poverty reduction strategies and health outcomes: jordan ... · voice” (mowaﬁ and khawaja 2005,...

Poverty Reduction Strategies and HealthOutcomes: Jordan as a Case Study

Thamer Sartawi

ContentsIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Social Determinants of Health (SDH), Poverty, and Health Inequalities . . . . . . . . . . . . . . . . . . . . . . . 4

Poverty, Ill Health, and Health Inequalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Health Components of Poverty Reduction Strategy Papers (PRSPs) . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

PRSPs and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10PRSPs and Health in the EM Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11PRSPs and Health Equity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Population Health and Health Inequalities in Jordan and the Wider Eastern Mediterranean(EM) Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Population Health Inequalities Between Countries in the EM Region . . . . . . . . . . . . . . . . . . . . . . 15The Jordanian Poverty Reduction Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Overview of the JPRS Health Component . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Poverty and Health Links in the JPRS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Social Determinants of Health and Health Inequalities in the JPRS . . . . . . . . . . . . . . . . . . . . . . . . 21Health Inequality Reduction and the JPRS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Opportunities for Addressing Health Inequalities via the JPRS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

AbstractThe relationship between poverty and ill health is very well established. One wayto examine the link between poverty, or low socioeconomic status, and health isutilizing the social determinants of health framework. This chapter uses Jordan asa case study to assess this link and subsequently examine the health impact ofJordan’s current poverty reduction strategy. Despite the existing health inequal-ities between socioeconomic groups in Jordan, the social gradient of healthinequalities is not addressed in public health policies in the country. As a result,

T. Sartawi (*)Saint Louis University, St Louis, MO, USAe-mail: [email protected]

© Springer Nature Switzerland AG 2020I. Laher (ed.), Handbook of Healthcare in the Arab World,https://doi.org/10.1007/978-3-319-74365-3_21-1

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this chapter assesses the potential contribution of the 2013–2020 JordanianPoverty Reduction Strategy (JPRS) to health of the poor in Jordan. First, thischapter presents a conceptual framework examining linkages between poverty,ill health, and health inequalities. The framework is used to assess the potentialhealth equity effects of the JPRS. In doing so, the analysis showed that for apoverty reduction strategy to contribute to improving health outcomes, it mustinclude health system, socioeconomic, and structural-level interventions tobreak the link between poverty and ill health and subsequently reduce healthinequalities. Second, this chapter presents the case for integration of targetedhealth interventions within a universal strategy. The strategy adopts explicitlytargeted health intervention approaches such as healthy villages project (HVP)and conditional cash transfers (CCTs). Therefore, the JPRS may lead toindividual-level health improvement on outcomes; however, at a populationlevel, this impact is unclear. This chapter also presents the case for intersectoralcollaboration and overemphasizes health sectoral policies go hand in hand withsocioeconomic and structural interventions. Nevertheless, the JPRS can poten-tially act as a catalyst toward designing a comprehensive poverty reductionstrategy that would benefit the health of the poor and result in the reduction ofhealth inequalities in Jordan.

KeywordsPoverty · Health inequalities · Social determinants of health · Poverty reductionstrategies · Jordan

AcronymsCCT Conditional Cash TransfersCSDH Commission on Social Determinants of HealthDOS Department of StatisticsEM Eastern MediterraneanGOJ Government of JordanHD Human DevelopmentHDR Human Development ReportHVP Healthy Villages ProjectIMF International Monetary FundIMR Infant Mortality RateJPRS Jordanian Poverty Reduction StrategyLE Life ExpectancyMM Maternal MortalityMMR Maternal Mortality RateMOH Ministry of HealthPFHS Population and Family Health SurveyPRS Poverty Reduction StrategyPRSP Poverty Reduction Strategy Paper

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SDH Social Determinants of HealthSEKN Social Exclusion Knowledge NetworkU5M Under-5 MortalityUNDP United Nations Development ProgrammeWB World BankWHO World Health Organization

Introduction

Human poverty is defined by the United Nations Development Programme (2000,p. 17) as “impoverishment in multiple dimensions—deprivations in a long andhealthy life, in knowledge, in a decent standard of living, in participation.” Multi-dimensional poverty – beyond the one dimension of income – portrays poverty asdeprivation that leads to a deficiency in “social capital, human capital, power, andvoice” (Mowafi and Khawaja 2005, p. 3). Thus, with the aim of tackling multi-dimensional poverty and deprivation, many countries have developed PRSs whichare “documents that set out frameworks for domestic policies and programmes toreduce poverty” (UNFPA 2013). The United Nations Population Fund (UNFPA)suggests that a common feature of all PRSs is the inclusion of “civil societyorganizations, representatives of the poor and women, the private sector, tradeunions, donors and UN system partner in addition to government” in the processof designing and implementing a PRS (UNFPA 2013).

In 1996, the IMF and WB launched the heavily indebted poor countries (HIPC)initiative that aimed at providing debt relief and concessional loans to poor countries.In 1999, the IMF and the WB required HIPCs to develop Poverty Reduction StrategyPapers (PRSPs) as a condition to be included in the HIPC initiative (IMF 1999). Innon-HIPC countries such as Jordan, PRSs are also intended to tackle poverty.

Common features of both the JPRS and PRSPs include the utilization of amultidimensional definition of poverty, the adoption of a multisectoral approach topoverty reduction, WB involvement in the PRS preparation process, and the inclu-sion of health components in both PRSs. Unlike HIPCs, the JPRS is not intended tohelp Jordan qualify for debt relief but rather as a comprehensive national documentto address poverty. This chapter uses the concepts regarding social determinants ofhealth inequalities to assess relationship between poverty, poverty reduction strate-gies, and within-country health inequalities in the Eastern Mediterranean(EM) region using Jordan as a case study.

Jordan is an excellent case study for the assessment of the interaction betweenhealth inequalities and poverty. Within Jordan, income inequalities and poverty ratesare high. This chapter assesses the stagnation and unequal distribution of Jordan’spopulation health gains over the past decade and explores the potential opportunitiesthat lay in poverty reduction strategies to impact health of the poor.

Poverty Reduction Strategies and Health Outcomes: Jordan as a Case Study 3

Social Determinants of Health (SDH), Poverty, and HealthInequalities

In 1978, conveners at the Alma-Ata Conference stated that health inequalities –defined as health differences that are “systematic, socially produced (and thereforemodifiable) and unfair” (Dahlgren and Whitehead 2006, p. 2) – are “politically,socially and economically unacceptable” (WHO 1978). Decades later, in 2003, theWorld Health Organization’s (WHO) Commission on Social Determinants of Health(CSDH) was created to promote evidence-informed policies and action to achieveequity in health and to support a global movement to achieve health equity (CSDH2008, p. 1). Dahlgren and Whitehead’s much cited “rainbow model” illustrates thedifferent SDH as multiple layers of influence – the outermost layer represents distaldeterminants of health, such as the structural and contextual determinants, whereasthe innermost layer represents the most proximal determinants such as age andgenetics (Dahlgren and Whitehead 1993). The CSDH (2008) proposes that livingand working conditions such as health services, education, unemployment, housingconditions, and income level represent the social conditions that affect individualhealth (CSDH 2008).

The CSDH also uses the SDH framework to explain health inequalities. TheCSDH proposes that the unequal distribution of social determinants such as educa-tional opportunities, income, and adequate healthcare services between more andless advantaged population groups and countries leads to the production of healthinequalities between and within countries (CSDH 2008, p. 9). In addressing healthinequalities, Graham also notes that it is essential to identify and tackle the socialdeterminants of health inequalities – the social processes that lead to the unevendistribution of SDH (Graham 2007). The CSDH defines social determinants ofhealth inequities as the “structural social stratification mechanisms, joined to andinfluenced by institutions and processes embedded in the socioeconomic and polit-ical context (e.g. redistributive welfare state policies)” (WHO 2010, p. 26). Accord-ingly, as major determinants of health lay beyond the reach of the health sector,improving the health of individuals mandates improving the social conditions inwhich people live in and the social processes that lead to their unequal distribution(Graham 2007).

Poverty, Ill Health, and Health Inequalities

Poverty and ill health are closely linked to each other, and many studies haveattempted to unpack these linkages and associations (e.g., Wagstaff 2002; Krishna2007; Braveman and Gruskin 2003; Leskošek 2012). Wagstaff proposed that healthand poverty influence each other in a bidirectional manner, creating a vicious cyclein which ill health and poverty perpetuate and cause each other (Wagstaff 2002).Poverty is often perceived as a risk factor for health and ill health as a predictivefactor of impoverishment (ibid.). Mowafi and Khawaja described poverty as being“. . .multidimensional in its symptoms, multivariate in its causes, dynamic in its

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trajectory, and quite complex in its interaction to health” (Mowafi and Khawaja2005, p. 1). This section discusses some of the links between poverty, ill health, andhealth inequalities from a SDH angle. In doing so, it unpacks the ill health andpoverty cycle from a health system, socioeconomic, and structural determinantperspective. The relevance of these different conceptualizations to assessing theJPRS is also presented.

Health Systems and Poverty GenerationIt is widely proposed that ill health reduces earning capacity of the poor and leads toincreased vulnerability to impoverishment (Wagstaff 2002). Generally, compared tomore advantaged groups, the poor adapt poor health-related behaviors to avoid therisk of losing income. Loss of income due to ill health is brought upon throughmissing working days and a reduction in worker productivity. When ill health leadsto disability or is in the form of a chronic debilitating disease, poor health leads to joblosses (McIntyre et al. 2007). Therefore, the poor are less likely to report illness,utilize health services when sick, or acknowledge illness at early stages (ibid.).Additionally, the financial costs associated with accessing health services cancause significant financial hardship and impoverishment affecting poor and vulner-able households (Dahlgren et al. 2001), especially in countries where health systemsare funded via regressive modes of healthcare payments such as user fees andcopayments. As a result, poor households and individuals contribute a greaterproportion of their income to access healthcare services compared to advantagedgroups (ibid.). Thus, as out-of-pocket payments and catastrophic health expenditurescause financial hardship, the poor and vulnerable are pushed further into poverty andimpoverishment and fall into a “medical poverty trap” (ibid.). Falling into such amedical poverty trap often leads to an increase in untreated illnesses, reducedhealthcare access to health services, long-term indebtedness, and increased socialvulnerability to disease (McIntyre et al. 2007).

Additionally, Krishna proposes that poverty reduction efforts are incompleteunless pathways and processes leading to the creation of poverty are addressed. Inthis regard, he points to the momentous role that healthcare expenses play in povertycreation. Healthcare expenses were found to lead to poverty creation in bothlow-income countries, such as Uganda and Kenya, and high-income countriessuch as the USA (Krishna 2007). This suggests that social institutions such as healthsystems are becoming poverty-generating institutions instead of promoting thewelfare of the population (Krishna 2007; Dahlgren and Whitehead 2006).

The Jordanian health system is one of the well-established systems in the MENAregion (WHO 2006). Nonetheless, it is a highly fragmented system that provides itsservices through three major arms of delivery: the public sector, the private sector,and the non-governmental organizations (WHO 2009). The public sector provideshealth services through the Royal Medical Services (RMS) and the Ministry ofHealth’s insurance through the Civil Insurance Program (CIP) (WHO 2006). Mostrecent estimates indicate that 22% of Jordanians are not insured (GOJ 2011). TheRoyal Medical Services (RMS) and the Ministry of Health (MOH) are the two majorpublic health insurers in Jordan, each insuring 34% and 27% of the population,


respectively, while the private sector and the non-governmental sector cover 8% and9% of Jordanians, respectively (GOJ 2011). Uninsured Jordanians can access MOHhealthcare facilities paying 15–20% copayments with the rest of the cost subsidizedby the GOJ (ibid.) or are forced to access healthcare through the private sector. As aresult of lack of health insurance, copayments, and user fees, 40% of healthcarefinancing in Jordan originates from out-of-pocket expenditure, and the rate ofcatastrophic health expenditure leading to impoverishment is estimated to be 7%(ibid.).

To remedy this ailment, Labonte proposes that pro-equity health system reform isessential. Labonte suggests that primary healthcare-oriented reform (opposed totertiary hospital-oriented reform) should be undertaken for it favors the poor overthe rich (Labonte 2010). In doing so, he calls for the creation of “progressivelyfinanced health insurance,” financed by cross subsidization from the advantagedhealthy and rich to the disadvantaged sick and poor (ibid.). This involves removal ofuser fees and copayments. In effect, these measures would lead to increase fairness inhealth systems and prevent financial hardship incurred by the poor to access healthservices (ibid.). Consequently, pro-equity primary healthcare reform would contrib-ute to promoting health equity.

Policy directions for pro-equity health reform in Jordan include the introductionof an essential services package (ESP) provided via primary healthcare centers(UNDP 2013b, p. 178). The ESP is proposed to include a variety of basic healthservices and medicines aiming to be “available and affordable or free of charge forall people at public health facilities” (UNDP 2013b, p. 178). Nonetheless, proposedhealthcare reform measures in Jordan do not include the elimination of copaymentsor user fees from accessing public health service. This calls into question whether thereform would make the Jordanian health system more equitable if regressive modesof healthcare financing are kept in place.

Socioeconomic Deprivation and SDH of Ill Health and HealthInequalitiesThe close association between socioeconomic deprivation and its impact on healthwas examined by Leskošek (2012) in Slovenia. The study assessed multiple socio-economic deprivation indicators such as the “multiple deprivation index” developedby Townsend and deprivation indices in countries such as the UK to establish thelinks between socioeconomic indicators and population health. The study proposedthat living in multidimensional poverty entails deprivation in ten major areas (seeBox 1). Leskošek suggests that since “deprivation begins before birth and amplifiesuntil death,” improved socioeconomic indicators through governmental policieswould contribute to improved health and well-being. Poor public policies leadingto deprivation in these socioeconomic indicators contribute significantly to ill healthof the poor (Leskošek 2012).

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Box 1 Major Areas of Socioeconomic Indicators That Matter for PopulationHealth (Leskošek 2012)• Material deprivation• Social capital• Unemployment• Housing conditions• Level of education• Profession• Living environment• Health• Human safety• Accessibility to services and ethnicity

Lantz and Pritchard examined the links between socioeconomic deprivation andhealth at the community level. They reflect on evidence from the USA as theyidentify the three main community indicators contributing to population health at acommunity level: community socioeconomic composition, social structure, andsocial cohesion and social capital (Lantz and Pritchard 2010). It is proposed thatsocioeconomic composition of a community, that is, the “levels of education,employment, income, and income security in a community,” has significant effectsin “creating and shaping risks and benefits for health, many of which accumulateover the life course. . .” (ibid.). Social structural factors, such as “income inequality,racial segregation and discrimination,” were also conveyed as an influential factorleading to ill health as these factors influence the socioeconomic environment at acommunity level. Finally, Lantz and Pritchard suggest that degree of social cohesion– “extent of connectedness and solidarity among groups in society within commu-nities” (Kawachi and Berkman 2000) – within communities has very positiveinfluences on health outcomes (ibid.). The CSDH’s Knowledge Network on UrbanSettings (KNUS) proposed that the effects of socioeconomic deprivation on healthare most elaborately seen in deprived urban areas (Kjellstrom and Mercado 2008).

Globally, it is estimated that more than half of the world’s population are living inurban settings. Although urbanization is proposed to lead to better living conditionsand health, the aggregate levels of health indicators in urban settings mask theuneven distribution of health gains within the urban population (Kjellstrom andMercado 2008). The poor urban setting is characterized by overcrowding, poorhousing, slum area production, poor basic infrastructure, and poor water, sanitation,health, and educational services (Kjellstrom and Mercado 2008; de Snyder et al.2011; Sverdlik 2011). Deprivation in urban settings led to the rise of the “urbanpenalty” phenomenon, where health status in urban settings is worse than health inrural settings and the rise of urban health inequalities (Sverdlik 2011). However,poor health in poor urban areas is not only a direct consequence of deprivation insocioeconomic environment but also a consequence of urban social inequalities(Kjellstrom and Mercado 2008). The urban penalty phenomenon is closely related


to social inequalities that lead to socioeconomic deprivation of the poor and theunequal distribution of SDH (Kjellstrom and Mercado 2008; Sverdlik 2011).

In Jordan, approximately 80% of the population live in urban areas. Healthindicators in Jordan point to the existence of the urban penalty phenomenon,manifested by the higher levels of IMR, MMR, and U5M in urban compared torural regions (UNDP 2013b, p. 174). A proxy for social inequalities in urban regionsin Jordan is the income inequality index (Gini index). Jordan’s largest city, Amman,is the most unequal city in the country; its Gini index is 0.387 compared to nationalaverage of 0.376 (ibid.). The Gini index in urban areas in Jordan is 0.385, comparedto 0.300 in rural regions (UNDP 2013a, p. 39). As proposed above, this urbanpenalty in Jordan can be attributed to social inequalities and socioeconomic depri-vation in urban compared to rural areas in Jordan.

In sum, living in poverty signifies deprivation in SDH to the extreme, andaccordingly poverty and deprivation lead to disproportionately poor health outcomesamong the poor (de Snyder et al. 2011). Nonetheless, although deprivation anddisadvantage in these socioeconomic indicators contribute greatly to poor populationhealth status, they can be modified via sound national policies. Leskošek proposesthat national antipoverty, social inclusion, and redistributive strategies have a sig-nificant role to play in this regard (Leskošek 2012). Accordingly, based onLeskošek’s proposal, the JPRS would include a socioeconomic deprivation andsocial inequalities analysis of poor health outcomes in Jordan, if it is to address thelink between socioeconomic deprivation and health.

Structural Links Between Poverty, Ill Health, and Health InequalitiesAs the previous two sections assessed the income-related and social dimensions ofthe links between poverty on ill health, this section suggests addressing the rootcauses of ill health of the poor and also constitutes addressing the structural driversof ill health and poverty. In this section, a social exclusion perspective is used toexamine the structural links between poverty, ill health, and health inequalities. TheWHO Social Exclusion Knowledge Network (SEKN) defines social exclusion as “adynamic, multi-dimensional process driven by unequal power relationships whichoperate along and interact across four main dimensions – economic, political, socialand cultural – and at different levels including individual, household, group, com-munity, country and global regional levels” (Popay et al. 2008). Living socioeco-nomically deprived is a byproduct of the uneven distribution of societal resourcesthat result in the creation of the state of poverty initially. At the root of it, it will besuggested that neoliberalism is the main structural link leading to poverty, ill healthof the poor, and health inequalities.

The SEKN proposes that social exclusionary processes and power imbalancesultimately lead to the unequal distribution of societal resources and increase socialvulnerability of the poor to ill health (Popay et al. 2008). Power imbalances withinsocieties often lead to the exclusion of people in poverty and force them to live inpoor housing conditions, receive poor healthcare, less educational opportunities, andless chances of employment. Neoliberal policies are proposed to have caused thesepower imbalances, the unequal distribution of resources, and resultant social

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exclusion (Popay et al. 2008; Mooney 2012). The SEKN proposed that neoliberalpolicies of international financial institutions – such as the World Bank – have led tothe entrenchment of social exclusion of the poor, as they have failed to address thedrivers of poverty and social inequality. The SEKN position is also supported byMooney. He proposes that neoliberal policies – being the main drivers of poverty andinequality – have consequently led to a compromised health status of the poor andhave exacerbated health inequalities at local, national, and global levels (Mooney2012).

Furthermore, Coburn presented data that reveals an association between increas-ing poverty and income inequalities and within-country health inequalities in coun-tries that adopt neoliberal policies compared to others governed by different politicaleconomies (Coburn 2004). Consequently, the production of health inequalities andpoor health of the poor is not only attributed solely to economic poverty but also to a“poverty of opportunity, of capability and of security. . .” (Kjellstrom and Mercado2008). Since Jordan is considered as one of the most open economies in the region, isgoverned by a neoliberal political economy, and is imposing IMF-led austeritymeasures, an assessment of the relationship between neoliberal polices and healthis much needed.

These different conceptualizations of links between ill health, health inequalities,and poverty from a SDH angle are highly relevant in the assessment of poverty andhealth links in the JPRS. This dissertation proposes that for a comprehensive PRS tocontribute to improving health equity, it should take into account all the possiblelinks between poverty, ill health, and health inequalities. Where a health componentis included in the overall strategy, it is suggested that it should contain health system,socioeconomic, and structural-level interventions to break the viscous cycle of illhealth and poverty (Box 2). In sum, a thorough understanding of these linkages inthe JPRS and their health equity effects is essential if the JPRS is to contribute toimproving the health of the poor and promoting health equity in Jordan. However, inaddition to the significance of addressing the links between poverty and health at alllevels, health inequality reduction necessitates action on all SDH at all levels. Thenext section presents a conceptualization of JPRS’s potential to address health of thepoor and health inequalities in Jordan (Box 2).

Box 2 Multiple-Level Interventions to Break the Poverty and Ill Health Cyclein PRS

Health system 1. Alleviate the financial burden of healthcare expenses off the poor2. Pro-equity health system reform

Socioeconomic 3. Socioeconomic interventions and policies to tackle socioeconomicdeprivation and improve the SDH in both urban and rural setting4. Proportionately universal social inclusion and health policies

Structural 5. Include interventions pointing toward addressing the structuraldeterminants of income inequality and poverty


Health Components of Poverty Reduction Strategy Papers(PRSPs)

Since their emergence in 2001, PRSPs’ contribution to health has received consid-erable attention (Verheul and Rowson 2001; WHO 2004; Bartlett 2011; Laterveeret al. 2003). The WHO launched a PRSPs’ monitoring project in 2003 that assesseswhether health components of PRSPs are pro-poor and whether they are leading tothe adoption of pro-poor health strategies in countries in which they areimplemented. In 2003, the WHO created an online database that holds detaileddesk reviews of health components of 50 PRSPs (WHO database on health inPRSPs http://apps.who.int/hdp/database/ (Last accessed 15 July 2013)). Moreovera 2004 WHO report examined 21 PRSPs in a collective manner and presentedoverarching findings across all PRSPs examined (WHO 2004). The WHO’s assess-ment of PRSPs and health examined whether (1) the complexity of the links betweenpoverty and health were presented, (2) health needs of the poor were identified, and(3) the health component of PRSP included pro-poor strategies (WHO 2004). Morerecently in 2011, Bartlett assessed whether the health components of Afghanistan’s,Haiti’s, and Liberia’s PRSPs reflected the main recommendations of the healthnutrition and population (HNP) chapter in the WB sourcebook (Bartlett 2011).This is of utmost significance to the JPRS as the WB was extensively involved inthe preparation of the strategy. PRSPs differ from the JPRS in that they are designedby HIPC governments for the purpose of debt relief and qualification for conces-sional loans from the IMF andWB. Nonetheless, the common features of PRSPs andthe JPRS allow for similar approaches to be adopted in the assessment of the effectsof these strategies on health equity. Accordingly, this section gives an account of themain findings of previous assessments of health components of PRSPs, focusing onPRSPs from EM countries such as Pakistan, Afghanistan, and Yemen.

PRSPs and Health

The WHO assessment of the health components of most PRSPs found them to belacking in many aspects. The report reveals that most PRSPs did not extensivelyinvestigate poverty and health links. It points that PRSPs included national healthdata on the major diseases in their countries; communicable diseases, life expec-tancy, and maternal and child health indicators were mentioned in all PRSPs.However, only few PRSPs, such as Vietnam’s, Gambia’s, and Guinea’s PRSPs,provided detailed data on the health needs of the poor or the disaggregated healthdata (WHO 2004). Nonetheless, most PRSPs fail to account whether these were thediseases that disproportionately affect the poor. In PRSPs which included an over-view of diseases specifically affecting the poor, this was not supported by statisticaldata or empirical evidence (WHO 2004). Thus, as the health component of PRSPslargely included an account of the overall disease burden instead of diseases thataffect the poor most, the ability of the PRSPs to address the health needs of the pooris weakened.

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http://apps.who.int/hdp/database/

In relation to the health system elements in PRSPs, the report indicates thatfinancial barriers and geographical barriers in health systems were mentioned inmost PRSPs, but other concerns with health services such as quality of services,informal payments, and corruption of health systems are not addressed (WHO2004). With regard to the degree of intersectoral collaboration to improve healthoutcomes of the poor, non-health sector contribution in health components ofassessed PRSPs was found to be limited (ibid.). For example, water and sanitationstrategies were addressed separately from health components of PRSPs. Plus, thelinks between the health sector and other sectors such as agriculture, housing, orlabor strategies were not drawn in most strategies. However, all of the assessedPRSPs included nutrition within their health component (ibid.). Few PRSPs such asAlbania’s included a link between educational levels and health outcomes (ibid.).Plus, PRSPs’ main pro-poor health interventions were directed toward improvingdelivery of affordable public health services and strengthening primary healthcare(WHO 2004). Although it is necessary to improve access to health services, theWHO assessment suggests that most PRSPs have “no consistent method of pro-poortargeting – whether rural/urban, regional or quintile – is used within the healthstrategies of PRSPs.” (ibid.)

Bartlett (2011) assessed PRSPs of Afghanistan, Haiti, and Liberia with regard totheir contribution to health. Bartlett specifically assessed whether health componentsof the PRSPs reflect the recommendations of the WB’s health in PRSP sourcebook.Bartlett’s assessment examines whether these three PRSPs present data on mainpopulation health outcomes, whether the data presented is disaggregated for incomegroups and geographic locations, and whether the proposed health strategies aredesigned to meet the needs of the poor (Bartlett 2011). The findings in his analysisare similar to those of the WHO assessment: that there is a lack of pro-poor targetingof health strategies, a dearth of disaggregated data, and “insufficient analysis toportray the health situation in each country” assessed (Bartlett 2011).

Finally, Laterveer and colleagues (2003) assessed whether 23 interim PRSPsimproved vertical equity in public health budget allocation, that is, whether PRSPsresulted in more resources being directed to meet the needs of the poor. The studyconcludes that most PRSPs have not resulted in increased health budget allocation tomeet the needs of the poor (Laterveer et al. 2003). Therefore, collectively, theweakness in pro-poor targeting of proposed health strategies in PRSPs, lack ofincreased budget allocations for health, and lack of disaggregated health data andintersectoral coordination largely undermine PRSPs’ ability to reach and improvehealth of the poor or contribute to improving health equity.

PRSPs and Health in the EM Region

The WHO assessment of health components of the Yemeni, Pakistani, and DjiboutiPRSPs (i.e., PRSPs within the EM region) showed similar results; and of these three,the Pakistani PRSP seems to have more detailed assessment concerning health. ThePakistani PRSP acknowledged the significance of ill health in the causation of


poverty and identified the central role that health plays in human development(WHO 2013c). Also, health data in the Pakistani PRSP highlighted the main diseasesthat disproportionately affect the poor and commented on the differential uptake ofvaccination between the rich and the poor. The Yemeni and Djibouti PRSP did notinclude disaggregated health data for income but did include disaggregate data forgender and geographical locations. Nonetheless, in these three countries, PRSPs’main health strategy was strengthening health system factors such as the accessibil-ity and affordability of healthcare services. In Djibouti, one of the main challengesidentified is the shortage in qualified personnel and their unequal distribution acrossthe country (WHO 2013d). In Yemen, illness was identified as the major cause ofpoverty, and the main challenge faced by the poor was their inability to finance theirtreatment. Also, intersectoral collaboration and coordination to improve health wasfound to be lacking.

PRSPs and Health Equity

The assessment of the PRSP health strategy documents reveals that they have notexplicitly tackled health inequalities in health outcomes, nor have they promotedpolicies to address the matter. This is evident by the shortcomings pointed out byboth Bartlett’s and the WHO’s assessment of the health components of more than24 PRSPs and in the assessment of PRSPs in the EM region. Most relevantshortcomings of PRSPs to health equity are the scarcity of disaggregated healthdata presented and the weakness of intersectoral collaboration to improve health ofthe poor. It is also manifested in the overemphasis of addressing the health needs ofthe poor through the health sector, rather than adopting a SDH approach to improvethe health of the poor. Nonetheless, the weak level of SDH and health equity analysisin PRSPs could be attributed to the weakness of health systems in HIPCs, which areunable to reach the poor. Thus, PRSPs in HIPCs prioritize health system strength-ening interventions as the main policy direction. However, this cannot be general-ized in the case in Jordan. The Jordanian health system is well established andensures good accessibility to services. Therefore, it should be pointed out that theresults of these assessments cannot be generalized to a middle-income country suchas Jordan. However, these assessments provide a frame of reference to point to thesignificant elements that need to be assessed in the health component of the JPRS.

In light of this assessment of PRSPs, it should be emphasized that healthcomponents of PRSPs should not to be considered comprehensive health strategiesdirected toward addressing the health needs of the poor or aimed at reducing healthinequalities. Consequently, Dodd and Hinshelwood point to the significance ofrecognizing the difference between “a health strategy for poverty reduction” and a“health strategy to meet the needs of the poor(est)” when discussing the healthcomponents of PRSPs (Dodd and Hinshelwood 2002). Although both conceptual-izations might overlap, they are distinct. The former stance proposes that health inPRSPs is a tool for poverty reduction rather than what the latter suggests that healthstrategies in PRSPs should be designed to improve the health of the poor. Dodd and

12 T. Sartawi

Hinshelwood indicate that the former conceptualization is mostly adopted in PRSPs(ibid.).

In sum, assessments of PRSPs point to the low priority that was given to health,but via increased intersectoral collaboration, it is acknowledged that PRSPs providea significant opportunity to increase the priority of health within national and globaldevelopment agendas (WHO 2004). The overemphasis of PRSPs on public healthservice delivery compared to action on SDH represents a narrow assessment ofstrategies needed to significantly improve the health of the poor. The main backdropis the lack of emphasis on improving living and working conditions of the poor as ameans of improving their health, demonstrated by the lack of intersectoral coordi-nation to orchestrate a comprehensive health intervention. On the other hand, thestudies did not assess the health effects of PRSPs from a SDH perspective, nor havethey included a health equity perspective to their analysis. The comprehensivenessof PRSPs and their poverty focus make the analysis of its health and health equityimpact relevant and necessary. Simply stated, “If the PRSP is to add value from ahealth perspective it should lead to a more detailed analysis of the how health canbetter contribute to poverty reduction and begin the process of making the healthstrategy more focused on the needs of the poorest” (Dodd and Hinshelwood 2002).

Population Health and Health Inequalities in Jordanand the Wider Eastern Mediterranean (EM) Region

The EM region is a highly diversified region consisting of 23 countries, 21 of whichare “Arab-speaking countries.” EM countries vary among each other with regard toincome levels (low-, middle-, and high-income countries), human development(HD) levels, and population health status (Mandil et al. 2013; Boutayeb and Serghini2006). The 2011 Human Development Report define human development as “theexpansion of people’s freedoms to live long, healthy and creative lives; to advanceother goals they have reason to value; and to engage actively in shaping developmentequitably and sustainably. . .” (Klugman 2011, p. 14). Table 1 shows the classifica-tion of EM countries according to human development and income levels. In themost recent Human Development Report (HDR), Jordan was ranked 100th out of186 countries, placing it into the “medium HD” group (UNDP 2013a).

Jordan, a small upper middle-income country located at the heart of the EasternMediterranean (EM) region, has a population of 6,249,000 individuals (DOS 2011),nearly 80% of whom reside in urban areas distributed across 12 governorates(UNDP 2013b). Amman, the capital –the largest city in Jordan – is considered tobe one of the most crowded cities in the world with a population of two million and apopulation density in some of the city’s neighborhoods of 20,000 per km2 (Ababsa2011). Jordan’s political economy is largely neoliberal. Generally, a neoliberalideology encourages trade liberalization and a diminished role of the state(Williamson 2009). Welfare service provision in neoliberal states is also minimaland is subject to strict eligibility criteria to receive social assistance by the state(Bambra 2011). Jordan initiated its economic liberalization program in 1989 and is


since portrayed by the WB and International Monetary Fund (IMF) as a modelneoliberal reformer (Harrigan et al. 2006).

Over the past decade, Jordan has enjoyed a period of sustained economic growth,averaging 6.5% of GDP per year during the period ranging from 2000 to 2009 (IMF2012). Jordan’s GDP per capita doubled between 2003 and 2012, increasing from$1974 USD to $4945 USD (ibid.). However, in 2010, Jordan’s economy sloweddown as a result of a series of exogenous economic shocks caused by the globaleconomic crisis. Growth rates dropped from the 2000–2009 average of 6.5% to2.33% of GDP in 2010, which leads to an increasing fiscal deficit to reach 6% ofGDP (IMF 2012). In response to the growing fiscal deficit, the IMF and theGovernment of Jordan (GOJ) agreed upon a $2 billion “standby” arrangement toaddress fiscal and external challenges and foster high and inclusive growth (IMF2012). IMF recommendations included a reduction in social spending whichincluded reducing universal subsidies that were in place for liquid petroleum gas(LPG) and food products (ibid.).

Moreover, the economic gains of the previous decade have not been distributedequally among the Jordanian population. Indeed, the past decade witnessed littleimprovements with regard to income inequality and poverty. Income inequality roseduring the period from 2002 to 2008 (Jordan’s Gini index increased from 0.376 to0.399 in 2006 and 0.393 in 2008) (UNDP 2013b). The trend of increasing incomeinequality reversed in 2010, declining back to 2002 levels of 0.376 (ibid.). In 2008,the wealthiest 10% in Jordan owned up to nine times more assets and wealth than thebottom 10% (UNDP and MoPIC 2011). In this situation, the poor in Jordan weremore vulnerable to income loss than the rich, and during 2006–2008, the real incomeof the poorest quartile decreased by 8.5% compared to a 0.8% decrease within therichest quartile (ibid.). Poverty rates in Jordan remained relatively constant over thepast decade. The GOJ estimates that in 2010, 14.4% of the population were livingbelow the national poverty line, compared to 14.2% living in poverty in 2002(UNDP 2013b). Consequently, as the past period of economic growth caused thepoor to get poorer and the rich to get richer, income inequality and poverty areconsidered among the significant human development challenges that face Jordan

Table 1 EM countries’ classification according to income and human development (HD) levels

Low income Middle income High income

Low HD Afghanistana, Djibouti, Sudan,Yemen, Pakistana, Somalia

MediumHD

Palestine, Egypt,Morocco, Syria, Jordan

High HD Iran, Libya, Algeria,Tunisia, Lebanon

Kuwait, SaudiArabiaBahrain, Oman

VeryHigh HD

Qatar, UnitedArab Emirates

Source: Author (Mandil et al. 2013; UNDP 2013a, Boutayeb and Serghini 2006)aAfghanistan and Pakistan are the only non-Arab-speaking countries in the EM region

14 T. Sartawi

(UNDP and MoPIC 2011). This has direct consequences for population health inJordan.

Population Health Inequalities Between Countries in the EM Region

Large gaps in population health levels exist between low-, middle-, and high-incomeEM countries. Population health levels in EM countries are shown to improve ascountries are closer to the upper end of the HD and income-level spectrum (Mandilet al. 2013; Boutayeb and Sirghini 2006). This differential population health statusbetween EM countries is illustrated in Table 2 which demonstrates that infantmortality rate (IMR), maternal mortality rate (MMR), and life expectancy (LE) allvary according to the level of economic development in the region (WHO 2008,p. 13). This table, which was developed by the WHO, shows that a 33-year gap inlife expectancy exists between low-income and high-income EM countries; LEreaches a low of 44 years in Afghanistan and reaches up to 77 years in Qatar. IMRin high-income countries reaches as low as 8 per 1000 while reaching up to 147 per1000 in other low-income EM countries. Plus, MMR is close to zero in high-incomeEM countries, whereas in low-income EM countries, 350–1600 maternal deathsoccur per 100,000 live births.

Population health status in Jordan is good compared to countries at differentincome levels in the region. Average LE in Jordan is 73.5 years (UNDP 2013a), IMRaverage is at 23.1 per 1000, U5M is at 28 per 1000 (DOS 2013), and MMR in Jordanis 30 per 1000 (DOS 2008). However, over the past decade, Jordan’s success inimproving health of its population slowed as population health gains stagnated. The

Table 2 Health status indicators in the EM region in 2006

Incomestatus

Newborns withbirth weight atleast 2.5 kg (%)

Children withacceptableweight for age(%)

Infantmortalityrate/1000live births

Maternalmortalityratio/100,000live births

Lifeexpectancyat birth(years)

Low-incomecountriesa

63–89 54–74 62–147 350–1600 44–64

Middle-incomecountriesb

88–95 87–99 17–108 11–294 58–73

High-incomecountriesc

92–95 86–93 8–19 0–22 73–77

Source: Building the knowledge base on SDH, review of seven countries in the EMR (WHO 2008,p. 13)aAfghanistan, Djibouti, Pakistan, Somalia, Sudan, YemenbEgypt, Islamic Republic of Iran, Iraq, Jordan, Lebanon, Libyan Arab Jamahiriya, Morocco,occupied Palestinian territory, Syrian Arab Republic, TunisiacBahrain, Kuwait, Oman, Qatar, Saudi Arabia, United Arab Emirates


2009 Jordanian Population and Family Health Survey (JPFHS) acknowledged that“if the 2007 levels of mortality were underestimated, then under-five mortality hasremained unchanged since the 2002 (27 per 1,000 in 2002 versus 28 per 1,000 in2009)” (DOS 2010). This is demonstrated in Fig. 1 which shows IMR and U5Mlevels over the past decade (DOS 2013).

In addition to health inequalities between countries in the EM region, within-country health inequalities exist in the EM region, but are not accounted for inTable 2. The World Bank (WB) brought attention to this matter in a 2012 publicationcalled “Health Equity and Financial Protection Datasheet: Middle East and NorthAfrica” (Bredenkamp et al. 2012). The publication presents a number of tables thatcontain disaggregated health data according to wealth quintiles in Jordan, Egypt,Morocco, Syria, Tunisia, and Yemen. The publication shows that poor groups ineach of these EM countries are disproportionately affected by ill health compared totheir more advantaged counterparts. IMR and under-5 mortality (U5M) rates wereworse among the poor in Egypt, Jordan, and Morocco (ibid.). In most countries, poorchildren were found to be disproportionately affected more by malnutrition, diar-rheal diseases, and acute respiratory infections. With regard to Jordan, as depicted inFigs. 2 and 3, the past decade also witnessed an unequal distribution of health gainsacross all socioeconomic groups in Jordan, favoring those in more advantagedwealth quintiles compared to the less advantaged (The disaggregated health datawere extracted from the JPFHS of 1997, 2007, and 2009).

During the period from 1997 to 2007, health gains in the wealthiest quintilesexceeded those in the poorest quintiles; U5M in poorest first quintile decreased by23% compared to the wealthier third and fourth quintile where U5M decreased by66% and 48%, respectively. The same pattern is also observed for IMR, malnutri-tion, and stunted growth in children (DOS 1998, 2008, 2010). It should be noted thathealth improvements over the past decade are unequally distributed among allsocioeconomic groups in Jordan. Therefore, rather than being a gap between the

34

29

2219

23

17

Infant mortality rate (<1 year)

Key

Under-5 mortality rate (0-4 years)

1990 1997 2002 2007 2009 2012

39

34

27

21

28

21

Fig. 1 IMR and U5M in Jordan. (Adapted from (DOS 2013, p. 22))

16 T. Sartawi

rich and the poor, health inequalities in Jordan occur along a social gradient, favoringthe more advantaged over the less advantaged at all socioeconomic levels.

However, since Jordan so far lacks any public health policy that explicitly seeksto address health inequalities or its social determinants, the 2013–2020 JordanianPoverty Reduction Strategy (JPRS) forms the focus of this chapter. The JPRS isJordan’s most comprehensive national strategy to date to include multisectoralcollaboration to address poverty in Jordan. The wide range of proposed interventionsin the JPRS has significant impact on a wide range of SDH of the poor such aseducation, health, and social welfare. This choice reflects the widely acknowledgedassociation between poverty and poor health (Wagstaff 2002) which suggest that acomprehensive multisectoral policy to tackle poverty could, at least potentially, playa role in addressing SDH of the poor and subsequently impact their health and lead toreduction of health inequalities (Leskošek 2012).

IMR according to wealth quintiles in jordan 1997-200940

35

30

25

20

15

10

5

0Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5

Key

IMR 1997

IMR 2007

IMR 2009

Fig. 2 Distribution of IMR according to wealth quintiles in Jordan (1997, 2007, and 2009).(Source: Author (using data from DOS 1998, 2008, 2010))

U5M according to wealth quintiles in jordan 1997-200945

40

35

30

25

20

15

10

5

0Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5

Key

IMR 1997

IMR 2007

IMR 2009

Fig. 3 Distribution of U5M according to wealth quintiles in Jordan (1997, 2007, and 2009).(Source: Author (using data from DOS 1998, 2008, 2010))


The Jordanian Poverty Reduction Strategy

The JPRS was prepared via a wide participatory process that included multiplestakeholders. Multiple governmental sectors, non-governmental organizations, inter-national multilateral UN agencies (such as the United Nations Development Pro-gramme (UNDP), WB), the Columbia University Middle East Research Centre, andrepresentatives of civil society in Jordan all participated in the preparation of theJPRS (UNDP 2013b). Its overall objective is to “contain and reduce poverty,vulnerability and inequality in the current socio-economic environment of Jordan,from 2013 to 2020” (UNDP 2013b, p. 8). To achieve these overarching goals, theJPRS has five main policy pillars: (1) social welfare and gender, (2) pro-pooremployment and entrepreneurship, (3) inclusive health and education services,(4) pro-poor agriculture, and (5) environment and rural development and transportand housing for the poor (UNDP 2013b, p. 8). The inclusion of the health componentin the overall strategy is proposed to contribute to poverty reduction throughinvestment in human capital of the poor. However, the strategy’s overarching aimof reducing inequality implies that reducing health inequality could also beaddressed in the strategy.

The JPRS aims to address poverty and socioeconomic inequality in Jordan, andits fourth strategic pillar – “inclusive health and education services” – is designed toachieve this goal. The main objective of this strategic pillar is to help poor and belowmiddle-class households overcome “spatial and socio-economic constraints” inaccessing health and education services (UNDP 2013b p. 170). This chapter seeksto assess whether the health elements proposed in the health component andelsewhere in the strategy are likely to contribute to reducing health inequalities inJordan. The previous two sections helped contextualize the JPRS and are referredback to for the assessment of the JPRS’s health equity contribution. Overall, thischapter will demonstrate that health elements of the JPRS would not significantlycontribute to improving the health of the poor or contribute to reducing healthinequalities in Jordan. Nonetheless, it concludes by stating that whether or not theJPRS is successful in achieving its overall objective of reducing socioeconomicinequalities is the main factor that will determine the impact of the policy documenton Jordan’s health equity.

In doing so, the next section presents an overview of the health component of theJPRS and the health policy recommendations. The second section examines thedegree to which health system, socioeconomics, and structural links of poverty andhealth were incorporated in the JPRS. The third section assesses the degree to whichhealth inequalities and SDH analysis appear to have been taken into consideration inthe design of the JPRS health component. Finally, the concluding section explorespossible opportunities that the JPRS present for the reduction of health inequalitiesin Jordan.

18 T. Sartawi

Overview of the JPRS Health Component

The JPRS health component is divided into two main areas: “health” and “repro-ductive health.” The first section – the health section – of the assessment addressesissues such as health system challenges, SDH, health indicators in Jordan, healthsector expenditure analysis, linkage between health and poverty in Jordan, and fourpolicy recommendations. The reproductive health section also included an assess-ment of the status of reproductive health of the poor, highlighting maternal mortality,infant mortality, and fertility reduction as the main policy areas for interventions.The reproductive health section recommended six policies to address these chal-lenges. Box 3 below presents the main policies in both sections.

Overall, the health component of the JPRS suffers from the similar shortcomingsof health components of PRSPs assessed above. The JPRS similar to PRSPspredominately includes health sector-related strategies and lacks an intersectoralcollaborative approach to improve the health of the poor; 6 out of 10 proposedstrategies are directed toward the health sector. The other strategies were two healthpromotion strategies: “raise awareness of reproductive health issues” and “improvewomen’s nutrition”; and finally, two social interventions, “reforming patterns ofparenthood” and “marriage and cohabitation practices,” were included under repro-ductive health interventions (UNDP 2013b). The proposed interventions addresshealth sector issues rather than socioeconomic conditions of the poor. The JPRSanalysis does include an account of the unfairness of healthcare finance in Jordanand recommends that health sector reform would aim at making health services“available and affordable or free of charge for all people at public health facilities”(UNDP 2013b, p. 178). However, the JPRS does not recommend the abolition ofuser fees and copayments from public health facilities, thus impeding its pro-equityhealthcare reform recommendations.

The health component includes urban/rural and gendered disaggregate health datafor neonatal mortality rates, IMR, and U5M (UNDP 2013b, p. 174). However,similar to PRSPs, it lacked a presentation of disaggregated health data for wealthquintiles. Plus, the JPRS does not include an account of diseases that disproportion-ately affect the poor. It does not mention IMR, although its rates are higher in poorerhouseholds. Nonetheless, maternal mortality (MM) and obesity are the two healthconditions identified in the JPRS. With regard to MM, the JPRS does not present adata indicating that this health condition occurs more in poor households. Plus, theproposed health intervention to reduce MM is a pure medical intervention mainlydirected toward improving post-miscarriage care (UNDP 2013b, p. 188). Withregard to obesity and overweight, the JPRS proposes that overweight affects 49%of poor women (UNDP 2013b, p. 181). However, there is no evidence that over-weight and obesity disproportionately affects poor women compared to more afflu-ent women; on the contrary, obesity and overweight seem to be distributedproportionately across wealth quintiles in Jordan (Bredenkamp et al. 2012).


Box 3 Health Policies of the JPRS (UNDP 2013b)Health Policies in the JPRS• Reform primary healthcare adopting a family practice approach, which

ensures access for the poor to a comprehensive essential services package(ESP) and essential medicines

• Review and update codes of ethics and conduct in health sector civil servicecontracts so as to enhance the ethics of the profession

• Reform in the health sector functions to improve efficiency, accountability,and effectiveness of the programs

• Improve women’s nutrition

Reproductive Health Policies in JPRS• Raise awareness of reproductive health issues• Reform marriage and cohabitation practices• Reform patterns of parenthood• Reduce maternal mortality and morbidity• Improve access to RH services• Improve health services for specific RH-related issues

Poverty and Health Links in the JPRS

The JPRS assessment of poverty and health links in Jordan was short. It starts theanalysis by stating that “poor health is also an important correlate of poverty;therefore, equitable access to health services is another important component ofPRS” (UNDP 2013b, p. 170). A later subsection titled “Linkages between Healthand Poverty in Jordan” (UNDP 2013b, p. 176) referred to “regressive healthfinancing arrangements” as the main links between poverty and health in Jordan.The subsection goes further by acknowledging the unfairness of the fragmentedJordanian health system. The subsection then concludes by identifying the charac-teristics of households that are at risk of catastrophic health expenditures in Jordan;urban rather than rural households, households headed by women, and overcrowdedhouseholds were among the households proposed to be at higher risk of catastrophichealth expenditure (UNDP 2013b, p. 176). However, the reason why these house-holds are at increased risk of catastrophic health expenditures is not developed. Thiscaptures a significant element of the link between ill health and poverty, i.e.,regressive healthcare finance. Nonetheless, the JPRS conceptualization of the com-plex interaction between poverty and health is weak and incomplete for manyreasons.

Firstly, the analysis does not point to the contribution of poverty to ill health andthe production of health inequalities. Secondly, the conceptualization of a viciouscycle linking poverty and ill health and the bidirectional relationship between themare not identified. Thirdly, the JPRS fails to link poor living and working conditions

20 T. Sartawi

to poor health in urban and non-urban settings. The analysis does not acknowledgethe effects of socioeconomic deprivation on health of the poor, which could explainthe urban penalty phenomenon in Jordan. Finally, it does not touch upon thestructural determinants that link poverty to poor health. This incomplete interpreta-tion of the poverty and ill health relationship has problematic policy implications. Itmisguides policy interventions toward health sector interventions, rather than tomore collaborative intersectoral interventions to improve the health of the poor. TheJPRS incorporates only two of the five proposed interventions in Box 2 (alleviate thefinancial burden of healthcare expenses off the poor and pro-equity health systemreform).

Thus, the financial, health system-related interpretation of JPRS’s account of thepoverty and health links in Jordan implies that the health component of the JPRS is“a health strategy for poverty reduction” (Dodd and Hinshelwood 2002) rather thanbeing a strategy to improve the health of the poorest. Nonetheless, since healthsystems are an important SDH, pro-equity primary healthcare-oriented health systemreforms proposed in the JPRS do seem likely to contribute to reducing healthinequalities in Jordan. However, the lack of attention to the social and structuraldeterminants of health in producing poor health outcomes of the poor compromisesthis equity contribution of the JPRS.

Social Determinants of Health and Health Inequalities in the JPRS

As opposed to the health components of PRSPs discussed previously, JPRS’s healthcomponent includes a brief account of SDH in Jordan. The JPRS included a SDHsubsection that discussed SDH and the community-based initiative healthy villagesproject (HVP). The SDH subsection includes a definition of SDH as being “theconditions in which people are born, grow, live, work and age, including the healthsystem” (UNDP 2013b, p. 172). It mentions structural determinants such as “distri-bution of money, power and resources at global, national and local levels” as maininfluences on these social conditions (UNDP 2013b, p. 172). The section alsoacknowledges the significance of SDH to health equity by explicitly stating that“SDH are mostly responsible for health inequities – the unfair and avoidabledifferences in health status seen within and between countries” (UNDP 2013b,p. 173). Finally, the JPRS identifies unemployment and poverty, unplanned urban-ization, high rates of immigration, a youthful population, a growing elderly popula-tion, and water scarcity as the main “SDH challenges in Jordan which are likely tocontribute to adverse health outcomes.” (UNDP 2013b, p. 174) However, theanalysis fails to build on the possible links between these different SDH to the healthof the poor or to the Jordanian population in general. Despite referring to the 2006WHO report on SDH in Jordan, the JPRS does not include an extensive analysis toexplain the possible pathways in which SDH contribute to health inequalities inJordan. However, the JPRS does point to the need for “a thorough analysis . . . totackle the SDH and inequities” in Jordan (UNDP 2013b, p. 174).


Additionally, the analysis points to the existence of regional health disparities andpresents disaggregated data based on urban/rural divide and gender. It demonstratesthat compared to neonatal mortality (IMR), U5M is higher in males as opposed tofemales and in urban rather than in rural areas (UNDP 2013b, p. 174). The reportalso points to the slowing down of health gains in Jordan indicated by the stagnationof improvements in IMR and U5M rates from 2007 to 2012 (ibid.). Furthermore, theJPRS puts emphasis on adopting an SDH perspective to explain regional disparitiesand the stagnation of the IMR and U5M rates. Plus, where SDH-related policies weresuggested, the intervention was related to reproductive health where the JPRS statesthat previous reproductive health programs “failed to address social and economicdeterminants of access and utilization of Reproductive Health services” (UNDP2013b, p. 182).

Otherwise, the JPRS analysis of SDH and health inequalities is both superficialand incomplete. The analysis suffers from a lack of explanation for higher mortalityin urban compared to rural regions. It also lacks a detailed assessment of thepathways that abovementioned SDH lead to poorer health outcomes. Plus, despiteexplicitly pointing to the existence of regional disparities, it does not includedisaggregate health data on income or geographical location (UNDP 2013b,p. 174). The JPRS does not acknowledge the existence of socioeconomic healthinequalities in Jordan. Finally, despite the MOH’s SDH mission statement whichcalls for health in all policies and intersectoral action to tackle SDH in Jordan (MOH2013), the JPRS lacks any calls for such action or implementation of health in allpolicies to improve the health of the poor. In contrast, the climate change section ofthe JPRS points to a joint project implemented in 2010 that aimed to enhanceadaptation to climate change in Jordan. The project involved five ministries along-side UNDP, WHO, FAO, and UNESCO to address climate change in Jordan andrecommended policy interventions through four sectors: water, health, agriculture,and education (UNDP 2013b, p. 217). This intersectoral collaboration seems to belacking with regard to health.

The second section is the HVP. It is a primary healthcare-oriented SDH programthat aims at improving both health and living conditions in disadvantaged villages(UNDP 2013b, p. 173). The HVP is a collaborative project between the MOH andWHO launched in two villages in 1992. Having been expanded since then, the HVPcurrently includes 46 villages covering approximately 71,674 individuals, i.e., 1.1%of the Jordanian population (ibid.). Alongside promotion of primary healthcare inthese villages, the HVP program adopts a comprehensive approach to improving“health, economic, social and environmental status of these villages” (UNDP 2013b,p. 173). The program offers a wide range of interventions aimed to enable villagersto achieve their social, economic, and heath potential. Provision of health andeducation services, development of “healthy living places,” aid in income generationguidance, ensuring food safety, and improvement of water and sanitation services inthe village are but a few of a wide range of interventions and services provided by theHVP program (ibid.).

However, the main drawback of the HVP program lies in its adoption of anexclusively targeted approach in the selection of villages; only villages that suffer

22 T. Sartawi

from severe social and economic disadvantage and their population does not exceed2000 villagers are eligible for the HVP to be implemented (UNDP 2013b, p. 173).Also, since HVP program targets rural villages, impoverished urban areas areexcluded due to ineligibility. Whether the HVP program is successful in improvingthe health of the population it serves is not assessed; as such assessments are notavailable on either the MOH website or on the Jordan WHO office website.However, the HVP program proves to be a good example of community-basedaction on SDH that has the potential to be scaled up, thus contributing to healthequity more efficiently. Adopting a less strict eligibility criteria and inclusion ofimpoverished urban centers could provide a significant tool to addressing healthinequalities in Jordan.

The other health intervention significant to health of the poor and health equity inJordan is the conditional cash transfers (CCT) proposed in the JPRS. The CCTprogram is administered by the largest social welfare institution in Jordan, theNational Aid Fund (NAF). The NAF provides cash assistance and services to7.5% of the population (UNDP 2013b, p. 53). It adopts both means, i.e., testingand categorical targeting, to identify its beneficiaries for CCTs. Its beneficiariesreceive cash assistance on the condition that their children are to attend regularclinic appointments and participate in national vaccination campaigns (UNDP2013b, p. 58). However, despite including 7.5% of the population, the NAF’scoverage of poor households is poor. It only covers 31% of the poorest decile and10% of the second poorest decile (UNDP 2013b, p. 55), and these two groupscombined receive 67% of NAF, while the rest is distributed to richer households(ibid.). NAF’s CCT programs operate within a limited universal health protection;public healthcare services can be used free of charge for children up to the age of6 (UNDP 2013b). Thus, the incomplete coverage of poor households and limitedhealth service protection after the age of 6 undermines NAF’s CCT programs’ abilityto contribute to the health of the poor or health equity.

Thus, it can be argued that the JPRSmight provide a useful tool in reducing healthinequalities in Jordan if the explicitly targeted approach adopted in the JPRS via theHVP and CCTs occurs within a universal strategy framework. However, in theabsence of a comprehensive national policy to address health inequalities throughaction on SDH, JPRS’s proposed targeted health intervention approaches are likelyto contribute to increasing rather than reducing health inequalities. As a result of thelack of proportionately universal health policies, the differential health outcomesalong the social gradient are not addressed in Jordan, therefore leading to thepersistence of health inequalities. In sum, the health component in the JPRS is notcomprehensive and inclusive of all social factors that might lead to differential healthoutcomes in different population groups. However, despite this lack of elaborateSDH assessment and health equity assessment in the JPRS, the JPRS analysis issignificant as it opens the door for further analysis of SDH in Jordan and implemen-tation of action on SDH.


Health Inequality Reduction and the JPRS

Reviewing national health strategies in developed countries, Graham notes thathealth inequalities can be either conceptualized as occurring along a social gradient,as a health gap between the better off and worst off, or being concerned with thehealth of the poorest groups in the society (Graham 2009). Graham provided amatrix through which these different conceptualizations and their implications onpublic policy can be viewed (see Table 3) (ibid.). Narrowing health gaps andimproving the health of the disadvantaged rely on the idea that health inequality isexplicitly linked to and concerned with the health conditions of the disadvantaged;thus, most policies proposed in this regard are usually targeted to these groups(ibid.). A social gradient interpretation considers that health inequalities are causedby the unequal distribution of SDH and are thus occurring across all socioeconomicgroups. As opposed to health gap and health deprivation interpretations of healthinequalities, universal health interventions are required to address the social gradientin health (ibid.).

It should be noted that although Graham’s matrix reflects on public healthdocuments in high-income settings, she proposes that it can be used for differentcontexts and can also be used “to position strategies. . .or to classify specific inter-ventions . . . to capture their potential contribution to reducing inequalities in accessto the determinants of good health” (Graham 2009). Therefore, these conceptuali-zations are of huge significance with regard to the assessment of the health equityeffects of the JPRS. Since the JPRS aims to reduce poverty in Jordan throughaddressing its multiple dimensions, the strategy contains health, education, socialwelfare, employment, housing, water, and sanitation policies that explicitly target thepoor (UNDP 2013b). In practice, from a health equity policy perspective, the JPRScan be thought of as a policy that explicitly targets the poor and influences the widerdeterminants of the health of the poorest. Accordingly, the debate on whether toadopt universal and targeted health strategies is closely linked to the possible impactand role that the JPRS would have on health equity in Jordan.

Table 3 Determinant-oriented approaches to tackling health inequalities (as appearing in Graham2009)

In broader determinants In individual risk factors

Tacklinghealthinequalities

Reducinghealthgradients

(1) Increase in level ofdeterminants in all groups tomatch that in most advantagedgroup

(2) Reduction in prevalencein all groups to match thatin most advantaged group

Narrowinghealth gaps

(3) Faster rate of improvement indeterminants in poorest groupthan comparator group

(4) Faster rate of reductionin risk factors in poorestgroup than comparatorgroup

Improvinghealth ofpoorestgroups

(5) Improvement in determinantsin poorest group

(6) Reduction in risk factorsin poorest group

24 T. Sartawi

With regard to targeted measures, conditional cash transfers (CCT) with healthcomponents (e.g., conditions to uptake preventive health services) are very relevanttargeted measures that are proposed to lead to both health improvements and povertyreduction among the poor (WHO 2013a, p. 45). Gaarder and colleagues reviewed theevidence concerning the health and nutrition effects of CCT programs in low- andmiddle-income countries (LMIC). Their study proposes that when compared to moreuniversal approaches, the success of CCT in improving health of the poor iscontingent upon the percentage of poor households that CCT programs cover andthe degree of leakage – that is, cash transfers being directed to richer households inthese programs (Gaarder et al. 2010).

Evidence from LMICs suggests that CCTs have resulted in health improvementsin recipients of cash transfers, improved child nutrition reduction of stunting rates,and slight reductions in morbidity and mortality among program enrollees (ibid.).Nonetheless, they also point to the shortcomings of CCT programs. As eligibility forCCTs is established through a rigorous process of means testing, Gaarder andcolleagues found that poor households that include children were more likely to beselected to receive assistance than households that have no children, thus excludingthose households from receiving assistance (ibid.). Other shortcomings of CCTsinclude strict eligibility criteria, stigmatization, poor quality of public services, andincomplete coverage of poor households, which were shown to have resulted inreducing uptake to both cash transfers and healthcare services (Gaarder et al. 2010;WHO 2013b). This largely weakens CCTs’ ability to improve the health of the poor.

These shortcomings are pointed out in a recent report by the WHO called“Closing the health equity gap: Policy options and opportunities” (WHO 2013b)which proposes that CCT programs were more successful in reaching their goals ifthey were implemented within a universal social protection system. The report refersto CCT programs in Brazil being linked to universal provision of health andeducational services (WHO 2013b). Opposed to CCTs and targeted policies, theabovementioned WHO report suggests that universal systems are “the most success-ful in reaching disadvantaged and marginalized groups as such policies avoid theproblems of social stigma that are inherent in targeting” (WHO 2013b, p. 44). Thereport also proposes simplifying eligibility criteria of CCT, and moving toward moreuniversal approaches in service provision is more likely to improve the health of thepoor and promote social cohesion (WHO 2013b). Consequently, a more universalapproach in health policies and interventions is more likely to contribute to thereduction of health inequalities than a targeted approach via CCT or any othermodality. This is also consistent with Marmot’s proposal of the adoption of aproportionately universal policy and health intervention approach introduced above.

Marmot proposes that a combined approach of targeted and universal healthintervention policies is needed in order to effectively reduce health inequalities, inwhat he terms as “proportionate universalism,” where universal health interventionstake aim at improving health along the continuum of the social gradient, and targetedapproaches are designed to meet to the health needs of the most disadvantaged at thebottom of the gradient (Marmot and Bell 2012). In all cases, these health interven-tions should include both SDH and individual risk factors if they were to be effective


in reducing health inequalities (Graham 2009). Thus, the main point being, that iftargeted health interventions in the JPRS are part of a universal health strategy aimedat improving population health in Jordan, then according to the principle of propor-tionate universalism, the JPRS in theory would contribute toward reducing healthinequalities in Jordan.

Opportunities for Addressing Health Inequalities via the JPRS

The assessment performed above proposes that the strategy in itself and its healthcomponent are unlikely to contribute to the reduction of health inequalities or even tonotably improve the health of the poor in Jordan. Yet, despite these weaknesses, theJPRS also seems to provide some opportunities for advancing an agenda to reducehealth inequalities within the Jordanian policy agenda. First, unlike other PRSPs, theJPRS recognizes the need for addressing SDH and health inequalities in Jordan(UNDP 2013b, p. 174). Second, the involvement of the MOH in the JPRS processindicates that the MOH is increasingly being recognized as a partner with regard tosocial, economic, and human development in Jordan. Third, intersectoral collabora-tion potential brought upon through the preparation of the JPRS and climate changestrategies provide an opportunity for the MOH to initiate an intersectoral dialogue onSDH and health inequality reduction in Jordan. As these opportunities are recog-nized, this dissertation reflects on these opportunities, JPRS shortcomings withregard to its contribution to improving health equity in Jordan, and on internationalevidence put forward in this dissertation, to present policy recommendations thatwould potentially contribute to reducing health inequalities in Jordan (see Box 4).

Box 4 Policy Recommendations to Address Health Inequalities in Jordan1. Promote public health research on the social determinants of child and

maternal health and noncommunicable diseases in Jordan to better under-stand the nature and extent of Jordan’s health problems

2. Build on the multisectoral coordination that took place in designing theJPRS and include multiple stakeholders to design a comprehensive healthinequity reduction strategy through action on SDH in Jordan

3. Pro-equity healthcare reform proposed in the JPRS to include the abolitionof regressive forms of healthcare finance such as user fees and copayments

4. Design proportionate universal health strategies to complement the healthinterventions proposed in the JPRS to address the social gradient in healthin Jordan

5. Consider scaling up the HVP to include more villages and poor urban areasand widening eligibility criteria of CCTs

6. Design policies to address root causes of health inequalities (structuraldeterminants) within the current political economic context

26 T. Sartawi

Conclusion

Over the past decade in Jordan population, health gains stagnated and healthinequalities increased. However, despite the existing health inequalities, Jordanlacks an explicit public health strategy that addresses SDH or health inequalities.This chapter sought to contribute to addressing health inequalities and health of thepoor in Jordan by assessing the likely health equity impact of Jordan’s mostcomprehensive national strategy to date, the JPRS. The financial health system-related, socioeconomic, and structural links between ill health and poverty arenumerous. At a policy level, interventions at distinct levels may aid to break thecycle of poverty and ill health in Jordan. The JPRS could be viewed as a publichealth strategy that addresses health inequality from a health deprivation perspec-tive; and in doing so, the JPRS’s health proposed interventions explicitly target thepoor. For the JPRS to contribute to health equity, it needs to be part of more universalpublic health strategy.

The JPRS’s shortcomings are mainly related to the weak conceptualization of therelationship between poverty and ill health and a failure to link social conditions andstructural determinants to ill health and poverty. In the JPRS, the analysis of povertyand health links in the JPRS excludes social and structural links. Consequently, theJPRS only included two of the five interventions proposed above: alleviate thefinancial burden of healthcare expenses off the poor and pro-equity health systemreform. Secondly, the JPRS included a weak analysis of SDH and health equity.Thirdly, the JPRS includes health interventions aiming to reduce MMR and obesity.However, it did not identify health conditions that mostly affect the poor – obesity isfound to be equally distributed equally across socioeconomic groups in Jordan. Thisdissertation argues that although the proposed pro-equity health system reform in theJPRS is a significant step toward improving health equity in Jordan, its overemphasison health sector interventions to achieve its health aims (as opposed to intersectoralcollaboration to improve health of the poor) undermines the strategy’s ability to(1) contribute to overall health equity in Jordan, (2) break the ill health and povertycycle in Jordan, or (3) reduce the prevalence of obesity and MMR.

Finally, based on Graham’s critique of adopting a health deprivation approach inaddressing health inequalities, and Marmot’s proposals for proportionately universalhealth interventions, this dissertation argued that the targeted health interventions inthe JPRS (the HVP and CCTs) are unlikely to contribute to health equity as they arenot components of a more universal public health strategy that aimed at addressinghealth inequalities in Jordan. The JPRS is unlikely to contribute to the reduction ofhealth inequalities in Jordan. However, despite identifying these challenges posed bythe JPRS for health equity, there are opportunities that the JPRS presents with regardto the advancement of health inequality reduction into the policy agenda in Jordan.Subsequently, six policy recommendations were suggested to promote the reductionof health inequalities in Jordan. Although the JPRS itself is unlikely to contribute tothe reduction of health inequalities in Jordan, it presents an opportunity to advancehealth inequality reduction strategies into the policy agenda in Jordan.


References

Ababsa M (2011) Social disparities and public policies in Amman. In: Collections électroniques del’Ifpo. Livres en ligne des Presses de l’Institut français du Proche-Orient, vol 6. Presses del’Ifpo, Beyrouth, pp 205–231

Bambra C (2011) Health inequalities and welfare state regimes: theoretical insights on a publichealth ‘puzzle’. J Epidemiol Community Health 65(9):740–745

Bartlett S (2011) Poverty reduction strategy papers and their contribution to health: an analysis ofthree countries. McGill J Med 13(2):22

Boutayeb A, Serghini M (2006) Health indicators and human development in the Arab region. Int JHealth Geogr 5(1):61

Braveman P, Gruskin S (2003) Defining equity in health. J Epidemiol Community Health57(4):254–258

Bredenkamp C,Wagstaff A, Buisman L, Prencipe L, Rohr D, Klingen N (2012)Middle East and NorthAfrica – health equity and financial protection datasheets. Health equity and financial protectiondatasheets. The World Bank, Washington, DC. http://documents.worldbank.org/curated/en/2012/08/16630808/middle-east-north-africa-health-equity-financial-protection-datasheets. Accessed11 Nov 2017

Coburn D (2004) Beyond the income inequality hypothesis: class, neo-liberalism, and healthinequalities. Soc Sci Med 58(1):41–56

CSDH (2008) Closing the gap in a generation: health equity through action on the social determi-nants of health. Final report of the Commission on Social Determinants of Health. World HealthOrganization, Geneva. https://www.who.int/social_determinants/final_report/csdh_finalreport_2008.pdf Accessed 1 Dec 2019

Dahlgren G, Whitehead M (1993) Tackling inequalities in health: what can we learn from what hasbeen tried? Working paper prepared for the King’s Fund International Seminar on TacklingInequalities in Health, September 1993, Ditchley Park, Oxfordshire. London, King’s Fund,accessible in: Dahlgren G, Whitehead M (2007) European strategies for tackling social ineq-uities in health: levelling up Part 2. WHO Regional Office for Europe, Copenhagen. http://www.euro.who.int/__data/assets/pdf_file/0018/103824/E89384.pdf. Accessed 1 Dec 2019

Dahlgren G, Whitehead M (2006) Concepts and principles for tackling social inequities in health:levelling up. Part 1. Studies on social and economic determinants of population health. WorldHealth Organization. http://www.euro.who.int/__data/assets/pdf_file/0010/74737/E89383.pdf.Accessed 10 Dec 2017

Dahlgren G, Whitehead M, Evans T (2001) Equity and health sector reforms: can low-incomecountries escape the medical poverty trap? Lancet 358(9284):833–836

de Snyder VNS, Friel S, Fotso JC, Khadr Z, Meresman S, Monge P, Patil-Deshmukh A (2011)Social conditions and urban health inequities: realities, challenges and opportunities to trans-form the urban landscape through research and action. J Urban Health 88(6):1183–1193

Department of Statistics (DOS) [Jordan] and ICF Macro (2010) Jordan Population and FamilyHealth Survey (JPFHS) 2009. Department of Statistics and ICF Macro, Calverton. https://dhsprogram.com/pubs/pdf/FR238/FR238.pdf. Accessed 10 Dec 2017

Department of Statistics (DOS) [Jordan] and ICF Macro (2013) Jordan Population and FamilyHealth Survey (JPFHS) (2012) preliminary report. Department of Statistics and ICF Macro,Calverton. https://dhsprogram.com/pubs/pdf/FR282/FR282.pdf. Accessed 10 Dec 2017

Department of Statistics (DOS) [Jordan] and Macro International Inc. (MI) (1998) Jordan Popula-tion and Family Health Survey (JPFHS) 1997. DOS and MI, Calverton. https://dhsprogram.com/pubs/pdf/FR96/FR96.pdf. Accessed 10 Dec 2017

Department of Statistics (DOS) [Jordan] and Macro International Inc. (MI) (2008) Jordan Popula-tion and Family Health Survey (JPFHS) 2007. Department of Statistics and Macro InternationalInc, Calverton. https://dhsprogram.com/pubs/pdf/FR209/FR209.pdf. Accessed 10 Dec 2017

Department of Statistics (DOS) in Jordan (2011) Population of Jordan by governance and sex.http://www.dos.gov.jo/dos_home_e/main/ehsaat/alsokan/2011/2-2.pdf. Accessed 10 Dec 2017

28 T. Sartawi

http://documents.worldbank.org/curated/en/2012/08/16630808/middle-east-north-africa-health-equity-financial-protection-datasheets

http://documents.worldbank.org/curated/en/2012/08/16630808/middle-east-north-africa-health-equity-financial-protection-datasheets

https://www.who.int/social_determinants/final_report/csdh_finalreport_2008.pdf

https://www.who.int/social_determinants/final_report/csdh_finalreport_2008.pdf

http://www.euro.who.int/__data/assets/pdf_file/0018/103824/E89384.pdf



https://dhsprogram.com/pubs/pdf/FR238/FR238.pdf






http://www.dos.gov.jo/dos_home_e/main/ehsaat/alsokan/2011/2-2.pdf

Dodd R, Hinshelwood E (2002) Poverty reduction strategy papers – their significance for health.World Health Organization, Geneva. https://www.who.int/hdp/en/prsp.pdf. Accessed 10 Dec2017

Gaarder MM, Glassman A, Todd JE (2010) Conditional cash transfers and health: unpacking thecausal chain. J Dev Effect 2(1):6–50

Government of Jordan (GOJ) (2011) National health accounts 2008. Technical report no 2. http://www.hhc.gov.jo/uploadedimages/NHA%202013.pdf. Accessed 10 Dec 2017

Graham H (2007) Unequal lives: health and socioeconomic inequalities. McGraw-Hill Interna-tional, Maidenhead; New York: Open University Press, pp 97–113

Graham H (2009) Health inequalities, social determinants and public health policy. Policy Polit37(4):463–479

Harrigan J, El-Said H, Wang C (2006) The IMF and the World Bank in Jordan: a case of overoptimism and elusive growth. Rev Int Organ 1(3):263–292

International Monetary Fund (2012) Jordan 2012 Article IV consultation. IMF country report no12/119. http://www.imf.org/external/pubs/ft/scr/2012/cr12119.pdf. Accessed 1 Dec 2019

International Monetary Fund (IMF) and International Development Association (1999) Povertyreduction strategy papers – operational issues. http://www.imf.org/external/np/pdr/prsp/poverty1.htm. Accessed 15 Aug 2013

Kawachi I, Berkman L (2000) Social cohesion, social capital, and health. In: Berkman LF, KawachiI (eds) Social epidemiology. Oxford University Press, New York, pp 174–190

Kjellstrom T, Mercado S (2008) Towards action on social determinants for health equity in urbansettings. Environ Urban 20(2):551–574

Klugman J (2011) Human development report 2011. sustainability and equity: A better future forall. Sustainability and Equity: A Better Future for All (November 2, 2011). UNDP-HDROHuman Development Reports

Krishna A (2007) Poverty and health: defeating poverty by going to the roots. Development50(2):63–69

Labonté R (2010) Health systems governance for health equity: critical reflections. Revista de SaludPública 12:62–76

Lantz PM, Pritchard A (2010) Socioeconomic indicators that matter for population health. PrevChronic Dis 7(4):A74

Laterveer L, Niessen LW, Yazbeck AS (2003) Pro-poor health policies in poverty reductionstrategies. Health Policy Plan 18(2):138–145

Leskošek V (2012) Social determinants of health: the indicators for measuring the impact of povertyon health. Slov J Public Health 51(1):21–32

Mandil A, Chaaya M, Saab D (2013) Health status, epidemiological profile and prospects: EasternMediterranean region. Int J Epidemiol 42(2):616–626

Marmot M, Bell R (2012) Fair society, healthy lives. Public Health 126:S4–S10McIntyre D, Whitehead M, Gilson L, Dahlgren G, Tang S (2007) Equity impacts of neoliberal

reforms: what should the policy responses be? Int J Health Serv 37(4):693–709Ministry of Health (MOH) (2013) Social determinants of health in Jordan. http://www.moh.gov.jo/

EN/PrimaryCommunityInitiatives/Pages/Social%20Determinants%20of%20Health.aspx. Lastaccessed 15 Aug 2013

Mooney G (2012) Neoliberalism is bad for our health. Int J Health Serv 42(3):383–401Mowafi M, Khawaja M (2005) Poverty. J Epidemiol Community Health 59(4):260–264Popay J, et al (2008) Social Exclusion Knowledge Network (SEKN). Understanding and tackling

social exclusion: final report to the WHO Commission on Social Determinants of Health. WHOCommission on the Social Determinants of Health

Sverdlik A (2011) Ill-health and poverty: a literature review on health in informal settlements.Environ Urban 23(1):123–155

United Nations Development Programme (UNDP) (2000) Human development report 2000:Human rights and human development. New York: Oxford University Press


https://www.who.int/hdp/en/prsp.pdf

http://www.hhc.gov.jo/uploadedimages/NHA%202013.pdf

http://www.hhc.gov.jo/uploadedimages/NHA%202013.pdf

http://www.imf.org/external/pubs/ft/scr/2012/cr12119.pdf

http://www.imf.org/external/np/pdr/prsp/poverty1.htm

http://www.imf.org/external/np/pdr/prsp/poverty1.htm

http://www.moh.gov.jo/EN/PrimaryCommunityInitiatives/Pages/Social%20Determinants%20of%20Health.aspx

http://www.moh.gov.jo/EN/PrimaryCommunityInitiatives/Pages/Social%20Determinants%20of%20Health.aspx

United Nations Development Program (UNDP) (2013a) Human development report 2013: The riseof the South, Human progress in a diverse world. http://hdr.undp.org/sites/default/files/reports/14/hdr2013_en_complete.pdf. Accessed 1 Dec 2019

United Nations Development Program (UNDP) (2013b) Jordan poverty reduction strategy: final report.https://www.undp.org/content/dam/jordan/docs/Poverty/Jordanpovertyreductionstrategy.pdf. Acc-essed 1 Dec 2019

United Nations Development Program (UNDP) and Ministry of Planning and International coop-eration (MoPIC) (2011) Jordan human development report 2011. http://hdr.undp.org/sites/default/files/jordan_nhdr_2011.pdf. Accessed 1 Dec 2019

United Nations Population Fund (UNFPA) (2013) Poverty reduction strategies: frameworks fordevelopment. http://www.unfpa.org/pds/poverty_reduction.html. Accessed 15 Aug 2013

Verheul E, Rowson M (2001) Poverty reduction strategy papers: it’s too soon to say whether thisnew approach to aid will improve health. Br Med J 323(7305):120

Wagstaff A (2002) Poverty and health sector inequalities. Bull World Health Organ 80(2):97–105Williamson J (2009) Short history of the Washington consensus. Law Bus Rev Am 15:7World Health Organization (1978) United Nations International Children’s Emergency Fund.

Alma-Alta Declaration 1978. Primary Health Care. WHO, GenevaWorld Health Organization (2004) PRSPs their significance for health: second synthesis report.

https://www.who.int/hdp/en/prspsig.pdf. Accessed 1 Dec 2019World Health Organization (2006) Health systems profile- Jordan. http://gis.emro.who.int/

HealthSystemObservatory/PDF/Jordan/Full%20Profile.pdf. Last accessed 25 July 2013World Health Organization (2008) Building the knowledge base on the social determinants of

health: review of seven countries in the Eastern Mediterranean Region WHO Regional Publi-cations, Eastern Mediterranean Series 31. http://applications.emro.who.int/dsaf/dsa939.pdf.Accessed 1 Dec 2019

World Health Organization (2009) Country cooperation strategy for WHO and Jordan 2008–2013.http://www.emro.who.int/docs/CCS_Jordan_2010_EN_14473.pdf. Accessed 1 Dec 2019

World Health Organization (2010) A conceptual framework for action on the social determinants ofhealth. https://apps.who.int/iris/bitstream/handle/10665/44489/9789241500852_eng.pdf. Accessed1 Dec 2019

World Health Organization (2013a) Closing the health equity gap: policy options and opportunities.http://new.paho.org/equity/index2.php?option=com_docman&task=doc_view&gid=103&Itemid.Accessed 30 July 2013

World Health Organization (2013b) WHO database on health in PRSPs: Pakistan. http://apps.who.int/hdp/database/highlight.aspx?fs=PAK.xml&txt=pakistan. Accessed 7 July 2013

World Health Organization (2013c) WHO database on health in PRSPs: Djibouti. http://apps.who.int/hdp/database/highlight.aspx?fs=DJI.xml&txt=Djibouti. Accessed 16 July 2013

World Health Organization (2013d) WHO database on health in PRSPs: Yemen. http://apps.who.int/hdp/database/highlight.aspx?fs=YEA.xml&txt=yemen. Accessed 16 July 2013

30 T. Sartawi

http://hdr.undp.org/sites/default/files/reports/14/hdr2013_en_complete.pdf

http://hdr.undp.org/sites/default/files/reports/14/hdr2013_en_complete.pdf

https://www.undp.org/content/dam/jordan/docs/Poverty/Jordanpovertyreductionstrategy.pdf

http://hdr.undp.org/sites/default/files/jordan_nhdr_2011.pdf

http://hdr.undp.org/sites/default/files/jordan_nhdr_2011.pdf

http://www.unfpa.org/pds/poverty_reduction.html

https://www.who.int/hdp/en/prspsig.pdf

http://gis.emro.who.int/HealthSystemObservatory/PDF/Jordan/Full%20Profile.pdf

http://gis.emro.who.int/HealthSystemObservatory/PDF/Jordan/Full%20Profile.pdf

http://applications.emro.who.int/dsaf/dsa939.pdf

http://www.emro.who.int/docs/CCS_Jordan_2010_EN_14473.pdf

https://apps.who.int/iris/bitstream/handle/10665/44489/9789241500852_eng.pdf

http://new.paho.org/equity/index2.php?option=com_docman&task=doc_view&gid=103&Itemid

http://apps.who.int/hdp/database/highlight.aspx?fs=PAK.xml&txt=pakistan

http://apps.who.int/hdp/database/highlight.aspx?fs=PAK.xml&txt=pakistan

http://apps.who.int/hdp/database/highlight.aspx?fs=DJI.xml&txt=Djibouti

http://apps.who.int/hdp/database/highlight.aspx?fs=DJI.xml&txt=Djibouti

http://apps.who.int/hdp/database/highlight.aspx?fs=YEA.xml&txt=yemen

http://apps.who.int/hdp/database/highlight.aspx?fs=YEA.xml&txt=yemen

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