Primary Health Care Provision in Jordan Summary and

Primary Health Care Provision in Jordan: Summary and Update Fadia Hasna Ph. D, November 2006

Jordan Governorates Syria Iraq West Bank Saudi Arabia

A country in demographic and fertility transition • • • 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 1990 s, 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 • • • 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 80 s; 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 • 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: 1. 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. 2. 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. 3. Facility development by upgrading and/or expanding the existing health centers and hospitals, and building, equipping and computerization of new facilities as needed. 4. 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. 5. 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 Primary Peripheral Health Centers MCH Centers Dental Clinics 57 368 238 385 274 47 333 265 345 237

Discrepancy in Utilization Capital/ Badia (source MOH) • • P R E N A T A L • Average Number of Prenatal Visits • • Directorates: [Capital] All Reported Months Years: [2006] 2006 2, 569 9, 156 • Average Number of Prenatal Visits Directorates: [North Badih] All Reported Months Years: [2006] • Year New Recur (New+Recur)/New • P R E N A T A L • • 4. 56 Year New Recur (New+Recur)/New • 2006 221 532 3. 41

Tetanus Immunization • P R E N A T A L • % Pregnant Women Tetanus Immunized • • • % Pregnant Women Tetanus Immunized • Directorates: [Capital] • Directorates: [Mafraq] • All Reported Months • Years: [2006] • Year TT_2 TT_3 TT_4 TT_5 New % (TT_2+TT_3+TT_4+TT_5)/New • 2006 549 337 228 130 2, 569 48. 42 • 2006 46 34 512 11 18. 75 5

Comprehensive Primary Health Care Centers CPHCCs: Research Findings • • • 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 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 Mo. H maintain that the Mo. H 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 1. 2. 3. 4. 5. 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 6. Al Manara Health Center/Amman 7. 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 Health. Center/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 1. • 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. • Availability of other government and private facilities makes it difficult to assess whether client need is underserved at the primary health care level. • Figures for postpartum care and family planning are consistently and significantly lower than antenatal care; inequitable utilization of services by women • Consequently, the health risk for newborns and their mothers is increased and • opportunities that have proven effective for introducing family planning counseling are missed. • IUD services, although requested, were not available (limited method choice). Solution : IUD insertion unit established in 2001 • Awareness raising campaign focusing on the significance and availability of family planning and particularly IUD services in the center using: • - Home visits • - Counseling clients about the services of the center - Educational sessions for the local community

PHCI: Achievements and Lessons Learnt 3. 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. • Raise the awareness of pregnant women about the importance of care in the postpartum period, • 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: • - Breastfeeding and its benefits to both mother and • infant • - The importance of antenatal and postpartum • nutrition • - Maternal and infant postpartum complications • - Maternal and infant postpartum personal hygiene • - 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 • 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. • 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. 6. 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 5. Training nursing personnel 6. 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 • 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. 7. Improving client flow in the clinics 8. Strengthening health education • 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) • • • 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.