A clean bill: One of the region’s leaders is looking to increase efficiency and capacity

With one of the best health care sectors in the Middle East, Jordan is the regional leader for medical tourism. Private-sector facilities host patients from both the region and further afield, and provide an important complement to public sector services. The Ministry of Health (MoH) is financially constrained – as are all public sector bodies in Jordan – however, it is working to boost efficiency through initiatives such as the development of an e-health platform, and to expand capacity for treatments which are in high demand.

SECTOR STRUCTURE: Health care services are offered through the public sector, the private sector and nongovernmental organisations. Public sector health care is provided primarily through the MoH, but also by the Royal Medical Services (RMS) and University Hospitals. As of 2010, 37.1% of total hospital beds were in MoH facilities, 20.5% in the RMS and 9.4% in University Hospitals, according to the MoH. In addition, the UN Relief and Works Agency provides primary health care services to around 1.66m registered Palestinian refugees through a network of 24 health care facilities. Primary, second and tertiary care services are offered by both the public and private sector.

Insurance is provided through the MoH, but also via the RMS, the University Hospitals and the private sector. “Around 70% of people are now insured,” Dr Taher Abu Elsamen, the secretary-general of the High Health Council, told OBG. Those without insurance are still able to access all of the MoH’s services through special provision from the Royal Court.

BOOSTING INSURANCE: “We plan for everyone in the country to be covered within the next 5-10 years,” Elsamen said. But such a project places a heavy financial burden on the MoH, whose Health Insurance Fund is currently providing coverage for around 42% of insured citizens. According to the State of Jordan’s “Population Report” for 2010, the fund’s ability to expand is financially constrained, despite the fact that Jordan is among the region’s highest spenders on health care resources. Around 10% of the budget is allocated to the health sector, according to the High Health Council. Nonetheless, the number of Jordanians with health insurance is increasing, and the importance of private health schemes, which cover around 9.5% of the total insured population, is growing quickly.

A June 2011 report by Capital Investments found that medical insurance premiums in Jordan rose at a compound annual growth rate of 16.6% between 2001 and 2010. “Private insurance cover is growing because an increasing number of companies are providing their employees with private schemes,” Walid Maaytah, director of marketing and business development at the private Al Khalidi Medical Centre, told OBG.

PRIVATE COVER: Rising insurance rates are good news for the private sector, which is able to offer treatment to an increasing number of patients. Dr Mohammed Ghazi Serhan, director of medical affairs at the private Arab Medical Centre, told OBG that around 70% of his patients are on insurance credit, but he expected this proportion to grow. Furthermore, under an agreement between the government and the private sector, citizens with MoH insurance can receive treatment in private hospitals by contributing 20% of the treatment costs, with the MoH covering the remaining 80%.

Coordinating and structuring the national insurance framework is proving challenging. “I would like to see public and private insurance schemes coordinated under one umbrella,” Dr Hassan Hawamdeh, medical director at the Prince Hamza Hospital, said, indicating that the various schemes can overlap inefficiently and those with private insurance cover can end up being treated at public expense. Around 8.2% of the insured population is covered by more than one scheme, observed Elsamen at the High Health Council. “It is very important that we reform our insurance system, and we are currently studying the options for doing so.”

UNNECESSARY EXPENSES: Policymakers say that inefficiencies of this kind add significantly to the financial burden on the MoH. Adding to the same burden is the costly business of referring patients out of the MoH’s facilities. In November 2011, Abdul Latif Wreikat, the minister of health, said that the MoH pays an average of JD2400 ($3372) per patient for external referrals, whereas it costs JD200 ($281) to treat patients in ministry hospitals. The total referral cost amounted to JD250m ($351.3m) every year, he said. Such financial strain is manifest in the books of the MoH’s Health Insurance Fund, which was reported to have a funding shortfall of around JD100m ($140.5m) in 2010.

Furthermore, the cost of unused or wasted medicines provided by the MoH amounts to JD35m ($49.2m) every year, said former minister of health, Yassin Husban, in May 2011. A solution to this problem is being sought by the National Strategy for Optimising Drug Expenditure, which is working with the Medical Transparency Alliance to assess the local pharmaceuticals market and reform national drug policy.

Policymakers recognise that enhancing coordination within the sector will be vital to reducing wasted expenditure and improving the quality of service. “Hospitals are not currently connected to one another, which means that a lot of time and money is wasted on the duplication of tests”, said Dr Ali Hyasat, general manager of the Prince Hamza Hospital.

ICT PLATFORM: To boost efficiency, the government is now looking to information and communications technologies (ICT). In 2011 the Health Care ICT Taskforce was launched as a partnership between Cisco, the King Abdullah II Development Fund for Development, Jordan’s Information Technology Association (Int@j) and local IT companies. The taskforce aims to enhance the use of ICT systems in the sector and promote Jordan as a regional hub for ICT solutions in health care.

Work has already begun on the Hakeem e-health programme, which will provide an electronic platform for the storage, retrieval and updating of electronic health records. Following a successful pilot project at the Prince Hamza Hospital in 2011, the taskforce is going to extend the system throughout public health centres and hospitals. This should cut unnecessary costs on duplicated tests and wasted medicines, and increase the efficiency of the MoH’s Health Insurance Fund. It should also enhance the quality of service available to patients, allowing for the better monitoring of chronic diseases and providing automatic warnings of drug interactions and allergies, among other benefits.

Mohammad Tahboub, chairman of Int@j, told OBG that he is optimistic not only about the current project, but also about prospects for its extension. “There is strong demand for increased connectivity between the public and private health care sectors,” he said. “Beyond Jordan as well, based on what I saw at the latest Arab Health Conference, I think that the Health care ICT Taskforce could export this sort of system to several countries in the region,” he told OBG.

Installing the platform in all public sector health care facilities is expected to take six years. This period will not be without its challenges. “Legislative issues, particularly with regard to the confidentiality of information and data sharing, need to be addressed. Another possible issue could be reluctance among some government institutions to share certain information,” Tahboub said. He added that all the hospitals still needed to be connected to a fibre-optic network, but that efforts to overcome this had been accelerated following the issuance of a royal directive.

PRIVATE SECTOR: The e-health programme is an illustration of the potential for indirect private sector contributions to the health sector. The private sector is equally important in a direct capacity: it comprised 58% of the country’s hospitals in 2010, according to the MoH, and its role looks set to grow.

“Private facilities are relieving pressure on the public sector,” Dr Awni Al Bashir, the president of the Private Hospitals Association (PHA), told OBG. “In the last year several private hospitals have opened in Jordan, so the country is already benefitting from strong investment interest,” he said. “This is due to our ability to offer high-quality service at a low cost in a business environment marked by political stability.” At the Higher Health Council, Elsamen agreed, adding, “It is very easy to acquire a licence to set up a new hospital, providing that one of the founding partners is a doctor.”

Private hospitals are not only targeting Jordanians. Ranked by the World Bank as the top destination for medical tourism in the Middle East and North Africa (MENA) and fifth globally, Jordan has become a major health care centre in the Arab world. The PHA reports that in 2010 Jordan received about 200,000 medical tourists, 90% of which came from the MENA region. The total number rose by 10% compared to 2009. Although regional instability was reported to have reduced incoming patients by 25% in the first half of 2011, by the end of the year hospitals were so full of Libyan medical tourists that the authorities were forced to intervene. With the government looking to promote the sector – which contributed $1bn or 4% of total GDP in 2010, according to the PHA – there should be strong potential for growth in private sector care (see analysis).

ACCREDITATION: Another factor boosting the international profile of Jordanian health care is its accreditation environment. Since its foundation in 2008, the Health Care Accreditation Council (HCAC) has been working to bring national standards in line with the recommendations of the International Society for Quality in Health Care. “The national accreditation system is very stringent,” said Hawamdeh, adding that Prince Hamza Hospital was able to become internationally certified before it gained HCAC certification.

Accreditation of a given hospital is determined by its implementation of the HCAC’s targets, which are released on an annual basis. Wreikat announced in February 2012 that six public hospitals and 11 other health facilities were accredited in 2011. “I expect to see all of our public hospitals internationally accredited within the next two or three years,” said Elsamen.

Beyond hospitals, accreditation is of equal importance to Jordan’s medical laboratories, pharmaceuticals companies and research community. “All of our laboratories should become certified,” Dr Hassib Sahyoun, CEO of MedLabs, one of Jordan’s leading medical laboratories, told OBG, adding that his laboratory was one of only two in the country to have the College of American Pathologists certification, the highest laboratory accreditation standard. “There should be an independent body to certify public and private bodies,” he said. Samer Najjar, the general manager at the Sana Pharmaceutical Research Company, agreed that the government should provide greater support and improve regulation in the field of pharmaceuticals production and research, noting that he considers the Food and Drugs Administration to be taking an overly rigid approach in enforcing quality assurance.

Many in the industry consider the Medical Malpractice Law – first drafted in 2010 and now working its way through parliament – to be of crucial importance to Jordan’s international profile. “Enacting this law is necessary if Jordan is to continue to attract customers from outside the country,” said Maaytah. The main aim of the law is to protect patients’ rights, ensure that practitioners abide by best practices and offer compensation in cases of malpractice. But enacting and implementing the law will not prove easy. “Doctors will need insuring, which will be costly. They will also need to get job descriptions written and then keep within the limits of those descriptions,” said Hawamdeh, noting that this could be difficult in hospitals with stretched human resources. However, Serhan at the Arab Medical Centre said the burden placed on hospitals by compliance with the new law is lessened by the fact that accredited hospitals already carry out credentialing.

EXPANDING CAPACITY: While Jordan is still hoping to expand its primary care services, the country has strong indicators in this area: life expectancy, neonatal and infant mortality rates, as well as maternal mortality rates, have improved markedly over the past decade and are now significantly above the regional average, according to the World Health Organisation’s 2011 “World Health Statistics” report. The MoH spends 80% of its budget on secondary health care and is looking to expand its capacity to deal with non-communicable diseases and conditions, often referred to as lifestyle-related illness, which are growing causes for concern.

A case in point is diabetes. The disease currently affects around 250,000 people, but this figure is expected to increase to 3m by 2050, according to Kamel Ajlouni, the director-general of the National Centre for Diabetes, Endocrinology and Genetics, a centre established in 1996 to provide health care, education and training in these three disciplines. The government is also expanding capacity for kidney transplants and dialysis. In 2009 a registry for renal failure was established, while 2010 saw 50 kidney transplants conducted at the Prince Hamza Hospital, increasing to 80 in 2011.

In October 2011 the MoH announced the opening of a transplant centre at the Al Bashir Hospital in Amman. In addition to heart transplants and cochlear implants, the centre will carry out kidney transplants. It is due to begin operations in 2012.

The public sector is also boosting its capacity to deal with cardiovascular diseases and cancer, the biggest killers in Jordan today. The King Hussein Cancer Centre has been operating in Jordan since 1997, and in 2007 it became the first hospital outside the US to have Disease Specific Accreditation. Treatment options at the hospital have been in extremely high demand: although originally designed to cater for 1500 patients a year, it has been treating more than double this number. An expansion in 2009, which increased the number of patient beds from 118 to 180, was therefore in urgent need. The hospital is currently undergoing another ambitious expansion project that is due to be completed in 2014. Once finished, the centre will be equipped with a further 200 adult and child inpatient rooms, as well as expanded outpatient capacity.

A new cardiovascular wing was inaugurated at the Prince Hamza Hospital in 2011. Hawamdeh said that 25 beds of the 50-bed wing are in use, with the remainder due to be phased in over the next two years. “The new beds are helping us to better meet the high demand for cardiac catheterisations,” he said, adding that the cost of intervention there is cheaper than in the private sector. “However, this means patients have to wait longer. We are hoping to resolve the issue through initiatives to recruit doctors from the private sector, although this could also prove challenging.”

PRACTITIONERS: Staffing is, indeed, one of the key problems facing the public sector. With higher salaries on offer both in the private sector and outside the country, the public sector finds it difficult to retain its qualified staff. “Jordan is constantly facing a shortage of doctors and especially nurses,” Walid Al Khalidi, the managing director at the Al Khalidi Medical Centre told OBG. “The nursing sector depends heavily on migrant workers, but the immigration procedures can be costly and time-consuming,” he added.

A reformed salary structure for public sector staff came into force in January 2012, implementing a unified civil service system and saving the state more than JD9m ($12.6m) every year, according to Khleif Al Khawaldeh, the minister of public sector development. However, at a time of limited financial resources, the government is finding it difficult to please everyone. In early 2012, nurses staged work stoppages in protest against the salary restructuring, although they agreed to suspend their sit-in after the MoH offered them a proposal whereby their financial incentives will be unified and nurseries established for children of nurses working for the ministry. The MoH is also going to request an increase in nurses’ allowances by 30%.

The government is taking steps to actively recruit doctors and nurses. The MoH is currently implementing a programme to train 300 doctors in MoH hospitals in specialisations in which the ministry is understaffed. And individual institutions are implementing their own initiatives. “We are pushing to recruit nurses straight out of university and working towards establishing a nursing college near the hospital to prepare staff.” Nader Al Khalili, general manager of Istiklal Hospital, told OBG.

Another significant employment drive, announced in January 2012, is being carried out under an agreement between the PHA and the Ministry of Labour. Under the scheme, JD1.5m ($2.1m) will be provided for the training and employment of male nursing graduates. The first phase of the scheme aims to train and employ 500 nurses, with the ministry agreeing to pay half of the salaries during their second year on the scheme as incentive to private employers.

STREAMLINING: In addition to obtaining new resources, Jordan is hoping to maximise the efficiency of its existing capacity. “The real challenge now is to improve the organisation and utilisation of the resources which we have already,” said Hawamdeh. He stressed that public hospitals need to be better managed. “The current decision-makers in our hospitals and centres are not always the best qualified for the job. We need to introduce more precise criteria to the system, so that we ensure that those at the top have the managerial and administrative skills which they require.”

Hospital occupancy and discharge could also be better organised, according to policymakers. According to Elsamen, official occupancy rates stand at around 65-70% in public hospitals, although the big hospitals in Amman are in far greater demand and are often 90-95% occupied. “We don’t need to build new hospitals for Jordanians. What’s important is that we reduce the average inpatient length of stay in order to free up more beds,” he told OBG. Hawamdeh at the Prince Hamza Hospital added that “the issue is not so much the occupancy rate as the high turnover in patients. It takes two or three hours to discharge patients, during which time their beds are sitting unoccupied.”

OUTLOOK: In the coming years, many of the sector’s organisational challenges may be addressed by the e-health platforms (especially in MoH hospitals), and by the extension of such connectivity throughout the entire health care system. While public health authorities are working to reduce wasted expenditure and reform the insurance framework, a comprehensive solution to such issues will not be found quickly. Expenses are likely to be strained by an increasing flow of refugees from Syria. Meanwhile, continued support to the private sector is expected, especially as the revenues which are derived from its strong medical tourism industry make a significant contribution to the economy.