An integrated national health insurance system for Jordan : costs, consequences and viability.
Arguably, in common with many other nation states, Jordan could be said to have
drifted into different ways of paying for health services without always foreseeing the
long run consequences of taking the strategic direction necessary. In part, of course, as
in many developing countries, the financing of Jordan's health care services has been
influenced by its colonial past. This partly explains why, historically, Jordan has
attempted not only to provide wholly free services, but to provide privileged access to
medical services, not only to the military personnel but also to public servants in
With world economic instability and recent economic difficulties, notwithstanding the
opportunities created by Jordan signing the peace treaty with Israel, and the unclear
but likely stark future conditions facing the Jordanian economy, it is highly improbable
that Jordan will continue to be in a position to sustain, from central government
monies, a health system which currently consumes about7percent of the GDP.
Financing strategies will, therefore, have to address the heightened expectations for
rising health expenditures. Options under active consideration at this time include:
introducing or extending the present system of user charges; community financing
(participation ); (increased) use of the private sector; public or private health
insurance; and, improving efficiency in the use of hospital and community resources.
These are all financing options open to the Jordanian government to adopt, whether
singly or in combination, to generate more resources for the health system and to make
better use of existing resources.
Examining the range of different modalities of health services' financing reveals, not
surprisingly, that there are advantages and disadvantages in each financing scheme.
Nevertheless, depending on Jordan 's circumstances, some of the approaches may be
more appreciated than others: that is
from a political, cultural, socio-economic, or
strictly fiscal point of view.
This thesis focuses upon one particular health financing approach, "National Health
Insurance (NU)", and is aimed to lead the government of Jordan to rigorously explore
the concept, consider the options, and develop an implementation strategy benefiting,
where appropriate, from other countries' experiences with systems of NHI.
Specifically, the thesis first provides an overview (or situation analysis) of the
healthiness of the Jordanian economy, its key demographic and epidemiological
characteristics, and salient features of the Jordanian health sector. This is followed by a
largely theoretical discussion of the principles of insurance, and its potential relevance
to the unpredictability and uncertainty of health and disease. Methodological problems
inherent in public or private health insurance schemes are highlighted, and then
considered in a comparative context, drawing on lessons and experience around the
The thesis considers as its basic premise that a system of national health insurance is
both desirable and feasible for Jordan as it faces the next millennium. To test that
premise, the study is conducted by means of a series of investigations emphasising
both secondary and primary sources of data, and a range of quantitative and qualitative
research methods including: content and document analysis; experimental and survey
methods; interviews; and questionnaires.
The conclusions drawn from the evidence supports the contention that the
introduction of NM is potentially both desirable and feasible in Jordan but subject to
meeting very strict conditionalities, not least government ownership of the scheme,
and the willingness to address the present choice and diversity in health service
provision through health sector reform. These matters are as much political as
technical matters. On the more technical front, nonetheless, the design of an
appropriate NHI is shown to raise critical issues regarding: coverage; benefits;
organisation and management; costing and financing; and, provider payment
mechanisms. Various technical options are discussed in the thesis, and were consulted
upon with key decision makers in Jordan. Further directions of research and
development are also identified, which likely have applicability beyond the specifics of