Efficiency analysis of the health-care facilities of the UN Relief and Works Agency for Palestine Refugees in the Near East in Jordan: a retrospective, descriptive study

Abstract

Background Through its health programme, the UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) is initiating reforms to transfer the decision-making capacity and responsibility to managers of health-care centres. To improve the efficiency of these reforms, we assessed the data by health-care facility and compared the facilities according to well established indicators of efficiency—namely, productivity and costs. Methods We undertook a retrospective, descriptive study of relevant data gathered during Jan 1, 2010, to Dec 31, 2010, from all 24 health-care centres of UNRWA in Jordan. We used a multidimensional approach to assess efficiency in which dimensions such as access, equity, use, and quality were included. Data were gathered for all these dimensions from several sources—departments of health, finance, procurement, and human resources at UNRWA. Estimates of population, health care, human resources, drugs and supplies, hospital admissions, and geographical access were obtained and, when possible, translated into monetary values. Data were compiled at UNRWA's health department and analysed with Microsoft Excel 2007 during Sept 1 to Nov 30, 2011. Findings The estimated overall expenditure on health care in 2010 was US$ 19·7 million, yielding a mean of $15·5 per beneficiary actively using the service. 60% of facility-attributed costs were for staff salaries, 27% for drugs and supplies, and 8% for hospital support. Expenditure per beneficiary on pharmaceutical drugs was $4·32 (range 3·17–8·38) and hospital care $1·35 (0·82–3·06). For every 10 000 refugees served by UNRWA's health-care centres, there was one medical officer. The number of contacts and consultations with UNRWA's health-care centres was 3·6 (2·4–8·0) and 1·16 (0·83–1·84), respectively, per patient. Efficiency, measured as daily consultations per day per medical officer, average daily contacts per nurse, midwife, and skilled birth attendants, total expenditure per contact, and drug expenditure per curative consultation, was 90 consultations (33–142) per day per medical officer, total expenditure per contact $4·28 (3·41–7·72), and drug expenditure per consultation $1·39 (0·88–1·71). Indicators of availability, service use, and efficiency showed large differences between facilities. 0·96 medical officers, ranging from 2·3 in Aqaba to 0·54 in Irbid Town, served 10 000 refugees. 2·4 nurses (including midwives), ranging from 1·4 in Amman Town to 7·0 in Waqqas, served 10 000 people. 3·4 skilled birth attendants (physicians, nurses, and midwives) served 10 000 refugees. Waqqas, Mashare, and Aqaba had more than eight skilled birth attendants per 10 000 people, whereas Irbid Town, Amman New Camp, and Amman Town had two per 10 000 population. Use of health-care facilities was highest at Jerash's health-care centre, with eight contacts (preventive and curative visits) per refugee, and lowest at Irbid Town and Amman Town health-care centres, neither of which had more than 2·5 contacts per person during the year. Productivity (consultations per medical officer per day) was lowest at Aqaba health-care centre with 33 consultations per medical officer; this number was almost four times higher in Msheirfieh and Jerash Camp health-care centres (142 and 140 consultations, respectively). Interpretation Resource availability, service use, and efficiency vary between the 24 health-care centres of UNRWA in Jordan. Overall, access to alternative public health-care providers (Ministry of Health and Royal Medical Services) seems to be the most important factor in determining efficiency of the health-care centres. For example, Jerash's health-care centre, which serves refugees from the Gaza Strip, occupied Palestinian territory, has the highest efficiency and serves the most refugees by contrast with Aqaba's health-care centre, which is attended by a small refugee population living far away from the largest towns and camps and has low efficiency. Although some centres' inefficiencies are unavoidable because of their location, UNRWA's health-care-system managers should reduce imbalances with an improved approach to resource allocation according to the actual number of people served and workload rather than the number of potential users. The data reported in this study cannot be easily compared with international data because UNRWA's health-care services are complementary to public health-care systems and mostly focused on primary health care. Funding UNRWA.