A Case Study from Cash&Voucher Assistance for Health

02 Cash & Voucher Assistance for Health Cash & Voucher Assistance for Health 03

Acknowledgements Executive summary

The activities described in this report would not have been possible without vidence is slowly emerging on the use of cash Vulnerable were targeted based on lack the financial support from various donors including Auswärtiges Amt (AA), and voucher assistance (CVA) to reach health of workforce within the household, expenditure, Chaîne du Bonheur (CdB), the Directorate-General for European Civil Protec- outcomes. The key entry point for CVA in debt levels, coping mechanisms adopted as well as tion and Operations (DG ECHO), the EU Regional Trust Fund Ehealth is the strategy Healthcare 2030, which lack of registration. They were identified by Medair in Response to the Syrian Crisis (‘Madad’), and the United Nations Office for aims at Universal Health Coverage (UHC) and access through community health volunteers based on the the Coordination of Humanitarian Affairs (OCHA). Medair would also like to to healthcare when people need it without inducing project’s selection criteria. Medair focused its health acknowledge its health staff and Community Health Volunteers (CHVs), who financial hardships CVA can be useful to improve project on assistance to pregnant women (delivery, have been devoted and tireless in their efforts to reach those in need. access to and utilization of health services in human- antenatal and postnatal care), individuals affected itarian settings, by reducing direct and indirect finan- by non-communicable diseases, acute health needs This report was authored by Stephen Chua, with assistance and reviews by cial barriers and/or by incentivizing the use of free and emergency needs of Jordanian host households. Alex Fergusson, Darine Abu Saadeh, Haneen Abu Laila, Margie Davis, Dominika preventive services. Bednarova and Namseon Beck – all from Medair. The capacity and quality of the supply side of health This study sheds light on the use of cash transfers services, although quite overstretched by the in- This report was reviewed by the Global Health Cluster (GHC) cash task team by Medair in Jordan between 2017 and 2019 as part creasing demand caused by the inflow of refugees and the Cash Learning Partnership (CaLP). The Medair case study helps build of its response to health-related needs of vulnerable to the country, was found to be adequate in Jordan; more evidence on the use of cash transfers for health outcomes. It is a great populations, both and host communities, Jordan’s health system is one of the strongest in example of how an organization integrated cash transfers into their health living in Jordan. the region. However, the preferred option, to ensure response and provides practical considerations on how to implement it. The coverage of vulnerable refugees under the national GHC cash task team and CaLP would like to emphasize that any decision The health and socio-economic impacts of the con- health insurance scheme, continues to experience on cash and voucher assistance (CVA) for health in other contexts needs to flict and displacement meant that much of the refu- gaps in coverage. Furthermore, when international be grounded in a contextual analysis of accessibility and barriers to health gee population in Jordan required access to health partners contract providers directly to purchase ser- needs and a response option analysis. services. While facing different and complex health vices, they are charged foreign rates of up to three needs, refugees living in Jordan have all reported times more than if refugees pay for the services All correspondence should be addressed to (Medair) Margie Davis: barriers in accessing required health services, of themselves. Hence, the next appropriate response [email protected], (WHO) Yassmin Moor: [email protected] or which financial constraints in paying user fees has option was to enable vulnerable populations to ac- (CaLP) Julie Lawson-McDowall: [email protected] been reported as the major one. This created a sig- cess services directly by making cash transfers to nificant barrier to accessing services and is a major patients to overcome financial constraints to ac- This publication of this study is made possible by the generous support of the reason why people postpone or forego healthcare cess healthcare at the time of need. Swiss Agency for Development and Cooperation (SDC). despite increased health needs.

Medair’s project in Jordan aimed to reduce these Refugees living in Jordan have financial barriers and help vulnerable populations ❝ access healthcare in a timely manner. Medair oper- all reported barriers in accessing ated in the governorates where the highest number required health services, of of refugees were present: , Irbid, Mafraq, and Zarqa. Between January 2017 and July 2019, Me- which financial constraints dair provided CVA for health for a total of 8,848 in- in paying user fees has been Cover image: dividuals, of which 6,892 were refugees. Medair also reported as the major one. A Syrian refugee family that received covered emergency health needs of host Jordanian CVA from Medair in Amman, Jordan. ©Medair/Deema Abdallah/2018 households that had been assessed as vulnerable. 04 Cash & Voucher Assistance for Health Cash & Voucher Assistance for Health 05

Acronyms and Abbreviations

disease, the cash transfers were made as a one-off ANC Antenatal care transfer or on a recurring basis. ATM Automated teller machine Based on Medair’s experience in CBO Community-based organization ❝ The cash transfers were predominantly made through CCF Common cash facility Jordan, it is concluded that CVA pre-paid bank cards under the common cash facility CCT Conditional cash transfer was an appropriate modality umbrella and at times through physical cash, also in the case of reimbursements. The amounts were set to CHV Community health volunteer to provide health assistance. include the cost for the delivery, consultations or treat- CS Caesarean section ments, as well as transportation costs in some cases. CVA Cash and voucher assistance FCM Feedback and complaints mechanism Medair conducted post-distribution monitoring and FGD Focus group discussion collected feedback from beneficiaries. Based on Me- GoJ Government of Jordan dair’s experience in Jordan, it is concluded that CVA HAUS Health Access and Utilization Survey When further analysing the feasibility of this ap- was an appropriate modality to provide health assis- proach, in addition to the availability of health servic- tance. Some of the challenges Medair faced could be ICU Intensive Care Unit es of acceptable quality, Medair noted the presence addressed through the following recommendations, JOD Jordanian Dinar of advanced banking systems and other financial made in the report: JRP Jordan Response Plan service providers, familiarity of use by targeted pop- MEAL Monitoring, Evaluation, Accountability and Learning ulations of these services, and relatively low securi- 1) recommendation to agencies implementing CVA MEB Minimum Expenditure Basket ty concerns and other protection-related risks in the for health (including Medair) and the health sector to MoH Ministry of Health case of CVA. Furthermore, the existing conditions standardize definitions of ‘quality care’ and provide combined with the widespread provision of cash as- tools for monitoring and quality on the supply side; MoI Ministry of Interior sistance for basic needs were deemed likely to pro- MoPIC Ministry of Planning and International Cooperation vide an environment where CVA for health would be 2) recommendation to the Global Health Cluster MPC Multipurpose cash used as intended to achieve health outcomes. and research institutions to design and conduct re- NCD Non-communicable disease search to understand the impact of CVA for health NVD Normal vaginal delivery For timely access to health services, Medair provided programmes on health outcomes, behaviours and OOP Out-of-pocket payment unconditional cash transfers for pregnant women to coping mechanisms, cost effectiveness and ad- PDM Post-distribution monitoring cover delivery and to Jordanian households to cover verse financial outcomes (for example, to track the for emergency health needs; conditional cash trans- proportion of the population pushed into poverty, PNC Postnatal care fers to incentivize access to essential public health and/or pushed further into poverty due to out-of- RAIS Refugee Assistance Information System services and preventive services, such as immuniza- pocket payments for health); 3) recommendation to UCT Unconditional cash transfer tion, antenatal care and compliance with consulta- the Government of Jordan and the donor community UHC Universal Health Coverage tions of non-communicable diseases. Under certain to review the functioning of the Multi-Donor Account UNHCR United Nations High Commissioner for Refugees conditions, Medair also provided cash transfers as and its support in the integration of refugees (and/or VAF Vulnerability Assessment Framework reimbursement for seeking health services for acute other vulnerable individuals) into the national health health needs. Depending on whether these were to insurance scheme, applying the same rates as for WHO World Health Organization cover for an emergency need, a delivery or a chronic Jordanians, to achieve Universal Health Coverage. WFP World Food Programme

06 Cash & Voucher Assistance for Health Cash & Voucher Assistance for Health 07 Contextual background Contextual background Contextual background Contextual background Contextual backgroundContextual background Jordan, an upper-middle-income country with a population Jordan, an upper-middle-income country with a population Contextual background Figure 1 Jordan, an upperof-middle close to-income 10 million country people with,8 a is population a host to almost 750,000 01. Introduction UNHCR Registered Persons Jordan, an upper-middle-income country with a population 8 of Concern Jordan Jordan, an upperof-middle close to-income 10 million country 8people with, a is population a host to almost 750,000 Jordan, anof close upper ofto 10close-middle million to people -10income million,8refugees is a hostcountry people to almostof with ,57 750,000 is a nationalities,a population host to almost the 750,000bulk of which – over Jordan, an upper-middle-income country with a pop- refugees of 578 nationalities, the bulk of which – over of refugeesclose toof 1057 nationalities,million people 8the bulk, isof awhich host – toover almost 9 750,000 ulation of close to 10 million people,8 is a host to al- of close to 10refugees million people of 57, 650,000 nationalities,is a host – areto almost fromthe9 Syriabulk 750,000 .of Of which these, –around over 83% are urban Objective of the case study 650,000 – are from 650,000Syria.9 Of these, – are around from 83 % are urban. Of these, around 83% are urban most 750,000 refugees of 57 nationalities, the bulk refugees650,000 of 57 –nationalities, are fromrefugees, Syria the. 9 residing Ofbulk these, of outside aroundwhich of–83 over%camps are urban alongside Jordanian 9 refugeesrefugees, of 57 residing nationalities, outside of camps 9the alongsidebulk of Jordanian which – over of which – over 650,000 – are from Syria. Of these, 650,000 – are fromrefugees, Syria. residingOf these, outside around of83 %camps are urban alongside Jordanian10 citizens, refugees,mostly in Amman, residing9 Irbid,citizens, Mafraq outside and mostly Zarqa of10 camps (inFigure Amman, alongside Irbid, MafraqJordanian and Zarqa (Figure This case study aims to present Medair’s work and financial barriers and support vulnerable populations around 83% are urban refugees, residing outside of 650,000 – are from Syriacitizens,. Of these,mostly around in Amman, 83% Irbid, are urban Mafraq and Zarqa10 (Figure experience in responding to health-related needs of access healthcare in a timely manner. Medair pro- camps alongside Jordanian citizens, mostly in Am- refugees,1). residing outside1). of camps alongside Jordanian10 10 refugees, residingcitizens, outside mostly of in camps Amman, alongside Irbid, Mafraq Jordanian and Zarqa (Figure vulnerable populations, both refugee and host com- gramme’s primary focus is on assistance to preg- man, Irbid, Mafraq and Zarqa (Figure 1). citizens, mostly in1). Amman, Irbid, Mafraq and Zarqa10 (Figure munities, living in Jordan. Medair began providing nant women (delivery, antenatal and postnatal care), citizens, mostly1). in Amman, Irbid, Mafraq and Zarqa10 (Figure 1 5 cash and voucher assistance (CVA) for health in non-communicable diseases , acute health needs and Refugees’ health needs: 1).Refugees’ health needs: Jordan in November 2015. emergency needs of Jordanian host households. 1). The health and socio-economicRefugees’ impacts of the healthconflict and needs: The health and socio-economic impacts of the con- Refugees’ health needs: The purpose of the CVA was for refugees to access2 Medair targets vulnerable populations, where the vul- flict and displacement mean that much of the refu- displacementRefugees’ mean that health much of the needs: refugee population in the existing public health services when they need it. nerability criteria is based on the dependency ratio6 gee population in Jordan require access to health Refugees’Jordan require health access to needs: healthThe services. health A Health and Accesssocio -economic impacts of the conflict and and Utilization SurveyThe (HAUS) health conducted and bysocio UNHCR-economic in 2018 impacts of the conflict and Findings showed that refugees often find themselves of the household size, expenditures, levels of debt, services. A Health Access and Utilization Survey Amman 270,418Refugees’ health needs: displacement mean that much of the refugee population in needing to resort to out-of-pocket payments (OOP)3 the coping mechanisms adopted, as well as lack of (HAUS) conducted by UNHCR in 2018 sampling 400 Irbid 135,992 The health and socio-economic impacts of the conflict and Al Mafraq 86,789 sampling 400 Syrian refugees living in non-camp settings 7 The health and sociodisplacement-economic mean impacts that ofmuch the ofconflict the refugee and population in to access health services. This is particularly prob- registration. Syrian refugees living in non-camp settings found Zarqa 51,437 found thatdisplacement 49% of Syrian refugees meanJordan required that require much healthcare ofaccess the, of refugee to health population services. in A Health Access Al Balqa 21,188The health and socio-economic impacts of the conflict and 11 lematic as it creates a significant barrier to accessing that 49% of Syrian refugees required healthcare, of Madaba 14,380 displacementwhich only 45% havemeanJordan access that to require these much services ofaccess the. refugee to health population services. in A Health Access services and is a major reason why people postpone The below table gives an overview of the project’s which only 45% have access to these services.11 Jarash displacement9,459 Jordanmean that require much accessand of theUtil to refugeeization health Survey population services. (HAUS) A in Health conducted Access by UNHCR in 2018 Ma’an 9,701 4 Jordan require accessand Util toization health Survey services. (HAUS) A Health conducted Access by UNHCR in 2018 or forego healthcare despite increased health needs. scope. More detailed breakdown is provided in later Al Karak 8,876 and Utilization Surveysampling (HAUS) 400 conductedSyrian refugees by UNHCR living in in 2018 non -camp settings Zatari (C) 76,339 Ajloun Jordan6,688 requireA systematic access review toof prevalencehealth services. surveys among A Health 2,799 Access Medair’s project in Jordan has aimed to reduce these sections of the study. A systematic review of prevalence surveys among Figure 1: UNHCR Registered Persons of Concern Jordan sampling 400 Syrian refugees living in non-camp settings Azraq (C) 40, 239 Al 1,908 andSyrian Util refugeesization (including Survey eight (HAUS) studies), conducted found that by29% UNHCR in 2018 2,799 Syrian refugees (including eight studies), El (C) 6,463 Other and780 Utilizationsampling Survey (HAUS) 400 Syrian foundconducted refugees that by49 %UNHCR living of Syrian in in non2018 refugees-camp settingsrequired healthcare, of Total Camps 123,041 Total Urban 621,775 found that 49% of Syrian refugees required healthcare, of found that 29% had a chronic disease, 32.9% had samplinghad a chronic 400 disease, Syrian 32.9 %refugees hadwhich a mental onlyliving health 45 inissue% havenon and- camp access settings to these services.11 Location Beneficiaries Health issues addressed by Medair project 14.4% were living with a physical disability.12 Additionally,sampling the 400 2019 found SyrianVulnerability that refugees Assessment 49% of living SyrianFramework in refugeesnon (VAF)-camp study required settings he althcare11 , of a mental health issue and 14.4% were living with a found that 49% whichof Syrian only refugees 45% have required access tohe thesealthcare services11 , of . 12 reported0- 20,000 20,000 that - 40,000 31% of40,000 Syrian - 60,000 refugee60,000 - 80,000 households80,000 - 185,000 have at least one member with a pre-existing medical condition that physical disability. Additionally, the 2019 Vulnera- found that 49which% of Syrian only 45 refugees% have accessrequired to thesehealthcare services11 , of. 13 which only 45% have access to these services. Amman 8,289 Antenatal care (ANC), normal vaginal bility Assessment Framework (VAF) study reported negatively impacts their daily life. which only 45 % have access toA thesesystematic services review.11 of prevalence surveys among 2,799 deliveries (NVD), caesarian section deliveries, that 31% of Syrian refugee households have at least ian women agedFigure 15 to 149: UNHCRyears were Registered pregnant at the Persons of Concern JordanA systematic review of prevalence surveys among 2,799 Figure 1: UNHCR Registered Persons of Concern Jordan Syrian refugees (including eight studies), found that 29% non-communicable disease, acute health need. one member with a pre-existing medical conditionFigure Among1time: UNHCR of non the- Syriansurvey, Registered refugees,compared Persons Iraqito 5.9% refugeesof ofConcern Jordanian reported Jordan the highestA proportion systematic of household review members of prevalence living with a surveys among 2,799 13 Syrian refugees (including eight studies), found that 29% that negatively impacts their daily life.Figure 1: UNHCRchronicwomen. Registered illness Syrians (42Persons also%) andreportedly of disability Concern have (12 a Jordan %much). This higher was observedA systematic to a lesser extent review among of otherhad prevalence refugeea chronic communities surveys disease, – among 32.9% had2,799 a mental health issue and Irbid 1,295 NVD, caesarian section deliveries, rate of teenage pregnancy (27.8% of Syrian womenA systematic Syrianreview refugees of prevalence (including surveys eight among studies), 2,799 found that 29% Figure 1: UNHCR Registered Yemeni Persons (19%), Sudanese of Concern and Somali Jordan (both 18%).14 The Jordan Population12 and hadFamily a Health chronic Survey disease, (JPFHS) also 32.9 found% had a mental health issue and non-communicable disease, acute health need. Among non-Syrian refugees, Iraqi refugees reported aged 1514.4 to 19,% compared were living to 3.1% withof Jordanians), a physical and disabilitySyrian refugees. Additionally, (including the eight 2019 studies),Vulnerability found Assessment that 29% Framework (VAF) study that 10.6% of Syrian women aged 15 to 49 yearsSyrian were 12refugees pregnanthad at (includingthe a chronictime of the eightdisease, survey, studies), compare 32.9%d tohadfound 5.9 %a of mentalthat 29 health% issue and the highest proportion of household members living14.4 higher% were fertility living rate among with women a physical aged 15 to disability 4912 (4.7 had. Additionally, a chronic disease, the 2019 32.9 Vulnerability% had a mental Assessment health issue Framework and (VAF) study ANC, NVD, caesarian section deliveries, Jordanianreported women. Syrians 15that 31also% reportedly of Syrian have refugee a much higher households rate of teenage have pregnancy at least (27.8 one% ofmember Syrian women with a pre-existing medical condition that Mafraq 5,170 with a chronic illness (42%) and disability14.4 (12%).% This were asliving opposed with to 2.6). a physical disability12 . had Additionally, a chronic disease,the 2019 32.9 Vulnerability% had a mental Assessment health Frameworkissue and (VAF) study non-communicable disease, acute health need. reported that 31% of Syrian refugee households13 have at least one member with a pre-existing medical condition that was observed to a lesser extent14.4 among% were other living refu- withaged 15anegatively tophysical 19, compared disability impacts to12 3.1% .of their Jordanians), Additionally, daily andlife higher. the fertility 2019 rate Vulnerability among women ageAssessmentd 15 to 49 (4.7 Framework as opposed (VAF) study 14.4% were livingreported with thata physical 3115% of disability Syrian refugee. Additionally, households13 the have2019 atVulnerability least one member Assessment with Frameworka pre-existing (VAF) medical study condition that gee communities – Yemeni (19%), Sudanese and Sonegatively- toWhile 2.6). the impacts health needs their of refugees daily life living. in Jor- Zarqa 5,642 ANC, NVD, caesarian section deliveries, reported that 31% of Syrian refugee households13 have at least one member with a pre-existing medical condition that mali (both 18%).14 Thereported Jordan Population that negatively31 and% Family of Syrian impacts dan refugee are complex their households daily and comparative life. have morbidity at least data one member with a pre-existing medical condition that non-communicable disease, acute health need. negatively impacts their daily life.13 Health Survey (JPFHS)negatively also found that impacts 10.6% of theirSyr- dailyWhileshow t differentAmonghelife health.13 disease needs non ofprofiles-Syrian refugees between livingrefugees, inthe Jordan refugee Iraqi are complex refugees and comparative reported morbidity the datahighest show different proportion disease of household members living with a Amongprofiles non between-Syrian the refugeerefugees, groups, Iraqi all have refugees reported barriersreported in accessing the highest required proportionhealth services. ofFinancial household members living with a Among nonconstraints-Syrianchronic torefugees, pay userillness fees Iraqi hav(42e %consistently refugees) and disability been reported reported (12 by %the about). Thishighest two -wasthirds proportion observedof refugees to to be of thea lesserhousehold greatest extentbarrier, members among otherliving refugeewith a communities – Among non-Syrianchronic refugees, illness Iraqi (42% refugees) and disability reported16,17 (12 %the). Thishighest was proportionobserved14 to of a lesserhousehold extent members among otherliving refugeewith a communities – 1 The term CVA has several synonyms including Cash-Based Interventions, Cash-Based Assistance and Cash Transfer Programming. This case study report uses Among non-Syrianchronic refugees, illnesswhich (42 alsoYemeniIraqi% impacts) andrefugees (19 retentiondisability%), Sudanesereported in care(12.% ).and the DespiteThis Somalihighest was the higherobserved (both proportion 14proportion 18% to). aof of The lesserpregnancies household Jordan extent and Population fertilityamongmembers rate, other andunder living Familyrefugee- with Health communitiesa Survey (JPFHS) – also found the term CVA, which is recommended by CaLP (Glossary of terminology for cash and voucher assistance, 2018). chronic illness (42Yemeni%) and (19 disability%), Sudanese (12% ).and This Somali was observed (both14 18% to). a Thelesser Jordan extent Population among other and Familyrefugee Health communities Survey (JPFHS) – also found 2 ‘Access’ is a broad term with varied dimensions: the comprehensive measurement of access requires a systematic assessment of the physical, economic and 8 Jordan’s status has oscillated between upper-middle-incomeYemeni and lower-middle-income (19% in), recent Sudanesethat years, in part10.6 due toand% the influxof Somali ofSyrian Syrian refugees. (both women In 2019, 18Jordan% age). dThe 15 Jordanto 49 yearsPopulation were andpregnant Family at Health the time Survey of (JPFHS)the survey, also foundcompare d to 5.9% of socio-psychological aspects of people’s ability to make use of health services. was reclassified as an upper-middle-incomechronic illness country by the (42World Bank% )(Data and - Jordan, disability 2019): https://data.worldbank.org/country/jordan (12 % ). This was observed14 to a lesser extent among other refugee communities – 3 WHO defines OOP as ‘direct payments made by individuals to providers at the time of service use. This excludes any prepayment for health services, 9 The Jordanian government states that itYemeni hosts about 1.3 million(19 Syrians.%), However,Sudanesethat this figure10.6 also and% includes of Somali Syrians Syrian who were (both alreadywomen in the 18 country% age) prior. to d Thethe 15crisis. Jordan to 49 yearsPopulation were andpregnant Family at Health the time Survey of (JPFHS)the survey, also foundcompare d to 5.9% of 8 Jordanian women.14 Syrians also reportedly have a much higher rate of teenage pregnancy (27.8% of Syrian women for example in the form of taxes or specific insurance premiums or contributions and, where possible, net of any reimbursements to the individual who made the Jordan Response Plan for theYemeni Syria Crisis, 2018–2020 (19% (MoPIC,),that Sudanese 2018). 10.6% andJordan’sof Syrian Somali status haswomen (both oscillated 18 agebetween%).d 15 Theupper to -Jordanmiddle 49 -yearsincome Population andwere lower -pregnantmiddle and-income Family at in recent theHealth years,time Survey in partof duethe (JPFHS) to survey,the influx also compare found d to 5.9% of payments.’ (WHO, 2020) https://www.who.int/health_financing/topics/financial-protection/out-of-pocket-payments/en/ 10 Statistics for Registered Persons of Concernthat in Jordan, 10.6 as of %31 October of 2019SyrianJordanian (UNHCR,of Syrian 2019).women refugees. women. age In 2019,d Syrians15 Jordan to was49 also reclassified years reportedly wereas an upper pregnant have-middle -aincome muchat countrythe higher time by the Worldofrate the Bank of survey, (Datateenage - Jordan, compare pregnancy 2019): d to (27.8 5.9%% ofof Syrian women 4 Health financing policy & implementation in fragile & conflict-affected settings: a synthesis of evidence and policy recommendations (Jowett, et al., 2019). 11 Health Access and Utilizationthat Survey (UNHCR,10.6 2018).% ofJordanian Syrian women women. ageage Syriansdd 15 15 to to 19also 49, compared yearsreportedly were to have3.1pregnant% aof much Jordanians), at thehigher time andrate of higherofthe teenage survey, fertility pregnancycompare rate amongd (27.8to women5.9%% of of Syrian age d 15 women to 49 (4.7 as opposed 5 NCDs addressed are hypertension, diabetes and a small number of asthma cases. These are prioritized because the prevalence in Jordan is high, treatment prevents 12 Health challenges and access to health care among Syrian refugees in Jordan:age a reviewhttps://data.worldbank.org/country/jordand (Dator, 15 Abunab, to 19 & Dao-ayen,, compared15 2018). to 3.1% of Jordanians), and higher fertility rate among women aged 15 to 49 (4.7 as opposed Jordanian women. 9Syrians also reportedly have a much higher rate of teenage pregnancy (27.8% of Syrian women high cost complications and to prevent morbidity. 13 VAF Population Study (UNHCR,Jordanian 2019). women.aged 15Syrians to 19 The ,also comparedJordanian15to reportedly2.6) government. to 3.1 stateshave% of that aJordanians), itmuch hosts about higher 1.3 andmillion rate higher Syrians. of teenageHowever, fertility this pregnancyrate figure amongalso includes (27.8 women Syrians% whoof age wereSyriand 15 towomen 49 (4.7 as opposed 6 The household ratio of dependants (non-autonomous adults, children and the elderly) to non-dependants (able-bodied, working-age members). 14 Comprehensive Food Security and Vulnerability Assessment, 2018 (WFP & REACH,to 2019).2.6). 7 Unregistered refugees are particularly vulnerable because they do not receive the assistance and support that registered refugees would get. 15 J ordan Population and Family Health Surveyage 2017–18d 15 (DOS to and ICF,19 2019)., compared15 already in to the 3.1country% ofprior Jordanians), to the crisis. Jordan and Response higher Plan fertilityfor the Syria rate Crisis, 2018among–2020 women(MoPIC, 2018) age. d 15 to 49 (4.7 as opposed aged 15 to 19,to compared 2.6). 10 to 3.1 % of Jordanians), and higher fertility rate among women aged 15 to 49 (4.7 as opposed to 2.6).15 Statistics for Registered Persons of Concern in Jordan, as of 31 October 2019 (UNHCR, 2019). to 2.6).15 11 HealthWhile Access and the Utilization health Survey needs (UNHCR, of refugees2018). living in Jordan are complex and comparative morbidity data show different disease While12 the health needs of refugees living in Jordan are complex and comparative morbidity data show different disease Healthprofiles challenges andbetween access to health the care refugee among Syrian groups, refugees inall Jordan: have a review reported (Dator, Abunab, barriers & Dao -ayen,in accessing 2018). required health services. Financial While the health13 VAF Population needs Study of refugees (UNHCR, 2019) living. in Jordan are complex and comparative morbidity data show different disease While the healthprofiles needs14 of between refugees the living refugee in Jordan groups, are complex all have and reported comparative barriers morbidity in accessing data show required different health disease services. Financial While the healthprofiles needs between of refugeesComprehensiveconstraints the living Foodrefugee Security in to Jordan pay groups,and user Vulnerability are fees complexall Assessment,havhavee consistentlyandreported 2018 comparative (WFP &barriers REACH, been 2019) morbidity reported in. accessing bydata about showrequired two different-thirds health ofdisease refugeesservices. toFinancial be the greatest barrier, profiles betweenconstraints the15 Jordan refugee Population to pay groups, and user Family fees Healthall havhave Surveye consistently 2017reported–18 (DOS andbarriers been ICF,16 2019),17 reported .in accessing by about required two-thirds health of refugeesservices. toFinancial be the greatest barrier, profiles betweenconstraints the refugee16 to Health paywhich service groups,user access alsofees andall havimpacts utilizationhavee consistently reported amongretention Syrian refugeesbeenbarriers 16in,17 care reported in Jo rdan.in accessing(Doocy, Despite by Lyles,about Akhu requiredthe two-Zaheya, higher-thirds Burton, health proportionof & Burnham,refugees services. 2016) ofto. bepregnanciesFinancial the greatest and barrier, fertility rate, under- constraints to paywhich user17 feesalso havimpactse consistently retention been 16in,17 care reported. Despite by about the two higher-thirds proportionof refugees ofto bepregnancies the greatest and barrier, fertility rate, under- constraints to whichpay user also fees impacts Prevalence have consistently of retention non-communicable inbeen carediseases reported. and accessDespite by to careabout theamong twohigher non-campthirds proportionSyrian of refugees refugees in ofnorthern topregnancies be Jordan the (Rehr, greatest et and al., barrier,fertility rate, under- 2018). 16,17 which also impacts retention in 16care,17 . Despite the higher proportion of pregnancies and fertility rate, under- which also impacts retention in care . Despite the higher proportion of pregnancies and fertility rate,8 under- 8 Jordan’s status has oscillated between upper-middle-income and lower-middle-income in recent years, in part due to the influx 8Jordan’s status has oscillated between upper-middle-income and lower-middle-income in recent years, in part due to the influx 8 Jordan’s status has of Syrianoscillated refugees. between In 2019, upper Jordan-middle was-income reclassified and lower as an-middle upper-income-middle -inincome recent country years, in by part the dueWorld to theBank influx (Data - Jordan, 2019): 8 Jordan’s status hasof Syrianoscillated https://data.worldbank.org/country/jordanrefugees. between In 2019, upper Jordan-middle was-income reclassified and lower as an-middle upper-income-middle -inincome recent country years, in by part the dueWorld to theBank influx (Data - Jordan, 2019): 8Jordan’s statusof has Syrian oscillated refugees. between In 2019, upper Jordan-middle was- incomereclassified and aslower an upper-middle-middle-income-income in recent country years, by in the part World due toBank the (Data influx - Jordan, 2019): of Syrian refugees.https://data.worldbank.org/country/jordan In 2019,9 TheJordan Jordanian was reclassified government as an states upper that-middle it hosts-income about country 1.3 million by the Syrians. World However, Bank (Data this - Jordan,figure also 2019) includes: Syrians who were of Syrian refugees.https://data.worldbank.org/country/jordan In 2019,9 Jordan was reclassified as an upper -middle-income country by the World Bank (Data - Jordan, 2019): https://data.worldbank.org/country/jordan9 The Jordanianalready government in the country states prior that to theit hosts crisis. about Jordan 1.3 Response million Syrians. Plan for However, the Syria thisCrisis, figure 2018 also–2020 includes (MoPIC, Syrians 2018) who. were https://data.worldbank.org/country/jordan The Jordanian government states that it hosts about 1.3 million Syrians. However, this figure also includes Syrians who were 9 The Jordanian governmentalready in10 the Statisticsstates country that for itprior Registeredhosts to aboutthe crisis.Persons 1.3 millionJordan of Concern Syrians.Response in However, Jordan Plan for thisthe Syriafigure Crisis, also includes2018–2020 Syrians (MoPIC, who 2018)were . 9 already in10 the country prior to the crisis. Jordan Response Plan for the Syria, as Crisis, of 31 2018October–2020 2019 (MoPIC, (UNHCR, 2018) 2019). . The Jordanian government Statistics states11 thatfor Registered it hosts about Persons 1.3 millionof Concern Syrians. in Jordan However,, as of this 31 figureOctober also 2019 includes (UNHCR, Syrians 2019) who. were already in10 theStatistics country for prior Registered toHealth the crisis.Persons Access Jordan andof Concern Utilization Response in Jordan PlanSurvey for, as(UNHCR, the of Syria31 October 2018) Crisis,. 20182019– (UNHCR,2020 (MoPIC, 2019) 2018). . already10 in the country prior11 to the crisis. Jordan Response Plan for the Syria Crisis, 2018–2020 (MoPIC, 2018). Statistics11 for Registered Health Persons12 AccessHealth andof challenges Concern Utilization in and Jordan Survey access, as(UNHCR, to of health 31 October 2018) care. among 2019 (UNHCR, Syrian refugees 2019). in Jordan: a review 10 Health12 Access and Utilization Survey (UNHCR, 2018). (Dator, Abunab, & Dao-ayen, 2018). Statistics11 for Registered Persons of Concern in Jordan, as of 31 October 2019 (UNHCR, 2019). 12 Health13 challenges and access to health care among Syrian refugees in Jordan: a review (Dator, Abunab, & Dao-ayen, 2018). 11 Health Access Health and challenges Utilization VAF and Survey Population access (UNHCR, to health Study 2018) care(UNHCR,. among 2019) Syrian. refugees in Jordan: a review (Dator, Abunab, & Dao-ayen, 2018). Health12 Access and Utilization13 Survey (UNHCR, 2018). Health13 challenges VAF and Populationaccess14 to health Study care(UNHCR, among 2019) Syrian. refugees in Jordan: a review 12 VAF Population Study Comprehensive (UNHCR, 2019) Food. Security and Vulnerability Assessment, 2018(Dator, (WFP Abunab, & REACH, & Dao 2019)-ayen,. 2018). Health13 challenges and14 access to health care among Syrian refugees in Jordan: a review (Dator, Abunab, & Dao-ayen, 2018). VAF Population14 Study Comprehensive15 Food Security and Vulnerability Assessment, 2018 (WFP & REACH, 2019). 13 Comprehensive (UNHCR, Food Jordan Security 2019) Population. and Vulnerability and Family Assessment,Health Survey 2018 2017 (WFP–18 (DOS& REACH, and ICF, 2019) 2019). . VAF 14Population Study 15(UNHCR, 2019). Comprehensive15 Food Jordan Security16 Population and Vulnerability and Family Assessment,Health Survey 2018 2017–18 (DOS and ICF, 2019). 14 Jordan Population Health and Family service Health access Survey and utilization 2017–18 (DOSamong (WFP and Syrian & ICF, REACH, 2019)refugees 2019). in. Jordan (Doocy, Lyles, Akhu-Zaheya, Burton, & Burnham, 2016). Comprehensive15 Food Security16 and Vulnerability Assessment, 2018 (WFP & REACH, 2019). Jordan16 Population Health and Family17 service Health access Survey and utilization 2017–18 among Syrian refugees in Jordan (Doocy, Lyles, Akhu-Zaheya, Burton, & Burnham, 2016). 15 Health service access Prevalence and utilization of non- communicableamong Syrian (DOS and refugeesdiseases ICF, 2019) inand Jo rdanaccess. (Doocy, to care Lyles, among Akhu non-Zaheya,-camp Syrian Burton, refugees & Burnham, in northern 2016) .Jordan (Rehr, et al., Jordan16 Population and17 FamilyPrevalence Health of Surveynon-communicable 2017–18 (DOS diseases and ICF, and 2019) access. to care among non-camp Syrian refugees in northern Jordan Health17 service access and2018) utilization. among Syrian refugees in Jordan (Doocy, Lyles, Akhu-Zaheya, Burton, & Burnham, 2016). (Rehr, et al., 16 Health service accessPrevalence and utilization of non-communicable among Syrian diseases refugees and in accessJordan to (Doocy, care among Lyles, Akhunon-camp-Zaheya, Syrian Burton, refugees & Burnham, in northern 2016) Jordan. (Rehr, et al., 17 Prevalence of non2018)-communicable. diseases and access to care among non-camp Syrian refugees in northern Jordan (Rehr, et al., 8 17 Prevalence of2018) non-.communicable diseases and access to care among non-camp Syrian refugees in northern Jordan (Rehr, et al., 2018). 8 2018). 8 8 8 08 Cash & Voucher Assistance for Health Cash & Voucher Assistance for Health 09

groups, all have reported barriers in accessing re- sic needs.26 Non-Syrian refugees are also highly vul- system indicators, such as the number of hospital (GoJ) enacting a policy that required Syrian refugees quired health services. Financial constraints to pay nerable, as they have limited access to services and beds and number of skilled health personnel (clini- to pay the uninsured Jordanian rate when accessing user fees have consistently been reported by about humanitarian assistance,27 and are subject to stricter cians, nurses and midwives) per 10,000 population, healthcare through the public sector. In early 2018, two-thirds of refugees to be the greatest barrier, regulations in accessing livelihood opportunities. decreased between 2012 and 2015.33,34,35 Finally, to- the (GoJ) revoked these subsidies and registered which also impacts retention in care.16,17 Despite the tal health expenditure has also increased by 45% in Syrian refugees were required to pay 80% of the full higher proportion of pregnancies and fertility rate, Jordan’s health system: primary care, 15% in hospital-based care and 22% in foreigner’s rate at MoH facilities (this represented a under-utilization of maternal health services among drug procurement since the inflow of Syrian refugees two- to five-fold increase in service rates). Syrians were incredibly alarming, primarily because While Jordan’s health system is one of the strong- began.36 The continued provision of (open and af- of prohibitive costs.18,19 Among those who reported est in the region, many challenges remain in the fordable) quality public services for Syrian refugees A Multi-Donor Account (MDA), an initiative to pool acute illness, 73% refrained from seeking healthcare provision of Universal Health Coverage (UHC)28,29 to has been difficult to maintain. donor funds at the government level to finance the due to economic reasons.20 ensure that everyone has access to required health- Jordanian public health system, was set up in 2019 to care services regardless of their place in society and Evolution of the user fee policy reinstate the subsidies for registered Syrian refugees 39 A 2019 VAF population study found that 78% of Syr- without falling into financial ruin. For instance, public in Jordan: that were in place. While the MDA should, in theory, ian refugee individuals in urban areas were living be- health insurance coverage remains suboptimal even reduce the financial burden of healthcare for refugees, low the Jordanian poverty line (96 USD per month).21 among Jordanian citizens,30 let alone among refu- At the beginning of the crisis, Syrian refugees who coverage gaps remain. It is also unclear whether the Moreover, a national survey reported that 89.4% of gees, who are a particularly vulnerable group.31 were registered37 could access free primary, sec- MDA has been fully implemented across Jordan, and Syrian-headed households were in the two lowest ondary and tertiary healthcare through the MoH fa- whether Syrian refugees are being charged subsidized wealth quintiles.22 Despite the introduction of the The fact that over 80% of refugees live in urban set- cilities. However, in November 2014,38 the increase rates. A brief timeline of these changes and their im- ‘Jordan Compact’ in 2016,23 there remains limited tings has placed a large burden on the Jordanian in number of Syrian refugees and the burden on the plications on rates – using the cost of a normal vagi- opportunity for Syrian refugees to generate sufficient public health system, since these refugees typically public health system led to the government of Jordan nal delivery (NVD) – is illustrated in Figure 2. income to cover their basic needs, with many still re- attend Ministry of Health (MoH) clinics, unlike those lying on low-wage casual work as a primary source in camps. According to WHO and the MoH, the num- Figure 2 Timeline of changes in Jordan’s healthcare policy for refugees (cost of NVD used to show implications) of livelihoods.24,25 ber of Syrians in public hospitals increased by almost 250%, and the number requiring surgical operations Persistent poverty among urban refugees has led to rose almost six-fold at times. Bed occupancy rates 2012-Oct 2014 Feb 2018 an increase in negative coping mechanisms, including exceeded 95%, and reserve medicine stocks, usually Free MoH GoJ increased rates 32 increasing debt, reduction in food consumption, with- at 100% of demand, dropped to 30%. With this lim- services for 60 JOD at MoH to 80% of 60 JOD drawing children from school in order to work to help itation, according to 2018 HAUS, among those ref- Syrian refugees the foreigner’s rate. residing outside ANC no longer free the family, or simply not accessing healthcare. About ugee households who sought health services (180 camps 86% of Syrian refugee households in non-camp set- out of 400 household surveyed), only 14% reached tings receive some form of institutional assistance, public hospitals, 37% accessed private pharmacies which remains crucial to their ability to meet their ba- and 35% accessed NGO/charity clinics. Key health

Nov 2014 Apr 2019 200 JOD Syrians seeking care at GoJ rolled back 2018 16 Health service access and utilization among Syrian refugees in Jordan (Doocy, Lyles, Akhu-Zaheya, Burton, & Burnham, 2016). MoH were obliged to pay regulation; Syrians can 17 Prevalence of non-communicable diseases and access to care among non-camp Syrian refugees in northern Jordan (Rehr, et al., 2018). the uninsured Jordanian access MoH at the 18 Maternal Health Care Utilization Among Syrian Refugees in Lebanon and Jordan (Tappis, et al., 2017). rate Services like ANC uninsured Jordanian 19 Health Access and Utilization Survey (UNHCR, 2018). remained free rate (covered by MDA) 20 The living conditions of Syrian refugees in Jordan (Tiltnes, Zhang, & Pedersen, 2019). 21 VAF Population Study (UNHCR, 2019). 22 Jordan Population and Family Health Survey 2017–18 (DOS and ICF, 2019). 23 A key target of the Compact is for the GoJ to issue up to 200,000 work permits to Syrian refugees. 24 The Jordan Compact: Lessons learnt and implications for future refugee compacts (Barbelet, Hagen-Zanker, & Mansour-Ille, 2018). 25 Still in Search of Work – Creating jobs for Syrian refugees: An update on the Jordan Compact (IRC, 2018). 26 The living conditions of Syrian refugees in Jordan (Tiltnes, Zhang, & Pedersen, 2019). 27 Comprehensive Food Security and Vulnerability Assessment, 2018 (WFP & REACH, 2019). 28 In 2015, the GoJ adopted the Sustainable Development Goals (SDGs), which includes achieving UHC by 2030. Here, UHC is considered a tool to achieve financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all as a priority. 33 Annual Human Resources for Health Report 2016 (HHC, 2017). The Jordan National Health Strategy for 2016–2020 has identified UHC as a long-stranding strategic goal. 34 Eastern Mediterranean Region: Framework for health information systems and core indicators for monitoring health situation and health system performance 2018 29 ‘Coverage’ of interventions is defined as the proportion of people who receive a specific intervention or service among those who need it. (WHO, 2019). 30 Jordanians also struggle with poverty and lack of access to healthcare. The 2019 JRP states that about one third of the Jordanian population is not covered by health 35 Health care and pharmacy practice in Jordan (Nazer & Tuffaha, 2017). insurance, and as a result, the GoJ has mandated that NGOs provide aid to Jordanians, to lessen the impact of the Syrian crisis on host communities, and subsequently 36 Public Expenditure Perspectives Update (2015–2017) Working Paper on Health Sector (DAI, 2015). reduce tensions between host communities and refugees. 37 To be registered, a Syrian refugee needs to possess the following documents: (i) a UNHCR-issued asylum-seeker certificate, and (ii) MoI service card, which is obtained 31 Health Care Cost Study at Ministry of Health and the Cost and Financial Impact of Expanding the Civil Insurance Program to Vulnerable Jordanians and Syrian from a local police station. Refugees (Shepard, et al., 2017). 38 Living on the margins – Syrian refugees in Jordan struggle to access health care (Amnesty International, 2016) 32 Out of the spotlight and hard to reach: Syrian refugees in Jordan’s cities (Healy & Tiller, 2013). 39 Letter from the Jordanian Minister of Health, March 2019. 10 Cash & Voucher Assistance for Health Cash & Voucher Assistance for Health 11

High out-of-pocket payments Unregistered Syrian refugees pose a major barrier to access 02. Medair’s Intervention health services: ❝ and refugees of other nationalities are not covered by As a result of the policy that necessitated OOP Figure 3 Rationale for provision of CVA for health in Jordan spending,42 refugees rely more on NGO-supported the subsidies and are therefore facilities, pharmacies or simply foregoing care when charged the foreigner’s rate ill. Studies conducted during periods when rates Suboptimal were not subsidized found that Jordanians were Financial Other Sufficient barriers to (indirect) utilization, Provision far more likely to access and use this care than ref- health services + accessing + barriers to + negative = of CVA for ugees.43,44 Syrian refugee households that incurred available health services health access coping health health-related costs spent a monthly average of 82 mechanisms Unregistered Syrian refugees and refugees of other USD out of a median annual income of 3,000–4,000 nationalities are not covered by the subsidies and are USD, with a mean household size of 5.3 persons.45 therefore charged the foreigner’s rate.40 This is espe- Among non-Syrians refugees, Sudanese households cially concerning as these persons of concern have reported the highest health expenditure (70 USD per Market Financial Risk analysis Beneficiary preference already been systematically excluded from livelihood month), followed by Yemeni (60 USD), Iraqi (43 USD) analysis Service (protection, Feasibility of (familiarity with opportunities (such as the Jordan Compact) and as- and Somali households (25 USD). Focus group dis- (Health services, + Provider + security, risk + = CVA transportation) assessment management) modality sistance under the Jordan Response Plan (JRP), and cussions (FGDs) conducted by WFP revealed that mechanisms) are consequently reliant on NGO-supported clinics, health issues remain one of the largest causes of which are limited in both number and scope.41 vulnerability affecting refugees living in host com- munities, with 74% of households surveyed noting ‘access to medicine and health services’ among their 46 A. Response option analysis top three unmet needs. The rationale for Medair’s decision is adapted from pensate them for their user fees and indirect costs the WHO Decision Tree, which shows the circum- when they were in need of a service. stances under which CVA can be a suitable modality for a health response,47 and integrates the elements to To inform its decision on the feasibility of using CVA be considered when assessing the feasibility of CVA.48 for its intervention, Medair drew from the experiences and assessments of the many other humanitarian ac- Given that vulnerable refugees continue to experience tors having used CVA modalities in Jordan. The Cash significant OOP and barriers to access essential ser- Working Group was able to provide valuable informa- vices – indicating that the coverage under the health tion to Medair for its response analysis. insurance scheme is still not fully implemented, and that direct purchasing of services by international There are several conditions present in Jordan that partners through contracts with providers (including support the use of CVA to reach health outcomes. vouchers) would significantly increase the budget These include: a number of advanced banking sys- requirements when having to pay foreign rates – the tems and wide distribution of ATMs; relatively low se- next best option is to provide cash to patients to com- curity concerns, allowing for free movement; availabil-

40 This is apart from Iraqis with legal residency rights. 41 On the Basis of Nationality – Access to Assistance for Iraqi and Other Asylum-Seekers and Refugees in Jordan (MCC, 2017) 42 WHO defines OOP as ‘direct payments made by individuals to health care providers at the time of service use. This excludes any prepayment for health services, for example in the form of taxes or specific insurance premiums or contributions and, where possible, net of any reimbursements to the individual who made the payments.’ (WHO, 2020): https://www.who.int/health_financing/topics/financial-protection/out-of-pocket-payments/en/ 43 Health service access and utilization among Syrian refugees in Jordan (Doocy, Lyles, Akhu-Zaheya, Burton, & Burnham, 2016). 44 8 Years into Exile (CARE, 2018). 45 Fafo Institute for Applied International Studies Government of Jordan. The living conditions of Syrian refugees in Jordan (Tiltnes, Zhang, & Pedersen, 2019). 47 Working paper for considering Cash Transfer Programming for Health in humanitarian contexts (GHC and WHO Cash Task Team, 2018). 46 Comprehensive Food Security and Vulnerability Assessment, 2018 (WFP & REACH, 2019). 48 CaLP’s Programme Quality Toolbox, 2018: https://www.calpnetwork.org/learning-tools/programme-quality-toolbox/ 12 Cash & Voucher Assistance for Health Cash & Voucher Assistance for Health 13

ity of health services of acceptable quality; and value the biggest concerns on the demand side, which al- 1. Identification of beneficiaries: 2. Selection criteria and process: placed on seeking care from appropriate providers. lows for a more successful implementation. Medair integrates its CVA for health programme into As documented in Medair’s SOPs, households that The widespread provision of cash assistance for ba- its community health activities, which is delivered are identified by CHVs or referred to Medair are con- sic needs (for instance, through multipurpose cash B. Program Design through a network of Community Health Volunteers sidered for selection to receive CVA if both the lev- (MPC) assistance, offered by UNHCR or WFP vouch- (CHVs). These CHVs are selected and trained by Me- el of vulnerability and the presence of a health need ers49) is also likely to provide an environment where Medair has developed Standard Operating Proce- dair, and are responsible for several key activities in meet the following criteria: CVA for health is used as intended to achieve health dures (SOPs)52 based on its experience in delivering the initial stage, including: outcomes. The success of CVA programmes is ‘de- CVA for health in Jordan, which describe the selec- l The type of medical treatment includes infant pendent on the magnitude of the barriers to access- tion process, conditions eligible for assistance53 and l Active case-finding: CHVs conduct door-to-door delivery for pregnant women, other urgent health ing services’,50 as well as the quality and availability of the documentation required. A flowchart describing visits to households in specific neighbourhoods needs and high morbidity of NCDs, the details of health services.51 this process, from the initial contact at the household known to host a higher concentration of refugees. which are listed in Medair’s SOPs. Health records, level to follow-up contacts after the cash assistance During these visits, CHVs will assess if these including diagnostic tests and medical reports, In the context of Jordan, financial considerations are has been provided and utilized, is illustrated below. households meet the vulnerability criteria54 and are used to verify the presence of the health need. if they have a health need that is within Medair’s l The estimated or actual costs for the required Figure 4 scope for CVA. Medair’s process for cash transfers for health treatment do not exceed the cap of 2,115 USD l Health promotion: CHVs deliver key health per individual. However, exceptions can be messages that are relevant to the specific made for certain lifesaving, acute needs, such CHVs visit and assess households health needs of the household. For instance, if as admissions to the neonatal Intensive Care a pregnant woman is present, then the CHV will Unit (ICU), if approved by Medair’s technical and discuss the importance of ANC and postnatal Senior Management staff. care (PNC) and highlight pregnancy-related Verification of household’s vulnerability and presence of health need l The household has not received (or has not danger signs for when the pregnant woman already been selected to receive) CVA for the should seek healthcare. Other topics include specified health need by other agencies. However, infant and young child feeding (IYCF), maternal Household information cross checked with RAIS, then selected for assistance if the household is receiving CVA for other and new-born care, family planning, and non- purposes, for instance MPC, it is still eligible for communicable diseases (NCDs). support from Medair.55 l Referral: Household members with other types Selected individual invited to receive CVA (through ATM card or affiliated hospital) l The household is considered vulnerable based on of needs – for example, those not in possession the adapted VAF score, which is focused on the of the necessary legal documentation such as dependency ratio of the household, expenditure birth certificates or Ministry of Interior (MoI) and debt levels, and coping mechanisms adopted. Individual obtains required health service cards – are referred by CHVs to other agencies The lack of registration (MoI service card) is also that are able to provide the required services. a factor to be considered in assessments of vulnerability. CHVs conduct follow up (through household visits or education sessions) Besides active case-finding through CHVs, Medair also receives referrals of refugees who require CVA This selection process is the same for both uncondi- for a health need from other agencies. Medair’s se- tional and conditional cash transfers. Medair allows PDM and FGD conducted periodically lection criteria has been communicated to external the verification of pregnancies to be carried out by referring agencies (including UNHCR). Any referrals senior CHVs (also referred to as CHV Focal Points), received from other agencies are first subject to Me- as these are straightforward to do using medical re- dair’s verification step prior to inclusion. ports. Other health (i.e. non-pregnancy needs), are al-

49 There are multiple NGO partners who are providing MPC assistance alongside UNHCR. 50 The impact of conditional cash transfers on health outcomes and use of health services in low- and middle-income countries (Lagarde, Haines, & Palmer, 2009). 51 Cash-based Interventions for Health programmes in Refugee settings – A review (UNHCR, 2015). 54 Medair utilizes an adapted version of UNHCR’s Vulnerability Assessment Framework assessment tool. Medair’s assessment measures the following: 52 Cash-for-Health Standard Operating Procedures Medair Jordan, 19 May 2020: (i) coping strategies employed, (ii) dependency ratio, (iii) debt score and (iv) expenditure score. These composite indicators are used to classify the assessed https://www.calpnetwork.org/publication/cash-for-health-standard-operating-procedures-medair-jordan/ household into one of four ratings (low, moderate, high or severe vulnerability). 53 Medair, in collaboration with other agencies and UNHCR, has gradually increased the number of medical conditions that are eligible to receive CVA. 55 Health costs have been accounted for in the Minimum Expenditure Basket (MEB) for Syrian refugees in Jordan. However, the amounts are usually insufficient for If a treatment is too expensive or outside of this list, Medair will refer these individuals to other organizations who are better placed to help. OOP expenses, especially for urgent health needs. 14 Cash & Voucher Assistance for Health Cash & Voucher Assistance for Health 15

ways verified by Medair staff, who are skilled health This relates to circumstance where assistance is still provided to unregistered Syrian or non- An ATM card distribution at a bank in Amman. professionals. © Medair/Tamara Elkouz Syrian refugees at other, non-affiliated, hospitals. The verification phase also involves cross-checking For example: (i) if the required treatment is not lists of households and individuals with other agen- available at affiliated hospitals, (ii) if the treatment cies to avoid duplications. This is typically done using cannot be provided within an appropriate the UNHCR-hosted Refugee Assistance Information timeframe, (iii) if the individual has an existing System (RAIS), which Medair actively uses. Besides clinical relationship with a provider at a different RAIS, Medair also liaises directly with other agencies facility (e.g. follow-up surgery), or (iv) if the cost of that provide CVA for health in Jordan,56 as RAIS only treatment is lower at another facility than at the includes households registered with UNHCR, and affiliated hospital. RAIS is not always up to date. As a separate and complementary project activity, 3. Transfer modalities: Medair also directly purchases health services at se- lected affiliated facilities. In response to the increase Medair’s project utilizes different transfer modalities, in healthcare rates for refugees, Medair initiated part- depending on the health needs of selected refugees, nerships with private hospitals that were previously including: assessed by UNHCR, so that services are sought from providers from which minimum quality stand- l Unconditional cash transfer (UCT) that is ards can be ensured. This allows refugees referred linked with a health need, such as a delivery. This by Medair to obtain the necessary healthcare ser- modality targets pregnant women who are unable vice of satisfactory quality and at negotiated rates, to cover the OOP cost of the delivery and is paid as stipulated by the partnership agreement. Medair at a predefined rate, usually through an ATM card. continues to encourage registered Syrian refugees to UCT is chosen here, as we know that a woman utilize MoH facilities for their health needs, and un- will deliver but cannot control when and where. registered Syrian and non-Syrian refugees to access Medair PDMs show that over 95% of women use affiliated hospitals, for reasons related to costs, as the cash to pay for the cost of the delivery. they do not distinguish individuals based on their na- tionality or registration status. This activity, although l Conditional cash transfer (CCT) is used to a direct purchase and not a cash transfer, is an im- UNHCR’s registration database. In addition to amounts. Up to 50 individuals are invited to each incentivize access to essential public health portant complement to the CVA parts of the project. low financial service provider fees,58 due to the distribution and are then given the appropriate services and preventive services, such as economies of scale that this collaboration model ATM cards and a unique PIN number. Medair immunization and ANC, as well as NCDs. These 4. Delivery mechanisms: offers, contracting was also made easier with staff are present to supervise the distribution and cash transfers are contingent upon proof of this delivery mechanism, as Medair currently to assist those who are unfamiliar with ATMs. compliance with recommended consultations, Households that meet the aforementioned criteria are participates in the CCF under UNHCR’s umbrella Guidance on how to use ATMs is important treatment and receipts of purchasing prescribed then selected to receive assistance. Medair utilizes contract. While the majority of CVA recipients because some individuals might require a top-up medicines. CCT is chosen to treat certain two different delivery mechanisms to provide CVA, receive cash through iris-enabled ATMs, Medair if the pre-loaded amounts were insufficient to morbidities and for ANC where there is a specific depending on the needs and circumstances of the se- provides its cash-for-health assistance primarily cover treatment costs. and identified need. lected individuals: ATM cards and physical cash. through ATM cards.59 Individuals selected to l Reimbursing of priority health services, from a receive CVA through ATM cards are invited l Physical cash: While Medair prefers to avoid pooled health emergency fund if possible, based l ATM: Medair utilizes the common cash facility to a Cairo Amman Bank branch in areas where providing cash in hand, due to increased risks on receipts provided by the beneficiaries. This (CCF), which is provided through Cairo Amman Medair is operating. The bank provides a space of theft or fraud, there are exceptional occasions is mostly used by Medair to reimburse health Bank in Jordan.57 The CCF is a system for on its premises for Medair to distribute ATM when providing cash directly to selected services that were sought for acute health needs. delivering cash assistance, which draws on cards that have been pre-loaded with specific individuals is warranted.

58 The current bank fee for the ATM cards is 1% of the total cash amount to be distributed, which is a reduction from previous rates. This is because the CCF offers economies of scale – the more net assistance delivered, the lower the bank fees for all CCF members. 59 ATM cards make up approximately 7–10% of the current CCF caseload. In 2016, Medair enrolled a group of beneficiaries to receive cash through CCF iris scans, however several beneficiaries experienced delays in receiving their cash assistance, as at the time, the iris method wasn’t optimized for delivering cash assistance for one-off, urgent cash transfers. Medair intends to conduct another trial of the use of iris scans to deliver its cash-for-health assistance. Physical cash is usually 57 Review of the Common Cash Facility Approach in Jordan (Gilert & Austin, 2017). given to the health facility on the provision of invoice and receipt, and acts in a similar way to reimbursement. 16 Cash & Voucher Assistance for Health Cash & Voucher Assistance for Health 17

Table 1 Summary of CVA for health delivery 5. Amount of assistance

In order to decide the amount of assistance to be eligible for CVA for health. Type of Transfer Delivery Description provided for eligible conditions, Medair’s staff and health need modality mechanism CHVs conduct phone calls and visits to health facili- For individuals receiving conditional cash for man- ties, both public and private, to inquire about the cost agement of their NCDs, a standard recurring amount Skilled delivery, Unconditional cash • ATM cards (or • Cash for delivery is the core of Medair’s of service for registered and unregistered Syrian ref- is used regardless of the severity of their condition both uncomplicated transfers (‘labelled’ physical cash in intervention, as maternal mortality can be ugees. Where possible, Medair tries to obtain an offi- and comorbidities. The amounts are based on a (NVD) and cash to encourage exceptional cases) significantly reduced through skilled care cial price list for health services. The average cost of review of receipts and feedback received during complicated (CS) use for health) before, during and after childbirth. Selected • Physical cash pregnant women will receive CVA to access NVDs and caesarean section (CS) deliveries are then quarterly health education sessions, and because skilled delivery services, which can be calculated to determine the amount that should be Medair covers a limited number of NCDs, the costs prohibitively expensive and thus cause unsafe pre-loaded onto ATM cards. Medair regularly moni- of the medicine are similar, allowing them to provide practices, such as home deliveries. tors these rates through a review of receipts and the an equal amount to each beneficiary. Unlike other ANC and PNC Conditional • Physical cash • The cash amounts provided account for costs frequency of ATM card top-ups it must make. Service service types for which Medair provides CVA, Me- cash transfers/ related to accessing preventive care (ANC rates are also cross-checked and verified with other dair does not deliver different amounts based on reimbursement and PNC) as well as transportation fees. agencies, such as UNHCR. the refugee’s nationality and/or registration status, (one off transfer) • It is based upon the showing of receipts. because of the range of NCDs and corresponding Medair does not provide pre-loaded ATM cards to needs (for example, only regular refilling of prescrip- Acute health need Reimbursement cash • Physical cash • Refugees with other acute health needs are refugee individuals with acute health needs, given tions are required). (one-off transfer) also able to receive CVA from Medair. Eligible conditions include emergency hospitalizations the breadth of conditions and treatment options (neonatal ICU admissions, acute myocardial available. However, for budgetary purposes, Medair The pre-loaded rates are shown in Table 2 below, infarction) and surgeries (appendectomy, gall uses the cost of ‘emergency surgery of gallbladder where the rates paid include the cost of transporta- bladder removal). removal’ as a proxy for an urgent condition that is tion to and from the health facility. • Due to the (often) unpredictable nature of the conditions, Medair reimburses the recipient when he has accessed a non-affiliated hospital (CVA). Table 2 Amount of CVA in pre-loaded ATM cards, by service type and nationality

NCD Conditional cash • ATM cards • Refugees with NCDs can receive recurring CVA transfers (Recurring for ongoing treatment of their conditions. Cash transfers, provided transfers are provided on a quarterly basis Type of health need Registered Unregistered Syrian on a quarterly basis) and are contingent upon proof of compliance Syrian refugees (USD) and non-Syrian refugees with recommended NCD treatment, such as (USD)project consultation records at MoH facilities, and receipts of purchasing prescribed medicines. Uncomplicated delivery (NVD) 84 353 Emergency Unconditional cash • ATM cards • In accordance with GoJ requirements, Medair cash assistance transfer (one-off also provides CVA to Jordanian households that – applicable transfer) have been assessed to be vulnerable. Complicated delivery (CS) 353 775 to Jordanian households only • The CVA is a one-time unconditional and Non-communicable disease (NCD) 141 141 unrestricted transfer. The modality and amount (183 USD) recognize the difference in needs among vulnerable Jordanian households com- pared to refugees in terms of healthcare access.

• Selected Jordanians who are pregnant are encouraged to purchase the national health insurance for pregnancy care to cover the package of delivery services, which include ANC and PNC.60

60 Jordanians can either be treated as a non-insured Jordanian and pay the fees when they go to the clinic or they can buy an insurance scheme that gives them access to MoH facilities for ANC, delivery and PNC. 18 Cash & Voucher Assistance for Health Cash & Voucher Assistance for Health 19

A Medair CHV conducting a 7. Follow-up with assisted beneficiary health education session on NCDs. © Medair/Tamara Elkouz

CHVs also conduct follow-up visits (also called ‘new- born visits’) to households where a woman selected to receive CVA has delivered, regardless of whether she used the CVA for the delivery or not.

Medair encourages CVA-for-delivery recipients to in- form Medair when they have delivered. CHV teams then arrange a visit to assess the health of the mother and new-born, as well as to reinforce good breastfeeding practices and the importance of PNC. Medair aims to provide these ‘new-born’ visits within two weeks of the delivery date. Individuals selected to receive CVA-for-NCDs are re- quired to attend follow-up sessions on a quarterly basis. These sessions are held in a group setting at a community-based organization (CBO), where Me- dair staff and CHVs will monitor compliance with NCD treatment (through reviewing documents such as prescriptions and receipts) and to provide educa- tion on lifestyle modification to control their NCDs. If these conditions are met, Medair staff will then ap- prove CVA transfers for the upcoming quarter.

6. Timing of assistance

For deliveries, Medair provides the unconditional cash justification for certain procedures that are performed transfers through ATM cards in the eighth or ninth (e.g. CS instead of an NVD), prior to paying. This month of pregnancy, in order to maximize the likelihood condition is included in the partnership agreements. of the cash being utilized for its intended purpose. In In cases where the individual receives care from the event that the initial amounts are insufficient, such other, non-affiliated facilities, Medair can cover or as a planned NVD that, at a later stage, needs an emer- reimburse the cost after reviewing the appropriate gency CS, Medair will top up payments to the respec- documents. tive individuals after verifying the medical report and receipt. These top-up amounts are transferred directly Individuals with NCDs receive conditional cash assis- to the individuals’ ATM cards. Reimbursements can be tance on a quarterly basis through ATM card top-ups, provided to women who have already delivered. contingent upon their compliance with treatment. This is explained further in the section on follow-up Medair requires medical reports and in some cases, activities below. 20 Cash & Voucher Assistance for Health Cash & Voucher Assistance for Health 21

03. Accountability measures: A Medair staff member during a household visit. monitoring and evaluation © Medair/Tamara Elkouz

Medair implements a range of activities as part of assuring accountability to all its stakeholders, including indi- viduals, CHVs and staff, donors, the MoH and the GoJ. These measures assist Medair to critically evaluate its programming and to use lessons learnt in improving its CVA programming.

l Post-distribution monitoring (PDM): Medair’s Monitoring, Evaluation, Accountability and Learning (MEAL) staff conduct quarterly PDMs, using trained enumerators. The exercise includes structured phone interviews with a random sample of individuals who received CVA for health within the preceding three months. The main objectives of the PDM is 1. to ensure that the appropriate amount of CVA was received; 2. to determine how the CVA was utilized; 3. whether the required healthcare services were accessed; 4. assess the overall health status of the assisted household and/or individual, and; 5. to evaluate the effectiveness of Medair’s CVA transfer process. l Focus group discussions: MEAL staff also organize and facilitate FGDs two to three times a year, in which a group of 8–12 individuals are invited to participate. This activity aims to collect more qualitative feedback to supplement and verify PDM findings. l Feedback and complaints mechanism (FCM): Medair’s FCM are operated by phone and managed by the MEAL teams. Calls received on the FCM hotline are received during office hours, and are then logged, categorized based on the level of urgency and assigned to the appropriate staff. The number for the FCM is distributed by CHVs during household visits and individuals attending ATM card distributions. 22 Cash & Voucher Assistance for Health Cash & Voucher Assistance for Health 23

04. Achievements Figure 5 Households assessed, January 2017 to July 2019, by nationality and governorate

Syrian Jordanian Other

14134 Amman 4755 728 Between January 2017 and July 2019,61 Medair trained 98 CHVs (91 female), who visited and assessed around 7535 65,000 refugee and Jordanian host community households. The breakdown of these households by national- Irbid 2912 25 ity and governorate is shown in Figure 5. Syrian-headed households comprise the majority of those that were 13116 visited (69.9%), followed by Jordanians (28.3%), and those headed by other nationalities (1.8%), of which Iraqis Mafraq 5250 were most commonly visited. 117 11006 A total of 8,848 individuals received CVA for health during this period, of which 6,892 were refugees. The break- Zarqa 5613 down of the type of refugees who received assistance is detailed in Figure 6. 279 0 2000 4000 6000 8000 10000 12000 14000 16000 A key indicator that Medair consistently measures is the proportion of recipients that used the CVA (earmarked for health) to access the health services. Based on PDM findings, over 90% utilized the CVA for its intended purpose. Non-health-related expenditure often included covering basic needs (including food and rent) and debt repayments. Figure 6 CVA provided, January 2017 to July 2019, by service type and nationality

Medair also consistently measures utilization of health services in regular PDMs, including health facility pref- Syrian Jordanian Other erence and uptake of preventive services, such as ANC and PNC. These access and utilization indicators are tracked in Figure 7 Emergency Cash (Jordanians) Non-communicable Disease

Acute Health Need

Cesarean Section

Normal Delivery

0 500 1000 1500 2000 2500 3000 3500

Figure 7 Access and utilization indicators, measured by PDM

CVA used as intended Accessed MoH Attended ≥4 ANC Attended PNC

100%

80%

60%

40%

20%

0% 61 Medair started using an adapted version of the VAF from January 2017. 2017 2017 2017 2018 2018 2018 2019 2019 PDM 1 PDM 2 PDM 3 PDM 1 PDM 2 PDM 3 PDM 1 PDM 2 24 Cash & Voucher Assistance for Health Cash & Voucher Assistance for Health 25

05. Challenges, lessons learned, and recommendations

Based on Medair’s experience in Jordan, CVA is an l Recommendation to agencies implementing Finally, a major challenge faced pertains to the sus- appropriate and feasible modality to provide health CVA for health (including Medair) and tainability of the intervention. Despite having an assistance. the Health Sector: Standardize definitions established programme, Medair is contending with of ‘quality care’ and provide tools for the question of how much longer it can and should Despite its relevance, Medair continues to confront monitoring and quality on the supply side. continue its CVA for health activities, especially con- numerous challenges in its CVA for health activities. sidering the protracted nature of the crisis and the The monitoring of the supply side remains difficult. An important, longer term aspect of Medair’s ap- evolving political situation within Syria, as well as Medair is attempting to address this in several ways. proach is related to health promotion and behaviour the uncertainty around whether healthcare subsi- For instance, Medair insists on requiring medical change. However, the evidence base regarding such dies will remain, particularly amid diminishing fund- justification for all planned CSs from all service pro- behaviour change is limited, given the recent emer- ing. While CVA can improve access and utilization viders, in order to control the high CS rate,62 which gence of CVA as a modality in the health sector. More of health services, it should be complementary to is 37.8% of the 5,321 refugees assisted by Medair research in this area is required to better understand provider payment mechanisms that aim to reduce for delivery. At affiliated hospitals, where Medair has the sustainability of the behaviour change desired, reliance on user fees and ‘should not inadvertently more control, Medair monitors individual clinicians and whether these behaviours are contingent on the contribute to a fee-charging culture for priority ser- and their propensity for conducting CSs, and a clini- financial incentive. Additionally, there is little evidence vices, which could pose a challenge for UHC in the cian has since been banned from providing care for of the effectiveness of CVA for health on health out- longer run’.66 The situation is complicated by the pregnant women referred by Medair. While medically comes, and there is a need to ‘better understand how lack of formal health insurance schemes available justified CSs can prevent maternal and perinatal mor- cash transfer programmes compare to, and/or adds for vulnerable Jordanians and refugees.67 While Me- tality and morbidity, unnecessary procedures can put value to complement, direct support to service deliv- dair is open to exploring ways to transition towards women and infants at short- and long-term risk.63 ery or supply side financing approaches’.64 more integrated and sustainable approaches, such as health insurance schemes, it needs to do so ju- While contracting services to affiliated hospitals l Recommendation to the Global Health diciously to avoid fragmentation of health program- provides Medair with more control over quality, Me- Cluster and research institutions: Design ming for refugees.68 dair continues to encourage the majority of selected and conduct research to understand the individuals to access MoH facilities, in order to pro- impact of CVA for health programmes on l Recommendation to the GoJ and the donor mote a more sustainable approach and to strength- health outcomes, behaviours and coping community: Review the functioning of the Multi- en the Jordanian public health system. Quality of mechanisms, cost effectiveness, and adverse Donor Account and its support in the integration care is also monitored through PDMs, where re- financial outcomes (for example, to track of refugees (and/or other vulnerable individuals) spondents are asked about their experience at the the proportion of the population pushed into into the national health insurance scheme, health facilities they attended, and feedback is col- poverty, and/or pushed further into poverty applying the same rates as for Jordanians, lected and provided to the respective facilities. due to OOP payments for health.65 to achieve Universal Health Coverage.

62 The CS rate was 21.7% among Syrians, according to the JPFHS (2018) and 32.2% as per Tappis, et al. (Maternal Health Care Utilization Among Syrian Refugees in Lebanon and Jordan, 2017). The JPFHS found that the decision to have a CS delivery was made before the onset of labour pains in 15% of births (planned CS), compared to 6.7% after the onset of labour (unplanned). This is a high ratio and may indicate that a large proportion of CS deliveries were unnecessary. 66 Health financing policy & implementation in fragile & conflict-affected settings: a synthesis of evidence and policy recommendations (Jowett, et al., 2019). 63 According to the WHO, the ideal rate for CS deliveries is between 10 and 15%. Above these, CS is no longer associated with reductions in maternal and new-born 67 Shepard et al. (Health Care Cost Study at Ministry of Health and the Cost and Financial Impact of Expanding the Civil Insurance Program to Vulnerable mortality (WHO, 2015). Jordanians and Syrian Refugees, 2017) calculated that expanding the CIP to registered Syrian refugees living among host communities would cost 268.9 JOD 64 Research agenda-setting on cash programming for health and nutrition in humanitarian settings (Woodward, Griekspoor, Doocy, Spiegel, & Savage, 2018). per person (with an aggregated cost of 139 million JOD), and 158.4 JOD per vulnerable Jordanian (amounting to 52 million JOD). 65 Tracking universal health coverage: first global monitoring report (WHO, 2015). 68 Analysing equity in health utilization and expenditure in Jordan with focus on maternal and child health services (Ravishankar & Gausman, 2016). 26 Cash & Voucher Assistance for Health

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