Elsevier

The Lancet

Volume 381, Issue 9870, 16–22 March 2013, Pages 939-948
The Lancet

Review
Health services in Iraq

https://doi.org/10.1016/S0140-6736(13)60320-7Get rights and content

Summary

After decades of war, sanctions, and occupation, Iraq's health services are struggling to regain lost momentum. Many skilled health workers have moved to other countries, and young graduates continue to leave. In spite of much rebuilding, health infrastructure is not fully restored. National development plans call for a realignment of the health system with primary health care as the basis. Yet the health-care system continues to be centralised and focused on hospitals. These development plans also call for the introduction of private health care as a major force in the health sector, but much needs to be done before policies to support this change are in place. New initiatives include an active programme to match access to health services with the location and needs of the population.

Introduction

In this Review, we aim to provide an appreciation of the health status of Iraqis, the function of Iraq's health system, the rapid changes occurring in the health sector, and the need for improved policies to guide these processes.

During the 1970s and 1980s, Iraqi health care and medical education were said to be the best in the region.1 The country boasted free health care in 172 hospitals and 1200 primary health-care clinics.1 Iraqi medical graduates would often receive specialty training and certification in the UK and Germany. From the late 1980s until 2004, most medical graduates were barred from leaving Iraq.

After Saddam Hussein came to power, funds were diverted from the health sector. The 1980–88 Iran–Iraq War killed perhaps half a million people on both sides, and further diverted resources and medical staff from civilian facilities.2 In 1991, Iraq invaded Kuwait, triggering the first Gulf War. The sanctions that followed had a major effect on Iraq's health system and the health status of Iraqis.3, 4 The subsequent oil-for-food programme mitigated some of the effect of sanctions, but serious damage had been done to the health system. At the time of the 2003 US-led invasion of Iraq, the health system was weak, with non-functioning equipment, inadequate drug supplies, and fragile infrastructure.5

The destruction and looting of health facilities that followed the invasion resulted in heavy loss of equipment and pharmaceutical stocks.6 Quality of care continued to deteriorate and shortages were widespread.7 Major loss of health staff from tertiary hospitals had an effect on teaching of trainees and care of patients.8 In 2012, the UN High Commissioner for Refugees estimated that 3·1 million people in Iraq were in need of assistance;9 about 1·4 million people are internally displaced.10 Both refugees and internally displaced individuals have unsatisfactory access to health services.11, 12, 13

During the 2003–11 occupation of Iraq by coalition forces $53 billion in assistance schemes were implemented with varying success.14 The Federal Ministry of Health went through difficult times, under the control of various sectarian groups. In the north, the Kurdish Regional Government in Erbil developed its own budget and management process, which was similar to that in Baghdad. Staffing of health facilities in the Kurdish area was augmented by immigration of doctors and nurses fleeing from elsewhere in Iraq.15

In May, 2006, Nouri al-Maliki became the Prime Minister of Iraq. British troops left Iraq in 2009;16 the last US forces were withdrawn in 2011. Although violence and political instability continue, normal life is returning to much of Iraq. However, the country faces staggering health challenges, especially to the function of its health system.16, 17, 18

Section snippets

Health status of Iraqis

Over the past four decades a rapid demographic and epidemiological transition has occurred in Iraq (figure 1,19 panel20, 21, 22, 23). The accompanying Review by Barry Levy and Victor Sidel24 includes a further summary of key health and demographic indicators. The population of Iraq is estimated to be 32·2 million with annual growth of 2·3%, down from 3·1% in 1990.25 This increase compares with 0·6% in Syria, 1·1% in Iran, and 1·7% in Egypt.21 From 1990 to 2010, the total fertility rate

Ministry of Health

The Ministry of Health was established in 1956. In the 1970s, it largely assumed its present configuration of a centralised model55 focused on hospitals and curative care, providing free universal coverage, but with most resources concentrated in Baghdad. Further changes to this model were made in 1981, 1983, and 2003. In the past 10 years, frequent changes of senior personnel in the Ministry of Health, political entanglements, and scarcity of investment have left the ministry striving to meet

Health service delivery

Iraq has 229 hospitals, including 61 teaching hospitals. 92 private hospitals exist, mainly located in the major population centres. Primary health care is provided by 2504 PHCCs, half of which do not have a medical doctor. Much of the population receives its health care through an estimated 10 000–12 000 private clinics staffed by off-duty doctors from the public sector.30 Richer households are more likely to use private clinics than the public sector PHCCs, which are preferred by poorer

Access to essential medicines

Until 2004, Kimadia, the state drug and medical appliances supplier, was the main importer and distributor of drugs and medical equipment for all Iraq. It now supplies only the public sector. In 2011, Kimadia's budget was $1·25 billion;30 17% of procurement goes to the Kurdish Regional Government and 83% to the rest of Iraq.30 Shortages of drugs and supplies are a regular feature in health facilities. Problems with lengthy procurement processes, cumbersome funding mechanisms, and a high

Health information systems

In Iraq, information flows from facilities and the District Health Office to the governorate Directorate of Health and then to the central Ministry of Health, largely using paper forms. Although some computerisation has occurred at the Central Health and Vital Statistics Department, this development has not led to improved capacity for analysis, dissemination, or use of information.30 To respond to disease outbreaks in a timely manner, governorates and health districts need the capacity and

Development of health systems research capacity

A consequence of Iraq's years of isolation and turmoil has been a loss of research capacity, although it seems to be recovering. During 2010, 22 publications were indexed in PubMed listing an author affiliation as University of Baghdad, rising to 63 in 2012. Many Iraqi universities publish their own medical and scientific journals (some only occasionally), and the Ministry of Health publishes the New Iraqi Journal of Medicine. Some journals have online links, but no Iraqi journals are indexed

Health workforce

Building and retaining an adequate workforce is one of the many challenges facing the health sector. Iraq lags behind regional averages for availability of health workers (table21). These numbers mask a serious maldistribution of professional staff. A disproportionately large number of Iraq's doctors and probably other health professionals, as well as hospital beds, are in Baghdad where 20% of the population live. Poorer governorates have lower numbers of doctors and other health workers than

Financing of health services

Creation of the first national health account was started in 2010, and subsequently incorporated into the Iraq private sector modernisation report.30 Earlier health financing data include the 2007 Iraq Household Socio-Economic Survey (IHSES) and WHO expenditure estimates.82, 83

In 2010, Iraq spent about 8·4% of its estimated gross domestic product (GDP) of $82·2 billion on health.83, 84 External resources spent on health amounted to only 0·8% of GDP.83 The actual amount was estimated to be $247

Future directions

Although Iraq's population has been transitioning through major epidemiological and demographic changes, the Ministry of Health has not kept pace in developing appropriate policy. Governance remains heavily centralised, and is not transparent. Many of the country's most pressing needs are for public health interventions, yet these are not fully addressed by a government still struggling to restore basic functions. Major policy changes are needed at almost every level of governance, but few data

Conclusions

Decades of sanctions and war have seriously compromised a once proud and functional health system. It now struggles to rebuild itself, having adequate financial resources, but with a shortage of skills and strategies. Although the fragmented health policy seems to emphasise further development of a health system based on the family health-care model, resources are heavily directed toward expansion of secondary and tertiary health-care facilities. Human resource development fails to link needs,

Search strategy and selection criteria

We searched PubMed and commercial search engines with the terms “Iraq health” and “Iraq” for work published between 1980 and the present. Documents in English and Arabic were reviewed. We used sources and databases from major media sources, non-government organisations, ReliefWeb, UNICEF, World Bank, and WHO. Additionally, we secured reports, official documents, evaluations, and assessments from the Iraqi Ministry of Health. Extensive discussions were carried out with Iraqi doctors working in

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