The Hashemite Kingdom of Jordan High Health Council Policy Brief Health Spending in Jordan Policy Brief May 2016 Key Messages Latest statistics from Jordan show that out of pocket expenditure (OOPE) on health as a share of total health spending has been coming down, but annual OOPE on health for the average household has gone up in absolute terms across all wealth quintiles. Though the overall incidence of catastrophic health expenditure remains low, some segments of the population notably the wealthiest quintile and refugees face higher risk of experiencing catastrophic health spending. Increasing insurance coverage by subsidizing the public insurance cover for poor and vulnerable households, offering a comprehensive and harmonized benefit package, and improving the quality of care through strategic purchasing will reduce health spending by households and move Jordan towards the goal of Universal Health Coverage (UHC). Greater Effort is needed to explore ways to bring Syrian refugees into national insurance mechanisms. OOPE on health payments made directly by households to health providers at the time of seeking care can lead some households to avoid seeking needed health services and impoverish others. Consequently, reducing the extent of OOPE on health and ensuring financial risk protection for all are central to the vision of UHC. Tracking OOPE on health, catastrophic health spending, and insurance coverage are critical for measuring a country s progress towards achieving UHC. A recent study commissioned by the High Health Council and UNICEF did precisely that for Jordan using data from the 2008, 2010 and 2013 rounds of the Household Expenditure and Income Survey (HEIS). Understanding the problem Households are spending more in absolute terms on healthcare. While OOPE on health as a share of total health expenditure has been declining, it still accounts for nearly a quarter of total spending as of 2012 [1]. Moreover, HEIS data shows that household direct spending has increased in absolute terms. After adjusting for inflation, annual OOPE on health for the average household increased from 136 dinars in 2008
and to 215 dinars in 2013 (figure 1). While richer households spent more than poorer households in all years, annual household OOPE increased across the three rounds for all income quintiles. Mean annual OOPE on health varied dramatically across governorates, ranging from 327 dinar in Amman (which is home to 42% of the national population according to 2015 Census estimates) to 72 in Tafieleh (home to 1% of the national population). In 2013, the most recent year for which we have survey data, expenditure on medicines accounted for 62.5% of OOPE on health. However, this was higher for the poorest quintile (69.4%) than for the richest quintile (58.8%), and varied dramatically across regions (from 54.3% in Mafraq to 74.5% in Tafiela). Health expenditure on maternal health services also varied widely across wealth quintiles. The 2012 Demographic and Health Survey (DHS) captured OOPE for maternal health and family planning services. Women in the poorest wealth quintile on average paid 38.04 dinar for a delivery, compared to 557.84 dinar for women in the wealthiest quintile, primarily because more women in the latter group delivered at private facilities. Women from higher wealth quintiles on average paid more for family planning services than women in the poorest quintile. Catastrophic health spending is high in some segments of the population. The HEIS data shows that the extent of catastrophic health spending 1 is low and has remained stable over time (figure 2). Like previous studies, it appears more households in the wealthiest quintile experience catastrophic health spending than in the poorest quintile, which is unexpected and contrary to popular perception [2]. 1. Catastrophic health expenditure refers to OOPE on health that drives a household into poverty and is measured by the share of households whose OOPE on health was over 40% of their non-subsistence or non-food expenditure in year.
Syrian refugee households are significantly more susceptible to experiencing catastrophic health expenditure. The Vulnerability Assessment Framework, a survey conducted by United Nations (UN) agencies focusing just on Syrian refugees, shows that nearly 21% of the households covered by the survey experienced catastrophic health expenditure. The 2014 and 2015 Health Access and Utilization Surveys also conducted by UN partners show that the percent of refugee women who reported incurring no costs for delivering a baby since entering Jordan dropped from 75% in 2014 to 49% in 2015 (Figure 3). While national coverage rates for health insurance have increased, the percentage of the population covered by the Ministry of Health scheme has grown modestly. Starting in 2010, the HEIS asked individuals if they had health insurance 2. The data shows that coverage of health insurance increased by nearly 10 percentage points between the two rounds (figure 3). However, the increase was minimal for the Ministry of Health s civil insurance fund (CIF), which has been identified as the main public insurance scheme for insuring those who are currently uninsured [3]. In contrast, the percent of individuals insured by the Royal Medical Services (RMS), a scheme for members of the armed forces and their dependents, increased significantly. These two schemes represent the two largest risk pools in the country. Despite both being public, their benefit packages are not harmonized, and nor are the premiums [3,4]. 2. Estimates of health insurance coverage based on membership data are higher than those presented here. However, they do not take into account that an individual may be covered by more than one form of health insurance. The HEIS, which asks if an individual has any health insurance, does not suffer from this problem of double counting. The 2015 Census estimates that 55% of the population is covered by health insurance, while the percentage for Jordanians reached 68%.
In 2010, individuals in the bottom 3 quintiles had higher insurance coverage than quintiles 4 and 5, but this pattern was reversed in 2013. There is considerable variation in health insurance coverage between regions. In 2013, 60% of Moving towards a policy solution Jordan needs to develop a comprehensive health financing strategy that articulates how the country will address the three basic dimensions of UHC: bring more people into risk pooling arrangements, increase the percentage of services in the benefit package, and reduce the amount of co-payment [2]. We offer a few policy recommendations based on this study. 1. Design and implement a concrete plan for attracting those who are uninsured from the bottom two quintiles into CIF, as recommended by several other recent reviews [3, 4]. Data from HEIS shows that the percent of the population covered by CIF barely increased between 2010 and 2013. The scheme should consider targeting households in the bottom two quintiles by offering partial subsidies for health insurance. A proper mechanism for means-testing would allow CIF to implement a graduated scale of premiums for households at different levels of income. There is considerable variation in insurance uptake across the regions. More research is needed to understand regional differences in perceptions and understanding of health insurance. 2. Explore ways to bring refugee households into CIF. Insurance subsidies could also be used to bring more refugee households into the main public health insurance scheme. This also offers a way for development partners to finance health services for refugees for example, by setting up an insurance subsidy pool -- without setting up a parallel health system to cater to them. people in Amman had some form of health insurance coverage compared to 94% in Ajlun. Equally troubling is the fact that health insurance coverage appears to have decreased from 2010 to 2013 in 5 out of 12 governorates including Aqaba, Jarash, Mafraq, Tafiela and Zarqa. 3. Explore ways to bring refugee households into CIF. Insurance subsidies could also be used to bring more refugee households into the main public health insurance scheme. This also offers a way for development partners to finance health services for refugees for example, by setting up an insurance subsidy pool -- without setting up a parallel health system to cater to them. 4. Increase strategic purchasing 3 : Increasing insurance coverage in the public scheme alone does not guarantee a reduction in OOPE if the quality of services is not adequate, which will drive households to seek services from providers not covered by the insurance scheme (typically higher cost private facilities) and pay for those services from their own pockets. Ensuring strategic purchasing is critical for improving quality, and has the potential to enhance efficiency. In the short-run, this can be achieved by moving away from input-based financing of providers to more output-oriented provider payment mechanisms within the CIF scheme. In the long-run, the idea offered by the National Health Strategy (2015-2019) of setting up a national institution to serve as the public insurer that will purchase services from different types of providers (including those operated by the Ministry of Health) will create a purchaser-provider split which will likely enhance strategic purchasing. 5. Harmonize and expand the benefit package: Having a comprehensive benefit package that is harmonized across the public schemes will reduce the need for households to seek services outside of the insurance cover and pay for it from their pockets. 33. Purchasing refers the process by which funds are allocated to healthcare providers. According to the World Health Report 2000, passive purchasing implies following a predetermined budget or simply paying bills when presented. Strategic purchasing involves a continuous search for the best ways to maximize health system performance by deciding which interventions should be purchased, how, and from whom.
Policy Implementation Challenges and Implications Implementing policy changes and options described above poses challenges, which can be addressed by having strong leadership and drawing lessons from the experience of other countries. 1. Targeting insurance subsidies to the poor through means-testing approaches can be both difficult to implement and costly. Learning from other countries that have attempted this would be one way to avoid making the same mistakes as others have. 2. Changing provider payment methods in the face of resistance from providers can be challenging. Articulating how the new payment methods will reward good performance and extensive stakeholder engagement will be needed to address this. References 1. Jordanian National Health Accounts 2012, Technical Report. Higher Health Council, Government of Jordan, 2014. 2. Abu Saif, J. (2010). Fairness in Financial Contribution in Jordan, High Health Council and Department of Statistics. 3. World Health Organization. World Health Report 2010. 4. DAI. Public Expenditure Perspectives Update (2015-2017) Working Paper on Health Sector. 2015. 5. World Bank. Towards Universal Health Coverage: A Comprehensive Review of the Health Financing System in Jordan. 2015. 3. Designing a comprehensive but affordable benefit package requires both high quality data on effectiveness and costs, which is often not available. However, leadership from the High Health Council and the Ministry of Health, as well as technical support from development partners like the UN agencies and programs supported by bilateral donors can enable Jordan to address these challenges, and move towards achieving UHC. High Health Council / General Secretariat PO Box 2365 Amman 1941 Jordan Email: hhealth@hhc.gov.jo Phone: 00962 6 5332605 Fax: 00962 6 5332703 http://www.hhc.gov.jo/