Primary Health Care
Provision in Jordan:
Summary and Update
Fadia Hasna PhD, November
2006
Jordan Governorates
Syria
Iraq
West
Bank
Saudi Arabia
A country in demographic and
fertility transition
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Over the next 50 years, Jordan’s demographics will change dramatically – This
will pose great challenges for the country (resources and services).
The country’s population is growing rapidly, doubling over the last 20 years and likely
to double again by 2029. However, it is undergoing a demographic transition : moves
from high fertility and mortality, to low fertility and mortality (David Bloom,
“Demographic Transition and Economic Opportunity: The Case of Jordan,” April
2001).
Fertility declines in Jordan have contributed to slowing the population growth rate
down to 3.2 percent in the second half of the 1990s, and to 2.8 percent in
2002.(JPFHS, 2002).
The urban population increased by 14 percent between 1980 and 1994, increasing
from 70 to 79 percent. (JPFHS, 2002).
Results of the 1994 census indicate that the age structure of the population has
changed considerably since 1979 – the result of changes in fertility, mortality, and
migration dynamics.
The proportion of the population under 15 years of age declined from 51 percent in
1979 to 39 percent by 2002, while the proportion of those age 65 and over has been
rising. (JPFHS, 2002).
Population and Development Efforts
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1973, the National Population Commission (NPC) was established, with
the mandate to formulate and implement a national population policy and to
address all population-related activities; nothing done till the late 80s;
1991, the NPC adopted the Birth Spacing National Program, in an effort to
promote better maternal and child health as well as reduce fertility through
advocating increased birth intervals.
1996: The NPC created the final national population strategy for Jordan,
which was approved by thecabinet in 1996 and was updated in 2000.
2002: Establishment of the Higher Population Council with a mandate: The
HPC mandate is to propose population policies that ensure the achievement
of socioeconomic development objectives. The HPC will serve as a
coordinating body in the area of population activities, dissemination of
information, and strengthening of NGO participation in planning,
management and implementation of population programs and projects in
compliance with the national population strategy.
The Ministry of Health (MOH), through its Maternal and Child Health
Centers (MCH), provided optional and predominantly free family planning
services as an unofficial and indirect intervention in the population policy.
The efforts made by the Jordan Association of Family Planning and
Protection (JAFPP), as well as by some voluntary nongovernmental
organizations, were invaluable in this regard.
National Health Strategy
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Aim: Creating a comprehensive health care system, utilizing both public
and private service providers, and covering all levels of care, from
preventive care to tertiary and rehabilitative care.
Objectives of period 2002-2005:
Coordination of primary, secondary, and tertiary health service delivery, in
order to improve the efficiency of the health system and to avoid
duplication among health providers and waste of resources.
Development of health-sector human resources through training programs
for medical staff to raise standards in all health-sector human resources
categories and to maintain quality standards throughout the system.
Facility development by upgrading and/or expanding the existing health
centers and hospitals, and building, equipping and computerization of
new facilities as needed.
Issuance of laws and regulations related to the organization of the health
sector, in addition to reconsideration of some existing health laws and
regulations expected to be approved during the plan period 2002-2005.
Computerization of the MOH existing health facilities all over the country,
including the development of a Geographic Information System (GIS) for
these facilities.
Challenges
• While low infant mortality rates and high life expectancy - are among
the best in the region, the population growth rate continues to be a
major development constraint - especially when analyzed in light of
the quantity and quality of services to be provided to
accommodate this rapid increase in population.
• The landmark passage of the National Population Strategy (NPS) in
March 1996 and the passage of the Reproductive Health Action
Plan, a sub-strategy of the NPS, in April 2004 make it clear that
Jordan is serious about family planning.
• Less than fully functional public health systems,
• An unmet demand for high quality maternal - child health care
services and information,
• A significant increase in the prevalence of chronic diseases.
MOH Structure for PHC
PROVISION
Health Centers in MOH 2000-2005
Type
2005
2000
Comprehensive
Health Centers
Primary
Health
Centers
Peripheral
Health
Centers
MCH
Centers
Dental
Clinics
57
368
238
385
274
47
333
265
345
237
Discrepancy in Utilization Capital/
Badia (source MOH)
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PR E NATAL
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PR E NATAL
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Average Number of Prenatal Visits
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Average Number of Prenatal Visits
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Directorates: [Capital]
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Directorates: [North Badih]
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All Reported Months
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All Reported Months
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Years: [2006]
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Years: [2006]
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Year New
Recur
(New+Recur)/New
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Year New
Recur
(New+Recur)/New
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2006 2,569
9,156
4.56
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2006 221
532
3.41
Tetanus Immunization
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PR E NATAL
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PR E NATAL
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% Pregnant Women Tetanus
Immunized
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% Pregnant Women Tetanus
Immunized
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Directorates: [Capital]
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Directorates: [Mafraq]
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All Reported Months
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All Reported Months
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Years: [2006]
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Years: [2006]
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Year TT_2
TT_3
TT_4
TT_5
New
%
(TT_2+TT_3+TT_4+TT_5)/New
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Year TT_2
TT_3
TT_4
TT_5
New
%
(TT_2+TT_3+TT_4+TT_5)/New
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2006 549
337
228
130
2,569
48.42
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2006 46
34
512
11
18.75
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Comprehensive Primary Health Care Centers CPHCCs:
Research Findings
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Staffed by general medical practitioners, nurses, midwives, dentists,
administrative support personnel and a limited number of diagnostic
technicians.
Role of rural nurses in Jordan (Francis, Nawafleh and Chapman, 2005)
showed:
Work of nurses task orientated and directed by the physicians.
Nursing staff were predominantly practical and aide nurses who were
recruited locally.
Nurses engaged in activities that are considered advanced practice such as
suturing and venipuncture and were largely unaware and non-compliant of
universal precaution recommendations.
The nurses did not engage with the community to promote health issues.
Dialogue with patients was limited to directions related to the therapy being
initiated.
Nurses had little understanding of contemporary health issues and
demonstrated a lack of awareness of ‘safe practice’.(Francis, Nawafleh and
Chapman, 2005)
The nurses’ roles traditionally are curative in nature and involve direct
patient care (Nahas, Nour &Al-Nobani 1999; Haddad 2002).
Most nurses have been trained/educated for practice within an acute care
environment and have had little, if any, orientation to practice that is primary
level and largely community base
Challenges and Recommendations
• Poor resources, inadequate educational preparation,
limited skill-mix and access to professional development,
lack of nursing leadership and role models, collegiate
support, and geographic isolation are factors impacting
on nursing practice in the rural CPHCCs.
• Recommendations: Resources be directed toward
improving the capacity of the CPHCCs and access to
education, training and professional development.
• Nursing critics of the MoH maintain that the MoH could
address the nursing shortage if they adopted a practice
of paying incentives to staff accepting positions in nondesirable areas (Alrai 2003
Policy and Health Care System Reform
Directives in Partnership with Funding
Agencies
Adopt a more competitive legal and regulatory framework for the health
sector by:
1. Heath insurance reforms
2. Decentralization of hospitals
3. Development of systems for continuous medical education
4. System of relevant health provider incentives
5. Better integration of on-going primary health services strategies
and programs that prevent and treat chronic diseases
6. Development and implementation of a national health
communication strategy encouraging Jordanians to practice
healthy lifestyles.
7. Expanding and strengthening the public-private-NGO sector
partnership will help ensure that the poor, the disadvantaged and
the hard to reach populations access PHC services
Primary Health Care Initiatives Project
• 380 PHC clinics
• Renovation and provision of furniture and
specialized medical equipment
• Clinical training of service providers,
• Establishment of performance
improvement review systems
• Improvement of the management
information system
Participating Teams: South
1. Al Amira Rahmeh Health Center/ Ma’an
2. Al Rabbeh Al Shamel Health Center/ Kerak
3. Mu’tah Health Center/ Kerak
4. Majra Health Center/ Kerak
5. Al Mazar Health Center/Kerak
6. Emre'e Health Center/Kerak
7. Al Adnanyeh Health Center/Kerak
8. Al-Amira Basmah Health Center/Aqaba
9. Al Khazan Health Center/Aqaba
10.Al Baldah Al Qadimah Health Center/Aqaba
11.Al Aqaba Health Center/Aqaba
12.Al Qadissyeh Health Center/Tafileh
13.Bassirah Health Center/Tafileh
14.Ein Al-Baida' Health Center/Tafileh
15.Al Tafileh Al-Shamel Health Center/Tafileh
16.Al Hassa Health Center/Tafileh
Central
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Al Jofeh Health Center/Balqa
Deir Allah Health Center/Balqa
Al-Salalem Health Center/Balqa
Al Jreineh Health Center/Madaba
Al-Zarqa’ Al-Jadidah Health Center/Zarqa
Al Manara Health Center/Amman
Al Qweismeh Health Center/Amman
North
1. Al Manshieh Health Center/Irbid
2. Al-Razi Health Center/Irbid
3. Eidoun Health Center/Irbid
4. Beit Eides Health Center/Irbid
5. Huwara Health Center/Irbid
6. Um-Qais HealthCenter/Irbid
7. Hai Al-Hussein Health Center/Mafrak
8. Rawdat Al-Amirah Basmah Health Center/Mafrak
9. Al Amir Hasan Health Center/Ajloun
10. Jerash Health Center/Jerash
11. Souf Health Center/Jerash
Primary Health Care Initiatives
Project USAID and MOH 1994
1. Seventy-seven MOH physicians, midwives, and nurses were trained to
instruct all health care workers in primary and reproductive health care
protocols and procedures, as well as counseling for healthier behavior.
2. 􀂾 Seventy Quality Assurance Coordinators are facilitating a quality
improvement process at the health centers.
3. 􀂾 Twelve research teams were prepared to study and disseminate findings
on clinical and management issues.
4. 􀂾 Computers and a new reporting system are enabling health centers and
directorates to input and retrieve information to improve client flow and
management decisions.
5. 􀂾 An intensive health promotion campaign has been launched in the media
and 42 health promoters are implementing a health promotion strategy that
focuses on building resource networks to help the community become
responsible for its own health.
6. 􀂾 All centers are being renovated to upgrade the physical appearance and
safety of the centers and provided with new furniture and equipment.
PHCI: Achievements and Lessons
Learnt
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Building effective referral systems:
Problem: No system for receiving feedback on referrals for
pregnancies with complications or for clients seeking family
planning methods not available at the center
Solution: Develop a referral log, Give each client a form to take to the
referral site and return with the information filled out, Assign an
officer at the referral center to obtain feedback, record information,
attach referral forms to client files, review the results of the referral
with clients and the referral center.
Lessons learnt: Personal follow-up with referral sites is important.
Counseling pregnant women about the benefits of special care and the
need to bring the feedback form back to the health center
increases commitment??
PHCI: Achievements and Lessons Learnt
2.
Reproductive health utilization:
Problem: The primary health care system in Jordan has not established a
calculation for determining an adequate reproductive health service
utilization rate.
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Availability of other government and private facilities makes it difficult to
assess whether client need is underserved at the primary health care
level.
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Figures for postpartum care and family planning are consistently and
significantly lower than antenatal care; inequitable utilization of services
by women
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Consequently, the health risk for newborns and their mothers is
increased and
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opportunities that have proven effective for introducing family planning
counseling are missed.
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IUD services,although requested, were not available (limited method
choice).
Solution : IUD insertion unit established in 2001
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Awareness raising campaign focusing on the significance and availability
of family planning and particularly IUD services in the center using:
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- Home visits
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- Counseling clients about the services of the center
- Educational sessions for the local community
PHCI: Achievements and Lessons Learnt
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Increasing post-partum care utilization:
Problem: Low post partum care utilization; Clients are not aware of the need for
postpartum care
Solution: Increase utilization by:
􀂾 Promote awareness of postpartum services in the community.
􀂾 Inform all female patients, especially MCH clients, about available postpartum
services.
􀂾 Create a brochure for women containing information about maternal care.
􀂾 Develop a register to log the number of expectant mothers, their addresses and
expected date of delivery to enable follow-up.
􀂾 Provide counseling about postpartum services during antenatal services.
􀂾 Contact women who missed their postpartum appointment by phone and home visits.
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Raise the awareness of pregnant women about the importance of care in the
postpartum period,
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The target group was pregnant, third trimester women.
􀂾 Recording the names of all target-group clients and their expected delivery date to
enable follow up.
􀂾 Providing and documenting health education messages delivered by physician and
MCH staff covering:
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- Breastfeeding and its benefits to both mother and
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infant
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- The importance of antenatal and postpartum
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nutrition
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- Maternal and infant postpartum complications
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- Maternal and infant postpartum personal hygiene
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- Counseling on family planning
PHCI: Chronic Illness-Compliance
with Standards
4. Prevalence of hypertension in Jordan among those over 25 is 31.8% while diabetes
accounts for 6.8% of adult illness.
Problem: Physicians inconsistently use standards in treating and documenting chronic
conditions, resulting in inconsistent service.
Objective: To ensure complete and routine nurse and physician compliance with the
protocols for diabetes and hypertension.
Action steps: PHCI-trained Health Team Trainers instructed the Health Center Director in
the use of the clinical case management protocols.
2. The Director trained center medical staff in the protocols, emphasizing the need for
compliance.
3. A monitoring plan to determine the rate of compliance with the steps of the protocols
was devised to randomly sample
medical staff treating these patients three times a week. The observations were
completed using the checklists supplied with the protocols. Baseline and post
training samples were taken to observe the difference. Client files were also
reviewed to determine whether the information recorded by the physician complied
with the protocol directions.
4. New client files for diabetic and hypertensive patients were created and a follow-up
chart was attached to each record.
5. The team agreed to review the data monthly
Uncontrolled diabetes
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Problem: Health care staff do not follow standards for treatment of diabetes, which
contributes to a large number of uncontrolled cases. In Jordan, 43% of diabetic
patients using health centers
are classified as uncontrolled.
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Solution:
1.
Define an overall strategy to include specific interventions and a monitoring plan.
2. Explain to staff the link between applying standards and measuring fasting blood sugar
levels to see results.
3. Provide the protocols.
4. Train 3 physicians and 8 nurses on implementing the protocols and completing the
follow up chart.
5. Discuss monitoring results during the QA team meetings.
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Monitor results of Blood Sugar fasting for individual patients for a period of 6
months and prepare reports on results.
7. Document the percentage of controlled and uncontrolled patients on a monthly basis.
8. Mark the records of patients with readings higher than 180 to refer them for intensive
counseling.
9. Report the results on the QA Coordinator monthly reports.
PHCI
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Training nursing personnel
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Promoting preventive services:
Problem: The primary health care system in Jordan has focused on curative care. Screening or early
detection programs that play a role in disease prevention are minimal. The Ministry has no
specific screening policy
A pilot screening program for breast cancer was carried out
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Lessons: A combination of conducting training, assigning responsibility and providing quality
services facilitates introduction and maintenance of new programs.
􀂾 A comprehensive program of promotion, education and quality service can increase awareness and
demand for the service.
􀂾 Screening programs can successfully detect new cases.
􀂾 Screening programs provide an opportunity for introducing other relevant health messages, for
example breastfeeding explanations were included during the screening process.
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Improving client flow in the clinics
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Strengthening health education
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Problem Staff were often unprepared to deliver a lecture, did not adequately plan for them, and
had poor presentation skills.
􀂾 Promotion of health education sessions was ineffective.
􀂾 Client needs for specific health information were not surveyed.
Health Systems Strengthening
Project (HSSP)
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5-year $45 million project started in April 2005 between USAID and in
partnership with the Government of Jordan, and other private and NGO
partners to further improve and institutionalize a responsive, quality-oriented
public health care system in Jordan.
Aim: Assist the Ministry of Health to build the capacity of health workers and
sustaining improvements in the quality of health care at the local
community, health center, hospital, governorate, and central government
levels.
Objectives:
– Improve the quality of health care services
– Develop and implement certification and accreditation systems for health care
facilities and service providers
– Computerize the health management information system networks
– Expand the health clinics’ outreach to their local communities.
– Improve safe motherhood and neonatal health care related services at primary
health care centers and hospitals
– Renovate and upgrade up to 28 hospitals and 32 primary health clinics belonging
to the Ministry of Health and the Royal Medical Services.