Primary Health Care

Iraq pledged to adopt the Primary Health Care (PHC) approach in 1978 but has always had a centrally run, vertically administered health system based more on hospitals.

The PHC approach requires decentralized, decision-making. The MOH has been a very hierarchical organization led by the Minister of Health and his three deputies. The 10 offices attached to the Minister or 3 offices of his first deputy have made many of the decisions that should occur at the local level. A similar hierarchy exists in governorate MOH offices. All the central directorates were represented in the DOH, but to a lesser administrative scale.

PHC is provided at more than 1000 health centers and sub-centers providing preventive and basic curative services and simple diagnostic procedures. They function from 8:00 –14:00 hours and charge nominal fees. Services provided are supposed to include:

·  MCH (antenatal, postnatal, neonatal care, growth monitoring for under-fives,

control of diarrheal diseases, control of acute respiratory infections, immunization

of mothers and children, dental care for mothers and children, and family

planning

·  Training of midwives, training of health staff and teachers,

·  Participation in the PHC local council

·  Health education activities,

·  School health services, including dental care and eye care

·  Monitoring of water quality and sanitation,

·  Monitoring of food safety in restaurants, cafés and hotels,

·  Epidemiological surveillance,

·  Prevention of non-communicable diseases,

·  Promotion of mental health,

·  Vital statistics registration

Groups of PHCCs located in the same district are affiliated to of the country’s 115 PHC sectors. The PHC section in the DOH leads the sectors. PHCCs are meant to refer to the second level of care at MOH’s 100 district and general hospital. These provide outpatient and inpatient care and diagnostic services. They function 24 hours a day and charge nominal fees. The third level of care includes teaching hospitals, specialized hospitals and specialized centers. These provide high-level diagnostic, curative and rehabilitative services.

Other Health Service Providers

The Semi-Private sector includes public clinics operating at PHCCs in the afternoon. They provide curative services and distribute drugs for patients with chronic diseases. Their fees are higher than those charged in the public centers, but lower than the private sector. The Private Sector includes private clinics, hospitals, day clinics, labs, imaging clinics, and pharmacies. All charge fees similar to a week’s average income. The private sector also includes polyclinics manned by junior doctors. They charge fees averaging 10% of the private offices. The Military Medical Services has provided care to the military their families free of user fees. It includes 31 hospitals with 1200 beds. They do not have PHCCs, but rather dispensaries for outpatient services.

Traditional, unqualified healers include traditional birth attendants, bonesetters, herbal medicine dispensers, parapsychologists and religious healers.

Manpower for the health sector includes doctors (graduates of medical colleges), paramedical staff (graduates of the college of medical technology or of health institutes) and nursing staff (graduates of nursing colleges, nursing institutes, nursing high schools, or nursing primary schools). Other staff includes pharmacists, engineers, technicians, statisticians, clerks, accountants, computer staff, and secretaries. Not all PHCCs are fully staffed; many have left their jobs or even the country.

Most health facilities are the property of the MOH. When such buildings are not available, the MOH rents buildings from the private owners.

Catchment areas and populations were not allocated for health centers. A new population census is needed to identify, categorize and assess the adequacy of PHCCs. The reform should include the restructuring of health facilities & their upgrading in terms of premises, staff and equipment. A new system of registration, record keeping and patient tracing for referrals will be needed. This should be accompanied by a countrywide information campaign to orient the population to the new primary care system.

Moral of primary care health workers is quite low due to poor working conditions and very low salaries. Many PHC of doctors have left primary care to work privately or in other countries. The number of health workers at most PHCCs is too low, resulting in a work overload and low quality. Outreach visits, health education and counseling activities have virtually disappeared. The number of staff should be raised initially to one __(Dr. Nada – one what?)____ per PHCC. IT should subsequently be raised to 1 per 20,000-population ratio. Also needed for the outreach services are easy transport and overtime pay.

Providers at secondary level facilities are overloaded with cases that can be adequately managed at the primary level. At the hospital level, we need competent feedback mechanisms, to always refer the patient back to the PHCC after discharge from a hospital.

The capacity of PHCCs was reduced by half compared to pre-war levels. Immunization coverage was estimated by UNICEF to be 60-70%. Disease surveillance is currently being implemented in sentinel sites, not routinely. It is anticipated that routine surveillance will be reactivated soon.

Dr. Nada – can you make some comparison of the theoretical staffing ratios in the table to actual staffing levels?

Suggestions

Conduct detailed study human resources in the health system (numbers, qualifications, job descriptions, job satisfaction and distribution), health facilities (types, duties, services, distribution, premises, equipment, and cost recovery), client satisfaction and utilization of the services provided. The PHC approach in the delivery of health services should be adopted.

Table 1: Staffing Norms for PHCCs

Unit / Staff / Staff/population
Curative / General Practitioner / 1/10,000
Medical Assistant / 1/10,000
Dental / Dentist / 1/20,000
Dental Assistant / 1/20,000
Pharmacy / Pharmacist / 1/20,000
Assistant Pharmacist / 1/20,000
Lab / Technician / 1/20,000
X-Ray / Radiologists
Dressing / One male and one female nurse
Special units (only in remote areas, 6-8 beds) / Emergency ward: nurse
Labor room: nurse/midwife
Admin. /service / Clerk, statistician, aide, driver
Preventive Unit / Doctor for MCH care / 1/20,000
CDD/ARI nurse, vaccinator, health audit, school health assistant, refractionist, record keeper

Table 2: Levels of Public Hospitals in Iraq

Hospital Level / Population Served / No. of Beds / Wards / Staff
Rural: Small hospital or ward in PHCC / 20,000+, population density not exceeding 5/sq.Km, radius of area 40-60 KM / 20-50 / 1.Medical
2.Obstetrics
3.Pediatrics
4.Basic surgical
5.Infectious
6.Geriatrics and chronic / GPs from PHCCs, nursing & para-medical
District Hospital / 60,000-150,000
*one per district
* patients are referred from PHCCs and private clinics within the area / 60-150 (1/1000) population / 1.Medical
2.Obstetrics and gynecology
3.Pediatrics
4.General surgery
5.Infectious
6.Geriatrics and chronic
7.Triage
8.Rehabilitation
9. Sub-specialties by visiting doctors / Specialists, Visiting doctors & GPs,
General Hospital / 200,000-400,000
*one or more per governorate
* patients are referred from PHCCs, private clinics, rural & district hospitals / 1.75-1.85 per 1000 population / All specialties and sub-specialties, with intensive care units, forensic medicine & occupational medicine / Specialists in major & sub-specialties, nursing & para-medical
Area Hospital / 2,000,000-4,000,000
** patients are referred from PHCCs, private clinics, rural, district & general hospitals / 1.75-1.85 per 1000 population for major specialties & 1.15-1.25 for rare specialties / All specialties and sub-specialties, with intensive care units, forensic medicine & occupational medicine. Also rare specialties: endocrinology, neurosurgery, cancer surgery, cardio thoracic surgery, faciomaxillary surgery, etc…
May also function as a teaching hospital. / Specialists in major & sub-specialties, as well as rare specialties nursing & para-medical

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