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Rehabilitation under fire: Health care in Iraq 2003-2007

Countries
Iraq
Sources
Medact
Publication date

(extract)

A health system under pressure

The demands on the Iraqi health system have increased considerably since 2003, including trauma and mental illness. Numerous reports document poor and generally deteriorating health. Collection of accurate health information is extremely difficult in a country described as currently the most violent and dangerous place on our planet (Global Peace Index 2007), but reputable studies suggest:

- High conflict-related mortality and morbidity (eg Burnham et al 2006, UNICEF 2007).

- Death rates of children under five sliding towards those of sub-Saharan Africa (Save the Children 2007).

- Eight million Iraqis in need of emergency aid (Oxfam/NCCI 2007).

The duty of the state to meet this demand is recognized in Iraq's 2005 constitution: 'The State takes care of public health and provides the means of prevention and treatment by building different types of hospitals and medical institutions.' However, the obstacles are formidable.

The health-supporting infrastructure, already in a fragile state following over 20 years of conflict and sanctions, was severely damaged by the invasion and subsequent looting. Despite some rehabilitation efforts, the provision of health care has become increasingly difficult since 2003. Doctors and nurses have emigrated en masse, exacerbating existing staff shortages. The health system is in disarray owing to the lack of an institutional framework, intermittent electricity, unsafe water supply, and frequent violations of medical neutrality. The Ministry of Health and local health authorities are mostly unable to meet these huge challenges, while the activities of UN agencies and nongovernmental organizations are severely limited.

User fees were eliminated in 2003 in line with the Coalition Provisional Authority's initial policy of care free at the point of delivery. They were quietly reinstated, however, as the negative knock-on effects of reduced flexible income on salaries and local purchasing had not been anticipated. The total health expenditure rose from US $23 per capita in 2003 to $58 in 2004 (the latest year for which figures are available), nearly half of it out-of-pocket payments (WHO 2007a). The Ministry of Health was unable to spend all of its budget in 2006-7 owing to bureaucratic obstacles and difficulties with imports.

Against this backdrop, the provision of basic, sustainable health services is very challenging. 'Iraqi hospitals are not equipped to handle high numbers of injured people at the same time,' says Dr Ali Haydar Azize, Sadr City Hospital (IRIN 2007a). Junior staff frequently perform procedures beyond their competence (Iraqi Medical Association 2007), while families usually provide nursing care. Professional expertise is in even shorter supply in remote and rural areas, and in primary health care. Many routine treatments are not available, including for chronic conditions like asthma and diabetes. Those who can afford it travel abroad - often to Jordan or Syria - to be treated at great risk and expense by Iraqi doctors practising privately.

The unregulated health economy, the need to maximize professional income, and the individualistic, specialty-focused traditions of Iraqi medicine are creating a fragmented fee-for-service system mainly delivering curative care. This cannot meet basic health needs effectively, and is beyond the average citizen's pocket.