Jordan NCD Country Experience and Case Study Presentation Regional Meeting on Strengthening the Integration and Management of Noncommunicable Diseases in Primary Health Care Cairo, 08-10 September 2014 D Ghazi Sharkas ,Associate NCD Director D Basheer Al-qaseer ,Director of PHCA D Mohammad Tarawneh, Director on NCD

Background Health care in Jordan is provided by the Ministry of Health (MOH), the Royal Medical Services, Universities hospitals, UNRWA, the private sector, and NGOs. The MOH provides health care through primary health care canters, comprehensive health care centers, and hospitals

Primary health care The primary health care administration provides its services through the 12 health directorate distributed over the country, besides a wide network of healthcare centers which covers all the population gatherings in jordan It provides care in general medicine, dentistry, public health, mother and child care , health promotion, health education, and other specialized services

Vital Statistics and health indicators According to 2012 official figures: Total estimated population: 6388000 Crude birth rate: 28.1/1000 Crude mortality rate:7/1000 Infant mortality rate:17/1000 live birth Average number of doctors 27.1/10,000 Health insurance coverage: 79% of the population(CHI 42%, RMS 27%, Companies 6%, Funds 3%, Universities 1%, Uninsured 21%

PHC Directorates Communicable diseases Non communicable diseases Respiratory diseases Mother and Child care Environmental health Occupational health School health Awareness and health information

Non communicable diseases The national program for breast cancer Jordan cancer registry National Hemophilia Registry National ESRD Registry Congenital and genetic diseases Cardiovascular diseases Cancer control Nutrition Prevention of blindness and deafness

Health facilities in numbers Health facility Number Total number of hospitals in Jordan 106 Total hospital beds in Jordan 12106 MOH hospitals 31 MOH hospital beds 4612 MOH Comprehensive health centers 92 MOH Primary health centers 372 MOH Peripheral health centers 211 MOH Maternity and childhood centers 444 MOH Respiratory diseases centers 12 MOH Mental health centers 3

NCD Jordan figures □ STEP-wise survey conducted at the national level in 2007 confirmed the: high prevalence of DM 16% > 30% of Jordanians aged ≥25 years had elevated FBS above 100 mg/100ml > 65% suffered from overweight or obesity, > 25% were hypertensive, and many had dyslipidemia. About 36% of Jordanians ≥25 years of age suffer from the metabolic syndrome criteria :abdominal obesity ,high fasting glucose, high blood pressure, hypertriglyceridemia ,low HDL cholesterol

NCD management □ NCD management is largly provided through a widespread healthcare canters in the MOH with a referral system that permits interchangeable services between public and non public sectors. □ Developing guidelines for management of: DM, HTN COPD Chronic kidney diseases the family based approach guidelines  □ Development of the national strategy for NCDs

Time to take action Increase awareness Advocacy and Marketing of NCD prevention National strategy developed National initiatives and programmes Capacity building and training Networking Technical support Cooperation and coordination

NCD integration into PHC About 79% of Jordan's population are insured, which is considered advantageous in the process of NCD integration Care for NCD is provided in the different health centers and hospital clinics Care is mainly provided by general practitioners and family medicine specialists Advanced care is usually provided through referral system No previous action on NCD integration into PHC Pilot efforts for special NCD care in Ajloun and Jarash governorate providing care by general practitioners or family medicine doctors in a separate clinic in selected comprehensive health centers

National capacity for NCD prevention and control Few clear policies and strategies. Limited resources. Fragmented and uncoordinated care. Low commitment to prevention. Lack of surveillance systems. Inadequate treatment guidelines. Severe lack of investment in research

Challenges and opportunities in Jordan The integration of NCD into PHC is faced with: The limited budget for implementation The scarce opportunities for staff training The loss of resources on fragmented and small peripheral health centers that are unable to cope with integration

The case study

Study objectives To establish baseline prevalence estimates of major NCDs and their behavioral risk factors in Ajloun and Jarash governorates, with particular emphasis on hypertension, diabetes, and obesity. To reduce the prevalence of NCDs ,and their risk factors by implementing physical activity intervention, dietary modification ,and health education programme To raise the awareness regarding health impacts of NCDs in Ajloun and Jarash Governorates. The prevalence of major modifiable NCD risk factors (tobacco use, physical inactivity, and unhealthy diet) was also estimated in these two governorates. The study findings aimed at encouraging use of data in planning and implementing a scalable NCD project, and in promoting the use of data among public health planners and policy makers.

Experience/initiative: The attempts to fight NCD and related risk factors were based on multi-sectorial approach and participation of concerned stakeholders according to the national strategy of NCD, and MOH strategy. Stakeholders from the ministry of health including NCD directorate, Ajloun health directorate, Jarash health directorate together with EMPHNET staff and CDC members, with active community leaders and NGOs worked together. Religious leaders played an important role; they were urged to brief information about the importance of NCD and risk factors in the prayers lessons, and the weekly Friday lesson.

Experience/initiative: NCDs were treated in a special and organised way in selected health centers from both governorates. The process includes diagnosis, management, awareness, referral for special care, and modification of lifestyle by enhancing physical activity and dietary modification. Physical Activity (PA) Counseling: Tracking forms were used to record patients information, and a software was installed for piloting in one of the selected HCs. PA Equipments were placed in the three selected health centers and community centers. Walking Groups & Healthy Kitchen were supported.

Challenges and lessons learned: People resistance to change their behaviours into a much healthier lifestyle could be overcomed by continuous awareness, and facilitation of the change process. Conflict of interest of the private sector could be minimized by making partnership ,and involving the private sector with the interventional process. Promote Model NCD Health Centers. Provide Support and On the Job training. Increase MOH involvement to secure sustainability. Increasing Community involvement. Empower Use Of knowledge

Impact: Proper access to NCD management is provided by the health care system through public health sectors including MOH facilities, military facilities , university hospitals ,and UNRWA NCD patients were provided by regular examinations, lab and other investigation procedures ,as well as treatment for the NCD complications in a partially integrated manner to the Primary Health Care (PHC) system. The basic services for NCD patients are provided in all primary health care canters, while the comprehensive health care canters and hospitals are providing advanced care through the referral system. Health services for NCD are highly affordable by the health insurance system in Jordan

Next steps/future directions: The next step is to follow the situation of NCD and risk factors under modification in Ajloun and Jarash governorates seeking for improved indicators, and to expand the interventional project of physical activity and dietary modification to other governorates all over Jordan

Key references/documents The National Strategy And Plan Of Action Against Diabetes, Hypertension, Dyslipidemia And Obesity in Jordan. Jordan Ministry of Health http://emphnet.net/Library/Reports/tabid/156/ItemId/20/Default.aspx