Jordan - Health sector study

Report No. 1541 8-JO Hashemite Kingdom of Jordan Health Sector Study August 12, 1996 Human Resources Division Country Department II Middlle East and North Africa Region Document of the World Bank  CURRENCY EQUIVALENTS Currency Unit = Jordanian Dinar (JD) JD 1.0 = 1000 fils JD 1.0 = US$ 1.41 (July 1996) US$ 1.0 =JD 0.71 (July 1996) FISCAL YEAR January I - December 31 LIST OF ACRONYMS ARI Acute Respiratory Infections CBR Crude Birth Rate CDR Crude Death Rate DALY Disability Adjusted Life Year DHS Demographic and Health Survey DRG Diagnosis Related Group EPI Expanded Program of Immunizations FSE Former Socialist Economies GDP Gross Domestic Product GOJ Government of Jordan IMR Infant Mortality Rate JAFPP Jordan Association of Family Planning and Protection JD Jordanian Dinar JUH Jordan University Hospital JUST Jordan University of Science and Technology MCH Maternal and Child Health MENA Middle East and North Africa MIS Management Infonnation System MOH Ministry of Health NGO Non-Governmental Organization NHA National Health Accounts NMI National Medical Institute NNMR Neonatal Mortality Rate NPC National Population Commission OECD Organization for Economic Cooperation and Development PNMR Post-Neonatal Mortality Rate PPP Purchasing Power Parity RMS Royal Medical Services TFR Total Fertility Rate TWG Technical Working Group UNICEF United Nations Children's Fund UNRWA United Nations Relief Works Agency U-5MR Under 5 Mortality Rate US United States WDR World Development Report WHO World Health Organization  HASHEMITE KINGDOM OF JORDAN HEALTH SECTOR STUDY TABLE OF CONTENTS Definition Of Terms Acknowledgments Executive Summary .......................................... i - iv 1. Introduction.I 11. Demographic and Epidemiological Situation .2 Demographic Trends .3 Epidemiological Profile .5 Maternal And Child Deaths .6 Principal Causes Of Death .7 Morbidity .8 Burden Of Disease .8 111. Health Care Financing And Delivery System .10 Overview Of Health Expenditures And System Resources .II Health Expenditures .13 Health System Resources .14 Jordan's Health Sector: An Institutional Overview .16 Major Health Care Financing And Delivery Programs .18 IV. Need For Reform .21 V. Financing Universal Coverage .27 Rationale For Universal Coverage .27 Modeling Altemative Approaches To Universal Coverage .28 Universal Coverage Options .28 Universal Coverage Through The Civil Insurance System .29 Universal Coverage Through The Social Security Law .31 VI. Reform Of Medical Care Provider Payment Systems .33 VIl. Delivery System Reforms ........................................ 36 Management Reforms ........................................ 36 Manpower Reforms ........................................ 38 Physical Infrastructure ........................................ 38 Vill. Reform Of Health Programs And Clinical Practice ......................................... 40 Maternal And Child Health Reforms ......................................... 42 Adult Health Reforms ......................................... 42 IX. Pharmaceutical Sector Reforms .43 X. A Proposed Health Reform Process .46 Reform Agenda .47 A Health Reform Process .49 ANNEXES Annex 1: Health Financing Model For Jordan Annex 2: Jordan's Health Service Delivery System Annex 3: Overview of Jordan's Health Care System References  TABLE OF CONTENTS (CONT.) TABLES Table 1. Demographic And Epidemiological Profiles For Selected Countries (1993) ......................... 3 Table 2. Main Causes Of Death In Jordan (1991 ) ................................................................................8 Table 3. Burden Of Disease ................................................................................... 10 Table 4. Health Expenditures By Source Of Payment (1989-1994) ................................................... 12 Table 5 Economic Performance Indicators (1989-1994) ................................................................... 12 Table 6. International Comparison Of Health Expenditures ............................................................... 13 Table 7. Health Expenditures By Type Of Service (1989-1994) ........................................................ 14 Table 8. Summary Of Health Personnel (1994) .......................................................................... 15 Table 9. Cost Of Providing Coverage To The Uninsured Through Civil Insurance ......... ................. 30 Table 10. Cost Of Providing Coverage To The Uninsured Through Social Security And Civil Insurance ................................................................................... 32 FIGURES Figure 1. Contraceptive Prevalence Rates In Selected Countries ................... .......................................5 Figure 2. Jordan Compares Favorably In Infant Mortality ................................... .................................6 Figure 3. Improvements In Infant And Child Mortality (1960-1994) ....................................................7 Figure 4. International Comparisons Of Hospital Beds And Physicians (1993) .................................. 16 Figure 5. Coverage Of The Population .......................................... ........................................ 17 Figure 6. Coverage By Program ........................ .......................................................... 17 Figure 7. Flow Of Funds In Jordan ............................. ..................................................... 34 Figure 8. Hospital Capital And Recurrent Expenditures Under Alternative Investment Strategies ........... 39 Figure 9. Cost Effectiveness Of Health Interventions In Jordan .......................................................... 41 BOXES Box 1. Population And Family Planning .......................... ..................................................5 Box 2. Organization Of The Ministry Of Health ........................................................................... 19 Box 3. Evaluating Health System Performance ........................................................................... 22 Box 4. Provider Payment Reform Lessons From OECD Countries .................... ................................ 34 This report is based on the findings of a mission which visited Jordan in November 1995. This report is the work of George Schieber (Mission Leader and Senior Health Financing Specialist), Gail Richardson (Health Specialist), Eduard Bos (Demographer), Mariam Claeson (Child Health Specialist), Peter Cowley (Burden of Disease Expert), Vivian Hon (Econometrician), Michael Hopkinson (Facility Rationalization Expert), Ernst Lauridsen (Pharmaceutical Specialist), James Mays (Health Financing Modeling Expert), and Robert Taylor (Management and Manpower Specialist). Jackie Perry provided editorial assistance. Fred Golladay (Principal Human Resources Economist) and Alex Preker (Senior Health Economist) were peer reviewers. This report was prepared under the overall supervision of Jacques Baudouy (Chief, MN2HR). This study was prepared in collaboration with the Technical Working Group and PHRD Grant Administration Committee in Jordan which included: Dr. Zuheir M. Teif (Ministry of Health), Dr. Reyad Amin Al-Ali (Ministry of Health), Dr. Faris Salameh Nicola Khoury (Ministry of Health), Mr. Mazen Muatamen Khalil Imadeddin (Ministry of Health), Dr. Matasem Awamleh (Ministry of Health), Engineer Mahmoud Rawashdeh (Ministry of Planning), Dr. Musa Taha Mohammad El-Ajlouni (Royal Medical Services), Dr. Mahmoud Najeeb Nusair (Social Security Corporation), Mr. Ibrahim Alhamed Al-Duwairi (Ministry of Finance), Ms. Muna Y. M. Issa (Ministry of Health), Mr. Adel Jamil Mahmoud Al-Ali (Arab Center for Heart and Special Surgery), Dr. Hashem Y. Al- Jaddou (Jordan University of Science and Technology and Ministry of Health), Mr. Khalid Omar Al-Jadeed (Ministry of Health), Dr. Mamoun Moh'd Amin Maabreh (Ministry of Health), and Mr. Ratib Hinnawi (Ministry of Health).  JORDAN HEALTH SECTOR STUDY Definition of Terms Contraceptive Prevalence Rate The percentage of married women of reproductive age who are using (or whose husbands are using) any form of contraception. Crude Birth Rate Number of live births per year per 1,000 people. Crude Death Rate Number of deaths per year per 1,000 people. Dependency Ratio Population 14 years or under and 65 years or older as a percentage of the population aged 15 to 64 years. Female/Male Literacy Rate The percentage of persons aged 12 and over who can read and write. Infant Mortality Rate Annual deaths of infants younger than 1 year old per 1,000 live births during the same year. Life Expectancy at Birth The number of years a newbom child would live if subject to the age-specific mortality rates prevailing at time of birth. Low Birth Weight Infants whose weight at birth is less than 2,500 grams. Maternal Mortality Rate Number of maternal deaths per 100,000 births in a given year attributable to pregnancy, childbirth, or postpartum. Rate of Population Growth The rate at which a population is increasing (or decreasing) in a given year due to natural increase and net migration, expressed as a percentage of the base population. Total Fertility Rate The average number of children a woman will have if she experiences a given set of age-specific fertility rates throughout her lifetime. Serves as an estimate of the number of children per family. Under-Five Mortality Rate Annual number of deaths of children under five years of age per 1,000 live births. This figure represents the probability of dying between birth and five years of age.  Acknowledgments This study could not have been completed without the valuable guidance provided by members of the Policy Steering Committee. The authors of the report would like to thank the members of this Committee for the information, insight, and guidance they were able, and will continue, to provide. The composition of the Policy Steering Committee is as follows: H.E. Dr. Aref Batayneh (Ministry of Health and Chair of the Committee) Dr. Yousef Mousa Goussous (Royal Medical Services) Dr. Nail J. Ajluni (Ministry of Health/Private Sector) Dr. Mamoun Moh'd Amin Maabreh (Ministry of Health) Dr. Mahmoud Abu-Khalaf (University of Jordan) Dr. Ibrahim Hussein Al-Ali Al-Abdulla Bani Hani (Faculty of Medicine) Mr. Zaidoun Ahmad Salim Rashdan (Ministry of Planning) Mr. Abdul Rahman Ajlouni (Ministry of Finance) Dr. Basem M. Dajani (Jordan Medical Association) Mr. Issa J. Hanania (Social Security Corporation)  JORDAN: HEALTH SECTOR STUDY EXECUTIVE SUMMARY Background 1. Jordan's health sector perforns well in terms of access and health outcomes, which are among the best in the region and among other middle income countries. An estimated 80 percent of Jordan's population has formal 'health insurance' coverage. Services are delivered through an extensive network of public and private facilities, and overall capacity in terms of hospital beds and physicians is high. 2. Jordan finances and delivers care through a complex amalgam of two major public health "insurance" programs--the Civil Insurance Program, administered by the Ministry of Health (MOH) and the Royal Medical Services (RMS), which both finance and deliver care, several other public programs including one small independent university-based public program--Jordan University Hospital (JUH), the United Nations Relief Works Agency (UNRWA), which provides services to Palestinian refugees, and a large and growing private sector. The MOH provides coverage for the poor and disabled through the Civil Insurance Program and is also the social safety net for those without coverage, since anyone can purchase services at MOH facilities at highly subsidized charges. Needfor Reform 3. While the system performs relatively well in terms of overall access and outcomes, it is expensive and inefficient, and there are geographic maldistributions of resources. Jordan spends an estimated 7.9 percent of its GDP ($374 in international dollars) on health care, well in excess of most middle income and even some western industrialized countries. While Jordan provides coverage for its poor and disabled, an estimated 20 percent of the population lacks formal coverage, and Government subsidies for health care could be better structured to reflect ability to pay. The largely unregulated private sector accounts for over 30 percent of service delivery capacity and over half of all health spending, and its shares are growing, resulting in a two-tiered system of care. Particularly problematic is the inadequate information on private sector spending, capacity, and utilization, especially for some three thousand private physician practices. Lack of a coordinated policy apparatus and relevant data for decision-making preclude effective policy-making across Jordan's multiple public and private financing arrangements and delivery systems. 4. There are significant inefficiencies in the service delivery system. There is excess overall capacity as evidenced by a hospital occupancy rate of 63 percent (69 percent in the public sector lInternational dollars are Jordanian Dinars converted into U.S. dollars using a special exchange rate called a "purchasing power parity (PPP)." PPPs differ from usual exchange rates by adjusting for cross country differences in price levels.  Executive Summary - ii - and 49 percent in the private sector). Yet, there are large geographic disparities in the availability and use of services. Inappropriate hospital use results from lack of an effective referral system and a hospital-based orientation for treatment. The centralized allocation process for supplying and equipping facilities and paying personnel in the public sector provides few incentives for the efficient delivery of services at the individual institution level. Lack of standard treatment protocols often leads to costly inpatient treatment of conditions that could be treated on an outpatient basis and excessive use of expensive drugs. There are inefficiencies in terms of overall management, procurement, storage, distribution, pricing policies, and the rational use of pharmaceuticals, which account for over one-fourth of health spending and over two percent of GDP. 5. Jordan could improve the health status of its population, provide universal coverage and better access to services, improve the economic efficiency, clinical effectiveness, and quality of its delivery system, and achieve long-run financial sustainability without significant increases in expenditures. Based on estimates from a financial impact model developed for this study, Jordan could provide formal universal coverage to its uninsured population for 3-6 percent of its current expenditures. Indeed, potential savings from efficiencies in the service delivery system and pharmaceutical sector as well as additional revenue enhancements through minor changes in the financing of the MOH and RMS programs could underwrite a budget neutral major reform effort. 6. Undertaking reforms now would result in better value for the almost 8 percent of GDP allocated to the health sector and enable Jordan to more effectively cope with the increasing future demands that will be placed on its health sector due to population aging, the changing composition of illness toward costly chronic conditions, and the emergence of new and sophisticated medical technologies. As Jordan's population ages over the next decades, increasing financial pressure will be placed on its system. An aged person consumes 3-4 times the amount of medical care as a non-aged person. Similarly, as birth rates decline, there will be less need for maternal and child health services. To effectively deal with both the changing composition and increased demands for health services in the near future, Jordan must begin the process of transforming its current system now. Proposed Reforms 7. A reform strategy for Jordan has been developed which builds upon the strengths of its present system, while addressing its weaknesses. The suggested reforms are designed to improve the performance of the financing, human and physical infrastructure bases of the public programs, while assuring effective coordination with the substantial delivery and technological capacity of the private sector. The sine qua non for an effective reform effort is the establishment of a permanent national body composed of representatives of all public programs, the private sector, and other stakeholders with a dedicated staff, policy analytic capacity, and budget with the responsibility to develop, evaluate, and implement sector wide health reform initiatives. 8. A proposal to establish such a body by reconstituting a modified version of Jordan's Higher Health Council has been submitted to the Government and could form the base for a  Executive Summary - iii - coordinated major health reform effort. Once established, the Council will need to prioritize its activities among competing reform priorities. Some of the reform activities recommended below, such as developing management information systems for public facilities, have already been initiated. Others, such as medical care provider payment reforms, will need to be undertaken over a more medium term focus. Management issues including obtaining relevant data for decision-making should be given a high priority since such information is needed for effective policy-making. For example, better coordination between public and private sectors can only occur if there is more transparency, and relevant information about private sector capacity, utilization, and costs is available. Health sector reform priorities will also have to be carefully reconciled with budget priorities as the costs of different reforms will have to be weighed against their benefits in terms of improvements in health outcomes, efficiency, equity, quality, and consumer satisfaction as well as alternative non-health investments. 9. The principal recommended reform initiatives are: (i) Improve management of the health sector by: * Developing and implementing at all levels of the system management information systems and appropriate information for decision-making including national health accounts, public and private insurance coverage information, information on private sector spending, delivery capacity, and utilization, and basic epidemiological information. X Decentralizing MOH and RMS management to the individual facility level, providing facility managers with institutional budgets, training, management information systems, as well as the responsibility and authority to effectively manage their facilities. (ii) Obtain better value for money by: * Developing an investment strategy based on needs and efficiency criteria as well as more effective use of combined public and private sector facilities. * Implementing an effective referral system to assure appropriate use of services at the lowest, least costly, levels of the system. * Developing, evaluating, and implementing new methods to pay hospitals, health centers, and physicians whereby money follows patients and medical care providers face financial incentives to use resources efficiently. * Adopting a series of reforms in the pharmaceutical sector including generic substitution, lists of essential drugs, better forecasting of demand, and achievement of economies of scale and scope through integration of the five separate systems for procurement, storage, and distribution.  Executive Summary - iv - (iii) Improve clinical practice, quality of care, and consumer satisfaction by: * Improving the design of facilities and the availability of appropriate staff, equipment, information systems, and supplies. * Adopting treatment protocols for communicable and non-communicable diseases. * Assuring more rational use of pharmaceuticals through the adoption of treatment protocols. (iv) Improve the fairness of the system and access to care by: * Providing formal coverage to the entire population. Spreading the financial risks associated with health services use more fairly by better basing premiums and cost-sharing on ability to pay. * Assuring better physical access to care through coordination across programs and sector wide investment and manpower planning. Conclusion 10. Jordan is at a crossroads in the evolution of its health system. Passive acceptance of the status quo is likely to result in a U.S. type system with high costs, access gaps for vulnerable populations, wasteful excess capacity, and poor value for money in terms of health outcomes. Moreover, the rising costs of public programs driven by the epidemiological transition, population aging, continued high rates of population growth, and clinical and economic inefficiencies in the service delivery system will hinder efforts to achieve macroeconomic stability and growth. 11. A carefully developed reform effort could improve the health status of the population, economic efficiency, clinical effectiveness, quality, and access. Savings from implementing a well designed comprehensive health reform strategy, should provide the necessary funds to provide formal universal coverage to the entire population and pay for needed health system enhancements. Moreover, such changes could help assure the long-run financial viability of the health system.  JORDAN: HEALTHSECTOR STUDY I. Introduction 1.1 Jordan is a small, lower middle-income country, with a population of 4.1 million. In 1994, its GDP was some 4.2 billion Jordanian Dinars (JD), about six billion U.S. dollars, US$1500 per capita. It has a small economy, limited natural resources, chronic water shortages, limited (5 percent) arable land, and must import virtually all energy sources. Strong Government commitments to health, education, and other social programs, have resulted in impressive social indicators. With a literacy rate of over 80 percent and a well developed human resource base, Jordan has compensated for its poor natural resource endowments by exporting its surplus labor to the oil exporting countries.' 1.2 The recent worldwide recession and Gulf War have adversely affected Jordan's economy, causing a major decline in income, high inflation, and an increase in unemployment and poverty. While real GDP is projected to grow at annual rates of about six percent for the next several years, in 1994 Jordan's per capita income was only about two-thirds of its 1987 level. Long-term debt in 1994 was 1 15 percent of GDP, a troublingly high figure. Unemployment and poverty are on the order of 15 percent.2 As Jordan develops policies to deal with its present economic circumstances and its transition to a globally-oriented, competitive market economy, it needs to provide its citizens with an effective social safety net, which under the current economic circumstances necessitates improved efficiency and reform of existing social safety net programs including better targeting of current public subsidies.3 This study focuses on Jordan's health sector, a sector with critical human and economic implications that currently accounts for almost 8 percent of Jordan's economy. 1.3 This joint Jordanian/World Bank Health Sector Study evaluates the performance of Jordan's health sector and provides recommendations for basic reforms. Health sector performance is evaluated in terms of improving the population's health status, assuring equity and access, promoting macroeconomic and microeconomic efficiency, improving the clinical effectiveness of the service delivery system, and enhancing quality and consumer satisfaction. Specific policy recommendations are developed to improve system performance along each of these dimensions and assure long-term financial sustainability of the system. i For a detailed discussion of Jordan's geo-physical, political, and macroeconomic situations, see Claiming the Future: Choosing Prosperity in the Middle East and North Africa, World Bank, Washington, D.C., 1995, Peace and th Jordanian Economy, World Bank, Washington, D.C., 1994, 'Country Economic Report: Consolidating Economic Adjustmnent and Establishing the Basis for Sustainable Growth", World Bank, Washington, D.C., August 1994, and Macroeconomy of the Middle East and North Africa Exploiting Potential for Growth and Financial Stability, International Monetary Fund, Washington, D.C., October 1995. 2 See World Bank, Hashemite Kino f Jordan Poverty Assessment, The World Bank, Washington, D.C., 1994. 3 See World Bank, "Jordan Country Brief," World Bank, Washington, D.C., February 1996, and "Jordan: Country Assistance Strategy," World Bank, Washington, D.C., September 8, 1995.  Jordan - Health Sector Study - 2 - 1.4 This study has been performed in collaboration with the Govermnent of Jordan (GOJ). Two groups of Jordanian experts worked with a multi-disciplinary team from the Bank. A Technical Working Group (TWG) of Jordanian health experts collaborated with Bank staff to develop information, analyze policy options, and develop recommendations in the various substantive areas. Overall policy guidance for the study was provided by a Policy Steering Committee, chaired by H.E. the Minister of Health, and composed of senior officials from the Royal Medical Services, Jordan University Hospital, the Ministries of Finance and Planning, the Social Security Corporation, and the private sector. 1.5 Jordan's health care financing and delivery system is both large and complex. In 1994, the health sector accounted for 7.9 percent of Gross Domestic Product (GDP), and health sector employment accounted for three percent of total employment. Health care is both financed and delivered through multiple public and private programs and providers with private financing accounting for over half of total health expenditures. Critical information for health policy development on mortality and morbidity, private health expenditures, and insurance coverage status was generally not available. Developing such information proved to be a major component of the study. Policy recommendations for reform of public health programs were developed on the basis of burden of illness/cost-effectiveness analyses, while options for universal health insurance coverage were developed on the basis of an economic impact model. 1.6 This report is divided into ten sections. Sections II-IV provide a detailed description and analysis of the strengths and weaknesses of the current health system. In particular, Section II analyzes Jordan's underlying demographic and epidemiological patterns. Section III describes the Jordanian health care financing and delivery system. In Section IV, the system's strengths, weakness, and need for reform are assessed. 1.7 Sections V-X provide the conceptual and empirical policy basis for health care reforms. In Section V, options for universal health insurance coverage are analyzed and cost impacts are estimated using a health sector financial impact model. In Section VI, policies to improve efficiency through medical care provider payment reforms are discussed. Section VII analyzes reforms to restructure and improve management of the delivery system, including both facilities and manpower. Section VIII provides recommendations for reform of basic health programs and clinical practice. Section IX discusses reforms of the pharmaceutical sector. Section X provides an overview of a potential reform agenda and possible next steps. 11. Demographic and Epidemiological Situation 2.1 Jordan's population composition and growth along with its basic epidemiological underpinnings have important implications for its present and future economic prosperity, health status of the population, and the demand/need for health and other social safety net services. Jordan's current population and epidemiological profiles are a result of both the demographic and epidemiological transitions that characterize most middle-income countries. Drastic declines in death rates and continued high birth rates along with the shifting composition of illness away from infectious diseases to non-communicable diseases shape Jordan's population and  Jordan - Health Sector Study - 3 - epidemiological circumstances. Table I contains the basic population and epidemiological indicators for Jordan and other relevant comparator countries. Table 1: Demographic and Epidemiolof,ical Profiles for Selected Countries (1993 1) Life Pop. IMR U-SMR TFR41 CBR CDR Expectancy Growth Male Female Rate Countries (per 1000 live births) (per woman) (per 1000 pop.) (Years) (%) ordan21 34 39 4.6 39 5 67 69 3.6 uS 9 9 2.0 17 9 72 79 1.0 OECD 9 9 1.9 14 9 73 79 0.7 Lower-Middle3/ 40 63 3.0 23 9 64 70 1.6 MENA3/ 52 70 4.7 33 7 65 67 2.7 Egypt 64 86 3.8 29 8 63 65 1.8 Iran 35 54 4.9 35 7 67 68 2.6 Iraq 56 71 5.6 38 7 65 68 2.5 Kuwait 17 21 3.1 24 2 73 77 4.4 Lebanon 33 40 3.0 26 7 67 71 2.8 Morocco 66 84 3.6 28 8 62 66 2.0 Oman 29 38 7.1 43 5 68 72 4.5 Saudi Arabia 28 38 6.3 35 5 69 72 3.4 Syria 38 46 5.8 41 6 66 70 3.3 Tunisia 42 52 3.1 25 6 67 69 1.8 Turkey 53 N.A. 2.7 23 7 64 68 1.9 Yemen 117 137 7.5 49 15 50 51 3.3 UAE 18 21 4.2 23 3 73 76 2.6 Notes: "NA." = not available I/ Or most recent year available. 2/ Data for Jordan are for 1994. 3/ Weighted average for the group, World Development Report 1995. 4/ For women 15-49, except in OECD and USA for women 15-44, Turkey from Demographic Health Survey (1993). Source: World Bank Economic and Social Database; OECD Eco Sante Database; various Demographic and Health Surveys. Demographic Trends 2.2 Jordan's (mid-year) 1994 population was 4.1 million. Infant and child mortality indicators are generally favorable compared with other countries in the region and with other countries at similar levels of income, although they are still high by Organization for Economic Cooperation and Development (OECD) standards. These impressive indicators are, as explained  Jordan - Health Sector Study -4 - below, due in large measure to the high education level4 and improvements in the nutritional status of the population. Despite declines in fertility in recent years (from 7-8 children per woman in the 1970's), Jordan's total fertility rate (TFR) of 4.6 children per woman is still quite high, well above the rates in neighboring Egypt, 3.8, and Turkey, 2.7, and far in excess of the 1.9 rate for the western industrialized OECD countries. 2.3 As a consequence of high fertility and moderately low mortality, the age structure shows a young population (over 40 percent is age 15 or younger), with a low crude death rate of 5 deaths per 1,000 population and a high crude birth rate of 39 births per 1,000 population (Table 1), producing a rate of natural increase of about 3.4 percent per year. With a net migration rate of 0.2 percent, overall population growth is about 3.6 percent per year, a rate well in excess of the industrialized countries and many other countries in the region and other countries with comparable income levels. Based on current demographic trends, Jordan's population is projected to increase from its current 4.1 million base to 7 million by the year 2015.5 2.4 Jordan's current high rate of population growth and young population have important implications for future developments. Population "momentum" as a result of increasing numbers of women entering the peak child bearing ages means that population growth will continue for decades to come, even if fertility continues to decline from its current high level. High population growth will increase the demand for public funding for education, health, and other social programs. As the large cohorts born in this decade become of working age, the overall dependency ratio will decline from its current 83 percent level to about 60 percent in 2015. As this happens, however, the number of old-age dependents will be growing, increasing the demand for all social programs, especially health care, while the lower number of newborns will be diminishing the demand for maternal and child health services. The percentage of the population age 65 and over is projected to increase from 2.7 percent in 1994 to 3.9 percent in 2015, while the population below age 15 is projected to decline from 42.4 percent to 33.6 percent. 2.5 A national population strategy was approved by Parliament in March 1996 which addresses Jordan's high rate of population growth, unmet need for family planning services, and relatively low contraceptive prevalence rate [35 percent of married women were using contraceptives in 1990, although 95 percent were familiar with various methods and knew where they could be procured6 (See Box 1)]. 4 Participation in education and literacy rates in Jordan are among the highest in middle income countries. Equality of opportunity for girls is well established at all stages, including higher education. In 1991-92, about 50 percent of basic and secondary students were females. See E. Bos, "Demographic Trends in Jordan," Report from the November 1995 Mission to Jordan, World Bank, Washington, D.C., 1995. 6 See "Jordan - Demographic and Health Survey," Ministry of Health, 1990.  Jordan - Health Sector Study - 5 - Box 1. POPULATION AND FAMILY PLANNING Policy Development. The principal policy board for guiding family planning program development is the National Population Commission (NPC), commissioned in 1973, yet not really activated until 1988 when the King first referred to the need for the provision of family planning services. The NPC, chaired by the Minister of Labor, includes senior representatives from the relevant ministries (ministries of Health, Islamic Affairs, etc.), the academic community, the private sector, and select non-governmental organizations (NGOs). A primary achievement of the NPC has been the preparation of a National Population Strategy for Jordan, approved by Parliament in March 19%. Tle new strategy has among its objectives to lower maternal deaths and infant mortality, reduce fertility, and increase the use of contraceptive methods. Provision of Family Planning Services. Most family planning services are provided by NGOs (in particular the Jordanian Association for Family Planning and Protection (JAFPP), an affiliate of the International Planned Parenthood Federation), and the private sector. The contraceptive prevalence rate in 1990 was about 35 percent among currently married women (about a 30 percent increase since 1983 when the contraceptive prevalence rate was 26 percent), of which over 75 percent are using a modem method (in particular, the IUTD, the pill, and female sterilization). The unmet need of fanily planning is estimated at 8 percent of married women wanting to delay the next birth and 15 percent wanting to prevent further childbearing. Figure 1. Contraceptive Prevalence Rates in Selected Countries Yemen, 1992 10 Turkey, 1993 63 Tunisia, 1994 60 Syria, 1993 _40 Traditional Qatar, 1991 [M32 Oman, 1992 9 Morocco, 1995 50 Egypt, 1992 : 47 Jordan, 1990 35 0 10 20 30 40 50 60 70 Percent Sources: "Morocco - Demographic and Health Survey," Ministry of Health, 1995; "DHS Newsletter," Vol. 7, No. 2, Macro International Inc., 1995; "Qatar - Child Health Survey," Ministry of Health, 1991; and "Oman - Child Health Survey," Ministry of Health, 1992. Epidemiological Profile 2.6 Providing a complete picture of Jordan's basic epidemiological profile is problematic since some 50 percent of deaths are not registered and there are few reliable indicators of  Jordan - Health Sector Study - 6 - morbidity.7 However, given the major efforts to reduce maternal and child deaths as well as the availability and use of appropriate measurement instruments, these measures are more reliable than deaths from chronic conditions, where there has been far less policy focus. Maternal and Child Deaths 2.7 The infant mortality rate (IMR) stands at about 34 deaths per 1,000 live births. As shown in Figure 2, Jordan's IMR is well below the level that would be predicted, based on the average relationship between per capita GDP and infant mortality found for other countries in the region. The under 5 mortality rate of 39 deaths per 1,000 live births and the maternal mortality rate of 45 deaths per 100,000 live births also compare favorable with other countries in the region.8 Figure 2. Jordan Compares Favorably in Infant Mortality 70 A MOR !5 60 LEGY I- 50 40 & 20 10 0 5000 10000 15000 20000 GDP per capita (international currency) Notes: IMR predicted: In(IMR)=9.8-0.7*1n(GDPPC), R square=0.83. GDP per capita converted into US dollars using purchasing power parities. Source: World Bank Economic and Social Data Base. 2.8 While further improvements in these rates should certainly be a major policy focus, one should not overlook Jordan's successful efforts over the past 30 years in reducing maternal and child mortality (Figure 3). The IMR has fallen from 135 in 1960 to 34 deaths per 1,000 live births in 1994. The under 5 mortality rate has also decreased significantly to 39 from 195 deaths per 1,000 live births in 1960, mainly due to declines in the child (1-4 years) mortality rate, which has decreased from 60 in 1960 to 5 deaths per 1,000 children age 1-4 years. 7 See P. Cowley and M. Claeson, "Public Health Interventions and Cost Effectiveness," Report from the November 1995 Mission to Jordan, World Bank, Washington, D.C., 1996. a See World Bank, Social Indicators of Development 1995, World Bank, Washington, D.C., 1995.  Jordan - Health Sector Study - 7 - Figure 3. Improvements in Infant and Childhood Mortality (1960-1994) 200 180 160 140 - 120 ri6 t- Jordan,UWorld Bank, Washington, 1994D 80 60 40 20 Source: ~IMR 1-4 MR U-5 MR Suc:E. Bos, "Demographic Trends in Jordan," Report from the November 1995 Mission to Jordan, World Bank, Washington, D.C., 1995. 2.9 These declines have occurred as a result of focused Government maternal and child health activities, and improvements in education, birth spacing, sanitation and access to clean water. Important factors for the drop in the mortality rate in ages 1-4 are increased vaccination coverage rates (fully immunized child coverage rates have doubled since 1980 from approximately 40 percent), the increased use of oral rehydration therapy, and overall better status of childhood nutrition. 2.10 Maternal deaths have also decreased, from 80 in 1979 to 45 deaths per 100,000 live births in 1993. During the same time period use of antenatal care has expanded, and about 90 percent of all births are attended by trained health personnel. Although progress has been made against maternal and infant mortality rates at the national level, there are three to one variations in these rates among governorates.9 Principal Causes of Death 2.11 Table 2 contains the percent distribution of the main causes of death, based on the 50 percent of deaths in Jordan that are reported. '0 As can be seen in Table 2, the leading cause of reported death in Jordan for males (44.2 percent of all reported male deaths) and females (34.5 percent of all reported deaths) are diseases of the cardiovascular system. Other important causes include accidents (particularly for males) and pneumonia. It is apparent that non-communicable diseases have become an important cause of registered deaths. 9 Ministry of Health, Jordan Population and Family Health Survey. 1990, Ministry of Health, Amman, Jordan, August 1992, p.79. to Age-specific breakdowns of the deaths were not available. There are also limitations to using these data for health policy planning; in particular, deaths in rural areas are probably under-registered at a greater frequency than in urban areas. This suggests that early childhood and perinatal deaths are under-registered at a greater frequency due to their greater prevalence in rural areas.  Jordan - Health Sector Study - 8 - Table 2: Main Causes of Death In Jordan (1991) (As Percentage of Total Reported Deaths) Cause of Death Male Female Cardiovascular Disease 44.2% 34.5% Accidents 15.4% 6.7% Pneumonia 5.0% 4.0% Malignant Neoplasm 2.2% 3.1% Diseases of Urinary Tract 1.9% 3.3% Diseases of the Liver 1.2% 1.4% Infectious Disease 0.3% 0.3% Other (Not Specified) 29.8% 46.7% Total 100% 100% Total Number of Cases 6,758 4,510 Source: 'Health Financing Study"; Center for Consultation, Technical Services, and Studies, University of Jordan; March 1995. Morbidity 2.12 There are no reliable indicators of morbidity patterns in Jordan. However, utilization indicators show that the major reasons for seeking care are diseases of the respiratory system, accounting for 36 percent of all registered visits in Jordan from 1991-1994. Infectious and parasitic diseases account for 12 percent of visits, while diseases of the digestive system account for 10 percent. Other data sources indicate that musculo-skeletal (mainly arthritis) and endocrine disease cases (mainly diabetes type II) have become increasingly frequent in those age 45 and above. Burden of Disease 2.13 One frequently used measure of the burden of disease is the disability adjusted life year (DALY) concept: a composite indicator measuring both death and disability. 1 As shown in Table 3, the greatest loss of DALYs in Jordan are a mixture of adult and very early childhood diseases.12 The greatest single loss of DALYs in Jordan is ischemic heart disease (25.0 percent of DALYs lost), while cerebrovascular disease is second (16.8 percent of DALYs lost). Closely The DALY is an indicator of the time lived with the disability and the time lost due to premature mortality. Years lost from premature mortality are estimated with respect to a standard expectation of life at each age. Years lived with a disability are translated into an equivalent time loss through multiplication by a set of weights that reflect reduction in functional capacity. As such, the DALY represents an attempt to combine in a single indicator the impact of disease on mortality (through a calculation of the duration of life lost due to death) and morbidity (through an assessment of the length of time lived with a disability). See World Bank, World Development Report* Investing in Health, World Bank, Washington, D.C., 1993 and N. Homedes, "The Disability Adjusted Life Year (DALY) - Definition, Measurement and Potential Use"; Human Capital Development Working Paper No. 68; World Bank, July 1996. 12 See Cowley and Claeson, op.cit. The total number of DALYs lost shown in Table 3 only reflects DALYs lost from a representative sample of the top causes of DALY loss and is not therefore complete. Particular omissions are neuro- psychiatric disorders and congenital abnormalities for which there are no available data. Congenital malformations are suspected to be particularly important due to the high levels of consanguineous unions.  Jordan - Health Sector Study - 9 - following ischemic heart and cerebrovascular disease in relative number of DALYs lost is perinatal death and disability (12.7 percent), acute respiratory infections in children under 5 (10.8 percent), diarrhea in children under 5 (10.5 percent), and motor vehicle accidents (9.6 percent).13 The results of the burden of disease analysis can be summarized as follows: * The nature of acute respiratory infections in under 5 year olds and perinatal disease at the levels shown in Jordan necessitate a coordinated curative and preventive strategy for early childhood and maternal diseases, emphasizing outpatient treatment and timely referral for effective hospital-based care when needed. * Progress has been made in reducing the reported mortality rates and DALYs lost from vaccine preventable disease, tuberculosis, and diarrhea. Nevertheless, these infectious diseases might re-emerge with their concomitant DALY loss, if efforts are not sustained in preventing and treating them. * Non-communicable diseases and illness are becoming increasingly prevalent in Jordan. Efforts to address these non-communicable diseases in a cost-effective manner become exceedingly important as treatment costs for these diseases are likely responsible for a large and growing percentage of health care costs. * Jordan is in the midst of the epidemiological transition with acute respiratory infections and perinatal diseases still causing a large loss of productive life. - Jordan, like other middle income countries, may be entering into a newly documented phase of the epidemiological transition known as the "protracted polarized model," which is characterized by rapid declines in mortality, continuing high incidence of infectious diseases (despite significant reductions in their mortality rates) coupled with an increase of non- communicable diseases, unequal distributions of wealth and incomplete coverage resulting in widening gaps in health status among income groups and geographic areas (i.e., "epidemiologic polarization"), and possible re-emergence of previously eradicated epidemic diseases.14 3 For the perinatal mortality rate only neonatal deaths were considered; stillbirths were not. 14 See J.L. Bobadilla et al., "The Epidemiologic Transition and Health Priorities," in D. Jamison et al. (eds) Disease Control Priorities in Developing Countries, Oxford University Press, New York, 1993.  Jordan - Health Sector Study - 10 - Table 3: Burden of Disease Disease Age Group DALY Lost Percent of Total Ischemic Heart Disease All 67,597 25.0% Cerebrovascular Disease All 45,381 16.8% Perinatal Under I month 34,250 12.7% Acute Respiratory Infection Under 5 29,280 10.8% Diarrhea Under 5 28,440 10.5% Motor Vehicle Accidents All 25,895 9.6% COPD All 12,165 4.5% Maternal Childbearing Age 8,943 3.3% Tuberculosis All 8,636 3.2% Diabetes All 2,686 1.0% Colon Cancer All 2,318 0.9% Breast Cancer Women 1,867 0.7% Lung Cancer All 1,584 0.6% Cervical Cancer Women 844 0.3% Total 269,887 100% Source: P. Cowley and M. Claeson, "Public Health Interventions and Cost Effectiveness," Report from the November 1995 Mission to Jordan, World Bank, Washington, D.C., 1996. 2.14 These demographic factors and their concomitant epidemiological effects have important ramifications for the design, costs and reform of the health system. Moreover, as incomes improve and urbanization increases, there is a danger of an urban health policy focus under which pre-transitional diseases that are largely rural in nature are neglected. Moreover road accidents, work-related injuries, and environmental related illnesses are likely to increase. These transition elements have important impacts on both the demand and need for services, and have important implications for government health activities as well as the financing and delivery of personal health services. III. Health Care Financing and Delivery System 3.1 Jordan's health system is a complex amalgam of two major public programs, the Ministry of Health (MOH) and Royal Medical Services (RMS), which both finance and deliver care, some smaller public programs including several university-based programs (i.e., Jordan University (JU) and Jordan University of Science and Technology (JUST)), a large private sector in terms of both the financing and delivery of care, and several NGOs, the largest of which is the United Nations Relief Works Agency (UNRWA) which provides care to Palestinian refugees. The MOH is responsible for the separate Civil Insurance Program for civil servants as well as the usual public health activities and health system regulatory functions. The 'system' is really not a single unified system, but rather separate multiple public and private programs which both finance and deliver care. First, the overall system is described in terms of health expenditures and health sector resource inputs and their use. Second, the health sector is described in detail in  Jordan - Health Sector Study - I1 - terms of overall eligibility, benefits covered, financing, reimbursement of medical care providers, and the delivery system. Third, the major individual public and private programs are described. Overview of Health Expenditures and System Resources 3.2 To fully analyze the system, in addition to qualitative information on each of the programs, quantitative information on coverage status and expenditures is needed. Unfortunately, obtaining reliable information on expenditures and insurance coverage status of the population for these programs is problematic. Jordan does not have National Health Accounts (NHA) which provide information on health expenditures by the sources of payment and type of service. Little information exists on the private sector regarding expenditures, private coverage through insurers and firms, and utilization of services by insurance status of the population. There are no official statistics on the uninsured. Furthermore, some of the public programs do not have information on the total numbers of people (including dependents) who are eligible for coverage, and the numbers of individuals with multiple coverages. 3.3 A great deal of effort has been put into developing a consistent time series data set on total, public and private health expenditures and developing a 1994 estimate of the insurance coverage status of the population. The data developed frequently depend on the assumptions made regarding demographic factors and utilization. The detailed methodology and assumptions used to develop a consistent NHA for Jordan as well as the coverage information are contained in Annex 1. 3.4 Tables 4-6 provide information on health expenditures. Table 4 provides information on health expenditures for Jordan for 1989-94 for total health expenditures as well as for each public and private program. X5 Table 5 displays the performance of Jordan's health sector over this period in terms of: total health expenditures, nominal and real per capita health spending, per capita health spending in exchange rate-based and international dollars, the health to GDP ratio, and the public share of total health spending and the overall Government budget. In Table 6 Jordan's 1994 expenditure levels are compared to those in neighboring countries and the OECD. 5 Conceptually, the "other public" category includes expenditures by JUH, JUST, and other university-based health programs as well as expenditures for all non-governmental organizations (NGOs). However, except for UNRWA, data for these other NGOs were not readily available. Therefore, the "other public" category may be slightly understated.  Jordan - Health Sector Study - 12 - Table 4. Health Expenditures By Source of Payment (1989-1994) (JD Million) 1989 1990 1991 1992 1993 1994 Ministry of Health 59 62 84 93 Royal Medical Services 29 28 33 37 Other Public 15 19 21 25 Total Public 92 95 103 109 138 155 Private 94 90 123 138 156 177 Total 186 185 226 247 294 332 Note: Source of program breaks were not available for 1989-90 due to the formulation of the National Medical Institute (NMI), under which all public hospital spending was consolidated in one budget. Source: J. Mays and V. Hon, "Health Financing Model for Jordan," Report from the November 1995 Mission to Jordan, World Bank, Washington, D.C., 1996. Table 5. Economic Performance Indicators (1989-1994) Total Growth 1989 1990 1991 1992 1993 1994 Rate (89-94) Total Health Expenditures (million JD) 186 185 226 247 294 332 78% Percent Public 49 52 46 44 47 47 Public Expenditures on Health as a % of Government Budget 8 10 10 Per Capita Health Expenditures (JD) 61 58 64 66 76 82 35% Real Per Capita Health Expenditures (JD) 61 56 56 54 60 64 5% Per Capita Health Expenditures (US$) 106 88 94 97 109 118 11% Per Capita Health Expenditures (PPP$) 321 278 303 314 344 374 17% GDP (million JD) 2372 2668 2855 3493 3811 4191 77% Per Capita GDP (JD) 776 842 805 936 980 1039 34% Real Per Capita GDP (JD) 776 756 688 758 770 786 1% PerCapitaGDP(US$) 1351 1268 1183 1376 1415 1486 10% Per Capita GDP (PPP$) 4084 4009 3833 4457 4455 4723 16% Health to GDP Ratio (%) 7.8 6.9 7.9 7.1 7.7 7.9 Other related statistics PPP (JD/international dollars) 0.19 0.21 0.21 0.21 0.22 0.22 Exchange Rates (JD/USS) 0.57 0.66 0.68 0.68 0.69 0.70 Medical CPI (1989=100) 100 104 114 123 125 128 GDP Deflator (1989= 100) 100 111 117 123 127 132 Notes: Conversions to USS based on official exchange rates. Purchasing Power Parities (PPPs) are exchange rates used to convert JDs into U.S. dollars which take account of price differences across countries. Source: J. Mays and V. Hon, 'Health Financing Model for Jordan," Report from the November 1995 Mission to Jordan, World Bank, Washington, D.C., 1996, and Jordan Ministry of Finance.  Jordan - Health Sector Study -13 - Table 6. International Companison of Health Expenditures Jordan Egypt Turkey OECD US (1994) (1991) (1992) (1993) (1993) onHealthtoDRi 7.9 4.7 3.8 8.1 14.1 Per Capita Expenditures on Health (US$) 118 30 105 1660 3299 Per Capita Expenditures on Health ($PPPs) 374 149 185 1500 3299 Public Share (%) 47 32 44 77 44 Notes: Conversions to US$ based on official exchange rates. Purchasing Power Parities (PPPs) are exchange rates used to convert JDs into U.S. dollars which take into account price differences across countries. Sources: J. Mays and V. Hon. 'Health Financing Model for Jordan," Report from the November 1995 Mission to Jordan, World Bank, Washington, D.C., 1996: Eco Sante Database; P. Berman et. al.. "Egypt: Strategies for Health Sector Change." (draft paper), Harvard University, Boston, August 1995; 'Turkey Health Financing Policy Options Study: Summary Report": Australian Health Insurance Commission, Ankara, 1995. Health Expenditures 3.5 Health expenditures in Jordan are high by any standard. In 1994, health expenditures in Jordan were an estimated 332 million JD, 7.9 percent of GDP, slightly above the 7.8 percent GDP share for 1989. Private spending accounted for 53 percent of total health expenditures up from a 51 percent share in 1989. Per capita spending was 82 JD in 1994, $118 in exchange rate deflated U.S. dollars, and $374 in international U.S. dollars, up from 61 JD per capita in 1989, 16 $106 in exchange rate deflated dollars, and $321 in international dollars. Since 1989, total nominal spending has increased by 78 percent, public spending by 68 percent, and private spending by 88 percent. Over this period, nominal GDP increased by 77 percent, slightly less than total health spending. Relative to nominal GDP, health spending has increased 4 percent per year more rapidly (i.e., the nominal elasticity of health spending relative to GDP is 1.04). 17 Adjusting for health care inflation, annual real per capita health spending (e.g., volume and intensity of services) is 5 percent higher than it was in 1989, indicating a small increase in the volume and intensity of services over this period.'8 On the other hand, real per capita GDP was essentially constant (i.e., one percent growth) over this period.'9 In summary, overall spending has increased in nominal terms over the past five years and has grown slightly more rapidly than GDP. Spending has also increased more rapidly than medical specific inflation. Nevertheless, Jordan's health spending, whether measured in per capita U.S. dollar terms or as a share of GDP, is high compared to countries of comparable income levels. 16 Based on purchasing power parities estimated for Jordan on the basis of similar countries. Purchasing power parities are exchange rates which adjust for price level differences across countries. 17 The elasticity of health spending with respect to GDP shows the relationship between percentage changes in GDP and percentage changes in health spending. Is On the other hand, if health expenditures are deflated by the GDP deflator instead of the medical care price index, real per capita health expenditures in 1994 are only 3 percent above the 1989 level. 19 Real GDP actually grew by over 30 percent. However, growth in population resulting from high rates of population growth and the influx of Jordanians as a result of the Gulf War offset this growth.  Jordan - Health Sector Study - 14 - 3.6 Table 7 contains information on the types of services purchased. In 1994, inpatient hospital care accounted for 36 percent of all health spending, ambulatory care 27 percent, pharmaceuticals 27 percent, and other health expenditures (i.e., public health) 10 percent.20 Since 1989, the pharmaceuticals share has increased by 6 percentage points, while the inpatient and ambulatory shares each fell by three percentage points. The share of pharmaceutical spending is rather high by OECD standards (i.e., 14 percent of total health spending), but is comparable to other countries in the region (e.g., Turkey 26 percent, Egypt 30 percent).21 Table 7. Health Expenditures By Type of Service (1989-1994) 1989 1990 1991 1992 1993 1994 Total (JD Million) 186 185 226 247 294 332 Inpatient Hospital (%) 39 39 38 38 37 36 Ambulatory Care (%) 30 29 29 28 28 27 Pharmaceuticals (%) 21 22 23 24 25 27 Other (%) 10 10 10 10 10 10 Note: "Pharmaceuticals" includes the expenditures for all pharmaceutical products used in the sector, including those consumed on an inpatient and outpatient basis. Source: J. Mays and V. Hon, "Health Financing Model for Jordan," Report from the November 1995 Mission to Jordan, World Bank, Washington, D.C., 1996. Health System Resources 3.7 Table 8 and Annex 2 provide information on the physical configuration of the service delivery system in terms of personnel and facilities for the private sector and for the individual public programs. In terms of availability and use of services, Jordan has 1.6 inpatient beds per thousand population; 11 percent of the population is admitted annually to hospitals; hospital lengths of stay average 3.4 days; individuals use on average 0.4 inpatient days per year; and the hospital occupancy rate is 63 percent. Jordan has 1.6 physicians, 0.93 nurses, and 0.75 pharmacists per thousand population. One-third of Jordan's physicians are specialists. 20 Some pharmaceuticals are taken to other countries and not consumed in Jordan. Conversely, some pharmaceutical products are brought into Jordan, having been purchased in other countries. The net effect of these transactions is not known. 21 See Egypt Ministry of Health and Harvard Data for Decision-Making Project, "National Health Accounts in Egypt," Harvard University, Boston, 1995, and OECD Eco Sante Data Base, op. cit.  Jordan - Health Sector Study - 15 - Table 8. Summary of Health Personnel (1994) Rate per Category MOH RMS JUH UNRWA Private Other Total 1,000 Doctors 2,217 814 238 61 3,215 56 6,601 1.64 Dentists 239 150 220 15 1,174 1,798 0.45 Pharmacists 170 74 6 2 2,774 3,026 0.75 Nurses (RN) 1,342 822 281 36 1,272 3,753 0.93 Midwives 538 54 5 15 210 822 0.20 Practical Nurses 2,512 700 0 0 0 3,212 0.80 Nurse Assistants 2,044 1,656 220 122 539 4,581 1.14 Technicians 5,742 1,401 239 Source: Ministry of Health, Jordan 3.8 Jordan has experienced substantial increases in capacity since 1989. The number of hospital beds has increased by 18 percent with the largest increase in the private sector, 37 percent, compared to a public sector increase of 12 percent. While the bed to population ratio fell from 1.8 to 1.6 beds per 1,000 population, the number of hospital days per person per year was unchanged at 0.4, and the hospital occupancy rate fell from 64 to 63 percent. Over this period, the number of physicians increased by 18 percent, although the physician to population ratio declined from 1.8 physicians per 1,000 population in 1989 to 1.6 in 1994. As shown in Figure 4, Jordan's bed capacity is comparable with the MENA region and other lower middle- income countries, while its physician to population ratio is higher than most of these countries. Jordan has more physicians and fewer beds than Turkey. However, there is significant excess bed capacity as indicated by the low hospital occupancy rate. Moreover, the ratio of nurses to physicians is low, 0.7 nurses (RNs and midwives) per physician.  Jordan - Health Sector Study - 16 - Figure 4. International Comparisons of Hospital Beds and Physicians, 1993 .0 0U Be 7.0 ~ ~ ~ ~ ~ ~ ~ ~~I NVote: Data are from 1993 or most recent year available. Snource: lordan MOH, OECD and the World Bank. Jordlan's Health Sector: An Institutional Overview 3.9 Annex 3 contains a detailed description of the system and individual programs in terms of the key health sector policy parameters of eligibility, benefits, financing (i.e., revenue raising), payment of medical care providers, and the service delivery systemY2 The general observations which follow provide a summary policy overview of the characteristics of the sector. 3.10 Eligibjiit. Figure 5 provides a conceptual description of the eligibility status of the population, while Figure 6 provides information on coverage under each of the separate public and private programsY2 As shown in Figure 5, the coverage situation is complicated by the fact that many individuals and their dependents are eligible for more than one program as well as the fact that many individuals with public coverage purchase private sector services through out of 240 pocket payments.4 As shown in Figure 6, an estimated 80 percent of Jordan's population is u See Cenmer for Consultation, Technical Services, and Studies, Jordan University, "Health Financing Study," Jordan University. Amman, March 199S. 3 See Annex 1 for a detailed description of the derivation of the coverage shares by program. t' The liberal definition of dependen used by the major public programs results in many individuals being covered by more than one program.  Jordan - Health Sector Study - 17 - formally covered through various public sector (68 percent) and private insurance (12 percent) programs, while 20 percent has no formal coverage. Yet, these individuals can purchase services at MOH facilities at highly subsidized prices. Figure 5. Coverage of the Population Figure 6. Coverage of the Population by Program, 1994 PrPvate 12 RMS 35% Uninsured 20% JUH/Other Public Civil Insurance 10 23% Sorurce: J. Mays and V. Hon, 'Health Financing Model for Jordan," Report from the November 1995 Mission to Jordan, World Bank. Washington, D.C.. 1996. 3.11 Benefits. Public prograrns generally cover a comprehensive array of services including pharmaceuticals with very limited patient cost-sharing. However, uninsured individuals, even those purchasing subsidized care in MOH facilities, must generally pay the full price of pharmaceuticals. Private insurance benefits are more variable and the usual forms of medical underwriting (e.g., pre-existing condition exclusions) are extant. 3.12 Financing. The public programs are financed by the general budget, premium contributions, and user fees. MOH. Civil Insurance and RMS budgets are determined annually  Jordan - Health Sector Study - 18 - through the Government's budgeting process.25 There are major cross-subsidies built into the budgets among public programs as well as from the General Arny Budget to the RMS. UJNRWA is financed through donor contributions. There is no available information on the 26 financing sources of private insurance. An important potential source of financing is through private firms via Article A.3.4 of Jordan's 1978 Social Security Law. This article provides for firns to contribute to health insurance for their employees through payroll taxes, but it has never been implemented.27 3.13 Payment of Providers. The MOH and RMS have centralized management systems for allocating resources to individual facilities. Individual facilities do not have budgets; rather, facilities receive allocations of supplies, equipment, pharmnaceuticals, salaries, etc. from central MOH and RMS departments. Facility managers have little discretion, and health personnel in the public sector are salaried. MOH and RMS facilities also receive reimbursements based on schedules of charges from uncovered individuals. The JUH has a budget but also receives reimbursements from charges for individuals not covered through Jordan University. Private sector facilities and practitioners are reimbursed on the basis of schedules of charges. Charge schedules differ across all programs, although all must be approved by the MOH. While MOH charges are heavily subsidized, those of the other programs more closely approximate actual costs or market prices. 3.14 Delivery System. Each major program has its own delivery system, and there is little coordination among them. There is no single managerial entity responsible for the overall health system. In addition to managing the Civil Insurance System, the MOH is responsible for public health, quality, standard setting, medical education and training, etc., but beyond setting standards and approving charge schedules has little control of the private sector. Each major program has its own pharmaceutical procurement, management, and distribution system. Major Health Care Financing and Delivery Programs 3.15 To fully understand how the 'system' works, each of the separate health financing programs is described in detail. Further discussions of these basic institutional features are contained in the evaluation of the system's performance in Section IV as well as in the rationales for the health reforms discussed in Sections V-X below. 3.16 Ministry of Health. The largest publicly financed health insurance program in terms of expenditures is run by the Ministry of Health (MOH), which accounted for 28 percent of total health expenditures in 1994. Over 80 percent of MOH expenditures are financed through the 25 Separate operating and capital budgets are submitted to the Ministry of Finance. Recurrent budget requests are broken down into four categories---administration, training/development, primary care, and secondary care. Each of these components is broken down in turn into three categories--salaries/allowances, operating expenses, and transfer expenditures. Capital budgets are broken down into buildings, depreciation, and equipment. 26 See World Bank, Report on Jordan's Insurance Sector, World Bank, Washington, D.C., April 1994. 27 The Law created the Social Security Corporation, an independent public agency which collects payroll tax contributions from firms of 5 or more employees for retirement pensions, disability allowances, and work-related accident and injury medical expenses for their employees.  Jordan - Health Sector Study - 19 - government budget, some six percent from insurance premiums from Civil Insurance enrollees, and the remainder from user charges.28 In addition to its general public health fimctions, the MOH has a dual financing function. First, it is responsible for administering the Civil Insurance Program which covers civil servants and their dependents. Individuals certified as poor, the disabled, and blood donors are also formally covered under the Civil Insurance Program, which covers a total of about 23 percent of the population.29 Civil servants pay very low premiums (2 percent of their monthly income with a maximum contribution of 8 JD per month) and receive care in MOH primary care centers and hospitals. There is some very minor cost-sharing for pharmaceuticals and certain other services. Second, the MOH is in effect the insurer of last resort for the entire population, since any individual can come to MOH facilities and pay highly subsidized charges (15 to 20 percent of the costs) for the entire range of MOH services.