Jordan - Health sector review

Report No. 4748-JO - - Jordan Health Sector Review May 25, 1984 Population, Health & Nutrition Department FOR OFFICIAL USE ONLY Document of the World Bank This document has a restricted distribution and may be used by recipients ornly in the pertormance ot their otticial duties Its contents may not otherwise be disclosed wvithout VVorld Bank authorization  CURRENCY EQUIVALENTS 1 Jordanian Dinar (JD) = US$2.839 (1982) 1 US Dollar ($) = JD 0.352 (1982) WEIGHTS AND MEASURES Metric System MAIN ACRONYMS AND TERMS USED IN THE REPORT (See Next Page) FISCAL YEAR January 1 - December 31  FOR OFFICIAL USE ONLY MAIN ACRONYMS AND TERMS USED IN THE REPORT CEH - Council on Higher Education CRS - Catholic Relief Services DOS - Department of Statistics ENT - Ear, Nose and Throat Department GDP - Gross Domestic Product GNP - Gross National Product HHC - Higher Health Council (sometimes translated as Supreme Health Council) IMF - International Monetary Fund IUD - Intra-uterine device JD - Jordanian dinar, the unit of national currency JFPPA - Jordan Family Planning and Protection Association, a private foundation JMA - Jordan Medical Association, the physicians' trade group or syndicate JMC - Jordan Medical Council, the official licensing body JUH - Jordan University Hospital KHMC - King Hussein Medical Center, an operating unit of the RMS MCH - Maternal and child health MOH - Ministry of Health NCC - National Consultative Council (the appointed legislature) NGO - Non-government organization NPC - National Planning Council ODA - United Kingdom Overseas Development Administration OADDB - Old age, disability, and death benefits PHC - Primary health care RMS - Royal Medical Services, i.e., the military medical services SSC - Social Security Corporation UNFPA - United Nations Fund for Population Activities UNRWA - United Nations Relief and Works Agency, operating the Palestinian refugee camps USAID - United States Agency for International Development This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.   JORDAN HEALTH SECTOR REVIEW TABLE OF CONTENTS Page No. SUMMARY AND CONCLUSIONS . . . . . . . . . . . . . . . . . i -xiv I. POPULATION, HEALTH AND NUTRITION STATUS . . . . . . . . . . 1 A. Population . . . . . . . . . . . . . . . . . . . . . . . B. Health ... . . . . . . . .. 3 C. Nutrition . . . . . . . . . . . . . . . . . . . . . . . 5 D. General Living Conditions . . . . . . . . . . . . . . . 7 E. Summary of Sector Problems . . . . . . . . . . . . . . . 8 II. SECTOR POLICIES AND RESOURCES . . . . . . . . . . . . . . . 9 A. Sector Policies . . . . . . . . . . . . . . . . . . . . 9 B. Health Care Providers ... . . . . .. . . . . . . . . 12 C. Health Manpower . . . . . . . . . . . . . . . . . . . . 15 D. Sector Planning and Coordination . . . . . . . . . . . . 17 E. Financial Resources . . . . . . . . . . . . . . . . . . 18 F. Health Insurance ....... . ........... . 29 TII. HEALTH SECTOR PERFORMANCE . . . . . . . . . . . . . . . . . 31 A. Human Resources ....... . ........ ... . 31 B. Physical Resources . . . . . . . . . . . . . . . 37 C. Pharmaceuticals . . . . . . . . . . . . . . . . 42 D. Public Health Laboratory Services . . . . . . . . . . . 43 E. Health Education . . . . . . . . . . . . . . . . . . . . 45 F. Family Planning Activities . . . . . . . . . . . . . . . 46 G. Nutrition Programs . . . . . . . . . . . . . . . . . . . 47 H. Assessment of Health Services . . . . . . . . . . . . . 48 IV. SECTOR DEVELOPMENT STRATEGY ..... . . .. . . . .. . . 50 A. Strengthening Primary Health Care . . . . . . . . . . . 52 B. Human Resource Development Program . . . . . . . . . . . 54 C. Improving Health Sector Management . . . . . . . . . . . 56 D. Hospital Facility Development Program . . . . . . . . . 59 E. Improving Public Health Laboratory Services . . . . . . 60 F. Sector Studies . . . . . . . . . . . . . . . . . . . . . 61 MAP No. 14569R This report was prepared by Anthony Measham (PHN), Bruce Herrick (Consultant), Willy de Geyndt (PHN), and William Adams (Consultant).  TABLES: 1.1 Deaths from all causes, all ages combined, Jordan, 1979 2.1 Selected Health Sector Indicators, Jordan, 1975-1982 2.2 Health Facilities and Eligible Population, by Provider Organization, 1982 2.3 Hospital Beds by Governorate, Jordan 1982 2.4 Primary Health Care Centers by Governorate, Jordan 1982 2.5 Health Manpower by Provider Organization, Jordan, 1982 2.6 Jordanian Government Current Account Spending on Health, 1978 and 1982 2.7 Composition of Estimated Total Health Sector Expenditures, 1982 2.8 Sources of Funds, Ministry of Health, 1978-1983 2.9 Sources of Funds, Jordan University Hospital, 1980-1983 2.10 Health Expenditures on Current Account, 1980-1985 2.11 Health Expenditures on Capital Account, 1980-1985 2.12 Ministry of Health Current Account Expenditures, 1976-1982 2.13 Sectoral Composition of Capital Expenditures in the Five-Year Plan, 1981-1985 2.14 Ministry of Health Capital Expenditures, 1980-1982 2.15 Current Insurance Coverage, 1980 3.1 Jordan Medical Association Membership, 1978-1982 3.2 Hospitals, Beds and Size of Hospitals by Delivery Organization, Jordan 1982 3.3 Measures of Hospital Utilization by Delivery Organization, Jordan 1982 3.4 Ambulatory Services by Provider Organization, Jordan 1982 3.5 Out-Patient Visits at Ministry of Health PHC Facilities, Jordan, 1982 3.6 Vaccines Manufactured by the Jordan Vaccine Institute, 1980-1982 3.7 Family Planning Acceptors, by Program and Method, Jordan, 1982  SUMMARY AND CONCLUSIONS Overview 1. During the last two decades, mortality levels in Jordan have declined by half, nutritional status has improved, and fertility levels have changed relatively little. Children under five and women in the reproductive age group are the most vulnerable population sub-groups, account for a disproportionate share of morbidity and mortality, and deserve first priority for health care. There do not appear to be major regional disparities in health conditions. Health has been given high priority, resulting in an extensive infrastructure that provides good physical access to service in all parts of the Kingdom. The Ministry of Health (MOH) and the Royal Medical Services (RMS) serve, respectively, more than a half and more than a quarter of the population. Jordan University Hospital (JUH) and the United Nations Relief and Works Agency (UNRWA) are also major providers of health services and there is a strong private sector, especially in Amman. In 1982 Jordan spent over JD 29 (US$87) per capita on health, or about 5.2% of GDP. Government spending accounted for 58% of this amount, the private sector - 41%, and UNRWA - 1%. Although the 1981-1985 Five Year Plan stresses preventive and primary health care (PHC), over three-quarters of all spending goes for curative care, and sector expenditures are heavily skewed toward hospital care. If Jordan proceeds with current plans to add 2,300 hospital beds, the recurrent costs of their operation will preclude needed strengthening of PHC services, unless there is an unprecedented increase in the health budget. It is recommended, therefore, that planned hospital investments be postponed to allow additional PHC expenditures that should reduce morbidity and mortality more cost-effectively. High priority also attaches to the need to reduce overlap of health services through joint planning and increased coordination between health care providers. These actions must also precede the introduction of a national health insurance scheme. Finally, action is necessary to expand the stock of female nurses and midwives and to incorporate the rapidly expanding number of physicians into the Kingdom's existing stock of practitioners. Population, Health and Nutrition Status 2. General and infant mortality have declined sharply in the last two decades, nutritional status has improved, and water and sewerage service have expanded. Life expectancy at birth rose from 47 in 1960 to 62 in 1981. Fertility has declined slightly, from about 9 live births per woman in the early sixties to a current level of about 7 live births. As a result, the crude birth rate is still high at 44 per 1,000 births, and the rate of natural increase is 3.4% per year. About one quarter of couples now use contraceptives. The rapid population growth rate constrains overall socio-economic development, while high fertility has a deleterious effect on the health of mothers and children.  - ii - 3. Health conditions do not vary greatly by geographic region, although the poor and less educated suffer more disease and higher mortality, as expected. Infant mortality appears to be highest in Karak and Ma'an governorates. The most pressing health problems in children under five are diarrheal and respiratory disease. Accidents, especially in motor vehicles, are a major cause of death in children aged 5-14 years. In those over 15 years of age, the leading causes of death are heart and circulatory disease, respiratory disease, accidents and cancer. The two most vulnerable groups -- children under five and women in the reproductive age group -- constitute 38% of the population. Prevention and basic curative treatment at the primary health care level can substantially reduce the toll of disease in these priority groups. There is a need to strengthen PHC, especially pre-natal and obstetrical care, contraceptive information and services, immunization, well baby care and treatment of childhood illnesses, health education, and nutrition education. PHC deserves priority over more costly, in-patient hospital care. For the rest of the population, highest priority should be given to prevention of chronic disease to minimize the need for costly high technology care. This will require energetic campaigns to reduce smoking, to promote exercise and good diet, to prevent accidents, and to ensure prompt detection and early treatment of diseases such as high blood pressure. Sector Policies and Resources 4. The 1981-1985 Five Year Plan set forth the following objectives for the health sector: (a) strengthen primary health care and preventive services; (b) extend coverage to all citizens; (c) increase the quality and supply of health personnel; (d) expand medical research; and (e) construct 36 new health centers and 2,300 additional hospital beds. Jordan has no policy to reduce the high population growth rate, but acknowledges the right of parents to decide the number and spacing of their children and supported the establishment of the Jordan Family Planning and Protection Association. Since 1979 the Ministry of Health has made available contraceptive services in some of its facilities, but does not promote their use. As for nutrition, there is no explicit policy nor any inter-sectoral body responsible for articulating one. 5. Jordan has a well developed health care infrastructure that provides good physical access to services. The Ministry of Health has the most extensive facilities, with over a third of hospital beds and a network of 476 health centers and clinics; it provides services to more than half of the population. One quarter of the population is eligible to receive care from the Royal Medical Services, which account for almost a third of hospital beds. Jordan University Hospital serves a relatively small proportion of the population but accounts for 10% of all hospital beds. About one quarter of the population qualifies, as refugees, for UNRWA services at its 17 health centers; the Agency has no hospital beds. Finally, the private sector has more than two-fifths of hospital beds and is thought to provide limited services to more than half of the population. The private sector is particularly well developed in the Amman  - iii - area. Although reliable data are lacking, there seems to be substantial duplication of health services. It appears, moreover, that the overwhelming majority of Jordanians are served by at least one health care provider. Many are eligible for services from two or three providers. Overall, the regional distribution of hospital beds and other health facilities is well balanced. 6. There is an ample supply of physicians, but a shortage of female nurses and midwives, and of some health technician categories. Jordan now has a physician/population ratio of 1:896, while for nurses and midwives the ratios are 1:2,553, and 1:9,080, respectively. There are 1.9 hospital beds per 1000 population. 7. Total spending on health for 1982 amounted to 5.2% of GDP, or about JD 29 (US$87) per capita. Government spending accounts for about three-fifths of the total, and the private sector accounts for most of the rest. The proportion of government current expenditures devoted to health is 11%. Patient fees and payroll deductions comprise 10-15% of MOH revenues, with the remainder provided by the central government budget. The Ministry of Defense budget is the principal source of RMS funds for recurrent costs. Patient fees and payroll deductions provide about one third of the current account budget of JUH, and the rest comes from the government budget. The United Nations provides funds to cover UNRWA's health services. 8. Curative care, mostly provided in hospitals, absorbs almost three-quarters of MOH's current account spending, despite the presence of several other major health care providers. Preventive care, on the other hand, consumes only one-seventh of the MOH current account budget. Similarly, over 90% of actual and estimated MOH and JUH capital expenditures for the period 1980-1985 are devoted to curative care, mostly for hospital construction. Overall, there is a basic contradiction between the stated goals of the Five Year Plan and the pattern of expenditures. While the Plan stresses preventive and primary care, in addition to hospital bed construction, an overwhelming share of resources is directed toward curative and especially hospital care, both in terms of current and capital expenditures. Moreover, the planned addition of 1,560 MOH beds would require a near-doubling of future MOH budgets for current expenditures on curative care. A budget increase of this magnitude appears unlikely. 9. A national health insurance plan is a policy option under active consideration at the highest level. Details of the plan under consideration are not known, but it would extend free or low-priced care to those not currently covered. Since those not covered probably comprise only about one quarter of the population, the strong impetus for adoption of an insurance plan comes in large measure from health care providers themselves. A national insurance plan could require a sizeable health budget increase that may be difficult to sustain under present economic circumstances. At the same time, health insurance could not only extend coverage to those not now covered, but also facilitate needed sector coordination. Rigorous quantitative assessment of the costs associated with proposed insurance plans is recommended before irreversible steps are taken to adopt a particular scheme.  - iv - 10, Jordan had 87 hospital admissions and 400 patient-days per 1,000 population in 1982. Both figures are on the high side of the utilization range for middle-income countries. Sector-wide hospital bed occupancy was 63% and the average length of stay was 4.3 days in 1982. These indicators are within the acceptable range, given Jordan's hospital market structure. Overall, the current hospitalization rate is not low and there is some unused hospital capacity. 11. In 1982, there were 6.6 million physician and 2.9 million non-physician ambulatory care visits, excluding private practice office visits. This means that the average Jordanian saw a physician or other health care provider for an ambulatory care visit at least 3.9 times in 1982, a rate at least as high as that in most other middle-income countries. Regional disparities in MOH service availability and utilization appear to be minimal. 12. A number of problems are evident in the health services delivery system. While immunization levels are high, coverage of pre-natal and delivery care is less satisfactory. About two out of five mothers are not attended in childbirth by professional personnel, and maternal mortality is said to be high. MOH midwives delivered an average of only 12 babies each in 1982. The MOH maternal and child health (MCH) care program operates mainly in the traditional mode of waiting for the patient to visit the health center. While the shortage of midwives and female nurses is an important constraint, there is a need for a more aggressive, interactive style of operation to increase MCH coverage. Sector Development Strategy 13. Given Jordan's success in developing an extensive health infrastructure, sector strategy should now focus on: (a) improving access to care; (b) containing costs; and (c) assuring quality of care. Six sets of operational activities are proposed to meet these goals. Strengthening Primary Health Care 14. Strengthening primary health care will require postponing or phasing hospital bed expansion in order to shift more resources to PHC. A shift of resources to primary health care will support Government's regional development objectives, since PHC tends to provide proportionally more resources to less developed areas. Substantial reductions in infant, child, and maternal mortality are possible. Operational targets are suggested, for example, reducing infant mortality from 69 per 1,000 live births to 50 per 1,000 by the year 1990 and to 30 per 1,000 by the year 2000. Other suggested targets are: (a) professional supervision of 80% of births by 1990 and 100% by the year 2,000; (b) achieving and maintaining immunization levels of 80%; and (c) increasing the prevalence of contraceptive use to 40% of women in the reproductive age group by 1990 and to 60% by the year 2000. In addition, health centers should become more dynamic and actively seek to expand coverage through increased home visiting and the use of population-based planning. This would allow each center to know the approximate number of individuals requiring pre-natal care and immunizations, for example, in a given time period. Second, more functions  -v - should be delegated to paramedical personnel so that they can treat uncomplicated cases of commlon disease. Third, health education and nutrition education deserve increased emphasis. Finally, there is a need to improve physical facilities by replacing rented premises and upgrading inadequate structures. Improvements in PHC facilities are needed more urgently than additional hospital beds. There does not, however, appear to be a need for all of the 150 separate MCH centers included in the Five Year Plan. Comprehensive centers would serve health needs more adequately and cost effectively. 15. Human Resource Development Program. Several actions are proposed to increase the supply of professional midwives and female nurses. First, career prospects, salaries, and working conditions should be competitive with other employment options for women. Second, training facilities in places other than Amman are needed to assure the supply of candidates and increase the likelihood of their wanting to work outside the capital. Third, midwives and nurses should be given more responsibility for treating uncomplicated cases, and, in the case of midwives, a much larger caseload of deliveries. The likely addition of 300-500 physicians a year to the existing stock will require energetic action to assure their absorption and productivity. Physicians should be encouraged to enter needed specialties such as the PHC specialties of pediatrics and obstetrics, and public health. The recently established medical specialty in family practice is a welcome development. 16. Improving Health Sector Management. The overlapping between health services providers, present economic circumstances, and interest in a national health insurance scheme all call for increased sector coordination. A first necessary step is coordinating the planning and budgeting for MOH, RMS and JUH so that their plans can be reviewed simultaneously by the Higher Health Council. Other actions recommended are increased sharing of facilities, for example, between MOH and RMS, joint planning of physical facility and human resource needs, and the participation of all service providers in developing the 1986-1990 Five Year Plan. The effort to increase sector coordination will require that additional resources be made available to the Social Sector Division of the National Planning Council, the Higher Health Council, and the Planning Unit of the MOH. 17. Introduction of a national health insurance scheme is almost certain to require government commitment to increase the health sector share of the budget. The following steps are recommended before an insurance scheme is adopted: (1) A detailed actuarial study to estimate costs and to inform the choice of an appropriate revenue system; (2) A plan to increase coordination between health care providers and thereby improve sector efficiency and effectiveness; (3) Appointment of a task force to make recommendations regarding how existing insurance schemes can be incorporated into a system covering all Jordanians;  - vi - (4) A management study charged with making recommendations regarding the administration of the scheme and assuring the necessary management capability. 18. Hospital Facility Development Program. There is no immediate need for net additions to the existing stock of hospital beds. Nevertheless, replacement beds, upgrading of support services to existing beds, and consolidation of smaller hospitals are needed. In addition, the country will require new beds to keep up with population growth. It is recommended that a Master Plan for Coordinated Physical Facilities Development be prepared. Additional haospital beds, health centers, or village clinics should only be approved for construction after careful evaluation of population-based needs on a sector-wide basis. 19. Improving Public Health Laboratory Services. It is recommended that a single institution be establshed within the Ministry of Health, combining responsibility for most of the activities currently undertaken by the Section of Laboratories and Blood Banks, the Jordan Vaccine Institute, and the Drug Quality Control Laboratory. 20. Sector Studies. The following studies and actions are recommended to strengthen sector analysis and planning; and to contribute to the design of future projects: (1) An actuarial study to estimate the costs of health insurance under various financial and organizational arrangements; (2) A health services utilization study to ascertain who obtains what services, from which provider, at what cost; (3) A national nutrition survey; (4) Re-activation of the National Population Commission with a mandate to draft a national population policy; (5) Health care financing studies to establish unit costs and investigate the cost-effectiveness of current and proposed health interventions; (6) The explicit inclusion of the recurrent costs associated with planned capital expenditures in all planning exercises and resultant plans.  - vii - cAu..,b I I -pL I LzI , i v c -139 I jwa~.J I ..... <, L-