UNDG Needs Assessment of Health Sector- DRAFT 1 - 12..08.03

NEEDS ASSESSMENT AND STRATEGY OPTION PROCESS

OVERALL DESCRIPTION OF THE SITUATION

  1. Prior to 1991, Iraq had one of the better medical care systems in the Middle East. WHO described Iraq’s health infrastructure as “a first class range of medical facilities.” that included some public health services, hospitals and primary care facilities. In general they were adequately supplied with medicines and equipment.
  2. The situation changed dramatically from 1990 onwards, with the Gulf War and the economic sanctions. The war damaged many facilities; expatriate health personnel, especially nurses left the country and financial resources for the health sector declined precipitously. Shortage of food and medicines affected the majority of the population. In 1991, infant and child mortality rates more than doubled, reaching 100 and 120 per 1000, respectively.
  3. The health situation in Iraq improved somewhat under the Oil for Food Program (OFFP). Human resource capacity received little attention historically. This problem continued under OFFP, especially in the Centre and South of the country, where the Program only provided medicines and medical equipment.
  4. War damage, looting, and post-war instability have seriously affected the health sector in 2003. There were persistent disruptions of electric power, water supply and sewage, widespread insecurity and a partial paralysis of financial, managerial, logistic and administrative support systems.

TREND ANALYSIS OF THE PAST 15 YEARS

  1. During the 1990’s Infant and under five mortality rates continued to plateau at a rate last seen more than two decades earlier. Infant and child deaths were highest in rural areas, among families with mothers having low educational achievement, in South of the country, and among mothers with many children. While conditions in the Centre and South had been better than in the North historically, they deteriorated in the Center and South in the 1990s while improving in the North. Maternal mortality was estimated to be 294 per 100,000 women during 1989 – 1998. This represents a more than doubling of the rate estimated at the beginning of the period.
  1. While there has been partial recovery of the vaccination program, it has an excessive focus on the number of vaccines distributed at the expense of its quality and outputs. In 2000, only 61% of two year olds had received all vaccine doses according to schedule.
  2. The ratio of doctors per 10,000 population was 4.7 in 2000. This is low by regional standards, where most countries have more than 10 per 10,000 population. The shortage of nursing staff is even greater. There are 3.0 nursing staff per 10,000 people in Iraq. In other words, there are less nursing staff than physicians. In most countries there are 3 – 6 nursing personnel per physician. More than a third of the physicians are specialists, while less than a third of the nurses were trained in post-high school programs.
  3. The number of beds per 10,000 population is around 17. Iraq is one of the countries in the region with a low bed to population ratio. The distribution of beds, primary care visits, and doctors is very equitable across all governorates, but the services offered are often not the appropriate ones for the country’s disease profile. Only 550 a third of the country’s more than 1,700 public hospitals and health centers are equipped to provide emergency obstetric care.

CURRENT STATUS AND ISSUES

a. SUMMARY STATUS OF SECTOR

Disease Burden

  1. Prior to 1990 Iraq was at an advanced stage in the demographic transition from infectious to chronic and degenerative diseases. It has since lost several decades of progress, returning to a morbidity and mortality profile in which infectious diseases predominate

The most important Communicable diseases now are upper respiratory infections and diarrheal diseases. Cholera and visceral leishmaniasis have become endemic in the south and malaria epidemics have occurred in the north. The incidence of the most important vaccine preventable disease, measles, has declined since vaccine coverage improved in the late 1990s.

Coverage Estimated by Doses Provided / Household Surveys
1999 / 2000 / 2001 / 2002 / 1996 / 2000
Measles / 94 / 93 / 80 / 80 / 80 / 78
  1. Damage to country’s electricity, water and sanitation infrastructure has increased the risk of outbreaks of water-borne diseases. A high early number of cases of cholera soon after the end of the war was feared to be the beginning of a disseminated epidemic; instead the number of cases plateaued early and has recently declined. HIV/AIDS is not considered a major public health problem. The 230 cumulative cases are mainly due to blood transfusions. This transmission stopped when screening began in the mid-1990s. Increase drug use and prostitution could result in increased sexual transmission. Non-communicable diseases (NCD): There are many registered patients with cardiovascular diseases, cancer, chronic obstructive lung disease, hypertension, or diabetes). If infectious conditions decline in the next few years, NCDs will become the leading contributors to death and disability.

Determinants of health

  1. The nutritional status of the Iraqi population is poor. The diet provided by the OFFP ration is high in carbohydrates, but meat, fruit and vegetable because are expensive and thus out of reach of poor people. 40% of adult males are overweight, but chronic malnutrition is common, as is anemia in children, adolescents and pregnant women. The iron supplementation program targets pregnant women and children below 5 years of age.
  2. In South and Central Iraq the rate of malnutrition increased steadily from 1991 to 1996. It then plateaued until 2000 and declined by about half by 2002. Malnutrition in the north was high in the early 1990s and declined continuously to reach low levels by 2002.
  3. During 1990-2001 low birth weight among deliveries in the South and Central Iraq increased from 4.5% to about 12%
  4. A 1994 vitamin A survey among those under 5 years of age revealed a prevalence of 2.2% of vitamin A related diseases.
  5. Regarding reproductive health, 65% of births occur outside of formal health institutions. The proportion of women delivering without trained assistance went up during the 1990s, to 30% in urban areas and 40% in rural areas. In 1998, 79% of deliveries were attended by traditional birth attendants (TBAs). Some 15% -20% of deliveries are at high risk and need advanced medical support. There are referral institutions at a district level to attend complicated births, but about half of these lack some key resources to provide appropriate care. Factors of risk for poor birth outcomes are the high rates of anemia, the short birth interval (41% spaced less than 2 years apart), high total fertility (7.7) and early marriage (40% prior to age 18).
  6. Life styles and health related behaviors: Few people engage in exercise voluntarily. Smoking prevalence is high among men.
  7. Stress related and other mental disorders. Continued severe stress resulting from war, instability and scarcity stresses the population. There is a dearth of mental health services, while social supports have declined and some families are disrupted. Food Safety: After the recent war, the food quality control measures were drastically affected. Food inspectors have not performed their work. There is shortage of chemical and biological reagents and there is pressing need for staff training and updating them with recent methods in food inspection.
  8. Environmental pollution and environmental modification: Poor sanitation and shortage of safe water supply have resulted in high risk for faeco-oral infections.. Lack of proper and efficient system of disposal of chemical and toxic effluents from factories have resulted in contamination of air, soil, water and plants with all the hazards of respiratory tract infections, cancer and chronic and acute chemical intoxication. Land reclamation projects and drainage of the marshes with consequent changing biohabitat resulted in exposure to vector borne diseases such as kala-azar in the South and Centre of Iraq.

Health Care System in Iraq

  1. Prior to the recent conflict, Iraq’s health care delivery system was highly centralized, a hospital-based, capital-intensive model of curative care. It required continuous large-scale imports of medicines, medical equipment and even service workers like nurses from aboard
  2. The structure of the MOH was very hierarchical with three Levels of Health Service Provision in the Public Sector: the First Level is the PHC center providing most preventive, and some curative services as well as simple diagnostic. The Second Level is the district and general hospital, providing curative outpatient and inpatient services as well as diagnostic services, the third Level includes teaching hospitals, specialized hospitals and specialized centers that provided high-level diagnostic, curative and rehabilitative services. There has never been an effective referral system among those components.
  3. Other health service providers include: a) the Semi-Private comprising the public clinics operating in the evening to provide curative services and distribute drugs for patients with chronic diseases; b) the Private Sector, comprising private clinics, hospitals, day clinics, labs, imaging clinics, pharmacies, all charging very high fees, and c) the Military Medical Services.
  4. Disease Control activities were usually carried out departments and sections within the General Directorate of Preventive Medicine within the Ministry of Health, including The Communicable Diseases Centre, the Immunization, Maternal and Child Health and NCD sections. In addition there are Tuberculosis Control Centres distributed throughout the governorates. A center has been established for the control of AIDS.
  5. Laboratory services are provided by almost all health facilities. Simple laboratory investigations are performed in PHC centers and health insurance clinics. Advanced services are provided in the main referral hospitals and in specialized centers. There has been reported reduction of performing such tests from around 1,500,000 in 1989 to around 640,000 in 2002.
  6. Blood transfusion and blood bank services. There is a National Blood Transfusion Center in Baghdad and one main blood bank in each governorate. Major hospitals have small blood transfusion units. The quality of the services is far from the required standards. Most if not all facilities dealing with blood need urgent upgrading
  7. Medical supplies: The war disrupted the supply chain of medicines. Computerized and paper inventory management systems were inefficient and facilitated corruption. Rehabilitation of the main Kimadia[1] warehouse management and inventory systems is occurring. The medical supplies began flowing again from Baghdad to the governorates in June, but second-tier distribution, to PHC, especially in rural areas is problematic due to insecurity and shortage of operating funds. Items that were in short supply in the immediate post-war period, such as insulin, asthma inhalants, anesthetics, and anti-hypertensive are now available, albeit in reduced quantities. There are some reports of shortages in laboratory reagents, TB antibiotics, oxygen, and drugs for some chronic diseases. However, assessments indicate that as far as medicines are concerned the situation is not alarming, except for vaccines and sera for which national stocks were lost as a result of prolonged electric power failures in Baghdad.
b. STATUS OF PHYSICAL INFRASTRUCTURE
  1. Health care is provided through a network of 269 hospitals , 1570 health centers, 308 "health insurance clinics", 254 "chronic illness pharmacies" and 32 "special pharmacies" for rare drugs. Less than a quarter of all institutions are private.
  2. There was little infrastructure investment or maintenance during the last 20 years. In 1998, NGOs and UN agencies started renovating selected health facilities. In early 2003, many health facilities were still not able to function properly and even private private hospitals, which looked much better, frequently had inappropriate physical plant.
  3. During and immediately after the recent armed conflict, about 12% of hospitals were partially damaged and 7% were looted. About 15% of the CCCUs (Community Child Care Units) are closed. The country’s two major public health laboratories, in Baghdad and Basrah were destroyed. The Institute of Vaccines and Sera was extensively looted and suffered from long power outages, resulting in the loss of vaccines. Two of the three rehabilitation hospitals in Baghdad were looted and are closed. Health departments, hospitals and primary health centers lost furniture, refrigerators and air conditioners. The Ministry of Health lost office equipment and facilities for communication and coordination at central and governorate levels. Particularly problematic were the loss of central level records.
  4. There are 31 military health facilities, to be integrated into the public health system of care with all their assets and staffs.
  5. War and looting have affected Kimadia's facilities. Four of seven central warehouses were looted. The warehouse for IV fluids in Baghdad was the most affected. All central and governorate warehouses require rehabilitation and replacement as most of them are aging and have not been regularly maintained.
  6. Overall, the national electricity grid serves 51% of health facilities: the other 49% depend on generators; however, 24% of health facilities have no generators.

c. HUMAN RESOURCES FOR HEALTH

  1. Reconstituted MoH payroll records list about 65,000 employees.
  2. In 2002, there were over 35,000 doctors registered with the Iraqi Medical Association: two thirds of them are outside Iraq. Human resources planning and health professional training received little attention in the 1990s.
  3. The distribution of health workers shows a strong emphasis on hospital-based care: in 1993, only 27% of doctors and 25% of nurses and midwives worked in primary health care.
  4. Medical education is the responsibility of the Ministry of Higher Education while the training sites are affiliated to MoH. In the year 2000 there were 14 medical colleges and in the last two years three more were established. Countrywide, there are around 1,200 medical faculty. More than 8,000 students are enrolled in these colleges which graduate more than 1,300 doctors a year. There are seven colleges for Pharmacy, six for Dentistry and three nursing colleges. In addition, there are three colleges for 4-years training in Health Technology and seven High Institutes for two-years training for Laboratory and Technical. 92 secondary or primary schools produce nurses: nursing does not have a licensure procedure; institutions call any and all untrained staff nurses.
  5. Public health training does not exist in Iraq. There are no programs for training epidemiologists, health managers, budget or planning officers. Also nursing specialties of community health, rehabilitation medicine, and health education and promotion do not exist.
  6. Post graduate medical education: Post graduate education is shouldered by the Iraqi Commission of Medical Specialties and provides postgraduate training programs in clinical specialties and for some disciplines there are sub-specialty training programs. Postgraduate training in UK and USA was the main source for specialization: it was reduced significantly in the '80s and ceased with the imposition of sanctions

d. CURRENT POLICY FRAMEWORK

Strategic Assumptions

  1. Re-establishing the functioning of the sector to prior-to-the-war levels requires funds for covering salaries and other priority recurrent expenditure. The budget of $211 M (excluding salaries) released in July by the Coalition Provisional Authority (CPA) for the next six months is an emergency measure, while preparatory work for the reconstruction conference is under way.
  2. Procurement, quality control and distribution of essential medicines and medical supplies is continuing. urgent equipment procurements, repair and maintenance. More precise assessments of the situation and estimates of needs will be possiblein the coming months.
  3. While the reorganized Ministry of Health will continue to be the main provider of health care in the country, it is possible to redress the highly centralized bureaucracy through the participation of main stakeholders in policy dialogue and a development of decentralisation of implementation responsibilities.

Strategic Constraints

  1. Iraq's past regime discouraged public, and also professional acccess to information and knowledge management. There is little in the country, in the line of health information systems and related culture and skills. Until this is changed, the Sector will face difficulties in measuring risks, monitoring progress and setting priorities.
  2. The large-scale investments needed to renovate the health infrastructure will not be available soon. Reconstruction of a health system commensurate with the expectations of the Iraqi population will take a long time.
  3. The mix of public and private services in Iraq is complex. The private and semi-public components are strong. Due to the prevailing situation in the country, there might be a fast and unregulated growth of private health care, as well as a significant increase in the activities of major NGOs posing the additional challenge of coordination to the health system.
  4. Social services, and the Health sector in particular, is a high priority of the CPA. Nonetheless, strategic and policy decisions in the health sector will continue to be constrained by limited funds and an unsure political arena.

e. CURRENT INSTITUTIONAL FRAMEWORK