Summative Evaluation of Canada’s Support to Jordan’s Health Fund for Refugees II (JHFR) - Executive summary

The findings, conclusions, recommendations, and lessons listed below are those of the Contractor and do not necessarily reflect the views of the Department or the Government of Canada. The Department does not guarantee the accuracy of the information provided in this report.

Table of contents

• Rationale and purpose of the evaluation
• Objectives of the evaluation
• Scope of the evaluation
• Development context
• Project description
• Evaluation approach and methodology
• Key findings
• Key conclusions
• Key recommendations
• Key lessons

Rationale and purpose of the evaluation

Jordan hosts the second-largest number of refugees per capita worldwide^{Footnote 1} and remains a key country of asylum, particularly for Syrians. Before the major events in Syria in December of 2024, the Office of the United Nations High Commissioner for Refugees (UNHCR) estimates indicated that over 660,000 Syrian refugees were officially registered in Jordan, with government sources suggesting that the total number of Syrians, including the unregistered Syrian refugees, was 1.3 million. After the December 8^th, 2024, events and to date around 149,000 registered refugees went back to Syria. Hence, as of August 2025, a total of 462,282 Syrian refugees were registered with UNHCR.^{Footnote 2} In addition to Syrians, Jordan also hosts tens of thousands of refugees from other nationalities (Sudan, Iraq, Yemen) as well as around  2.39 million registered Palestine refugees - the largest number of Palestine refugees of all United Nations Relief and Works Agency for Palestine Refugees (UNRWA) field Offices. These populations are primarily concentrated in urban areas.

Jordan’s health system delivers primary and secondary healthcare services to Jordanians, refugees, and foreign residents, through a network of health facilities in the public, private and charity sector. 

• Public Sector: Public sector provision includes health facilities operated by the Ministry of Health (MOH), Royal Medical Services (RMS), University Hospitals, King Hussein Cancer Center and the Center for Diabetes, Endocrinology and Genetics. The MOH offers healthcare services via 32 MOH hospitals^{Footnote 3}, 134 comprehensive health centers, 354 primary healthcare centers, 137 sub health centers, and 488 Maternal and Child Health (MCH) services centers.
• Private sector: Jordan has 71 private hospitals and hundreds of private clinics and diagnostic centers across all governorates.
• UN agencies and the charity sector: UNRWA (covering Palestinian refugees), and Non-Governmental Organizations (NGOs) provide cash for health support to refugees.

Population health coverage is fragmented. Coverage is provided by public insurance schemes (MOH Insurance scheme (CIP), RMS or University Hospitals Insurance), private insurance schemes and UNHCR/ NGOS support. Some groups remain entirely uninsured.

The Jordan Health Fund for Refugees (JHFR) was launched in 2018 to support the Government of Jordan (GoJ) offset the additional costs of providing health services to Syrian refugees through the public health system. It was later expanded to cover all UNHCR registered refugees. It is a collaborative financing initiative, through a Joint Financing Arrangement (JFA), supported by Canada, the USA, Denmark, Qatar, Germany, Italy, and the World Bank, raising, as of 2025, over 76 million Jordanian Dinars. The JFA, between the donors and GoJ, provides the overall framework for JHFR, with each donor concluding separate bilateral agreements. The JFA was renewed, for the second time, in 2024 and extended till December 2028. The Ministry of Planning and International Cooperation (MoPIC) manages contributions, while the MOH implements projects aligned with national priorities and refugees needs.

An evaluation was needed to assess the impact of this multi-donor support ongoing since 2018 and to examine the Fund's outcomes, effectiveness, relevance, factors affecting its success, offering insights into the sustainability of its interventions. This is the first comprehensive evaluation of the Fund's performance since its inception. It aims to provide insights for future health sector programming and will benefit relevant stakeholders, such as MOH and donors, to support evidence-based decisions.

Objectives of the evaluation

The primary purpose of this evaluation was to assess the overall performance and impact of the Fund from the time of its establishment in 2018 until 2024. However, a greater focus was placed on the period corresponding to JHFR II (FY 2022-23 to the present). The evaluation aims to present the extent to which the Fund has achieved its intended outcomes, particularly in improving access to subsidized primary and secondary healthcare services amongst refugees and strengthening the national health infrastructure. The objectives of this summative evaluation are:

1. Assess the relevance, in alignment with the needs and priorities of MOH and primary beneficiaries.
2. Assess the results achieved including results related to gender equality.
3. Identify the key factors, within the project and the enabling environment, that contributed to or hindered the achievement of results and their sustainability.
4. Provide insights into gender and environmental considerations.
5. Provide findings, conclusions, lessons, and recommendations to fulfill the evaluation purpose.

Scope of the evaluation

This evaluation was intended to be participatory in nature, actively and meaningfully engaging DFATD and implementing partners, as well as the primary beneficiaries (UNHCR registered refugees, particularly women and girls, and marginalized groups), to the greatest extent possible, in the design, implementation and reporting. The evaluation was implemented across five governorates: Amman, Zarqa, Irbid, Mafraq and Balqa, selected, together with MOH, for hosting refugee populations and relevance to JHFR-supported projects.

Development context

Even though the main purpose of the evaluation is to look backwards and compile lessons learnt, the timing of it coincided with significant contextual changes in Jordan. So far, 149,000 UNHCR registered Syrian refugees returned home after as Syria’s borders reopened following the fall of Asad’s regime. Others chose to remain in Jordan due to the security concerns, uncertainty about Syria’s political future and lack of basic service inside Syria. 

At the same time, Jordan’s health system has been facing increased pressure including changes in the funding landscape particularly around humanitarian donor funding cuts in January 2025 and USAID’s dismantling. Despite these developments, the evaluation and subsequent recommendations remain highly relevant given the sustained pressure on Jordan’s health system, continued presence of large refugee populations and ongoing financial constraints faced by refugees affecting their access to health services.

Project description

The JHFR is a multi-donor pooled fund created to support Jordan’s healthcare system in delivering affordable services to UNHCR registered Syrian as well as non-Syrian refugees. The Fund was created in exchange for a government’s health policy towards UNHCR-registered refugees. In return for donor support, the Jordanian government adopted a policy, in 2019 for registered Syrian refugees and in 2020 for registered non-Syrian refugees, to reduce their healthcare co-payment to the same rate as uninsured Jordanians (at 20% copay). By 2025, MOH received over 76 million JOD through the Fund, funding 49 healthcare interventions, of which 20 have been completed, 17 are ongoing and 12 new interventions are planned. Total expenditure, to date, reached 48 million JOD.

JHFR covers interventions at the policy, access, service, and resource levels to improve healthcare delivery for refugees. JHFR workplan is updated every year with a list of projects that is endorsed yearly, at the Fund’s Steering Committee meetings. JHFR covers the following key themes: 

1. Policy advocacy for refugee access to primary and secondary healthcare facilities at the same rates as uninsured Jordanians, covering no more than 20% of actual costs.
2. Infrastructure upgrades in the form of service expansion, infrastructure development, refurbishing infrastructure, provision of specialized services and of medical equipment at public health facilities located in high refugee density governorates, such as Amman, Mafraq, Irbid and Zarqa.
3. Capacity building and awareness of the health workforce through the establishment of an MOH training center and the distribution of the policy manual and services guidelines.

Specifically for Canada, and in the bilateral agreement between DFATD and MOH, two additional themes were added.

4. JHFR advocated for and supported the establishment of a Gender Unit at the MOH. The Unit works with the focal points from the different directorates at MOH. It oversees gender mainstreaming plans at the ministry. While the formation of the unit represents a structural step towards institutionalizing gender equality within MOH, further progress has been demonstrated through concrete activities. These include conducting a Training of Trainers (TOT) program on gender mainstreaming in health and reviewing policies and indicators for gender integration.
5. JHFR supports environmentally sustainable healthcare delivery. Through a complementary Canada funded technical assistance project, capacity strengthening was conducted for engineers at MOH on the environmental impact of constructing and maintaining healthcare facilities.

In 2019, the MOH, with support from the Government of Canada, developed a Performance Measurement Framework (PMF) to track and monitor the Ultimate, Intermediate, and Immediate outcomes of the JHFR project. This framework outlines a results chain linking long-term goals to measurable outcomes at different levels. The MOH monitors these outcomes and reports them annually to donors through the JHFR Annual Report. For further details on PMF, refer to Section 4.9 & Annex 3 of the Final Report.

JHRF’s main stakeholders are:

• Implementing partner: The Ministry of Health
• Primary beneficiaries:  Syrian and non-Syrian refugees registered with UNHCR (women, men and children) and MOH facilities.
• Secondary beneficiaries: Healthcare providers and MOH staff
• Donors: Current donors include the USA, World Bank, Denmark, Italy, and Qatar. Other donors since 2018, include Germany.
• Government oversight entity: MoPIC -overseeing international assistance in Jordan.

Evaluation approach and methodology

This evaluation was guided by a tailored evaluation matrix aligned with OECD criteria and JHFR’s PMF. The evaluation matrix detailed indicators, judgment metrics, and data sources, enabling systematic and rigorous assessment of performance against stated objectives and evaluation questions (Annex 6: Evaluation Matrix). The summative evaluation of the JHFR adopted a mixed-method, theory-based and participatory evaluation approach to assess the Fund’s contribution to strengthening Jordan’s healthcare system for refugees and host communities. A sequential evaluation design was used, starting with secondary data review to inform primary data collection.

A Theory of Change (ToC) developed during the inception phase guided the evaluation in mapping contributions to short and long-term outcomes (Annex 2: Theory of Change).

 Participatory involvement through interviews and discussions ensured that diverse stakeholder voices were represented, including refugees, donors, and government personnel. The purposive sampling strategy was deployed, and key stakeholders were selected based on the inputs received during the inception meeting, secondary review, and confirmation from MOH and Global Affairs of Canada (GAC).

The sample size of the evaluation included (a) 21 key informant interviews (KII) with donors, GoJ, UN agencies, public health facilities and (b) 11 Focus Group Discussions (FGDs) conducted with refugees residing in host communities (58 participants) and International and Local Non-Governmental Organizations (NGOs) working in the health sector. Prior to the field phase, a desk review was conducted.

The following addresses limitations of this evaluation with the key recommendations for each at the end of the summary.

• Limited number of indicators within the PMF that can be directly attributed to JHFR. The current framework includes broad, high-level indicators that reflect the overall performance of Jordan’s health system but do not isolate the specific contributions or outcomes of JHFR-funded interventions. This significantly weakens the ability to draw clear causal links between JHFR inputs and outcomes leading to observed system-level changes.
• Low FGD participation rates among refugees. Hesitation among refugees were observed, to openly share opinions due to the current general context of returns.
• Limited baseline data. Limited baseline data around budget utilization and assessments.
• Inability to separate the impact of Canada’s funding from other donors. Given this is a multi-donor account, it is impossible to assess the impact of the contribution of each donor.

Key findings

To what extent has the project achieved its expected outcomes? And were there any unintended results (positive or negative)?

The evaluation highlights that JHFR demonstrated measurable progress at the ultimate, intermediate, and immediate (less pronounced) outcomes, showing improved and more equitable health for refugees, particularly for children, girls, and women, through accessing public health facilities with reduced financial burden given the GoJ policy allowing refugees to pay subsidized cost as uninsured Jordanians. The continuation of the government’s policy towards refugees reflects a major commitment from the government and ongoing support from donors. It is important to note that even with this support, the GoJ continues to allocate a portion of its budget to cover refugee-related costs. The Fund directly contributed to a combination of infrastructure development, equipment provision and technical assistance.  JHFR has also generated several unintended results, both positive and negative, that have shaped the broader health landscape.

In terms of positive unintended results, donor engagement through JHFR unexpectedly became a platform for broader health sector reform dialogue with the MOH (through the Projects Management, Planning and International Cooperation Directorate, PMPIC), fostering long-term partnerships and system planning beyond the original scope of the JHFR. Savings from infrastructure upgrades and the provision of new specialized services were also noted. Flexibility of the use of funds during the COVID-19 greatly contributed to the national response to the pandemic. In addition, the extension of coverage to all UNHCR registered refugees is another major unintended positive result when the fund was initially developed in exchange of government policy towards Syrian refugees only.   

Some challenges that were observed include, the concentration of infrastructure and equipment investments in Amman and central governorates may have unintentionally widened regional disparities. Furthermore, the lack of donor visibility at intervention sites limits opportunities for enhanced recognition and accountability. While ensuring high-quality service delivery should remain at the forefront, it is also important to recognize the role of donor visibility in fostering transparency, strengthening partnerships, and sustaining engagement.

Which key factors of the design and implementation supported or hindered the achievement of the project’s results?

JHFR’s design supported strong coordination, strategic alignment with national strategies, and operational flexibility which supported the project’s results delivery. JHFR strengthened public health infrastructure in the refugee centric areas to ensure better access and affordability by refugees. Investments in policy advocacy, health infrastructure, advanced equipment and capacity building were key enablers to achieve project outcomes. Flexible design of the JHFR also allowed MOH to deal with national crisis especially during the COVID-19 pandemic. Despite all the key factors that supported the achievements, gaps were observed in refugee-centric planning and ground-level participatory consultations which limited the project's overall effectiveness and equity

Were the project’s results relevant to the needs and priorities of the primary beneficiaries (refugees in urban communities), camp residents (in case of referrals to health facilities located in host communities) and the implementer (MOH)?

JHFR aligned well with international and national priorities including the Economic Modernization Vision (EMV), MOH Vision 2023-2025, the Jordan Response Plan (JRP) 2015, the Jordan Partnership Paper (Brussels Conference II, 2018), and Sustainable Development Goal 3 (SDG). These policies and strategies collectively emphasize equitable access to quality healthcare services for vulnerable populations, including refugees. JHFR addresses refugee needs by improving access, affordability, awareness, and quality of care for vulnerable groups. It also contributes to health system strengthening while reducing referral barriers. Project interventions contribute to addressing the needs and priorities of both MOH and refugees in urban communities (and those referred from camps).

What were the key factors that influenced the achievement or non-achievement of sustainability of the project’s results (including considerations of gender and environment)?

JHFR contributed to long-term sustainability, of the project’s results, by investing in Jordan’s public health system thereby increasing the MOH’s institutional capacity and supporting the establishment of permanent systems that enhances resilience to future crises. While broader reforms in gender and environmental integration have taken place such as institutionalization of gender mainstreaming efforts, training of MOH on gender concept and environmental impact, and review of gender related indicators- these can represent important steppingstones towards integrating gender and environmental consideration. Sustainability is hindered by several factors such as donor fatigue and the absence of a concrete, predictable, long-term financial plan and a changing donor funding landscape.

How is the information /data management system established capturing results/impact of the Fund?

The current data system supports routine monitoring of refugee health service utilization but lacks the analytical capacity to assess long-term impacts and inform adaptive management which limits its effectiveness in guiding strategic decisions. The PMF indicates that while several indicators such as the Maternal Mortality Ratio (MMR), Under 5 Child Mortality and ANC visits, have improved, it remains challenging to determine the extent to which these improvements can be attributed to JHFR. Indicators concerning access, utilization, capacity, and awareness are also influenced by broader health system reforms and other donor-funded initiatives, making it difficult to attribute changes solely to JHFR. Additionally, the system lacks sufficient analytical capacity and qualitative indicators to assess long-term impact, which limits its effectiveness in guiding strategic decisions.

Key conclusions

The evaluation concludes that due to JHFR, the government has, so far, maintained its health policy towards UNHCR registered refugees (paying only 20% of service costs). It has contributed to improving equitable access for UNHCR registered Syrian and non-Syrian refugees at par with uninsured Jordanians. The Fund’s design facilitated strategic alignment, strong multistakeholder coordination and operational flexibility, supporting an integrated and effective health response. Notably, it strengthened Jordan’s public health system (in the facilities where investments were made) and institutional capacity, laying the groundwork for sustainability. Institutional efforts to mainstream gender equity and environmental considerations are more difficult to assess yet have an opportunity to sustain impact.  Regardless of commendable achievements, gaps remain in aligning top-down planning with refugee needs, particularly in addressing affordability and service availability for chronic and specialized care. Moreover, the evolving funding landscape combined with a lack of a robust predictable, long-term financial plan threatens the sustainability of outcomes. Critically, the current M&E framework lacks the rigor required to capture the Fund’s true impact and guide evidence-based decision making.

Key recommendations

*Represented by the INGO Forum, for INGOs and representatives of local NGOs working in health programming.

Key lessons

The following are the main lessons learned from the period covered by the evaluation:

1. Donor support through a pooled multi-donor account model is an effective approach to strengthen national health systems.
2. Strong government-led coordination enhances strategic alignment, reduced duplications, ownership, and adaptability in multi-donor settings.
3. Supporting PMPIC is essential to ensure effective implementation and accountability.
4. Strong program design from the early planning stages is essential to ensure coherence between project objectives, expected results, and monitoring systems.
5. Ensuring the sustainability of pooled funding mechanism requires predictable financing and a clear transition plan.
6. The integration of gender equality and environmental considerations makes impact stronger and more sustainable.
7. Given prevention is key, it is essential to reaffirm the critical need to invest in primary health facilities which serve as the first point of care for refugees.
8. Robust, outcome-oriented monitoring and evaluation system and evidence-based foundations for the yearly workplans are essential for strategic learning and efficient resource utilization.
9. Multi-donor funds that address refugee health in a protracted crisis remain relevant to support a national health system that was overstretched while catering to a crisis. For JHFR, this is critical as the funding landscape changes eventually affecting services offered to refugees residing in camps (who are not covered under the JHFR).