Iraq's health ministry recently warned that hospitals may “lose control” in the coming days. The country has recorded its highest single-day rise in coronavirus cases since the start of the pandemic that severely hit Iraq’s already fragile health system.
In the past, the Iraqi healthcare system used to be the most advanced in the Middle East. Worldwide, Iraq was celebrated as a success story for being one of the few countries that achieved universal health care during the ‘60s to ‘80s. Students from the region traveled to Iraq to study medicine in the highly respected medical universities, and patients visited Iraq to receive medical care. Today, Iraqi citizens are the ones that are forced to seek medical care outside of their country if their financial circumstances allow them. This is the result of decades of war, military interventions and economic sanctions that caused a fragmented and weakened healthcare system that’s hardly able to handle the current health crisis.
The presence of a strong healthcare system positively impacts the vitality and competency of a nation. In this light, rebuilding health services and public health policies that respond to the demands of the population is a serious prerequisite for the sustainable development of Iraq and its independence. Such tenable and healthy (re)construction of the Iraqi health system should include a deep understanding of the context in which the system was built and dismembered. Disregarding such context leads to reducing and attributing problems and shortcomings of the health system to mere corruption. The World Health Organization (WHO) identifies corruption as a significant predictor of negligence of the health system and a cause of negative health outcomes such as child mortality. Additionally, Iraq's health ministry's director that was in place during the 2003 US occupation stated that “corruption is so endemic that the sector’s infrastructure would have to be rebuilt with the help of the international community”.
Paradoxically, it has been this same structural interference of the international community that caused a breeding ground for corruption. This article attempts to shed light on the circumstances that made this possible. Likewise, we aim to provide insights into the way Iraqi healthcare reforms are constructed and instrumentalized to steer Iraqi social order over the past decades.
Strengthening Iraqi medical infrastructure in the light of British interests
During the first World War and the ensuing occupation of Mesopotamia by Great Britain, British military doctors took strict medical and hygiene regulations to protect their troops. They analyzed the region through the framework of Tropical Medicine, which dealt with diseases that occur in (sub)tropical continents, to allow their troops to survive better in the region. However, the unfamiliarity with Iraq still led British troops to suffer from a range of medical complaints. Expanding Iraq’s healthcare network was therefore specifically in British interests, as it would increase their chances to survive the local Mesopotamian ecology. A comprehensive healthcare system would contribute to the success of future western colonial endeavors in Iraq. At the same time, it was believed that anti-British sentiments in Iraq would decrease by constructing a stronger health infrastructure.
The overall aim of the British Mandate was to create a self-governing state operated by Iraqis and supervised by the British, but attempts to establish a central health government failed several times. In the meantime the British administration’s steering was facilitated by tropical medicine researchers that collected health data in Iraq. To enable the flow of goods and people throughout the country and beyond, the British administration invested in the transportation infrastructure. However, the enhanced mobility that resulted from the modernization of the Iraqi transportation network made it possible for disease to spread more quickly. In 1923 Iraq faced a cholera epidemic, demanding quick responses and the upscaling of health services. This event was used by the British administration to underline the importance of a central, quick-responding body that was able to manage the country’s healthcare system.
In 1927, the British Mandate established the first modern medical school of Iraq. Future Iraqi doctors studied under a British medical curriculum and were supervised by British authorities. Throughout the years, thousands of Iraqi medical graduates received grants to continue their specialization in the United Kingdom (UK), expanding Iraq’s healthcare infrastructure internationally and shaping the foundations of Iraqi doctors. The access of medical students to receive training in the United Kingdom granted them an elite status in comparison with other professions and was strongly entangled with the British interests to produce a modern nation-state with an Iraqi elite, friendly to British interests in Iraq, at the top. The interaction between Iraq and the UK became embedded in the medical school system and would subsist even after Iraq’s independence. During the more recent years of war, thousands of physicians fled Iraq, resulting in the British National Health Services (NHS) currently hosting the largest population of Iraqi doctors outside Iraq.
Iraqi independence: rise & downfall of the healthcare system (1958-2003)
The 1958 July revolution ended almost 40 years of British occupation and Hashemite rule. The postcolonial period of governance was characterized by the integration of wider aspects of social life into the medical infrastructure. Medical education became more accessible to the wider public, and new medical schools and public hospitals were built. Compulsory rural service was introduced to medical school graduates and medical staff was trained in conducting door-to-door surveys. The Ministry of Health (MOH) that was inaugurated towards the end of the British rule still utilized a curative, hospital-oriented and capital-intensive health model that required large-scale import of medicines and medical equipment. Pharmaceutical products imported into Iraq were reviewed by the National Board of the Selection of Drugs (NBSD) that acted as the scientific and technical agency regulating drug selection and supervising registration, drug information and post marketing surveillance. To be able to finance such an expensive model, the healthcare system was government-subsidized through revenues from the nationalized oil industry. At the same time, the out of pocket cost of healthcare was extremely low, enabling Iraqis to make use of the services (almost) for free. During this period the infant mortality rate decreased from 80 to 40 per 1,000 live births, reflecting rapid improvements of the quality and accessibility of the system as well as the overall population health.
Improvements lasted until the Iran-Iraq war (1980-1988) during which budget cuts in the Iraqi healthcare system reached 90%. The budget cuts and the high number of injuries from the war in combination with the reallocation of medical professions to the military, placed immense pressure on healthcare facilities. By the end of the war, Iraq was struggling with high debts, barely able to deal with the aftermath of the 8 year conflict. During this period, the MOH incorporated a primary care model. This model aims to raise the standard of living by making healthcare more accessible. It enabled care provision to shift away from expensive hospital care towards primary healthcare clinics (PHCCs), run by general practitioners and nurses. Additionally, healthcare governance was partly decentralized towards the provinces, each with its own Directorate of Health that monitored the performance of the PHCCs. Although this policy-change contained some promising implications, effective implementation and a clear strategy were largely absent due to the focus on the Iraq-Iran war, the upcoming US-led Operation Desert storm and the subsequent UN and US-imposed sanctions.
The next twelve years, economic sanctions, being one of the greatest tragedies of the Iraqi healthcare system, would prevent the state from restoring its infrastructure. The sanctions included the halting of food and other humanitarian goods in an effort to force the Iraqi population into submission. As soon as the sanctions were implemented, Iraq started suffering from food, medication and equipment shortages. Such sanctions hit Iraq’s health system extra hard as it was, as previously discussed, designed to be highly dependent on the import of high-tech equipment and curative medication. The UN-sanctions on Iraq resulted in a humanitarian disaster and extremely deteriorating health rates. A 2006 survey showed that about 25% of Iraqi children were chronically malnourished and many more were underweight. Another Harvard survey reports a massive increase of child mortality from 40 per 1,000 between 1985-1990 to 198 per 1,000 between 1990-1995. Additionally, shortages of key medical products led to increased chronic disease mortality. Laboratory exams provided in the years of the sanctions dropped down with 70% and surgical interventions declined by 50%. In Baghdad alone, since spare tires were not permitted during sanctions due to their supposed potential military use, only 5 of the 100 public ambulances were working. The NSBD became progressively weaker, removing adequate focus on quality in drug procurement and distribution. The almost uninhabitable conditions led to a mass exodus of physicians which led to even greater shortages.
New Public Management and the rebuilding of Iraqi healthcare post-2003
At the time of the US-led invasion, the strong base on which the health system was constructed between the 50’s and 80’s was already weakened. Iraq was dealing with non-functioning and outdated equipment, inadequate drug supplies and a fragile infrastructure barely able to respond to the needs of the people.
The US-led invasion destroyed health facilities and looted them of their supplies, which resulted in further loss of equipment and pharmaceutical stocks. Hospitals, medical centers, Community Child Care units and the two major health laboratories were all looted and destroyed. Two of the three rehabilitation hospitals in Baghdad were looted to the extent that they had to close. Additionally, the unpredictability of electricity and water supply, and the general insecurity created almost impossible working environments for health personnel.
Not only health facilities were targeted; the health of the people deteriorated as well. According to a study conducted by the University of Basrah, cancer is emerging as the major cause of death in the country’s southern provinces. This might indicate that low survival rates are related to the underdeveloped state of oncological care, but also raises many questions about the toxic legacies of the war on the Iraqi people. International scientific studies demonstrate causality between the US military use of depleted uranium and the rise in congenital deformities and many other diseases. According to one research, “the Iraqi population shows the highest genetic damage in any population ever studied”. Currently, the Global South is dealing with the double burden of disease, and Iraq is no exemption. Both non-communicable diseases (eg. heart & vascular disease and diabetes) and communicable diseases (eg. hepatitis and tuberculosis) are growing as a result of a toxic war-environment, the lower accessibility of care and an unhealthy lifestyle. The latter is often referred to as ‘cocacolonization’ by medical experts, representing the spread of unhealthy American foods overseas.
During the US occupation of Iraq, rebuilding healthcare infrastructure was again, as was the case under the British mandate, instrumentalized as a tool for political reconstruction and counterinsurgency. Military operations were used alongside soft power health interventions practiced by government-tied NGOs as part of wider imperialist objectives. The US occupation forces redesigned healthcare policies by implementing the neoliberal doctrine of New Public Management (NPM) into the Iraqi health system. NPM was first introduced in the UK's academia and became worldwide known as the golden standard for healthcare reforms. The ultimate aim of NPM is to deregulate state governance in favor of market forces by moving the locus of governing outside the state. Relations between the government and the third sector are commercialized by introducing market-competition, and the citizen’s own participation is centralized. This ultimately created a system that’s vulnerable to market based economies and foreign interference. A weak public sector is the result, as most of the care is currently delivered through private sector providers which are largely located outside the national health supervision system. Currently, Iraqi healthcare is unevenly provided by approximately 12.000 private clinics vs. 2.500 public PHCCs. As a result, out-of-pocket health expenditures increased to an alarming extent of 70% in 2015, according to the WHO the percentage should not exceed 30%. Hence, households are forced to borrow money in order to meet health expenditure, which pushes them into debt and financial difficulties.
The era of US occupation reinforced the legacy of the British-Iraqi healthcare system as an instrument of colonial rule. It has never been solely an Iraqi project but is rather shaped by decades of imposed British rule and Western influence. Such arrangements made in the domain of health policy are rarely accompanied by the elimination of the old structures. An understanding of the historical construction of Iraq’s health system is of high importance as policy designs made decades ago may be eliminated on paper but still have their effect in the present day’s practice. However, healthcare systems are constantly examined to adjust to the changing demographics and demand of a population, and this also applies to Iraq. Even though Iraq had to deal with a large history of extremely difficult circumstances, a more positive future is certainly possible. Today’s health policy should be designed in the context of gaining independence from the power relations that were created over the years. Sovereignty to determine what’s best for Iraq's health system should therefore be returned to the resilient Iraqi people.