WHO-EM/ARD/034/E

Country Cooperation Strategy for WHO and Jordan 2008–2013 Jordan

WHO-EM/ARD/034/E

Country Cooperation Strategy for WHO and Jordan 2008–2013 Jordan

Contents

Abbreviations 5

Section 1. Introduction 7

Section 2. Country Health and Development Challenges 11 2.1 Geographic location and administrative structure 13 2.2 Population overview 13 2.3 Economic and social development 13 2.4 Health system 14 2.5 Resources for health care 16 2.6 Health status 19 2.7 Major challenges 25 2.8 Enabling factors 26

Section 3. Development Cooperation and Partnerships 27

3.1 Overview 29 3.2 United Nations system 30 3.3 Donors/lenders group 30 3.4 Donors assistance to health 31 3.5 Coordination with UN agencies 31

Section 4. Current Country Programme 33 4.1 Brief historical perspective 35 4.2 Key roles and areas of work 35 4.3 Existing resources 37 4.4 Country programme budget 37 4.5 Challenges 37 4.6 Strengths and weaknesses of WHO cooperation 38

Section 5. Strategic Agenda for WHO Cooperation 39 5.1 Introduction 41 5.2 Framework for collaboration 42 5.3 Strategic directions for cooperation 43 Section 6. Implementing the Strategic Agenda: Implications for WHO 45 6.1 Overview 47 6.2 Country level 50 6.3 Regional level 50 6.4 Headquarters level 51

Annexes 52 1. Members of the CCS Team Abbreviations

BMI Body mass index CCA Common Country Assessment CCM Country Coordination Mechanism CCS Country Cooperation Strategy CEHA Centre for Environmental Health Activities CIP Civil Insurance Programme EC European Commission EMRO Regional Office for the Eastern Mediterranean FAO Food and Agriculture Organization of the United Nations GDP Gross Domestic Product GPW General Programme of Work HIV/AIDS Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome IT Information technology JD Jordanian dinars JPFHS Jordan Population and Family Health Survey JPRM Joint Programme Review and Planning Mission JUH Jordan University Hospital JUST Jordan University of Science and Technology ILO International Labour Organization KAH King Abdullah Hospital MDGs Millennium Development Goals MOF Ministry of Finance MOH Ministry of Health MOSD Ministry of Social Development MOU Memorandum of Understanding NA National Agenda NHSIS National Health Statistical Information System PHC Primary health care

RMS Royal Medical Services

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Abbreviations

SO Strategic Objective UNAIDS Joint United Nations Programme on HIV/AIDS UNCT United Nations Country Team UNESCO United Nations Educational, Scientific and Cultural Organization UNFPA United Nations Population Fund UNHCR Office of the United Nations High Commissioner for Refugees UNICEF United Nations Children’s Fund UNIFEM United Nations Development Fund for Women UNDAF United Nations Development Assistance Framework UNDP United Nations Development Programme UNODC United Nations Office on Drugs and Crime UNRWA United Nations Relief and Works Agency for Palestine Refugees in the Near East USAID United States Agency for International Development WFP World Food Programme WHO World Health Organization

6 Section 1

Introduction

Section 1. Introduction

The Country Cooperation Strategy (CCS) This strategy document for 2008–2013 reflects a medium-term vision of WHO for follows the previous CCS for Jordan, technical cooperation with a given country which covered the period 2003–2007. Its and defines a strategic framework for formulation is the result of analysis of the working in and with the country. The CCS health and development situation and of aims to bring together the strength of WHO WHO’s current programme of activities. support at country, Regional Office and For its development, a national CCS team headquarters levels in a coherent manner to was formed representing officials from the address the country’s health priorities and Ministry of Health and High Health Council challenges. The CCS process examines the along with WHO staff from the country and health situation in the country within a holistic regional offices and headquarters (Annex 1). approach that encompasses the health During its preparation, key officials within sector, socioeconomic status, determinants the Ministry of Public Health and Population of health and national policies and strategies as well as officials from various other that have a major bearing on health. The government authorities, United Nations exercise aims to identify the health priorities agencies, nongovernmental organizations in the country and place WHO support and private institutions were consulted. The within a framework of 4–6 years in order to critical challenges for health development strengthen the impact on health policy and were identified. Based on the health health system development, as well as the priorities of the country, a strategic agenda linkages between health and cross-cutting for WHO collaboration was developed. issues at the country level. The CCS as a Clear guiding principles were used to medium-term strategy does not preclude identify the challenges as they relate to the response to other specific technical and context of Jordan, national and partnership managerial areas in which the country may frameworks, the prioritized areas of work require WHO assistance. and strategic directions.

The CCS takes into consideration the work The key challenges identified in Jordan’s of all other partners and stakeholders in CCS 2008–2012 are focused on six health and health-related areas. The process areas: health system governance, human is sensitive to evolutions in policy or strategic resources for health, health information and exercises that have been undertaken by research, health financing, healthy lifestyle the national health sector and other related promotion and risk factor management, and partners. The overall purpose is to provide a emergency preparedness. Special emphasis foundation and strategic basis for planning is given to cross-cutting issues interlinking as well as to improve WHO’s collaboration environment, poverty and gender as they with Member States towards achieving the influence the strategic directions and areas Millennium Development Goals (MDGs). of priority.

9

Section 2

Country Health and Development Challenges

Section 2. Country Health and Development Challenges

2.1 Geographic location and birth rate of 29 per 1000 population, death administrative structure rate of 7 per 1000 population and an annual population growth rate of 2.3%. In 2004, Jordan is a small country with a total area 60.7% of Jordanians were under the age of of 89 342 square kilometres. Three quarters 25 years and children below the age of 15 of the total area of Jordan is sparsely years constituted 37.3% of the population. populated desert. The country has limited Individuals 65 years and over made up 3% natural resources and suffers from severe of the population and the dependency ratio fresh water scarcity; it is ranked among the was 68.2%.3 Despite the declining fertility, five most water-poor countries in the world.1 the total population is expected to double within the next 30 years. Jordan is a constitutional monarchy and has a parliamentary system composed of Migration from neighbouring countries is a an elected lower house of representatives strain on the social welfare sector; in addition and an upper house appointed by the king. to the estimated 1.7 million Palestinian Administratively, the country is divided into refugees, there are also an estimated 450 000 twelve governorates, each run by a governor to 500 000 displaced Iraqis in Jordan. appointed by the king. Governors are the sole authorities for all government departments 2.3 Economic and social and development projects in their respective development areas. The Human development report 2006 2.2 Population overview ranked Jordan at 86 out of 177 countries in terms of human development indicators, Jordan is a developing country with an moving up from 90 in 2004. Jordan is a estimated population of 5.6 million.2 82.6% lower-middle income country with a per of the population is urban, with the majority capita GDP of US$ 2542 for 2006.4 In 2007, (71.5%) concentrated in the country’s three the unemployment rate was estimated at largest urban areas (15.7% of the total area 14.3%, and was highest among women of Jordan): central Amman, Zarka and Irbid (25.4%) and young people (51.3%). governorates. The National Poverty Alleviation Strategy Jordan is in demographic transition, with a (2002) indicates that up to a third of relatively high total fertility rate of 3.7, crude Jordanians live below the poverty line.5

1 United Nations. Common Country Assessment: Jordan 2006 2 Department of Statistics. Jordan in Figures 2006 3 Department of Statistics. Jordan in Figures 2005 4 Department of Statistics. Preliminary Estimates of the GDP for 2006 5 Ministry of Social Development. Poverty Alleviation for a stronger Jordan: a comprehensive national strategy, 2002

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The official figure for income poverty stands participate with the Ministry of Health in at 14.2% and the national poverty line is regulating and monitoring functions. JD 392 (US$ 554) per capita per year. In Governance within the Ministry of Health is rural and urban areas, 18.7% and l2.9% of highly centralized, and the main challenges the population, respectively, live below the facing the Ministry are improving efficiency, poverty line.6 cost containment and quality of patient In 2005, Jordan launched a National care. A review of attempts to introduce Agenda to achieve a set of ambitious decentralization in the Ministry of Health macroeconomic and social development which were undertaken in the 1990s could targets, i.e. reduction of unemployment assist in guiding the process, especially and poverty rates.7 Major highlights in in light of the development of locality the National Agenda health sector policy administration in Jordan. There is also a reform include: universal health insurance; need to include representation from health- efficiency and quality of public services; related sectors such as water, environment focus on preventive medicine and primary and population in the High Health Council. health care; emergency medical services; and human resources for health. The themes 2.4.2 Health care system of the National Agenda feed into efforts to organization achieve the health-related national targets of Public sector providers of care the Millennium Development Goals (MDGs). The Ministry of Health is the major 2.4 Health system health care provider in Jordan and is 2.4.1 Governance responsible for all health matters in the country, including health promotion and The Government of Jordan is committed protection, administration of the Civil to making quality health care services Insurance Programme (CIP), organization available and accessible to all citizens. The and supervision of health services provided governance of the health care system in by both the public and private sectors, and Jordan is vested in the Ministry of Health, establishment of educational and health mandated by the Public Health Law and other training programmes. A list of health care legislation to license, monitor and regulate providers by sector is given in Table 1. all health professions and institutions in the The Royal Medical Services (RMS) country. Professional associations, other provides health care and comprehensive health councils and independent public health insurance to active and retired military organizations (Jordan Medical Council, personnel and their families. High Health Council, High Nursing Council, Jordan Food and Drug Administration, Private Hospitals Association and others)

6 The Hashemite Kingdom of Jordan/ World Bank. Jordan Poverty Assessment. Main Report, Volume 2. December 2004 7 Government of Jordan. National Agenda 2006–2015

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Table 1. Providers of health care and eligible/beneficiaries in Jordan Sector Authority Eligible/beneficiary Public Ministry of Health Civil insurance (MOH) Any citizen, resident or visitor Other insurance – MOU Royal Medical Military insurance Services (RMS) Private customers (include visitors) Other insurance – MOU University hospitals Jordan University Their own and specialized Hospital constituency centres King Abdullah I Other insurance Hospital (JUST) King Hussein Private customers Cancer Centre Private Clinics Private insurance

Hospitals Private customers Treatment abroad Visitors, Other insurance

International UNRWA Registered Palestinian refugees Nongovernmental National Red Crescent Society organizations International Clinics and hospitals

RMS also provides services to uninsured families, students enrolled in the university, patients referred from the Ministry of Health referrals from the Ministry of Health and and the private sector on a fee-for-service RMS, or independent private patients. These basis. A new memorandum of understanding hospitals serve primarily as teaching facilities has been signed with universities to for undergraduate and postgraduate training coordinate training and services. RMS of health professionals. King Hussein Cancer has training institutions and a structured Centre is the primary cancer treatment facility continuous professional development in the country. programme for its staff. Private sector Jordan University Hospital (JUH) in Amman The private sector contains much of the and King Abdullah I Hospital (KAH) at Jordan country’s medical expertise, in addition to University of Science and Technology in high technological capacity and quality of Irbid provide high quality secondary and services. It attracts a significant number of tertiary health care services. Patients of both patients from neighbouring countries. hospitals are university employees and their

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Nongovernmental and international estimates of the impact of catastrophic health organizations expenditure as defined by WHO.10

The United Nations Relief and Works The government share of total health Agency for Palestine Refugees in the Near expenditure has declined from 51% in 1998 East (UNRWA) operates a health programme to 41% in 2005 (including external sources focused on the direct provision of essential and donors). This reinforces the growing health services to the registered Palestinian importance of private sources, estimated at refugee population in Jordan.8 Its services 59%. In the period 1998–2003, the financing include school health, health education share of the Ministry of Health from total programmes and environmental health government sources remained fairly stable services in refugee camps. It currently (58%–60%). Meanwhile, secondary health operates 23 public health facilities inside care/hospitals absorb a disproportionately and outside the camps. It also subsidizes large share of public spending on health (76%), secondary and tertiary care for refugees while the share of expenditure on primary through contracts with the Ministry of health care has been steadily declining.11 Health, RMS and private hospitals. The Although pharmaceuticals account for major responsibilities of the Jordanian Red 14% of the total public spending on health, Crescent Society health facilities are to they account for almost one third of the total provide health during emergencies and for health expenditure in Jordan, putting Jordan refugees in Jordan, such as some of the Iraqi among the highest spenders on medicines population in Jordan. in the world, estimated at more than 3% of 2.5 Resources for health care GDP. 2.5.1 Health care finances 2.5.2 Human resources for health

Jordan’s total expenditure on health is Jordan fares well with regard to its health among the highest in the Region, at 9.8% workforce and is a supplier of human of GDP (compared to an average 5% in the resources for health to many countries in the Region). Jordanians spend an average of region. It is almost self-sufficient in the pre- US$ 228 per capita per year on health (2005), service health and medical education, and to compared to an average of US$ 91 in the a large extent in postgraduate major specialty Region. The contribution of social security to training. Jordan is recognized in the Region government expenditure on health in Jordan is as a training centre for health professions. negligible, when compared to its contribution However, Jordan lacks a comprehensive in the Region and globally.9 There are no

8 UNRWA. Annual Report of the Department of Health, 2004 9 WHO. World Health Statistics, 2007 10 Ke Xu et al. Household catastrophic health expenditure: a multicountry analysis. Lancet, 2003, 362: 111–7 11 Ministry of Finance. Jordan Public Expenditure Review, 2006 (Arabic)

16 Country Cooperation Strategy for WHO and Jordan human resources for health plan and strategy 2.5.3 Pharmaceuticals to address both local and regional needs. Jordan produced only 25% of its Overall, 13.5% of the Ministry of Health staff pharmaceutical needs in 2003, yet it are physicians (all types including residents), is an exporter of pharmaceuticals, and 27.8% are nurses (all categories), 15% in this industry is considered one of the administration and about 24% in ancillary promising industries in national economic services. However, nearly two thirds of the development plans. The national medicine Ministry of Health doctors (64%) and the policy, developed in 2000 in collaboration majority of registered nurses (86%) work in with WHO and the World Bank and currently hospitals, leaving a small percentage to work under revision, serves as a framework for in primary health care facilities. Meanwhile, future development and upgrading of the 9% of total Ministry staff work in the central pharmaceutical sector. The Jordanian Food Ministry of Health, which is considered a and Drug Administration is in charge of significantly high percentage when compared quality control of locally manufactured and to some other countries in the Region.12 The imported medicine, medical supplies, drug public sector employs around 40% of all registration, licensing and pricing. practising physicians in the country, 7% of pharmacists and 64% of nurses. The physician 2.5.4 Health information systems to population ratio is 24.5 per 10 000, higher and health research than most other countries in the Region and The National Health Statistical Information other middle-income countries. System (NHSIS) at the Ministry of Health Human resource development is the focal point of health information in assessments supported by WHO (1998) Jordan. Major constraints facing the NHSIS and USAID (2004) showed gaps in are lack of qualified human and financial human resources management, including resources, inadequate linkages between performance management, job descriptions, institutions, and lack of accurate data on recruitment, hiring, firing, transfer and health services and financing in the private promotion. As well, there is no formal sector. Furthermore, there is no national continuing education system and the health research system in place. Main relationship between health service provision achievements of the NHSIS include the and pre-service training institutions is launch of the Ministry of Health website and not strong. Budget allocations for human establishing national registries for cancer. resource development in the Ministry of Health education initiatives are currently Health and the private sector are minimal.13 taking place, mainly through the Ministry

12 EMRO 2006. Regional Health Systems Observatory. Health System Profile: Jordan 13 Ministry of Finance. Jordan Public Expenditure Study. Health Sector Draft Report 2004

17 CountryCountry Cooperation Cooperation StrategyStrategy for for WHO WHO and andYemen Jordan of Health’s department of health education. (and residents) who are not covered by any Recently, a partnership on health promotion health insurance. The National Agenda is was established called Our Health targeting universal health insurance coverage (Sehetna). A comprehensive review of by the year 2012. Discussions are currently current awareness-raising activities for under way to create an independent health behaviour-related disease is in order. insurance agency.

2.5.5 Health insurance 2.5.6 Health service delivery, coverage and utilization Currently, an estimated 65%–75% of Jordanians have some form of health Primary health care insurance (civil, military, UNRWA, private) depending on the reporting authority. Any Jordan has nationwide primary health individual can utilize the Ministry of Health care coverage, with about 2.4 primary care services and pay subsidized fees (15%–20% centres per 100 000 population and an of cost). In this sense, the Ministry of Health average patient travel time of 30 minutes to provides a safety net for Jordanians who the nearest centre. This represents a high require health care and have no insurance. density system by international standards, with 97% access estimated by the Ministry The Civil Insurance Programme (CIP) of Health in 2007. covers all government employees and their dependents, the poor, the disabled, Jordanians make about 3.6 outpatient children under six years of age and blood visits a year on a per capita basis, almost donors. The plan is covering about 20% of half of which occur at the Ministry of Health Jordanians. RMS is the largest health insurer facilities and 40% at facilities operated by and covers 27% of the population, mainly RMS, JUH, UNRWA and other organizations. military personnel and their dependents. Populations that are illiterate, poor or living in UNRWA provides free primary health care rural areas are more likely to use the Ministry 14 to eligible Palestinian refugees in Jordan, of Health outpatient services. However, and contributes to the cost of inpatient care. weak or no reporting of the private sector UNRWA is reported to cover 11.4% of the may affect these figures. population. Health insurance by private The average cost per visit at primary insurance companies is available for people health care centres is JD 4.5 (US$ 6.4). who want it. Determinants of the cost per visit are mainly The CIP has an optional subsidized health volume of patients seen per day, type of insurance programme for pregnant women facility and the nature of services provided. and senior citizens. The CIP has offered The highest cost per visit is seen in facilities health insurance to all Jordanian citizens with low volume of patients, village clinics and pre-natal/post-natal services facilities.15

14 USAID Primary Health Care Initiative. Household survey 2001 15 USAID Primary Health Care Initiative. Rationalization of staffing patterns and cost analysis of primary care services in Jordan 2000

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Improvement of the quality of care, expansion Despite the country’s success in of services, cost containment and activation attracting foreign patients, a number of of a referral system for the primary health issues need to be addressed, including care network are needed. the lack of coordinated marketing efforts, discrepancy between the quality of care Secondary and tertiary health care provided and the charges incurred, Jordan has 1.9 inpatient hospital beds recurrent malpractice issues and inadequate per 1000 population.16 About 12.3% of the quality control. Launching of health care population is admitted annually to hospitals, quality management and control would with an average length of stay of 3.2 days. enhance the medical tourism sector. The The average overall hospital occupancy rate Ministry of Health is seeking accreditation is estimated at 60.9%, with variation between mechanisms to maintain adequate levels of the public and private sectors. JUH has the competitiveness and is urging all hospitals to highest bed occupancy rate (75%), followed work towards achieving international quality by RMS (74.3%) and Ministry of Health indicators within an established time-frame. hospitals (65.8%).There is a significant 2.6 Health status excess in bed capacity, as indicated by low bed occupancy rates in the private sector 2.6.1 Mortality trends (45.9%). The crude death rate for 2005 was Medical tourism estimated at 7 per 1000 population (revised in light of 2004 census). Although Medical tourism contributes to the national death registration is mandatory by law, economy, as the country receives more registration is not universal (estimated at than 100 000 patients from neighbouring 37%) and certification by cause of death is countries per year. The majority of these not completely accurate.18 However, recent patients come from Yemen, Libyan Arab efforts have been effective in improving the Jamahiriya, Palestine and Sudan, seeking mortality statistics in Jordan. specialized medical care in the private sector. In 2001 the private sector received Mortality levels and trend analysis about US$ 600 million in revenues from (Figure 1) indicate that cardiovascular foreign patients. The Jordan national health diseases are the main cause of death, accounts exercise reported that in 2001, accounting for 38% of all deaths in 2004. 32% of hospital revenue was from medical Cancer ranks second (14%) and external tourism.17 causes including injuries (11%) ranks third.

16 Ministry of Health. Annual Statistical Report 2006 17 WHO Regional Health Systems Observatory 2006. Health System Profile: Jordan 18 WHO. World Health Statistics 2007

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Antenatal care coverage has expanded, five mortality in Jordan, neonatal mortality, covering 99% of pregnant women in 2004, the major contributor to under-five mortality and all births (100%) are attended by skilled in Jordan, should be addressed. health personnel.19 However, the quality of antenatal care and proper attendance of 2.6.2 Morbidity trends delivery, including caesarean section rates, Morbidity data are still in question. National morbidity data are not collected The infant mortality rate has declined from according to a standardized methodology 122 per 1000 live births in 1961 to 22 per and are not available in a comprehensive 1000 live births in 2002. Under-five mortality manner. Most of the available data relate has declined from 39 per 1000 live births in to reportable diseases, and the majority of 1990 to 27 per 1000 in 2002. The decline hospitals and health care facilities do not is due to intensive focus on maternal and code or classify diseases. Admissions and child health activities. The neonatal mortality discharges are properly categorized as (Figure 2) rate declined from 21 to 16 deaths system-related categories, and surgeries per 1000 live births over the period 1985– are only coded as major and minor. In 2006, 2002; however, its contribution to overall diseases related to the respiratory system infant mortality increased, from 63% in 1985 were responsible for 42% of health problems 20 to 70% in 2002. Therefore, to achieve the treated at the Ministry of Health primary MDG target of two-thirds reduction in under- health care facilities.17 Data from Al Bashir

40 35 Circulatory disorders 30 Cancer 25 Endocrine disorders 20 Unknown and specified Perinatal conditions % 15 External causes 10 Respiratory disorders 5 Congenital disorders 0

Males Females

Figure 1. Leading causes of death in Jordan, by sex, 2004

Source: Ministry of Health Information Directorate, 2007

19 Ministry of Health 2007. National Death Registry Report for 2004 20 Department of Statistics. Jordan Population and Family Health Surveys, 1990, 1997, 2002

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80 70 60

Deaths 50 per 1000 40 1–4 years live births Post neonatal 30 Neonatal 20 10 0 1973- 1978- 1983- 1988- 1993- 1998- 1977 1982 1987 1992 1997 2002

Figure 2. Trend in components of under-5 mortality, 1973–2002

Source: Department of Statistics. Jordan Population and Family Health Surveys, 1990, 1997, 2002 hospital (a tertiary hospital) confirm the Jordan is a low prevalence country for importance of cardiovascular disease, renal HIV/AIDS, with an estimated prevalence of failure, diabetes, pneumonia and asthma. less than 0.01%22. As of December 2006, the cumulative number of HIV/AIDS reported Communicable diseases cases in Jordan was 492, of which 35% were Although the disease profile in Jordan is Jordanians (Ministry of Health data). The changing, infectious diseases are still major estimated number of people living with HIV is causes of morbidity. Diarrhoeal diseases, below 1000. Sexual contact is the main mode acute respiratory infections and hepatitis of transmission. Available data rely on passive are the leading causes of morbidity reported case reporting, which may underestimate the from health facilities in Jordan, especially true situation and overlook vulnerable groups. among children. There has been a dramatic Several biological and behavioural surveillance drop in the incidence of vaccine-preventable activities were conducted on most-at-risk diseases. No cases of polio were reported populations between 2006 and 2008. Besides in the country since the outbreak of 1991. sex workers, men having sex with men and Good surveillance and follow-up of all injecting drug users, migrant workers and cases and contacts have resulted in a drop prisoners were also identified as high-risk in tuberculosis rates from 7.3 per 100 000 populations. The Government of Jordan has in 1993 to 2.8 per 100 000 in 2004.21 All developed a comprehensive multisectoral malaria cases currently detected in Jordan national HIV/AIDS strategy (2005–2009), are imported. including major awareness raising and focus on vulnerable groups. It is estimated that 100

21 Ministry of Health, Disease Control Directorate. Report to the WHO Joint Programme Review Mission 2005 22 WHO/UNAIDS. Report on HIV/AIDS 2006

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HIV patients are in need antiretroviral treatment; the carbohydrate share of the dietary energy the reported number of those receiving the supply decreasing (though it remains high, treatment is 53, i.e. coverage of 53%. at 62%). The decrease was accompanied by an increase in the share of energy Chronic and noncommunicable diseases, supply from fat. The protein share remained lifestyle and behavioural risk factors relatively stable, fluctuating around 10%. Jordan is witnessing an increasing This increasing share of fat may contribute trend in the number and severity of to the epidemiological shift towards 25 noncommunicable diseases, particularly noncommunicable diseases. cardiovascular diseases, cancer, diabetes The National Cancer Registry was and chronic respiratory conditions. The established in 1996. The crude incidence major cardiovascular diseases prevalent rate for all cancers among Jordanians in 2004 in Jordan are hypertension, coronary heart was 67.1 per 100 000 population (63.9 for disease and stroke. There is an increasing males and 70.5 for females). However, when prevalence of risk factors when compared rates are adjusted to the world standard to 2004 data (see Table 2). A 2007 survey population, gender differences disappear conducted among adult Jordanians 18 (age-standardized rates per 100 000: males years or older found the prevalence of 112.5 and females 112.6). The highest reported hypertension to be 26% (31% in males, 22% crude cancer incidence rate was observed in females), diabetes 16%, impaired fasting in Amman governorate (112.9), followed by glucose 24% (50% increase from 2005) and Irbid (61.8). The lowest (20.3) was observed hypercholesterolaemia 34%. The prevalence in Mafraq. Reasons are attributed to lifestyle, of overweight (BMI ≥ 25 kg/m2) was 66% but the method of registering the case is very (63% in males, 70% among females). Levels important. Breast cancer ranked first among of physical inactivity are high and estimates females, accounting for 32.9% of all female show moderate inactivity at 32% (improved cancers, while colorectal cancer was the from 50% in 2005). Almost 29% of the commonest among males, 14.1% of all male Jordanians smoke cigarettes regularly (50% cancers. The majority of cancer cases are males, 6% females) and another 9% smoke diagnosed in late stages of the disease.26 waterpipe. About 60% of smokers started smoking before the age of 18. 23,24 Accidents and injuries constitute the second leading cause of death in Jordan Based on FAO statistics, the average daily and have become an increasingly significant per capita dietary energy supply increased problem. In 2006, the Jordan Traffic Institute by 25% during the period 1962–2002, with

23 Ministry of Health. Main results of behavioural factors and risk factors of chronic diseases in Jordan (released 22 November 2007) 24 Ministry of Health and USAID 2006. Jordan behavioural risk factor survey for 2004–2005 25 FAOSTAT data 2005. Available at http//faostat.fao.org/faostat/collectives 26 Ministry of Health 2007. National Cancer Registry. Incidence of Cancer in Jordan 2004

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Table 2. Prevalence of risk factors among adult Jordanians (18+), 1996, 2004 and 2007

Risk factor 1996 2004 2007 Hypertension % 32 29.1 26 Diabetes % 7 13.2 16 Impaired fasting glucose % NA NA 24 Hypercholesterolaemia % NA 22.1 34 Overweight (BMI ≥ 25 kg/m2) % NA 73 66 Moderate physical inactivity % NA 51 32

Source: Jordan behavioural risk factor surveys, 1996, 2004 and 2007 reported 98 055 road traffic accidents, with a carrier rate of 3.4%. There are more resulting in 18 019 injuries and 899 deaths.27 than 1000 cases of thalassaemia registered Injuries occurred more commonly in the at the Ministry of Health hospitals, with age group 15 to 30 years and deaths in the patients on a regular treatment regimen. The age groups of 0 to 11 years and 50 years or annual cost of treatment is estimated at about more. Occupational accidents amounted to JD 7 million (US$ 9.9 million). Premarital 112 859 in 2004, resulting in an estimated screening for thalassaemia and some other loss of 97 522 working days. hereditary diseases is now mandatory by law and is provided free of charge in Ministry Osteoporosis is another emerging health of Health centres. problem in Jordan. A study conducted on 821 post-menopausal Jordanian women 2.6.3 Nutritional disorders aged 50–89 years showed an overall prevalence of 23% when all skeletal sites The latest estimates of reported were combined.28 malnutrition among children under five years of age include stunting at 9%, underweight Hereditary diseases are fairly common at 4% and wasting at 2%. Although these in Jordan and are closely associated estimates reflect good general nutrition with consanguineous marriage. The high among children under five years, there are consanguinity rate (50% of all marriages) some regional variations mainly favouring contributes to the increase of autosomal the northern part of Jordan and reflecting the recessive disorders.29 Thalassaemia is the strong influence of certain socioeconomic commonest screenable hereditary disease determinants.30

27 Royal Hashemite Court, Department of Research and Public Opinion 2006. Traffic Injuries 2006 28 Masri B et al. The First National Osteoporosis Record 2005 29 Khoury SA, Massad D. Consanguineous Marriage in Jordan. American journal of medical genetics, 1992; 43:769–75 30 Department of Statistics and ORC Macro 2003. Jordan Population and Family Health Survey 2002

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Anaemia is a public health problem. A 2.6.5 Environmental health national survey on iron deficiency anaemia, conducted in 2002, showed that anaemia Water, sanitation and waste management affected 32% of women in reproductive age In 2004, 97% of the Jordanian population and one fifth of children under five years, with had access to piped water supply.34 variations between governorates. Iodine However, intermittent supply and inadequate deficiency disorders were a problem in distribution systems are major problems. early 1990s.32 The problem was addressed Acute water scarcity is aggravated by relatively through a universal salt iodization programme high population growth. The available water launched in 1995. Evaluation in 2000 and from the existing renewable sources per 2002 showed that 98% of households are person per year is projected to fall from 159 consuming iodized salt effectively. centimetres in 2003 to about 90 centimetres 2.6.4 Reproductive health by 2025. Water scarcity is exacerbated by pollution of water sources caused by Coverage indicators for maternal health inadequate and inefficient management of have improved in Jordan. However, only domestic wastewater, uncontrolled disposal 50% of pregnant women are covered by of industrial waste, leakage from solid waste two or more doses of tetanus toxoid, mostly landfills and seepage from excessive use due to an increasing number of pregnancies of fertilizers and pesticides. While 60% of and deliveries being attended in the private the population has access to improved sector.33 Antenatal clinics distribute iron sanitation (unrealistically reported at 93% and folic acid supplements. However, the in some references), wastewater collection percentage of women receiving postnatal and treatment systems are overloaded and care remains low. In 2002 the Jordan effluent from them does not meet national Population and Family Health Survey standards. Solid waste collection, which reported that 65% of mothers examined covers 75% of Jordanians and more than immediately after birth do not return for 90% of the population of greater Amman, postpartum examination. The public sector, seems to be satisfactory. Nevertheless, UNRWA, nongovernmental organizations the design and operation of most of these and the private sector offer family planning disposal sites need improvement not to services. In 2005, the modern contraceptive contribute to pollution. prevalence rate was around 43%. Emissions of five principal air pollutants (suspended particulate matter, sulfur dioxide, nitrogen dioxide, carbon monoxide

32 Ministry of Health 1993. National Research Committee on Iodine Deficiency Disorders in Jordan. Report prepared for WHO and UNICEF 33 Ministry of Health 2007. WHO/UNICEF joint reporting on immunization for 2006 34 UNDP. Human Development Report 2006

24 Country Cooperation Strategy for WHO and Jordan and lead) have all increased significantly in and outbreak reporting system. Foodborne Jordan in the past two decades. Specific diseases include cholera, bloody diarrhoea, measures for regulating polluting industries food poisoning, hepatitis A, brucellosis, and decreasing automobile emissions are typhoid and paratyphoid fever. currently being considered. There is a clear need to reinforce consumer Food safety protection laws, improve coordination between various sectors, increase food Overall, the reported incidence of safety budget and drastically improve foodborne diseases in Jordan is decreasing; monitoring and inspection. More emphasis however, strong publicity given to mass food is needed on the control of water used for poisoning accidents has put the issue in the irrigation of vegetables eaten uncooked and public eye. Limited data are available to on safety standards in slaughterhouses, assess the burden of illness resulting from butcher shops and public places selling or foodborne pathogens. The Jordan Food serving food. and Drug Administration, established in 2003, is the agency officially mandated to Another issue of concern is pesticide regulate and supervise food safety activities, residue in the agricultural products of Jordan. for both imported and locally produced Records indicate that for 2002, about 6% of food, including ensuring the enforcement of tested samples had pesticide residue greater food legislation. Food safety activities have than the maximum allowable limit and 19% proven to be inadequate, as evidenced by had residue within acceptable limits. An the recurrent outbreaks of food poisoning in integrated strategy for monitoring use of mayonnaise and shawarma. pesticides in agriculture is urgently needed. There is a need for collaborative efforts of The government has recognized the all concerned parties, including ministries of true extent of health and economic environment, health, agriculture, and water 35 consequences of food-borne diseases. and irrigation. Constraints to food safety include limited human resources, inadequate consumer 2.7 Major challenges awareness, overlap of responsibilities across the food chain, lack of regulation The main challenges of health sector in of street foods and food handlers, lack of Jordan fall within the following two clusters: multidisciplinary inspection teams and limited health system (governance, financing, laboratory services. The Ministry of Health is human resources, evidence and research); responsible for the surveillance of foodborne and epidemiological transition (chronic and diseases, notification of individual cases noncommunicable diseases, lifestyle and behavioural risk factors).

35 WHO in collaboration with the Ministry of Health carried out a population survey in 2003–2004 to study the burden of illness due to salmonella, shigella and brucellosis. The study indicated a large burden of foodborne pathogens and highlighted the magnitude of under-reporting and under-diagnosis of foodborne illness at all stages of the surveillance system

25 CountryCountry Cooperation Cooperation StrategyStrategy for for WHO WHO and andYemen Jordan

Specific challenges include the following. 2.8 Enabling factors

Lack of systematic burden of disease Achievement of good health status and assessment good health services in comparison with other countries of similar socioeconomic High expenditure on health as a status percentage of GDP (9.4%, with 41% out of pocket) Well established primary health care network (referral system limited to public Relatively high percentage of total health sector expenditure on pharmaceuticals (30%) High level political commitment, reflected Lack of universal health insurance in the national agenda. coverage Functioning High Health Council Lack of evidence-based health system performance Clear government policy on equity for health Weak health system research Presence of legislation and public health Variable quality of health services laws Concerns on equity of the health system National health strategy being re-drafted Incomplete role and regulation of the Presence of strategies and plans for the private sector (domestic, medical health-related sector tourism, pharmaceutical sector) Availability of quality health workers Need for more attention to environmental health and food safety Relatively high population coverage for health insurance (2/3 of population)

26 Section 3

Development Cooperation and Partnerships

Section 3. Development Cooperation and Partnerships

3.1 Overview Capital expenditures rose by 25% as a result of implementing a large number of Historically, foreign aid has played a developmental projects across the country. vital role in the economic development of many developing as well as low-middle During 2006, the total amount income countries, and Jordan stands at committed by the donor community no exception. For many years, Jordan has was US$ 675 million. The committed grants received assistance from bilateral and reached US$ 485.4 million, representing multilateral donors who constitute an integral about 72% of total foreign assistance, source of its development funding. and the loans reached US$189.6 million, representing about 28% of total assistance In 2006, Jordan’s general budget achieved (Figure 3). good results with the overall budget deficit declining from 5% of GDP in 2005 to 3.8% in In 2006 the support from bilateral donors 2006.36 Current expenditures rose by 7.3% amounted to US$ 432.6 million, representing as a result of the increase in international 64% of total assistance, whereas the total oil prices, which was clearly reflected amount received by multilateral donors by the cost of fuel subsidies amounting amounted to US$ 242.4 million, representing 37 to JD 215.7 million (US$ 304.7 million). 36% of total assistance.

800 700 600 500 Grants 400 Loans 300 Total

US$ million 200 100 0 2004 2005 2006 Year

Figure 3. Foreign aid to Jordan 2004–2006*

Source: Ministry of Planning and International Cooperation Foreign Assistance to Jordan 2006 *Oil grants are not included

36 Ministry of Planning, Jordan (website) 37 Ministry of Planning and International Cooperation. Foreign Assistance to Jordan 2006

29 CountryCountry Cooperation Cooperation StrategyStrategy for for WHO WHO and andYemen Jordan

3.2 United Nations system Quality of and equitable access to social services and income generating Since 1952, the United Nations system opportunities are enhanced with focus has continued to provide technical support on poor and vulnerable groups to Jordan. In 2006, UN programmes (UNDP, UNIFEM and UNODC) committed a total Good governance mechanisms and of US$ 1.77 million, while the World Bank practices established towards poverty committed to a total of US$ 20.85 million. reduction, protection of human rights UNDP support for health and related and gender equality in accordance with areas is limited to collaboration with the the Millennium Declaration Department of Statistics and collaboration Sustainable management of natural with interagency projects led by WHO, such resources and the environment as HIV/AIDS prevention, media and health, and healthy villages. UNICEF’s scope of The UN agencies have identified a number work is centred on areas relating to nutrition, of areas where two or more agencies primary health care and healthy lifestyle can combine efforts and map out joint promotion. UNFPA is committing resources programming initiatives for achieving the to address integration of reproductive health agreed upon objectives. The total budget into primary health care and contributes estimated for implementation of the UNDAF to improvement of vital statistics and vital (2008–2012) is US$ 45.9 million. The core registration. resources needed from agencies’ budgets are US$ 13.7 million (29.8%), in addition In 2007, the UN system finalized the to resources that will need to be mobilized United Nations Development Assistance from partners, estimated at US$ 32.2 million Framework (UNDAF) for Jordan for the period (70.2%). 2008–2012. The UNDAF was prepared on basis of the Common Country Assessment 3.3 Donors/lenders group (CCA). The UNDAF is the strategic tool for cooperation between Jordan and the The donors and lenders group is an UN system for the period 2008–2012. The informal consultative body consisting of UNDAF is based on national priorities as heads of missions of donor and lender identified by National Agenda, as well as countries and representatives of UN the Millennium Development Goals (MDGs). agencies. The group is chaired by one of Programmes emerging from the UNDAF will its member from the heads of diplomatic address all MDGs and will contribute to the missions and rotation is carried out every achievement of the three following UNDAF six months. The Resident Coordinator’s outcomes by 2012. Office acts as the secretariat for the consultative group. The donors/lenders group has been functioning since 2000. One

30 Country Cooperation Strategy for WHO and Jordan of the objectives of the group is to improve 3.5 Coordination with UN agencies harmonization and identify constructive synergies among donors/lenders and UN The WHO office in Jordan has excellent agencies. The group has six subgroups for communications and collaboration with all education, environment, governance and UN agencies. WHO participates actively in public sector, private sector development, various meetings of UN agencies and in the water and social development. CCA and UNDAF processes. It undertook leadership of the UNDAF thematic group 3.4 Donor support for health on sustainable management of national resources and environment. It also chaired In the past two years, the health sector the UNAIDS thematic group for the past was the third largest recipient of donor funds five years and chaired the UNDP MDG in Jordan, after direct budget support and Achievement Fund Thematic Window for the water sector. Total foreign assistance Youth, Employment and Migration in 2007. committed by donors and financing institutions for the health sector was The WHO office also has a close relationship US$ 94.04 million in 2005 and US$ 118.3 with many governmental, nongovernmental, million in 2006. These amounts, respectively, educational and private sector organizations constituted 15% and 17.5% of the total foreign in Jordan. WHO is playing a vital role in assistance to the country. assisting the national committees for violence and injury prevention, tobacco control and For many years, USAID has been a leading healthy lifestyles promotion while ensuring donor to the health sector and has been a stronger UN presence with involvement of diligently working with the Ministry of Health various UN agencies. WHO has actively sought and other health related ministries. Areas of collaboration with UNICEF and UNFPA in the support were centred towards population areas of Integrated Management of Childhood policies and strategies, management of Illnesses, road safety, tobacco control, information systems, reproductive health, violence, youth and reproductive health. quality assurance, and strengthening of Moreover, WHO is collaborating with UNHCR, epidemiological surveillance system for UNICEF, UNFPA and the International Red diseases. Other donors are the European Cross and Red Crescent Society to provide Union, Governments of Germany and health services for Iraqi refugees in Jordan. Japan, Saudi Development Fund, Islamic WHO is an active member in the Country Development Bank, Arab Fund for Economic Coordination Mechanism (CCM) which is led and Social Development, OPEC Fund for by the Ministry of Health. International Development, the World Bank, and Governments of Norway, Spain, Greece, Switzerland, Canada, Korea, Italy and China.

31

Section 4

Current Country Programme

Section 4. Current Country Programme

4.1 Brief historical perspective group, and participated in the poverty and education working groups. WHO is fully In 1985, the WHO country office was involved in the development of national established in Jordan in to provide technical health plans, strategies and major national support to the Ministry of Health and other health activities and is currently the lead health related ministries and sectors. UN agency for health development in the Apart from the WHO Representative’s country. WHO has played a key supporting office, Amman hosts the WHO Centre for role in the development of major national Environmental Health Activities (CEHA) plans and strategies such as the National for the Eastern Mediterranean Region. Agenda, the national health strategy, and CEHA staff provide technical support to the national strategy on HIV/AIDS, the the WHO office in specific areas relating to school health strategy, and the national food water, sanitation, chemical safety and other and nutrition policy. Furthermore, the WHO environmental health activities. As well, the office has been acting as back-up hub for United Nations Relief and Works Agency neighbouring countries such as Lebanon, for the Palestine Refugees in the Near East Iraq and the occupied Palestinian territory (UNRWA) is located in Amman. The UNRWA during emergencies and has facilitated many Director of Health for the five areas of administrative procedures. operation is a WHO-seconded senior staff. 4.2.2 Areas of work 4.2 Key roles and areas of work Avian influenza 4.2.1 Roles WHO has assumed the role of reference WHO provides technical and financial point for avian influenza and enjoys a very support and collaborates with the Ministry close relationship with FAO in assisting of Health, other governmental sectors, the country in preparedness and response nongovernmental organizations, medical to avian influenza. WHO also has assisted and allied sciences institutions and WHO the office of the UN Resident Coordinator Collaborating Centres. The collaborative and UNCT in preparing, implementing and programme covers: technical advice, monitoring the UN Contingency Plan on provision of experts/consultants, organizing pandemic influenza for UN staff in Jordan fellowships/study tour to train nationals, and Iraq. providing supplies and equipment, and supporting operational research and Community-based initiatives information and knowledge exchange. As part of the UN drive towards interagency WHO has played a key and vital role in collaboration, the WHO Office in Jordan the development of CCA and UNDAF in cooperates with the UNIFEM Regional Office 2005–2007, chairing the health working for Arab States on health and gender issues,

35 CountryCountry Cooperation Cooperation StrategyStrategy for for WHO WHO and andYemen Jordan including awareness on reproductive health, organizations are not sufficiently strategic sexual health rights, early detection of or solid. WHO has facilitated a successful breast cancer and prevention of obesity and partnership among concerned stakeholders smoking. These efforts are part of existing on tobacco, road safety and HIV/AIDS. projects implemented by both organizations Partnership building is expanding to in Jordan and the region: WHO’s healthy include the High Health Council, Ministry of villages project and UNIFEM’s village project, Environment, Ministry of Transport, Ministry which are aimed at poverty reduction and of Interior, Ministry of Agriculture, Ministry of community empowerment for health and Education and Civil Defence. local development. Additionally, WHO is There are five WHO collaborating centres closely collaborating with UNRWA in the in Jordan: National Blood Bank; National development of healthy villages and healthy Centre for Diabetes, Endocrinology and lifestyle promotion in refugee camps. Genetics at the University of Jordan; HIV/AIDS Faculty of Nursing at the Jordan University of Science and Technology; King Hussein WHO has been the chair of the active Cancer Centre; and National Council for UN theme group on HIV/AIDS since Family Affairs. The role of collaborating 2001. The group, which includes national centres needs further strengthening. AIDS programme management and nongovernmental organizations, USAID Crisis management and involvement in and other donors, has played a crucial role the Iraq influx into Jordan in accomplishing the three “ones” (one WHO is working with UNHCR, UNICEF, national framework, one national authority UNFPA and other partners in coordinating and one monitoring and evaluation system). and harmonizing health support. WHO This theme group was noted in the mid term played a major role in the preparation of the review report of the UNDAF 2003–2007 as ministerial consultation to support displaced a huge and unprecedented success in the Iraqis which convened in Damascus, Syrian UN system Arab Republic, on 29–30 July 2007 and The country office in collaboration with resulted in a common action framework for all the Regional Office, headquarters and the partners working for the health of displaced Global Fund to fight AIDS, Tuberculosis and Iraqis in Jordan, Syrian Arab Republic and Malaria has assisted the Ministry of Health Egypt. WHO is also supporting UNHCR in developing successful proposals for activities in health, including psychosocial Global Fund support for both HIV/AIDS and support to vulnerable displaced groups. tuberculosis programmes. Furthermore, WHO is leading the UN system in preparing medical evacuation plans for Partnerships with other ministries and Jordan and logistical support for WHO staff agencies in Lebanon and Iraq.

Relationships with some ministries and It is anticipated that more efforts will be with civil society and nongovernmental needed for support to displaced Iraqis and

36 Country Cooperation Strategy for WHO and Jordan for assisting neighbouring countries. the WHO regular budget in order in the past two bienniums across priority areas is shown 4.3 Existing resources in Figure 4. The priority areas identified were In addition to the WHO Representative, the communicable diseases, noncommunicable WHO office in Jordan includes the following diseases, emergency preparedness, health fixed term staff. systems strengthening, health promotion and protection and sustainable development. National programme officer (health system) 4.5 Challenges Harmonization with the National Agenda. National programme officer (health The National Agenda, launched in 2005, protection and promotion) sets the framework for development and has been used as a reference in the CCS One national senior administrative staff process. WHO collaboration and the (office director) implementation of the CCS should be One national IT assistant harmonized with the main National Agenda themes of poverty reduction; sustainable One national clerk environment; education; training and youth employment; population and health; One national secretary public and private sector development; Two drivers and equity and equality issues, including gender The current country office is Refocusing. There is need for more accommodated by the Government of emphasis on health system strengthening Jordan in a rented three-story building. and on the prevention and treatment of Only one and half floors are used by WHO. noncommunicable diseases Recently the Government of Jordan offered land (2500 square metres) in the middle of Focus on major strategic initiatives and Amman city for construction of a new office sustainability. The major emphasis should building. Construction is expected to start be on key strategic issues that support by mid 2008. building national capacity and facilitate sustainability, such as integrated human 4.4 Country programme budget resources development for health, building local capacity and institutional The WHO country budgets for the strengthening bienniums 2006–2007 and 2008–2009 were US$ 790 000 and US$ 795 000 respectively Partnership with national stakeholders (Figure 4). The regular budget comprised outside the Ministry of Health. The Ministry about 20%–50% of the total programme of Health continues to be WHO’s main budget while extrabudgetary sources ranged counterpart; however, partnership with widely, from US$ 606 500 to US$ 4 254 000. A other national collaborators should be breakdown comparison of the distribution of strengthened.

37 CountryCountry Cooperation Cooperation StrategyStrategy for for WHO WHO and andYemen Jordan

900 800 700 600 500 06-07 400 08-09

US$ (00) 300 200 100 0 Noncommunicable Health Sustainable diseases systems development Total Communicable Health diseases Emergency promotion

Figure 4. Distribution of regular budget among different programes for 2006–2007 and 2008–2009 bienniums

4.6 Strengths and weaknesses 4.6.2 Weaknesses of WHO cooperation Insufficient number of professional and 4.6.1 Strengths support staff to respond to overwhelming demand Motivated and qualified staff Inadequate IT infrastructure and support Responsive and committed team Overemphasis on support for routine High credibility and visibility activities

Main source of health information in Jordan Too many programmes with less focus on strategic impact Catalyst for strategic change Limited cooperation with other health- Strong advocacy role with highest political related sectors support Inadequate focus on key national strategic Strong technical support priorities Good follow-up with the Regional Office Little correlation between the CCS and and headquarters on ongoing activities JPRM 2004–2007 Lead in UNCT thematic groups (HIV/AIDS, environment and avian influenza)

38 Section 5

Strategic Agenda for WHO Cooperation

Section 5. Strategic Agenda for WHO Cooperation

5.1 Introduction in implementation and in knowledge. WHO’s response is translated into priorities in the The General Programme of Work is a following areas according to its results- requirement specified in Article 28(g) of the based management framework. WHO Constitution. The General Programme of Work analyses current health challenges Providing support to countries in moving in light of WHO’s core functions and sets to universal coverage with effective public broad directions for its future work. The core health interventions functions as stated in the Eleventh General Strengthening global health security Programme of Work, covering the period 2006–2015, are as follows. Generating and sustaining action across sectors to modify the behavioural, Providing leadership on matters critical to social, economic and environmental health and engaging in partnership where determinants of health joint action is needed Increasing institutional capacities to Shaping the research agenda, and deliver core public health functions under stimulating the generation, dissemination the strengthened governance of ministries and application of valuable knowledge of health Setting norms and standards, and Strengthening WHO’s leadership at global promoting and monitoring their and regional levels and by supporting the implementation work of governments at country level Articulating ethical and evidence-based The Medium-term strategic plan 2008– policy actions 2013—an integral element in WHO’s Providing technical support, catalysing framework for results-based management— change and building sustainable translates the Eleventh General Programme institutional capacity of Work’s long-term vision for health into strategic objectives, reflects country Monitoring the health situation and priorities (particularly those expressed assessing health trends in country cooperation strategies) and provides the basis for the Organization’s The analysis in the Eleventh General detailed operational planning. The strategic Programme of Work reveals several areas objectives provide clear and measurable of unrealized potential for improving health, expected results of the Organization. particularly the health of the poor. The gaps are identified in social justice, in responsibility, The structure of WHO’s Secretariat assures involvement with countries.

41 CountryCountry Cooperation Cooperation StrategyStrategy for for WHO WHO and andYemen Jordan

Headquarters focuses on issues of global used to identify challenges related to the concern and technical backstopping for priority areas. regions and countries. Regional offices focus on technical support and building of national Alignment with national priorities capacities. WHO’s presence in countries Harmonization with programmes of other allows it to have a close relationship with partners ministries of health and with its partners inside and outside government. The Organization Linkage with WHO global and regional also collaborates closely with other bodies priorities of the United Nations system and provides Contribution to MDGs and related health channels for emergency support. goals In developing strategic priorities for Equity and social protection collaboration between WHO and the Government of Jordan during the mid- Gender equity, human rights and health term period 2008–2013, special care has security been taken by the CCS mission to ensure that these priorities are in line with the Strengthening technical and evidence- Organization-wide priorities and overall based practice and management strategic directions during the same period. Partnership 5.2 Framework for collaboration Sustainability The direction of WHO cooperation The development of the strategic with Jordan during 2008–2013 will not directions for WHO collaboration with Jordan deviate radically from previous strategies, during 2008–2013 involved a comprehensive which have resulted in the stable and consultative process. The overall approach steady improvement in health status and included as many stakeholders as needed development of the health system. However, to ensure intersectoral and intrasectoral WHO collaboration will focus primarily on integration and coordination, leaving room the health system (governance, financing, to identify or revise roles and expectations human resources, evidence and research) to help ensure harmonization and aid and challenges of epidemiological transition effectiveness. (chronic and noncommunicable diseases, Extensive technical discussion, lifestyle and behavioural risk factors). consultations and group work allowed the Furthermore, the prioritized strategic CCS team to address the issues within a directions are consistent with national framework of cooperation between the WHO priorities and WHO’s mid-term strategic and the Government of Jordan. The CCS plan 2008–2013) of the Eleventh General team focused on the development of the Programme of Work (2008–2017) as well as strategic directions. During the development with the regional priorities. process, certain guiding principles were

42 Country Cooperation Strategy for WHO and Jordan

5.3 Strategic directions for Establishing a functional coordinating cooperation mechanism to bring together all stakeholders 1. Strengthening health sector governance and health system policy Setting up a national accreditation system development and management for health professions education

Developing health policies and strategies Formulating policies for retention, to be incorporated in all sectors for management and performance-linked improving health continuing professional development Strengthening capacity for effective 3. Strengthening information research decentralization, especially quality, equity and knowledge management and the primary health care referral system Strengthening an integrated national health information system for evidence- Building capacity to enhance partnership based policy formulation, decision- among all stakeholders for health and making, monitoring and evaluation effective intrasectoral and intersectoral collaboration Strengthening the national health research system Strengthening regulation of the private sector to ensure the quality of care and Strengthening knowledge management patient rights and sharing

Promoting cost containment and rational 4. Developing a fair sustainable health use of health technologies to prevent the financing system covering the entire unnecessary escalation of health care population costs, particularly in relation to growing Developing a national health financing medical tourism policy based on social health insurance Strengthening regulation of the Developing a fair financing system for pharmaceutical industry and rational use equitable contribution and reduction of of medicines catastrophic health expenditures 2. Strengthening comprehensive Institutionalizing the national health national health human resource account and analysis development, planning, production and utilization

Developing an integrated national health human resources development plan

43 CountryCountry Cooperation Cooperation StrategyStrategy for for WHO WHO and andYemen Jordan

5. Supporting policy, programmes Building the capacity of Ministry of and coordinating mechanisms for Health staff in early preparedness and integrated health promotion and response based on hazard mapping, and protection, risk factor management developing a national strategy for health and injury prevention emergency and preparedness

Developing a national strategy for health Upgrading a legal framework and promotion addressing lifestyle-related risk contingency plans factors and their management 7. Providing advocacy and technical Continuing support for road traffic support for health protection, accident and injury prevention especially environmental health and food safety through assessment, Re-orienting human resources capacity building and coordination development to develop the required health workforce for health promotion and Ensuring drinking-water security in overall risk factor management development

Networking and improving intrasectoral Strengthening health, environment, and intersectoral collaboration food and life style information systems, especially at city level Strengthening noncommunicable disease and risk factor surveillance Promoting dialogue on population, water scarcity and health Strengthening maternal mortality surveillance 8. Monitoring achievements on communicable disease control, 6. Strengthening national emergency including the surveillance system preparedness plans and strategies based on hazard mapping and risk assessment

Developing a unit for health emergency preparedness in the Ministry of Health

44 Section 6

Implementing the Strategic Agenda: Implications for WHO

Section 6.Implementing the Strategic Agenda: Implications for WHO

6.1 Overview to provide additional support as identified in the strategic directions. Table 4 shows The implementation of the CCS puts the strategic directions versus the existing additional demand on WHO not only to programmes and required staff. maintain its active and effective role but also

Table 4. Strategic directions, existing workplans and resources needed

Strategic direction Workplan title Resources needed 1. Supporting appropriate evidence-based Governance Health system health system policies and strategies to be Evidence and strengthening officer incorporated in all sectors for improving information for policy One support staff health Health policy and Strengthening capacity for effective strategic planning decentralization National medicine Building capacity for partnership and policies based on systematic intrasectoral and intersectoral essential medicines collaboration Quality control and quality assurance (patient safety initiative and health district empowerment) School health strategy and accreditation guidelines

2. Strengthening comprehensive national Human resources Health system health human resource development, policy planning and strengthening officer planning, production and utilization management (human Consultant resources development) Developing an integrated national health human resources development plan Nursing development and leadership for Establishing a functional coordination change programme mechanism to bring together all stakeholders Setting up a national accreditation system for health professions education Formulating policies for retention, management and performance-linked continuing professional development

47 CountryCountry Cooperation Cooperation StrategyStrategy for for WHO WHO and andYemen Jordan

Strategic direction Workplan title Resources needed 3. Strengthening information research and Evidence and Health system knowledge management information for policy strengthening officer Strengthening an integrated national National health Collaborating health information system for evidence- priorities identification network based policy formulation, decision- National burden of Independent making, monitoring and evaluation disease estimation research for policy Strengthening the national health including strengthening research system ICD10 and mortality systems Strengthening knowledge management Governance and sharing mechanism MDG monitoring and monitoring of the UNDAF results matrix

4. Developing a fair sustainable health Health insurance Health system financing system covering all population programme and health strengthening officer care financing Development of a national health Consultant financing policy based on social health National programme on insurance rational use of medicine Promoting fairness in financial Supporting Medicines contribution and reduction of Transparency Alliance catastrophic health expenditures pilot activity in Jordan

48 Country Cooperation Strategy for WHO and Jordan

Strategic direction Workplan title Resources needed 5. Supporting policy, programmes and Promotion of healthy Health promotion coordinating mechanisms for integrated lifestyles, nutrition and officer health promotion and protection and risk rehabilitation Media and factor management Genetic disorders and communication Developing a national strategy on emerging priorities national officer healthy lifestyles and risk factor Mental health including Administrative management substance abuse support staff Re-orienting human resources Noncommunicable development to develop the required diseases including health-force for health promotion and blindness and deafness risk management Health of special Networking intrasectoral and groups: school health, intersectoral activities occupational health and health of the elderly Child health including integrated management of childhood illness Food safety and nutrition Violence and injuries Women’s health Sustainable development approaches: healthy villages Assessment of risk factors for noncommunicable disease AIDS and sexually transmitted infections

49 CountryCountry Cooperation Cooperation StrategyStrategy for for WHO WHO and andYemen Jordan

Strategic direction Workplan title Resources needed 6. Strengthening the national emergency- Emergency and Emergency national preparedness plans and strategies through disaster management officer preparation of hazard mapping, risk Pandemic influenza assessment, and updating legal framework UN Contingency Plan and contingency plans monitoring Preparation of hazard mapping and risk assessment Updating legal framework and contingency plans Building capacity of Ministry of Health staff in early preparedness and response

7. Enhancing the national environmental Environmental health CEHA and national health protection through assessment, including food safety programme officer capacity building and coordination Administrative support staff

6.2 Country level 6.3 Regional level

Human resource needs Participation and substantive involvement in planning, provision of prompt Fixed term post for a national health technical support for mobilization and system strengthening officer implementation of strategic directions

Fixed term post for a national health Prompt and effective provision of promotion and protection officer technical support

New post for a national crisis Monitoring and evaluation management, emergency preparedness officer Sharing of regional experiences, resources and regional work plans New post for a media and communication national officer Capacity building in terms of staff development Two posts for administrative support staff Support for development of project Logistical and administrative needs proposals and backstopping for resource Moving the WHO offices to a more mobilization spacious and secure premises

Improving the communication system

50 Country Cooperation Strategy for WHO and Jordan

6.4 Headquarters level Necessary financial support through additional budget allocations (to be Prompt and effective provision of reflected in operational plans) and technical support extrabudgetary resources

Monitoring and evaluation Coordination of support with the Regional Office and country office Sharing of global experiences

Standard setting and clearinghouse for information and publication

51 CountryCountry Cooperation Cooperation StrategyStrategy for for WHO WHO and andYemen Jordan

Annexes

Annex 1 Ministry of Health Members of the CCS Team Dr Ruwaida Rashid, Director of Women and Child Health Directorate WHO Regional Office and headquarters Dr Qasem Rabee, Directorate of Planning Dr Shambhu Acharya, Department of and Project Management Country Focus, WHO headquarters Dr Abdul Razaq Al Shafei, Director of Dr Ghanem Al Sheikh, Coordinator, Human Health Economics Directorate Resources Development, WHO Regional Dr Jamal Abu Seif, Director of Technical Office for the Eastern Mediterranean Affairs, Studies and Research Mr Kaiumars Khoshchashm, Programme Planning, Monitoring and Evaluation, WHO Regional Office for the Eastern Mediterranean

WHO country office

Dr Hashim Ali El-Zein El-Mousaad, WHO Representative

Dr Saher Shuqaidef, Short-term Consultant

Dr Sana Naffa, National Programme Officer

Ms Tatyana El-Kour, Technical Officer

52 www.emro.who.int