Access to Quality Health Care in Iraq - A Gender and Life-Cycle

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 Introduction Executive Summary Health Statistics Four Dimensions of „Accessibility‟ Recommendations Background Barriers to Accessing Health Facilities and Services 1. Deterioration in the Security Situation, including Psychological and Social Impacts 2. Deterioration in Health Services and Standards 3. Economic and Geographical Barriers 4. Displacement 5. Cultural Issues  UNCT Response to Health Services – a review of the gender perspective 3 4 5 7 10 11 14 17 17 21 24 25 26 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. 2. 3. 4. 5. The deterioration* in the security situation, including the psychological and social Impacts; The deterioration* in healthcare services and out-dated standards; Economic and geographical barriers; Displacement; 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 addre sses 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 cycle 2 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 suffering 3. 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 welltrained 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 governorates 6.  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 infections 7. 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 age 11. 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 refuge 12,13,14. 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 data 15.   Infant mortality rate: Estimated at 35 per 1000 live births 16. Under-five mortality rate: Estimated at 41 per 1000 live births 17. 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 water 19. 23% of children in southern Iraq are chronically malnourished 20. 25.9% of children under five in Iraq suffer from stunted growth 21. 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 violence 22 and over 30% of the refugee children surveyed said they had no hope for the future 23. Male gynaecologists are being targeted for violence and intimidation by Islamic extremists, accused of invading the privacy of women 24. 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 abroad 25.  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 needs 26. Ten percent of Iraqis in Lebanon suffer from chronic disease 27. The two main clinics that service Iraqi refugees in Amman do not have medicine to prevent pregnancy or HIV transmission for rape survivors 28. Mental health care is also generally not available for Iraqis in Jordan who survived or witnessed violence 29. 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 considered 31. 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 healthnursing 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 studied 35. 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 33 Interview with Dr. Georges Georgi, UNFPA Representative, Iraq Programme, Amman, 12 August 2008. Adapted from Iraq Watching Briefs: Health and Nutrition, WHO and UNICEF, July 2003 34 Ibid. 35 Ibid. 11 Outcome 1 Output 1.1 Output 1.2 Output 1.3 Output 1.4 Output 1.5 Output 1.6 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 vulnerable groups and on women’s reproductive health and family planning services. Policies, strategies and guidelines related to health and nutrition developed if 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 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 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 awarenessraising 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 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 genderspecific 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 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 wellequipped 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 healthcare 36. 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 years 38. 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 doubled 42. 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 sanctions 43. 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.undppogar.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 children 45. 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 operational 46. 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 years 48. In addition, while there are approximately 1,700 functioning PHCCs in Iraq, only half of these are staffed by at least one medical doctor 49. Assessments carried out by WHO indicate that approximately 12% of hospitals were damaged in the 2003 war 50. 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 killed 51. 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 treatment 52. 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 upand-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 facilities 55. 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 li mit 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 population 56. 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 available 57. 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, sexdisaggregated 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 violence 58. 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 57 UNICEF/WHO, Iraq Social Sector Watching Briefs: Health and Nutrition, Juan Diaz and Richard Garfield 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 medi cal 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 24 th 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 symptoms 62. 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 situations 63 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 62 Ibid. 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 resort 64. 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 2004 66. 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 countries 67. 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 health 70. As of 2003, it was estimated that only 70% of deliveries were attended by a trained health worker 71. 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 staff 72. 64 65 IRIN, 17 August 2007 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_MaternalMortality_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 Iraq 73. 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 2003 75. Advances in family planning methods are unavailable and neither healthcare providers nor Iraqi women are aware of newer family planning options 76. In addition, due to looting, lack of basic supplies and inadequate training, over half of PHCCs no longer provide family planning services 77. 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 HIV 78. Breast cancer currently ranks as the most common type of cancer in Iraq79. Gynaecological care is difficult to access for most of the population 80 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 cancers 81. As of 2005, radiotherapy facilities existed in Baghdad and Mosul only, and drugs for cancer treatment were not usually available 82. 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 unknown 83. 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 74 UNFPA, Iraq Reproductive Health Assessment, 2003 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 standards 84. 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 responsibilities 85. 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 threehour 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 women 89. 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 relative 90. 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 request 91. 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 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; review based on standard human rights and principles. Institutional and personnel capacity of health/nutrition and related programmes strengthened for improved quality service delivery. Enhanced functional capacity of health and health related facilities and institutions (services) in low coverage areas (rehabilitation and procurement). 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. 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. Emergency preparedness and response. Access to basic health services to the most vulnerable people affected by the ongoing humanitarian crisis assured. Outcome 1 Output 1.1 Output 1.2 Output 1.3 Output 1.4 Output 1.5 Output 1.6 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 he alth 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