TOTAL LAIOg 10103 CTUOU) 452.0 569.0 736.0 131*1.3 (113dM) 5.0 5.4 4.4 LO.4 23.2