A changing landscape: New investments and initiatives to improve quality of care

The World Bank ranks Jordan as one of the most advanced health care systems in the MENA region. According to the most recent World Bank data, Jordanian life expectancy at birth was over 73 years in 2010, compared to a regional average of 70 years. Also, the infant mortality rate in 2011 was 18 per 1000 live births, compared to an average of 35 in the Arab world. Jordan has long made quality health care a national priority. All national socioeconomic strategies developed since the early 1980s have stressed the importance of access to health care, and the country has achieved good progress in lowering primary health risks for both children and infants. Universal child immunisation was achieved in 1988, and Jordan has been free of polio since the mid-1990s. Investment in the sector is also strong: a November 2012 estimate by the Jordan Investment Board indicated that the medical industry had attracted the third-largest share of investment within the country during the first three quarters of 2012.

PUBLIC SERVICE: Health care in the kingdom is provided by a mix of public and private operators, as well as aid agencies. Public-sector care is led by the Ministry of Health (MoH), which was set up in 1950 and responsible for monitoring, licensing and regulating all health institutions and professions in Jordan. A number of health councils, independent public organisations and professional associations assist the MoH with its monitoring and regulatory duties. The MoH operates through a centralised system of governance and provides both funding and health care. Additional public funding and care is provided by the Royal Medical Services (RMS), which was established in the 1940s and focuses on secondary and tertiary care. Staff of the Royal Court, active and retired military personal and their dependents, and some university staff are among those who receive RMS care. Furthermore, the RMS also delivers care to some uninsured patients. The High Health Council (HHC), which is led by the prime minister and vice-chaired by the minister of health, determines health policy. Membership includes the ministers of finance, planning, labour and social development, as well as two appointed health-sector experts. A key task is to coordinate the activities of the MoH, the private health industry and the RMS.

PRIVATE SECTOR: Many private companies offer their employees health coverage by either self-insuring or buying private health insurance. Most medical expertise, as well as high-tech health services, is located in the private sector. Privately run clinics and hospitals are both available in the kingdom. In the past, there used to be a quality gap between public and private health care facilities; however, this has diminished in recent years as public and private organisations have developed a more collaborative relationship.

While some public-private interaction needs better coordination, Jordan is an appealing market for private health firms due to a rising demand for medical care. “Private health care is one of the most attractive areas for investment in Jordan because the needs currently outweigh the capabilities,” Dr Awni Al Bashir, the former director of Shmeisani Hospital, a private facility in Amman, told OBG. "Health care is always a long-term investment, but there is a growing interest for investors in hospital shares,” he said.

DONORS: Aid agencies make up the third category of health care providers in Jordan. The UN Relief and Works Agency for Palestinian Refugees in the Near East ( UNR-WA), a development organisation set up in the mid1980s, provides a number of services to Palestinian refugees, including social and emergency aid, education and health care. As of early 2012, the agency was providing services to more than 1.9m registered refugees spread between 10 official and three unofficial camps in Jordan, according to UNRWA figures. The organisation maintains 24 health centres, which receive over 2.3m visits per year. Many of the patients that receive care from the UNRWA are also covered through the RMS and the MoH. Services delivered by UNRWA include dental care, medical treatments, prenatal and postnatal care, physiotherapy, disease control and prevention, and environmental health. The organisation is working to fulfil needs for psychological health, child disability and early cancer diagnosis among Jordan’s Palestinian refugee population. In order to expand care, the agency is taking on projects that include procuring new equipment for field health centres and building new health care-related buildings at three camps.

Another donor agency delivering health care in the kingdom is the Jordanian Red Crescent Society (JRCS). Part of the International Red Cross and Red Crescent Movement, the JRCS delivers emergency health care during disasters and also serves refugees living in the country, such as parts of Jordan’s Iraqi population and refuges from the Syrian conflict.

INSURANCE: The first medical insurance system in the kingdom appeared in 1963 and was implemented among members of the army. Jordan’s first civil health insurance scheme shortly followed, becoming available in 1965. The MoH is now the largest provider of medical insurance, although the RMS, private companies, the UNRWA and university hospitals also provide coverage. The MoH’s Civil Insurance Programme provides insurance for several groups, including all Jordanian government employees and their dependents, lower-income and disabled individuals, and children under six. The RMS’s military coverage system is the second-largest insurance programme in the country.

Estimates on the percentage of the population covered by some form of health insurance vary between 50% to more than 80%. For those without medical coverage, the government runs a safety net system. The MoH is required to provide health care to any Jordanian citizen without insurance and in need of care at a subsidised price of around 15% to 20% of cost, according to figures cited by the World Health Organisation.

HOSPITALS: Jordan’s Department of Statistics (DoS) indicated in its most recent annual report that there were a total of 102 hospitals in operation throughout the kingdom in 2011. The largest group of hospitals – nearly 50% – were located in the capital, with the next largest concentration, about 16% of the total, located in the north-eastern city of Irbid. Over 59 of Jordan’s hospitals were privately operated in 2011, while the MoH ran 31 hospitals and 14 facilities were operated by other government agencies. Hospital beds reached almost 12,000 during the same year, around 33% of which were part of privately run hospitals.

Admissions to MoH hospitals rose from roughly 315,000 in 2007 to 333,000 in 2011, an increase of nearly 6%. Conversely, the annual bed-occupancy rate dipped from 69% in 2007 to a little less than 67% in 2011, according to recent DoS data. Surgical operations at MoH hospitals also dropped, falling by 5% over the period from around 83,000 operations in 2007 to under 79,000 five years later. As of 2011, approximately 4700 nurses, 1450 resident physicians, 1000 specialists, 550 midwives, 200 general doctors, 200 pharmacists and 100 dentists were on MoH hospital payrolls. The average MoH patient in 2011 spent 3.1 days in hospital.

The MoH operated close to 1500 health centres and clinics in 2011 – a jump of 8% when compared to the 1380 facilities in operation in 2007. Recent DoS data indicates that the majority of facilities in 2011 were comprehensive and primary health centres, whereas dental clinics numbered 377 and village clinics stood at 220.

The number of pharmacies in Jordan rose by nearly 11% between 2007 and 2011, from about 1800 pharmacies in 2007 to close to 2000 five years later, as per DoS figures. Almost 84% of those pharmacies in operation in 2011 were located in one of the kingdom’s three most-populous cities: Amman, Irbid and Zarqa.

FACILITIES: One of Jordan’s major privately operated hospitals is the King Hussein Cancer Centre (KHCC). Launched in 1997, the KHCC is a non-governmental, non-profit facility that delivers comprehensive cancer care to both adults and children.

The centre treats over 3500 new cancer patients per year and employs 163 oncologists and consultants, as well as around 550 oncology-trained nurses, according to KHCC figures. Facilities at the centre include six operating rooms, 180 beds and 18 intensive care units, six of which are for paediatric patients. As one of the leading comprehensive cancer centres in the region, the KHCC treats a significant number of international patients. Jordan’s health sector is also adding several new facilities. The planned Farah Medical Complex (FMC) is a hospital set to open in 2013 that will feature 20 “ambient experience” rooms, the largest installation of such equipment in any hospital in the world. Ambient experience rooms are designed to produce a calming environment for patients through a combination of light, sound and images. Developed by Philips Electronics, the technology has also been found to help caregivers work more effectively. Philips also reached an agreement with the FMC in late 2012 to provide the new hospital with a total of 15 imaging systems and health care informatics tools. Al Faisaliah Medical Systems, a Riyadh-headquartered company that acts as Philips’ distributer in Jordan, will supply the FMC with the equipment. The new hospital will also be the first hospital in the kingdom to be certified by Leadership in Energy and Environmental Design (LEED), an environmental rating standard. By adhering to LEED green building standards, the FMC should both lower its energy costs and boost sustainability in the long term.

CONSTRUCTION: Work is also nearing completion on the Prince Hashem bin Abdullah II Hospital (PHAH) to be located in Aqaba. With 200 beds and an investment value of $70m, the entire campus area of the PHAH covers around 150,000 sq metres, 50,000 sq metres of which will be residential, according to the Aqaba Development Corporation, a local firm working to expand the Aqaba Special Economic Zone. The total building area of 37,000 sq metres will include general clinics (4300 sq metres), specialised clinics (6900 sq metres), emergency services (1350 sq metres) and offices (2200 sq metres), among other facilities. The Kuwait Fund for Arab Economic Development is financing the project. Another major development is an oncology centre at the Queen Alia Military Hospital (QAMH). Officially inaugurated in October 2012, the facility will provide care to 40 RMS cancer patients on a daily basis and employ staff who have received training in the US as well as at the KHCC in Amman, according to The Jordan Times. While JD12m ($16.8m) was invested in the oncology centre, the new facility should save the RMS an estimated JD4m ($5.6m) by serving patients that would have needed to go to non-RMS affiliated centres in the past. Established in 1987, the QAMH is located in the northwestern part of Amman and has more than 230 beds.

NEW PROCEDURES, NEW PATIENTS: New medical procedures are also being introduced. The Amman Surgical Hospital, a privately run facility, carried out its first bio-absorbable vascular stent (ABSORB scaffold) implantations in September 2012. Implanted in several patients with blocked coronary arteries, the ABSORB scaffolds provide necessary support for a period of six to 12 months, after which the scaffolds dissolve. The new procedure has a high success rate and offers patients an alternative to permanent metallic implants.

Meanwhile, additional steps are being taken to boost health tourism. The Private Hospitals Association (PHA), for example, negotiated an agreement that will see more Nigerians referred to Jordan for medical treatment. In addition, a Nigerian consulting firm will be responsible for promoting Jordanian health care in Nigeria, and measures will be taken to expedite the visa process for Nigerians travelling to the kingdom for medical care. The PHA also negotiated an agreement in 2012 with the Gulf Health Insurance Association; the deal will permit the health insurance of Jordanian and Palestinian expatriates working in the Gulf to be accepted by health care facilities in the kingdom.

Ongoing efforts to improve health care standards by accrediting Jordan’s medical facilities should also help support the expansion of the medical tourism sector. The initiative is being led by the Health Care Accreditation Council (HCAC) in collaboration with the Jordan Healthcare Accreditation Project (JHAP), a programme funded by the US Agency for International Development. A non-profit set up within the Ministry of Trade and Industry in late 2007, the HCAC has accredited 12 hospitals and 33 health centres as of mid-2012, according to HCAC figures. In December 2011, King Abdullah II issued a new requirement for at least one HCACaccredited hospital in every governorate.

HIGH-TECH MEDICINE: The expanding information and communications technology (ICT) industry is playing a growing role in Jordan’s health sector as well. An initiative known as the Healthcare ICT Taskforce (HICTT) was set up in November 2011 to increase ICT cooperation in the medical industry, as well as to support Jordanian firms providing technology-driven health care solutions. The HICTT is an open-platform of technology companies in the kingdom and operates under the umbrella of the Information and Communications Technology Association of Jordan (int@j), an association founded in 2000 and supported by the ICT sector. As of February 2013, over 30 companies were stakeholders of the new task force, as per numbers from int@j. The group is funded by both the King Abdullah II Fund for Development, a non-governmental organisation, and the global networking firm Cisco Systems. Also in collaboration with Cisco, the government launched a health clinic in 2011 in which Cisco Technology will link specialists at the Prince Hamzah Hospital in Amman with patients and physicians at Mafraq Public Hospital.

Another key development is the planned expansion of Mobile Doctors 24-7 into Jordan. Once in operation, the Dubai-based firm will offer virtual clinic services and care through its Physicians Helpline to anyone in the kingdom with phone access. The helpline uses telemonitoring and telemedicine technology, such as an electronic medical record system to allow Mobile Doctors’ physicians to retrieve a patient’s medical history at any time. In emergency situations, the firm will also be able to send medics to a patient. The launch of Mobile Doctors in Jordan should help individual patients, as well as the government by reducing spending on health care. Before launching the services, Mobile Doctors aims to develop a network of doctors as well as hospitals and health care centres in-country.

MEDICAL DEVICES: While the local market for medical devices is fairly limited in scope, a nascent medical device manufacturing industry is developing. Atlas Medical set up a facility at the free zone area near Amman to manufacture products for its customers in the Middle East as well as East Asia. In addition to manufacturing space, the Jordan-based facility includes research and development (R&D) labs, quality-control labs, a warehouse and administrative offices.

The UK-based company specialises in several areas including latex kits for serology, stains for microbiology and histopathology, rapid immuno-chromatograhpy tests and clinical chemistry equipment. While Atlas Medical exports a large percentage of its products, there is also demand from the local economy for higher quality medical products. And perhaps the best path forward for the kingdom’s medical devices industry is to focus on innovation. This includes developing better ties with Jordanian universities in order to create a stronger local R&D environment.

“In terms of regulation, labs operating in Jordan are particularly well-off when compared to the region,” Dr Hassib A Sahyoun, CEO of MedLabs, a research consultancy group, told OBG. “There is, however, a need for a standardisation overhaul across the entire labs sector. There is a discrepancy in the quality standards across the board for all the operating laboratories,” he added.

OUTLOOK: As Jordan’s health sector expands, the industry still faces challenges such as a shortage of nurses, a general demand for more hospital beds and relatively high spending (as a percentage of total health care expenditure) on pharmaceuticals. The population is also growing, and on average Jordanians are living longer – meaning that more people require care for extended periods of time. Further, as is common in other parts of the world, health care in Jordan is becoming more expensive. Nonetheless, the industry is growing in key areas such as medical facility accreditation and technology-driven health solutions. The sector should be further strengthened as it receives support from abroad. The Ministry of Planning and International Cooperation recently announced that a portion of pledged financial support from Saudi Arabia would be used to build several hospitals as well as supply medical equipment to numerous established hospitals in the kingdom.