A regional leader in service delivery and speciality care, Jordan’s health sector benefits from a large skilled workforce; a high-quality, low-cost medical tourism segment; and a robust pharmaceuticals manufacturing base. Expenditure on health care provision has risen consistently over the last decade, supporting strong improvements in indicators and outcomes.
The sector does face significant challenges, however. Most notably, perhaps, has been the rapid growth in the refugee population, which has seen some 1.3m Syrians settle in Jordan since 2011, resulting in unprecedented pressure on health care and hospital networks in the north of the country. Regional volatility has also considerably affected medical tourism inflows and weighed on pharmaceuticals export growth.
Yet, the sector’s long-term outlook remains positive. The authorities are increasing efforts to restructure state health insurance to achieve universal coverage, and partnerships with international donors support new private investment across a number of segments.
Background
Jordan’s health care sector comprises a mix of public, private, international and non-governmental service providers. The Ministry of Health (MoH) regulates sector institutions and professionals under Public Health Law No. 47 of 2008, while public bodies including the High Health Council (HHC), the Jordanian Medical Council and the Jordanian Nursing Council direct industry policy. The HHC formulates policy for the public and private sectors, but this role is limited.
MoH figures show that there were 676 health centres operating in Jordan at the end of 2016, spread among 102 comprehensive, 380 primary and 194 secondary health centres. There were also 405 dentistry clinics and 464 maternal and child health centres.
Jordan’s Private Hospital Association (PHA) reports that there are 117 hospitals offering services to Jordanian and non-Jordanian patients, comprising 31 hospitals overseen by the MoH, 69 private hospitals, 15 hospitals operated by the Royal Medical Services (RMS) – which serves members of the military and their families – and two university hospitals: University of Jordan Hospital and King Abdullah University Hospital.
Refugee Population
The UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) and the UN Office of the High Commissioner for Refugees also operate medical clinics for the refugee population, which has grown to 1.3m since the Syrian crisis began in 2011. Meanwhile, the UNRWA reports that there are 2.18m registered Palestinian refugees living in Jordan, about 370,000 of which – or 17% of the total – live in 10 camps across the country.
The rising number of refugees has created problems for Jordan’s public health care system. Just under 10,000 Syrian refugees were treated at MoH health centres in September 2012, and the HHC reports that this number had risen to approximately 44,000 by July 2014. Syrian patient volumes at MoH hospitals followed a similar trend during the period, rising from around 3000 to just over 20,000. The MoH spent JD53m ($74.8m) on refugee health care in 2013, including JD20m ($28.2m) for vaccination campaigns.
However, according to the US Agency for International Development (USAID), the sector requires an estimated $532.6m of additional funding annually between 2016 and 2018 to improve the health status of those in Jordan’s refugee communities.
“Health authorities are under heavy pressure with the Syrian refugees crisis, so this should become an incentive to increase cooperation between public and private entities within the sector,” Hassib Sahyoun, chairman and CEO of MedLabs, told OBG.
Authorities estimate that 22% of the population could be receiving inadequate health care as a result of the rising refugee demand, with local comprehensive health centres in affected areas often serving more than the national standard of one centre per 60,000 people.
Patient Coverage
Despite these constraints, Jordan benefits from a large, skilled workforce with substantial expertise in medical specialties, such as cardiac surgery, acute care, orthopaedics, psychiatry, paediatric care, rehabilitation, cosmetic surgery and oncology. The King Hussein Cancer Centre, for example, is a major dedicated cancer hospital treating adult and paediatric patients from across the Middle East.
Jordan has 28,000 physicians, according to the PHA, or 28.6 per 10,000 residents. This is one of the highest doctor-to-patient ratios in the region. Some doctors have been board-certified in the US, Canada, the UK or the EU, others in Jordan or the greater Arab region, while a growing proportion of nurses have experience in advanced patient care. There are 32 nurses, 17.8 pharmacists and 10.4 dentists per 10,000 people in Jordan.
Sector Financing
The government accounts for the majority of health care spending in the kingdom, including for the health insurance system. The MoH and the RMS are both public insurers, covering a combined 90% of the insured population, according to a June 2017 report by Palladium Group, an international development consultancy. All Jordanian citizens receive MoH benefits in the form of subsidised fees, which do not cover the actual cost of delivered health services.
The kingdom’s civil health insurance fund pays the full cost of care for civil servants classified as low-income by the Ministry of Social Development, while the MoH also provides free medication for contagious diseases, cancer, kidney disease, tuberculosis, HIV/AIDS and addiction. The Social Security Corporation’s Council of Insurance, led by the secretary-general of the MoH, oversees public health insurance.
Insurance Growth
The MoH reported that 86% of the population was covered by health insurance in 2013, although this figure does not include beneficiary cases of medical exemptions provided by the non-insured patient affairs unit at the Royal Court. Jordan Investment Trust reported in 2016 that total medical insurance premiums rose from JD105.82m ($149.3m) in 2011 to JD154.4m ($217.8m) in 2015, a 45.9% increase.
The MoH estimated that 8% of citizens held more than one type of health insurance in 2013. The civil insurance fund covered 44% of the population, the RMS provided for 27% and private health companies 6.9%. UNRWA primary care services covered an additional 6.8% of the population. The HHC reports that with the exception of citizens holding more than one type of health insurance, the true proportion of health insurance coverage did not exceed 78% in 2013.
Spending
While health insurance uptake has risen gradually, so has sector spending. The HHC reports that health care expenditure more than doubled between 2007 and 2015, growing from JD1.02bn ($1.4bn) in 2007 to JD1.54bn ($2.2bn) in 2010, JD1.88bn ($2.7bn) in 2013 and JD2.25bn ($3.2bn) in 2015, the most recent year for which statistics are available. Health spending per capita has also demonstrated upward movement, increasing from JD178 ($250) in 2007 to a high of JD269 ($380) in 2009, before moderating to JD232 ($327) in 2013. Per capita health expenditure stood at JD237 ($334) in 2014 and JD236 ($333) in 2015.
Despite growth in absolute terms, health care expenditure as a percentage of GDP has declined since peaking at 9.52% in 2009, falling to a nine-year low of 7.58% in 2012 before rising to equal 7.89%, 8.2% and 8.44% of GDP in 2013, 2014 and 2015, respectively. The Department of Statistics (DoS) reported that 7.7% of the budget was allocated to the MoH in 2016, against 11.3% to the Ministry of Education.
Government outlay has accounted for the largest proportion of health expenditure since 2007, and its share of the total has risen in recent years. According to the HHC, public spending accounted for 54.9% of overall health expenditure in 2007, rising to a high of 65.75% in 2009, decreasing to 59.24% by 2014 and remaining neutral at 60.69% in 2015. Private health spending as a percentage of the total has fallen from a high of 40.2% in 2007 to 34.54% in 2015, while donor funding accounted for 4.76% of all expenditure in 2015, against a nine-year high of 6.11% in 2014.
Basic Indicators
A robust medical workforce, strong expenditure levels, and efforts to reduce communicable diseases and expand insurance coverage have all had a positive impact on basic health indicators. For example, HHC figures show that average life expectancy for men rose from 70.6 years in 2006 to 72.4 years in 2013, while female life expectancy increased from 72.4 years to 76.7 years in the same time frame. The maternal mortality rate fell from 110 per 100,000 live births in 1990 to 58 in 2015, according to the World Health Organisation (WHO), while infant mortality for children under five years old declined from 36.6 deaths per 1000 live births to 17.9 over the same period.
In 2016 the MoH recorded 10.8m treatments of parasitic disease, tumours, endocrine disorders, blood diseases, nervous and respiratory system ailments, and digestive, urinary and reproductive cases. A further 30.55m vaccines for measles, polio, hepatitis, haemophilia, influenza and tetanus were administered.
The ministry reports that hospitals in the kingdom are under “huge pressures”, with 2.98m outpatients recorded in 2016. Hospitals performed 88,305 surgeries in the same year, while the number of live births stood at 72,168. Meanwhile, DoS figures show that annual hospital admissions at MoH facilities rose from 354,700 in 2014 to 369,500 in 2015 and 374,800 in 2016, an increase of 5.7% over the two-year period.
The DoS also reports that, despite the total number of hospitals in the kingdom rising from 104 in 2014 to 110 in 2016, Jordan’s patient-to-bed ratio grew from 710:1 in 2014 to 714:1 in 2016. Furthermore, the doctor-to-patient ratio increased from 22.1 per 10,000 people in 2014 to 25.6 in 2015, then fell to 21.8 in 2016.
Shifting Focus
Jordan has been a regional leader in protecting children against disease since the launch of a national vaccination programme in 1979, eliminating polio and significantly reducing the incidence of tetanus, diphtheria, measles and tuberculosis. However, the influx of refugees has reversed some of these gains, with the MoH reporting 34,314 cases of communicable diseases in 2013 and 2014, including 138 cases of tuberculosis. MoH figures show 460 new cases of tuberculosis were diagnosed in 2016.
Non-communicable diseases (NCDs), which are largely a result of lifestyle choices, pose a far more serious challenge to health outcomes in Jordan, especially given the population’s extremely high prevalence of tobacco use. The University of Washington reported in January 2014 that 43.4% of Jordanian men smoke, compared to 41.3% in Palestine and 39% in Turkey, giving Jordan the highest smoking ratio in the Middle East.
According to the WHO, the leading cause of death in the kingdom is cardiovascular disease, which accounts for 35% of all deaths. This is followed by other NCDs at 16%, cancers (15%), communicable, maternal, perinatal and nutritional conditions (13%), injuries (11%), diabetes (7%) and chronic respiratory diseases (3%). The WHO reports that out of an estimated 26,000 annual deaths, NCDs account for 76% of the total. NCDs are also a major concern for Syrian refugees, with more than half of such households estimated to have a member suffering from an NCD in 2015.
Mid-term Planning
Jordan’s mid-term policy for the sector is outlined in the National Strategy for the Health Sector in Jordan (NSHSJ) 2016-2020. In the document, the HHC reports that lower crude mortality rates and rising fertility rates, as well as the high rate of forced migration from neighbouring countries, has contributed to rapid population growth. The council estimates that if annual growth remains at the 2014 level of 2.2%, the population will double within 31.5 years. The proportion of people aged over 65 years is forecast to rise from 4.6% in 2012 to 4.9% in 2020, while the proportion of people aged 15 years and younger will fall from 35.4% to 33.4% over the same period.
Shifting demographics are also expected to see the proportion of people of working age reach 65% by 2030. This group is forecast to benefit from long-term policy priorities such as providing enhanced and specialised NCD care, expanding health insurance schemes to achieve universal coverage, and offering improved preventative, therapeutic and rehabilitative services.
Private Participation
The NSHSJ targets boosting private investment in the health sector to support macroeconomic growth and competitiveness, with the medical tourism and pharmaceuticals segments holding significant potential for future investment.
In December 2016 the authorities also announced the launch of the Jordan Health Finance and Governance (HFG) project funded by USAID. This five-year programme seeks to expand health insurance coverage among the population; enhance sector efficiency, governance and public financial management; and increase health spending across all levels.
As noted by the HHC, 16% of the state’s health budget is allocated to primary and preventative health care, while the remaining 74% is spent on curative services. The plan aims to identify gaps and deficiencies in sector governance, increasing the quality of health spending by improving the efficiency of public health resources.
In a promising move for private investors, the HFG will also focus on expanding the role of the private sector in service provision, including through public-private dialogue and private sector representation in committees and working groups focused on policy development. The private sector will also be engaged to promote innovative financing for service expansion.
Insurance Challenges
One important target of the NSHSJ is to restructure the health insurance scheme by establishing a binding health insurance law, setting a standard for medical coverage in the kingdom. This comes in response to several challenges that continue to prevent the implementation of universal health coverage. Palladium Group reports that different social classes of Jordanians receive qualitatively different care through the MoH and RMS delivery systems, with neither public insurer undertaking risk management activities; moreover, there is no mandatory insurance participation rule in Jordan.
Enrolment is not carefully tracked or coordinated among insurers, and premiums are not actuarially based: policyholders who are able to pay more are not charged more, meaning that the rich do not subsidise the poor. Further exacerbating the challenges in achieving universal coverage, the Insurance Commission of Jordan was dissolved in 2012 and regulatory responsibilities were shifted to the Ministry of Industry and Trade’s insurance administration directorate. Although the Central Bank of Jordan was to assume responsibility for monitoring the sector – including private health insurance companies – by February 2017, the process has been delayed (see Financial Services chapter).
Health Insurance Review
The government is nonetheless making solid progress towards drafting an insurance law under the HFG programme. In July 2017 Palladium Group reported that it is working with HFG experts to review MoH and RMS insurance regulations, as well as those for the private health insurance industry, including third-party payers and self-insured Jordanian entities. The review will be used by HFG stakeholders to identify new public-private partnership opportunities in up to three priority areas, with an overarching focus on reforming insurance regulations to ensure consumers are charged fair and reasonable prices for coverage, and providers receive contracted payments for delivered health care services.
Existing regulations will also be reviewed to identify the most critical gaps, and the review will help set a work plan for the HFG project in 2018, which should support its efforts at drafting the health insurance law.
Medical Tourism
Another priority of the NSHSJ is to boost private investment in medical tourism, which includes hospital, clinic and spa tourism, pharmaceuticals, biomedical research and production, medical equipment and Dead Sea wellness products.
The HHC notes that Jordan ranked first among Arab countries and was classified as one of the top-10 countries globally for medical tourism in 2012, with 250,000 medical tourists representing 23% of all patients that year, and total revenue surpassing $1bn. According to the PHA, hospitals account for 35% of industry revenue, with the remainder spread across 20 related areas, including aviation, transportation, hospitality and retail.
Competitive Advantage
One of Jordan’s strongest advantages – outside of its large and highly skilled workforce – is a much lower price point than other medical tourism destinations. According to the PHA, an angioplasty procedure costs an average of $8000 in Jordan, compared to $50,000 in the US, $25,000 in the UK, and $10,000 in Singapore and Thailand, while the price of a hip replacement is $11,000, as opposed to $40,000 in the US, $20,000 in the UK, and $12,000 in Thailand and Singapore. Furthermore, hospitals in Jordan charge an average of $11,000 for a coronary artery bypass graft, compared to $100,000 in the US, $35,000 in the UK and $13,000 in Singapore.
“Our prices are very competitive – the most competitive in the region. Procedures in Jordan cost an average of 30% less than they would in our primary competitors, such as Turkey and Lebanon,” Dr Abdallah Bashir, general manager and consultant surgeon at Jordan Hospital, told OBG. “Our hospitals are accredited and we have all the specialty equipment patients need.”
Indeed, nine Jordanian hospitals are accredited by Joint Commission International and a further 25 are accredited by the National Health Accreditation Council, according to the PHA. As a result, Jordan is also a leading destination for patients seeking orthopaedic and kidney transplant surgery, although the industry is facing serious near-term growth constraints.
Segment Challenges
As with the broader health care sector, medical tourism has come under pressure in recent years as a result of both regional volatility and rising competition. In December 2016 the International Medical Tourism Journal reported that medical tourism patient numbers to Jordan fell by 40% year-on-year during the first nine months of 2016, owing to new visa restrictions on patients from countries experiencing conflict and political instability, as well as rising competition from the UAE, Turkey and India. In September 2016 the PHA reported that visa restrictions rolled out for patients from Libya, Sudan, Syria, Yemen, Chad and Nigeria significantly reduced patient numbers from these countries. Patient volumes from Libya dropped by 80%, tourist numbers from Yemen declined by 50% and cases from Sudan shrank by 48%.
Although the Ministry of Interior (MoI) committed to processing all medical tourism visa requests within 48 hours in early 2017, the PHA reports that Sudanese patients continue to wait up to four weeks for approval. Efforts to tap new markets in Oman and Kazakhstan have also faced hurdles, as these countries are already served by direct flights to Turkey, but not to Jordan.
Regional Instability
With many of its largest source markets beset by severe political instability, medical tourist bills that would have normally been covered by national governments have also gone unpaid. For example, the Libyan government and associated agencies owed approximately $300m in outstanding debt to Jordanian hospitals as of December 2016, prompting some hospitals to refuse to treat Libyan patients until the debts have been paid.
Jordan’s geographic location in a politically volatile region, including shared borders with Syria and Iraq, has acted as a deterrent to potential patients from Asia, Europe and the US. At the same time, GCC countries’ moves to reduce outbound medical tourism have also affected patient numbers, including from Jordan’s largest medical tourist market, Saudi Arabia.
Reforms
Moves to promote the segment abroad could help reverse some of these losses. For example, in March 2017 the Cabinet endorsed a new process for issuing visas to Sudanese and Yemeni patients. Under the updated regulations, airlines will now be required to provide a list of names of Yemeni patients to the MoI, which will then issue tourist visas and provide security clearance within 48 hours. Sudanese patients who are over 50 years old and possess at least $5000 in cash will also be permitted entry at border crossings, along with up to two accompanying persons.
While the PHA has praised the government for loosening medical tourism regulations, it believes that the age limit remains restrictive. It urged the government to implement regulations similar to those for Egyptian patients, where women, children under 15 and men above 50 are exempt from visa requirements.
Destination Jordan
Marketing has also been somewhat challenging, with the segment excluded from Jordan’s 2017 tourism development strategy and lacking a dedicated industry association, such as a medical tourism board. Reforms are under way, though, after the PHA launched a two-year medical tourism strategy in September 2016, supported by USAID’s Jordan Competitiveness Programme. According to the International Medical Tourism Journal, as part of the strategy, private hospitals involved in medical tourism adopted specific membership standards, such as having international accreditation and centres of excellence.
The PHA has also partnered with national carrier Royal Jordanian as it seeks to improve flight connections to potential markets. The association also aims to carry out a wider array of marketing activities, including exhibitions and delegations for foreign agencies responsible for sending patients abroad for treatment. Efforts will target expanding potential markets such as Kazakhstan, Algeria, Nigeria, Chad, Oman and Saudi Arabia, using the slogan “Jordan, your health destination”.
Pharmaceuticals
Medication also holds significant opportunities for private investors. Jordan’s pharmaceuticals industry dates back to the early 1960s, with the kingdom having developed a strong reputation for safe, high-quality pharmaceuticals manufacturing in the years since, often at a lower price point than many of its competitors. There are 127 health care companies in Jordan worth an estimated $80.18m, including 21 pharmaceuticals factories employing 10,000 people, of which some 3700 are women.
Jordan exports pharmaceuticals to more than 70 countries and the segment has risen to become one of the country’s top foreign-exchange earners, with the Amman Chamber of Commerce and the Arab-German Chamber of Commerce and Industry reporting that pharmaceuticals exports stood at €510m in 2015, against €538m in 2014. Major export markets in 2015 included Saudi Arabia, which purchased €120m, Algeria at €59m, Sudan (€54m) and the UAE (€39m). Jordan also exported €23m worth of pharmaceuticals to the US in 2015 and €6m to Europe. According to Mohammad Ali Shahin, chairman of the Jordanian Association of Pharmaceutical Manufacturers and Medical Appliances in a May 2017 interview with local media, pharmaceuticals contributed $1bn to the export bill in 2016.
Growth Potential
The segment retains strong growth potential for the future. In a March 2017 report on the local industry, Swiss nutritional supplement and vitamin manufacturer Cedem reported that Jordanian pharmaceuticals factories are equipped with advanced machinery to support increased production capacities, offering opportunities for foreign firms to enter into licensing agreements with domestic manufacturers. Moreover, in 2016, 27 countries – including the US, Switzerland and Germany – conducted clinical studies at 18 accredited sites in Jordan.
Investment in pharmaceuticals manufacturing is rising: the International Finance Corporation announced plans for a $45m equity investment in MS Pharma in June 2017, following a similar $50m investment from the European Bank for Reconstruction and Development in 2016. The investments will be used to support MS Pharma’s international expansion plans and aid in efforts to promote access to affordable generic pharmaceuticals and other health products.
Outlook
Despite the external headwinds facing the health care sector, it continues to benefit from robust human resources, high standards of care, low-cost medical tourism offerings and a well-developed pharmaceuticals manufacturing segment. With authorities ramping up efforts to implement the sector’s mid-term strategy, private investors are set to benefit from new opportunities and partnerships in health care delivery. Reforms to visa rules, insurance frameworks, medical tourism marketing and export regulations should also support stable long-term growth, helping the sector remain resilient in the face of near-term challenges.
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