Background

Since 1948, the Palestinian- Israeli conflict has displaced millions of Palestinians from their homeland. In 1948-49 and after the Six-Day War in 1967, hundreds of thousands of Palestinians crossed the Jordanian border, and entered four refugee camps provided for Palestinians.1 The influx of Palestinian refugees has decreased in recent years, however, in 2016 150,000 Palestinians migrated out of Gaza and the West Bank into Jordan.2 Currently 2.3 million Palestinian refugees are registered in Jordan and reside in 13 official and unofficial refugee camps specifically for Palestinians.3

Over time, the increase in the refugee population has exacerbated financial and economic issues in Jordan’s health system, overwhelming the capacity of primary care centers as well as reducing access to health services in refugee camps.4 To accommodate this influx of various refugee groups, Jordan’s Ministry of Health has heavily relied on international and private sector organizations, including the United Nations Refugee Works Agency (UNRWA). The UNRWA was established in the 1950s, and was originally designed to provide emergency relief to refugees by providing health services aid within Jordan.5

The UNRWA’s role has greatly evolved over time and it currently provides education, social services and healthcare to millions of refugees in Jordan and other countries.4 Despite the increase in population served, PHC in Jordan has significantly improved over the last decade with significant increases in vaccination rates and a decrease in maternal and infant mortality.6 These overall improvements are due to a variety of population health management reforms that have been implemented in partnership with the UNRWA, including the introduction of family health teams and virtual outreach services.

How Population Health Management was integrated into reforms

As of 2019, 25 UNRWA primary health centres were in operation across Jordan, providing over 1.9 million general consultations. Primary health centres provide a range of comprehensive curative and preventive primary care services Palestine refugees, including NCD services, maternal and child health care and dental services, laboratory services, vaccinations, and other services.7 8 Recently, the UNRWA upgraded the outreach-based health point in the Madaba refugee camp to a primary health centre to improve access to PHC for refugees living in remote areas. The Madaba health centre is open six days a week and provides the full range of primary care services listed above. 

Across all the UNRWA’s primary care facilities, new practices for conducting and delivering primary care to patients are now centered in the Family Health Team (FHT) model. The FHT program empanels the refugee population in primary care, and creates a patient-centered environment that provides refugees with a team of doctors, nurses and other health workers that work together to provide care to the patient.9 Health education materials such as a Mother and Child Handbook for refugee mothers are translated and tailored to the community in an effort to provide patient-centered care.7 Healthcare workers involved in the FHT program have also completed trainings regarding important mental health indications that patients might present with due to the higher incidence of mental health disorders in the refugee population. Alongside trainings, the development of an updated health information system has allowed for a more efficient and simpler way for health workers to report and refer patients presenting mental health disorders to specialists.7

What is Proactive Population Outreach?

Proactive population outreach involves the active provision of care in homes or communities, particularly for communities who are underserved or marginalized. The UNRWA’s outreach programs target refugee populations and are aligned with local priorities such as educating the community and young adults on reproductive health and gender based violence by creating and presenting lessons on the topic in schools. The UNRWA also increased the scope of primary care services in the Madaba Health Centre to improve the refugee community’s access to a more comprehensive set of services.

Also in 2019, the UNRWA introduced two eHealth applications, called the e-Maternal and Child Health app (e-MCH) and the e-Non-Communicable Disease app (e-NCD), which are designed to increase refugees’ involvement in their care and access to services for a range of conditions. Various population health management strategies have been built-in to the e-MCH and e-NCD apps that help achieve these aims. The e-MCH app includes the ability to 1) receive appointment notifications, 2) access health records for mothers and their children, 3) provide health education based on health status, and 4) play nursery rhymes and lullabies to help mothers sooth their children and 5) store and capture family photos.10 The e-NCD app provides similar services such as reminding patients about upcoming appointments, providing access to health records, and giving health advice tailored to current health status and risk factors for those suffering from NCDs.7 At the facility and community level, the UNRWA has also recently introduced educational programs and campaigns to raise community awareness about gender-based violence and reproductive health.7 

Outcomes and impact

Decades of health service provision and outreach strategies have helped to improve health outcomes and improve access to primary care services for the Palestinian refugee population.11 12 Despite these gains, Palestine refugees continue to face significant access barriers and poor health outcomes. Maternal and infant mortality have significantly decreased among Palestinian refugees in Jordan but remain relatively high, and as of 2019, only about 40% of women had adequate antenatal coverage. Mental health and non-communicable disease burden are also on the rise, in part due to ongoing conflict and security issues and lifestyle changes.11 12 As of 2019, the UNRWA’s primary health centres only served around half of all registered Palestine refugees and about a quarter of the population in the Madaba camp.7 11 In addition, various barriers have limited eHealth uptake in the Palestinian refugee population, including user skepticism toward eHealth technologies and a lack of internet access in user homes.13

Despite these gaps, primary health centres provide comprehensive services to over a million of refugees in the country, including in remote and conflict-prone areas. Without the advances of the Madaba Health Centre, for example, refugees living in the Madaba camp would travel 30km to reach the closest primary care health center in the Amman camp.7 At the point of care, the FHT model and eHealth system have helped to improve the quality and efficiency of primary care services, although more work is needed to increase the use of eHealth technologies among patients and providers.7 13 Mental health training for health care workers and community engagement efforts have also contributed to these gains.7 Improving access and health outcomes will depend on continued investments in comprehensive primary care services and eHealth technologies as well as models of care that adapt to the complex needs of refugee populations in Jordan. Users can read more about the UNRWA’s primary health centres and various population health management strategies here.

References:

  1. Khalidi WA, Faris NA, Brice WC, Albright WF, Jones AHM, Khalidi RI, et al. Palestine- Palestine and the Palestinians (1948–67) [Internet]. Encyclopedia Britannica. 2021 [cited 2021 Aug 4]. Available from: https://www.britannica.com/place/Palestine/Palestine-and-the-Palestinians-1948-67
  2. Minority Rights Group International. Palestinians | World Directory of Minorities and Indigenous Peoples [Internet]. Minority Rights Group International. [cited 2021 Aug 3]. Available from: https://minorityrights.org/minorities/palestinians-2/
  3. UNRWA. Where We Work | UNRWA [Internet]. United Nations Relief Works Agency For Palestine Refugees in the Near East. [cited 2021 Aug 4]. Available from: https://www.unrwa.org/where-we-work/jordan
  4. Francis A. Jordan’s Refugee Crisis  [Internet]. Carnegie Endowment for International Peace. 2015 [cited 2021 Aug 4]. Available from: https://carnegieendowment.org/2015/09/21/jordan-s-refugee-crisis-pub-61338
  5. Bocco R. UNRWA AND THE PALESTINIAN REFUGEES: A HISTORY WITHIN HISTORY. 2010 May 31; 
  6. UNICEF. Health and nutrition  [Internet]. UNICEF Jordan. [cited 2021 Aug 4]. Available from: https://www.unicef.org/jordan/health-and-nutrition
  7. UNRWA. Health Department Annual Report 2019 [Internet]. 2019 [cited 2021 Aug 4]. Available from: https://www.unrwa.org/sites/default/files/content/resources/health_department_annual_report_2019_-final.pdf
  8. UNRWA. UNRWA Health-Care Services Cover Basic Medical Needs of Palestine Refugees in Syria  [Internet]. UNRWA for Palestine Refugees in the Near East. 2019 [cited 2021 Aug 13]. Available from: https://www.unrwa.org/newsroom/photos/unrwa-health-care-services-cover-basic-medical-needs-palestine-refugees-syria
  9. Al Shdaifat A, Zink T. Pilot study to build capacity for family medicine with abbreviated, low-cost training programme with minimal impact on patient care for a cohort of 84 general practitioners caring for Palestinian refugees in Jordan. BMJ Open. 2019 Aug 1;9(8):e028240. 
  10. UNRWA. An application that tracks the health of mother and child: every pregnant women’s dream!  [Internet]. United Nations Relief and Works Agency for Palestinian Refugees in the Near East. 2019 [cited 2021 Aug 4]. Available from: https://www.unrwa.org/newsroom/features/application-tracks-health-mother-and-child-every-pregnant-women%E2%80%99s-dream
  11. UNRWA. Health in Jordan  [Internet]. UNRWA Palestine Refugees in the Near East. 2019 [cited 2021 Aug 10]. Available from: https://www.unrwa.org/activity/health-jordan
  12. UNRWA. UNRWA: Annual Report 2019. UNRWA; 2019. 
  13. Nasir S, Goto R, Kitamura A, Alafeef S, Ballout G, Hababeh M, et al. Dissemination and implementation of the e-MCHHandbook, UNRWA’s newly released maternal and child health mobile application: a cross-sectional study. BMJ Open. 2020 Mar 9;10(3):e034885.