WORLD HEALTH ORGANIZATION

Iraq Briefing

Northern Governorates: Human Resources and Education

November 2000

Current status

The ‘brain drain’ of the past 15 years has left the Northern Governorates desperately short of skilled medical, nursing and paramedical staff. Most hospitals lack consultants in a number of specialties and only a third of primary health care centres are staffed by doctors. This not only affects patient care but also limits career development for young doctors.

Health facilities in the headquarter towns of Erbil, Sulaimaniyah and Dohuk are relatively better off, but finding doctors to stay in smaller towns and rural areas where living conditions are harsh and there is less opportunity for the private practice after their one year’s obligatory rural duty is difficult.

Primary health care centres are nominally linked to secondary care facilities, but there is no real supervision, training or encouragement that would allow people in the peripheries to improve their skills.

There are plenty of nurses, but numbers hide significant problems. Few nurses have skills that let them do more than hand out drugs and those that do are often prevented from using their knowledge because job descriptions of nurses are the same regardless of level of training. There is also a shortage of female nurses because nursing has poor social status and even poorer pay and, while families will allow their daughters to work as doctors – 50% of medical college students are female –there is little desire to go against social norms for such a low prestige job as nursing.

“All our students are from poor families. They come because of economic needs. No one who is rich will allow their girls to come to nursing,” says director of Erbil Nursing School for Girls, Ms Alia Younis.

Some hospital directors say there is an urgent need to increase nursing share in the management of patients, both to improve care and to compensate for the shortage of doctors, but this will require considerable changes in training and attitudes.

Medical and nursing education

Medical and nursing education is free; some female nursing students are even paid a small stipend (US$5/month) to encourage candidates.

Of the three medical colleges in the Northern Governorates only Erbil’s Salahudin University (650 students) is recognised by the Government of Iraq and therefore accepted and externally examined by the General Medical Council (GMC) of Britain. Sulaimaniyah, which is the Northern region’s original university (500 students), and smaller Dohuk are members of the International Association of Universities and both are trying to gain GMC acceptance. All colleges are desperately short of lecturers despite the fact that university professors are paid more in the north than the rest of Iraq.

Nurses are trained at three levels: intermediate and preparatory schools which produce male and female graduates at 15 and 18 respectively after three years study, and technicalinstitutes which take high school science graduates or selected pupils from preparatory school level for a two year course. Institute nurses are qualified to take higher studies, e.g. masters studies in the College of Nursing in

Baghdad or Mosul, though in practice those from the Northern Governorates find gaining a place in these institutions difficult. There is no university-level nursing education in the Northern Governorates.

In terms of premises and equipment, the situation for most colleges and schools has improved significantly in the past year as renovations and orders via SCR 986 have started to materialise (see below). However, academic facilities are dogged by the same problems as clinical ones such as incomplete equipment and lack of user knowledge. As a result, many students continue to be trained in old fashioned techniques which will inevitably affect standards of care in the long term.

WHO activities

  • Renovation: WHO architects and engineers are responsible for a heavy programme of renovation and construction of medical and nursing schools using SCR 986 funds. New nursing schools have been built in Dohuk and Sulaimaniyah and in Erbil, the 60 pupil Nursing School for Girls has been completely renovated. Three new lecture amphitheatres are being built for Dohuk Medical College, while laboratories and libraries have been renovated in Erbil and Sulaimaniyah. New housing for nurses and doctors is being built in several sites to improve working conditions.
  • Equipment: WHO’s biomedical engineering teams in the three governorates supervise the supply and installation of SCR 986 equipment for medical and nursing colleges ranging from ventilators and microscopes to thermometers, patient dummies and school furniture.
  • Academic staffing: WHO is hoping to recruit several consultants to help strengthen the academic staff of the three medical schools. An international consultant has also recently arrived to help reform the nursing curriculum and support the development of the profession.
  • Practical support: WHO’s team of three national nurses are leading a series of workshops which aim firstly to develop a more professional standard of nursing through attention to job descriptions management and teaching methods, and secondly to enhance the skills of existing and student nurses via a series of refresher courses in areas such as basic life signs, surgical and cardiac care, burns, care of children and an introduction to primary care nursing.
  • Public health approach: The first community-orientated summer training for medical students took place this year, arranged by Sulaimaniyah College of Medicine and supported by WHO using SCR 986 funds. Designed to expose 30 4th year students to a practical public health exercise, the course involved gathering and analysing epidemiological data and information about the communities and developing and carrying out public health recommendations.

Issues

  1. Intellectual isolation: All staff including technicians continue to suffer from the intellectual restrictions on Iraq. Reference and text books date at best from 1990. Staff in the Northern Governorates rarely receive permission to leave the country for training or study, therefore are largely unable to source new techniques and approaches.

Although local officials travel unofficially into neighbouring countries, UN agencies such as WHO cannot facilitate overseas training on such a basis. For the few specialists who do manage to

travel abroad in this way, there is no structured way in which they can share their new expertise on their return. A combination of outside exposure and assignment of overseas experts to the Northern Governorates is needed to build up teaching as well as clinical skills.

  1. Motivation and private practice: Qualified doctors earn around 1500 Northern dinars (US$83), nurses earn 300 dinars ($17) a month. This, together with poor opportunities for career development, not surprisingly decreases motivation. Many female graduates simply do not take up positions but return to family life, while male doctors focus on their private practice or take up other jobs. People who do receive extra training – particularly technicians – often leave public service to start their own businesses. To try and combat this drain and keep good staff in the system, WHO identifies competent professionals and supports their work in critical public health areas.