Transnational interdependency and healthcare system change: The role of humanitarian and development aid in shaping health policy in Jordan

Introduction

The objective of our study is to examine whether external financing as a form of transnational interdependency has brought about healthcare system expansion in Jordan. To do so, we trace the trajectory of public healthcare financing and the definition of policy priorities over a 10-year period from 2008 to 2018. During this time, the Jordanian healthcare system was subject to various exogenous shocks in the form of recurrent and large influxes of refugees from Iraq and Syria. This led to a significant increase in humanitarian and development aid that brought with it resources for both the displaced and host population. In this study, we address the question of whether significant external financing has affected the relative expansion of the Jordanian state in healthcare spending and on policy change, especially as regards the adoption of policy goals advanced by the international community such as universalism and health as a human right (United Nations General Assembly, 1948; WHO, 2017). More generally, we ask, does increased external financing in the form of overseas development aid necessarily translate into healthcare system expansion for both citizens and refugees?

As this study is exploratory, we do not set out to test specific hypotheses but rather wish to observe how the healthcare system in Jordan has developed within a context of increased international financing. Our study follows in line with global social and health policy scholarship, which goes beyond classical welfare state literature typically preoccupied with the OECD world and domestic determinants of policy change. Accordingly, we examine the role of transnational factors such as humanitarian and development aid as a response to the movement of large numbers of migrants and refugees across national borders. As we assume that such factors do not play a unidirectional role in influencing policy, but that they interact with nationally embedded actors and institutions following their own logic and histories, we refer to this relationship as interdependent. Taken together, development and global health policy scholarship, alongside the present analytical focus on transnational interdependency, provides a useful basis for studying a case such as Jordan where significant amounts of external financing interact with an otherwise well-entrenched healthcare system.

In what follows, we begin by providing a background on the role of external actors and interdependency, summarizing key assumptions derived from extant scholarship which help to inform this study’s analytical focus. We then proceed to outline our research design and methods, as well as highlight the significance of Jordan within the context of global health policy and as a case for investigation. The latter section also includes a summary of the basic features of the Jordanian healthcare system. In the remaining sections, we report and discuss our findings related to changes in financing and policy priorities specific to both the host and refugee populations. Finally, we draw a number of tentative conclusions that also serve as next steps for research.

Global health policy: the role of external actors and interdependency

The study of healthcare systems has long been the subject of classical welfare state literature, which generally sees social policy developments through a national lens with a prominent role for domestic political factors such as power resources (Huber and Stephens, 2001; Korpi, 1983; Stephens, 1979), party differences (Castles, 1982; Hibbs, 1977), as well as institutional actors and veto players/points (Hacker, 2002), to mention only a few (see also Béland and Mahon, 2016). Even more holistic theoretical frameworks, which embrace the significance of international or exogenous variables, such as the global recession of the 1970s or the financial crisis of the late 2000s, as triggers for healthcare system change, tend to center on the role of nationally embedded socio-economic and political factors in explaining the direction that such change ultimately takes (see for example, Frisina Doetter et al., 2015; Rothgang et al., 2010). The analytical focus of extant research reflects an underlying empirical bias largely rooted in the study of the highly developed OECD world – typically Western Europe and North America, but also the Asian antipodes of Japan and South Korea (Peng and Wong, 2010). Accompanying such a focus are various assumptions of state sovereignty, particularly in matters of domestic social policy, which do not generally account for the role of linkages between states or between states and international governmental and non-governmental organizations in influencing healthcare and other areas of welfare policy.

Yet, when looking beyond the scope of the OECD world to the Global South, ¹ which includes middle-income countries such as Jordan, we find that international organizations (IOs) and bilateral state transfers may serve as a significant source of external financing for social policy in the form of humanitarian and development aid. With money comes increasing contact with members of the international community, its values, norms, and expertise (see for example, Béland and Mahon, 2016), but also rules and conditions on receiving aid (see Biesma et al., 2009; Khan et al., 2018; Sridhar, 2012). The ways in which such exposure and incentives come to affect national healthcare systems make up important strands of both development studies and global social policy research (see, for example, Groves and Hinton, 2013; Hein and Kohlmorgen, 2003, 2008; Kaasch, 2015; Kickbusch, 2004; Lee et al., 2002; Midgley et al., 2019). In the case of global social policy research, this points especially to the role of policy diffusion (see, for example, Orenstein, 2003), policy transfer (Dolowitz and Marsh, 2000), as well as specific policy dissemination mechanisms, which include legal obligations (international law, European Union law, etc.), financial power (loans, conditional transfers, economic integration standards, etc.), as well as the transmission of ideas and normative standards about specific health policy challenges and their solutions (Kaasch, 2015; McNeill, 2005; Stone and Maxwell, 2005). At the heart of this research agenda is a theoretical interest in explanatory factors that transcend the nation-state as a closed policymaking box to incorporate a multi-level, transnational network of actors. Within this context, policy transfer often emerges as the result of policymakers looking abroad for alternative models which they subsequently implement in the form of new ideas resulting from iterative policymaking processes (Dolowitz and Marsh, 2000). This places great weight on the significance of transnational ideas as a source for policy learning and diffusion.

Thus far, extant findings from development studies and health policy research suggest that external financing and the involvement of IOs can lead to mixed policy outcomes, depending on the type of institutions involved and their particular mandates (Koivusalo and Ollila, 1997), as well as the scope of their policy activity (Biesma et al., 2009; Orenstein, 2005). In particular, in cases of significant external financing such as in Jordan, evidence points to two trends: First, external financing in the form of earmarked funding and conditional loans inevitably leads to the substantial influence of donors on national healthcare systems. Even in the case of direct budgetary support and a recent focus on health system strengthening, donors may continue to exert influence over national policy decision-making (Shiffman, 2006, 2008; Swedlund, 2017). This often occurs through selective, disease-specific interventions which may undermine longer term goals of universalism and inclusive healthcare systems (Marchal et al., 2009), and that raises concerns over state sovereignty (Hafner and Shiffman, 2013; Koeberle, 2003). Second, the presence of external financing and, in particular Development Assistance for Health (DAH), has been correlated with a decrease in national health spending. In fact, while ministries of health may remain committed to strengthening the health system, ministries of finance may cut budgets based on the presence of external financing (Farag et al., 2009; Gottret et al., 2006; Lu et al., 2010).

This body of literature has contributed greatly to expanding the analytical focus of welfare state research to capture the added complexity of healthcare systems, especially concentrated in the Global South, that interact regularly and with varying degrees of economic dependency with international organizations. In doing so, however, global health policy scholarship has tended to skew this focus on the extra- or international sphere at times to the neglect of nationally embedded determinants of policy change which classical welfare state literature has long identified as relevant. Furthermore, few studies have emphasized the effects of external financing and global health initiatives on domestic healthcare systems (Biesma et al., 2009; Chima and Homedes, 2015) or the perspectives of domestic policymakers with regard to the influence of donors on health policy (Khan et al., 2018).

For this reason, in this study we emphasize the utility of adopting an interdependence-centered approach, as put forth in the research program of the Collaborative Research Centre 1342 (CRC) at the University of Bremen (CRC, 2018). As an institute, the CRC is dedicated to examining the common determinants of social policy in the context of transregional and global interrelationships. While this approach still considers the nation-state as a significant unit of analysis, it takes a more dynamic view which emphasizes the role of various cross-border interactions between nation-states and their respective societies, as well as between nation-states and IOs in explaining developments in social policy. Systematic interactions are said to lead to interdependencies, which may be of a symmetric or asymmetric nature, and that can involve anything from trade relations, migration, and information flows, to more coercive ties as in war or colonization. This approach goes beyond that of Elkins and Simmons (2005) who, while also interested in interdependence, limit their use of the concept to describe uncoordinated policy decisions among actors arising in the absence of ‘collaboration, imposition or otherwise programmed effort on the part of any actors’ (p. 39). Differently, interdependency is viewed here as the consequence of conscious and intentional policy choices – that is, the decision to provide financial support to Jordan by donor countries and IOs on the one hand; and the decision to accept such support on the part of the Jordanian government, on the other hand.

Of crucial interest to this study is the potential role of interdependency arising between the Jordanian state and external actors (other states and IOs) in the form of financial flows in humanitarian and development aid – itself the result of interdependency involving the cross-border movement of people from crisis countries within the region. Our analytical focus, therefore, does not lie in the actors that are linked in the process (i.e. the Jordanian state and specific IOs or donor/lending countries), but rather in one type of linkage – external financing – as an interdependent factor potentially shaping the healthcare system. Drawing on the aforementioned assumptions from development studies (see Farag et al., 2009; Gottret and Schieber, 2006; Lu et al., 2010; Shiffman, 2008; Swedlund, 2013), we can expect that where interdependency in the form of external financing increases, national healthcare spending will decrease while policy will come to align with the influence and interests of external actors. Given its growing permeability and interdependency as a policy making environment, Jordan serves as an invaluable case for testing these assumptions, while also affording us the opportunity of distinguishing between the effects of external financing on two distinct (and potentially competing) populations residing within the country: the Jordanian host population versus refugees. Given the dearth of research on this topic, as well as on healthcare systems of middle-income countries in general – particularly those of the Middle East and North Africa (MENA) region – this study addresses a significant gap in the literature.

Research design and methods

In this exploratory case study, we examine developments in public health expenditure to identify potential expansion or contraction by the state in the presence of increased external financing. We also explore potential changes in health policy formulation by the Jordanian government, as regards the inclusion of specific policy goals in line with values advanced by the international community such as universalism and health as a human right. Our period of observation includes years 2008–2018, reflecting our interest in healthcare system change during a period marked by grave geopolitical instabilities that led to increases in external financing.

We rely on quantitative data on external financing provided by the OECD and the WHO (online statistics), as well as national data by the Jordanian Ministry of Health and the High Health Council on public expenditure for healthcare. By external financing, we refer specifically to financial flows from overseas bilateral and multilateral donors in the form of grants and loans. Data for public expenditure refer to government expenditure for health expressed as a percentage of GDP or of overall domestic spending for health. Tracking the amounts of financing flowing into Jordan, however, has its limitations as the available data often lack transparency. For example, while Gulf donors have tended to subsidize governments, including the Government of Jordan directly, a majority of western donors prefer to finance UN agencies due to a perceived lack of accountability within national governments (Culbertson et al., 2016). In fact, funding flows from donors, UN agencies, and private groups which support various funding streams including humanitarian, development, bilateral, and multilateral streams, have proven difficult to keep track of. Moreover, different accounting systems, which often exclude certain forms of funding such as funding from Gulf donors, national budgets, or development funding, further complicate the overall picture (Culbertson et al., 2016). As a result, while data used in our study reflect the best possible available sources, we cannot rule out potential inaccuracies in reporting.

To identify potential changes in the definition of policy goals by the Jordanian government, we also relied on qualitative data involving all national policy documents relating to healthcare and emerging during our period of observation. These documents are available online and in English: the ‘National Health Strategic Framework 2008-2012,’ (High Health Council, 2008) the ‘National Strategy and Plan of Action Against Diabetes, Hypertension, Dyslipidemia and Obesity in Jordan (Government of Jordan, 2011),’ the ‘Ministry of Health Strategic Plan 2013-2017 (Ministry of Health of Jordan, 2013),’ the ‘National Strategy for the Health Sector 2015-2019’ and, finally, the ‘National Strategy for Health 2016-2020’. As several government policy documents on reforms and national agendas include sections on healthcare, these have also been incorporated in the analysis, including the ‘National Agenda 2006-2015’ and the ‘Jordan 2025: A National Vision and Strategy (Government of Jordan, 2015),’ which was formulated in 2015. Moreover, we have also included the four iterations of the nationally led ‘Jordan Response Plan for the Syria Crisis’ between 2015 and 2018, which contain requests for international assistance for healthcare for both Syrian refugees and Jordanian host communities. The analysis was conducted by reviewing the mission statements of the documents and coding the content in Atlas.ti. More specifically, documents were uploaded into the software program and then their contents were perused by both authors for any statements/information relating to one of the following categories also used as codes: ‘policy priorities/policy values/policy goals/policy objectives’, ‘policy expansion’, and ‘policy contraction’. Once the first round of coding was completed and the results of each author compared, a second round of analysis focusing only on the coded sections of documents was carried out in order to compare priorities and determine policy shifts over time. During this round, we also searched for any references (within the coded sections) to policy goals upheld by the international community – health as a human right and universalism – to explore whether policy changes in accordance with the values and normative expectations of external actors could be detected. We also looked for any differences in policy directed at the host versus the refugee/migrant populations.

In addition to the analysis of policy documents, semi-structured expert interviews were conducted with select government officials, humanitarian and development actors, and donor organizations involved in health. This was done in order to garner insights into the policy making process, particularly as concerns changes in national spending on healthcare in relation to external financing; changes in policy objectives over time; as well as the prioritization of particular policy goals over others (e.g. the financing of programs/services for certain parts of the population rather than others). Interview participants were identified using the snowball technique. In total, 16 semi-structured interviews were conducted for a duration of ca. 60 minutes. All qualitative data analysis was carried out in conjunction with Atlas.ti software following the same procedure for coding and analysis used for policy documents described earlier (note interview data were first transcribed and uploaded into Atlas.ti).

The significance of Jordan within the context of global health policy

Jordan is considered to have one of the most advanced and high-quality healthcare systems in the MENA region, making the country a popular destination of medical tourism in the area (Nazer and Tuffaha, 2017). Attracted by the high technical diagnostic capacity of many clinics, medical tourists from neighboring countries contribute more than US$1 billion in revenue (High Health Council, 2016). On average, the country spends more per capita on health than its neighbors – up to US$797.6 per person or approximately 7.5% of GDP in 2014 (WHO, 2014). In comparison, Lebanon spent only 6.5% of GDP on health in the same year (WHO, 2014). Notwithstanding the strengths of the healthcare system, the country faces several challenges which include rapid population growth, high dependency ratios, structural deficits, and the recent arrival of large numbers of refugees from Syria.

Since the early 1960s, the population of Jordan has been on a rapid expansion course, increasing fivefold by the early 2000s and doubling to ca. 10 million people to date (Department of Statistics of Jordan, 2017). Population growth is attributable to longer life expectancy of 74 years of age for both men and women, relatively high fertility rates, but also and crucially the influx of refugees from Syria and Iraq (Department of Statistics of Jordan, 2017). Significantly, the country faces high dependency ratios due to the large proportion of children and older adults (Ajlouni, 2011) and has started to undergo the typical demographic transition of many middle-income countries. In 2012, an estimated 4.6% of the population was above the age of 65 – a figure that is expected to rise to close to 5% by 2020 (High Health Council, 2015).

Alongside demographic challenges, Jordan is faced with severe structural deficits within its healthcare system. These include a lack of qualified professionals and facilities, inadequate systems for collecting data, difficulties in collaboration among agencies (WHO, 2006), as well as poor coordination between the public and private sectors (High Health Council, 2016). Moreover, despite efforts by successive governments to introduce universal health insurance over the past decades, today only 70% of Jordanians and ca. 55% of the total population enjoys coverage by formal health insurance, including government-sponsored insurance, private health insurance schemes, and insurance provided by the United Nations Relief Works Agency (UNRWA) to Palestinian refugees (High Health Council, 2016). Of the 55% who do have insurance – mainly Jordanian nationals – more than 80% are covered by public health insurance, while the remainder is covered by private insurance, UNRWA, and other sources (Nazer and Tuffaha, 2017). For Jordanian citizens classified as ‘poor’, the Ministry of Health waives out-of-pocket expenses and offers free treatment for a limited number of conditions such as cancer, dialysis, AIDS, and addiction (Ajlouni, 2011; High Health Council, 2016). Recent reforms to the public Health Insurance Fund have successfully expanded coverage to include all children under the age of 6, family members of organ donors for up to 5 years, as well as rural populations. Moreover, all citizens, including pregnant women and older people may now participate in insurance through the Health Insurance Fund on a voluntary basis (High Health Council, 2016).

The structural limitations characterizing the healthcare system have been dramatically compounded by the large influx of refugees with higher rates of disability and war-related injuries (Ministry of Planning and International Cooperation, 2013). As a result, unlike most other countries of similar wealth and size, population aging and increased dependency in Jordan are unfolding within a larger geopolitical context marked by grave instability. This has led to the arrival of an estimated 1.3 million Syrians over the past 10 years, of whom 660,000 are considered refugees by the United Nations High Commissioner for Refugees (UNHCR, 2018a). Hence, in contrast to other middle-income peers, the Jordanian public sector faces special external pressures that stand to exacerbate its own endogenous deficits and the exigencies brought on by demographic change.

Developments in healthcare financing in Jordan, years 2008–2018

During the period between 2008 and 2018, there was a significant increase in external financing to Jordan due in part to a series of exogenous shocks across the region. As illustrated in Figure 1 below, the arrival of large numbers of refugees from Syria served as the catalyst for a rapid expansion of external financing to Jordan in the form of official humanitarian and development grants, and loans from governments and international financial institutions. As can be seen in the graph (Figure 1), total net funding rose from US$480 million to as high as US$3 billion in 2017 (OECD, 2019). Overall overseas development funding to Jordan increased by 525% between 2008 and 2018, making Jordan the seventh largest recipient of gross overseas development assistance in the world. The largest donors in 2017 were the United States, followed by the United Arab Emirates, Germany, and EU institutions (OECD, 2019).

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Figure 1.

Overseas development funding to Jordan.

As documented by the government-led Jordan Response Plan (JRP) to the Syria Crisis, it is possible to follow the trajectory of government requests for support for both ‘refugees’ and ‘resilience’, especially as regards the healthcare sector (see Figure 2). Here, requests for resilience financing for strengthening public institutions and infrastructure outweigh requests for refugee financing. Between 2016 and 2018, the government requested an average of more than US$500,000 a year for healthcare, amounting to approximately 6.5% of total budget requests for those years (Ministry of Planning and International Cooperation, 2015, 2016, 2017, 2018). Based on the latest available data, however, donors tended to privilege requests for refugee support – 87% funded – as compared to resilience support, where only 78% received funding in 2017 (Ministry of Planning and International Cooperation, 2018).

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Figure 2.

Funding of the Jordan response plan to the Syria crisis (2008–2018).

Overall, our data show an inverse relationship between external and domestic funding for healthcare in Jordan. On the one hand, international financing from the part of donors, financial institutions and IOs increased considerably between 2008 and 2018. On the other hand, as can be observed in Figure 3 below, domestic and government spending on healthcare reduced both as a proportion of GDP and as a proportion of overall health spending.

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Figure 3.

Domestic general government health expenditure as a % of GDP.

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Figure 4.

(World Bank, 2015) Current health expenditure per capita (current USD).

At the same time, though costs of healthcare services both for the public healthcare system and for individual patients increased, overall healthcare expenditure in Jordan declined from 9% to 6% of GDP between 2008 and 2015 (Figure 3). This correlates with a decline in domestic spending (including from the public and private sectors) from 99% to 93% of all current expenditure. In terms of government health expenditure, overall spending declined from 61% to 57% of all health spending.

Developments in healthcare policy formulation, years 2008–2018

This section provides an overview of the evolving objectives and mission statements contained within all national policy documents relating to health and healthcare between 2008 and 2018, and explores whether an increase in external healthcare financing brought about a greater commitment to generosity and expansion within national policy making. Given the significant presence of Syrian refugees in the country, it is useful to trace the evolution of state policies toward all residents living in Jordan, including refugees. In this context, our analysis reveals a marked discrepancy between the growing amounts of external financing for healthcare, the expansive international commitments made by the Government of Jordan, and the actual services provided by the state to refugees and citizens. On the one hand, the Government of Jordan was not only the recipient of increasing international financing in the form of grants and loans dedicated to strengthening institutions and services for both nationals and Syrian refugees, but also committed to increasing the protection of refugees residing within its borders. On the other hand, however, the state substantially reduced its support for healthcare services and subsidies for refugees, while at the same time increasing privatization, decentralization, and providing a limited expansion of services for citizens.

Discussion and conclusion

As can be observed in a review of the policy documents related to health and healthcare between 2008 and 2018, external shocks and the presence of donors, UN organizations and NGOs, as well as considerable external funding have played an important role in national policy formulation. On the one hand, the increased dependence on external funding and global policy actors may have supported the formulation of more expansive policies for universal health coverage and investment in the national healthcare system. On the other hand, these ambitious policy objectives and universalist and human rights-based values have been undermined by the curtailing of public services for refugees and a greater focus on privatization, decentralization, and a shrinking role of the state in the financing and provision of healthcare services. Overall, there appears to be a disconnect between the expansion promises stated in ambitious policy objectives and the actual budget allocations and government expenditure for health. Moreover, incremental trends toward greater inclusiveness of the domestic population within the healthcare system have run parallel to the progressive exclusion of refugees.

In fact, at the height of the refugee crisis in 2014, more than US$3.5 billion in international grants and loans flowed into the country to support Syrian refugees and vulnerable Jordanians. At the same time, however, the government stated that it could no longer afford to provide free healthcare for refugees and reversed its policies on access to health services. The introduction of a more bureaucratic and stringent registration mechanism not only made access to public services more difficult for refugees, but also curtailed the freedom of movement of Syrians to and from refugee camps. As a result, the burden of financing and providing healthcare services increasingly fell upon the humanitarian and development sector, and contributed to a reduction in service utilization among refugees (Profili, 2018).

On a domestic level, 2014 also represents a turning point for national policy formulation and financing. Policy documents from 2014 and 2015 show a distinct shift toward more expansive and universalist objectives for healthcare in particular with respect to health insurance schemes and universal health coverage. In fact, detailed plans for universal health coverage beginning in 2015 not only clearly mention the support and collaboration between the government and IOs and financial institutions, but also focus on human rights language. These expansionist health policy documents were followed by international commitments to securing universal health coverage for the entire population in Jordan – including refugees.

Despite claims toward universalism, inclusiveness and a human rights framework, however, over the past decade the state has consistently reduced its budget and spending on healthcare. Based on the most recent available data, overall health spending declined from 9.5% to 6.3% of GDP between 2009 and 2015 (World Bank, 2015) or, in terms of spending per capita, from US$332 to US$257 (WHO, 2015). Furthermore, economic dependence on humanitarian and development organizations as well as bilateral and financial institutions appears to have had little effect on reducing unequal access to healthcare services. While data on inequality are sparse or based entirely on government reporting, local studies show that the current healthcare and social protection systems increasingly favor the urban middle classes at the expense of residents in rural areas, migrants, poor people and, in particular, refugees (Batniji et al., 2014).

Moreover, the proliferation of non-state actors has led to a further fragmentation of healthcare service delivery and regulation – from refugee camps administered by the UN, village clinics run by NGOs, to a growing role for the private sector. The greater participation of external state and non-state actors in the financing and provision of healthcare services has not only created parallel systems for healthcare provision, but has also strengthened a dependency loop between the government and external funders. In fact, an unintended consequence of the arrival of large numbers of NGOs, external funding, and health coordination mechanisms has been increased state reliance on international support and technical expertise in the face of mounting ‘donor fatigue’. While foreign governments invested in the Syria crisis began to discuss their withdrawal from Jordan – also known as ‘exit strategy’ – in as early as 2017, officials at the Ministry of Health reported feeling abandoned and betrayed by the international community and its promises of continued support. As one official stated in an interview, the effects of a rapid exit could ultimately have devastating effects for patients:

The greatest gaps I am facing is that some international organizations are withdrawing from Jordan . . . I think there will be gaps in treating the patients. The financial protection of the population is very important and I don’t know how big the gaps will be. If they have to pay for medicines, then they will not eat or pay for their house. If NGOs leave, I don’t know where the patients will be treated if there are no facilities. ⁴

To date, scholarship on national healthcare policymaking processes in low- and middle-income countries have largely neglected the role of global health policy actors and the transnational dimension of policymaking processes. In this case study, we not only stress the central role of the national healthcare system in Jordan within the transnational social policymaking space of agenda setting, discourses and health strategies, but also view some of the activities undertaken by IOs as an expression of global governance processes with far-reaching effects on the shaping and formulating of domestic policies (Kaasch, 2015). As one representative from one of the largest donor organizations explained, for example, funding and support for Jordan’s healthcare system depended in part on the country’s ‘special relationship’ with the United States and its strategic position in the Middle East. ⁵

Overall, an analysis of Jordan’s health policy documents along with interviews with donors and government officials uncovered a contradictory and disjointed policy paradigm. National and global actors demonstrated often contradictory policy objectives for healthcare, as well as varying levels of commitment to following national and international agendas. In the case of donors, despite stating an intended alignment with national strategies, representatives often stated differing views on their mission, whether this involved supporting universal health coverage or greater privatization. These often incoherent strategies appear to indicate a lack of a clear, unified vision and, possibly, a lack of experience in operating in stable, middle-income countries with relatively strong institutions.

From a government perspective, inconsistencies between expansive promises of universalism and human rights, and contradictory policies pushing for greater privatization and decentralization suggest a lack of commitment to the values and ideas supported by some donors and non-governmental organizations. Though beyond the analytic scope of this article, such promises of expansion and health sector reform suggest an attempt to maximize international financing and support, and delay inevitable ‘exit strategies’ from the part of donors.

Our results suggest that increasing levels of external financing coupled with conditional loans and the promise of greater integration into the global economy have not necessarily translated into healthcare system expansion in Jordan. In fact, in line with some of the literature on DAH (Farag et al., 2009; Gottret et al., 2006; Lu et al., 2010), our results found a possible correlation between an increase in external financing and a decrease in national spending for health. Furthermore, the findings suggest that the significant presence of IOs and their close collaboration with the government in agenda-setting and policymaking have led to the transfer and dissemination of international values, frameworks and policy reform models to the national level. However, there appears to be a disconnect between the promises of universalism and human rights stated in ambitious policy objectives, and the actual budget allocations and government expenditures for health. While requiring further analysis and qualitative interviews, we hypothesize that this may indicate a wider trend in which governments adhere to specific norms, values, and terms required by donors, but in practice steer their healthcare systems toward greater privatization, decentralization, and the gradual exclusion of refugees. While our conclusions represent an initial exploratory study, they point to the need for further research on the effects of humanitarian and development financing on national policy formulation and reform.