Our action for health

A story of survival, by a Syrian refugee in Jordan


The chaotic story of a Syrian refugee in Jordan is told by Pierre Salignon, project manager at AFD’s Health and Social Protection Division.

Amman, Jordan, April 2017 – When the old man opens the door of the room where he lives with his family, he makes an effort to smile. But immediately has a violent coughing fit. With his heavy cover on his shoulders and after a few days without shaving, he looks exhausted. The only thing that puts a big smile on his now grey face is his 2-year-old daughter who is fidgeting next to her mother on threadbare mattresses placed directly on the floor.He is originally from Homs in Syria and came to Jordan with his family nearly 4 years ago to flee from the war and violence of the regime in Damascus.

Taken hostage
A plumber by trade, he has lost everything. At the time, he was married to another woman, who was killed in the bombing right at the start of the civil war. He has no news of four children from this first marriage who all fled to Turkey. He is now married to the young woman sitting beside him. “She also lost her husband”, he points out. We will subsequently learn that she was detained for a while, “taken hostage”, he goes on to say, for several months, by an armed group. It does not matter which. With modesty, he tells that her detention “was terrible”. When they met, he decided to quickly marry her “to protect her”.
Living conditions had become so hard in Homs that they decided to flee to Jordan. They were hosted at the Zaatari camp in the Jordanian desert for 6 months, then decided to leave and settle in Amman at the risk of being in an illegal situation. “Living conditions were bad at the refugee camp. We didn’t have the right to move around freely”. He will not say any more.

 Camp de Zaatari © Dominic Chavez - World Bank

Assistance from Première urgence internationale
They are now living in the East of the Jordanian capital and manage to get by. He has untreated asthma. She has just given birth to a second child. “We are going to pick him up at the hospital just after lunch” she beams. She does not say anything else. She is discreet, very reserved.
She gave birth following a complicated pregnancy in a hospital in Amman and benefits from assistance from the French NGO Première urgence internationale (PUI). Thanks to financial support from AFD, she was able to pay the fees for the hospitalization and caesarean section. Some USD 500 of “cash for health” which they would not been able to pay up front without getting further into debt. Their debt is currently estimated at about USD 800. And it could well increase. “My wife has epileptic seizures. She has a regular treatment to take which stops her from breastfeeding. We are going to have to buy powdered milk”.

USD 150 a month
The only resources they have are the USD 150 a month they receive from the United Nations High Commissioner for Refugees (UNHRC), which only allows them to pay the rent for their precarious living area, water and electricity. The food vouchers they receive from the World Food Programme (WFP) barely cover their daily needs. For health, it is even more complicated. The administrative procedures are so complicated that they turn people away from access to healthcare. “Even if I’m told I am entitled to it, I have no treatment for my breathing problems, and I can’t afford to pay for it”, sighs the head of the family between two excruciating wheezes.
The social worker from the NGO Première Urgence Internationale takes notes. Listens carefully. She offers to go with him to High Commissioner for Refugees and refer him to another Jordanian medical partner who may be able to prescribe him an appropriate treatment.
“And the future?” … Everything goes silent. “Look at the state I’m in, I can’t work… she can’t either”. Their little girl smiles while watching a cartoon on a timeless TV. “You know, as long as “Bashar” is there, we won’t go back. He has destroyed everything. We have nothing left. I came here with only the clothes on my back”, he adds. While the expulsions of refugees by the Jordanian authorities are increasing, their life boils down to this unhealthy and damp room, and their relations with refugee neighbors who are also originally from Homs. “We don’t leave the neighborhood unless we need to”. 

No rapid return to Syria
The war in Syria holds out no prospects for a rapid return to their country. The chronic nature of the crisis pulls more and more Syrian refugees into extreme poverty every day, in Jordan like elsewhere in the region. The cycle is known; the longer the crisis lasts, the more the prospect of returning to a decent life becomes remote. Precarious refuge and temporary status. Dependence on assistance, ban on working, rapid indebtedness and child labor. Even prostitution and the development of early marriages, pressure to return home…   
Remains that the assistance program of the NGO Première urgence internationale and its network of Jordanian partners provides Syrian refugees with assistance which, albeit modest, is tailored to individuals and without which they would not be able to cope. AFD feels that this program deserves to be supported and should continue with assistance from the other donors.

Pierre Salignon, Project Manager, Health and Social Protection Division, AFD

For further reading on iD4D: “ Syrian refugees : “Development assistance in Lebanon and Jordan must be unconditional ”, by Haneen Ismail Sayed, World Bank Program Leader for Human Development in Lebanon, Syria and Jordan.

For further reading on iD4D: “ Refugee crises: supporting the development of host countries is key ”, by Paolo Verme, Senior Economist at the World Bank.

For further reading on iD4D: “ Refugee crisis in Lebanon : the viewpoint of a social enterprise ”, by
Kim Issa External relations manager of arcenciel

Aga Khan Health Services and French agencies partner to improve Palliative Care in Kenya and Tanzania


The Aga Khan Health Services (AKHS), an agency of the Aga Khan Development Network (AKDN) and Expertise France today signed an agreement to enhance the quality of palliative care services in the Aga Khan Hospitals in both Kenya and Tanzania. The programme is being grant funded by the Agence Francaise de Developpement under which AKHS will receive 250,000 € to conduct specialised training for 4 doctors and 4 nurses – also known as “champions” through the Institut Curie.

The Euros 250,000 grant will go towards the implementation of a pilot palliative care training project for professionals from four hospitals of the Aga Khan Health Services in Kenya (Nairobi, Kisumu and Mombasa) and Tanzania (Dar Es Salaam). The programme will be implemented by Institut Curie, world renowned for their technical expertise in palliative and supportive care and their pragmatic, tailor-made trainings. Expertise France has been instrumental in working with the Aga Khan Health Services and Institut Curie to develop the overall implementation plan.

According to Dr Alexis Burnod, the project’s key expert and responsible for implementing Institut Curie’s training activities, « The spread of palliative care culture as a criterion of healthcare excellence towards patients and their families is a universal invitation. It is the result of the work of an entire team dedicated to promote a comprehensive care focused on the patient. This partnership programme with our Kenyan and Tanzanian counterparts reinforces this international humanist dynamic”.

“Our 15 years of experience creating partnerships and exchanges between hospitals in the North and the South have shown the value of giving healthcare professionals the opportunity to learn from one another – improving not only skills, but also the organisation and the continuum of care” added Mr Sebastien Mosneron Dupin, CEO of expertise France.

The partnership will bring Kenya and Tanzania closer to their goal of establishing palliative care services in the region by providing specialised clinical training as well as by enabling hospital professionals to establish designated palliative care units. Experts from Institut Curie and Expertise France will provide continual support and feedback throughout the process, resulting in invaluable information for advocacy, policy changes and scaling-up of the programme.

Palliative care in low-income countries

The quality of life of patients and their families facing life-limiting illness is a growing concern in low-income countries, particularly in Africa. Low income countries are disproportionately burdened with chronic diseases such as cancer, HIV-AIDS, kidney, heart and respiratory disease and face particular challenges in providing palliative care.

According to WHO and the World Palliative Care Alliance, a staggering 78% of the 19.2 million adults requiring palliative care are estimated to be in middle- and low-income countries. Often, health facilities in these countries lack pain medication, adequate hospital facilities, specially-trained medical staff, designated palliative care units and government or policy support. In particular, opioid pain-relief is very limited, and often prohibited from importation in a large number of African and Central/South Asian countries: an estimated 80% of the world’s population currently lacks access to opioids for pain relief at the end of one’s life.

“This partnership comes at a time when there is a large unmet need for palliative care within the health systems in Kenya and Tanzania,” said Dr. Gijs Walraven, Director of Health, signing the agreement on behalf of the Aga Khan Development Network. “There is an urgent need for education, and for advocacy with decision makers to take action and create enabling environments for palliative care at the national level.”

Improving palliative care in Kenya and Tanzania

The enhancement of palliative care in middle and low-income countries is a key priority for the Aga Khan Development Network (AKDN), working mainly in Africa, Asia and the Middle East. Expertise France has also responded to the burden of chronic and non-transmissible diseases in its strategy for improving health in middle- and low-income countries. The Institut Curie is a leading French institution for cancer care and research and has developed an innovative, multidisciplinary and comprehensive approach to palliative care.


About Aga Khan Health Services
The Aga Khan Health Services (AKHS) is one of three agencies of the Aga Khan Development Network (AKDN) that support activities in health.  The others are the Aga Khan Foundation (AKF) and the Aga Khan University (AKU). Together, the three agencies provide quality health care to five million people annually and work closely on planning, training and resource development.  AKHS also works with the Aga Khan Education Services (AKES) and the Aga Khan Agency for Habitat (AKAH) on the integration of health issues into specific projects. The AKDN health system has been operating in East Africa for over 80 years. Its expanding East Africa Integrated Health System is dedicated to providing high-quality health coverage at affordable prices to an economically diverse population.

About Expertise France
Expertise France is the French public agency for international technical assistance. It aims at contributing to sustainable development based on solidarity and inclusiveness, mainly through enhancing the quality of public policies within the partner countries. Expertise France designs and implements cooperation projects addressing skills transfers between professionals. The agency also develops integrated offers, assembling public and private expertise in order to respond to the partner countries' needs. ► www.expertisefrance.fr

About the Institut Curie
A leading player in the fight against cancer, Institut Curie brings together an internationally-renowned research centre and an advanced hospital group that provides care for all types of cancer – including the rarest forms. Founded in 1909 by Nobel laureate Marie Curie, Institut Curie comprises three sites (Paris, Saint-Cloud and Orsay), where more than 3,300 members of staff are dedicated to achieving three objectives: hospital care; scientific research; and the sharing of knowledge and the preserving of legacy. As a private charitable foundation since 1921 that is recognised as serving the public interest, Institut Curie is supported by donations and grants. This support is used to fund discoveries that will improve treatment and the quality of life of cancer patients.

Private sector at the bedside of health


Access to healthcare – and to high-quality care – is a challenge for a large section of the population in Sub-Saharan Africa. It is often small private structures which meet needs in rural areas and for the poorest. The Medical Credit Fund foundation works alongside them and demonstrates that in the health sector, it is possible to effectively combine a social purpose with entrepreneurial projects.

Sub-Saharan Africa has 16% of the world’s population, but only accounts for 2% of global health expenditure. Yet over the years, population growth, the rise in chronic diseases, but also socioeconomic progress, have created an increasingly pressing demand for healthcare. But the African subcontinent suffers from a clear lack of investment.

In this extremely tense context, some 50% of total healthcare delivery is already provided by the private sector, which plays a key role at all levels, from healthcare provision to retail trade. It even has a predominant place in certain countries, such as Uganda or Ghana, with over 60% of total healthcare provision. “Contrary to common belief, the private sector is sometimes the only healthcare provider in rural areas and deprived urban areas”, explains Aurore Lambert, health project manager at AFD. “It is a far cry from provision just for rich people!”.

These structures are often small or medium-sized, yet they face two major problems which are intrinsically linked: the poor quality of healthcare and the difficulty of gaining access to financing to allow investments to address this. In reality, the banking sector generally considers that their activities are risky.


Some 600 health centers financed

Medical Credit Fund (MCF) is a foundation whose purpose is precisely to facilitate financing for these structures, while helping to improve their quality standards. The foundation is based in the Netherlands and is, for the time being, the only one of its kind. Since it was set up 5 years ago, MCF has financed 586 health centers, mainly in Kenya and Ghana, but also in Nigeria and Tanzania.

The average loan amount stands at EUR 20,000 and loans are mainly used to renovate buildings or purchase equipment. For example, a few months ago, South B Hospital, a small hospital structure with 45 beds located in a popular neighborhood of Nairobi, benefited from a loan to finance the creation of intensive care, nephrology and hemodialysis units. The hospital teams will follow a healthcare quality improvement program throughout the duration of the loan.


Photo Dorte Hopmans © Diorte


MCF is a not-for-profit foundation, but it is also a private actor: MCF does not allocate grants, but aims to grow in order to achieve financial equilibrium. Equilibrium ensures that the project is autonomous and gains in strength. “It is a social business”, explains Selvan Pajaniradja, who develops this sector of operations at AFD, “The aim is indeed to build high-quality health service provision for all at an affordable price. MCF consequently works for development, but at the same time generates the revenue which is essential for the sustainability of the project!”.


French-speaking Africa for tomorrow?

The originality of MCF can be seen in its inclusive and partnership-based method. The foundation works with local financial institutions, providing them with its knowledge of the health sector and assisting them in the appraisal and follow-up of files. “The aim is to work with local partners and help them develop their range of loans for the sector”, adds Aurore Lambert, “It involves showing that financing health services in Africa can be a profitable activity.” 

As the MCF project fits in with its core objectives for health and social business, in December 2016, AFD decided to take part in a funding round, via a EUR 3m concessional loan and EUR 1m grant from its social business facility. It has thereby joined up with the International Finance Corporation (IFC) and Calvert Foundation . AFD’s long-term objective is to help MCF establish itself in French-speaking Africa, in particular in Côte d’Ivoire, Cameroon and Senegal, where there are also considerable needs. “Given its expertise in the health and financial sectors in a number of countries”, points out Arjan Poels, Chief Executive Officer of MCF, “AFD is a key partner in supporting our project to improve the financing capacity of health structures and, more generally, healthcare quality in Africa.”

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