essay about health in jordan

The Healthcare System in Jordan

Facts About Healthcare in Jordan

The healthcare system in Jordan includes public and private sectors . The public sector provides a majority of Jordan’s 12,081 hospital beds. The private sector contributes to the country primarily through the provision of home healthcare. There is a total of 106 hospitals , public and private, in Jordan. Due to recent shifts in the political climate in the Middle East, Jordan has accepted a high rate of refugees. More refugees, coupled with an increase in the domestic population, has greatly increased the demand for hospitals. To keep up with the growing population and improve the healthcare system in Jordan, lawmakers implemented a national e-health system. This e-health system intends to connect all public and university hospitals, maintain organization and establish easily accessible health records for all.

Primary clinics supply rapid access medical care along with vaccinations, maternity and childcare and quick treatment for chronic conditions. Until recently, healthcare in Jordan lacked a formalized home healthcare system . Without this system, patients needing long-term care must remain in acute care facilities for weeks, even months, at a time. Since the implementation of Jordan’s home healthcare initiative in 2017, the industry has trained 300 health professionals and gained the participation of 28 healthcare facilities, both public and private. The country is currently expanding home healthcare policy while other countries in the Middle East lack a structured home healthcare system, putting Jordan at one of the most modern healthcare systems in the region.

Infant Mortality in Jordan

The infant mortality rate, one of the lowest rates in the region , stands at 13.9% and has steadily declined over the last 10 years. Furthermore, the maternal mortality rate is 62 per 100,000. This rate is much lower than the average of 420 per 100,000 live births in the Eastern Mediterranean region. The consistent betterment of the health conditions of children and infants is in part due to the universal child immunization that the country achieved in 1998. Since then, Jordan has made it a significant priority to improve the conditions of healthcare that it provides to women and children. Unfortunately, this priority does not stand true in most countries surrounding Jordan.

National Health Policy and Organization

Given Jordan’s sectoral organization of the healthcare system, the country has one of the most modern systems in the region. Its high expenditure in healthcare goes toward developing newer methods of treatment and expanding healthcare accessibility sets Jordan apart from other countries. In 2003, the healthcare expenditure comprised about 10.4% of Jordan’s GDP. Each sector has its own independent financial and managerial systems that reflect the regulation and delivery of services. This distribution of regulation allows for the country to target and improve specific elements of its healthcare system.

In the last decade, Jordan has reformed and improved its health information systems and human resources teams. Additionally, Jordan’s government introduced a National Health Insurance system to provide large-scale accessibility to health insurance to a large part of the country’s population. Overall, the net population of insured individuals in the last four years was around 55% . However, in other countries surrounding Jordan like Egypt, healthcare insurance coverage relies heavily on an individual’s financial status and income. As a result, only those who are very well-off receive effective coverage.

Given the recent changes in prioritization of the healthcare system in Jordan, the country has improved its standard of care greatly in the last 10 years. Compared with other Middle Eastern nations, Jordan stands out with its advanced healthcare system. Currently, though, the healthcare assistance that Jordan provides to Syrian refugees begins to decline due to financial burdens on its budget. Therefore, continued support from the U.N. is necessary to sustain refugee healthcare accessibility.

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

• Living reference work entry
• First Online: 27 February 2020
• Cite this living reference work entry

• Thamer Sartawi 2  

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The relationship between poverty and ill health is very well established. One way to examine the link between poverty, or low socioeconomic status, and health is utilizing the social determinants of health framework. This chapter uses Jordan as a case study to assess this link and subsequently examine the health impact of Jordan’s current poverty reduction strategy. Despite the existing health inequalities between socioeconomic groups in Jordan, the social gradient of health inequalities is not addressed in public health policies in the country. As a result, this chapter assesses the potential contribution of the 2013–2020 Jordanian Poverty Reduction Strategy (JPRS) to health of the poor in Jordan. First, this chapter presents a conceptual framework examining linkages between poverty, ill health, and health inequalities. The framework is used to assess the potential health equity effects of the JPRS. In doing so, the analysis showed that for a poverty reduction strategy to contribute to improving health outcomes, it must include health system, socioeconomic, and structural-level interventions to break the link between poverty and ill health and subsequently reduce health inequalities. Second, this chapter presents the case for integration of targeted health interventions within a universal strategy. The strategy adopts explicitly targeted health intervention approaches such as healthy villages project (HVP) and conditional cash transfers (CCTs). Therefore, the JPRS may lead to individual-level health improvement on outcomes; however, at a population level, this impact is unclear. This chapter also presents the case for intersectoral collaboration and overemphasizes health sectoral policies go hand in hand with socioeconomic and structural interventions. Nevertheless, the JPRS can potentially act as a catalyst toward designing a comprehensive poverty reduction strategy that would benefit the health of the poor and result in the reduction of health inequalities in Jordan.

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Introduction and Summary of Poverty and Well-Being in East Africa: A Multifaceted Economic Approach

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Abbreviations.

Conditional Cash Transfers

Commission on Social Determinants of Health

Department of Statistics

Eastern Mediterranean

Government of Jordan

Human Development

Human Development Report

Healthy Villages Project

International Monetary Fund

Infant Mortality Rate

Jordanian Poverty Reduction Strategy

Life Expectancy

Maternal Mortality

Maternal Mortality Rate

Ministry of Health

Population and Family Health Survey

Poverty Reduction Strategy

Poverty Reduction Strategy Paper

Social Determinants of Health

Social Exclusion Knowledge Network

Under-5 Mortality

United Nations Development Programme

World Health Organization

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Sartawi, T. (2020). Poverty Reduction Strategies and Health Outcomes: Jordan as a Case Study. In: Laher, I. (eds) Handbook of Healthcare in the Arab World. Springer, Cham. https://doi.org/10.1007/978-3-319-74365-3_21-1

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Does the health information system in Jordan support equity to improve health outcomes? Assessment and recommendations

• Ahmad H. Alnawafleh   ORCID: orcid.org/0000-0003-2069-5658 1 &
• Hoda Rashad 2  

Archives of Public Health volume  82 , Article number:  48 ( 2024 ) Cite this article

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This study is based on extensive evidence-based assessments. The aim of this paper is to evaluate how well Jordan’s health information system (HIS) incorporates social determinants of health inequity (SDHI) and to propose suggestions for future actions.

An extensive evidence-based assessment was performed. A meta-synthesis of the inclusion of the SDHI in the HIS in Jordan was conducted. After searching and shortlisting, 23 papers were analyzed using Atlas.ti 9.0 employing thematic analysis technique.

The HIS in Jordan is quite comprehensive, comprising numerous data sources, various types of information, and data from multiple producers and managers. Nevertheless, the HIS confronts several obstacles and fails to ensure the timely and secure publication of available data. The assessment of the inclusion of the SDHI in the HIS showed that the HIS allows for the measurement of progress in relation to social policies and actions but has a very limited database for supporting the inclusion of health inequity measures. One reason for the difficulty in identifying fairness is that certain crucial information necessary for this task cannot be obtained through the available institutional HIS or population survey tools. Additionally, relevant modules for fairness may be missing from population surveys, possibly due to a failure to fully utilize the capabilities of the institutional HIS.

There are opportunities to make use of Jordan’s dedication to fairness and its already established strong HIS. Some social determinants of health exist in the HIS, but much more data, information, and effort are needed to integrate the SDHI into the Jordanian HIS. A proposal from a regional initiative has put forward a comprehensive set of indicators for integrating SDHI into HIS, which could aid in achieving health equity in Jordan.

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A framework that focuses on the social determinants of health acknowledges that factors beyond the healthcare system within society contribute to health disparities [ 1 , 2 , 3 , 4 ]. These disparities are influenced by variations in the environment, community, family, and individual levels. The framing of social determinants of health inequities (SDHI) differs from that of social determinants of health (SDH) in two key features [ 2 , 5 ]. The SDHI places great importance on the examination of inequality and recognizes that various factors contribute to the determinants of health [ 2 ]. The SDHI proposes that disparities in health outcomes among social groups stem from inequitable distributions of social, economic, and cultural resources, as well as unequal access to opportunities for improving their circumstances. According to the principles of SDHI, the problem of unequal access to health resources can be traced back to larger political and economic systems and policies, as well as social factors and public services [ 2 , 3 ]. This inequality is evident in the way society is divided into groups based on factors such as wealth and education and in how policies and practices favor certain groups over others in meeting their health needs.

Health information should first perceive and critically examine the occurrence of health disparities and any clustering among marginalized and underresourced communities. The distribution of health inequalities by social stratification should also be investigated, and this distribution should be linked to the fairness and responsiveness of macrostructures, policies, intermediate forces, and public services. An absence of acknowledgment of inequities and their consequences for health distribution could sustain them and might lead to their propagation. This could widen the health divide by disproportionately providing resources and opportunities to nonmarginalized groups that have already received a relatively greater share of health-related benefits. More importantly, acknowledging inequities supports a movement from targeting the disadvantaged to changing the distribution of their disadvantage. It supports the adoption of transformative, fair, and responsive policies and actions [ 2 , 3 ]. The focus on SDHI to decrease health inequalities helps to realize development anchored on social justice and human rights and on ‘Leaving no One Behind’, as pursued by the Sustainable Development Goals (SDGs) [ 3 , 6 ].

A HIS that follows the SDHI framework caters to a diverse group of people at various levels [ 2 ]. At the level of health professionals, the HIS should offer insight and facilitate effective communication, which can aid in diagnosing health issues and taking appropriate actions within local communities. If the HIS is successful in providing this support, health professionals can become more compassionate toward their patients and deliver health services that are responsive to the context of SDH [ 7 ]. This is especially important when navigating obstacles to accessing healthcare and other services during direct interactions with health services. Moreover, it is also valuable for implementing comprehensive social and health interventions at the community level. At the policy and public sector level, such a system can motivate the adoption of strategies that promote health equities in all policies (HEiAP) and intersectoral actions for health [ 2 , 3 , 7 ]. It can help promote well-being and health equity as a measure of development and social success.

The significance of incorporating the SDHI into Jordan’s HIS is acknowledged in this paper, which delves into the subject and provides suggestions for future actions. A thorough examination of pertinent resources and materials was conducted to produce this paper. Initially, the research methodology employed is outlined, followed by a depiction of Jordan’s HIS. An evaluation of the HIS and Jordan’s initiatives to enhance it ensues. The paper concludes with a discussion of the integration of SDH and health equity into the information system, along with an analysis of the results and recommendations for future steps.

To gain a better understanding of how social factors contribute to health inequalities within Jordan’s HIS, a thorough examination of evidence was conducted. This involved conducting a comprehensive search of various databases and websites between June and August 2021, including scientific and gray literature sources such as www.google.jo . The search focused on specific keywords related to SDH, electronic medical records, HISs, health equity, health inequality, and Jordan. The authors have access to a wide range of databases and reports. Through this access, they reviewed a large volume of gray literature, including a wide range of relevant articles, mini-reviews, editorials, book chapters, newspaper articles, unpublished thesis papers, and nonscientific articles. The next step involved scanning and reading the article abstracts and content tables to determine which papers were relevant and should be included. All duplicates and studies not related to the Jordan HIS were excluded.

The method used to analyze the papers and reports that met the criteria involved employing the thematic analysis technique with the support of Atlas.ti 9.0 software. This approach involves identifying and organizing themes from the data, analyzing them, and presenting a summary. One benefit of using thematic analysis is that it enables researchers to gain a deeper understanding of the themes that emerge. This process is particularly useful for summarizing a large amount of data and literature in a structured and organized way.

With support from contacts in relevant departments at the Ministry of Health (MoH) in Jordan and other agencies involved in the HIS, the authors managed to collect over 120 documents. Various research techniques, such as literature reviews, theoretical research, technical reports, case studies, and other qualitative, quantitative, and mixed methods or approaches, were utilized to identify relevant studies or reports. After eliminating duplicates and articles that did not meet the literature foci, 76 articles were selected. During the full reading of the articles, 53 papers were excluded because they were deemed unsuitable for the meta-synthesis. After this sorting process, 23 papers were selected for analysis and uploaded to Atlas.ti 9.0, which is software used for data analysis and synthesis.

The HIS in Jordan is well organized and encompasses a wide range of data sources, information types, and individuals responsible for producing and managing the data. Certain data tools used involve physical forms that are subsequently verified, coded, entered, and processed. Additionally, electronic records and completely automated systems are utilized for certain data types and by some data management systems.

Currently, in Jordan’s HIS, the evaluation of various types of data shows that birth registrations are almost complete (99%), while death registrations represent 75%. According to Khader, Alyahya et al. [ 8 ], some neonatal deaths and stillbirths are not fully registered due to a malfunctioning reporting system that places the responsibility of registration on families [ 9 ].

The quality of reporting for the cause of death statistics in Jordan does not meet the quality-of-care standards. According to the SCORE data report, only 59% of total deaths in Jordan were accompanied by a medical certificate with the cause of death (MCCD) and ICD coding [ 10 ]. The accuracy of the certificates in determining the cause of death varied between 20% and 29%, according to Alyahya et al.‘s [ 11 ] research. This study emphasizes the need for ongoing training of Jordanian healthcare practitioners in utilizing the ICD-10 coding system when implementing new health technology, as well as the relative novelty of electronic health records (EHRs) and ICD-10 use in public hospitals in Jordan [ 12 , 13 ]. The research suggests that the current program is not standardized and lacks the necessary coding system to precisely identify and record the causes of death [ 11 ].

Electronic medical records in the field of obstetrics lack a comprehensive template for a record because it sometimes does not track the patient’s entire medical journey [ 14 , 15 , 16 , 17 ]. This is because records were established to record patient visits from the initial care provided during admission to the emergency department through the triage process, and the process of assessing and managing patients in labor wards to any destination should be documented until the treatment is completed [ 15 , 16 ].

The inclusion of SDHI in the information system

To provide information on health inequalities and the underlying social factors, an information system with an SDHI framework should be implemented. This system should also provide data on the fairness of upstream policies and public services that shape the social factors of health inequalities [ 2 ]. In Jordan, the institutional HIS (see Table  1 ) is rich in data on health inequalities and their social underpinnings, but it allows for measurements based only on geographic stratifiers and not other social stratifiers, such as gender and age. Population-based (see Table  2 ) surveys and submodules designed for this purpose are valuable for producing knowledge and recommendations on health inequalities and their social determinants [ 18 , 19 ].

Surveys are valuable because of their ability to link individual-level data with different social determinants across multilevel pathways of influence. This includes how social stratifications in society are reflected in the proximate level of behaviors, livelihoods, and community contextual forces.

An example of the value of population surveys in investigating health inequalities and their social determinants is available in two recent studies [ 14 , 20 ]. These studies used data provided by the Jordan Population and Family Health Survey (JPFHS) of 2012 and 2017, respectively. These studies have investigated inequality challenges in Jordan and have produced important analyses, findings, and recommendations related to health inequalities and their social underpinnings.

The analysis of the 2012 JPFHS indicated that the summary inequality measures by geographic and gendered cultural context stratifiers are relatively small compared to those of the wealth stratifiers and four other Arab countries (Egypt, Morocco, Oman, and Sudan) [ 14 ]. The rich data from the 2017 JPFHS have allowed a more comprehensive investigation of inequalities and their trends [ 18 ]. The investigation covered additional dimensions of health and added nationality as a social stratifier that is quite relevant to the Jordanian context. The rich data provided important findings covering child health and wellbeing, adult health and noncommunicable diseases (NCDs), sexual and reproductive health, and health sector performance and capacity [ 20 ]. Other earlier studies indicated that Jordan, in comparison to other countries with similar per capita gross domestic product (GDP), exhibits low inequality [ 21 , 22 ]. Such inequalities have been at a low level since 2006, with fluctuations during recent decades [ 21 ]. The more recent past, however, is pointing to an increase in health inequalities [ 14 ].

In terms of the data to investigate the fair responsiveness of public services, special modules can be incorporated in a population-based survey to collect data that allows such an investigation [ 10 , 18 ]. Additionally, the potential of institutional HIS could be more effectively capitalized on. These assessments (population and institutional surveys) revealed the limitations of the HIS and that very few studies have performed such investigations. One of the studies used the JPFHS of 2017 to integrate a module on health system capacity and performance in the data collection instrument [ 20 , 23 ]. This allowed important findings that showed the severe inequitable distribution of health sector capacity, insurance coverage, and health sector performance by four stratifiers [ 20 ]. The inequalities in health service provision by the level of education, employment, income, residence area and other dimensions were also indicated in a World Health Organization and Regional Office for the Eastern Mediterranean study. The World Health Organization and Regional Office for the Eastern Mediterranean [ 22 ] emphasized that institutionally based HIS data at the subnational level in Jordan would allow measurement of area inequality for the provision of health services.

The only consistent sources of information on the quality and extent of health services in Jordan are the HIS and Civil Registry of Vital Statistics (CRVS) systems, which are based on institutions [ 20 , 24 ]. Nevertheless, there is no conclusive proof that this information can accurately measure health equity with regard to social stratifiers other than geographic classifications.

The ability of the HIS in Jordan to measure progress in SDH policies and actions was inferred from the application of a global assessment tool (SCORE) performed by the MoH and relevant stakeholders in Jordan [ 10 ]. The WHO and its collaborators created a SCORE for the health data technical package with the aim of supporting Jordan’s data systems and abilities in tracking advancements toward the SDGs pertaining to health, such as Universal Health Coverage (UHC), health priorities and objectives at the national and subnational levels [ 6 , 19 ]. According to the World Health Organization [ 25 ], the SCORE assessment showed that progress on SDH has been achieved. The World Health Organization [ 10 ] reported that 81% of health indicators have data available to monitor health-related SDGs. The capacity of the system is mostly moderate in the process of monitoring the SDGs based on the availability of the latest data [ 6 ].

The inability of the HIS to provide the necessary data to investigate inequities in policies is explained by the fact that the data needed to conduct the policy analysis for the investigation of inequities are not incorporated into the HIS in Jordan. This is particularly true since the information required at the policy level does not lend itself to the institutional HIS and population survey tools.

In Jordan, HIS evaluation reveals a complicated system that involves multiple data sources, various types of information, and numerous data producers and managers [ 26 ]. Unfortunately, the system does not guarantee the prompt availability of data or the timely release of information. Despite these issues, the HIS’s richness can be better utilized to promote health in Jordan and support its development plans [ 27 ]. The evaluation acknowledged the challenges in strengthening the HIS, but it also identified various recommendations and efforts to address them.

There is a need for legislation that mandates hospitals and other healthcare providers to promptly report births directly to the Department of Civil Status and Passports [ 13 ]. In essence, modifying the registration process by transferring responsibility from families to healthcare providers is necessary to achieve full registration of births and deaths [ 12 ]. To facilitate the registration process, an electronic system linking hospitals to the Department of Civil Status and Passports has been recommended [ 12 , 22 ]. The HIS should gather all pertinent information about direct, indirect causes and contributing factors of death to accurately calculate statistics for cause of death. This will allow healthcare professionals and stakeholders to review and audit deaths to prevent future similar occurrences. The adoption of the International Classification of Diseases (ICD-10) coding system, based on the assessment of evidence, has various benefits [ 17 , 22 ]. It enables healthcare providers to classify diseases, enhance the documentation of diagnoses and related complications, and effectively assess health care outcomes, especially in underprivileged and rural areas.

The inclusion of health inequity in the HIS was shown to be quite deficient, and it is not receiving the attention of the many efforts to strengthen the HIS. To effectively address health inequity in the HIS, it is necessary to collect data that go beyond measuring social disparities and identifying the policies responsible for creating unjust social stratification in society. These data should consider the equitable distribution of public services that respond to the diverse needs of various social groups.

The initial category of information can be collected from surveys conducted among the general population. In fact, the evaluation showed that the data obtained from the JPFHS provided comprehensive insights into the extent and trajectory of health disparities across various social groups [ 18 ].

Population-based surveys, capture new health challenges and new social drivers, yet the total reliance on them to replace institutional HIS is not efficient. This is explained by the periodic nature of these surveys and the fact that they do not make use of the richness and wide range of information provided in routine and more regular institutional sources of the HIS [ 1 , 18 ]. There is a clear need to cross-link individual records with socioeconomic, behavioral and contextual determinants [ 24 ]. This would be possible through linking the CRVS, for example, with the geographic location and the population surveys. These cross linkages can support the investigation and monitoring of health inequalities and their social underpinnings.

The second type of data relating to the fairness of public policies can be based on the institutional information systems of different sectors, including the institutional HIS. These could be easily modified to measure the fairness of the provision of services to different social groups [ 10 , 21 ]. However, linking the distribution of services to inequalities in health outcomes is more difficult, as it requires linking data on services, social stratifiers, and health outcomes.

The contributions of surveys to investigating inequities in public services rely on the introduction of additional well-concepted modules. These modules can be guided by the specialized health facility submodules added to the most recent Jordan Population and Family Health (JPFH) survey in Jordan [ 10 , 18 , 19 , 21 , 28 ].

The third type of data on the fairness of upstream policies and their impact is glaringly missing in the Jordan HIS. Similar to the majority of other countries, the absence of relevant data and information is reinforced by the fact that the mainstream of HEiAP has not been embraced by Jordan. The WHO has called for health in all policies (HiAP) to be replaced by HEiAP and to be implemented as a policy approach [ 2 , 3 , 14 ]. This automatically produces the type of data that the HIS currently lacks.

It should be emphasized, however, that the inclusion of the equity lens in the HIS requires additional conceptual and methodological innovations. These pertain to the identification of policies responsible for social stratification in society, the specifications of the data and information needed to investigate the fairness of these policies, the inclusion of these data in the proposed data repository, and the analytical and methodological skills to utilize these varied pieces of information to investigate the multilevel drivers of inequalities and the tracing of such inequalities to their root causes.

An important next step is to develop a database needed for applying the multilevel conceptual framework that integrates both the relevant social stratifiers with their manifestations in risks and opportunities for health, as well as their underpinnings of policies and public services. Currently, in the first phase of an ambitious activity, such a framework has been applied, and a detailed set of indicators that are needed to ensure the inclusion of SDHI in the HIS [ 2 ]. The next step is to adapt the proposed indicators to the context of Jordan to demonstrate its relevance to equity policies in Jordan and to illustrate their value in mainstreaming an equity lens in the implementation of programs.

Challenges and limitations

The health system in Jordan is facing several challenges due to the lack of a national reference entity for research and health studies and the inadequate computerization of the health system [ 19 , 21 , 22 , 26 ]. These challenges include weaknesses in modern electronic health system (E-Health) applications, limited access to private sector data and information, and difficulties formulating evidence-based policies and decisions [ 26 ]. To overcome these challenges, there is a need for a unified source of health information in Jordan, as the current data generated through different sources are not well integrated with the HIS, leading to gaps in its availability and readiness [ 19 ]. Furthermore, the HIS in Jordan lacks linkages and integration with routine information from various departments within the MoH and other ministries such as the CRVS [ 26 ].

Recommendations

Three types of data are required for SDHI inclusion:

This study provides data and information on health inequalities that could be linked to their social underpinnings.

The data and information on the fairness of public policies could be linked to their consequences for health inequalities.

The data and information on the fairness of upstream policies could be linked to their impact on social stratification and on the equity of public services and social arrangements.

Conclusions

Jordan recognizes the significance of fairness to people’s health and well-being and has a strategic commitment to equity. The country’s availability of a solid HIS foundation and the many efforts to strengthen it present an opportunity to help the country secure the needed evidence base to support development and well-being. Some data on social determinants of health are included in the Jordanian HIS, but much more data, information, and effort are needed to integrate the SDHI into the HIS of Jordan. The recently proposed package of indicators can be utilized to incorporate SDHI into HIS, and serve as the foundation for Jordan’s health equity policies and interventions. Incorporating this package into a comprehensive HIS and tailoring it to the country’s particular circumstances is essential.

Data availability

All data generated or analyzed during this study are included in this manuscript, in addition to the published articles and the supplementary information links below:

Equity and Social Determinants of Health in Health Information Systems: https://www.aucegypt.edu/research/src/equity-health-information-system .

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Health Information System Strategic Plan 2019–2023: https://www.moh.gov.jo/ebv4.0/root_storage/en/eb_list_page/health_information_system_strategic_plan(2019-2023).pdf .

Abbreviations

Civil Registry of Vital Statistics

Demographic and Health Survey

Department of Statistics

Electronic health records

Emerging Trends in Computing and Engineering Applications

Gross Domestic Product

Health Equity in all policies

Health in all policies

• Health information system

Health Metrics Network

International Classification of Diseases

International Development Research Centre

Jordan Population and Family Health

Jordan Population and Family Health Survey

Jordan stillbirths and neonatal deaths surveillance

Medical certificate with the cause of death

Middle East and North African Health Informatics Association

Ministry of Health

noncommunicable diseases

Sustainable Development Goals

• Social determinants of health

Social determinants of health inequity

Universal Health Coverage

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Acknowledgements

This paper describes one of the outcomes of the “Equity/SDH in Health Information Systems to Inform Policies and Guide Reproductive Health Programs” project. This project was carried out by the Social Research Center of the American University in Cairo (SRC-AUC) in collaboration with the Faculty of Health Sciences at the American University of Beirut (FSH-AUB) and with support from the IDRC in Canada. This project seeks to strengthen the role of HIS in guiding policy change and improving the effectiveness of health programs for the purpose of achieving health equity in Arab countries. It supports policy-level changes and guides program implementation. For more details on the project and its publication, visit the website: https://www.aucegypt.edu/research/src/equity-health-information-system .

The American University of Beirut received funding from the International Development Research Centre (IDRC) in Canada.

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Alnawafleh, A.H., Rashad, H. Does the health information system in Jordan support equity to improve health outcomes? Assessment and recommendations. Arch Public Health 82 , 48 (2024). https://doi.org/10.1186/s13690-024-01269-6

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As Bird Flu Looms, the Lessons of Past Pandemics Take On New Urgency

By John M. Barry

Mr. Barry, a scholar at the Tulane University School of Public Health and Tropical Medicine, is the author of “The Great Influenza: The Story of the Deadliest Pandemic in History.”

In 1918, an influenza virus jumped from birds to humans and killed an estimated 50 million to 100 million people in a world with less than a quarter of today’s population. Dozens of mammals also became infected.

Now we are seeing another onslaught of avian influenza. For years it has been devastating bird populations worldwide and more recently has begun infecting mammals , including cattle, a transmission never seen before. In another first, the virus almost certainly jumped recently from a cow to at least one human — fortunately, a mild case.

While much would still have to happen for this virus to ignite another human pandemic, these events provide another reason — as if one were needed — for governments and public health authorities to prepare for the next pandemic. As they do, they must be cautious about the lessons they might think Covid-19 left behind. We need to be prepared to fight the next war, not the last one.

Two assumptions based on our Covid experience would be especially dangerous and could cause tremendous damage, even if policymakers realized their mistake and adjusted quickly.

The first involves who is most likely to die from a pandemic virus. Covid primarily killed people 65 years and older , but Covid was an anomaly. The five previous pandemics we have reliable data about all killed much younger populations.

The 1889 pandemic most resembles Covid (and some scientists believe a coronavirus caused it). Young children escaped almost untouched and it killed mostly older people, but people ages 15 to 24 suffered the most excess mortality , or deaths above normal. Influenza caused the other pandemics, but unlike deaths from seasonal influenza, which usually kills older adults, in the 1957, 1968 and 2009 outbreaks, half or more deaths occurred in people younger than 65. The catastrophic 1918 pandemic was the complete reverse of Covid: Well over 90 percent of the excess mortality occurred in people younger than 65. Children under 10 were the most vulnerable, and those ages 25 to 29 followed.

Any presumption that older people would be the chief victims of the next pandemic — as they were in Covid — is wrong, and any policy so premised could leave healthy young adults and children exposed to a lethal virus.

The second dangerous assumption is that public health measures like school and business closings and masking had little impact. That is incorrect.

Australia, Germany and Switzerland are among the countries that demonstrated those interventions can succeed. Even the experience of the United States provides overwhelming, if indirect, evidence of the success of those public health measures.

The evidence comes from influenza, which transmits like Covid, with nearly one-third of cases transmitted by asymptomatic people. The winter before Covid, influenza killed an estimated 25,000 here ; in that first pandemic winter, influenza deaths were under 800. The public health steps taken to slow Covid contributed significantly to this decline, and those same measures no doubt affected Covid as well.

So the question isn’t whether those measures work. They do. It’s whether their benefits outweigh their social and economic costs. This will be a continuing calculation.

Such measures can moderate transmission, but they cannot be sustained indefinitely. And even the most extreme interventions cannot eliminate a pathogen that escapes initial containment if, like influenza or the virus that causes Covid-19, it is both airborne and transmitted by people showing no symptoms. Yet such interventions can achieve two important goals.

The first is preventing hospitals from being overrun. Achieving this outcome could require a cycle of imposing, lifting and reimposing public health measures to slow the spread of the virus. But the public should accept that because the goal is understandable, narrow and well defined.

The second objective is to slow transmission to buy time for identifying, manufacturing and distributing therapeutics and vaccines and for clinicians to learn how to manage care with the resources at hand. Artificial intelligence will perhaps be able to extrapolate from mountains of data which restrictions deliver the most benefits — whether, for example, just closing bars would be enough to significantly dampen spread — and which impose the greatest cost. A.I. should also speed drug development. And wastewater monitoring can track the pathogen’s movements and may make it possible to limit the locations where interventions are needed.

Still, what’s achievable will depend on the pathogen’s severity and transmissibility, and, as we sadly learned in the United States, how well — or poorly — leaders communicate the goals and the reasons behind them.

Specifically, officials will confront whether to impose the two most contentious interventions, school closings and mask mandates. What should they do?

Children are generally superspreaders of respiratory disease and can have disproportionate impact. Indeed, vaccinating children against pneumococcal pneumonia can cut the disease by 87 percent in people 50 and older. And schools were central to spreading the pandemics of 1957, 1968 and 2009. So there was good reason to think closing schools during Covid would save many lives.

In fact, closing schools did reduce Covid’s spread, yet the consensus view is that any gain was not worth the societal disruption and damage to children’s social and educational development. But that tells us nothing about the future. What if the next pandemic is deadlier than 1957’s but as in 1957, 48 percent of excess deaths are among those younger than 15 and schools are central to spread? Would it make sense to close schools then?

Masks present a much simpler question. They work. We’ve known they work since 1917, when they helped protect soldiers from a measles epidemic. A century later, all the data on Covid have actually demonstrated significant benefits from masks.

But whether to mandate masks is a difficult call. Too many people wear poorly fitted masks or wear them incorrectly. So even without adding in the complexities of politics, compliance is a problem. Whether government mask mandates will be worth the resistance they foment will depend on the severity of the virus.

That does not mean that institutions and businesses can’t or shouldn’t require masks. Nor does it mean we can’t increase the use of masks with better messaging. People accept smoking bans because they understand long-term exposure to secondhand smoke can cause cancer. A few minutes of exposure to Covid can kill. Messaging that combines self-protection with communitarian values could dent resistance significantly.

Individuals should want to protect themselves, given the long-term threat to their health. An estimated 7 percent of Americans have been affected by long Covid of varying severity, and a re-infection can still set it off in those who have so far avoided it. The 1918 pandemic also caused neurological and cardiovascular problems lasting decades, and children exposed in utero suffered worse health and higher mortality than their siblings. We can expect the same from the next pandemic.

What should we learn from the past? Every pandemic we have good information about was unique. That makes information itself the most valuable commodity. We must gather it, analyze it, act upon it and communicate it.

Epidemiological information can answer the biggest question: whether to deploy society-wide public health interventions at all. But the epidemiology of the virus is hardly the only information that matters. Before Covid vaccines were available, the single drug that saved the most lives was dexamethasone. Health officials in Britain discovered its effectiveness because the country has a shared data system that enabled them to analyze the efficacy of treatments being tried around the country. We have no comparable system in the United States. We need one.

Perhaps most important, government officials and health care experts must communicate to the public effectively. The United States failed dismally at this. There was no organized effort to counter social media disinformation, and experts damaged their own credibility by reversing their advice several times. They could have avoided these self-inflicted wounds by setting public expectations properly. The public should have been told that scientists had never seen this virus before, that they were giving their best advice based on their knowledge at the time and that their advice could — and probably would — change as more information came in. Had they done this, they probably would have retained more of the public’s confidence.

Trust matters. A pre-Covid analysis of the pandemic readiness of countries around the world rated the United States first because of its resources. Yet America had the second-worst rate of infections of any high-income country.

A pandemic analysis of 177 countries published in 2022 found that resources did not correlate with infections. Trust in government and fellow citizens did. That’s the lesson we really need to remember for the next time.

John M. Barry, a scholar at the Tulane University School of Public Health and Tropical Medicine, is the author of “The Great Influenza: The Story of the Deadliest Pandemic in History.”

The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips . And here’s our email: [email protected] .

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Letitia James Asked to Turn Over Documents

R epresentative Jim Jordan is asking New York Attorney General Letitia James to hand over documents and communications related to a prosecutor working on former President Donald Trump 's hush money case.

Jordan, the Ohio Republican who chairs the House Judiciary Committee, sent a letter to James requesting all documents and communications about Matthew Colangelo, an attorney working for Manhattan District Attorney Alvin Bragg previously employed by James' office and the Department of Justice (DOJ).

Bragg's office is trying Trump on 34 counts of falsifying business records related to an alleged hush money payment to adult film actor Stormy Daniels ahead of the 2016 presidential election. Bragg alleged the payment was meant to prevent her from speaking publicly about her claims of having an affair with the former president.

Trump has denied having an affair with Daniels and pleaded not guilty to all criminal charges. He maintains his innocence and has accused Bragg and other prosecutors of targeting him for political purposes, criticizing the trial as a form of election interference.

Trump supporters have raised concerns about Colangelo's previous experience at the DOJ, where he also worked on cases involving the former president.

Republicans have accused prosecutors of unjustly targeting Trump, the presumptive Republican presidential nominee, for political purposes. Some conservatives have also spread claims that the connection is evidence that President Joe Biden is behind the prosecution, but no evidence has been presented to support those allegations.

Jordan's committee has been probing what he views as the "weaponization" of the legal system against Trump and other conservatives. His letter to James comes amid his efforts to look into these concerns. In the letter, he expressed concerns about "the perception that the Justice Department is assisting in District Attorney Bragg's politicized prosecution."

"The fact that a former senior Biden DOJ official—whose previous employment consisted of leading 'a wave of state litigation against Trump administration policies'—is now leading the prosecution of President Biden's chief political rival only adds to the perception that the Biden DOJ is politicized and weaponized," Jordan wrote.

He argued that Colangelo's employment shows an alleged "obsession with investigating a person rather than prosecuting a crime."

Jordan requested all documents and communications since January 1, 2017, between Colangelo and any employee of the Manhattan DA's Office, the Fulton County DA's Office in Georgia (where Trump is facing election interference charges), the DOJ, the Democratic National Committee or Biden for President referring to or related to Trump, The Trump Organization and any other entity associated with Trump, according to the letter.

He also requested all personnel files related to Colangelo's hiring, employment or termination at the AG's office. Jordan asked James to deliver all files to him by May 29, 2024, at 5 p.m.

Newsweek reached out to James' and Bragg's offices for comment via email.

Colangelo spent two years in a senior position at the DOJ , overseeing the Antitrust, Civil, Civil Rights, Environment and Natural Resources, and Tax divisions, according to a press release announcing his hiring in December 2022

In the press release, Bragg wrote: "Matthew Colangelo brings a wealth of economic justice experience combined with complex white-collar investigations, and he has the sound judgment and integrity needed to pursue justice against powerful people and institutions when they abuse their power."

It also noted that Colangelo worked at the New York State Office of the Attorney General, where he investigated the Trump Foundation.

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Why writing by hand beats typing for thinking and learning

Jonathan Lambert

If you're like many digitally savvy Americans, it has likely been a while since you've spent much time writing by hand.

The laborious process of tracing out our thoughts, letter by letter, on the page is becoming a relic of the past in our screen-dominated world, where text messages and thumb-typed grocery lists have replaced handwritten letters and sticky notes. Electronic keyboards offer obvious efficiency benefits that have undoubtedly boosted our productivity — imagine having to write all your emails longhand.

To keep up, many schools are introducing computers as early as preschool, meaning some kids may learn the basics of typing before writing by hand.

But giving up this slower, more tactile way of expressing ourselves may come at a significant cost, according to a growing body of research that's uncovering the surprising cognitive benefits of taking pen to paper, or even stylus to iPad — for both children and adults.

Is this some kind of joke? A school facing shortages starts teaching standup comedy

In kids, studies show that tracing out ABCs, as opposed to typing them, leads to better and longer-lasting recognition and understanding of letters. Writing by hand also improves memory and recall of words, laying down the foundations of literacy and learning. In adults, taking notes by hand during a lecture, instead of typing, can lead to better conceptual understanding of material.

"There's actually some very important things going on during the embodied experience of writing by hand," says Ramesh Balasubramaniam , a neuroscientist at the University of California, Merced. "It has important cognitive benefits."

While those benefits have long been recognized by some (for instance, many authors, including Jennifer Egan and Neil Gaiman , draft their stories by hand to stoke creativity), scientists have only recently started investigating why writing by hand has these effects.

A slew of recent brain imaging research suggests handwriting's power stems from the relative complexity of the process and how it forces different brain systems to work together to reproduce the shapes of letters in our heads onto the page.

Your brain on handwriting

Both handwriting and typing involve moving our hands and fingers to create words on a page. But handwriting, it turns out, requires a lot more fine-tuned coordination between the motor and visual systems. This seems to more deeply engage the brain in ways that support learning.

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Feeling artsy here's how making art helps your brain.

"Handwriting is probably among the most complex motor skills that the brain is capable of," says Marieke Longcamp , a cognitive neuroscientist at Aix-Marseille Université.

Gripping a pen nimbly enough to write is a complicated task, as it requires your brain to continuously monitor the pressure that each finger exerts on the pen. Then, your motor system has to delicately modify that pressure to re-create each letter of the words in your head on the page.

"Your fingers have to each do something different to produce a recognizable letter," says Sophia Vinci-Booher , an educational neuroscientist at Vanderbilt University. Adding to the complexity, your visual system must continuously process that letter as it's formed. With each stroke, your brain compares the unfolding script with mental models of the letters and words, making adjustments to fingers in real time to create the letters' shapes, says Vinci-Booher.

That's not true for typing.

To type "tap" your fingers don't have to trace out the form of the letters — they just make three relatively simple and uniform movements. In comparison, it takes a lot more brainpower, as well as cross-talk between brain areas, to write than type.

Recent brain imaging studies bolster this idea. A study published in January found that when students write by hand, brain areas involved in motor and visual information processing " sync up " with areas crucial to memory formation, firing at frequencies associated with learning.

"We don't see that [synchronized activity] in typewriting at all," says Audrey van der Meer , a psychologist and study co-author at the Norwegian University of Science and Technology. She suggests that writing by hand is a neurobiologically richer process and that this richness may confer some cognitive benefits.

Other experts agree. "There seems to be something fundamental about engaging your body to produce these shapes," says Robert Wiley , a cognitive psychologist at the University of North Carolina, Greensboro. "It lets you make associations between your body and what you're seeing and hearing," he says, which might give the mind more footholds for accessing a given concept or idea.

Those extra footholds are especially important for learning in kids, but they may give adults a leg up too. Wiley and others worry that ditching handwriting for typing could have serious consequences for how we all learn and think.

What might be lost as handwriting wanes

The clearest consequence of screens and keyboards replacing pen and paper might be on kids' ability to learn the building blocks of literacy — letters.

"Letter recognition in early childhood is actually one of the best predictors of later reading and math attainment," says Vinci-Booher. Her work suggests the process of learning to write letters by hand is crucial for learning to read them.

"When kids write letters, they're just messy," she says. As kids practice writing "A," each iteration is different, and that variability helps solidify their conceptual understanding of the letter.

Research suggests kids learn to recognize letters better when seeing variable handwritten examples, compared with uniform typed examples.

This helps develop areas of the brain used during reading in older children and adults, Vinci-Booher found.

"This could be one of the ways that early experiences actually translate to long-term life outcomes," she says. "These visually demanding, fine motor actions bake in neural communication patterns that are really important for learning later on."

Ditching handwriting instruction could mean that those skills don't get developed as well, which could impair kids' ability to learn down the road.

"If young children are not receiving any handwriting training, which is very good brain stimulation, then their brains simply won't reach their full potential," says van der Meer. "It's scary to think of the potential consequences."

Many states are trying to avoid these risks by mandating cursive instruction. This year, California started requiring elementary school students to learn cursive , and similar bills are moving through state legislatures in several states, including Indiana, Kentucky, South Carolina and Wisconsin. (So far, evidence suggests that it's the writing by hand that matters, not whether it's print or cursive.)

Slowing down and processing information

For adults, one of the main benefits of writing by hand is that it simply forces us to slow down.

During a meeting or lecture, it's possible to type what you're hearing verbatim. But often, "you're not actually processing that information — you're just typing in the blind," says van der Meer. "If you take notes by hand, you can't write everything down," she says.

The relative slowness of the medium forces you to process the information, writing key words or phrases and using drawing or arrows to work through ideas, she says. "You make the information your own," she says, which helps it stick in the brain.

Such connections and integration are still possible when typing, but they need to be made more intentionally. And sometimes, efficiency wins out. "When you're writing a long essay, it's obviously much more practical to use a keyboard," says van der Meer.

Still, given our long history of using our hands to mark meaning in the world, some scientists worry about the more diffuse consequences of offloading our thinking to computers.

"We're foisting a lot of our knowledge, extending our cognition, to other devices, so it's only natural that we've started using these other agents to do our writing for us," says Balasubramaniam.

It's possible that this might free up our minds to do other kinds of hard thinking, he says. Or we might be sacrificing a fundamental process that's crucial for the kinds of immersive cognitive experiences that enable us to learn and think at our full potential.

Balasubramaniam stresses, however, that we don't have to ditch digital tools to harness the power of handwriting. So far, research suggests that scribbling with a stylus on a screen activates the same brain pathways as etching ink on paper. It's the movement that counts, he says, not its final form.

Jonathan Lambert is a Washington, D.C.-based freelance journalist who covers science, health and policy.

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Does the health information system in Jordan support equity to improve health outcomes? Assessment and recommendations

Ahmad h. alnawafleh.

1 Faculty of Nursing, Mutah University, 61710 Mutah, Jordan

Hoda Rashad

2 Social Research Center, American University in Cairo, 11835 Cairo, Egypt

Associated Data

All data generated or analyzed during this study are included in this manuscript, in addition to the published articles and the supplementary information links below:

Equity and Social Determinants of Health in Health Information Systems: https://www.aucegypt.edu/research/src/equity-health-information-system .

Package of Indicators and Measures to Monitor Health Inequities and Guide Policies: https://documents.aucegypt.edu/Docs/src/Package%20of%20Indicators%20and%20Measures.pdf .

Health Information System Strategic Plan 2019–2023: https://www.moh.gov.jo/ebv4.0/root_storage/en/eb_list_page/health_information_system_strategic_plan(2019-2023).pdf .

This study is based on extensive evidence-based assessments. The aim of this paper is to evaluate how well Jordan’s health information system (HIS) incorporates social determinants of health inequity (SDHI) and to propose suggestions for future actions.

An extensive evidence-based assessment was performed. A meta-synthesis of the inclusion of the SDHI in the HIS in Jordan was conducted. After searching and shortlisting, 23 papers were analyzed using Atlas.ti 9.0 employing thematic analysis technique.

The HIS in Jordan is quite comprehensive, comprising numerous data sources, various types of information, and data from multiple producers and managers. Nevertheless, the HIS confronts several obstacles and fails to ensure the timely and secure publication of available data. The assessment of the inclusion of the SDHI in the HIS showed that the HIS allows for the measurement of progress in relation to social policies and actions but has a very limited database for supporting the inclusion of health inequity measures. One reason for the difficulty in identifying fairness is that certain crucial information necessary for this task cannot be obtained through the available institutional HIS or population survey tools. Additionally, relevant modules for fairness may be missing from population surveys, possibly due to a failure to fully utilize the capabilities of the institutional HIS.

There are opportunities to make use of Jordan’s dedication to fairness and its already established strong HIS. Some social determinants of health exist in the HIS, but much more data, information, and effort are needed to integrate the SDHI into the Jordanian HIS. A proposal from a regional initiative has put forward a comprehensive set of indicators for integrating SDHI into HIS, which could aid in achieving health equity in Jordan.

A framework that focuses on the social determinants of health acknowledges that factors beyond the healthcare system within society contribute to health disparities [ 1 – 4 ]. These disparities are influenced by variations in the environment, community, family, and individual levels. The framing of social determinants of health inequities (SDHI) differs from that of social determinants of health (SDH) in two key features [ 2 , 5 ]. The SDHI places great importance on the examination of inequality and recognizes that various factors contribute to the determinants of health [ 2 ]. The SDHI proposes that disparities in health outcomes among social groups stem from inequitable distributions of social, economic, and cultural resources, as well as unequal access to opportunities for improving their circumstances. According to the principles of SDHI, the problem of unequal access to health resources can be traced back to larger political and economic systems and policies, as well as social factors and public services [ 2 , 3 ]. This inequality is evident in the way society is divided into groups based on factors such as wealth and education and in how policies and practices favor certain groups over others in meeting their health needs.

Health information should first perceive and critically examine the occurrence of health disparities and any clustering among marginalized and underresourced communities. The distribution of health inequalities by social stratification should also be investigated, and this distribution should be linked to the fairness and responsiveness of macrostructures, policies, intermediate forces, and public services. An absence of acknowledgment of inequities and their consequences for health distribution could sustain them and might lead to their propagation. This could widen the health divide by disproportionately providing resources and opportunities to nonmarginalized groups that have already received a relatively greater share of health-related benefits. More importantly, acknowledging inequities supports a movement from targeting the disadvantaged to changing the distribution of their disadvantage. It supports the adoption of transformative, fair, and responsive policies and actions [ 2 , 3 ]. The focus on SDHI to decrease health inequalities helps to realize development anchored on social justice and human rights and on ‘Leaving no One Behind’, as pursued by the Sustainable Development Goals (SDGs) [ 3 , 6 ].

A HIS that follows the SDHI framework caters to a diverse group of people at various levels [ 2 ]. At the level of health professionals, the HIS should offer insight and facilitate effective communication, which can aid in diagnosing health issues and taking appropriate actions within local communities. If the HIS is successful in providing this support, health professionals can become more compassionate toward their patients and deliver health services that are responsive to the context of SDH [ 7 ]. This is especially important when navigating obstacles to accessing healthcare and other services during direct interactions with health services. Moreover, it is also valuable for implementing comprehensive social and health interventions at the community level. At the policy and public sector level, such a system can motivate the adoption of strategies that promote health equities in all policies (HEiAP) and intersectoral actions for health [ 2 , 3 , 7 ]. It can help promote well-being and health equity as a measure of development and social success.

The significance of incorporating the SDHI into Jordan’s HIS is acknowledged in this paper, which delves into the subject and provides suggestions for future actions. A thorough examination of pertinent resources and materials was conducted to produce this paper. Initially, the research methodology employed is outlined, followed by a depiction of Jordan’s HIS. An evaluation of the HIS and Jordan’s initiatives to enhance it ensues. The paper concludes with a discussion of the integration of SDH and health equity into the information system, along with an analysis of the results and recommendations for future steps.

To gain a better understanding of how social factors contribute to health inequalities within Jordan’s HIS, a thorough examination of evidence was conducted. This involved conducting a comprehensive search of various databases and websites between June and August 2021, including scientific and gray literature sources such as www.google.jo . The search focused on specific keywords related to SDH, electronic medical records, HISs, health equity, health inequality, and Jordan. The authors have access to a wide range of databases and reports. Through this access, they reviewed a large volume of gray literature, including a wide range of relevant articles, mini-reviews, editorials, book chapters, newspaper articles, unpublished thesis papers, and nonscientific articles. The next step involved scanning and reading the article abstracts and content tables to determine which papers were relevant and should be included. All duplicates and studies not related to the Jordan HIS were excluded.

The method used to analyze the papers and reports that met the criteria involved employing the thematic analysis technique with the support of Atlas.ti 9.0 software. This approach involves identifying and organizing themes from the data, analyzing them, and presenting a summary. One benefit of using thematic analysis is that it enables researchers to gain a deeper understanding of the themes that emerge. This process is particularly useful for summarizing a large amount of data and literature in a structured and organized way.

With support from contacts in relevant departments at the Ministry of Health (MoH) in Jordan and other agencies involved in the HIS, the authors managed to collect over 120 documents. Various research techniques, such as literature reviews, theoretical research, technical reports, case studies, and other qualitative, quantitative, and mixed methods or approaches, were utilized to identify relevant studies or reports. After eliminating duplicates and articles that did not meet the literature foci, 76 articles were selected. During the full reading of the articles, 53 papers were excluded because they were deemed unsuitable for the meta-synthesis. After this sorting process, 23 papers were selected for analysis and uploaded to Atlas.ti 9.0, which is software used for data analysis and synthesis.

The HIS in Jordan is well organized and encompasses a wide range of data sources, information types, and individuals responsible for producing and managing the data. Certain data tools used involve physical forms that are subsequently verified, coded, entered, and processed. Additionally, electronic records and completely automated systems are utilized for certain data types and by some data management systems.

Currently, in Jordan’s HIS, the evaluation of various types of data shows that birth registrations are almost complete (99%), while death registrations represent 75%. According to Khader, Alyahya et al. [ 8 ], some neonatal deaths and stillbirths are not fully registered due to a malfunctioning reporting system that places the responsibility of registration on families [ 9 ].

The quality of reporting for the cause of death statistics in Jordan does not meet the quality-of-care standards. According to the SCORE data report, only 59% of total deaths in Jordan were accompanied by a medical certificate with the cause of death (MCCD) and ICD coding [ 10 ]. The accuracy of the certificates in determining the cause of death varied between 20% and 29%, according to Alyahya et al.‘s [ 11 ] research. This study emphasizes the need for ongoing training of Jordanian healthcare practitioners in utilizing the ICD-10 coding system when implementing new health technology, as well as the relative novelty of electronic health records (EHRs) and ICD-10 use in public hospitals in Jordan [ 12 , 13 ]. The research suggests that the current program is not standardized and lacks the necessary coding system to precisely identify and record the causes of death [ 11 ].

Electronic medical records in the field of obstetrics lack a comprehensive template for a record because it sometimes does not track the patient’s entire medical journey [ 14 – 17 ]. This is because records were established to record patient visits from the initial care provided during admission to the emergency department through the triage process, and the process of assessing and managing patients in labor wards to any destination should be documented until the treatment is completed [ 15 , 16 ].

The inclusion of SDHI in the information system

To provide information on health inequalities and the underlying social factors, an information system with an SDHI framework should be implemented. This system should also provide data on the fairness of upstream policies and public services that shape the social factors of health inequalities [ 2 ]. In Jordan, the institutional HIS (see Table  1 ) is rich in data on health inequalities and their social underpinnings, but it allows for measurements based only on geographic stratifiers and not other social stratifiers, such as gender and age. Population-based (see Table  2 ) surveys and submodules designed for this purpose are valuable for producing knowledge and recommendations on health inequalities and their social determinants [ 18 , 19 ].

Institutional health information system

Source Study data sources

Population health information system

Surveys are valuable because of their ability to link individual-level data with different social determinants across multilevel pathways of influence. This includes how social stratifications in society are reflected in the proximate level of behaviors, livelihoods, and community contextual forces.

An example of the value of population surveys in investigating health inequalities and their social determinants is available in two recent studies [ 14 , 20 ]. These studies used data provided by the Jordan Population and Family Health Survey (JPFHS) of 2012 and 2017, respectively. These studies have investigated inequality challenges in Jordan and have produced important analyses, findings, and recommendations related to health inequalities and their social underpinnings.

The analysis of the 2012 JPFHS indicated that the summary inequality measures by geographic and gendered cultural context stratifiers are relatively small compared to those of the wealth stratifiers and four other Arab countries (Egypt, Morocco, Oman, and Sudan) [ 14 ]. The rich data from the 2017 JPFHS have allowed a more comprehensive investigation of inequalities and their trends [ 18 ]. The investigation covered additional dimensions of health and added nationality as a social stratifier that is quite relevant to the Jordanian context. The rich data provided important findings covering child health and wellbeing, adult health and noncommunicable diseases (NCDs), sexual and reproductive health, and health sector performance and capacity [ 20 ]. Other earlier studies indicated that Jordan, in comparison to other countries with similar per capita gross domestic product (GDP), exhibits low inequality [ 21 , 22 ]. Such inequalities have been at a low level since 2006, with fluctuations during recent decades [ 21 ]. The more recent past, however, is pointing to an increase in health inequalities [ 14 ].

In terms of the data to investigate the fair responsiveness of public services, special modules can be incorporated in a population-based survey to collect data that allows such an investigation [ 10 , 18 ]. Additionally, the potential of institutional HIS could be more effectively capitalized on. These assessments (population and institutional surveys) revealed the limitations of the HIS and that very few studies have performed such investigations. One of the studies used the JPFHS of 2017 to integrate a module on health system capacity and performance in the data collection instrument [ 20 , 23 ]. This allowed important findings that showed the severe inequitable distribution of health sector capacity, insurance coverage, and health sector performance by four stratifiers [ 20 ]. The inequalities in health service provision by the level of education, employment, income, residence area and other dimensions were also indicated in a World Health Organization and Regional Office for the Eastern Mediterranean study. The World Health Organization and Regional Office for the Eastern Mediterranean [ 22 ] emphasized that institutionally based HIS data at the subnational level in Jordan would allow measurement of area inequality for the provision of health services.

The only consistent sources of information on the quality and extent of health services in Jordan are the HIS and Civil Registry of Vital Statistics (CRVS) systems, which are based on institutions [ 20 , 24 ]. Nevertheless, there is no conclusive proof that this information can accurately measure health equity with regard to social stratifiers other than geographic classifications.

The ability of the HIS in Jordan to measure progress in SDH policies and actions was inferred from the application of a global assessment tool (SCORE) performed by the MoH and relevant stakeholders in Jordan [ 10 ]. The WHO and its collaborators created a SCORE for the health data technical package with the aim of supporting Jordan’s data systems and abilities in tracking advancements toward the SDGs pertaining to health, such as Universal Health Coverage (UHC), health priorities and objectives at the national and subnational levels [ 6 , 19 ]. According to the World Health Organization [ 25 ], the SCORE assessment showed that progress on SDH has been achieved. The World Health Organization [ 10 ] reported that 81% of health indicators have data available to monitor health-related SDGs. The capacity of the system is mostly moderate in the process of monitoring the SDGs based on the availability of the latest data [ 6 ].

The inability of the HIS to provide the necessary data to investigate inequities in policies is explained by the fact that the data needed to conduct the policy analysis for the investigation of inequities are not incorporated into the HIS in Jordan. This is particularly true since the information required at the policy level does not lend itself to the institutional HIS and population survey tools.

In Jordan, HIS evaluation reveals a complicated system that involves multiple data sources, various types of information, and numerous data producers and managers [ 26 ]. Unfortunately, the system does not guarantee the prompt availability of data or the timely release of information. Despite these issues, the HIS’s richness can be better utilized to promote health in Jordan and support its development plans [ 27 ]. The evaluation acknowledged the challenges in strengthening the HIS, but it also identified various recommendations and efforts to address them.

There is a need for legislation that mandates hospitals and other healthcare providers to promptly report births directly to the Department of Civil Status and Passports [ 13 ]. In essence, modifying the registration process by transferring responsibility from families to healthcare providers is necessary to achieve full registration of births and deaths [ 12 ]. To facilitate the registration process, an electronic system linking hospitals to the Department of Civil Status and Passports has been recommended [ 12 , 22 ]. The HIS should gather all pertinent information about direct, indirect causes and contributing factors of death to accurately calculate statistics for cause of death. This will allow healthcare professionals and stakeholders to review and audit deaths to prevent future similar occurrences. The adoption of the International Classification of Diseases (ICD-10) coding system, based on the assessment of evidence, has various benefits [ 17 , 22 ]. It enables healthcare providers to classify diseases, enhance the documentation of diagnoses and related complications, and effectively assess health care outcomes, especially in underprivileged and rural areas.

The inclusion of health inequity in the HIS was shown to be quite deficient, and it is not receiving the attention of the many efforts to strengthen the HIS. To effectively address health inequity in the HIS, it is necessary to collect data that go beyond measuring social disparities and identifying the policies responsible for creating unjust social stratification in society. These data should consider the equitable distribution of public services that respond to the diverse needs of various social groups.

The initial category of information can be collected from surveys conducted among the general population. In fact, the evaluation showed that the data obtained from the JPFHS provided comprehensive insights into the extent and trajectory of health disparities across various social groups [ 18 ].

Population-based surveys, capture new health challenges and new social drivers, yet the total reliance on them to replace institutional HIS is not efficient. This is explained by the periodic nature of these surveys and the fact that they do not make use of the richness and wide range of information provided in routine and more regular institutional sources of the HIS [ 1 , 18 ]. There is a clear need to cross-link individual records with socioeconomic, behavioral and contextual determinants [ 24 ]. This would be possible through linking the CRVS, for example, with the geographic location and the population surveys. These cross linkages can support the investigation and monitoring of health inequalities and their social underpinnings.

The second type of data relating to the fairness of public policies can be based on the institutional information systems of different sectors, including the institutional HIS. These could be easily modified to measure the fairness of the provision of services to different social groups [ 10 , 21 ]. However, linking the distribution of services to inequalities in health outcomes is more difficult, as it requires linking data on services, social stratifiers, and health outcomes.

The contributions of surveys to investigating inequities in public services rely on the introduction of additional well-concepted modules. These modules can be guided by the specialized health facility submodules added to the most recent Jordan Population and Family Health (JPFH) survey in Jordan [ 10 , 18 , 19 , 21 , 28 ].

The third type of data on the fairness of upstream policies and their impact is glaringly missing in the Jordan HIS. Similar to the majority of other countries, the absence of relevant data and information is reinforced by the fact that the mainstream of HEiAP has not been embraced by Jordan. The WHO has called for health in all policies (HiAP) to be replaced by HEiAP and to be implemented as a policy approach [ 2 , 3 , 14 ]. This automatically produces the type of data that the HIS currently lacks.

It should be emphasized, however, that the inclusion of the equity lens in the HIS requires additional conceptual and methodological innovations. These pertain to the identification of policies responsible for social stratification in society, the specifications of the data and information needed to investigate the fairness of these policies, the inclusion of these data in the proposed data repository, and the analytical and methodological skills to utilize these varied pieces of information to investigate the multilevel drivers of inequalities and the tracing of such inequalities to their root causes.

An important next step is to develop a database needed for applying the multilevel conceptual framework that integrates both the relevant social stratifiers with their manifestations in risks and opportunities for health, as well as their underpinnings of policies and public services. Currently, in the first phase of an ambitious activity, such a framework has been applied, and a detailed set of indicators that are needed to ensure the inclusion of SDHI in the HIS [ 2 ]. The next step is to adapt the proposed indicators to the context of Jordan to demonstrate its relevance to equity policies in Jordan and to illustrate their value in mainstreaming an equity lens in the implementation of programs.

Challenges and limitations

The health system in Jordan is facing several challenges due to the lack of a national reference entity for research and health studies and the inadequate computerization of the health system [ 19 , 21 , 22 , 26 ]. These challenges include weaknesses in modern electronic health system (E-Health) applications, limited access to private sector data and information, and difficulties formulating evidence-based policies and decisions [ 26 ]. To overcome these challenges, there is a need for a unified source of health information in Jordan, as the current data generated through different sources are not well integrated with the HIS, leading to gaps in its availability and readiness [ 19 ]. Furthermore, the HIS in Jordan lacks linkages and integration with routine information from various departments within the MoH and other ministries such as the CRVS [ 26 ].

Recommendations

Three types of data are required for SDHI inclusion:

• This study provides data and information on health inequalities that could be linked to their social underpinnings.
• The data and information on the fairness of public policies could be linked to their consequences for health inequalities.
• The data and information on the fairness of upstream policies could be linked to their impact on social stratification and on the equity of public services and social arrangements.

Conclusions

Jordan recognizes the significance of fairness to people’s health and well-being and has a strategic commitment to equity. The country’s availability of a solid HIS foundation and the many efforts to strengthen it present an opportunity to help the country secure the needed evidence base to support development and well-being. Some data on social determinants of health are included in the Jordanian HIS, but much more data, information, and effort are needed to integrate the SDHI into the HIS of Jordan. The recently proposed package of indicators can be utilized to incorporate SDHI into HIS, and serve as the foundation for Jordan’s health equity policies and interventions. Incorporating this package into a comprehensive HIS and tailoring it to the country’s particular circumstances is essential.

Acknowledgements

This paper describes one of the outcomes of the “Equity/SDH in Health Information Systems to Inform Policies and Guide Reproductive Health Programs” project. This project was carried out by the Social Research Center of the American University in Cairo (SRC-AUC) in collaboration with the Faculty of Health Sciences at the American University of Beirut (FSH-AUB) and with support from the IDRC in Canada. This project seeks to strengthen the role of HIS in guiding policy change and improving the effectiveness of health programs for the purpose of achieving health equity in Arab countries. It supports policy-level changes and guides program implementation. For more details on the project and its publication, visit the website: https://www.aucegypt.edu/research/src/equity-health-information-system .

Abbreviations

Ahmad h. al-nawafleh.

(PhD, MPA, CI, RN), associate Professor of health systems and nursing Leadership at Mutah University in Jordan. He became a nurse in 1992, Ahmad became an assistant professor after earning his PhD in nursing studies from the University of Nottingham, UK and then promoted to associate professor since 2015. Currently beside his academic position, serves as consultant with WHO for improving PHC in Jordan and non-communicable diseases, beside other consultations for Higher Health Council in Jordan, American University of Cairo and other clients regarding communicable diseases, social determinants of health and health information systems. After earning his BSN degree, he became a critical care nurse specializing in coronary care. He practiced nursing care with clients of all ages in various hospitals, emergency care facilities, clinics, medical wards, and private practice. Then he taught more than 16 different courses for more than 14 years to undergraduate and postgraduate students and supervised more than 30 postgraduate research projects too. His nursing research has focused on qualitative studies, nursing management, health policy, public health, patient safety, decision making, primary health services performance measurement and improvement, ethical and legal nursing and staffing issues. He had presented on these topics at numerous conferences and published over 27 papers in peer reviewed journals. His abiding passion continues to focus on the recognition and amelioration of staffing and policies, wherever it exists.

Author contributions

A.A. conducted review and produced a draft version of the paper. H.R. restructured the paper and added the last three sections of the paper. All authors reviewed the manuscript.

The American University of Beirut received funding from the International Development Research Centre (IDRC) in Canada.

Data availability

Declarations.

Not applicable.

All the authors, their institutions, and the funding agents declare that they have no competing interests.

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Jordan Foils Arms Plot as Kingdom Caught in Iran-Israel Shadow War

FILE PHOTO: Demonstrators carry flags and banners during a protest in support of Palestinians in Gaza, amid the ongoing conflict between Israel and the Palestinian Islamist group Hamas, in Amman, Jordan May 3, 2024. REUTERS/Jehad Shelbak/File Photo

By Samia Nakhoul and Suleiman Al-Khalidi

AMMAN (Reuters) -Jordan has foiled a suspected Iranian-led plot to smuggle weapons into the U.S.-allied kingdom to help opponents of the ruling monarchy carry out acts of sabotage, according to two Jordanian sources with knowledge of the matter.

    The weapons were sent by Iranian-backed militias in Syria to a cell of the Muslim Brotherhood in Jordan that has links to the military wing of Palestinian group Hamas, the people told Reuters. The cache was seized when members of the cell, Jordanians of Palestinian descent, were arrested in late March, they said.  

The alleged plot and arrests, reported here for the first time, come at a time of sky-high tensions in the Middle East, with an American-backed Israel at war in Gaza with Hamas, part of Iran's "Axis of Resistance" network of proxy groups built up over decades to oppose Israel.

War in Israel and Gaza

In a statement on Wednesday, Hamas said it had "no ties to any acts targeting Jordan" and that it only sought to target Israel.

The two Jordanian sources, who requested anonymity to discuss security matters, declined to say what acts of sabotage were allegedly being planned, citing ongoing investigations and covert operations.

They said the plot's aim was to destabilize Jordan, a country that could become a regional flashpoint in the Gaza crisis as it hosts a U.S. military base and shares borders with Israel as well as Syria and Iraq, both home to Iranian-backed militias.

The sources didn't specify what weapons were seized in the March raid, though said in recent months security services have thwarted numerous attempts by Iran and its allied groups to smuggle in arms including Claymore mines, C4 and Semtex explosives, Kalashnikov rifles and 107mm Katyusha rockets.

Most of the clandestine flow of arms into the country has been bound for the neighbouring Israeli-occupied West Bank Palestinian territory, according to the Jordanian sources. However, some of the weapons - including those seized in March - were intended for use in Jordan by the Brotherhood cell allied to Hamas militants, they said.

"They hide these weapons in pits called dead spots, they take their location via GPS and photograph their location and then instruct men to retrieve them from there," said one of the sources, an official with knowledge of security matters, referring to the modus operandi of the smugglers.

The Muslim Brotherhood is a transnational Islamist movement, of which Hamas is an offshoot founded in the 1980s. The movement says it does not advocate violence, and Jordan's Brotherhood has operated legally in the kingdom for decades.

Jordanian authorities believe Iran and its allied groups like Hamas and Lebanon's Hezbollah are trying to recruit young, radical members of the kingdom's Brotherhood to their anti-Israel, anti-U.S. cause in a bid to expand the Tehran's regional network of aligned forces, according to the two sources.

A senior representative of Jordan's Muslim Brotherhood confirmed that some of its members were arrested in March in possession of weapons but said whatever they did was not approved by the group and that he suspected they were smuggling arms to the West Bank rather than planning acts in Jordan.

"There is dialogue between the Brotherhood and the authorities. They know if there are mistakes it's not the MB, only individuals and not MB policy," said the representative, asking not to be named due to the sensitivity of the matter.

Another senior figure in Brotherhood, who also requested anonymity, told Reuters the arrested cell members had been recruited by Hamas chief Saleh al-Arouri, who masterminded the Palestinian group's operations in the West Bank from exile in Lebanon. Arouri was killed by a drone strike in Beirut in January in an attack widely attributed to Israel.

Spokespeople for the Jordanian government and the U.S. Department of Defense declined to comment for this article, while the Iranian foreign ministry wasn't immediately available. Israeli officials from the prime minister's office and foreign ministry didn't immediately respond to requests for comment.

Over the past year, Jordan has said it has foiled many attempts by infiltrators linked to pro-Iranian militias in Syria who it says have crossed its borders with rocket launchers and explosives, adding that some of the weapons managed to get through undetected. Iran has denied being behind such attempts.

IN A FIX: JORDAN'S KING ABDULLAH

Jordan's King Abdullah is walking a tightrope.

Most of his 11 million people are of Palestinian origin, because Jordan took in millions of Palestinian refugees fleeing their homeland in the turbulent years following the founding of Israel. The Gaza crisis has put him in a tough position, struggling to reconcile support for the Palestinian cause with a long-standing U.S. alliance and decades-old recognition of Israel.

The war has sparked widespread public anger, with calls by protesters to cut ties with Israel and street demonstrations erupted in recent week.

Last month, after Jordan joined a U.S.-led effort to help Israel in downing salvos of drones and missiles fired by Iran, critics posted concocted images on social media of the king wrapped in an Israeli flag with comments such as "traitor" and "Western puppet".

The disconnect between the government's position and public sentiment has never been more pronounced in the wake of the shooting down of the drones, according to Jordanian journalist Bassam Badari.

"There was discontent," he said. "Jordan used to skilfully stand at an equal distance from all the countries in the region, but with its intervention Jordan aligned itself with the American axis."

Adding to Abdullah's concerns, any tension with the Brotherhood could also carry risks, said two Jordanian politicians who requested anonymity due to the sensitivity of the matter. The group commands wide popular support in the country.

Jordanian authorities have not spoken publicly about the alleged weapons plot and the arrests.

One of the two Jordanian sources with knowledge of the alleged plot said intelligence officials had called in 10 senior Brotherhood figures to inform them that they arrested a cell that acted as a bridge between their movement and Hamas.

'NO SUCH THING AS A JORDAN OPTION'

The Jordanian decision to join Western powers in the downing of Iranian drones bound for Israel was partly driven by fears among officials that the kingdom could be sucked into Iran's strategic struggle against Israel, according to Saud Al Sharafat, a former brigadier-general in the Jordanian General Intelligence Directorate.

"The Iranians have instructions to recruit Jordanians and penetrate the Jordan arena through agents," he added. "Their recruitment efforts span all segments of society."

Another motivating force for Jordan, according to many officials and diplomats in the region, was the unprecedented attack on a U.S. military base in Jordan in January by Iran-aligned groups based in Iraq, which left three U.S. soldiers dead and 40 injured. The attack was reportedly in support of Hamas in its war with Israel.

A diplomat close to Tehran said the Iranian ambition to establish a proxy foothold in Jordan went back to Qassem Soleimani, the commander of Iran's elite Revolutionary Guards who was assassinated by the U.S. in 2020.

Soleimani believed that given Jordan's strong ties with the U.S. and the West, building up an allied group there capable of fighting Israel was crucial to Tehran's strategic ascendancy in the region, the diplomat told Reuters.

The hostility between Iran and Jordan dates back to 2004, in the wake of the U.S.-led invasion of Iraq, when King Abdullah accused Iran of trying to create a "Shi'ite crescent" to expand its regional power.

   King Abdullah defended his decision to shoot down the drones as an act of self-defence, not carried out for the benefit of Israel. He warned that "Jordan will not be a battlefield for any party".

The military intervention also aimed to signal to Israeli Prime Minister Benjamin Netanyahu's government that Jordan was a crucial buffer zone for regional security, according to the two Jordanian politicians.

The Jordanian monarchy supports the establishment of a Palestinian state. While some right-wing politicians in Israel have envisaged Jordan becoming an alternative Palestinian state, King Abdullah has repeatedly warned that there is no such thing as a "Jordan option".

"The official position is that a two-state solution is not only in Palestinians' interest," said Marwan Muasher, a former Jordanian foreign minister who is vice president for studies at the Carnegie Endowment for International Peace, a Washington-based think-tank.

"It is also in Jordan's interests because it will establish a Palestinian state on Palestinian soil rather than a state on Jordan's soil."

(Reporting by Samia Nakhoul and Suleiman Al-Khalidi; Additional reporting by Dan Williams in Jerusalem and Idrees Ali in Washington; Editing by David Gauthier-Villars and Pravin Char)

Copyright 2024 Thomson Reuters .

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Tags: Iran , Lebanon , United States , Israel , Syria , Middle East , Jordan

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