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									                              HEALTH SECTOR

   Health and Health Care System in Iraq: An overview and Options
                                                    for the Future

                                Iraq Health System: Historical Background
                                                       Overview of Health Care in Iraq

 A formal health care system in Iraq began with British occupation following the end
of the First World War in 1918. In 1921 the first Directorate of Public health Services
 was formed which was upgraded to become a Ministry of Health in September of the
        same year. It was annexed in the following year to the Ministry of Interior as a
 Directorate. In 1952 the Ministry of Health was re-established and its organizational
 structure was formalized in 1959. The basic organization structure has changed little
                                                              since then. See Figure 1.

          In 1978, Iraq signed the Alma-Ata Declaration on Primary Health Care and
     strengthened the Department of Preventive Medicine through the construction of
                                             health centers throughout the country.

     In 1981, a Public Health Law was enacted. It stated that health is a right for each
      citizen and the responsibility of the state to provide all means to promote health
         prevent and treat diseases. The main functions of the Ministry of Health were
                                                                            described as:

                          Establishment and management of health facilities.       
                                          Control of communicable diseases.        
                        School health and maternal and child health services.      
                                                     Promotion of nutritional      
                                          Provision of mental health services      
                      Supply of drugs, vaccines, sera and other medical goods      

     Referral systems, communications, and training to integrate health centers into a
  primary care strategy were planned for in the early 1980s. These plans were put on
                                                               hold when war began.

 Services are provided by 269 hospitals (public and private), 1570 health centers, 308
health insurance clinics, 254 chronic illness pharmacies and 32 special pharmacies for
                                                                            rare drugs.

Most health services are provided by MOH facilities. The private sector constitutes a
          rising minority of all beds and medical visits. Hospitals are managed by the
Directorate of Technical Affairs. Outpatient care is managed by Directorate of Public
 Clinics. These afternoon clinics charge nominal fees and dispense drugs for patients
                                        registered in the chronic illnesses card system.




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    Preventive services and the management of health centers is the responsibility of the
        Directorate of Preventive Medicine’s Primary Health Care Department. “Health
       insurance clinics” are public clinics in rural areas where new graduates provide 2
                                                                   years of social service.

                               Most of the country’s 110 specialized centers are Baghdad.

                                                              Health Care Resources

The doctor to population ratio increased from 1977 to 1998 but was still low at 4.7 per
       10,000 compared to most other countries in the region with ratios above 10 per
    10,000. Nurses per population were always lower, and fell off precipitously after
  foreign workers left in 1990. There are 3.0 nursing staff per 10,000 people; in most
    countries there are 3 – 6 nursing personnel per physician. More than a third of the
   physicians are specialists, while less than a third of the nurses were trained in post-
                                                                   high school programs.

         The bed to population and PHC to population ratios were also low compared to
          regional averages. There are 12 beds per 10,000 population. Iraq is one of the
     countries in the region with a low bed to population ratio. The distribution of beds,
        primary care visits, and doctors is very equitable across all governorates, but the
     services offered are often not the appropriate ones for the country’s disease profile.
    Only 550 a third of the country’s more than 1,700 public hospitals and health centers
                                        are equipped to provide emergency obstetric care.

                           Public Visits per 1000 Persons, 2000
                                                                    PHC
                    Emergency        Specialized Centres           Centres         Total
     Baghdad          151.6                 123.2                   671.6           946
       Basrah         212.7                  27.3                   726.2           965
       Ninewa         188.7                  28.5                   947.8          1166
      Maysan           78.3                  13.4                   708.9           800
    Qadissiyah        195.4                  23.4                   650.8           869
        Diallah        86.8                  105                    548.3           740
         Anbar        130.9                   1.3                   513.5           646
          Babil       161.7                  24.3                   348.1           388
       Kerbala        145.7                  28.7                   355.6           531
        Tamim         203.4                  59.6                  1040.8          1304
         Wasit        120.1                  208                    723.4          1051
        Thiqar        130.5                   0.8                   551.6           683
      Muthena         171.3                  47.4                   468.3           586
       Saladin        105.4                    4                     961           1070
          Najaf        81.4                   0.5                   388.1           470

              All      147.5                  42.5                   650.2          840


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                                                                        Financing
Until 1997 when the self financing system was introduced, health care services were
financed entirely by the central government. Services were generally provided free of
charge in hospitals, outpatients and dispensaries.

Per capita public health expenditure was projected by WHO in 2000 as $65 public and
  $40 private. Self-financing probably shifted this from 60/40 to 40/60 public/private
  expense ratio. Quality of services did not notably improve but medical incomes up
                         and funding of recurrent expenses became more sustainable.


Health Status
With respect to infant mortality rate, Iraq ranked 104th among the 176 states in 1978
while Jordan ranked 88th. In 1998, Iraq ranked 149th while Jordan ranked 72nd.
Regarding maternal mortality, of 159 countries Iraq ranked as 101st and Jordan ranked
                                                                               as 78th.

Infectious diseases rose notably in the early 1990s. The system of notifable diseases
only partly recorded this change. Immunization services improved in the latter part of
the 1990s, and the reported number of vaccine-preventable diseases declined
                                                                          somewhat.




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                  Vaccine Preventable, Notifiable Diseases, 1989 - 2001
100,000
                                                                                   Diphtheria



                                                                                   German
 10,000                                                                            Measles

                                                                                   Meningitis


  1,000
                                                                                   Mumps



                                                                                   Neonatal
                                                                                   Tetanus
   100

                                                                                   Pertussis



       10                                                                          Poliomyeliti
                                                                                   s

                                                                                   Tetanus

       1
            1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001




   Developmental Priorities
        A decentralized approach to health care services would put the Ministry of Health as
       in a place to “steer more, row less”. District health authorities (DHA) are responsible
        for planning and delivery of health services for each governorate. The DHA should
              be provided with sufficient authority with accountability to improve quality of
                                                                                      services.

       Such decentralization should only proceed after careful study, capacity development,
         and in the context of political and organizational development of the state. For the
       short term, capacity of the existing system should be strengthened and key aspects of
                                    the system should be identified for possible later reform.

   Since health is not the sole responsibility of health, a national body should be assigned
   responsibility of formulating a national health policy. A prepayment scheme would
                                                                improve fairness and equity.

   The current dichotomy between the institutions responsible for production of different
   categories of health manpower (mainly the Ministry of Higher Education) and the
   beneficiaries of such manpower (mainly the Ministry of Health) needs to be bridged.
   This could be achieved by the establishment of a joint body composed of


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representatives of different stakeholders to monitor training programmes and to make
sure that training objectives are relevant to community health needs. Such a body
should establish standards of practice.

A health research policy is needed. Health system research should be prioritized.
The formation of a health research council as an independent body could be a step in
that direction.

A health information system is needed. It should include indicators of: death rate
after 48 hours of admission to a hospital, rate of nosocomial infection, postoperative
infection rate, infant death rate in a paediatric ward, maternal death rate and others.



References:

The Health Status of Iraq in half a Century 1981

Public Health Act, Ministry of Justice 1981

                             1977: Statistical Compass, Ministry of Health, Iraq, 1977

       1990-1998: Arabic Council Health for Childhood and Development, Statistical
                                                                  Report. 2001.




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