Access 20to 20Quality 20Health 20Care 20in 20Iraq 20 20A 20Gender 20and 20Life Cycle 20Perspective by HC111111101445

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									               Access1 to Quality Health Care in Iraq:
                      A Gender and Life-Cycle Perspective




    Alongside Iraq‟s constitutional provisions that aim to promote the health of all Iraqi citizens through provision
       of public health services, Iraqi law provides broad measures aimed at supporting maternal health, family
      planning, and children‟s health. The law does not, however, appear to provide detailed regulations for the
    provision of women‟s health care facilities and makes no provision for the prevention and treatment of illnesses
               specific to women, apart from those associated with pre-natal and post-natal health care.
ABA/ILDP, The Status of Women in Iraq: Update to the Assessment of Iraq‟s De Jure and De Facto Compliance
                           with International Legal Standards, December 2006



                                           Siobhán Foran
                                       GenCap Gender Advisor**
                              OCHA Iraq/UNAMI (Information Analysis Unit)*

                                                  July/August 2008


                                 *Information Analysis Unit (IAU)
    The IAU is an interagency unit within the RC/HC‟s Office in UNAMI. It was created in January
     2008 to improve the impact of the humanitarian and development response in Iraq through the
                                     strategic use of information.
                         IAU Participating UN Agencies and NGOs
             UNAMI, OCHA, UNDP, UNICEF, UNFPA, WFP, FAO, WHO, UNHCR, IOM
                     Mercy Corps, International Medical Corps, and IMMAP

1
 „Access‟ – non-discrimination, physical accessibility, economic accessibility and information accessibility - is defined
on page
Index


                                                                                             Page

       Purpose of the Report                                                                 3

       Introduction                                                                          4

       Executive Summary                                                                     5

       Health Statistics                                                                     7

       Four Dimensions of „Accessibility‟                                                    10

       Recommendations                                                                       11

       Background                                                                            14

       Barriers to Accessing Health Facilities and Services                                 17

            1. Deterioration in the Security Situation, including Psychological and Social   17
               Impacts
            2. Deterioration in Health Services and Standards                                 21
            3. Economic and Geographical Barriers                                             24
            4. Displacement                                                                   25
            5. Cultural Issues                                                                26
       UNCT Response to Health Services – a review of the gender perspective                 27




** The author of this report is a GenCap Gender Advisor deployed to the UNCT Iraq from
February to August 2008. GenCap is a standby roster of gender experts managed by the IASC
Sub-Working Group on Gender in Humanitarian Action and NRC. GenCap Advisors (UN P4/P5
equivalent) are deployed to humanitarian situations for six to twelve months to sit in the HC/RC‟s
office and provide support to information collection and analysis, programme planning, capacity
building, coordination and advocacy on gender equality programming.




                                                                                                   2
PURPOSE OF THE REPORT

The Inter-agency Information and Analysis Unit (IAU) is a group composed of analysts from different
participating UN agencies and NGOs in Iraq. The IAU was formed in early 2008 to improve the
effectiveness of programming, advocacy, policy and coordination of the international response in Iraq
and, therefore, the impact of the humanitarian and development response through the strategic use of
information. A GenCap Gender Advisor (** see page 2) is deployed to the IAU to ensure a gender
perspective and analysis is included in all of the Unit‟s work.
The IAU identified that, while many of the obstacles, gaps and needs in the health sector are well
documented, there is a dearth of data and information on the gender and life cycle perspective –
relating to different vulnerabilities, needs, impacts, access for women, men, girls and boys - of these
obstacles, gaps and needs. This gap in knowledge meant that the Unit is not in a position to analyse
the challenges, threats and opportunities that would guide the UNCT and the UN‟s partners on the
optimal intervention to promote gender and age equality in the health sector. Accordingly, the purpose
of this report is to explore the gendered nature of the factors contributing to obstructing women and
men, girls and boys‟ (including adolescents‟) equal access to quality healthcare facilities and services
in Iraq and to make recommendations to the UNCT and its operational partners for moving forward on
the issue.
While it is encouraging to see the emphasis that the Health & Nutrition SOT (H&N SOT) has put on
equitable access to health services, the engagement of women‟s representatives in policies, strategies
and guidelines and promoting equity, rights-based social justice and gender mainstreaming in the
health sector (UN Assistance Strategy 2008 – 2011 and, to some degree, within the CAP 2008), it is
envisaged that the recommendations within this report will assist the H&N SOT to enhance and to
operationalise these commitments and to strengthen the gender and life cycle perspective within the
CAP 2009 and other strategic and policy documents.



A special word of thanks to Chen Reis, Technical Officer - Gender and Gender-Based Violence
Emergency Response and Operations, Health Action in Crises, World Health Organization, Geneva
for reviewing and providing valuable comments on an earlier draft of this paper.




                                                                                                      3
INTRODUCTION

The focus of this briefing paper is on the gender-equality perspective of access to healthcare in Iraq.
Presently, the most significant obstacles to health include the following;

    1.   The deterioration* in the security situation, including the psychological and social Impacts;
    2.   The deterioration* in healthcare services and out-dated standards;
    3.   Economic and geographical barriers;
    4.   Displacement;
    5.   Cultural factors;
* The deterioration in the security situation and the deterioration in healthcare services cannot be
taken to be general across the whole of Iraq; security and services conditions are frequently relative
to specific ethnic/religious groups, to specific geographical locations and to areas and populations
that were neglected under the previous regime; indeed, in some instances, improvements have been
noted.

Each of these factors impact on women, men, girls and boys‟ access to quality healthcare in different
ways and to different degrees. It is the nature and extent of these differences that shapes the gendered
nature of access to healthcare, which is the subject of this report.
The observations and recommendations below must be viewed in the context of an overall analysis of
the health system in Iraq with regard to the establishment of a national framework for healthcare
across primary, secondary and tertiary healthcare, including reproductive health, mental health and
which is reflected in health professional teaching/training (medicine, nursing, midwifery). While this
national framework has been the subject of a number of studies and reports and addresses broader
issues, including the strategic re-orientation of the health care system from a hospital-based approach
to a primary health care centre (PHCC) approach with a parallel enhancement of and an operational
referral system to secondary and tertiary facilities, the focus of this report is more specific, addressing
a gender and life cycle2 perspective of the barriers to accessing quality healthcare.
In addition, while the observations and recommendations below focus on the need to improve the
situation of girls and women in particular, it is important that girls and women are not seen as a
homogeneous group; Iraq has a very diverse population and access to healthcare will as much depend
on a person‟s social status, ethnicity, geographical location (especially in terms of whether they are
urban- or rural-based), culture/religion, etc. as on their gender and age. In view of the time-scale
involved in developing this report and the breadth of study required to examine an age, gender and
diversity matrix of analysis, it was not possible to explore the intersections between gender and these
other characteristics in the context of this report. However, in reading the observations and the
recommendations, this issue must be borne in mind.




2
  The term „life cycle‟ is adapted from UNFPA‟s „life cycle approach‟ model, which recognizes that “reproductive
health is a lifetime concern for both women and men, from infancy to old age” and that we must supports health and
nutrition programming tailored to the different challenges faced at different times in life. “In many cultures, the
discrimination against girls and women that begins in infancy can determine the trajectory of their lives. The important
issues of education and appropriate health care arise in childhood and adolescence. These continue to be issues in the
reproductive years, along with family planning, sexually transmitted diseases and reproductive tract infections,
adequate nutrition and care in pregnancy, and the social status of women and concerns about cervical and breast cancer.
Male attitudes towards gender and sexual relations arise in boyhood, when they are often set for life. Men need early
socialisation in concepts of sexual responsibility and ongoing education and support in order to experience full
partnership in satisfying sexual relationships and family life”.




                                                                                                                      4
EXECUTIVE SUMMARY

   The most significant threat to Iraqis‟ health comes from the overall deterioration in health
    facilities and services resulting from the cumulative effect of many years of economic sanctions,
    neglect and war. Access to quality health care for all Iraqi people is severely undermined.
   Thousands of Iraq‟s medical doctors, among them the most experienced and specialised, have fled
    Iraq due to the increasing threats and violence directly against them thus affecting the overall
    capacity to deliver health services in Iraq.
   The cumulative affect of years of neglect of the health service and the ongoing security situation
    affect the people of Iraq – to varying degrees - regardless of their sex, age, ethnicity, religion or
    [urban or rural] location.
   “The immediate impact of conflict on physical and mental health accounts for a relatively small
    proportion of the suffering3. In the longer term too, health is harmed by conflict-related damage to
    essential health-sustaining infrastructure and to the health system, as well as the corrosive effects
    of conflict-related factors such as poverty, unemployment, disrupted education and low morale. It
    is difficult if not impossible to disentangle the indirect effects of conflict on health in Iraq from
    other under-lying health trends, especially in the absence of reliable, valid, current data. Because
    the impacts are interactive and cumulative, it is also extremely difficult to make causal
    connections with each successive war or period of conflict”4.
    It is in this complex context that this report attempts to examine the gendered and life cycle
    perspective on access to quality health services, how particular obstacles to access affect women,
    men, girls and boys in different ways and to different degrees and to conclude with some
    recommendations to assist the Health & Nutrition SOT.

         Consistent reliable data, disaggregated by sex and age must be available to allow for
                          analysis of health trends and access to health care

   Prior to the Iran-Iraq war of September 1980 – August 1988 and the subsequent years of conflict
    and decade of sanctions, Iraq had a high standard of health care relative to the rest of the Arab
    region. Health care was free, centrally-administered through the Ministry of Health (MoH) and
    was well-equipped and well-supplied, with modern hospitals and an adequate number of well-
    trained medical personnel. In addition, the 1970 Constitution, through the equality clause (Article
    19) guaranteed equal access to health care.
   The deterioration of the health care service, together with an increase in food insecurity and the
    deterioration in the supply and quality of water began in 1980 with the Iran-Iraq war and
    continued to decline throughout the subsequent years of war and economic sanctions.
   While Iraqi law provides for a right to health care and specifies that children and women should
    be afforded health security, the legal framework is inadequate to ensure women‟s equal access to
    health care. It also fails to address the full range of women‟s, especially adolescent girls and
    women‟s reproductive health issues and concerns, including GBV, instead focusing primarily on
    prenatal and maternal health.
   The law does not regulate the provision of health services in such a way as to ensure that quality
    health care is accessible and affordable to women, especially widowed women or women heading
    up households. The privatisation of some health care facilities and the resulting fee structure has
    further limited women‟s access to health care. The problem is particularly acute in rural areas,
    where health care facilities are often non-existent due to the emphasis on the provision of
    hospital-based care, which are located in bigger urban areas.

3
  Santa Barbara, J. and MacQueen, G. (2004) Peace Through Health: Key Concepts, The Lancet, 24 July, cited in
MEDACT (2004) Enduring Effects of War: Health in Iraq, pg. 3
4
  MEDACT (2004) Enduring Effects of War: Health in Iraq, pg. 3


                                                                                                           5
      Early marriage and pregnancy, preferential treatment within the household for men in access to
       food and traditional practice whereby women must obtain permission from a male relative before
       seeking medical care are significant cultural barriers to good health for women and girls.
      Men may suffer other health disadvantages related to their gender role socialisation. For example,
       men‟s roles as protectors and providers may place a greater responsibility on them to take risks
       during ongoing insecurities, therefore, exposing them to random or discriminatory violence,
       meaning that they limited health services are stretched to address their medical care needs if
       injured.
      The current emphasis in the health sector appears to be on women‟s reproductive health;
       neglecting issues specific to women, girls and adolescents throughout their life cycle and the
       creation of an environment that is conducive to such extended care.
      Our understanding of the trends in the health service in general and gender trends in particular
       during this period up to the present day is curtailed severely by the dearth of consistent, reliable
       data, the absence of sex-disaggregated data and the fact that it is not possible to disentangle a
       myriad of other social, political and economic dynamics that were occurring at the same time,
       including the deterioration in the education system and the subsequent increase in illiteracy levels
       especially among girls and women; increasingly weak stewardship of the health sector and
       consequent “creeping privatisation and commercialisation of health care”5 which may have
       excluded an increasing number of widows and female-headed households, as well as exposing a
       degree of preferential treatment for men in accessing health outside of maternal health care; and
       chronic under-funding as financial and human resources were diverted to the ongoing military
       operations.




5
    MEDACT, Enduring Effects of War: Health in Iraq, 2004


                                                                                                         6
HEALTH STATISTICS

Set out below is some of the information and data that are available:
   In 2006 there were 94,815 health workers, giving a ratio of 3.5 health workers to every 1,000
    people. This compares to the East Mediterranean average of 4.2:1,000.
    In the 1990s, there were approximately 34,000 doctors registered with the Iraqi Medical
    Association but, by 2005, this number was down to 18,126, with half of these in Baghdad, Basra
    and Ninewa governorates6.
   According to the Iraq Living Conditions Survey (ILCS), 2004, between 1991 (beginning of the
    first Gulf war) and 2001 Iraq had approximately 1,800 PHCCs.
    By 2001, this number had fallen to 929, of which one third were considered to require
    rehabilitation.
   Also according to the ILCS 2004, in 2001, as a result of the diversion of finance to fund three
    consecutive wars, the era of sanctions and re-prioritisation away from the health sector, the total
    expenditure on health was 3.2% of GDP (compared to 9.55% in Jordan).
    By 2008, this percentage has fallen even further to 2.5% of GDP and is among the lowest in the
    region.
   The Iraq Family Health Survey (IFHS) 2006 indicates a high proportion of out-of-pocket
    spending on health (13% of monthly household expenses).
   Environmental health, more specifically related to the availability of potable water and adequate
    sanitation, has also deteriorated. Poor sewage and waste management systems have affected the
    health status of many urban-based people. Two thirds of childhood mortality is due to diarrhoea
    and respiratory infections7.
   Multiple sources indicate that, with increased food insecurity, the nutritional status of the
    population deteriorated considerably as demonstrated by worsening indicators (with wide range
    between different sub-groups): Low birth weight 15%, stunting 21%, underweight 8% and
    wasting 5% (MoH/UNICEF MICS III, 2006)8.
   Chronic non-communicable diseases afflict many adults: hypertension 40%, diabetes 10%,
    overweight 34% and obesity 33% (MoH and WHO, 2006). The situation is further exacerbated by
    shortages of health services and drug supplies (10 out of 32 essential medicines are not regularly
    available).
    Violence-related injuries were conservatively estimated at an average of 400 per day over the
    period 2003-2006 (IFHS, 2007).
    Mental health status estimates showed that 4% of the population have severe mental health
    disturbances and 20% have common disturbances (WHO, 2006) while 35.5% of people claimed
    emotional stress (IFHS, 2007). There are very few adequate, well-developed curative services or
    prevention/rehabilitation programmes available.
   Of those women who deliver in public or private health institutions, many received inadequate
    care because of the lack of essential drugs, transport to referral institutions is not possible or is not
    timely, or medical personnel lack training in emergency obstetric care. It is mainly referral
    institutions at a district level that have the capacity to attend complicated births and many of these
    lack some key resources to provide appropriate care. Women are at increased risk of poor birth


6
  Adapted from the UN Assistance Strategy 2008 - 2011 Situation Analysis for the Health & Nutrition Sector Outcomes
Team, pgs 16 - 17
7
  Ibid.
8
  Ibid.


                                                                                                                 7
    outcomes with high rates of anaemia, short birth intervals and early marriage/pregnancy and need
    advanced medical support.
   Appropriate family planning is essential to the health of women and children. According to MICS
    III (2006), a total of 10.8% of currently married women nationwide (due to the sensitivity of the
    subject matter, only married women were asked questions about contraceptive use during the
    survey) aged 15 – 49 years have an unmet need for contraception; there is significant geographical
    variation, with the highest unmet need (17.7%) in Dohuk and the lowest (5.9%) in Basra.
   9
     On average, between 75 and 80% of the displaced in any crisis are women and children10. The
    Iraqi Red Crescent Society estimates that more than 83% of those displaced inside Iraq are
    women and children, and the majority of the children are under 12 years of age11.
   There have been numerous reports of women and girls forced into prostitution and children sent
    out to the work to help support their impoverished families both in Iraq and in neighbouring
    countries of refuge12,13,14.
   Iraq remains on the list of the 60 countries in the world with the highest infant, under-five and
    maternal mortality rates, according to available data15.
             Infant mortality rate: Estimated at 35 per 1000 live births16.
             Under-five mortality rate: Estimated at 41 per 1000 live births17. Diarrhoea and acute
              respiratory infections account for about two out of three under-five deaths, with
              malnutrition a major contributing factor.
             Maternal mortality rate: 84 per 100,000 live births (2004)18.
   According to UNICEF, in 2007 only one in three children under five years of age in Iraq has
    access to safe drinking water19.
   23% of children in southern Iraq are chronically malnourished20.
   25.9% of children under five in Iraq suffer from stunted growth21.
   An April 2007 report found that 43% of the Iraqi refugee children it surveyed in Amman had
    witnessed violence in Iraq; 39% said they lost someone close through violence22 and over 30% of
    the refugee children surveyed said they had no hope for the future23.
   Male gynaecologists are being targeted for violence and intimidation by Islamic extremists,
    accused of invading the privacy of women24. In addition, according to the Iraqi Medical
    Association, at least 75% of doctors, pharmacists and nurses in Iraq have left their jobs at
    universities, clinics and hospitals. Of these, at least 55% have fled abroad25.

9
  Footnotes 8 – 28 are cited in The Women‟s Commission for Refugee Women and Children, „Women, Children and
Youth in the Iraq Crisis: A Fact Sheet‟, January 2008
10
   UNFPA. State of the World‟s Population 2002
11
   Iraqi Red Crescent Society. The internally displaced people in Iraq – update 27. October 24, 2007.
12
   Hassan, Nihal. '50,000 Iraqi refugees' forced into prostitution. The Independent. June 24, 2007. 11 Lyon, Alistair.
Iraqi refugees turn to sex trade in Syria. Reuters. December 31, 2007.
13
   IOM. Tension in the North Poses Additional Burden on Internally Displaced. November 2, 2007.
14
   Lyon, Alistair. Iraqi refugees turn to sex trade in Syria. Reuters. December 31, 200
15
   WHO. Iraq Annual Report. 2006.
16
   Cluster D. Multiple Indicator Cluster Survey – MICS3. 2006.
17
   Ibid.
18
   IFHS 2006, compared to 192/100,000 reported in the UNDP Iraq Living Conditions Survey – ILCS. 2004.
19
   Report of the Secretary General to the UN Security Council. October 15, 2007.
20
   Harper, Andrew. Iraq: growing needs amid continuing displacement. Forced Migration Review. November 2007.
21
   WFP and Government of Iraq: Food Security and Vulnerability Analysis in Iraq. May 2006.
22
   World Vision. Trapped! The Disappearing Hopes of Iraqi Refugee Children. April 2007.
23
   Ibid.
24
   Ibid.
25
   IRIN. Iraq: Male gynaecologists attacked by extremists. November 13, 2007.


                                                                                                                    8
    As of August 2007, 19% of refugees registered with the UNHCR in Syria reported having
     significant medical conditions and 14% of those registered in Jordan were identified as having
     special needs26. Ten percent of Iraqis in Lebanon suffer from chronic disease27.
    The two main clinics that service Iraqi refugees in Amman do not have medicine to prevent
     pregnancy or HIV transmission for rape survivors28. Mental health care is also generally not
     available for Iraqis in Jordan who survived or witnessed violence29.
    In a 2004 survey30 of 1,000 women from different educational, economic, ethnic and religious
     backgrounds in seven cities in three governorates carried out by Women for Women International,
     57.1% said that their families lacked adequate medical care. However, the greatest needs declared
     were for electricity (95%), work opportunities (87.3%) and access to clean water (63.5%).




26
   UNFPA, UNHCR, UNICEF, WFP and WHO. Health sector appeal – Meeting the health needs of Iraqis displaced in
neighbouring countries. September 18, 2007.
27
   UNHCR. Surveys give valuable data on plight of Iraqi refugees. December 14, 2007.
28
   Women‟s Commission for Refugee Women and Children. Iraqi Refugee Women and Youth in Jordan: Reproductive
Health Findings. September 2007.
29
   Ibid.
30
    Women for Women International, Windows of Opportunity: The Pursuit of Gender Equality in Post-War Iraq,
January 2005, re-released in March 2005.


                                                                                                          9
FOUR DIMENSIONS OF ACCESSIBILITY

There are a number of dimensions to accessibility to health services that must be considered31.
Iraq is a State Party to the ICESCR, wherein it specifies that accessibility to health care services
means that health facilities, goods and services (6) must be accessible to everyone without
discrimination, within the jurisdiction of the State party.
Accessibility has four overlapping dimensions:
Non-discrimination: health facilities, goods and services must be accessible to all, especially the
most vulnerable or marginalised sections of the population, in law and in fact, without discrimination
on any of the prohibited grounds. (7)
Physical accessibility: health facilities, goods and services must be within safe physical reach for all
sections of the population, especially vulnerable or marginalised groups, such as ethnic minorities and
indigenous populations, women, children, adolescents, older persons, persons with disabilities and
persons with HIV/AIDS. Accessibility also implies that medical services and underlying determinants
of health, such as safe and potable water and adequate sanitation facilities, are within safe physical
reach, including in rural areas. Accessibility further includes adequate access to buildings for persons
with disabilities.
Economic accessibility (affordability): health facilities, goods and services must be affordable for all.
Payment for health-care services, as well as services related to the underlying determinants of health,
has to be based on the principle of equity, ensuring that these services, whether privately or publicly
provided, are affordable for all, including socially disadvantaged groups. Equity demands that poorer
households should not be disproportionately burdened with health expenses as compared to richer
households.
Information accessibility: accessibility includes the right to seek, receive and impart information and
ideas (8) concerning health issues. However, accessibility of information should not impair the right to
have personal health data treated with confidentiality.




31
     From http://www.unhchr.ch/tbs/doc.nsf/(symbol)/E.C.12.2000.4.En)




                                                                                                      10
RECOMMENDATIONS

      Despite the legal guarantees, maternal and child health services are inadequate resulting in poor
       access to prenatal care and family planning services and high maternal mortality rate. Greater
       emphasis must be given to providing services and information, or enhancing the governments‟
       capacity to provide services and information on reproductive health, family planning and modern
       contraceptives. According to UNFPA32, several local studies show that there has been an increase
       in the incidence of abortion. The existing family planning policy and strategy should be reviewed
       and publicised and trained professionals should provide reproductive health services that are
       easily accessible for women both in urban and rural areas.
      The Health & Nutrition SOT must lobby the governments to address harmful social practices,
       such early marriage and early pregnancy; preferential treatment for men in access to food; the
       traditional practice whereby women must obtain permission from a male relative before seeking
       medical care; and female genital cutting in Iraqi Kurdistan, through focused efforts to enhance
       awareness of the risks to women‟s health and the importance of equal treatment for all members
       of the family.
      As part of the decentralisation programme, focus on the recruitment, training and employment of
       female health workers and related health disciplines, as well as the promotion of the social status
       of the nursing profession in the overall context of the development of a strong community health-
       nursing programme.
      In collaboration with colleagues in the Education SOT, the H&N SOT, through its ongoing work
       in the development of community-based health services, must encourage the development of
       health education for behavioural change through schools, newspapers, religious institutions and
       leaders, television and radio. Popular education and promotion should be developed in areas of
       personal hygiene, life skills for adolescents, immunisation, breast-feeding, oral health, avoidance
       of early marriage and short birth intervals, pre- and post-natal care and nutrition33.
      Emergency obstetric care should be upgraded with equipment, drugs, training and referral
       capacity. Addressing the primary health care needs of pregnant women, and the secondary care
       needs of women with complicated deliveries, will greatly improve birth outcomes and reduce
       maternal mortality34.
      Almost all of the limited information available on health status is focused on young children or
       pregnant women. Population groups with little known needs including adolescents, elderly, IDPs,
       widows, female-headed households, street children and orphans, those with mental health needs
       and those with disabilities must be studied35.
      While it is encouraging to see the emphasis that the Health & Nutrition SOT has put on equitable
       access to health services, the engagement of women‟s representatives in policies, strategies and
       guidelines and promoting equity, rights-based social justice and gender mainstreaming in the
       health sector (UN Assistance Strategy 2008 – 2010), it is also important that gender equality and
       women‟s empowerment dimensions are explicitly incorporated in all planned outputs, as follows
       (comments added in bold type):




32
   Interview with Dr. Georges Georgi, UNFPA Representative, Iraq Programme, Amman, 12 August 2008.
33
   Adapted from Iraq Watching Briefs: Health and Nutrition, WHO and UNICEF, July 2003
34
   Ibid.
35
     Ibid.


                                                                                                       11
                                     HEALTH AND NUTRITION
                  By 2010, health- and nutrition-related programmes enhanced to ensure 20%
                  increase in equitable access to quality health care services with special focus on
    Outcome 1
                  vulnerable groups and on women’s reproductive health and family planning
                  services.
                  Policies, strategies and guidelines related to health and nutrition developed if
    Output 1.1    required; or reviewed within a gender sensitive approach based on standard
                  human rights and principles.
                  Institutional and personnel capacity of health/nutrition and related programmes
    Output 1.2    strengthened for improved quality service delivery, including gender equality
                  programming.
                  Enhanced functional capacity of health and health related facilities and institutions
                  (services) in low coverage areas (rehabilitation and procurement). This must
    Output 1.3    include a comprehensive package of reproductive health services as standard.
                  The H&N SOT is encouraged to consider the development of protocols in this
                  regard for discussion with the governments.
                  Empowered and engaged local communities and private sector to enhance
                  equitable access to health and nutrition services with special focus on missed
                  opportunities in access to health. This will include training and awareness-
    Output 1.4
                  raising on age, gender and diversity mainstreaming. In addition, there must
                  be a focus on national social safety nets that ensure access to health and
                  nutrition services for those with limited economic access.
                  Enhanced monitoring and evaluation mechanisms in place to track progress and
                  identify gaps in the provision of health and nutrition services with special
                  emphasis on the un-reached. Recognising the specific obstacles to girls’ and
    Output 1.5    women’s access to health care services, and the lack of consistent sex- and
                  age-disaggregated data on the provision of health and nutrition services, it is
                  imperative that all monitoring and evaluation exercises include gender-
                  specific indicators and a gender analysis.
                  Emergency preparedness and response. Access to basic health services to the most
                  vulnerable people affected by the ongoing humanitarian crisis assured. Such
    Output 1.6
                  emergency preparedness and response planning must include a strong gender
                  perspective.

    Together with the Protection OT, prioritise the development and use of protocols for the ethical
     research, documenting and monitoring of GBV and of Standard Operating Procedures for the care
     of survivors of GBV specifically adapted to the Iraqi context;
    Where training of medical staff is a component or focus of a project, attention must be given to
     training on medical confidentiality and psycho-medical management of GBV, including rape
     survivors, where appropriate;
    Where appropriate and possible, the relevant personnel at medical centres must be trained and
     facilitated in the development of confidential referral mechanisms for health and psychosocial
     services for rape survivors;
    In developing proposals based on the project sheets, refer to the recommendations within the
     IAU‟s paper and database entitled „GBV in Iraq: the effects of violence – real and perceived – on
     the lives of women, men, girls and boys in Iraq‟;
    Ensure that there is a space available within the medical facility for private consultation
     with/examination of GBV survivors
    Within the UN Assistance Strategy, the Health & Nutrition Sector undertakes to “provide
     support to improve the performance of the national health system and provide equal access to


                                                                                                     12
    services, with special emphasis on vulnerable, marginalized and excluded individuals and
    families”. It is suggested that this commitment needs to be amended to read “provide support
    to improve the performance of the national health system to provide equal access to services,
    with special emphasis on vulnerable, marginalized and excluded individuals and families”.
    While recognising the space limitations of the actual UN Assistance Strategy document and
    the fact that the Health & Nutrition SOT may in fact have looked at the issue, the terms
    vulnerability, marginalisation and exclusion need further exploration and definition and must
    include a gender analysis.
   In terms of advocacy, under the UN Assistance Strategy, the Health & Nutrition SOT
    undertakes to “assist in developing position papers on: governance, financing, human
    resources, health care delivery, drug policies, promoting equity, ‘rights-based’ social
    justice, gender mainstreaming and the allocation of resources in the health sector (emphasis
    added”. It is proposed that this paper and the recommendations herein is a „starting point‟ on
    the development of a gender equality and gender mainstreaming position paper.




                                                                                               13
BACKGROUND
Prior to the Iran-Iraq war (September 1980 – August 1988) and the subsequent decade of sanctions
against Iraq, the country had a high standard of health care relative to the rest of the rest of the Arab
region. Health care was free, centrally administered through the Ministry of Health (MoH) and well-
equipped and –supplied, with modern hospitals and an adequate number of health service personnel.
The deterioration of services began in 1980 with the Iran-Iraq war and continued to decline throughout
the subsequent conflicts and economic sanctions. However, according to UNDP‟s Programme on
Governance in the Arab Region, even as late as 1991, it is estimated that up to 97% of urban and 71%
of rural populations had access to healthcare36.
In the 1990s, however, the health infrastructure, supplies of medical equipment and consumables and
food availability became severely compromised by the economic sanctions. By August 1990, it was
estimated that food and medicine imports had fallen by 85-90%37. Malnutrition became commonplace
and, by 1996, had affected 30% of children under five years38.
The UN-supported Oil for Food Programme (OFFP) started in 1996 and supplied two-thirds of the
nation‟s food39, providing up to 2,215 calories per day per person receiving rations. Even after the
programme‟s inception, widespread protein deficiencies and malnutrition continued.
Within the OFFP, US$ 4,749 million was allocated to the health sector (73% of this for
Central/Southern Iraq and 27% for Northern Iraq). Half of the funding was for medicines and half for
medical equipment and other supplies. However, investment in medical supplies was not matched by
internal investment in salaries, training and recurring expenses, making the system weak in terms of
human resources and service quality40.
By 1996, over 30% of all hospital beds had been closed and public hospitals were struggling to
provide essentials such as electricity, water and food to patients41. Basic medicines were often
unavailable during this period. As a result of these deprivations, the distribution of health services and
supplies in Iraq fell dramatically and infant mortality doubled42. It is estimated that more than 60
children died every day between August 1990 and March 1998 as a result of health and nutritional
deficiencies caused by the sanctions43. James Owen Drife, writing in the British Medical Journal on 16
April 2005 states that, “[d]uring the 1990s maternal mortality in Iraq rose to medieval levels as a
result of sanctions. Many women and babies died for the want of drugs and transfusions.”
During this period, trained health personnel fled the country for more stable and financially rewarding
jobs in neighbouring countries, while those who remained were unable to gain access to new
technologies and education.
In late 2003, WFP, together with COSIT and the MoH carried out a study on the public distribution
system (PDS) that allocates food aid to most of the population. The survey found that 27% of under
fives in Iraq had chronic malnutrition and that 6.5 million people (a quarter of the population) were
highly dependent on food aid. The report found that “[a]cute malnutrition (wasting rates) for children

36
      UNDP Programme on Governance in the Arab Region (POGAR) at http://www.undp-
pogar.org/countries/iraq/gender-pw.html
37
   Garfield, Richard, Health and Wellbeing in Iraq: Sanctions and the Impact of the Oil for Food Programme, 2002,
cited in ABA/ILDP December 2006
38
   UNICEF/Iraq, Situation Analysis of Children and Women in Iraq, 1998, cited in ABA/ILDP December 2006
39
   Ibid.
40
   WHO/UNICEF, Iraq Watching Briefs: Health and Nutrition, July 2003
41
   Garfield, Richard, Jean Lennock and Sarah Zaidi, Medical Care in Iraq After Six Years of Sanctions, 1997, cited in
ABA/ILDP
42
    UN/World Bank Joint Iraq Needs Assessment – Health, Working Paper, October 2003, cited in ABA/ILDP,
December 2006
43
   Baram, Amatzia, The Effect of Iraqi Sanctions: Statistical Pitfalls and Responsibility, The Middle East Journal, Vol.
54, No. 2, Spring 2000, cited in ABA/ILDP, December 2006


                                                                                                                    14
under five within the sample is 4.4%, underweight 11.5%, and chronic malnutrition or stunting is
27.6%” and concludes that, without the PDS, the figures would be dramatically higher.
The 1970 Constitution guaranteed equal access to health care by way of the overarching equality
clause (Art. 19). The 2005 Constitution goes further by specifically guaranteeing equal rights to health
care, explicitly identifying women and children (Art. 3044).
Although free health care is not guaranteed by the 2005 Constitution, the Iraqi Public Health Law
obliges the State to enforce the right of each citizen of Iraq to physical and mental health, as well as
regulating maternity, children‟s health and family health care, including nutrition.
In the late 1990s, during the UN sanctions imposed after the Gulf War, a Revolutionary Command
Council decision (RCC Order No. 124, 1997) allowed some public hospitals to convert to a fee-based,
private structure, thus limiting free services to those who could not afford it.
The Iraqi Public Health Law also obliges the MoH to educate women in maternal health and childcare
and to provide periodic health tests for pregnant women. The law also supports family planning by
advising “the family to keep a reasonable period of time between one pregnancy and another in
accordance with the health needs of the mother, child and family” and provides for ongoing medical
and nutritional care for children45.
Over the past five years of the current conflict, access to health care, food and water has deteriorated
even further. Water treatment plants have been severely damaged by the war and only about half of
the country‟s sewage treatment plants are operational46. In some governorates, particularly those in the
south, over 80% of those living in rural areas lack clean drinking water and only 3% of rural
households are connected to a sewage system as compared to 47% in urban areas47.
Food insecurity remains a reality for many families and chronic malnutrition persists for almost a
quarter of children between the ages of six months and five years48.
In addition, while there are approximately 1,700 functioning PHCCs in Iraq, only half of these are
staffed by at least one medical doctor49. Assessments carried out by WHO indicate that approximately
12% of hospitals were damaged in the 2003 war50. However, the distribution of health services is
often disproportionate. A 2004 report by the MoH revealed that at least four governorates (Basrah,
Nasiriya, Wasit and Missan) have minimal or non-existent health services, while Baghdad is relatively
better staffed. Even when healthcare is free, particular geographic areas are often isolated from
healthcare facilities and have no access whatsoever. These problems have been exacerbated by
curfews and continued insecurity. In addition, for safety reasons, many health facilities have reduced
their hours significantly, opening only in the mornings and early afternoons.
Although estimates of the rate and causes of the loss of medical personnel – especially experienced
doctors and specialists - vary, the negative trend is clear. An October 2006 study by the Brookings



44
   Article 30 of the 2005 Constitution reads – “First: The State guarantees to the individual and the family - especially
children and women - social and health security and the basic requirements for leading a free and dignified life. The
state also ensures the above a suitable income and appropriate housing. Second: The State guarantees social and health
security to Iraqis in cases of old age, sickness, employment disability, homelessness, orphanage or unemployment, and
shall work to protect them from ignorance, fear and poverty. The State shall provide them housing and special
programmes of care and rehabilitation. This will be organised by law.”
45
   ABA/ILDP, The Status of Women in Iraq: Update to the Assessment of Iraq‟s De Jure and De Facto Compliance
with International Legal Standards, December 2006
46
   IRIN, Iraq Focus on Water and Sanitation, 28 September 2004
47
   UNDP/Ministry of Planning and Development Coordination, Iraq Living Conditions Survey 2004, 2005
48
   Ibid.
49
   Alwan, Dr. Ala‟din, Health in Iraq: the Current Situation, Our Vision for the Future and Areas of Work, MoH, 2nd
Edition, December 2004
50
   UNICEF/WHO, Iraq Social Sector Watching Briefs: Health and Nutrition, Juan Diaz and Richard Garfield


                                                                                                                     15
Institution concluded that 12,000 physicians have left Iraq since the beginning of the 2003 invasion,
representing more than one-third of all registered physicians. An additional 2,000 have been killed51.
Often perceived as members of the elite, Iraqi doctors have increasingly been threatened, attacked and
kidnapped for ransom. According to UNAMI‟s HRO Report for the period 1 May – 30 June 2006, an
estimated 250 Iraqi doctors were kidnapped between May 2003 and June 2006. In addition, the Iraqi
MoH reports that, during the same period, 102 doctors, 164 nurses and 142 non-medical staff were
killed. And finally, due to the proliferation of weapons, medical staff face insecurity inside the
hospitals, including pressure by militias to sign certificates or to prioritise treatment52.
The flight of experienced medical personnel has resulted in many hospitals now being chronically
understaffed and medical residents undertaking medical operations they are not yet qualified to
perform. The departure of experienced physicians also leaves a void of trainers for the country‟s up-
and-coming health professionals, which threatens to prolong the human resources crisis in the
country‟s health sector. “The displacement of doctors and other health care professionals, coupled
with lack of adequate facilities, equipment and shortages in medicine, have resulted in an overall
decline in the quality of medical services”53.
By 1999, the Two-Year Assessment and Review Exercise of the Security Council Resolution 986
operation estimated that the reconstruction of the health care system in Iraq required investments of
US$ 2 to 3 billion54.
Before the start of the war in 2003, the public medical system in Iraq included 282 hospitals; 1,570
PHCCs; 146 warehouses; 14 research centres and 10 drug production plants. Even then, few
institutions had facilities and staff to provide triage, trauma and emergency medical care. The MoH
maintained blood-bank facilities solely within central urban facilities55.
In addition to the more general problems that affect the entire population‟s access to adequate health
services – to some degree or the other – serious problems persist at a more specific level with the
availability and quality of health services available to women, including pre- and post-natal care,
reproductive health, cancers specific to women, etc.




51
   The Brookings Institute, Iraq Index: Tracking Variables of Reconstruction and Security in Post-Saddam Iraq, 5
October 2006
52
   UNAMI Human Rights Office, Human Rights Report, 1 May to 30 June 2006
53
   ABA/ILDP, The Status of Women in Iraq: Update to the Assessment of Iraq‟s De Jure and De Facto Compliance
with International Legal Standards, December 2006
54
   UNICEF/WHO, Iraq Social Sector Watching Briefs: Health and Nutrition, Juan Diaz and Richard Garfield
55
   Ibid.


                                                                                                            16
BARRIERS TO HEALTH CARE

1. THE DETERIORATION OF THE SECURITY SITUATION THAT LIMITS ACCESS TO HEALTH
    SERVICES

Attacks on Health Facilities and Health Personnel (HRO Human Rights Report)
11 December 2007 – the Director of al-Rashad Hospital for Mental Illnesses was gunned down in the
Baladiyyat area of Baghdad.
Between 2003 and March 2007 - According to the Brookings Institution, 12,000 out of 34,000 doctors
had left Iraq, 250 had been kidnapped and 2,000 killed.
25 September 2006, the Minister of Health and the Diyala Governor survived assassination attempts.
April 2007 edition of the British Medical Journal - In an article entitled, „Exodus of Medical Staff
Strains Iraq‟s Health Facilities‟, it was reported that 14 staff members and volunteers from the Iraqi
Red Crescent Society had been killed and 45 abducted (whereabouts of 12 remain unaccounted).
Between April 2003 and the end of May 2006 - MoH reported that 102 doctors and 164 nurses were
killed and 77 wounded; 142 non-medical staff (drivers, guards, administration personnel) were killed
and 117 wounded.
In May 2006 alone, eight doctors were killed and 42 wounded; eight nurses were killed and seven
wounded and, among non-medical staff, six were killed and four wounded.
The Medical Association in Mosul informed UNAMI HRO that, since April 2003, at least 11 doctors
had been killed while another 66 had left the city.
Mosul, 8 May 2006 - Unknown gunmen arrived in two private cars to the Al-Zayzafon pharmacy,
opposite Al-Khansa hospital in Al-Sukar district. The men took the pharmacist and executed him in
public before setting the pharmacy alight.
Mosul, 15 May 2006 - In Garage Al-Shemal area, unknown gunmen assassinated a doctor as he was
leaving his private clinic. Two other doctors were said to have been killed the same week in Mosul.
According to the MoH in the KRG, between January 2006 and December 2007, at least 53 Arab
medical doctors from other parts of Iraq were employed in the Region. The figure did not include
other doctors who migrated to the Region to work as private practitioners or in other jobs.
9 April 2006, a group of armed men gunned down the Director of the Ear, Nose and Throat Centre at
the University of Baghdad at the door of his clinic.
As a result of the violence, many health workers left the country or relocated to safer areas. In western
regions of Iraq, where ongoing military operations have resulted in increased number of casualties,
hospitals reported a lack of adequate supplies, military surveillance of medical facilities and
intimidation and harassment of medical personnel. UNAMI‟s HRO reports that health workers state
that they failed to receive adequate protection during military operations and they were unable to carry
out their work in safety.
Apart from threats to their personal safety, health care providers faced difficulties in carrying out their
work because of the limited supply of electricity and the growing number of patients due to the
increase in violence. Furthermore, because of the proliferation of weapons, doctors and nurses faced
insecurity inside the hospitals, the kidnapping of patients, pressure by militias and other armed forces
and groups to prioritise treatment. Corruption in hospitals was also noted as one of the obstacles for
access to health by the population.
The attacks against health care providers, their displacement to safer areas of the country or to other
countries, coupled with the lack of adequate facilities, equipment and shortages in medicine reportedly
resulted in an overall decline in the quality of medical service.



                                                                                                       17
The closure, deterioration and destruction of health care facilities and infrastructure during military
operations, including the use of or direct attacks by military actors are all issues that limit the number
of bed-spaces and the level of health-care available to Iraqis. There are specific articles in
International Humanitarian Law on medical neutrality (see ICRC database on IHL for the specific
provisions in 1949 Conventions and in the two 1977 Additional Protocols)
Between 1 July and 31 December 2007, UNAMI HRO recorded three separate attacks on civilian
hospitals; a mortar attack on al-Sadr Hospital in Basra (24 July); an attack by unknown gunmen on a
hospital in western Baghdad (22 September); and a hijacking by unknown actors of an ambulance
carrying eight passengers in Ba‟quba in Diyala governorate (16 September).
Security events that limited access to health facilities (UNAMI HRO Human Rights Reports)
November 2006, HRO submitted an official memorandum to MNF-I Chief of Staff, Maj. Gen.
Thomas L. Moore, Jr., requesting information on a number of incidents involving MNF-I activities in
Ramadi and Fallujah, including the use of hospitals as military bases. According to the Ramadi
General Hospital, in the first week of November, MNF-I snipers were reported as having allegedly
killed 13 civilians. For several months, patients refrained from using the hospital for fear of snipers
allegedly placed on the hospital roof, in addition to the military occupation of the hospital garden.
Between September and October 2006, military operations by MNF-I and Iraqi Security Forces in
Ramadi continued to affect the local population. The Iraqi forces occupied the garden of the local
hospital and used it as a recruitment centre. Adjacent residents, fearing being caught in cross-fire,
evacuated their homes. MNF-I snipers were reportedly placed over civilian houses, on high buildings
and on the roof of the Ramadi Faculty of Medicine and General Hospital. As a result, most medical
staff and local population were reluctant to access these facilities and some patients sought treatment
in Tikrit General Hospital, Salaheddin Governorate, some 100 kilometres away.
5 July 2006, the MNF-I occupied Al-Ramadi Specialised Hospital because it allegedly harboured
“terrorists.” Following negotiations with health officials in Al-Anbar, the MNF-I left the hospital on
13 July but maintained an outdoor patrol.
1 November – 31 December 2005 report – HRO received reports that Tel Afar Hospital was occupied
by MNF-I and ISF forces for six months, limiting patients‟ access to the facility and putting the lives
of staff and drivers observed by insurgent forces entering the hospital premises at risk. Reports were
also received alleging that access to Ramadi Teaching Hospital was restricted for several months by
MNF-I roadblocks placed in the vicinity. The teaching hospital was reportedly searched on 8
November by the MNF-I claiming that they were looking for insurgents.
The HRO received numerous allegations that medical facilities were damaged and operations
otherwise disrupted by MNF-I raids, involving in some cases the detention of medical personnel.
October 2005 - According to reports from WHO, during military operations in Al Anbar Governorate,
medical doctors were detained and medical facilities occupied by armed forces. The UN raised this
issue repeatedly with the MoH on the basis that such actions are contrary to international law
governing armed conflict and in any event they constitute a denial of the protection of international
human rights law.
4 October 2005 - According to a report released by Doctors for Iraq (www.doctorsforiraq.org) on 10
November 2005, in the course of an attack on the city of Haditha in western Iraq, US and Iraqi
soldiers declared a curfew in the city and entered and occupied the hospital building; they occupied
the building for seven days, arrested the hospital‟s manager and another doctor. Medical personnel at
the hospital reported that the military used violence against doctors in the course of interrogations,
accusing them of being insurgents.
Doctors for Iraq Report (30 August 2005) - reports received from medical staff in Al Qaim Hospital in
western Iraq that a field clinic in Al Karablaa village was bombed. Medical staff at Al Qaim Hospital
also reported that the electricity at the hospital had been cut and that the Manager of the hospital had
closed the hospital temporarily because of the “unsafe conditions in the area”.



                                                                                                       18
As mentioned in „Background‟ above, the Iraqi health system is based on a centralised, hospital-based
approach. Therefore, in the absence of an outreach/PHCC system, combined with damages to
hospitals and other centralised facilities, the population‟s access to health services is immediately
reduced.
Insecurity is a major barrier to Iraqis‟ health. As of 2003, assessments estimated that security concerns
impede healthcare access for up to 50% of the Iraqi population56. Neither more recent figures are not
available nor sex-disaggregated data is available and, therefore, it is not possible to say with complete
accuracy if and to what extent this issue affects women and men differently. For example, some
reports emanating from Iraq suggest that men and boys, because of their gender roles and
responsibilities have more freedom of movement, while other reports have suggested that, due to the
fact that men and boys are more likely to be randomly rounded-up and detained, women have more
freedom of movement. However, the ABA/ILDP Study (December 2006) contains the results of
interviews with focal groups which suggest that Iraq‟s deteriorating security situation discourages
many more women from leaving their homes, thus restricting them and, in many cases, their children
from accessing the few health services that are available57.
Insecurity – real and perceived – has also reduced the number of women and men working in the
health sector. However, statistics are not available on the sex-disaggregation of medical personnel
over the period of the last five years and, therefore again it is not possible to say conclusively whether
the issue of insecurity, and other factors, has limited male and female medical personnel‟s access to
work to the same or to a greater or lesser degree.
Violence creates a steady flow of medical emergencies that diverts already over-stretched resources
away from health problems that are not viewed as critical, such as ordinary maternal care and
paediatrics. Once again, there is no concrete data on this but, if we look at the rising number of home
births and the level of maternal deaths, then we can have some idea of its impact. However, sex-
disaggregated figures for fatalities as a result of unattended injuries and sicknesses is also not
available so, once again, we are left to conjecture on the nature and extent of the gendered difference,
if any, in this regard.
There are a large number of credible reports that women have been victims of increased harassment
and violence58. One effect of this is that women‟s access to health care is constrained for both
themselves and their children.
While it seems that the majority of women and girls who experience sexual violence do not seek
medical care or pursue legal recourse due to the fear that this may provoke an „honour killing‟ or
social stigmatisation, where a woman does want to pursue a police investigation, which itself requires
forensic examination, or medical assistance, they are often hampered from seeking assistance because
“some hospital staff do not regard treating victims of sexual violence as their responsibility, or give
such care low priority given their limited resources due to the war and its aftermath”59.
As Human Rights Watch (HRW) states in their July 2003 report „Climate of Fear‟60, “insecurity
affects women‟s and girls‟ access to health in complex ways”; they may have greater difficulties in
accessing routine and preventative health care, including reproductive health care, when they are
dependent on male family members to escort them to health facilities. In addition, women and girls
who do make it to the health facility may find that female medical personnel are staying home due to



56
   UNICEF/WHO, Iraq Social Sector Watching Briefs: Health and Nutrition, Juan Diaz and Richard Garfield
57
   ABA/ILDP, The Status of Women in Iraq: Update to the Assessment of Iraq‟s De Jure and De Facto Compliance
with International Legal Standards, December 2006
58
   GenCap Gender Advisor / UNAMI Information Analysis Unit, GBV in Iraq: The Effects of Violence – Real and
Perceived – on Women, Men, Girls and Boys, June 2008
59
   Human Rights Watch, Climate of Fear: Sexual Violence and Abduction of Women and Girls in Baghdad, July 2003
60
   Ibid.


                                                                                                          19
insecurity “leaving them to choose between foregoing treatment or accepting treatment from a male
doctor who may lack appropriate expertise or sensitivity”61.
The denial of or delay in medical treatment for victims of sexual violence may deprive a women or
girl from access to medication to treat STIs that, untreated, can result in infertility.
In the course of their research for the 2003 report, HRW spoke to medical personnel in the Maternity
Hospital in Baghdad who confirmed that they do treat victims of sexual violence. However, HRW also
spoke to and documented several cases of women and girls who sought medical assistance but who
were turned away from the Maternity Hospital, other hospitals in Baghdad and from the Institute for
Forensic Medicine.
The Institute of Forensic Medicine is the only institute that conducts forensic examinations upon
official referral. The Institute turns away victims who present without the required referral. The
Institute does not provide any medical assistance; the victim must go to a hospital for medical
treatment, enduring, it may be presumed, another possible round of questions and examinations. The
need to obtain an official referral from the police places a significant burden on women and girls who
do not want to report the incident but do want to obtain medical treatment.
In terms of psychological and social health support for Iraqis who are distressed by the security
situation, in „Iraq Watching Briefs: Health & Nutrition‟ (July 2003), WHO and UNICEF note that
“[i]nformation on mental health status is limited to that which is available via the services provides by
the two mental hospitals in Baghdad and wards in several other regional centres. This provides no
information on the magnitude of need, coping mechanisms or adaptation methods for any population
groups” (pg. 23).
In an IRIN report dated 24th May 2007, it was stated that mental health specialists in Iraq say that
there has been an increase in domestic violence against children predominately as a result of the way
that the violence that has gripped Iraq since the conflict began in 2003 has affected people‟s
behaviour. According to Ala‟a al‟Sahaddi, Vice-President of the Iraq Psychologists Association (IPA),
the majority of the perpetrators of violence against children are the children‟s own parents, with
parental punishment becoming increasingly harsher. Ibrahim Abdullah, a psychiatrist and member of
the National League for the Study of Health Disorders (NLSHD) reported that the majority of the
children he sees are suffering from PTSD and exhibit “disturbed behaviour”. There are, reportedly,
only 40 psychiatrists or psychologists in Iraq, as the majority of them have fled the country. The IRIN
reports goes on to say that, in a privately-funded study, „The effects of war on psychological distress‟
by the IPA with the support of the NLSHD in Baghdad, Anbar, Diyala and Babil governorates, of the
2,500 families interviewed, 87% had observed a family member with psychological distress; 91% of
the children interviewed said they faced more aggression at home than before the onset of the conflict
in 2003; and nearly 38% had serious haematomas after beatings.
In 2004, the MoH identified high rates of depression, anxiety and somatisation (the manifestation of
mental illness in physical symptoms62. In addition to mental illness, related behavioural problems,
such as domestic violence against spouses and children, and acts of public violence greatly increase in
conflict and post-conflict situations63
In May 2008, UNICEF released a report based on the results of a rapid assessment by their partner
IMC of parents, children and teachers in Sadr City Sectors 1, 2 and 6, involving formal interviews in
schools and homes of 120 individuals. The report contains the results of the assessment and
recommendations for providing assistance to those affected by the then recent violence in the city.


61
   Ibid.
62
   Ministry of Health (2004) Mental Health Programme in Iraq: Summary of Situation Appraisal, Recommendations
and Implementation Plans, cited in MEDACT (2004), Enduring Effects of War: Health in Iraq, pg. 4
63
   WHO (2002) World Report on Violence and Health cited in MEDCAT (2004) Enduring Effects of War: Health in
Iraq, pg. 4


                                                                                                         20
While the report focuses on (non sex-disaggregated) children, there are some revealing findings which
most certainly be equally applied to (again, non sex-disaggregated) adults;
   Ongoing violence and insecurity has curtailed children‟s mobility severely, preventing them from
    going outside their homes to play or interact with other children. A childhood lived in such
    conditions, deprived of basic needs and filled with restrictions, threats and violence impacts
    negatively on a child‟s emotional and behavioural development. Filled with feelings of fear,
    anxiety and uncertainty, children and young adults struggle to cope with a range of psychosocial
    problems created by the breakdown in their living conditions and the social networks that
    normally protect them.
   Parents acknowledged feelings of helplessness and inability to help children cope with the
    situation, both in terms of material and emotional needs.
   Parents indicated that the greatest needs for children include:
        o Open and safe places for children to play;
        o Basic food items and vitamins to meet child-specific nutrition needs;
        o Good education;
        o Playgrounds and sports centres;
        o Extra-curricular education activities and cultural centres.
   Teaching personnel also indicated that the most pressing problems facing their students include
    the lack of security and basic services, lack of healthy food and basic health issues. The children
    identified as most vulnerable are orphans and those coming from families with extremely low
    socioeconomic status.
   Teachers requested training in mental health, which would provide them with the skills they need
    to identify and support children with traumatic stress disorders.
   Children were asked how life was different for them during the increased insecurity and conflict.
    They consistently mentioned the shooting and military presence as well as the increased stresses
    they see among their adult family members.
   Currently, IMC noticed that children‟s main coping mechanisms come from their own families.
    Most children stated that when they are sad or angry they talk to a parent, an older sibling or
    another family member. Several children stated that they wished their parents and family
    members were happier or that they feel sad when their families are upset, indicating how
    dependent children are upon their immediate caregivers for support, particularly because the
    restricted lifestyle limits their social interactions with the rest of society.
   The majority of children and youth in conflict-affected areas have unaddressed basic needs for
    shelter, clean water, proper nutrition and security. Previous research by IMC suggests that
    between 30-40% will have more significant psychological symptoms and disorders in response to
    the disruption of their lives. Such disorders include depression, anxiety, post-traumatic disorders
    as well as other emotional and behavioural problems such as increased aggression, fear, anxiety,
    sleep disturbances, recurrent nightmares and phobias, bedwetting, anger and emotional ability.
    Very young children report more generalised fears such as stranger or separation anxiety,
    avoidance of situations, sleep disturbances, feeding problems and repetitive trauma focused play.
    Breakdown of social and family support combined with lack of routine and recreation places
    children and adolescents at the risk of psychosocial problems and mental health disorders.
While the rapid psychosocial assessment carried out by IMC for UNICEF is generally to be
welcomed, the report gives no sense of whether girls‟ and boys‟, women‟s and men‟s experiences of,
coping mechanisms for and responses to stress are the same and, if not, where the differences may lie.
This is an area that requires greater investigation in order to inform the most effective response.




                                                                                                    21
2. THE DETERIORATION IN HEALTH SERVICES AND STANDARDS

In its report of 17 August, 2007, IRIN quoted Dr. Ibrahim Khalil, a gynaecologist at al-Karada
Maternity Hospital who said that in emergency deliveries at the hospital one out of every six mothers
or newborns will die. The doctor went onto say that “Mothers are usually anaemic and children are
born underweight as a result of poor nutrition and lack of pre-natal care”. He added that, while there
are no official statistics, “we can see that the number [of such cases] has doubled since Saddam
Hussein‟s time”.
In the absence of district health centres and district health staff, women, especially women in rural
areas, faced with insecurity and violence on the roads, curfews and road blocks, will only attempt to
go to hospital as a very last resort64.
According to UNFPA‟s “Iraq Reproductive Health Assessment” (2003), each Iraqi woman bears on
average five children. Consequently, the economic sanctions of the 1990s had a devastating effect on
the health of the approximate 2,000 women who give birth on a daily basis in Iraq65. The maternal
mortality rate doubled between 1989 and 2004 and stood at 292 deaths per 100,000 in 200466.
Although statistics a year later in 2005 indicate that the maternal mortality rate fell to 250 deaths per
100,000, this number remains exceedingly high, especially in comparison with most developed
countries67. In addition, between 1990 and 2005, skilled attendance at delivery dropped while infant
mortality increased from 61 deaths per 1,000 live births to 88 per 1,000 live births.
The rate at which women access prenatal care is estimated to be less than 60%68 and less than 50% of
PHCCs are able to provide basic maternal and child health services due to lack of equipment and
qualified staff69.
The lack of trained professionals attending childbirths is a central issue to women‟s maternal health70.
As of 2003, it was estimated that only 70% of deliveries were attended by a trained health worker71.
The use of midwives is on the rise, particularly in poor and rural areas, but they may not be properly
equipped to deal with complications, with resulting fatalities. The MoH estimates that 30% of women
in urban areas and 40% in rural areas deliver without assistance from qualified personnel. Many
PHCCs lack basic supplies and equipment needed for antenatal services. Half of district-level
institutions to which high risk pregnancies are referred lack essential resources and trained staff72.




64
   IRIN, 17 August 2007
65
   McKenna, Megan, Preparing for War in Iraq: Making Reproductive Health Care a Priority, Women‟s Commission
for Refugee Women and Children. 2003, cited in ABA/ILDP, The Status of Women in Iraq: Update to the Assessment
of Iraq‟s De Jure and De Facto Compliance with International Legal Standards, December 2006
66
   Physicians for Human Rights, One Year Later: Iraq Reconstruction Efforts Show Gaps in Women‟s Health and
Trauma Recovery; Comprehensive Process for Justice and Accountability for Past Abuses Lagging, March, 2004, cited
in ABA/ILDP, The Status of Women in Iraq: Update to the Assessment of Iraq‟s De Jure and De Facto Compliance
with International Legal Standards, December 2006
67
     According to figures available at http://www.unicef.org/specialsession/about/sgreport-pdf/09_Maternal-
Mortality_D7341Insert_English.pdf, the maternal mortality rate in the developed world generally was less than 100 per
100,000 live births in 2001. The MENA rate in 2001 was over 300 per 100,000 live births, but this was likely skewed
by very high numbers in Yemen. Information cited in ABA/ILDP, The Status of Women in Iraq: Update to the
Assessment of Iraq‟s De Jure and De Facto Compliance with International Legal Standards, December 2006
68
   According to the Iraqi MoH, cited in WHO, Briefing Note on the Potential Impact of Conflict on Health in Iraq,
March 2003.
69
   UNFPA, Iraq Reproductive Health Assessment, 2003.
70
   ABA/ILDP, The Status of Women in Iraq: Update to the Assessment of Iraq‟s De Jure and De Facto Compliance
with International Legal Standards, December 2006
71
   United Nations/World Bank, Joint Iraq Needs Assessment – Health Working Paper, October 2003.
72
   Ministry of Health (2004) Health in Iraq: A Brief Review of the Current Health Situation and the Challenges Facing
Health Development in Iraq, cited in MEDACT (2004) Enduring Effects of War: Health in Iraq


                                                                                                                 22
Other maternal health problems identified include chronic iron-deficiency, estimated by the UNFPA
to be as high as 50–70% of all pregnant women in Iraq73. Other concerns include the lack of pre-natal
vitamin supplements, high rates of infection, high blood pressure and diabetes. Miscarriages,
infertility and congenital defects have reportedly been abnormally high since the onset of the Iran-Iraq
war and subsequent conflicts where the use of chemical weapons and depleted uranium were
common74.
According to UNFPA‟s 2003 Iraq Reproductive Health Assessment, Iraq has had an official policy of
providing family planning and contraception for the last 14 years. However, it is unclear to what
extent women are able to access family planning services. Amnesty International reported in 2005 that
almost one-third of family planning institutions were destroyed during 200375. Advances in family
planning methods are unavailable and neither healthcare providers nor Iraqi women are aware of
newer family planning options76. In addition, due to looting, lack of basic supplies and inadequate
training, over half of PHCCs no longer provide family planning services77. According to UNFPA
(2004), prostitution, now much more common as a result of increasing poverty and social breakdown
is associated with increased levels of STIs, including HIV78.
Breast cancer currently ranks as the most common type of cancer in Iraq79. Gynaecological care is
difficult to access for most of the population80 and the State no longer has the funding, equipment or
expertise to carry out routine examinations and diagnosis. In addition, there is little awareness
regarding the importance of self-examination for cancers81. As of 2005, radiotherapy facilities existed
in Baghdad and Mosul only, and drugs for cancer treatment were not usually available82. There are
reports that the MoH does keep statistics on the prevalence of the disease through a population-based
cancer registry established in 1976. However, the quality of the data and its usages remain unknown83.
Another area of concern relates to health services for adolescent girls and boys. Women‟s health
concerns are, more generally, defined as maternal health concerns and ignore those important years
between puberty and pregnancy and the period after reproductive years, including menopause.
Adolescent girls and boys may not be encouraged to seek medical assistance in an environment that
does not consider their specific medical needs. This is an area of life cycle health care approach that
must be considered.




73
   UNFPA, Iraq Reproductive Health Assessment, 2003
74
   ABA/ILDP, The Status of Women in Iraq: Update to the Assessment of Iraq‟s De Jure and De Facto Compliance
with International Standards, December 2006, pg. 45
75
   Amnesty International, Iraq: Decades of Suffering – Now Women Deserve Better, 2005
76
   UNFPA, Iraq Reproductive Health Assessment, 2003
77
   Ibid.
78
   UNFPA (2004) Gender Profile: Iraq cited in MEDACT (2004) Enduring Effects of War: Health in Iraq, pg. 4
79
   Alwan, Ala‟din, Health in Iraq: The Current Situation – Our Vision for the Future and Areas of Work, MoE, Second
Edition, December 2004, cited in ABA/ILDP, December 2006
80
   UNFPA, Iraq Reproductive Health Assessment, 2003
81
   Alwan, Ala‟din, Health in Iraq: The Current Situation – Our Vision for the Future and Areas of Work, MoE, Second
Edition, December 2004, cited in ABA/ILDP, December 2006
82
   UNFPA, Iraq Reproductive Health Assessment, 2003
83
   ABA/ILDP, The Status of Women in Iraq: Update to the Assessment of Iraq‟s De Jure and De Facto Compliance
with International Standards, December 2006


                                                                                                               23
3. ECONOMIC AND GEOGRAPHIC BARRIERS TO ACCESSING QUALITY HEALTH SERVICES
A fee-for-service based system of healthcare was first introduced in 1997. Currently, there is a charge
at public hospitals and public health clinics. All public health services, such as immunisation, prenatal
care and health education are provided free-of-charge at PHCCs. If available at all, many public and
private services, while subsidised, are often below acceptable standards.
Healthcare consultancy, treatments and medicines represent a significant cost in a country where the
average annual income was $800 in 2004. According to Lynn Amowitz and colleagues writing in the
American Medical Association in March 2004, an estimated 50% of the population uses the private
sector as a first choice despite the considerably higher cost by Iraqi economic standards84.
Longer waiting times for free medical services force many Iraqi women to forego medical care for
themselves and their families. Anecdotal reports suggest a disorganised healthcare system in which
appointments are not available. In addition, the shortage of supplies, equipment and medical
personnel, together with the large numbers of injured patients, often force patients to wait all day to
receive state-funded care. Substantial waiting times are particularly problematic for Iraq‟s ever
increasing number of widows and single/female-headed households, who lack anyone with whom to
share their childcare responsibilities85. Long waiting times can also be prohibitive for those Iraqi
women who must work to support their families. Even those who are able to wait for care find
themselves rushed through a health system unresponsive to their needs. In their June 2005 report, „Iraq
Health Systems Profile‟, WHO reports that doctors see between 30 and 100 patients during each three-
hour shift, making consultation times between two and six minutes per patient, the brevity of which
creates an increased risk of misdiagnosis and mistreatment of patients.
Transportation costs to reach services, especially for those in rural areas, add further to the cost of
healthcare. With the increasing number of widow/female-headed households, the burden of healthcare
for themselves, their children and other dependents has become ever more difficult for women.
Contraception is not considered essential and, therefore, is not fully covered by the State. Yet, as
reported above under health statistics, according to MICS III (2006), a total of 10.8% of married
women nationwide aged 15 – 49 years have an unmet need for contraception, with significant
geographical variation - highest unmet need (17.7%) is in Dohuk; lowest (5.9%) is in Basra.
The greater level of security in the Iraqi Kurdistan Region has led to relative benefits for its residents
in terms of the availability of resources and services in the health sector. According to the MoH in the
KRG, in 2006, at least 53 medical doctors from other regions of Iraq have been employed in
Kurdistan. This figure does not include doctors who have relocated to the region and are working as
private practitioners. Iraqi Kurdistan-based respondents in the American Bar Association/Iraq Legal
Development Project surveys in 2006 reported that many of the health sector problems they witnessed
following the 2003 invasion improved significantly since 2005. Respondents referred to the arrival of
new equipment, the increase from one to three in number of intensive care units, and the availability
of internal heart surgery as evidence of general improvements in the quality of medical services.
In terms of women‟s health, Iraqi Kurdistan-based respondents in the 2006 ABA/ILDP survey also
reported that health centres specialising in maternal and post-natal care are free and available “all over
Kurdistan”. The greater level of security and mobility enjoyed by Kurdish women also means that
health care is more accessible to them than it is to women in other regions of the country. However,
despite these relative advantages, respondents to the ABA/ILDP survey acknowledged that the
standard of care still fails to meet their expectation.



84
   Amowitz, Lynn, Human Rights Abuses and Concerns about Women‟s Health and Human Rights in Southern Iraq,
American Medical Association, March 2004.
85
   ABA/ILDP, The Status of Women in Iraq: Update to the Assessment of Iraq‟s De Jure and De Facto Compliance
with International Legal Standards, December 2006, pg. 43


                                                                                                         24
4. DISPLACEMENT
In an article entitled „Iraq‟s Internally Displaced Persons: Scale, Plight, and Prospects‟ , Dana Graber
Ladek states that “[t]he majority of Iraqi IDPs (66% of those assessed by IOM) are unemployed and
without the means to cover basic needs such as rent, household goods, health care, rising fuel costs,
and even food. Some who are less fortunate must find shelter in abandoned buildings or build
makeshift housing on public land, facing the constant threat of eviction. These “homes” tend to be
overcrowded and lack basic services such as running water, electricity, or sanitation facilities”86.
In terms of food and nutrition, Graber Ladek, writing in the same article, reports that only 29% of
IDPs report regular access to the Public Distribution System (PDS) food rations and only 41% report
receiving food assistance from another source. In view of the fact that females usually outnumber
males in IDP (and refugee) situations, it is reasonable to extrapolate that women‟s and girls‟
nutritional levels are relatively more detrimentally affected.
In IDP environments, the lack of access to quality healthcare increases the spread of disease and
deterioration of chronic health conditions. In this regard, Graber Ladek goes on to state in the report
that 14% of IDPs who were interviewed reported that they have no access to healthcare services and
30% reported that they cannot access the medicines they require. While specialised health assistance,
such as gynaecology and reproductive health services, is difficult for all Iraqis to acquire, it becomes
even more elusive for IDPs.
Water shortages and the lack of access to potable water also affect IDPs‟ health and living conditions
negatively. Of the IDPs interviewed, 20% do not have regular access to water, a number that is likely
to increase with the periods of drought affecting Iraq this year, especially in the north.
In the same publication87, writing in an article called „Brain Drain and Return‟, Sasson states that
“[Iraqi professional] women also may be reluctant to return, as they tend to focus on access to health
care and education for their families and are often deterred by religious dogma and the associated
erosion of women‟s rights”.
Extrapolating from reports from the education sector that some Arabic-speaking IDP children are
being excluded from accessing education in Iraqi Kurdistan where Kurdish is the language of
instruction, it may be reasonable to assume that some Arabic-speaking IDPs in Iraqi Kurdistan may
have problems in making themselves understood where the health service is also functioning in the
Kurdish language.




86
   Iraq‟s Refugee and IDP Crisis: Human Toll and Implications, The Middle East Institute, Washington, DC,
http://www.mideasti.org/publications/iraqs-refugee-idp-crisis
87
     Ibid.


                                                                                                      25
5. CULTURAL FACTORS
Some cultural and social barriers also impede women‟s health and wellbeing. Early marriage is on the
increase, particularly in rural areas, jeopardising the reproductive and mental health of young girls
who may not be physically, mentally or emotionally prepared to give birth. Social and religious beliefs
sometimes prohibit the use of family planning and restrict women‟s ability to choose the spacing and
number of children in their families. Moreover, the preference for larger families compounds risks for
women when comprehensive maternal health services are not available.
Several respondents in the ABA/ILDP survey (2006) also noted that some women may receive lower
food quantities than the male members of their households, fuelling malnutrition rates among
women88. As of 2004, over 40% of adult males in Iraq are overweight, while chronic malnutrition and
anaemia was reported to be common in children, adolescents and pregnant women89.
Traditional notions of women‟s roles and preferential treatment of male members of the family may
also act as a barrier to women‟s and girls‟ health. A 2003 American Medical Association survey of
Iraqi women found that only 18% of Iraqi women surveyed reported that they were unable to obtain
healthcare without the approval of a male relative90.
There are reports that female genital cutting (FGC) has resurfaced in the northern part of Iraq.
Although the practice has serious consequences for women‟s long-term health, there appear to be no
specific law against the practice. Amnesty International has reported that midwives in Northern Iraq
regularly see women who have been cut and that doctors have carried out female genital cutting on
married women at their husband‟s request91.
The social stigma attached to crimes of sexual violence discourages many women from attempting to
access medical treatment for injuries, wounds and STIs. Reporting assaults and rapes can also lead to
other serious social and cultural consequences such as rejection or violence for having caused shame
to the family – „honour‟ crimes and killings (see „GBV in Iraq: The Effects of Violence – Real and
Perceived – on the Lives of Iraqi Women, Men, Girls and Boys‟ Report and database).




88
   ABA/ILDP, The Status of Women in Iraq: Update to the Assessment of Iraq‟s De Jure and De Facto Compliance
with International Standards, December 2006
89
   Alwan, Ala‟din, Health in Iraq: The Current Situation – Our Vision for the Future and Areas of Work, MoE, Second
Edition, December 2004, cited in ABA/ILDP, December 2006
90
   Amowitz, Lynn, Human Rights Abuses and Concerns about Women‟s Health and Human Rights in Southern Iraq,
American Medical Association, March 2004.
91
   Amnesty International, Iraq: Decades of Suffering – Now Women Deserve Better,2005


                                                                                                               26
UNCT’S RESPONSE TO HEALTH SERVICES – A REVIEW OF THE GENDER PERSPECTIVE

The Health & Nutrition SOT has emphasised equitable access to health services, the engagement of
women‟s representatives in policies, strategies and guidelines and promoting equity, rights-based
social justice and gender mainstreaming in the health sector within the UN Assistance Strategy 2008 –
2010 and, to a lesser extent, the CAP 2008. However, gender equality and women‟s empowerment
perspectives must be explicitly incorporated in all planned outputs, as set out in the recommendations
on page 11 of this paper.


                                       HEALTH AND NUTRITION
                  By 2010, health- and nutrition-related programmes enhanced to ensure 20% increase
    Outcome 1     in access to quality health care services with special focus on vulnerable groups
                  Policies, strategies and guidelines related to health and nutrition developed if required;
    Output 1.1    review based on standard human rights and principles.
                  Institutional and personnel capacity of health/nutrition and related programmes
    Output 1.2
                  strengthened for improved quality service delivery.
                  Enhanced functional capacity of health and health related facilities and institutions
    Output 1.3
                  (services) in low coverage areas (rehabilitation and procurement).
                  Empowered and engaged local communities and private sector to enhance equitable
    Output 1.4    access to health and nutrition services with special focus on missed opportunities in
                  access to health.
                  Enhanced monitoring and evaluation mechanisms in place to track progress and
    Output 1.5    identify gaps in the provision of health and nutrition services with special emphasis on
                  the un-reached.
                  Emergency preparedness and response. Access to basic health services to the most
    Output 1.6
                  vulnerable people affected by the ongoing humanitarian crisis assured.

General observations on the strength of the gender perspective in the CAP 2008 and the UN
Assistance Strategy (2008 – 2011) health section:
     While reference is made in the analysis narrative (CAP 2008, pgs 21-22) to the effect of conflict
      on the mental health and emotional stress of “victims and their communities, especially women
      and children”, there is no analysis or explanation as to the need for a special focus on women and
      children in this regard.
     There is no attempt within the analysis to consider the different health care needs of women, men,
      girls and boys.
     Despite the fact that the “provision of reproductive health and emergency obstetric care services”
      is listed among the six activity areas, there is no corresponding baseline or indicator included to
      measure progress in this regard.
     The health sector is an important entry point for addressing issues of GBV. However, despite the
      inclusion of UNFPA‟s project on „saving women‟s life and dignity: increase access and utilisation
      of basic and comprehensive emergency obstetric care/reproductive health services, and
      counselling for GBV victims at 30 PHCCs and ten district hospitals‟, WHO/IMC/UNIFEM‟s
      project on „Emergency Assistance for victims of injuries and violence – mental health and
      psychosocial services in CAP 2008, there is no analysis, objectives, activities or indicators
      included on GBV in the UN Assistance Strategy 2008 – 2011 and minimal references in the CAP
      2008.
     There is an absence of sex-disaggregation in most of the project sheets, both in terms of the
      analysis of need and in the proposed activities, expected outcomes and indicators;



                                                                                                        27
   While there are references to the collection in health facilities of data related to GBV, there is no
    mention of the development and use of protocols for the ethical research, documenting and
    monitoring of GBV or of Standard Operating Procedures for the care of survivors of GBV.
   The Health and Nutrition Sector‟s Assistance Strategy will “provide support to improve the
    performance of the national health system and provide equal access to services, with special
    emphasis on vulnerable, marginalized and excluded individuals and families”. It is suggested that
    there is a small but significant amendment that needs to be made to this comment, which should
    in fact read “provide support to improve the performance of the national health system to provide
    equal access to services, with special emphasis on vulnerable, marginalized and excluded
    individuals and families”. In addition, while recognising the space limitations of the actual UN
    Assistance Strategy document, the issue of vulnerability, marginalisation and exclusion needs
    further exploration and definition and must include a gender analysis.
   In terms of advocacy, under the UN Assistance Strategy, the Health & Nutrition SOT undertakes
    to “assist in developing position papers on: governance, financing, human resources, health care
    delivery, drug policies, promoting equity, ‘rights-based’ social justice, gender mainstreaming
    and the allocation of resources in the health sector (emphasis added”. It is proposed that this paper
    and the recommendations herein is a „starting point‟ on the development of a gender equality and
    gender mainstreaming position paper.




                                                                                                      28

								
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