Policy Implementation Experiences from Jordan by Dr Jamal

: Policy Implementation: Experiences from Jordan by Dr. Jamal Abu Saif MD, Arab Board in Community Medicine Director of Technical Affairs and Studies NHA Project Manager High Health Council - HHC Amman-Jordan

Vision A distinguished healthcare system within an integrated health sector that achieves an outstanding status for the kingdom on the health world map.

Mission To draw up integrated health policies with the participation with all health sectors within the kingdom; so as to ensure the provision of distinguished healthcare services with a noble humanitarian goal within a sound health economy that strengthens Jordan’s leading position in the field of healthcare.

High Health Council - HHC Law No. 9 for the year 1999 Objective: To formulate the general policy of the health sector and to put forward the strategy to achieve it in order to organize and develop the health work in the Kingdom as a whole.

Membership of HHC Chairperson: The Prime Minister Vice-chairperson: The Minister of Health Members: 11 § Minister of Finance § Minister of Planning and International Cooperation § Minister of Social Development § Minister of Labor § The General Director of Royal Medical Services § The president of Private Hospital Association § Dean of one of the medical faculties in the official Jordanian universities appointed by the president every two years. § The president of Jordan medical association. § The head of one of the health associations appointed by the president every two years. § Two experts from the private sector appointed by the president every two years.

HHC Responsibilities § Periodic evaluation of health policies and introducing needed amendments after implementation. § Identifying the needs of the health sector and taking decisions regarding equitable distribution of health services across the kingdom ( Jordan health map experience- equitable distribution of public health centers and decreasing social influence)

HHC Responsibilities § Coordinating work of health institutions in both public and private sectors to guarantee integration of their work (Regular meetings with liaison officers) § Studying the proposed laws, bylaws, and regulations of the HHC and the health sector and submitting the necessary recommendations. ( Medical liability law. NHA data collection bylaw)

HHC Responsibilities § Studying problems and obstacles facing the health sector and providing statistics and data for decision making pertaining to health system restructuring. üJordan HRH observatory : equitable distribution of health work force. üJordan National Health Accounts annual technical reports (6 rounds)

NHA reports in Jordan Fiscal year Issued / Year Hosted by NHA team Rank No. 1998 2000 MOH (PHR Project) First 2000 -2001 2006 MOH (PHR plus Project) First 2007 2009 HHC (WHO TA) Second 2008 2011 HHC (WHO TA) Second 2009 2012 HHC (WHO TA) Second 2010 -2011 2013 HHC (WHO TA) Second

Cross-country comparison of NHA indicators WHO regional Health Observatory, 2011 Country Jordan THE as percentage Per capita health of GDP exp (US $) Public exp on health as percentage of THE 7. 7 357 67 Iran 8 247 81 Lebanon 7 651 39 Egypt 5 123 37 Tunisia 6 238 54 Yemen 5 63 24

Per capita health care spending (JD) Jordan NHA 2007 -2011 300. 0 250. 0 200. 0 150. 0 177. 5 2010 236 2011 269. 3 251. 5 50. 0 252. 9 100. 0 2009 2008 2007 0. 0

Distribution of HH Exp. By public and private Health Insurance coverage rate is 72% ( without duplication)

Breakdown of OOP Health Expenditure in the Private Health Sector 2011 Drugs 124. 8 (35%) Curative 128. 3 ( 36 %) Other Private Facilities 103. 4 29%

Drug expenditure as percent of GDP 20072011 3. 50% 3. 00% 2. 50% 2. 00% 1. 50% 3. 10% 2010 3. 08% 2011 2. 66% 2. 26% 0. 50% 2. 09% 1. 00% 0. 00% 2009 2008 2007

Per capita spending on drugs (JD) 2007 -2011 90. 00 80. 00 70. 00 60. 00 50. 00 40. 00 2011 2010 2009 2008 60. 3 0. 00 84. 86 75. 15 10. 00 69. 30 20. 00 68. 46 30. 00 2007 Drug Exp. US$ 605 Million 27% of THE (36% OF THE in 2001)

Public Expenditures by Function 2009 -2011 % 74. 8 16 7. 5 2010 ﺍﻹﻧﻔﺎﻕ EXP. 688. 4 147. 5 69. 2 % 75. 3 15. 9 7. 2 ﺍﻟﺴﻨﺔ Year 2009 ﺍﻹﻧﻔﺎﻕ EXP. 688. 2 145. 1 66. 1 % 76. 5 14. 7 6. 8 ﺍﻹﻧﻔﺎﻕ EXP. 757. 7 145. 6 67. 1 ﺍﻟﺼﺤﻲ ﺍﻹﻧﻔﺎﻕ Health Exp. ﺍﻟﻌﻼﺟﻴﺔ ﺍﻟﺮﻋﺎﻳﺔ Hospital Care ﺍﻷﻮﻟﻴﺔ ﺍﻟﺮﻋﺎﻳﺔ PHC ﻭﺍﻟﺨﺪﻣﺎﺕ ﺍﻹﺩﺍﺭﺓ ﺍﻟﻤﺴﺎﻧﺪﺓ Admin. & Services Training ﺍﻟﺘﺪﺭﻳﺐ and Research 1. 6 0. 1 14. 3 1. 4 0. 2 12. 8 2. 2 1. 3 0. 6 13. 3 6. 5 Others ﺃﺨﺮﻯ 100 920. 8 100 914. 3 100 NHA Technical Reports, HHC-Jordan 990. 2 THE Public ﺍﻟﻤﺠﻤﻮﻉ

Uses of National Health Accounts (NHA) § Policy and planning tools. § Understanding health care financing & expenditures. § Focus on resource allocation and allocative efficiency. § Facilitate evidence-based decision making. § Provide insight when dealing with insurance sector.

Updating the National Agenda of the health sector 2005 -2017 Agenda of the health sector The Prime Minister has formed four committees. The Minister of planning is the head of ministerial committee of all sectors in the country. The SG of the Ministry of Planning is the head of sectoral coordination committee (HHC-SG is a member) The head of health sector committee is the HHC-SG A technical committee was formed at HHC and was reporting to HHC-SG (NA : updated 2013 -2022 after preparing a progress report on the achievements of the national agenda interventions ( up to 2012) (HHC in collaboration with health and health related partners: MOH, RMS, JNC, UHs, HPC, JHA, JFDA, GDCD, …. )

The Prime Minister of planning Ministerial committee of all sectors in the country The SG of the Ministry of Planning Sectoral coordination committee HHC-SG Health sector committee HHC Technical Director Technical Committee

Main Health Sector Goals. National Agenda 2022 § Improving health care services in accordance with international standards. § Strengthening public-private partnership in order to create a distinguished healthcare system based on integration, and to limit waste and duplication. § Improving health system performance. § Extending health insurance coverage to all citizens. § Limit the prevalence of NCDs

Causes of mortality in Jordan C-V cancer Accidents Infectious Other

Moving towards comprehensive Health Insurance § Providing all people with access to needed health services § Reviving primary health care services § Controlling health care costs § Utilizing scarce resources efficiently

Moving towards comprehensive Health Insurance § Equity in accessing affordable health care services. § Increasing the financial protection of the people and protecting households from facing impoverishment and catastrophic health expenditures. § Accessible and affordable services. § Decreasing households’ expenditures on health.

Main HHC achievements § § § Health Map Medical responsibility law National agenda 2022 NHSs (NHS, NHS for health communication, NHS for the elderly, RHAP) Human Resources for Health observator. Surveys and studies such as: health insurance and OOP spending, availability of drugs at facility level and from HH perspectives, , and FFC.

Main HHC achievements National surveys, studies, technical reports and policy briefs, such as § Health insurance coverage and health exp. survey § Distribution of health care payments and FFC study § HH and facility survey on availability and pricing of drugs § Study on corruption in health sector § Policy brief on HRH- Jordan’s coordination and facilitation policy. § Policy brief on retention of MOH physicians in remote underserved areas. § National Health Accounts NHA annual technical reports

Future HHC activities § § Analysis of studying medical sciences and setting recommendations to address market needs. Linking the incentive system of the public employees with the performance indicators. Medical ethics in conducting experimental clinical trials in Jordan. Building national capacity on Costing of health care services (refugees, contracting)

Future HHC activities § Adopting certificate of need to control capital expenditure in health care services, & limit the unnecessary expansion of these services. § Supporting and improving primary healthcare services. § Ensuring equity in access to affordable healthcare focusing on the poor, disabled, and other high risk categories. § Setting national clinical practice guidelines. (accreditation, medical tourism, Medical liability)

Main Causes of health care system inefficiencies § Health System Fragmentation Ø Radical change was failed in 1988 (combing MOH and RMS) § Irrational use of Medicine and Health Technology. Ø HHC strategy on Dug Rationalization 2012 -2016 Ø Me. TA Project – JFDA ( availability, accessibility and affordability of drugs) § Inadequate financial and other incentives prevalent in the system Ø Absence of performance based incentives program

Policy implementation • Implementation is the process of turning policy into practice. ØAre Policy Formulation and Implementation interdependent? ØIf yes, should policy initiators consider them in combination?

Challenges Facing HHC and policy implementation § Limited financial resources allocated for national health projects, health policy research, and health policy analysis. § Lack of updated information and statistics needed for health policy formulation. § Policy research and analysis § Lack of monitoring and evaluation capacity in the area of health policies (Evaluation is crucial for policy improvement or policy termination)

Challenges Facing HHC and policy implementation § High turnover of Governments which affect implementation § Week representation of private sector. § Convening stakeholders § Lack of capacity on leadership which is necessary to resolve the conflict of interest regarding policy design and implementation. § low motivation or commitment due to different priorities, lack of incentives, and limited resources.

Reasons of Policy failure can occur as a result of: Ø bad execution Ø bad policy Ø bad luck. • Ineffective implementation will be viewed by policy-makers as bad execution or bad luck. • policy-makers don’t admit that the policy itself was defective or bad.

Reasons of Policy failure Ø Policy failure or an implementation gap can occur when policy is imposed from the centre with no thought given to how it might be perceived or received at local level. Ø A balance between the bottom up and top down approaches to policy and action is often necessary. Ø policy could be modified or adapted in advance of its implementation.

Reasons of Policy failure Ø Implementation should involve a process of interaction between organizations whose members may have different values, perspectives and priorities. Ø If policy is to be successfully implemented then those who have responsibility for its implementation should be involved in its design.

Thank you