Health Inequalities in Jordan and their Social Determinants: Evidence and Policy Implications

2019

Disclaimer The analysis, views and policy recommendations in this publication are those of the authors and do not necessarily represent the views of the World Health Organization (WHO). The report also does not reflect the views of the American University in Cairo. The report is the work of an independent team of authors from the Social Research Center of the American University in Cairo supported by the World Health Organization/ Jordan (WHO /Jordan).

Recommended Citation: Khadr, Z., Rashad, H., & Shawky. S. “Health Inequalities in Jordan and their Social Determinants: Evidence and Policy Implications.” The Social Research Center of the American University in Cairo and the World Health Organization/ Jordan (2019).

TABLE OF CONTENT

Table of content ...... 2 List of figures ...... 5 List of tables ...... 10 ACKNOWLEDGEMENTS ...... 12 EXECUTIVE SUMMARY ...... 13 SECTION 1: INTRODUCTION ...... 13 SECTION 2: JORDAN: SETTING THE SCENE ...... 13 SECTION 3: CONCEPTUAL FRAMEWORK AND METHODOLOGY ...... 14 SECTION 4: CHILD HEALTH AND WELLBEING ...... 16 SECTION 5: ADULT HEALTH AND NCDS ...... 18 SECTION 6: SEXUAL AND REPRODUCTIVE HEALTH ...... 19 SECTION 7: HEALTH SECTOR PERFORMANCE AND CAPACITY ...... 22  Health sector performance ...... 23  Health sector capacity ...... 26 SECTION 8: HEALTH INSURANCE COVERAGE ...... 27 SECTION 9: OVERVIEW OF THE HEALTH AND HEALTH EQUITY CHALLENGES IN JORDAN ...... 28 SECTION 10: POLICY RECOMMENDATIONS ...... 30 1 INTRODUCTION ...... 33 1.1 Health equity a marker for social success ...... 34 2 Setting the Scene: the Hashemite Kingdom of Jordan ...... 37 2.1 Jordan: A high human development nation ...... 37 2.2 Health policy context in Jordan...... 39 3 Framework and methodology...... 44 3.1 The framework for health inequity investigation ...... 44 3.2 The methodology ...... 45 3.2.1 Data and health indicators ...... 45 3.2.2 Choice of social stratifications: ...... 1 3.2.3 Analytical Methods ...... 2 4 Child health and wellbeing ...... 4 4.1 Mortality indicators ...... 4 4.2 Child health and wellbeing risk factors indicators ...... 7

4.2.1 Infant health risk factors ...... 7 4.2.2 Child nutrition risk factors...... 11 4.2.3 Child development risk factors ...... 14 4.3 Concluding remarks ...... 18 5 Adult health and non-communicable diseases ...... 19 5.1 Mortality and NCDs ...... 19 5.2 Diabetes in Jordan ...... 20 5.3 NCDs risk factors ...... 23 5.4 Concluding remarks ...... 26 6 Sexual and reproductive health ...... 28 6.1 Social reproductive health risk factors ...... 28 6.2 HIV/AIDS-related knowledge and attitudes ...... 32 6.3 Domestic violence risk factors ...... 38 6.4 Concluding remarks ...... 46 7 Health sector performance and capacity: ...... 49 7.1 Health sector performance ...... 49 7.1.1 Health sector performance for infant health ...... 49 7.1.2 Health sector performance for child health ...... 53 7.1.3 Health sector performance for maternal health ...... 59 7.1.4 Health sector performance for family planning indicators ...... 63 7.1.5 Health sector performance for other reproductive health indicators ...... 67 7.2 Health sector capacity: ...... 70 7.3 Concluding remarks ...... 74 8 Health insurance coverage in Jordan (UHC) ...... 76 8.1 UHC in Jordan ...... 76 8.2 Concluding remarks ...... 81 9 Health and health equity priorities in Jordan: Patterns and trends ...... 82 9.1 What are the main health priorities in Jordan and their trend between 2012 and 2017? ...... 82 9.2 What is the distribution of health priorities for different social groups and which social group is the most vulnerable social group? ...... 85 9.2.1 The priorities structures for the social groups for different stratifiers ...... 85 9.2.2 Social groups experiencing worst performance ...... 86 9.3 What is the distribution of severity of health inequality for different stratifier and which stratifier is more severely unequal? ...... 87

9.4 What are the trends in the inequality summary measures for the different health aspect by the different stratifiers between 2012 and 2017? ...... 89 9.5 Concluding remarks ...... 90 10 Health and health equity priorities in Jordan: current status and the way forward ...... 92 Jordan health and health equity priorities: Strategic directions versus data reality ...... 92 Anemia among women in reproductive age and children, ...... 93 Jordan health and health equity priorities: International commitments and global strategies...... 94 Jordan health and health equity priorities: The way forward ...... 97 POLICY RECOMMENDATIONS ...... 98 References ...... 101 Appendixes ...... 103 Appendix A: Fact sheets ...... 104 Child health and wellbeing ...... 105 NCDs and adult health ...... 108 Sexual and Reproductive health ...... 111 Health sector performance and capacity ...... 115 Health sector capacity ...... 119 Health insurance coverage...... 121 Appendix B: Health indicators prevalence, gaps and inequality summary measures for all stratifiers 123 Appendix C: Health indicators prevalence and their prevalence classification ...... 125 Appendix D: The social groups with highest prevalence for the indicators across the stratifiers ...... 129 Appendix E: Inequality measures and their severity classification for the health indicators by their prevalence classification ...... 131 Appendix F: Trends in prevalence and inequality summary measures for health indicators ...... 134 ...... 136

LIST OF FIGURES

Figure 1 Jordan and its governorates...... 37 Figure 2 Percent reduction in HDI for inequality and inequality reduction by HDI dimensions, 2017 ...... 39 Figure 3: Social determinants of health inequities framework ...... 46 Figure 4 Neonatal, infant and child mortality for the preceding five years before the survey, JPFHS, 2012- 2017 ...... 4 Figure 5 Neonatal, infant and child mortality in the governorates and their measures of inequality, JPFHS, 2017 ...... 5 Figure 6 Neonatal, infant and child mortality by wealth quintiles and their measures of inequality, JPFHS, 2017 ...... 5 Figure 7 Neonatal, infant and child mortality by levels of mothers’ educational attainment and their measures of inequality, JPFHS, 2017 ...... 6 Figure 8 Neonatal, infant and child mortality by nationalities and their measures of inequality, JPFHS, 2017 ...... 6 Figure 9 Infant health risk factors indicators, JPFHS, 2012 &2017 ...... 8 Figure 10 Infant health risk factors by governorates and their measures of inequality, JPFHS, 2017 ...... 8 Figure 11 Infant health risk factors by wealth quintile and their measures of inequality, JPFHS, 2017 ...... 9 Figure 12 Infant health risk factors by educational attainment and their measures of inequality, JPFHS, 2017 ...... 9 Figure 13 Infant health risk factors by nationalities and their measures of inequality, JPFHS, 2017 ...... 10 Figure 14 Child nutrition health risk factors indicators, JPFHS, 2012 &2017 ...... 11 Figure 15 Child nutrition risk factors by governorates and their measures of inequality, JPFHS, 2017 ..... 11 Figure 17 Child nutrition risk factors by education attainment and their measures of inequality, JPFHS, 2017 ...... 13 Figure 18 Child nutrition risk factors by nationalities and their measures of inequality, JPFHS, 2017 ...... 13 Figure 19 Child development factors indicators, JPFHS, 2012 &2017 ...... 15 Figure 20 Child development risk factors by governorates and their measures of inequality, JPFHS, 2017 ...... 15 Figure 21 Child development risk factors by wealth and their measures of inequality, JPFHS, 2017 ...... 16 Figure 22 Child development risk factors by education attainment and their measures of inequality, JPFHS, 2017 ...... 16 Figure 23 Child development risk factors by nationalities and their measures of inequality, JPFHS, 2017 ...... 17 Figure 24 Distribution of death by main cause of death in Jordan, WHO (2018) ...... 19 Figure 26 Prevalence of diagnosed diabetes in Jordan, JPFHS, 2017 ...... 20 Figure 28 Prevalence of diagnosed diabetes indicators by wealth and their measures of inequality, JPFHS, 2017 ...... 21 Figure 29 Prevalence of diagnosed diabetes indicators by education and their measures of inequality, JPFHS, 2017 ...... 22 Figure 30 Prevalence of diagnosed diabetes indicators by nationality from the national levels and their measures of inequality, JPFHS, 2017 ...... 22 Figure 31 Prevalence of NCDs risk factors in Jordan, JPFHS, 2017 ...... 23

Figure 32 Prevalence of NCDs risk factors indicators by governorates and their measures of inequality, JPFHS, 2017 ...... 24 Figure 33 Prevalence of NCDs risk factors indicators by wealth and their measures of inequality, JPFHS, 2017 ...... 25 Figure 34 Prevalence of NCDs risk factors indicators by education attainment and their measures of inequality, JPFHS, 2017 ...... 25 Figure 35 Prevalence of NCDs risk factors indicators by nationalities and their measures of inequality, JPFHS, 2017 ...... 26 Figure 36 Prevalence of social RH risk factors in Jordan, JPFHS, 2017 ...... 28 Figure 37 Prevalence of social RH risk factors indicators by governorates and their measures of inequality, JPFHS, 2017 ...... 29 Figure 38 Prevalence of social RH risk factors indicators by wealth and their measures of inequality, JPFHS, 2017 ...... 30 Figure 39 Prevalence of social RH risk factors indicators by education attainment and their measures of inequality, JPFHS, 2017 ...... 30 Figure 40 Prevalence of social RH risk factors indicators by nationalities and their measures of inequality, JPFHS, 2017 ...... 31 Figure 41 Prevalence of HIV/AIDS related risk factors in Jordan, JPFHS, 2017 ...... 32 Figure 42 Prevalence of HIV/AIDS risk factors indicators for women by governorates and their measures of inequality, JPFHS, 2017 ...... 33 Figure 43 Prevalence of HIV/AIDS risk factors indicators for men by governorates and their measures of inequality, JPFHS, 2017 ...... 34 Figure 44 Prevalence of HIV/AIDS risk factors indicators for women by wealth and their measures of inequality, JPFHS, 2017 ...... 34 Figure 45 Prevalence of HIV/AIDS risk factors indicators for men by wealth and their measures of inequality, JPFHS, 2017 ...... 35 Figure 46 Prevalence of HIV/AIDS risk factors indicators for women by education attainment and their measures of inequality, JPFHS, 2017 ...... 35 Figure 47 Prevalence of HIV/AIDS risk factors indicators for men by education attainment and their measures of inequality, JPFHS, 2017 ...... 36 Figure 48 Prevalence of HIV/AIDS risk factors indicators for women by nationalities and their measures of inequality, JPFHS, 2017 ...... 36 Figure 49 Prevalence of HIV/AIDS risk factors indicators for men by nationalities and their measures of inequality, JPFHS, 2017 ...... 37 Figure 50 Prevalence of domestic violence related risk factors in Jordan, JPFHS, 2017 ...... 39 Figure 51 Prevalence of very high prevalence domestic violence related risk factors indicators by governorates and their measures of inequality, JPFHS, 2017 ...... 39 Figure 52 Prevalence of high prevalence domestic violence related risk factors indicators by governorates and their measures of inequality, JPFHS, 2017 ...... 40 Figure 53 Prevalence of moderate prevalence domestic violence related risk factors indicators by governorates and their measures of inequality, JPFHS, 2017 ...... 41 Figure 54 Prevalence of very high prevalence domestic violence related risk factors indicators by wealth and their measures of inequality, JPFHS, 2017 ...... 41

Figure 55 Prevalence of high prevalence domestic violence related risk factors indicators by wealth and their measures of inequality, JPFHS, 2017 ...... 42 Figure 56 Prevalence of moderate prevalence domestic violence related risk factors indicators by wealth and their measures of inequality, JPFHS, 2017 ...... 42 Figure 57 Prevalence of very high prevalence domestic violence related risk factors indicators by education attainment and their measures of inequality, JPFHS, 2017...... 43 Figure 58 Prevalence of high prevalence domestic violence related risk factors indicators by education attainment and their measures of inequality, JPFHS, 2017 ...... 43 Figure 59 Prevalence of moderate prevalence domestic violence related risk factors indicators by education attainment and their measures of inequality, JPFHS, 2017...... 44 Figure 60 Prevalence of very high prevalence domestic violence related risk factors indicators by nationalities and their measures of inequality, JPFHS, 2017 ...... 44 Figure 61 Prevalence of high prevalence domestic violence related risk factors indicators by nationalities and their measures of inequality, JPFHS, 2017 ...... 45 Figure 62 Prevalence of moderate prevalence domestic violence related risk factors indicators by nationalities and their measures of inequality, JPFHS, 2017 ...... 45 Figure 63 Prevalence of infant health HS performance indicators in Jordan, ...... 49 JPFHS, 2012 & 2017 ...... 49 Figure 64 Prevalence of infant health HS performance indicators by governorates and their measures of inequality, JPFHS, 2017 ...... 50 Figure 65 Prevalence of infant health HS performance indicators by wealth and their measures of inequality, JPFHS, 2017 ...... 51 Figure 66 Prevalence of HS performance for infant health indicators by education attainment and their measures of inequality, JPFHS, 2017 ...... 51 Figure 67 Prevalence of HS performance for infant health indicators by nationalities and their measures of inequality, JPFHS, 2017 ...... 52 Figure 68 Prevalence of HS performance for child health indicators in Jordan, ...... 54 JPFHS, 2012 & 2017 ...... 54 Figure 69 Prevalence of HS performance for child health indicators by governorates and their measures of inequality, JPFHS, 2017 ...... 55 Figure 70 Prevalence of HS performance for child health indicators by wealth and their measures of inequality, JPFHS, 2017 ...... 56 Figure 71 Prevalence of HS performance for child health indicators by education attainment and their measures of inequality, JPFHS, 2017 ...... 56 Figure 72 Prevalence of HS performance for child health indicators by nationality and their measures of inequality, JPFHS, 2017 ...... 57 Figure 73 Prevalence of HS performance for maternal health indicators in Jordan, ...... 59 Figure 74 Prevalence of HS performance for maternal health indicators by governorates and their measures of inequality, JPFHS, 2017 ...... 60 Figure 75 Prevalence of HS performance for maternal health indicators by wealth and their measures of inequality, JPFHS, 2017 ...... 61 Figure 76 Prevalence of HS performance for maternal health indicators by education attainment and their measures of inequality, JPFHS, 2017 ...... 61

Figure 77 Prevalence of HS performance for maternal health indicators by nationalities and their measures of inequality, JPFHS, 2017 ...... 62 Figure 78 Prevalence of family planning HS performance indicators in Jordan, ...... 64 JPFHS, 2012 & 2017 ...... 64 Figure 79 Prevalence of family planning HS performance indicators by governorates and their measures of inequality, JPFHS, 2017 ...... 64 Figure 80 Prevalence of family planning HS performance indicators by wealth and their measures of inequality, JPFHS, 2017 ...... 65 Figure 81 Prevalence of family planning HS performance indicators by education attainment and their measures of inequality, JPFHS, 2017 ...... 65 Figure 82 Prevalence of family planning HS performance indicators by nationalities and their measures of inequality, JPFHS, 2017 ...... 66 Table 25 Measures of inequality in family planning HS performance indicators across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017 ...... 66 Figure 83 Prevalence of HS performance for other RH indicators in Jordan, ...... 67 Figure 84 Prevalence of HS performance for other RH indicators by governorates and their measures of inequality, JPFHS, 2017 ...... 68 Figure 85 Prevalence of HS performance for other RH indicators by wealth and their measures of inequality, JPFHS, 2017 ...... 68 Figure 86 Prevalence of HS performance for other RH indicators by education attainment and their measures of inequality, JPFHS, 2017 ...... 69 Figure 87 Prevalence of HS performance for other RH indicators by nationalities and their measures of inequality, JPFHS, 2017 ...... 69 Figure 88 Prevalence of HS capacity indicators in Jordan, JPFHS, 2012 & 2017 ...... 70 Figure 89 Prevalence of HS capacity indicators by governorates and their measures of inequality, JPFHS, 2017 ...... 71 Figure 90 Prevalence of HS capacity indicators by wealth and their measures of inequality, JPFHS, 2017 ...... 72 Figure 91 Prevalence of HS capacity indicators by education attainment and their measures of inequality, JPFHS, 2017 ...... 72 Figure 92 Prevalence of HS capacity indicators by nationalities and their measures of inequality, JPFHS, 2017 ...... 73 Figure 93 Health insurance coverage in Jordan, JPFHS, 2012 & 2017 ...... 77 Figure 94 Prevalence of health insurance coverage indicators in Jordan, JPFHS, 2012 & 2017 ...... 78 Figure 94 Prevalence of health insurance coverage indicators by governorates and their measures of inequality, JPFHS, 2017 ...... 79 Figure 95 Prevalence of health insurance coverage indicators by wealth and their measures of inequality, JPFHS, 2017 ...... 79 Figure 96 Prevalence of health insurance coverage indicators by education attainment and their measures of inequality, JPFHS, 2017 ...... 80 Figure 97 Prevalence of health insurance coverage indicators by nationalities and their measures of inequality, JPFHS, 2017 ...... 81 Figure 99 Number of health indicators by prevalence classifications for the different health dimensions...... 83

Figure 100 Number of health indicators by the change in their prevalence between 2012 and 2017 ...... 84 Figure 101 Number of health indicators for the different health aspects by the change in their prevalence between 2012 and 2017 ...... 84 Figure 102 Number of priority health indicators out of the 84 investigated indicators for each governorate in Jordan...... 85 Figure 103 Number of priority health indicators out of the 85 investigated indicators by wealth, education and nationality in Jordan...... 86 Figure 104 Number of indicators with the highest prevalence in the governorates in Jordan...... 86 Figure 105 Number of indicators with the highest prevalence by social groups by wealth, education and nationality ...... 87 Figure 106 Distribution of indicators by their inequality severity across the different stratifiers ...... 88 Figure 107 Distribution of indicators by their prevalence classification and severity of inequality across the different stratifiers ...... 88 Figure 108 Number of indicators by the change in their inequality summary measures and their severity classification between 2012 and 2017 by the different stratifiers ...... 89 Figure 109 Number of indicators that changed the severity of their inequality by different stratifiers for the different health aspects ...... 90 Figure 110 SDGs health specific targets and Jordan’s defined health priorities ...... 94 Figure 111 Entry points of interventions for addressing health and health equity priorities ...... 97 The way forward necessitates adopting the content of each level of the framework for each aspect of health investigated. It also requires development of evidence and plans of actions for each entry level. This adaptation was implemented in earlier analytical reports investigating SRH in different Arab countries2. Also the methodology for development of plans has been discussed in a recently produced methodology document26 ...... 97

LIST OF TABLES

Table 1 Measures of inequality for neonatal, infant and child mortality across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017 ...... 7 Table 2 Summary results of neonatal, infant and under 5 mortality ...... 7 Table 3 Measures of inequality in infant health risk factors across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017 ...... 10 Table 4 Summary results of infant risk factors ...... 10 Table 5 Measures of inequality in child nutrition risk factors across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017 ...... 14 Table 6 Summary results of child nutrition risk factors ...... 14 Table 7 Measures of inequality in child development risk factors across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017 ...... 17 Table 9 Summary for child health and wellbeing ...... 18 Table 10 Measures of inequality in NCDs risk factors across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017 ...... 26 Table 11 Summary results of NCDs and their risk factors ...... 27 Table 12 Measures of inequality in social RH risk factors across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017 ...... 31 Table 13 Summary results of social reproductive health risk factors ...... 32 Table 14 Measures of inequality in HIV/AIDS related risk factors across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017 ...... 37 Table 15 Summary results of HIV/AIDS related risk factors ...... 38 Table 16 Measures of inequality in domestic violence related risk factors across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017 ...... 46 Table 17 Summary results of domestic violence related risk factors ...... 46 Table 18 summary measures of reproductive health ...... 48 Table 19 Measures of inequality in infant health HS performance indicators across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017 ...... 53 Table 20 Summary results of health sector performance for infant health ...... 53 Table 21 Measures of inequality in child health health sector performance indicators across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017 ...... 58 Table 22 Summary results of health sector performance for child health ...... 59 Table 23 Measures of inequality in maternal health HS performance indicators across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017 ...... 63 Table 24 Summary results of health sector performance for maternal health ...... 63 Table 26 Summary results of health sector performance for family planning ...... 67 Table 27 Measures of inequality in other RH health sector performance indicators across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017 ...... 69 Table 28 Summary results of health sector performance for other reproductive health ...... 70 Table 29 Measures of inequality in health sector capacity indicators across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017 ...... 73 Table 30 Summary results of health sector capacity ...... 74 Table 31 Summary indicators for health sector performance and capacity ...... 75

Table 32 Summary results of health insurance coverage ...... 81 Table 33 The indicators in the latest JPFHS (2017) report in comparison to the SDGs 2030 targeted indicators...... 95

ACKNOWLEDGEMENTS

This report is one output of an analytical study implemented by the Social Research Center of the American University in Cairo (SRC/AUC) and supported by the Jordan Country Office of the World Health Organization (WHO/Jordan).

SRC research team would like to thank both Dr. Ghada Al Kayyali and Dr. Wasiq Khan for their many contributions. In particular, Dr. Ghada Al Kayyali initiated the idea of this work and continuously supported it. Also, she and Dr. Wasiq Khan have shared substantive comments on earlier versions of this report, and are encouraging a wider dissemination of the findings.

The interest and encouragements of WHO/EMRO and WHO/Jordan in supporting evidence based policies are greatly appreciated.

EXECUTIVE SUMMARY

This report provides the findings of an analytical study of 2017 Jordan Population and Family Health Survey (JPFHS, 2017). The study is implemented by the Social Research Center of the American University in Cairo (SRC/AUC) and supported by the World Health Organization/ Jordan. The study aims to

 Provide evidence on the social patterns of different health dimensions and the changes in these patterns over time.

 Provide an analysis on the social inequalities in health care utilization and insurance coverage.

 Trace inequalities in social patterns to their underlying social determinants using a multilevel conceptual framing and an equity lens.

 Identify priority challenges and provide policy recommendations.

The report investigates Jordan health challenges in terms of level of prevalence of negative aspects, severity of inequality and trend between 2012 and 2017. The report also applies a Social Determinants of Health Inequity (SDHI) framework. This framework is reflected in interpreting inequalities as inequities, in investigating fairness in health care aspects, and in guiding the recommendations for the future. The investigation is performed in relation to five aspects of health and health care, as well as in a general overview of health challenges. The report also concludes by synthesizing the findings in relation to the adopted health strategy and to Jordan international commitments, as well as providing recommendations for the way forward. The report is divided into 10 sections. The following presents a brief summary of the main findings of the detailed analytical report and its recommendations. The appendixes provide all the basic indicators supporting the findings. SECTION 1: INTRODUCTION The introduction in the report provides brief information on the study, as well the evolution of the SDHI framing and the policy movement linked to it.

SECTION 2: JORDAN: SETTING THE SCENE This section offers an overview of the socioeconomic situation in Jordan and its health policy context. This section showed Jordan as an upper middle-income country categorized among the high human development countries, experiencing some improvement across time in a number of general social dimensions. Two specific features in the Jordanian context are noted. The first feature is the large flood of refugees from neighboring countries, impacting the population structure and the pressure on many service sectors. The second feature is the role played by the inequality in reducing the human development index (HDI) ranking of Jordan. Jordan Human Development Index ranked 95 among 189 countries and UN recognized territories with a score of 0.735 categorizing Jordan among the high human development countries.

Jordan was able to improve its ranking over the period 2012 to 2017 by 5 points from rank 100 to 95. Factoring in inequality, Jordan HDI falls by 16% reaching 0.617 due to inequality in HDI indices. Income inequality coefficient was the highest contributing dimension to this reduction (20.5%), while the health dimension was the least contributing dimension in the reduction (10.7%). Furthermore, Gender Development Index which relates the HDI calculated for women (0.658) to that for men (0.767) equals 0.857, indicating that women HDI is less than men HDI by 14.3%. This difference was mainly the product of women lower Gross National Income (GNI) per capita compared to men (2,459 versus 13,971) but this gap was compensated by women higher life expectancy (76.3 versus 72.8), better expected years of schooling (13.4 versus 12.9) and their almost equal performance on the mean years of schooling (10.1 versus 10.6) compared to men. In terms of policy context, the strategic vision and national strategy for Jordan as well as the 2016-2020 health sector strategy, formulated by the High Health Council (HHC), were shown to provide excellent anchors for situating the findings and recommendations of this report. In particular, the following is noted:  Jordan Vision 2030 places the individual’s welfare at the heart of the development process,  The concern with development inequalities, the excess poverty of some governorates, as well as with fragile situation of low middle income families,  The existence of a high level institutional structure to improve health namely the HHC,  The strategic health goals that speak to health system governance and investment, responsiveness to health services’ needs, as well as universal health coverage,  The identification of major health concerns, encompassing a number of impact measures (such as specific non communicable diseases, sexual and reproductive health…) as well as social risk factors (smoking, consanguinity, early marriage…). SECTION 3: CONCEPTUAL FRAMEWORK AND METHODOLOGY This section discusses the conceptual framework and the adopted methodology in the analysis. The conceptual framework

The report applies a multilevel social determinants of health inequity (SDHI) framing. The framing, similar to the traditional social determinants of health (SDH) framing, recognizes that health inequalities are largely shaped by factors outside the health systems. The SDHI framing, however, emphasizes the unfairness consideration and the upstream determinants of health. SDHI postulates that health inequalities are inequities driven by people’s unfair access to social, economic and cultural resources and opportunities. The multilevel framing implies that the unfairness of access to resources for health originates from macro political and economic structures and policies, as well as intermediary social arrangements and public services. The unfairness that is shaped at these upstream levels is reflected in societal stratification (distribution of social groups by stratifiers of wealth, education…etc.) and the responsiveness to the different needs of social group within these stratifiers. The systematic health inequalities among social groups within stratifers operate through differences at environment/community levels, as well as differences in awareness, living conditions and livelihoods. These differences greatly influence behavioral and biological risk factors of the social groups and their health status impact measures.

The methodology

The JPFHS 2017 allowed a wealth of data on reproductive health, but relatively limited information on the other issues of general health. The analysis covered 85 indicators of health classified in 5 broad groups, namely child health and wellbeing, adult health and NCDs, reproductive health, health system performance and capacity and health insurance coverage. Four stratifiers were used to investigate the social patterns of health. These are geographic residence (measured in terms of the governorates), household wealth, education attainment and nationality. For the purpose of describing the health and health care challenges, the study ordered the indicators (that express a negative aspect of health) into three categories, namely very high levels with a prevalence of 40% or more, high levels with a prevalence ranging between 20% to 40% and moderate/ low levels with prevalence of less than 20%. In investigating the prevalence at the level of the social groups, the moderate and low category was further classified to two subcategories, namely below the national level and above the national level. While the below the national subcategory was classified as low or moderate prevalence, the above national level subcategory was classified as high prevalence. These three prevalence categories (very high, high, and moderate) were sometimes referred to as high priority, priority and moderate priority, respectively. Another criterion for the prevalence categorization was used for few indicators (infant mortality, diabetes, early marriage, adolescent childbearing …….). This criterion used a comparison with the SDG goals or global and other experiences. Any indicator exceeding the comparison group is considered a high prevalent indicator. The investigation of inequalities used the gap to indicate the absolute difference between the best off and worst off social categories. The gap draws attention to the importance of targeting the social group that is carrying a larger share of the burden. Also, the data provided can be used to identify more than one social group carrying relatively large shares of burden. The analysis also used two summary measures to indicate the degree of inequality in the distribution. It should be noted that these summary measures of inequality are more appropriate than the gap in investigating the distribution of the indicators across social groups of a stratifier. They use in their calculations the size of the exposed population in different social groups and the actual level of the health indicators. They provide an average measure of the differences between the actual burden of ill health of the social groups given their size and the expected burden, if such social groups were exposed to similar level of the health indicators. The summary measures of inequalities are interpreted as average excess burden of ill health that needs to be addressed to improve health and achieve equality in health. In other words, the summary measures of inequality refer to the degree of variability in the share of the burden of ill health across different categories of the stratifier. This variability moves the discussion from targeting the disadvantaged to achieving a fair distribution of social stratifiers and social arrangements. The two measures are the index of dissimilarity (ID) and the concentration index (CI). The index of dissimilarity is used for categorical stratifiers (the governorates and the nationality in the current report) and the concentration index was used for ordinal stratifiers (wealth and education in the current study). The concentration index can either be negative or positive, the negative sign indicates higher burden of ill health indicator among disadvantaged social groups, while positive sign indicates higher burden of ill health indicators among the advantaged social groups. These summary measures equal zero when the health indicator is similar across the different social groups.

The degree of inequality was defined as severe when the ID or CI exceeds a 10% cutoff point, as moderate when the measure falls between 5% and 10% and as low when they are less than 5%. The analysis in sections four through eight investigated different aspects of health and health care, namely child health and wellbeing, NCDs and adult health, sexual and reproductive health, health system performance and capacities and health insurance coverage. The following provides summary of key findings for each health aspect, followed by more explanations of these findings for each health dimension within each health aspect. SECTION 4: CHILD HEALTH AND WELLBEING The analysis of child health and wellbeing covered three dimensions. The first relates to infant and child mortality, the second to biological and nutritional health risk factors closely linked to physical health and the third relates to care and violence that could be considered as risk factors to child development. It should be noted that a number of additional indicators of child health have been analyzed separately in section (7). These additional indicators lend themselves easily to health sector programmes, and were used to assess health sector performance. OVERALL FINDINGS  The impact indicators continue to show relatively high prevalence.  Large number of the risk factors for infant health and for child nutrition and development continue to show very high/high prevalence.  Lack of food rich in iron, lack of dietary diversity, and lack of acceptable diet for children 6-23 month and any violent discipline for children 1-14 years were highly prevalent across all social categories.  The governorates and education stratifiers show the largest gaps between the best off and worst off social groups.  The distribution of the indicators by the governorates and education stratifiers shows larger number of severe/moderate inequalities than wealth or nationality stratifiers.  The two governorates Madaba and Mafraq show high prevalence for all child health and wellbeing indicators, while the governorate of Ajloun shows the largest number of very high prevalence indicators compared to the other governorates.  Children in the poorest wealth quintile and those born to mothers with no education or Syrian mothers show the largest number of at least highly prevalent health indicators.  All indicators of the child nutrition risk factors increased in prevalence between 2012 and 2017 with only one of them increasing by more than 25% of its level in 2012 namely lack of minimum meal frequency. In contrast, one of the infant health risk factors (low birth weight) and one of the child development risk factors (children <5years left with inadequate care) showed an increase in prevalence between 2012 and 2017 with only the latter indicator increasing by more than 25% of its 2012 level.  Inequality by the governorates increased for the majority of the child health and wellbeing, while increases in inequality by wealth and education were less prevalent. The increases in the inequality were associated with increases in their severity degree.

The following provides further details for each health dimension separately.

Infant and child mortality At the national level, Jordan achieved the sustainable development goals for the neonatal mortality. However, noting that Jordan ranks 38 out of the 52 countries classified in the high human development

category for the under 5 mortality, also noting some increase in the post neonatal mortality between 2012 and 2017, Jordan can continue to improve its performance on this front. On inequality front, two positive features emerge. The first is that there are no marked differences in neonatal, infant and child mortality distribution by wealth. This is evidenced by the small gap in the wealth stratifier compared to other stratifiers and by a CI measure that is equal or less than 2% for all three indicators by wealth. The second positive observation is that both Jordanian and other, non-Syrian, nationalities are equal in terms of their experience with neonatal, infant and child mortality. In terms of the gap, some governorates and those of Syrian nationalities carry higher burden of morality. The two governorates of Balqa and Aquaba stand out as high achievers, while the governorates of Madaba and Aljune are lagging behind. The gap in infant mortality is as high as 14 points. In terms of nationality, the gap in mortality between Syrian and other nationalities is relatively high with an excess of 11 points in infant mortality. Furthermore, the summary measure of inequality in the distribution of infant mortality by governorates (ID=10.1%) is the highest compared to other stratifiers.

Biological and nutritional risk factors The biological and nutrition risk factors included eight indicators. Two of them were related to infant health and the other six focused on nutritional indicators for children at the age 6-59 months. At the national level, almost all children biological and nutritional risk factors were classified as high prevalence indicators (the prevalence exceeding 20%). The data also showed that the prevalence of these risk factors increased between 2012 and 2017 but only lack of minimum meal frequency increased by more than 25% of its level in 2012. On the inequality front, in terms of the gap, gaps between the worst off and best off governorates, wealth and education were large across all risk factors. In particular, the gaps across the different stratifiers was large for the lack of the minimum dietary diversity among children 6 to 23 children reaching as high as 43 points across the education categories. The governorate of Tafielh showed the worst performance on three of child risk factors. Madaba followed Tafielh by showing the worst performance on two indicators. Across the other stratifiers, the poorest and poorer quintiles, those with no education and Syrians were the worst performing social groups In terms of the inequality in distribution, the inequality summary measures showed that only limited number of these risk factors were severely unequal. This severe degree of inequality was mainly observed across education stratifier for infant risk factors (CI=-10 and -10.2 for very small size infant and low birth weight, respectively) and across wealth stratifier for anemia among children (CI=-0.11). The governorates and education stratifiers also underlie moderate inequality for many indicators. In contrast, wealth and nationality showed low degrees of inequality for seven of these risk factors indicators. It is also important to note that the inequality summary measures increased between 2012 and 2017 for the almost all risk factors indicators across the governorates with the majority of them increasing in their severity degree. In contrast, the wealth and education attainment stratifier showed increases in the inequality measures for the infant risk factors associated with increases in the severity of these inequalities.

Development risk factors Four indicators explored child care and wellbeing were used as proxy for child development. At the national level, two of these indicators (children not on the development track and violence discipline to children 1-14 years) showed very high / high prevalence exceeding 20%. The other two indicators (physical violence is necessary for discipline and children less than 5 years left with inadequate care) were classified as moderate prevalence. The prevalence of all child development indicators declined between 2012 and 2017, except for children less than 5 years left with inadequate care which increased by more than 25% of its level in 2012. On the inequality front, in terms of the gaps, the gaps were relatively large compared to the prevalence of these indicators across the four stratifiers. The governorate of Maan was the worst preforming governorate on three of these four indicators, while the governorate of Tafielh (against it performance in child nutrition) was major achiever in this health dimension. Those with no education and Syrians again showed the worst performance on three of these indicators. For wealth, while the poorest wealth quintile showed worst performance on two indicators, middle and richest wealth quintiles were worst preforming quintiles on any violent discipline to children 1 to 14 years and children less than 5 years left with inadequate care, respectively. In terms of the inequality in distribution, the inequality summary measures showed that the four indicators of child development showed low inequality by all stratifiers with only three exceptions. Children not on the development track were moderately unequal by the governorates and by education and physical violence is necessary for discipline by the governorate. It is important to note that inequality increased between 2012 and 2017 across all stratifiers for any violence discipline among 1 to 14 year children and for physical violence is necessary discipline by the governorates and wealth.

SECTION 5: ADULT HEALTH AND NCDS In terms of adult health and NCDs, previously published data support the prioritization of NCDs and their risk factors. Published international reports indicate that 78% of all deaths in Jordan are attributed to NCDs. Earlier WHO STEPS survey (2007) showed very high prevalence of obesity or overweight (66.7%) particularly among women. The same survey showed many NCDs risky behaviors with the non- engagement with physical activities approaching the very high levels (37.8%) and high levels of smoking. Available tabulations from a very recent WHO STEPS survey for non-communicable disease risk factors (2019) also confirmed high prevalence of many risk factors. Among the adult population (18-69 years), more than 60% of the adult population were overweight or obese and 40.1% of them were currently smokers with 34.6% are daily smokers. However, obesity was more common among women (68.8%) compared to men (53.2%), while smoking was more common among men (65.3% currently smoking and 58% daily smokers) compared to women (16.4% currently smokers and 10.8% daily smokers). Low physical activities according to WHO physical activity criteria was observed for 31.3% of adult population with no significant differences between men and women. The combination of these different risk factors showed that almost 25% of the adult population in Jordan had more than 10 years of Cardiovascular diseases (CVD)risk greater than 30 or are with existing CVD. These high prevalence of risk factors also contributed to high prevalence of non-communicable diseases among the adult population in Jordan. Within the past

12 months, the data showed that among the adult population (18-69 years), about 15.1% of was diagnosed with hypertension, 12.8% diagnosed with diabetes, 17.7% diagnosed with raised cholesterol. JPFHS 2017 data provided some information on diabetes and some NCDs risk factors that focused on women in reproductive age and one risk factor indicator for men, namely smoking.

OVERALL FINDINGS  Diabetes is highly prevalent in Jordan, while most of the NCDs risk factors are very highly prevalent.  The governorates stratifier shows the largest gaps between the best off and worst off social groups.  The distribution of the social groups by the education stratifier shows large number of severe inequalities followed wealth.  Aqaba governorate shows the largest number of very highly prevalent NCDs and their risk factors indicators.  Individuals from the poorest and poorer wealth quintiles show the largest number of highly prevalent NCDs risk factors. Individuals with education less than secondary education show the largest number of high prevalence diabetes indicators with those with primary and preparatory education showing the largest number of very highly prevalent NCDs risk factors.  Jordanian show high prevalence of diabetes, while Syrians show very high prevalence of diabetes among older adult women. Other non- Syrian nationalities suffer more the burden of NCDs risk factors than Syrians and Jordanian. They were followed by Syrian.  For the NCDs risk factors, the trend in prevalence show more than 25% increase in three indicators between 2012 and 2017, namely anemia among women 15-49 year, never heard of pap test and no self or professional breast exam.  Between 2012 and 2017, increases in inequality in the distribution of the risk factors was only limited to the governorates stratifier. Inequality by the governorates increased for four of the indicators with the increase in inequality for lack of knowledge of pap test moving it to a severe degree of inequality. SECTION 6: SEXUAL AND REPRODUCTIVE HEALTH Maternal mortality and morbidity indicators are not covered. However, other sources of data indicate that at national level, Jordan succeeded in decreasing its maternal mortality ratio from 70 per 100,000 live birth in 2000 to 46 per 100,000 in 2017viii. More recently, Jordan Minister of Health declared that Jordan has succeeded in decreasing its maternal mortality ratio to 29.5 deaths per 100,000 live births in 2018ix. In contrast to impact indicators for reproductive health (RH), data from JPFHS (2017) offer a wide range of risk factors indicators covering many RH dimensions. These indicators were classified in three categories. The first category was social RH risk factors indicators associated with adverse impact on women’s reproductive health. The second was HIV/AIDS related risk factors indicators, while the third was domestic violence related risk factors indicators. It should be noted that health has been analyzed separately in section (7). These indicators lend themselves easily to health sector programmes, and were used to assess health sector performance.

OVERALL FINDINGS  The majority of the social risk factors indicators for reproductive health are at least highly prevalent.  Almost all risk factors related to HIV/AIDS and domestic violence show very high prevalence.  The governorates stratifier shows the largest gaps between the best off and worst off social groups, followed by the education stratifier.  While the education stratifier shows severe inequalities in large number of risk factors, the governorates stratifier shows moderate inequalities in large number of indicators.  Inequality in the mere knowledge of HIV/AIDS is severe in three of the four investigated stratifiers  Zarqua governorate showed the largest number of very highly prevalent reproductive risk factors indicators. This is particularly true for the domestic violence related risk factors. It was followed by the governorate of Balqa that showed large number of highly prevalent reproductive risk factors indicators.  All reproductive health risk factors indicators are highly prevalent for individuals in the poorest wealth quintile, those with less than secondary education and non-Jordanians.  The prevalence of ten of the 18 investigated sexual and reproductive health indicators increased between 2012 and 2017 with five of them increasing by more than 25% of their levels in 2012. These five indicators are no knowledge of HIV/AIDs, lack of knowledge of STI in HIV/AIDS related risk factors and experience of any form of spousal violence in the past 12 months, agreeing to wife beating and women never sought help against spousal violence in domestic violence related risk factors.  Between 2012 and 2017, the trend in inequality in distribution of risk factors was variant among stratifiers. Inequality by the governorates increased for 14 of the 18 investigated indicators with almost all increases showing an increased degree of the severity of inequality. Inequality by education was observed in 9 of investigated indicators with 5 of them showing increased severity. For inequality by wealth, 6 indicators showed an increase in inequality with four of them showing increased in the degree of the inequality severity.

The following provides further details for each classification of risk factors

Social reproductive health risk factors Six indicators were investigated to assess the social reproductive health risk factors. These indicators are adolescent childbearing, women not owning their health care decision, early marriage, having 5 or more children (multiparity), consanguinity, and risky birth intervals less than 23 months. These indicators reflect the social context in which women live and affect the reproductive health. At the national level, except for women who does not own their health care decision; the other four indicators were classified as high prevalence. The majority of these indicators showed improvement between 2012 and 2017. In particular, in multiparity and consanguinity showed large declines exceeding 7 points between the two years. On the inequality front, in terms of the gap, gaps between the worst off and best off across the social groups by the different stratifiers were relatively large compared to the risk factors prevalence. In particular, the gaps across the education stratifier was large reaching as high as 45 points for early marriage. For this particular indicator, while the highly educated individual were the best achievers, preparatory educated individuals were the worst performing social group. While no particular governorate showed consistent ill performance in these risk factors, the poorest wealth quintile, those

with less than preparatory education were the worst performing social groups. Syrians were consistently showing the worst off performance on these risk factors. In terms of the inequality in distribution, the inequality summary measures showed that these risk factors were severely unequal for many indicators particularly by education and nationalities. Adolescent child bearing, women not owning their health care decision and early marriage showed severe degrees of inequality across wealth, education and nationality stratifiers. It is also important to note that the severity of the inequality summary measures increased between 2012 and 2017 for the all risk factors indicators by all stratifier with four exceptions. These are women not owning their health care decision by governorates, consanguinity by wealth and risky birth intervals by wealth and education.

HIV/AIDS-related knowledge and attitudes Six indicators have been identified in JPFHS 2017 to address the HIV/AIDS-related knowledge and attitudes. These indicators were available for women and men. While the literature defines the indicators available in JPFHS as health sector performance indicators, we argue that lack of knowledge represented by these indicators is also a major social risk factors. At the national level, the data show that for both women and men, except for the mere knowledge of HIV, the prevalence of all indicators exceeded the 40% the threshold of very high prevalence. In other words, while individuals know of HIV, there is significant lack of more detailed knowledge for HIV/AIDS and STI. On the inequality front, in terms of the gap, for women, the three indicators of lack of knowledge of HIV/AIDS, MTCT and STI showed large gaps by the governorates and education. While no specific governorate was consistently under performing on these risk factors among women, for the education, women with no education showed the highest prevalence for these indicators. By wealth and nationality, the gap was only large for lack of knowledge of STI with the poorest quintile and Syrians showing the highest prevalence for these two indicators. For men, the gaps between the worst off and best off for all indicators across the governorates were relatively large compared to their prevalence with Amman and Madaba are the two governorates showing the highest prevalence for two of those indicators. Lack of knowledge of HIV/AIDS, MTCT and STI also showed large gaps by education reaching as high as 30 points for lack of knowledge of STI. Individuals with no education showed the highest prevalence. In terms of the inequality in distribution, the inequality summary measures showed that except for lack of knowledge of HIV/AIDS and the lack of knowledge of STI, all other indicators for both men and women were classified as low inequality. Lack of the mere knowledge of HIV/AIDS were severely unequal across all stratifiers, while lack of knowledge of STI were moderately unequal across the wealth quintiles. Only women HIV/AIDS related risk factors were available for comparison of inequality between 2012 and 2017. The data showed that the severity of the Inequality across the governorates only for the lack of knowledge of STI. Domestic violence risk factors Nine indicators were used to explore domestic violence risk factors. The findings show that women and men agreeing to wife beating for any reason and not seeking help against the spousal violence rank as

very high prevalence indicators. Also in comparison to their prevalence in 2012, the prevalence of these two indicators increased. The four indicators of experience of any form of spousal violence over the past 12 months, experience of physical violence since age 15 years, ever experience any form of spousal violence and not able to negotiate sexual intercourse were classified as high prevalence indicators. On the inequality front, in terms of the gap, gaps were large across the governorates and by education for all indicators relative to their prevalence. The gap reaches as high as 50 points for men agreeing to wife beating for the listed reasons across the governorates. Karak registered the highest prevalence for this indicator (95%). Across education attainment social groups, not able to negotiate sexual intercourse showed the highest gap (29 points) with primary educated women showing the highest prevalence while the highly educated women showing the lowest prevalence. For the wealth stratifier, women agreeing to wife beating for any of the listed reasons showed the largest gap (29.5 points) with systematic gradient by wealth quintiles. It is important to note that other, non-Syrian, nationalities showed the highest prevalence for many domestic violence risk factors indicators compared to the other nationalities. In terms of the inequality in distribution, the inequality summary measures showed that only limited number of the domestic violence risk factors indicators were classified as severely unequal across the different stratifiers (4 across governorates, 3 across education and 1 across wealth). It is important to note that, between 2012 and 2017, there was an increase in the inequality measures across the governorates for all indicators. For wealth, there was a decrease in the inequality for all indicators with two exceptions, namely women agreeing to wife beating for any of the listed reasons and women never sought help against spousal violence. For education, there was an increase in the inequality for all indicators except for experience of any form of spousal violence in the past 12 months. SECTION 7: HEALTH SECTOR PERFORMANCE AND CAPACITY The indicators for the health sector performance and capacity were identified in WHO framework for monitoring and evaluation of health systems strengthening (2009). Health sector performance was assessed using five sets of risk factors indicators. The first two sets are related to infant and child health. The other three are related to reproductive health, namely maternal health, family planning and other reproductive health. Health sector capacity was defined in terms of difficulties facing women access to health services.

 Health sector performance OVERALL FINDINGS  The majority of health sector performance indicators show moderate / low prevalence. Other reproductive health services related to lack of knowledge of HIV test place and no premarital test, and children not receiving iron and vitamin A supplement and not seeking health services for diarrhea are the only highly prevalent indicators.  The governorates and education stratifiers show the largest gaps between the best off and worst off social groups.  The distribution of the indicators by the education stratifier shows the largest number of indicators with severe inequalities (9 indicators out of 26 investigated indicators) followed by the governorates (6 indicators) and wealth (5 indicators) stratifiers, respectively.  The two governorate of Mafraq and Maan show the largest number of health performance indicators with high prevalence. Individuals in the poorest wealth quintiles, with primary education and other non- Syrian nationalities suffer more than the other comparable social groups from the ill performance of health sectors.  The prevalence of ten of 24 investigated health sector performance indicators increased between 2012 and 2017. Eight of these ten indicators showed an increase of more than 25% of their levels in 2012 with four indicators falling in health sector performance for child health and three falling in health sector performance for maternal health.  Between 2012 and 2017, the trend in inequality in distribution of risk factors was variant among stratifiers. Inequality by governorates increased for half of the 24 investigated indicators with only one of them showing higher severity degree of inequality. Inequality by wealth increased for five indicators with only one of them showing more severe degree of inequality. For inequality by education, nine indicators showed an increase in their inequality with four of them displaying higher degree of inequality severity.

The following provides further details for each set of indicators

Infant and child health Ten indicators were used to assess health sector performance for infant and child health. For infant, the four indicators focused on lack of breastfeeding and postnatal care. For the child, the health sector performance indicators focused on not receiving nutritional supplements, not seeking heath service for fever and diarrhea and non-coverage of vaccinations. At the national, all indicators for infant health were classified as moderate/low prevalence indicators. For child health, both lack of nutrition supplement (iron and vitamin A) and not seeking health service were classified as very high /high prevalence, while indicators related to non-coverage of vaccination were classified as moderate/low prevalence. On the inequality front, in terms of the gap, overall the gaps were relatively large compared to the level of the indicators’ prevalence for all indicators and all stratifiers. However, it is important to note that the gaps were substantially larger across the governorates for all the infant and child health indicators. Education and nationality also showed large gaps for many indicators of child health. In contrast, the gaps were relatively small across the wealth quintiles.

For the infant health, infants living in Mabada were suffering more than infants living in other governorates from the ill performance of the health sector on many indicators. For child health, the children living in Maan were suffering more than other children were from the ill performance of the health sector. Also, children born to mothers with no education were persistently suffering more than any other children. The same can be true for children born to mother of other, non- Syrian, nationalities as they suffer more from the ill performance of the health sector. However, Syrian children were also suffering from the ill performance of the health sector but in less number of indicators. In terms of the inequality in distribution, the inequality summary measures showed that inequity was classified as severe for many indicators by education followed by the governorates. However, the governorates also showed many moderately unequal indicators than any other stratifier. The inequality by nationality was also noticeable as it was severe for the two indicators of not receiving all age appropriate vaccinations among children age 12-23 months and lack of knowledge of ORS. In contrast, wealth showed either low or moderate inequality across all indicators for infant and child health. It is also important to note that for the first time none of the inequality measures has increased in its severity level and the majority of the increases in the inequality measures was within the same category of inequality classification.

Maternal health Jordan has achieved important progress in the area of maternal health. As indicated earlier, maternal mortality declined significantly. Jordan progress is also evident in the coverage of the maternal health service including prenatal care, delivery at health service unit and assisted delivery. According to the JPFHS 2017, 99.9% of women are assisted by professional health workers during delivery and 99% deliver in a health service unit. Coverage prenatal care reached 99.1% in 2012, but, by 2017, it declined to reach 97.6%. On the other hand, progress in the area of postnatal care has not matched that on the prenatal care. More than 12% of women still do not receive postnatal care, declining from 13.9% in 2012. However, recent evidence points to some weakening in prenatal care as the non-coverage of any or regular prenatal care and receiving of iron tablets increased by more than 25% of their level in 2012 between 2012 and 2017. On the hand, there was improvement on the postnatal front and cesarean section as they declined during the same period. But it is important to note that only cesarean section and not receiving iron tablets among all maternal health performance indicators showed a prevalence that exceeded the 20% threshold for high prevalence. On the inequality front, in terms of the gap, the gaps again were relatively large compared to the indicators level of prevalence across all stratifiers. However, the largest gaps were observed across the educational attainment categories followed by those across the different governorates. The lowest gaps were observed across the wealth quintiles. It is important to highlight the systematic gradients observed for both education and to less extent for wealth for the different indicators. The only exception is the almost positive relationship between cesarean section and wealth and the curved relationship between cesarean section and education in which both women with no education and those with the higher education showing the highest prevalence. It is important to note that women with no education tend to

suffer substantially more than those in any other categories from the ill performance of the health sector. Same pattern can be observed for women in the poorest wealth quintile but it it was more attenuated. Syrian women were also the most vulnerable nationalities suffering from the ill performance of the health sector. In terms of the inequality in distribution, the inequality summary measures showed the inequality was limited to the four indicators related to antenatal and postnatal care. These four indicators were severe unequal by education and by wealth. By the governorates, only the two indicators related to absence of any antenatal or postnatal care were severely unequal. Inequality was moderate by nationality for all four indicators. It is important to note that the inequality measures between 2012 and 2017 did not show substantial changes across the majority of indicators by all stratifiers.

Family planning Four indicators, namely unmet need, use of traditional methods, non-use of contraception and non-users receive no counselling were used to assess health sector performance in family planning. All indicators showed an increase in their prevalence between 2012 and 2017. The prevalence of lack of counselling for non-users of contraceptive and nonuse of contraceptive was classified as very high / high prevalence, respectively. Despite that the prevalence of use of traditional methods and unmet was less than 20%, comparing these figures to the global standards placed them as high prevalence indicators. On the inequality front, in terms of the gap, the gaps were relatively large across the governorates and by education for all indicators. Residents of Maan were the most burdened with the ill performance the health sector on the family planning front. Education showed a systematic gradient for unmet need, lack of counselling for non-users of contraceptive and nonuse of contraceptive with women with no education showing the highest prevalence. Unexpectedly, use of traditional methods showed positive relationship with education. In terms of the inequality in distribution, the inequality summary measures showed that inequality is commonly low for all indicators and stratifiers. Only use of traditional methods by governorates and no use of contraceptive by education were moderately unequal. It is important to note that for the majority of indicators, there was no significant changes in their inequality measures except for no use of contraceptive which the inequality by education increased from low inequality to moderate inequality between 2012 and 2017.

Other reproductive health indicators At the national level, lack of premarital examination for women and their husband and women and men lack of knowledge of HIV/AIDS testing place showed very high prevalence exceeding 40% with improvement between 2012 and 2017. On the inequality front, in terms of the gap, gaps were relatively large for the majority of the indicators compared to their prevalence across all stratifiers. While residents of Mafraq showed the highest prevalence among the different governorates in two indicators of the four investigated ones, education

showed a systematic gradient with the prevalence of ill performance of the health system in all indicators. For the wealth, lack of knowledge of HIV/AIDS testing place revealed systematic gradient with wealth but there was no clear pattern with lack of premarital exams related indicators. Syrians showed the highest prevalence in of knowledge of HIV/AIDS testing place, but other non- Syrian nationalities were the social groups that suffer most of the health sector performance in lack of premarital exams related indicators. In terms of the inequality in distribution, the inequality summary measures showed that only premarital test relate indicators showed severe inequality across education with the severity of the inequality by education increasing between 2012 and 2017.

 Health sector capacity JPFHS 2017 included four indicators to assess the capacity of the health sector. These indicators were related to difficulties facing women in accessing health services. These indicators are unavailability of female provider, distance to health care facility, unaffordability of the health care service, and need to take transportation. OVERALL FINDINGS  All health sector capacity indicators show high prevalence.  The governorates and education stratifiers show the largest gaps between the best off and worst off social groups.  The distribution of the social groups by the education and wealth stratifiers shows large number of severe inequalities followed by the governorates and nationality stratifiers, respectively.  Six of the twelve governorates in Jordan suffer from significantly low capacity of health sector.  Women in the poorest and poorer wealth quintile, with less than higher education, from Syrian and other nationalities suffer from significantly low capacity of the health sectors.  All health sector capacity indicators showed a decline in prevalence between 2012 and 2017.  The trend of inequality in distribution for all health sector capacity indicators showed an increase in their severity degree particularly by governorates and education between 2012 and 2017.

The following provides further details

At the national level, all indicators showed high prevalence as their prevalence exceeds the threshold of 20%. However, between 2012 and 2017, except for unaffordability of the health care services that showed small improvement, the other indicators showed large improvements. On the inequality front, in terms of the gap, gaps were relatively large compared to the indicators prevalence across all stratifiers. Across the governorates, the governorates of Mafraq and Maan showed the highest prevalence in two indicators of limited health sector capacity. For wealth and education, there was a clear systematic gradient with the poorest and those with no education are showing the highest prevalence. By nationality, Syrian were the most suffering nationalities from limited health system capacity followed by the other nationalities. In terms of the inequality in distribution, the inequality summary measures showed severe inequality across wealth and education for all indicators. Across the governorates, only distance to health care facility and unaffordability of the health care service were severely unequal and only unaffordability of

the health care service was severely unequal across the nationality. It is important to note that inequality summary measures increased for all indicators and across all stratifiers.

SECTION 8: HEALTH INSURANCE COVERAGE Similar to all countries that endorsed the SDGs, Jordan is committed to the achievement of the Universal Health Coverage (UHC) by 2030. This commitment has been reiterated in all health related strategies in Jordan. In Jordan 2025, “developing an effective and comprehensive health insurance system” was among the five targeted scenarios. In Jordan 2016-2020 health sector strategy, the third strategic goals stated, “Provide health, financial and social protection to the entire population on a fair basis. The Ministry of Health strategic plan 2018-2022 had a strategic objective that called for Increase inclusion of citizens in the universal health coverage.

OVERALL FINDINGS  All health insurance coverage indicators show high prevalence.  Two important positive features of the health insurance coverage in Jordan. One feature relates to the higher coverage for women compared to men (58% versus 50%). The other positive feature is the more coverage of those living in rural areas compared to those living in urban areas (75% versus 52%).  The governorates and nationality stratifiers show the largest gaps between the best off and worst off social groups.  The distribution of the social groups by the governorates stratifier shows large number of severe inequalities followed by the nationality and education stratifiers , respectively.  The governorate of Amman shows the lowest level of health insurance coverage on all indicators compared to other governorates. It Is followed by Balqa and Zarqua governorates.  All wealth quintiles, except for the middle quintile show low level of health insurance coverage on all indicators. This wealth quintile also showed moderate prevalence for coverage among users of inpatient service.  Individuals with less than secondary education and non-Jordanian suffer from high prevalence of low coverage.

The following provides further details

JPFHS (2017) provides four indicators on health insurance coverage by sex and by use of inpatient and outpatient services. The data confirmed the above gender patterns where women were more covered than men. However, lack of health insurance coverage for both women and men showed very high prevalence (41.7% for women and 49.6% for men). The data also showed that the prevalence of lack of health insurance among users of inpatient and outpatient health services showed high prevalence exceeding 20%. On the inequality front, in terms of the gap, gaps were large across the governorates, by education and nationalities for all indicators relative to their prevalence. However, the gaps were the largest by the governorates with Amman was showing the lowest health insurance coverage for all the four indicators investigated for health insurance coverage. By education, while there was a systematic gradient in the prevalence of the health insurance coverage for women and men with those with no education showing

the highest prevalence, there was no clear pattern of the prevalence among those using health service. By nationality, other non-Syrians nationalities showed the highest prevalence in lack of health insurance for both gender and among users of health services with more than 71% of them lack insurance coverage for all indicators. In terms of the inequality in distribution, the inequality summary measures showed that all indicators were severely unequal by the governorates, while only indicators of health insurance coverage among users of health services were severely unequal across nationalities.

SECTION 9: OVERVIEW OF THE HEALTH AND HEALTH EQUITY CHALLENGES IN JORDAN In addition to the above specific findings for the different health aspects, this section synthesizes the findings and offers answers to four basic questions. A. What are the main health priorities in Jordan?  The current effort in Jordan has succeeded in addressing and improving a wide range of health issues. Yet, the evidence in this report showed that the health agenda is still unfinished. More than 63 indicators of the 85 investigated indicators in the current study still fall in the high prevalence category in which their prevalence exceeded 20%(see Appendix B for prevalence categorization of the indicators). This places these indicators as main health challenges or priorities that need focused and programmatic efforts.  These challenges are not just on the impact front but expands to social and biological risk factors. The current report showed that while all the impact indicators continue to show high prevalence, 36 of the 44 risk investigated factors indicators were also classified as high prevalence. In contrast, the evidence showed that the health system performance was on the right track with the majority of its indicators classified as moderate prevalence (less than 20%). Only health sector performance for other RH issues (premarital tests and places for HIV test) was classified as a health challenge. The success of the health system performance was achieved despite the ongoing challenges on the health system capacities. The current evidence highlights the high prevalence of the limited health system capacities in Jordan.  On the health insurance coverage, the recent evidence showed the limited coverage of the current health insurance where almost 50% of the population still lack health insurance coverage. However, interestingly the evidence showed that the health insurance coverage was very gender sensitive and women were more likely to be covered by health insurance than men (51% versus 60%). B. What is the distribution of health priorities for different social groups and which social group is the most vulnerable social group?  The current report was also able to specifically identify vulnerable social groups (see appendix C for the prevalence of all indicators for the different social groups and their prevalence categorization by different stratifiers and appendix D for the social groups showing the worst prevalence by all stratifiers). The five governorates of Mafraq, Madaba, Maan, Balqa and Irbid

showed large number of very high prevalence and high prevalence indicators. Furthermore, individuals in the poorest and poorer wealth quintiles and in all education categories, other than highly educated individuals, also had large number of very high prevalence and high prevalence indicators. Syrians and other nationalities also showed large number of very high prevalence and high prevalence indicators. C. What is the distribution of severity of health inequality for different stratifier and which stratifier is more severely unequal?  Another main contribution in the current report is to provide detailed evidence on the distribution of ill health among the social groups of the different stratifiers (see appendix B for the gaps and measures of inequality by all stratifiers). The report showed a relatively large number of indicators with severe inequality for the four stratifiers used. In particular, the education and governorates were shown as stratifiers that reflect severe degrees of inequalities. On the other hand, wealth and nationality did not show large number of severely unequal health indicators.  Focusing on severe inequality within the investigated health aspects, the current report showed the following ranking of the different health aspects by the relative number of indicators that show severe inequality by the four stratifiers: health sector capacity health insurance coverage, health sector performance, sexual and reproductive health.  Furthermore, the evidence showed that severity of the inequality is increasing in Jordan alongside the improvement in health conditions (see appendix E for the levels of inequality summary measures and their severity classification by the indicators prevalence classification). This implies that the benefits of these improvements are not equally shared among the different social groups. D. What are the trends in prevalence and inequality summary measures between 2012 and 2017?  Slightly more than half of the investigated indicators with comparable figures in 2012 experienced a decrease in prevalence between the 2012 and 2017 (34 indicators out of the 66 indicators). In contrast, the prevalence of 32 indicators increased during the same period (See Appendix F for the trend in prevalence between 2012 and 2017).  The prevalence of 18 of those indicators increased in 2017 by more than 25% of their level in 2012. All indicators in the child nutrition risk factors showed an increase in prevalence, while NCDs risk factors, domestic violence related risk factors, health sector performance for child health and health sector performance for maternal health showed an increase in prevalence of more than 50% of their indicators.  Exploring trends in inequality in distribution by the different stratifiers showed that Inequality by governorates showed the largest number of indicators that experience an increases in their inequality (46 indicators) followed by inequality by wealth and education (25 and 20 indicators, respectively) (See Appendix F for the trend in inequality summary measures for all stratifiers between 2012 and 2017).  Changes in the severity of the inequality classification was observed in 23 indicators by governorates with the majority of those indicators falling in the domestic violence related risk factors, social RH risk factors and health sector capacity, followed by the child mortality and infant and child risk factors.

 Changes in the severity of the inequality classification was also observed in 8 indicators by wealth with the majority of those indicators falling in the social RH risk factors, and infant health risk factors  Changes in the severity of the inequality classification was also observed in 13 indicators by education with the majority of those indicators falling in the domestic violence related risk factors, health sector capacity followed by infant health risk factors, reproductive health risk factor and health sector performance for other RH aspects. SECTION 10: POLICY RECOMMENDATIONS The SDHI framework adopted in the current study suggests that policies and interventions can operate at four different entry levels and be led by different actors within each level. These levels are Level A: Effective and equitable health sector programs respond to differentiated health care needs, and to address systematic differences in risk factors and, Level B: Community level interventions to impact and address inequitable exposure, Level C: Targeted initiatives and national level interventions catering for differentiated needs of social groups, and national level interventions addressing unfair social stratifications Level D: Whole of government approach ensuring equitable structural drivers.

Using these different levels of entry points of policies and intervention, the report concluded with some policy recommendations that capitalize on the current success in Jordan’s health experience and situates these recommendations within the different levels of entry points of policies and interventions. I. Improve Equitable Performance of the Health Sector

Jordan is clearly on the right track in terms of its health policies and performance. In particular, Jordan is pursuing health priorities that are supported by evidence, and engaging in effective health sector programs. Jordan is encouraged to continue its current efforts and to focus more attention to address the specific health challenges presented in this report (indicators showing high prevalence). Many Health Sector interventions at entry level A are required. Such interventions should cater for health care needs and target provision of equitable health to address the highly prevalent and inequitable distribution of social risk factors. Such interventions are generally led by the health sector in close collaboration with other sectors. The challenges facing particular social groups suggest that, despite the positive impact of the initiatives targeting the poorest and least advantaged areas, there is a need to target other disadvantaged social groups at lower levels of education and Syrian refugees. In addition, the challenges in the inequality distribution call for securing the requested adequate and fair health resources for all social groups. These recommendations entail actions at the entry levels B and C. At level B, it is important to implement a primary health care model, that goes beyond medical care, to provide an enabling and equitable environment. This model includes:

 Targeting the levels and inequitable exposure to unhealthy living conditions and livelihoods for the purpose of influencing behavioral and biological risks.  The implementation of community level intersectoral development initiatives. The actions at level C includes a more effective and equitable UHC program.  Such a program not only responds to the challenges demonstrated in this report, but also avoids further contributing to the unfair stratification in society. Out of pocket expenditures on health are well known as an influential driver of poverty. II. Hold Social Sectors Responsible for Health

Social sectors need to realize that they are key stakeholders and contributors for achieving better health outcomes in the society. Indeed, the role of social sectors goes beyond their contribution to intersectoral actions. The evidence of systematic and severe inequalities among social stratifiers suggest the importance of moving the focus from inequalities to inequities. The inequity focus emphasizes the lead responsibility of social sectors and the whole of government for producing fair distribution of resources for health. This requires actions at the entry levels C and D. At level C, the call is for sectoral initiatives to rectify the unfairness of developmental differences at the governorate level and to target alleviation of poverty and ensure non- discrimination by gender and nationalities. At level D, the call is for adoption of a comprehensive multisectoral equitable health strategies to promote health and to address the priority health and health inequality challenges. These stratigies need to spell out targeted, time bound and quantified, health equality goals and to specify the responsibility of each sector for the achievement of specific health related targets. In particular, adoption of such a health strategy builds on the existence of an appropriate institutional structure in Jordan, currently represented by the Higher Health Council in Jordan. It also builds on the opportunity presented in Jordan plans to revisit its current health strategy. The revisiting of Jordan strategy for health, should ensure a wide participatory engagement in its development, implementation, monitoring and evaluation. Also, as referred to earlier, it should adopt policies and devote resources to support intermediary actors and intervening forces to foster equality among social groups and to be responsive to differentiated needs and higher risks of disadvantaged social groups. In addition to the role of social sectors within the articulated strategy for health, social sectors should be held accountable for the impact of their sectoral agendas on health inequities. For each health- related policy and/or initiative adopted by the social sector, a demonstration of positive impact, or at least of a no negative impact on health, should be considered as success criteria.

III. Systematic Measurements and Monitoring of Health Inequities

The existence of an adequate health information system for systematically and periodically measuring and monitoring health and health inequalities is a pre-condition for building the recommended health strategy.

Jordan is fortunate to have a series of recently collected surveys that are also made widely accessible. This availability of data is a very positive feature that can allow the contributions of the research and development stakeholders, and also avail needed evidence for policies. As indicated earlier, even with a very rich JPFHS and a focus on reproductive health, yet many aspects of health have not been measured. The road ahead is to invest in securing an information system for health. Such a system needs to include a minimum set of core indicators that adequately reflect the health spectrum of Jordan population. The data for the indicators should allow the formulation of context sensitive stratifiers (e.g: nationality in case of Jordan), and also include additional pieces of information needed to trace and relate inequality to their structural root causes and to fairness of these causes. Such data is expected to draw on a mix of routine sources of information and specialized surveys. In brief, a movement from the traditional health information system to a broader information system for health is very much called for.

IV. Pushing Equity to the Forefront as a Development Goal and a Whole of Government and Society Performance Measure.

The concern with inequality is very evident in Jordan development vision. The key framing of this report appreciates that systematic inequalities among social groups are measures of unfairness, and, that systematic health inequalities are impact measures that speak to the end results of all developmental efforts and their fairness. Fairness and the achievement of the health equity are measures of social success. Their absence underlies unrest and polarization in society. In particular embracing fairness requires integrating an equity lens in all policies and social arrangements. It requires ensuring fair distribution of power, money, resources and transformative opportunities. More importantly More specifically embracing fairness require:  Articulating health as a whole of government responsibility and developing an equity-based health strategies and plans  Enforcing health impact assessment in all policy approaches The Higher Health Council is well poised to play a stewardship role to place HE as a benchmark for a fair and developed society, and to monitor the implementation of the whole of government responsibility and the accountability process.

1 INTRODUCTION

The current study is an analytical study of the health in Jordan with particular emphasis on identifying challenges and successes in health and health equity (HE). The study is implemented jointly by the Social Research Center of the American University in Cairo (SRC/AUC) and WHO/Jordan. More specifically the report aims to:

 Providing evidence on the social patterns of different health dimensions and the changes in these patterns over time.

 Analysis of the social inequalities in health care utilization and insurance coverage.

 Tracing inequalities in social patterns to their underlying social determinants using a multilevel conceptual framing and an equity lens.

 Identifying priority challenges and providing policy recommendations.

The current report expands on and updates two previous research efforts investigating health equity and social determinants of health in Jordan. Boutayeb (2016) with the support of the WHO/Jordan explored health and health inequalities in Jordan. He implemented advanced statistical techniques to highlight spatial inequality across the Jordanian governorates on the basis of different health and socioeconomic indicators. Boutayed analysis of health inequality focused on a restricted number of health indicators from the Jordan Population and Family Health Survey 2012 (JPFHS 2012) (12 indicators) and was simply based on presenting the distribution of these indicators across the commonly used stratifiers in the JPFHS report. Inequality was assessed in terms of simple measure of inequality such as ratios.

The second research effort was the regional report and Jordan national analytical report produced through the regional initiative on “Sexual and Reproductive Health Equity.” This initiative was a joint activity launched by the United Nations Population Fund for Arab States Regional Office (UNFPA/ASRO) during 2018 in partnership with the Social Research Center of the American University in Cairo (SRC/AUC). The initiative targets supporting governance and policy reforms to address sexual and reproductive health (SRH) inequities. The initiative analyzed the most recent accessible empirical sexual and Reproductive health data for five Arab countries (Egypt, Jordan, Morocco, Oman and Sudan). Rashad and colleagues (2019) in the regional report proposed an SRH adapted version of the social determinants of health conceptual framework. The social determinants of health inequity (SDHI) that is particularly concerned with the distribution of the determinants within the multilevel framing of the social determinants of health. This framework traces health inequalities to the distribution of the different forces that shape them. These forces were shown to operate at different levels starting from the risky health behaviors that characterize different social groups up to the structural levels of governance and public policies. Details on the regional initiative and their findings are provided in analytical reports (Jordan national report1 and regional report2.

The current report applies the SDHI framework using data from the recent JPFHS (2017). It expands beyond the SRH to incorporate other dimensions of health including child health, non-communicable diseases and health insurance coverage. It also adds the nationality stratifer to the traditional stratifier commonly used. Overall, the analysis includes 85 health indicators analyzed across four stratifiers, namely, governorates, wealth, education and nationality. The analysis use three measures of inequality: The gap, the index of dissimilarity for categorical data, and the concentration index for ordinal data. The gap is used to simply show the difference between the best and worst performing social group, while both the index of dissimilarity and concentration index compare the distribution of the health indicators against the distribution of the population and hence capture the ill distribution of the health indicators across the all social groups. The analysis further explores trends of these indicators and their inequalities, based upon availability, between 2012 and 2017.

The report is divided into 10 parts. The introduction offers a discussion of health equity and its evolution over time in the international development thinking. Part Two sets the scene with a general overview of the human development context in Jordan. Part Three presents the framework and methodology offering a discussion of the framework guiding the current study and the methodology adopted in the analysis including data, health indicators, stratifiers, measures of inequality and analytical techniques. Results of the study are presented in part four to eight covering child health, non-communicable diseases, reproductive health and universal health insurance. Part nine goes beyond the single indicator analysis presented in the results to providing an overall assessment of health and health equity issues in Jordan. Part ten offers a conclusion and policy recommendations

1.1 HEALTH EQUITY A MARKER FOR SOCIAL SUCCESS Recognition of the social determinants of health and the concerns with health inequality can be traced to the seventies of the previous century. Alma Ata (1978)3 declaration was the first to recognize health as a social phenomenon and that its promotion invites the actions of more than one social sector. Different articles in this declaration referred to the role of social sectors (article 1), to the unacceptability of inequality and the need for all countries to be concerned with it (article 2). More importantly, the Alma Ata declaration recommended the adoption of primary health care (PHC) as a modality that emphasized community level actions and participation, as well as actions at the more structural level of economic and socio-cultural conditions of the country.

Unfortunately, the actual implementations of the PHC did not capture this broad vision of Alma Ata. The biomedical model dominated the approach, and the vertical solutions were adopted under the proximate social determinants frame and neglected in practice the true essence of Alma Atta. They did not manage to escape the entrapment of economics, health expenditure and functioning of health care. The framing of these solutions was built around the premise that the only causes of ill health are attributed to inadequate spending on health care and the malfunction of the health care system. The role of social forces and social policies were ignored or addressed within a proximate determinants frame.

The interpretation of the SDH frame was translated into a call for policies and interventions targeting the most disadvantaged aiming mainly to change proximate determinants of risky health behavioral practices emphasizing direct awareness interventions.

It was soon realized that the exaggerated focus on behavior changes through simplistic awareness programs was not an effective solution. It was argued that the behavioral proximate determinants are not usually shaped by an individual free and informed choice. They are mainly reflecting the limitations experienced by the disadvantaged groups in knowledge, resources and opportunities for health.

The focus on behavioral changes was gradually complemented with the need to improve the socio- economic situation of the target group and to empower them to make informed choices. The role of structural determinants in shaping the situation of vulnerable groups was starting to take prominence in the discourse on SDH. It should be emphasized here that, at this stage, the role of the state and structural determinants was couched in a moral frame. It was also confined to targeting the most disadvantaged. Changing the distribution of disadvantage was not yet central.

The human rights movement provided the Moral Rationale for the duty of the state and communities to prevent the extra health sufferings whenever feasible. The focus on proximate SDH and the Moral Obligation couched the whole discourse in a social development discourse constrained by the available economic resources and ineffective policies. Improvements in health alongside socioeconomic progress convinced policy actors that the combination of effective socioeconomic policies and targeting is indeed the right way ahead.

The year 2008 was a major turning point in crystalizing the difference between health inequality and health equity. The Commission on the Social Determinants of Health (2008) called for pushing health equity to the forefront and its consideration as a whole of government performance indicator. The Commission directed the attention to the unfair distribution of structural SDH as root causes of ill-health. The CSDH argued that the health landscape is challenged by major social and economic mal-distribution with consequent significant inequalities. It is now important to recognize that inequities are largely governed by factors outside of the Health system and are driven by people’s unfair access to social, economic and cultural resources and opportunities. Such access intersects across macro political and economic structures and policies, as well as social arrangements. They operate at a community and social grouping levels and through living and working conditions, as well as, individual lifestyle factors4.

The concern with health inequities indicated that action is essential as such differences are unjust and remain beyond the control of the individual and the health system. Indeed, poor health associated with social inequity is avoidable and amendable. It became evident that if action is taken to redress health inequities, there will be a notable reduction in the associated health burden and social cost.

Since then, the concern with health inequities and the call for action on SDH became quite central in the current development paradigm. Currently, SDHI (Social Determinants of health inequity) is more accurate acronym expressing the current framing of SDH. The nature of actions, guided by SDHI framing, targeted social transformations through more fair public policies and social arrangements. The policy movement expressed in CSDH, 2008 report and embraced by the SDGs entails the following:

 Push health equity to the forefront of attention and consider health equity as a social success.

 The systematic monitoring of health inequalities and the tracing of their origin linking them to the performance of political, social and economic forces (causes of the causes) as well as the fairness

of these policies (from inequality to inequities) are pre-requisites to demonstrate such country commitment.

 Health Equity in All Policies is an expression of the commitment. The concern with health equity is the mandate of the whole development field and the social sectors and cannot be delegated to the health sector alone. Indeed, the commitment to SDGs is an opportunity for both health and development field to work together to achieve both health and other sectoral goals (health is an input and outcome) through adoption of fair transformative social public policies. The SDGs are excellent manifestations that health and wellbeing for all are both input and outcome measures of development.

 Policies and actions on the social determinants of health inequities must embrace a wider group of actors. Such policies and actions must involve the whole government, civil society and local communities, business, global forums and international agencies. Health Equity in All Policies is an expression of a corporate priority and responsibility of the state. Intersectoral actions (ISA) are an important modality of work that requires structural, logistical and financial considerations.

 Health system inequities are a significant part and parcel of social determinants of health, but equity in health care is not a proxy for equity in health status. It is necessary but not sufficient. The CSDH made sure to define health system as an SDH.

 The Ministry of Health is critical to the needed policy reform movement. It can champion social determinants of health equity approach at the highest level of society, demonstrate effectiveness through good practice, and support other ministries in creating policies that promote health equity. The World Health Organization (WHO) as the global body for health must do the same on the world stage. This necessitates a new stewardship role of the Ministry of Health or even better the establishment of a high health council or a multisector body concerned with SDGs and health equity. The stewardship role implies redefinition of the role of the body entrusted with health. This body is not “Producer of health and health care” but “Purveyor of a wider set of social norms and values”5.

2 SETTING THE SCENE: THE HASHEMITE KINGDOM OF JORDAN

This part offers an overview of the general socioeconomic situation in Jordan with particular emphasis on issues of inequality. It is intended to set the scene for the investigation of health and health inequity in Jordan. This part encompasses two main sections. The first section presents an overview of Jordan and its main human development attributes. The second section focuses on health and health policies and strategies in Jordan with the aim of identifying the main policy Figure 1 Jordan and its governorates directions in the area of general health and in particular reproductive health.

2.1 JORDAN: A HIGH HUMAN DEVELOPMENT NATION Jordan, The Hashemite Kingdom of Jordan is a constitutional monarchy country. The king and his council of ministers are entrusted with the executive authority, while the bicameral National Assembly (Chamber of Deputies and Chamber of Senates) is the main legislative body in the country.

Geographically, Jordan occupies a total territorial area of 89,300 Km2 in the northern Arabian Peninsula and lies at the crossway among the three continents of Asia, Africa and Europe. Administratively, Jordan is divided into 12 governorates (figure 1). Each is headed by a governor who is appointed by the king. Governors are the sole authorities for all government departments and development projects in their governorates.

In accordance with Jordan 2025 vision, Jordan is embarking on its decentralization reform. The reform started by issuing 2015 Decentralization and the Municipality Law and the on-going gradual creation of provisional government through elected governorate and local councils and building capacities of members of these councils. According to the legal structure of for the decentralization process, these councils are expected to execute public policies of the state, deal with emergences, protect public property and prepare a budget for the province and capital investment proposals for their respective governorates or municipalities in coordination with the central government. It worth mentioning that the implementation of this process revealed many drawbacks in its governing legal framework and many researchers have called for its amendment (see for example Maddln, Binda & Khasawneh, 20186; Sowell 20177).

Demographically, according to the 2015 Census Jordan housed more than 9,559 thousand inhabitants and in 2018, Department Of Statistics (DES) estimated the current population of Jordan to be 10,309 thousand8 and a growth rate of 1.38% in 2019. Non-Jordanians accounted for about 32 percent of the total population. Jordan population is a mature population with a median age of 22 years with more than 38.6% of its population under age 15 years and 4.1% are aged 60 years and older. Total fertility rate has recently declined after a long stagnation around 3.5 from 2002 to 2012 to reach 2.7 in 2017. However, according to recent data, there are significant differences in the total fertility rate by various socioeconomic attributes in particular wealth. For example, women in the lowest wealth quintile have a TFR of 3.9 compared to 1.4 among women in the richest wealth quintile.

The dramatic flood of refugees from neighboring countries to Jordan over the past several decades not only affected the population structure, but also placed significant pressure on the country’s limited resources. The 1.3 million Syrian refugees who are accommodated in the country have added strain on the country’s economy and infrastructure and exacerbated the pressure on all sectors including education, health, housing, water, municipal services and electricity supply

Economically, according to the World Bank, Jordan is an upper middle income with a gross national income per capita of $4,210 and annual GDP growth rate of 1.9% in 2018 (World bank indicator)9. The rate of economic growth in Jordan is inadequate to resolve long-standing developmental challenges. In 2017, the consumer price index (CPI) increased by 3.2 percent, and the GDP growth dropped to 1.8 percent with the external trade deficit reaching 2.149 billion dinars (about 3b US$).

In 2018, unemployment rate among Jordanians was 18.6 percent (26.8 percent among women and 16.5 percent among men) while employment rate was 36.2 percent with women’s participation rate in the labor force was 15.4 percent in comparison to 56.4 percent among men.

Only limited data are available on poverty in Jordan. The latest available data for 2010 shows that the absolute poverty line was JD 814.0 (US$1150) per capita per year. Poverty incidence has increased from 13.3 percent to 14.4 percent between 2008 and 2010. Moreover, the latest Household Income and Expenditure Survey (2017) shows that the expenditure on non-food items and services constituted 67.4 percent, increasing from 57.2 percent in 2010. Expenditure on health care out of the total household expenditure increased from 2.2 percent in 2010 to 3.8 percent in 2017.

Although Jordan's ranking improved substantially in the Global Competitiveness Index between 2002 and 2003 (from 44/80 to 34/102), the 2017 rank shows substantial setback (65/137).

One the social dimension, Jordan has achieved significant progress in education and literacy in particular. The literacy rate in Jordan is about 98.2 among population aged 15 + years (97.8 percent for the female population of age 15+ years, and 98.6 percent in males). Among younger generation, Jordan has almost achieved universal literacy with 99.3% of its population aged 15-24 years are literate with 99.5% of young female are literate in comparison to 99.2 percent of young males10. Children of age 6-15 years are enrolled in schools (95 percent) with no gender gaps. Non-Jordanian children account for 28 percent of those enrolled in government owned schools. According to 2018 figures, the illiteracy ratio among the total population of age 15+ years has decline to 1.8% (2.2% among female and 1.4% among males).

Overall, in 2017, Jordan Human Develop Index ranked 95 among 189 countries and UN recognized territories with a score of 0.735 categorizing Jordan among the high human development countries11. It is important to note that Jordan was able to improve its ranking over the period 2012 to 2017 by 5 points from rank 100 to 95. Factoring in inequality, Jordan HDI falls by 16% reaching 0.617 due to inequality in HDI indices. Income inequality coefficient was the highest contributing dimension to this reduction, while the health dimension was the least contributing dimension in the reduction1 (figure 2).

25 20.5 20 16 16.9 15 10.7 10

5

0 Human inequality Inequality in life Inequality in education Inequality in income coefficient expectancy at birth

Figure 2 Percent reduction in HDI for inequality and inequality reduction by HDI dimensions, 2017

However, there was a significant gender gap in the HDI as women score was 0.658 and men’s score was 0.767. This gender Gap was mainly the product of women lower GNI per capita compared to men (2,459 versus 13,971). However, this major gap was compensated by women higher life expectancy (76.3 versus 72.8), better expected years of schooling (13.4 versus 12.9) and almost equal performance on the mean years of schooling (10.1 versus 10.6) compared to men. The final result was a Gender Development Index for Jordan of 0.857 indicating that women HDI is less than men HDI by 14.3%11.

Another measure of gender and its impact on human development is the UNDP Gender Inequality Index assessing gender inequality across three main dimensions, namely reproductive health, empowerment and economic activity. Jordan was ranked 108 out of the 160 countries with a score of 0.460. The GII score for Jordan was mainly taxed by relatively low performance of Jordan on reproductive health indicators as reflected in its relatively high maternal mortality (58 per 100,000 live birth), high adolescent birth rate (22.4% per 100 women aged 15-19). The score also reflected the low female participation in parliamentary life (15.4% female seats in parliament) and low female participation in the labor market (14% for women compared to 63.7% for men). This score is by far much lower than the average score for countries in the high human development category to which Jordan belongs (0.289) but is significantly higher than the average for the Arab states (0.531).

2.2 HEALTH POLICY CONTEXT IN JORDAN In Jordan, 2015 marked an era of strategic development efforts, with concerns for equity and individual welfare in all dimensions of life with particular emphasis on the health dimension that have been pushed

1 It should be noted that HDI relies on life expectancy in assessing health. The current report will explore other health indicators and assess their inequality.

to the forefront on the political agenda. This era started with the launching of “Jordan 2025” the vision and national strategy12. This strategy was developed as the country blueprint to prosperity and resiliency. It puts the Jordanian citizens at the heart of the development process and recognizes that the individuals’ welfare is the most efficient and direct path to achieving community prosperity. In its description of the current situation in the country, the strategy acknowledged the presence of development gap between the governorates in Jordan, in particular the significant disparities in poverty rates among them. Seven governorates were reported to exceed the national poverty level. It further highlighted the fragile situation of the low middle-income families.

To address these challenges, the strategy called for better targeting of the vulnerable population and adopting human development and capacity building approach to enable fragile and vulnerable families to escape the poverty entrapment. Within the health arena, high prevalence of some non-communicable diseases and its impact on the average healthy life years was stressed.

In terms of citizen health, Jordan 2025 put five targeted scenarios and set their priority initiatives. These targeted scenarios were

 Improving the institutional framework for the health care sector  Developing an effective and comprehensive health insurance system  Improving the operational performance of the public health care system  Improving the delivery of emergency medical services  Improving education for professionals in the health field  Strengthening preventative efforts to combat non-communicable diseases  Strengthening partnerships and cooperation in health care sector  Promoting mental health and drug abuse services  Controlling emerging and reemerging diseases. These targeted scenarios were further articulated in Jordan 2016-2020 health sector strategy formulated by the High Health Council13. The health sector strategy provided the general framework for the health with the aim of ensuring the provision of safe, effective and efficient, equitable and affordable health services to citizens of all age groups. It embraced equity as one of its principal values and was clearly stated in its vision and mission.

Vision: Effective health system with humanitarian economic dimension that ensures accessibility to quality lifelong health care to the entire population and puts the Kingdom at a cutting-edge position.

Mission: Developing health-integrated policies with the participation of all health sectors operating in the Kingdom to ensure the provision of comprehensive and sustainable high quality health services for the entire population according to health economic standards that enhances the Jordan's leading position in the field of health care.

In exploring the current situation, the national health sector strategy highlighted many general health challenges for Jordan including population growth and its implications on the age structure, population distribution across the country, the wide spread non communicable diseases in particular Cardiovascular diseases, diabetes and cancer, and the high prevalence of smoking in the population in particular the male population. For reproductive health, the national health strategy identified many challenges including the

neonatal mortality and its disparities across the different governorates, high prevalence of anemia among women in reproductive age and children and significant lack of knowledge of sexually transmitted diseases. The strategy was particularly concerned with consanguinity and early marriage and their negative impact on women’s health and social wellbeing.

The strategy also highlighted challenges concerning senior citizens, mental health and road traffic accidents in Jordan. Health insurance was a major concern in the Health sector strategy. The recent 2015 census showed that 55% of the population and 68% among Jordanian citizens were covered by some type of insurance, with clear disparities in insurance coverage across the governorates. Refugees from the neighboring countries and their serious impact on the already strained health system resources was also stressed in the national health strategy.

In addressing these challenges, the strategy formulated four main strategic goals that aim to achieve a decent standard of health for the population of Jordan

 First Strategic Goal: Support the policy environment and good governance in the health system

 Second Strategic Goal: Provide individual-centered integrated health services and respond to the growing needs

 Third Strategic Goal: Provide health, financial and social protection to the entire population on a fair basis.

 Fourth Strategic Goal: Promote investment in the health sector to support the national economy.

By 2018, the Ministry of Health also launched its own strategy. The Ministry of Health strategic plan 2018- 2022 was built on a self-assessment SWAT analysis of the current performance of the ministry. It complied with the health vision in the “Jordan 2025” National vision and strategy and embraced the global sustainable development agenda in particular the third goal that call for ensuring healthy and promoting wellbeing for all ages. The strategy had seven strategic objectives and their related specific objectives as follows

1. Provide equitable and high quality health care services 2. Improve effectiveness and the efficiency of human resources management 3. Increase inclusion of citizens in the universal health coverage 4. Improve effectiveness and efficiency of infrastructure management 5. Improve effectiveness and efficiency of knowledge management based on digital transformation and technology 6. Improve effectiveness and efficiency of financial resources management 1. 7. Maximize governance and the supervisory role of the Ministry, and implement decentralization In addition to the health strategies in Jordan, in 2013, the High Population Council launched the National Reproductive Health and Family Planning strategy (2013-2017). The strategy identified the use of traditional method, the rates of discontinuation and the unmet need as major challenges for Jordan family planning program. It called for directing more attention on counseling and follow-up, which can reduce discontinuation rate by helping women deal with various obstacles to continued use. The strategy also

recognized the substantial disparities among the different governorates and social groups in their access and utilization of reproductive health and family planning services.

The strategy sets forward the general goal of “Reproductive Health/Family Planning environment (policies/services/information) that supports achievement of the Demographic Opportunity and contributes to the welfare of Jordan’s citizens.” The achievement of this goal called for the need for three intermediate results. The following presents these intermediate results and related, which are

 Policies supporting RH/FP issues: This result aims to improve the RH/FP policy environment and leadership’s commitment to provide resources and approve policies that will contribute to achieving the Strategy goals. This result addresses policies and interventions supportive of RH/FP issues that will help overcome barriers and thus contribute to enabling the policy environment.

 Equitable and high quality RH/FP information and services made accessible: This result aims to equitably distribute high quality RH/FP services that guarantee economic, social and geographic equity, as well as the establishment of a comprehensive system for managing the RH/FP program that is implemented at all levels.

 Positive change in reproductive health beliefs and behaviors in the communities: This result aims to address the social culture and awareness on RH/FP and population issues to change individual attitudes toward positive attitudes and adopt initiatives that enhance positive behavior in this regard.

Concerns for non-communicable diseases was also reflected in Jordan’s National Strategy And Plan Of Action Against Diabetes, Hypertension, Dyslipidemia And Obesity14. The strategy was not time-bound and focused on tackle chronic diseases through raising awareness on means to reduce their prevalence. According to the strategy, about 7.5% of Jordan population were diagnosed with having diabetes with more than one third of all cases of diabetes were missed or undiagnosed. and this figure was projected to reach three million by 2050. The strategy also reported that more than 30% of the population suffer from hypertension, 38% suffer from high cholesterol and almost 80% of the population were overweight or obese. In addition, about 36% of Jordanians aged 25 years and more were found to suffer from the metabolic syndrome which refers to clustering of three or more of the risk factors of cardiovascular disease. The final report of the strategy focused on diabetes with the ultimate goal as “Reduction of the incidence of diabetes and its complications in Jordan.”

To achieve this goal, the strategy had no time frame and included six main area of actions

 Develop a national strategy and action plan for diabetes mellitus  Prevention of diabetes mellitus  Improve management of diabetes  Strengthening multi-sectoral collaboration  Diabetes research  Monitoring and evaluation

In sum, these strategies have highlighted major health concerns in Jordan, which can be summarized in:

 Population growth and its implications on the age structure,  Population distribution across the country,  Non-communicable diseases in particular Cardiovascular diseases, diabetes and cancer,  Smoking in the population in particular the male population.  Neonatal mortality  Anemia among women in reproductive age and children  Knowledge of sexually transmitted diseases.  Consanguinity and early marriage and their negative impact on women’s health and social wellbeing.  Use of traditional method,  Rates of contraception discontinuation  Unmet need. In addition to these health issues, all strategies pointed to the presence of development gap between the governorates and its impact on various health dimensions in Jordan.

3 FRAMEWORK AND METHODOLOGY

This section presents the adopted framework, conceptual thinking and methodology clarifying the new contributions of the SDHI framing of health and the systematic approach adopted. It also discusses the data sources and the availability of relevant indicators.

3.1 THE FRAMEWORK FOR HEALTH INEQUITY INVESTIGATION The SDHI framework adopted in the analysis is presented in Figure 3. The framework describes the conceptual thinking explaining the relationships and pathways through which social determinants influence health and their distribution across the various social groups in the population. The framework is an adaptation of the multilevel conceptual framework of the CSDH.

In the conceptual framework of CSDH, the concept of SDH covers three levels. The first level covers the full set of social conditions in which people are born, grow, live, work and age. Such conditions are characteristics of particular social groups. This level includes the health care system as a social determinant. According to the framework, systematic and persisting health inequalities can be linked to the unequal distribution of these conditions reflected in the social position. This forms the second level. The social positions are the product of the wider upstream social, economic, political, environmental and cultural systems and structures. Such systems and structures are the third level of determinants referred to by CSDH as "the causes of the causes".

The CSDH framework has two defining features. The first feature is the careful incorporation of structural upstream social determinants of SRH (governance, public policies, cultural and societal forces). The second feature is its attention to the social patterns of health inequalities and the tracing of this pattern to the unfairness of structural forces.

It is important to note that the framework does not address differences that are a result of variations in individual preferences, agencies and biological endowments. Such variations are random and do not produce the systematic patterns that are the subject of this report.

The adopted conceptual framework adapts the CSDH framework by reorganizing the framework and articulating two intermediary determinants. The reorganization pays special emphasis to the intermediary social arrangements that lend themselves more readily to policy interventions. The new adapted framework similar to the CSDH has three levels of determinants. The first and third levels are the same as the CSDH frame are referred to as proximate and structural determinants. The second level is the focal point of the adaptation. This level is referred to as intermediary determinants including both the social stratification and intervening forces that lend themselves for policy interventions.

The adaptation of these intermediary determinants explicitly recognized that the social determinants of health may be different from the social determinants of health inequalities. The latter are determinants that influence the distribution of health among different categories of a particular stratifier. For example, gender norms are a well-known social determinant of reproductive health. However, gender norms only become a social determinant of reproductive health inequalities when gender norms are different among social groups and when these differences have unequal influences on health.

The adopted SDHI stresses the importance of the intermediary level determinants. It linked the distribution of the stratifiers with the distribution of health5 inequalities in both the impact and risk factors. It also traced inequalities in these intermediary forces to their structural causes shaping the social stratification and influencing the capacity and performance of intervening forces. This emphasis moves the policy discourse from its usual sole focus on changing risky behavior and on improving general socioeconomic conditions to recognizing the need to address the structural determinants with its own pathway of influence on the distribution of the intermediate determinants.

3.2 THE METHODOLOGY This section is divided into three subsections. The first subsection presents an overview of the data used in the current study and the health indicators used in the analysis. The second subsection defines the main stratifiers implemented in the analysis. The final and third subsection describes the analytical methods used in assessing health and health inequalities challenges implemented in the study.

3.2.1 Data and health indicators The current study uses data from the Jordan 2017-18 and 2012 Population and Family Health survey. These two surveys are the sixth and seventh round of the Demographic and Health surveys implemented since 1990. These surveys are designed to provide data for monitoring the population and health situations in Jordan with particular emphasis on fertility, marriage, maternal and child health and nutrition, HIV/AIDS and other sexually transmitted infections, chronic diseases, household health expenditure and women’s experience of gender based violence. The 2017-18 survey was also the first survey to incorporate a male survey. The survey collected information on men’s basic demographic and social characteristics, on their knowledge and use of family planning methods, and on their knowledge and attitudes towards HIV and other sexually transmitted infections (STIs).

The 2017-18 survey sample is nationally representative and has been designed to produce estimates of major survey variables for the country as a whole, urban and rural areas, three regions (Central, North and South), twelve governorates, and Jordanian, Syrian, and other nationalities. More than 19,000 households, 14,870 ever-married women age 15-49, and 6,640 men age 15-59 were interviewed between October 2017 and January 2018.

For the purpose of current study, a review of the information available in JPFHS was carried out. The review revealed that the survey included wealth of data on reproductive health, but limited information on issues of general health. The tabulated and raw data of JPFHS 2017-18 covered 85 indicators. These indicators were selected to cover main health issues addressed in the JPFHS 2017 as well as main indicators needed to monitor the SDG for Jordan. The indicators were classified into the 5 broad groups of health indicators, namely child health and wellbeing, adult health and NCDs, reproductive health, health system performance and capacity and universal health coverage. Each group of indicators, if relevant, was further classified into impact, and risk factors. To allow for ranking indicators according to magnitude of challenge, all indicators express a negative aspect of health. See annex A for classification of the indicators, their definitions, and relation to SDG indicators.

Intermediary Determinants (Social Arrangements) Social stratification Proximate Determinants  Geographic classification Structural Forces  Other social Inequitable Proximate determinants categories  Living conditions  Governance  Gender norms  Public services’ Systematic  Policy classifications Distribution conditions differences in (macro- of health (Health care, health economic, and education,..) related social, well being Intervening forces  Conditions of work and behaviors, environmental  Health care system leisure psychological and health)  Other public  Homes , communities and  Cultural and systems societal forces  Enabling environments

Figure 3: Social determinants of health inequities framework Source: Adapted from CSDH framework4

3.2.2 Choice of social stratifications: Measuring health inequalities involves identifying the appropriate socio-economic stratification that captures the difference in the population experience. The literature offers a wealth of information that can be used to reflect the social dimensions of ill-health and guide policies to improve health and promote health equity. These stratifiers include gender, wealth, educational level, occupational status and place of residence. However, the use of many social stratifiers will not allow for identifying priority health inequalities. Thus, a minimum list of stratifiers will perform better in identifying priority health inequalities.

For the current study, four main stratifiers are considered, namely geographic area represented by the governorates, wealth, education and nationality. These stratifiers are considered good candidates for reflecting health inequalities. The reasoning for this builds on the availability of data on these dimensions in almost all data sets. Furthermore, they provide a direct or less controversial way in interpreting inequalities, which is appealing to policy makers.

1. A country’s administrative geographic classification reflects the experience of the entire population within a geographic area and captures the potential health vulnerabilities as well as services coverage within a locality. Most importantly, the geographic administrative classification is used for planning services and allows policy makers to identify the underprivileged geographic locations. Furthermore, the geographic administrative classification attracts attention to health inequalities and produce a standard method for monitoring progress overtime and even comparison between countries. In Jordan, the geographic administration stratifier used in the analysis was based on the three main regions in the country; namely North, central and South region as well as on the level of the governorates. 2. The wealth index is a common measure of living condition implemented in surveys. It is based on household physical attributes as well as possession of consumer durable goods. For investigations of inequalities, it is commonly classified into 5 quintiles. The wealth quintiles allow for identifying social inequality in health, as well as help in detecting the socially disfavored groups. Furthermore, the wealth classification allows policy makers to promote the package of social policies in a country. 3. Education is another social stratifier commonly used in studies of health inequality. One advantage of use of education as a stratifier is that education is one of key determinant of the socioeconomic social categorization after specific age. Access to education provides the individual with access to information and social network that can support their health behavior and access to health services. 4. Nationality of the head of the household gained significant attention in the past five years. Jordan has always been the first station for forced migration in the area of northern Arab peninsula. For many decades, Jordan has been home for many Palestinian families. With the invasion of Iraq, Jordan received many Iraqi families. Because of the recent conflict situation in Syria, Jordan received more than 2 million Syrian. Overall, according to Jordan 2015 census, there are 2.9 million non-Jordanian living in Jordan, which represent 44% of the total population living in Jordan. From a humanitarian perspective, this large non-Jordanian 1

population need to equitably achieve their potential health and have access to services and opportunities for their wellbeing. One of the major contribution of the JPFHS(2017) is presenting the nationality of the head of the household as a major background attribute for the individuals.

3.2.3 Analytical Methods The analysis in the current study was carried out according to the following steps

 For identifying priority health and health system challenges, measures of magnitude (prevalence/incidence) for the different indicators were calculated. Three main cutoff points were used for the prevalence of any health dimension as follows: o 40% indicating very high level/ prevalence in which 40% or more of the population are suffering from this indicator o 20%-<40% indicating a high level/ prevalence where more than one fifth of the population is suffering from this indicator o <20% indicating moderate/low level or prevalence where less than one fifth of the population is suffering from this indicator

These categories were sometimes referred to as high priority, priority and moderate prioirty , respectively. Another criterion for the categorization was used for few indicators (infant mortality, diabetes, unmet need, use of traditional methods …….). This criterion used a comparison with the SDG goals or global and other experiences. The health indicator is classified as high level/ prevalence if it exceeded the comparison cutoff point.

 For assessing priority health inequality challenges, three different measures of inequality was implemented. The first was the simple measure of Gap that indicate the absolute difference between the best off and worst off social categories. The other two measures were the index of dissimilarity and the concentration index. The index of dissimilarity (ID) is used for categorical stratifier(the governorates and the nationality in the current report) and the concentration index was used for ordinal stratifiers (wealth and education in the current study). The index of Dissimilarity is defined as

100 푛 푛 퐷퐼% = ∑ |푆 − 푆 | / ∑ 푆 , 푛 푖=1 표 푝 푖=1 푝 where n: the number of categories, 푆표: health indicator distribution by the social stratifier,

푆푝: population distribution by social stratifier.

The concentration index is defined as 2 푛 1 퐶퐼 = ∑ ℎ 푟 − 1 − , 푛휇 푖=1 푖 푖 푛

where ℎ푖: the health indicator, 휇 : the average of the health indicator and ℎ푖: the fractional rank of social stratifier.

2

These summary measures equal zero when the health indicator is similar across the different social groups. The degree of inequality was defined as

 Severe when the DI or IC exceeds a 10% cutoff point,  Moderate when the ID or IC fall between 5% and 10% and  Low when ID or IC are less than 5%.

It should be noted that these summary measures of inequality are more appropriate in investigating the distribution of the indicators across social groups of a stratifier. They use in their calculation the size of the exposed population indifferent social groups. They provide an average measure of the differences between the actual burden of the social groups given their size and the expected burden, if such social groups were exposed to similar level of the health indicators. The concentration index can either be negative or positive, the negative sign indicates higher burden of ill health indicator among disadvantage social groups, while positive sign indicates higher burden of ill health indicators among the advantage social groups.

 For monitoring the changes in the heath and health system challenges and their inequalities between 2012 and 2017, the study explored the change in their overall prevalence and the changes in their inequalities, when available. Increases in the prevalence that exceeded 25% of the 2012 level was considered alarming signs for policy makers. For the measures of inequality increases in the severity degree of the health inequality (from low to moderate or severe inequality and from moderate to severe inequality) were also identified as alarming signs.

It is important to indicate that the findings for each indicator need to be viewed on their own. For each indicator, the findings are intended to guide the appropriate programmatic intervention for reducing the burden of ill health. The gap draws attention to the importance of targeting the social group that is carrying a larger share of the burden. Also, the data provided can be used to identify more than one social group carrying relatively large shares of burden. The summary measures of inequality refer to the degree of variability in the share of the burden of ill health across different categories of the stratifier. This variability moves the discussion from targeting the disadvantaged to achieving a fair distribution of social stratifier and social arrangements. A summary of key findings and summary table for each health aspect is provided at the end of each health aspect.

The following analysis in sections four through eight investigates the different aspects of health and health care, namely child health and wellbeing, NCDs and adult health, sexual and reproductive health, health system performance and capacities and health insurance coverage.

3

4 CHILD HEALTH AND WELLBEING

Data in Jordan Population and Family Health Survey (JPFHS 2017) usually encompass wealth of information on child health and wellbeing. It covers different dimensions of child health and wellbeing starting from infancy and across the different stages of childhood. It also incorporates the three main domains in health, namely impact, risk factors and health sector performance.

The following subsections attempts to identify the main national priorities across these three domains and identifying the most vulnerable social groups for these three domains.

4.1 MORTALITY INDICATORS Between 2012 and 2017, Jordan succeeded in lowering both its neonatal mortality and under 5 mortality. However, it is important to highlight the recent slow-down in the declines in Jordan’s infant mortality. Starting at 19 per thousand in 2007, the infant mortality declined to 17 per thousand in 2012 and maintained this level in 2017. However, this stagnation in declines in infant mortality was associated with declines in neonatal mortality from 14 deaths per thousand in 2012 to 11 deaths per thousand in 2017 and a decline from 21 per thousand for under 5 mortality in 2012 to 19 per thousand in 2017. The data suggested that post-neonatal mortality increased between 2012 and 2017.

These figures for child survival clearly indicate that Jordan at the national level has succeeded in achieving the SDG for child survival that calls for a neonatal mortality rate of less than 12 per thousand and an under 5 mortality of less than 25 per thousand. However, Jordan ranks 38 out of the 52 countries classified in the high human development category for the under 5 mortality according to 2016 data11. In other words, Jordan has not succeeded in matching other countries in this category.

25.0 21.0 19.0 20.0 17.0 17.0 14.0 15.0 11.0 10.0

5.0

0.0 Neonatal mortality Infant mortality Under 5 mortality

2012 2017

Figure 4 Neonatal, infant and child mortality for the preceding five years before the survey, JPFHS, 2012-2017 With this satisfactory but still main health priority2, figure 5 explores the inequalities among Jordan’s 12 governorates in child survival indicators. It shows a wide range of variability in mortality indicators for the different governorates. For neonatal mortality, Balqa showed a very low neonatal mortality of 4 per thousand, while Ajloun showed the highest level of mortality with 14 per thousand. This generated a gap of 10 points and the disparities among the governorates was classified as severe

2 Investigations on the inequality was carried out on the probability of mortality among children born ten years preceding the survey 4 inequality (ID%≥10). Wide disparities among the governorates for infant and under 5 mortality with a gap of 14 points observed for the two of them. Both indicators were classified as being moderately unequal (5%≤ID%<10%).

Gap=10.0 Gap=14.0 Gap=14.0 ID=13.2 ID=8.8 ID=6.8 25 22 20 20 20 19 20 18 17 18 17 18 17 17 14 14 15 15 15 14 15 12 12 12 11 11 11 11 10 8 9 8 9 8 8 10 6 6 4 4 5 0 neonatal mortality infant mortality Under 5 mortality Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Aljoun Karak Tafilh Maan Aquaba Figure 5 Neonatal, infant and child mortality in the governorates and their measures of inequality, JPFHS, 2017

Differences in child mortality indicators by wealth quintiles are quite minor and surprisingly the richest are not the best performing. The distribution shows different pattern for each indicator. For all indicators, the best performing wealth quintiles were the poorer and richer quintile compared to other wealth quintiles. For infant and under 5 mortality, only the poorest quintile were the worst performing quintiles compared to the others.

Gap=4 Gap=6 Gap=4 CI=-1.0 CI=-2.0 CI=-1.7 19.0 20.0 18.0 17.0 16.0 16.0 15.0 15.0 15.0 15.0 12.0 12.0 11.0 11.0 10.0 10.0 8.0 7.0

5.0

0.0 Neonatal mortality Infant mortality Under 5 mortality

Poorest Poorer Middle Richer Richest

Figure 6 Neonatal, infant and child mortality by wealth quintiles and their measures of inequality, JPFHS, 2017

These differences resulted in a gap of 4 points, but their measure of inequality placed them in the low inequality.

Differences in child mortality indicators show a systematic gradient with education in which the population in the low educational attainment are commonly overburden with child loss. Although the differences in neonatal mortality was relatively small among the different educational attainment, the differences in infant and child mortality were substantially large. Mothers with no education or primary educated showed levels of mortality that exceeded those for mothers with higher education by 4 points in the case of neonatal mortality. In contrast, mothers with no or primary education exceed those for mothers with higher education by 9 points. The overall inequality across the wealth quintiles

5 classified infant mortality and under 5 mortality as moderate inequality and neonatal mortality as low inequality.

Gap=4 Gap=9 Gap=9 CI=-4.5 CI=-9.6 CI=-7.7 25 22 20 20 20 20 17 15 15 16 13 13 13 15 11 10 9 9 10 5 0 neonatal mortality infant mortality Under 5 mortality No education Primary Prep. Secondary Higher

Figure 7 Neonatal, infant and child mortality by levels of mothers’ educational attainment and their measures of inequality, JPFHS, 2017

Syrian refugees are clearly overburdened by child mortality. Syrians scored the highest prevalence on all indicators with large differences from both the Jordanians or children from other nationalities. The gap between Syrians and other best nationality ranged between 7 points for neonatal mortality and 11 points for infant mortality. In contrast, Jordanian and other nationalities showed almost the same levels of child mortality indicators. The inequality measure for all indicators classified them as moderate inequality.

Gap=7 Gap=11 Gap=9 ID=6.2 ID=7.6 ID=5.6

30 24 24 25 20 15 13 14 15 15 15 9 8 10 5 0 neonatal mortality infant mortality Under 5 mortality Jordanian Syrian Others Figure 8 Neonatal, infant and child mortality by nationalities and their measures of inequality, JPFHS, 2017

Monitoring changes in levels of inequalities for child mortality across the three stratifiers, geographic, wealth and education, table 1 shows that inequalities among the different governorates have increased between 2012 and 2017 for all indicators. In contrast, inequalities by wealth and education have decreased during the same period.

6

Table 1 Measures of inequality for neonatal, infant and child mortality across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017 Gov Wealth Education Indicator 2012 2017 2012 2017 2012 2017 Neonatal mortality 7.5 10.1 -10.5 -1.0 -10.1 -4.5 Infant mortality 4.8 6.8 -12.7 -2.0 -11.1 -9.6 Under 5 mortality 5.0 6.8 -11.0 -1.7 -9.6 -7.7 Note: colored cells indicate increase in inequality measure between 2012 and 2017

In brief, table 2 and the investigation of the child mortality can be summarized as:  Despite the declines in child mortality indicators between 2012 and 2017, child mortality indicators are classified as health priority  Neonatal mortality shows severe inequality by governorates and moderate inequality by nationality but low inequality by wealth and education.  Both infant and child mortality show moderate inequality across governorate, education and nationality but there was absence of inequality across wealth quintiles.  Between 2012 and 2017, inequality increased across the governorates, but declined for both wealth and education.  Residents of Madaba, Mafraq and Ajloun, the poorest wealth quintiles, those with no education or with primary education and Syrians were the social groups that suffer from an appreciable extra burden of child mortality as indicated by scoring the highest incidence and high incidence compared to others.

Table 2 Summary results of neonatal, infant and under 5 mortality stratifiers Preval Educatio Nationalit Indicator ence Gov Wealth n y Neonatal mortality (-) (+) (-) (-) Infant mortality (-) (+) (-) (-) Under 5 mortality (-) (+) (-) (-) Note: (-) indicates decrease between 2012 and 2017 and (+) indicates increase between 2012 and 2017.

For prevalence Moderate Prevalence<20%) High 20%40%

For inequality Low (ID/IC<5%) Moderate (5%

4.2 CHILD HEALTH AND WELLBEING RISK FACTORS INDICATORS Data from the JPFHS 2017 offer a wide range of indicators related to child health and wellbeing risk factors addressing infant health, child nutrition, and child discipline. The current study investigated 9 indicators to explore the child risk factors across these dimensions.

4.2.1 Infant health risk factors Two indicators assessed infant health risks, namely being small in size and of low birth weight. Figure 9 shows that while small size infants decreased between 2012 and 2017, low birth weight increased during the same period. However, considering the fact that the prevalence of small size infants in low and middle income countries was 19.3% with uncertainty range of 17.6% and 31.9%15and that the global prevalence of low birth weight is 15.5% 16, these figures classify infant size as moderate prevalence health indicator and low birth weight as high prevalence health indicator in Jordan.

7

25.0 19.7 20.0 16.7 13.7 13.8 15.0 10.0 5.0 0.0 Very small/small in size Low Birthweight

2012 2017

Figure 9 Infant health risk factors indicators, JPFHS, 2012 &2017

Differences in the prevalence of small size infants and low birth weight was large across all governorates. For small size infant, Balqa showed the lowest prevalence (9.1%), while Irbid showed the highest prevalence (17.4%) with a gap of 8.3 points.

Gap=9.3 Gap=10.8 ID=7.8 ID=6.0

30.0 25.6

25.0 22.4

20.0

19.0

18.3

17.5 17.5

20.0 17.4

16.3

16.2

15.4 15.4

15.0

14.9 14.9

14.8

14.5

14.3

14.0

13.9 12.5

15.0 12.1 10.2 10.0 9.1 5.0 0.0 Very small/small in size Low Birthweight Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Aljoun Karak Tafilh Maan Aquaba

Figure 10 Infant health risk factors by governorates and their measures of inequality, JPFHS, 2017

For low birth weight, Zarqua showed the lowest prevalence of 14.8%, while Madaba showed the highest prevalence of 25.9% with a gap of 10.9 points. However, despite these differences in prevalence of both indicators, they were classified as moderate inequality.

The prevalence of small size infants was negatively related to wealth. The poor quintiles showed higher levels than others. The low birth weight showed a distorted negative relationship with wealth where it declined with wealth but increased for the richest quintile. These patterns resulted in relatively large gaps and classified small infant size as severe inequality and low birth weight as moderate inequality.

8

Gap=7.5 Gap=5.6 CI=-11.8 CI=-6.5 25.0 19.4 20.0 18.4 16.4 16.8 16.0 13.8 14.3 15.0 12.4 9.8 8.9 10.0

5.0

0.0 Very small/small in size Low Birthweight Poorest Poorer Middle Richer Richest

Figure 11 Infant health risk factors by wealth quintile and their measures of inequality, JPFHS, 2017

Both small infant size and low birth weight were negatively associated with education attainment. One exception to this pattern is the low prevalence small infant size among women with no education as the show lower prevalence than those with primary education. The overall inequality across the education quintiles classified both indicators as severe inequality.

Gap=10.0 Gap=15.3 28.4 30.0 CI=-10.2 CI=-10.0 23.4 25.0 20.8 20.0 18.2 18.1 16.0 15.4 14.7 13.1 15.0 10.8 10.0 5.0 0.0 Very small/small in size Low Birthweight No education Primary Preparatory Secondary Higher Figure 12 Infant health risk factors by educational attainment and their measures of inequality, JPFHS, 2017

For the effect of nationality on the prevalence of infant health, Figure 14 shows that Syrian children were the most overburdened with infant risk factors as they showed the highest prevalence for both indicators. They were followed by the Jordanians. The gaps between the Syrian children and those from other nationality was relatively large.

9

Gap=11.5 Gap=10.0 ID=5.1 ID=3.8 25.0 22.0 19.3 20.0 16.1 15.0 13.1 12.0 10.0 7.8 5.0 0.0 Very small/small in size Low Birthweight Jordanian Syrian Others

Figure 13 Infant health risk factors by nationalities and their measures of inequality, JPFHS, 2017

A comparison between the inequality measures for the infant health risk factors indicators for 2012 and 2017 revealed that inequality has increased over this period for the two indicators and across all stratifiers (table 3).

Table 3 Measures of inequality in infant health risk factors across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017 Gov Wealth Education Indicator 2012 2017 2012 2017 2012 2017 Very small/small in size 3.0 7.8 -2.1 -11.8 -5.7 -10.2 Low Birthweight 4.6 6.0 -3.2 -6.5 -8.3 -10.0

In brief, table 4 and the investigation of the infant health risk factors for infant can be summarized as follows:

 Despite the decline in the prevalence of the small infant size between 2012 and 2017, its inequality was severe by wealth and education but was moderate across the governorates and nationality.  Low birth weight is considered a health priority in comparison to the international standard and its prevalence increased between 2012 and 2017.  Low birth weight inequality was only severe across education, moderate across governorates and wealth and low across nationality  Inequality has been increasing across the two indicators for all stratifiers.  Residents of Madaba, Karak, and Mafraq, the poorest and poorer wealth quintiles, those with no education or with primary education and Syrians were the social groups that suffer from an appreciable extra burden of infant risk factors as indicated by scoring the highest prevalence for the indicators

Table 4 Summary results of infant risk factors stratifers Prevalence Indicator Gov Wealth Education Nationality Very small/small in size (-) (+) (+) (+) Low Birthweight (+) (+) (+) (+) Note: (-) indicates decrease between 2012 and 2017 and (+) indicates increase between 2012 and 2017.

For prevalence Moderate Prevalence<20%) High 20%40%

For inequality Low (ID/IC<5%) Moderate (5%

4.2.2 Child nutrition risk factors Child nutrition risk factors were measured using six indicators, namely anemia among children (6-59 months), lack of food rich in vitamin A, lack of minimum meal frequency, lack of food rich in iron, lack of minimum dietary diversity and lack of minimum acceptable diet with the last five indicators were measured for children 6-23 months. Figure 14 shows that except for lack of minimum meal frequency, the prevalence of all indicators have increased slightly between 2012 and 2017. For the lack of minimum meal frequency, there was large increase (18.7 points) in the prevalence between 2012 and 2017. The figure also shows that lack of food rich in iron, lack of minimum dietary diversity and lack of minimum acceptable diet were classified as very high prevalence as their prevalence exceeded 40%. Anemia among children (6-59 months), lack of food in vitamin A, lack of minimum meal frequency as high prevalence since their prevalence ranged between 20% and 40%.

100.0 High prevalence Very high prevalence 76.5

80.0 66.7 48.6

60.0 44.9

40.4

39.5

37.8

32.8

32.4 32.2

40.0 31.6 19.1 20.0 0.0 Anemia children No food rich in No minimum meal No food rich in No minimum No minimum 6-59 months vitamin A (6-23 frequency (6-23 iron (6-23 months) dietary diversity acceptable diet (6- months) months) (6-23 months) 23 months)

2012 2017

Figure 14 Child nutrition health risk factors indicators, JPFHS, 2012 &2017

For the high prevalence indicators of child nutrition risk factors, all governorates showed a prevalence that exceeded 20% for all three indicators. Only Tafielh showed a prevalence of child anemia lower than 20%. However, some of the governorates exceeded the 40% cutoff for very high prevalence. Ajloun showed a prevalence of anemic of 40.6%. Tafielh showed a prevalence of 39.9% for lack of food rich in vitamin A and Mafraq, Maan and Aqaba showed a prevalence of lack of minimum meal frequency close to 40%. This high prevalence places these indicators as health challenge in their governorates. Assessment of overall inequality among the governorates classified anemia and lack of food with vitamin A as moderate inequality, while lack of minimum meal frequency was classified as low inequality.

Gap=23.5 Gap=13.9 Gap=23.8 Gap=26.1 Gap=15.9

100.0 ID=9.3 ID=5.9 ID=5.6 ID=6.7 ID=2.9 87.2

Gap=19.7 86.9

85.7

83.6 82.0

90.0 81.5 79.4

ID=3.5 76.9 75.8

75.8 73.4

80.0 72.2 65.1

70.0 61.3

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44.6 42.7

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31.0

29.9

26.8 26.8 25.0 30.0 24.8 20.0 17.1 10.0 0.0 Anemia children 6-59 No food rich in vitamin No minimum meal No food rich in iron (6- No minimum dietary No minimum months A (6-23 months) frequency (6-23 23 months) diversity (6-23 months) acceptable diet (6-23 months) months)

Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Aljoun Karak Tafilh Maan Aquaba

Figure 15 Child nutrition risk factors by governorates and their measures of inequality, JPFHS, 2017 11

For the very high prevalence indicators, the prevalence of the three indicators exceeded the 40% cutoff point in all governorates. The only exception was Amman that showed a prevalence of 33.4 % for no food rich in iron and 39% for lack of minimum dietary diversity. The prevalence of the three indicators also showed large variations with large gaps among the best off and worst off performing governorates. These gaps ranged between 15.9 points for lack of minimum acceptable diet and 26.1 points for lack of minimum dietary diversity. The measure of inequality classified both lack of food rich in iron and lack of minimum dietary diversity as moderately unequal and lack of minimum acceptable diet as low inequality.

Figure 16 revealed the wide spread of the burden of nutrition deprivation in the low wealth quintiles. However, it is important to note that the poorest wealth quintile was not always the worst performing wealth group on all indicators.

Gap=20.1 Gap=15.9 Gap=12.6 Gap=12.8 Gap=23.3 Gap=13.9 CI=-11.0 CI=-4.5 CI=-5.2 ID=-3.5 CI=-5.8 CI=-2.9

90.0 84.9

78.6

73.6 72.2 80.0 71.0

70.0 54.3

60.0 53.6

47.6

47.5

44.1

44.0 41.8

50.0 39.4

39.2

38.0

37.9

37.0

36.5

36.3

35.1

33.8

33.5

32.8

31.5

31.2 31.0

40.0 29.9 24.3 30.0 22.1 20.0 17.8 10.0 0.0 Anemia children 6- No food rich in No minimum meal No food rich in iron No minimum No minimum 59 months vitamin A (6-23 frequency (6-23 (6-23 months) dietary diversity (6- acceptable diet (6- months) months) 23 months) 23 months) Poorest Poorer Middle Richer Richest Figure 16 Child nutrition risk factors by wealth and their measures of inequality, JPFHS, 2017

In the case of lack of food with vitamin A and lack of food with iron, the poorer was the worst performing quintile. Overall, the inequality measure shows that only anemia showed severe inequality, Lack of minimum meal frequency and lack of minimum dietary diversity were classified as moderate inequality. Lack of food rich in vitamin A, lack of food rich in iron and lack of minimum acceptable diet were classified as low inequality.

Figure 17 shows a clear association between Low educational attainment and deprivation in nutritional status among children. Except for anemia among children, children to mothers with no education showed the highest level of deprivation in all indicators. The difference between the best and worst performing educational attainment shows a wide range of gaps. The smallest gap was observed in anemia in children (9.4 points), while the largest gap was found in lack of minimum dietary diversity (42.9 points). However, the overall measure of inequality classified only anemia and lack of minimum meal frequency as moderate inequality, while all the other indicators were classified as low inequality.

12

Gap=9.4 Gap=28.0 Gap=25.4 Gap=24.0 Gap=42.9 Gap=22.1

CI=-6.4 CI=-4.9 CI=-5.8 CI=-1.5 CI=-2.4 CI=-1.5 97.2

100.0 89.0 86.1

90.0 82.8 76.5

80.0 75.1

63.1

59.9 59.0

70.0 58.0 50.0

60.0 47.9

46.3

46.1

42.2

42.1

40.3

39.4

39.1 38.8

50.0 38.2

36.4

36.0

35.6

34.7

33.6

32.7 32.6

40.0 30.0 30.0 26.9 20.0 10.0 0.0 Anemia children No food rich in No minimum No food rich in No minimum No minimum 6-59 months vitamin A (6-23 meal frequency iron (6-23 dietary diversity acceptable diet months) (6-23 months) months) (6-23 months) (6-23 months) No education Primary Preparatory Secondary Higher

Figure 17 Child nutrition risk factors by education attainment and their measures of inequality, JPFHS, 2017

Overall, Syrian children in Jordan are more exposed to lower nutrition status compared to Jordanian children. The only exception to this pattern is observed for lack of minimum meal frequency in which the other nationalities children showed a prevalence slightly higher than that for Syrian children. However, it is important to indicate that the range of differences in not as large as that observed in the case of wealth or education. The gap between Syrians and the Jordanians never exceeded 10 points. In addition to Syrian children, children from other nationalities were found to suffer more from lack from dietary diversity and acceptable diet compared to the Jordanians. In addition to the low gaps among the different nationalities, the overall measure of inequality classified all these indicators as low inequality indicators.

Gap=3.2 Gap=5.7 Gap=9.8 Gap=5.5 Gap=7.9 Gap=9.2

ID=0.9 ID=1.6 ID=3.1 ID=0.9 ID=1.8 ID=1.4

85.4 80.9

90.0 76.2 80.0

70.0

55.5

49.9 47.6

60.0 46.2

45.2

43.2

40.1

37.7 36.9

50.0 36.4

34.3

32.2

31.7 31.2 40.0 31.1 30.0 20.0 10.0 0.0 Anemia children No food rich in No minimum meal No food rich in No minimum No minimum 6-59 months vitamin A (6-23 frequency (6-23 iron (6-23 dietary diversity acceptable diet months) months) months) (6-23 months) (6-23 months) Jordanian Syrian Others

Figure 18 Child nutrition risk factors by nationalities and their measures of inequality, JPFHS, 2017

Table 5 explores the differences in the levels of the inequality measures between 2012 and 2017 across the main three stratifiers for the four indicators. It shows increased inequality in all indicators across the governorates. For wealth and education, the inequality decreased for all indicators except for anemia among children. Inequality in child anemia across wealth and education increased between 2012 and 2017.

13

Table 5 Measures of inequality in child nutrition risk factors across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017 Gov Wealth Education Indicator 2012 2017 2012 2017 2012 2017 Anemia children 6-59 months 5.1 9.3 -7.3 -11.0 -3.3 -6.4 No food rich in vitamin A (6-23 months) 5.1 5.9 -9.3 -4.5 -6.1 -4.9 No minimum meal frequency (6-23 months) 3.0 3.5 -9.9 -5.2 -13.8 -5.8 No food rich in iron (6-23 months) 3.3 5.6 -6.8 -3.5 -3.8 -1.5 No minimum dietary diversity (6-23 months) 3.7 6.7 -10.6 -5.8 -6.3 -2.4 No minimum acceptable diet (6-23 months) 2.8 2.9 -5.6 -2.9 -4.1 -1.5 In sum, table 6 and the investigation of the child nutrition risk factors can be summarized as follows:

 All indicators of child nutrition showed increases in their prevalence between 2012 and 2017.  All indicators were classified as a high prevalent indicators exceeding 20% threshold with three of them, namely lack of food rich with iron, lack of minimum dietary diversity or acceptable diet exceeding the very high prevalence threshold (prevalence>40%).  Only anemia was severely unequal across wealth, while all other indicators were either moderate or low inequality across all stratifiers  Inequality has been increasing for all indicators across the governorates and wealth except for wealth disparities in the lack of minimum acceptable diet.  For education only, inequality has been decreasing for all indicators except for anemia and lack of minimum meal frequency.  Women with no education or with primary education and Syrians were the social groups that suffer from an appreciable extra burden of child nutrition risk factors as indicated by scoring the highest prevalence for many indicators, .

Table 6 Summary results of child nutrition risk factors stratifiers Prevalence Indicator Gov Wealth Education Nationality Anemia children 6-59 months (+) (+) (+) (+) No food rich in vitamin A (6-23 months) (+) (+) (-) (-) No minimum meal frequency (6-23 months) (+) (+) (-) (-) No food rich in iron (6-23 months) (+) (+) (-) (-) No minimum dietary diversity (6-23 months) (+) (+) (-) (-) No minimum acceptable diet (6-23 months) (+) (+) (-) (-) Note: (-) indicates decrease between 2012 and 2017 and (+) indicates increase between 2012 and 2017.

For prevalence Moderate Prevalence<20%) High 20%40%

For inequality Low (ID/IC<5%) Moderate (5%

14 home, the prevalence of all the other indicators slightly declined between 2012 and 2017 with the largest declined was registered by the child discipline indicators in particular considering physical violence necessary for child discipline.

Moderate prevalence High prevalence Very high prevalence 100.0 89.4 90.0 81.3 80.0 70.0 60.0 50.0 40.0 31.1 29.3 22.8 30.0 16.4 20.0 13.9 9.4 10.0 0.0 Physical violence is Children <5 years left with Children not on the Any violent discipline necessary inadequate care developmental track children 1-14 years 2012 2017

Figure 19 Child development factors indicators, JPFHS, 2012 &2017

Prevalence of the child development risk factors indicators shows high disparities among the different governorates (figure 20). These disparities produced relatively large gaps between the best and worst performing governorates. The gaps ranges between 8.3 points for considering physical violence is necessary to 22.1 points for children missing on their developmental track. The variation among the governorates and the large gaps were translated in morderate inequality for considering physical violence necessary and children missing on the developmental track, while the other two indicators were classified as low inequality.

Gap=8.3 Gap=9.7 Gap=22.1 Gap=18.3

ID=7.8 ID=4.9 ID=5.8 ID=3.4 91.9

100.0 89.5

86.1

86.0

84.9 84.9

83.3 81.5

90.0 79.2

75.0 75.9 80.0 73.6 70.0

60.0 47.4

50.0 45.8

36.2

36.1

33.6

32.2

28.5 28.4

40.0 27.0

26.1

25.3

23.3

21.9

21.7

21.2 17.9

30.0 17.4

16.9

16.5 16.5

16.2

16.1

15.8

15.3

15.0

14.7

14.4

13.6

12.9

12.7

11.4 10.7 20.0 8.9 10.0 0.0 Physical violence is Children <5 years left with Children not on the Any violent discipline necessary inadequate care developmental track children 1-14 years

Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Aljoun Karak Tafilh Maan Aquaba

Figure 20 Child development risk factors by governorates and their measures of inequality, JPFHS, 2017

Except for children left without adequate care, all child development indicators show an attenuated negative relationship with wealth (figure 21). In contrast, the indicator of children left without adequate care shows an attenuated positive relationship with wealth. Despite the gaps between the best and worst performing quintiles were relatively large, the inequality measure classified all indicators as low inequality.

15

Gap=5.1 Gap=6.5 Gap=9.5 Gap=17.1 CI=-3.8 CI=-2.7 CI=-4.9 CI=-3.4

100.0

86.5

86.1 84.1

90.0 78.5

80.0 69.5 70.0 60.0

50.0

33.9 30.0

40.0 28.7

26.1 24.4

30.0 21.0

16.6

16.3 16.3

16.1

14.5 14.5 14.5 11.8 20.0 11.5 10.0 0.0 Physical violence is Children <5 years left with Children not on the Any violent discipline necessary inadequate care developmental track children 1-14 years Poorest Poorer Middle Richer Richest

Figure 21 Child development risk factors by wealth and their measures of inequality, JPFHS, 2017

Except for the indicator of children not on the developmental track, the other three indicators have no clear pattern with education (figure 22). Children not on the developmental track showed systematic negative relationship with education. For the indicator of considering physical violence necessary for child discipline and the indicator of children left without adequate care, children to mothers with no education showed the highest prevalence followed by children to mothers with higher education. For experience of any violence discipline for children 1-15 years, the relationship with education was positive with the exception of children of mother with higher education. This latter group showed the lowest prevalence among all educational categories.

With the varying gaps for the four indicators, only the indicator of children not on the developmental track showed the largest gap and was classified as moderate inequality, while all the other indicates were classified as low inequality.

Gap=8.6 Gap=8.0 Gap=24.1 Gap=11.6 CI=-0.4 CI=-2.4 CI=-5.2 CI=-2.5

100.0

86.7

85.3

81.3 80.1 80.0 75.1

60.0 50.8

36.2 32.3

40.0 29.1

26.7

21.9

21.1

17.2

16.3

15.2

14.1

13.4

13.3 13.3 20.0 13.1

0.0 Physical violence is Children <5 years left with Children not on the Any violent discipline necessary inadequate care developmental track children 1-14 years No education Primary Preparatory Secondary Higher

Figure 22 Child development risk factors by education attainment and their measures of inequality, JPFHS, 2017

Child development indicators revealed that except for children left without adequate care, Syrian children followed by Jordanian children are the most vulnerable children (figure 23). For the children left without adequate care, the most vulnerable group was the other nationalities followed by Jordanian children. Differences among the nationalities were relatively large but the overall inequality was low for all indicators.

16

Gap=6.1 Gap=9.9 Gap=12.3 Gap=11.1 ID=1.8 ID=1.7 ID=1.6 ID=0.5

100.0

83.9 81.8

80.0 72.8

60.0 34.2

40.0 29.1

24.0

21.9

16.4

14.3

14.1 14.1

20.0 8.2 0.0 Physical violence is Children <5 years left with Children not on the Any violent discipline necessary inadequate care developmental track children 1-14 years Jordanian Syrian Others

Figure 23 Child development risk factors by nationalities and their measures of inequality, JPFHS, 2017

A comparison between the inequality measure in 2012 and 2017 across the three main stratifiers and the four indicators shows that the except for considering physical violence necessary for child discipline across governorates and wealth, and experience of violence for children 1-14 years across all stratifiers, the inequality in the other indicators decreases across all stratifiers (table 7). In contrast, Inequality in considering physical violence necessary for child discipline and experience of violence for children 1-14 increased across the governorates and wealth quintiles between 2012 and 2017. The inequality latter indicators also increased across the education attainment stratifier.

Table 7 Measures of inequality in child development risk factors across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017 Gov Wealth Education Indicator 2012 2017 2012 2017 2012 2017 Physical violence is necessary 3.0 7.8 3.6 -3.8 1.3 -0.4 Children <5 years left with inadequate care 8.8 4.9 -7.3 2.7 -6.4 2.4 Children not on the developmental track 6.0 5.8 -5.4 -4.9 -13.7 -5.2 Any violent discipline children 1-14 years 1.2 3.4 -1.4 -3.4 -1.2 -2.5

In sum, table 8 and the investigation of the child development risk factors for infant can be summarized as follows:  Child development indicators have been decreasing between 2012 and 2017 except for children left without adequate care.  Experience of any violent discipline was classified as very highly prevalent health indicator, while children not on the development track was classified as highly prevalent health indicator.  All indicators were classified as low inequality across all stratifiers except for moderate inequality in physical violence is necessary across governorates and children not on the development track across the governorates and wealth.  The poorest wealth quintiles, those with no education or with primary education and Syrians were the social groups that suffer from an appreciable extra burden of child discipline risk factors as indicated by scoring the highest prevalence on many child development risk factors indicators.

17

Table 8 Summary results of child development risk factors Stratifiers Indicator Prevalence Gov Wealth Education Nationality Physical violence is necessary (-) (+) (+) (-) Children <5 years left with inadequate care (+) (-) (-) (-) Children not on the developmental track (-) (-) (-) (-) Any violent discipline children 1-14 years (-) (+) (+) (+) Note: (-) indicates decrease between 2012 and 2017 and (+) indicates increase between 2012 and 2017. For prevalence Moderate Prevalence<20%) High 20%40%

For inequality Low (ID/IC<5%) Moderate (5%

4.3 CONCLUDING REMARKS  Between 2012 and 2017, there was improvement in child health and wellbeing indicators except for child nutrition.  Despite the declines in many child health indicators between 2012 and 2017, many of them are still classified as at least highly prevalent indicators.  Severe inequality is not common in the child health and wellbeing and only shows in four situations: neonatal across governorates, small infant by wealth and education, and anemia by wealth.  Governorates show moderate inequality in 12 of the 15 child health indicators. For the majority of the indicators the inequality was increasing.  For education, inequality was at least moderate for 8 indicators with two of them were severely unequal. Inequality across education was decreasing for the majority of the indicators.  For wealth, only five indicators showed at least moderate inequality with two of them severely unequal. Inequality across wealth was increasing for the majority of the indicators  Nationality was moderately unequal for impact indicators and infant health indicators.  The poorest wealth quintiles, those with no education or with primary education and Syrians were the social groups that suffer from an appreciable extra burden of child health and wellbeing health impact and risk factors Table 9 Summary for child health and wellbeing

stratifiers Prevalence Indicator Gov Wealth Education Nationality Neonatal mortality (-) (+) (-) (-) Infant mortality (-) (+) (-) (-) Under 5 mortality (-) (+) (-) (-) Very small/small in size (-) (+) (+) (+) Low Birthweight (+) (+) (+) (+) Anemia children 6-59 months (+) (+) (+) (+) No food rich in vitamin A (6-23 months) (+) (+) (+) (-) No minimum meal frequency (6-23 months) (+) (+) (+) (+) No food rich in iron (6-23 months) (+) (+) (+) (-) No minimum dietary diversity (6-23 months) (+) (+) (+) (-) No minimum acceptable diet (6-23 months) (+) (+) (-) (-) Physical violence is necessary (-) (+) (+) (-) Children <5 years left with inadequate care (+) (-) (-) (-) Children not on the developmental track (-) (-) (-) (-) Any violent discipline children 1-14 years (-) (+) (+) (+) For prevalence Moderate Prevalence<20%) High 20%40%

For inequality Low (ID/IC<5%) Moderate (5%

18

5 ADULT HEALTH AND NON-COMMUNICABLE DISEASES

5.1 MORTALITY AND NCDS Non-communicable diseases in Jordan have received significant attention in the health policy documents and strategies. WHO report (2018) showed that 78% of all deaths in Jordan are estimated to be attributed to NCDs (figure 24) with the majority of these deaths related to cardiovascular diseases and cancers17. WHO (2018) also highlighted that the risk of premature death due to to NCDs was 19% among individuals aged 30-70 years with risk among men (23%) compared to women (16%).

injuries ; 11%

Communicable, maternal, preinatal, and nutritional Cardiovascular conditions; 11% diseases; 37%

other NCDs; 20%

Diabetes; 6% Chronic respiratory Cancers; 12% diseases ; 3%

Figure 24 Distribution of death by main cause of death in Jordan, WHO (2018)

Figure 25 shows the prevalence of chronic conditions and some risk factors based on 2007 Jordan Behavioral Risk Factors Surveillance survey18. Obesity/overweight were very highly prevalent reaching to 66.5% of the adult population. The same study also showed that there was large underestimation of the prevalence of chronic conditions based on self-reported information in Jordan.

high blood pressure 17.8 diabetes 9.9 heart diseases 8.1 high bood cholesterol 7.5

Asthma 6.8 chronic conditions chronic obesity or overweight 66.5 engagement in moderate physical activity 37.8 smoking 29

riskfactors ≥14 unhealthy mental/physical days 18.1 0 10 20 30 40 50 60 70

Figure 25 Prevalence of chronic conditions and some risk factors (2007 Jordan Behavioral Risk Factors Surveillance survey)

The study showed that women suffer from higher obesity/overweight, blood pressure, and cholesterol than men.

19

For the behavioral risk factors, non-engagement in physical activities was close to the cutoff point for very high prevalence. Also, while the overall prevalence of smoking was 29%, yet smoking is very highly prevalent among men (50%) compared to women (6%). In contrast, overweight and obesity were high prevalent among women (69.5%) compared to men (62.4%).

Available tabulations from a very recent WHO STEPS survey for non-communicable disease risk factors (2019)19 also confirmed high prevalence of many risk factors. Among the adult population (18-69 years), more than 60% of the adult population were overweight or obese and 40.1% of them were currently smokers with 34.6% are daily smokers. However, obesity was more common among women (68.8%) compared to men (53.2%), while smoking was more common among men (65.3% currently smoking and 58% daily smokers) compared to women (16.4% currently smokers and 10.8% daily smokers). Low physical activities according to WHO physical activity criteria was observed for 31.3% of adult population with no significant differences between men and women. The combination of these different risk factors showed that almost 25% of the adult population in Jordan had more than 10 years of Cardiovascular diseases (CVD)risk greater than 30 or are with existing CVD. These high prevalence of risk factors also contributed to high prevalence of non-communicable diseases among the adult population in Jordan. Within the past 12 months, the data showed that among the adult population (18-69 years), about 15.1% of was diagnosed with hypertension, 12.8% diagnosed with diabetes, 17.7% diagnosed with raised cholesterol.

The latest round of JPFHS 2017 provides more recent data and information on diagnosed diabetes and some NCDs risk factors that focused on women in reproductive age and only one indicator for men namely, smoking.

5.2 DIABETES IN JORDAN JPFHS 2017 included a question on diabetes “Has any member of your household ever been told by a doctor or other health worker that he/she has diabetes?” In the current study, answers to this question as diagnosed diabetes thereafter. Data from the JPFHS 2017 revealed that 7.6% and 7.8% of adult women and men, respectively, were diagnosed with diabetes (figure 26). These figures are slightly lower than the global prevalence of diabetes. However, it should be noted that the figures for Jordan are for the diagnosed diabetes, which is generally believed to significantly underestimate the actual prevalence of diabetes by almost 50%. Figures for the population aged 60 and older are higher or close to the upper limit of the global prevalence that estimate this proportion to range between 22% and 33%. These figures place Diabetes as a high health priority whether for the general population or for older adults.

40.0 34.6 29.3 30.0

20.0 7.8 10.0 7.6

0.0 Diabetes (18+ years/ Diabetes (60+ years/ Diabetes (18+ years/ Diabetes (60+ years/ women) women) men) men)

Figure 26 Prevalence of diagnosed diabetes in Jordan, JPFHS, 2017

Figure 27 shows the differences in the prevalence of the four indicators of diagnosed diabetes across the different governorates. The gaps between the best off and worst off governorates were large relative to the level of prevalence of diabetes. Figure (27) also shows that in general, Irbid scored the 20 highest prevalence on three of the four indicators, while Karak and Maan tend to display the lowest prevalence.

Applying the international boundaries for the prevalence of diabetes among older adult women, figure 27 shows that all governorates exceeded the lower boundary of 22% and six governorates exceeded the upper bound of 33%. These governorates are Amman, Zarqua, Irbid, Jerash, Ajloun, and Aqaba. For men the situation is a little better. All governorates, with exception of Karak and Maan, showed a prevalence that exceeded the 22% but none of them reached the upper boundary of 33%. It should be noted that while the differences resulted in relatively large gaps but the overall measure of the inequality distribution across the governorates was classified as low inequality, except for diabetes among adult men, which is at the low boundaries of moderate inequality.

Gap=4.6 Gap=3.6 Gap=12.0 Gap=19.5 ID=4.5 ID=5.5 ID=3.7 ID=3.1

44.0 42.9

38.5

38.1

36.5

34.3

32.9

32.0

31.0

30.4

30.0 29.9

33.0 29.4

29.0

28.6

27.3

26.9

24.4

23.8

23.4

21.9 20.0

22.0 20.0

8.6

8.5

8.2

8.0 7.8

11.0 7.2

7.1 7.1

6.6 6.6 6.6

6.3

6.2

6.1

5.9 5.9

5.6 5.6

5.5

5.0

4.6 4.4

0.0 Diabetes (18+ years/ Diabetes (18+ years/ men) Diabetes (60+ years/ men) Diabetes (60+ years/ women) women)

Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Aljoun Karak Tafilh Maan Aquaba

Figure 27 Prevalence of diagnosed diabetes indicators in the governorates and their measures of inequality, JPFHS, 2017

Figure 28 revealed non-significant differences among wealth quintiles in the diagnosed diabetes indicators (gap not exceeding 2.5) except for older adult women for which the gap equals 5.8 point. The pattern of differences is not systematic with a tendency for the richest quintile to experience close or slightly less prevalence of diabetes than the poorest. Also, the summary measure if inequality by wealth is low except for adult women for which inequality was moderate.

Gap=1.4 Gap=2.3 Gap=2.5 Gap=5.8

CI=-3.3 CI=-6.1 CI=-0.1 CI=-1.7

36.8 36.7

40.0 36.2

33.7

31.0

30.3 30.1

35.0 30.0 28.0 30.0 27.8 25.0 20.0

15.0

8.8

8.5

8.4

7.9

7.8

7.5 7.5

7.1 6.8 10.0 6.5 5.0 0.0 Diabetes (18+ years/ Diabetes (18+ years/ men) Diabetes (60+ years/ men) Diabetes (60+ years/ women) women) Poorest Poorer Middle Richer Richest

Figure 28 Prevalence of diagnosed diabetes indicators by wealth and their measures of inequality, JPFHS, 2017 21

Figure 29 shows a clear association between Low educational attainment and higher prevalence of diagnosed diabetes among adult women and men. While older adult women showed a semi negative relationship between education and diagnosed diabetes, the prevalence of diabetes had no specific pattern with education among older adult men. For older adult women, women with no or primary education had slightly lower prevalence than those with preparatory education. For older adult men, the highest prevalence was registered for those with higher education, while the lowest was registered for those with preparatory education. These distributions of prevalence of diabetes among the different educational attainment a wide range of gaps. The gaps ranged between 21.5 points among adult women and 5.7 points among older adult men. Overall inequality was classified as highly severe among adult women, severe among adult men, low among older adult men and moderate among older adult women.

Gap=13.4 Gap=5.7 Gap=11.7 Gap=21.5 CI=-4.3 CI=1.7 CI=-14.8 CI=-41.5

45.0

38.1 37.5

40.0 36.1

31.7 30.6

35.0 30.5

28.7

27.7

26.0 24.7 30.0 24.7

25.0

19.0 16.7

20.0 14.6 12.4

15.0 10.7

6.8 5.0

10.0 4.6 5.0 3.2 0.0 Diabetes (18+ years/ Diabetes (18+ years/ men) Diabetes (60+ years/ men) Diabetes (60+ years/ women) women) no education primary preparatory secondary higher

Figure 29 Prevalence of diagnosed diabetes indicators by education and their measures of inequality, JPFHS, 2017

Examination of diagnosed diabetes prevalence by the nationality reveals that except among older adult women, Jordanians were more likely to be diagnosed with diabetes compared to other nationalities (figure 30). They were followed by Syrians for adult women and older adult men and by other nationalities for adult men. For older adult women, Syrians showed the highest prevalence followed by Jordanians. The gaps between the nationalities were not large for the adult women and men but relatively large for the older adult women and men. However, the overall inequality across the nationality was classified as low for all indicators.

Gap=1.5 Gap=3.1 Gap=7.9 Gap=16.1 ID=1.3 ID=2.8 ID=1.6 ID=1.2 50.0 44.6 40.0 34.4 29.7 28.6 30.0 25.0 21.9 20.0 7.9 6.9 6.4 7.8 6.4 10.0 4.7 0.0 Diabetes (18+ years/ Diabetes (18+ years/ men) Diabetes (60+ years/ men) Diabetes (60+ years/ women) Jordanian Syrian Others women)

Figure 30 Prevalence of diagnosed diabetes indicators by nationality from the national levels and their measures of inequality, JPFHS, 2017

22

5.3 NCDS RISK FACTORS Only six NCDs risk factor indicators were available in the JPFHS 2017. These are smoking behavior for women and men, women nutritional status assessed in term of anemia and the obesity, never had breast exam for cancer and never heard of pap test. Figure 31 shows that four of these indicators exceed the 40% threshold for being very highly prevalent, namely anemia among women, smoking among men, obesity among women and never had breast exam. The prevalence of women who did not have self or professional breast exam showed the highest prevalence of 79% and this prevalence increased between 2012 and 2017. Anemia among women also increased form 33.5% in 2012 to 42.6% in 2017. Never had a pap test showed a prevalence that exceeded 20% and increased substantially from 25.7% in 2012 to 35.3% in 2017 classifying it as highly prevalent health indicator. Smoking among women declined from 18% on 2012 reaching 12% in 2017, which place it in the moderate prevalence category.

90.0 Moderate high prevalence Very high prevalence 79.0 80.0 prevalence 70.0 61.2 60.0 54.8 54.1 47.8 50.0 42.6 40.0 35.3 33.5 30.0 25.7 18.0 20.0 12.0 10.0 0.0 Smoking women Never heard of pap Anemia among Smoking men 15- Obesity No breast exam 15-49 test women 15-49 49 /overweight self or professional among women 15- 2012 2017 49

Figure 31 Prevalence of NCDs risk factors in Jordan, JPFHS, 2017

Despite the moderately prevalence of women smoking, the governorates show a wide range of prevalence ranging from 2% in Karak to 19.3% in Balqa. This produced a gap of 17.3% and was classified as severe inequality (figure 32).

Although the national prevalence of never heard of pap places it as a highly prevalent indicator, it showed a wide range of prevalence with five governorates exceeding the 40% threshold for very high prevalence (Balqa, Madaba, Mafraq, Maan and Aqaba) with Balqa displaying a prevalence of 62.2%. This places this indicator as very highly prevalent in these governorates. In contrast, Ajloun showed the lowest prevalence (28.3%). Difference between the Balqa and Ajloun produced a gap of 33.9 point. Assessing the inequality across all governorate showed that this indicator falls in the moderate inequality category.

23

Gap=17.3 Gap=33.9 Gap=14.2 Gap=21.2 Gap=18.7 Gap=18.9

ID=18.7 ID=8.8 ID=2.0 ID=2.0 ID=2.0 ID=2.1 93.1

100.0 89.6

86.2

85.5

83.9 83.0

90.0 82.7

78.2

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80.0 74.2 63.9

70.0 62.2

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50.0 39.6

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33.6 30.2

40.0 29.5 28.3

30.0 19.3

15.8

14.1 10.9

20.0 8.9

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5.6

3.5 2.3 10.0 2.0 0.0 Smoking women Never heard of pap Anemia among Smoking men 15- Obesity No breast exam 15-49 test women 15-49 49 /overweight self or professional among women 15- 49

Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Aljoun Karak Tafilh Maan Aquaba

Figure 32 Prevalence of NCDs risk factors indicators by governorates and their measures of inequality, JPFHS, 2017

Prevalence of anemia among women in the different governorates was very close. With the exception of Madaba that showed lowest prevalence of anemia among the governorates (35.4%), all the other governorates were either very close to the 40% threshold or exceeding it. The difference between Madaba and the other governorates resulted in a large gap of 14.2 points, but the inequality measure classified this indicator as low inequality.

Prevalence of smoking among men showed different level of prevalence. Tafielh showed the lowest prevalence (33.8%), while the Madaba displayed the highest prevalence (55%) producing a gap of 21.2 points. However, the overall inequality was also low for this indicator.

Obesity among women and not having self or breast exam showed prevalence that exceeded the 40% for all governorates placing them as very highly prevalent indicators for all. Moreover, the inequality measure classified them as low inequality.

With the exception of smoking among women, wealth had a systematic negative relationship with NCDs risk factors that over burden the poor with higher risks compared to the other wealth quintiles (figure 33). In contrast, smoking among women was positively related to wealth. Figure 33 also shows that except for anemia among women, the differences among the wealth quintiles prevalence was large. This has contributed to relatively large gaps for all indicators. These gaps ranged between 7.2 points for anemia among women and 24 points for never heard of pap test. The measure of inequality classified women smoking and never heard of pap test as severe inequality. However, the inequality was positive for women smoking indicating high concentration among the rich while the inequality was negative for never heard of pap test indicating high concentration among the poor. Smoking among men was classified as moderate prevalence and all the other indicators were classified as low prevalence.

24

Gap=8.3 Gap=24.0 Gap=7.2 Gap=11.7 Gap=11.4 Gap=17.4

CI=13.8 CI=-13.8 CI=-2.1 CI=-5.3 CI=-3.4 CI=-4.0

85.6 83.2

90.0 80.3 76.6

80.0 68.2

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60.0 49.4

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40.0 30.6 27.2

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20.0 8.5 10.0 0.0 Smoking women Never heard of pap Anemia among Smoking men 15- Obesity No breast exam 15-49 test women 15-49 49 /overweight self or professional among women 15- Poorest Poorer Middle Richer Richest 49

Figure 33 Prevalence of NCDs risk factors indicators by wealth and their measures of inequality, JPFHS, 2017

Educational attainment showed a clear negative relationship with never heard of pap test, obesity among women and never had self or professional breast test (figure 34). For the other indicators, the middle educational categories showed higher prevalence than those in no education or higher education.

Gap=4.4 Gap=41.2 Gap=9.1 Gap=29.4 Gap=14.4 Gap=18.0

CI=-3.7 CI=-11.1 CI=-1.7 CI=-1.3 CI=-2.7 CI=-3.2 91.8

100.0 89.6

83.4

79.7

73.8 70.3

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40.0 29.1

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11.8 10.7 20.0 9.5 0.0 Smoking women Never heard of Anemia among Smoking men 15- Obesity No breast exam 15-49 pap test women 15-49 49 /overweight self or professional among women 15- No education Primary Preparatory Secondary Higher49

Figure 34 Prevalence of NCDs risk factors indicators by education attainment and their measures of inequality, JPFHS, 2017

Differences in the prevalence among the educational attainment showed a wide range of gaps. The gaps range between 4.4 points for smoking among women and 41.2 points for never heard of pap test. Exploring the inequality across the educational attainment categories revealed that all indicators, except for never heard of pap test, were classified as low inequality. Never heard of pap test was classified as severe inequality with IC=-11.1.

NCDs risk factors showed no specific pattern in their relationship with the nationality (figure 35). Jordanians showed the lowest prevalence in never heard of pap test, anemia among women and not having self or profession breast exam. Syrian showed the lowest prevalence in smoking among women and men. Other nationalities showed the lowest prevalence in women obesity. Similarly, different nationalities scored the highest prevalence. Except for never heard pap test that was classified as moderate inequality, all other indicators were classified as low inequality.

25

Gap=4.8 Gap=32.3 Gap=2.83 Gap=4.9 Gap=10.8 Gap=13.6 ID=2.6 ID=9.0 ID=0.2 ID=0.9 ID=0.8 ID=1.5

100.0 91.2 81.4

80.0 77.6

63.9

55.7 54.5

60.0 51.4

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44.9

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20.0 12.3 8.3

0.0 Smoking women Never heard of Anemia among Smoking men 15- Obesity No breast exam 15-49 pap test women 15-49 49 /overweight self or professional among women 15- Jordanian Syrian Others 49

Figure 35 Prevalence of NCDs risk factors indicators by nationalities and their measures of inequality, JPFHS, 2017

Comparison between the inequality measures for all indicators across the three stratifiers between 2012 and 2017 shows that governorate based inequality has increased for all indicators except for obesity among women (table 10). For wealth, the inequality increased for women smoking and obesity but decrease for all the other indicators, while for education, the inequality decreased for all indicators.

Table 10 Measures of inequality in NCDs risk factors across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017 Gov Wealth Education Indicator 2012 2017 2012 2017 2012 2017 Smoking women 15-49 15.1 18.7 13.7 13.8 -7.8 -3.7 Anemia among women 15-49 5.9 2.0 -2.7 -2.1 -3.6 -1.7 Obesity /overweight among women 15-49 1.6 2.0 -1.8 -3.4 -3.9 -2.7 Never heard of pap test 2.5 8.8 -19.6 -13.8 -14.2 -11.1 No breast exam self or professional 1.9 2.1 -5.8 -4.0 -4.7 -3.2

5.4 CONCLUDING REMARKS In brief, table 11 and the investigation of the NCDs and their risk factors can be summarized as follows:

 All diabetes indicators were classified as high prevalence, while all NCDs risk factors were classified as very high prevalence. Only women smoking was classified as moderate prevalence.  All NCDs risk factors have increased over time except for women smoking.  Inequality was moderate for diabetes among adult men across governorates and wealth  Inequality was severe for diabetes among older adults across education  Inequality was severe for women smoking across the wealth, governorates and low by education and nationality  Never heard of pap test was moderately unequal across the governorates, but severely unequal across wealth and education.  Men smoking was moderately unequal by wealth and obesity was moderately unequal by nationality  Other NCDs risk factors showed low inequality across all stratifiers.

26

 Between 2012 and 2017, inequality by education and wealth has been decreasing for many indicators but has been increasing across governorates  Adults with no education are overburdened with the highest prevalence of diagnosed diabetes compared to the other educational categories  Individuals in the poorest wealth quintile, with no education or primary education and Syrians are the social groups who more overburdened with NCDs risk factors.

Table 11 Summary results of NCDs and their risk factors Stratifiers Indicator Prevalence Gov Wealth Education Nationality Diabetes (18+ years/ women) Diabetes (18+ years/ men) Diabetes (60+ years/ men) Diabetes (60+ years/ women) Smoking women 15-49 (-) (+) (+) (-) Never heard of pap test (+) (+) (-) (-) Anemia among women 15-49 (+) (-) (-) (-) Smoking men 15-49 Obesity /overweight among women 15-49 (+) (+) (+) (-) No breast exam self or professional (+) (+) (-) (-) Note: (-) indicates decrease between 2012 and 2017 and (+) indicates increase between 2012 and 2017. For prevalence Moderate Prevalence<20%) High 20%40%

For inequality Low (ID/IC<5%) Moderate (5%

27

6 SEXUAL AND REPRODUCTIVE HEALTH

Impact indicators for reproductive health are mainly related to maternal mortality and morbidity. Unfortunately, there is no data on maternal morbidity in JPFHS 2017. Furthermore, due to the nature of the Maternal Mortality ratio and its requirement of specialized survey, there are only data at the level of Jordan. According to the World Bank statistics, Jordan succeeded in decreasing its maternal mortality ratio from 70 per 100,000 live birth in 2000 to 46 per 100,000 in 201720. However, more recently, Jordan Minister of Health21 declared that Jordan has succeeded in decreasing its maternal mortality ratio to 29.5 deaths per 100,000 live births in 2018. This figure was reported in the first national report for maternal mortality for 2018.

In contrast to impact indicators for reproductive health, data from JPFHS (2017) offer a wide range of risk factors indicators covering many RH dimensions. These indicators were classified in three categories. The first category was social risk factors indicators associated with adverse impact on women’s reproductive health. The second was HIV/AIDS related risk factors indicators, while the third was domestic violence related risk factors indicators.

6.1 SOCIAL REPRODUCTIVE HEALTH RISK FACTORS Six indicators were investigated to assess the social reproductive health risk factors. These indicators are adolescent childbearing, women not owning their health care decision, early marriage, having 5 or more children (multiparity), consanguinity, and risky birth intervals less than 23 months. These indicators reflect the social context in which women live and affect the reproductive health. Figure 36 shows that only adolescent child bearing and women not own their health care decision showed a prevalence less than 20% and hence were classified as moderate prevalence. The other indicators showed a prevalence more than 20% but less than 40% classifying them as high prevalence health indicators. It also shows that except for adolescent childbearing and early marriage, the prevalence of the other indicators declined between 2012 and 2017.

Moderate prevalence High prevalence

40.0 34.6

31.9

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30.0 27.5

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20.8 20.5

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7.9 5.2

10.0 4.5 0.0 Adolescent child Women who does Early marriage Multiparity (5+ Consanguinity Risky birth bearing (<18 not own health (<18 years) children) intervals (23 years) care decision 2012 2017 months)

Figure 36 Prevalence of social RH risk factors in Jordan, JPFHS, 2017

The prevalence of the RH social risk factors showed large variation among the different governorates with different governorates ranking as best and worst performing governorates (figure 37). For the prevalence of adolescent childbearing, the highest was observed in Mafraq (13.1%), with a large different from the second highest prevalence observed in Zarqua (7.4%). In contrast, the lowest prevalence for adolescent child bearing was observed in Tafielh (2.0%). For women not owning their health decision, the highest prevalence was observed in Maan (13%) followed by Balqa (11.1), while the lowest prevalence was observed in Karak (3%). Early marriage showed its highest prevalence in Irbid (28.2%) followed by Jerash (25.6%) while the lowest prevalence was observed in Karak(12.5%).

28

It worth mentioning that more than eight governorates registered a prevalence less than 20%, which classifies early marriage as a moderate prevalence in these governorates. This leaves only 4 governorates (Irbid, Jerash, Madaba and Zarqua) above the moderate prevalence threshold for this indicator keeping it as a high prevalence indicator in these governorates. For multiparity, the highest prevalence was observed in Irbid (34.6%) followed by Jerash (32.9%), while the lowest prevalence was registered for Aqaba (15.4%). It worth mentioning that only 3 governorates (Amman, Aqaba and Maan) showed prevalence less than 20% placing this indicator as moderate prevalence for these governorates. For consanguinity, the highest prevalence was observed in Jerash(39%) followed by Marfaq (36.3%), while the lowest prevalence was observed in Aqaba and Tafielh (20.9%). For risky birth interval, the highest prevalence was observed in Aqaba (34.8) followed by Madaba (33.8%).

These figures have contributed to large gaps between the best and worst performing governorates. These gaps range between 8.3 points in the case of risky birth interval and 19.2 points in multiparity. The overall measure of inequality was highly servere inequality in adolescent childbearing. The inequality level for risky birth intervals is low inequality. The other three indicators were classified as moderate inequality with the index of dissimilarity (ID) ranging between 5% and 10%

Gap=11.1 Gap=9.5 Gap=15.7 Gap=19.2 Gap=18.1 Gap=8.3 ID=23.2 ID=7.7 ID=6.3 ID=8.4 ID=6.6 ID=3.5

45.0 39.0

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2.8 2.4 5.0 2.0 0.0 Adolescent child Women who does Early marriage Multiparity (5+ Consanguinity Risky birth bearing (<18 years) not own health (<18 years) children) intervals (23 care decision months) Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Aljoun Karak Tafilh Maan Aquaba

Figure 37 Prevalence of social RH risk factors indicators by governorates and their measures of inequality, JPFHS, 2017

Prevalence of all social RH risk factors indicators shows clearly negative relationship to wealth where the poor are always overburdened with high prevalence of these risk factors (Figure 38). These patterns resulted in moderate gaps ranging from 5.9 points for women not owning their health care decision to 14.4 points for early marriage. However, the overall inequality measure classified adolescent child bearing as highly severe inequality, women not owning their health care decision and early marriage as severe inequality. All the remaining indicators were classified as moderate

29 inequality. Gap=12.4 Gap=5.9 Gap=14.4 Gap=10.7 Gap=11.0 Gap=9.4 CI=-46.2 CI=-13.3 CI=-10.7 CI=-8.9 CI=-7.3 CI=-6.1

40.0 33.4

35.0 31.7

30.0

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3.8 2.1

5.0 0.6 0.0 Adolescent child Women who does Early marriage (<18 Multiparity (5+ Consanguinity Risky birth intervals bearing (<18 years) not own health years) children) (23 months) care decision Poorest Poorer Middle Richer Richest

Figure 38 Prevalence of social RH risk factors indicators by wealth and their measures of inequality, JPFHS, 2017

Prevalence of the different RH social risk factors indicators showed different patterns for each indicator (figure 39). Education was negatively related to adolescent child bearing, women not owning their health care decision and multiparity. However, for adolescent childbearing and multiparity, the prevalence for women with no education was lowest that those with primary education. Early marriage showed a positive relationship with education until preparatory education, but declined gradually after that. For consanguinity and risky birth interval, the high prevalence was observed for the middle education stages. This varying prevalence among the wealth quintiles showed large differences ranging between 10.5 points for risky birth interval and 44.8 points for early marriage

Gap=26.9 Gap=21.9 Gap=44.8 Gap=30.4 Gap=14.8 Gap=10.5 CI=-35.5 CI=-20.8 CI=-29.8 CI=-16.7 CI=-10.0 CI=-0.9

60.0 48.0

50.0 42.9

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10.0 3.2 0.4 0.0 Adolescent child Women who does Early marriage (<18 Multiparity (5+ Consanguinity Risky birth intervals bearing (<18 years) not own health years) children) (23 months) care decision No education Primary Preparatory Secondary Higher

Figure 39 Prevalence of social RH risk factors indicators by education attainment and their measures of inequality, JPFHS, 2017

The overall inequality assessment classified adolescent childbearing, women not owning their health care decision and early marriage as highly severe inequality, multiparity and consanguinity as severe inequality and risky birth interval as low inequality.

Syrian women were commonly overburdened with RH social risk factors. Except for multiparity and consanguinity, women from other nationalities came second in vulnerability (figure 40). For multiparity and consanguinity, the Jordanian women came second in vulnerability.

30

Gap=24.7 Gap=10.1 Gap=26.7 Gap=16.9 Gap=10.7 Gap=9.4 ID=37.7 ID=12.5 ID=10.3 ID=2.4 ID=1.7 ID=4.3

50.0 45.1

36.9 35.2

40.0 32.9

30.1

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27.5

27.3

23.4 22.6

30.0 22.2

18.4

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20.0 11.8 6.7

10.0 3.1 0.0 Adolescent child Women who does Early marriage (<18 Multiparity (5+ Consanguinity Risky birth intervals bearing (<18 years) not own health years) children) (23 months) care decision Jordanian Syrian Others

Figure 40 Prevalence of social RH risk factors indicators by nationalities and their measures of inequality, JPFHS, 2017

Differences in the prevalence of the indicators showed large differences ranging from 9.4 points for risky birth intervals to 26.7 points for early marriage. In addition, the overall inequality measure classified adolescent child bearing as highly severe inequality, and women not owning their health care decision and early marriage as severe inequality. All the other indicators were classified as low inequality.

A comparison between 2012 and 2017 inequalities in the RH social risk factors indicators across the three stratifiers showed an increase in the inequalities in all indicators and across all stratifiers (table 12) with four exception women not owning their health care decision across governorates, consanguinity across wealth and risky birth intervals across wealth and education.

Table 12 Measures of inequality in social RH risk factors across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017

Gov Wealth Education Indicator 2012 2017 2012 2017 2012 2017 Adolescent child bearing (<18 years) 8.8 23.2 -9.4 -46.2 -42.9 -35.5 Women who does not own health care 7.8 7.7 -8.6 -13.3 -8.2 -20.8 decision Early marriage (<18 years) 3.1 6.3 -8.8 -10.7 -37.1 -29.8 Multiparity (5+ children) 3.7 8.4 -6.2 -8.9 -16.3 -16.7 Consanguinity 4.1 6.6 -8.9 -7.3 -7.0 -10.0 Risky birth intervals (23 months) 2.7 3.5 7.9 -6.1 -1.0 -0.9

In sum, table 13 and the investigation of the social reproductive health risk factors for infant can be summarized as follows:  Overall, all social RH risk factors declined between 2012 and 2017, except for adolescent child bearing and early marriages  Despite the improvement in these indicators, between 20% and 30% of the population are still suffering from four of these indicators namely early marriage, consanguinity, multiparity and risky birth intervals  Severe inequality is frequently observed across the four stratifiers and all indicators.  Adolescent child bearing and early marriage were severely unequal across the four stratifiers.  Except for governorates, women not owning their health care decision were severely unequal for all other stratifiers. It was moderately unequal for governorates.

31

 Multiparity and consanguinity were severely unequal cross governorates and education but moderately unequal for wealth.  Risky birth intervals showed low inequality across all stratifiers  For the majority of the indicators inequality across governorates, wealth and education increased between 2012 and 2017 except for four indicators namely women not owning their health care decision across governorates, consanguinity across wealth and risky birth intervals across wealth and education.

Table 13 Summary results of social reproductive health risk factors Stratifiers Prevalence Indicator Gov Wealth Education Nationality Adolescent child bearing (<18 years) (+) (+) (+) (+) Women who does not own health care decision (-) (-) (+) (+) Early marriage (<18 years) (+) (+) (+) (+) Multiparity (5+ children) (-) (+) (+) (+) Consanguinity (-) (+) (-) (+) Risky birth intervals (23 months) (-) (+) (-) (-) Note: (-) indicates decrease between 2012 and 2017 and (+) indicates increase between 2012 and 2017. For prevalence Moderate Prevalence<20%) High 20%40%

For inequality Low (ID/IC<5%) Moderate (5%

6.2 HIV/AIDS-RELATED KNOWLEDGE AND ATTITUDES Six indicators have been identified in JPFHS 2017 to address the challenges in HIV/AIDS-related knowledge and attitudes. These indicators were available for women and men. It worth mentioning at this point that while some of the literature define the indicators available in JPFHS as health sector performance indicators, we argue that lack of knowledge represented by these indicators is also a major social risk factors. Figure 41 shows that except for knowing of HIV, the prevalence of all indicators exceeded the 40% the threshold of very high prevalence. In other words, while individuals know of HIV, there is significant lack of more detailed knowledge for HIV/AIDS and STI.

Figure 41 shows also that there were no large differences between women and men in all indicators. However, men showed more lack of knowledge with regard to knowing HIV/AIDS, knowledge of mother to child transmission (MTCT), knowledge about Sexually Transmitted Infection (STI), and adopted more discriminatory attitudes against people living which HIV/AIDS (PLWH). However, women were less informed about comprehensive knowledge of HIV for both the adults and young

people.

97.5

93.4

92.2

91.9

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90.8

89.7 87.4 100.0 87.1

90.0 66.8

80.0 66.1 58.2 70.0 58.0 60.0 50.0 50.0 40.4 40.0

30.0 10.9

20.0 5.5 10.0 0.8 0.0 2012 2017 2017 No knowledge of HIV/AIDS Women No Knowledge of MTCT Men No knowledge of STI Discriminatry attitudes against PLWH No comprehensive knowledeg of HIV No comprehensive knowledge of HIV for young (15-24)

Figure 41 Prevalence of HIV/AIDS related risk factors in Jordan, JPFHS, 2017

Comparing 2012 to 2017, figure 48 shows no specific patterns. Lack of knowledge increased for knowing HIV, STI, and comprehensive knowledge of HIV for both adults and young people. In the 32 meanwhile, there was an increase in knowledge for MTCT and in adoption of discriminatory attitudes against PLWH.

Inequality in HIV/AIDS related indicators is investigated for women and men separately. Figure 42 shows that there are relatively small variations in the prevalence of the three indicators of lack of comprehensive Knowledge for women and young women and adopting discriminatory attitudes against PLWH among the governorates. It worth mentioning that Tafielh was the best performing governorate on all three indicators, while different governorates showed the highest prevalence. The converging prevalence across the governorates produced relatively small gaps, which never exceeded 11%. This low variation in prevalence also contributed to classifying their overall inequality as low inequality.

Gap=16.2 Gap=28.7 Gap=36.2 Gap=8.2 Gap=8.6 Gap=10.1

ID=19.5 ID=3.5 ID=4.8 ID=1.4 ID=0.7 ID=1.3

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96.3

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3.1

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2.6

1.9 1.3 10.0 1.1 0.0 No knowledge of No Knowledge of No knowledge of Discriminatory No comprehensive No comprehensive HIV/AIDS MTCT STI attitudes against knowledge of HIV knowledeg of HIV PLWH for young (15-24) Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Aljoun Karak Tafilh Maan Aquaba

Figure 42 Prevalence of HIV/AIDS risk factors indicators for women by governorates and their measures of inequality, JPFHS, 2017

In contrast, there was large variations in the prevalence of lack of knowledge of HIV/AIDS, MTCT and STI. For lack of knowledge of HIV, Balqa showed a distinct high prevalence for the lack of knowledge of HIV/AIDS and MTCT and it showed the second highest prevalence for lack of Knowledge of STI after Marfaq. In contrast, the lowest prevalence was displayed by different governorates, Ajloun for lack of knowledge of HIV/AIDS. Jerash for lack of knowledge MTCT and Tafielh for lack of knowledge of STI.

Differences among the governorates resulted in large gaps ranging between 16.2 points for lack of knowledge of HIV/AIDS and 36.2 points for lack of knowledge of STI. These large differences and wide variations among the governorates produced severe inequality for lack of knowledge of HIV/AIDS, but low inequality for lack of knowledge of MTCT and STI.

Similar to women, except for lack of knowledge of HIV/AIDS, the prevalence of all indicators in all governorates exceeded the 40% threshold for being very highly prevalent (figure 43). One exception to this pattern is the prevalence of lack of knowledge of MTCT in Karak, which registered a prevalence below 40% (38.2%). In contrast to women, variation in the prevalence for the different governorates was large in all indicators among men. This large variation produced relatively large gaps between the best and worst preforming governorates ranging between 18.3 points for lack of knowledge of HIV and 30.7 for lack of knowledge of MTCT. This variation also classified lack of knowledge of HIV as severe inequality, lack of comprehensive knowledge among young men and lack of knowledge of STI as moderate inequality and the others indicators as low inequality.

33

Gap=18.3 Gap=30.7 Gap=27.1 Gap=22.9 Gap=21.7 Gap=23.8

ID=13.2 ID=3.2 ID=5.3 ID=2.9 ID=3.0 ID=6.4

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20.0 3.8 2.0 2.1 2.0 0.0 No knowledge of No Knowledge of No knowledge of Discriminatory No comprehensive No comprehensive HIV/AIDS MTCT STI attitudes against knowledge of HIV knowledge of HIV PLWH for young (15-24) Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Aljoun Karak Tafilh Maan Aquaba

Figure 43 Prevalence of HIV/AIDS risk factors indicators for men by governorates and their measures of inequality, JPFHS, 2017

Prevalence of HIV/AIDS risk factors indicators across the wealth quintiles for women revealed close convergence between the prevalence for the quintiles in two indicators, namely lack of knowledge of MTCT and adopting discriminatory attitudes against PLWH (figure 44). In contrast, wealth was negatively related to no knowledge of STI and no comprehensive knowledge of HIV among adult women and young women. For lack of knowledge of HIV/AIDS, women in the poorest and richest quintiles showed the highest prevalence. These varying patterns produced a wide range of gaps. These gaps ranged from 1.9 points for adopting discriminatory attitudes against PLWH to 21.8 points for lack of knowledge of STI. Furthermore, only lack of knowledge of HIV/AIDs and STI were classified as moderate inequality, while all the other indicators were showing low inequality.

Gap=4.5 Gap=5.3 Gap=21.8 Gap=1.9 Gap=8.8 Gap=8.0

CI=-6.7 CI=-1.3 CI=-6.4 CI=-0.4 CI=-1.0 CI=-1.7

95.3

94.3

94.2

93.6

92.8

92.3

90.6

90.5

90.4

90.3 90.3

90.0

88.7 87.3

100.0 85.5

76.6 71.6

80.0 65.2

61.2

54.8

52.1

51.8

50.8 48.3 60.0 46.8

40.0

8.4

6.6

4.5 4.3 20.0 3.9 0.0 No knowledge of No Knowledge of No knowledge of Discriminatory No comprehensiveNo comprehensive HIV/AIDS MTCT STI attitudes against knowledge of HIV knowledge of HIV PLWH for young (15-24) Poorest Poorer Middle Richer Richest

Figure 44 Prevalence of HIV/AIDS risk factors indicators for women by wealth and their measures of inequality, JPFHS, 2017

For men, there was clear convergence in the prevalence across the wealth quintiles in four indicators, namely, lack of knowledge of STI and comprehensive knowledge of HIV for adult men and young men and adopting discriminatory attitudes against PLWH (figure 45). This is evident in the small gaps among the prevalence of the best and worst performing quintile, which did not exceed 6 points. In contrast, both lack of knowledge of HIV/AIDS and MTCT was negatively related to wealth and they showed relatively large gaps. However, the overall inequality measure showed that only lack of knowledge of HIV/AIDS was classified as moderate inequality, while all the other indicators were classified as low inequality. 34

Gap=10.1 Gap=13.4 Gap=4.7 Gap=5.1 Gap=3.8 Gap=4.5

CI=-15.2 CI=-4.4 CI=-0.1 CI=1.4 CI=-0.8 CI=-1.0

94.3

93.6

92.9

92.3

91.4 91.4

91.2

90.2

89.9

89.8 89.5

100.0 89.1

85.5 85.2

90.0 85.1 68.6

80.0 68.2

67.7

66.7

64.7

63.9 60.6

70.0 60.5 55.7

60.0 51.2 50.0 40.0

30.0

17.1

11.5 10.8 20.0 9.6 10.0 7.0 0.0 No knowledge of No Knowledge of No knowledge of Discriminatory No comprehensiveNo comprehensive HIV/AIDS MTCT STI attitudes against knowledge of HIV knowledge of HIV PLWH for young (15-24) Poorest Poorer Middle Richer Richest

Figure 45 Prevalence of HIV/AIDS risk factors indicators for men by wealth and their measures of inequality, JPFHS, 2017

Among women, except adopting discriminatory attitudes against PLWH, education was negatively related to the other HIV/AIDS risk factors indicators with large gaps ranging between 10.7 points lack of comprehensive knowledge among young women and 30.2 points for no knowledge of STI (figure 46). Adopting discriminatory attitudes against PLWH showed converging prevalence across the different education attainment levels with a gap of only 3.1 points. The overall inequality measure classified lack of knowledge of HIV/AIDS as highly severe inequality, lack of knowledge of STI as moderate inequality and all the other indicators as low inequality.

Gap=24.4 Gap=19.7 Gap=30.2 Gap=3.1 Gap=10.7 Gap=14.1

CI=-23.8 CI=-3.8 CI=-7.7 CI=-0.4 CI=-2.4 CI=-2.0

100.0

98.9

98.2

98.1

96.9

94.9

94.8

91.8

91.7

90.4

90.2

89.1

88.6

87.5 85.9

100.0 84.3

78.3

76.8 70.0

80.0 66.1

55.0

54.4

54.1 50.1 60.0 46.4

40.0 28.1

10.3

7.4 4.5 20.0 3.7 0.0 No knowledge of No Knowledge of No knowledge of Discriminatory No comprehensiveNo comprehensive HIV/AIDS MTCT STI attitudes against knowledge of HIV knowledge of HIV PLWH for young (15-24) No education Primary Preparatory Secondary Higher

Figure 46 Prevalence of HIV/AIDS risk factors indicators for women by education attainment and their measures of inequality, JPFHS, 2017

Similar patterns of the relationship between education and the prevalence of the HIV/AIDS risk factors indicators for women were observed for men (figure 47). Adopting discriminatory attitudes against PLWH showed converging prevalence across the different levels of education with a gap of 5.3 points. Other indicators’ prevalence showed clear negative relationship with education with relatively large gaps. These gaps ranged between 9.8 points for no comprehensive knowledge for young men and 28.7 points for lack of knowledge of STI. Overall inequality measure classified lack of knowledge of HIV/AIDS as severe inequality, lack of knowledge of STI as moderate inequality and other indicators were classified as low inequality.

35

Gap=23.3 Gap=28.7 Gap=19.9 Gap=5.3 Gap=10.3 Gap=9.8

CI=-15.1 CI=-6.2 CI=-2.7 CI=0.6 CI=-1.5 CI=-1.5

98.5

97.5

96.6

95.4

94.6

92.7

92.3

92.0

89.9

88.9

88.7

87.2 86.8

100.0 85.1

84.6

82.3

77.4

73.2

68.6 68.4

80.0 66.9

63.1

62.4 60.8

60.0 48.7

40.0 29.7

14.6

12.7 11.7

20.0 6.4 0.0 No knowledge of No Knowledge of No knowledge of Discriminatry No comprehensive No comprehensive HIV/AIDS MTCT STI attitudes against knowledeg of HIV knowledge of HIV No education Primary PreparatoryPLWHSecondary Higher for young (15-24)

Figure 47 Prevalence of HIV/AIDS risk factors indicators for men by education attainment and their measures of inequality, JPFHS, 2017

Disparities in prevalence of HIV/AIDS risk factors indicators by nationality showed no large difference by nationality (figure 48). Gaps between the best and worst performing nationality was highest for lack of knowledge of STI (11.2 points) followed by lack of knowledge of HIV/AIDS (9.5 points). However, in four indicators(lack of knowledge of STI, adopting discriminatory attitudes against PLWH and comprehensive knowledge of HIV/AIDS for adult and young women), Syrian women showed the highest prevalence. Other nationalities showed the highest prevalence in the knowledge of HIV and MTCT. Overall inequality only classified lack of knowledge of HIV/AIDS as severe inequality, but all the others as low inequality.

Gap=9.5 Gap=3.2 Gap=11.2 Gap=1.2 Gap=7.1 Gap=6.7 ID=10.1 ID=0.4 ID=1.2 ID=0.1 ID=0.6 ID=0.4

120.0

96.5

96.0

92.8

90.9

90.6

89.8

89.6 89.4

100.0 88.9

75.3 65.3

80.0 64.1

53.0 50.5 60.0 49.8

40.0

15.1 9.2

20.0 5.6 0.0 No knowledge of No Knowledge of No knowledge of Discriminatry No comprehensiveNo comprehensive HIV/AIDS MTCT STI attitudes against knowledge of HIV knowledeg of HIV PLWH for young (15-24) Jordanian Syrian Others

Figure 48 Prevalence of HIV/AIDS risk factors indicators for women by nationalities and their measures of inequality, JPFHS, 2017

Among men, disparities in prevalence by nationalities for the HIV/AIDS risk factors indicators showed close and converging prevalence across all indicators (figure 49). The gaps among the best and worst performing nationalities never exceeded 9 points, but the overall inequality measure classified all of indicators as low inequality.

36

Gap=5.3 Gap=8.9 Gap=4.1 Gap=4.5 Gap=5.2 Gap=1.8 ID=3.1 ID=1.2 ID=0.6 ID=0.3 ID=0.4 ID=0.2

120.0

95.5

93.6

92.9

92.8

91.8 91.6

100.0 90.3

87.2

87.1 70.7

80.0 70.0

66.6

66.1 62.5 60.0 57.2

40.0

15.8 11.8 20.0 10.5

0.0 No knowledge of No Knowledge of No knowledge of Discriminatry No comprehensiveNo comprehensive HIV/AIDS MTCT STI attitudes against knowledeg of HIV knowledge of HIV PLWH for young (15-24) Jordanian Syrian Others

Figure 49 Prevalence of HIV/AIDS risk factors indicators for men by nationalities and their measures of inequality, JPFHS, 2017

Only women had comparable prevalence for the HIV related risk factor indicators in 2012. A comparison between the 2012 and 2017 inequality showed that only discriminatory attitudes among PLWH exhibited an increase in inequality across the three stratifiers (table 14). Inequality across the governorates also increased for no knowledge of HIV and for no knowledge of STI. Absence of comprehensive knowledge among young people also showed an increase in inequality across wealth and education.

Table 14 Measures of inequality in HIV/AIDS related risk factors across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017 Gov Wealth Education Indicator 2012 2017 2012 2017 2012 2017 No knowledge of HIV/AIDS 4.5 19.5 -40.6 -6.7 -74.6 -23.8 No Knowledge of MTCT 3.8 3.5 3.2 -1.3 3.9 -3.8 No knowledge of STI 3.7 4.8 -10.5 -6.4 -12.5 -7.7 Discriminatory attitudes against PLWH 0.3 1.4 -0.3 -0.4 -0.2 -0.4 No comprehensive knowledge of HIV for young 1.2 0.7 -0.9 -1.0 -1.3 -2.4 people (15-24) No comprehensive knowledge of HIV 3.1 1.3 -2.5 -1.7 -2.8 -2.0

In brief, table 15 and the investigation of the HIV/AIDS related risk factors for women and men can be summarized as follows:

o All HIV/AIDS risk factors for men and women were classified as very highly prevalent except for the mere knowledge of HIV/AIDS o Inequality is mainly low across all indicators and stratifiers except for the low prevalent indicator of no knowledge of HIV/AIDS. o For the mere knowledge of HIV/AIDS, inequality is severe across governorates, education and nationality, but moderate by wealth for women. o For the mere knowledge of HIV/AIDS, inequality is severe across all stratifiers for men o Moderate inequality is observed for no knowledge of STI by wealth and education for women and by education for me.

37

Table 15 Summary results of HIV/AIDS related risk factors Stratifiers Prevalence Indicator Gov Wealth Education Nationality Women No knowledge of HIV/AIDS (+) (+) (-) (-) No Knowledge of MTCT (-) (-) (+) (+) No knowledge of STI (+) (+) (+) (-) Discriminatory attitudes against PLWH (-) (+) (+) (+) No comprehensive knowledge of HIV for (-) (+) (-) (+) young (15-24) No comprehensive knowledge of HIV (-) (+) (-) (-) Men No knowledge of HIV/AIDS No Knowledge of MTCT No knowledge of STI Discriminatory attitudes against PLWH No comprehensive knowledge of HIV for young (15-24) No comprehensive knowledge of HIV Note: (-) indicates decrease between 2012 and 2017 and (+) indicates increase between 2012 and 2017. For prevalence Moderate Prevalence<20%) High 20%40%

For inequality Low (ID/IC<5%) Moderate (5%

6.3 DOMESTIC VIOLENCE RISK FACTORS Nine indicators were used to explore domestic violence risk factors. Figure 50 shows that women and men agreeing to wife beating for any reason and not seeking help against the spousal violence rank as a very highly prevalent, in which their prevalence exceeds 40%. Also in comparison to their prevalence in 2012, the prevalence of these two indicators increased.

Four indicators fell in the high prevalence category in which their prevalence exceeds 20%. These indicators are experience of any form of spousal violence over the past 12 months, experience of physical violence since age 15 years, ever experience any form of spousal violence and not able to negotiate sexual intercourse.

38

Moderate prevalence High prevalence Very high prevalence

80.0 69.1 70.0 67.2

60.0 46.8

50.0 46.2

34.3 32.9

40.0 31.7 30.1

30.0 25.9

20.8

20.4

14.4 14.1

20.0 12.6 7.0

10.0 2.4 0.0 Ever Experience Experience Experience Ever Not able to Women Women Men (15-50 experience of physical any form of of physical experience negotiate (15-49 never years) violence violence in spousal violence any form of sexual years) sought help agreeing to during the past 12 violence in since age spousal intercourse agreeing to against wife pregnancy months the past 12 15 years violence wife spousal beating for months beating for violence any of the any of the listed listed reason 2012 2017 reason

Figure 50 Prevalence of domestic violence related risk factors in Jordan, JPFHS, 2017

It worth noting that the prevalence of both experience any form of violence in the past 12 months and ever experience any form of spousal violence have declined between 2012 and 2017. Ever experience violence during pregnancy and experience of physical violence in the past 12 months were classified as moderate prevalence in which the prevalence is less than 20%.

Prevalence of the three very high prevalence indicators across the governorates showed that the prevalence of men agreeing to wife beating and women not seeking help against violence exceeds the 40% threshold (figure 51). However, among the different governorates, the gap between the best and worst prevalence is substantially large reaching 50.4 points for men agreeing to wife beating and 22.7 points for not seeking help against violence. For women agreeing to wife beating, the prevalence showed wide variation. The prevalence ranges between 32.5 in Amman and 81.2% in Karak. Despite these large differences, only women agreeing to wife beating is classified as severe inequality while the other two indicators were classified as low inequality.

Gap=48.7 Gap=22.7 Gap=50.4 ID=13.3 ID=4.5 ID=4.7 120.0

100.0 95.3

81.5

81.2

80.3

79.2

78.2

77.7

76.4

75.7 75.7

72.8

72.1

71.3

71.2

68.7

67.9

67.6

67.4

67.0

66.2 66.1

80.0 65.4

62.9

62.5

61.1

60.4

58.8

56.2

52.5

46.0 44.9

60.0 44.8

44.5

41.2 36.5 40.0 32.5 20.0 0.0 Women (15-49 years) agreeing to wife Women never sought help against Men (15-50 years) agreeing to wife beating for any of the listed reason spousal violence beating for any of the listed reason Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Aljoun Karak Tafilh Maan Aquaba

Figure 51 Prevalence of very high prevalence domestic violence related risk factors indicators by governorates and their measures of inequality, JPFHS, 2017

Indicators with high prevalence included four indicators, namely experience of any form of spousal violence in the past 12 month, experience of physical violence since age 15 years, ever experience any 39 form of spousal violence and not able to negotiate sexual intercourse. For not being able to negotiate sexual intercourse, only Tafielh showed a prevalence less than 20% classifying this indicator as moderate prevalence compared to all the other governorates for which this indicator is classified as highly prevalent indicator (figure 52). In contrast, Zarqua showed a prevalence of 43.3% classifying this indicator as very high prevalence for this governorate.

Gap=25.9 Gap=24.8 Gap=26.5 Gap=26.3 ID=11.4 ID=10.1 ID=9.1 ID=4.8 50.0

45.0 43.3

36.1

35.8 34.8

40.0 34.5

33.1

31.9

31.5

31.2

30.9

30.5 29.5

35.0 29.3

28.5

26.7

26.5

26.3

25.7

25.6 24.3

30.0 24.2

23.3

22.7

22.5

21.1

20.7

20.3

20.0 20.0 20.0

25.0 19.0

18.6

17.8

17.0

16.8

15.7

15.3

14.8 14.2

20.0 14.1

13.7

12.7 9.7

15.0 9.6

7.8

7.3 6.4 10.0 5.6 5.0 0.0 Experience any form of Experience of physical Ever experience any form ofNot able to negotiate sexual spousal violence in the past violence since age 15 years spousal violence intercourse 12 months Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Aljoun Karak Tafilh Maan Aquaba

Figure 52 Prevalence of high prevalence domestic violence related risk factors indicators by governorates and their measures of inequality, JPFHS, 2017

For ever experience any form of spousal violence, four governorates (Ajloun, Karak, Tafielh and Aqaba) showed a moderate prevalence lower than the 20%. In contrast, Balqa and Zarqua showed the highest prevalence on this indicator. For experience of physical violence since age 15 years, six governorates (Irbid, Jerash, Ajloun, Karak,Tafielh and Aqaba) showed a prevalence less than 20% and again Balqa and Zarqua showed the highest prevalence for this indicator. The same six governorates that showed the low prevalence of the latter indicators also showed the low prevalence for experience of any form of spousal violence in the last 12 months with one more governorate (Marfaq). Similar to the previous indicators, Balqa showed the highest prevalence on this indicator followed by Zarqua.

The above differences in the prevalence across the governorates produced large gaps exceeding 24 points. Figure also shows that as the prevalence of the indicators start declining and the performance of different governorates start to differ, the inequality in the distribution of the indicators begins to increase. Accordingly, the measure of inequality classified as severe inequality, ever experience any form of spousal violence as moderate inequality and not able to negotiate sexual intercourse as low inequality.

Moderate prevalence indicators included two indicators, namely ever experience violence during pregnancy and experience of physical violence in the past 12 months. Figure 53 shows that the prevalence of ever experience violence during pregnancy was less than 5% across all governorates with a gap between the worst and best performing governorates 3.3 points. At this low prevalence, the differences among the governorates placed this indicator in the severe inequality category. For experience of physical violence in the past 12 months, the different governorates showed a wide range of prevalence with the lowest prevalence registered by Karak (3%) and the highest prevalence exhibited by Balqa (22.9%) placing this indicator as highly prevalent in this governorate.

40

Gap=3.3 Gap=19.9 25.0 ID=13.6 22.9 ID=13.2 19.5 20.0 17.6 15.9 15.7 15.0 12.6 11.9 11.2 9.7 10.0 7.7

5.0 2.7 3.5 3.3 3.1 3.0 2.3 1.4 1.6 2.0 1.3 2.1 1.6 0.2 1.0 0.0 Ever experience violence during pregnancy Experience of physical violence in the past 12 months Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Aljoun Karak Tafilh Maan Aquaba

Figure 53 Prevalence of moderate prevalence domestic violence related risk factors indicators by governorates and their measures of inequality, JPFHS, 2017

Across the wealth quintiles, the prevalence of the two indicators of women not seeking help against violence and men agreeing to wife beating showed an increase in the middle three quintiles compared to the poorest and richest quintile with small differences among them (figure 54). The indicator of women agreeing to wife beating showed a clear gradient with the poor women agreeing more to wife beating. These two patterns resulted in classifying women agreeing to wife beating as severe inequality, while the other two indicators were classified as low inequality

Gap=29.5 Gap=16.5 Gap=6.9

CI=-12.8 CI=-1.1 CI=-0.4

72.4

71.8

71.5

70.9

69.8

69.6

66.7 65.5

80.0 65.1

60.4

55.3 54.5

60.0 45.1 38.4

40.0 30.9 20.0 0.0 Women (15-49 years) agreeing to Women never sought help against Men (15-50 years) agreeing to wife wife beating for any of the listed spousal violence beating for any of the listed reason reason Poorest Poorer Middle Richer Richest

Figure 54 Prevalence of very high prevalence domestic violence related risk factors indicators by wealth and their measures of inequality, JPFHS, 2017

For the high prevalence indicators, Figure 55 shows clearly the gradient in the relationship between these indicators and wealth. For the three indicators, experience of any form of spousal violence in the past 12 month, experience of physical violence since age 15 years, and ever experience any form of spousal violence, the recurrent pattern is similar high prevalence for the first two quintile that exceeds 20% for being a highly prevalent. This is followed with almost same moderate prevalence for the other three wealth quintiles that is less than 20 and placing these indicators as moderate prevalence for these wealth quintiles. For the indicator not able to negotiate sexual intercourse, there was a clear gradient from the poorest to the richest with the poorest registering a prevalence of 40% classifying this indicator as a very high prevalence for this quintile.

41

Gap=6.0 Gap=7.7 Gap=7.9 Gap=15.3 CI=-5.9 CI=-8.1 CI=-5.5 CI=-9.4

45.0 40.0 37.9

40.0 33.6 30.0

35.0 29.5

28.4

25.6

24.7

24.3

24.0 23.7

30.0 23.6

23.2 22.1

25.0 19.3

18.3

18.0

17.9 17.8 20.0 17.7 15.0 10.0 5.0 0.0 Experience any form of Experience of physical Ever experience any form of Not able to negotiate sexual spousal violence in the past violence since age 15 years spousal violence intercourse 12 months Poorest Poorer Middle Richer Richest

Figure 55 Prevalence of high prevalence domestic violence related risk factors indicators by wealth and their measures of inequality, JPFHS, 2017

These two patterns resulted almost equal gaps for the first three indicators and a large gap for the last one (figure 56). However, the inequality measure classified experience of any form of spousal violence in the past 12 month and ever experience any form of spousal violence as low inequality and experience of physical violence since age 15 years and not able to negotiate sexual intercourse as moderate inequality.

The two moderate prevalence indicators show two different pattern with wealth quintiles (figure 56). The first is a curved relationship between wealth and experience of violence during pregnancy through which the poorest and richest quintiles showed high prevalence, while the middle three quintiles showed low prevalence. Despite low prevalence and the low gap between the lowest and highest prevalence (1.9 points) for this indicator, the measure of inequality classified this indicator as moderate inequality. In contrast, experience of physical violence in the last 12 month was negatively related to wealth with a gap of 5.1 points and was also classified as moderate inequality.

Gap=1.9 Gap=5.1 20.0 CI=-7.5 CI=-6.8 16.5 16.8 13.8 15.0 12.7 11.7 10.0

5.0 3.5 2.2 1.6 2.2 2.4 0.0 Ever experience violence during pregnancy Experience of physical violence in the past 12 months Poorest Poorer Middle Richer Richest

Figure 56 Prevalence of moderate prevalence domestic violence related risk factors indicators by wealth and their measures of inequality, JPFHS, 2017

Education showed a systematic pattern with the prevalence of the very high prevalence indicators (figure 57). With increases in educational attainment, the prevalence of women agreeing to wife beating and the prevalence of not seeking help against violence decline. In contrast, the prevalence of men agreeing to wife beating increases with increases in educational attainment.

42

Gap=19.5 Gap=15.8 Gap=16.9 CI=-7.4 CI=-1.1 CI=0.5

90.0 82.3 72.4

80.0 71.5

67.7

66.8

66.5

65.2 64.8

70.0 64.5

58.3

55.5 54.1 60.0 54.1

50.0 47.6 38.8 40.0 30.0 20.0 10.0 0.0 Women (15-49 years) agreeing to Women never sought help against Men (15-50 years) agreeing to wife wife beating for any of the listed spousal violence beating for any of the listed reason reason No education Primary Preparatory Secondary Higher

Figure 57 Prevalence of very high prevalence domestic violence related risk factors indicators by education attainment and their measures of inequality, JPFHS, 2017

However, the overall inequality measure revealed that only women agreeing to wife beating was classified as moderate inequality, while the other two indicators were classified as low inequality.

Except for not being able to negotiate intercourse, all high prevalence indicators show a semi gradient patterns with education (figure 58). In this pattern women with no education show lower prevalence than those with primary education. However, the gradual decline in prevalence starts from primary to higher education. For the indicator not able to negotiate intercourse the gradient was clear for no education to higher education, with those with education attainment less than secondary scoring a prevalence that exceeds 40% classifying this indicator as very high prevalence for them.

Gap=9.5 Gap=25.6 Gap=16.2 Gap=28.9 CI=-8.7 CI=-14.0 CI=-10.7 CI=-10.3

60.0 55.3

50.0 45.3

40.3 35.7

40.0 33.3

31.2

29.9

28.5

27.9

27.4

26.4

25.6

25.3 23.4

30.0 23.4

21.8

21.6

19.5 16.1

20.0 14.3 10.0 0.0 Experience any form of Experience of physical Ever experience any form ofNot able to negotiate sexual spousal violence in the past violence since age 15 years spousal violence intercourse 12 months No education Primary Preparatory Secondary Higher

Figure 58 Prevalence of high prevalence domestic violence related risk factors indicators by education attainment and their measures of inequality, JPFHS, 2017

The above patterns resulted in gaps ranging from 9.5 points for experience of any form of violence in the past 12 months to 28.9 points for not able to negotiate sexual intercourse. The measure of inequality for the distribution of the indicators across wealth quintile classified experience any form of spousal violence as moderate inequality but all the other three were classified as severe inequality.

Moderate prevalence indicators also showed semi gradient patterns with education with two exceptional patterns (figure 59). In the first pattern, the downward decline in the prevalence starts

43 with primary education for experience of violence during pregnancy. For the second pattern, primary educated women break the declining pattern for experience of physical violence in the last 12 months.

Gap=4.3 Gap=11.1 CI=-29.0 CI=-11.8 25.0 21.7 20.3 20.0 16.4 14.8 15.0 10.6 10.0 4.6 5.2 3.5 2.6 5.0 0.9 0.0 Ever experience violence during pregnancy Experience of physical violence in the past 12 months

No education Primary Preparatory Secondary Higher Figure 59 Prevalence of moderate prevalence domestic violence related risk factors indicators by education attainment and their measures of inequality, JPFHS, 2017

Within this latter pattern, women with no education and those with preparatory education show prevalence that exceeds 20% placing this indicator as a high prevalence for these two education categories. The gaps were relatively large for the two indicators and the inequality measure classified them as highly severe unequal for experience of violence during pregnancy and moderately unequal for experience of violence in the past 12 months.

Syrians are the most vulnerable group across the two indicators of women agreeing to wife beating and no seeking help against violence (figure 60). In contrast, Jordanians showed the highest prevalence of men agreeing to wife beating. Despite the large gaps for the two indicators of women agreeing to wife beating and no seeking help against violence (18.9 and 10.3 points, respectively) and the small gap for men agreeing to wife beating, the overall measure of inequality classified all indicators as low inequality.

Gap=18.9 Gap=10.3 Gap=4.2

ID=2.7 ID=2.1 ID=0.5 89.6

100.0 86.3

79.3

69.5 66.9

80.0 65.3 60.9

60.0 45.0 42.0 40.0 20.0 0.0 Women (15-49 years) agreeing to Women never sought help against Men (15-50 years) agreeing to wife wife beating for any of the listed spousal violence beating for any of the listed reason reason Jordanian Syrian Others

Figure 60 Prevalence of very high prevalence domestic violence related risk factors indicators by nationalities and their measures of inequality, JPFHS, 2017

For the high prevalence indicators, there was clear gradient in which other nationalities are commonly exhibiting the highest prevalence followed by Syrians and then Jordanians (figure 61). This gradient showed a prevalence of more than 40% for not able to negotiate sexual intercourse for other nationalities and Syrians and placing this indicator as very high prevalence for these two groups of the population.

44

Gap=2.1 Gap=12.4 Gap=9.3 Gap=13.0 ID=0.3 ID=4.0 ID=2.0 ID=4.4 50.0 44.1 44.3 34.6 40.0 32.2 31.3 27.0 30.0 23.7 25.3 20.4 19.8 21.9 19.8 20.0 10.0 0.0 Experience any form of Experience of physical Ever experience any form Not able to negotiate sexual spousal violence in the past violence since age 15 years of spousal violence intercourse 12 months Jordanian Syrian Others

Figure 61 Prevalence of high prevalence domestic violence related risk factors indicators by nationalities and their measures of inequality, JPFHS, 2017

This gradient produced a wide range of gaps ranging from 2.1 points for experience of any form of spousal violence in the past 12 months to 13 points for not able to negotiate sexual intercourse. However, the measure of inequality classified all indicators as low inequality.

The previous pattern observed for the highly prevalent indicators was also observed for the moderate prevalence indicators (figure 62). Other nationalities showed the highest prevalence in the two indicators followed by Syrian and Jordanian. Experience of violence during pregnancy showed a large gap (4.9 points) compared to it prevalence and was classified as severe inequality. Experience of physical violence in the past 12 months showed a gap of 5.4 points and was classified as low inequality.

Gap=4.9 Gap=5.4 ID=13.8 ID=2.8 25.0 19.3 20.0 16.1 13.9 15.0

10.0 6.9 3.6 5.0 2.0 0.0 Ever experience violence during pregnancy Experience of physical violence in the past 12 months

Jordanian Syrian Others

Figure 62 Prevalence of moderate prevalence domestic violence related risk factors indicators by nationalities and their measures of inequality, JPFHS, 2017

The comparisons between the inequality measures of violence against women risk factors between the two year 2012 and 2017 revealed that there was an increase in the inequality measures across the governorates for all indicators (table 16). For wealth, there was a decrease in the inequality for all indicators with two exceptions, namely women agreeing to wife beating for any of the listed reasons and women never sought help against spousal violence. For education, there was an increase in the inequality for all indicators except for experience of any form of spousal violence in the past 12 months.

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Table 16 Measures of inequality in domestic violence related risk factors across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017 Gov Wealth Education Indicator 2012 2017 2012 2017 2012 2017 Experience of physical violence in the past 12 months 8.5 13.2 -12.5 -6.8 -11.0 -11.8 Any form of spousal violence in the past 12 months 6.0 11.4 -15.1 -5.9 -8.9 -8.7 Experience of physical violence since 15 year of age 4.9 10.1 -9.7 -8.1 -9.6 -14.0 Any form of spousal violence in the ever 3.9 9.1 -9.4 -5.5 -8.9 -10.7 Agree to wife beating for at least one reason women 15-49 6.0 13.3 -4.7 -12.8 -4.3 -7.4 years Women never sought help against spousal violence 3.1 4.5 1.1 -1.1 0.9 -1.1

In sum, table 17 and the investigation of the domestic violence related risk factors can be summarized as follows:

 Between 2012 and 2017, there was a general decrease in violence against women except for experience of physical violence since 15 years of age and experience of spousal violence.  Inequality is severe by governorates and education in many low and moderate prevalence indicators for domestic violence risk factors, but inequality was moderate for these types of indicators across wealth.  For the very highly prevalent indicators, except only for women agreeing to wife beating, inequality was low. For women agreeing to wife beating, inequality was severe for governorates and wealth, moderate for education and low for nationality.  Inequality has been increasing for the majority of the indicators across the governorates and education, but decreasing by wealth.  Individuals in the poor quintiles (poorest and poorer) and those with low educational attainment (no education and primary) are the most vulnerable to domestic violence risk factors compared to other social groups.

Table 17 Summary results of domestic violence related risk factors Stratifiers Indicator Prevalence Gov Wealth Education Nationality Ever experience violence during pregnancy (-) (+) (-) (+) Experience of physical violence in the past 12 months (-) (+) (-) (+) Experience any form of spousal violence in the past 12 (-) (+) (-) (-) months Experience of physical violence since age 15 years (+) (+) (-) (+) Ever experience any form of spousal violence (+) (+) (-) (+) Not able to negotiate sexual intercourse Women (15-49 years) agreeing to wife beating for any (-) (+) (+) (+) of the listed reason Women never sought help against spousal violence (-) (+) (+) (+) Men (15-50 years) agreeing to wife beating for any of the listed reason Note: (-) indicates decrease between 2012 and 2017 and (+) indicates increase between 2012 and 2017. For prevalence Moderate Prevalence<20%) High 20%40%

For inequality Low (ID/IC<5%) Moderate (5%

6.4 CONCLUDING REMARKS  Twenty-one of the twenty- seven indicators of reproductive health indicators were at least 20% prevalent health indicators. Out of those twenty- one, 13 indicators were very high

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prevalence with a prevalence greater than 40%. Ten of these 13 indicators were related to HIV/AIDS related risk factors and 3 in the domestic violence risk factors.  The majority of the indicators showed improvements between 2012 and 2017.  Inequality was wide spread by education and wealth followed by the governorates and nationality. The severity of inequality was high by education followed by wealth and governorates o Twelve indicators were severely unequal by education and four were moderately unequal. o Five indicators were severely unequal by wealth, while 11 indicators were moderately unequal o Across governorates, 9 indicators of the investigated indicators showed severe inequality and 3 were moderately unequal. o For nationality, only five indicators were severely unequal and two were moderately unequal.  Inequality has been increasing across the governorates and education but decreasing by wealth.  Individuals in the poorest or poorer wealth quintiles, those with no education and Syrian are the most vulnerable social groups showing the highest prevalence in the majority of the indicators

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Table 18 summary measures of reproductive health

STratifiers Prevalence Indicator Gov Wealth Education Nationality Adolescent child bearing (<18 years) (+) (+) (+) (-) Women who does not own health care (-) (-) (+) (+) decision Early marriage (<18 years) (+) (+) (+) (-) Multiparity (5+ children) (-) (+) (+) (+) Consanguinity (-) (+) (-) (+) Risky birth intervals (23 months) (-) (+) (-) (-) No knowledge of HIV/AIDS (women) (+) (+) (-) (-) No Knowledge of MTCT (women) (-) (-) (+) (+) No knowledge of STI (women) (+) (+) (+) (-) Discriminatory attitudes against PLWH (-) (+) (+) (+) (women) No comprehensive knowledge of HIV for (-) (+) (-) (+) young (15-24) (women) No comprehensive knowledge of HIV (-) (+) (-) (-) (women) No knowledge of HIV/AIDS (men) No Knowledge of MTCT (men) No knowledge of STI (men) Discriminatory attitudes against PLWH (men) No comprehensive knowledge of HIV for young (15-24) (men) No comprehensive knowledge of HIV (men) Ever experience violence during pregnancy (-) (+) (-) (+) Experience of physical violence in the past 12 (-) (+) (-) (+) months Experience any form of spousal violence in (-) (+) (-) (-) the past 12 months Experience of physical violence since age 15 (+) (+) (-) (+) years Ever experience any form of spousal violence (+) (+) (-) (+) Not able to negotiate sexual intercourse Women (15-49 years) agreeing to wife beating (-) (+) (+) (+) for any of the listed reason Women never sought help against spousal (-) (+) (-) (+) violence Men (15-50 years) agreeing to wife beating for any of the listed reason For prevalence Moderate Prevalence<20%) High 20%40%

For inequality Low (ID/IC<5%) Moderate (5%

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7 HEALTH SECTOR PERFORMANCE AND CAPACITY:

The health system is an important determinant of the health and health inequality. According to the conceptual framework adopted in this study the health system is an intermediary social arrangement. The fairness of the health system is judged by its ability to respond to the differentiated health needs of the different social groups. The current section is dedicated to exploration of the health sector and its ability to meet the required health needs in Jordan. In investigating health sector, the indicators for the health sector performance and capacity were identified in WHO framework for monitoring and evaluation of health systems strengthening (2009)22. health sector indicators were classified in to health sector performance and health sector capacity. JPFHS 2017 offers an extensive and large number of indicators that can assess the health sector performance in Jordan with particular focus on maternal and reproductive health and child health. In the current work, health sector performance indicators incorporate indicators that are mainly the responsibility of the health sector. However, it should be noted that these indicators also are not solely the responsibility of the health sector since other sectors and factors might influence these indicators and hence these sectors are partners and major stakeholders in improving these indicators. For example, absence of postnatal care can be attributed to ill performance of the health sector but it can also be attributed to cultural factors. Overall, the JPFHS 2017 offered 34 indicators for health sector performance. To allow proper exploration of their priorities and inequality priorities, these indicators were further classified into 6 main subcategories according to their area of performance, namely. Infant health, child health and nutrition, prenatal care, delivery and postnatal care, family planning and other reproductive health.

In contrast to the large number of indicators exploring health sector performance, only limited number of indicators assessed health sector capacity and they were all related to women facing difficulties in accessing health services.

7.1 HEALTH SECTOR PERFORMANCE 7.1.1 Health sector performance for infant health Four indicators are explored health sector performance for infant health. These are related to breastfeeding practices and receiving postnatal care. Figure 63 shows that all health performance indicators have improved significantly between 2012 and 2017. Only exception is the percentage of infant who were not breastfed, which increased during the same period from 6.9 in 2012 to 8.3 in 2017. It also important to note that except for the no breastfeeding, the other three indicators declined from being a high prevalent health indicator in 2012 to being moderate prevalent in 2017.

40.0 32.4 30.0 25.3 20.8 17.4 20.0 13.1 14.1 6.9 8.3 10.0 0.0 No breastfeeding No postnatal care for child No postnatal check during No breastfeeding within 1 the first 2 days after birth day of birth

2012 2017

Figure 63 Prevalence of infant health HS performance indicators in Jordan, JPFHS, 2012 & 2017

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Despite the fact that all four indicators for health sector performance for infant health exhibited moderate prevalence at the national level, their prevalence exceeded the 20% threshold for being highly prevalent health indicators in some governorates (figure 64). This is observed for no breastfeeding within the first day of birth in Zarqua, Madaba and Ajloun. For no postnatal care in the first two days of birth, the governorates of Madaba, Mafraq, Karak, Maan, and Aquaba showed prevalence that exceeded 20% classifying this indicator as high prevalence indicator for these governorates. For no postnatal care for the child, Madaba, Mafraq, Karak, Maan and Aquaba had high prevalence approaching or exceeding the 20% threshold for a high prevalence classification. For the no breastfeeding, almost all governorates showed similar prevalence of less than 10%, but four governorate stand out as they exhibit a prevalence greater than 10% namely Zarqua, Mafraq, Tafielh and Maan.

Gap=8.1 Gap=14.8 Gap=16.9 Gap=11.5 ID=11.5 ID=13.5 ID=13.7 ID=9.0

30.0

26.3

24.6

24.5

23.9 23.9

23.6

23.4 23.1

25.0 22.1

21.5

21.3

20.8

19.6

18.4

18.3

18.0 17.2

20.0 17.2

15.4

14.5

13.7

13.6 13.6

13.4

13.1

13.0 12.4

15.0 12.3

11.7

11.6 11.6

11.2

10.8

10.4

10.1

9.9

9.7

9.4

9.3

9.0

8.9 8.9

8.8

8.7 8.7 8.6

10.0 8.2 5.5 5.0 0.0 No breastfeeding No postnatal care for child No postnatal check within theNo breastfeeding within 1 day first 2 days of birth of birth

Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Aljoun Karak Tafilh Maan Aquaba

Figure 64 Prevalence of infant health HS performance indicators by governorates and their measures of inequality, JPFHS, 2017

The above differences generated gaps ranging between 8.1 points for no breastfeeding and 16.9 points for no postnatal care within the first two days of birth. Inequality for the indicators distribution across the governorates showed that the three indicators (no postnatal care for child, no postnatal care within the first two days of birth and no breastfeeding were classified as severe inequality, while on breastfeeding was classified as moderate inequality.

For wealth quintiles, Figure 65 shows a repeated pattern across the four indicators. This pattern implies no large differences among the five wealth quintiles but the two worst performing quintiles are the poorest and richer quintiles. For breastfeeding related indicators, the worst performing wealth quintile is the richer. Also for these two indicators, the richest showed very low prevalence compared to all the other quintiles.

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Gap=5.2 Gap=7.0 Gap=7.3 Gap=7.7 CI=-3.4 CI=-8.0 CI=-7.7 CI=-3.5

25.0

19.1

18.8

18.6

17.5 17.4

20.0 17.4

14.2

12.7

12.6

12.3

12.2

11.6 11.4

15.0 11.3

10.5

10.3

9.3 8.0

10.0 7.5 5.1 5.0 0.0 No breastfeeding No postnatal care for child No postnatal check within No breastfeeding within 1 the first 2 days of birth day of birth Poorest Poorer Middle Richer Richest Figure 65 Prevalence of infant health HS performance indicators by wealth and their measures of inequality, JPFHS, 2017

For the postnatal related indicators it was the poorest quintile that showed the worst prevalence with a large difference from all other wealth quintiles (figure 74). For these two indicators, the richest showed the best performance but the differences compared to the others was not large. Gaps due to these differences was relatively small. The inequality of these indicators across the wealth quintile showed high concentration among the poor but the magnitude of this inequality was low for breastfeeding related indicators, but moderate for the no postnatal related indicators.

Differences in the prevalence of the four health sector performance for infant health showed systematic gradient for the postnatal related indicators where women with no education are suffering more from the ill performance of the health sector compared to others(figure 66). Women with no education showed the highest prevalence and exceeded the 20% threshold for being a high prevalence indicator. Women with primary education comes in the next place with prevalence exceeding or approaching the 20% threshold placing them as a high prevalence indicator for this group. The breastfeeding indicators has their own pattern in which the primary educated women were the worst performing group followed by the those with secondary and higher education. Women with no education and those with preparatory educated women were the best performing educational group on these two indicators.

Gap=5.0 Gap=18.8 Gap=18.9 Gap=8.6 CI=1.8 CI=-10.1 CI=-8.9 CI=3.0 35.0 30.0 31.2 30.0 20.9 25.0 19.7 20.6 17.818.3 20.0 17.1 17.3 13.4 15.0 10.8 12.411.2 12.3 12.0 12.0 8.3 8.6 10.0 5.8 6.2 5.0 0.0 No breastfeeding No postnatal care for child No postnatal check within No breastfeeding within 1 the first 2 days of birth day of birth No education Primary Preparatory Secondary Higher

Figure 66 Prevalence of HS performance for infant health indicators by education attainment and their measures of inequality, JPFHS, 2017

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The above difference has contributed to small gaps for the breastfeeding related indicators and large gaps for the postnatal related indicators. Inequality across the educational attainment was classified as low inequality for the breastfeeding related indicators with high concentration among the rich not the poor. For the postnatal related indicators, they showed severe inequality for no postnatal care and moderate for no postnatal care within the first two days with high concentration among the poor.

Similar to wealth and education, both the breastfeeding related indicators and the postnatal related indicators have their own patterns (figure 67). For the postnatal car, Syrian and the other nationalities were the worst performing groups with prevalence greater than 20% placing these two indicators as priorities for these two groups. For the breastfeeding related indicators, Jordanian and other nationalities were the worst performing group but their prevalence was classified as moderate prevalence.

Gap=2.7 Gap=9.2 Gap=8.5 Gap=3.3 ID=3.3 ID=8.9 ID=7.9 ID=2.7 25.0 20.4 20.9 21.3 20.9 17.9 20.0 16.7 14.6 15.0 11.7 12.8 9.2 8.8 10.0 6.5 5.0

0.0 No breastfeeding No postnatal care for child No postnatal check within No breastfeeding within 1 the first 2 days of birth day of birth Jordanian Syrian Others

Figure 67 Prevalence of HS performance for infant health indicators by nationalities and their measures of inequality, JPFHS, 2017

Postnatal related indicators showed relatively large gaps and were classified as moderate inequality. For the breastfeeding related indicators, the gaps were relatively small and the inequality among these groups was classified as low inequality.

Although all indicators of health sector performance for infant health improved between 2012 and 2017, table 19 shows that inequalities have changed for all indicators and across all stratifiers. The figure shows that inequality across the governorates has decreased between 2012 and 2017. For the wealth, the inequality changed direction from being concentrated among the rich to being concentrated among the poor. For educational attainment, postnatal related indicators showed an increase in inequality, while for the breastfeeding related indicators, there was a decrease in the inequality.

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Table 19 Measures of inequality in infant health HS performance indicators across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017 Gov Wealth Education Indicators 2012 2017 2012 2017 2012 2017 No breastfeeding 11.5 11.5 5.2 -3.4 -7.6 1.8 No postnatal care for child 24.6 13.2 2.9 -8.0 -1.3 -10.1 No postnatal check within the first 2 days 21.7 13.7 2.4 -7.7 -2.4 -8.9 of birth No breastfeeding within 1 day of birth 7.4 9.0 8.5 -3.5 4.1 3.0 In brief, table 20 and the investigation of the health sector performance for infant health can be summarized as follows:

 All indicators are classified as high prevalence.  Governorates show severe inequality across all indicators except for no breastfeeding within the first day  Breastfeeding related indicators showed low inequality across wealth, education and nationality  Postnatal related indicators were moderately unequal across wealth, education and nationality and lack of postnatal care for child was severely unequal by education.  Residents of Madaba and Mafraq, individual from the poorest quintile, with no education and Syrians were the most vulnerable social groups in postnatal care  For breastfeeding, the most vulnerable social groups were those from the richer wealth quintile, primary educated and Jordanians.

Table 20 Summary results of health sector performance for infant health Stratifiers Prevalence Indicator Gov Wealth Education Nationality No breastfeeding (+) (0) (-) (-) No postnatal care for child (-) (-) (+) (+) No postnatal check during the first 2 (-) (-) (+) (+) days after birth No breastfeeding within 1 day of birth (-) (+) (+) (-) Note: (-) indicates decrease between 2012 and 2017 and (+) indicates increase between 2012 and 2017. For prevalence Moderate Prevalence<20%) High 20%40%

For inequality Low (ID/IC<5%) Moderate (5%

7.1.2 Health sector performance for child health Health sector performance for child health was assessed by 8 indicators. These indicators relate to receiving nutritional supplements, health seeking behavior and knowledge and receiving vaccinations.

Figure 68 reveals that prevalence of receiving nutritional supplements and the health seeking behavior fall in the very high and high prevalence categories in which the prevalence exceeds 40% and 20%, respectively. This is followed by vaccination and knowledge of ORS, which fall in the moderate prevalence category with a prevalence <20%.

Figure 68 also shows that while the prevalence of the very highly and highly prevalent indicators have either decreased or stabilized, all the moderate prevalence indicators experienced an increase in the prevalence. The prevalence was doubled for three of the four indicators in this category.

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Moderate prevalence High prevalence very high prevalence

100.0 95.9 89.0 90.0 87.3

80.0 72.5 70.0

60.0 45.6

50.0 44.3 31.6 40.0 31.2

30.0

19.5

17.5 14.9

20.0 14.3

8.0

7.0 6.9

10.0 0.3 0.0 Not receiving Not receiving No knowledge Not receiving Children with Children with Not receiving Not receiving all basic any age of ORS all age fever not diarrhea not vitamin A iron vaccination appropriate appropriate seeking seeking supplement supplement 12-23 months vaccination vaccination treatment or treatment or (6-59 months) (6-59 months) 12-23 months 12-23 months advise advice 2012 2017

Figure 68 Prevalence of HS performance for child health indicators in Jordan, JPFHS, 2012 & 2017 Investigation of differences across the governorates shows that for receiving supplements exceeded the 40% threshold for all governorates with no large differences among them (figure 69). This places these indicators as very highly prevalent in for all governorates. For the prevalence of health seeking behaviors, all the governorates exceeded the 20% threshold for being highly prevalent in all governorates.

However, for health seeking behavior for diarrhea, the prevalence exceeded the 40% for 10 of governorates and only Karak and Tafielh showed a prevalence >30%. For health seeking behavior for fever, the prevalence in four governorates (Karak, Tafielh, Maan and Aqaba) exceeded the threshold of 40% placing it as very highly prevalent in these governorates, while this indicator was classified as highly prevalent in all the other governorates.

For vaccination and knowledge of ORS indicators, the prevalence for almost all the governorates fall below the 20% threshold placing these indicators as moderate prevalence. However, the prevalence of Maan and Aqaba for all these indicators exceeded or approached the 20% threshold placing these indicators as highly prevalent in these governorates. In addition, the prevalence of knowledge of ORS and not receiving age appropriate vaccination exceeded the 20% threshold for Madaba and Mafraq classifying these indicators as highly prevalent in these governorates.

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Gap=18.3 Gap=26.8 Gap=19.7 Gap=29.0 Gap=35.1 Gap=20.9 Gap=18.9 Gap=16.5

ID=14.3 ID=6.9 ID=9.3 ID=6.0 ID=9.5 ID=3.2 ID=2.2 ID=2.9

96.3

96.2 95.6

100.0 95.3

91.2

90.2

88.0

87.9 87.1

90.0 82.6

80.6

80.1

77.8 77.8

76.7

76.2 72.3

80.0 * 71.7

64.6 63.7

70.0 61.7 54.9

60.0 53.8

50.2

49.8

48.5

47.2

45.7

44.5

43.3 43.1

50.0 42.1

38.4

35.9

34.4

34.0 33.7

40.0 33.2

29.9

27.6

26.6

24.7

24.3 24.3 22.7

30.0 22.3

20.9

20.7

20.2

19.8

19.1

19.0

18.9

18.0

17.1

16.7

15.2

14.2

14.0

13.1

13.0

12.6 12.1

20.0 12.1

10.6

10.4

9.9

9.5

9.3

8.9 8.9

8.3

6.6

6.2

5.1

4.6

3.0

2.8 2.7 10.0 2.2 0.0 Not receiving Not receiving No knowledge Not receiving Children with Children with Not receiving Not receiving any age all basic of ORS all age fever not diarrhea not vitamin A iron appropriate vaccination appropriate seeking seeking supplement supplement vaccination 12-23 months vaccination treatment or treatment or (6-59 months) (6-59 months) 12-23 months 12-23 months advise advice

Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Aljoun Karak Tafilh Maan Aquaba * calculated for <25 cases Figure 69 Prevalence of HS performance for child health indicators by governorates and their measures of inequality, JPFHS, 2017

The above differences produced large gaps ranging between 16.5 points for not receiving iron supplement to 29 points for not receiving age appropriate vaccination. However, the overall inequality assessment of the distribution of these indicators across the governorates showed that all very highly prevalent indicators showed low inequality. All the other indicators, with the exception of not receiving any age appropriate vaccination showed moderate prevalence. Not receiving any age appropriate vaccination showed severe inequality.

Differences in health sector performance for child health across the wealth quintiles revealed small differences among these quintiles with a gradient overburdening the lower wealth quintiles with more ill performance of the health sector (figure 70). The only exception to this pattern is the positive association between not receiving all age appropriate vaccination and wealth. Another two exceptions are the richest quintile showing the highest prevalence of not receiving all basic vaccination for compared to other quintiles and richer quintile showing the lowest prevalence in health seeking behavior for diarrhea.

The above patterns showed different gaps that ranged between 4.7 points in not receiving all basic vaccinations and 24 points for health seeking behavior for diarrhea. However, the assessment of the overall inequality in the distribution of these indicators across the wealth quintile revealed that only three indicators, namely not receiving any vaccination, no knowledge of ORS and health seeking behavior for fever show moderate inequality, while all the others show low inequality.

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Gap=5.4 Gap=4.7 Gap=8.4 Gap=8.3 Gap=16.3 Gap=24.0 Gap=6.8 Gap=15.8 CI=-7.3 CI=0.7 CI=-8.5 CI=3.8 CI=-6.8 CI=-3.8 CI=-1.1 CI=-2.8

100.0 92.1

88.7 88.3

90.0 83.3

76.3

74.5 73.8

80.0 73.6 70.0 70.0 67.7

60.0 54.7 50.1

50.0 45.4

38.4

35.8

35.0 32.1

40.0 30.7

26.4

24.6 23.7

30.0 20.8

19.6 19.6

19.5

17.5

16.3

15.8

15.5

15.3 15.3

15.2

14.4 13.2

20.0 12.8

9.3

7.5

7.3 6.7 10.0 3.9 0.0 Not receiving Not receiving No Not receiving Children with Children with Not receiving Not receiving any age all basic knowledge of all age fever not diarrhea not vitamin A iron appropriate vaccination ORS appropriate seeking seeking supplement supplement vaccination 12-23 months vaccination treatment or treatment or (6-59 months)(6-59 months) 12-23 months 12-23 months advise advice Poorest Poorer Middle Richer Richest

Figure 70 Prevalence of HS performance for child health indicators by wealth and their measures of inequality, JPFHS, 2017

Except for the prevalence of health seeking behavior for fever, education was found to be positively related to all indicators of health sector performance for children (figure 71). However, women with no education are overburdened with the ill performance of the health system with regard to vaccinations where the differences between this group and the other educational attainment are large. The prevalence nutrition supplement indicators for all wealth quintiles exceeded 40% placing them as very highly prevalent for all the whole population.

Gap=31.9 Gap=42.0 Gap=28.1 Gap=38.3 Gap=12.8 Gap=9.8 Gap=12.0 Gap=14.3

CI=-10.1 CI=-0.8 CI=-15.9 CI=-1.5 CI=-6.9 CI=-2.7 CI=-0.5 CI=-1.9

98.6 92.2

100.0 92.1

87.4 84.3

90.0 83.8

75.4

72.3 72.3 80.0 71.7

70.0

53.5

52.7 52.7

60.0 49.1

45.3 43.7

50.0 41.5

36.8 36.8

35.9 35.0

40.0 29.0

24.1

24.0 23.7

30.0 21.8

16.6

16.3

15.8

15.4

14.4

13.4

12.4 11.8

20.0 10.7

6.4

6.3

4.0 0.0 10.0 0.0 0.0 Not receiving Not receiving No Not receiving Children with Children with Not receiving Not receiving any age all basic knowledge of all age fever not diarrhea not vitamin A iron appropriate vaccination ORS appropriate seeking seeking supplement supplement vaccination 12-23 months vaccination treatment or treatment or (6-59 months)(6-59 months) 12-23 months 12-23 months advise advice

No education Primary Preparatory Secondary Higher

Figure 71 Prevalence of HS performance for child health indicators by education attainment and their measures of inequality, JPFHS, 2017

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For health seeking behavior, the prevalence for all wealth quintiles exceeded the 20% threshold indicating it as a highly prevalent for the whole population. Women with no education exceeded the 20% threshold for all the remaining indicator placing them as high prevalence for this group. Primary educated women had no knowledge of ORS and not receiving all age appropriate vaccination as high prevalence for this group

Gaps among the worst and best performing educational groups were large for the vaccination related indicators and no knowledge of ORS exceeding 32 points. For all the other indicators, gaps was less than 15 points. Assessment of the indicators distribution across the educational attainment showed that the same indicators classified as moderate inequality for wealth was also classified as severe or moderate inequality for education while all the other indicators showed low inequality (IC<5%). Both Not receiving any vaccination and no knowledge of ORS were classified as severe inequality while health seeking behavior for fever was classified as moderate inequality.

Prevalence of health sector performance for child health reveals two distinct patterns by nationalities (figure 72). The first and the most common pattern is Jordanian showing the lowest prevalence and either or both Syrian and other nationalities showing the highest prevalence

Gap=13.5 Gap=12.5 Gap=21.4 Gap=12.3 Gap=12.2 Gap=18.1 Gap=3.3 Gap=11.4 ID=9.3 ID=11.2 ID=14.8 ID=8.3 ID=1.8 ID=1.6 ID=0.3 ID=0.6

100.0 91.4 87.0

90.0 80.0

75.5 73.2 80.0 72.2 70.0 62.8

60.0

46.8

44.7 40.8

50.0 37.7

35.8

31.2

29.8 29.0

40.0 28.6

24.8 24.2

30.0 19.5

17.5

14.4 12.3

20.0 8.8 10.0 6.0 0.0 Not receiving Not receiving No Not receiving Children with Children with Not receiving Not receiving any age all basic knowledge of all age fever not diarrhea not vitamin A iron appropriate vaccination ORS appropriate seeking seeking supplement supplement vaccination 12-23 months vaccination treatment or treatment or (6-59 months)(6-59 months) 12-23 months 12-23 months advise advice Jordanian Syrian Others

Figure 72 Prevalence of HS performance for child health indicators by nationality and their measures of inequality, JPFHS, 2017

The second pattern is observed in only two indicators, namely health seeking behavior for fever and not receiving iron supplement in which the Jordanian exhibiting the highest or second highest prevalence. Prevalence of all nutrition supplement indicators and health seeking behavior for diarrhea exceeded 40% for all nationalities placing in very highly prevalent category for all the population. All other indicators except for not receiving any age appropriate vaccination exceeded the 20% threshold for being highly prevalent for Syrian and other nationalities. For the Jordanian, only health seeking behavior for fever exceeded the 20% threshold in the latter groups of indicators. The above patterns showed varying gaps for all the indicators ranging between 3.3 points for not receiving vitamin A and 18.1 points for not seeking health services for diarrhea. However, the inequality measure reveals that only not receiving all basic vaccination and no knowledge of ORS were classified as severe inequality and not receiving any vaccination and not receiving all age appropriate vaccination as moderate inequality, while all the others were classified as low inequality.

A comparison between the inequality measures for 2012 and 2017 revealed a general trend of decline in inequalities of the indicators that were classified as severe or moderate inequalities (CI/ID>10%) in

57

2012 (table 21). In contrast, indicators that were classified as low inequalities experienced an increase in the inequalities but still classified as low inequalities. The exceptions to the latter pattern are wealth and educational inequalities in health seeking behavior for fever. Inequalities across these two stratifiers increased from low inequality to moderate ones.

Table 21 Measures of inequality in child health health sector performance indicators across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017

Gov Wealth Education indicators 2012 2017 2012 2017 2012 2017 Not receiving any age appropriate vaccination 78.0 14.3 -64.5 -7.3 -73.2 -10.1 12-23 months Not receiving all basic vaccination 12-23 months 17.3 6.9 -8.6 0.7 -12.1 -0.8 No knowledge of ORS 8.7 9.3 -13.3 -8.5 -12.0 -15.9 Children with fever not seeking treatment or 18.5 9.5 2.4 -6.8 -3.8 -6.9 advise Children with diarrhea not seeking treatment or 4.6 3.2 1.4 -3.8 -5.6 -2.7 advice Not receiving vitamin A supplement (6-59 0.8 2.2 -0.7 -1.1 0.0 -0.5 months) Not receiving iron supplement (6-59 months) 0.7 2.9 0.0 -2.8 0.2 -1.9

In brief, table 22 and the investigation of the health sector performance for child health can be summarized as follows:

 Vaccination related indicators and knowledge of ORS were classified as moderate health priority. Health seeking behavior was classified as highly prevalent for fever, and very highly prevalent for diarrhea. Lack of supplements was classified as very high prevalence.  Inequality is mainly observed for moderate prevalence and highly prevalent indicators.  Among moderate prevalence and highly prevalent indicators, severe inequality can be observed for not receiving all basic vaccination by governorates and education, not receiving any age appropriate vaccination by nationality and no knowledge of ORS by education and nationality.  Low inequality was observed for not receiving all basic vaccination by nationality, not receiving any age appropriate vaccination by wealth and education, not receiving all age appropriate vaccination by education, not seeking health care for fever by nationality.  For very highly prevalent indicators, only not seeking health care for diarrhea showed moderate inequality by wealth. Other than the previous case, all indicators showed low inequality by all stratifiers  Inequality has been decreasing across the governorates for the majority of indicators, but increasing for the majority of the indicators by wealth and education.  The most vulnerable social groups to ill performance of health sector for child health were children to families in the poorest or poorer wealth quintiles, mothers with no education and other non-Syrian nationalities as they show the highest prevalence on many indicators

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Table 22 Summary results of health sector performance for child health Stratifiers Indicator Prevalence Gov. Wealth Education Nationality Not receiving all basic vaccination 12- (-) (-) (-) (-) 23 months Not receiving any age appropriate (-) (-) (-) (-) vaccination 12-23 months No knowledge of ORS (-) (-) (-) (+) Not receiving all age appropriate vaccination 12-23 months Children with fever not seeking (-) (-) (+) (+) treatment or advise Children with diarrhea not seeking (-) (-) (+) (-) treatment or advice Not receiving vitamin A supplement (+) (+) (+) (+) (6-59 months) Not receiving iron supplement (6-59 (+) (+) (+) (+) months) Note: (-) indicates decrease between 2012 and 2017 and (+) indicates increase between 2012 and 2017. For prevalence Moderate Prevalence<20%) High 20%40%

For inequality Low (ID/IC<5%) Moderate (5%

Figure 73 explores aspects of maternal health and pregnancy care for women. It shows that some weakening in prenatal care as the non-coverage of any prenatal care, regular prenatal care and receiving of iron tablets increased between 2012 and 2017.

Moderate prevalence High prevalence 28.0

30.0 25.8

25.0 22.1 17.9

20.0 16.6

15.4 13.9 15.0 12.4

10.0 7.9

5.5 2.4

5.0 0.9 0.0 No antenatal care No antenatal care No postnatal care No postnatal care No iron tablet Cesarean section regular <2 days during pregnancy 2012 2017

Figure 73 Prevalence of HS performance for maternal health indicators in Jordan, JPFHS, 2012 & 2017

59

On the hand, there was improvement on the postnatal front and cesarean section as they declined during the same period. Appling the threshold for high prevalence, only Cesarean section and not receiving iron tablets showed a prevalence that exceeded the 20% threshold.

Differences across the governorates show that only non-coverage of iron tablet during pregnancy exceeds the very high prevalence threshold (prevalence >40%) in Karak (figure 74). However, many governorates exceeded the high prevalence threshold (prevalence>20%) for can be observed for cesarean section and non-coverage of iron tablets and only few governorates exceeded this threshold for postnatal care indicators. Only two governorates, Maan and Aqaba showed a prevalence of cesarean section less than 20%, and addition, Zarqua, Irbid and Jerash were the only three governorate showing a non-coverage of iron tablets less than 20% placing these two indicators as priorities for all the other governorates. For postnatal care, Mafraq scored more than 20% for both any postnatal care and postnatal care within the first two days of birth and Tafielh registered 22.9% for no postnatal care within the first two days of birth, classifying these as indicators as highly prevalent for these two governorates.

Gap=5.6 Gap=9.6 Gap=17.6 Gap=17.3 Gap=26.0 Gap=20.1 ID=17.8 ID=9.7 ID=12.4 ID=8.2 ID=8.3 ID=2.7

45.0 40.3

40.0 37.1

35.0 32.9

29.0

28.4

28.3

28.0

27.8

27.2

26.1 25.9

30.0 25.9

24.9

24.2

23.2

22.9

22.8 21.7

25.0 21.5

19.7

19.0

18.9

18.7

17.7 17.7

17.3

16.7 16.7 16.5

20.0 15.7

15.1

15.0

14.3

13.6

13.5

13.4

13.2

13.1

12.8

12.1 12.1

10.6

10.4 15.0 10.4

9.6

8.9

8.3

8.1

7.9

6.9

6.6

6.3 6.3

10.0 6.2

5.3

4.0

3.6

3.0

2.9

2.4

2.3

2.0

1.7

1.5 1.3

5.0 0.7 0.0 No antenatal care No antenatal care No postnatal care No postnatal care No iron tablet Cesarean section regular <2 days during pregnancy

Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Aljoun Karak Tafilh Maan Aquaba

Figure 74 Prevalence of HS performance for maternal health indicators by governorates and their measures of inequality, JPFHS, 2017

For prenatal care, Balqa showed higher levels of non-coverage for both any or regular prenatal care compared to other governorates and Mafraq and Maan exceeded the other governorates as well for the non-coverage of regular prenatal care.

The above differences different levels of gaps that range between 5.6% for non-coverage of any prenatal care and 26% for non-coverage of iron tablets. However, the overall inequality across the governorate showed that inequalities in non-coverage of prenatal care and postnatal care are classified as severe (ID>10), while inequalities in non-coverage for regular prenatal care, postnatal care within the first two days of birth and iron tablets are classified as moderate inequalities (5%

With the exception of Cesarean section, differentials in maternal care across the wealth quintile show a clear gradient in which the poor are overburdened with high service deprivation (figure 75). Figure 75 also shows that non-coverage with iron tablets exceeded the 20% for all wealth quintiles except for the middle one. For the poorest quintile, postnatal care with the first two days of birth and the non-coverage with iron tablets for exceeded the 20% threshold for being a highly prevalent. This puts these indicators as a highly prevalent for these wealth quintiles. In contrast, Cesarean section, while

60 having a prevalence of more than 20% for all wealth quintiles, it was more prevalent among the rich wealth quintile compared to others.

Gap=2.3 Gap=6.3 Gap=8.7 Gap=8.7 Gap=4.4 Gap=4.5 CI=2.6

CI=-9.4 CI=-16.1 CI=-14.6 CI=-10.1 CI=-3.3

28.3 26.9

30.0 26.7

25.1 23.8

25.0 23.6

21.6

20.8

20.6

20.3

19.2 17.9

20.0 17.3

15.7

13.2

12.8 12.1

15.0 11.7

9.8

9.2 9.2

10.0 8.6

6.4

5.9

5.4

3.6

3.5 2.4

5.0 1.7 1.3 0.0 No antenatal care No antenatal care No postnatal care No postnatal care No iron tablet Cesarean section regular <2 days during pregnancy Poorest Poorer Middle Richer Richest

Figure 75 Prevalence of HS performance for maternal health indicators by wealth and their measures of inequality, JPFHS, 2017

The gaps between the worst and best preforming wealth quintiles were relatively small not exceeding 10% for all indicators. However, the overall inequality of the indicators distribution across the wealth quintile showed severe inequality in non-coverage of regular prenatal care, and postnatal care indictors where the concentration index exceeded 10%. Non-coverage of any prenatal care was moderately unequal across the quintiles and non-coverage of iron tablets showed low inequality. Cesarean section showed a positive low inequality measure indicating higher prevalence among the rich quintile.

Except for cesarean section, educational attainment shows clear gradient with coverage with maternal health services (figure 76). Women with no education clearly deviate from women in the other educational attainment in all services. For cesarean section, although the differences are not large among women in the different educational attainment but Figure 76 shows that cesarean section are more prevalent among women with no education and higher education compared to other women.

Gap=6.6 Gap=12.8 Gap=19.9 Gap=19 Gap=30.0 Gap=6.0 CI=-16.0 CI=-10.0 CI=-15.6 CI=-10.8 CI=-4.9 CI=4.5

60.0 50.0 50.0

40.0

32.4

29.3

28.4

27.5

27.0 25.0

30.0 23.5

22.4 22.4

21.3

21.1 21.1

21.0

20.7

20.0

18.2

16.6

14.4 13.4

20.0 13.1

11.5

9.4

8.5

8.3

8.2 5.1

10.0 3.2

2.2 1.9 0.0 No antenatal care No antenatal care No postnatal care No postnatal care No iron tablet Cesarean section regular <2 days during pregnancy No education Primary Preparatory Secondary Higher

Figure 76 Prevalence of HS performance for maternal health indicators by education attainment and their measures of inequality, JPFHS, 2017

61

Differences between the worst and best educational attainment groups showed a wide range that goes from 6.6 points in non-coverage of any prenatal care to 30.0 points in non-coverage of iron tablets. Overall inequality measure showed that all prenatal and postnatal indicators are classified as severe inequality with women in the lower education attainment are suffering more from ill performance of the health system. Non-coverage of iron tablets and cesarean section were classified as low inequality with the former more prevalence among the lower education attainment, while the latter more prevalent among the more educated.

Differences in non-coverages of maternal health services by nationality show higher levels of ill performance of the health system among non-Jordanian and in particular among Syrians (figure 77). Syrian showed the highest prevalence in non-coverage for regular prenatal care, the two indicator for postnatal care and iron tablets. They were followed by the other nationalities in all these indicators. Jordanians showed the highest prevalence in cesarean section but all the three nationalities exceeded the 20% threshold for being a health priority.

Non-coverage with iron tablets also exceeded the 20% threshold for all nationalities. Syrian exceeded this threshold for all indicators except for those related to prenatal care. Relatively small gaps can be observed among the worst and best performing nationality. The highest gap was observed in non- coverage with any postnatal care (10.8 points) followed by non-coverage for postnatal care within two days of birth (8.9 points). All indicators showed moderate overall except for non-coverage by iron tablets and cesarean section.

Gap=1.7 Gap=7.6 Gap=10.8 Gap=8.9 Gap=2.9 Gap=4.9 ID=7.5 ID=9.2 ID=9.8 ID=6.5 ID=1.6 ID=2.5

30.0 26.6

24.2

24.0

23.5

22.6 21.8

25.0 21.7

21.1 20.6

20.0

15.3

14.7 14.5

15.0

11.0 8.1

10.0 7.2

3.9 3.5

5.0 2.2 0.0 No antenatal care No antenatal careNo postnatal care No postnatal care No iron tablet Cesarean section regular <2 days during pregnancy

Jordanian Syrian Others

Figure 77 Prevalence of HS performance for maternal health indicators by nationalities and their measures of inequality, JPFHS, 2017

Comparing the inequality measures between 2012 and 2017 show declines in the level of inequality across all stratifiers (table23). The only exception from this pattern is the non-coverage for prenatal care and cesarean section for governorates and education.

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Table 23 Measures of inequality in maternal health HS performance indicators across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017 Gov Wealth Education indicator 2012 2017 2012 2017 2012 2017 No antenatal care 16.4 17.8 -46.8 -9.4 -41.3 -16.9 No antenatal care regular 10.9 9.7 -31.9 -16.1 -27.9 -10.0 No postnatal care 15.4 12.4 -18.0 -14.6 -21.6 -15.6 No postnatal care <2 days 16.6 8.2 -11.2 -10.1 -18.3 -10.8 No iron tablet during pregnancy 7.2 8.3 -23.0 -3.3 -12.8 -4.9 Cesarean section 2.4 2.7 5.3 2.6 0.7 4.5 In brief, table 24 and investigation of health sector performance for maternal health indicators summarized in the following:

 HS performance for maternal health indicators show moderate prevalence except for lack of iron tablets and cesarean sections.  Severe inequality is common among the moderate prevalence for all stratifiers except nationality. This is particularly evident for wealth and education.  For the highly prevalent indicators, only education showed moderate inequality for the two indicators and the governorates showed moderate inequality for lack of iron tablets.  Wealth inequality decreased across all indicators between 2012 and 2017. Inequality across the governorates decreased for the moderate prevalence indicators but increased for the highly prevalent indicators. For education, inequality showed mix of increases and decreases  Poor women, those with no education and Syrian women were the most vulnerable to ill performance of health sector in maternal health. The only exception is the high prevalence of cesarean section among those in the richer wealth quintile.

Table 24 Summary results of health sector performance for maternal health Stratifiers Prevalence Indicator Gov. Wealth Education Nationality No antenatal care (+) (-) (-) (+) No antenatal care regular (+) (-) (-) (-) No postnatal care (-) (-) (-) (-) No postnatal care <2 days (-) (-) (-) (-) No iron tablet during pregnancy (+) (+) (-) (-) Cesarean section (-) (+) (-) (+) Note: (-) indicates decrease between 2012 and 2017 and (+) indicates increase between 2012 and 2017. For prevalence Moderate Prevalence<20%) High 20%40%

For inequality Low (ID/IC<5%) Moderate (5%

7.1.4 Health sector performance for family planning indicators Performance of the health sector was assessed in terms of four indicators, namely unmet need, use of traditional methods, non-use of contraception and non-users receive no counselling. All indicators showed an increase in their prevalence between 2012 and 2017 (figure 78). Prevalence for lack of counselling for non-users of contraceptive mounted to almost 74%, while nonuse of contraceptive showed a prevalence of 38.8%, a prevalence approaching the very high prevalence threshold. These figures classify these two indicators as very highly prevalent health indicators. However, use of traditional methods and unmet need do not adhere the prevalence classification criteria due to their

63 specific nature23 since unmet need was found to range between 7 and 31 in developing countries and the upper bound for use of traditional methods was found 25%24. Accordingly, these figures place all three indicators as highly prevalent health sector performance indicators.

100.0 78.7 80.0 73.9 60.0 48.2 38.8 40.0 14.2 14.4 20.0 11.7 13.0 0.0 Unmet need Use of traditional methods No use of contraceptives Nonusers of FP did not discuss FP either with field workers or health facility 2012 2017

Figure 78 Prevalence of family planning HS performance indicators in Jordan, JPFHS, 2012 & 2017 Differences in the prevalence of the four indicators show large difference compared to the level of each indicators (figure 79). For example, the gap between the best and worst performing governorates reached 7.5 points, while the gap increased to 28.6 points for no counselling for non- users. Overall summary measure of inequality for all indicators except for use of traditional methods were classified as low inequality. Use of traditional use shows moderate inequality.

Gap=7.5 Gap=8.4 Gap=18.8 Gap=28.6 ID=2.9 ID=5.8 ID=2.4 ID=2.2

100.0

87.4

83.9

82.4 82.4

82.3 80.6

90.0 79.1

76.9 76.5

80.0 75.9

64.8 60.5

70.0 58.8

56.6

56.2

52.9

48.7 48.6

60.0 48.6

46.2

45.3

42.9 42.2 50.0 41.8 40.0

30.0 19.2

17.6

17.4

17.2

16.5

16.1

15.4

15.4

15.1 15.1

15.0

14.8

14.7

14.3

13.9 13.9

13.1

12.1

11.5

11.5

10.7

10.5 10.0 20.0 9.9 10.0 0.0 Unmet need Use of traditional methods No use of contraceptives Nonusers of FP did not discuss FP either with field workers or health facility

Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Aljoun Karak Tafilh Maan Aquaba

Figure 79 Prevalence of family planning HS performance indicators by governorates and their measures of inequality, JPFHS, 2017

Prevalence by wealth quintile also showed small differences among the different quintiles for all four indictors (figure 80). Furthermore, gap between worst and best performing quintile were relatively small with the largest gap not exceeding 8%. Even the overall inequality measures classified all indicators as low inequality.

64

Gap=3.9 Gap=4.9 Gap=7.4 Gap=3.3

CI=-2.9 CI=-0.5 CI=-1.4 CI=0.3

80.5 79.2

90.0 78.9 77.7 80.0 77.2

70.0

52.4 49.9

60.0 48.5 45.8 50.0 44.9 40.0

30.0

16.8

16.5

15.7

14.8

14.6

13.7

13.2

13.0 12.9 20.0 11.6 10.0 0.0 Unmet need Use of traditional methods No use of contraceptives Nonusers of FP did not discuss FP either with field workers or health facility Poorest Poorer Middle Richer Richest

Figure 80 Prevalence of family planning HS performance indicators by wealth and their measures of inequality, JPFHS, 2017

In contrast to wealth, education attainment had specific direction for its relationship with the four indicators of family planning (figure 81). Unmet need, no use of contraceptive and lack of counselling for nonusers showed a negative relationship with education, while use of traditional method was positively related to education.

Gaps between the best and worst performing educational attainment group was relatively large compared to the prevalence of the indicators. The gap ranged between 7.4 points for unmet need and 27.4 points for non-use of contraceptive. Overall measures of inequality classified nonuse of contraceptive as moderate inequality, while all the others were classified as low inequality.

Gap=7.4 Gap=6.8 Gap=27.4 Gap=16.4

100.0 CI=0.3 CI=4.1 CI=-6.1 92.6 CI=-1.9

82.7

81.2

78.1 76.2

80.0 69.8

64.5 50.3

60.0 47.3 42.4

40.0

20.3

17.3

15.2

14.9 14.9

14.6

13.2

12.9 11.0

20.0 8.4 0.0 Unmet need Use of traditional methods No use of contraceptives Nonusers of FP did not discuss FP either with field No education Primary Preparatory Secondary Higherworkers or health facility

Figure 81 Prevalence of family planning HS performance indicators by education attainment and their measures of inequality, JPFHS, 2017

Prevalence across the nationality revealed that Syrian were the most burdened with ill performance of the health sector in the use of traditional methods and nonuse of contraceptive (figure 82). Other nationalities were the most vulnerable for lack of counselling for nonusers. Unmet need showed the same high prevalence of all non-Jordanians. While the gap between Jordanian and Syrian and other nationalities were relatively large, overall inequality measures for the distribution of the indicators across all stratifier were classified as low inequality.

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Gap=5.0 Gap=3.4 Gap=9.0 Gap=11.7 ID=4.0 ID=2.2 ID=1.3 ID=1.4 100.0 89.1 83.9 77.4 80.0 55.6 60.0 47.6 46.6 40.0 18.6 18.6 16.7 14.4 20.0 13.6 13.3 0.0 Unmet need Use of traditional methods No use of contraceptives Nonusers of FP did not discuss FP either with field workers or health facility Jordanian Syrian Others

Figure 82 Prevalence of family planning HS performance indicators by nationalities and their measures of inequality, JPFHS, 2017

Comparing inequality measures for the four indicators across the three stratifier shows a decline in inequality by wealth for all indicators (table 25). For the governorate and education stratifiers, the inequality declined for unmet need and use of traditional methods but increased for the nonuse of contraceptive and lack of counselling for nonusers. It is important to note that even with the increases the inequality levels in 2017 never exceeded 7% classifying all indicators as low to moderate inequality.

Table 25 Measures of inequality in family planning HS performance indicators across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017

Gov Wealth Education indicator 2012 2017 2012 2017 2012 2017 Unmet need 2.6 2.9 -9.0 -2.9 -8.0 -1.4 Use of traditional methods 3.8 5.8 1.9 -0.5 4.4 4.1 No use of contraceptives 2.8 2.4 -1.2 -1.4 -0.9 -6.1 Nonusers of FP did not discuss FP either with 1.0 2.2 2.6 0.3 0.3 -1.9 field workers or health facility

In brief, table 26 and the investigation of health sector performance for family planning indicators summarized in the following

 The prevalence of all indicators decreased between 2012 and 2017 except for use of traditional methods  Unmet need and use of traditional methods were classified as highly prevalent. No use of contraceptives and nonusers of FP not discussing FP with any health professional were classified as very highly prevalent.  Inequality is commonly low for all indicators and stratifiers. Only use of traditional methods across governorates and no use of contraceptive by education were moderately unequal.  For the majority of indicators, inequality across governorates increased, but inequality by wealth decreased  Women with no education and Syrian women were the most vulnerable social groups to the ill performance of health sector for family planning 66

Table 26 Summary results of health sector performance for family planning Stratifiers Prevalence Indicator Gov. Wealth Education Nationality Unmet need (-) (+) (-) (-) Use of traditional methods (+) (+) (-) (-) No use of contraceptives (-) (-) (+) (+) Nonusers of FP did not discuss FP (-) (+) (-) (+) either with field workers or health facility Note: (-) indicates decrease between 2012 and 2017 and (+) indicates increase between 2012 and 2017. For prevalence Moderate Prevalence<20%) High 20%40%

For inequality Low (ID/IC<5%) Moderate (5%

7.1.5 Health sector performance for other reproductive health indicators This subsection explores health sector performance with regard to coverage of premarital examination for women and their husband and women and men knowledge of HIV/AIDS testing place. Figure 83 shows that there is improvement in all indicators between 2012 and 2017. Nevertheless, all four indicators maintain their very high prevalence status with prevalence the exceeded 40%.

100.0 79.4 80.0 72.8 59.6 60.2 59.6 60.0 46.8 48.0 40.0

20.0 0.0 No premarital exam women No premarital exam No information on test No information on test women's husband place for HIV/AIDS men place for HIV/AIDS women

2012 2017

Figure 83 Prevalence of HS performance for other RH indicators in Jordan, JPFHS, 2012 & 2017 It also shows that men are better informed of testing place for HIV/AIDS compared to women but they are slightly more likely not to take their premarital exams compare to women.

Prevalence of the marital examination and knowledge of HIV/AIDS testing place across the governorates reveal that all governorates exceeded the very high prevalence threshold of 40% (figure 84). With even the best performing governorate exceeding the 40%. Furthermore, the gaps between the best and worst performing governorates were large. For premarital exams, the gap was 18 points for women and 16.3 points for men. Knowledge of testing place for HIV/AIDS showed even larger gaps reaching 31.1 points for men and 26.3 points for women. However, the overall inequality was classified as low inequality with ID<5% for all indicators.

67

Gap=18.0 Gap=16.3 Gap=31.1 Gap=26.3 ID=2.6 ID=2.6 ID=4.4 ID=2.6

90.0 83.1

80.2

79.9

78.0

76.6 74.1

80.0 72.9

71.6

71.0

70.4

69.7 69.7 69.1

70.0 66.7

62.0

60.1

59.3

58.6

57.3

56.8

56.2

54.8

54.4

53.2 53.1

60.0 52.9

51.3

51.2

51.1

50.4

50.3 50.3

49.2

47.9

47.2

46.9 46.9

46.4

45.7

44.9 44.9

44.7

43.4 43.2

50.0 42.5

41.0

40.6 40.5 40.0 30.0 20.0 10.0 0.0 No premarital exam women No premarital exam No information on test placeNo information on test place women's husband for HIV/AIDS men for HIV/AIDS women

Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Aljoun Karak Tafilh Maan Aquaba

Figure 84 Prevalence of HS performance for other RH indicators by governorates and their measures of inequality, JPFHS, 2017

Differences in the prevalence by wealth show no clear pattern for the premarital examination, but a gradient for the information on testing place for HIV/AIDS (figure 85). The gap between the best and worst performing wealth quintile showed a wide range from 9.2 points for no premarital for women to 21.2 for no information on HIV/AIDS testing place for women. Furthermore, overall inequality measure across all wealth quintiles falls in the low inequality with the no information on HIV/AIDS testing place for women falling on the boarder of moderate inequality.

Gap=9.5 Gap=14.2 Gap=16.4 Gap=21.2

100.0 CI=-0.3 CI=2.9 CI=-3.6 89.6 CI=-5.2

77.6

74.5 70.5

80.0 70.3

60.8

60.1

59.4

58.6

58.2

54.1

53.2

52.6

52.2

51.2 49.8

60.0 47.1

44.4

44.0 43.1 40.0 20.0 0.0 No premarital exam women No premarital exam No information on test No information on test women's husband place for HIV/AIDS men place for HIV/AIDS women Poorest Poorer Middle Richer Richest

Figure 85 Prevalence of HS performance for other RH indicators by wealth and their measures of inequality, JPFHS, 2017

Prevalence of the four indicators showed clear gradient with education attainment with the higher educated individuals scoring less than the 40% threshold for very high prevalence for all indicators except for women knowledge of HIV/AIDS testing place (figure 86). The gap between those with no education and those with higher education was very large. The gaps ranged between 25.1 points for no information on HIV/AIDS testing place for women and 45.2 points for premarital examination for women. In addition, the overall inequality of the indicators distribution over the educational attainment were classified as severe for premarital examination indicators and moderate for no knowledge of HIV/AIDS testing place indicators.

68

Gap=45.2 Gap=41.7 Gap=33.3 Gap=25.1 CI=-14.2 CI=-13.3 CI=-9.2 CI=-6.2

100.0

87.5 86.6

90.0 81.0

78.3

76.5

76.1

75.7 72.9

80.0 71.4

69.7

65.1 62.8

70.0 62.4

60.5 60.2

60.0

49.8 48.6

50.0 42.4 34.8 40.0 33.1 30.0 20.0 10.0 0.0 No premarital exam women No premarital exam No information on test No information on test women's husband place for HIV/AIDS men place for HIV/AIDS women

No education Primary Preparatory Secondary Higher

Figure 86 Prevalence of HS performance for other RH indicators by education attainment and their measures of inequality, JPFHS, 2017

Figure 87 shows that all indicators for all social categories exceeded the 40% for being a very highly prevalent. However, while other nationalities were less likely to carry out the premarital exams, Syrian were less likely to know of the HIV/AIDS test place. The gaps also showed varying magnitude but the overall inequality measures for all four indicators were classified as low inequality.

Gap=14.0 Gap=5.1 Gap=12.4 Gap=13.8 ID=2.6 ID=0.3 ID=1.4 ID=1.5 100.0 85.3 71.8 71.5 73.6 80.0 63.5 54.6 59.4 56.6 56.0 61.1 59.4 60.0 45.4 40.0 20.0 0.0 No premarital exam No premarital exam No information on test No information on test women women's husband place for HIV/AIDS men place for HIV/AIDS women Jordanian Syrian Others

Figure 87 Prevalence of HS performance for other RH indicators by nationalities and their measures of inequality, JPFHS, 2017

A comparison between 2012 and 2017 inequality measures across all stratifiers for the two indicators of lack of premarital exam for women and their husband revealed increase inequality across the governorates and the education attainment (table 88). For wealth, the inequality decreased for no premarital exam for women but the inequality increased and switched direction for men.

Table 27 Measures of inequality in other RH health sector performance indicators across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017 Gov Wealth Education indicator 2012 2017 2012 2017 2012 2017 No premarital exam women 1.0 2.9 -1.9 -0.3 -9.0 -14.2 No premarital exam women's husband 1.3 2.6 -1.7 2.9 -9.2 -13.3 No information on test place for HIV/AIDS 1.9 2.6 -2.9 -5.2 6.2 -6.2 women

69

In brief, table 28 and investigation of health sector performance for other reproductive health indicators summarized in the following

 Despite the improve in all indicators, they are still classified as very highly prevalent  Inequality was low for all indicators across governorates and by nationality and for premarital related indicators and not knowing HIV test place for men.  Education inequality was severe for premarital relate indicators, but moderate for not knowing HIV test place related indicators.  Wealth inequality was moderate for women not knowing place for HIV test.  Individuals in the poorest quintile, those with no education and Syrians were the most vulnerable social groups for no information on HIV test place related indicators, for the no premarital exam related indicators, the most vulnerable group was individuals with no education

Table 28 Summary results of health sector performance for other reproductive health Stratifiers Prevalence Indicator Gov. Wealth Education Nationality No premarital exam women (-) (-) (+) (+) No premarital exam women's husband (-) (-) (-) (-) No information on test place for HIV/AIDS men No information on test place for HIV/AIDS (-) (-) (-) (-) women Note: (-) indicates decrease between 2012 and 2017 and (+) indicates increase between 2012 and 2017. For prevalence Moderate Prevalence<20%) High 20%40%

For inequality Low (ID/IC<5%) Moderate (5%

7.2 HEALTH SECTOR CAPACITY: JPFHS 2017 has only four indicators to assess the capacity of the health sector and they are all related to difficulties facing women in accessing health services. These indicators are unavailability of female provider, distance to health care facility, unaffordability of the health care service, and need to take transportation. Figure 88 shows that all four indicators fall in the high prevalence category as their prevalence exceeds the threshold of 20%. However, it also shows that there were large improvement in all four indicators between 2012 and 2017. Only the unaffordability of the health care services showed a very small decline between 2012 and 2017.

35.0 29.5 28.6 30.0 26.4 25.2 25.0 22.0 22.5 22.1 20.1 20.0 15.0 10.0 5.0 0.0 Unavailability of female Distance to health care Unaffordability of the health Need to take transportation provider facility care service

2012 2017

Figure 88 Prevalence of HS capacity indicators in Jordan, JPFHS, 2012 & 2017 70

Difference in the prevalence of the four indicators of health sector capacity across the different governorates showed that all indicators fall in the high prevalence health indicators category with a prevalence greater than 20% with only limited number of governorates that fall below this threshold (figure 89). Zarqua, Ajloun, Karak ,Tafielha and Aqaba showed a prevalence <20% for unavailability of female provider. Amman, Zarqua, and Karak showed a prevalence of less than 20% for distance to health care and unaffordability of health care. For need to take transportation, only Zarqa showed a prevalence less than 20%. In contrast, Marfaq scored a prevalence of almost or more than 40% for distance to the health facility and the need to take transportation, which put them in the very high prevalence category of health indicators.

Gap=16.3 Gap=27.3 Gap=21.2 Gap=26.4

ID=7.5 ID=13.3 ID=11.2 ID=9.4 43.7

50.0 43.4

39.6

38.0 36.5

40.0 34.9

31.8

31.4

28.7

28.6

28.5

27.4

27.2

26.9

26.4

26.0

24.7

24.2 24.2 24.0

30.0 23.3

22.8

22.7

22.3

22.2

22.1 22.1

21.6

21.1

20.3

20.0 20.0

19.3 19.3

19.0

18.6

18.2

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16.7

16.1

15.7

15.5 15.3 20.0 15.3 10.0 0.0 Unavailability of female Distance to health care Unaffordability of the health Need to take transportation provider facility care service Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Aljoun Karak Tafilh Maan Aquaba

Figure 89 Prevalence of HS capacity indicators by governorates and their measures of inequality, JPFHS, 2017

For Maan, the prevalence of the need to take transportation exceeded 40% placing it in the very high prevalence category for this governorate. With those exceptional cases, all the four indicators fell in the high prevalence category for all the other governorates.

These differences have produced large gaps across the four indicators. The gaps ranged between 16.3 points for unavailability of female providers and 26.4 for need to take transportation. Assessing inequality in the distribution of health capacity indicators across the governorates showed severe inequality in distance to health care facility and unaffordability of health care, but moderate inequality for unavailability of female provider and need to take transportation.

Differences in the health sector capacity across the wealth quintile show clear gradient pattern in which the wealth is negatively related to low health sectors capacity indicators (figure 90). The lowest two wealth quintiles (poorest and poorer) persistently showed a prevalence that exceed the 20% for all indicators placing them as high prevalent health indicators for these wealth quintiles. It is important to note that the unaffordability of the health services showed a prevalence of 40.6% for the poorest wealth quintile, which places this indicator in the very high prevalence category for this wealth quintile. For the middle wealth quintile, only the prevalence of distance to health care facility and need to take transportation exceeded the 20% threshold placing them in the high prevalence category for this social group. The richer wealth quintile showed a prevalence exceeding 20% for the need to take transportation only. None of the indicators exceeded the 20% threshold of the richest quintile.

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Gap=18.0 Gap=28.5 Gap=31.5 Gap=21.0 CI=-17.1 CI=-23.4 CI=-26.3 CI=-15.2

45.0 40.6 37.8 40.0 36.8

35.0

29.5

27.2 26.1

30.0 25.7

23.5

22.5 20.9

25.0 20.7

19.5

18.7

16.8 16.8

20.0 15.7 15.1

15.0 11.5 9.1 10.0 8.3 5.0 0.0 Unavailability of female Distance to health care Unaffordability of the health Need to take transportation provider facility care service Poorest Poorer Middle Richer Richest

Figure 90 Prevalence of HS capacity indicators by wealth and their measures of inequality, JPFHS, 2017

These differences in the prevalence across wealth quintiles for all indicators produced large gaps that ranged between 18 points for unavailability of female providers and 31.5 points for distance to health care facility. They also resulted in large inequalities in the four indicators’ distribution across the wealth quintiles. The concentration index confirms the vulnerability of the poor population and classifies both distance to health care facility and unaffordability in a severely high inequality category in which CI>20%, while unavailability of female provider and need to take transportation in the server inequality category where CI exceeds 10%. Similar to wealth, education showed a clear gradient for all four indicators of health sector capacity where the low levels of education experiencing lower levels of health sector capacity (figure 91). Women with no education showed prevalence that exceeded the 40% threshold for very high prevalence for the three indicators of distance to the health facilities, unaffordability of the health care services and need to take transportation placing them in very high prevalence category. In addition, women with no education showed a prevalence that exceeded 20% for unavailability of female provider placing this indicator in the high prevalence category. Women with primary education had a prevalence greater than 40% for unaffordability of health care services and need to take transportation, placing these two indicators in the very high prevalence category, while the other two indicators were classified as highly prevalent indicators. For the preparatory and secondary educated women, all the indicators were classified as highly prevalent indicators. In contrast, none of the indicators exceeded the 20% threshold for high prevalence for women with higher education.

Gap=20.1 Gap=29.6 Gap=31.3 Gap=25.8 CI=-14.0 CI=17.9 CI=-22.0 CI=-12.7

50.0 45.0

43.7

43.6

43.4

40.2 38.2

40.0 34.2

32.1

31.3

30.5 28.5

30.0 25.1

23.7

23.0

22.9

21.4

19.2 14.1

20.0 14.0 12.4 10.0 0.0 Unavailability of female Distance to health care Unaffordability of the health Need to take transportation provider facility care service no education primary preparatory secondary higher

Figure 91 Prevalence of HS capacity indicators by education attainment and their measures of inequality, JPFHS, 2017 72

These differences produced large gaps and high levels of inequality. Assessing inequality across the educational attainment categories classified unavailability of female providers, distance to health care facilities and need to take transportation as severe inequality. Unaffordability of health care services showed a severely high inequality (CI>20%). Differences in health sector capacity indicators reveal the vulnerable status of Syrians followed by the other nationalities. More than 40% of Syrians experience unaffordability of health care services and need to take transportation classifying them as very high prevalence for Syrians (figure 92). The prevalence for the other two indicators exceeded the threshold of 20% by a large differences placing them in the high prevalence category.

Gap=12.7 Gap=18.8 Gap=29.3 Gap=18.1 60.0 ID=5.9 ID=7.6 ID=12.3 ID=7.2 48.3 50.0 38.8 41.2 40.0 34.9 31.4 32.9 27.0 30.0 24.6 23.1 18.7 20.0 19.0 20.0 10.0 0.0 Unavailability of female Distance to health care Unaffordability of the Need to take transportation provider facility health care service Jordanian Syrian Others

Figure 92 Prevalence of HS capacity indicators by nationalities and their measures of inequality, JPFHS, 2017

For the other nationalities, all the indicators exceeded the 20% placing them in the high prevalence category. Among Jordanian, only the prevalence of the distance to health care facilities and need to take transportation exceeded the 20% threshold placing them as highly prevalent health indicators. The above differences produced large gaps among Syrian and Jordanian ranging between 12.7 points for unavailability of female providers to 29.3 points for unaffordability of health care services. Assessing inequality across the three classification of nationality classified only unaffordability of health services as severe inequality, while the other three indicators were classified as moderate inequality.

Although all indicators of health sector capacity improved between 2012 and 2017, table shows that inequalities increased for all indicators and across all stratifiers. For example, the inequality of unaffordability of health care services increased from 3.2% to 11.2% across the governorates and from -24.1% to -26.3% across the wealth index.

Table 29 Measures of inequality in health sector capacity indicators across governorates, wealth and educational attainment between 2012 and 2017, JPFHS, 2012 &2017

Gov Wealth Education indicator 2012 2017 2012 2017 2012 2017 Unavailability of female provider 4.2 7.5 -6.3 -17.1 -3.9 -14.0 Distance to health care facility 2.5 13.3 -11.4 -23.4 -7.1 -17.9 Unaffordability of the health care service 3.2 11.2 -24.1 -26.3 -20.5 -22.0 Need to take transportation 5.5 9.4 -11.9 -15.2 -5.8 -12.7

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In brief, table 30 and investigation of health sector capacity indicators summarized in the following:  Despite the improvement in the health sector capacity indicators between 2012 and 2017, all indicators are classified as highly prevalent indicators.  Severe inequality is highly common across all stratifiers. All indicators were severely unequal by wealth and education.  Unavailable of female provider and need to take transportation were moderately unequal by governorates and nationality. In addition, distance to health care facility was moderately unequal by nationality.  Residents of Maan and Mafraq, individuals in the poorest wealth quintile, with no education and Syrian women are the most vulnerable social groups for health sector capacity indicators

Table 30 Summary results of health sector capacity Stratifiers Prevalence Indicator Gov. Wealth Education Nationality Unavailability of female provider (-) (+) (+) (+) Distance to health care facility (-) (+) (+) (+) Unaffordability of the health care (-) (+) (+) (+) service Need to take transportation (-) (+) (+) (+) Note: (-) indicates decrease between 2012 and 2017 and (+) indicates increase between 2012 and 2017. For prevalence Moderate Prevalence<20%) High 20%40%

For inequality Low (ID/IC<5%) Moderate (5%

7.3 CONCLUDING REMARKS  Thirteen indicators of the 30 health sector performance and capacity were classified very highly prevalent and seven were classified as highly prevalent.  Twenty-one indicators achieved improvement between 2012 and 2017  Inequality by education was highest and the most severe among the stratifers. Governorates followed with relatively high severity. Wealth showed the small number of inequalities and severe inequality indicators and nationality showed the least inequality or severe inequality o By education, 9 were severely unequal and 10 indicators were moderately unequal o Across the governorates, six indicators were severely unequal and 9 were moderately unequal o By wealth, 3 were severely unequal and 13 indicators were moderately unequal o By nationality, 2 indicators were severely unequal and 7 were moderately unequal  Overall, inequality has been declining for the majority the indicators and all stratifiers  Individuals in the poorest wealth quintile, with no education or primary education and Syrian were commonly the most vulnerable across the majority of the indicators of the health sector performance and capacity

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Table 31 Summary indicators for health sector performance and capacity

Stratifiers Preval Indicator Gov Wealth Education National No breastfeeding (+) (0) (+) (-) No postnatal care for child (-) (-) (+) (+) No postnatal check during the first 2 days after birth (-) (-) (+) (+) No breastfeeding within 1 day of birth (-) (+) (+) (-) Not receiving all basic vaccination 12-23 months (-) (-) (-) (-) Not receiving any age appropriate vaccination 12-23 months (-) (-) (-) (-) No knowledge of ORS (-) (-) (-) (+) Not receiving all age appropriate vaccination 12-23 months Children with fever not seeking treatment or advise (-) (-) (+) (+) Children with diarrhea not seeking treatment or advice (-) (-) (+) (-) Not receiving vitamin A supplement (6-59 months) (+) (+) (+) (+) Not receiving iron supplement (6-59 months) (+) (+) (+) (+) No antenatal care (+) (-) (-) (+) No antenatal care regular (+) (-) (-) (-) No postnatal care (-) (-) (-) (-) No postnatal care <2 days (-) (-) (-) (-) No iron tablet during pregnancy (+) (+) (-) (-) Cesarean section (-) (+) (-) (+) Unmet need (-) (+) (-) (-) Use of traditional methods (+) (+) (-) (-) No use of contraceptives (-) (-) (+) (+) Nonusers of FP did not discuss FP either with field workers or health (-) (+) (-) (+) facility No premarital exam women (-) (-) (+) (+) No premarital exam women's husband (-) (-) (-) (-) No information on test place for HIV/AIDS men No information on test place for HIV/AIDS women (-) (-) (-) (-) Unavailability of female provider (-) (+) (+) (+) Distance to health care facility (-) (+) (+) (+) Unaffordability of the health care service (-) (+) (+) (+) Need to take transportation (-) (+) (+) (+) For prevalence Moderate Prevalence<20%) High Very high Prevalence>40% 20%

For inequality Low (ID/IC<5%) Moderate (5% Severe (10%

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8 HEALTH INSURANCE COVERAGE IN JORDAN (UHC)

Concerns and calls for UHC can be traced to the 2012 when the United Nations General Assembly endorsed a resolution on Global Health and Foreign Policy urging countries to accelerate progress toward universal health coverage (UHC).. The main essence of this declaration is the need to secure access to quality, affordable health care as an essential requirement for international development. However, Member states also recognized that the importance of universal coverage within their national health systems in achieving social inclusion and equity with particular focus on the most vulnerable groups of their populations.

In 2015, UHC was adopted as a target in the SDGs and implied financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all. This commitment was reiterated in 2019, the United Nation General Assembly, recognizing the slow progress towards the achievement of the UHC, launched the political declaration of the high-level meeting on universal health coverage “universal Health coverage: moving together to build a healthier world”25. The declaration recognized the fundamental and critical as well as the reciprocal relationship between universal health coverage and the achievement of not only the sustainable development goals related to health and wellbeing but also all the other SDGs.

According to the declaration, universal health coverage implies that “all people have access, without discrimination to nationally determined sets of the needed promotive, preventive, curative, rehabilitative and palliative essential health services and essential safe affordable, effective and quality medicine and vaccines, while ensuring that the use of these services does not expose the users to financial hardship with a special emphasis on the poor, vulnerable and marginalized segments of the population.”

The declaration committed to accelerating the efforts towards the achievement of the universal health coverage by 2030 to ensure healthy lives and promote wellbeing for all throughout the life course.

8.1 UHC IN JORDAN Similar to all countries that endorsed the SDGs, Jordan committed to the achievement of the UHC by 2030. This commitment has been reiterated in all health related strategies in Jordan. In Jordan 2025, “developing an effective and comprehensive health insurance system” was among the five targeted scenarios.

In Jordan 2016-2020 health sector strategy, the third strategic goals stated, “Provide health, financial and social protection to the entire population on a fair basis. The Ministry of Health strategic plan 2018-2022 had a strategic objective that called for Increase inclusion of citizens in the universal health coverage.

One of the first steps towards UHC is the assessment of the current health insurance system and its coverage. In Jordan, Health insurance is provided by a number of different organizations; namely

a) Ministry of Health, b) Royal Military c) University Hospital d) United Nations Welfare Refugee Association 76

e) United Nations High Commissioner for refugees. f) Private and non-governmental forms of health insurance are also available. (Ministry of Health Strategic Plan 2018-2022 n.d.)

Generally, these insurance providers cover the following social groups:

a) Civil employees, retirees and their dependents b) Children under the age of 6 c) Family members of organ donors (up to 5 years) d) Blood donors (up to 6 months) e) Households with an annual income of less than 300 JD f) Individuals receiving aid from the national aid fund g) Jordanians aged 60 and above h) Pregnant women

Other groups can apply for health insurance coverage voluntarily. Of these, only the first group are required to pay an insurance fee. In addition, services for certain health issues are provided free of charge regardless of insurance state. (Cancer, HIV/AIDS, kidney diseases, anemia, mass poisoning) (Ministry of Health Strategic Plan 2018-2022 n.d.) but there no information about the amount of coverage provided for cancer treatment and what treatments fall under that category.

Figure 93 offers some figures on the health insurance coverage with specific comparisons among two extremes social groups for both men and women. General speaking, women are more likely to be covered by health insurance. People living in rural areas are more likely to be covered than those living in urban areas and highly educated persons were more likely to be insured than those with no education.

100% 79% 80% 72% 67% 58% 59% 50% 56% 60% 48% 43% 40% 28% 20% 0% Total Coverage Rural Areas Urban Areas Illiterate individuals Secondary education or higher

Percentage of women with insurance coverage Percentage of men with insurance coverage

Figure 93 Health insurance coverage in Jordan, JPFHS, 2012 & 2017

Data from the JPFHS2017, men are more likely not to be covered by health insurance with almost 50% not covered compared to almost 42% among women. Another important indication for health insurance coverage is the percentage of uncovered people who are in need of this coverage as indicated by usage of outpatient or inpatient. Figure showed that this percentage is higher among users of outpatients compared to users of inpatients (30.8% versus 23.1%). These figures might indicate relatively good coverage among people in need. However, they are not capturing the individuals who are in need of medical services but was unable to obtain it due to lack of financial resources.

77

On the base of the prevalence cutoff points, figure 94 on health insurance coverage for men and women clearly falls among the very highly prevalent health indicators category, while coverage for inpatient and outpatient users fall in the high prevalence health indicators category.

Very high prevalence 60 High prevalence 49.6 50 41.7 40 30.8 30 23.1 20

10

0 No insurance for inpatient No insurance for outpatient Not covered by any health Not covered by any health users users insurance women (15-49) insurance men (15-49)

Figure 94 Prevalence of health insurance coverage indicators in Jordan, JPFHS, 2012 & 2017 The main essence of UHC is ensuring equity and securing high quality predetermined health services. While data on the health services covered by Jordan health insurance is not available, JPFHS 2017 data provided information on coverage by different stratifiers

Figure 108 shows the distribution of these four indicators within the governorates. It should be noted that due to the small number of inpatient users, the coverage for inpatient was not calculated at the governorate level. Applying the prevalence cutoff points at the governorate level, only very small number of all the governorates showed moderate prevalence in these four indicators. For the percentage not covered among men, all the governorates exceeded the high prevalence cutoff point (>20%). The only exception was the governorate of Ajloun. In comparison, Amman, Zarqua and Maan showed a prevalence greater than 40% indicating very high prevalence for this indicator.

For the percentage not covered among women, only four governorates registeredmoderate prevalence (<20%) namely, Tafilha, Karak, Ajloun and Jerash. In comparison, Amman and Zarqua registered prevalence exceeding the very high prevalence cutoff point (>40%).

For the percentage not covered among users of outpatient, figure 95 revealed that Maan, Tafilha, Karak, Ajloun and Jerash scored less than 20% indicatingmoderate prevalence for this indicator and in contrast, Amman scored more than 40% putting this indicator in the very high prevalence category for Amman.

Assessing the magnitude of inequality in the four indicators revealed large gaps between the best and worst performing governorates. The gaps range between 37.1 points for non- coverage for outpatients and 45.6 points for non-coverage for women. Assessing the inequality within the distribution of these indicators across the governorates, the ID revealed that all the three indicators fall in the severe inequality category (ID>10%).

78

Gap=37.1 Gap=45.6 Gap=45.0 ID=11.0 ID=17.3 ID=14.0

70.0

62.9 60.0

60.0 55.9

53.0 51.1

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7.8 5.4 10.0 4.9 0.0 No insurance for outpatient users Not covered by any health insurance Not covered by any health insurance women (15-49) men (15-49) Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Aljoun Karak Tafilh Maan Aquaba

Figure 94 Prevalence of health insurance coverage indicators by governorates and their measures of inequality, JPFHS, 2017 For inequality across wealth quintiles, figure 95 reveals that there are small differences across the wealth quintiles for all indicators. Applying the prevalence criteria, all wealth quintiles fall in the very high prevalence category for the percentage of men and women not covered by health insurance.

For the other two indicators they continue to fall in the high prevalence category for all wealth quintile in which their prevalence exceeds the threshold of 20%. The only exception to this pattern is the middle quintile for non-coverage among users of inpatient in which the prevalence reaches 17.9%. Assessment of the gaps between the best and worst wealth quintile shows small relative gaps. The gaps range between 3.9 points for non-coverage among women and 10.1 point for non-coverage among men. The overall assessment of inequality also revealed low inequality (IC<5%)

Gap=8.8 Gap=5.0 Gap=3.9 Gap=10.1 CI=-1.2 CI=0.3 CI=1.43 CI=-0.5

60.0 54.9

51.0

49.2

47.7 44.8

50.0 44.2

42.4

41.2

40.6 40.3

40.0

32.2 32.2

31.8

30.1

27.2 26.7

30.0 26.1

23.4 23.1

20.0 17.9 10.0 0.0 No insurance for inpatient No insurance for outpatient Not covered by any health Not covered by any health users users insurance women (15-49) insurance men (15-49)

Poorest Poorer Middle Richer Richest Figure 95 Prevalence of health insurance coverage indicators by wealth and their measures of inequality, JPFHS, 2017 79

Differences in health insurance coverage are substantially large by educational attainment. Applying the prevalence criteria across the educational attainment categories reveal the privileged status of those with higher education across three of the four indicators (figure 96) Those with the higher education scored the lowest prevalence in the non-coverage of men, women and users of outpatients. Among users of inpatient, those with secondary education followed by those with no education registered the lowest non-coverage by health insurance. For the other educational categories, non-coverage for men and women maintained their classification as very highly prevalence and non- coverage for users of inpatient or outpatient continues to be classified as a highly prevalent.

Gap=8.3 Gap=9.5 Gap=23.5 Gap=21.9

CI=-1.2 CI=-5.1 CI=-8.4 CI=-10.3 56.6

60.0 54.9

51.0

50.2

48.9

47.7 47.6

50.0 45.3

35.5

33.0 33.0 32.4

40.0 32.0

29.3

27.9

26.0 26.0 24.8

30.0 22.1 19.6 20.0 10.0 0.0 No insurance for inpatient No insurance for outpatient Not covered by any health Not covered by any health users users insurance women (15-49) insurance men (15-49) No education Primary Preparatory Secondary Higher

Figure 96 Prevalence of health insurance coverage indicators by education attainment and their measures of inequality, JPFHS, 2017 The above differences in the four indicators resulted in varying gaps between the best and worst performing educational attainment. The gap ranges between 8.3 points for non- coverage among users of inpatients and 23.5 points for non-coverage of women. Assessing the inequality across the distribution by the educational attainment classified non-coverage for inpatient as low inequality, non-coverage for outpatient and women as moderate inequality and non-coverage for men as severe inequality. It is important to note that for the latter three indicators, the inequality direction indicates higher concentration of deprivation of health insurance coverage among those with lower educational attainment. Non-coverage of health insurance by nationality revealed substantial differences with the other nationalities are more deprived than Jordanian or Syrians across all the four indicators. However, figure 97 clearly shows that non-coverage across the four indicators among Syrian and Other nationalities is consistently classified as very highly prevalent with prevalence >40%. For the Jordanian, only non-coverage for men is classified as very highly prevalent, non-coverage for women and users of outpatient is classified as a highly prevalent and finally non-coverage for users of inpatient is classified as moderate prevalence with a prevalence of 17.4%. The above difference contributed large gaps between the prevalence for Jordanian and other nationality. The gap ranges between 56.7 points of non-coverage among users of inpatients and 30 points of non-coverage among men. The inequality measure across the whole distribution by nationality confirmed the highly severe inequality in non-coverage among users of inpatient with ID>20% followed with severe inequality in non-coverage among users

80 of outpatient (ID>10%), moderate inequality in non-coverage among women (ID>5%) and low inequality in non-coverage among men (ID<5%).

Gap=56.7 Gap=49.7 Gap=33.0 Gap=30.0 DI=22.8 ID=13.1 ID=6.9 ID=2.9 100.0 86.6 74.2 75.9 80.0 71.4 56.9 60.7 56.6 61.3 60.0 50.8 38.4 40.0 26.2 17.4 20.0 0.0 No insurance for inpatient No insurance for outpatient Not covered by any health Not covered by any health users users insurance women (15-49) insurance men (15-49) Jordanian Syrian Others

Figure 97 Prevalence of health insurance coverage indicators by nationalities and their measures of inequality, JPFHS, 2017

8.2 CONCLUDING REMARKS In brief, table 32 and the investigation of health and health equity priority in health insurance coverage can be summarized in the following  The two indicators for health insurance coverage for men and women were classified as very highly prevalent, while the two indicators of health insurance coverage for users of in and out patient was classified as highly prevalent.  Except for wealth, all other stratifiers showed at least moderate inequality for health insurance coverage.  Across governorates, all indicators showed severe inequality.  For education, lack of insurance among users of inpatient showed low inequality, lack of insurance among users of outpatient and no health insurance coverage for women showed moderate inequality, and only no health insurance coverage for men showed severe inequality.  No health insurance coverage among women was moderately unequal by nationality, while lack of health insurance among inpatients and outpatients were severely unequal.  Residents of Amman, individuals in the poorest quintile, those with no education or primary education, and those with other nationalities were the most vulnerable social groups in health insurance coverage. Table 32 Summary results of health insurance coverage Sttratifiers Prevalence Indicator Gov. Wealth Education Nationality No insurance for inpatient users na No insurance for outpatient users Not covered by any health insurance women (15-49) Not covered by any health insurance men (15-49) Note: na indicates inequality was not assessed due to small numbers across the governorates For prevalence Moderate Prevalence<20%) High 20%40%

For inequality Low (ID/IC<5%) Moderate (5%

9 HEALTH AND HEALTH EQUITY PRIORITIES IN JORDAN: PATTERNS AND TRENDS

The previous sections investigated the levels separately for the five aspects of health, and the inequalities and trends for each health indicators across the four stratifiers. The current section attempts to bring together all the separate findings to draw ageneral picture on health and health inequality in Jordan. The current section answers the following questions.

 What are the main health priorities in Jordan and their trend between 2012 and 2017?  What is the distribution of health priorities for different social groups and which social group is the most vulnerable social group?  What is the distribution of severity of health inequality for different stratifier and which stratifier is more severely unequal?  What are the trends in prevalence and inequality summary measures between 2012 and 2017?

9.1 WHAT ARE THE MAIN HEALTH PRIORITIES IN JORDAN AND THEIR TREND BETWEEN 2012 AND 2017? Figure 98 shows the distribution of the classifications of the 85 investigated indicators. It shows that 31 indicators out of the 85 indicators had a prevalence of 40% classifying them as very high prevalence. In addition, 32 indicators showed a prevalence of 20% to 40% or exceeded their international standard classifying them as high prevalence or priority. In other words, at least one fifth of the population are burdened by the ill health assessed in those 63 health indicators. This leaves 22 indicators with moderate or low prevalence.

Moderate/ low Very high prevalence; 22 prevalence ; 31

High prevalence; 32

Figure 98 Distribution of health indicators by their prevalence classification

On the basis of the investigated health indicators, the important question is how this distribution of priority classification is divided among different health aspects. Figure 99 shows that overall, Jordan has many health priorities across different investigated health aspects and there are many ill health indicators that affect at least 20% of the population. However, there are different structure of these 82 challenges across the main groupings of health indicators. Health impact indicators for child mortality and diabetes, health sector capacity and health insurance coverage are placed in the very high and high prevalence classification, and hence constitute priority challenges. For the risk factors indicators, Figure 99 shows that majority of them are classified as very high /high prevalence health indicator. This high dominance of priority health indicators was observed particularly among health risk factors related to domestic violence, HIV/AIDS, child nutrition and NCDs. In contrast, the situation is more attenuated for the indicators of the health sector performance where they mostly fall in the moderate/low prevalence classification. This is particularly true for HS performance for infant and maternal health. Only HS performance for other RH issues (premarital examination and knowledge of the HIV/AIDS test place) was classified as health priority.

In other words, figure 99 demonstrates the significance of the impact indicators, risk factors, health sector capacity and health insurance coverage in shaping Jordan’s health priorities. It also provides evidence on the success of the health sector in Jordan to expand its coverage to large segments of the population in particular in the area of infant and maternal health. However, it needs to spend more effort in other health dimensions.

Impact Diabetes 4 Child mortality 3

Infant health 1 1 child nutrition 6 child development 3 1 Risk factors NCDs 5 1 Social RH 4 2 HIV/AIDS related (f) 5 1 HIV/AIDS related (f) 5 1 Domestic violence 7 1

Health sector Infant health 4 performance Child health 4 4 Maternal health 2 4 Family Planning 2 2 Other RH 4

HS capacity 4

Health insurance coverage 4 0 1 2 3 4 5 6 7 8 9 at least high prevalence moderate prevalence

Figure 99 Number of health indicators by prevalence classifications for the different health dimensions.

Monitoring the trend in the prevalence can provide policy makers with early warning signals for some health dimensions as well as the success or failure of the interventions and programs implemented in those dimensions. Figure 100 shows that out of the 66 health indicators that have comparable prevalence in 2012, the prevalence of 32 indicators increased between 2012 and 2017. It also shows that 18 of those indicators increased by more than 25% of their levels in 2012. In other words, the prevalence of almost 50% of the investigated indicators increased between 2012 and 2017 and more than 27% of the indicators increased by more than 25% of its level in 2012.

83

increased >=25%; 18

same of decreased; 34

increased <25%; 14

Figure 100 Number of health indicators by the change in their prevalence between 2012 and 2017

Figure 101 compares the changes in the prevalence across the different health aspects. It shows that the prevalence of all the indicators for child mortality, risk factors for infant health, health sector performance for other RH (premarital examination and knowledge of HIV/AIDS testing place) and health sector capacity has declined between 2012 and 2017. In contrast, increases in the prevalence of more than half the health aspect indicators can be observed in

a) Child nutrition risk factors where all indicators increase in prevalence, b) NCDs risk factors, domestic violence related risk factors, health sector performance for child health and health sector performance for maternal health where more than 50% of their indicators increased be more than 25% of its 2012 c) The remaining health aspects showed a decline in prevalence in the majority of their indicators and most of the increases in the prevalence were less than 25% of its 2012.

For more specific details on the changes in prevalence for all indicators, see appendix D.

Impact Child mortality 3 RF_Infant health 2 RF_ child nutrition 0 5 1 Risk factor RF- Child development 3 1 RF_NCDs 2 3 RF_ Social RH 4 2 RF_ HIV/AIDS related 2 2 2 RF_Domestic violence related 1 2 3 HSP_Infant health 3 1 Health sector HSP_Child health 1 2 4 performance HSP_Maternal health 3 3 HSP_FP 3 1 HSP_Other RH 3 Health sector HS capacity 4 capacity 0 2 4 6 8 decreased increased <25% increased >25%

Figure 101 Number of health indicators for the different health aspects by the change in their prevalence between 2012 and 2017

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9.2 WHAT IS THE DISTRIBUTION OF HEALTH PRIORITIES FOR DIFFERENT SOCIAL GROUPS AND WHICH SOCIAL GROUP IS THE MOST VULNERABLE SOCIAL GROUP? Four stratifiers were used in the current study. In this section, the profile of health priorities for the different social groups is investigated. These profiles are further compared against the national profile of health priorities with the aim of identifying the more disadvantaged social group. Two approaches were implemented to assess the different social groups priorities.

The first approach: The distribution of indicators by prevalence classification

This approach classifies the health indicators on the basis of the prevalence criterion used throughout this report. This criterion divides the health indicators into three categories very high prevalence, high prevalence and moderate prevalence. The first two categories of very high and high prevalence are classified as priority. In addition to the three prevalence categorization, one extra classification is applied. This classification is applied to the indicators that fall in the moderate / low prevalence category. Within the moderate category, any prevalence higher than the national level is considered a priority. In other words, the national level or a prevalence of 20% is considered the threshold beyond which the health indicator is classified as a priority. (For a complete profile of indicators and their prevalence classification for each social groups across the four stratifiers implemented in this study, see appendix B). To summarize these profiles, the current section presents an overview of the priority distribution for the different social groups within each stratifier.

The second approach: The social groups experiencing the highest prevalence performance

This approach is based on counting the number of indicators for which the social groups scored the worst among the different social groups across each stratifier. (For a full list of the worst performing social group on the different indicators for each stratifier, see Appendix C).

9.2.1 The priorities structures for the social groups for different stratifiers Figure 102 shows the distribution of the health indicators by their priority classification for each governorate in Jordan. It clearly shows that for all the governorates at least 54 of the 85 health indicators were classified as a priority or high priority indicators. Considering the national level of high priority/priority indicator is 63 indicators, seven governorates had number of high priority/ priority less that this national level, namely Amman, Zarqua, Jerash, Ajloun, Karak, Tafielh and Aqaba. In contrast, the number of high priority/priority indicators was the highest in Mafraq (76 indicators) followed by Madaba (74 indicators) and Maan (70 indicators).

80.0 74 76 70 69 67 70.0 62 62 57 57 59 60.0 54 54 50.0 40.0 30.0 20.0 10.0 0.0 Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Aljoun Karak Tafilh Maan Aquaba

Figure 102 Number of priority health indicators out of the 84 investigated indicators for each governorate in Jordan.

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Clearly, all governorates in Jordan experience a large share of health challenges and three governorates suffer from a high share of the priority health challenges.

For wealth and education attainment, there was a clear gradient (figure 103) in the number of priority health indicators. The poorest registered the highest number of priority indicators (74 out of 85 indicators) compared to the richest (57 indicators). Similarly, individual with no or primary education exhibited the highest number of priority indicators (78 out of 85 indicators) compared to the number of priority indicators among those with higher education (55 indicators). For the nationality, Syrians registered the largest number of priority indicators (78 indicators) followed by other nationalities (75 indicators).

90.0 76.0 78.0 78.0 78.0 80.0 75.0 75.0 66.0 70.0 64.0 58.0 60.0 57.0 58.0 60.0 55.0 50.0 40.0 30.0 20.0 10.0 0.0

Figure 103 Number of priority health indicators out of the 85 investigated indicators by wealth, education and nationality in Jordan.

9.2.2 Social groups experiencing worst performance Figure 104 shows the number of the indicators for which each governorate scored the highest prevalence. According to this approach, Madaba and Maan were the two governorates that scored highest on 13 indicators followed by Mafraq with 12 indicators and Balqa with 10 indicators. These four governorates matches the top four governorate identified in the priority-structure distribution approach. In contrast, Zarqua and Ajloun were the two indicators who exhibited the smallest number of indicators for which they scored the highest prevalence.

14 13 13 12 12 10 10 8 6 6 5 5 5 5 4 4 3 3 2 0 Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Aljoun Karak Tafilh Maan Aquaba

Figure 104 Number of indicators with the highest prevalence in the governorates in Jordan.

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Figure 105 explores the number of indicators for which the different social categories by wealth, education and nationality scored the highest prevalence. It clearly shows vulnerable status of the poorest wealth quintile, individuals with no education and Syrians. These three groups scored the highest prevalence in 53, 52 and 49 indicators out of the 85 indicators, respectively. It is worth noting that contrary to the governorates stratifier, these other three stratifiers reflect a much larger difference in the number of indicators that showed the highest prevalence for the poorest quintile, those with no education and Syrians compared to the next social groups. In contrast, the middle wealth quintile, the secondary educated and the Jordanian were the social groups that scored the best across all the indicators.

60 53 52 49 50 40 27 30 18 20 13 10 9 6 7 10 4 2 3 0

Figure 105 Number of indicators with the highest prevalence by social groups by wealth, education and nationality

In sum, the two approaches implemented in this subsection confirmed that the four governorates of Madaba, Mafraq, Maan and Balqa were the most health disadvantaged governorates in Jordan. It also confirmed that the poorest, individuals with no education and Syrians were the most vulnerable social groups.

9.3 WHAT IS THE DISTRIBUTION OF SEVERITY OF HEALTH INEQUALITY FOR DIFFERENT STRATIFIER AND WHICH STRATIFIER IS MORE SEVERELY UNEQUAL? The distribution of each health indicator within the different stratifiers is an expression of the inequality of the share of the burden among the social groups within each stratifier. For each indicator, the summary measure of inequality provided in earlier sections was classified into the three categories of severe, moderate and low inequality. This section investigates the distribution of the degree of inequality of all indicators for each stratifier and according to indicators’ prevalence classification. This investigation allows an identification of the stratifiers suffering from the largest number of severe inequality.

In terms of stratifiers reflecting severe inequality, education showed severe inequality for 29 indicators out of the 85 investigated ones. This was followed by the governorates across which 19 indicators showed severe inequality (figure 106). So despite the fact that the distribution of the number of health priorities was not markedly different across the governorates, yet a large number of indicators was severely unequal.

In terms of the wealth and nationality stratifiers, despite the frequent identification of the poorest quintile and the Syrian as carrying the higher burden of ill health, yet few summary measures of inequality were classified as severe across them (14 and 7, respectively).

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governorates 19 32 34

wealth 14 23 48

education 29 10 46

nationality 8 12 65

0 10 20 30 40 50 60 70 80 90

severe moderate low

Figure 106 Distribution of indicators by their inequality severity across the different stratifiers

In terms of the relationship between the level of the prevalence and the degree of inequality, figure 107 shows that the number of indicators classified as severely unequal increases with the decline in the prevalence. This suggests that improvements in health are not equally shared among all the social groups.

Similar patterns emerge between the stratifiers by the classification of the indicators according to their prevalence category. Among moderate prevalence indicators, inequality across the governorates and by education exhibited more severely unequal indicators than wealth or nationality, respectively.

Among high prevalence indicators, the severity of inequality was highest by education followed by wealth, governorates and nationality. For the very high prevalence indicators, governorates and education show again the same number of severely unequal indicators, followed by wealth. There were no high priority indicators with severe inequality by nationality.

very high 3 4 24 high 5 19 8

Govern. moderate 11 9 2

very high 1 3 27 high 6 13 13 Wealth moderate 7 7 8

very high 3 1 27 high 15 8 9

Education moderate 11 1 10

very high 1 31 high 3 7 23

Nationality moderate 4 8 11 0 5 10 15 20 25 30 35

severe moderate low

Figure 107 Distribution of indicators by their prevalence classification and severity of inequality across the different stratifiers

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9.4 WHAT ARE THE TRENDS IN THE INEQUALITY SUMMARY MEASURES FOR THE DIFFERENT HEALTH ASPECT BY THE DIFFERENT STRATIFIERS BETWEEN 2012 AND 2017? In investigating the sexual and reproductive health in four Arab countries, Rashad and colleagues (2019) showed that inequality in Jordan across the two stratifiers of the governorates and wealth was relatively speaking low compared to Egypt and Morocco. The current section explores the changes in the different health indicators inequality summary measures across the four investigated stratifiers between 2012 and 2017.

Figure 108 shows that out of the 66 indicators that were compared between 2012 and 2017, the governorate stratifier showed the largest number of indicators that experience an increase in their inequality summary measure (46 out of 66 indicators). However, the more alarming signal is the change in the severity classification of these inequality from low to moderate inequality or from low or moderate to severe inequality. Out of the 46 increases in inequality by governorates, the inequality in 23 indicators increased in their severity classification. For inequality by wealth, only 20 indicators showed an increase with 8 indicators showing an increased in the severity of their inequality classification. For education, 25 indicators showed an increase in their summary inequality measures with 13 indicators showing an increased in their severity classification. In other words, almost 50% of the increases in inequality measures across the three stratifiers showed an increase in the inequality classification.

Educ. 41 12 13

Wealth 46 12 8

GOV 20 23 23

0 10 20 30 40 50 60 70

same/decline increase with no change in severity increased with increase severity

Figure 108 Number of indicators by the change in their inequality summary measures and their severity classification between 2012 and 2017 by the different stratifiers

Focusing on the indicators that their inequalities classification changed to higher degree of severity, figure 109 shows that the 23 indicators, for which the severity of their inequality by the governorates increased between 2012 and 2017, were found in 10 of the 14 investigated health aspects. However, they were more concentrated in the domestic violence related risk factors, social RH risk factors and Health sector capacity, followed by the child mortality and infant and child risk factors.

For the 8 indicators, for which the severity of their inequality by wealth increased between 2012 and 2017, they fell in 5 of the 14 investigated health aspects. They were more concentrated in the social RH risk factors, and infant health risk factors. For the 13 indicators, for which the severity of their inequality by education increased between 2012 and 2017, they were found in 6 of the 14 investigated health aspects. They were more concentrated in the domestic violence related risk factors, health sector capacity followed by infant health risk factors, reproductive health risk factor and health sector performance for other RH aspects. (for more details of the increase in summary inequality measures for the different health indicators and stratifiers, see appendix D)

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By governorate By wealth By education

Child mortality 2 0 0 RF_Infant health 2 2 2 RF_ child nutrition 2.0 1.0 0.0 RF- Child… 1.0 0.0 0.0 RF_NCDs 1.0 0.0 0.0 RF_ Social RH 4.0 3.0 2.0 RF_ HIV/AIDS… 1.0 0.0 0.0 RF_Domestic… 5.0 1.0 3.0 HSP_Infant health 0.0 0.0 0.0 HSP_Child health 0.0 0.0 0.0 HSP_Maternal… 0.0 0.0 0.0 HSP_FP 1.0 0.0 1.0 HSP_Other RH 0.0 0.0 2.0 HS capacity 4.0 1.0 3.0 0.0 2.0 4.0 6.0 0.0 2.0 4.0 0.0 2.0 4.0

Figure 109 Number of indicators that changed the severity of their inequality by different stratifiers for the different health aspects

9.5 CONCLUDING REMARKS  The 63 indicators of the 85 health indicators investigated were classified as a priority affecting at least 20% of the population or exceeding international standards.  Classifying health indicators across the four categories namely impact, risk factors and health sector, the findings of the current study showed that o All Health impact, health insurance coverage and health sector capacity indicators were classified as health very high /high prevalence indicating they are priority challenge o The majority of the risk factor indicators were classified as health very high/ high prevalence. This is particularly critical for domestic violence, HIV/AIDs, child nutrition and NCDs risk factors. o Health sector performance indicators demonstrated the success of Jordan health system meeting the health needs of large population segments as indicated by the large number of moderate prevalence indicators among them. This is particularly true for infant and maternal health. o However, health sector performance lags in meeting the needs of the population in some dimensions of RH particularly premarital test and knowledge of testing place for HIV/AIDs.  Exploring trends in prevalence showed that o 32 indicators of the 66 compared indicators experience an increase in prevalence between 2012 and 2017. Among the indicators that increased in prevalence, 18 of them increased by more than 25% of their 2012 levels. o Increases in the prevalence in more than half the health aspect indicators was observed in child nutrition risk factors where all indicators increase in prevalence, NCDs risk factors, domestic violence related risk factors, health sector performance for child health and health sector performance for maternal health where more than 50% of their indicators increased be more than 25% of its 2012  The most vulnerable social groups across the four stratifiers used in the current study were o The five governorates of Mafraq, Madaba, Maan, Balqa and Irbid showed number of very high/ high prevalence indicators exceeding the national level of 63 indicators.

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o Individuals in the poorest and poorer wealth quintiles registered larger number of very high/ high prevalence indicators than the national level o Except for highly educated individuals, individuals in all other education categories scored a number of very high/ high prevalence indicators that exceed the national level o Syrians and other nationalities also exceeded the national level in the number of indicators classified as very high/ high prevalence indicators.  The same findings are confirmed using another approach in identifying the most vulnerable social groups. This approach was based on counting the number of health indicators in which the different social categories scored the highest prevalence. In particular, o The four governorates of Mafraq, Madaba, Maan, and Balqa scored the highest prevalence in at least 10 indicators. o Individuals in the poorest quintile, those with no education and Syrians were the social groups that scored highest on largest number of indicators in comparison to other social groups with the same stratifiers  Exploration of inequality revealed that o Overall, education showed the largest number of severe inequality followed by governorates. The wealth and nationality stratifiers showed less severely unequal number of indicators o The severity of inequality increases as the indicators move down the prevalence classifications. moderate prevalence indicators show more severe inequality than those for very high/ high prevalence indicators.  Exploring trends in inequality summary measures by the different stratifiers showed that o Inequality by governorates showed the largest number of indicators that experience an increases in their inequality (46 indicators) followed by inequality by wealth and education (25 and 20 indicators, respectively). o Changes in the severity of the inequality classification was also observed in 23 indicators by governorates with the majority of those indicators falling in the domestic violence related risk factors, social RH risk factors and Health sector capacity, followed by the child mortality and infant and child risk factors , o Changes in the severity of the inequality classification was also observed in 8 indicators by wealth with the majority of those indicators falling in the social RH risk factors, and infant health risk factors o Changes in the severity of the inequality classification was also observed in 13 indicators by education with the majority of those indicators falling in the domestic violence related risk factors, health sector capacity followed by infant health risk factors, reproductive health risk factor and health sector performance for other RH aspects.

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10 HEALTH AND HEALTH EQUITY PRIORITIES IN JORDAN: CURRENT STATUS AND THE WAY FORWARD

This section offers an overview of the current health status in Jordan and attempts to support ongoing efforts by highlighting success and defining appropriate points of interventions for future improvements on the health and health equity fronts. This section is divided into four parts. The first provides a synthesis of the findings of the current study and assess them in the light of health strategic directions and SDGs for Jordan. The second deals with Jordan health and health equity priorities in relation to international commitments and global strategies. The third part discusses broad guidelines for the way forward. The fourth part presents policy recommendations. However, before proceeding to these subsections, it is important to draw attention to the aspects of health that were not fully investigated due to data limitations. JPFHS 2017 offers a wealth of data on health situation in Jordan. It provides data on marriage, maternal and child health and nutrition, HIV/AIDS and other sexually transmitted infections, and women’s experience of gender based violence. It also includes some limited data on chronic diseases in particular diabetes, some of the NCDs risk factors and health insurance coverage. The richness of the data in JPFHS has allowed an extensive investigation of the available health indicators as well as a thorough examination of their inequalities. Despite the wealth of information on reproductive health, the survey did not cover some important dimensions in sexual and reproductive health. For example, the survey did not cover issues regarding puberty, infertility, reproductive morbidity, menopause and psychological and wellbeing aspects. Furthermore, the focus on issues of reproductive health has not allowed the collection of more detailed data and information on other health dimensions such as those related to NCDs and their risk factors and issues related to mental health. Therefore, with these limitations in mind, it is important to recognize the underrepresentation of some health aspects in the current report.

JORDAN HEALTH AND HEALTH EQUITY PRIORITIES: STRATEGIC DIRECTIONS VERSUS DATA REALITY

Over the past 10 years, Jordan launched four strategy documents that addressed health in Jordan at different levels. These strategy documents started with Jordan 2025: vision and strategy, followed by the health sector strategy, Ministry of Health strategy and the reproductive health strategy. In addition, in 2005 Jordan launched its National Strategy and Plan of Action against Diabetes, Hypertension, Dyslipidemia and Obesity. A review of these strategy documents showed that a number of specific health challenges have been identified in Jordan:  Population growth and its implications on the age structure,  Population distribution across the country,  Non-communicable diseases in particular Cardiovascular diseases, diabetes and cancer,  Smoking in the population in particular the male population,  Neonatal mortality

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ANEMIA AMONG WOMEN IN REPRODUCTIVE AGE AND CHILDREN,

 Knowledge of sexually transmitted diseases,  Consanguinity and early marriage and their negative impact on women’s health and social wellbeing,  Use of traditional family planning methods and  Unmet need for contraceptive methods. The findings in the current study lend full support to the identified health priorities in Jordan health strategies. It also allowed a number of other findings. First and foremost, the current efforts in Jordan have succeeded in addressing and improving a wide range of health issues. Yet, the evidence in this report showed that the health agenda is still unfinished. More than two thirds of the investigated indicators showed very high/high prevalence. In other words, at least one out of five of the exposed population continue to suffer from the burden of these indicators. This places these indicators as main health challenges or priorities that need focused and programmatic efforts. Half of those highly prevalent indicators fall in social health risk factors in particular those health risk factors related to domestic violence, HIV/AIDS, child nutrition and NCDs. In contrast, the evidence showed that the health system performance was on the right track with a large number of its investigated indicators classified as moderate prevalence (less than 20%). This is particularly true for health sector performance for infant and maternal health. Only health sector performance for indicators of other RH issues (premarital tests and places for HIV test) were classified in the very high/high prevalence and constitute health challenges. In terms of inequality, the health sector performance indicators show many moderate and severe inequalities by the four investigated stratifiers that match those in the social health risk factors groups. The relative success of the health system performance was achieved despite the challenges on the health system capacities. The current evidence highlight that limited number of health system capacities indicators investigated in the current study show very high/high prevalence. On the health insurance coverage, the recent evidence showed the limited coverage of the current health insurance with almost 46% of the population still lack health insurance coverage. However, interestingly the evidence showed that the health insurance coverage was very gender sensitive and women were more likely to be covered by health insurance than men (58.3% versus 50.4% for women and men age 15-49, respectively). The health strategy in Jordan recognized the extra burden of ill health born by some governorates as well as low/middle income families. Evidence from the current study supported the importance of responding to the challenges of the disadvantaged social groups within the two stratifiers of governorates and wealth stratifiers. The five governorates of Mafraq, Madaba, Maan, Balqa and Irbid showed large number of very high prevalence and high prevalence indicators. Iindividuals in the poorest and poorer wealth quintiles also showed large number of very high / high prevalence indicators. The evidence provided in this report introduced further recent detailed information on the burden born by other different social groups such as individuals in the low levels of education and it emphasized the vulnerable status of Syrians. Another main contribution in the current study was to move the focus from the identification of the vulnerable social groups to providing detailed evidence on the distribution of ill health among the 93 social groups within the different stratifiers. In particular, the education and the governorates were shown as stratifiers that reflect severe degrees of inequalities (summary measures>10%). On the other hand, wealth and nationality did not show large number of severely unequal health indicators. Furthermore, the evidence showed that while the degree of inequality in Jordan is relatively lower than a number of other Arab countries, yet, with the exception of the health sector performance, the severity of the inequality is increasing in Jordan alongside the improvements in health conditions. This implies that the benefits of these improvements are not equally shared among the different social groups.

JORDAN HEALTH AND HEALTH EQUITY PRIORITIES: INTERNATIONAL COMMITMENTS AND GLOBAL STRATEGIES

Jordan strategies adequately speak to the SDGs health specific targets, summarized in figure (110). Indeed, Jordan prioritization of the five investigated aspects of health is supported by the findings of this report.

Child SRH health Health and capacity well- being

Adult Health health insurance & coverage NCDs Health performance

Figure 110 SDGs health specific targets and Jordan’s defined health priorities

The indicators provided in the current report in comparison to the quantified SDG2030 targeted indicators are presented in table 33. This table shows that again, with the exception of the maternal mortality, infant and child mortality and births attended by skilled personnel, Jordan should accelerate its effort to achieve the SDGs targets particularly for family planning, adolescent childbearing, smoking, child development, violence against women and children, and early marriage.

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Table 33 The indicators in the latest JPFHS (2017) report in comparison to the SDGs 2030 targeted indicators. Indicators 2030 targets Jordan less than 70 per 100,000 live 3.1.1 Maternal mortality ratio 29.5 per 100,000 live births births 3.1.2 Proportion of births attended by skilled 99.7% of births health personnel At least as low as 25 per 1,000 3.2.1 Under-five mortality rate 19 per 1000 live births live births At least as low as 12 per 1,000 3.2.2 Neonatal mortality rate 11 per 1000 live births live births 3.7.1 Proportion of women of reproductive age 56.7% of women of reproductive age (aged 15-49 years) who have their need for family Ensure universal access to (aged 15-49 years) planning satisfied with modern methods sexual and reproductive health- 3.7.2 Adolescent birth rate (aged 10-14 years; care services aged 15-19 years) per 1,000 women in that age 27 per 1000 group Strengthen the implementation 3.a.1 Age-standardized prevalence of current of the World Health 44.6% for men aged 15 years and older tobacco use among persons aged 15 years and Organization Framework 12.0% for women aged 15 years and older Convention on Tobacco Control older in all countries, as appropriate Support the research and development of vaccines and medicines for the communicable and non- For children communicable diseases that 3.b.1 Proportion of the target population covered a) Coverage of DPT containing vaccine primarily affect developing by all vaccines included in their national (3rd dose) 90.0% countries, provide access to programme b) Coverage of measles containing affordable vaccine (2nd dose) 89.1% essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement and Public Health 4.2.1 Proportion of children under 5 years of age who are developmentally on track in health, 70.7% of children under 5 years of age learning and psychosocial well-being. Among ever partnered women and 5.2.1 Proportion of ever-partnered women and girls aged 15 years and older girls aged 15 years and older subjected to a) Any violence 20.4% physical, sexual or psychological violence by a b) Physical violence 12.7% current or former intimate partner in the previous c) Sexual violence 3.3% 12 months d) Psychological violence 16.1 % Of women aged 20-24 years were 5.3.1 Proportion of women aged 20-24 years who married were married or in a union before age 15 and a) Before age 15 1.5% before age 18 b) Before age 18 9.7% 16.2.1 Percentage of children aged 1-17 years who experienced any physical punishment and/or 81.3% of children aged 1-17 years psychological aggression by caregivers in the past month 16.9.1 Proportion of children under 5 years of age whose births have been registered with a civil 98% of children under 5 years of age authority

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As indicated earlier, Jordan had already articulated many national strategies to address its health challenges (e.g.: SRH, NCDs strategies) 26,14, and to improve health sector performance, as well as achieve universal health coverage. These strategies are guided by the international consensus on evidence-based solutions and the contextual Jordanian realities. The analysis in the current report and the many recommendations that will follow are in full agreement with the foundational directions of the many global reports produced by WHO and other development partners. The following highlights this agreement by referring to one example of the international consensus, provided in the WHO Report of the WHO Independent High-Level Commission on Non-Communicable Diseases (2018) (NCDs/WHO)19. The recommendations of the NCDs/WHO report start by emphasizing the importance of situating the actions at the top. This is consistent with the SDHI framing adopted in the current report. Indeed, the NCDs/WHO report states “Heads of States and Government, not ministers of Health only, should oversee the process of creating ownership at the natural level of NCDs and mental health” and emphasizes different levels of leaderships of actions, as well as the comprehensiveness of local actions, implemented jointly with the health sector. Furthermore, the NCDs/WHO report recognizes the need to identify specific set of priorities within the overall NCD and mental health agenda, based on public health needs. The current Jordan report again provides the evidence needed for such prioritization for NCDs as well as for the other investigated aspects of health. The role of health system and universal health coverage are also detailed in the NCDs/WHO report as is the case of the current report. Finally, the necessity of a whole of society approach, the availing of financial resources and of accountability are highlighted in the NCDs/WHO respectively. The current Jordan report is well situated within international directions, and captures country specificity by relying mainly on a recent 2017 set of data for Jordan. Moreover, a specific added contribution of the Jordan report is in its mainstreaming of an explicit equity lens in both the analysis and the recommendations. Such an equity lens was championed by the Commission of Social Determinants of Health and embraced by the recently established EMRO-commission11. The mainstreaming of the equity lens in the analysis was demonstrated by the detailed investigations of the systematic partners of inequality and their trend over time. It was also demonstrated by investigating the fairness of the two intervening intermediary forces of health sector and health insurance. The fairness investigation was conducted through analyzing the inequality of health system performances and capacities among the different social groups. It was also conducted by analyzing the differences in UHC coverage among social groups. More importantly, the equity lens is emphasized in the following policy recommendations, and is referred to at every level of actions and for every actor. Indeed, starting from the diagnosis of priorities to the judgment of performance of actors to monitoring impact up to measuring development; the concern with the inequality distribution is evident.

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JORDAN HEALTH AND HEALTH EQUITY PRIORITIES: THE WAY FORWARD

The SDHI framing implies that health inequalities should be pushed to the forefront as a measure of development and of its fairness. It also emphasizes the role of upstream forces and the whole of government responsibility for achieving health equities. The framing also suggests that policies and interventions can operate at four different entry levels and be led by different actors within each level. These levels are presented below and provided in figure 111. Level A: Effective and equitable health sector programs respond to differentiated health care needs, and to address systematic differences in risk factors and, Level B: Community level interventions to impact and address inequitable exposure, Level C: Targeted initiatives and national level interventions catering for differentiated needs of social groups, and national level interventions addressing unfair social stratifications Level D: Whole of government approach ensuring equitable structural drivers.

Figure 111 Entry points of interventions for addressing health and health equity priorities

The way forward necessitates adapting the content of each level of the framework for each aspect of health investigated. It also requires development of evidence and plans of actions for each entry level. This adaptation was implemented in earlier analytical reports investigating SRH in different Arab countries2. Also the methodology for development of plans has been discussed in a recently produced methodology document27

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POLICY RECOMMENDATIONS

This section suggests some policy recommendations to capitalize on the current success in Jordan’s health experience and situates these recommendations within the different levels of entry points of policies and interventions.

V. Improve Equitable Performance of the Health Sector

Jordan is clearly on the right track in terms of its health policies and performance. In particular, Jordan is pursuing health priorities that are supported by evidence, and engaging in effective health sector programs. This encourages Jordan to continue its current efforts and to focus more attention to address the specific health challenges presented in this report (indicators showing high prevalence). Many Health Sector interventions at entry level A are required. Such interventions should cater for health care needs and target provision of equitable health to address the highly prevalent and inequitable distribution of social risk factors. Such interventions are generally led by the health sector in close collaboration with other sectors. The challenges facing particular social groups suggest that, despite the positive impact of the initiatives targeting the poorest and least advantaged areas, there is a need to target other disadvantaged social groups at lower levels of education and Syrian refugees. In addition, the challenges in the inequality distribution call for securing the requested adequate and fair health resources for all social groups. These recommendations entail actions at the entry levels B and C. At level B, it is important to implement a primary health care model, that goes beyond medical care, to provide an enabling and equitable environment. This model includes:  Targeting the levels and inequitable exposure to unhealthy living conditions and livelihoods for the purpose of influencing behavioral and biological risks.  The implementation of community level intersectoral development initiatives. The actions at level C includes a more effective and equitable UHC program.  Such a program not only responds to the challenges demonstrated in this report, but also avoids further contributing to the unfair stratification in society. Out of pocket expenditures on health are well known as an influential driver of poverty. VI. Hold Social Sectors Responsible for Health

Social sectors need to realize that they are key stakeholders and contributors for achieving better health outcomes in the society. Indeed, the role of social sectors goes beyond their contribution to intersectoral actions. The evidence of systematic and severe inequalities among social stratifiers suggest the importance of moving the focus from inequalities to inequities. The inequity focus emphasizes the lead responsibility of social sectors and the whole of government for producing fair distribution of resources for health. This requires actions at the entry levels C and D.

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At level C, the call is for sectoral initiatives to rectify the unfairness of developmental differences at the governorate level and to target alleviation of poverty and ensure non- discrimination by gender and nationalities. At level D, the call is for adoption of a comprehensive multisectoral equitable health strategies to promote health and to address the priority health and health inequality challenges. These strategies need to spell out targeted, time bound and quantified, health equality goals and to specify the responsibility of each sector for the achievement of specific health related targets. In particular, adoption of such a health strategy builds on the existence of an appropriate institutional structure in Jordan, currently represented by the Higher Health Council in Jordan. It also builds on the opportunity presented in Jordan plans to revisit its current health strategy. The revisiting of Jordan strategy for health, should ensure a wide participatory engagement in its development, implementation, monitoring and evaluation. Also, as referred to earlier, it should adopt policies and devote resources to support intermediary actors and intervening forces to foster equality among social groups and to be responsive to differentiated needs and higher risks of disadvantaged social groups. In addition to the role of social sectors within the articulated strategy for health, social sectors should be held accountable for the impact of their sectoral agendas on health inequities. For each health- related policy and/or initiative adopted by the social sector, a demonstration of positive impact, or at least of a no negative impact on health, should be considered as success criteria.

VII. Systematic Measurements and Monitoring of Health Inequities

The existence of an adequate health information system for systematically and periodically measuring and monitoring health and health inequalities is a pre-condition for building the recommended health strategy. Jordan is fortunate to have a series of recently collected surveys that are also made widely accessible. This availability of data is a very positive feature that can allow the contributions of the research and development stakeholders, and also avail needed evidence for policies. As indicated earlier, even with a very rich JPFHS and a focus on reproductive health, yet many aspects of health have not been measured. The road ahead is to invest in securing an information system for health. Such a system needs to include a minimum set of core indicators that adequately reflect the health spectrum of Jordan population. The data for the indicators should allow the formulation of context sensitive stratifiers (e.g: nationality in case of Jordan), and also include additional pieces of information needed to trace and relate inequality to their structural root causes and to fairness of these causes. Such data is expected to draw on a mix of routine sources of information and specialized surveys. In brief, a movement from the traditional health information system to a broader information system for health is very much called for.

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VIII. Pushing Equity to the Forefront as a Development Goal and a Whole of Government and Society Performance Measure.

The concern with inequality is very evident in Jordan development vision. The key framing of this report appreciates that systematic inequalities among social groups are measures of unfairness, and, that systematic health inequalities are impact measures that speak to the end results of all developmental efforts and their fairness. Fairness and the achievement of the health equity are measures of social success. Their absence underlies unrest and polarization in society. In particular embracing fairness requires integrating an equity lens in all policies and social arrangements. It requires ensuring fair distribution of power, money, resources and transformative opportunities. More importantly More specifically embracing fairness require:  Articulating health as a whole of government responsibility and developing an equity-based health strategies and plans  Enforcing health impact assessment in all policy approaches The Higher Health Council is well poised to play a stewardship role to place HE as a benchmark for a fair and developed society, and to monitor the implementation of the whole of government responsibility and the accountability process.

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1. Zoubi A., Elmoneer R. 2018. Inequalities in Sexual and Reproductive Health: The Case of Jordan. National Study; AUC/SRC and UNFPA/ASRO. http://schools.aucegypt.edu/research/src/Docume nts/SRH-Inequities/JORDAN-Report.pdf 2. Rashad H, Shawky S, Khadr Z, Afifi M, Sahbani S. 2019. Reproductive Health Equity in the Arab Region: Fairness and Social Success. Regional Report; The Social Research Center/The American University in Cairo, the United Nations Population Fund / Arab States Regional Office. 3. WHO (World Health Organization). Declaration of Alma-Ata International Conference on Primary Health Care; 1978 September 6-12; Alma-Ata, USSR. http://www.who.int/publications/almaata_declaration_en.pdf. Accessed 11 October 2018. 4. CSDH (Commission on Social Determinants of Health). Closing the gap in a generation: Health equity through action on the social determinants of health. Final report of the commission on social determinants of health. Geneva, Switzerland: World Health Organization; 2008. 5. Gilson L. Trust and development of health care as a social institution. Social Science & Medicine 2003; 56(7):1453-68. 6. Maddln, E., Binda, C. & Khasawneh, M. 2018. Legal Review of the Jordanian Decentralization Law: Final Report Karak Castle Center for Consultations and Training in cooperation with Friedrich- Ebert-Stiftung (FES). Downloaded from https://bindaconsulting.org/wp- content/uploads/2019/02/Legal-Review-of-the-Jordanian-Decentralization-Law-EN.pdf 7. Sowell, K. 2017. Jordan’s Quest for Decentralization. Sada: Middle East Analysis. Carnegie Endowment for international peace. Downloaded from https://carnegieendowment.org/sada/72905 8. Jordan Department of Statistics. 2019. Population Estimates. Downloaded from dosweb.dos.gov.jo/DataBank/Population_Estimares/ 9. World Bank. 2019. Jordan Data. Downloaded from https://data.worldbank.org/country/jordan 10. UNESCO Institute of Statistics. 2019. Jordan. Downloaded from http://uis.unesco.org/country/JO 11. UNDP. 2019. Inequalities in Human Development in the 21st Century: Briefing note for countries on the 2019 Human Development Report: Jordan. 12. Ministry of Planning and International Cooperation. Jordan 2015: National Vision and Strategy. 13. Jordan High Health Council. 2016. The National Strategy for Health Sector in Jordan 2016- 2020 14. Jordan Ministry of Health . 2011. National Strategy and Plan Of Action Against Diabetes, Hypertension, Dyslipidemia And Obesity. 15. Lee A, Kozuki N, Cousens S, Stevens G, Blencowe H, Silveira M et al. 2017. Estimates of Burden and Consequences of Infants Born Small for Gestational Age in Low and Middle Income Countries with INTERGROWTH-21st Standard: Analysis of CHERG Datasets. BMJ 358: j3677. DOI: 10.1136/bmj.j3677. 16. Mahumud R, Sultana M, and Sarke A. 2017. Distribution and Determinants of Low Birth Weight in Developing Countries. J Prev Med Public Health. 50(1): 18– 28.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5327679/ 17. WHO. 2018. Noncommunicable Diseases (NCD) Country Profiles, 2018. Geneva, Switzerland: World Health Organization. 18. Al-Nsour M, Zindah M, Belbeisi A, Hadaddin R, Brown DW, Walke H. 2012. Prevalence of Selected Chronic, Noncommunicable Disease Risk Factors in Jordan: Results of the 2007 Jordan Behavioral Risk Factor Surveillance Survey. Prev Chronic Dis 9:110077. DOI: ttp://dx.doi.org/10.5888/pcd9.110077

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19. Time to deliver: report of the WHO Independent High-level Commission on Noncommunicable Diseases. Geneva: World Health Organization; 2018. Licence: CC BY-NCSA 3.0 IGO. 20. WHO, UNICEF, UNFPA, World Bank Group, and the United Nations Population Division. 2019. Trends in Maternal Mortality: 2000 to 2017. Geneva, World Health Organization. 21. The Jordan Times. 2019. Jordan Maternal Mortality Rate Sees Decline — Health Minister. Downloaded from https://jordantimes.com/news/local/jordan-maternal-mortality-rate-sees- decline-%E2%80%94-health-minister 22. World Health Organization. 2009. Monitoring and Evaluation of Health Systems Strengthening: An Operational Framework. Paper prepared by WHO (Ties Boerma and Carla Abou‐Zahr), World Bank (Ed Bos), GAVI (Peter Hansen) and Global Fund (Eddie Addai and Daniel Low‐Beer) as part of the joint work on health systems strengthening and IHP+ common evaluation framework. 23. Sedgh G et al. 2016. Unmet Need for Contraception in Developing Countries: Examining Women’s Reasons for Not Using a Method. New York: Guttmacher Institute. 24. United Nations, Department of Economic and Social Affairs, Population Division. 2019. Contraceptive Use by Method 2019: Data Booklet (ST/ESA/SER.A/435). 25. United Nations. 2019. Political Declaration of the High Level Meeting on Universal Health Coverage” Universal Health Coverage: Moving Together to Build a Healthier World” 26. Higher Population Council. 2013. National Reproductive Health/Family Planning strategy 2013- 2017. Amman, Jordan 27. Shawky, S., Rashad, H. & Khadr, Z. (forthcoming). Improving Sexual and Reproductive Health in Arab Countries: A Methodology to Guide Evidence Based Policies and Actions. AUC/SRC and UNFPA/ASRO

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APPENDIXES

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APPENDIX A: FACT SHEETS

The following provides fact sheets, including key messages, covering the different health aspects investigated in the report. The indicators are classified into three categories based on their prevalence classification, namely very high prevalence (the prevalence is equal or exceeded 40%), high prevalence (the prevalence ranges between 20% and 40%), and moderate or low prevalence (the prevalence equals or less than 20%). Another criterion for the classification is was used for few indicators (infant mortality, diabetes, unmet need, adolescent pregnancy …….). This criterion used a comparison with the SDG goals or global and other experiences. At the level of the social groups defined by the stratifier, the indicator was classified as highly prevalent if it was moderately or low prevalent but exceed national level. For inequality, the degree of inequality is defined as severe if the summary measures of inequality exceed 10%, moderate if they fall between 5% and 10%, and low if they are less than 5%.

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Child health and wellbeing Prevalence and inequality  The impact indicators continue to show relatively high levels.  Large number of the risk factors for infant health and for child nutrition and development continue to show very high/high prevalence.  Lack of food rich in iron, lack of dietary diversity, and lack of acceptable diet for children 6-23 month and any violent discipline for children 1-14 years were highly prevalent across all social categories.  The governorates and education stratifiers show the largest gaps between the best off and worst off social groups.  The distribution of indicators among the social groups of the governorates and education stratifiers shows larger number of severe/moderate inequalities than wealth or nationality stratifiers.

Level/prevalence of child health and wellbeing indicators, gaps and inequality summary measures Gap Inequality summary measure Health indicator Preval Govern. Wealth Educat Nation. Govern. Wealth Educat Nation. aspects Neonatal mortality 11.0 10.0 4.0 4.0 7.0 10.1 -1 -4.5 6.2 Child mortality Infant mortality 17.0 14.0 6.0 9.0 11.0 6.8 -2 -9.6 7.6 Under 5 mortality 19.0 14.0 4.0 9.0 9.0 6.8 -1.7 -7.7 5.6 Very small/small in size 13.7 8.3 7.5 10.0 11.5 7.8 -11.8 -10.2 5.1 RF_Infant health Low Birthweight 16.7 10.8 5.6 15.3 10.0 6.0 -6.5 -10.0 3.8 Anemia children 6-59 months 32.4 23.5 20.1 9.5 3.2 9.3 -11.0 -6.4 0.9 No food rich in vitamin A (6-23 months) 32.8 13.1 15.9 28.0 5.7 5.9 -4.5 -4.9 1.6 RF_ child No minimum meal frequency (6-23 months) 37.8 19.7 12.6 25.4 9.8 3.5 -5.2 -5.8 3.1 nutrition No food rich in iron (6-23 months) 40.4 23.8 12.8 24.0 5.5 5.6 -3.5 -1.5 0.9 No minimum dietary diversity (6-23 months) 48.6 26.1 23.3 42.9 7.9 6.7 -5.8 -2.4 1.8 No minimum acceptable diet (6-23 months) 76.5 15.0 13.9 22.1 9.2 2.9 -2.9 -1.5 1.4 Physical violence is necessary 13.9 8.3 5.1 8.6 6.1 7.8 -3.8 -0.4 1.8 RF- Child Children <5 years left with inadequate care 16.4 9.7 6.5 8.0 9.9 4.9 2.7 2.4 1.7 development Children not on the developmental track 29.3 22.1 9.5 24.1 12.3 5.8 -4.9 -5.2 1.6 Any violent discipline children 1-14 years 81.3 18.3 17.0 11.6 11.1 3.4 -3.4 -2.5 0.5 For prevalence: Very high High Moderate For the gap: The largest gap across the four stratifiers For summary inequality measures: Severe Moderate Low

The most vulnerable social groups  The two governorates Madaba and Mafraq show high prevalence for all child health and wellbeing indicators.  The governorate of Ajloun shows the largest number of very high prevalence indicators compared to the other indicators.

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Level/ prevalence of child health and wellbeing by the governorates and their prevalence categorization Health aspect Governorates Indicators Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Ajloun Karak Tafielh Maan Aquaba Neonatal mortality 8.0 4.0 11.0 11.0 12.0 11.0 9.0 15.0 9.0 9.0 6.0 3.0 Child mortality Infant mortality 15.0 9.0 18.0 19.0 15.0 17.0 11.0 18.0 10.0 17.0 18.0 5.0 Under 5 mortality 16.0 11.0 18.0 21.0 18.0 23.0 13.0 21.0 13.0 17.0 18.0 10.0 RF_Infant Very small/small in size 12.1 9.1 12.5 15.4 17.4 16.3 15.4 14.5 14.3 13.9 14.0 10.2 health Low Birthweight 14.9 18.3 14.8 25.6 17.5 20.0 15.0 14.9 22.4 17.5 19.0 16.2 Anemia children 6-59 months 24.8 32.2 38.3 26.8 37.4 36.9 38.2 40.6 29.9 17.1 37.1 31.0 No food rich in vitamin A (6-23 months) 26.8 37.5 37.4 34.5 33.5 34.8 33.9 38.2 37.2 39.9 37.3 38.4 RF_ child No minimum meal frequency (6-23 months) 38.6 39.0 38.6 39.5 34.7 42.7 32.2 32.6 25.0 37.8 39.5 44.7 nutrition No food rich in iron (6-23 months) 33.4 48.5 44.6 46.0 40.5 42.7 40.8 46.9 45.7 57.2 44.7 47.2 No minimum dietary diversity (6-23 months) 39.0 58.7 54.2 61.3 48.1 55.7 55.6 49.1 53.1 65.1 55.5 54.6 No minimum acceptable diet (6-23 months) 72.2 83.6 82.0 87.2 75.8 85.7 79.4 73.4 76.9 86.9 81.5 75.8 Physical violence is necessary 12.9 14.4 11.4 16.1 16.5 15.0 10.7 12.7 15.8 8.9 21.9 16.5 RF- Child Children <5 years left with inadequate care 14.7 21.7 16.2 21.2 17.4 17.9 16.9 15.3 16.5 13.6 23.3 15.6 development Children not on the developmental track 27.0 32.2 28.4 36.2 26.1 36.1 28.5 33.6 25.3 45.8 47.4 37.4 Any violent discipline children 1-14 years 75.0 79.2 89.5 83.3 84.9 86.0 91.9 86.1 81.5 73.6 84.9 75.9 Very high prevalence high prevalence Moderate Prevalence > national level Moderate prevalence

 Children born to show high prevalence for all indicators as well as the largest number of very high prevalent indicators.  Children in the poorest wealth quintile and those born to mothers with no education Syrian mothers show the largest number of highly prevalent health indicators.

Level/ prevalence of child health and wellbeing by the wealth, educational status and nationality, and their prevalence categorization Wealth index Educational status nationality Health aspect indicator 1st 2nd 3rd 4th 5th no ed prim pre seco high Jordan Syria Others Neonatal mortality 10.0 7.0 11.0 8.0 11.0 12.0 13.0 10.0 9.0 9.0 9.0 15.0 9.0 Child mortality Infant mortality 18.0 12.0 16.0 12.0 15.0 21.0 21.0 15.0 16.0 11.0 14.0 24.0 14.0 Under 5 mortality 19.0 15.0 17.0 15.0 16.0 22.0 22.0 16.0 18.0 13.0 16.0 25.0 16.0 RF_Infant Very small/small in size 16.4 16.8 12.4 9.8 8.9 16.0 20.8 15.4 14.7 10.8 13.1 19.3 7.8 health Low Birthweight 19.4 18.4 13.8 14.3 16.0 28.4 23.4 18.2 18.1 13.1 16.1 22.0 12.0 Anemia children 6-59 months 37.9 35.1 32.8 24.3 17.8 32.6 36.0 36.4 34.7 26.9 31.7 34.3 31.1 No food rich in vitamin A (6-23 months) 33.8 38.0 29.9 33.5 22.1 58.0 35.6 38.2 32.7 30.0 32.2 36.9 31.2 RF_ child No minimum meal frequency (6-23 months) 44.1 36.3 36.5 31.5 37.0 59.0 46.3 42.1 38.8 33.6 36.4 45.2 46.2 nutrition No food rich in iron (6-23 months) 41.8 44.0 39.4 39.2 31.2 63.1 39.1 42.2 40.3 39.4 40.1 43.2 37.7 No minimum dietary diversity (6-23 months) 53.6 54.3 47.5 47.6 31.0 89.0 59.9 50.0 46.1 47.9 47.6 55.5 49.9 No minimum acceptable diet (6-23 months) 84.9 73.6 78.6 72.2 71.0 97.2 86.1 82.8 75.1 76.5 76.2 85.4 80.9 Physical violence is necessary 16.6 11.5 14.5 14.5 11.8 21.9 13.4 13.3 13.3 14.1 14.1 14.3 8.2 RF- Child Children <5 years left with inadequate care 16.3 16.1 14.5 16.3 21.0 21.1 13.1 15.2 16.3 17.2 16.4 14.1 24.0 development Children not on the developmental track 33.9 28.7 26.1 30.0 24.4 50.8 36.2 32.3 29.1 26.7 29.1 34.2 21.9 Any violent discipline children 1-14 years 84.1 86.1 86.5 78.5 69.5 80.1 81.3 85.3 86.7 75.1 81.8 83.9 72.8 Very high prevalence high prevalence Moderate Prevalence > national level Moderate prevalence

Trends in prevalence and inequality  All indicators of the child nutrition risk factors increased in prevalence between 2012 and 2017 with only one of them increasing by more than 25% of its level in 2012 namely lack of minimum meal frequency.  One of the infant health risk factors (low birth weight) and one of the child development risk factors (children <5years left with inadequate care) showed an increase in prevalence between 2012 and 2017 with only the latter indicator increasing by more than 25% of its 2012 level.  Inequality by the governorates increased for the majority of the child health and wellbeing.  Increases in inequality by wealth and education were less prevalent.  The increases in the inequality were associated with increases in their severity degree.

Trends in prevalence and inequality summary measures for child health and wellbeing Prevalence Gov Wealth Education Health aspect Indicator 2012 2017 2012 2017 2012 2017 2012 2017 Neonatal mortality 11.0 8.0 7.5 10.1 -10.5 -1.0 -10.1 -4.5 Child mortality Infant mortality 18.0 13.0 4.8 6.8 -12.7 -2.0 -11.1 -9.6 Under 5 mortality 20.0 14.0 5.0 6.8 -11.0 -1.7 -9.6 -7.7 Very small/small in size 19.7 13.7 3.0 7.8 -2.1 -11.8 -5.7 -10.2 RF_Infant health Low Birthweight 13.8 16.7 4.6 6.0 -3.2 -6.5 -8.3 -10.0 Anemia children 6-59 months 31.6 32.4 5.1 9.3 -7.3 -11.0 -3.3 -6.4 No food rich in vitamin A (6-23 months) 32.2 32.8 5.1 5.9 -9.3 -4.5 -6.1 -4.9 No minimum meal frequency (6-23 months) 19.1 37.8 3.0 3.5 -9.9 -5.2 -13.8 -5.8 RF_ child nutrition No food rich in iron (6-23 months) 39.5 40.4 3.3 5.6 -6.8 -3.5 -3.8 -1.5 No minimum dietary diversity (6-23 months) 44.9 48.6 3.7 6.7 -10.6 -5.8 -6.3 -2.4 No minimum acceptable diet (6-23 months) 66.7 76.5 2.8 2.9 -5.6 -2.9 -4.1 -1.5 Physical violence is necessary 22.8 13.9 3.0 7.8 3.6 -3.8 1.3 -0.4 RF- Child Children <5 years left with inadequate care 9.4 16.4 8.8 4.9 -7.3 2.7 -6.4 2.4 development Children not on the developmental track 31.1 29.3 6.0 5.8 -5.4 -4.9 -13.7 -5.2 Any violent discipline children 1-14 years 89.4 81.3 1.2 3.4 -1.4 -3.4 -1.2 -2.5 For trend in prevalence: Increased by more than 25% Increased by less than 25% Decreased or the same For trend in inequality: Increased in severity classification Increased but within same classification Decreased or the same

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NCDs and adult health Prevalence and inequality  Diabetes is highly prevalent in Jordan, while most of the NCDs risk factors are very highly prevalent.  The governorates stratifier shows the largest gaps between the best off and worst off social groups.  The distribution of the social groups by the education stratifier shows large number of severe inequalities followed wealth.  The severe to moderate inequality in distribution across all stratifiers are observed in the lack of knowledge of pap test.

Level/prevalence of NCDs and adult health indicators, gaps and inequality summary measures Gap Inequality summary measure Health indicator Preval Govern. Wealth Educat Nation. Govern. Wealth Educat Nation. aspects Diabetes (18+ years/ women) 7.6 4.6 1.4 21.5 1.5 4.5 -3.3 -41.5 1.3 Diabetes (18+ years/ men) 7.8 3.9 2.3 11.7 3.1 5.5 6.1 -14.8 2.8 Diabetes Diabetes (60+ years/ men) 29.3 12.0 2.5 5.7 7.9 3.7 0.1 1.7 1.6 Diabetes (60+ years/ women) 34.6 19.5 5.8 13.4 16.1 3.1 -1.7 -4.3 1.2 Smoking women 15-49 12.0 17.3 8.3 4.4 4.8 18.7 13.7 -3.7 2.6 Anemia among women 15-49 42.6 14.2 7.2 9.1 2.8 2.0 -2.1 -1.7 0.2 Smoking men 15-49 47.8 21.2 11.7 29.4 4.9 2.8 -5.3 -1.3 0.9 RF_NCDs Obesity /overweight among women 15-49 54.1 18.7 11.4 14.4 10.8 2.0 -3.4 -2.7 0.8 Never heard of pap test 35.3 33.9 24.0 41.2 32.3 8.8 -13.8 -11.1 9.0 No breast exam self or professional 79.0 18.9 17.4 18.0 13.6 2.1 -4.0 -3.2 1.5 For prevalence: Very high High Moderate For the gap: The largest gap across the four stratifiers For summary inequality measures: Severe Moderate Low

The most vulnerable social groups  Aqaba governorates shows the largest number of very highly prevalent NCDs and their risk factors indicators.  The governorates of Amman, Zarqua and Irbid show high prevalence for all NCDs and their risk factors indicators.

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Level/ prevalence of child health and wellbeing by the governorates and their prevalence categorization Governorates Indicators Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Ajloun Karak Tafilh Maan Aquaba Diabetes (18+ years/ women) 7.8 8.2 9.0 7.1 8.6 6.6 7.2 7.1 4.4 5.5 5.6 5.6 Diabetes (18+ years/ men) 8.0 6.3 7.9 5.9 8.5 6.6 6.1 6.2 5.0 5.9 4.6 6.6 Diabetes Diabetes (60+ years/ men) 29.9 24.4 31.4 21.9 32.0 30.0 26.9 23.8 20.0 28.6 20.0 30.4 Diabetes (60+ years/ women) 34.3 32.9 38.8 31.0 36.5 29.0 38.5 38.1 23.4 27.3 29.4 42.9 Smoking women 15-49 15.8 19.3 14.1 10.9 6.9 6.5 7.1 3.5 2.0 2.3 5.6 8.9 Anemia among women 15-49 42.3 39.6 40.4 35.4 44.0 45.7 47.1 46.8 40.8 39.6 49.6 46.5 Smoking men 15-49 43.8 45.7 47.5 55.0 45.8 37.6 51.6 46.1 37.4 33.8 38.1 47.9 RF_NCDs Obesity /overweight among women 15-49 54.4 48.2 58.6 54.4 52.3 57.3 52.0 53.3 52.7 63.9 48.3 45.2 Never heard of pap test 29.5 62.2 34.2 40.9 33.6 51.8 30.2 28.3 37.1 39.7 51.0 44.8 No breast exam self or professional 76.7 86.2 78.2 83.0 76.8 83.9 74.2 78.1 93.1 89.6 85.5 82.7 Very high prevalence high prevalence Moderate Prevalence > national level Moderate prevalence

 Individuals from the poorest and poorer wealth quintiles show the largest number of highly prevalent NCDs risk factors.  Individuals with education less than secondary education show the largest number of high prevalence diabetes indicators with those with primary and preparatory education showing the largest number of very highly prevalent NCDs risk factors.  Jordanian show high prevalence of diabetes but Syrians show very high prevalence of diabetes among older adult women.  Other non- Syrian nationalities suffer more the burden of NCDs risk factors than Jordanian and Syrian. They were followed Syrians.

Level/ prevalence of child health and wellbeing by the wealth, educational status and nationality, and their prevalence categorization Wealth index Educational status nationality Health aspect indicator 1st 2nd 3rd 4th 5th no ed prim pre seco high Jordan Syria Others Diabetes (18+ years/ women) 8.5 8.4 7.8 7.1 7.5 24.7 19.0 12.4 4.6 3.2 7.9 6.9 6.4 Diabetes (18+ years/ men) 6.5 6.8 7.5 7.9 8.8 16.7 14.6 10.7 5.0 6.8 7.8 4.7 6.4 Diabetes Diabetes (60+ years/ men) 30.3 28.0 30.0 27.8 30.1 28.7 30.5 26.0 27.7 31.7 29.7 25.0 21.9 Diabetes (60+ years/ women) 33.7 36.8 36.7 36.2 31.0 36.1 37.5 38.1 30.6 24.7 34.4 44.6 28.6 Smoking women 15-49 8.5 9.9 10.8 14.5 16.7 9.5 11.8 13.9 12.7 10.7 12.3 8.3 13.2 Anemia among women 15-49 47.0 42.7 41.2 39.8 42.5 43.3 50.2 42.7 42.9 41.1 42.4 45.2 42.8 RF_NCDs Smoking men 15-49 49.4 47.9 47.4 42.6 37.7 29.8 59.2 45.9 42.6 44.8 45.0 40.1 41.8

Obesity /overweight among women 15-49 56.1 59.2 54.6 54.2 47.8 59.1 65.9 57.0 54.0 51.5 54.5 55.7 44.9

Never heard of pap test 50.9 40.3 30.6 27.2 26.9 70.3 53.8 43.5 33.1 29.1 31.6 63.9 51.4 No breast exam self or professional 85.6 83.2 80.3 76.6 68.2 91.8 89.6 83.4 79.7 73.8 77.6 91.2 81.4 Very high prevalence high prevalence Moderate Prevalence > national level Moderate prevalence

Trends in prevalence and inequality  For the NCDs risk factors, the trend in prevalence show more than 25% increase in three indicators between 2012 and 2017, namely anemia among women 15-49 year, never heard of pap test and no self or professional breast exam.  Between 2012 and 2017, increases in inequality in the distribution of the risk factors was only limited to the governorates stratifier.

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 Inequality by the governorates increased for four of the indicators with the increase in inequality for lack of knowledge of pap test moving it to a severe degree of inequality.

Trends in prevalence and inequality summary measures for NCDs risk factors Prevalence Gov Wealth Education Health aspect Indicator 2012 2017 2012 2017 2012 2017 2012 2017 Smoking women 15-49 18.0 12.0 15.1 18.7 13.7 13.8 -7.8 -3.7 Anemia among women 15-49 33.5 42.6 5.9 2.0 -2.7 -2.1 -3.6 -1.7 RF_NCDs Obesity /overweight among women 15-49 54.8 54.1 1.6 2.0 -1.8 -3.4 -3.9 -2.7 Never heard of pap test 25.7 35.3 2.5 8.8 -19.6 -13.8 -14.2 -11.1 No breast exam self or professional 61.2 79.0 1.9 2.1 -5.8 -4.0 -4.7 -3.2 For trend in prevalence: Increased by more than 25% Increased by less than 25% Decreased or the same For trend in inequality: Increased in severity classification Increased but within same classification Decreased or the same

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Sexual and Reproductive health Prevalence and inequality  The majority of the social risk factors indicators for reproductive health are at least highly prevalent.  Almost all risk factors related to HIV/AIDS and domestic violence show very high prevalence.  The governorates stratifier shows the largest gaps between the best off and worst off social groups, followed by the education stratifier.  While the education stratifier shows severe inequalities in large number of risk factors, the governorates stratifier shows moderate inequalities in large number of indicators.  Inequality in the mere knowledge of HIV/AIDS is severe in three of the four investigated stratifiers.

Level/prevalence of reproductive health indicators, gaps and inequality summary measures Health Gap Inequality summary measure indicator Preval aspects Govern. Wealth Educat Nation. Govern. Wealth Educat Nation. Adolescent child bearing (<18 years) 5.2 11.1 12.4 26.9 24.7 23.2 -46.2 -35.5 37.7 Women who does not own health care decision 7.9 9.5 5.9 21.9 10.1 7.7 -13.3 -20.8 12.5 Early marriage (<18 years) 20.8 15.7 14.4 44.8 26.7 6.3 -10.7 -29.8 10.3 RF_ Social RH Multiparity (5+ children) 23.5 19.2 10.7 30.4 16.9 8.4 -8.9 -16.7 2.4 Consanguinity 27.5 18.1 11.0 14.8 10.7 6.6 -7.3 -10.0 1.7 Risky birth intervals (23 months) 29.0 8.6 9.4 10.5 9.4 3.5 -6.1 -0.9 4.3 No knowledge of HIV/AIDS 5.5 16.2 4.5 24.4 9.5 19.5 -6.7 -23.8 10.1 No Knowledge of MTCT 50.0 28.7 5.3 19.7 3.2 3.5 -1.3 -3.8 0.4 RF_ HIV/AIDS No knowledge of STI 66.1 36.2 21.8 30.2 11.2 4.8 -6.4 -7.7 1.2 related Discriminatory attitudes against PLWH 87.4 8.2 1.9 3.1 1.2 1.4 -0.4 -0.4 0.1 (women) No comprehensive knowledge of HIV for young (15-24) 92.2 8.6 8.8 10.7 7.1 0.7 -1.0 -2.4 0.6 No comprehensive knowledge of HIV 93.4 10.1 8.0 14.1 6.7 1.3 -1.7 -2.0 0.4 No knowledge of HIV/AIDS 10.9 18.3 10.1 23.3 5.3 13.2 -15.2 -15.1 3.1 No Knowledge of MTCT 58.0 30.7 13.5 28.7 8.9 3.2 -4.4 -6.2 1.2 RF_ HIV/AIDS No knowledge of STI 66.8 27.1 4.7 19.9 4.1 5.3 -0.1 -2.7 0.6 related Discriminatory attitudes against PLWH 89.7 22.9 5.1 5.3 4.5 2.9 1.4 0.6 0.3 (men) No comprehensive knowledge of HIV 90.8 21.7 3.8 10.3 5.2 3.0 -0.8 -1.5 0.4 No comprehensive knowledge of HIV for young (15-24) 91.9 23.8 4.5 9.8 1.8 6.4 -1.0 -1.5 0.2 Experience of physical violence in the past 12 months 14.4 19.9 5.1 11.1 5.4 13.2 -6.8 -11.8 2.8 Any form of spousal violence in the past 12 months 20.4 25.9 6.0 9.5 2.1 11.4 -5.9 -8.7 0.3 Experience of physical violence since 15 year of age 20.8 24.8 7.7 15.6 12.4 10.1 -8.1 -14.0 4.0 RF_Domestic Any form of spousal violence in the ever 25.9 26.5 7.9 16.2 9.3 9.1 -5.5 -10.7 2.0 violence Not able to negotiate sexual intercourse 32.9 26.3 15.3 28.9 13.0 4.8 -9.4 -10.3 4.4 related Agree to wife beating for at least one reason women 15-49 46.2 48.7 29.5 19.5 18.9 13.3 -12.8 -7.4 2.7 Women never sought help against spousal violence 67.2 22.5 16.5 15.8 10.3 4.5 -1.1 -1.1 2.1 Agree to wife beating for at least one reason men 15-50 69.1 50.4 6.9 16.9 4.2 4.2 -0.4 0.5 0.5 For prevalence: Very high High Moderate For the gap: The largest gap across the four stratifiers For summary inequality measures: Severe Moderate Low

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The most vulnerable social groups  Zarqua governorate showed the largest number of very highly prevalent reproductive risk factors indicators. This is particularly true for the domestic violence related risk factors. It was followed by the governorate of Balqa that showed large number of highly prevalent reproductive risk factors indicators.

Level/ prevalence of reproductive health by the governorates and their prevalence categorization Governorates Indicators Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Ajloun Karak Tafilh Maan Aquaba Adolescent child bearing (<18 years) 3.8 6.2 7.4 6.1 13.1 6.8 4.3 3.0 2.4 2.0 3.1 2.8 Women who does not own health care decision 7.0 11.1 7.5 8.0 6.7 10.9 5.8 7.2 3.5 10.3 6.4 13.0 Early marriage (<18 years) 19.7 19.0 23.6 15.8 22.9 28.2 25.6 19.2 12.5 13.6 18.0 15.9 RF_ Social RH Multiparity (5+ children) 19.6 23.8 24.2 27.4 27.0 34.6 32.9 31.4 21.0 28.5 19.2 15.4 Consanguinity 24.4 25.3 29.5 34.2 30.1 36.3 39.0 33.0 25.0 20.9 25.2 20.9 Risky birth intervals (23 months) 27.5 28.7 31.9 33.8 27.3 31.6 30.2 27.9 26.2 28.1 33.3 34.8 No knowledge of HIV/AIDS 6.6 17.3 4.2 4.5 3.1 5.3 1.3 1.1 4.0 2.8 2.6 1.9 No Knowledge of MTCT 51.9 65.6 48.2 47.6 46.9 47.5 36.8 40.1 53.9 43.4 53.0 47.3 RF_ HIV/AIDS No knowledge of STI 60.9 77.4 66.4 63.3 75.0 81.8 65.3 70.2 64.3 45.6 57.3 50.9 related Discriminatory attitudes against PLWH 87.1 91.7 91.6 88.7 93.0 91.1 88.0 93.0 92.7 84.8 87.2 89.6 (women) No comprehensive knowledge of HIV for young (15-24) 88.4 91.4 92.7 97.0 93.3 93.6 93.4 92.3 95.4 88.7 94.4 93.2 No comprehensive knowledge of HIV 92.4 88.6 93.7 95.5 94.6 94.8 96.3 95.4 95.0 86.2 93.8 92.9 No knowledge of HIV/AIDS 9.9 12.2 11.2 2.1 15.0 20.3 13.7 3.8 3.9 2.0 4.6 2.0 No Knowledge of MTCT 56.2 60.6 62.2 48.5 60.9 61.2 64.4 51.4 38.2 66.2 68.9 57.4 RF_ HIV/AIDS No knowledge of STI 75.7 57.6 63.6 63.1 63.1 71.1 73.8 52.3 60.1 59.3 48.6 49.9 related Discriminatory attitudes against PLWH 92.8 80.5 79.8 91.1 84.2 86.7 78.9 87.2 92.2 69.9 89.1 88.2 (men) No comprehensive knowledge of HIV 96.3 92.9 90.9 96.5 79.9 91.3 88.4 82.5 74.8 94.0 93.8 89.3 No comprehensive knowledge of HIV for young (15-24) 96.1 90.8 93.3 97.8 85.9 91.0 90.9 85.2 74.0 97.0 94.8 85.4 Experience of physical violence in the past 12 months 15.9 22.9 19.5 15.7 9.7 12.6 7.7 3.1 3.0 11.9 17.6 11.2 Any form of spousal violence in the past 12 months 22.7 31.5 25.7 20.0 14.2 19.0 15.3 5.6 7.3 12.7 24.3 16.8 Experience of physical violence since 15 year of age 20.0 29.5 31.2 20.3 17.8 22.5 15.7 7.8 6.4 13.7 20.7 14.1 RF_Domestic Any form of spousal violence in the ever 26.7 36.1 35.8 24.2 21.1 26.3 20.0 9.7 9.6 14.8 28.5 18.6 violence related Not able to negotiate sexual intercourse 33.1 25.6 43.3 29.3 31.9 34.8 30.9 30.5 23.3 17.0 34.5 26.5 Agree to wife beating for at least one reason women 15-49 32.5 52.5 44.5 62.9 61.1 67.4 44.8 46.0 81.2 36.5 65.4 41.2 Women never sought help against spousal violence 62.5 77.7 72.8 79.2 60.4 72.1 66.2 67.6 67.0 58.8 80.3 81.5 Agree to wife beating for at least one reason men 15-50 71.3 71.2 56.2 44.9 66.1 75.7 75.7 76.4 95.3 67.9 68.7 78.2 Very high prevalence high prevalence Moderate Prevalence > national level Moderate prevalence

 All reproductive health risk factors indicators are highly prevalent for individuals in the poorest wealth quintile, those with less than secondary education and non-Jordanians.

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Level/ prevalence of reproductive health by the wealth, educational status and nationality, and their prevalence categorization Wealth Education Nationality Subcategory Indicator 1st 2nd 3rd 4th 5th no ed prim pre seco high Jordan Syria Others Adolescent child bearing (<18 years) 13.0 6.8 3.8 2.1 0.6 13.0 27.3 7.5 3.8 0.4 3.1 27.8 11.8 Women who does not own health care decision 12.2 8.0 6.4 6.3 6.5 27.0 13.5 11.3 7.4 5.1 6.7 16.8 12.6 Early marriage (<18 years) 29.6 24.6 18.4 16.0 15.2 35.8 42.9 48.0 23.2 3.2 18.4 45.1 22.6 RF_ Social RH Multiparity (5+ children) 30.0 24.1 21.6 22.1 19.3 35.9 42.7 35.7 25.5 12.3 23.4 30.1 13.2 Consanguinity 31.7 29.8 28.9 25.8 20.7 24.3 33.1 35.3 30.4 20.5 27.3 32.9 22.2 Risky birth intervals (23 months) 33.4 29.4 28.0 24.0 25.9 24.4 34.9 29.7 27.2 29.2 27.5 36.9 35.2 No knowledge of HIV/AIDS 8.4 4.5 4.3 3.9 6.6 28.1 10.3 7.4 4.5 3.7 5.6 9.2 15.1 No Knowledge of MTCT 51.8 52.1 46.8 50.8 48.3 66.1 55.0 54.4 50.1 46.4 49.8 50.5 53.0 RF_ HIV/AIDS No knowledge of STI 76.6 71.6 65.2 61.2 54.8 84.3 78.3 76.8 70.0 54.1 65.3 75.3 64.1 related Discriminatory attitudes against PLWH 90.6 90.4 90.3 90.0 88.7 90.2 91.7 89.1 90.4 88.6 89.6 90.6 89.4 (women) No comprehensive knowledge of HIV for young (15-24) 94.3 92.8 92.3 90.5 85.5 98.2 98.1 94.9 91.8 87.5 90.9 96.0 88.9 No comprehensive knowledge of HIV 94.2 95.3 93.6 90.3 87.3 100.0 98.9 96.9 94.8 85.9 92.8 96.5 89.8 No knowledge of HIV/AIDS 17.1 10.8 11.5 9.6 7.0 29.7 14.6 11.7 12.7 6.4 10.5 15.8 11.8 No Knowledge of MTCT 64.7 60.6 60.5 55.7 51.2 77.4 63.1 66.9 60.8 48.7 57.2 62.5 66.1 RF_ HIV/AIDS No knowledge of STI 68.2 66.7 67.7 63.9 68.6 82.3 73.2 68.4 68.6 62.4 66.6 70.7 70.0 related Discriminatory attitudes against PLWH 85.1 85.5 85.2 89.5 90.2 85.1 89.9 84.6 86.8 88.9 87.2 87.1 91.6 (men) No comprehensive knowledge of HIV 92.9 91.4 91.4 89.9 89.1 97.5 94.6 92.7 92.0 87.2 90.3 92.8 95.5 No comprehensive knowledge of HIV for young (15-24) 93.6 94.3 92.3 91.2 89.8 96.6 98.5 95.4 92.3 88.7 91.8 92.9 93.6 Experience of physical violence in the past 12 months 16.5 16.8 12.7 13.8 11.7 21.7 16.4 20.3 14.8 10.6 13.9 16.1 19.3 Any form of spousal violence in the past 12 months 23.2 23.7 17.8 19.3 17.7 23.4 23.4 25.6 21.6 16.1 20.4 19.8 21.9 Experience of physical violence since 15 year of age 25.6 24.0 18.0 18.3 17.9 25.3 29.9 27.9 21.8 14.3 19.8 23.7 32.2 RF_Domestic Any form of spousal violence in the ever 30.0 29.5 22.1 24.3 23.6 28.5 35.7 31.2 27.4 19.5 25.3 27.0 34.6 violence related Not able to negotiate sexual intercourse 40.0 37.9 33.6 28.4 24.7 55.3 45.3 40.3 33.3 26.4 31.3 44.1 44.3 Agree to wife beating for at least one reason women 15-49 60.4 54.5 45.1 38.4 30.9 54.1 58.3 54.1 47.6 38.8 45.0 60.9 42.0 Women never sought help against spousal violence 65.1 69.8 71.5 71.8 55.3 82.3 71.5 65.2 66.8 66.5 79.3 89.6 86.3 Agree to wife beating for at least one reason men 15-50 66.7 70.9 69.6 72.4 65.5 55.5 64.5 64.8 72.4 67.7 69.5 66.9 65.3 Very high prevalence high prevalence Moderate Prevalence > national level Moderate prevalence

Trends in prevalence and inequality  The prevalence of ten of the 18 investigated sexual and reproductive health indicators increased between 2012 and 2017 with five of them increasing by more than 25% of their levels in 2012. These five indicators are no knowledge of HIV/AIDs, lack of knowledge of STI in HIV/AIDS related risk factors and experience of any form of spousal violence in the past 12 months, agreeing to wife beating and women never sought help against spousal violence in domestic violence related risk factors.  Between 2012 and 2017, the trend in inequality in distribution of risk factors was variant among stratifiers. Inequality by the governorates increased for 14 of the 18 investigated indicators with almost all increases showing an increased degree of the severity of inequality.  Inequality by education was observed in 9 of investigated indicators with 5 of them showing increased severity.  For inequality by wealth, 6 indicators showed an increase in inequality with four of them showing increased in the degree of the inequality severity

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Trends in prevalence and inequality summary measures for reproductive health risk factors Prevalence Governorate Wealth Education Health aspect indicator 2012 2017 2012 2017 2012 2017 2012 2017 Adolescent child bearing (<18 years) 4.5 5.2 8.8 23.2 -9.4 -46.2 -42.9 -35.5 Women who does not own health care decision 11.3 7.9 7.8 7.7 -8.6 -13.3 -8.2 -20.8 Early marriage (<18 years) 20.5 20.8 3.1 6.3 -8.8 -10.7 -37.1 -29.8 RF_ Social RH Multiparity (5+ children) 31.7 23.5 3.7 8.4 -6.2 -8.9 -16.3 -16.7 Consanguinity 34.6 27.5 4.1 6.6 -8.9 -7.3 -7.0 -10.0 Risky birth intervals (23 months) 31.9 29.0 2.7 3.5 7.9 -6.1 -1.0 -0.9 No knowledge of HIV/AIDS 0.8 5.5 4.5 19.5 -40.6 -6.7 -74.6 -23.8 No Knowledge of MTCT 58.2 50.0 3.8 3.5 3.2 -1.3 3.9 -3.8 RF_ HIV/AIDS No knowledge of STI 40.4 66.1 3.7 4.8 -10.5 -6.4 -12.5 -7.7 related Discriminatory attitudes against PLWH 97.5 87.4 0.3 1.4 -0.3 -0.4 -0.2 -0.4 (women) No comprehensive knowledge of HIV for young people (15-24) 87.1 92.2 1.2 0.7 -0.9 -1.0 -1.3 -2.4 No comprehensive knowledge of HIV 91.4 93.4 3.1 1.3 -2.5 -1.7 -2.8 -2.0 Experience of physical violence in the past 12 months 12.6 14.4 8.5 13.2 -12.5 -6.8 -11.0 -11.8 Any form of spousal violence in the past 12 months 14.1 20.4 6.0 11.4 -15.1 -5.9 -8.9 -8.7 RF_Domestic Experience of physical violence since 15 year of age 34.3 20.8 4.9 10.1 -9.7 -8.1 -9.6 -14.0 violence related Ever experience of any form of spousal violence 31.7 25.9 3.9 9.1 -9.4 -5.5 -8.9 -10.7 Agree to wife beating for at least one reason women 15-49 years 30.1 46.2 6.0 13.3 -4.7 -12.8 -4.3 -7.4 Women never sought help against spousal violence 46.8 67.2 3.1 4.5 1.1 -1.1 0.9 -1.1 For trend in prevalence: Increased by more than 25% Increased by less than 25% Decreased or the same For trend in inequality: Increased in severity classification Increased but within same classification Decreased or the same

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Health sector performance and capacity Health sector performance Prevalence and inequality  The majority of health sector performance indicators show moderate / low prevalence.  Other reproductive health services related to lack of knowledge of HIV test place and no premarital test, and children not receiving iron and vitamin A supplement and not seeking health services for diarrhea are the only highly prevalent indicators.  The governorates and education stratifiers show the largest gaps between the best off and worst off social groups.  The distribution of the indicators by the education stratifier shows the largest number of indicators with severe inequalities (9 indicators out of 26 investigated indicators) followed by the governorates (6 indicators) and wealth (5 indicators) stratifiers, respectively.

Level/prevalence of health sector performance indicators, gaps and inequality summary measures Gap Inequality summary measure

Indicator Preval Health aspects Govern. Wealth Educat Nation. Govern Wealth Educat Nation. No breastfeeding 8.3 8.1 5.2 5.0 2.7 11.5 -3.4 1.8 3.3 No postnatal care for child 13.1 14.8 7.0 18.8 9.2 13.2 -8.0 -10.1 8.9 HP_Infant health No postnatal check within the first 2 days of birth 14.1 16.9 7.3 18.9 8.5 13.7 -7.7 -8.9 7.9 No breastfeeding within 1 day of birth 17.4 11.5 7.7 8.6 3.3 9.0 -3.5 3.0 2.2 Not receiving any age appropriate vaccination 12-23 months 6.9 18.3 5.4 31.9 13.5 14.3 -7.3 -10.1 9.3 Not receiving all basic vaccination 12-23 months 14.3 26.8 4.7 42.0 12.5 6.9 0.7 -0.8 11.2 No knowledge of ORS 17.5 19.7 8.4 28.1 21.4 9.3 -8.5 -15.9 14.8 Not receiving all age appropriate vaccination 12-23 months 19.5 29.8 8.3 38.3 12.3 6.0 3.8 1.5 8.3 HSP_Child health Children with fever not seeking treatment or advise 31.6 35.1 16.3 12.8 12.2 9.5 -6.8 -6.9 1.8 Children with diarrhea not seeking treatment or advice 45.6 20.9 24.0 9.8 18.1 3.2 -3.8 -2.7 1.6 Not receiving vitamin A supplement (6-59 months) 72.5 18.9 6.8 12.1 3.3 2.2 -1.1 -0.5 0.3 Not receiving iron supplement (6-59 months) 87.3 16.5 15.8 14.3 11.4 2.9 -2.8 -1.9 0.6 No antenatal care 2.4 5.6 2.3 6.6 1.7 17.8 -9.4 -16.9 7.5 No antenatal care regular 7.9 9.6 6.3 12.8 7.6 9.7 -16.1 -10.0 9.2 HSP_Maternal No postnatal care 12.4 17.6 8.7 19.9 10.8 12.4 -14.6 -15.6 9.8 health No postnatal care <2 days 16.6 17.3 8.7 19.0 8.9 8.2 -10.1 -10.8 6.5 No iron tablet during pregnancy 22.1 26.0 4.4 30.0 2.9 8.3 -3.3 -4.9 1.6 Cesarean section 25.8 20.1 4.5 6.0 4.9 2.7 2.6 4.5 2.5 Unmet need 11.7 7.5 3.9 7.4 5.0 2.9 -2.9 -1.4 4.0 Use of traditional methods 18.9 8.4 4.9 6.8 3.4 5.8 -0.5 4.1 2.2 HSP_FP No use of contraceptives 38.8 18.8 7.4 27.4 9.0 2.4 -1.4 -6.1 1.3 Nonusers of FP did not discuss FP either with field workers or health facility 73.9 28.6 3.3 16.4 11.7 2.2 0.3 -1.9 1.4 No premarital exam women 46.8 18.0 9.5 45.2 14.0 2.9 -0.3 -14.2 2.6 No premarital exam women's husband 48.0 16.3 14.2 41.7 5.1 2.6 2.9 -13.3 0.3 HSP_Other RH No information on test place for HIV/AIDS men 59.6 31.1 16.4 33.3 12.4 4.4 -3.6 -9.2 1.4 No information on test place for HIV/AIDS women 72.8 26.3 21.2 25.1 13.8 2.6 -5.2 -6.2 1.5 For prevalence: Very high High Moderate For the gap: The largest gap across the four stratifiers For summary inequality measures: Severe Moderate Low

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The most vulnerable social groups  The two governorate of Mafraq and Maan show the highest number of health performance indicators with high prevalence

Level/ prevalence of health sector performance by the governorates and their prevalence categorization Governorates Indicators Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Ajloun Karak Tafilh Maan Aquaba No breastfeeding 5.5 8.7 11.6 9.3 8.6 10.4 8.9 8.9 8.2 13.6 13.4 8.7 No postnatal care for child 13.0 9.0 9.7 23.6 8.8 23.4 11.7 10.8 19.6 11.6 20.8 21.3 HSP_Infant No postnatal check within the first 2 days of birth 13.7 9.4 10.1 26.3 9.9 24.6 12.3 11.2 23.1 13.6 21.5 24.5 health No breastfeeding within 1 day of birth 13.1 15.4 23.9 23.9 17.2 18.0 18.4 22.1 17.2 18.3 14.5 12.4 Not receiving any age appropriate vaccination 12-23 months 8.3 2.7 6.6 5.1 6.2 4.6 6.1 2.8 2.2 3.0 20.5 17.1 Not receiving all basic vaccination 12-23 months 15.2 9.9 14.0 13.1 13.0 12.6 12.2 8.9 12.1 9.3 35.7 24.3 No knowledge of ORS 16.7 18.9 10.4 24.7 20.7 22.3 14.3 9.5 20.9 10.6 29.2 20.2 Not receiving all age appropriate vaccination 12-23 months 19.8 14.2 18.0 24.3 19.1 22.7 12.4 8.9 19.0 12.1 38.7 33.2 HSP_Child Children with fever not seeking treatment or advise 26.6 61.7 38.4 33.7 27.6 29.9 30.0 34.4 49.8 43.3 47.7 45.7 health Children with diarrhea not seeking treatment or advice 47.2 53.8 44.5 48.5 42.1 43.1 44.0 50.2 35.9 34.0 48.3 54.9 Not receiving vitamin A supplement (6-59 months) 72.3 77.8 63.7 64.6 71.7 76.7 79.4 82.6 77.8 80.1 77.3 76.2 Not receiving iron supplement (6-59 months) 80.6 87.1 87.9 90.2 91.2 95.6 97.1 96.2 95.3 96.3 91.2 88.0 No antenatal care 2.9 6.3 2.4 3.0 0.7 2.8 2.0 2.3 1.7 1.3 5.3 1.5 No antenatal care regular 8.3 13.2 6.6 6.9 6.2 12.0 8.1 8.9 6.3 3.6 10.6 4.0 HSP_Maternal No postnatal care 9.6 7.9 10.4 18.9 12.1 25.5 13.5 12.1 13.6 17.3 16.7 13.4 health No postnatal care <2 days 15.1 10.4 13.1 21.7 16.7 27.7 15.7 15.0 19.7 22.9 19.0 16.5 No iron tablet during pregnancy 21.5 24.2 14.3 29.0 17.7 25.0 17.7 22.8 40.3 28.4 37.1 26.1 Cesarean section 25.9 28.3 24.9 32.9 27.2 25.4 25.9 27.8 23.2 28.0 18.7 12.8 Unmet need 14.3 14.8 13.9 17.4 15.1 16.5 10.5 9.9 12.1 10.0 15.4 13.9 Use of traditional methods 13.1 11.5 15.0 10.7 16.1 19.2 15.4 17.2 15.1 17.6 14.7 11.5 HSP_FP No use of contraceptives 48.6 56.6 45.3 52.9 46.2 48.6 42.2 41.8 48.7 42.9 60.5 56.2 Nonusers of FP did not discuss FP either with field workers or health facility 80.6 83.9 75.9 82.3 76.9 82.4 76.5 64.8 58.8 79.1 87.4 82.4 No premarital exam women 45.7 53.1 50.3 51.1 46.9 58.6 44.9 44.9 43.4 46.9 47.2 40.6 No premarital exam women's husband 46.4 54.4 51.3 41.0 47.9 50.4 49.2 50.3 57.3 42.5 51.2 44.7 HSP_Other RH No information on test place for HIV/AIDS men 62.0 56.2 71.0 71.6 53.2 66.7 54.8 43.2 52.9 40.5 69.1 59.3 No information on test place for HIV/AIDS women 70.4 78.0 76.6 80.2 74.1 83.1 72.9 79.9 56.8 60.1 69.7 69.7 Very high prevalence high prevalence Moderate Prevalence > national level Moderate prevalence

 Individuals in the poorest wealth quintiles, with primary education and from other non- Syrian nationalities suffer more the other comparable social groups from the ill performance of health sectors.

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Level/ prevalence of health sector performance by the wealth, educational status and nationality, and their prevalence categorization Wealth Education Nationality Health aspect Indicator 1st 2nd 3rd 4th 5th no ed prim pre seco high Jordan Syria Others No breastfeeding 9.3 8.0 7.5 10.3 5.1 5.8 10.8 6.2 8.3 8.6 9.2 6.5 8.8 HSP_Infant No postnatal care for child 17.5 11.6 10.5 12.6 12.2 30.0 19.7 17.1 12.4 11.2 11.7 20.4 20.9 health No postnatal check within the first 2 days of birth 18.6 12.7 11.3 14.2 12.3 31.2 20.9 17.3 13.4 12.3 12.8 21.3 20.9 No breastfeeding within 1 day of birth 18.8 17.4 17.4 19.1 11.4 12.0 20.6 12.0 17.8 18.3 17.9 14.6 16.7 Not receiving any age appropriate vaccination 12-23 months 9.3 6.7 3.9 7.3 7.5 35.9 11.8 4.0 6.4 6.3 6.0 8.8 19.5 Not receiving all basic vaccination 12-23 months 15.2 13.2 12.8 14.4 17.5 52.7 16.3 10.7 12.4 15.4 12.3 24.2 24.8 No knowledge of ORS 23.7 15.3 15.3 15.5 15.8 41.5 35.0 24.1 15.8 13.4 14.4 35.8 31.2

Not receiving all age appropriate vaccination 12-23 months 19.6 16.3 19.6 20.8 24.6 52.7 23.7 14.4 16.6 21.8 17.5 29.8 29.0 HSP_Child Children with fever not seeking treatment or advise 35.0 35.8 26.4 32.1 19.5 na 29.0 36.8 36.8 24.0 40.8 37.7 28.6 health Children with diarrhea not seeking treatment or advice 45.4 50.1 54.7 30.7 38.4 na 53.5 49.1 45.3 43.7 44.7 46.8 62.8 Not receiving vitamin A supplement (6-59 months) 73.8 74.5 70.0 73.6 67.7 83.8 75.4 72.3 71.7 72.3 72.2 73.2 75.5 Not receiving iron supplement (6-59 months) 92.1 88.7 88.3 83.3 76.3 98.6 92.2 92.1 87.4 84.3 87.0 91.4 80.0 No antenatal care 3.6 2.4 1.3 1.7 3.5 8.5 5.1 3.2 2.2 1.9 2.2 3.5 3.9 No antenatal care regular 11.7 8.6 6.4 5.4 5.9 21.0 14.4 13.1 8.2 8.3 7.2 14.7 8.1 HSP_Maternal No postnatal care 17.9 12.8 9.2 9.8 9.2 29.3 18.2 21.3 11.5 9.4 11.0 21.8 14.5 health No postnatal care <2 days 20.8 17.3 15.7 12.1 13.2 32.4 20.7 23.5 16.6 13.4 15.3 24.2 20.6 No iron tablet during pregnancy 23.6 21.6 19.2 20.6 20.3 50.0 27.5 21.1 21.1 20.0 21.1 24.0 23.5 Cesarean section 23.8 26.7 25.1 28.3 26.9 27.0 22.4 22.4 25.0 28.4 26.6 21.7 22.6 Unmet need 16.8 13.7 13.2 12.9 14.8 20.3 17.3 14.9 12.9 14.6 13.6 18.6 18.6 Use of traditional methods 13.0 14.6 16.5 15.7 11.6 8.4 11.0 13.2 14.9 15.2 13.3 16.7 14.4 HSP_FP No use of contraceptives 52.4 48.5 44.9 45.8 49.9 69.8 64.5 50.3 47.3 42.4 47.6 55.6 46.6 Nonusers of FP did not discuss FP either with field workers or health facility 79.2 77.2 78.9 77.7 80.5 92.6 82.7 81.2 78.1 76.2 77.4 83.9 89.1 No premarital exam women 49.8 52.6 43.1 47.1 52.2 78.3 71.4 60.2 48.6 33.1 45.4 54.6 59.4 No premarital exam women's husband 51.2 44.0 44.4 58.2 53.2 76.5 72.9 60.5 49.8 34.8 56.6 56.0 61.1 HSP_Other RH No information on test place for HIV/AIDS men 70.5 60.8 60.1 54.1 58.6 75.7 69.7 65.1 62.8 42.4 59.4 71.8 63.5 No information on test place for HIV/AIDS women 89.6 77.6 74.5 70.3 59.4 87.5 86.6 81.0 76.1 62.4 71.5 85.3 73.6 Very high prevalence high prevalence Moderate Prevalence > national level Moderate prevalence

Trends in prevalence and inequality  The prevalence of ten of 24 investigated health sector performance indicators increased between 2012 and 2017. Eight of these ten indicators showed an increase of more than 25% of their levels in 2012 with four indicators falling in health sector performance for child health and three falling in health sector performance for maternal health.  Between 2012 and 2017, the trend in inequality in distribution of risk factors was variant among stratifiers.  Inequality by governorates increased for half of the 24 investigated indicators with only one of them showing higher severity degree of inequality.  Inequality by wealth increased for five indicators with only one of them showing more severe degree of inequality.  For inequality by education, nine indicators showed an increase in their inequality with four of them displaying higher degree of inequality severity.

117

Trends in prevalence and inequality summary measures for health sector performance Prevalence Governorate Wealth Education Health aspect indicator 2012 2017 2012 2017 2012 2017 2012 2017 No breastfeeding 6.9 8.3 11.5 11.5 5.2 -3.4 -7.6 1.8 No postnatal care for child 20.8 13.1 24.6 13.2 2.9 -8.0 -1.3 -10.1 HSP_Infant health No postnatal check within the first 2 days of birth 25.3 14.1 21.7 13.7 2.4 -7.7 -2.4 -8.9 No breastfeeding within 1 day of birth 32.4 17.4 7.4 9.0 8.5 -3.5 4.1 3.0 Not receiving any age appropriate vaccination 12-23 months 0.3 6.9 78.0 14.3 -64.5 -7.3 -73.2 -10.1 Not receiving all basic vaccination 12-23 months 7.0 14.3 17.3 6.9 -8.6 0.7 -12.1 -0.8 No knowledge of ORS 8.0 17.5 8.7 9.3 -13.3 -8.5 -12.0 -15.9

Children with fever not seeking treatment or advise 14.9 19.5 18.5 9.5 2.4 -6.8 -3.8 -6.9 HSP_Child health Children with diarrhea not seeking treatment or advice 31.2 31.6 4.6 3.2 1.4 -3.8 -5.6 -2.7 Not receiving vitamin A supplement (6-59 months) 44.3 45.6 0.8 2.2 -0.7 -1.1 0.0 -0.5 Not receiving iron supplement (6-59 months) 89.0 72.5 0.7 2.9 0.0 -2.8 0.2 -1.9 No antenatal care 0.9 2.4 16.4 17.8 -46.8 -9.4 -41.3 -16.9 No antenatal care regular 5.5 7.9 10.9 9.7 -31.9 -16.1 -27.9 -10.0

No postnatal care 13.9 12.4 15.4 12.4 -18.0 -14.6 -21.6 -15.6 HSP_Maternal No postnatal care <2 days 17.9 16.6 16.6 8.2 -11.2 -10.1 -18.3 -10.8 health No iron tablet during pregnancy 15.4 22.1 7.2 8.3 -23.0 -3.3 -12.8 -4.9 Cesarean section 28.0 25.8 2.4 2.7 5.3 2.6 0.7 4.5 Unmet need 14.2 11.7 2.6 2.9 -9.0 -2.9 -8.0 -1.4 Use of traditional methods 13.0 18.9 3.8 5.8 1.9 -0.5 4.4 4.1 HSP_FP No use of contraceptives 48.2 38.8 2.8 2.4 -1.2 -1.4 -0.9 -6.1 Nonusers of FP did not discuss FP either with field workers or health facility 78.7 73.9 1.0 2.2 2.6 0.3 0.3 -1.9 No premarital exam women 59.6 46.8 1.0 2.9 -1.9 -0.3 -9.0 -14.2 HSP_Other RH No premarital exam women's husband 60.2 48.0 1.3 2.6 -1.7 2.9 -9.2 -13.3 No information on test place for HIV/AIDS women 79.4 72.8 1.9 2.6 -2.9 -5.2 6.2 -6.2 For trend in prevalence: Increased by more than 25% Increased by less than 25% Decreased or the same For trend in inequality: Increased in severity classification Increased but within same classification Decreased or the same

118

Health sector capacity Prevalence and inequality  All health sector capacity indicators show high prevalence.  The governorates and education stratifiers show the largest gaps between the best off and worst off social groups.  The distribution of the social groups by the education and wealth stratifiers shows large number of severe inequalities followed by the governorates and nationality stratifiers , respectively.

Level/prevalence of health sector capacity indicators, gaps and inequality summary measures Health Gap Inequality summary measure Indicator Preval aspects Govern Wealth Educat Nation. Govern Wealth Educat Nation. Unavailability of female provider 20.1 16.3 18.0 20.1 12.7 7.5 -17.1 -14.0 5.9 Health sector Distance to health care facility 22.0 27.3 28.5 29.6 18.8 13.3 -23.4 -17.9 7.6 capacity Unaffordability of the health care service 22.1 21.2 31.5 31.3 29.3 11.2 -26.3 -22.0 12.3 Need to take transportation 25.2 26.4 21.0 25.8 18.1 9.4 -15.2 -12.7 7.2 For prevalence: Very high High Moderate For the gap: The largest gap across the four stratifiers For summary inequality measures: Severe Moderate Low

The most vulnerable social groups  Six of the twelve governorates in Jordan suffer from significantly low capacity of health sector.

Level/ prevalence of health sector capacity by the governorates and their prevalence categorization Health Governorates Indicators aspect Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Ajloun Karak Tafilh Maan Aquaba Unavailability of female provider 18.6 22.1 15.5 24.2 24.0 27.2 21.1 19.0 15.7 16.7 31.8 19.3 Health Distance to health care facility 17.3 26.9 16.1 22.8 27.0 43.4 28.6 26.4 18.2 22.2 38.0 20.3 sector Unaffordability of the health care service 19.3 28.5 15.3 20.0 26.7 36.5 31.4 24.2 15.3 20.0 34.9 22.3 capacity Need to take transportation 22.7 28.7 17.3 21.6 30.6 39.6 27.4 26.0 22.1 24.7 43.7 23.3 Very high prevalence high prevalence Moderate Prevalence > national level Moderate prevalence

 Women in the poorest and poorer wealth quintile, with less than higher education, from Syrian and other nationalities suffer from significantly low capacity of the health sectors.

119

Level/ prevalence of health sector capacity by the wealth, educational status and nationality, and their prevalence categorization Wealth Education Nationality Health aspect Indicator 1st 2nd 3rd 4th 5th no ed prim pre seco high Jordan Syria Others Unavailability of female provider 29.5 23.5 19.5 15.7 11.5 34.2 32.1 23.7 21.4 14.1 18.7 31.4 24.6 Health sector Distance to health care facility 36.8 25.7 20.9 16.8 8.3 43.6 38.2 28.5 22.9 14.0 20.0 38.8 27.0 capacity Unaffordability of the health care service 40.6 26.1 18.7 15.1 9.1 43.7 43.4 31.3 23.0 12.4 19.0 48.3 32.9 Need to take transportation 37.8 27.2 22.5 20.7 16.8 45.0 40.2 30.5 25.1 19.2 23.1 41.2 34.9 Very high prevalence high prevalence Moderate Prevalence > national level Moderate prevalence

Trends in prevalence and inequality  All health sector capacity indicators showed a decline in prevalence between 2012 and 2017  All inequality summary measures for all indicators across all stratifiers increased between 2012 and 2017.  The trend of inequality in distribution for all health sector capacity indicators showed an increase in their severity degree particularly by governorates and education between 2012 and 2017.

Trends in prevalence and inequality summary measures for health sector capacity Prevalence Governorate Wealth Education indicator 2012 2017 2012 2017 2012 2017 2012 2017 Unavailability of female provider 29.5 20.1 4.2 7.5 -6.3 -17.1 -3.9 -14.0 Distance to health care facility 26.4 22.0 2.5 13.3 -11.4 -23.4 -7.1 -17.9 Unaffordability of the health care service 22.5 22.1 3.2 11.2 -24.1 -26.3 -20.5 -22.0 Need to take transportation 28.6 25.2 5.5 9.4 -11.9 -15.2 -5.8 -12.7 For trend in prevalence: Increased by more than 25% Increased by less than 25% Decreased or the same For trend in inequality: Increased in severity classification Increased but within same classification Decreased or the same

120

Health insurance coverage Prevalence and inequality  All health insurance coverage indicators show high prevalence.  Two important positive features of the health insurance coverage in Jordan. One feature relates to the higher coverage for women compared to men (58% versus 50%).  The governorates and nationality stratifiers show the largest gaps between the best off and worst off social groups.  The distribution of the social groups by the governorates stratifier shows large number of severe inequalities followed by the nationality and education stratifiers, respectively.

Level/prevalence of health insurance coverage indicators, gaps and inequality summary measures Health Gap Inequality summary measure indicator Preval aspects Govern. Wealth Educat Nation. Govern. Wealth Educat Nation. No insurance for inpatient users 23.1 8.8 8.3 56.7 -1.2 1.2 22.8 Health No insurance for outpatient users 30.8 37.1 5.0 9.5 49.7 11.0 0.3 -5.1 13.1 insurance Not covered by any health insurance women (15-49) 41.7 45.6 3.9 23.5 33.0 17.3 1.4 -8.4 6.9 coverage Not covered by any health insurance men (15-49) 49.6 45.0 10.1 21.9 30.0 14.0 -0.5 -10.3 2.9 For prevalence: Very high High Moderate For the gap: The largest gap across the four stratifiers For summary inequality measures: Severe Moderate Low

The most vulnerable social groups  The governorate of Amman shows the lowest level of health insurance coverage on all indicators compared to other governorates. It Is followed by Balqa and Zarqua governorates.

Level/ prevalence of health insurance coverage by the governorates and their prevalence categorization Health Governorates Indicators aspect Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Ajloun Karak Tafilh Maan Aquaba No insurance for inpatient users Health No insurance for outpatient users 42.0 37.3 36.8 25.3 29.3 30.5 10.2 5.4 7.8 4.9 8.9 22.4 insurance Not covered by any health insurance women (15-49) 55.9 43.3 51.1 31.9 27.2 21.8 16.8 10.3 13.6 10.9 29.2 31.6 coverage Not covered by any health insurance men (15-49) 62.9 45.6 60.0 41.2 34.4 25.4 24.3 17.9 30.0 30.3 53.0 41.1 Very high prevalence high prevalence Moderate Prevalence > national level Moderate prevalence

 All wealth quintiles, except for the middle quintile show low level of health insurance coverage on all indicators.  The middle wealth quintile shows only moderate prevalence for coverage among users of inpatient service.  Individuals with less than secondary education suffer from high prevalence of low coverage.  Syrians and other nationalities suffer from very high prevalence of low coverage of health insurance. 121

Level/ prevalence of reproductive health by the wealth, educational status and nationality, and their prevalence categorization Wealth Education Nationality Subcategory Indicator 1st 2nd 3rd 4th 5th no ed prim pre seco high Jordan Syria Others No insurance for inpatient users 26.7 23.1 17.9 23.4 26.1 22.1 24.8 27.9 19.6 26.0 17.4 56.9 74.2 Health No insurance for outpatient users 32.2 30.1 27.2 32.2 31.8 32.0 35.5 32.4 29.3 26.0 26.2 50.8 75.9 insurance Not covered by any health insurance women (15-49) 41.2 40.6 40.3 42.4 44.2 56.6 48.9 47.6 45.3 33.0 38.4 60.7 71.4 coverage Not covered by any health insurance men (15-49) 54.9 47.7 44.8 49.2 51.0 54.9 47.7 50.2 51.0 33.0 56.6 61.3 86.6 Very high prevalence high prevalence Moderate Prevalence > national level Moderate prevalence

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APPENDIX B: HEALTH INDICATORS PREVALENCE, GAPS AND INEQUALITY SUMMARY MEASURES FOR ALL STRATIFIERS

Gap Inequality summary measure

.

Health indicator c.

Preval

Gov. Gov. aspects Educ Edu

Wealth Wealth

Nation. Nation.

Neonatal mortality 11.0 10.0 4.0 4.0 7.0 10.1 -1 -4.5 6.2 Child mortality Infant mortality 17.0 14.0 6.0 9.0 11.0 6.8 -2 -9.6 7.6 Under 5 mortality 19.0 14.0 4.0 9.0 9.0 6.8 -1.7 -7.7 5.6 RF_Infant Very small/small in size 13.7 8.3 7.5 10.0 11.5 7.8 -11.8 -10.2 5.1 health Low Birthweight 16.7 10.8 5.6 15.3 10.0 6.0 -6.5 -10.0 3.8 Anemia children 6-59 months 32.4 23.5 20.1 9.5 3.2 9.3 -11.0 -6.4 0.9 No food rich in vitamin A (6-23 months) 32.8 13.1 15.9 28.0 5.7 5.9 -4.5 -4.9 1.6 RF_ child No minimum meal frequency (6-23 months) 37.8 19.7 12.6 25.4 9.8 3.5 -5.2 -5.8 3.1 nutrition No food rich in iron (6-23 months) 40.4 23.8 12.8 24.0 5.5 5.6 -3.5 -1.5 0.9 No minimum dietary diversity (6-23 months) 48.6 26.1 23.3 42.9 7.9 6.7 -5.8 -2.4 1.8 No minimum acceptable diet (6-23 months) 76.5 15.0 13.9 22.1 9.2 2.9 -2.9 -1.5 1.4 Physical violence is necessary 13.9 8.3 5.1 8.6 6.1 7.8 -3.8 -0.4 1.8 RF- Child Children <5 years left with inadequate care 16.4 9.7 6.5 8.0 9.9 4.9 2.7 2.4 1.7 development Children not on the developmental track 29.3 22.1 9.5 24.1 12.3 5.8 -4.9 -5.2 1.6 Any violent discipline children 1-14 years 81.3 18.3 17.0 11.6 11.1 3.4 -3.4 -2.5 0.5 Diabetes (18+ years/ women) 7.6 4.6 1.4 21.5 1.5 4.5 -3.3 -41.5 1.3 Diabetes (18+ years/ men) 7.8 3.9 2.3 11.7 3.1 5.5 6.1 -14.8 2.8 Diabetes Diabetes (60+ years/ men) 29.3 12.0 2.5 5.7 7.9 3.7 0.1 1.7 1.6 Diabetes (60+ years/ women) 34.6 19.5 5.8 13.4 16.1 3.1 -1.7 -4.3 1.2 Smoking women 15-49 12.0 17.3 8.3 4.4 4.8 18.7 13.7 -3.7 2.6 Anemia among women 15-49 42.6 14.2 7.2 9.1 2.8 2.0 -2.1 -1.7 0.2 Smoking men 15-49 47.8 21.2 11.7 29.4 4.9 2.8 -5.3 -1.3 0.9 RF_NCDs Obesity /overweight among women 15-49 54.1 18.7 11.4 14.4 10.8 2.0 -3.4 -2.7 0.8 Never heard of pap test 35.3 33.9 24.0 41.2 32.3 8.8 -13.8 -11.1 9.0 No breast exam self or professional 79.0 18.9 17.4 18.0 13.6 2.1 -4.0 -3.2 1.5 Adolescent child bearing (<18 years) 5.2 11.1 12.4 26.9 24.7 23.2 -46.2 -35.5 37.7 Women who does not own health care decision 7.9 9.5 5.9 21.9 10.1 7.7 -13.3 -20.8 12.5 Early marriage (<18 years) 20.8 15.7 14.4 44.8 26.7 6.3 -10.7 -29.8 10.3 RF_ Social RH Multiparity (5+ children) 23.5 19.2 10.7 30.4 16.9 8.4 -8.9 -16.7 2.4 Consanguinity 27.5 18.1 11.0 14.8 10.7 6.6 -7.3 -10.0 1.7 Risky birth intervals (23 months) 29.0 8.6 9.4 10.5 9.4 3.5 -6.1 -0.9 4.3 No knowledge of HIV/AIDS 5.5 16.2 4.5 24.4 9.5 19.5 -6.7 -23.8 10.1 No Knowledge of MTCT 50.0 28.7 5.3 19.7 3.2 3.5 -1.3 -3.8 0.4 RF_ HIV/AIDS No knowledge of STI 66.1 36.2 21.8 30.2 11.2 4.8 -6.4 -7.7 1.2 related Discriminatory attitudes against PLWH 87.4 8.2 1.9 3.1 1.2 1.4 -0.4 -0.4 0.1 (women) No comprehensive knowledge of HIV for young (15-24) 92.2 8.6 8.8 10.7 7.1 0.7 -1.0 -2.4 0.6 No comprehensive knowledge of HIV 93.4 10.1 8.0 14.1 6.7 1.3 -1.7 -2.0 0.4 No knowledge of HIV/AIDS 10.9 18.3 10.1 23.3 5.3 13.2 -15.2 -15.1 3.1 No Knowledge of MTCT 58.0 30.7 13.5 28.7 8.9 3.2 -4.4 -6.2 1.2 RF_ HIV/AIDS No knowledge of STI 66.8 27.1 4.7 19.9 4.1 5.3 -0.1 -2.7 0.6 related Discriminatory attitudes against PLWH 89.7 22.9 5.1 5.3 4.5 2.9 1.4 0.6 0.3 (men) No comprehensive knowledge of HIV 90.8 21.7 3.8 10.3 5.2 3.0 -0.8 -1.5 0.4 No comprehensive knowledge of HIV for young (15-24) 91.9 23.8 4.5 9.8 1.8 6.4 -1.0 -1.5 0.2 For prevalence: Very high High Moderate For the gap: The largest gap across the four stratifiers For summary inequality measures: Severe Moderate Low

123

Gap Inequality summary measure

Health indicator . .

Preval

Gov. Gov. aspects Educ Educ

Wealth Wealth

Nation. Nation.

Experience of physical violence in the past 12 months 14.4 19.9 5.1 11.1 5.4 13.2 -6.8 -11.8 2.8 Any form of spousal violence in the past 12 months 20.4 25.9 6.0 9.5 2.1 11.4 -5.9 -8.7 0.3 Experience of physical violence since 15 year of age 20.8 24.8 7.7 15.6 12.4 10.1 -8.1 -14.0 4.0 Any form of spousal violence in the ever 25.9 26.5 7.9 16.2 9.3 9.1 -5.5 -10.7 2.0 RF_Domest Not able to negotiate sexual intercourse 32.9 26.3 15.3 28.9 13.0 4.8 -9.4 -10.3 4.4 ic violence Agree to wife beating for at least one reason women related 46.2 48.7 29.5 19.5 18.9 13.3 -12.8 -7.4 2.7 15-49 Women never sought help against spousal violence 67.2 22.5 16.5 15.8 10.3 4.5 -1.1 -1.1 2.1 Agree to wife beating for at least one reason men 15- 69.1 50.4 6.9 16.9 4.2 4.2 -0.4 0.5 0.5 50 No breastfeeding 8.3 8.1 5.2 5.0 2.7 11.5 -3.4 1.8 3.3 HP_Infant No postnatal care for child 13.1 14.8 7.0 18.8 9.2 13.2 -8.0 -10.1 8.9 health No postnatal check within the first 2 days of birth 14.1 16.9 7.3 18.9 8.5 13.7 -7.7 -8.9 7.9 No breastfeeding within 1 day of birth 17.4 11.5 7.7 8.6 3.3 9.0 -3.5 3.0 2.2 Not receiving any age appropriate vaccination 12-23 6.9 18.3 5.4 31.9 13.5 14.3 -7.3 -10.1 9.3 months Not receiving all basic vaccination 12-23 months 14.3 26.8 4.7 42.0 12.5 6.9 0.7 -0.8 11.2 No knowledge of ORS 17.5 19.7 8.4 28.1 21.4 9.3 -8.5 -15.9 14.8 Not receiving all age appropriate vaccination 12-23 19.5 29.8 8.3 38.3 12.3 6.0 3.8 1.5 8.3 HSP_Child months health Children with fever not seeking treatment or advise 31.6 35.1 16.3 12.8 12.2 9.5 -6.8 -6.9 1.8 Children with diarrhea not seeking treatment or 45.6 20.9 24.0 9.8 18.1 3.2 -3.8 -2.7 1.6 advice Not receiving vitamin A supplement (6-59 months) 72.5 18.9 6.8 12.1 3.3 2.2 -1.1 -0.5 0.3 Not receiving iron supplement (6-59 months) 87.3 16.5 15.8 14.3 11.4 2.9 -2.8 -1.9 0.6 No antenatal care 2.4 5.6 2.3 6.6 1.7 17.8 -9.4 -16.9 7.5 No antenatal care regular 7.9 9.6 6.3 12.8 7.6 9.7 -16.1 -10.0 9.2 HSP_Mater No postnatal care 12.4 17.6 8.7 19.9 10.8 12.4 -14.6 -15.6 9.8 nal health No postnatal care <2 days 16.6 17.3 8.7 19.0 8.9 8.2 -10.1 -10.8 6.5 No iron tablet during pregnancy 22.1 26.0 4.4 30.0 2.9 8.3 -3.3 -4.9 1.6 Cesarean section 25.8 20.1 4.5 6.0 4.9 2.7 2.6 4.5 2.5 Unmet need 11.7 7.5 3.9 7.4 5.0 2.9 -2.9 -1.4 4.0 Use of traditional methods 18.9 8.4 4.9 6.8 3.4 5.8 -0.5 4.1 2.2 HSP_FP No use of contraceptives 38.8 18.8 7.4 27.4 9.0 2.4 -1.4 -6.1 1.3 Nonusers of FP did not discuss FP either with field 73.9 28.6 3.3 16.4 11.7 2.2 0.3 -1.9 1.4 workers or health facility No premarital exam women 46.8 18.0 9.5 45.2 14.0 2.9 -0.3 -14.2 2.6 HSP_Other No premarital exam women's husband 48.0 16.3 14.2 41.7 5.1 2.6 2.9 -13.3 0.3 RH No information on test place for HIV/AIDS men 59.6 31.1 16.4 33.3 12.4 4.4 -3.6 -9.2 1.4 No information on test place for HIV/AIDS women 72.8 26.3 21.2 25.1 13.8 2.6 -5.2 -6.2 1.5 Unavailability of female provider 20.1 16.3 18.0 20.1 12.7 7.5 -17.1 -14.0 5.9 Health Distance to health care facility 22.0 27.3 28.5 29.6 18.8 13.3 -23.4 -17.9 7.6 sector Unaffordability of the health care service 22.1 21.2 31.5 31.3 29.3 11.2 -26.3 -22.0 12.3 capacity Need to take transportation 25.2 26.4 21.0 25.8 18.1 9.4 -15.2 -12.7 7.2 No insurance for inpatient users 23.1 8.8 8.3 56.7 -1.2 1.2 22.8 Health No insurance for outpatient users 30.8 37.1 5.0 9.5 49.7 11.0 0.3 -5.1 13.1 insurance Not covered by any health insurance women (15-49) 41.7 45.6 3.9 23.5 33.0 17.3 1.4 -8.4 6.9 coverage Not covered by any health insurance men (15-49) 49.6 45.0 10.1 21.9 30.0 14.0 -0.5 -10.3 2.9 For prevalence: Very high High Moderate For the gap: The largest gap across the four stratifiers For summary inequality measures: Severe Moderate Low

124

APPENDIX C: HEALTH INDICATORS PREVALENCE AND THEIR PREVALENCE CLASSIFICATION

By the governorates Governorates Indicators Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Ajloun Karak Tafilh Maan Aquaba Neonatal mortality 8.0 4.0 11.0 11.0 12.0 11.0 9.0 15.0 9.0 9.0 6.0 3.0 Child Infant mortality 15.0 9.0 18.0 19.0 15.0 17.0 11.0 18.0 10.0 17.0 18.0 5.0 mortality Under 5 mortality 16.0 11.0 18.0 21.0 18.0 23.0 13.0 21.0 13.0 17.0 18.0 10.0 RF_Infant Very small/small in size 12.1 9.1 12.5 15.4 17.4 16.3 15.4 14.5 14.3 13.9 14.0 10.2 health Low Birthweight 14.9 18.3 14.8 25.6 17.5 20.0 15.0 14.9 22.4 17.5 19.0 16.2 Anemia children 6-59 months 24.8 32.2 38.3 26.8 37.4 36.9 38.2 40.6 29.9 17.1 37.1 31.0 No food rich in vitamin A (6-23 months) 26.8 37.5 37.4 34.5 33.5 34.8 33.9 38.2 37.2 39.9 37.3 38.4 No minimum meal frequency (6-23 38.6 39.0 38.6 39.5 34.7 42.7 32.2 32.6 25.0 37.8 39.5 44.7 months) RF_ child No food rich in iron (6-23 months) 33.4 48.5 44.6 46.0 40.5 42.7 40.8 46.9 45.7 57.2 44.7 47.2 nutrition No minimum dietary diversity (6-23 39.0 58.7 54.2 61.3 48.1 55.7 55.6 49.1 53.1 65.1 55.5 54.6 months) No minimum acceptable diet (6-23 72.2 83.6 82.0 87.2 75.8 85.7 79.4 73.4 76.9 86.9 81.5 75.8 months) Physical violence is necessary 12.9 14.4 11.4 16.1 16.5 15.0 10.7 12.7 15.8 8.9 21.9 16.5 Children <5 years left with inadequate 14.7 21.7 16.2 21.2 17.4 17.9 16.9 15.3 16.5 13.6 23.3 15.6 care RF- Child Children not on the developmental development 27.0 32.2 28.4 36.2 26.1 36.1 28.5 33.6 25.3 45.8 47.4 37.4 track Any violent discipline children 1-14 75.0 79.2 89.5 83.3 84.9 86.0 91.9 86.1 81.5 73.6 84.9 75.9 years Diabetes (18+ years/ women) 7.8 8.2 9.0 7.1 8.6 6.6 7.2 7.1 4.4 5.5 5.6 5.6 Diabetes (18+ years/ men) 8.0 6.3 7.9 5.9 8.5 6.6 6.1 6.2 5.0 5.9 4.6 6.6 Diabetes Diabetes (60+ years/ men) 29.9 24.4 31.4 21.9 32.0 30.0 26.9 23.8 20.0 28.6 20.0 30.4 Diabetes (60+ years/ women) 34.3 32.9 38.8 31.0 36.5 29.0 38.5 38.1 23.4 27.3 29.4 42.9 Smoking women 15-49 15.8 19.3 14.1 10.9 6.9 6.5 7.1 3.5 2.0 2.3 5.6 8.9 Anemia among women 15-49 42.3 39.6 40.4 35.4 44.0 45.7 47.1 46.8 40.8 39.6 49.6 46.5 Smoking men 15-49 43.8 45.7 47.5 55.0 45.8 37.6 51.6 46.1 37.4 33.8 38.1 47.9 RF_NCDs Obesity /overweight among women 15- 54.4 48.2 58.6 54.4 52.3 57.3 52.0 53.3 52.7 63.9 48.3 45.2 49 Never heard of pap test 29.5 62.2 34.2 40.9 33.6 51.8 30.2 28.3 37.1 39.7 51.0 44.8 No breast exam self or professional 76.7 86.2 78.2 83.0 76.8 83.9 74.2 78.1 93.1 89.6 85.5 82.7 Adolescent child bearing (<18 years) 3.8 6.2 7.4 6.1 13.1 6.8 4.3 3.0 2.4 2.0 3.1 2.8 Women who does not own health care 7.0 11.1 7.5 8.0 6.7 10.9 5.8 7.2 3.5 10.3 6.4 13.0 decision RF_ Social RH Early marriage (<18 years) 19.7 19.0 23.6 15.8 22.9 28.2 25.6 19.2 12.5 13.6 18.0 15.9 Multiparity (5+ children) 19.6 23.8 24.2 27.4 27.0 34.6 32.9 31.4 21.0 28.5 19.2 15.4 Consanguinity 24.4 25.3 29.5 34.2 30.1 36.3 39.0 33.0 25.0 20.9 25.2 20.9 Risky birth intervals (23 months) 27.5 28.7 31.9 33.8 27.3 31.6 30.2 27.9 26.2 28.1 33.3 34.8 No knowledge of HIV/AIDS 6.6 17.3 4.2 4.5 3.1 5.3 1.3 1.1 4.0 2.8 2.6 1.9 No Knowledge of MTCT 51.9 65.6 48.2 47.6 46.9 47.5 36.8 40.1 53.9 43.4 53.0 47.3 RF_ HIV/AIDS No knowledge of STI 60.9 77.4 66.4 63.3 75.0 81.8 65.3 70.2 64.3 45.6 57.3 50.9 related Discriminatory attitudes against PLWH 87.1 91.7 91.6 88.7 93.0 91.1 88.0 93.0 92.7 84.8 87.2 89.6 (women) No comprehensive knowledge of HIV 88.4 91.4 92.7 97.0 93.3 93.6 93.4 92.3 95.4 88.7 94.4 93.2 for young (15-24) No comprehensive knowledge of HIV 92.4 88.6 93.7 95.5 94.6 94.8 96.3 95.4 95.0 86.2 93.8 92.9 No knowledge of HIV/AIDS 9.9 12.2 11.2 2.1 15.0 20.3 13.7 3.8 3.9 2.0 4.6 2.0 No Knowledge of MTCT 56.2 60.6 62.2 48.5 60.9 61.2 64.4 51.4 38.2 66.2 68.9 57.4 RF_ HIV/AIDS No knowledge of STI 75.7 57.6 63.6 63.1 63.1 71.1 73.8 52.3 60.1 59.3 48.6 49.9 related Discriminatory attitudes against PLWH 92.8 80.5 79.8 91.1 84.2 86.7 78.9 87.2 92.2 69.9 89.1 88.2 (men) No comprehensive knowledge of HIV 96.3 92.9 90.9 96.5 79.9 91.3 88.4 82.5 74.8 94.0 93.8 89.3 No comprehensive knowledge of HIV 96.1 90.8 93.3 97.8 85.9 91.0 90.9 85.2 74.0 97.0 94.8 85.4 for young (15-24) Very high prevalence High prevalence Moderate Prevalence > national level Moderate prevalence

125

By the governorates (cont.) Governorates Indicators Amman Balqa Zarqua Madaba Irbid Mafraq Jerash Ajloun Karak Tafilh Maan Aquaba Experience of physical violence in the past 12 15.9 22.9 19.5 15.7 9.7 12.6 7.7 3.1 3.0 11.9 17.6 11.2 months Any form of spousal violence in the past 12 22.7 31.5 25.7 20.0 14.2 19.0 15.3 5.6 7.3 12.7 24.3 16.8 months Experience of physical violence since 15 year 20.0 29.5 31.2 20.3 17.8 22.5 15.7 7.8 6.4 13.7 20.7 14.1 of age RF_Domestic Any form of spousal violence in the ever 26.7 36.1 35.8 24.2 21.1 26.3 20.0 9.7 9.6 14.8 28.5 18.6 violence Not able to negotiate sexual intercourse 33.1 25.6 43.3 29.3 31.9 34.8 30.9 30.5 23.3 17.0 34.5 26.5 related Agree to wife beating for at least one reason 32.5 52.5 44.5 62.9 61.1 67.4 44.8 46.0 81.2 36.5 65.4 41.2 women 15-49 Women never sought help against spousal 62.5 77.7 72.8 79.2 60.4 72.1 66.2 67.6 67.0 58.8 80.3 81.5 violence Agree to wife beating for at least one reason 71.3 71.2 56.2 44.9 66.1 75.7 75.7 76.4 95.3 67.9 68.7 78.2 men 15-50 No breastfeeding 5.5 8.7 11.6 9.3 8.6 10.4 8.9 8.9 8.2 13.6 13.4 8.7 No postnatal care for child 13.0 9.0 9.7 23.6 8.8 23.4 11.7 10.8 19.6 11.6 20.8 21.3 No postnatal check within the first 2 days of HSP_Infant 13.7 9.4 10.1 26.3 9.9 24.6 12.3 11.2 23.1 13.6 21.5 24.5 birth health No breastfeeding within 1 day of birth 13.1 15.4 23.9 23.9 17.2 18.0 18.4 22.1 17.2 18.3 14.5 12.4 Not receiving any age appropriate 8.3 2.7 6.6 5.1 6.2 4.6 6.1 2.8 2.2 3.0 20.5 17.1 vaccination 12-23 months Not receiving all basic vaccination 12-23 15.2 9.9 14.0 13.1 13.0 12.6 12.2 8.9 12.1 9.3 35.7 24.3 months No knowledge of ORS 16.7 18.9 10.4 24.7 20.7 22.3 14.3 9.5 20.9 10.6 29.2 20.2 Not receiving all age appropriate vaccination 19.8 14.2 18.0 24.3 19.1 22.7 12.4 8.9 19.0 12.1 38.7 33.2 12-23 months HSP_Child Children with fever not seeking treatment or 26.6 61.7 38.4 33.7 27.6 29.9 30.0 34.4 49.8 43.3 47.7 45.7 health advise Children with diarrhea not seeking treatment 47.2 53.8 44.5 48.5 42.1 43.1 44.0 50.2 35.9 34.0 48.3 54.9 or advice Not receiving vitamin A supplement (6-59 72.3 77.8 63.7 64.6 71.7 76.7 79.4 82.6 77.8 80.1 77.3 76.2 months) Not receiving iron supplement (6-59 months) 80.6 87.1 87.9 90.2 91.2 95.6 97.1 96.2 95.3 96.3 91.2 88.0 No antenatal care 2.9 6.3 2.4 3.0 0.7 2.8 2.0 2.3 1.7 1.3 5.3 1.5 No antenatal care regular 8.3 13.2 6.6 6.9 6.2 12.0 8.1 8.9 6.3 3.6 10.6 4.0 HSP_Matern No postnatal care 9.6 7.9 10.4 18.9 12.1 25.5 13.5 12.1 13.6 17.3 16.7 13.4 al health No postnatal care <2 days 15.1 10.4 13.1 21.7 16.7 27.7 15.7 15.0 19.7 22.9 19.0 16.5 No iron tablet during pregnancy 21.5 24.2 14.3 29.0 17.7 25.0 17.7 22.8 40.3 28.4 37.1 26.1 Cesarean section 25.9 28.3 24.9 32.9 27.2 25.4 25.9 27.8 23.2 28.0 18.7 12.8 Unmet need 14.3 14.8 13.9 17.4 15.1 16.5 10.5 9.9 12.1 10.0 15.4 13.9 Use of traditional methods 13.1 11.5 15.0 10.7 16.1 19.2 15.4 17.2 15.1 17.6 14.7 11.5 HSP_FP No use of contraceptives 48.6 56.6 45.3 52.9 46.2 48.6 42.2 41.8 48.7 42.9 60.5 56.2 Nonusers of FP did not discuss FP either with 80.6 83.9 75.9 82.3 76.9 82.4 76.5 64.8 58.8 79.1 87.4 82.4 field workers or health facility No premarital exam women 45.7 53.1 50.3 51.1 46.9 58.6 44.9 44.9 43.4 46.9 47.2 40.6 No premarital exam women's husband 46.4 54.4 51.3 41.0 47.9 50.4 49.2 50.3 57.3 42.5 51.2 44.7 HSP_Other No information on test place for HIV/AIDS 62.0 56.2 71.0 71.6 53.2 66.7 54.8 43.2 52.9 40.5 69.1 59.3 RH men No information on test place for HIV/AIDS 70.4 78.0 76.6 80.2 74.1 83.1 72.9 79.9 56.8 60.1 69.7 69.7 women Unavailability of female provider 18.6 22.1 15.5 24.2 24.0 27.2 21.1 19.0 15.7 16.7 31.8 19.3 Health sector Distance to health care facility 17.3 26.9 16.1 22.8 27.0 43.4 28.6 26.4 18.2 22.2 38.0 20.3 capacity Unaffordability of the health care service 19.3 28.5 15.3 20.0 26.7 36.5 31.4 24.2 15.3 20.0 34.9 22.3 Need to take transportation 22.7 28.7 17.3 21.6 30.6 39.6 27.4 26.0 22.1 24.7 43.7 23.3 No insurance for inpatient users No insurance for outpatient users 42.0 37.3 36.8 25.3 29.3 30.5 10.2 5.4 7.8 4.9 8.9 22.4 Health Not covered by any health insurance women insurance 55.9 43.3 51.1 31.9 27.2 21.8 16.8 10.3 13.6 10.9 29.2 31.6 (15-49) coverage Not covered by any health insurance men 62.9 45.6 60.0 41.2 34.4 25.4 24.3 17.9 30.0 30.3 53.0 41.1 (15-49) Very high prevalence High prevalence Moderate Prevalence > national level Moderate prevalence

126

By wealth, education and nationality Wealth index Educational status nationality subcategory indicator 1st 2nd 3rd 4th 5th no ed prim pre seco high Jordan Syria Others Neonatal mortality 10.0 7.0 11.0 8.0 11.0 12.0 13.0 10.0 9.0 9.0 9.0 15.0 9.0 Child mortality Infant mortality 18.0 12.0 16.0 12.0 15.0 21.0 21.0 15.0 16.0 11.0 14.0 24.0 14.0 Under 5 mortality 19.0 15.0 17.0 15.0 16.0 22.0 22.0 16.0 18.0 13.0 16.0 25.0 16.0 RF_Infant Very small/small in size 16.4 16.8 12.4 9.8 8.9 16.0 20.8 15.4 14.7 10.8 13.1 19.3 7.8 health Low Birthweight 19.4 18.4 13.8 14.3 16.0 28.4 23.4 18.2 18.1 13.1 16.1 22.0 12.0 Anemia children 6-59 months 37.9 35.1 32.8 24.3 17.8 32.6 36.0 36.4 34.7 26.9 31.7 34.3 31.1 No food rich in vitamin A (6-23 months) 33.8 38.0 29.9 33.5 22.1 58.0 35.6 38.2 32.7 30.0 32.2 36.9 31.2 No minimum meal frequency (6-23 44.1 36.3 36.5 31.5 37.0 59.0 46.3 42.1 38.8 33.6 36.4 45.2 46.2 months) RF_ child No food rich in iron (6-23 months) 41.8 44.0 39.4 39.2 31.2 63.1 39.1 42.2 40.3 39.4 40.1 43.2 37.7 nutrition No minimum dietary diversity (6-23 53.6 54.3 47.5 47.6 31.0 89.0 59.9 50.0 46.1 47.9 47.6 55.5 49.9 months) No minimum acceptable diet (6-23 84.9 73.6 78.6 72.2 71.0 97.2 86.1 82.8 75.1 76.5 76.2 85.4 80.9 months) Physical violence is necessary 16.6 11.5 14.5 14.5 11.8 21.9 13.4 13.3 13.3 14.1 14.1 14.3 8.2 Children <5 years left with inadequate RF- Child 16.3 16.1 14.5 16.3 21.0 21.1 13.1 15.2 16.3 17.2 16.4 14.1 24.0 care development Children not on the developmental track 33.9 28.7 26.1 30.0 24.4 50.8 36.2 32.3 29.1 26.7 29.1 34.2 21.9 Any violent discipline children 1-14 years 84.1 86.1 86.5 78.5 69.5 80.1 81.3 85.3 86.7 75.1 81.8 83.9 72.8 Diabetes (18+ years/ women) 8.5 8.4 7.8 7.1 7.5 24.7 19.0 12.4 4.6 3.2 7.9 6.9 6.4 Diabetes (18+ years/ men) 6.5 6.8 7.5 7.9 8.8 16.7 14.6 10.7 5.0 6.8 7.8 4.7 6.4 Diabetes Diabetes (60+ years/ men) 30.3 28.0 30.0 27.8 30.1 28.7 30.5 26.0 27.7 31.7 29.7 25.0 21.9 Diabetes (60+ years/ women) 33.7 36.8 36.7 36.2 31.0 36.1 37.5 38.1 30.6 24.7 34.4 44.6 28.6 Smoking women 15-49 8.5 9.9 10.8 14.5 16.7 9.5 11.8 13.9 12.7 10.7 12.3 8.3 13.2 Anemia among women 15-49 47.0 42.7 41.2 39.8 42.5 43.3 50.2 42.7 42.9 41.1 42.4 45.2 42.8 RF_NCDs Smoking men 15-49 49.4 47.9 47.4 42.6 37.7 29.8 59.2 45.9 42.6 44.8 45.0 40.1 41.8 Obesity /overweight among women 15- 56.1 59.2 54.6 54.2 47.8 59.1 65.9 57.0 54.0 51.5 54.5 55.7 44.9 49 Never heard of pap test 50.9 40.3 30.6 27.2 26.9 70.3 53.8 43.5 33.1 29.1 31.6 63.9 51.4 No breast exam self or professional 85.6 83.2 80.3 76.6 68.2 91.8 89.6 83.4 79.7 73.8 77.6 91.2 81.4 Adolescent child bearing (<18 years) 13.0 6.8 3.8 2.1 0.6 13.0 27.3 7.5 3.8 0.4 3.1 27.8 11.8 Women who does not own health care 12.2 8.0 6.4 6.3 6.5 27.0 13.5 11.3 7.4 5.1 6.7 16.8 12.6 decision RF_ Social RH Early marriage (<18 years) 29.6 24.6 18.4 16.0 15.2 35.8 42.9 48.0 23.2 3.2 18.4 45.1 22.6 Multiparity (5+ children) 30.0 24.1 21.6 22.1 19.3 35.9 42.7 35.7 25.5 12.3 23.4 30.1 13.2 Consanguinity 31.7 29.8 28.9 25.8 20.7 24.3 33.1 35.3 30.4 20.5 27.3 32.9 22.2 Risky birth intervals (23 months) 33.4 29.4 28.0 24.0 25.9 24.4 34.9 29.7 27.2 29.2 27.5 36.9 35.2 No knowledge of HIV/AIDS 8.4 4.5 4.3 3.9 6.6 28.1 10.3 7.4 4.5 3.7 5.6 9.2 15.1 No Knowledge of MTCT 51.8 52.1 46.8 50.8 48.3 66.1 55.0 54.4 50.1 46.4 49.8 50.5 53.0 RF_ HIV/AIDS No knowledge of STI 76.6 71.6 65.2 61.2 54.8 84.3 78.3 76.8 70.0 54.1 65.3 75.3 64.1 related Discriminatory attitudes against PLWH 90.6 90.4 90.3 90.0 88.7 90.2 91.7 89.1 90.4 88.6 89.6 90.6 89.4 (women) No comprehensive knowledge of HIV for 94.3 92.8 92.3 90.5 85.5 98.2 98.1 94.9 91.8 87.5 90.9 96.0 88.9 young (15-24) No comprehensive knowledge of HIV 94.2 95.3 93.6 90.3 87.3 100.0 98.9 96.9 94.8 85.9 92.8 96.5 89.8 No knowledge of HIV/AIDS 17.1 10.8 11.5 9.6 7.0 29.7 14.6 11.7 12.7 6.4 10.5 15.8 11.8 No Knowledge of MTCT 64.7 60.6 60.5 55.7 51.2 77.4 63.1 66.9 60.8 48.7 57.2 62.5 66.1 RF_ HIV/AIDS No knowledge of STI 68.2 66.7 67.7 63.9 68.6 82.3 73.2 68.4 68.6 62.4 66.6 70.7 70.0 related Discriminatory attitudes against PLWH 85.1 85.5 85.2 89.5 90.2 85.1 89.9 84.6 86.8 88.9 87.2 87.1 91.6 (men) No comprehensive knowledge of HIV 92.9 91.4 91.4 89.9 89.1 97.5 94.6 92.7 92.0 87.2 90.3 92.8 95.5 No comprehensive knowledge of HIV for 93.6 94.3 92.3 91.2 89.8 96.6 98.5 95.4 92.3 88.7 91.8 92.9 93.6 young (15-24) Very high prevalence High prevalence Moderate Prevalence > national level Moderate prevalence

127

By wealth, education and nationality (cont.) Wealth Education Nationality Subcategory Indicator 1st 2nd 3rd 4th 5th no ed prim pre seco high Jordan Syria Others Experience of physical violence in the past 16.5 16.8 12.7 13.8 11.7 21.7 16.4 20.3 14.8 10.6 13.9 16.1 19.3 12 months Any form of spousal violence in the past 23.2 23.7 17.8 19.3 17.7 23.4 23.4 25.6 21.6 16.1 20.4 19.8 21.9 12 months Experience of physical violence since 15 25.6 24.0 18.0 18.3 17.9 25.3 29.9 27.9 21.8 14.3 19.8 23.7 32.2 year of age RF_Domestic Any form of spousal violence in the ever 30.0 29.5 22.1 24.3 23.6 28.5 35.7 31.2 27.4 19.5 25.3 27.0 34.6 violence Not able to negotiate sexual intercourse 40.0 37.9 33.6 28.4 24.7 55.3 45.3 40.3 33.3 26.4 31.3 44.1 44.3 related Agree to wife beating for at least one 60.4 54.5 45.1 38.4 30.9 54.1 58.3 54.1 47.6 38.8 45.0 60.9 42.0 reason women 15-49 Women never sought help against 65.1 69.8 71.5 71.8 55.3 82.3 71.5 65.2 66.8 66.5 79.3 89.6 86.3 spousal violence Agree to wife beating for at least one 66.7 70.9 69.6 72.4 65.5 55.5 64.5 64.8 72.4 67.7 69.5 66.9 65.3 reason men 15-50 No breastfeeding 9.3 8.0 7.5 10.3 5.1 5.8 10.8 6.2 8.3 8.6 9.2 6.5 8.8 No postnatal care for child 17.5 11.6 10.5 12.6 12.2 30.0 19.7 17.1 12.4 11.2 11.7 20.4 20.9 HSP_Infant No postnatal check within the first 2 days health 18.6 12.7 11.3 14.2 12.3 31.2 20.9 17.3 13.4 12.3 12.8 21.3 20.9 of birth No breastfeeding within 1 day of birth 18.8 17.4 17.4 19.1 11.4 12.0 20.6 12.0 17.8 18.3 17.9 14.6 16.7 Not receiving any age appropriate 9.3 6.7 3.9 7.3 7.5 35.9 11.8 4.0 6.4 6.3 6.0 8.8 19.5 vaccination 12-23 months Not receiving all basic vaccination 12-23 15.2 13.2 12.8 14.4 17.5 52.7 16.3 10.7 12.4 15.4 12.3 24.2 24.8 months No knowledge of ORS 23.7 15.3 15.3 15.5 15.8 41.5 35.0 24.1 15.8 13.4 14.4 35.8 31.2 Not receiving all age appropriate 19.6 16.3 19.6 20.8 24.6 52.7 23.7 14.4 16.6 21.8 17.5 29.8 29.0 vaccination 12-23 months HSP_Child Children with fever not seeking treatment 35.0 35.8 26.4 32.1 19.5 na 29.0 36.8 36.8 24.0 40.8 37.7 28.6 health or advise Children with diarrhea not seeking 45.4 50.1 54.7 30.7 38.4 na 53.5 49.1 45.3 43.7 44.7 46.8 62.8 treatment or advice Not receiving vitamin A supplement (6-59 73.8 74.5 70.0 73.6 67.7 83.8 75.4 72.3 71.7 72.3 72.2 73.2 75.5 months) Not receiving iron supplement (6-59 92.1 88.7 88.3 83.3 76.3 98.6 92.2 92.1 87.4 84.3 87.0 91.4 80.0 months) No antenatal care 3.6 2.4 1.3 1.7 3.5 8.5 5.1 3.2 2.2 1.9 2.2 3.5 3.9 No antenatal care regular 11.7 8.6 6.4 5.4 5.9 21.0 14.4 13.1 8.2 8.3 7.2 14.7 8.1 HSP_Maternal No postnatal care 17.9 12.8 9.2 9.8 9.2 29.3 18.2 21.3 11.5 9.4 11.0 21.8 14.5 health No postnatal care <2 days 20.8 17.3 15.7 12.1 13.2 32.4 20.7 23.5 16.6 13.4 15.3 24.2 20.6 No iron tablet during pregnancy 23.6 21.6 19.2 20.6 20.3 50.0 27.5 21.1 21.1 20.0 21.1 24.0 23.5 Cesarean section 23.8 26.7 25.1 28.3 26.9 27.0 22.4 22.4 25.0 28.4 26.6 21.7 22.6 Unmet need 16.8 13.7 13.2 12.9 14.8 20.3 17.3 14.9 12.9 14.6 13.6 18.6 18.6 Use of traditional methods 13.0 14.6 16.5 15.7 11.6 8.4 11.0 13.2 14.9 15.2 13.3 16.7 14.4 HSP_FP No use of contraceptives 52.4 48.5 44.9 45.8 49.9 69.8 64.5 50.3 47.3 42.4 47.6 55.6 46.6 Nonusers of FP did not discuss FP either 79.2 77.2 78.9 77.7 80.5 92.6 82.7 81.2 78.1 76.2 77.4 83.9 89.1 with field workers or health facility No premarital exam women 49.8 52.6 43.1 47.1 52.2 78.3 71.4 60.2 48.6 33.1 45.4 54.6 59.4 No premarital exam women's husband 51.2 44.0 44.4 58.2 53.2 76.5 72.9 60.5 49.8 34.8 56.6 56.0 61.1 No information on test place for HIV/AIDS HSP_Other RH 70.5 60.8 60.1 54.1 58.6 75.7 69.7 65.1 62.8 42.4 59.4 71.8 63.5 men No information on test place for HIV/AIDS 89.6 77.6 74.5 70.3 59.4 87.5 86.6 81.0 76.1 62.4 71.5 85.3 73.6 women Unavailability of female provider 29.5 23.5 19.5 15.7 11.5 34.2 32.1 23.7 21.4 14.1 18.7 31.4 24.6 Health sector Distance to health care facility 36.8 25.7 20.9 16.8 8.3 43.6 38.2 28.5 22.9 14.0 20.0 38.8 27.0 capacity Unaffordability of the health care service 40.6 26.1 18.7 15.1 9.1 43.7 43.4 31.3 23.0 12.4 19.0 48.3 32.9 Need to take transportation 37.8 27.2 22.5 20.7 16.8 45.0 40.2 30.5 25.1 19.2 23.1 41.2 34.9 No insurance for inpatient users 26.7 23.1 17.9 23.4 26.1 22.1 24.8 27.9 19.6 26.0 17.4 56.9 74.2 No insurance for outpatient users 32.2 30.1 27.2 32.2 31.8 32.0 35.5 32.4 29.3 26.0 26.2 50.8 75.9 Health Not covered by any health insurance insurance 41.2 40.6 40.3 42.4 44.2 56.6 48.9 47.6 45.3 33.0 38.4 60.7 71.4 women (15-49) coverage Not covered by any health insurance men 54.9 47.7 44.8 49.2 51.0 54.9 47.7 50.2 51.0 33.0 56.6 61.3 86.6 (15-49) Very high prevalence High prevalence Moderate Prevalence > national level Moderate prevalence

128

APPENDIX D: THE SOCIAL GROUPS WITH HIGHEST PREVALENCE FOR THE INDICATORS ACROSS THE STRATIFIERS

Governorate Wealth Education Nationality

Health

indicators aspect

Irbid

prep

Syria

Tafilh

Maan

Balqa

Karak

Ajloun higher

Richer

Middle

Jerash Poorer Others

no edu Jordan

Mafraq

Zarqua

second

Richest primary

Amman Aquaba Poorest

Madaba Neonatal mortality Child Infant mortality mortality Under 5 mortality RF_Infant Very small/small in size health Low Birthweight Anemia children 6-59 months No food rich in vitamin A (6-23 months) RF_ child No minimum meal frequency (6-23 months) nutrition No food rich in iron (6-23 months) No minimum dietary diversity (6-23 months) No minimum acceptable diet (6-23 months) Physical violence is necessary RF- Child Children <5 years left with inadequate care developmen Children not on the developmental track t Any violent discipline children 1-14 years Diabetes (18+ years/ women) Diabetes (18+ years/ men) Diabetes Diabetes (60+ years/ men) Diabetes (60+ years/ women) Smoking women 15-49 Anemia among women 15-49 Smoking men 15-49 RF_NCDs Obesity /overweight among women 15-49 Never heard of pap test No breast exam self or professional Adolescent child bearing (<18 years) Women who does not own health care

decision RF_ Social Early marriage (<18 years) RH Multiparity (5+ children) Consanguinity Risky birth intervals (23 months) No knowledge of HIV/AIDS No Knowledge of MTCT RF_ No knowledge of STI HIV/AIDS Discriminatory attitudes against PLWH related No comprehensive knowledge of HIV for (women) young (15-24) No comprehensive knowledge of HIV No knowledge of HIV/AIDS No Knowledge of MTCT RF_ No knowledge of STI HIV/AIDS Discriminatory attitudes against PLWH related No comprehensive knowledge of HIV (men) No comprehensive knowledge of HIV for

young (15-24) Experience of physical violence in the past 12

months Any form of spousal violence in the past 12

months Experience of physical violence since 15 year RF_Domesti of age c violence Any form of spousal violence in the ever related Not able to negotiate sexual intercourse Agree to wife beating for at least one reason

women 15-49 Women never sought help against spousal

violence

129

Agree to wife beating for at least one reason

men 15-50 The highest prevalence

Governorate Wealth Education nationality

Health aspect indicators

Irbid

prep

Syria

Tafilh

Maan

Balqa

Karak

Ajloun higher

Richer

Middle

Jerash Poorer Others

no edu Jordan

Mafraq

Zarqua

second

Richest primary

Amman Poorest

Aquaba

Madaba No breastfeeding No postnatal care for child HSP_Infant No postnatal check within the first 2 days of health birth No breastfeeding within 1 day of birth Not receiving any age appropriate

vaccination 12-23 months Not receiving all basic vaccination 12-23

months No knowledge of ORS Not receiving all age appropriate vaccination

12-23 months HSP_Child Children with fever not seeking treatment or health advise Children with diarrhea not seeking treatment

or advice Not receiving vitamin A supplement (6-59

months) Not receiving iron supplement (6-59 months) No antenatal care No antenatal care regular HSP_Maternal No postnatal care health No postnatal care <2 days No iron tablet during pregnancy Cesarean section Unmet need Use of traditional methods HSP_FP No use of contraceptives Nonusers of FP did not discuss FP either with

field workers or health facility No premarital exam women No premarital exam women's husband HSP_Other No information on test place for HIV/AIDS

RH men No information on test place for HIV/AIDS

women Unavailability of female provider Health sector Distance to health care facility capacity Unaffordability of the health care service Need to take transportation No insurance for inpatient users No insurance for outpatient users Health Not covered by any health insurance women insurance (15-49) coverage Not covered by any health insurance men

(15-49) The highest prevalence

130

APPENDIX E: INEQUALITY MEASURES AND THEIR SEVERITY CLASSIFICATION FOR THE HEALTH INDICATORS BY THEIR PREVALENCE CLASSIFICATION

Very high prevalence indicators Stratifiers Subcategory Indicators GOV Wealth Education Nationality Child 1. No minimum acceptable diet (6-23 months) 2.9 -2.9 -1.5 1.4 nutrition 2. No minimum dietary diversity (6-23 months) 6.7 -5.8 -2.4 1.8 3. No food rich in iron (6-23 months) 5.6 -3.5 -1.5 0.9 RF_Child 4. Any violent discipline children 1-14 years 3.4 -3.4 -2.5 0.5 development RF_NCDs 5. No breast exam self or professional 2.1 -4.0 -3.2 1.5 6. Obesity /overweight among women 15-49 2.0 -3.4 -2.7 0.8 7. Smoking men 15-49 2.8 -5.3 -1.3 0.9 8. Anemia among women 15-49 2.0 -2.1 -1.7 0.2 RF_HIV/AIDS 9. No comprehensive knowledge of HIV 1.3 -1.7 -2.0 0.4 related 10. No comprehensive knowledge of HIV for young (15-24) 0.7 -1.0 -2.4 0.6 (women) 11. Discriminatory attitudes against PLWH 1.4 -0.4 -0.4 0.1 12. No knowledge of STI 4.8 -6.4 -7.7 1.2 13. No Knowledge of MTCT 3.5 -1.3 -3.8 0.4 RH_HIV/AIDS 14. No comprehensive knowledge of HIV for young (15-24) 6.4 -1.0 -1.5 0.2 related 15. No comprehensive knowledge of HIV 3.0 -0.8 -1.5 0.4 (men) 16. Discriminatory attitudes against PLWH 2.9 1.4 0.6 0.3 17. No knowledge of STI 5.3 -0.1 -2.7 0.6 18. No Knowledge of MTCT 3.2 -4.4 -6.2 1.2 RF_Domestic 19. Agree to wife beating for at least one reason men 15-50 4.2 -0.4 0.5 0.5 violence 20. Women never sought help against spousal violence 4.5 -1.1 -1.1 2.1 related 21. Agree to wife beating for at least one reason women 15-49 13.3 -12.8 -7.4 2.7 HSP _Child 22. Not receiving iron supplement (6-59 months) 2.9 -2.8 -1.9 0.6 health 23. Not receiving vitamin A supplement (6-59 months) 2.2 -1.1 -0.5 0.3 24. Children with diarrhea not seeking treatment or advice 3.2 -3.8 -2.7 1.6 HSP_FP 25. Nonusers of FP did not discuss FP either with field workers 2.2 0.3 -1.9 1.4 or health facility HSP_Other 26. No information on test place for HIV/AIDS women 2.6 -5.2 -6.2 1.5 RH 27. No information on test place for HIV/AIDS men 4.4 -3.6 -9.2 1.4 28. No premarital exam women's husband 2.6 2.9 -13.3 0.3 29. No premarital exam women 2.9 -0.3 -14.2 2.6 Health 30. Not covered by any health insurance men (15-49) 14.0 -0.5 -10.3 2.9 insurance 31. Not covered by any health insurance women (15-49) 17.3 1.4 -8.4 6.9 coverage For summary inequality measures: Severe Moderate Low

131

High prevalence indicators Stratifiers Indicator group Indicators GOV Wealth Education Nationality Child mortality 1. Under 5 mortality 6.8 -2.3 7.7 5.6 2. Infant mortality 8.8 -1.8 -24.6 10.0 3. Neonatal mortality 13.2 -3.7 -9.9 9.2 RF_Infant health 4. Low Birthweight 6.0 -6.5 -10.0 3.8 5. Very small/small in size 7.8 -11.8 -10.2 5.1 RF_Child nutrition 6. No minimum meal frequency (6-23 months) 3.5 -5.2 -5.8 3.1 7. No food rich in vitamin A (6-23 months) 5.9 -4.5 -4.9 1.6 8. Anemia children 6-59 months 9.3 -11.0 -6.4 0.9 RF_Child 9. Children not on the developmental track 5.8 -4.9 -5.2 1.6 development Diabetes 10. Diabetes (60+ years/ women) 3.1 -1.7 -4.3 1.2 11. Diabetes (60+ years/ men) 3.7 0.1 1.7 1.6 12. Diabetes (18+ years/ men) 5.5 6.1 -14.8 2.8 13. Diabetes (18+ years/ women) 4.5 -3.3 -41.5 1.3 RF_NCDs 14. Never heard of pap test 8.8 -13.8 -11.1 9.0 RF_Social RH 15. Risky birth intervals (23 months) 3.5 -6.1 -0.9 4.3 16. Consanguinity 6.6 -7.3 -10.0 1.7 17. Multiparity (5+ children) 8.4 -8.9 -16.68 2.4 18. Early marriage (<18 years) 6.3 -10.7 -29.76 10.3 19. Not able to negotiate sexual intercourse 4.8 -9.4 -10.3 4.4 RF_Domestic 20. Ever experience any form of spousal violence 9.1 -5.5 -10.7 2.0 violence related 21. Experience of physical violence since 15 year of age 10.1 -8.1 -14.0 4.0 22. Any form of spousal violence in the past 12 months 11.4 -5.9 -8.7 0.3 HSP _child health 23. Children with fever not seeking treatment or advise 9.5 -6.8 -6.9 1.8 HSP_ Maternal 24. Cesarean section 2.7 2.6 4.5 2.5 health 25. No iron tablet during pregnancy 8.3 -3.3 -4.9 1.6 HSP_FP 26. No use of contraceptives 2.4 -1.4 -6.1 1.3 HS capacity 27. Need to take transportation 9.4 -15.2 -12.7 7.2 28. Unaffordability of the health care service 11.2 -26.3 -22.0 12.3 29. Distance to health care facility 13.3 -23.4 -17.9 7.6 30. Unavailability of female provider 7.5 -17.1 -14.0 5.9 Health insurance 31. No insurance for outpatient users 11.0 0.3 -5.1 13.1 coverage 32. No insurance for inpatient users na -1.2 1.2 22.8 For summary inequality measures: Severe Moderate Low

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Moderate prevalence indicators Stratifiers Indicator group Indicators GOV Wealth Education Nationality RF_Child 1. Children <5 years left with inadequate care 4.9 2.7 2.4 1.7 development 2. Physical violence is necessary 7.8 -3.8 -0.4 1.8 RF_NCDs 3. Smoking women 15-49 18.7 13.7 -3.7 2.6 4. Women who does not own health care decision 7.7 -13.3 -20.8 12.5 5. Adolescent child bearing (<18 years) 23.2 -46.2 -35.5 37.7 RH_HIV/AIDS 6. No knowledge of HIV/AIDS 19.5 -6.7 -23.8 10.1 related 7. No knowledge of HIV/AIDS 13.2 -15.2 -15.1 3.1 RF_Domestic 8. Experience of physical violence in the past 12 months 13.2 -6.8 -11.8 2.8 violence related HSP_ infant 9. No breastfeeding within 1 day of birth 9.0 -3.5 3.0 2.2 health 10. No postnatal check within the first 2 days of birth 13.7 -7.7 -8.9 7.9 11. No postnatal care for child 13.2 -8.0 -10.1 8.9 12. No breastfeeding 11.5 -3.4 1.8 3.3 HSP_Child health 13. Not receiving all age appropriate vaccination 12-23 6.0 3.8 1.5 8.3 months 14. No knowledge of ORS 9.3 -8.5 -15.9 14.8 15. Not receiving all basic vaccination 12-23 months 6.9 0.7 -0.8 11.2 16. Not receiving any age appropriate vaccination 12-23 14.3 -7.3 -10.1 9.3 months HSP_Maternal 17. No postnatal care <2 days 8.2 -10.1 -10.8 6.5 health 18. No postnatal care 12.4 -14.6 -15.6 9.8 19. No antenatal care regular 9.7 -16.1 -10.0 9.2 20. No antenatal care 17.8 -9.4 -16.9 7.5 HSP_FP 21. Use of traditional methods 5.8 -0.5 4.1 2.2 22. Unmet need 2.9 -2.9 -1.4 4.0 For summary inequality measures: Severe Moderate Low

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APPENDIX F: TRENDS IN PREVALENCE AND INEQUALITY SUMMARY MEASURES FOR HEALTH INDICATORS

Prevalence Gov Wealth Education Health aspect Indicator 2012 2017 2012 2017 2012 2017 2012 2017 Neonatal mortality 11.0 8.0 7.5 10.1 -10.5 -1.0 -10.1 -4.5 Child mortality Infant mortality 18.0 13.0 4.8 6.8 -12.7 -2.0 -11.1 -9.6 Under 5 mortality 20.0 14.0 5.0 6.8 -11.0 -1.7 -9.6 -7.7 RF_Infant Very small/small in size 19.7 13.7 3.0 7.8 -2.1 -11.8 -5.7 -10.2 health Low Birthweight 13.8 16.7 4.6 6.0 -3.2 -6.5 -8.3 -10.0 Anemia children 6-59 months 31.6 32.4 5.1 9.3 -7.3 -11.0 -3.3 -6.4 No food rich in vitamin A (6-23 months) 32.2 32.8 5.1 5.9 -9.3 -4.5 -6.1 -4.9 RF_ child No minimum meal frequency (6-23 months) 19.1 37.8 3.0 3.5 -9.9 -5.2 -13.8 -5.8 nutrition No food rich in iron (6-23 months) 39.5 40.4 3.3 5.6 -6.8 -3.5 -3.8 -1.5 No minimum dietary diversity (6-23 months) 44.9 48.6 3.7 6.7 -10.6 -5.8 -6.3 -2.4 No minimum acceptable diet (6-23 months) 66.7 76.5 2.8 2.9 -5.6 -2.9 -4.1 -1.5 Physical violence is necessary 22.8 13.9 3.0 7.8 3.6 -3.8 1.3 -0.4 RF- Child Children <5 years left with inadequate care 9.4 16.4 8.8 4.9 -7.3 2.7 -6.4 2.4 development Children not on the developmental track 31.1 29.3 6.0 5.8 -5.4 -4.9 -13.7 -5.2 Any violent discipline children 1-14 years 89.4 81.3 1.2 3.4 -1.4 -3.4 -1.2 -2.5 Smoking women 15-49 18.0 12.0 15.1 18.7 13.7 13.8 -7.8 -3.7 Anemia among women 15-49 33.5 42.6 5.9 2.0 -2.7 -2.1 -3.6 -1.7 RF_NCDs Obesity /overweight among women 15-49 54.8 54.1 1.6 2.0 -1.8 -3.4 -3.9 -2.7 Never heard of pap test 25.7 35.3 2.5 8.8 -19.6 -13.8 -14.2 -11.1 No breast exam self or professional 61.2 79.0 1.9 2.1 -5.8 -4.0 -4.7 -3.2 Adolescent child bearing (<18 years) 4.5 5.2 8.8 23.2 -9.4 -46.2 -42.9 -35.5 Women who does not own health care decision 11.3 7.9 7.8 7.7 -8.6 -13.3 -8.2 -20.8 Early marriage (<18 years) 20.5 20.8 3.1 6.3 -8.8 -10.7 -37.1 -29.8 RF_ Social RH Multiparity (5+ children) 31.7 23.5 3.7 8.4 -6.2 -8.9 -16.3 -16.7 Consanguinity 34.6 27.5 4.1 6.6 -8.9 -7.3 -7.0 -10.0 Risky birth intervals (23 months) 31.9 29.0 2.7 3.5 7.9 -6.1 -1.0 -0.9 No knowledge of HIV/AIDS 0.8 5.5 4.5 19.5 -40.6 -6.7 -74.6 -23.8 No Knowledge of MTCT 58.2 50.0 3.8 3.5 3.2 -1.3 3.9 -3.8 RF_ HIV/AIDS No knowledge of STI 40.4 66.1 3.7 4.8 -10.5 -6.4 -12.5 -7.7 related Discriminatory attitudes against PLWH 97.5 87.4 0.3 1.4 -0.3 -0.4 -0.2 -0.4 (women) No comprehensive knowledge of HIV for young people (15- 87.1 92.2 1.2 0.7 -0.9 -1.0 -1.3 -2.4 24) No comprehensive knowledge of HIV 91.4 93.4 3.1 1.3 -2.5 -1.7 -2.8 -2.0 Experience of physical violence in the past 12 months 12.6 14.4 8.5 13.2 -12.5 -6.8 -11.0 -11.8 Any form of spousal violence in the past 12 months 14.1 20.4 6.0 11.4 -15.1 -5.9 -8.9 -8.7 RF_Domestic Experience of physical violence since 15 year of age 34.3 20.8 4.9 10.1 -9.7 -8.1 -9.6 -14.0 violence ever experience of any form of spousal violence 31.7 25.9 3.9 9.1 -9.4 -5.5 -8.9 -10.7 related Agree to wife beating for at least one reason women 15-49 30.1 46.2 6.0 13.3 -4.7 -12.8 -4.3 -7.4 years Women never sought help against spousal violence 46.8 67.2 3.1 4.5 1.1 -1.1 0.9 -1.1 No breastfeeding 6.9 8.3 11.5 11.5 5.2 -3.4 -7.6 1.8 HSP_Infant No postnatal care for child 20.8 13.1 24.6 13.2 2.9 -8.0 -1.3 -10.1 health No postnatal check within the first 2 days of birth 25.3 14.1 21.7 13.7 2.4 -7.7 -2.4 -8.9 No breastfeeding within 1 day of birth 32.4 17.4 7.4 9.0 8.5 -3.5 4.1 3.0 Not receiving any age appropriate vaccination 12-23 months 0.3 6.9 78.0 14.3 -64.5 -7.3 -73.2 -10.1 Not receiving all basic vaccination 12-23 months 7.0 14.3 17.3 6.9 -8.6 0.7 -12.1 -0.8 No knowledge of ORS 8.0 17.5 8.7 9.3 -13.3 -8.5 -12.0 -15.9 HSP_Child Children with fever not seeking treatment or advise 14.9 19.5 18.5 9.5 2.4 -6.8 -3.8 -6.9 health Children with diarrhea not seeking treatment or advice 31.2 31.6 4.6 3.2 1.4 -3.8 -5.6 -2.7 Not receiving vitamin A supplement (6-59 months) 44.3 45.6 0.8 2.2 -0.7 -1.1 0.0 -0.5 Not receiving iron supplement (6-59 months) 89.0 72.5 0.7 2.9 0.0 -2.8 0.2 -1.9 For trend in prevalence: Increased by more than 25% Increased by less than 25% Decreased or the same For trend in inequality: Increased in severity classification Increased but within same classification Decreased or the same 134

Prevalence Gov Wealth Education Health aspect Indicator 2012 2017 2012 2017 2012 2017 2012 2017 No antenatal care 0.9 2.4 16.4 17.8 -46.8 -9.4 -41.3 -16.9 No antenatal care regular 5.5 7.9 10.9 9.7 -31.9 -16.1 -27.9 -10.0

No postnatal care 13.9 12.4 15.4 12.4 -18.0 -14.6 -21.6 -15.6 HSP_Maternal No postnatal care <2 days 17.9 16.6 16.6 8.2 -11.2 -10.1 -18.3 -10.8 health No iron tablet during pregnancy 15.4 22.1 7.2 8.3 -23.0 -3.3 -12.8 -4.9 Cesarean section 28.0 25.8 2.4 2.7 5.3 2.6 0.7 4.5 Unmet need 14.2 11.7 2.6 2.9 -9.0 -2.9 -8.0 -1.4 Use of traditional methods 13.0 18.9 3.8 5.8 1.9 -0.5 4.4 4.1

No use of contraceptives 48.2 38.8 2.8 2.4 -1.2 -1.4 -0.9 -6.1 HSP_FP Nonusers of FP did not discuss FP either with field workers or 78.7 73.9 1.0 2.2 2.6 0.3 0.3 -1.9 health facility No premarital exam women 59.6 46.8 1.0 2.9 -1.9 -0.3 -9.0 -14.2 HSP_Other RH No premarital exam women's husband 60.2 48.0 1.3 2.6 -1.7 2.9 -9.2 -13.3 No information on test place for HIV/AIDS women 79.4 72.8 1.9 2.6 -2.9 -5.2 6.2 -6.2 Unavailability of female provider 29.5 20.1 4.2 7.5 -6.3 -17.1 -3.9 -14.0 Distance to health care facility 26.4 22.0 2.5 13.3 -11.4 -23.4 -7.1 -17.9 HS capacity Unaffordability of the health care service 22.5 22.1 3.2 11.2 -24.1 -26.3 -20.5 -22.0 Need to take transportation 28.6 25.2 5.5 9.4 -11.9 -15.2 -5.8 -12.7 For trend in prevalence: Increased by more than 25% Increased by less than 25% Decreased or the same For trend in inequality: Increased in severity classification Increased but within same classification Decreased or the same

135

136