Resuscitating Iraq’s healthcare

Iraq’s healthcare system faces severe shortages in many critical areas – doctors, equipment, and medication. Nonetheless it has managed, against all odds, to maintain a functional health service throughout the war, and now, with the appointment of the new minister of health, appears to have turned the corner on the road to recovery. Callan Emery speaks to Dr Adel Abdullah, the inspector-general for the Iraqi Ministry of Health, about the current state of affairs.

Dr Adel Abdullah, the inspector-general for the Iraqi Ministry of Health knows his figures. In fluent English (he lived in the United Kingdom for many years and returned to Iraq in 2003) he rattles off the number of nurses, doctors, hospitals and clinics across the country with an ease as if he were counting from one to ten. “These figures are important,” he says. “They are proof of the state of healthcare in the country.” And what is the state of healthcare in Iraq? According to the doctor it is quite a bit better than one would expect based on the numerous news stories which, in large part, cast a gloomy picture of a failing health system in a war ravaged country.

“It is not so,” he says. “And of this I am very proud! When most other government services fell apart in the war, the health services maintained. The doctors and nurses came to work everyday in extremely difficult conditions and, in many cases, with no pay for months.”

Callan Emery: Can we start with a bit of background? Does the MoH cover the entire Iraq, including Kurdistan?
Adel Abdullah: Yes it does. But Kurdistan is independent in a sense that they have their own budget, own recruitment and their own policies. The rest of Iraq is completely under the MoH.

CE: I know a lot of doctors have left the country. Can you give me an indication of the numbers?
AA:We currently have 15,500 doctors in Iraq. Approximately 8,000 left during the war.

CE: How many doctors do you need to reach capacity?
AA: Well it depends what system we implement. But if we use the GP-referral system like they do in the UK, for example, we will need around 60,000 doctors.

Let me give you more figures. They are all from 2007. We have 217 hospitals in Iraq, including Kurdistan. We have 1,910 Primary Healthcare Centres; 31,000 nurses; 36,000 paramedics – that is doctors assistants, pharmacists, ambulance assistants and so on. The total number of employees in the MoH is 150,000.

We have 20 medical schools. They are all operational. And we graduate just under 2,000 doctors annually.

CE: There is a conception outside Iraq that quite a few of the hospital and medical schools have been damaged in the war. Is this true? Is there a shortage of hospitals?
AA: Yes, some were damaged and exposed to looting, but we have repaired most of these facilities and they are now operational.

We have 36,000 hospital beds. There is a large shortage here. If you are working to the standard of 3 beds per 1,000 head of population, and we have around 30 million population, then this means we need 90,000 beds. And with a growth rate of 3% we need about 750 additional beds a year, in addition to the shortage.

For 22 years, since Sadam’s time, no single hospital was built.

To give you the scale of the problem – the budget for the MoH in 2002 [the year before the US-led invasion of Iraq to topple Sadam] was US$16 million, which shows how flawed the health budget was then – $16 million is nothing in a country this size. You can’t even run a clinic with this amount.

Now our budget [for 2008] is around $2 billion. In 2007 the budget was $1.5 billion.

In addition to this the local consul for each governate has their own budget and they usually allocate between 10%- 15% for health. This is separate to the MoH budget.

CE: What are the key responsibilities of the MoH?
AA: Our vision is that we should make they highest standard of health service available for all Iraqis regardless of their sectarian, geographical or tribal affiliations. We are working for the whole of Iraq. This is our aim, vision and mission.

CE: Is healthcare free for all citizens?
AA: Yes, healthcare is 100% free for Iraqis.

CE: You mentioned in your presentation at Arab Health 2008 (in Dubai in January) that 2006 was a particularly bad year for the health service in Iraq. Why?
AA: It was a very bad year. We had 100,000 injured and 37,000 killed. This is an enormous figure for any health service anywhere in the world to handle.

I’ll give you an example, in England – when there was that explosion on the Underground [metro railway] there were around 50 killed and 70 injured. At that time everything was stopped – no leave was allowed. And everyone pooled their resources to deal with the incident. Now compare that to our situation.

CE: How did you cope with that situation?
AA: Well, I wouldn’t say we provided the best service in the world. Nonetheless, we managed to save a lot of people, although we would have saved a lot more people if we had a better setup and better resources. However, I am very proud of what we achieved.

CE: Was 2007 a better year?
AA: 2007 was a better year for the whole of Iraq, although it got off to a bad start. For example, our morgue usually keeps the bodies of people killed and found dead in the streets. The average was 100- 150 bodies a day in Baghdad.

Now it is between 4 and 10 bodies a day, which is not bad for a population of 7 million. And this body count is not only for those killed violently, but also represents those killed in accidents and so on.

If we look at figures of the number killed across Iraq year on year you can see the decline in deaths. In October 2006 there were 1,495 deaths. In October 2007 there were 290 deaths. In November 2006 there were 1,650 deaths and in November 2007 there were 285 deaths.

This is an important indicator of the improving security situation in Iraq.

CE: The sectarian conflict that is taking place in Iraq – has this in any way been reflected in the MoH?
AA: Yes, it was until about a year ago. The MoH was in a sense a victim of the sectarian political infighting. Now we have an independent minister. He is not affiliated with any party and is completely professional. And I think we can now begin to restore confidence in the MoH and improve its reputation.

We need to show that we are working for all of Iraq irrespective of the Iraqi people’s political or sectarian affiliations. We need to use our resources for those most in need and not according to sectarian or political pressures. I think if we can show we are doing this we will restore trust in the MoH.

CE: Going forward … In 2008 what do you see as your main challenges?
AA: Firstly, let me point out that in 2007 we had no health minister. Now we have a health minister – [Dr Salih Al Hasnawi was sworn in on 29 November 2007] with a vision and strategy. He was a directorgeneral in one of the governates and a senior lecturer at one of the universities. He never left Iraq and so has full knowledge of the ins and outs of healthcare in Iraq.

The main challenge for the MoH is the great vacancy of expertise created by the number of senior doctors who left during the war.

That’s why we hope this programme [led by the UK Government to retrain Iraqi doctors] will be a quick fix to fill part of the gap which is left in Iraq.

(As part of the programme to rebuild Iraq, the UK Government has been bringing over teams of Iraqi doctors to the UK for a short, intensive retraining course. The doctors are also being trained as trainers and on return to Iraq are passing on their newly acquired knowledge to other doctors in the community.)

The drainage of doctors has more or less stopped now.

We have developed an incentive package, with the approval of the prime minister, to encourage doctors to return to Iraq.

Firstly, we can offer a better security situation. Secondly, we are offering an improved salary package. This year we have increased the salaries for doctors by 100% and the nurses by 50%.

We are also going to make an extra payment in addition to the normal, regulation payment. Doctors with a subspeciality will benefit from a new payment structure, which is a basic payment plus a payment per procedure. This will provide them with much more income and encourage them to work harder. It will also provide greater competition.

The second challenge is the budget. Although going from $16 million to $2 billion is a vast improvement, the $2 billion works out to about only $68 per capita. If you compare this with neighbouring countries like Jordan, for example, where government healthcare expenditure is around $500 per capita, or the UAE’s $1,500 per capita, obviously this budget is still too small. And we also want to build a health system and provide a service at the same time.

The third challenge is to reform the entire health system and upgrade it. We are currently setting the vision of the reforms with the new minister and can then create the mechanisms to implement the changes.

CE: Is there a timeline for implementing these reforms?
AA: There will be, but we have not yet completed the initial planning phase. Only after this can a time line be put in place.

It is very early days.

CE: What are your top priorities?
AA: The top priority is to deal with the shortage of pharmaceuticals and medical supplies. Setting up new supply channels is currently taking up a lot of the ministry’s time.

[A second priority is] medical equipment. When we have sorted this out then the rest will follow.

CE: Can you tell me about the MoH’s reconstruction plans?
AA: We have a plan this year to build 10 hospitals of 400 beds each.

CE: Where will the hospitals be built?
AA: They will be built all around Iraq after looking at scientific criteria to determine which areas are in most need.

CE: Who will build these hospitals?
AA: This is a big challenge. In Iraq we don’t have the expertise to build these complex constructions. We have invited companies that specialise in building hospitals and are in consultation with them.

We have drawn up the specifications, which is the most important step, as without specifications we cannot design the hospital. We have had a lot of support in this regard from the Department of Health in England. And we are grateful for it.

CE: Has there been a resurgence of any diseases, such as TB or cholera, during the conflict with the collapse of the health system?
AA: Well firstly, let me make it clear that the health system never collapsed during the conflict. The Iraqi government collapsed, but the health service continued to operate. Doctors and nurses remained at work, in many cases with no pay. They continued to serve in the hospitals. I am very proud of this.

And no, there hasn’t been a resurgence of disease. In fact we continued our disease eradication programme. We have managed to eradicate poliomyelitis. Malaria has been eradicated from Iraq. In 1995 we used to have 100,000 cases of malaria and now it is 29. We have reduced paediatric diseases, like measles, mumps, chicken pox and a disease called kala-azar (visceral leishmaniasis), by 50%.

CE: And this has been ongoing through the conflict?
AA: Yes. And this has been done through a systemic, wellorganised vaccination programme.

We managed to protect all of Iraq from cholera and avian flu, which has affected some of our neighbouring countries. This is hard work.

CE: So generally you are saying morbidity indicators have remained stable?
AA: Yes. Another indicator is child mortality. Mortality for children under five in 1999 was 128 per 1,000. In 2007 a WHO and Iraqi MoH survey found child mortality had fallen to 41 per 1,000. This is a huge decline.

In 1999 maternal mortality was 294 per 10,000 live births. It is now 84 per 10,000 live births.

These figures do the talking!

CE: What other improvements are you seeing?
AA: Security has got much better. We recently held a conference in Baghdad, which attracted a lot of ex-Iraqi doctors and expertise from the United States and other countries. This was a big step. It was very successful.

(The continuing medical education (CME)/continuing professional development (CPD) conference in Baghdad in January was the first national conference held in the city since the 1980s. The conference was a joint initiative of the Ministry of Health, International Medical Society, Medical Alliance for Iraq, and the Health Attaché's Office of the US Embassy.)

However, people still have great fear about the security even though it has improved. They need to be reassured …to be told that the situation is better, in order to get pharmaceutical companies, medical supply companies, and construction companies to help us rebuild Iraq.

We have the money. In 2008 Iraq allocated $20 billion – equivalent to entire GDP of Egypt – to rebuild Iraq. But we cannot do it alone. We need help from investors, big companies, people with experience.

CE: Do you think they are sitting on the sidelines waiting for the security to improve?
AA: Definitely. Iraq is going to possibly be the biggest market in the world, because there is the money and there is a need.

CE: If you could make a plea to the international medical community, what would it be? AA: We need expertise for the training of doctors and the building of hospitals. We need pharmaceutical and medical supplies.

Iraq is like a wealthy businessman who is short of cash. The country has a lot of assets, not only natural, but also human assets. The Iraqis are an intelligent, hard working people.

We need a hand until we can build our system.

 Date of upload: 3rd May 2008

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