Country profiles

Jordan

Overview

Jordan, with a land area of 91 100 km², lies east of the River Jordan. About 80% of the land area of Jordan is desert. The population is concentrated in the northern and central highlands where the major towns are located, near the River Jordan system, and where rainfall is sufficient to support cultivation. In 1998, the population was estimated at 4 732 000 .The capital, Amman, has grown rapidly over the past 23 years. The population of the Greater Amman Conurbation, which effectively includes Zarqa, Rusaifa, Wadi al Sir and Suwailih, was estimated at 2 089 900. The size of this "city state," which contains nearly 53% of the country’s overall population, is a cause of anxiety for economic planners. The percentages of population below 15 years and above 65 years of age, in 1995, were 41.4% and 2.6%, respectively. Additionally, the total adult literacy rate and the female adult literacy rate, in 1997, were estimated to be 86.2% and 80.9%, respectively. In 1997, infant mortality was estimated at 28 per 1000 live births and in 1996, the probability of dying before reaching the age of five was 39 per 1000 live births. Life expectancy at birth was 68 years in 1997. The crude birth rate per 1000 population was 34 in 1998. The maternal mortality rate, in 1997, was estimated at 4.1 per 10 000 live births. The main causes of death in adults in 1989 were diseases of the circulatory system, diseases of the respiratory system, neoplasms, and injury and poisoning.The per capita gross national product was US$ 1530 in 1997.

The constitution of Jordan states that "health is for all" and that it is the responsibility of the government to make it available to all citizens. There is political commitment at the highest level to achieving the goal for health for all, as manifest in the King Hussein’s speech to parliament affirming the government’s obligation to make health care available to all by the year 2000. The Higher Health Council was established by law and is headed by the Prime Minister; its membership comprises representatives of the various health sectors. This council plays a major role in health planning and in adopting new health strategies.

Three sectors remain the main providers of health in the country, namely the public, the private and the international sector. The public sector is composed of the Ministry of Health (which is the principal provider), the Royal Medical Services, the University of Jordan and the Social Security Organization. The private sector provides services through 29 hospitals with 1563 beds in addition to private clinics and the activities of the nongovernmental organizations. The international sector includes the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) and other UN bodies as well as foreign charity organizations.

The Ministry of Health’s services are provided through a series of primary health care centres and district hospitals. Each of the thirteen districts is self-sufficient in services and referrals to the capital are only made for cases needing specialized tertiary care.

Monitoring and evaluation are conducted at the national level. However, a standard format for monitoring and evaluating the activities of primary health care exists and is being used for assessment purposes. Various training courses, including the leadership development programme organized by the World Health Organization, have been made available for the purpose of increasing the managerial capabilities of staff working at the Ministry of Health.

Primary health care committees have been formed at the level of the health centre and are composed of members of the community. These committees meet regularly in order to identify needs and problems and find solutions. Representatives from these primary health care committees are also members of the Higher Health Council and other councils concerned with health. Communities are also involved in the provision of resources through donation of buildings or plots of land for health centres.

Health education is included in school educational curricula in order to increase awareness of health problems. In addition, health education as a discrete subject has been included in the curricula of nursing and paramedical staff. Moreover, the time allocated to the various health education programmes in the mass media has been increased. Nongovernmental organizations also contribute to the implementation of health strategies by coordinating with the Ministry of Health on various projects. Representatives of the nongovernmental organizations also serve as members of the various health councils.

In 1990, the budget of the Ministry of Health represented 2.1% of the general governmental budget. National health expenditure, including the private sector, represented 7.5% of the GNP in 1997.

In 1997, there were 16.6 physicians per 10 000 population. Of the total number of 5811 physicians, 2545 were working in the private sector, the majority (64%) in urban areas. The distribution of physicians was more or less equitable, the ratio between the highest and lowest rate per 10 000 population being 3:1. The overall number of physicians increased from 11.1 per 10 000 population in 1982 to 16.6 per 10 000 population in 1990. There are still severe shortages, however, of nurses and midwives.

In 1990, there were 28 public and 29 private hospitals with 5753 beds in all. The private hospitals represented only 27% of the total (1563 beds). There were 524 primary health care centres, 214 of which were in rural areas. A major development in the infrastructure of primary health care services is that school health services, maternal and child health services and health education have now been included in the activities of health centres.

When extensive development projects are initiated, a committee is formed made up of representatives from the health sector to determine the effect of such projects on health; for example, the effect of major irrigation projects on the spread of schistosomiasis, or that of various industrial projects on environmental pollution.

The national health plan is part of the socioeconomic development plan and is implemented through a health system based mainly on primary health care. Efforts have been made to orient the private sector towards primary health care by drawing up contracts with physicians in the private sector, making them responsible for performing primary health care duties such as immunization, maternal and child care services, and registration of vital statistics, with occasional referral to health centres for diagnostic purposes. The physicians’ contracts also bind them to work in any catchement area specified by the Ministry of Health.

The real handicapping shortage, however, lies in nursing; it was found that over 91% of health centres do not have even one registered nurse. Furthermore, 88.4% of centres do not have practical nurses, and some centres are subject to a shortage of other staff: 15.9% are short of assistant pharmacists, 85.5% do not have laboratory technicians and 79.7% have no statistician.

Existing health centres offer primary health care to 95.5% of the community, and 86.1% of the population can reach these centres in less than 30 minutes; 79% of the target group find these services acceptable and 77.4% actually benefit from them. Two factors have contributed to more effective use of health centres: first, the Ministry of Health has introduced medical visiting cards to be used by patients, each card indicating the specific health centre to be used; and second, all primary health care services including maternal and child health services, school health services and health education, have been grouped into one health centre.

MENTAL HEALTH

Mental health services in Jordan reflect the various changes in the history of the country. Until 1966, mental health services in Jordan were delivered through only one mental hospital in Bethlehem, concerning both East and West Banks. After the 1967 war, patients on the East Bank had no access to the services of this hospital. Hence, the Ministry of Health established a 60-bed mental hospital at Fahis (East Bank), with a specialized clinic three days a week. In 1987, the National Centre for Mental Health was opened to provide mental health services. In 1987, a national committee was formed for the development and implementation of the national programme of mental health.

The mental health services in Jordan consist of the National Centre for Mental Health, with 200 beds, and two public mental hospitals with 390 beds, at Fahis and Na’our. The National Centre for Mental Health has a recognized teaching and training role, promoting training of hospital residents, nurses, social workers, psychologists and medical students. In addition, the Royal Medical Services unit offers 40 beds, and there is one day centre and one rehabilitation centre. There are 31 psychiatric clinics in cities and towns all over the country, although establishment of psychiatric units in general hospitals has not been implemented to date. In the private sector, there are 22 clinics. There are two private hospitals under construction with 118 beds and two geriatric homes with 200 beds.

There are 50 psychiatrists in the country. Of these, 12 work under the health ministry, 3 in the academic departments, 22 in the private sector and 13 in other areas. There are 13 psychologists working for the mental health services. Of these, 8 have BS degrees, 3 have MS degrees, and 2 have PhDs. There are only two psychiatric nurses. There are 24 social workers in the mental health services. In addition, there are over 300 educational psychologists working in the Ministry of Education. There is a psychiatry residency programme with two positions.

The medical undergraduates receive 120 hours devoted to psychiatry and the clinical training consists of clinical work and internship.

The national programme of mental health was formulated by a national committee and discussed in a national workshop in Amman in July 1988.

The programme objectives are: maintaining socioeconomic growth for the improvement of citizens’ quality of life; improving public health services and integrating mental health services therein; preventing mental disorders an promoting public awareness in this respect; and treating mental cases in a more efficient and less costly way. The national mental health programme also outlined the service strategies, training strategies, management strategies and strategies for mental health promotion.

It was envisaged that by 1995, the national mental health programme would provide diagnostic aids in at least 50% of the health centres in the country; establish mental health sections in 50% of public hospitals; establish mental guidance centres in 50% of schools; initiate a programme for mental health promotion; include psychosocial components in the health curricula of educational institutions; and provide rehabilitation centres for, at least, 50% of the mentally handicapped in the country.

During the past nine years, there have been initiatives to train 105 general physicians in mental health and 70 nurses in mental health care, and to start a school mental health programme. Preventive activities have been implemented through primary health care centres, schools and the mass media. Mental health has been promoted through disseminating information to the public, primary health care doctors and leading health administrators.

The problem of drug abuse and dependence is an important priority and it is being tackled in collaboration with other sectors as a national strategy.

A major source of problem has been the limited human resources. Many professionals seek vacancies with better salaries in neighbouring countries while others move to private sectors. Therefore, there is a shortage of qualified psychiatrists in the Ministry of Health. There are also problems in implementing rehabilitation and occupational therapy efficiently. These problems stem from a lack of continuous financial support as well as a lack of experts in this field.

A psychiatric special committee is reviewing the Jordan Mental Health Act. There is also a special committee of the Ministry of Justice planning the amendments to the sectors relevant to mental health in Jordanian criminal law, Jordanian civil law, and the Jordanian law of correct procedures.