Iraq healthcare system: An update Volume 4 - Issue 3

Aamir Jalal Al-Mosawi^1,2*

• ¹Advisor doctor and expert Baghdad Medical City and Iraqi Ministry of Health Baghdad, Iraq
• ²Headquarter of Copernicus Scientists, International Panel Baghdad, Iraq

Received: January 22, 2020;   Published: January 28, 2020

*Corresponding author: Aamir Jalal Al-Mosawi, Advisor doctor and expert Baghdad Medical City and Iraqi Ministry of Health Baghdad, Headquarter of Copernicus Scientists, International Panel Baghdad, Iraq

DOI: 10.32474/LOJMS.2020.04.000190

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Abstract

Background: Many shortcomings in the healthcare systems that lead to poor quality health services are partly associated with ignoring accessible data, information, and knowledge. Managing healthcare systems without having adequate knowledge is a logic obstacle for the delivery of high-quality health care services. We have previously provided a concise description of the Iraq health care system. The aim of this paper is to provide an updated account on the healthcare system in Iraq.

Materials and methods: The available published and unpublished information about healthcare system in Iraq were identified and reviewed. The information documents included more than 100 relevant published and unpublished information documents including journal articles, books, official reports documents of the Iraqi Ministry of Planning and Iraqi Ministry of Health. In addition, relevant useful information available at internet web sites was also examined. The retrieved information were classified into the following categories: Demographic information relevant to healthcare, information related to the organizational structure of the healthcare system, information related to national healthcare policies including national healthcare mission, vision, strategic goals and plans, information related to healthcare system financing, information about healthcare services delivery, information about the workforce in the Iraq healthcare system, information related to maternal and child health, information about infectious disease, information about chronic disorders and main causes of morbidity and mortality, information about medical education and healthcare education, information about professional training and development, and information about leadership in healthcare. Many relevant healthcare information for three provinces (The Kurdish provinces in the north of Iraq) of the eighteen provinces in Iraq were not available in English or Arabic.

Results: Iraq has been witnessing a noticeable growth in population from 28,506,000 in 2006 to 35,095,772. However, the organizational structure of the Iraq health system, the backbone of the Iraq healthcare system witnessed no important change from the previous description. The declared mission and visions of the Iraqi Ministry of Health have been updated. A priority values for the Iraqi Ministry of Health has also been claimed. The total number of physicians increased from 15994 in 2007 to 30913 in 2013. It was also estimated during the year 2013 that 8.5 of children under the age of five years were underweight. During the same year infant mortality rate was estimated to be 17.9 and mortality rate for children under the age of five years was 22.5. Neonatal cardiopulmonary disorders were the most common cause of death in children under the age of five years. Infective hepatitis and tuberculosis were the two most common chronic infectious diseases diagnosed during the year 2013. Cerebro-vascular disorders were the most common causes of mortality. A large number of reports and documents showed that In Iraq, corruption including scientific professional, and academic corruption not only resulted in loss of the financial allocations for the health sector, but also resulted in loss of leadership in healthcare, undergraduate and postgraduate medical education.

Conclusion: The most striking finding in this research was identifying the increasing recognition of the role of scientific, professional and academic corruption in the deterioration of medical education and healthcare services in Iraq.

Keywords: Healthcare system; Cerebro-vascular disorders; paramedics, dentists, medical laboratory technologists

Introduction

A health care system can be defined as the organization of personnel, institutions, and the available resources to deliver health care services required by intended populations. Throughout the world various forms health systems have been evolving following different histories and organizational structures. In some states, health system planning is shared mostly by market participants, while in other regions, collaborative efforts shared by governments, trade unions, charities, religious, and relevant bodies establish health care services delivery. Health care planning has been increasingly considered to be an evolutionary process rather than revolutionary process. The World Health Organization suggested that a health system should not be merely a network of publicly owned facilities that deliver personal health services, and it should be viewed as including all the elements playing role in establishing a healthcare system including a mother caring for a sick child at home; private providers; behavior change programs; vector-control campaigns; health insurance organizations; occupational health and safety legislations. Table-1 outlines the important aspects of healthcare systems. In a healthcare system, healthcare providers include institutions or individuals providing health care services. Individuals including health professionals and allied health professionals; they can be self-employed or working as an employee in a hospital, clinic, or other health care institution, whether government operated, private for-profit, or private not-forprofit (e.g. non-governmental organization) [1-5]. In a healthcare system, healthcare providers may have duties not directly related to patients’ care structure, as in a government health departments or other agencies, medical laboratory, or health training institution. Examples of health personnel include doctors, nurses, midwives, dietitians, paramedics, dentists, medical laboratory technologists, therapists, psychologists, pharmacists, community health workers, and others. Most health systems depend on a mix of the five funding models shown in Table 1. The management of healthcare systems is generally achieved through a set of policies and plans approved by government, private sector. Many shortcomings in the healthcare systems that lead to poor quality health services are partly associated by ignoring accessible data, information, and knowledge. Managing healthcare systems without having adequate knowledge is a logic obstacle for the delivery of high quality health care services. We have previously provided a concise description of the Iraq health care system [1,2,4,5]. The aim of this paper is to provide an updated account on the healthcare system in Iraq.

Materials and Methods

The available published and unpublished information about healthcare system in Iraq were identified and reviewed. The information documents included more than 100 relevant published and unpublished information documents including journal articles, books, official reports documents of the Iraqi Ministry of Planning and Iraqi Ministry of Health. In addition, relevant useful information available at internet web sites was also examined. The retrieved information were classified into the following categories: Demographic information relevant to healthcare, information related to the organizational structure of the healthcare system, information related to national healthcare policies including national healthcare mission, vision, strategic goals and plans, information related to healthcare system financing, information about healthcare services delivery, information about the workforce in the Iraq healthcare system, information related to maternal and child health, information about infectious disease, information about chronic disorders and main causes of morbidity and mortality, information about medical education and healthcare education, information about professional training and development, and information about leadership in healthcare. Many relevant healthcare information for three provinces (The Kurdish provinces in the north of Iraq) of the eighteen provinces in Iraq were not available in English or Arabic.

Results

Demographic information relevant to healthcare

According to the latest report of the Iraqi Ministry of planning which was available during the 2013, the total population of Iraq was estimated at 35,095,772 (17,864,258 males and 17,231,514 females) including 4,777,409 living in the three Kurdish provinces (Erbil, Duhok, and Sulaimayia) in the North of Iraq, and 7,457,773 living in Baghdad, and 22,760,594. 39.5% of the total Iraq population was estimated to be under the age of fifteen years including 14% under the age of five. 55.5% of the total Iraq population was estimated to be between the ages of fifteen and sixty years, and only 5% of the population was above the age of sixty years. 69.44% of the Iraq population was considered to live in urban areas, while 30.56% of the population was considered to live in rural areas.72 births occurred for every 1000 females between the ages of fifteen and nineteen years in thirteen of the eighteen provinces (except the three Kurdish provinces in the north of Iraq).

Organizational structure of the Iraq health system

The organizational structure of the Iraq health system witnessed no important change from the previous description. The Iraqi Ministry of health remains the backbone of the health system in Iraq and the main health care provider. Private medical sector also exists and other agencies such as the Red Crescent also contribute to the health services. Therefore, the major components of health system infrastructure of Iraq are directed by the Iraqi Ministry of Health.Figure-1 shows a simplification of the National Iraqi Health systems. In, the previous description of the Iraq healthcare system, there were three deputies of health in the ministry in addition to the minister; deputy of technical affairs, deputy of administrative affairs and deputy of building and construction affairs [1,3]. The deputy of building and construction affairs does no longer exist; this administrative position was removed in attempt to reduce the unnecessary expenditures for the unjustified financial privileges for the positions of the minister’s deputy. They were also the position of Inspector general of the Iraqi Ministry of Health. This position did also not exist as it was abolished for the same reason of abolishing the position of the third minister deputy. There are several central directorates in the headquarter in addition to the two health directorates in Baghdad and the health directorates in each province of Iraq. Table 2 shows the current structure of the Iraqi Ministry of Health. The administrative structure of the peripheral directorates is similar to the structure of the Iraqi Ministry of Health. Hospitals (General and teaching), primary health care clinics and health centers are affiliated with peripheral health directorates. The health directorates of 3 northern provinces (Sulaimanyia, Erbil, and Dohouk) affiliated with Ministry of Health the Kurdistan.

Information related to national healthcare policies: Many of the claimed national health policies in the Iraq healthcare system have been included in articles 30, 31, 32, and 33 of the constitution and witnessed no change. However, recently has been increasing public criticism for the whole constitution of the country and serious demands for writing a new constitution. Table 3 shows the claimed national health policies in the Iraq healthcare system included in the constitution. The declared mission and visions of the Iraqi Ministry of Health have been updated. Table-4 shows the previously published mission and visions of the Iraqi Ministry of Health. The latest available claimed mission of the Iraqi Ministry of Health stated “The Ministry of Health works to ensure the availability of integrated and complete healthcare to all society members in highest level of quality, through the investment in compliance with the professional ethics and society values, which is to achieve sustainable health development and to reduce morbidity and mortality”. A general vision statement for the years 2013-2017 has been introduced “A society that is physically, mentally, and socially healthy”. A priority values for the Iraqi Ministry of Health has also been claimed and included equity and equality, patient first, transparency, professionalism, reassurance and insurance, and teamwork. Prolonged redundant impractical vision statements like an irrelevant essay have also been introduced.

Information related to healthcare system financing: The Iraqi Ministry of Health remained largely funded centrally by the government. The total governmental budget for the Iraq healthcare system during the year 2013 was estimated at 7.360.552.000.000 Iraq Dinnars (about 61.337.933.333).

Information related to the workforce in the Iraq healthcare system: In 2007 there were 15994 doctors in Iraq including 4982 specialist doctor and 11012 practitioners (Non specialists). Table 4 shows the number of various health workers during several years.

Information about healthcare services delivery: The health services are delivered through hospitals, primary health centers and public health clinics. In 2003 there were 1717 primary health care centers in Iraq; about 50% of them were staffed by doctors, the rest by nurses and medical assistants. In 2005 the number of primary health care centers increased to 1854. The latest available report of the Iraqi Ministry of health in 2013 reported a total of 2642 primary health care centers in Iraq, 1313 of them were managed by physicians while 1329 centers were managed other healthcare professionals. It was estimated that there was 0.8 primary health care centers for each 10000 population. In 2007 there were 232 hospitals excluding hospital in the three northern Kurdish provinces of Kurdistan .There were 156 governmental hospitals which had 32641 beds and a bed occupancy rate of 57.1. The latest available report of the Iraqi Ministry of health in 2013 reported a total of 255 governmental hospitals with 44997 beds and a bed occupancy rate of 50%, and 105 private hospitals in all Iraq. 67 of the governmental hospitals were considered teaching hospitals. It was estimated that there was 0.7 hospitals for each 100000 population. Figure 2 shows the main types of hospitals in Iraq.

Information about the workforce in the Iraq healthcare system: In 2007, the total workforce in the Iraq healthcare system was estimated to be 3586 including 15994 physicians (4982 specialist doctor and 11012 non specialists’ practitioners, 3515 dentists, 3357 pharmacists, 31782 nurses, 2581 assistant nurses. The latest available report of the Iraqi Ministry of health in 2013 reported the total workforce in Iraq healthcare system was 273318 including 30913 physicians (9856 of them were specialist physicians), 7541 dentists, 7879 pharmacists, and 65474 nursing staff. It was estimated that there were 8.8 doctors, 2.1 dentists, 2.2 pharmacists, and 18.7 nursing staff for each 10000 of population

Information related to maternal and child health: The latest reports of the Iraqi Ministry of Health available was for the year 2013, estimated that 8% of women had unmet need for family planning and 52.5% of women used some contraceptive methods. 34 % of women excluding women living in the three Kurdish provinces were considered received satisfactory antenatal care with at least four visits. It was estimated that 87.7% of births excluding births taking place in the three Kurdish provinces were attended by skilled personnel. 73.2% of women gave birth by normal vaginal delivery and 26.5% by caesarian section excluding births taking place in the three Kurdish provinces. It was estimated that only 3.5% of women aged between 15-24 years had a comprehensive knowledge about acquired immune deficiency syndrome (AIDS), and the incidence rate of AIDS in was probably 0.075. It was also estimated during the year 2013 that about 10% of the newborn infants had weigh below 2.5 kilograms, and 8.5% of children under the age of five years were underweight. Figure-3 shows the available estimates nutritional status for children less than five years for the year 2011. During the same year a total of 4001 births (0.4%) from the Iraqi provinces excluding births taking place in the three Kurdish provinces had congenital malformations. Table 5 shows the main types of congenital malformations which accounted for 82% of all congenital malformations. Infant mortality rate was estimated to be 17.9 and mortality rate for children under the age of five years was 22.5. Table 6 shows the main causes of neonatal deaths according to the latest available report of the Iraqi Ministry of Health in 2013. Table 7 shows the main causes of infant deaths according to the latest available report of the Iraqi Ministry of Health in 2013. Table 8 shows the main causes of mortality in children under the age of five years according to the latest available report of the Iraqi Ministry of Health in 2013.

Information about infectious diseases: A total of 29059 (15590 males and 13469 females) cases of various types of infective hepatitis, and 8883 (4376 males and 4507 females) cases of tuberculosis were diagnosed during the year 2013; 5360 had pulmonary tuberculosis and 3523 had extrapulmonary tuberculosis. A total of 67546 cases (36308 males and 31238females) were notified during the year 2013. A total of 3044 cases (1151 males and 1893 females) of brucellosis , 2471 cases (1177 males and 1294 females) of pertusis, 1653 cases (927 males and 726 females) of cutaneous leishmaniasis, 1572 cases (912 males and 660 females) of various types of meningitis, 1267 cases (23 males and 1244 females) of toxoplasmosis, 907 cases (561 males and 346 females) of typhoid fever, 881 cases (323 males and 858 females) of hydatid cyst, 668 cases (377 males and 291 females) of measles, 576 case (302 males and 274 females) of kala azar, 545 cases (284 males and 261 females) of bacillary dysentery, 402 cases (225 males and 177 females) of acute flaccid paralysis, 66 cases (35 males and 31 females) of neonatal tetanus, and 30 cases (21 males and 9 females) of German measles, were notified during the year 2013. Only 9 cases (4 males and 5 females) of neonatal tetanus, 8 cases of rabies (7 males and 1 female), 4 cases of diphtheria (2 males and 2 females), one male patient with cholera, Only 20 cases (15 males and 5 females) of Acquired immune deficiency syndrome were detected during the year 2013, and one of them died during the same year.

Information about chronic disorders and main causes of morbidity and mortality: Table 9 shows the main causes of outpatient morbidity according to the latest available report of the Iraqi Ministry of Health in 2013. Table10 shows the main causes of morbidity leading to hospitalization according to the latest available report of the Iraqi Ministry of Health in 2013. Table 11 shows the main causes of mortality in males according to the latest available report of the Iraqi Ministry of Health in 2013. Table 12 shows the main causes of mortality in females according to the latest available report of the Iraqi Ministry of Health in 2013.

Information about medical education and healthcare education: During the year 2013, there were 20 governmental colleges of medicine, 12 colleges of dentistry including one private college, 12 colleges of pharmacy including 2 private colleges, 9 governmental colleges of nursing, 16 governmental health and technical institutes, 55 governmental nursing secondary schools, and 16 obstetrics secondary schools. Many reports and documents showed that medical education in Iraq has been increasingly criticized for not meeting the acceptable international standards and not achieving acceptable positions in the international ranking of medical colleges. Deterioration in medical education has been attributed to the lack of academic leadership resulting from the fact that for decades, heads of clinical departments in hospitals , heads of academics departments in medical colleges , deans of medical school, and heads of boards of medical specializations have been appointed in most instances regardless of their professional and scientific qualifications.

Information about professional training and development: Many reports and documents showed that despite the claims of conducting a large number of training courses for doctors and other healthcare professionals and workers, the vast majority of these course were not accredited and were mostly conducted by unqualified personnel. However, few courses (including medical and healthcare leadership courses, Training of trainer’s courses, pediatric psychiatry courses, and advanced English language courses [4- 8] had international accreditation and their scientific contents and training methodologies were published in academic books.

Information about leadership in healthcare: It is a matter of fact that the majority of challenges in developing world in the field of healthcare are mostly attributed to the lack of financial resources necessary for the production of adequate number of qualified doctors to face the challenges of the provision of the health services. The lack of financial resources also leads to shortage in the diagnostic equipment’s, preventive interventions and medicines necessary to deal with emerging challenges in healthcare [3-5]. A large number of reports and documents showed that In Iraq, corruption including scientific professional, and academic corruption not only resulted in loss of the financial allocations for the health sector, but also resulted in loss of leadership in healthcare, undergraduate and postgraduate medical education. Heads of clinical departments in hospitals, heads of academic’s departments in medical colleges, teaching hospital directors, general directors of health directorates, deans of medical school, and heads of boards of medical specializations have been appointed in most instances regardless of their professional and scientific qualifications. Many documents showed that corrupt laws and legislation, over many years gradually destroyed the infrastructure of healthcare organization and medical education institution including medical colleges and disrupted the healthy hierarchy of these organization. The people ruling the country issued laws and regulations aiming at enabling their followers to take the highest rank professional and academic positions and receive high salaries and pensions regardless of their qualifications, and regardless of the fact that such thing leads to loss of the associated leadership merits of these positions. This position is called “The special degrees” which include the ministers’ minister deputies and general directors, presidents of universities, deans of colleges including medical colleges. Many documents showed that these positions “The special degrees or ranks” are not political and should not have been controlled by people ruling the country.

Discussion

The Iraqi Ministry of Health was established after the establishment of the modern Iraqi government during the year 1921.The ministry persisted for few months before it was converted into Health General Administration affiliated to the ministry of Labor and Social affairs. That Health General Administration concentrated mainly on curative services and to some extent preventive services. The Iraqi Health General Administration activities expanded after the establishment of the WHO in 1947as that period witnessed advances in curative and preventive medicine. In November 23, 1952 the Iraqi Ministry of Health was re-establishment again as independent ministry. During that time the ministry consisted of two main directorates; the directorate of preventive medicine and the directorate of general medical services. The preventive directorate included eleven institutes (Nutrition institute, Tuberculosis institute, Bejel institute for the treatment of venereal disorders, Vaccine & Sera institute, Endemic diseases institute, Maternal and Child health institute, Health engineering institute, School services institute, Capital and city health institute, Epidemics, and world health institutes. The directorate of general medical services included hospitals, central medical clinics, dispensaries, and institutes for investigations (X-ray, bacteriology and pathology institute). A higher council of health was formed to plan the curricula of health administration (the curative and preventive services). Several administrative offices (directorates) were established in the governorates and were called “Liwa”. In each Liwa, a preventive and health directorate were established. Until 2003, the military health services provided healthcare to military personnel and their families. The military medical facilities have now been transferred to the Ministry of Health and most of military health professionals have transferred to the ministry institutions. All governmental general, teaching hospitals, and primary care health centers are affiliated with Iraqi Ministry of Health [1-3].

Conclusion

The most striking finding in this research was identifying the increasing recognition of the role of scientific, professional and academic corruption in the deterioration of medical education and healthcare services in Iraq.

Acknowledgement

Table 1 was published previously in a book [3] but the author has its copyright.
The New Iraqi Journal of Medicine kindly gave us the permission to publish (Figure 1), and (Table 2).

References

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2. Ameen MH, Al Mosawi AJ, Anoze A (2011) The evolution of modern healthcare and health education in Iraq. The N Iraqi J Med 7(1): 72-80.
3. Al-Mosawi AJ (2014) Healthcare system in Iraq. LAP Lambert Academic Publishing, Saarbrücken, Germany.
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