November 11, 2019
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The following is the paper presented by the former Minister of Health, His Excellency Dr. Mahmoud Al-Shayyab, in a symposium held by the Center for Strategic Studies at the University of Jordan on Thursday, October 24, 2019 at the University of Jordan.
In the building of Prince Al-Hussein bin Abdullah II College of International Studies at the University of Jordan, entitled:
(“Health, Public Health, and Health Policies.. Strategic Vision”),
Health, public health, and health policies .. a strategic vision
His Excellency Dr. Mahmoud Al Sheyab
This paper is an invitation to open the door for dialogue about the health and health sector situation in Jordan and the challenges and obstacles facing the health care system in an attempt to come up with a strategic vision that establishes clear policies to improve the results and implications for citizens and beneficiaries.
The opinion poll carried out by the Center for Strategic Studies on 10/13/2019 confirmed these challenges facing service recipients. Jordan also declined in some health indicators as a result of the sudden increase in the population resulting from forced migrations and crises in the surrounding countries.
Most of the national health strategies have clarified a set of challenges facing the health sector in Jordan, which included challenges related to health policies; finance; health spending; the health insurance system; health human resources; and health information systems, as well as challenges related to health sector fragmentation, fair distribution, access and quality of services.
The existence of such challenges and obstacles facing the health sector puts us in front of questions about the future of the health system and health services in the absence of a unified vision and frame of reference for the health sector that lays down policies and strategies for the sub-sectors, supervises their implementation and activates accountability systems for this.
The following is a description of the health system in Jordan and the relevant strategies, laws, regulations and instructions. This paper also describes the challenges facing the health sector in detail in an attempt to come up with a strategic vision that establishes clear interventions towards improving the results and repercussions of this on the health sector, citizens and beneficiaries.
The health system in Jordan
The health sector in Jordan consists of service-providing sub-sectors, which are: the public sector; the private sector; international organizations; NGOs; charities; There are institutions and councils working to develop health policies, such as: the Higher Health Council; the Higher Population Council; the medical board; the Nursing Council; the National Council for Family Affairs; the Food and Drug Administration; and the Unified Procurement Department, which includes the public sector: the Ministry of Health; Royal Medical Services; University hospitals (the University of Jordan Hospital and the Founding King Hospital) and the Diabetes, Genetics and Endocrinology Center, and the private sector includes: private hospitals; diagnostic and treatment centers; In addition to hundreds of private clinics. The sector of international organizations, NGOs and charities provides its services through the clinics of the United Nations Relief and Works Agency for Palestine Refugees (UNRWA); the United Nations High Commissioner for Refugees (UNHCR) and some charitable hospitals, such as: the King Hussein Cancer Center; the Islamic Hospital; the Nour Al Hussein Foundation and Caritas; the Jordanian Family Planning Association; and charitable organizations.
The National Health Accounts Report for the year 2015 showed that Jordan spends annually on the health of the individual 236 dinars, and the volume of total health spending amounted to (2 billion and 200 million), and the volume of total health spending as a percentage of GDP; It reached 58%, while the total expenditure on medicine amounted to about 581 million dinars; It constituted 22% of the GDP and 26% of the total expenditure on health. It is indicated here that the proportion of expenditure out of pocket of the citizen of the total expenditure for the year 2015 amounted to about 26%. Jordan achieved universal childhood immunization in 1988, and made significant progress in reducing major health risks to infants and children.
The percentage of believers reached 68% of Jordanian citizens and 55% of the Kingdom’s population, according to the 2015 census, which amounted to about 9.5 million people, including 6.6 million Jordanian citizens. Health insurance is divided into: civil health insurance, which covers about 44.5% of the total proportion of the insured, and military health insurance, which covers about 38% of the insured, while other insurances amounted to about 17.5% of the total proportion of the insured.
The volume of expenditures on medicine in 2015 amounted to about 581 million dinars, distributed between the two sectors: the public; and private at 45.5% and 54.6%, respectively. The volume of expenditure on medicines out of the total health expenditure in Jordan is high; This percentage amounted to 25.8% in 2015 compared to 19% in the countries of the European Union. As for the per capita expenditure on medicine; It reached 61 dinars during the same year.
The Jordanian pharmaceutical industry faces several challenges, the most important of which are: the low share of the Jordanian drug in the therapeutic bill, which does not exceed 24%, the intensity of competition with international companies locally and abroad, as well as the imposition of closure and protectionist policies by many countries in export markets; And the absence of homogeneous legislation for the registration, examination and pricing of medicines at the regional level.
Currently, Jordan is one of the countries with the lowest infant and maternal mortality rates in the region. The country has been polio-free since 1995. All social and economic strategies from the early 1980s emphasized everyone’s right to health and health care. There has also been a significant decline in death rates with the continued high rates of fertility and births, in addition to the decrease in the rates of infectious diseases, the high rates of chronic diseases and forced migration from neighboring Arab countries on the disease and health indicators of the population in Jordan, and the available data on morbidity confirm the prevalence of cardiovascular diseases, diabetes and other diseases. Respiratory system among the population in Jordan.
The health sector in Jordan witnessed a development for citizens, and public health indicators reflected the quality and efficiency of the health services provided, which placed Jordan in an advanced rank among the countries of the world. The overall average life expectancy at birth was stable at 73 years for the year 2016, and the maternal mortality rate decreased from 41 per One hundred thousand births in 1996 to reach 19 per hundred thousand live births in 2016. This is in addition to expanding the umbrella of civil health insurance and making voluntary insurance coverage available to all willing citizens, including pregnant women; children under the age of six; the elderly; those living in remote and less fortunate areas; The beneficiaries of the social safety net, where the percentage of the population insured in health reached 55 percent, according to the general statistics for the year. 2015 Jordan has one of the most modern healthcare infrastructures in the Middle East. The Ministry of Health operates a wide network of primary health care facilities, with 10 health centers per 100,000 citizens. This represents a high-density health care system according to international standards, and Jordan has 14 beds for every ten thousand people. And 14% of the population is admitted to hospitals annually, and the average length of stay in the hospital was 3 days, and the occupancy rate of hospital beds was 60% for the year 2016.
Jordan visited more than 250 thousand patients in 2015 and the Kingdom’s revenues from medical tourism were 1.2 billion dollars. However, the current reality clearly indicates a decrease in the number of patients coming from many countries, which were a major source of medical and hospital tourism in the Kingdom, where statistics indicate As a result, the average number of patients coming to Jordanian hospitals in 2016 decreased by 30% compared to the years 2014 and 2015.
The Kingdom has recently witnessed an increasing interest in digital transformation, based on the royal vision, as an inevitable and necessary result to keep pace with developments and developments in the field of information and communication technology, because of its major and important role in raising the efficiency and effectiveness of services, and its impact on improving the life of citizens. A number of basic digital transformation initiatives have been launched in the health sector, such as: the “Hakeem initiative to computerize medical and financial files for patients” and the “paperless government” initiative. Despite the availability of these initiatives, the implementation of digital transformation plans in the health sector faces many obstacles that limit the speed of completion of these plans as required.
The health care system in Jordan has evolved significantly over the past two decades. It has been rated as one of the best in the Middle East. It is a mixture of different policy-making bodies (councils; institutions), and three main service delivery sectors: the public sector; private sector; and non-profit organizations.
The following figure shows the components of the health system:
The general health policy in Jordan is drawn up by the Higher Health Council in accordance with Law No. 9 of 1999 and its amendments for the year 2017. The Council aims to draw up, organize and develop the health sector in general, with the aim of expanding the scope of health services for all citizens according to the latest methods and scientific and technological development.
The national strategy for the health sector is in line with the objectives of the “National Agenda”, “We are all Jordan”, “Jordan Vision 2025” and “Executive Development Program 2016-2019”, as well as the strategies and plans of the health and health-related sectors.
public health sector
The public sector consists of: the Ministry of Health; Royal Medical Services; In addition to two programs on a smaller scale based on the public university sector, namely: University of Jordan Hospital; and King Abdullah Founder Hospital.
Ministry of Health
The Ministry of Health is considered the largest sub-sector in terms of size, operation and use compared to other sub-sectors. It is responsible for all matters related to health in the Kingdom through the following tasks and duties:
1. Maintaining public health through prevention, treatment and health control services.
2. Organizing and supervising health services provided by other public and private health sectors.
3. Providing health insurance within the available capabilities.
4. Establish and monitor the management of health education institutions and centers in accordance with the relevant provisions of the enacted legislation.
The Ministry of Health provides primary, secondary and post-secondary health care services, and primary health care is primarily provided through a network of health centers (102 comprehensive centers, 380 primary health centers, 194 sub-health centers, 464 maternal and child centers and 405 oral health clinics). .
As for secondary and post-secondary health care services; It is provided through 31 hospitals affiliated to the Ministry of Health distributed over 12 governorates in Jordan, and the number of beds is 5,177 beds, which represents more than a third of the number of beds in hospitals in Jordan (36.4%).
The Ministry of Health is responsible for managing the civil health insurance program that covers civil servants and their beneficiaries, individuals classified as poor, people with disabilities, children under 6 years of age and blood or organ donors are officially covered by the civil health insurance program. The Ministry of Health recently opened Its services are for all citizens, part of them are refugees, whereby any individual can receive the health services available through any center affiliated with the ministry with fees subsidized by the government.
Royal Medical Services
Royal Medical Services provides secondary and post-secondary health care and has 15 hospitals (10 general hospitals and 5 specialized hospitals), the total number of beds is 3232, i.e. (22.7%) of the number of hospital beds in Jordan in 2016.
It is responsible for providing health care services and comprehensive health insurance for members of the armed forces, the beneficiaries of which represent approximately 38% of the percentage of insured citizens in Jordan. They include military personnel who are on the job, military retirees and beneficiaries, Royal Court employees, Royal Airlines employees, Mutah University and others.
The Royal Medical Services acts as a transformative center by providing high-quality health care, which includes advanced operations and specialized treatment for Jordanian and non-Jordanian patients, in addition to its politically important role by participating in providing health services in afflicted and conflict areas through medical teams and field hospitals. There are also 9 military health centers and clinics distributed in various regions of the Kingdom, in addition to air medical evacuation services.
University hospitals include the University of Jordan Hospital and King Abdullah University Hospital, the founder, and they provide health insurance and health services to university employees and their beneficiaries, and each of them is a referral center from other health sectors and educational centers for medical students. University hospitals are considered high-tech medical centers specialized in the public sector. The number of beds in the University of Jordan Hospital is 599 beds (4.2% of the total number of beds in the Kingdom) for the year 2016, and the number of beds in the founding King Abdullah University Hospital is 542 beds (3.8% of the number of beds). total in the Kingdom).
The private sector provides primary, secondary and post-secondary health care services through a network of clinics, medical centers and private hospitals. There are 62 hospitals in the sector that have approximately one-third of the number of beds in the Kingdom’s hospitals (4,496 beds, representing approximately 31.5% of the total family), and the majority of Hospitals and private clinics in the capital.
1. Refugee Relief and Works Agency (UNRWA)
The United Nations Relief and Works Agency (UNRWA) is responsible for providing health services to 2.29 million Palestinian refugees. The agency seeks to improve the health status of Palestinian refugees in Jordan and achieve the highest attainable level of health as referred to in the first human development goal “Refugee health is protected.” The Agency provides primary health care services through 25 primary health facilities, which handle more than 2 million visits annually. The services provided by UNRWA include: medical care, dental treatment, psychological treatment, antenatal, prenatal and postnatal care, family planning, Disease prevention, health protection and promotion, environmental health. The program also covers partial financial reimbursement for admissions to government hospitals, with a ceiling of 150 dinars for refugees within the safety net, and pregnant women with high-risk pregnancies, at approximately 100 dinars for an ordinary refugee, and the remaining part of the bill is borne by the beneficiary himself.
2. King Hussein Cancer Center (KHCC)
The King Hussein Cancer Center (KHCC) is considered a leading specialized center for cancer treatment in Jordan and the region, with 350 beds, representing 2.5% of the total number of beds in the Kingdom’s hospitals. It became the first center outside the United States to have specific accreditation for the disease. The center has established a program that focuses on all stages of comprehensive cancer care, from prevention to early detection of cancer through diagnosis and treatment, to palliative care.
3. National Center for Diabetes, Endocrinology and Genetics (NCDEG)
This center was established in 1996 as an independent non-profit organization and as one of the centers affiliated to the Higher Council for Science and Technology with the aim of providing high quality care, in addition to education and training in the field of diabetes, endocrinology and genetics.
4. Other charitable clinics: Non-profit organizations include about 44 charitable clinics distributed in all regions of the Kingdom.
The most important achievements of the health sector in Jordan
Jordan is considered a pioneer in the field of medical tourism in the Arab world and fifth in the world (World Bank, 2010), as it was named by the International Medical Tourism Journal to be the “medical tourism destination for the year 2014”, which will increase investment and development opportunities, which was evident on the Over the past decade in the number of hospitals and beds available
One of the lowest maternal and infant mortality rates in the region.
The total number of hospitals in the Kingdom for all health sectors reached about (110) hospitals for the year 2017, including 32 hospitals for the Ministry of Health, including 9 educational hospitals, which are distributed over most of the Kingdom’s governorates and districts, achieving a high rate of coverage and comprehensiveness of health services provided to citizens. In the Ministry’s hospitals, the number of beds in the Kingdom is about 13,731. It is worth noting that the rate of one bed per 10,000 citizens has decreased significantly recently. This is due to the increase in the population of Jordan, according to the 2015 census, and due to migrations. The successive witnessed by Jordan and the most Syrian asylum.
Availability of the wide network of health centers and hospitals affiliated to the Ministry for all population centers in the Kingdom
Implementation of health institution accreditation projects
Continuous expansion of the health insurance umbrella and the inclusion of the poor and less fortunate groups
Having a good infrastructure and modern medical technology in the areas of diagnostic, therapeutic and rehabilitative services
Adoption of the E-Health Project (Hakim)
Existence of national records such as the National Cancer, Kidney and Death Registry
Subsidized health services that include all types of health services, even tertiary ones, that the citizen obtains within his financial capabilities
The most important health strategies and policies
1- The National Health Sector Strategy in Jordan 2016-2020
2- The National Strategy for Human Resources for Health in Jordan 2018-2022
3- The strategic plan of the Ministry of Health 2018-2022
4- The executive plan for reforming the health sector in the Kingdom 2018-2022
5- The communication strategic plan of the Ministry of Health in the field of family planning (2019-2023)
6- The Ministry of Health’s knowledge management strategy for the years 2018-2022
7- National Health Accounts
The most prominent demographic challenges affecting the health system in Jordan
The high rate of natural population growth resulting from high fertility rates and a slowdown in the decline in the total fertility rate
High rates of forced migration, especially the migration of Syrian brothers
There is still a rise in the proportion of young people, a change in the age structure of the population and the trend of the population of the elderly population to rise
Large and unplanned population increase in urban areas, especially in Amman and major cities
The most prominent economic challenges affecting the health system in Jordan
Low GDP growth rate
An increase in the overall public debt ratio
High budget deficit
High rates of poverty and unemployment
The economic burden of Syrian asylum and the weakness of international donors’ fulfillment of their financial obligations
The most prominent challenges facing health system governance in Jordan
Weak cooperation and coordination between the various components of the health sector
There is overlap and duplication in some health laws and policies
Weak oversight systems over the private sector
Weak follow-up, evaluation and accountability systems for the implementation of national health strategies and plans
Weakness in enabling citizens to gain support and participate in defining health needs and priorities
The main challenges facing health insurance
The lack of mandatory health insurance has left a quarter of the population outside the health insurance umbrella
Lack of equity in the financial contributions of insurance beneficiaries
The process of providing the service is not separated from its purchase at the Ministry of Health, Royal Medical Services and university hospitals
The lack of a health insurance reference to issue accurate statistics on insurance coverage in the Kingdom
The most important challenges facing financing in the health sector
About 25% of the population is not covered by health insurance
Poor implementation of cost containment strategies
The multiplicity of insurance agencies in the public sector and the duplication of government health insurance
High out-of-pocket health spending
High rate of spending on medicine
Uncontrolled and unplanned expansion of health services
Underinvestment in primary health care services
Continuous rise in health care costs
The main challenges facing primary health care in Jordan
Poor spending on primary health care
Although there are many strategies and plans for primary care programs, some of them are not fully or partially implemented, such as: those related to non-communicable diseases control, smoking control and mental health
The shortage of health personnel working in the field of primary health care
Activating a program to rehabilitate and train newcomers before joining them to work in health centers
The modest or non-existent contribution of the rest of the health sector components with the Ministry of Health in providing health care services
Weak health information systems and their lack of connection with secondary and tertiary health care levels and the need to develop and implement an effective transfer system between health centers and hospitals
Steady population growth and the presence of a large number of refugees on Jordanian soil
The epidemiological shift in the pattern of disease incidence in Jordan towards noncommunicable diseases with high cost and high burden of disease, as a result of the increase in the life expectancy rate at birth, in addition to the high prevalence of noncommunicable diseases risk rates, most of which are related to unhealthy lifestyle patterns and behaviors such as smoking, obesity, lack of physical activity and poor health. nutrition
Environmental risks resulting from climate change, the significant shortage of water supply to citizens, the failure to cover many regions of the Kingdom with sewage networks, ambient air pollution, and the low level of solid household waste management service
Weak citizens’ confidence in the quality and efficiency of health services provided in health centers
The increase in poverty and unemployment, which is considered one of the most important factors threatening health.
The main challenges facing secondary and tertiary health care
The need for more continuous improvement in the quality of services provided and the reliability of hospitals
The need for more qualified and experienced human cadres in some rare specialties
The need to develop ambulance and emergency services and limit their migration by motivating them instead of making them difficult
The most important challenges facing human resources for health in Jordan
Poor decision-making and policy-making based on evidence
The absence of an approved national job description for most health professions
The lack of a national system for licensing/renewing the licensing of health human cadres
Lack of an updated database for nursing and midwifery
Weak cooperation and coordination between health care institutions
Adoption of the performance appraisal system followed in the Civil Service Bureau, which does not reflect the actual performance of the employee
Lack of awareness and skills on the part of senior management levels regarding the importance of linking strategic planning and human resource planning
The difficulty of attracting and retaining qualified health personnel in the government sector
Limited supply of some medical specialties in the labor market, as the production of these specialties requires a lot of time
Misdistribution of health human resources among different geographical areas according to gender, skill mix, professions, and levels of service provision
Weak link between the human resource planning system on the one hand and the performance management systems, rewards, incentives, training and development on the other hand
Shortage of midwives
High turnover rates
Weak effectiveness of information systems related to health human resources, especially those related to the private sector
Lack of coherence between CPD and other HR policies
Weakness of the technical skills required to carry out the training and development process for those who work in the fields of training and development
The absence of a national system for continuous professional development linked to the health personnel license renewal system
Lack of funding for the development of health human resources
Weak capacity building activities and continuing education initiatives
Poor advanced healthcare skills such as neonatal resuscitation and comprehensive nursing care among health service providers
The educational programs do not meet the national, regional and international health needs and do not keep pace with technological progress
Insufficient quality and short duration of clinical training
Dispersion of research and studies and not integrating them with clinical practices
Lack of opportunities to enroll in internship programs for some health professions
Limited adoption and application of the concept of comprehensive health care
The most important health laws in Jordan
1- The Public Health Law and its amendments
2- Jordanian Nursing Council Law قانون
3- General Food and Drug Corporation Law No. 41 of 2008
4- Drug Studies Procedures Law
5- Pharmacists Syndicate Law and its amendments No. 51 of 1972
6- The law of the use of human body organs and its amendments
7- Law of the Syndicate of Nurses and Legal Midwives No. 18 of 1972
8- The Jordanian Medical Council Law
9- Law of the Higher Health Council المجلس
10- Food Law No. 30 of 2015
11- Narcotics and Psychotropic Substances Law
12- Law of Medicine and Pharmacy and its amendments No. 12 of 2013
13- Law of the Jordanian Medical Association and its amendments No. 13 of 1972
14- Law of the Dental Syndicate and its amendments No. 17 of 1972
15- Law amending the Pharmacists Syndicate Law No. (23) of 2015
The most important health systems in Jordan
1- The system of specialization and technical classification in the profession of nursing and midwifery issued in accordance with Articles (4, (6)) and (13) of the Jordanian Nursing Council Law
2- Marketing control system for breast milk substitutes
3- Supplements to the medical committee system
4- Licensing system for dental clinics and centers
5- Pharmaceutical Institutions Licensing System
6- The system of practicing the profession of pronunciation
7- Licensing system for clinics and human medicine centers
8- Private Hospital System
9- Occupational therapy practice system
10- The system of practicing the profession of judgment therapy
11- System of practicing the profession of audiology
12- Physicians and Pharmacists Incentive System and its Amendments No. 32 of 1992
13- Licensing system for private medical laboratories
14- System of practicing the profession of nutrition
15- System of practicing the profession of clinical psychology
16- Regulation of practicing the profession of associate nurse and the profession of assistant nurse
17- Drug screening system
18- Administrative Organization System of the Ministry of Health
19- Health Insurance System Guide
20- Health insurance system نظام
21- Smoking prevention system
22- Renal failure treatment system
23- The system of practicing the professions of vision examination, processing eyeglasses and installing contact lenses
24- The system of the Jordanian College of Nursing in the Ministry of Health
25- The overall examination system for physicians’ licensing
26- System of the Allied Medical Professions Institute
27- Medical Committees System 2014
28- The system of practicing the profession of massage and massage
29- System of practicing the profession of skin care and hair removal وإزالة
30- Prince Hamzah Hospital System
31- Tobacco Products Display Regulation for the Year 2013
32- Paramedic Profession System
33- Anesthesia Profession System
34- Dental technicians practice system
35- A modified system for the paramedic profession
36- The system of practicing the profession of dental health advisor
37- A modified system for the licensing system for dental clinics and centers for the year 2015
38- The system for monitoring women’s deaths during pregnancy, childbirth and the puerperium for the year 2016
39- The unified procurement system for medicines and medical supplies and its amendments No. 91 of 2002
40- Licensing System for Home Health Care Services Institutions No. (84) of 2016
41- Dental clinics and centers licensing system No. (52) of 2016
42- The system of practicing the profession of prosthetics and orthotics
43- The Government Services Development System for the year 2016 issued in accordance with Article (120) of the Constitution
44- Dental practice licensing system for the year 2016
The most important instructions for health in Jordan
1- Instructions No. (1) of (2019) – Amended Instructions for Regulating and Using the Electronic Procurement System in the Unified Procurement Department for the year (2018)
2- Instructions for implementing the regulation and marketing of breast milk substitutes for the year 2018
3- Instructions for Licensing Prosthetic Limb Centers and Orthotics No. 1 of 2017
4- Instructions for Incentives for Workers in the Nursing Profession No. (83) for the year 2004 and its amendments
5- Instructions for the technical and administrative classification of the human doctor, dentist and pharmacist No. (1) of 2010 and its amendments until 12/3/2018
6- Instructions for issuing health insurance cards for the age group of pregnant women
7- Instructions for issuing health insurance cards for the age group of sixty years and over
8- Medical waste management instructions
9- Instructions No. (1) of 2013 Instructions (preventing the occurrence of a health hazard related to health damage resulting from the housing units of labor gatherings) issued under the provisions of Article (49) of the Public Health Law
10- Instructions for using the file and electronic prescription in hospitals and centers affiliated with the Ministry of Health for the year 2013 issued in accordance with Article (40) of the Civil Health Insurance Law No. (83) for the year 2004
11- Instructions for practicing the profession of paramedic
12- Instructions for transferring human body parts
13- The general framework of the charter for the provision of government services
14- Instructions for granting rewards and incentives to civil servants
15- Instructions for the conditions that must be met in human medicine clinics and centers
1- The National Health Sector Strategy in Jordan 2016-2020
2- The National Strategy for Human Resources for Health in Jordan 2018-2022
3- The strategic plan of the Ministry of Health 2018-2022
4- The executive plan for reforming the health sector in the Kingdom 2018-2022
5- National Health Accounts Report 2015
6- Opinion poll carried out by the Center for Strategic Studies on 10/13/2019
His Excellency Dr. Mahmoud Al Sheyab