Jordan's health care sector is adapting to influx of Syrian refugees

With a long history of advanced surgery, a well established medical tourism industry and more than 60 private hospitals and clinics, the health care sector in Jordan has long been regarded as a regional example of excellence. For many years, the kingdom has been more advanced than most other countries in the Middle East by many international health indicators, but the escalating emergency and humanitarian situations in neighbouring countries have posed a number of challenges for the sector. There has been a drop off in the number of medical tourists, and the public health care system is struggling to cope with the medical needs and long-term care of more than a million new refugees.

Hospitals

According to the country’s Private Hospitals Association (PHA), there are 61 private hospitals in Jordan, with a total of 4600 beds, and these facilities employ about half of the country’s health care workers. In addition, the Ministry of Health (MoH) reported in its most recent annual yearbook for 2014 that there were 31 MoH hospitals, 12 hospitals run by the Jordanian military’s Royal Medical Services (RMS) and two run by state universities, namely King Abdullah University Hospital and Jordan University Hospital.

These public sector hospitals had more than 8000 beds between them, according to MoH data. The public sector also runs the National Centre for Diabetes, Endocrinology and Genetics. Non-governmental organisations (NGOs) also deliver a number of health care services in Jordan through the King Hussein Cancer Centre, charity association clinics and two UN bodies – the UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) and the UN High Commissioner for Refugees.

Gcc Funding 

In late 2011 four GCC countries agreed to award $5bn in grants to Jordan over a five-year period leading up to 2016, with Saudi Arabia, the UAE, Kuwait and Qatar each contributing $1.25bn. In February 2015 the Saudi Fund for Development (SFD) signed five grant agreements with a combined value of $176m for health care projects in Jordan under the 2011 agreement. Jordan’s state news agency, Petra, also reported in February 2015 that $6m would be spent on new laboratories for the Jordan Food and Drug Administration, $12m on a new X-ray centre, $37m on improvement works at King Hussein Medical Centre and $52m on expanding the King Hussein Cancer Centre.

New Facilities

In addition to the other SFD health care projects, a $70m grant is being used to construct and equip Princess Basma Educational Hospital, a new 500-bed infirmary, which is being built to serve 1.25m people who live in the southern region of the Irbid governorate.

Tenders for the construction contract were called for in November 2015, and by January 2016 the Ministry of Public Works and Housing had begun the pre-qualification process for 13 bidders, which included Jordanian contractors and others from Saudi Arabia. The hospital will offer all specialities, with the exception of paediatrics, obstetrics and gynaecology, services which are already provided by other hospitals in the area.

In March 2016 a new 40-bed private hospital opened in the Marka district of Eastern Amman. Khansa General Hospital employs 150 people and became the third private hospital in that part of the city. A few months earlier in October 2015 the Italian Hospital, which was founded by the Italian Association of Missionaries Abroad in 1926, opened new wards to offer urology and nephrology services.

Medical Tourism 

A significant proportion of the patients using Jordan’s private sector hospitals and clinics are medical tourists, who account for 40% of private hospital revenues. However, in March 2016 the PHA noted there had been a 15% fall in medical tourism during 2015, blaming the decline on political instability in source markets such as Libya, Yemen and Iraq, as well as new visa restrictions imposed by the Jordanian government at the end of 2015 on Libyan and Yemeni visitors.

The most recent PHA data shows that 250,000 medical tourists were treated in Jordan in 2014, with significant numbers of patients also coming from Sudan and Saudi Arabia. In the same year private hospitals had revenues of JD1bn ($1.4bn); however, this fell to JD850m ($1.2bn) in 2015. In response, the PHA has organised a marketing campaign using both traditional advertising and social media to target potential patients in Saudi Arabia, Oman, Algeria, Chad, Nigeria and Kazakhstan.

The PHA announced in August 2016 that the Jordanian cabinet had approved some of their recommendations to boost medical tourism, with a particular focus on visa restrictions. Dr Fawzi Al Hammouri, chairman of the PHA, told The Jordan Times that restriction on medical visas for Libya, Sudan, Syria, Yemen, Chad and Nigeria had led to a drop in patient numbers of 70-80%. The PHA has welcomed the changes, including a move to allow hospitals in Amman to expand to more than eight floors, government funds being allocated to promote medical tourism via the Jordan Tourism Board, rather than the PHA’s own pocket, mandatory local or international accreditation for health institutions and permission for hospitals to generate electricity from alternative sources, among other things.

However, the PHA still faces some obstacles. For example, while the Ministry of the Interior has said it will process medical visas within 48 hours, it is requiring Sudanese citizens to submit a letter from the Sudanese government confirming their medical need, a request which Al Hammouri said will be difficult to meet as the Sudanese government does not cover medical tourists’ expenses, and even then such a process could take two to four weeks. Despite a need to iron out the wrinkles, the move by the cabinet does indicate that there is recognition of a problem and a desire to address it.

Supervision

The umbrella body responsible for health care policy across all sectors in Jordan is the High Health Council (HHC). The HHC is chaired by Mahmoud Al Sheyyab, the minister of health, and its members are drawn from both public and private health care providers.

The HHC also has an executive arm, the HHC General Secretariat, which drew up national health strategies for the 2008-12, 2012-16 and 2016-20 periods. In preparing these plans, the HHC also consulted with the World Health Organisation. Other key supervisory bodies formulating health care policy and with seats on the HHC include the Jordanian Medical Association, the Supreme Council of the Population, the Jordanian Nursing Council and the Jordan Food and Drug Administration.

Insurance: 

One of the strategic objectives of the National Strategy for the Health Sector for 2015-19 is to achieve universal health insurance coverage for Jordanian citizens. According to the 2015 census published by the Department of Statistics (DoS), 68% of Jordanians and 55% of the population have medical insurance. These figures included 312,000 children under six years of age, who receive free medical treatment by royal decree. If children six years of age and under are discounted from the survey, the rate drops to 63% of Jordanians. The census found that there were 9.5m people living in Jordan, including 2.9m refugees and expatriates, who together represent 30.6% of the population.

According to the DoS census, among the insured Jordanian population MoH insurance covered 41.7%, the RMS insured 38% and private insurance firms covered another 12.4%. A smaller number of Jordanians received health coverage provided by the country’s two university hospitals. In addition, UNRWA provides some coverage for primary health care to just under a million people. The census also found that only a quarter of non-Jordanians residing in the country have any health insurance.

Out Of Pocket

In May 2016 the HHC collaborated with UNICEF to produce a policy brief that examined patterns of health care expenditure in Jordan, and the extent to which people in the country are exposed to the risk of catastrophic health expenditures by paying for private treatments, resulting in financial ruin for individuals and their families.

The research paper, which examined data from 2008, 2010 and 2013 household expenditure and income surveys, found that although the incidence of catastrophic health payment was low, it was most prevalent among poor Syrian refugees and the wealthiest 5% of the Jordanian population. It also showed that while overall out-of-pocket expenditure (OOPE) fell over the five-year period, the average family’s OOPE on health care increased from JD136 ($191) in 2008 to JD215 ($302) in 2013. In 2013 62.5% of OOPE was on medicines.

Data from the Vulnerability Assessment Framework, a UN survey, found that nearly 21% of Syrian refugees had faced catastrophic health care expenditures, with further data showing that the number of Syrian women entering the country who incurred expenses for the delivery of a baby dropped from 75% in 2014 to 49% in 2015.

The policy paper also noted that take-up of the MoH insurance policy administered by the Civil Insurance Fund (CIF) only increased by two percentage points between 2010 and 2013. During the same period the percentage of people that were insured through the RMS, which covers military personnel, increased from 25.4% to 38.4%.

The policy paper recommended that the CIF should target uninsured families from the two lowest-income quintiles in society, possibly by offering them subsidies, as well as focusing on populations in regions where insurance uptake is lowest. It also recommended exploring ways in which refugees could access the CIF, possibly via subsidies. Another suggestion was for public health care providers to engage in more strategic purchasing and budgeting, as a means to improve facilities and reduce the number of people who are choosing to pay for more effective treatment at expensive private facilities.

The 2015 census data used in preparing the report enabled the HHC and UNICEF to base its conclusions on up-to-date information. The HHC had previously raised the point that there was a paucity of data on coverage, including overlapping insurance coverage, and that this had hindered its plans to develop a universal health insurance strategy. The HHC also reported the welcome news that there was political will to pursue this objective, and that health insurance reform measures, such as those recently pursued in Dubai, were being studied closely as a potential model for reform.

Hakeem: 

Another area in which Jordan is improving the collection, analysis and utilisation of data is in the provision of electronic medical services. In November 2015 the government signed a five-year agreement with the Electronic Health Solutions Company, a non-profit body representing stakeholders from both the public and private sector, to implement the Hakeem e-health programme across Jordan. The plan is to create a database of patient notes across the country so that medical professionals have instant access to a patient’s medical records. In its initial phase the scheme covered 10 public hospitals and 33 health centres, and the database included files for 1.4m patients. The scheme is due to be rolled out to all 31 public hospitals and 700 health centres across the country by 2020. In addition, the government hopes to encourage private hospitals to use Hakeem by making its adoption a condition of national accreditation.

Population Pressure

The headline figures from the 2015 census, the first to be completed since 2004, paint a stark picture of the challenge facing health care services in response to an 86.2% increase in Jordan’s population in that decade.

The 2004 census counted 5.1m people in the country, 93% of who were Jordanian nationals. By late 2015 the total population had grown to 9.5m. The population of Jordanian nationals had grown by nearly 39% from 4.75m to 6.6m, while the number of non-Jordanians had grown by 729% from 349,933 in 2004 to an estimated 2.9m, including 1.26m Syrians, who constituted 13.3% of the total population in 2015, according to that year’s census.

The figures also revealed that Jordan hosts 636,270 Egyptians, 634,182 Palestinians, 130,911 Iraqis, 31,163 Yemenis, 22,700 Libyans and 197,385 people of other nationalities. Nearly half of non-Jordanians live in the capital city, and Amman is also home to slightly under 40% of Jordanians. Expansion of public health facilities has not kept pace with this decade of population growth. Over that time, the number of MoH hospitals has grown from 29 in 2004 to only 31 in 2014, and two more RMS hospitals have opened since 2004, bringing the total to 12.

Syria Crisis

The influx of refugees has had a major impact on the quality of care available to Jordanian citizens, and the strain on public service facilities has been particularly acute in northern governorates near the Syrian border, with hospital bed occupancy in Mafraq and Ramtha public hospitals reaching 100%, according to the HHC.

The result for the entire public health care sector is a strain on resources, personnel and government finances. According to HHC data on key health indicators, staffing levels and hospital bed numbers per 10,000 people have fallen since the influx of Syrian refugees began. According to the HHC’s 2014 annual report, in 2013, before the crisis, the ratio of staff to 10,000 people was 28.6 for doctors, 10.4 for dentists, 44.8 for nurses and 17.8 for pharmacists. After the crisis these numbers were 23.4 for doctors, 8.5 for dentists, 36.6 for nurses and 14.5 for pharmacists. The average number of beds per 10,000 citizens was 18 before the Syria crisis, but fell to 15.1 – and in Mafraq specifically this figure fell from eight to six. Overall, the percentage of the population covered by health services fell from 98% to 90% over the same period.

The HHC has calculated that if Syrian refugees in Jordan are to remain in the medium to long term, it will be necessary to increase health care services for them by providing an additional 367 beds, 658 physicians, 1038 nurses and 418 pharmacists.

The MoH provides a relatively extensive range of free primary health care services for Syrians in refugee camps, including immunisation, reproductive health, and monitoring communicable diseases and epidemics. The MoH also keeps records of injuries, and registers births and deaths. It supplies hospitals in the camps with blood and serums, and handles the disposal of medical waste, as well as providing hygiene, water and sanitation services.

For many years, Jordan was ahead of most countries in the Middle East, according to international health care indicators, but the influx of refugees has reversed many gains.

“We were clear of polio for more than 15 years, but now we are seeing new cases,” Abdel Razzaq Shafei, director of the MoH’s Health Economy Directorate, told OBG. “It has also had an impact on the resources of our secondary and tertiary units. We have carried out 50,000 operations on refugees and have treated 350,000 inpatients and 1.5m outpatients at our health centres.”

Communicable Diseases

The incidence of communicable diseases among the refugee population and the concern that infections might spread to host communities will require JD20m ($28.1m) to be spent on vaccination campaigns out of an estimated JD83m ($116.7m) in additional expenses incurred by the country’s public health service due to the refugee crisis, according to the HHC.

Medical staff have found that the incidence of pulmonary tuberculosis among Jordanian citizens was five cases per 100,000 people, compared to 13 cases among the equivalent population of Syrian refugees. In addition, there were 2.8 cases of measles per 1m Jordanians, compared to 51.2 per 1m Syrian refugees, and cutaneous leishmaniasis, a disease that is spread by infected sand flies, affected 3.1 people per 1m Jordanians, compared to 158.1 per 1m Syrian refugees.

Despite costs, the state is committed to providing for its Syrian population. “Jordan remains committed to providing humanitarian aid to Syrian refugees, despite the fact that this has a serious impact on the health care system in the public sector due to the lack of funding, the limited number of workers in health care and the lack of necessary facilities to provide health services for Syrian refugees,” Hani Al Kurdi, secretary-general of the HHC, told OBG.

International Response

There has been a significant response to the Syrian refugee crisis in Jordan by UN bodies and international charities and aid organisations, but despite these efforts Jordan’s public health care sector is facing major challenges. “We have 75 international NGOs in Jordan, and they help in a number of ways, but some of them only provide relatively inexpensive medical intervention services, such as mental health or reproductive health education,” Shafei told OBG. “These are important services, but what we need are NGOs prepared to offer secondary and tertiary health care, such as operations.”

In addition, Jordan’s ability to cope with non-communicable diseases such as hypertension, diabetes and coronary heart disease among its own population is compromised when refugees requiring ongoing treatment and medication for the same conditions are granted access to receive MoH drugs and care. Shafei told OBG, “For instance, a patient requiring dialysis or treatment for coronary heart disease may need $500 worth of treatment per day, and in the end these people are being treated by Jordan’s public health sector. The public sector cannot turn away chronic cases, but we do not have sufficient facilities to cope.”

Air Ambulance

In August 2015 a new air ambulance service began flying mercy missions to offer a lifeline to people living in remote areas of the country, far from the specialist medical facilities and services available in Amman.

Jordan’s Air Ambulance Centre (AAC) was established as an independent government organisation following a royal directive and was equipped with two AgustaWestland AW139 helicopters provided by King Adbullah II ibn Al Hussein.

The aircraft, which are based at Amman’s Marka International Airport, are equipped with state-of-the-art intensive care facilities. A typical flight carries two pilots, two medical staff and has room for two patients. Doctors, nurses and paramedics are seconded to the AAC after they have first taken a course in aviation medicine.

The AAC has a unique operational structure: rather than operating as a branch of the emergency services, and its services have to be commissioned by one of the country’s hospitals. “We are doing very well in terms of building business partnerships with private hospitals, the MoH and insurance companies,” Rami Adwan, CEO of the AAC, told OBG. “There are 6.5m people with health insurance, and if they live in an area where they are unable to access a particular kind of medical procedure or facility, they can be flown to Amman for treatment.”

According to the AAC, there are more than 35 helipads across the country where patients can be picked up. In Amman there are four helipads serving Al Hussein Medical City, one at Prince Hamzah Hospital and one at Jordan Hospital. To increase the scope of the service, new private hospitals with more than 100 beds will be legally required to have helipads, and existing facilities with sufficient space that are not in built-up residential areas will also be encouraged to construct landing sites.

Labs: 

The kingdom has also made significant strides in the quality of its laboratories. While previously hospitals created competition, most lab work is now taken care of by external standalone labs, most of which are in the private sector. Growing insurance coverage has also helped labs to reach a wider range of clients, as well as resulting in timelier payments.

With around 500 labs in both the public and private sectors, there is still room for growth in the Jordanian market. However, Dr Hassib Sahyoun, CEO of MedLabs, agrees that there is also a need for more stringent quality standards and mandatory accreditation, as suggested recently by the Ministry of Health and the Healthcare Accreditation Council, which accredits hospitals around the country. The industry faces challenges due to certain practices by insurance firms and a high rate of turnover – 16% – among employees. While insurance firms do pay on time, there is a high rejection rate in an attempt to avoid covering medical costs, which can leave labs out of pocket when patients cannot cover the costs themselves.

Talent going overseas and a lack of extensive training has also affected the segment, as Jordanian graduates often require additional training, and once they have gained experience often leave for opportunities in the Gulf. April 2016 saw the fourth International Jordanian Conference of the Jordan Society for Medical Laboratory Sciences take place in Amman. The three-day event brought together 440 international experts and highlighted the importance of delivering quality lab results as a key component of diagnosis and health care.

Outlook: 

Although Jordan has enjoyed peace and stability for many years, in recent times it has been affected by the ongoing conflicts in neighbouring countries, and the kingdom’s health care professionals have been working at the sharp end by treating victims of these conflicts. With no end in sight to the war in Syria, Jordan must work with its international partners to provide sustainable health care solutions for the 1.2m people who are living in refugee camps or host communities. The MoH estimates there are 400,000 Syrians in Amman alone, and if they remain for an extended period of time, additional medical facilities will have to be provided.

Jordan is now faced with the prospect of working with its international allies to find lasting solutions to these pressing needs, including the construction of new facilities, along with new models of health insurance that provide coverage for the poorest Jordanians as well as for the refugee population. Government officials are fully aware that, in the meantime, the kingdom’s own citizens are seeing the quality of care that they receive being compromised.