Assessment of Social Determinants of Health in

Assessment of Social Determinants of Health in Selected Slum Areas in Jordan: Amman and Aqaba

Dr. Musa Ajlouni May, 2013

I

Instead of considering slum residents as law violators who should be evacuated by force, local authorities should develop new plans and tools to understand, protect, include and empower those vulnerable people who are forced to live in these unhealthy and inhuman environments. II

Local authorities are asked to change their strategy dealing with informal slum areas from exclusion to inclusion. III

ACKNOWLEDGMENT The MOH and WHO office in Amman have made this study possible. I express my thanks to Dr.Abdel Aziz Alshafei and Dr.Taiseer Fardous

from

MOH

and

Dr.

Mervat

Mheirat

(director

of

Environmental Health, Grater Amman Municipality) for their support and valuable coordinating efforts. My sincerest thanks and appreciation go to Dr.Akram Eltom (WR Jordan) for his guidance, support and personal involvement during all stages of the study. Special thanks to Ms Miranda Shami, Ms Banan Kharabsheh and Ms Mary Sweidan (WHO, Amman Office) for their managerial efforts, logistic support and personal participation during the field visits to Amman and Aqaba. Special thanks to Dr. Montaser Mansi (research fellow) for his significant contribution in collecting the socio-economic data and coordinating the focus group meeting for Aqaba slums residents. Many thanks to all men, women and children who participated in the two focus group meetings and represented the slum dwellers in Amman

and Aqaba for their sincere

input, time

and positive

contribution to this study. In addition, I extend my appreciation and thanks to members of the technical

team:

Ms

Amal

Ajlouni,Noora

Alzakleh

and

Mr

Mouatsem Ajlouni, who performed the audio-visual recording, transcription and the video tapes for their professional work and dedication. My thanks are also extended to Ms Manal Shahrouri for her efforts in translating the summary and the case studies from Arabic to English.

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CONTENT ACRONYMS ............................................................................................................................................ VII ACKNOWLEDGEMENT .....................................................................ERROR! BOOKMARK NOT DEFINED.VIII 1

INTRODUCTION .............................................................................................................................. 1 SOCIAL DETERMINATES OF HEALTH: GENERAL BACKGROUND............................................................................... 1 URBANIZATION AND “SLUM” INFORMAL SETTLEMENTS ...................................................................................... 2 URBANIZATION AND INFORMAL SETTLEMENTS IN JORDAN ................................................................................... 3

2

OBJECTIVES AND METHODOLOGY .................................................................................................. 5 2.1 2.2 2.3 2.4 2.5 2.6

3

JORDAN’S SOCIO-ECONOMIC, POLITICAL AND HEALTH CONTEXT ................................................. 10 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 3.10

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SOCIO-CULTURAL , POLITICAL AND ECONOMIC FACTORS .......................................................................... 10 SOCIAL DETERMINANTS OF HEALTH (SDH) .......................................................................................... 13 HEALTH STATUS ............................................................................................................................ 14 HEALTH SYSTEM ORGANIZATION ....................................................................................................... 15 GOVERNANCE OF THE HEALTH SYSTEM ............................................................................................... 16 HEALTH CARE EXPENDITURE AND FINANCE........................................................................................... 16 HEALTH HUMAN RESOURCES ............................................................................................................ 17 HEALTH SERVICE DELIVERY ............................................................................................................... 17 PHARMACEUTICALS ........................................................................................................................ 18 CONCLUSION ........................................................................................................................... 18

RESULTS AND DISCUSSION............................................................................................................ 19 4.1 4.2 4.3

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OBJECTIVES .................................................................................................................................... 5 CONCEPTUAL FRAMEWORK ................................................................................................................ 5 INCLUSION CRITERIA: ........................................................................................................................ 6 STUDY SITES ................................................................................................................................... 7 DATA COLLECTION ........................................................................................................................... 8 ETHICAL ISSUES ............................................................................................................................... 9

SITES OF THE TWO SLUM SETTLEMENTS .............................................................................................. 19 DEMOGRAPHIC, SOCIAL AND ECONOMIC CHARACTERISTICS OF SLUM RESIDENTS ........................................... 19 FOCUS GROUP DISCUSSIONS WITH SLUM RESIDENTS AT AMMAN AND AQABA .............................................. 22

CONCLUSION AND RECOMMENDATIONS...................................................................................... 45 5.1 5.2

CONCLUSION ................................................................................................................................ 45 RECOMMENDATIONS ...................................................................................................................... 45

6

REFERENCES.................................................................................................................................. 48

7

ANNEXES................................................................................. ERROR! BOOKMARK NOT DEFINED.54

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TABLES TABLE 3.1: DEMOGRAPHIC INDICATORS, 2006-2011 .......................................................................................... 12 TABLE 3.2: INDICATORS OF HEALTH STATUS, 2011 ............................................................................................. 14 TABLE 4.1: DEMOGRAPHIC AND EDUCATIONAL CHARACTERISTICS OF HOUSEHOLD EMBERS LIVING IN AMMAN AND AQABA SLUM AREAS ..................................................................................................................................... 20 TABLE 4.2: ECONOMIC CHARACTERISTICS OF HOUSEHOLD MEMBERS LIVING IN MAN AND AQABA SLUM AREAS ................. 21

FIGURES AC FIGURES FIGURE 1.1: PERCENTAGE OF URBAN POPULATION LIVING IN “SLUMS” I N DIFFERENT COUNTRIES .................................... 3 FIGURE 2.1: WHO MODEL FOR SOCIAL DETERMINANTS OF HEALTH ......................................................................... 6 FIGURE 2.2: LOCATION OF AMMAN SLUMS AT ADAN AREA/ALNASIR DISTRICT ............................................................ 7 FIGURE 2.3: LOCATION OF AQABA SLUMS AT KHAZAN AREA ................................................................................... 7 FIGURE 3.1: NOMINAL AND REAL GROWTH GDP RATES 2005-2011, JORDAN ......................................................... 11 FIGURE 3.2: HUMAN DEVELOPMENT INDEX: HEALTH , EDUCATION AND INCOME , JORDAN 2011 .................................... 13 FIGURE 3.3: JORDAN HEALTH CARE SUB - SYSTEMS ............................................................................................. 16

APPENDICES

ANNEX 1: HOUSEHOLD SOCIOECONOMIC DATA .................................................................................................. 54 ANNEX 2: SLUM RESIDENTS PERCEPTION ABOUT SDH: FOCUS GROUP AGENDA ......................................................... 55

VI

ACRONYMS ASEZA

Aqaba Special Economic Zone Authority

CBI

Community Based Initiative

DOS

Department Of Statistics

EMR

East Mediterranean

GDP

Gross Domestic Product

HDI

Human Development Index

JD

Jordan Dinar

JUH

Jordan University Hospital

KAH

King University Hospital

MENA

Middle East North Africa

MOH

Ministry of Health

NGOs

Non-Government Organizations

PHC

Primary Health Care

RMS

Royal Medical Services

SDH

Social Determinants of Health

TFR

fertility rate

UNDP

United Nations Development Programme

UNFPA

United Nations Population Fund

UN-HABITAT

The United Nations Human Settlements Programme

UNRWA

United Nations Relief Works Agency

WHO

World Health Organization

VII

EXECUTIVE SUMMARY I. Introduction The social determinates of health (SDH) have been described as 'the causes of the causes' they are the social, economic and environmental conditions that influence the health of communities from birth to the death; and that potentially can be altered by informed action. Rapid unplanned urbanization creates social stratification manifested by slums and informal settlements. It is estimated that 43 per cent of the urban population in developing countries lives in “slums”. Squatter slums are constructed of crude materials such as cartoons, old wood, thatch, or mud brick; people living in these slums have limited or no access to public utilities and face the constant threat of eviction. Around 82.6% of Jordan’s population lives in urban areas, with about 50% of the population lives in Greater Amman Area. The unplanned urbanization has overtime created informal settlements “slums” around big cities as Amman, Zerka and Aqaba with substandard housing or illegal and inadequate building structures. These households are more likely to experience disease, injury and premature death due to poverty, social exclusion, poor-quality housing, overcrowding, unhygienic surroundings, lack of infrastructure and minimal access to refuse collection, health care or other essential services. II. Objectives and Methodology This study aims at highlighting the most common challenges related to social determinants of health in selected slum areas in Amman and Aqaba and Suggesting policy directions and interventions to meet these challenges. The SDH model developed by WHO, Commission on Social Determinants of Health (2010) was used as a conceptual framework for this study. According to this model, this assessment will cover the three levels of SDH for slum areas as follows: the national policy level (Socioeconomic and political context); the structural determinants of SDH (education, income, occupation, gender, ethnicity, social class) and the intermediary

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determinants of SDH (living and work conditions, sanitation, water, transportation, food availability, behavioral and lifestyle, health services). UN-HABITAT inclusion criteria were followed. The slum household to be included in the study is defined as a group of individuals living under the same roof in an urban area who lack one or more of the following: durable housing; sufficient living space (not more than three people sharing the same room); easy access to safe water; access to a private or public toilet; and security of tenure. Two sites in Amman and Aqaba were selected because the slum households in the two locations were found lacking the 5 conditions of the inclusion criteria mentioned above. Since this is a descriptive qualitative study, data related to the national policy level (Socioeconomic and political context) were collected from secondary date through comprehensive disk review. While data related to the structural and the intermediary determinants of health for slum residents in the two study sites were collected using a special data collection sheet (for socio economic data) and conducting focus group meetings for representatives of the dwellers living in the two locations. Verbal consents were taken from participants to collect data, conduct the focus group meetings and perform the audiovisual recording. III. Jordan’s Socio-economic, Political and Health Context Jordan's current population and epidemiological profiles are a result of both the demographic and epidemiological transitions that characterize most middle-income countries. Drastic declines in death rates and continued high birth rates along with the shifting composition of illness away from infectious diseases to non-communicable diseases shape Jordan's population and epidemiological circumstances. Executive authority is vested in the king and his council of ministers. Legislative power rests in the bicameral National Assembly (Chamber of Deputies and Chamber of Senates). Administratively, Jordan is divided into 12 governorates, each headed by a governor appointed by the king. Jordan’s performance is among the better Arab states in terms of life expectancy, adult literacy, school enrolment, female literacy, and according to other basic indicators. Jordan has one of the most modern health care infrastructures in the Middle East. Jordan’s health system is a complex IX

amalgam of three major sectors: public, private, and donors. Jordan has achieved universal child immunization coverage and made major progress in lowering the infant and child mortality rates, as well as the maternal mortality rates. About 82% of the population in Jordan is covered by formal health insurance. Total health expenditure is high when compared to other MENA and middle-income countries (9.5% of GDP with average per capita 381 US dollars). National SDH challenges which are likely to contribute to adverse health outcomes in Jordan include: high rates of unemployment and poverty; unplanned urbanization; the rapidly growing youthful population requires an investment of significant resources in education and health services; the elderly population is growing and has increasing demands for health care; high rates of immigration, especially of migrants who are poorly educated and have few skills; scarcity of natural and water resources; the rate of economic growth is inadequate to resolve long-standing developmental challenges. IV .Results Demographic, Social and Economic Characteristics of Slum Residents

The average family size for both locations is almost the same as the national figure which was 5.4 for the year 2011. The illiteracy rate among people 18 years of age or more is very high (more than 15% in both locations) compared to the national rate of 6.7%. The household income per month is very low in the two study locations and near to poverty line in Jordan (323 JD monthly). The unemployment rate is also very high in the two locations (more than 50%); it is more than four times of the national figure. Most of the self employed in the two locations raise sheep that barley provides them with income to meet their basic life needs. Focus Group Discussions with Slum Residents at Amman and Aqaba

To assess the social determinants of health from the perspective of slum residents, focus group participants in the two slums sites were asked questions related to income, education, employment, gender, ethnicity, material circumstances, social environment, lifestyle and healthcare services. The feedback from the focus groups in the two locations indicates that residents suffer from severe poverty; unemployment; illiteracy and low

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education attainments; gender discrimination; insufficient and poor diet; social and official exclusion; unhealthy environment ;lack of water supply, electricity and basic sanitation facilities; high prevalence of diseases; and insufficient and inappropriate health services. V .Recommendations Local authorities are asked to change their strategy dealing with informal slum areas from exclusion to inclusion. Instead of considering slum residents as law violators who should be evacuated by force, local authorities should develop new plans and tools to understand, protect, include and empower those vulnerable people who are forced to live in these unhealthy and inhuman environments. Specific interventions to minimize the socio-economic and health inequalities among slum residents were recommended and grouped into three main clusters: social protection, social inclusion and empowerment.

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1

Introduction

Social Determinates of Health: General Background Health is influenced by a wide range of social, economic and environmental factors. The social determinates of health (SDH) have been described as 'the causes of the causes' they are the social, economic and environmental conditions that influence the health of communities from birth to the death; and that potentially can be altered by informed action. [1] The (SDH) refer to both specific features and pathways by which social characteristics affect health and that potentially can be altered by informed action. Better housing and living conditions, access to safe water and good sanitation, efficient waste management systems, safer working environments and neighborhoods, food security, and access to services like education, health, welfare, public transportation and child care are examples of social determinants of health that can be addressed to improve health and socioeconomic status of population. [2, 3] In order to have real impact on the quality of life of the people and to achieve substantial and sustainable health gains, it has been considered necessary to address all social determinants of health. At the 2004 World Health Assembly, WHO announced the launching of an initiative to act upon the social causes of ill health and inequities by calling for a global Commission on Social Determinants of Health. The Commission's report emphasized the fact that social factors are the major determinants of health rather than health systems and aimed at “setting the foundation for sustained processes to profile and integrate the social determinants of health within policy and practice”. [4] Many community- based initiatives (CBI) have been promoted during the last three decades by WHO in most EMR countries including Jordan. Examples on CBI include: Basic Development Needs, Healthy Cities Program, Healthy Villages Program, Women in Health and Development and Macro-economics and Health. [5]

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Urbanization and “Slum” Informal Settlements The world is becoming more urban, it was estimated that more than half of the worlds’ population lives in urban areas. Urbanization is rapidly spreading throughout the developing world and has been accompanied by massive urban poverty and ill health. [6] The United Nations Population Fund (UNFPA) predicts that almost all the world’s growth in population over the next 2–3 decades will be in urban areas in developing countries. The urban population in developing countries is expected to grow from 2 billion in 2000 to 3.9 billion in 2030, while total world population may grow from 6 to 8 billion, with the most rapid pace of growth expected in Asia and Africa. [7] Urbanization is a major public health challenge for the 21st century, as urban populations are rapidly increasing, basic infrastructure is insufficient and social and economic inequities in urban areas result in significant health inequalities. The urban setting itself is a social determinant of health. The living and working conditions (e.g. unsafe water, unsanitary conditions, poor housing, overcrowding, hazardous locations and exposure to extremes of temperature) create health vulnerability especially among the urban poor and vulnerable sub-groups e.g. women, very young children, the elderly, and the disabled. [8] Rapid unplanned urbanization creates social stratification manifested by slums and informal settlements. According to the 2003 Global Report on Human Settlements, 43 per cent of the urban population in developing countries lives in “slums”; in the least developing countries, the figure rises to 78 per cent (Figure 1.1). [2] Few countries plan for healthy conditions during urbanization, and urban poverty remains largely unaddressed. The labeling of an area as a “slum” in itself creates discrimination against “slum dwellers”, who most often have no political power and are disregarded in planning and development decisions. [2] The word "slum" is a generic term referring to a variety of lower class settlements within the city. Legal slums are officially recognized and receive municipal water and are often constructed of stable materials such as concrete. Squatter slums are constructed of crude materials such as bamboo, cartoons, old wood, thatch, or mud brick; people living in these slums have limited or no access to public utilities and face the constant threat of eviction. [9] 2

A number of different factors are at work to create slum settlements: rapid rural to urban migration, tenure insecurity, and lack of access to basic services. Another major cause of slum increase among urban dwellers is poor public policies. The UN-Habitat program outlines several policyrelated factors, including ―the failure to plan the city to cater for urban demographic trends . . . the failure to address people‘s needs, inequalities in access to services, insecurity of tenure, and inequalities between men and women. [10] Figure 1.1: Percentage of Urban Population Living In “Slums” In Different Countries

Source: WHO Centre for Health Development, Kobe, Japan (2007). Our Cities, Our Health, Our Future: Acting On Social Determinants for Health Equity In Urban Settings.

Urbanization and Informal Settlements in Jordan The population of Jordan almost doubled from 2.1 million people in 1979 to 4.2 million in 1994 and continued to grow to 6.4 million people in 2011. Nearly one quarter of the total population growth is attributed to inmigration, particularly the forced migration waves of Palestinian refugees as a result of the Arab-Israeli wars in 1948 and 1967, and the Jordanian returnees from the Gulf States following the 1990-1991 Gulf Crises in 3

addition to other refugees as a result of the US-led war on Iraq. If the population growth rate remains at 2.2 per cent, the population of Jordan will double within the next 30 years to reach 13 million. Over the last 50 years urban populations have grown dramatically in Jordan. While in 1950 approximately 30% of the Jordan’s population was living in urban areas, by 2011 this figure had reached around 82.6%, with about 50% of the population lives in Greater Amman Area. [11] This unplanned urbanization has overtime created informal settlements “slums” around big cities as Amman, Zerka and Aqaba with substandard housing or illegal and inadequate building structures. These households are more likely to experience disease, injury and premature death due to poverty, social exclusion, poor-quality housing, overcrowding, unhygienic surroundings, lack of infrastructure and minimal access to refuse collection, health care or other essential services. [12] Information and statistics about slum settlements in Jordan are not available. According to the population census for the year 2004,the total number of housing units in Jordan was 940147 of those 10539 houses were classified as not suitable for human housing and not amenable for maintenance or development and should be demolished and replaced by new housing units. These housing units include: slum houses, tents, dry mud houses, caves, caravans and rickety houses. [13] No specific studies about socio-economic or social determinants of health for people living in informal settlements were found.

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Objectives and Methodology

2.1 Objectives The MOH in collaboration with WHO office in Jordan is supporting an exploratory study to assess the social determinants of health (SDH) in selected slum areas in Amman and Aqaba to: 1. Highlight the most common challenges related to social determinants of health in these areas. 2. Suggest policy directions and interventions to meet these challenges. 2.2 Conceptual Framework Since people living in informal settlements and slum areas usually suffer from health inequalities as stated above, WHO model (Figure 2.1), which was developed by Commission on Social Determinants of Health [14], will be used as a conceptual framework for this study. It explains how social inequalities in health are the results of interactions between different levels of causal conditions, from the individual to communities to the level of national health policies. According to this framework, this assessment will cover the three levels of SDH for slum areas as follows: The national policy level (Socioeconomic and political context): macroeconomic policies; social policies related to housing, land, education health, social protection; culture and societal values. The structural determinants of SDH of health inequities in slum areas: education, income, occupation, gender, ethnicity, social class. The intermediary determinants of SDH: living and work conditions, sanitation, water, transportation, food availability, behavioral and lifestyle, health services.

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Figure 2.1: WHO Model for Social Determinants of Health

Source: WHO, Commission on Social Determinants of Health (2010), A Conceptual Framework for Action on the Social Determinants of Health, Geneva 2010.

2.3 Inclusion Criteria: For the purpose of this study, the UN-HABITAT definition of a slum household was adopted. [10] Accordingly, the slum household to be included in the study is defined as a group of individuals living under the same roof in an urban area who lack one or more of the following: 1. Durable housing of a permanent nature that protects against extreme climate conditions. 2. Sufficient living space which means not more than three people sharing the same room. 3. Easy access to safe water in sufficient amounts at an affordable price. 4. Access to adequate sanitation in the form of a private or public toilet shared by a reasonable number of People. 5. Security of tenure that prevents forced evictions.

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2.4 Study Sites The study team did several field visits to poor residential areas in Amman and Aqaba to locate the two slum study sites (one for each city). Amman and Aqaba sites (Figure 2 and Figure 3) were selected because the slum households in the two locations were found lacking the 5 conditions of the UN-HABITAT inclusion criteria mentioned above. Figure 2.2: Location of Amman Slums at Adan Area/Alnasir District

Figure 2.3: Location of Aqaba Slums at Khazan Area

2.5 Data Collection § Disk review was conducted to collect data related to the national policy level (Socioeconomic and political context).Official reports, stipulated policies, strategies and research publications pertaining to macroeconomic policies; social policies and culture and societal values were reviewed .The interaction of Socioeconomic and political context with other structural determinants of health for the slum residents was highlighted in the results discussion. § Data related to the structural and the intermediary determinants of health for slum residents in the two study sites were collected using the following tools: 1) Socioeconomic data collection sheet for each household was prepared (Annex 1) and the data was collected by trained research assistants through personal interview with the family heads. The data collected for each member of the household include (wherever applicable): age, sex, marital status, education level, job, monthly income and diseases and disabilities. The sheet also collects data for each household about number of children died before age of 5, number of children who dropped out of school before completing the tenth class, health insurance status, number of people supported by the household head other than children and wife. 2) Assessment of the structural and the intermediary determinants of health as perceived by slum residents in the two study locations was performed through conducting focus group meetings with representatives of households in the two locations. The two focus group meetings (one for each location) were conducted by the principal researcher according a pre set agenda (Annex 2). The objectives of the focus group meeting were: · To find how residents perceive the structural determinants and socioeconomic of health (income, education, occupation, occupation, ethnicity, social class). · To find how residents perceive the intermediary determinants of health (material circumstances, social-environmental or

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psychosocial circumstances, behavioral and biological factors, the health system). · To assess the perception of residents about their health, common health problems, availability of health services, etc. · To obtain their opinions on major health and socio economic issues or priorities as identified by the local community representatives. · To gather local community suggestions for further improvements of SDH. Number of participants in each focus group was about 15 persons purposely selected from the households in each location to represent the following categories: Two community leaders(one Sheik) One widow Two senior/old residents (> seventy years old)/male and female. Two school students(girl and boy) Two housewives. One unemployed. One self employed. Two youth residents (male and female)/18-25 years of age one (university or college graduate, if available). One employed resident. The focus group meetings were recorded and documented by professional photographer using video camera. 2.6 Ethical issues Verbal consents were taken from participants to collect data, conduct the focus group meetings and perform the audiovisual recording. Their rights to withdraw anytime and not to be recorded or pictured were explained for them. They were assured that all documents and recordings related to this study will be used for study purposes and official uses by WHO and MOH.

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3.The National Policy Level: Jordan’s SocioEconomic, Political and Health Context

2.7 Socio-cultural, Political and Economic Factors Jordan is a small lower-middle income country with limited natural resources and scarce fresh water supplies (one of the world’s 10 most water stressed countries).Jordan has a total land territorial area of 89,300 square kilometers, of which only 7.8% is arable land. Jordan is a constitutional monarchy. [11] Executive authority is vested in the king and his council of ministers. Legislative power rests in the bicameral National Assembly (Chamber of Deputies and Chamber of Senates). Administratively, Jordan is divided into 12 governorates, each headed by a governor appointed by the king. Jordan's population is 6.3 million people (2012). The average annual population growth rate is 2.2%. 82% of the Jordanian population is below the age of 40. Literacy rate for 2011 (15 years of age and older who are able to read and write) was 93.3%. The total fertility rate (TFR) is relatively high, though it has declined steadily in recent years to 3.8 in 2011. Life Expectancy rate in 2011 is 73 (71.6 years for men, 74.4 years for women). Infant mortality rate for 2010 was 23 per 1000 births. [15, 16, 17] The real GDP rate has declined from 8.2% in 2007 to 2.6% in 2011.The GDP of Jordan in 2011 was US$ 28.4 billion. The per capita GDP of Jordan at current prices was US$ 4628, in 2011. Rate of price inflation was 4.4% in 2011, and the currency has been stable with an exchange rate fixed to the U.S. dollar since 1995. [18, 19] Nevertheless, the economy's capacity for growth remains vulnerable to external shocks, and the rate of growth is inadequate to resolve long-standing developmental challenges. The stock of external debt remains high. Jordan’s performance is among the better Arab states in terms of life expectancy, adult literacy, school enrolment, female literacy, and according to other basic indicators. Human Development Index (HDI) rose by 1.0% annually from 0.509 to 0.698 (2011), which gives the country a rank of 95 out of 169 countries. Health Development Index scored the highest (0.841) 10

compared to education and income indexes as shown in figure 3.2 below. [20] The unemployment rate during the fourth quarter of 2012 was 12.5%, while the corresponding rate for the youth in the age group 20-24 years was 28.8%. The unemployment rate during the same period has reached 10.8% for males while it was 19.9% for females. [21] Thus, Unemployment is the most striking challenge the young people in Jordan face. Poverty incidence is 14.4% (2010) .Poverty is significantly higher in rural areas, where 37% are poor compared to 29% in the urban areas. [22,5] Figure 0.1: Nominal and Real Growth GDP Rates 2005-2011, Jordan

Source: MOPIC web site http://193.188.65.54/Dashboard/en/EconomicMainFrm.aspx

Unlike the other countries, Jordan has experienced since its foundation the influx of forced displacements of population groups from the neighboring areas – the first of which was the displacement/immigration of the Palestinian population in 1948, and again in 1967, followed by the return of hundreds of thousands of Jordanian and Palestinian expatriates from Kuwait in 1990, the migration of hundreds of thousands of Iraqis who came to Jordan during the last ten years and finally the influx of hundreds of thousands of Syrians who poured into Jordan during the last two years.

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These unnatural increases in population have created crises in managing the Jordanian economy. This has also placed an additional pressure on managing the country's resources, infrastructure and basic services like education, health care, transportation and road network. Likewise, additional stress has been put on the labor market apart from the huge challenges the nation has faced in terms of creating thousands of job opportunities for the new entrants into the labor market. Alongside with these major transformations, poverty emerged during the last two decades as a key problem and challenge to the socio-economic decision-makers in Jordan. Jordan also faces serious challenges in natural resources scarcity and human resources development. Overall, the country has made significant progress in meeting the Millennium Development Goals of universal primary education and reduction in child mortality. However, the cost in terms of public expenditures has been relatively high. Given demographic pressure, the significant gains made on human development to date cannot be sustained without major improvements in the quality and efficiency of education and health services. Table 0.1: Demographic indicators, 2006-2011

Indicators

2006

2008

2010

2011

Total population

5600000 5850000

Crude Birth Rate

29.1

29.1

30.1

28.9

Crude Death Rate

7.0

7.0

7.0

7.0

Population Growth Rate

2.3

2.2

2.2

2.2

Dependency Ratio

68.0

68.1

68.2

68.2

%population seventy years old)/male and female. Two school students(girl and boy) One housewife. One unemployed. One self employed. Two youth residents (male and female)/18-25 years of age one) university or college graduate, if available). · One employed resident. 4. Facilities and logistics · 3flip paper charts · Recorder and camera. · Coffee breaks and lunch services 5. Program 1) The facilitator welcomes the participants, introduces himself to them and asks everyone to introduce him/herself to the group. 2) The facilitator gives a 10 minute brief about SDH, objectives and agenda of the meeting and methodology of discussions. 6. Session one The participants are asked to give their feedback and opinion about the following SDH topics:  Income (resources, wage earning, household income, dependency ratio, unemployment, job insecurity, poverty)  Education (literacy, years of completed education, children leaving school, education of mothers, health education, access to schools)  Occupation(main occupation categories ,self –employed/informal jobs, work conditions, employment opportunities, work of women, child employment, illegal jobs)  Gender (age of marriage for girls, gender-based discrimination/ limitations on girls’ and women’s ability to obtain education and to gain access to respected employment, pregnancy and delivery issues, etc). 56

 Ethnicity (do other residents or officials look at slum residents as different “social group”? Social exclusion/ is health status and outcomes among slum residents worse than Aqaba residents?  Material circumstances: housing structure, crowding, building materials, internal conditions, damp, bad odors, garbage disposal, sanitation ,heat, cold, indoor contamination, toilets, hot and cold water, neighborhood accidents ,  Social-environmental or psychosocial circumstances: psychosocial stressors (for example, negative life events and job strain), stressful living circumstances (e.g. high debt) and (lack of) social support, social inequalities, social interaction (solidarity and community spirit),unmarried people, social exclusion, mental stress related to uncertainty about the financial situation, probability of experiencing threats of violence, insecurity, uncertainty and stressful events. Age of marriage and other issues related to marriage.  Behavioral and biological factors: smoking, diet and nutrition, exercise, obesity, substance abuse.  The health system: access to health care, health insurance, main health problems, disabilities, responsiveness of the HCS to their needs, health inequalities, out-of pocket payments, the health centre situation: Convenience of center’s location Ease of reaching health center Adequacy of health center hours Availability of public transportation Other accessibility issues (financial, security, social, cultural etc.) 7. Session two: The participants are asked to discuss the following questions and agree on answers:  What are the main issues and concerns of the residents related to SDH in priority order? (not more than five)  What are your suggestions to address these issues in priority order? (not more than five)

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