primary health care provision in jordan: summary and update fadia hasna phd, november 2006
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Primary Health Care Primary Health Care Provision in Jordan Provision in Jordan
Summary and UpdateSummary and UpdateFadia Hasna PhD November Fadia Hasna PhD November
20062006
Jordan GovernoratesJordan GovernoratesSyria
Saudi Arabia
Iraq
West Bank
A country in demographic and A country in demographic and fertility transitionfertility transition
bull Over the next 50 years Jordanrsquos demographics will change dramatically ndash This will pose great challenges for the country (resources and services)
bull The countryrsquos 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 ldquoDemographic Transition and Economic Opportunity The Case of Jordanrdquo April 2001)
bull Fertility declines in Jordan have contributed to slowing the population growth rate down to 32 percent in the second half of the 1990s and to 28 percent in 2002(JPFHS 2002)
bull The urban population increased by 14 percent between 1980 and 1994 increasing from 70 to 79 percent (JPFHS 2002)
bull Results of the 1994 census indicate that the age structure of the population has changed considerably since 1979 ndash the result of changes in fertility mortality and migration dynamics
bull 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 EffortsPopulation and Development Effortsbull 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
bull 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
bull 1996 The NPC created the final national population strategy for Jordan which was approved by thecabinet in 1996 and was updated in 2000
bull 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
bull 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 StrategyNational Health Strategybull 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
bull Objectives of period 2002-20051 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 andor 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
ChallengesChallenges
bull 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
bull 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
bull Less than fully functional public health systemsbull An unmet demand for high quality maternal - child health care
services and information bull A significant increase in the prevalence of chronic diseases
MOH Structure for PHC MOH Structure for PHC PROVISIONPROVISION
Health Centers in MOH 2000-2005Health Centers in MOH 2000-2005
Type
2005
Comprehensive Health Centers
Primary Health Centers
Peripheral Health Centers
MCH Centers
Dental Clinics
57368238385274
200047333265345237
Discrepancy in Utilization Capital Discrepancy in Utilization Capital Badia (source MOH)Badia (source MOH)
bull P R E N A T A L
bull
bull Average Number of Prenatal Visits
bull
bull Directorates [Capital]
bull All Reported Months
bull Years [2006]
bull Year New Recur (New+Recur)New
bull 2006 2569 9156 456
bull P R E N A T A L
bull
bull Average Number of Prenatal Visits
bull
bull Directorates [North Badih]
bull All Reported Months
bull Years [2006]
bull Year New Recur (New+Recur)New
bull 2006 221 532 341
Tetanus ImmunizationTetanus Immunization bull P R E N A T A L
bull
bull Pregnant Women Tetanus Immunized
bull
bull Directorates [Capital]
bull All Reported Months
bull Years [2006]
bull Year TT_2 TT_3 TT_4 TT_5 New
(TT_2+TT_3+TT_4+TT_5)New
bull 2006 549 337 228130 2569 4842
bull P R E N A T A L
bull
bull Pregnant Women Tetanus Immunized
bull
bull Directorates [Mafraq]
bull All Reported Months
bull Years [2006]
bull Year TT_2 TT_3 TT_4 TT_5 New
(TT_2+TT_3+TT_4+TT_5)New
bull 2006 46 34 115 512 1875
Comprehensive Primary Health Care Centers CPHCCs Comprehensive Primary Health Care Centers CPHCCs Research FindingsResearch Findings
bull Staffed by general medical practitioners nurses midwives dentists administrative support personnel and a limited number of diagnostic technicians
bull Role of rural nurses in Jordan (Francis Nawafleh and Chapman 2005) showedbull Work of nurses task orientated and directed by the physicians bull Nursing staff were predominantly practical and aide nurses who were recruited
locally bull 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
bull The nurses did not engage with the community to promote health issues bull Dialogue with patients was limited to directions related to the therapy being
initiated bull Nurses had little understanding of contemporary health issues and demonstrated
a lack of awareness of lsquosafe practicersquo(Francis Nawafleh and Chapman 2005)bull The nursesrsquo roles traditionally are curative in nature and involve direct patient
care (Nahas Nour ampAl-Nobani 1999 Haddad 2002)bull Most nurses have been trainededucated 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 RecommendationsChallenges and Recommendations
bull 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
bull Recommendations Resources be directed toward improving the capacity of the CPHCCs and access to education training and professional development
bull 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 non-desirable areas (Alrai 2003
Policy and Health Care System Reform Policy and Health Care System Reform Directives in Partnership with Funding Directives in Partnership with Funding
AgenciesAgenciesAdopt a more competitive legal and regulatory framework for the health
sector by 1 Heath insurance reforms2 Decentralization of hospitals3 Development of systems for continuous medical education4 System of relevant health provider incentives5 Better integration of on-going primary health services strategies
and programs that prevent and treat chronic diseases6 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 ProjectPrimary Health Care Initiatives Project
bull 380 PHC clinics
bull Renovation and provision of furniture and specialized medical equipment
bull Clinical training of service providers
bull Establishment of performance improvement review systems
bull Improvement of the management information system
Participating Teams SouthParticipating Teams South
1 Al Amira Rahmeh Health Center Marsquoan2 Al Rabbeh Al Shamel Health Center Kerak3 Mursquotah Health Center Kerak4 Majra Health Center Kerak5 Al Mazar Health CenterKerak6 Emree Health CenterKerak7 Al Adnanyeh Health CenterKerak8 Al-Amira Basmah Health CenterAqaba9 Al Khazan Health CenterAqaba10Al Baldah Al Qadimah Health CenterAqaba11Al Aqaba Health CenterAqaba12Al Qadissyeh Health CenterTafileh13Bassirah Health CenterTafileh14Ein Al-Baida Health CenterTafileh15Al Tafileh Al-Shamel Health CenterTafileh16Al Hassa Health CenterTafileh
CentralCentral
1 Al Jofeh Health CenterBalqa2 Deir Allah Health CenterBalqa3 Al-Salalem Health CenterBalqa4 Al Jreineh Health CenterMadaba5 Al-Zarqarsquo Al-Jadidah Health
CenterZarqa6 Al Manara Health CenterAmman7 Al Qweismeh Health CenterAmman
NorthNorth
1 Al Manshieh Health CenterIrbid2 Al-Razi Health CenterIrbid3 Eidoun Health CenterIrbid4 Beit Eides Health CenterIrbid5 Huwara Health CenterIrbid6 Um-Qais HealthCenterIrbid7 Hai Al-Hussein Health CenterMafrak8 Rawdat Al-Amirah Basmah Health CenterMafrak9 Al Amir Hasan Health CenterAjloun10Jerash Health CenterJerash11Souf Health CenterJerash
Primary Health Care Initiatives Primary Health Care Initiatives Project USAID and MOH 1994Project 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 1048766 Seventy Quality Assurance Coordinators are facilitating a quality improvement process at the health centers
3 1048766 Twelve research teams were prepared to study and disseminate findings on clinical and management issues
4 1048766 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 1048766 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 1048766 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 PHCI Achievements and Lessons LearntLearnt
1 Building effective referral systemsbull 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 importantCounseling 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 LearntPHCI Achievements and Lessons Learnt2 Reproductive health utilizationProblem The primary health care system in Jordan has not established a calculation
for determining an adequate reproductive health service utilization rate bull Availability of other government and private facilities makes it difficult to assess
whether client need is underserved at the primary health care levelbull Figures for postpartum care and family planning are consistently and significantly
lower than antenatal care inequitable utilization of services by womenbull Consequently the health risk for newborns and their mothers is increased andbull opportunities that have proven effective for introducing family planning
counseling are missedbull IUD servicesalthough requested were not available (limited method choice)Solution IUD insertion unit established in 2001bull Awareness raising campaign focusing on the significance and availability of
family planning and particularly IUD services in the center usingbull - Home visitsbull - Counseling clients about the services of the center
- Educational sessions for the local community
PHCI Achievements and Lessons LearntPHCI Achievements and Lessons Learnt3 Increasing post-partum care utilizationProblem Low post partum care utilization Clients are not aware of the need for postpartum careSolution Increase utilization by1048766 Promote awareness of postpartum services in the community1048766 Inform all female patients especially MCH clients about available postpartum services1048766 Create a brochure for women containing information about maternal care1048766 Develop a register to log the number of expectant mothers their addresses and expected date of
delivery to enable follow-up1048766 Provide counseling about postpartum services during antenatal services1048766 Contact women who missed their postpartum appointment by phone and home visitsbull Raise the awareness of pregnant women about the importance of care in the postpartum
periodbull The target group was pregnant third trimester women 1048766 Recording the names of all target-group clients and their expected delivery date to enable follow up1048766 Providing and documenting health education messages delivered by physician and MCH staff
coveringbull - Breastfeeding and its benefits to both mother andbull infantbull - The importance of antenatal and postpartumbull nutritionbull - Maternal and infant postpartum complicationsbull - Maternal and infant postpartum personal hygienebull - Counseling on family planning
PHCI Chronic Illness-Compliance PHCI Chronic Illness-Compliance with Standardswith Standards
4 Prevalence of hypertension in Jordan among those over 25 is 318 while diabetes accounts for 68 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 diabetesUncontrolled diabetesbull 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 uncontrolledbull Solution 1 Define an overall strategy to include specific interventions and a monitoring plan2 Explain to staff the link between applying standards and measuring fasting blood sugar
levels to see results3 Provide the protocols4 Train 3 physicians and 8 nurses on implementing the protocols and completing the
follow up chart5 Discuss monitoring results during the QA team meetings6 Monitor results of Blood Sugar fasting for individual patients for a period of 6
months and prepare reports on results7 Document the percentage of controlled and uncontrolled patients on a monthly basis8 Mark the records of patients with readings higher than 180 to refer them for intensive
counseling9 Report the results on the QA Coordinator monthly reports
PHCIPHCI5 Training nursing personnel6 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 bull Lessons A combination of conducting training assigning responsibility and providing quality
services facilitates introduction and maintenance of new programs1048766 A comprehensive program of promotion education and quality service can increase awareness and
demand for the service1048766 Screening programs can successfully detect new cases1048766 Screening programs provide an opportunity for introducing other relevant health messages for
example breastfeeding explanations were included during the screening process7 Improving client flow in the clinics8 Strengthening health educationbull Problem Staff were often unprepared to deliver a lecture did not adequately plan for them
and had poor presentation skills1048766 Promotion of health education sessions was ineffective1048766 Client needs for specific health information were not surveyed
Health Systems Strengthening Health Systems Strengthening Project (HSSP)Project (HSSP)
bull 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
bull 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
bull Objectives ndash Improve the quality of health care servicesndash Develop and implement certification and accreditation systems for health care
facilities and service providersndash Computerize the health management information system networksndash Expand the health clinicsrsquo outreach to their local communities ndash Improve safe motherhood and neonatal health care related services at primary
health care centers and hospitalsndash Renovate and upgrade up to 28 hospitals and 32 primary health clinics belonging
to the Ministry of Health and the Royal Medical Services
Jordan GovernoratesJordan GovernoratesSyria
Saudi Arabia
Iraq
West Bank
A country in demographic and A country in demographic and fertility transitionfertility transition
bull Over the next 50 years Jordanrsquos demographics will change dramatically ndash This will pose great challenges for the country (resources and services)
bull The countryrsquos 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 ldquoDemographic Transition and Economic Opportunity The Case of Jordanrdquo April 2001)
bull Fertility declines in Jordan have contributed to slowing the population growth rate down to 32 percent in the second half of the 1990s and to 28 percent in 2002(JPFHS 2002)
bull The urban population increased by 14 percent between 1980 and 1994 increasing from 70 to 79 percent (JPFHS 2002)
bull Results of the 1994 census indicate that the age structure of the population has changed considerably since 1979 ndash the result of changes in fertility mortality and migration dynamics
bull 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 EffortsPopulation and Development Effortsbull 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
bull 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
bull 1996 The NPC created the final national population strategy for Jordan which was approved by thecabinet in 1996 and was updated in 2000
bull 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
bull 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 StrategyNational Health Strategybull 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
bull Objectives of period 2002-20051 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 andor 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
ChallengesChallenges
bull 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
bull 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
bull Less than fully functional public health systemsbull An unmet demand for high quality maternal - child health care
services and information bull A significant increase in the prevalence of chronic diseases
MOH Structure for PHC MOH Structure for PHC PROVISIONPROVISION
Health Centers in MOH 2000-2005Health Centers in MOH 2000-2005
Type
2005
Comprehensive Health Centers
Primary Health Centers
Peripheral Health Centers
MCH Centers
Dental Clinics
57368238385274
200047333265345237
Discrepancy in Utilization Capital Discrepancy in Utilization Capital Badia (source MOH)Badia (source MOH)
bull P R E N A T A L
bull
bull Average Number of Prenatal Visits
bull
bull Directorates [Capital]
bull All Reported Months
bull Years [2006]
bull Year New Recur (New+Recur)New
bull 2006 2569 9156 456
bull P R E N A T A L
bull
bull Average Number of Prenatal Visits
bull
bull Directorates [North Badih]
bull All Reported Months
bull Years [2006]
bull Year New Recur (New+Recur)New
bull 2006 221 532 341
Tetanus ImmunizationTetanus Immunization bull P R E N A T A L
bull
bull Pregnant Women Tetanus Immunized
bull
bull Directorates [Capital]
bull All Reported Months
bull Years [2006]
bull Year TT_2 TT_3 TT_4 TT_5 New
(TT_2+TT_3+TT_4+TT_5)New
bull 2006 549 337 228130 2569 4842
bull P R E N A T A L
bull
bull Pregnant Women Tetanus Immunized
bull
bull Directorates [Mafraq]
bull All Reported Months
bull Years [2006]
bull Year TT_2 TT_3 TT_4 TT_5 New
(TT_2+TT_3+TT_4+TT_5)New
bull 2006 46 34 115 512 1875
Comprehensive Primary Health Care Centers CPHCCs Comprehensive Primary Health Care Centers CPHCCs Research FindingsResearch Findings
bull Staffed by general medical practitioners nurses midwives dentists administrative support personnel and a limited number of diagnostic technicians
bull Role of rural nurses in Jordan (Francis Nawafleh and Chapman 2005) showedbull Work of nurses task orientated and directed by the physicians bull Nursing staff were predominantly practical and aide nurses who were recruited
locally bull 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
bull The nurses did not engage with the community to promote health issues bull Dialogue with patients was limited to directions related to the therapy being
initiated bull Nurses had little understanding of contemporary health issues and demonstrated
a lack of awareness of lsquosafe practicersquo(Francis Nawafleh and Chapman 2005)bull The nursesrsquo roles traditionally are curative in nature and involve direct patient
care (Nahas Nour ampAl-Nobani 1999 Haddad 2002)bull Most nurses have been trainededucated 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 RecommendationsChallenges and Recommendations
bull 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
bull Recommendations Resources be directed toward improving the capacity of the CPHCCs and access to education training and professional development
bull 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 non-desirable areas (Alrai 2003
Policy and Health Care System Reform Policy and Health Care System Reform Directives in Partnership with Funding Directives in Partnership with Funding
AgenciesAgenciesAdopt a more competitive legal and regulatory framework for the health
sector by 1 Heath insurance reforms2 Decentralization of hospitals3 Development of systems for continuous medical education4 System of relevant health provider incentives5 Better integration of on-going primary health services strategies
and programs that prevent and treat chronic diseases6 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 ProjectPrimary Health Care Initiatives Project
bull 380 PHC clinics
bull Renovation and provision of furniture and specialized medical equipment
bull Clinical training of service providers
bull Establishment of performance improvement review systems
bull Improvement of the management information system
Participating Teams SouthParticipating Teams South
1 Al Amira Rahmeh Health Center Marsquoan2 Al Rabbeh Al Shamel Health Center Kerak3 Mursquotah Health Center Kerak4 Majra Health Center Kerak5 Al Mazar Health CenterKerak6 Emree Health CenterKerak7 Al Adnanyeh Health CenterKerak8 Al-Amira Basmah Health CenterAqaba9 Al Khazan Health CenterAqaba10Al Baldah Al Qadimah Health CenterAqaba11Al Aqaba Health CenterAqaba12Al Qadissyeh Health CenterTafileh13Bassirah Health CenterTafileh14Ein Al-Baida Health CenterTafileh15Al Tafileh Al-Shamel Health CenterTafileh16Al Hassa Health CenterTafileh
CentralCentral
1 Al Jofeh Health CenterBalqa2 Deir Allah Health CenterBalqa3 Al-Salalem Health CenterBalqa4 Al Jreineh Health CenterMadaba5 Al-Zarqarsquo Al-Jadidah Health
CenterZarqa6 Al Manara Health CenterAmman7 Al Qweismeh Health CenterAmman
NorthNorth
1 Al Manshieh Health CenterIrbid2 Al-Razi Health CenterIrbid3 Eidoun Health CenterIrbid4 Beit Eides Health CenterIrbid5 Huwara Health CenterIrbid6 Um-Qais HealthCenterIrbid7 Hai Al-Hussein Health CenterMafrak8 Rawdat Al-Amirah Basmah Health CenterMafrak9 Al Amir Hasan Health CenterAjloun10Jerash Health CenterJerash11Souf Health CenterJerash
Primary Health Care Initiatives Primary Health Care Initiatives Project USAID and MOH 1994Project 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 1048766 Seventy Quality Assurance Coordinators are facilitating a quality improvement process at the health centers
3 1048766 Twelve research teams were prepared to study and disseminate findings on clinical and management issues
4 1048766 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 1048766 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 1048766 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 PHCI Achievements and Lessons LearntLearnt
1 Building effective referral systemsbull 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 importantCounseling 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 LearntPHCI Achievements and Lessons Learnt2 Reproductive health utilizationProblem The primary health care system in Jordan has not established a calculation
for determining an adequate reproductive health service utilization rate bull Availability of other government and private facilities makes it difficult to assess
whether client need is underserved at the primary health care levelbull Figures for postpartum care and family planning are consistently and significantly
lower than antenatal care inequitable utilization of services by womenbull Consequently the health risk for newborns and their mothers is increased andbull opportunities that have proven effective for introducing family planning
counseling are missedbull IUD servicesalthough requested were not available (limited method choice)Solution IUD insertion unit established in 2001bull Awareness raising campaign focusing on the significance and availability of
family planning and particularly IUD services in the center usingbull - Home visitsbull - Counseling clients about the services of the center
- Educational sessions for the local community
PHCI Achievements and Lessons LearntPHCI Achievements and Lessons Learnt3 Increasing post-partum care utilizationProblem Low post partum care utilization Clients are not aware of the need for postpartum careSolution Increase utilization by1048766 Promote awareness of postpartum services in the community1048766 Inform all female patients especially MCH clients about available postpartum services1048766 Create a brochure for women containing information about maternal care1048766 Develop a register to log the number of expectant mothers their addresses and expected date of
delivery to enable follow-up1048766 Provide counseling about postpartum services during antenatal services1048766 Contact women who missed their postpartum appointment by phone and home visitsbull Raise the awareness of pregnant women about the importance of care in the postpartum
periodbull The target group was pregnant third trimester women 1048766 Recording the names of all target-group clients and their expected delivery date to enable follow up1048766 Providing and documenting health education messages delivered by physician and MCH staff
coveringbull - Breastfeeding and its benefits to both mother andbull infantbull - The importance of antenatal and postpartumbull nutritionbull - Maternal and infant postpartum complicationsbull - Maternal and infant postpartum personal hygienebull - Counseling on family planning
PHCI Chronic Illness-Compliance PHCI Chronic Illness-Compliance with Standardswith Standards
4 Prevalence of hypertension in Jordan among those over 25 is 318 while diabetes accounts for 68 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 diabetesUncontrolled diabetesbull 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 uncontrolledbull Solution 1 Define an overall strategy to include specific interventions and a monitoring plan2 Explain to staff the link between applying standards and measuring fasting blood sugar
levels to see results3 Provide the protocols4 Train 3 physicians and 8 nurses on implementing the protocols and completing the
follow up chart5 Discuss monitoring results during the QA team meetings6 Monitor results of Blood Sugar fasting for individual patients for a period of 6
months and prepare reports on results7 Document the percentage of controlled and uncontrolled patients on a monthly basis8 Mark the records of patients with readings higher than 180 to refer them for intensive
counseling9 Report the results on the QA Coordinator monthly reports
PHCIPHCI5 Training nursing personnel6 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 bull Lessons A combination of conducting training assigning responsibility and providing quality
services facilitates introduction and maintenance of new programs1048766 A comprehensive program of promotion education and quality service can increase awareness and
demand for the service1048766 Screening programs can successfully detect new cases1048766 Screening programs provide an opportunity for introducing other relevant health messages for
example breastfeeding explanations were included during the screening process7 Improving client flow in the clinics8 Strengthening health educationbull Problem Staff were often unprepared to deliver a lecture did not adequately plan for them
and had poor presentation skills1048766 Promotion of health education sessions was ineffective1048766 Client needs for specific health information were not surveyed
Health Systems Strengthening Health Systems Strengthening Project (HSSP)Project (HSSP)
bull 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
bull 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
bull Objectives ndash Improve the quality of health care servicesndash Develop and implement certification and accreditation systems for health care
facilities and service providersndash Computerize the health management information system networksndash Expand the health clinicsrsquo outreach to their local communities ndash Improve safe motherhood and neonatal health care related services at primary
health care centers and hospitalsndash Renovate and upgrade up to 28 hospitals and 32 primary health clinics belonging
to the Ministry of Health and the Royal Medical Services
A country in demographic and A country in demographic and fertility transitionfertility transition
bull Over the next 50 years Jordanrsquos demographics will change dramatically ndash This will pose great challenges for the country (resources and services)
bull The countryrsquos 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 ldquoDemographic Transition and Economic Opportunity The Case of Jordanrdquo April 2001)
bull Fertility declines in Jordan have contributed to slowing the population growth rate down to 32 percent in the second half of the 1990s and to 28 percent in 2002(JPFHS 2002)
bull The urban population increased by 14 percent between 1980 and 1994 increasing from 70 to 79 percent (JPFHS 2002)
bull Results of the 1994 census indicate that the age structure of the population has changed considerably since 1979 ndash the result of changes in fertility mortality and migration dynamics
bull 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 EffortsPopulation and Development Effortsbull 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
bull 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
bull 1996 The NPC created the final national population strategy for Jordan which was approved by thecabinet in 1996 and was updated in 2000
bull 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
bull 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 StrategyNational Health Strategybull 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
bull Objectives of period 2002-20051 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 andor 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
ChallengesChallenges
bull 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
bull 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
bull Less than fully functional public health systemsbull An unmet demand for high quality maternal - child health care
services and information bull A significant increase in the prevalence of chronic diseases
MOH Structure for PHC MOH Structure for PHC PROVISIONPROVISION
Health Centers in MOH 2000-2005Health Centers in MOH 2000-2005
Type
2005
Comprehensive Health Centers
Primary Health Centers
Peripheral Health Centers
MCH Centers
Dental Clinics
57368238385274
200047333265345237
Discrepancy in Utilization Capital Discrepancy in Utilization Capital Badia (source MOH)Badia (source MOH)
bull P R E N A T A L
bull
bull Average Number of Prenatal Visits
bull
bull Directorates [Capital]
bull All Reported Months
bull Years [2006]
bull Year New Recur (New+Recur)New
bull 2006 2569 9156 456
bull P R E N A T A L
bull
bull Average Number of Prenatal Visits
bull
bull Directorates [North Badih]
bull All Reported Months
bull Years [2006]
bull Year New Recur (New+Recur)New
bull 2006 221 532 341
Tetanus ImmunizationTetanus Immunization bull P R E N A T A L
bull
bull Pregnant Women Tetanus Immunized
bull
bull Directorates [Capital]
bull All Reported Months
bull Years [2006]
bull Year TT_2 TT_3 TT_4 TT_5 New
(TT_2+TT_3+TT_4+TT_5)New
bull 2006 549 337 228130 2569 4842
bull P R E N A T A L
bull
bull Pregnant Women Tetanus Immunized
bull
bull Directorates [Mafraq]
bull All Reported Months
bull Years [2006]
bull Year TT_2 TT_3 TT_4 TT_5 New
(TT_2+TT_3+TT_4+TT_5)New
bull 2006 46 34 115 512 1875
Comprehensive Primary Health Care Centers CPHCCs Comprehensive Primary Health Care Centers CPHCCs Research FindingsResearch Findings
bull Staffed by general medical practitioners nurses midwives dentists administrative support personnel and a limited number of diagnostic technicians
bull Role of rural nurses in Jordan (Francis Nawafleh and Chapman 2005) showedbull Work of nurses task orientated and directed by the physicians bull Nursing staff were predominantly practical and aide nurses who were recruited
locally bull 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
bull The nurses did not engage with the community to promote health issues bull Dialogue with patients was limited to directions related to the therapy being
initiated bull Nurses had little understanding of contemporary health issues and demonstrated
a lack of awareness of lsquosafe practicersquo(Francis Nawafleh and Chapman 2005)bull The nursesrsquo roles traditionally are curative in nature and involve direct patient
care (Nahas Nour ampAl-Nobani 1999 Haddad 2002)bull Most nurses have been trainededucated 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 RecommendationsChallenges and Recommendations
bull 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
bull Recommendations Resources be directed toward improving the capacity of the CPHCCs and access to education training and professional development
bull 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 non-desirable areas (Alrai 2003
Policy and Health Care System Reform Policy and Health Care System Reform Directives in Partnership with Funding Directives in Partnership with Funding
AgenciesAgenciesAdopt a more competitive legal and regulatory framework for the health
sector by 1 Heath insurance reforms2 Decentralization of hospitals3 Development of systems for continuous medical education4 System of relevant health provider incentives5 Better integration of on-going primary health services strategies
and programs that prevent and treat chronic diseases6 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 ProjectPrimary Health Care Initiatives Project
bull 380 PHC clinics
bull Renovation and provision of furniture and specialized medical equipment
bull Clinical training of service providers
bull Establishment of performance improvement review systems
bull Improvement of the management information system
Participating Teams SouthParticipating Teams South
1 Al Amira Rahmeh Health Center Marsquoan2 Al Rabbeh Al Shamel Health Center Kerak3 Mursquotah Health Center Kerak4 Majra Health Center Kerak5 Al Mazar Health CenterKerak6 Emree Health CenterKerak7 Al Adnanyeh Health CenterKerak8 Al-Amira Basmah Health CenterAqaba9 Al Khazan Health CenterAqaba10Al Baldah Al Qadimah Health CenterAqaba11Al Aqaba Health CenterAqaba12Al Qadissyeh Health CenterTafileh13Bassirah Health CenterTafileh14Ein Al-Baida Health CenterTafileh15Al Tafileh Al-Shamel Health CenterTafileh16Al Hassa Health CenterTafileh
CentralCentral
1 Al Jofeh Health CenterBalqa2 Deir Allah Health CenterBalqa3 Al-Salalem Health CenterBalqa4 Al Jreineh Health CenterMadaba5 Al-Zarqarsquo Al-Jadidah Health
CenterZarqa6 Al Manara Health CenterAmman7 Al Qweismeh Health CenterAmman
NorthNorth
1 Al Manshieh Health CenterIrbid2 Al-Razi Health CenterIrbid3 Eidoun Health CenterIrbid4 Beit Eides Health CenterIrbid5 Huwara Health CenterIrbid6 Um-Qais HealthCenterIrbid7 Hai Al-Hussein Health CenterMafrak8 Rawdat Al-Amirah Basmah Health CenterMafrak9 Al Amir Hasan Health CenterAjloun10Jerash Health CenterJerash11Souf Health CenterJerash
Primary Health Care Initiatives Primary Health Care Initiatives Project USAID and MOH 1994Project 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 1048766 Seventy Quality Assurance Coordinators are facilitating a quality improvement process at the health centers
3 1048766 Twelve research teams were prepared to study and disseminate findings on clinical and management issues
4 1048766 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 1048766 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 1048766 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 PHCI Achievements and Lessons LearntLearnt
1 Building effective referral systemsbull 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 importantCounseling 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 LearntPHCI Achievements and Lessons Learnt2 Reproductive health utilizationProblem The primary health care system in Jordan has not established a calculation
for determining an adequate reproductive health service utilization rate bull Availability of other government and private facilities makes it difficult to assess
whether client need is underserved at the primary health care levelbull Figures for postpartum care and family planning are consistently and significantly
lower than antenatal care inequitable utilization of services by womenbull Consequently the health risk for newborns and their mothers is increased andbull opportunities that have proven effective for introducing family planning
counseling are missedbull IUD servicesalthough requested were not available (limited method choice)Solution IUD insertion unit established in 2001bull Awareness raising campaign focusing on the significance and availability of
family planning and particularly IUD services in the center usingbull - Home visitsbull - Counseling clients about the services of the center
- Educational sessions for the local community
PHCI Achievements and Lessons LearntPHCI Achievements and Lessons Learnt3 Increasing post-partum care utilizationProblem Low post partum care utilization Clients are not aware of the need for postpartum careSolution Increase utilization by1048766 Promote awareness of postpartum services in the community1048766 Inform all female patients especially MCH clients about available postpartum services1048766 Create a brochure for women containing information about maternal care1048766 Develop a register to log the number of expectant mothers their addresses and expected date of
delivery to enable follow-up1048766 Provide counseling about postpartum services during antenatal services1048766 Contact women who missed their postpartum appointment by phone and home visitsbull Raise the awareness of pregnant women about the importance of care in the postpartum
periodbull The target group was pregnant third trimester women 1048766 Recording the names of all target-group clients and their expected delivery date to enable follow up1048766 Providing and documenting health education messages delivered by physician and MCH staff
coveringbull - Breastfeeding and its benefits to both mother andbull infantbull - The importance of antenatal and postpartumbull nutritionbull - Maternal and infant postpartum complicationsbull - Maternal and infant postpartum personal hygienebull - Counseling on family planning
PHCI Chronic Illness-Compliance PHCI Chronic Illness-Compliance with Standardswith Standards
4 Prevalence of hypertension in Jordan among those over 25 is 318 while diabetes accounts for 68 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 diabetesUncontrolled diabetesbull 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 uncontrolledbull Solution 1 Define an overall strategy to include specific interventions and a monitoring plan2 Explain to staff the link between applying standards and measuring fasting blood sugar
levels to see results3 Provide the protocols4 Train 3 physicians and 8 nurses on implementing the protocols and completing the
follow up chart5 Discuss monitoring results during the QA team meetings6 Monitor results of Blood Sugar fasting for individual patients for a period of 6
months and prepare reports on results7 Document the percentage of controlled and uncontrolled patients on a monthly basis8 Mark the records of patients with readings higher than 180 to refer them for intensive
counseling9 Report the results on the QA Coordinator monthly reports
PHCIPHCI5 Training nursing personnel6 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 bull Lessons A combination of conducting training assigning responsibility and providing quality
services facilitates introduction and maintenance of new programs1048766 A comprehensive program of promotion education and quality service can increase awareness and
demand for the service1048766 Screening programs can successfully detect new cases1048766 Screening programs provide an opportunity for introducing other relevant health messages for
example breastfeeding explanations were included during the screening process7 Improving client flow in the clinics8 Strengthening health educationbull Problem Staff were often unprepared to deliver a lecture did not adequately plan for them
and had poor presentation skills1048766 Promotion of health education sessions was ineffective1048766 Client needs for specific health information were not surveyed
Health Systems Strengthening Health Systems Strengthening Project (HSSP)Project (HSSP)
bull 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
bull 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
bull Objectives ndash Improve the quality of health care servicesndash Develop and implement certification and accreditation systems for health care
facilities and service providersndash Computerize the health management information system networksndash Expand the health clinicsrsquo outreach to their local communities ndash Improve safe motherhood and neonatal health care related services at primary
health care centers and hospitalsndash Renovate and upgrade up to 28 hospitals and 32 primary health clinics belonging
to the Ministry of Health and the Royal Medical Services
Population and Development EffortsPopulation and Development Effortsbull 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
bull 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
bull 1996 The NPC created the final national population strategy for Jordan which was approved by thecabinet in 1996 and was updated in 2000
bull 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
bull 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 StrategyNational Health Strategybull 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
bull Objectives of period 2002-20051 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 andor 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
ChallengesChallenges
bull 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
bull 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
bull Less than fully functional public health systemsbull An unmet demand for high quality maternal - child health care
services and information bull A significant increase in the prevalence of chronic diseases
MOH Structure for PHC MOH Structure for PHC PROVISIONPROVISION
Health Centers in MOH 2000-2005Health Centers in MOH 2000-2005
Type
2005
Comprehensive Health Centers
Primary Health Centers
Peripheral Health Centers
MCH Centers
Dental Clinics
57368238385274
200047333265345237
Discrepancy in Utilization Capital Discrepancy in Utilization Capital Badia (source MOH)Badia (source MOH)
bull P R E N A T A L
bull
bull Average Number of Prenatal Visits
bull
bull Directorates [Capital]
bull All Reported Months
bull Years [2006]
bull Year New Recur (New+Recur)New
bull 2006 2569 9156 456
bull P R E N A T A L
bull
bull Average Number of Prenatal Visits
bull
bull Directorates [North Badih]
bull All Reported Months
bull Years [2006]
bull Year New Recur (New+Recur)New
bull 2006 221 532 341
Tetanus ImmunizationTetanus Immunization bull P R E N A T A L
bull
bull Pregnant Women Tetanus Immunized
bull
bull Directorates [Capital]
bull All Reported Months
bull Years [2006]
bull Year TT_2 TT_3 TT_4 TT_5 New
(TT_2+TT_3+TT_4+TT_5)New
bull 2006 549 337 228130 2569 4842
bull P R E N A T A L
bull
bull Pregnant Women Tetanus Immunized
bull
bull Directorates [Mafraq]
bull All Reported Months
bull Years [2006]
bull Year TT_2 TT_3 TT_4 TT_5 New
(TT_2+TT_3+TT_4+TT_5)New
bull 2006 46 34 115 512 1875
Comprehensive Primary Health Care Centers CPHCCs Comprehensive Primary Health Care Centers CPHCCs Research FindingsResearch Findings
bull Staffed by general medical practitioners nurses midwives dentists administrative support personnel and a limited number of diagnostic technicians
bull Role of rural nurses in Jordan (Francis Nawafleh and Chapman 2005) showedbull Work of nurses task orientated and directed by the physicians bull Nursing staff were predominantly practical and aide nurses who were recruited
locally bull 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
bull The nurses did not engage with the community to promote health issues bull Dialogue with patients was limited to directions related to the therapy being
initiated bull Nurses had little understanding of contemporary health issues and demonstrated
a lack of awareness of lsquosafe practicersquo(Francis Nawafleh and Chapman 2005)bull The nursesrsquo roles traditionally are curative in nature and involve direct patient
care (Nahas Nour ampAl-Nobani 1999 Haddad 2002)bull Most nurses have been trainededucated 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 RecommendationsChallenges and Recommendations
bull 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
bull Recommendations Resources be directed toward improving the capacity of the CPHCCs and access to education training and professional development
bull 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 non-desirable areas (Alrai 2003
Policy and Health Care System Reform Policy and Health Care System Reform Directives in Partnership with Funding Directives in Partnership with Funding
AgenciesAgenciesAdopt a more competitive legal and regulatory framework for the health
sector by 1 Heath insurance reforms2 Decentralization of hospitals3 Development of systems for continuous medical education4 System of relevant health provider incentives5 Better integration of on-going primary health services strategies
and programs that prevent and treat chronic diseases6 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 ProjectPrimary Health Care Initiatives Project
bull 380 PHC clinics
bull Renovation and provision of furniture and specialized medical equipment
bull Clinical training of service providers
bull Establishment of performance improvement review systems
bull Improvement of the management information system
Participating Teams SouthParticipating Teams South
1 Al Amira Rahmeh Health Center Marsquoan2 Al Rabbeh Al Shamel Health Center Kerak3 Mursquotah Health Center Kerak4 Majra Health Center Kerak5 Al Mazar Health CenterKerak6 Emree Health CenterKerak7 Al Adnanyeh Health CenterKerak8 Al-Amira Basmah Health CenterAqaba9 Al Khazan Health CenterAqaba10Al Baldah Al Qadimah Health CenterAqaba11Al Aqaba Health CenterAqaba12Al Qadissyeh Health CenterTafileh13Bassirah Health CenterTafileh14Ein Al-Baida Health CenterTafileh15Al Tafileh Al-Shamel Health CenterTafileh16Al Hassa Health CenterTafileh
CentralCentral
1 Al Jofeh Health CenterBalqa2 Deir Allah Health CenterBalqa3 Al-Salalem Health CenterBalqa4 Al Jreineh Health CenterMadaba5 Al-Zarqarsquo Al-Jadidah Health
CenterZarqa6 Al Manara Health CenterAmman7 Al Qweismeh Health CenterAmman
NorthNorth
1 Al Manshieh Health CenterIrbid2 Al-Razi Health CenterIrbid3 Eidoun Health CenterIrbid4 Beit Eides Health CenterIrbid5 Huwara Health CenterIrbid6 Um-Qais HealthCenterIrbid7 Hai Al-Hussein Health CenterMafrak8 Rawdat Al-Amirah Basmah Health CenterMafrak9 Al Amir Hasan Health CenterAjloun10Jerash Health CenterJerash11Souf Health CenterJerash
Primary Health Care Initiatives Primary Health Care Initiatives Project USAID and MOH 1994Project 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 1048766 Seventy Quality Assurance Coordinators are facilitating a quality improvement process at the health centers
3 1048766 Twelve research teams were prepared to study and disseminate findings on clinical and management issues
4 1048766 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 1048766 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 1048766 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 PHCI Achievements and Lessons LearntLearnt
1 Building effective referral systemsbull 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 importantCounseling 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 LearntPHCI Achievements and Lessons Learnt2 Reproductive health utilizationProblem The primary health care system in Jordan has not established a calculation
for determining an adequate reproductive health service utilization rate bull Availability of other government and private facilities makes it difficult to assess
whether client need is underserved at the primary health care levelbull Figures for postpartum care and family planning are consistently and significantly
lower than antenatal care inequitable utilization of services by womenbull Consequently the health risk for newborns and their mothers is increased andbull opportunities that have proven effective for introducing family planning
counseling are missedbull IUD servicesalthough requested were not available (limited method choice)Solution IUD insertion unit established in 2001bull Awareness raising campaign focusing on the significance and availability of
family planning and particularly IUD services in the center usingbull - Home visitsbull - Counseling clients about the services of the center
- Educational sessions for the local community
PHCI Achievements and Lessons LearntPHCI Achievements and Lessons Learnt3 Increasing post-partum care utilizationProblem Low post partum care utilization Clients are not aware of the need for postpartum careSolution Increase utilization by1048766 Promote awareness of postpartum services in the community1048766 Inform all female patients especially MCH clients about available postpartum services1048766 Create a brochure for women containing information about maternal care1048766 Develop a register to log the number of expectant mothers their addresses and expected date of
delivery to enable follow-up1048766 Provide counseling about postpartum services during antenatal services1048766 Contact women who missed their postpartum appointment by phone and home visitsbull Raise the awareness of pregnant women about the importance of care in the postpartum
periodbull The target group was pregnant third trimester women 1048766 Recording the names of all target-group clients and their expected delivery date to enable follow up1048766 Providing and documenting health education messages delivered by physician and MCH staff
coveringbull - Breastfeeding and its benefits to both mother andbull infantbull - The importance of antenatal and postpartumbull nutritionbull - Maternal and infant postpartum complicationsbull - Maternal and infant postpartum personal hygienebull - Counseling on family planning
PHCI Chronic Illness-Compliance PHCI Chronic Illness-Compliance with Standardswith Standards
4 Prevalence of hypertension in Jordan among those over 25 is 318 while diabetes accounts for 68 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 diabetesUncontrolled diabetesbull 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 uncontrolledbull Solution 1 Define an overall strategy to include specific interventions and a monitoring plan2 Explain to staff the link between applying standards and measuring fasting blood sugar
levels to see results3 Provide the protocols4 Train 3 physicians and 8 nurses on implementing the protocols and completing the
follow up chart5 Discuss monitoring results during the QA team meetings6 Monitor results of Blood Sugar fasting for individual patients for a period of 6
months and prepare reports on results7 Document the percentage of controlled and uncontrolled patients on a monthly basis8 Mark the records of patients with readings higher than 180 to refer them for intensive
counseling9 Report the results on the QA Coordinator monthly reports
PHCIPHCI5 Training nursing personnel6 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 bull Lessons A combination of conducting training assigning responsibility and providing quality
services facilitates introduction and maintenance of new programs1048766 A comprehensive program of promotion education and quality service can increase awareness and
demand for the service1048766 Screening programs can successfully detect new cases1048766 Screening programs provide an opportunity for introducing other relevant health messages for
example breastfeeding explanations were included during the screening process7 Improving client flow in the clinics8 Strengthening health educationbull Problem Staff were often unprepared to deliver a lecture did not adequately plan for them
and had poor presentation skills1048766 Promotion of health education sessions was ineffective1048766 Client needs for specific health information were not surveyed
Health Systems Strengthening Health Systems Strengthening Project (HSSP)Project (HSSP)
bull 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
bull 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
bull Objectives ndash Improve the quality of health care servicesndash Develop and implement certification and accreditation systems for health care
facilities and service providersndash Computerize the health management information system networksndash Expand the health clinicsrsquo outreach to their local communities ndash Improve safe motherhood and neonatal health care related services at primary
health care centers and hospitalsndash Renovate and upgrade up to 28 hospitals and 32 primary health clinics belonging
to the Ministry of Health and the Royal Medical Services
National Health StrategyNational Health Strategybull 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
bull Objectives of period 2002-20051 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 andor 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
ChallengesChallenges
bull 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
bull 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
bull Less than fully functional public health systemsbull An unmet demand for high quality maternal - child health care
services and information bull A significant increase in the prevalence of chronic diseases
MOH Structure for PHC MOH Structure for PHC PROVISIONPROVISION
Health Centers in MOH 2000-2005Health Centers in MOH 2000-2005
Type
2005
Comprehensive Health Centers
Primary Health Centers
Peripheral Health Centers
MCH Centers
Dental Clinics
57368238385274
200047333265345237
Discrepancy in Utilization Capital Discrepancy in Utilization Capital Badia (source MOH)Badia (source MOH)
bull P R E N A T A L
bull
bull Average Number of Prenatal Visits
bull
bull Directorates [Capital]
bull All Reported Months
bull Years [2006]
bull Year New Recur (New+Recur)New
bull 2006 2569 9156 456
bull P R E N A T A L
bull
bull Average Number of Prenatal Visits
bull
bull Directorates [North Badih]
bull All Reported Months
bull Years [2006]
bull Year New Recur (New+Recur)New
bull 2006 221 532 341
Tetanus ImmunizationTetanus Immunization bull P R E N A T A L
bull
bull Pregnant Women Tetanus Immunized
bull
bull Directorates [Capital]
bull All Reported Months
bull Years [2006]
bull Year TT_2 TT_3 TT_4 TT_5 New
(TT_2+TT_3+TT_4+TT_5)New
bull 2006 549 337 228130 2569 4842
bull P R E N A T A L
bull
bull Pregnant Women Tetanus Immunized
bull
bull Directorates [Mafraq]
bull All Reported Months
bull Years [2006]
bull Year TT_2 TT_3 TT_4 TT_5 New
(TT_2+TT_3+TT_4+TT_5)New
bull 2006 46 34 115 512 1875
Comprehensive Primary Health Care Centers CPHCCs Comprehensive Primary Health Care Centers CPHCCs Research FindingsResearch Findings
bull Staffed by general medical practitioners nurses midwives dentists administrative support personnel and a limited number of diagnostic technicians
bull Role of rural nurses in Jordan (Francis Nawafleh and Chapman 2005) showedbull Work of nurses task orientated and directed by the physicians bull Nursing staff were predominantly practical and aide nurses who were recruited
locally bull 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
bull The nurses did not engage with the community to promote health issues bull Dialogue with patients was limited to directions related to the therapy being
initiated bull Nurses had little understanding of contemporary health issues and demonstrated
a lack of awareness of lsquosafe practicersquo(Francis Nawafleh and Chapman 2005)bull The nursesrsquo roles traditionally are curative in nature and involve direct patient
care (Nahas Nour ampAl-Nobani 1999 Haddad 2002)bull Most nurses have been trainededucated 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 RecommendationsChallenges and Recommendations
bull 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
bull Recommendations Resources be directed toward improving the capacity of the CPHCCs and access to education training and professional development
bull 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 non-desirable areas (Alrai 2003
Policy and Health Care System Reform Policy and Health Care System Reform Directives in Partnership with Funding Directives in Partnership with Funding
AgenciesAgenciesAdopt a more competitive legal and regulatory framework for the health
sector by 1 Heath insurance reforms2 Decentralization of hospitals3 Development of systems for continuous medical education4 System of relevant health provider incentives5 Better integration of on-going primary health services strategies
and programs that prevent and treat chronic diseases6 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 ProjectPrimary Health Care Initiatives Project
bull 380 PHC clinics
bull Renovation and provision of furniture and specialized medical equipment
bull Clinical training of service providers
bull Establishment of performance improvement review systems
bull Improvement of the management information system
Participating Teams SouthParticipating Teams South
1 Al Amira Rahmeh Health Center Marsquoan2 Al Rabbeh Al Shamel Health Center Kerak3 Mursquotah Health Center Kerak4 Majra Health Center Kerak5 Al Mazar Health CenterKerak6 Emree Health CenterKerak7 Al Adnanyeh Health CenterKerak8 Al-Amira Basmah Health CenterAqaba9 Al Khazan Health CenterAqaba10Al Baldah Al Qadimah Health CenterAqaba11Al Aqaba Health CenterAqaba12Al Qadissyeh Health CenterTafileh13Bassirah Health CenterTafileh14Ein Al-Baida Health CenterTafileh15Al Tafileh Al-Shamel Health CenterTafileh16Al Hassa Health CenterTafileh
CentralCentral
1 Al Jofeh Health CenterBalqa2 Deir Allah Health CenterBalqa3 Al-Salalem Health CenterBalqa4 Al Jreineh Health CenterMadaba5 Al-Zarqarsquo Al-Jadidah Health
CenterZarqa6 Al Manara Health CenterAmman7 Al Qweismeh Health CenterAmman
NorthNorth
1 Al Manshieh Health CenterIrbid2 Al-Razi Health CenterIrbid3 Eidoun Health CenterIrbid4 Beit Eides Health CenterIrbid5 Huwara Health CenterIrbid6 Um-Qais HealthCenterIrbid7 Hai Al-Hussein Health CenterMafrak8 Rawdat Al-Amirah Basmah Health CenterMafrak9 Al Amir Hasan Health CenterAjloun10Jerash Health CenterJerash11Souf Health CenterJerash
Primary Health Care Initiatives Primary Health Care Initiatives Project USAID and MOH 1994Project 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 1048766 Seventy Quality Assurance Coordinators are facilitating a quality improvement process at the health centers
3 1048766 Twelve research teams were prepared to study and disseminate findings on clinical and management issues
4 1048766 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 1048766 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 1048766 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 PHCI Achievements and Lessons LearntLearnt
1 Building effective referral systemsbull 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 importantCounseling 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 LearntPHCI Achievements and Lessons Learnt2 Reproductive health utilizationProblem The primary health care system in Jordan has not established a calculation
for determining an adequate reproductive health service utilization rate bull Availability of other government and private facilities makes it difficult to assess
whether client need is underserved at the primary health care levelbull Figures for postpartum care and family planning are consistently and significantly
lower than antenatal care inequitable utilization of services by womenbull Consequently the health risk for newborns and their mothers is increased andbull opportunities that have proven effective for introducing family planning
counseling are missedbull IUD servicesalthough requested were not available (limited method choice)Solution IUD insertion unit established in 2001bull Awareness raising campaign focusing on the significance and availability of
family planning and particularly IUD services in the center usingbull - Home visitsbull - Counseling clients about the services of the center
- Educational sessions for the local community
PHCI Achievements and Lessons LearntPHCI Achievements and Lessons Learnt3 Increasing post-partum care utilizationProblem Low post partum care utilization Clients are not aware of the need for postpartum careSolution Increase utilization by1048766 Promote awareness of postpartum services in the community1048766 Inform all female patients especially MCH clients about available postpartum services1048766 Create a brochure for women containing information about maternal care1048766 Develop a register to log the number of expectant mothers their addresses and expected date of
delivery to enable follow-up1048766 Provide counseling about postpartum services during antenatal services1048766 Contact women who missed their postpartum appointment by phone and home visitsbull Raise the awareness of pregnant women about the importance of care in the postpartum
periodbull The target group was pregnant third trimester women 1048766 Recording the names of all target-group clients and their expected delivery date to enable follow up1048766 Providing and documenting health education messages delivered by physician and MCH staff
coveringbull - Breastfeeding and its benefits to both mother andbull infantbull - The importance of antenatal and postpartumbull nutritionbull - Maternal and infant postpartum complicationsbull - Maternal and infant postpartum personal hygienebull - Counseling on family planning
PHCI Chronic Illness-Compliance PHCI Chronic Illness-Compliance with Standardswith Standards
4 Prevalence of hypertension in Jordan among those over 25 is 318 while diabetes accounts for 68 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 diabetesUncontrolled diabetesbull 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 uncontrolledbull Solution 1 Define an overall strategy to include specific interventions and a monitoring plan2 Explain to staff the link between applying standards and measuring fasting blood sugar
levels to see results3 Provide the protocols4 Train 3 physicians and 8 nurses on implementing the protocols and completing the
follow up chart5 Discuss monitoring results during the QA team meetings6 Monitor results of Blood Sugar fasting for individual patients for a period of 6
months and prepare reports on results7 Document the percentage of controlled and uncontrolled patients on a monthly basis8 Mark the records of patients with readings higher than 180 to refer them for intensive
counseling9 Report the results on the QA Coordinator monthly reports
PHCIPHCI5 Training nursing personnel6 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 bull Lessons A combination of conducting training assigning responsibility and providing quality
services facilitates introduction and maintenance of new programs1048766 A comprehensive program of promotion education and quality service can increase awareness and
demand for the service1048766 Screening programs can successfully detect new cases1048766 Screening programs provide an opportunity for introducing other relevant health messages for
example breastfeeding explanations were included during the screening process7 Improving client flow in the clinics8 Strengthening health educationbull Problem Staff were often unprepared to deliver a lecture did not adequately plan for them
and had poor presentation skills1048766 Promotion of health education sessions was ineffective1048766 Client needs for specific health information were not surveyed
Health Systems Strengthening Health Systems Strengthening Project (HSSP)Project (HSSP)
bull 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
bull 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
bull Objectives ndash Improve the quality of health care servicesndash Develop and implement certification and accreditation systems for health care
facilities and service providersndash Computerize the health management information system networksndash Expand the health clinicsrsquo outreach to their local communities ndash Improve safe motherhood and neonatal health care related services at primary
health care centers and hospitalsndash Renovate and upgrade up to 28 hospitals and 32 primary health clinics belonging
to the Ministry of Health and the Royal Medical Services
ChallengesChallenges
bull 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
bull 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
bull Less than fully functional public health systemsbull An unmet demand for high quality maternal - child health care
services and information bull A significant increase in the prevalence of chronic diseases
MOH Structure for PHC MOH Structure for PHC PROVISIONPROVISION
Health Centers in MOH 2000-2005Health Centers in MOH 2000-2005
Type
2005
Comprehensive Health Centers
Primary Health Centers
Peripheral Health Centers
MCH Centers
Dental Clinics
57368238385274
200047333265345237
Discrepancy in Utilization Capital Discrepancy in Utilization Capital Badia (source MOH)Badia (source MOH)
bull P R E N A T A L
bull
bull Average Number of Prenatal Visits
bull
bull Directorates [Capital]
bull All Reported Months
bull Years [2006]
bull Year New Recur (New+Recur)New
bull 2006 2569 9156 456
bull P R E N A T A L
bull
bull Average Number of Prenatal Visits
bull
bull Directorates [North Badih]
bull All Reported Months
bull Years [2006]
bull Year New Recur (New+Recur)New
bull 2006 221 532 341
Tetanus ImmunizationTetanus Immunization bull P R E N A T A L
bull
bull Pregnant Women Tetanus Immunized
bull
bull Directorates [Capital]
bull All Reported Months
bull Years [2006]
bull Year TT_2 TT_3 TT_4 TT_5 New
(TT_2+TT_3+TT_4+TT_5)New
bull 2006 549 337 228130 2569 4842
bull P R E N A T A L
bull
bull Pregnant Women Tetanus Immunized
bull
bull Directorates [Mafraq]
bull All Reported Months
bull Years [2006]
bull Year TT_2 TT_3 TT_4 TT_5 New
(TT_2+TT_3+TT_4+TT_5)New
bull 2006 46 34 115 512 1875
Comprehensive Primary Health Care Centers CPHCCs Comprehensive Primary Health Care Centers CPHCCs Research FindingsResearch Findings
bull Staffed by general medical practitioners nurses midwives dentists administrative support personnel and a limited number of diagnostic technicians
bull Role of rural nurses in Jordan (Francis Nawafleh and Chapman 2005) showedbull Work of nurses task orientated and directed by the physicians bull Nursing staff were predominantly practical and aide nurses who were recruited
locally bull 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
bull The nurses did not engage with the community to promote health issues bull Dialogue with patients was limited to directions related to the therapy being
initiated bull Nurses had little understanding of contemporary health issues and demonstrated
a lack of awareness of lsquosafe practicersquo(Francis Nawafleh and Chapman 2005)bull The nursesrsquo roles traditionally are curative in nature and involve direct patient
care (Nahas Nour ampAl-Nobani 1999 Haddad 2002)bull Most nurses have been trainededucated 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 RecommendationsChallenges and Recommendations
bull 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
bull Recommendations Resources be directed toward improving the capacity of the CPHCCs and access to education training and professional development
bull 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 non-desirable areas (Alrai 2003
Policy and Health Care System Reform Policy and Health Care System Reform Directives in Partnership with Funding Directives in Partnership with Funding
AgenciesAgenciesAdopt a more competitive legal and regulatory framework for the health
sector by 1 Heath insurance reforms2 Decentralization of hospitals3 Development of systems for continuous medical education4 System of relevant health provider incentives5 Better integration of on-going primary health services strategies
and programs that prevent and treat chronic diseases6 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 ProjectPrimary Health Care Initiatives Project
bull 380 PHC clinics
bull Renovation and provision of furniture and specialized medical equipment
bull Clinical training of service providers
bull Establishment of performance improvement review systems
bull Improvement of the management information system
Participating Teams SouthParticipating Teams South
1 Al Amira Rahmeh Health Center Marsquoan2 Al Rabbeh Al Shamel Health Center Kerak3 Mursquotah Health Center Kerak4 Majra Health Center Kerak5 Al Mazar Health CenterKerak6 Emree Health CenterKerak7 Al Adnanyeh Health CenterKerak8 Al-Amira Basmah Health CenterAqaba9 Al Khazan Health CenterAqaba10Al Baldah Al Qadimah Health CenterAqaba11Al Aqaba Health CenterAqaba12Al Qadissyeh Health CenterTafileh13Bassirah Health CenterTafileh14Ein Al-Baida Health CenterTafileh15Al Tafileh Al-Shamel Health CenterTafileh16Al Hassa Health CenterTafileh
CentralCentral
1 Al Jofeh Health CenterBalqa2 Deir Allah Health CenterBalqa3 Al-Salalem Health CenterBalqa4 Al Jreineh Health CenterMadaba5 Al-Zarqarsquo Al-Jadidah Health
CenterZarqa6 Al Manara Health CenterAmman7 Al Qweismeh Health CenterAmman
NorthNorth
1 Al Manshieh Health CenterIrbid2 Al-Razi Health CenterIrbid3 Eidoun Health CenterIrbid4 Beit Eides Health CenterIrbid5 Huwara Health CenterIrbid6 Um-Qais HealthCenterIrbid7 Hai Al-Hussein Health CenterMafrak8 Rawdat Al-Amirah Basmah Health CenterMafrak9 Al Amir Hasan Health CenterAjloun10Jerash Health CenterJerash11Souf Health CenterJerash
Primary Health Care Initiatives Primary Health Care Initiatives Project USAID and MOH 1994Project 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 1048766 Seventy Quality Assurance Coordinators are facilitating a quality improvement process at the health centers
3 1048766 Twelve research teams were prepared to study and disseminate findings on clinical and management issues
4 1048766 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 1048766 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 1048766 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 PHCI Achievements and Lessons LearntLearnt
1 Building effective referral systemsbull 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 importantCounseling 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 LearntPHCI Achievements and Lessons Learnt2 Reproductive health utilizationProblem The primary health care system in Jordan has not established a calculation
for determining an adequate reproductive health service utilization rate bull Availability of other government and private facilities makes it difficult to assess
whether client need is underserved at the primary health care levelbull Figures for postpartum care and family planning are consistently and significantly
lower than antenatal care inequitable utilization of services by womenbull Consequently the health risk for newborns and their mothers is increased andbull opportunities that have proven effective for introducing family planning
counseling are missedbull IUD servicesalthough requested were not available (limited method choice)Solution IUD insertion unit established in 2001bull Awareness raising campaign focusing on the significance and availability of
family planning and particularly IUD services in the center usingbull - Home visitsbull - Counseling clients about the services of the center
- Educational sessions for the local community
PHCI Achievements and Lessons LearntPHCI Achievements and Lessons Learnt3 Increasing post-partum care utilizationProblem Low post partum care utilization Clients are not aware of the need for postpartum careSolution Increase utilization by1048766 Promote awareness of postpartum services in the community1048766 Inform all female patients especially MCH clients about available postpartum services1048766 Create a brochure for women containing information about maternal care1048766 Develop a register to log the number of expectant mothers their addresses and expected date of
delivery to enable follow-up1048766 Provide counseling about postpartum services during antenatal services1048766 Contact women who missed their postpartum appointment by phone and home visitsbull Raise the awareness of pregnant women about the importance of care in the postpartum
periodbull The target group was pregnant third trimester women 1048766 Recording the names of all target-group clients and their expected delivery date to enable follow up1048766 Providing and documenting health education messages delivered by physician and MCH staff
coveringbull - Breastfeeding and its benefits to both mother andbull infantbull - The importance of antenatal and postpartumbull nutritionbull - Maternal and infant postpartum complicationsbull - Maternal and infant postpartum personal hygienebull - Counseling on family planning
PHCI Chronic Illness-Compliance PHCI Chronic Illness-Compliance with Standardswith Standards
4 Prevalence of hypertension in Jordan among those over 25 is 318 while diabetes accounts for 68 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 diabetesUncontrolled diabetesbull 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 uncontrolledbull Solution 1 Define an overall strategy to include specific interventions and a monitoring plan2 Explain to staff the link between applying standards and measuring fasting blood sugar
levels to see results3 Provide the protocols4 Train 3 physicians and 8 nurses on implementing the protocols and completing the
follow up chart5 Discuss monitoring results during the QA team meetings6 Monitor results of Blood Sugar fasting for individual patients for a period of 6
months and prepare reports on results7 Document the percentage of controlled and uncontrolled patients on a monthly basis8 Mark the records of patients with readings higher than 180 to refer them for intensive
counseling9 Report the results on the QA Coordinator monthly reports
PHCIPHCI5 Training nursing personnel6 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 bull Lessons A combination of conducting training assigning responsibility and providing quality
services facilitates introduction and maintenance of new programs1048766 A comprehensive program of promotion education and quality service can increase awareness and
demand for the service1048766 Screening programs can successfully detect new cases1048766 Screening programs provide an opportunity for introducing other relevant health messages for
example breastfeeding explanations were included during the screening process7 Improving client flow in the clinics8 Strengthening health educationbull Problem Staff were often unprepared to deliver a lecture did not adequately plan for them
and had poor presentation skills1048766 Promotion of health education sessions was ineffective1048766 Client needs for specific health information were not surveyed
Health Systems Strengthening Health Systems Strengthening Project (HSSP)Project (HSSP)
bull 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
bull 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
bull Objectives ndash Improve the quality of health care servicesndash Develop and implement certification and accreditation systems for health care
facilities and service providersndash Computerize the health management information system networksndash Expand the health clinicsrsquo outreach to their local communities ndash Improve safe motherhood and neonatal health care related services at primary
health care centers and hospitalsndash Renovate and upgrade up to 28 hospitals and 32 primary health clinics belonging
to the Ministry of Health and the Royal Medical Services
MOH Structure for PHC MOH Structure for PHC PROVISIONPROVISION
Health Centers in MOH 2000-2005Health Centers in MOH 2000-2005
Type
2005
Comprehensive Health Centers
Primary Health Centers
Peripheral Health Centers
MCH Centers
Dental Clinics
57368238385274
200047333265345237
Discrepancy in Utilization Capital Discrepancy in Utilization Capital Badia (source MOH)Badia (source MOH)
bull P R E N A T A L
bull
bull Average Number of Prenatal Visits
bull
bull Directorates [Capital]
bull All Reported Months
bull Years [2006]
bull Year New Recur (New+Recur)New
bull 2006 2569 9156 456
bull P R E N A T A L
bull
bull Average Number of Prenatal Visits
bull
bull Directorates [North Badih]
bull All Reported Months
bull Years [2006]
bull Year New Recur (New+Recur)New
bull 2006 221 532 341
Tetanus ImmunizationTetanus Immunization bull P R E N A T A L
bull
bull Pregnant Women Tetanus Immunized
bull
bull Directorates [Capital]
bull All Reported Months
bull Years [2006]
bull Year TT_2 TT_3 TT_4 TT_5 New
(TT_2+TT_3+TT_4+TT_5)New
bull 2006 549 337 228130 2569 4842
bull P R E N A T A L
bull
bull Pregnant Women Tetanus Immunized
bull
bull Directorates [Mafraq]
bull All Reported Months
bull Years [2006]
bull Year TT_2 TT_3 TT_4 TT_5 New
(TT_2+TT_3+TT_4+TT_5)New
bull 2006 46 34 115 512 1875
Comprehensive Primary Health Care Centers CPHCCs Comprehensive Primary Health Care Centers CPHCCs Research FindingsResearch Findings
bull Staffed by general medical practitioners nurses midwives dentists administrative support personnel and a limited number of diagnostic technicians
bull Role of rural nurses in Jordan (Francis Nawafleh and Chapman 2005) showedbull Work of nurses task orientated and directed by the physicians bull Nursing staff were predominantly practical and aide nurses who were recruited
locally bull 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
bull The nurses did not engage with the community to promote health issues bull Dialogue with patients was limited to directions related to the therapy being
initiated bull Nurses had little understanding of contemporary health issues and demonstrated
a lack of awareness of lsquosafe practicersquo(Francis Nawafleh and Chapman 2005)bull The nursesrsquo roles traditionally are curative in nature and involve direct patient
care (Nahas Nour ampAl-Nobani 1999 Haddad 2002)bull Most nurses have been trainededucated 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 RecommendationsChallenges and Recommendations
bull 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
bull Recommendations Resources be directed toward improving the capacity of the CPHCCs and access to education training and professional development
bull 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 non-desirable areas (Alrai 2003
Policy and Health Care System Reform Policy and Health Care System Reform Directives in Partnership with Funding Directives in Partnership with Funding
AgenciesAgenciesAdopt a more competitive legal and regulatory framework for the health
sector by 1 Heath insurance reforms2 Decentralization of hospitals3 Development of systems for continuous medical education4 System of relevant health provider incentives5 Better integration of on-going primary health services strategies
and programs that prevent and treat chronic diseases6 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 ProjectPrimary Health Care Initiatives Project
bull 380 PHC clinics
bull Renovation and provision of furniture and specialized medical equipment
bull Clinical training of service providers
bull Establishment of performance improvement review systems
bull Improvement of the management information system
Participating Teams SouthParticipating Teams South
1 Al Amira Rahmeh Health Center Marsquoan2 Al Rabbeh Al Shamel Health Center Kerak3 Mursquotah Health Center Kerak4 Majra Health Center Kerak5 Al Mazar Health CenterKerak6 Emree Health CenterKerak7 Al Adnanyeh Health CenterKerak8 Al-Amira Basmah Health CenterAqaba9 Al Khazan Health CenterAqaba10Al Baldah Al Qadimah Health CenterAqaba11Al Aqaba Health CenterAqaba12Al Qadissyeh Health CenterTafileh13Bassirah Health CenterTafileh14Ein Al-Baida Health CenterTafileh15Al Tafileh Al-Shamel Health CenterTafileh16Al Hassa Health CenterTafileh
CentralCentral
1 Al Jofeh Health CenterBalqa2 Deir Allah Health CenterBalqa3 Al-Salalem Health CenterBalqa4 Al Jreineh Health CenterMadaba5 Al-Zarqarsquo Al-Jadidah Health
CenterZarqa6 Al Manara Health CenterAmman7 Al Qweismeh Health CenterAmman
NorthNorth
1 Al Manshieh Health CenterIrbid2 Al-Razi Health CenterIrbid3 Eidoun Health CenterIrbid4 Beit Eides Health CenterIrbid5 Huwara Health CenterIrbid6 Um-Qais HealthCenterIrbid7 Hai Al-Hussein Health CenterMafrak8 Rawdat Al-Amirah Basmah Health CenterMafrak9 Al Amir Hasan Health CenterAjloun10Jerash Health CenterJerash11Souf Health CenterJerash
Primary Health Care Initiatives Primary Health Care Initiatives Project USAID and MOH 1994Project 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 1048766 Seventy Quality Assurance Coordinators are facilitating a quality improvement process at the health centers
3 1048766 Twelve research teams were prepared to study and disseminate findings on clinical and management issues
4 1048766 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 1048766 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 1048766 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 PHCI Achievements and Lessons LearntLearnt
1 Building effective referral systemsbull 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 importantCounseling 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 LearntPHCI Achievements and Lessons Learnt2 Reproductive health utilizationProblem The primary health care system in Jordan has not established a calculation
for determining an adequate reproductive health service utilization rate bull Availability of other government and private facilities makes it difficult to assess
whether client need is underserved at the primary health care levelbull Figures for postpartum care and family planning are consistently and significantly
lower than antenatal care inequitable utilization of services by womenbull Consequently the health risk for newborns and their mothers is increased andbull opportunities that have proven effective for introducing family planning
counseling are missedbull IUD servicesalthough requested were not available (limited method choice)Solution IUD insertion unit established in 2001bull Awareness raising campaign focusing on the significance and availability of
family planning and particularly IUD services in the center usingbull - Home visitsbull - Counseling clients about the services of the center
- Educational sessions for the local community
PHCI Achievements and Lessons LearntPHCI Achievements and Lessons Learnt3 Increasing post-partum care utilizationProblem Low post partum care utilization Clients are not aware of the need for postpartum careSolution Increase utilization by1048766 Promote awareness of postpartum services in the community1048766 Inform all female patients especially MCH clients about available postpartum services1048766 Create a brochure for women containing information about maternal care1048766 Develop a register to log the number of expectant mothers their addresses and expected date of
delivery to enable follow-up1048766 Provide counseling about postpartum services during antenatal services1048766 Contact women who missed their postpartum appointment by phone and home visitsbull Raise the awareness of pregnant women about the importance of care in the postpartum
periodbull The target group was pregnant third trimester women 1048766 Recording the names of all target-group clients and their expected delivery date to enable follow up1048766 Providing and documenting health education messages delivered by physician and MCH staff
coveringbull - Breastfeeding and its benefits to both mother andbull infantbull - The importance of antenatal and postpartumbull nutritionbull - Maternal and infant postpartum complicationsbull - Maternal and infant postpartum personal hygienebull - Counseling on family planning
PHCI Chronic Illness-Compliance PHCI Chronic Illness-Compliance with Standardswith Standards
4 Prevalence of hypertension in Jordan among those over 25 is 318 while diabetes accounts for 68 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 diabetesUncontrolled diabetesbull 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 uncontrolledbull Solution 1 Define an overall strategy to include specific interventions and a monitoring plan2 Explain to staff the link between applying standards and measuring fasting blood sugar
levels to see results3 Provide the protocols4 Train 3 physicians and 8 nurses on implementing the protocols and completing the
follow up chart5 Discuss monitoring results during the QA team meetings6 Monitor results of Blood Sugar fasting for individual patients for a period of 6
months and prepare reports on results7 Document the percentage of controlled and uncontrolled patients on a monthly basis8 Mark the records of patients with readings higher than 180 to refer them for intensive
counseling9 Report the results on the QA Coordinator monthly reports
PHCIPHCI5 Training nursing personnel6 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 bull Lessons A combination of conducting training assigning responsibility and providing quality
services facilitates introduction and maintenance of new programs1048766 A comprehensive program of promotion education and quality service can increase awareness and
demand for the service1048766 Screening programs can successfully detect new cases1048766 Screening programs provide an opportunity for introducing other relevant health messages for
example breastfeeding explanations were included during the screening process7 Improving client flow in the clinics8 Strengthening health educationbull Problem Staff were often unprepared to deliver a lecture did not adequately plan for them
and had poor presentation skills1048766 Promotion of health education sessions was ineffective1048766 Client needs for specific health information were not surveyed
Health Systems Strengthening Health Systems Strengthening Project (HSSP)Project (HSSP)
bull 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
bull 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
bull Objectives ndash Improve the quality of health care servicesndash Develop and implement certification and accreditation systems for health care
facilities and service providersndash Computerize the health management information system networksndash Expand the health clinicsrsquo outreach to their local communities ndash Improve safe motherhood and neonatal health care related services at primary
health care centers and hospitalsndash Renovate and upgrade up to 28 hospitals and 32 primary health clinics belonging
to the Ministry of Health and the Royal Medical Services
Health Centers in MOH 2000-2005Health Centers in MOH 2000-2005
Type
2005
Comprehensive Health Centers
Primary Health Centers
Peripheral Health Centers
MCH Centers
Dental Clinics
57368238385274
200047333265345237
Discrepancy in Utilization Capital Discrepancy in Utilization Capital Badia (source MOH)Badia (source MOH)
bull P R E N A T A L
bull
bull Average Number of Prenatal Visits
bull
bull Directorates [Capital]
bull All Reported Months
bull Years [2006]
bull Year New Recur (New+Recur)New
bull 2006 2569 9156 456
bull P R E N A T A L
bull
bull Average Number of Prenatal Visits
bull
bull Directorates [North Badih]
bull All Reported Months
bull Years [2006]
bull Year New Recur (New+Recur)New
bull 2006 221 532 341
Tetanus ImmunizationTetanus Immunization bull P R E N A T A L
bull
bull Pregnant Women Tetanus Immunized
bull
bull Directorates [Capital]
bull All Reported Months
bull Years [2006]
bull Year TT_2 TT_3 TT_4 TT_5 New
(TT_2+TT_3+TT_4+TT_5)New
bull 2006 549 337 228130 2569 4842
bull P R E N A T A L
bull
bull Pregnant Women Tetanus Immunized
bull
bull Directorates [Mafraq]
bull All Reported Months
bull Years [2006]
bull Year TT_2 TT_3 TT_4 TT_5 New
(TT_2+TT_3+TT_4+TT_5)New
bull 2006 46 34 115 512 1875
Comprehensive Primary Health Care Centers CPHCCs Comprehensive Primary Health Care Centers CPHCCs Research FindingsResearch Findings
bull Staffed by general medical practitioners nurses midwives dentists administrative support personnel and a limited number of diagnostic technicians
bull Role of rural nurses in Jordan (Francis Nawafleh and Chapman 2005) showedbull Work of nurses task orientated and directed by the physicians bull Nursing staff were predominantly practical and aide nurses who were recruited
locally bull 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
bull The nurses did not engage with the community to promote health issues bull Dialogue with patients was limited to directions related to the therapy being
initiated bull Nurses had little understanding of contemporary health issues and demonstrated
a lack of awareness of lsquosafe practicersquo(Francis Nawafleh and Chapman 2005)bull The nursesrsquo roles traditionally are curative in nature and involve direct patient
care (Nahas Nour ampAl-Nobani 1999 Haddad 2002)bull Most nurses have been trainededucated 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 RecommendationsChallenges and Recommendations
bull 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
bull Recommendations Resources be directed toward improving the capacity of the CPHCCs and access to education training and professional development
bull 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 non-desirable areas (Alrai 2003
Policy and Health Care System Reform Policy and Health Care System Reform Directives in Partnership with Funding Directives in Partnership with Funding
AgenciesAgenciesAdopt a more competitive legal and regulatory framework for the health
sector by 1 Heath insurance reforms2 Decentralization of hospitals3 Development of systems for continuous medical education4 System of relevant health provider incentives5 Better integration of on-going primary health services strategies
and programs that prevent and treat chronic diseases6 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 ProjectPrimary Health Care Initiatives Project
bull 380 PHC clinics
bull Renovation and provision of furniture and specialized medical equipment
bull Clinical training of service providers
bull Establishment of performance improvement review systems
bull Improvement of the management information system
Participating Teams SouthParticipating Teams South
1 Al Amira Rahmeh Health Center Marsquoan2 Al Rabbeh Al Shamel Health Center Kerak3 Mursquotah Health Center Kerak4 Majra Health Center Kerak5 Al Mazar Health CenterKerak6 Emree Health CenterKerak7 Al Adnanyeh Health CenterKerak8 Al-Amira Basmah Health CenterAqaba9 Al Khazan Health CenterAqaba10Al Baldah Al Qadimah Health CenterAqaba11Al Aqaba Health CenterAqaba12Al Qadissyeh Health CenterTafileh13Bassirah Health CenterTafileh14Ein Al-Baida Health CenterTafileh15Al Tafileh Al-Shamel Health CenterTafileh16Al Hassa Health CenterTafileh
CentralCentral
1 Al Jofeh Health CenterBalqa2 Deir Allah Health CenterBalqa3 Al-Salalem Health CenterBalqa4 Al Jreineh Health CenterMadaba5 Al-Zarqarsquo Al-Jadidah Health
CenterZarqa6 Al Manara Health CenterAmman7 Al Qweismeh Health CenterAmman
NorthNorth
1 Al Manshieh Health CenterIrbid2 Al-Razi Health CenterIrbid3 Eidoun Health CenterIrbid4 Beit Eides Health CenterIrbid5 Huwara Health CenterIrbid6 Um-Qais HealthCenterIrbid7 Hai Al-Hussein Health CenterMafrak8 Rawdat Al-Amirah Basmah Health CenterMafrak9 Al Amir Hasan Health CenterAjloun10Jerash Health CenterJerash11Souf Health CenterJerash
Primary Health Care Initiatives Primary Health Care Initiatives Project USAID and MOH 1994Project 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 1048766 Seventy Quality Assurance Coordinators are facilitating a quality improvement process at the health centers
3 1048766 Twelve research teams were prepared to study and disseminate findings on clinical and management issues
4 1048766 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 1048766 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 1048766 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 PHCI Achievements and Lessons LearntLearnt
1 Building effective referral systemsbull 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 importantCounseling 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 LearntPHCI Achievements and Lessons Learnt2 Reproductive health utilizationProblem The primary health care system in Jordan has not established a calculation
for determining an adequate reproductive health service utilization rate bull Availability of other government and private facilities makes it difficult to assess
whether client need is underserved at the primary health care levelbull Figures for postpartum care and family planning are consistently and significantly
lower than antenatal care inequitable utilization of services by womenbull Consequently the health risk for newborns and their mothers is increased andbull opportunities that have proven effective for introducing family planning
counseling are missedbull IUD servicesalthough requested were not available (limited method choice)Solution IUD insertion unit established in 2001bull Awareness raising campaign focusing on the significance and availability of
family planning and particularly IUD services in the center usingbull - Home visitsbull - Counseling clients about the services of the center
- Educational sessions for the local community
PHCI Achievements and Lessons LearntPHCI Achievements and Lessons Learnt3 Increasing post-partum care utilizationProblem Low post partum care utilization Clients are not aware of the need for postpartum careSolution Increase utilization by1048766 Promote awareness of postpartum services in the community1048766 Inform all female patients especially MCH clients about available postpartum services1048766 Create a brochure for women containing information about maternal care1048766 Develop a register to log the number of expectant mothers their addresses and expected date of
delivery to enable follow-up1048766 Provide counseling about postpartum services during antenatal services1048766 Contact women who missed their postpartum appointment by phone and home visitsbull Raise the awareness of pregnant women about the importance of care in the postpartum
periodbull The target group was pregnant third trimester women 1048766 Recording the names of all target-group clients and their expected delivery date to enable follow up1048766 Providing and documenting health education messages delivered by physician and MCH staff
coveringbull - Breastfeeding and its benefits to both mother andbull infantbull - The importance of antenatal and postpartumbull nutritionbull - Maternal and infant postpartum complicationsbull - Maternal and infant postpartum personal hygienebull - Counseling on family planning
PHCI Chronic Illness-Compliance PHCI Chronic Illness-Compliance with Standardswith Standards
4 Prevalence of hypertension in Jordan among those over 25 is 318 while diabetes accounts for 68 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 diabetesUncontrolled diabetesbull 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 uncontrolledbull Solution 1 Define an overall strategy to include specific interventions and a monitoring plan2 Explain to staff the link between applying standards and measuring fasting blood sugar
levels to see results3 Provide the protocols4 Train 3 physicians and 8 nurses on implementing the protocols and completing the
follow up chart5 Discuss monitoring results during the QA team meetings6 Monitor results of Blood Sugar fasting for individual patients for a period of 6
months and prepare reports on results7 Document the percentage of controlled and uncontrolled patients on a monthly basis8 Mark the records of patients with readings higher than 180 to refer them for intensive
counseling9 Report the results on the QA Coordinator monthly reports
PHCIPHCI5 Training nursing personnel6 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 bull Lessons A combination of conducting training assigning responsibility and providing quality
services facilitates introduction and maintenance of new programs1048766 A comprehensive program of promotion education and quality service can increase awareness and
demand for the service1048766 Screening programs can successfully detect new cases1048766 Screening programs provide an opportunity for introducing other relevant health messages for
example breastfeeding explanations were included during the screening process7 Improving client flow in the clinics8 Strengthening health educationbull Problem Staff were often unprepared to deliver a lecture did not adequately plan for them
and had poor presentation skills1048766 Promotion of health education sessions was ineffective1048766 Client needs for specific health information were not surveyed
Health Systems Strengthening Health Systems Strengthening Project (HSSP)Project (HSSP)
bull 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
bull 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
bull Objectives ndash Improve the quality of health care servicesndash Develop and implement certification and accreditation systems for health care
facilities and service providersndash Computerize the health management information system networksndash Expand the health clinicsrsquo outreach to their local communities ndash Improve safe motherhood and neonatal health care related services at primary
health care centers and hospitalsndash Renovate and upgrade up to 28 hospitals and 32 primary health clinics belonging
to the Ministry of Health and the Royal Medical Services
Discrepancy in Utilization Capital Discrepancy in Utilization Capital Badia (source MOH)Badia (source MOH)
bull P R E N A T A L
bull
bull Average Number of Prenatal Visits
bull
bull Directorates [Capital]
bull All Reported Months
bull Years [2006]
bull Year New Recur (New+Recur)New
bull 2006 2569 9156 456
bull P R E N A T A L
bull
bull Average Number of Prenatal Visits
bull
bull Directorates [North Badih]
bull All Reported Months
bull Years [2006]
bull Year New Recur (New+Recur)New
bull 2006 221 532 341
Tetanus ImmunizationTetanus Immunization bull P R E N A T A L
bull
bull Pregnant Women Tetanus Immunized
bull
bull Directorates [Capital]
bull All Reported Months
bull Years [2006]
bull Year TT_2 TT_3 TT_4 TT_5 New
(TT_2+TT_3+TT_4+TT_5)New
bull 2006 549 337 228130 2569 4842
bull P R E N A T A L
bull
bull Pregnant Women Tetanus Immunized
bull
bull Directorates [Mafraq]
bull All Reported Months
bull Years [2006]
bull Year TT_2 TT_3 TT_4 TT_5 New
(TT_2+TT_3+TT_4+TT_5)New
bull 2006 46 34 115 512 1875
Comprehensive Primary Health Care Centers CPHCCs Comprehensive Primary Health Care Centers CPHCCs Research FindingsResearch Findings
bull Staffed by general medical practitioners nurses midwives dentists administrative support personnel and a limited number of diagnostic technicians
bull Role of rural nurses in Jordan (Francis Nawafleh and Chapman 2005) showedbull Work of nurses task orientated and directed by the physicians bull Nursing staff were predominantly practical and aide nurses who were recruited
locally bull 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
bull The nurses did not engage with the community to promote health issues bull Dialogue with patients was limited to directions related to the therapy being
initiated bull Nurses had little understanding of contemporary health issues and demonstrated
a lack of awareness of lsquosafe practicersquo(Francis Nawafleh and Chapman 2005)bull The nursesrsquo roles traditionally are curative in nature and involve direct patient
care (Nahas Nour ampAl-Nobani 1999 Haddad 2002)bull Most nurses have been trainededucated 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 RecommendationsChallenges and Recommendations
bull 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
bull Recommendations Resources be directed toward improving the capacity of the CPHCCs and access to education training and professional development
bull 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 non-desirable areas (Alrai 2003
Policy and Health Care System Reform Policy and Health Care System Reform Directives in Partnership with Funding Directives in Partnership with Funding
AgenciesAgenciesAdopt a more competitive legal and regulatory framework for the health
sector by 1 Heath insurance reforms2 Decentralization of hospitals3 Development of systems for continuous medical education4 System of relevant health provider incentives5 Better integration of on-going primary health services strategies
and programs that prevent and treat chronic diseases6 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 ProjectPrimary Health Care Initiatives Project
bull 380 PHC clinics
bull Renovation and provision of furniture and specialized medical equipment
bull Clinical training of service providers
bull Establishment of performance improvement review systems
bull Improvement of the management information system
Participating Teams SouthParticipating Teams South
1 Al Amira Rahmeh Health Center Marsquoan2 Al Rabbeh Al Shamel Health Center Kerak3 Mursquotah Health Center Kerak4 Majra Health Center Kerak5 Al Mazar Health CenterKerak6 Emree Health CenterKerak7 Al Adnanyeh Health CenterKerak8 Al-Amira Basmah Health CenterAqaba9 Al Khazan Health CenterAqaba10Al Baldah Al Qadimah Health CenterAqaba11Al Aqaba Health CenterAqaba12Al Qadissyeh Health CenterTafileh13Bassirah Health CenterTafileh14Ein Al-Baida Health CenterTafileh15Al Tafileh Al-Shamel Health CenterTafileh16Al Hassa Health CenterTafileh
CentralCentral
1 Al Jofeh Health CenterBalqa2 Deir Allah Health CenterBalqa3 Al-Salalem Health CenterBalqa4 Al Jreineh Health CenterMadaba5 Al-Zarqarsquo Al-Jadidah Health
CenterZarqa6 Al Manara Health CenterAmman7 Al Qweismeh Health CenterAmman
NorthNorth
1 Al Manshieh Health CenterIrbid2 Al-Razi Health CenterIrbid3 Eidoun Health CenterIrbid4 Beit Eides Health CenterIrbid5 Huwara Health CenterIrbid6 Um-Qais HealthCenterIrbid7 Hai Al-Hussein Health CenterMafrak8 Rawdat Al-Amirah Basmah Health CenterMafrak9 Al Amir Hasan Health CenterAjloun10Jerash Health CenterJerash11Souf Health CenterJerash
Primary Health Care Initiatives Primary Health Care Initiatives Project USAID and MOH 1994Project 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 1048766 Seventy Quality Assurance Coordinators are facilitating a quality improvement process at the health centers
3 1048766 Twelve research teams were prepared to study and disseminate findings on clinical and management issues
4 1048766 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 1048766 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 1048766 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 PHCI Achievements and Lessons LearntLearnt
1 Building effective referral systemsbull 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 importantCounseling 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 LearntPHCI Achievements and Lessons Learnt2 Reproductive health utilizationProblem The primary health care system in Jordan has not established a calculation
for determining an adequate reproductive health service utilization rate bull Availability of other government and private facilities makes it difficult to assess
whether client need is underserved at the primary health care levelbull Figures for postpartum care and family planning are consistently and significantly
lower than antenatal care inequitable utilization of services by womenbull Consequently the health risk for newborns and their mothers is increased andbull opportunities that have proven effective for introducing family planning
counseling are missedbull IUD servicesalthough requested were not available (limited method choice)Solution IUD insertion unit established in 2001bull Awareness raising campaign focusing on the significance and availability of
family planning and particularly IUD services in the center usingbull - Home visitsbull - Counseling clients about the services of the center
- Educational sessions for the local community
PHCI Achievements and Lessons LearntPHCI Achievements and Lessons Learnt3 Increasing post-partum care utilizationProblem Low post partum care utilization Clients are not aware of the need for postpartum careSolution Increase utilization by1048766 Promote awareness of postpartum services in the community1048766 Inform all female patients especially MCH clients about available postpartum services1048766 Create a brochure for women containing information about maternal care1048766 Develop a register to log the number of expectant mothers their addresses and expected date of
delivery to enable follow-up1048766 Provide counseling about postpartum services during antenatal services1048766 Contact women who missed their postpartum appointment by phone and home visitsbull Raise the awareness of pregnant women about the importance of care in the postpartum
periodbull The target group was pregnant third trimester women 1048766 Recording the names of all target-group clients and their expected delivery date to enable follow up1048766 Providing and documenting health education messages delivered by physician and MCH staff
coveringbull - Breastfeeding and its benefits to both mother andbull infantbull - The importance of antenatal and postpartumbull nutritionbull - Maternal and infant postpartum complicationsbull - Maternal and infant postpartum personal hygienebull - Counseling on family planning
PHCI Chronic Illness-Compliance PHCI Chronic Illness-Compliance with Standardswith Standards
4 Prevalence of hypertension in Jordan among those over 25 is 318 while diabetes accounts for 68 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 diabetesUncontrolled diabetesbull 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 uncontrolledbull Solution 1 Define an overall strategy to include specific interventions and a monitoring plan2 Explain to staff the link between applying standards and measuring fasting blood sugar
levels to see results3 Provide the protocols4 Train 3 physicians and 8 nurses on implementing the protocols and completing the
follow up chart5 Discuss monitoring results during the QA team meetings6 Monitor results of Blood Sugar fasting for individual patients for a period of 6
months and prepare reports on results7 Document the percentage of controlled and uncontrolled patients on a monthly basis8 Mark the records of patients with readings higher than 180 to refer them for intensive
counseling9 Report the results on the QA Coordinator monthly reports
PHCIPHCI5 Training nursing personnel6 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 bull Lessons A combination of conducting training assigning responsibility and providing quality
services facilitates introduction and maintenance of new programs1048766 A comprehensive program of promotion education and quality service can increase awareness and
demand for the service1048766 Screening programs can successfully detect new cases1048766 Screening programs provide an opportunity for introducing other relevant health messages for
example breastfeeding explanations were included during the screening process7 Improving client flow in the clinics8 Strengthening health educationbull Problem Staff were often unprepared to deliver a lecture did not adequately plan for them
and had poor presentation skills1048766 Promotion of health education sessions was ineffective1048766 Client needs for specific health information were not surveyed
Health Systems Strengthening Health Systems Strengthening Project (HSSP)Project (HSSP)
bull 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
bull 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
bull Objectives ndash Improve the quality of health care servicesndash Develop and implement certification and accreditation systems for health care
facilities and service providersndash Computerize the health management information system networksndash Expand the health clinicsrsquo outreach to their local communities ndash Improve safe motherhood and neonatal health care related services at primary
health care centers and hospitalsndash Renovate and upgrade up to 28 hospitals and 32 primary health clinics belonging
to the Ministry of Health and the Royal Medical Services
Tetanus ImmunizationTetanus Immunization bull P R E N A T A L
bull
bull Pregnant Women Tetanus Immunized
bull
bull Directorates [Capital]
bull All Reported Months
bull Years [2006]
bull Year TT_2 TT_3 TT_4 TT_5 New
(TT_2+TT_3+TT_4+TT_5)New
bull 2006 549 337 228130 2569 4842
bull P R E N A T A L
bull
bull Pregnant Women Tetanus Immunized
bull
bull Directorates [Mafraq]
bull All Reported Months
bull Years [2006]
bull Year TT_2 TT_3 TT_4 TT_5 New
(TT_2+TT_3+TT_4+TT_5)New
bull 2006 46 34 115 512 1875
Comprehensive Primary Health Care Centers CPHCCs Comprehensive Primary Health Care Centers CPHCCs Research FindingsResearch Findings
bull Staffed by general medical practitioners nurses midwives dentists administrative support personnel and a limited number of diagnostic technicians
bull Role of rural nurses in Jordan (Francis Nawafleh and Chapman 2005) showedbull Work of nurses task orientated and directed by the physicians bull Nursing staff were predominantly practical and aide nurses who were recruited
locally bull 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
bull The nurses did not engage with the community to promote health issues bull Dialogue with patients was limited to directions related to the therapy being
initiated bull Nurses had little understanding of contemporary health issues and demonstrated
a lack of awareness of lsquosafe practicersquo(Francis Nawafleh and Chapman 2005)bull The nursesrsquo roles traditionally are curative in nature and involve direct patient
care (Nahas Nour ampAl-Nobani 1999 Haddad 2002)bull Most nurses have been trainededucated 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 RecommendationsChallenges and Recommendations
bull 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
bull Recommendations Resources be directed toward improving the capacity of the CPHCCs and access to education training and professional development
bull 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 non-desirable areas (Alrai 2003
Policy and Health Care System Reform Policy and Health Care System Reform Directives in Partnership with Funding Directives in Partnership with Funding
AgenciesAgenciesAdopt a more competitive legal and regulatory framework for the health
sector by 1 Heath insurance reforms2 Decentralization of hospitals3 Development of systems for continuous medical education4 System of relevant health provider incentives5 Better integration of on-going primary health services strategies
and programs that prevent and treat chronic diseases6 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 ProjectPrimary Health Care Initiatives Project
bull 380 PHC clinics
bull Renovation and provision of furniture and specialized medical equipment
bull Clinical training of service providers
bull Establishment of performance improvement review systems
bull Improvement of the management information system
Participating Teams SouthParticipating Teams South
1 Al Amira Rahmeh Health Center Marsquoan2 Al Rabbeh Al Shamel Health Center Kerak3 Mursquotah Health Center Kerak4 Majra Health Center Kerak5 Al Mazar Health CenterKerak6 Emree Health CenterKerak7 Al Adnanyeh Health CenterKerak8 Al-Amira Basmah Health CenterAqaba9 Al Khazan Health CenterAqaba10Al Baldah Al Qadimah Health CenterAqaba11Al Aqaba Health CenterAqaba12Al Qadissyeh Health CenterTafileh13Bassirah Health CenterTafileh14Ein Al-Baida Health CenterTafileh15Al Tafileh Al-Shamel Health CenterTafileh16Al Hassa Health CenterTafileh
CentralCentral
1 Al Jofeh Health CenterBalqa2 Deir Allah Health CenterBalqa3 Al-Salalem Health CenterBalqa4 Al Jreineh Health CenterMadaba5 Al-Zarqarsquo Al-Jadidah Health
CenterZarqa6 Al Manara Health CenterAmman7 Al Qweismeh Health CenterAmman
NorthNorth
1 Al Manshieh Health CenterIrbid2 Al-Razi Health CenterIrbid3 Eidoun Health CenterIrbid4 Beit Eides Health CenterIrbid5 Huwara Health CenterIrbid6 Um-Qais HealthCenterIrbid7 Hai Al-Hussein Health CenterMafrak8 Rawdat Al-Amirah Basmah Health CenterMafrak9 Al Amir Hasan Health CenterAjloun10Jerash Health CenterJerash11Souf Health CenterJerash
Primary Health Care Initiatives Primary Health Care Initiatives Project USAID and MOH 1994Project 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 1048766 Seventy Quality Assurance Coordinators are facilitating a quality improvement process at the health centers
3 1048766 Twelve research teams were prepared to study and disseminate findings on clinical and management issues
4 1048766 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 1048766 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 1048766 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 PHCI Achievements and Lessons LearntLearnt
1 Building effective referral systemsbull 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 importantCounseling 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 LearntPHCI Achievements and Lessons Learnt2 Reproductive health utilizationProblem The primary health care system in Jordan has not established a calculation
for determining an adequate reproductive health service utilization rate bull Availability of other government and private facilities makes it difficult to assess
whether client need is underserved at the primary health care levelbull Figures for postpartum care and family planning are consistently and significantly
lower than antenatal care inequitable utilization of services by womenbull Consequently the health risk for newborns and their mothers is increased andbull opportunities that have proven effective for introducing family planning
counseling are missedbull IUD servicesalthough requested were not available (limited method choice)Solution IUD insertion unit established in 2001bull Awareness raising campaign focusing on the significance and availability of
family planning and particularly IUD services in the center usingbull - Home visitsbull - Counseling clients about the services of the center
- Educational sessions for the local community
PHCI Achievements and Lessons LearntPHCI Achievements and Lessons Learnt3 Increasing post-partum care utilizationProblem Low post partum care utilization Clients are not aware of the need for postpartum careSolution Increase utilization by1048766 Promote awareness of postpartum services in the community1048766 Inform all female patients especially MCH clients about available postpartum services1048766 Create a brochure for women containing information about maternal care1048766 Develop a register to log the number of expectant mothers their addresses and expected date of
delivery to enable follow-up1048766 Provide counseling about postpartum services during antenatal services1048766 Contact women who missed their postpartum appointment by phone and home visitsbull Raise the awareness of pregnant women about the importance of care in the postpartum
periodbull The target group was pregnant third trimester women 1048766 Recording the names of all target-group clients and their expected delivery date to enable follow up1048766 Providing and documenting health education messages delivered by physician and MCH staff
coveringbull - Breastfeeding and its benefits to both mother andbull infantbull - The importance of antenatal and postpartumbull nutritionbull - Maternal and infant postpartum complicationsbull - Maternal and infant postpartum personal hygienebull - Counseling on family planning
PHCI Chronic Illness-Compliance PHCI Chronic Illness-Compliance with Standardswith Standards
4 Prevalence of hypertension in Jordan among those over 25 is 318 while diabetes accounts for 68 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 diabetesUncontrolled diabetesbull 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 uncontrolledbull Solution 1 Define an overall strategy to include specific interventions and a monitoring plan2 Explain to staff the link between applying standards and measuring fasting blood sugar
levels to see results3 Provide the protocols4 Train 3 physicians and 8 nurses on implementing the protocols and completing the
follow up chart5 Discuss monitoring results during the QA team meetings6 Monitor results of Blood Sugar fasting for individual patients for a period of 6
months and prepare reports on results7 Document the percentage of controlled and uncontrolled patients on a monthly basis8 Mark the records of patients with readings higher than 180 to refer them for intensive
counseling9 Report the results on the QA Coordinator monthly reports
PHCIPHCI5 Training nursing personnel6 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 bull Lessons A combination of conducting training assigning responsibility and providing quality
services facilitates introduction and maintenance of new programs1048766 A comprehensive program of promotion education and quality service can increase awareness and
demand for the service1048766 Screening programs can successfully detect new cases1048766 Screening programs provide an opportunity for introducing other relevant health messages for
example breastfeeding explanations were included during the screening process7 Improving client flow in the clinics8 Strengthening health educationbull Problem Staff were often unprepared to deliver a lecture did not adequately plan for them
and had poor presentation skills1048766 Promotion of health education sessions was ineffective1048766 Client needs for specific health information were not surveyed
Health Systems Strengthening Health Systems Strengthening Project (HSSP)Project (HSSP)
bull 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
bull 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
bull Objectives ndash Improve the quality of health care servicesndash Develop and implement certification and accreditation systems for health care
facilities and service providersndash Computerize the health management information system networksndash Expand the health clinicsrsquo outreach to their local communities ndash Improve safe motherhood and neonatal health care related services at primary
health care centers and hospitalsndash Renovate and upgrade up to 28 hospitals and 32 primary health clinics belonging
to the Ministry of Health and the Royal Medical Services
Comprehensive Primary Health Care Centers CPHCCs Comprehensive Primary Health Care Centers CPHCCs Research FindingsResearch Findings
bull Staffed by general medical practitioners nurses midwives dentists administrative support personnel and a limited number of diagnostic technicians
bull Role of rural nurses in Jordan (Francis Nawafleh and Chapman 2005) showedbull Work of nurses task orientated and directed by the physicians bull Nursing staff were predominantly practical and aide nurses who were recruited
locally bull 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
bull The nurses did not engage with the community to promote health issues bull Dialogue with patients was limited to directions related to the therapy being
initiated bull Nurses had little understanding of contemporary health issues and demonstrated
a lack of awareness of lsquosafe practicersquo(Francis Nawafleh and Chapman 2005)bull The nursesrsquo roles traditionally are curative in nature and involve direct patient
care (Nahas Nour ampAl-Nobani 1999 Haddad 2002)bull Most nurses have been trainededucated 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 RecommendationsChallenges and Recommendations
bull 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
bull Recommendations Resources be directed toward improving the capacity of the CPHCCs and access to education training and professional development
bull 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 non-desirable areas (Alrai 2003
Policy and Health Care System Reform Policy and Health Care System Reform Directives in Partnership with Funding Directives in Partnership with Funding
AgenciesAgenciesAdopt a more competitive legal and regulatory framework for the health
sector by 1 Heath insurance reforms2 Decentralization of hospitals3 Development of systems for continuous medical education4 System of relevant health provider incentives5 Better integration of on-going primary health services strategies
and programs that prevent and treat chronic diseases6 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 ProjectPrimary Health Care Initiatives Project
bull 380 PHC clinics
bull Renovation and provision of furniture and specialized medical equipment
bull Clinical training of service providers
bull Establishment of performance improvement review systems
bull Improvement of the management information system
Participating Teams SouthParticipating Teams South
1 Al Amira Rahmeh Health Center Marsquoan2 Al Rabbeh Al Shamel Health Center Kerak3 Mursquotah Health Center Kerak4 Majra Health Center Kerak5 Al Mazar Health CenterKerak6 Emree Health CenterKerak7 Al Adnanyeh Health CenterKerak8 Al-Amira Basmah Health CenterAqaba9 Al Khazan Health CenterAqaba10Al Baldah Al Qadimah Health CenterAqaba11Al Aqaba Health CenterAqaba12Al Qadissyeh Health CenterTafileh13Bassirah Health CenterTafileh14Ein Al-Baida Health CenterTafileh15Al Tafileh Al-Shamel Health CenterTafileh16Al Hassa Health CenterTafileh
CentralCentral
1 Al Jofeh Health CenterBalqa2 Deir Allah Health CenterBalqa3 Al-Salalem Health CenterBalqa4 Al Jreineh Health CenterMadaba5 Al-Zarqarsquo Al-Jadidah Health
CenterZarqa6 Al Manara Health CenterAmman7 Al Qweismeh Health CenterAmman
NorthNorth
1 Al Manshieh Health CenterIrbid2 Al-Razi Health CenterIrbid3 Eidoun Health CenterIrbid4 Beit Eides Health CenterIrbid5 Huwara Health CenterIrbid6 Um-Qais HealthCenterIrbid7 Hai Al-Hussein Health CenterMafrak8 Rawdat Al-Amirah Basmah Health CenterMafrak9 Al Amir Hasan Health CenterAjloun10Jerash Health CenterJerash11Souf Health CenterJerash
Primary Health Care Initiatives Primary Health Care Initiatives Project USAID and MOH 1994Project 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 1048766 Seventy Quality Assurance Coordinators are facilitating a quality improvement process at the health centers
3 1048766 Twelve research teams were prepared to study and disseminate findings on clinical and management issues
4 1048766 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 1048766 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 1048766 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 PHCI Achievements and Lessons LearntLearnt
1 Building effective referral systemsbull 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 importantCounseling 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 LearntPHCI Achievements and Lessons Learnt2 Reproductive health utilizationProblem The primary health care system in Jordan has not established a calculation
for determining an adequate reproductive health service utilization rate bull Availability of other government and private facilities makes it difficult to assess
whether client need is underserved at the primary health care levelbull Figures for postpartum care and family planning are consistently and significantly
lower than antenatal care inequitable utilization of services by womenbull Consequently the health risk for newborns and their mothers is increased andbull opportunities that have proven effective for introducing family planning
counseling are missedbull IUD servicesalthough requested were not available (limited method choice)Solution IUD insertion unit established in 2001bull Awareness raising campaign focusing on the significance and availability of
family planning and particularly IUD services in the center usingbull - Home visitsbull - Counseling clients about the services of the center
- Educational sessions for the local community
PHCI Achievements and Lessons LearntPHCI Achievements and Lessons Learnt3 Increasing post-partum care utilizationProblem Low post partum care utilization Clients are not aware of the need for postpartum careSolution Increase utilization by1048766 Promote awareness of postpartum services in the community1048766 Inform all female patients especially MCH clients about available postpartum services1048766 Create a brochure for women containing information about maternal care1048766 Develop a register to log the number of expectant mothers their addresses and expected date of
delivery to enable follow-up1048766 Provide counseling about postpartum services during antenatal services1048766 Contact women who missed their postpartum appointment by phone and home visitsbull Raise the awareness of pregnant women about the importance of care in the postpartum
periodbull The target group was pregnant third trimester women 1048766 Recording the names of all target-group clients and their expected delivery date to enable follow up1048766 Providing and documenting health education messages delivered by physician and MCH staff
coveringbull - Breastfeeding and its benefits to both mother andbull infantbull - The importance of antenatal and postpartumbull nutritionbull - Maternal and infant postpartum complicationsbull - Maternal and infant postpartum personal hygienebull - Counseling on family planning
PHCI Chronic Illness-Compliance PHCI Chronic Illness-Compliance with Standardswith Standards
4 Prevalence of hypertension in Jordan among those over 25 is 318 while diabetes accounts for 68 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 diabetesUncontrolled diabetesbull 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 uncontrolledbull Solution 1 Define an overall strategy to include specific interventions and a monitoring plan2 Explain to staff the link between applying standards and measuring fasting blood sugar
levels to see results3 Provide the protocols4 Train 3 physicians and 8 nurses on implementing the protocols and completing the
follow up chart5 Discuss monitoring results during the QA team meetings6 Monitor results of Blood Sugar fasting for individual patients for a period of 6
months and prepare reports on results7 Document the percentage of controlled and uncontrolled patients on a monthly basis8 Mark the records of patients with readings higher than 180 to refer them for intensive
counseling9 Report the results on the QA Coordinator monthly reports
PHCIPHCI5 Training nursing personnel6 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 bull Lessons A combination of conducting training assigning responsibility and providing quality
services facilitates introduction and maintenance of new programs1048766 A comprehensive program of promotion education and quality service can increase awareness and
demand for the service1048766 Screening programs can successfully detect new cases1048766 Screening programs provide an opportunity for introducing other relevant health messages for
example breastfeeding explanations were included during the screening process7 Improving client flow in the clinics8 Strengthening health educationbull Problem Staff were often unprepared to deliver a lecture did not adequately plan for them
and had poor presentation skills1048766 Promotion of health education sessions was ineffective1048766 Client needs for specific health information were not surveyed
Health Systems Strengthening Health Systems Strengthening Project (HSSP)Project (HSSP)
bull 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
bull 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
bull Objectives ndash Improve the quality of health care servicesndash Develop and implement certification and accreditation systems for health care
facilities and service providersndash Computerize the health management information system networksndash Expand the health clinicsrsquo outreach to their local communities ndash Improve safe motherhood and neonatal health care related services at primary
health care centers and hospitalsndash Renovate and upgrade up to 28 hospitals and 32 primary health clinics belonging
to the Ministry of Health and the Royal Medical Services
Challenges and RecommendationsChallenges and Recommendations
bull 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
bull Recommendations Resources be directed toward improving the capacity of the CPHCCs and access to education training and professional development
bull 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 non-desirable areas (Alrai 2003
Policy and Health Care System Reform Policy and Health Care System Reform Directives in Partnership with Funding Directives in Partnership with Funding
AgenciesAgenciesAdopt a more competitive legal and regulatory framework for the health
sector by 1 Heath insurance reforms2 Decentralization of hospitals3 Development of systems for continuous medical education4 System of relevant health provider incentives5 Better integration of on-going primary health services strategies
and programs that prevent and treat chronic diseases6 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 ProjectPrimary Health Care Initiatives Project
bull 380 PHC clinics
bull Renovation and provision of furniture and specialized medical equipment
bull Clinical training of service providers
bull Establishment of performance improvement review systems
bull Improvement of the management information system
Participating Teams SouthParticipating Teams South
1 Al Amira Rahmeh Health Center Marsquoan2 Al Rabbeh Al Shamel Health Center Kerak3 Mursquotah Health Center Kerak4 Majra Health Center Kerak5 Al Mazar Health CenterKerak6 Emree Health CenterKerak7 Al Adnanyeh Health CenterKerak8 Al-Amira Basmah Health CenterAqaba9 Al Khazan Health CenterAqaba10Al Baldah Al Qadimah Health CenterAqaba11Al Aqaba Health CenterAqaba12Al Qadissyeh Health CenterTafileh13Bassirah Health CenterTafileh14Ein Al-Baida Health CenterTafileh15Al Tafileh Al-Shamel Health CenterTafileh16Al Hassa Health CenterTafileh
CentralCentral
1 Al Jofeh Health CenterBalqa2 Deir Allah Health CenterBalqa3 Al-Salalem Health CenterBalqa4 Al Jreineh Health CenterMadaba5 Al-Zarqarsquo Al-Jadidah Health
CenterZarqa6 Al Manara Health CenterAmman7 Al Qweismeh Health CenterAmman
NorthNorth
1 Al Manshieh Health CenterIrbid2 Al-Razi Health CenterIrbid3 Eidoun Health CenterIrbid4 Beit Eides Health CenterIrbid5 Huwara Health CenterIrbid6 Um-Qais HealthCenterIrbid7 Hai Al-Hussein Health CenterMafrak8 Rawdat Al-Amirah Basmah Health CenterMafrak9 Al Amir Hasan Health CenterAjloun10Jerash Health CenterJerash11Souf Health CenterJerash
Primary Health Care Initiatives Primary Health Care Initiatives Project USAID and MOH 1994Project 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 1048766 Seventy Quality Assurance Coordinators are facilitating a quality improvement process at the health centers
3 1048766 Twelve research teams were prepared to study and disseminate findings on clinical and management issues
4 1048766 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 1048766 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 1048766 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 PHCI Achievements and Lessons LearntLearnt
1 Building effective referral systemsbull 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 importantCounseling 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 LearntPHCI Achievements and Lessons Learnt2 Reproductive health utilizationProblem The primary health care system in Jordan has not established a calculation
for determining an adequate reproductive health service utilization rate bull Availability of other government and private facilities makes it difficult to assess
whether client need is underserved at the primary health care levelbull Figures for postpartum care and family planning are consistently and significantly
lower than antenatal care inequitable utilization of services by womenbull Consequently the health risk for newborns and their mothers is increased andbull opportunities that have proven effective for introducing family planning
counseling are missedbull IUD servicesalthough requested were not available (limited method choice)Solution IUD insertion unit established in 2001bull Awareness raising campaign focusing on the significance and availability of
family planning and particularly IUD services in the center usingbull - Home visitsbull - Counseling clients about the services of the center
- Educational sessions for the local community
PHCI Achievements and Lessons LearntPHCI Achievements and Lessons Learnt3 Increasing post-partum care utilizationProblem Low post partum care utilization Clients are not aware of the need for postpartum careSolution Increase utilization by1048766 Promote awareness of postpartum services in the community1048766 Inform all female patients especially MCH clients about available postpartum services1048766 Create a brochure for women containing information about maternal care1048766 Develop a register to log the number of expectant mothers their addresses and expected date of
delivery to enable follow-up1048766 Provide counseling about postpartum services during antenatal services1048766 Contact women who missed their postpartum appointment by phone and home visitsbull Raise the awareness of pregnant women about the importance of care in the postpartum
periodbull The target group was pregnant third trimester women 1048766 Recording the names of all target-group clients and their expected delivery date to enable follow up1048766 Providing and documenting health education messages delivered by physician and MCH staff
coveringbull - Breastfeeding and its benefits to both mother andbull infantbull - The importance of antenatal and postpartumbull nutritionbull - Maternal and infant postpartum complicationsbull - Maternal and infant postpartum personal hygienebull - Counseling on family planning
PHCI Chronic Illness-Compliance PHCI Chronic Illness-Compliance with Standardswith Standards
4 Prevalence of hypertension in Jordan among those over 25 is 318 while diabetes accounts for 68 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 diabetesUncontrolled diabetesbull 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 uncontrolledbull Solution 1 Define an overall strategy to include specific interventions and a monitoring plan2 Explain to staff the link between applying standards and measuring fasting blood sugar
levels to see results3 Provide the protocols4 Train 3 physicians and 8 nurses on implementing the protocols and completing the
follow up chart5 Discuss monitoring results during the QA team meetings6 Monitor results of Blood Sugar fasting for individual patients for a period of 6
months and prepare reports on results7 Document the percentage of controlled and uncontrolled patients on a monthly basis8 Mark the records of patients with readings higher than 180 to refer them for intensive
counseling9 Report the results on the QA Coordinator monthly reports
PHCIPHCI5 Training nursing personnel6 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 bull Lessons A combination of conducting training assigning responsibility and providing quality
services facilitates introduction and maintenance of new programs1048766 A comprehensive program of promotion education and quality service can increase awareness and
demand for the service1048766 Screening programs can successfully detect new cases1048766 Screening programs provide an opportunity for introducing other relevant health messages for
example breastfeeding explanations were included during the screening process7 Improving client flow in the clinics8 Strengthening health educationbull Problem Staff were often unprepared to deliver a lecture did not adequately plan for them
and had poor presentation skills1048766 Promotion of health education sessions was ineffective1048766 Client needs for specific health information were not surveyed
Health Systems Strengthening Health Systems Strengthening Project (HSSP)Project (HSSP)
bull 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
bull 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
bull Objectives ndash Improve the quality of health care servicesndash Develop and implement certification and accreditation systems for health care
facilities and service providersndash Computerize the health management information system networksndash Expand the health clinicsrsquo outreach to their local communities ndash Improve safe motherhood and neonatal health care related services at primary
health care centers and hospitalsndash Renovate and upgrade up to 28 hospitals and 32 primary health clinics belonging
to the Ministry of Health and the Royal Medical Services
Policy and Health Care System Reform Policy and Health Care System Reform Directives in Partnership with Funding Directives in Partnership with Funding
AgenciesAgenciesAdopt a more competitive legal and regulatory framework for the health
sector by 1 Heath insurance reforms2 Decentralization of hospitals3 Development of systems for continuous medical education4 System of relevant health provider incentives5 Better integration of on-going primary health services strategies
and programs that prevent and treat chronic diseases6 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 ProjectPrimary Health Care Initiatives Project
bull 380 PHC clinics
bull Renovation and provision of furniture and specialized medical equipment
bull Clinical training of service providers
bull Establishment of performance improvement review systems
bull Improvement of the management information system
Participating Teams SouthParticipating Teams South
1 Al Amira Rahmeh Health Center Marsquoan2 Al Rabbeh Al Shamel Health Center Kerak3 Mursquotah Health Center Kerak4 Majra Health Center Kerak5 Al Mazar Health CenterKerak6 Emree Health CenterKerak7 Al Adnanyeh Health CenterKerak8 Al-Amira Basmah Health CenterAqaba9 Al Khazan Health CenterAqaba10Al Baldah Al Qadimah Health CenterAqaba11Al Aqaba Health CenterAqaba12Al Qadissyeh Health CenterTafileh13Bassirah Health CenterTafileh14Ein Al-Baida Health CenterTafileh15Al Tafileh Al-Shamel Health CenterTafileh16Al Hassa Health CenterTafileh
CentralCentral
1 Al Jofeh Health CenterBalqa2 Deir Allah Health CenterBalqa3 Al-Salalem Health CenterBalqa4 Al Jreineh Health CenterMadaba5 Al-Zarqarsquo Al-Jadidah Health
CenterZarqa6 Al Manara Health CenterAmman7 Al Qweismeh Health CenterAmman
NorthNorth
1 Al Manshieh Health CenterIrbid2 Al-Razi Health CenterIrbid3 Eidoun Health CenterIrbid4 Beit Eides Health CenterIrbid5 Huwara Health CenterIrbid6 Um-Qais HealthCenterIrbid7 Hai Al-Hussein Health CenterMafrak8 Rawdat Al-Amirah Basmah Health CenterMafrak9 Al Amir Hasan Health CenterAjloun10Jerash Health CenterJerash11Souf Health CenterJerash
Primary Health Care Initiatives Primary Health Care Initiatives Project USAID and MOH 1994Project 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 1048766 Seventy Quality Assurance Coordinators are facilitating a quality improvement process at the health centers
3 1048766 Twelve research teams were prepared to study and disseminate findings on clinical and management issues
4 1048766 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 1048766 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 1048766 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 PHCI Achievements and Lessons LearntLearnt
1 Building effective referral systemsbull 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 importantCounseling 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 LearntPHCI Achievements and Lessons Learnt2 Reproductive health utilizationProblem The primary health care system in Jordan has not established a calculation
for determining an adequate reproductive health service utilization rate bull Availability of other government and private facilities makes it difficult to assess
whether client need is underserved at the primary health care levelbull Figures for postpartum care and family planning are consistently and significantly
lower than antenatal care inequitable utilization of services by womenbull Consequently the health risk for newborns and their mothers is increased andbull opportunities that have proven effective for introducing family planning
counseling are missedbull IUD servicesalthough requested were not available (limited method choice)Solution IUD insertion unit established in 2001bull Awareness raising campaign focusing on the significance and availability of
family planning and particularly IUD services in the center usingbull - Home visitsbull - Counseling clients about the services of the center
- Educational sessions for the local community
PHCI Achievements and Lessons LearntPHCI Achievements and Lessons Learnt3 Increasing post-partum care utilizationProblem Low post partum care utilization Clients are not aware of the need for postpartum careSolution Increase utilization by1048766 Promote awareness of postpartum services in the community1048766 Inform all female patients especially MCH clients about available postpartum services1048766 Create a brochure for women containing information about maternal care1048766 Develop a register to log the number of expectant mothers their addresses and expected date of
delivery to enable follow-up1048766 Provide counseling about postpartum services during antenatal services1048766 Contact women who missed their postpartum appointment by phone and home visitsbull Raise the awareness of pregnant women about the importance of care in the postpartum
periodbull The target group was pregnant third trimester women 1048766 Recording the names of all target-group clients and their expected delivery date to enable follow up1048766 Providing and documenting health education messages delivered by physician and MCH staff
coveringbull - Breastfeeding and its benefits to both mother andbull infantbull - The importance of antenatal and postpartumbull nutritionbull - Maternal and infant postpartum complicationsbull - Maternal and infant postpartum personal hygienebull - Counseling on family planning
PHCI Chronic Illness-Compliance PHCI Chronic Illness-Compliance with Standardswith Standards
4 Prevalence of hypertension in Jordan among those over 25 is 318 while diabetes accounts for 68 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 diabetesUncontrolled diabetesbull 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 uncontrolledbull Solution 1 Define an overall strategy to include specific interventions and a monitoring plan2 Explain to staff the link between applying standards and measuring fasting blood sugar
levels to see results3 Provide the protocols4 Train 3 physicians and 8 nurses on implementing the protocols and completing the
follow up chart5 Discuss monitoring results during the QA team meetings6 Monitor results of Blood Sugar fasting for individual patients for a period of 6
months and prepare reports on results7 Document the percentage of controlled and uncontrolled patients on a monthly basis8 Mark the records of patients with readings higher than 180 to refer them for intensive
counseling9 Report the results on the QA Coordinator monthly reports
PHCIPHCI5 Training nursing personnel6 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 bull Lessons A combination of conducting training assigning responsibility and providing quality
services facilitates introduction and maintenance of new programs1048766 A comprehensive program of promotion education and quality service can increase awareness and
demand for the service1048766 Screening programs can successfully detect new cases1048766 Screening programs provide an opportunity for introducing other relevant health messages for
example breastfeeding explanations were included during the screening process7 Improving client flow in the clinics8 Strengthening health educationbull Problem Staff were often unprepared to deliver a lecture did not adequately plan for them
and had poor presentation skills1048766 Promotion of health education sessions was ineffective1048766 Client needs for specific health information were not surveyed
Health Systems Strengthening Health Systems Strengthening Project (HSSP)Project (HSSP)
bull 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
bull 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
bull Objectives ndash Improve the quality of health care servicesndash Develop and implement certification and accreditation systems for health care
facilities and service providersndash Computerize the health management information system networksndash Expand the health clinicsrsquo outreach to their local communities ndash Improve safe motherhood and neonatal health care related services at primary
health care centers and hospitalsndash Renovate and upgrade up to 28 hospitals and 32 primary health clinics belonging
to the Ministry of Health and the Royal Medical Services
Primary Health Care Initiatives ProjectPrimary Health Care Initiatives Project
bull 380 PHC clinics
bull Renovation and provision of furniture and specialized medical equipment
bull Clinical training of service providers
bull Establishment of performance improvement review systems
bull Improvement of the management information system
Participating Teams SouthParticipating Teams South
1 Al Amira Rahmeh Health Center Marsquoan2 Al Rabbeh Al Shamel Health Center Kerak3 Mursquotah Health Center Kerak4 Majra Health Center Kerak5 Al Mazar Health CenterKerak6 Emree Health CenterKerak7 Al Adnanyeh Health CenterKerak8 Al-Amira Basmah Health CenterAqaba9 Al Khazan Health CenterAqaba10Al Baldah Al Qadimah Health CenterAqaba11Al Aqaba Health CenterAqaba12Al Qadissyeh Health CenterTafileh13Bassirah Health CenterTafileh14Ein Al-Baida Health CenterTafileh15Al Tafileh Al-Shamel Health CenterTafileh16Al Hassa Health CenterTafileh
CentralCentral
1 Al Jofeh Health CenterBalqa2 Deir Allah Health CenterBalqa3 Al-Salalem Health CenterBalqa4 Al Jreineh Health CenterMadaba5 Al-Zarqarsquo Al-Jadidah Health
CenterZarqa6 Al Manara Health CenterAmman7 Al Qweismeh Health CenterAmman
NorthNorth
1 Al Manshieh Health CenterIrbid2 Al-Razi Health CenterIrbid3 Eidoun Health CenterIrbid4 Beit Eides Health CenterIrbid5 Huwara Health CenterIrbid6 Um-Qais HealthCenterIrbid7 Hai Al-Hussein Health CenterMafrak8 Rawdat Al-Amirah Basmah Health CenterMafrak9 Al Amir Hasan Health CenterAjloun10Jerash Health CenterJerash11Souf Health CenterJerash
Primary Health Care Initiatives Primary Health Care Initiatives Project USAID and MOH 1994Project 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 1048766 Seventy Quality Assurance Coordinators are facilitating a quality improvement process at the health centers
3 1048766 Twelve research teams were prepared to study and disseminate findings on clinical and management issues
4 1048766 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 1048766 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 1048766 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 PHCI Achievements and Lessons LearntLearnt
1 Building effective referral systemsbull 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 importantCounseling 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 LearntPHCI Achievements and Lessons Learnt2 Reproductive health utilizationProblem The primary health care system in Jordan has not established a calculation
for determining an adequate reproductive health service utilization rate bull Availability of other government and private facilities makes it difficult to assess
whether client need is underserved at the primary health care levelbull Figures for postpartum care and family planning are consistently and significantly
lower than antenatal care inequitable utilization of services by womenbull Consequently the health risk for newborns and their mothers is increased andbull opportunities that have proven effective for introducing family planning
counseling are missedbull IUD servicesalthough requested were not available (limited method choice)Solution IUD insertion unit established in 2001bull Awareness raising campaign focusing on the significance and availability of
family planning and particularly IUD services in the center usingbull - Home visitsbull - Counseling clients about the services of the center
- Educational sessions for the local community
PHCI Achievements and Lessons LearntPHCI Achievements and Lessons Learnt3 Increasing post-partum care utilizationProblem Low post partum care utilization Clients are not aware of the need for postpartum careSolution Increase utilization by1048766 Promote awareness of postpartum services in the community1048766 Inform all female patients especially MCH clients about available postpartum services1048766 Create a brochure for women containing information about maternal care1048766 Develop a register to log the number of expectant mothers their addresses and expected date of
delivery to enable follow-up1048766 Provide counseling about postpartum services during antenatal services1048766 Contact women who missed their postpartum appointment by phone and home visitsbull Raise the awareness of pregnant women about the importance of care in the postpartum
periodbull The target group was pregnant third trimester women 1048766 Recording the names of all target-group clients and their expected delivery date to enable follow up1048766 Providing and documenting health education messages delivered by physician and MCH staff
coveringbull - Breastfeeding and its benefits to both mother andbull infantbull - The importance of antenatal and postpartumbull nutritionbull - Maternal and infant postpartum complicationsbull - Maternal and infant postpartum personal hygienebull - Counseling on family planning
PHCI Chronic Illness-Compliance PHCI Chronic Illness-Compliance with Standardswith Standards
4 Prevalence of hypertension in Jordan among those over 25 is 318 while diabetes accounts for 68 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 diabetesUncontrolled diabetesbull 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 uncontrolledbull Solution 1 Define an overall strategy to include specific interventions and a monitoring plan2 Explain to staff the link between applying standards and measuring fasting blood sugar
levels to see results3 Provide the protocols4 Train 3 physicians and 8 nurses on implementing the protocols and completing the
follow up chart5 Discuss monitoring results during the QA team meetings6 Monitor results of Blood Sugar fasting for individual patients for a period of 6
months and prepare reports on results7 Document the percentage of controlled and uncontrolled patients on a monthly basis8 Mark the records of patients with readings higher than 180 to refer them for intensive
counseling9 Report the results on the QA Coordinator monthly reports
PHCIPHCI5 Training nursing personnel6 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 bull Lessons A combination of conducting training assigning responsibility and providing quality
services facilitates introduction and maintenance of new programs1048766 A comprehensive program of promotion education and quality service can increase awareness and
demand for the service1048766 Screening programs can successfully detect new cases1048766 Screening programs provide an opportunity for introducing other relevant health messages for
example breastfeeding explanations were included during the screening process7 Improving client flow in the clinics8 Strengthening health educationbull Problem Staff were often unprepared to deliver a lecture did not adequately plan for them
and had poor presentation skills1048766 Promotion of health education sessions was ineffective1048766 Client needs for specific health information were not surveyed
Health Systems Strengthening Health Systems Strengthening Project (HSSP)Project (HSSP)
bull 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
bull 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
bull Objectives ndash Improve the quality of health care servicesndash Develop and implement certification and accreditation systems for health care
facilities and service providersndash Computerize the health management information system networksndash Expand the health clinicsrsquo outreach to their local communities ndash Improve safe motherhood and neonatal health care related services at primary
health care centers and hospitalsndash Renovate and upgrade up to 28 hospitals and 32 primary health clinics belonging
to the Ministry of Health and the Royal Medical Services
Participating Teams SouthParticipating Teams South
1 Al Amira Rahmeh Health Center Marsquoan2 Al Rabbeh Al Shamel Health Center Kerak3 Mursquotah Health Center Kerak4 Majra Health Center Kerak5 Al Mazar Health CenterKerak6 Emree Health CenterKerak7 Al Adnanyeh Health CenterKerak8 Al-Amira Basmah Health CenterAqaba9 Al Khazan Health CenterAqaba10Al Baldah Al Qadimah Health CenterAqaba11Al Aqaba Health CenterAqaba12Al Qadissyeh Health CenterTafileh13Bassirah Health CenterTafileh14Ein Al-Baida Health CenterTafileh15Al Tafileh Al-Shamel Health CenterTafileh16Al Hassa Health CenterTafileh
CentralCentral
1 Al Jofeh Health CenterBalqa2 Deir Allah Health CenterBalqa3 Al-Salalem Health CenterBalqa4 Al Jreineh Health CenterMadaba5 Al-Zarqarsquo Al-Jadidah Health
CenterZarqa6 Al Manara Health CenterAmman7 Al Qweismeh Health CenterAmman
NorthNorth
1 Al Manshieh Health CenterIrbid2 Al-Razi Health CenterIrbid3 Eidoun Health CenterIrbid4 Beit Eides Health CenterIrbid5 Huwara Health CenterIrbid6 Um-Qais HealthCenterIrbid7 Hai Al-Hussein Health CenterMafrak8 Rawdat Al-Amirah Basmah Health CenterMafrak9 Al Amir Hasan Health CenterAjloun10Jerash Health CenterJerash11Souf Health CenterJerash
Primary Health Care Initiatives Primary Health Care Initiatives Project USAID and MOH 1994Project 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 1048766 Seventy Quality Assurance Coordinators are facilitating a quality improvement process at the health centers
3 1048766 Twelve research teams were prepared to study and disseminate findings on clinical and management issues
4 1048766 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 1048766 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 1048766 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 PHCI Achievements and Lessons LearntLearnt
1 Building effective referral systemsbull 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 importantCounseling 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 LearntPHCI Achievements and Lessons Learnt2 Reproductive health utilizationProblem The primary health care system in Jordan has not established a calculation
for determining an adequate reproductive health service utilization rate bull Availability of other government and private facilities makes it difficult to assess
whether client need is underserved at the primary health care levelbull Figures for postpartum care and family planning are consistently and significantly
lower than antenatal care inequitable utilization of services by womenbull Consequently the health risk for newborns and their mothers is increased andbull opportunities that have proven effective for introducing family planning
counseling are missedbull IUD servicesalthough requested were not available (limited method choice)Solution IUD insertion unit established in 2001bull Awareness raising campaign focusing on the significance and availability of
family planning and particularly IUD services in the center usingbull - Home visitsbull - Counseling clients about the services of the center
- Educational sessions for the local community
PHCI Achievements and Lessons LearntPHCI Achievements and Lessons Learnt3 Increasing post-partum care utilizationProblem Low post partum care utilization Clients are not aware of the need for postpartum careSolution Increase utilization by1048766 Promote awareness of postpartum services in the community1048766 Inform all female patients especially MCH clients about available postpartum services1048766 Create a brochure for women containing information about maternal care1048766 Develop a register to log the number of expectant mothers their addresses and expected date of
delivery to enable follow-up1048766 Provide counseling about postpartum services during antenatal services1048766 Contact women who missed their postpartum appointment by phone and home visitsbull Raise the awareness of pregnant women about the importance of care in the postpartum
periodbull The target group was pregnant third trimester women 1048766 Recording the names of all target-group clients and their expected delivery date to enable follow up1048766 Providing and documenting health education messages delivered by physician and MCH staff
coveringbull - Breastfeeding and its benefits to both mother andbull infantbull - The importance of antenatal and postpartumbull nutritionbull - Maternal and infant postpartum complicationsbull - Maternal and infant postpartum personal hygienebull - Counseling on family planning
PHCI Chronic Illness-Compliance PHCI Chronic Illness-Compliance with Standardswith Standards
4 Prevalence of hypertension in Jordan among those over 25 is 318 while diabetes accounts for 68 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 diabetesUncontrolled diabetesbull 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 uncontrolledbull Solution 1 Define an overall strategy to include specific interventions and a monitoring plan2 Explain to staff the link between applying standards and measuring fasting blood sugar
levels to see results3 Provide the protocols4 Train 3 physicians and 8 nurses on implementing the protocols and completing the
follow up chart5 Discuss monitoring results during the QA team meetings6 Monitor results of Blood Sugar fasting for individual patients for a period of 6
months and prepare reports on results7 Document the percentage of controlled and uncontrolled patients on a monthly basis8 Mark the records of patients with readings higher than 180 to refer them for intensive
counseling9 Report the results on the QA Coordinator monthly reports
PHCIPHCI5 Training nursing personnel6 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 bull Lessons A combination of conducting training assigning responsibility and providing quality
services facilitates introduction and maintenance of new programs1048766 A comprehensive program of promotion education and quality service can increase awareness and
demand for the service1048766 Screening programs can successfully detect new cases1048766 Screening programs provide an opportunity for introducing other relevant health messages for
example breastfeeding explanations were included during the screening process7 Improving client flow in the clinics8 Strengthening health educationbull Problem Staff were often unprepared to deliver a lecture did not adequately plan for them
and had poor presentation skills1048766 Promotion of health education sessions was ineffective1048766 Client needs for specific health information were not surveyed
Health Systems Strengthening Health Systems Strengthening Project (HSSP)Project (HSSP)
bull 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
bull 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
bull Objectives ndash Improve the quality of health care servicesndash Develop and implement certification and accreditation systems for health care
facilities and service providersndash Computerize the health management information system networksndash Expand the health clinicsrsquo outreach to their local communities ndash Improve safe motherhood and neonatal health care related services at primary
health care centers and hospitalsndash Renovate and upgrade up to 28 hospitals and 32 primary health clinics belonging
to the Ministry of Health and the Royal Medical Services
CentralCentral
1 Al Jofeh Health CenterBalqa2 Deir Allah Health CenterBalqa3 Al-Salalem Health CenterBalqa4 Al Jreineh Health CenterMadaba5 Al-Zarqarsquo Al-Jadidah Health
CenterZarqa6 Al Manara Health CenterAmman7 Al Qweismeh Health CenterAmman
NorthNorth
1 Al Manshieh Health CenterIrbid2 Al-Razi Health CenterIrbid3 Eidoun Health CenterIrbid4 Beit Eides Health CenterIrbid5 Huwara Health CenterIrbid6 Um-Qais HealthCenterIrbid7 Hai Al-Hussein Health CenterMafrak8 Rawdat Al-Amirah Basmah Health CenterMafrak9 Al Amir Hasan Health CenterAjloun10Jerash Health CenterJerash11Souf Health CenterJerash
Primary Health Care Initiatives Primary Health Care Initiatives Project USAID and MOH 1994Project 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 1048766 Seventy Quality Assurance Coordinators are facilitating a quality improvement process at the health centers
3 1048766 Twelve research teams were prepared to study and disseminate findings on clinical and management issues
4 1048766 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 1048766 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 1048766 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 PHCI Achievements and Lessons LearntLearnt
1 Building effective referral systemsbull 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 importantCounseling 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 LearntPHCI Achievements and Lessons Learnt2 Reproductive health utilizationProblem The primary health care system in Jordan has not established a calculation
for determining an adequate reproductive health service utilization rate bull Availability of other government and private facilities makes it difficult to assess
whether client need is underserved at the primary health care levelbull Figures for postpartum care and family planning are consistently and significantly
lower than antenatal care inequitable utilization of services by womenbull Consequently the health risk for newborns and their mothers is increased andbull opportunities that have proven effective for introducing family planning
counseling are missedbull IUD servicesalthough requested were not available (limited method choice)Solution IUD insertion unit established in 2001bull Awareness raising campaign focusing on the significance and availability of
family planning and particularly IUD services in the center usingbull - Home visitsbull - Counseling clients about the services of the center
- Educational sessions for the local community
PHCI Achievements and Lessons LearntPHCI Achievements and Lessons Learnt3 Increasing post-partum care utilizationProblem Low post partum care utilization Clients are not aware of the need for postpartum careSolution Increase utilization by1048766 Promote awareness of postpartum services in the community1048766 Inform all female patients especially MCH clients about available postpartum services1048766 Create a brochure for women containing information about maternal care1048766 Develop a register to log the number of expectant mothers their addresses and expected date of
delivery to enable follow-up1048766 Provide counseling about postpartum services during antenatal services1048766 Contact women who missed their postpartum appointment by phone and home visitsbull Raise the awareness of pregnant women about the importance of care in the postpartum
periodbull The target group was pregnant third trimester women 1048766 Recording the names of all target-group clients and their expected delivery date to enable follow up1048766 Providing and documenting health education messages delivered by physician and MCH staff
coveringbull - Breastfeeding and its benefits to both mother andbull infantbull - The importance of antenatal and postpartumbull nutritionbull - Maternal and infant postpartum complicationsbull - Maternal and infant postpartum personal hygienebull - Counseling on family planning
PHCI Chronic Illness-Compliance PHCI Chronic Illness-Compliance with Standardswith Standards
4 Prevalence of hypertension in Jordan among those over 25 is 318 while diabetes accounts for 68 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 diabetesUncontrolled diabetesbull 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 uncontrolledbull Solution 1 Define an overall strategy to include specific interventions and a monitoring plan2 Explain to staff the link between applying standards and measuring fasting blood sugar
levels to see results3 Provide the protocols4 Train 3 physicians and 8 nurses on implementing the protocols and completing the
follow up chart5 Discuss monitoring results during the QA team meetings6 Monitor results of Blood Sugar fasting for individual patients for a period of 6
months and prepare reports on results7 Document the percentage of controlled and uncontrolled patients on a monthly basis8 Mark the records of patients with readings higher than 180 to refer them for intensive
counseling9 Report the results on the QA Coordinator monthly reports
PHCIPHCI5 Training nursing personnel6 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 bull Lessons A combination of conducting training assigning responsibility and providing quality
services facilitates introduction and maintenance of new programs1048766 A comprehensive program of promotion education and quality service can increase awareness and
demand for the service1048766 Screening programs can successfully detect new cases1048766 Screening programs provide an opportunity for introducing other relevant health messages for
example breastfeeding explanations were included during the screening process7 Improving client flow in the clinics8 Strengthening health educationbull Problem Staff were often unprepared to deliver a lecture did not adequately plan for them
and had poor presentation skills1048766 Promotion of health education sessions was ineffective1048766 Client needs for specific health information were not surveyed
Health Systems Strengthening Health Systems Strengthening Project (HSSP)Project (HSSP)
bull 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
bull 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
bull Objectives ndash Improve the quality of health care servicesndash Develop and implement certification and accreditation systems for health care
facilities and service providersndash Computerize the health management information system networksndash Expand the health clinicsrsquo outreach to their local communities ndash Improve safe motherhood and neonatal health care related services at primary
health care centers and hospitalsndash Renovate and upgrade up to 28 hospitals and 32 primary health clinics belonging
to the Ministry of Health and the Royal Medical Services
NorthNorth
1 Al Manshieh Health CenterIrbid2 Al-Razi Health CenterIrbid3 Eidoun Health CenterIrbid4 Beit Eides Health CenterIrbid5 Huwara Health CenterIrbid6 Um-Qais HealthCenterIrbid7 Hai Al-Hussein Health CenterMafrak8 Rawdat Al-Amirah Basmah Health CenterMafrak9 Al Amir Hasan Health CenterAjloun10Jerash Health CenterJerash11Souf Health CenterJerash
Primary Health Care Initiatives Primary Health Care Initiatives Project USAID and MOH 1994Project 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 1048766 Seventy Quality Assurance Coordinators are facilitating a quality improvement process at the health centers
3 1048766 Twelve research teams were prepared to study and disseminate findings on clinical and management issues
4 1048766 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 1048766 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 1048766 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 PHCI Achievements and Lessons LearntLearnt
1 Building effective referral systemsbull 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 importantCounseling 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 LearntPHCI Achievements and Lessons Learnt2 Reproductive health utilizationProblem The primary health care system in Jordan has not established a calculation
for determining an adequate reproductive health service utilization rate bull Availability of other government and private facilities makes it difficult to assess
whether client need is underserved at the primary health care levelbull Figures for postpartum care and family planning are consistently and significantly
lower than antenatal care inequitable utilization of services by womenbull Consequently the health risk for newborns and their mothers is increased andbull opportunities that have proven effective for introducing family planning
counseling are missedbull IUD servicesalthough requested were not available (limited method choice)Solution IUD insertion unit established in 2001bull Awareness raising campaign focusing on the significance and availability of
family planning and particularly IUD services in the center usingbull - Home visitsbull - Counseling clients about the services of the center
- Educational sessions for the local community
PHCI Achievements and Lessons LearntPHCI Achievements and Lessons Learnt3 Increasing post-partum care utilizationProblem Low post partum care utilization Clients are not aware of the need for postpartum careSolution Increase utilization by1048766 Promote awareness of postpartum services in the community1048766 Inform all female patients especially MCH clients about available postpartum services1048766 Create a brochure for women containing information about maternal care1048766 Develop a register to log the number of expectant mothers their addresses and expected date of
delivery to enable follow-up1048766 Provide counseling about postpartum services during antenatal services1048766 Contact women who missed their postpartum appointment by phone and home visitsbull Raise the awareness of pregnant women about the importance of care in the postpartum
periodbull The target group was pregnant third trimester women 1048766 Recording the names of all target-group clients and their expected delivery date to enable follow up1048766 Providing and documenting health education messages delivered by physician and MCH staff
coveringbull - Breastfeeding and its benefits to both mother andbull infantbull - The importance of antenatal and postpartumbull nutritionbull - Maternal and infant postpartum complicationsbull - Maternal and infant postpartum personal hygienebull - Counseling on family planning
PHCI Chronic Illness-Compliance PHCI Chronic Illness-Compliance with Standardswith Standards
4 Prevalence of hypertension in Jordan among those over 25 is 318 while diabetes accounts for 68 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 diabetesUncontrolled diabetesbull 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 uncontrolledbull Solution 1 Define an overall strategy to include specific interventions and a monitoring plan2 Explain to staff the link between applying standards and measuring fasting blood sugar
levels to see results3 Provide the protocols4 Train 3 physicians and 8 nurses on implementing the protocols and completing the
follow up chart5 Discuss monitoring results during the QA team meetings6 Monitor results of Blood Sugar fasting for individual patients for a period of 6
months and prepare reports on results7 Document the percentage of controlled and uncontrolled patients on a monthly basis8 Mark the records of patients with readings higher than 180 to refer them for intensive
counseling9 Report the results on the QA Coordinator monthly reports
PHCIPHCI5 Training nursing personnel6 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 bull Lessons A combination of conducting training assigning responsibility and providing quality
services facilitates introduction and maintenance of new programs1048766 A comprehensive program of promotion education and quality service can increase awareness and
demand for the service1048766 Screening programs can successfully detect new cases1048766 Screening programs provide an opportunity for introducing other relevant health messages for
example breastfeeding explanations were included during the screening process7 Improving client flow in the clinics8 Strengthening health educationbull Problem Staff were often unprepared to deliver a lecture did not adequately plan for them
and had poor presentation skills1048766 Promotion of health education sessions was ineffective1048766 Client needs for specific health information were not surveyed
Health Systems Strengthening Health Systems Strengthening Project (HSSP)Project (HSSP)
bull 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
bull 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
bull Objectives ndash Improve the quality of health care servicesndash Develop and implement certification and accreditation systems for health care
facilities and service providersndash Computerize the health management information system networksndash Expand the health clinicsrsquo outreach to their local communities ndash Improve safe motherhood and neonatal health care related services at primary
health care centers and hospitalsndash Renovate and upgrade up to 28 hospitals and 32 primary health clinics belonging
to the Ministry of Health and the Royal Medical Services
Primary Health Care Initiatives Primary Health Care Initiatives Project USAID and MOH 1994Project 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 1048766 Seventy Quality Assurance Coordinators are facilitating a quality improvement process at the health centers
3 1048766 Twelve research teams were prepared to study and disseminate findings on clinical and management issues
4 1048766 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 1048766 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 1048766 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 PHCI Achievements and Lessons LearntLearnt
1 Building effective referral systemsbull 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 importantCounseling 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 LearntPHCI Achievements and Lessons Learnt2 Reproductive health utilizationProblem The primary health care system in Jordan has not established a calculation
for determining an adequate reproductive health service utilization rate bull Availability of other government and private facilities makes it difficult to assess
whether client need is underserved at the primary health care levelbull Figures for postpartum care and family planning are consistently and significantly
lower than antenatal care inequitable utilization of services by womenbull Consequently the health risk for newborns and their mothers is increased andbull opportunities that have proven effective for introducing family planning
counseling are missedbull IUD servicesalthough requested were not available (limited method choice)Solution IUD insertion unit established in 2001bull Awareness raising campaign focusing on the significance and availability of
family planning and particularly IUD services in the center usingbull - Home visitsbull - Counseling clients about the services of the center
- Educational sessions for the local community
PHCI Achievements and Lessons LearntPHCI Achievements and Lessons Learnt3 Increasing post-partum care utilizationProblem Low post partum care utilization Clients are not aware of the need for postpartum careSolution Increase utilization by1048766 Promote awareness of postpartum services in the community1048766 Inform all female patients especially MCH clients about available postpartum services1048766 Create a brochure for women containing information about maternal care1048766 Develop a register to log the number of expectant mothers their addresses and expected date of
delivery to enable follow-up1048766 Provide counseling about postpartum services during antenatal services1048766 Contact women who missed their postpartum appointment by phone and home visitsbull Raise the awareness of pregnant women about the importance of care in the postpartum
periodbull The target group was pregnant third trimester women 1048766 Recording the names of all target-group clients and their expected delivery date to enable follow up1048766 Providing and documenting health education messages delivered by physician and MCH staff
coveringbull - Breastfeeding and its benefits to both mother andbull infantbull - The importance of antenatal and postpartumbull nutritionbull - Maternal and infant postpartum complicationsbull - Maternal and infant postpartum personal hygienebull - Counseling on family planning
PHCI Chronic Illness-Compliance PHCI Chronic Illness-Compliance with Standardswith Standards
4 Prevalence of hypertension in Jordan among those over 25 is 318 while diabetes accounts for 68 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 diabetesUncontrolled diabetesbull 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 uncontrolledbull Solution 1 Define an overall strategy to include specific interventions and a monitoring plan2 Explain to staff the link between applying standards and measuring fasting blood sugar
levels to see results3 Provide the protocols4 Train 3 physicians and 8 nurses on implementing the protocols and completing the
follow up chart5 Discuss monitoring results during the QA team meetings6 Monitor results of Blood Sugar fasting for individual patients for a period of 6
months and prepare reports on results7 Document the percentage of controlled and uncontrolled patients on a monthly basis8 Mark the records of patients with readings higher than 180 to refer them for intensive
counseling9 Report the results on the QA Coordinator monthly reports
PHCIPHCI5 Training nursing personnel6 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 bull Lessons A combination of conducting training assigning responsibility and providing quality
services facilitates introduction and maintenance of new programs1048766 A comprehensive program of promotion education and quality service can increase awareness and
demand for the service1048766 Screening programs can successfully detect new cases1048766 Screening programs provide an opportunity for introducing other relevant health messages for
example breastfeeding explanations were included during the screening process7 Improving client flow in the clinics8 Strengthening health educationbull Problem Staff were often unprepared to deliver a lecture did not adequately plan for them
and had poor presentation skills1048766 Promotion of health education sessions was ineffective1048766 Client needs for specific health information were not surveyed
Health Systems Strengthening Health Systems Strengthening Project (HSSP)Project (HSSP)
bull 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
bull 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
bull Objectives ndash Improve the quality of health care servicesndash Develop and implement certification and accreditation systems for health care
facilities and service providersndash Computerize the health management information system networksndash Expand the health clinicsrsquo outreach to their local communities ndash Improve safe motherhood and neonatal health care related services at primary
health care centers and hospitalsndash Renovate and upgrade up to 28 hospitals and 32 primary health clinics belonging
to the Ministry of Health and the Royal Medical Services
PHCI Achievements and Lessons PHCI Achievements and Lessons LearntLearnt
1 Building effective referral systemsbull 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 importantCounseling 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 LearntPHCI Achievements and Lessons Learnt2 Reproductive health utilizationProblem The primary health care system in Jordan has not established a calculation
for determining an adequate reproductive health service utilization rate bull Availability of other government and private facilities makes it difficult to assess
whether client need is underserved at the primary health care levelbull Figures for postpartum care and family planning are consistently and significantly
lower than antenatal care inequitable utilization of services by womenbull Consequently the health risk for newborns and their mothers is increased andbull opportunities that have proven effective for introducing family planning
counseling are missedbull IUD servicesalthough requested were not available (limited method choice)Solution IUD insertion unit established in 2001bull Awareness raising campaign focusing on the significance and availability of
family planning and particularly IUD services in the center usingbull - Home visitsbull - Counseling clients about the services of the center
- Educational sessions for the local community
PHCI Achievements and Lessons LearntPHCI Achievements and Lessons Learnt3 Increasing post-partum care utilizationProblem Low post partum care utilization Clients are not aware of the need for postpartum careSolution Increase utilization by1048766 Promote awareness of postpartum services in the community1048766 Inform all female patients especially MCH clients about available postpartum services1048766 Create a brochure for women containing information about maternal care1048766 Develop a register to log the number of expectant mothers their addresses and expected date of
delivery to enable follow-up1048766 Provide counseling about postpartum services during antenatal services1048766 Contact women who missed their postpartum appointment by phone and home visitsbull Raise the awareness of pregnant women about the importance of care in the postpartum
periodbull The target group was pregnant third trimester women 1048766 Recording the names of all target-group clients and their expected delivery date to enable follow up1048766 Providing and documenting health education messages delivered by physician and MCH staff
coveringbull - Breastfeeding and its benefits to both mother andbull infantbull - The importance of antenatal and postpartumbull nutritionbull - Maternal and infant postpartum complicationsbull - Maternal and infant postpartum personal hygienebull - Counseling on family planning
PHCI Chronic Illness-Compliance PHCI Chronic Illness-Compliance with Standardswith Standards
4 Prevalence of hypertension in Jordan among those over 25 is 318 while diabetes accounts for 68 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 diabetesUncontrolled diabetesbull 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 uncontrolledbull Solution 1 Define an overall strategy to include specific interventions and a monitoring plan2 Explain to staff the link between applying standards and measuring fasting blood sugar
levels to see results3 Provide the protocols4 Train 3 physicians and 8 nurses on implementing the protocols and completing the
follow up chart5 Discuss monitoring results during the QA team meetings6 Monitor results of Blood Sugar fasting for individual patients for a period of 6
months and prepare reports on results7 Document the percentage of controlled and uncontrolled patients on a monthly basis8 Mark the records of patients with readings higher than 180 to refer them for intensive
counseling9 Report the results on the QA Coordinator monthly reports
PHCIPHCI5 Training nursing personnel6 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 bull Lessons A combination of conducting training assigning responsibility and providing quality
services facilitates introduction and maintenance of new programs1048766 A comprehensive program of promotion education and quality service can increase awareness and
demand for the service1048766 Screening programs can successfully detect new cases1048766 Screening programs provide an opportunity for introducing other relevant health messages for
example breastfeeding explanations were included during the screening process7 Improving client flow in the clinics8 Strengthening health educationbull Problem Staff were often unprepared to deliver a lecture did not adequately plan for them
and had poor presentation skills1048766 Promotion of health education sessions was ineffective1048766 Client needs for specific health information were not surveyed
Health Systems Strengthening Health Systems Strengthening Project (HSSP)Project (HSSP)
bull 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
bull 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
bull Objectives ndash Improve the quality of health care servicesndash Develop and implement certification and accreditation systems for health care
facilities and service providersndash Computerize the health management information system networksndash Expand the health clinicsrsquo outreach to their local communities ndash Improve safe motherhood and neonatal health care related services at primary
health care centers and hospitalsndash Renovate and upgrade up to 28 hospitals and 32 primary health clinics belonging
to the Ministry of Health and the Royal Medical Services
PHCI Achievements and Lessons LearntPHCI Achievements and Lessons Learnt2 Reproductive health utilizationProblem The primary health care system in Jordan has not established a calculation
for determining an adequate reproductive health service utilization rate bull Availability of other government and private facilities makes it difficult to assess
whether client need is underserved at the primary health care levelbull Figures for postpartum care and family planning are consistently and significantly
lower than antenatal care inequitable utilization of services by womenbull Consequently the health risk for newborns and their mothers is increased andbull opportunities that have proven effective for introducing family planning
counseling are missedbull IUD servicesalthough requested were not available (limited method choice)Solution IUD insertion unit established in 2001bull Awareness raising campaign focusing on the significance and availability of
family planning and particularly IUD services in the center usingbull - Home visitsbull - Counseling clients about the services of the center
- Educational sessions for the local community
PHCI Achievements and Lessons LearntPHCI Achievements and Lessons Learnt3 Increasing post-partum care utilizationProblem Low post partum care utilization Clients are not aware of the need for postpartum careSolution Increase utilization by1048766 Promote awareness of postpartum services in the community1048766 Inform all female patients especially MCH clients about available postpartum services1048766 Create a brochure for women containing information about maternal care1048766 Develop a register to log the number of expectant mothers their addresses and expected date of
delivery to enable follow-up1048766 Provide counseling about postpartum services during antenatal services1048766 Contact women who missed their postpartum appointment by phone and home visitsbull Raise the awareness of pregnant women about the importance of care in the postpartum
periodbull The target group was pregnant third trimester women 1048766 Recording the names of all target-group clients and their expected delivery date to enable follow up1048766 Providing and documenting health education messages delivered by physician and MCH staff
coveringbull - Breastfeeding and its benefits to both mother andbull infantbull - The importance of antenatal and postpartumbull nutritionbull - Maternal and infant postpartum complicationsbull - Maternal and infant postpartum personal hygienebull - Counseling on family planning
PHCI Chronic Illness-Compliance PHCI Chronic Illness-Compliance with Standardswith Standards
4 Prevalence of hypertension in Jordan among those over 25 is 318 while diabetes accounts for 68 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 diabetesUncontrolled diabetesbull 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 uncontrolledbull Solution 1 Define an overall strategy to include specific interventions and a monitoring plan2 Explain to staff the link between applying standards and measuring fasting blood sugar
levels to see results3 Provide the protocols4 Train 3 physicians and 8 nurses on implementing the protocols and completing the
follow up chart5 Discuss monitoring results during the QA team meetings6 Monitor results of Blood Sugar fasting for individual patients for a period of 6
months and prepare reports on results7 Document the percentage of controlled and uncontrolled patients on a monthly basis8 Mark the records of patients with readings higher than 180 to refer them for intensive
counseling9 Report the results on the QA Coordinator monthly reports
PHCIPHCI5 Training nursing personnel6 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 bull Lessons A combination of conducting training assigning responsibility and providing quality
services facilitates introduction and maintenance of new programs1048766 A comprehensive program of promotion education and quality service can increase awareness and
demand for the service1048766 Screening programs can successfully detect new cases1048766 Screening programs provide an opportunity for introducing other relevant health messages for
example breastfeeding explanations were included during the screening process7 Improving client flow in the clinics8 Strengthening health educationbull Problem Staff were often unprepared to deliver a lecture did not adequately plan for them
and had poor presentation skills1048766 Promotion of health education sessions was ineffective1048766 Client needs for specific health information were not surveyed
Health Systems Strengthening Health Systems Strengthening Project (HSSP)Project (HSSP)
bull 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
bull 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
bull Objectives ndash Improve the quality of health care servicesndash Develop and implement certification and accreditation systems for health care
facilities and service providersndash Computerize the health management information system networksndash Expand the health clinicsrsquo outreach to their local communities ndash Improve safe motherhood and neonatal health care related services at primary
health care centers and hospitalsndash Renovate and upgrade up to 28 hospitals and 32 primary health clinics belonging
to the Ministry of Health and the Royal Medical Services
PHCI Achievements and Lessons LearntPHCI Achievements and Lessons Learnt3 Increasing post-partum care utilizationProblem Low post partum care utilization Clients are not aware of the need for postpartum careSolution Increase utilization by1048766 Promote awareness of postpartum services in the community1048766 Inform all female patients especially MCH clients about available postpartum services1048766 Create a brochure for women containing information about maternal care1048766 Develop a register to log the number of expectant mothers their addresses and expected date of
delivery to enable follow-up1048766 Provide counseling about postpartum services during antenatal services1048766 Contact women who missed their postpartum appointment by phone and home visitsbull Raise the awareness of pregnant women about the importance of care in the postpartum
periodbull The target group was pregnant third trimester women 1048766 Recording the names of all target-group clients and their expected delivery date to enable follow up1048766 Providing and documenting health education messages delivered by physician and MCH staff
coveringbull - Breastfeeding and its benefits to both mother andbull infantbull - The importance of antenatal and postpartumbull nutritionbull - Maternal and infant postpartum complicationsbull - Maternal and infant postpartum personal hygienebull - Counseling on family planning
PHCI Chronic Illness-Compliance PHCI Chronic Illness-Compliance with Standardswith Standards
4 Prevalence of hypertension in Jordan among those over 25 is 318 while diabetes accounts for 68 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 diabetesUncontrolled diabetesbull 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 uncontrolledbull Solution 1 Define an overall strategy to include specific interventions and a monitoring plan2 Explain to staff the link between applying standards and measuring fasting blood sugar
levels to see results3 Provide the protocols4 Train 3 physicians and 8 nurses on implementing the protocols and completing the
follow up chart5 Discuss monitoring results during the QA team meetings6 Monitor results of Blood Sugar fasting for individual patients for a period of 6
months and prepare reports on results7 Document the percentage of controlled and uncontrolled patients on a monthly basis8 Mark the records of patients with readings higher than 180 to refer them for intensive
counseling9 Report the results on the QA Coordinator monthly reports
PHCIPHCI5 Training nursing personnel6 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 bull Lessons A combination of conducting training assigning responsibility and providing quality
services facilitates introduction and maintenance of new programs1048766 A comprehensive program of promotion education and quality service can increase awareness and
demand for the service1048766 Screening programs can successfully detect new cases1048766 Screening programs provide an opportunity for introducing other relevant health messages for
example breastfeeding explanations were included during the screening process7 Improving client flow in the clinics8 Strengthening health educationbull Problem Staff were often unprepared to deliver a lecture did not adequately plan for them
and had poor presentation skills1048766 Promotion of health education sessions was ineffective1048766 Client needs for specific health information were not surveyed
Health Systems Strengthening Health Systems Strengthening Project (HSSP)Project (HSSP)
bull 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
bull 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
bull Objectives ndash Improve the quality of health care servicesndash Develop and implement certification and accreditation systems for health care
facilities and service providersndash Computerize the health management information system networksndash Expand the health clinicsrsquo outreach to their local communities ndash Improve safe motherhood and neonatal health care related services at primary
health care centers and hospitalsndash Renovate and upgrade up to 28 hospitals and 32 primary health clinics belonging
to the Ministry of Health and the Royal Medical Services
PHCI Chronic Illness-Compliance PHCI Chronic Illness-Compliance with Standardswith Standards
4 Prevalence of hypertension in Jordan among those over 25 is 318 while diabetes accounts for 68 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 diabetesUncontrolled diabetesbull 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 uncontrolledbull Solution 1 Define an overall strategy to include specific interventions and a monitoring plan2 Explain to staff the link between applying standards and measuring fasting blood sugar
levels to see results3 Provide the protocols4 Train 3 physicians and 8 nurses on implementing the protocols and completing the
follow up chart5 Discuss monitoring results during the QA team meetings6 Monitor results of Blood Sugar fasting for individual patients for a period of 6
months and prepare reports on results7 Document the percentage of controlled and uncontrolled patients on a monthly basis8 Mark the records of patients with readings higher than 180 to refer them for intensive
counseling9 Report the results on the QA Coordinator monthly reports
PHCIPHCI5 Training nursing personnel6 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 bull Lessons A combination of conducting training assigning responsibility and providing quality
services facilitates introduction and maintenance of new programs1048766 A comprehensive program of promotion education and quality service can increase awareness and
demand for the service1048766 Screening programs can successfully detect new cases1048766 Screening programs provide an opportunity for introducing other relevant health messages for
example breastfeeding explanations were included during the screening process7 Improving client flow in the clinics8 Strengthening health educationbull Problem Staff were often unprepared to deliver a lecture did not adequately plan for them
and had poor presentation skills1048766 Promotion of health education sessions was ineffective1048766 Client needs for specific health information were not surveyed
Health Systems Strengthening Health Systems Strengthening Project (HSSP)Project (HSSP)
bull 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
bull 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
bull Objectives ndash Improve the quality of health care servicesndash Develop and implement certification and accreditation systems for health care
facilities and service providersndash Computerize the health management information system networksndash Expand the health clinicsrsquo outreach to their local communities ndash Improve safe motherhood and neonatal health care related services at primary
health care centers and hospitalsndash Renovate and upgrade up to 28 hospitals and 32 primary health clinics belonging
to the Ministry of Health and the Royal Medical Services
Uncontrolled diabetesUncontrolled diabetesbull 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 uncontrolledbull Solution 1 Define an overall strategy to include specific interventions and a monitoring plan2 Explain to staff the link between applying standards and measuring fasting blood sugar
levels to see results3 Provide the protocols4 Train 3 physicians and 8 nurses on implementing the protocols and completing the
follow up chart5 Discuss monitoring results during the QA team meetings6 Monitor results of Blood Sugar fasting for individual patients for a period of 6
months and prepare reports on results7 Document the percentage of controlled and uncontrolled patients on a monthly basis8 Mark the records of patients with readings higher than 180 to refer them for intensive
counseling9 Report the results on the QA Coordinator monthly reports
PHCIPHCI5 Training nursing personnel6 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 bull Lessons A combination of conducting training assigning responsibility and providing quality
services facilitates introduction and maintenance of new programs1048766 A comprehensive program of promotion education and quality service can increase awareness and
demand for the service1048766 Screening programs can successfully detect new cases1048766 Screening programs provide an opportunity for introducing other relevant health messages for
example breastfeeding explanations were included during the screening process7 Improving client flow in the clinics8 Strengthening health educationbull Problem Staff were often unprepared to deliver a lecture did not adequately plan for them
and had poor presentation skills1048766 Promotion of health education sessions was ineffective1048766 Client needs for specific health information were not surveyed
Health Systems Strengthening Health Systems Strengthening Project (HSSP)Project (HSSP)
bull 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
bull 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
bull Objectives ndash Improve the quality of health care servicesndash Develop and implement certification and accreditation systems for health care
facilities and service providersndash Computerize the health management information system networksndash Expand the health clinicsrsquo outreach to their local communities ndash Improve safe motherhood and neonatal health care related services at primary
health care centers and hospitalsndash Renovate and upgrade up to 28 hospitals and 32 primary health clinics belonging
to the Ministry of Health and the Royal Medical Services
PHCIPHCI5 Training nursing personnel6 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 bull Lessons A combination of conducting training assigning responsibility and providing quality
services facilitates introduction and maintenance of new programs1048766 A comprehensive program of promotion education and quality service can increase awareness and
demand for the service1048766 Screening programs can successfully detect new cases1048766 Screening programs provide an opportunity for introducing other relevant health messages for
example breastfeeding explanations were included during the screening process7 Improving client flow in the clinics8 Strengthening health educationbull Problem Staff were often unprepared to deliver a lecture did not adequately plan for them
and had poor presentation skills1048766 Promotion of health education sessions was ineffective1048766 Client needs for specific health information were not surveyed
Health Systems Strengthening Health Systems Strengthening Project (HSSP)Project (HSSP)
bull 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
bull 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
bull Objectives ndash Improve the quality of health care servicesndash Develop and implement certification and accreditation systems for health care
facilities and service providersndash Computerize the health management information system networksndash Expand the health clinicsrsquo outreach to their local communities ndash Improve safe motherhood and neonatal health care related services at primary
health care centers and hospitalsndash Renovate and upgrade up to 28 hospitals and 32 primary health clinics belonging
to the Ministry of Health and the Royal Medical Services
Health Systems Strengthening Health Systems Strengthening Project (HSSP)Project (HSSP)
bull 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
bull 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
bull Objectives ndash Improve the quality of health care servicesndash Develop and implement certification and accreditation systems for health care
facilities and service providersndash Computerize the health management information system networksndash Expand the health clinicsrsquo outreach to their local communities ndash Improve safe motherhood and neonatal health care related services at primary
health care centers and hospitalsndash Renovate and upgrade up to 28 hospitals and 32 primary health clinics belonging
to the Ministry of Health and the Royal Medical Services