the impact of syrian refugees on the health sector in jordan by dr musa t ajlouni

The Impact of Syrian Refugeeson the Jordanian Health Sector:

Challenges and Policy Directions

The Impact of Syrian Refugees onthe Jordanian Health Sector:

Challenges and Policy Directions

Conference on Syrian Refugees in Jordan: The Question of Society and MediaConference on Syrian Refugees in Jordan: The Question of Society and Media

88--1010 DecDec 20142014 ––Kempinski Hotel Dead SeaKempinski Hotel Dead Sea

Dr. Musa T. AjlouniDr. Musa T. AjlouniPhiladelphia UniversityPhiladelphia University

Objectives of the Study:Objectives of the Study:

1.1. To explore the burden of the Syrian refugeesTo explore the burden of the Syrian refugeeson the health care sector in Jordanon the health care sector in Jordan

2.2. To highlight the main challenges related to thisTo highlight the main challenges related to thisburdenburden

3.3. To suggest policy directions to meet theseTo suggest policy directions to meet thesechallenges.challenges.

MethodologyMethodology

•• This is a qualitative study that adopted a descriptive andThis is a qualitative study that adopted a descriptive andanalytical methodology based mainly on secondaryanalytical methodology based mainly on secondaryinformation.information.

•• Data were compiled and analysed from reports,Data were compiled and analysed from reports,evaluations and web sites related to the Ministry ofevaluations and web sites related to the Ministry ofHealth (MOH), World Health Organization, High HealthHealth (MOH), World Health Organization, High HealthCouncil, Department of Statistics, Ministry of Planning,Council, Department of Statistics, Ministry of Planning,and National and International Organizations.and National and International Organizations.

•• Personal and telephone interviews were conducted withPersonal and telephone interviews were conducted withidentified representatives from MOH and other healthidentified representatives from MOH and other healthcare sectors to fill in the gaps from the reports.care sectors to fill in the gaps from the reports.

Findings and ResultsFindings and Results

UNHCR Registered SyriansUNHCR Registered Syriansas ofas of 2525 OctoberOctober 20142014

54%620,016(25 Oct.2014)

SyrianrefugeesregisteredwithUNHCR

15.7%Camps

84.3%Urban

Official Figure for SRs(2014) 1,400,000

Planned Figures of SRs Registered byPlanned Figures of SRs Registered byUNHCR forUNHCR for 20152015

2014 2015 + %

620,016 937,830 51%

Distribution of Syrian Refugees according to AgeDistribution of Syrian Refugees according to AgeGroupsGroups

Age GroupMale %Female%Total%

4 -09.29.218.4

11-510.510.220.7

17-127.47.214.6

59-1819.223.843

+601.41.93.3

Total47.752.3100

(1)Screeningand First

Aid

(2)PHCand

BasicSecondary

(3)Primary

+Secondary

+Tertiary

RMS+

DonorsMostlyDonors

MostlyMOH

ServiceLevel

Place

ServiceProvider

Providers of Health Services to Syrian Refugees

Boarders Camps Cities

Syrian Refugees are Granted Access toHealth Services as Jordanians

“Jordan provides asylum for a large number“Jordan provides asylum for a large number

of refugees, including from Syria and Iraq.of refugees, including from Syria and Iraq.

It hasIt has granted Syrian refugees access togranted Syrian refugees access to

services, such as health and education,services, such as health and education,

in host communities.in host communities.””

Percentage of Syrian Patients per totalPercentage of Syrian Patients per totalPatients by GovernoratesPatients by Governorates

Source: Ministry of Planning and International Cooperation: Needs Assessment Review of the Impact of the SyrianCrisis on Jordan, November 2013

The Burden on MOH hospitalsThe Burden on MOH hospitals



•• RamthaRamtha Government Hospital, reports havingGovernment Hospital, reports havingreceivedreceived 2525,,000000 war wounded Syrian refugeeswar wounded Syrian refugeesinin 20132013. Seven thousand were admitted to the. Seven thousand were admitted to thehospital, whilehospital, while 1919,,000000 were referred to otherwere referred to otherhospitals in the Kingdom.hospitals in the Kingdom.

Source: Ministry of Planning and International Cooperation :National Resilience Plan(2014-2016)

Syrian refugees attended MOHSyrian refugees attended MOHHospitals JanHospitals Jan 20122012 --AugustAugust 20132013

Syrian refugees attended MOH PHCSyrian refugees attended MOH PHC CentersCentersJanJan 20122012 --AugustAugust 20132013


Syrian refugee cancer and renal failure casesSyrian refugee cancer and renal failure casespresenting at health facilities in Jordanpresenting at health facilities in Jordan

Year Cancer Cases Renal Failure

2011 134 120

2012 188 176

2013 317 300

Source: Ministry of Planning and International Cooperation: Needs Assessment Review of the Impact of the Syrian Crisis on Jordan, November2013

Morbidity Picture among Syrian RefugeesMorbidity Picture among Syrian Refugees


Source: Ministry of Planning and International Cooperation: Needs Assessment Review of the Impact of the Syrian Crisis on Jordan, November2013

The Health Sector in JordanThe Health Sector in Jordan

Health Care System Achievements

•• Extensive network of PHC facilitiesExtensive network of PHC facilities

•• High bed/population ratesHigh bed/population rates

•• Physician to population ratio is higher than most ofPhysician to population ratio is higher than most ofMENAMENA

•• Highly skilled HRHHighly skilled HRH

•• Strong higher education systemStrong higher education system

•• 7575 toto 8080 % of the population in Jordan is covered by% of the population in Jordan is covered byformal health insuranceformal health insurance

Health Care System Achievements

•• MOH provides health safety net for allMOH provides health safety net for all

•• Government commitmentGovernment commitment

•• Improvement in health indicatorsImprovement in health indicators

•• Modern health care infrastructuresModern health care infrastructures

•• Accreditation ProgramAccreditation Program

•• Medical TourismMedical Tourism

222/19/2

Jordan Ranks 83/191 According to WHO Rankingof the World’s Health SystemsSystems

23

1 France2 Italy3 San Marino4 Andorra5 Malta6 Singapore7 Spain8 Oman9 Austria10 Japan11 Norway12 Portugal13 Monaco14 Greece15 Iceland

16 Luxembourg17 Netherlands18 UK19 Ireland20 Switzerland--83 Jordan-----191Sierra Leone

Source:http://www.who.int/healthinfo/paper30.pdf

Human Development Index, JordanHuman Development Index, Jordan 20122012Health scored the highestHealth scored the highest

(0.841)(0.700)

Health SystemChallenges

Epidemiological, Socio-economic challenges

Impact of Syrian Refugees on JordanHealth Sector

Health System Challenges

ServiceDelivery

} High occupancy rates in MOHhospitals: Some hospitals such as Princess Basma, Princess Rahma,Ramtha and Mafraq hospital have recorded 100 percent bed occupancy rates.

} At the health centre level, the dailyworkload has increased by 9 to 50percent .

} Hospital beds/10000 pop droppedfrom 18 to 15.1

} Adverse effect on quality of healthservices.

} Longer waiting lists and queues.} More complaints and dissatisfaction

rates.

Impact onHealth Sector

282/19/2

WorkforceHealthWorkforce

All hospitals in Northern governorates} All hospitals in Northern governoratesreported severe staff shortages inmost medical specialties:dermatology, gynecology psychiatry,emergency, orthopedic,anesthesiology, internal,ophthalmology, family medicine,pediatrics and dentistry.

} Sharp increase of the daily workloadof existing specialists, which cannotbe sustained and may lead to Highdrop out rate.


NationalHealthNationalHealth Indicators /Indicators /20132013//20142014

Indicator 2013Without Syrians(6.4 mils)

2014With Syrians(8 mils)

Physician/10000 pop 28.6 23.4Dentist/10000 pop 10.4 8.5Nurse (all categ.)/10000 pop 44.8 36.6Pharmacist/10000 pop 17.8 14.5Hospital beds/10000 pop 18 15.1Hospital beds/10000 pop in Mafraq 8 6Coverage by health care services % 98 90

Estimated

Drugs,

vaccines

Drugs,medicines and

vaccines

Impact on HealthSector

} All hospitals in Northern governoratesreported serious deficiencies in the supplyof vaccines, delivery-related medications,cardio-vascular drugs and oral rehydrationtherapy.

} Re-appearance of polio as a result of therecent outbreak of polio in Syria willrequire massive immunization campaigns.

312/19/2

MedicalTechnology

} Shortage of Medical equipmentin most Northern hospitals andclinics(delivery tables, kidney dialysisunits, emergency trolleys, surgicalequipments and sets, radiology and labequipment, etc.)

} Overuse of medical equipment} Maintenance issues


Financing

} Budget deficit and Shortage of finance tohigher demand and utilization rates

} MOH has already incurred JD 253 million inadditional costs annually.

} Higher expenditure on health(HE) as apercentage of GDP.

} Less expenditure per capita.} Higher percentage of total (HE) on

pharmaceuticals.} Inefficiencies (Over -utilization)


2/19/2

Inequalities} Access to health services is uneven

across Governorates} Higher Out-of- Pocket Spending


•• Out of PocketOut of Pocket

342/19/2

Out of Pocket

35

out-of-pocket expenditure

•• Push some households intoPush some households intopovertypoverty

•• Reduce expenditures onReduce expenditures onother basic needsother basic needs

•• May cause households toMay cause households toforgo seeking health careforgo seeking health careand suffer illnessand suffer illness

35

Risk of financialcatastrophe

Out-of-pockethealth expenditure

362/19/2

Epidemiological, Socio-economic challenges(SDH)

Demography

} Increase of young people} High dependency ratios.} Increasing fertility rates

among Syrians} May slow reaching the

demographic opportunity

SocialDeterminants

challenges

Sources: Department of Statistics 2012; UNHCR projections through end of 2013

Epidemiology

} Increase prevalence rates ofNCDs and injuries.

} Re-emerging of somecommunicable diseases

} Environmental health challenges

SocialDeterminantsChallenges

Socio-economic

} Low economic growth ,high debitrates

} Scarcity of water resources} Unplanned urbanization (about

50% of population lives in GreaterAmman Area).

} High rates of poverty andunemployment

} Unfinished MDGs agenda(beyond2015)

Socio-economicchallenges

Source : REACH ,Evaluating the Effect of the Syrian Refugee Crisis on Stability and Resilience in Jordanian HostCommunities :Preliminary Impact Assessment, January 2014

Tension of Local communitiesTension of Local communities concernedconcernedaffordable housing, education, and health servicesaffordable housing, education, and health services

The Health Index Went Down byThe Health Index Went Down by 1212PointsPoints

0.745

0.829

0.7390.715

Human Development Indexالتنمیة البشریة االجمالي

Health Indexالصحة Education Indexالتعلیم Income Indexالدخل

2014دلیل التنمیة البشریة في االردن لعام Human Development Index,Jordan 2014

Source: UNDP ,Human Development Report 2014

2012

0.841

Proposed Policy Interventionsto Meet Health Sector ChallengesResulting from Syrian Asylum

Proposed Policy InterventionsProposed Policy Interventionsü Significant investment from the donor community should

be secured support MOH budget to reduce the financialgap resulting from the additional case load created by theSyrian refugee influx.

Tertiary

Secondary

Primary

Donors Should Move Vertical Upward

Donors Should Move Horizontally from CampsTo Communities

Reg. RefugeesOutside Camps

Hospital BedsNeeded

No. of FieldHospitals

2014 522334 940 10X(100 beds)2015 790590 482 5x(100 beds)

Field Hospitals Needed to Serve Registered Refugees LivingOutside Camps

ü Expanding the bed, surgical, outpatient, emergency,maternity, lab and other infrastructure capacity of up to20 MOH hospitals and 30 health care centres

üü Strengthen MOH preventive programmesStrengthen MOH preventive programmes

üü Strengthen emergency services capacityStrengthen emergency services capacity

üü Support to human resources development andSupport to human resources development andplanning.planning.

Proposed Policy InterventionsProposed Policy Interventions

Proposed Policy InterventionsProposed Policy Interventions

üü Coordination and control of of international healthCoordination and control of of international healthprograms and services working for Syrianprograms and services working for Syrianrefugees.refugees.

üü Strategic partnership among all health sectors .Strategic partnership among all health sectors .

üü Relying on studies and research to determine realRelying on studies and research to determine realimpact ofimpact of Syrian Asylum on the health sectorSyrian Asylum on the health sector

49

If well implemented the National Resilience PlanIf well implemented the National Resilience Plan 20142014--20162016 willwilltranslate most of the proposed policy directions into actionstranslate most of the proposed policy directions into actions

Health Services for SRs Covered by International Community(Existing Situation)

2/19/2015 51

Pooledfunds

Total health expenditure

% Costcovered

51

Breadth (% SRs covered)

Depth and quality(services covered)

51

Health Services for SRs to be Covered by InternationalCommunity

(Required Situation)

2/19/2015 52

Pooled funds

Total health expenditure

% Costcovered

52

Breadth (% SRs covered)

Depth and quality(services covered)

52

√√

Thank You

the impact of syrian refugees on the health sector in jordan by dr musa t ajlouni

Healthcare