Submitted by: M. Alsarifi and Z. Khazai
Iraq is facing large scale health care problems causing people to suffer and die from conditions for which effective proven preventive as well as curative interventions are abound (O’Donnell, 2007). Ever since the 2003 US led war on Iraq, initiatives that aim to improve the growing underutilization of effective health care have multiplied. Interventions such as mental health support programs, the training of health personnel, mobile clinics, nutrition and reproductive health advice and more are repeatedly being implemented by different stakeholders (WHO, 2017). The major challenge that we are facing in public health policy today is therefore not the lack of ideas and initiatives, but the lack of an understanding on how to beneficially support the sustainability of health care interventions that prompt the continuation of health benefits over time. Despite all efforts, many of the health programs lack research-based policy analysis and solid health impact assessments. This results in wasted funds and missed opportunities to structurally improve the population’s health and wellbeing. Health programs tend to be imported or carried out by international organizations without critical appraisal, understanding or adaptation to the local Iraqi health care environment causing them to be ineffectively embedded in their setting.
Concerns about Iraq’s public health became predominant during the past decades in which Iraq witnessed several wars and conflicts. During the first gulf war of 1991 Iraq faced vast destruction of the Iraqi major infrastructures essential for a functioning health system. The economic sanctions that followed caused public health to reach rock bottom due to extreme shortages coupled with a budget cut of almost 90%. Finally, due to the 2003 US-led invasion of Iraq a large part of the infrastructure and healthcare buildings were bombed. Laboratories and hospitals were extensively looted, reducing the country’s ability to respond to day-to-day challenges as well as to health crises, such as cholera outbreaks (Kruk et al., 2009).
In this article we explore the challenges public health in Iraq is facing. We discuss important contextual factors such as epidemiological, demographic and socio-political factors that play a role since the 2003 US invasion and continue to influence the Iraqi health care environment. This article is part of research to understand the Iraqi health care sector and the experience of Iraqis with the health system.
Epidemiologic consequences of the war on Iraq
The several wars that assaulted the Iraqi national health system were the main cause of the destruction of clinical and medical infrastructure, the fleeing of health professionals, and the interruption of drugs and other medical supplies. In addition, disease multiplied as a result of the war. The link between the wars and the incidence of disease in bombarded Iraqi cities is demonstrated in several studies conducted by independent Iraqi researchers. During the US-led invasion, both the USA and United Kingdom used depleted uranium (DU). DU contains uranium oxides and is used to produce projectiles such as bullets used by military forces. The moment the projectile pierces, DU dust circulates into the environment, which then can be ingested or inhaled. This disastrously continues to impact the health of Iraqis. High concentrations of DU were found in bones, blood and tissues of cancer patients.
In Basra, one of the most affected cities during the wars, it was found that people living close to bombarded areas had weak immune systems. Congenital birth defects have increased by 17-fold according to the Al Basra Maternity hospital. This includes that babies are i.e. born with neurological problems, paralysis, congenital heart disease or missing limbs. In Fallujah, after the US assaults, Iraqi doctors have been overwhelmed by the high increase of birth defects and cancer. A study found that infant mortality was 80 per 1000 births, in comparison to Egypt (19), Jordan (17) and Kuwait (9.7). Additionally, a high increase of brain tumors in adults, a 38-fold increase in leukemia and a 10-fold increase in female breast cancer: all were found to be significantly related to the war on Iraq.
Currently, the burden of chronic non-communicable disease (NCDs) - such as cardiovascular diseases and cancer - in Iraq is immense. Preventable NCDs like hypertension and diabetes mellitus demonstrate rapidly rising trends. This may, in turn, enhance the occurrence of ischemic heart diseases and CVA. The rate of patients is based on the ones attending the health facilities rather than the real prevalence, so this may only reflect the utilization of such services giving an obvious unavoidable underestimation. Diabetes mellitus increased significantly from 19.5/1000 in the year 2000 up to 42.1/1000 in 2015 with a percent change of 115%.
Policy consequences of the war on Iraq
As previously mentioned, the consecutive wars and sanctions not only had a devastating impact on the population’s health, but also on the health system in the form of shortages and a brain drain (Yousif, 2007). However, the overall worsening performance of the Iraqi health system as a whole should not simplistically be framed as an unintended consequence of war. Today’s health system performance in Iraq rather has to be understood in the context of the intended economic free market (also called privatization) reforms related to the 2003 invasion.
In the field of public health policy, a ‘reform’ is defined as an effort or activity that seeks to improve health sector performance by making fundamental changes in the way healthcare is organized, financed, and paid for, as well as the way legal mechanisms regulate clinical processes. Reform measures, such as privatization reform, can act as drivers for quality and safety of care but can also negate desired health outcomes. Hence, analyzing them is important before attempting to gain an understanding of the health care needs of Iraqis in order to implement health interventions.
After the 2003 US-led invasion, the national health system weakened, which in turn paved the way for international humanitarian agencies, NGOs and international governments to step in. Robinson (2006) in his article refers to ‘a dramatic NGO-ization’ of Iraq after 2003. NGOs were mainly focused on providing emergency response and relief during the war, while the investments of international governments were mostly concentrated on the aftermath, including the reconstruction and recovery of health services. However, both were not simply employed ‘for health’s sake’, but were explicitly linked into political strategies of stabilisation, reconstruction and counterinsurgency. The United States for example has spent $49 billion dollars on the overall reconstruction of Iraq since 2003, raising legitimate concerns over the wider effects of politicising health aid, with little proof that the claimed benefits were effective in practice (McInnes & Rushton, 2014).
One of the great restructuring measures implemented after the 2003 invasion that define the way Iraqi health care is regulated includes the Washington based International Monetary Fund (IMF) and the World Bank’s controversial “structural adjustment plans''. In exchange for loans, Iraq was forced to make major changes in Iraq’s health care system. The institutions required Iraq to implement privatization, liberalized trade and foreign investment in order to obtain financial loans. This went hand in hand with the disproportionate cutting of national budgets. Health care was forced to decentralize from the central government as a single actor in the health care provision towards private care providers. In practice, the measure was only producing a fractured health system with higher costs for the patient and great benefits for the private sector (Looney, 2006). At the same time, private health care remains largely unsupervised. As a result of the privatization, a robust private retail pharmacy sector has emerged counting around 10,000 outlets in 2013. A well functioning regulatory framework to manage commercial pharmaceutical importation has however yet to be developed.
Evidence shows that transitions from public to private care provision fail to positively influence the overall population health in low and middle income countries as equity is inconsistent within the free market distribution of health care (Alkhamis, 2017; O’Donnell, 2007; Looney, 2006; Al Hilfi et al., 2013). Additionally, detailed macroeconomic analyses report that the optimal expected life span is dramatically longer for high-income versus low-income individuals in the case of privatized health models (Ozkan, 2017). In Iraq, this also negatively influences the accessibility of quality health services in rural areas where financial profitability incentives are lower for private clinics and hospitals; creating health service delivery concentrated on urban areas. However, surveys carried out in rural regions find very low use of public health facilities despite these being, in principle, free. The reason is the poor quality of care, although the private sector alternatives were also of dubious quality. Demand directly reacts to quality. If the available health care is of poor quality and the private care is too expensive, it is not surprising to find a limited demand (O’Donnell 2007). In fact, countries with advanced private health models make use of health insurance models, in contrast to Iraq where health care funding currently is a major challenge and quality care is unaffordable for the majority (Al-Jumaili & Hussain, 2013).
Prevention focused care
Many generations will keep suffering from the horrifying attacks and the chemical footprints that the American war left on Iraq. Garfield (2010) in his research on Iraq’s public health stresses the importance of strengthening national health monitoring systems, refocusing health policy toward maximizing scarce resources and emphasizing preventive over curative medicine. This includes an expanded use of existing resources in health education of the general population with a focus on vulnerable groups. Preventive focused care is cost-effective and important in war affected areas as high morbidity and mortality often persist long after the conflict ends. It is therefore important to focus on the early detection of birth defects and congenital anomalies. Many effective prevention-focused interventions are not prohibitively expensive or complex to implement (O’Donnell, 2007; Reubi et al., 2017).
Instead of merely designing temporary solutions in the form of humanitarian health aid programs, the roots that caused the health system to continue to be a victim until today must be recognised. Furthermore, a shift is needed from humanitarian aid and foreign interventions to community based health interventions and change from within local Iraqi communities. This in order to achieve a sustainable impact on Iraq’s health care system that is to the benefit of the Iraqi citizen. Insufficient understanding may lead to improvement measures that do not connect to the experience of the Iraqi patient and the desired outcomes. Without an understanding of reforms that have resulted in damaging budget cuts, health care disparities and the disastrous replacement of a public system, expensive and ineffective health aid programs will continue to be built on unhealthy foundations.
M. Alsarifi and Z. Khazai who are members of Weqaya, an organization that studies healthcare in Iraq.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect those of IraqNow.