Roots of Iraq's maternal and child health crisis run deep

Abstract

The health system in Iraq is still recovering from decades of brutal war and conflict and indicators for maternal and child health remain poor. Paul C Webster reports.Nabil Al-Khalisi's preoccupation with the plight of Iraq's health system has personal roots. In 2010, just 1 year after completing his medical training at Baghdad University, he was forced to flee Iraq after being threatened with violence in several Baghdad hospitals. Exiled in the USA, where he now works as a clinical improvement analyst at the Athens Regional Medical Center, in Athens, Georgia, Al-Khalisi began investigating the links between violence in Iraq and physician emigration. His findings reveal a lot about why infant and maternal mortality remain acute problems there.With help from public records from the Iraq Medical Association, in June, 2011, Al-Khalisi contacted 1395 Iraqi physicians and asked them to respond to a questionnaire about their experiences. The effort yielded responses from 562 Iraqi-trained physicians, 65% of whom are living outside Iraq—a figure that Al-Khalisi notes is roughly proportionate with the share of Iraqi doctors who have fled since the US-led occupation in 2003. Of the 34 000 doctors in the country before the occupation, Al-Khalisi notes, citing Brookings Institution data, that 2000 have been murdered, 250 kidnapped, and 20 000 have emigrated. “70% of the medical specialists in Iraq before 2003 have left”, he explains.In a presentation last July at a conference on medicine in Iraq, Al-Khalisi revealed a set of startling findings that explain why so many physicians like him fled. Among the 202 respondents to his survey who were living in Iraq, 8% reported having been kidnapped and 18% reported having survived assassination attempts. More than 50% of all the 562 physicians Al-Khalisi interviewed living inside and outside Iraq said they had been threatened, and about 70% of them described working conditions for physicians today in Iraq as “risky”.One of the physicians Al-Khalisi interviewed was Mustafa Saudi, a recently graduated general physician currently working in a paediatrics hospital in Sadr City, an ultra-violent Baghdad district. He vividly explains the risks that so many physicians in Iraq face. “Iraq is uniquely dangerous due to the enormous number of weapons in circulation, and the intense sectarian violence”, Saudi explains. “We treat the victims and the belligerents and we encounter their families and friends. Security in the hospitals is lax and anyone can walk in. Clinicians encounter a lot of quarrelling on every shift. One of my colleagues was threatened and quit practising immediately.”Of the 24 physicians who graduated in Saudi's cohort 2 years ago, five have now left Iraq. Ominously, almost half of the 202 physicians still working in Iraq who responded to Al-Khalisi's questionnaire said they too were planning to leave. “Although the rate of emigration among Iraqi doctors peaked in 2006”, Al-Khalisi explains, “it still remains relatively high. And that, alongside a number of other key factors, explains why the health indicators for Iraqi women and children are so disastrous.”In an updated survey of 26 doctors in Iraq done for The Lancet last month, Al-Khalisi says, “there was a general consensus that health-care management is a total fiasco and the staff shortage is overwhelming. Talking about child and maternal health, senior doctors said the trend shifted from malnutrition, drug shortages, and poverty before 2003, to violence (both terrorist and domestic), psychological trauma, outbreaks of infectious disease, and failing infrastructure after 2003.”An Iraqi mother and her malnourished 2-year-old child wait to see a doctor, Basra, May, 2003View Large Image Copyright © 2013 CorbisMaternal and child health10 years after American and British forces toppled Saddam Hussein and helped initiate a decade of intense violence, life expectancy at birth in Iraq is 59 years—at least 12 years less than in Egypt, Syria, Morocco, and Jordan, all of which are far poorer countries. The rate of children dying in the first year of life is 32 deaths for every 1000 livebirths—about the same as it was in 1989. Yemen, with just a quarter of Iraq's per head wealth, is the only country in the region with a similar infant mortality.Iraq's maternal mortality figures are equally disturbing. With 84 women dying in childbirth per 100 000 livebirths, according to a Health Sector Assessment and Functional Review published by Iraq's Ministry of Health and WHO in 2011, Iraq is among the group of 68 countries that account for 97% of all maternal and child deaths globally. While neighbouring Iran cut its maternal death rate by 220% between 2000 and 2010, Iraq's rate dropped by a tenth as much during this period. And there has been “relatively little improvement” in under-5 mortality during the past 15 years, according to a 2011 Multiple Indicator Cluster Survey of 36 500 households published last December by the Government of Iraq and UNICEF.The newly published multiple indicator survey offers many clues to why Iraq is lagging on maternal and child health, says Mehdi Al-Allak, Iraq's Deputy Minister of Planning and the Head of its Central Statistics Organization. In a country where half the population are children younger than 18 years, he notes, only 10% are not deprived of essentials such as health care, nutrition, education, water and sanitation, protection, and shelter. “Not only do we now know that there are 5·3 million children deprived of many services but we know exactly which services they are”, Al-Allak claimed after the survey was launched.In laying bare some of the main causes of Iraq's child mortality crisis, the survey revealed that more than 8% of children are moderately or severely underweight and nearly one in four are stunted. Less than half of children younger than 2 years received vaccinations recommended by age 1 year. Rates of diarrhoea among children younger than 5 years are high, but only 26% receive appropriate treatment. Safe disposal of children's faecal matter was registered in only 18% of homes, and 16% of the population drinks unsafe water.“Only 20% of children aged less than 6 months are exclusively breastfed”, the survey notes about a crucial practice in protecting children from infection, “a level considerably lower than recommended”. And, the survey continues, even though more than a fifth of the population live on less than US$2 a day, many mothers “stop breastfeeding too soon and there are often pressures to switch to infant formula which can contribute to growth faltering and micronutrient malnutrition, and is unsafe if clean water is not readily available”.The survey offered similarly potent clues to causes of the maternal mortality crisis. While the average Iraqi woman bears 4·5 children and 12% of mothers give birth before age 18 years, the survey revealed, 22% of expectant mothers received no antenatal care, and only half of all expecting mothers receive the minimum levels of antenatal care recommended by UNICEF and WHO.In rural areas, where 65% of women do not have health cards, 22% of childbirths are not attended by skilled personnel. 35% of pregnant women are anaemic and a quarter of all mothers encounter severe complications during childbirth. Emergency obstetrical care is often unavailable.Health spendingThe roots of Iraq's maternal and child health crisis are deep. Although between 1979 and 1989 under-5 mortality rates fell from 120 to 60 per 1000 livebirths, during the 1990s, wars and economic sanctions led to an estimated 90% cut to national health spending, and serious declines in population health outcomes as many health professionals left the country. From 1990 to 1996, infant, child, and maternal mortality rates more than doubled. Progress since then, through a period of renewed violence triggered by the US-led occupation in 2003, has been achingly slow. “The health sector is still recovering from decades of war and conflict and needs extensive, carefully targeted reforms”, says Syed Jaffar Hussain, WHO's head of mission in Iraq.After crediting the Iraqi Government for substantially expanding the health budget and forging substantial progress in improving, and opening-up access to, public health care, Hussain notes that Iraq's per head health spending of $215 remains low compared with neighbouring countries such as Jordan, where per head spending is $336, and Iran, where it is $305.In an analysis presented at a regional summit on the Millennium Development Goals (MDG) in Dubai in late January, Hussain argued that it is unlikely Iraq can meet its goal of reducing maternal mortality to 20 deaths per 100 000 livebirths by 2015, and child deaths to 15 per 1000 livebirths. But progress is accelerating, he stressed, and Iraq could achieve a 30% reduction in child and maternal deaths by 2015 by scaling up family planning, skilled birth attendance, vaccine coverage, nutrition, integrated management of childhood illnesses, and domestic access to clean water and sanitation.Doing all this, Hussain warns, will require the Iraqi Government to increase health spending from just over $220 million annually to nearly $500 million. “The current spending levels are not sufficient for health-sector modernisation”, he says, adding that the private sector, which currently accounts for an estimated 20% of outpatient visits, cannot meet the need for additional capacity, in part because many professionals working in private settings are in fact full-time public employees with little additional time to devote to patients.In calling on the Iraqi Government to boost spending to reduce child and maternal deaths, Hussain points to numerous obstacles. “The Ministry of Health lacks a strategic plan for the period up to, say 2020”, he complains, before acknowledging that the government's National Development Plan does include a timetable for implementing health system strengthening, better disease control, a modernised medical information system, health budget increases, health workforce improvements, and efforts to improve health legislation and combat corruption.Sensible as this plan may look, however, many realities are less palatable. Although the investment budget for new health facilities has doubled in recent years to 20%, for example, as much as 70% of this money remained unspent in recent years due to what officials call “low absorption capacity”, a term which they explain to mean “limited capacity among the staff for preparing sector strategies, feasibility reports, and appropriate project costing”, and “weaknesses in procurement and contracting”.Christian Kinch, the chief executive officer of Bactiguard, a Swedish company that manufactures bacterial-resistant catheters, describes procurement as an especially fraught area among the panoply of problems bedevilling Ministry officials. On a trip to Baghdad in February, Kinch said ceaseless security emergencies transformed doing basic business matters—even with the blessing of senior government officials—into “a fight for survival every day”.And while Kinch describes government health officials as candid in acknowledging the severity of the medical crisis—including the extremely high rates of hospital-acquired infections—he says officials are often paralysed by compound constraints ranging from the security crisis, to technical incompetence and decaying infrastructure.View Large Image Copyright © 2013 Corbis“If you look at the country versus 2003, it's a mess, and at times it seems to still be going backwards. They basically have to rebuild from scratch”, he muses. “They have lost enormous amounts of know-how in the government because of the brain-drain. To get it back on its feet they will have to focus on education and health care.”Plainer words still come from Taghreed AIhaidari, who serves as professor of obstetrics and gynaecology at Baghdad University, physician at the Elwiyah Maternity Teaching Hospital, and a member of the government's maternal health advisory board. “There is more money now but the level of primary health-care service remains inadequate—especially in rural areas.” In view of this situation, AIhaidari finds the government's claims regarding recent progress on maternal health unconvincing. The government's current claim that the mortality rate may now have dropped as low as 63 per 1000 livebirths, she worries, “doesn't seem realistic”.More substantial progress is being made towards other MDG goals, Alhaidari adds, including nutrition and gender equity. But regarding the core health goals, she feels, “new strategies come and go from the Ministry and the UN and the WHO, but sustainability is the problem. There is still no long-term vision”.A US-sponsored health-care clinic for women and children, Camp Victory, Iraq, 2007View Large Image Copyright © 2013 CorbisWHO's Hussain is similarly blunt. Political interference is rife in decision making within the Ministry of Health, he confirms. “Professionals at mid-level are mostly chosen on political grounds rather than merit”, he complains, “so there aren't many expert people around to tell you the truth in the Ministry of Health”.Health system strengtheningThe talent problem at the ministry, Hussain reflects, mirrors the overall lack of medical expertise throughout the country. According to government figures, with 24 745 physicians currently in practice, Iraq's physician-to-population ratio is about 60% lower than the average for the other 23 nations in WHO's Eastern Mediterranean Region. The nurse-to-patient ratio is about 35% lower than the regional average.Migration of health professionals “is still a big concern”, according to the 2011 Health Sector Assessment, which notes that although “no accurate figures could be obtained” on the issue, “according to key informants, factors behind external migration are lack of political stability and security, better opportunities for quality education and financial reasons”.The lack of family physicians in Iraq is especially dire. Only 182 family physicians have been trained since 1999 and there are only 127 currently in practice, according to the 2011 Health Sector Assessment. And while the Assessment called for 20 000 family physicians by 2021, it also predicted a shortfall of almost 19 000 by that date. “The lack of family doctors and the lack of primary health care capacity as a whole is a major part of the child and maternal mortality crisis”, Hussain confirms.Yaseen Abbas, president of the Iraqi Red Crescent Society, agrees. The overarching impediment blocking progress on maternal and child mortality, he argues, is no longer violence and insecurity, which for much of the past decade prevented patients from reaching health professionals. “The medical teams are now reaching all parts of Iraq”, he reports. “But the problems now are structural. The number of primary care facilities is inadequate. The years of embargoes and the former regime's strategies held Iraq back in medical science. This, and the brain drain, remain the main things retarding health care here.”Mustafa Saudi, the recently graduated emergency room physician in Sadr City, offers a disturbing clinical perspective on these problems. “The emergency rooms in general hospitals are a mess. The number of patients vastly exceeds capacity, especially in the evenings. There is more equipment available but we still lack basic things like viral assay capability, incubators, ventilators, scanners. Even the quality of the antibiotics we use is unreliable”, he charges.Alongside the lack of doctors and supplies, Saudi warns, the Iraqi health-care crisis is steadily intensified by a population explosion that began outstripping growth in Jordan, Iran, and Syria in the late 1980s. At 35 new births per 1000 people, Iraqi population growth is now 50% higher than Jordan and Syria's and twice as high as Iran's. Basic education on family planning and contraception has withered among poorer families. “This obviously puts large numbers of women at risk. They are constantly facing malnutrition, complications, and stillbirths. In urban hospitals the numbers of emergency caesareans performed is huge. But in rural areas where primary care is primitive these are often not available.”“But by far the most serious problems we face are explosive population growth and far too few doctors”, Saudi warns. “Not many have come back. In fact, lots of young doctors continue to leave.” The health system in Iraq is still recovering from decades of brutal war and conflict and indicators for maternal and child health remain poor. Paul C Webster reports. Nabil Al-Khalisi's preoccupation with the plight of Iraq's health system has personal roots. In 2010, just 1 year after completing his medical training at Baghdad University, he was forced to flee Iraq after being threatened with violence in several Baghdad hospitals. Exiled in the USA, where he now works as a clinical improvement analyst at the Athens Regional Medical Center, in Athens, Georgia, Al-Khalisi began investigating the links between violence in Iraq and physician emigration. His findings reveal a lot about why infant and maternal mortality remain acute problems there. With help from public records from the Iraq Medical Association, in June, 2011, Al-Khalisi contacted 1395 Iraqi physicians and asked them to respond to a questionnaire about their experiences. The effort yielded responses from 562 Iraqi-trained physicians, 65% of whom are living outside Iraq—a figure that Al-Khalisi notes is roughly proportionate with the share of Iraqi doctors who have fled since the US-led occupation in 2003. Of the 34 000 doctors in the country before the occupation, Al-Khalisi notes, citing Brookings Institution data, that 2000 have been murdered, 250 kidnapped, and 20 000 have emigrated. “70% of the medical specialists in Iraq before 2003 have left”, he explains. In a presentation last July at a conference on medicine in Iraq, Al-Khalisi revealed a set of startling findings that explain why so many physicians like him fled. Among the 202 respondents to his survey who were living in Iraq, 8% reported having been kidnapped and 18% reported having survived assassination attempts. More than 50% of all the 562 physicians Al-Khalisi interviewed living inside and outside Iraq said they had been threatened, and about 70% of them described working conditions for physicians today in Iraq as “risky”. One of the physicians Al-Khalisi interviewed was Mustafa Saudi, a recently graduated general physician currently working in a paediatrics hospital in Sadr City, an ultra-violent Baghdad district. He vividly explains the risks that so many physicians in Iraq face. “Iraq is uniquely dangerous due to the enormous number of weapons in circulation, and the intense sectarian violence”, Saudi explains. “We treat the victims and the belligerents and we encounter their families and friends. Security in the hospitals is lax and anyone can walk in. Clinicians encounter a lot of quarrelling on every shift. One of my colleagues was threatened and quit practising immediately.” Of the 24 physicians who graduated in Saudi's cohort 2 years ago, five have now left Iraq. Ominously, almost half of the 202 physicians still working in Iraq who responded to Al-Khalisi's questionnaire said they too were planning to leave. “Although the rate of emigration among Iraqi doctors peaked in 2006”, Al-Khalisi explains, “it still remains relatively high. And that, alongside a number of other key factors, explains why the health indicators for Iraqi women and children are so disastrous.” In an updated survey of 26 doctors in Iraq done for The Lancet last month, Al-Khalisi says, “there was a general consensus that health-care management is a total fiasco and the staff shortage is overwhelming. Talking about child and maternal health, senior doctors said the trend shifted from malnutrition, drug shortages, and poverty before 2003, to violence (both terrorist and domestic), psychological trauma, outbreaks of infectious disease, and failing infrastructure after 2003.” Maternal and child health10 years after American and British forces toppled Saddam Hussein and helped initiate a decade of intense violence, life expectancy at birth in Iraq is 59 years—at least 12 years less than in Egypt, Syria, Morocco, and Jordan, all of which are far poorer countries. The rate of children dying in the first year of life is 32 deaths for every 1000 livebirths—about the same as it was in 1989. Yemen, with just a quarter of Iraq's per head wealth, is the only country in the region with a similar infant mortality.Iraq's maternal mortality figures are equally disturbing. With 84 women dying in childbirth per 100 000 livebirths, according to a Health Sector Assessment and Functional Review published by Iraq's Ministry of Health and WHO in 2011, Iraq is among the group of 68 countries that account for 97% of all maternal and child deaths globally. While neighbouring Iran cut its maternal death rate by 220% between 2000 and 2010, Iraq's rate dropped by a tenth as much during this period. And there has been “relatively little improvement” in under-5 mortality during the past 15 years, according to a 2011 Multiple Indicator Cluster Survey of 36 500 households published last December by the Government of Iraq and UNICEF.The newly published multiple indicator survey offers many clues to why Iraq is lagging on maternal and child health, says Mehdi Al-Allak, Iraq's Deputy Minister of Planning and the Head of its Central Statistics Organization. In a country where half the population are children younger than 18 years, he notes, only 10% are not deprived of essentials such as health care, nutrition, education, water and sanitation, protection, and shelter. “Not only do we now know that there are 5·3 million children deprived of many services but we know exactly which services they are”, Al-Allak claimed after the survey was launched.In laying bare some of the main causes of Iraq's child mortality crisis, the survey revealed that more than 8% of children are moderately or severely underweight and nearly one in four are stunted. Less than half of children younger than 2 years received vaccinations recommended by age 1 year. Rates of diarrhoea among children younger than 5 years are high, but only 26% receive appropriate treatment. Safe disposal of children's faecal matter was registered in only 18% of homes, and 16% of the population drinks unsafe water.“Only 20% of children aged less than 6 months are exclusively breastfed”, the survey notes about a crucial practice in protecting children from infection, “a level considerably lower than recommended”. And, the survey continues, even though more than a fifth of the population live on less than US$2 a day, many mothers “stop breastfeeding too soon and there are often pressures to switch to infant formula which can contribute to growth faltering and micronutrient malnutrition, and is unsafe if clean water is not readily available”.The survey offered similarly potent clues to causes of the maternal mortality crisis. While the average Iraqi woman bears 4·5 children and 12% of mothers give birth before age 18 years, the survey revealed, 22% of expectant mothers received no antenatal care, and only half of all expecting mothers receive the minimum levels of antenatal care recommended by UNICEF and WHO.In rural areas, where 65% of women do not have health cards, 22% of childbirths are not attended by skilled personnel. 35% of pregnant women are anaemic and a quarter of all mothers encounter severe complications during childbirth. Emergency obstetrical care is often unavailable. 10 years after American and British forces toppled Saddam Hussein and helped initiate a decade of intense violence, life expectancy at birth in Iraq is 59 years—at least 12 years less than in Egypt, Syria, Morocco, and Jordan, all of which are far poorer countries. The rate of children dying in the first year of life is 32 deaths for every 1000 livebirths—about the same as it was in 1989. Yemen, with just a quarter of Iraq's per head wealth, is the only country in the region with a similar infant mortality. Iraq's maternal mortality figures are equally disturbing. With 84 women dying in childbirth per 100 000 livebirths, according to a Health Sector Assessment and Functional Review published by Iraq's Ministry of Health and WHO in 2011, Iraq is among the group of 68 countries that account for 97% of all maternal and child deaths globally. While neighbouring Iran cut its maternal death rate by 220% between 2000 and 2010, Iraq's rate dropped by a tenth as much during this period. And there has been “relatively little improvement” in under-5 mortality during the past 15 years, according to a 2011 Multiple Indicator Cluster Survey of 36 500 households published last December by the Government of Iraq and UNICEF. The newly published multiple indicator survey offers many clues to why Iraq is lagging on maternal and child health, says Mehdi Al-Allak, Iraq's Deputy Minister of Planning and the Head of its Central Statistics Organization. In a country where half the population are children younger than 18 years, he notes, only 10% are not deprived of essentials such as health care, nutrition, education, water and sanitation, protection, and shelter. “Not only do we now know that there are 5·3 million children deprived of many services but we know exactly which services they are”, Al-Allak claimed after the survey was launched. In laying bare some of the main causes of Iraq's child mortality crisis, the survey revealed that more than 8% of children are moderately or severely underweight and nearly one in four are stunted. Less than half of children younger than 2 years received vaccinations recommended by age 1 year. Rates of diarrhoea among children younger than 5 years are high, but only 26% receive appropriate treatment. Safe disposal of children's faecal matter was registered in only 18% of homes, and 16% of the population drinks unsafe water. “Only 20% of children aged less than 6 months are exclusively breastfed”, the survey notes about a crucial practice in protecting children from infection, “a level considerably lower than recommended”. And, the survey continues, even though more than a fifth of the population live on less than US$2 a day, many mothers “stop breastfeeding too soon and there are often pressures to switch to infant formula which can contribute to growth faltering and micronutrient malnutrition, and is unsafe if clean water is not readily available”. The survey offered similarly potent clues to causes of the maternal mortality crisis. While the average Iraqi woman bears 4·5 children and 12% of mothers give birth before age 18 years, the survey revealed, 22% of expectant mothers received no antenatal care, and only half of all expecting mothers receive the minimum levels of antenatal care recommended by UNICEF and WHO. In rural areas, where 65% of women do not have health cards, 22% of childbirths are not attended by skilled personnel. 35% of pregnant women are anaemic and a quarter of all mothers encounter severe complications during childbirth. Emergency obstetrical care is often unavailable. Health spendingThe roots of Iraq's maternal and child health crisis are deep. Although between 1979 and 1989 under-5 mortality rates fell from 120 to 60 per 1000 livebirths, during the 1990s, wars and economic sanctions led to an estimated 90% cut to national health spending, and serious declines in population health outcomes as many health professionals left the country. From 1990 to 1996, infant, child, and maternal mortality rates more than doubled. Progress since then, through a period of renewed violence triggered by the US-led occupation in 2003, has been achingly slow. “The health sector is still recovering from decades of war and conflict and needs extensive, carefully targeted reforms”, says Syed Jaffar Hussain, WHO's head of mission in Iraq.After crediting the Iraqi Government for substantially expanding the health budget and forging substantial progress in improving, and opening-up access to, public health care, Hussain notes that Iraq's per head health spending of $215 remains low compared with neighbouring countries such as Jordan, where per head spending is $336, and Iran, where it is $305.In an analysis presented at a regional summit on the Millennium Development Goals (MDG) in Dubai in late January, Hussain argued that it is unlikely Iraq can meet its goal of reducing maternal mortality to 20 deaths per 100 000 livebirths by 2015, and child deaths to 15 per 1000 livebirths. But progress is accelerating, he stressed, and Iraq could achieve a 30% reduction in child and maternal deaths by 2015 by scaling up family planning, skilled birth attendance, vaccine coverage, nutrition, integrated management of childhood illnesses, and domestic access to clean water and sanitation.Doing all this, Hussain warns, will require the Iraqi Government to increase health spending from just over $220 million annually to nearly $500 million. “The current spending levels are not sufficient for health-sector modernisation”, he says, adding that the private sector, which currently accounts for an estimated 20% of outpatient visits, cannot meet the need for additional capacity, in part because many professionals working in private settings are in fact full-time public employees with little additional time to devote to patients.In calling on the Iraqi Government to boost spending to reduce child and maternal deaths, Hussain points to numerous obstacles. “The Ministry of Health lacks a strategic plan for the period up to, say 2020”, he complains, before acknowledging that the government's National Development Plan does include a timetable for implementing health system strengthening, better disease control, a modernised medical information system, health budget increases, health workforce improvements, and efforts to improve health legislation and combat corruption.Sensible as this plan may look, however, many realities are less palatable. Although the investment budget for new health facilities has doubled in recent years to 20%, for example, as much as 70% of this money remained unspent in recent years due to what officials call “low absorption capacity”, a term which they explain to mean “limited capacity among the staff for preparing sector strategies, feasibility reports, and appropriate project costing”, and “weaknesses in procurement and contracting”.Christian Kinch, the chief executive officer of Bactiguard, a Swedish company that manufactures bacterial-resistant catheters, describes procurement as an especially fraught area among the panoply of problems bedevilling Ministry officials. On a trip to Baghdad in February, Kinch said ceaseless security emergencies transformed doing basic business matters—even with the blessing of senior government officials—into “a fight for survival every day”.And while Kinch describes government health officials as candid in acknowledging the severity of the medical crisis—including the extremely high rates of hospital-acquired infections—he says officials are often paralysed by compound constraints ranging from the security crisis, to technical incompetence and decaying infrastructure.“If you look at the country versus 2003, it's a mess, and at times it seems to still be going backwards. They basically have to rebuild from scratch”, he muses. “They have lost enormous amounts of know-how in the government because of the brain-drain. To get it back on its feet they will have to focus on education and health care.”Plainer words still come from Taghreed AIhaidari, who serves as professor of obstetrics and gynaecology at Baghdad University, physician at the Elwiyah Maternity Teaching Hospital, and a member of the government's maternal health advisory board. “There is more money now but the level of primary health-care service remains inadequate—especially in rural areas.” In view of this situation, AIhaidari finds the government's claims regarding recent progress on maternal health unconvincing. The government's current claim that the mortality rate may now have dropped as low as 63 per 1000 livebirths, she worries, “doesn't seem realistic”.More substantial progress is being made towards other MDG goals, Alhaidari adds, including nutrition and gender equity. But regarding the core health goals, she feels, “new strategies come and go from the Ministry and the UN and the WHO, but sustainability is the problem. There is still no long-term vision”.A US-sponsored health-care clinic for women and children, Camp Victory, Iraq, 2007View Large Image Copyright © 2013 CorbisWHO's Hussain is similarly blunt. Political interference is rife in decision making within the Ministry of Health, he confirms. “Professionals at mid-level are mostly chosen on political grounds rather than merit”, he complains, “so there aren't many expert people around to tell you the truth in the Ministry of Health”. The roots of Iraq's maternal and child health crisis are deep. Although between 1979 and 1989 under-5 mortality rates fell from 120 to 60 per 1000 livebirths, during the 1990s, wars and economic sanctions led to an estimated 90% cut to national health spending, and serious declines in population health outcomes as many health professionals left the country. From 1990 to 1996, infant, child, and maternal mortality rates more than doubled. Progress since then, through a period of renewed violence triggered by the US-led occupation in 2003, has been achingly slow. “The health sector is still recovering from decades of war and conflict and needs extensive, carefully targeted reforms”, says Syed Jaffar Hussain, WHO's head of mission in Iraq. After crediting the Iraqi Government for substantially expanding the health budget and forging substantial progress in improving, and opening-up access to, public health care, Hussain notes that Iraq's per head health spending of $215 remains low compared with neighbouring countries such as Jordan, where per head spending is $336, and Iran, where it is $305. In an analysis presented at a regional summit on the Millennium Development Goals (MDG) in Dubai in late January, Hussain argued that it is unlikely Iraq can meet its goal of reducing maternal mortality to 20 deaths per 100 000 livebirths by 2015, and child deaths to 15 per 1000 livebirths. But progress is accelerating, he stressed, and Iraq could achieve a 30% reduction in child and maternal deaths by 2015 by scaling up family planning, skilled birth attendance, vaccine coverage, nutrition, integrated management of childhood illnesses, and domestic access to clean water and sanitation. Doing all this, Hussain warns, will require the Iraqi Government to increase health spending from just over $220 million annually to nearly $500 million. “The current spending levels are not sufficient for health-sector modernisation”, he says, adding that the private sector, which currently accounts for an estimated 20% of outpatient visits, cannot meet the need for additional capacity, in part because many professionals working in private settings are in fact full-time public employees with little additional time to devote to patients. In calling on the Iraqi Government to boost spending to reduce child and maternal deaths, Hussain points to numerous obstacles. “The Ministry of Health lacks a strategic plan for the period up to, say 2020”, he complains, before acknowledging that the government's National Development Plan does include a timetable for implementing health system strengthening, better disease control, a modernised medical information system, health budget increases, health workforce improvements, and efforts to improve health legislation and combat corruption. Sensible as this plan may look, however, many realities are less palatable. Although the investment budget for new health facilities has doubled in recent years to 20%, for example, as much as 70% of this money remained unspent in recent years due to what officials call “low absorption capacity”, a term which they explain to mean “limited capacity among the staff for preparing sector strategies, feasibility reports, and appropriate project costing”, and “weaknesses in procurement and contracting”. Christian Kinch, the chief executive officer of Bactiguard, a Swedish company that manufactures bacterial-resistant catheters, describes procurement as an especially fraught area among the panoply of problems bedevilling Ministry officials. On a trip to Baghdad in February, Kinch said ceaseless security emergencies transformed doing basic business matters—even with the blessing of senior government officials—into “a fight for survival every day”. And while Kinch describes government health officials as candid in acknowledging the severity of the medical crisis—including the extremely high rates of hospital-acquired infections—he says officials are often paralysed by compound constraints ranging from the security crisis, to technical incompetence and decaying infrastructure. “If you look at the country versus 2003, it's a mess, and at times it seems to still be going backwards. They basically have to rebuild from scratch”, he muses. “They have lost enormous amounts of know-how in the government because of the brain-drain. To get it back on its feet they will have to focus on education and health care.” Plainer words still come from Taghreed AIhaidari, who serves as professor of obstetrics and gynaecology at Baghdad University, physician at the Elwiyah Maternity Teaching Hospital, and a member of the government's maternal health advisory board. “There is more money now but the level of primary health-care service remains inadequate—especially in rural areas.” In view of this situation, AIhaidari finds the government's claims regarding recent progress on maternal health unconvincing. The government's current claim that the mortality rate may now have dropped as low as 63 per 1000 livebirths, she worries, “doesn't seem realistic”. More substantial progress is being made towards other MDG goals, Alhaidari adds, including nutrition and gender equity. But regarding the core health goals, she feels, “new strategies come and go from the Ministry and the UN and the WHO, but sustainability is the problem. There is still no long-term vision”. WHO's Hussain is similarly blunt. Political interference is rife in decision making within the Ministry of Health, he confirms. “Professionals at mid-level are mostly chosen on political grounds rather than merit”, he complains, “so there aren't many expert people around to tell you the truth in the Ministry of Health”. Health system strengtheningThe talent problem at the ministry, Hussain reflects, mirrors the overall lack of medical expertise throughout the country. According to government figures, with 24 745 physicians currently in practice, Iraq's physician-to-population ratio is about 60% lower than the average for the other 23 nations in WHO's Eastern Mediterranean Region. The nurse-to-patient ratio is about 35% lower than the regional average.Migration of health professionals “is still a big concern”, according to the 2011 Health Sector Assessment, which notes that although “no accurate figures could be obtained” on the issue, “according to key informants, factors behind external migration are lack of political stability and security, better opportunities for quality education and financial reasons”.The lack of family physicians in Iraq is especially dire. Only 182 family physicians have been trained since 1999 and there are only 127 currently in practice, according to the 2011 Health Sector Assessment. And while the Assessment called for 20 000 family physicians by 2021, it also predicted a shortfall of almost 19 000 by that date. “The lack of family doctors and the lack of primary health care capacity as a whole is a major part of the child and maternal mortality crisis”, Hussain confirms.Yaseen Abbas, president of the Iraqi Red Crescent Society, agrees. The overarching impediment blocking progress on maternal and child mortality, he argues, is no longer violence and insecurity, which for much of the past decade prevented patients from reaching health professionals. “The medical teams are now reaching all parts of Iraq”, he reports. “But the problems now are structural. The number of primary care facilities is inadequate. The years of embargoes and the former regime's strategies held Iraq back in medical science. This, and the brain drain, remain the main things retarding health care here.”Mustafa Saudi, the recently graduated emergency room physician in Sadr City, offers a disturbing clinical perspective on these problems. “The emergency rooms in general hospitals are a mess. The number of patients vastly exceeds capacity, especially in the evenings. There is more equipment available but we still lack basic things like viral assay capability, incubators, ventilators, scanners. Even the quality of the antibiotics we use is unreliable”, he charges.Alongside the lack of doctors and supplies, Saudi warns, the Iraqi health-care crisis is steadily intensified by a population explosion that began outstripping growth in Jordan, Iran, and Syria in the late 1980s. At 35 new births per 1000 people, Iraqi population growth is now 50% higher than Jordan and Syria's and twice as high as Iran's. Basic education on family planning and contraception has withered among poorer families. “This obviously puts large numbers of women at risk. They are constantly facing malnutrition, complications, and stillbirths. In urban hospitals the numbers of emergency caesareans performed is huge. But in rural areas where primary care is primitive these are often not available.”“But by far the most serious problems we face are explosive population growth and far too few doctors”, Saudi warns. “Not many have come back. In fact, lots of young doctors continue to leave.” The talent problem at the ministry, Hussain reflects, mirrors the overall lack of medical expertise throughout the country. According to government figures, with 24 745 physicians currently in practice, Iraq's physician-to-population ratio is about 60% lower than the average for the other 23 nations in WHO's Eastern Mediterranean Region. The nurse-to-patient ratio is about 35% lower than the regional average. Migration of health professionals “is still a big concern”, according to the 2011 Health Sector Assessment, which notes that although “no accurate figures could be obtained” on the issue, “according to key informants, factors behind external migration are lack of political stability and security, better opportunities for quality education and financial reasons”. The lack of family physicians in Iraq is especially dire. Only 182 family physicians have been trained since 1999 and there are only 127 currently in practice, according to the 2011 Health Sector Assessment. And while the Assessment called for 20 000 family physicians by 2021, it also predicted a shortfall of almost 19 000 by that date. “The lack of family doctors and the lack of primary health care capacity as a whole is a major part of the child and maternal mortality crisis”, Hussain confirms. Yaseen Abbas, president of the Iraqi Red Crescent Society, agrees. The overarching impediment blocking progress on maternal and child mortality, he argues, is no longer violence and insecurity, which for much of the past decade prevented patients from reaching health professionals. “The medical teams are now reaching all parts of Iraq”, he reports. “But the problems now are structural. The number of primary care facilities is inadequate. The years of embargoes and the former regime's strategies held Iraq back in medical science. This, and the brain drain, remain the main things retarding health care here.” Mustafa Saudi, the recently graduated emergency room physician in Sadr City, offers a disturbing clinical perspective on these problems. “The emergency rooms in general hospitals are a mess. The number of patients vastly exceeds capacity, especially in the evenings. There is more equipment available but we still lack basic things like viral assay capability, incubators, ventilators, scanners. Even the quality of the antibiotics we use is unreliable”, he charges. Alongside the lack of doctors and supplies, Saudi warns, the Iraqi health-care crisis is steadily intensified by a population explosion that began outstripping growth in Jordan, Iran, and Syria in the late 1980s. At 35 new births per 1000 people, Iraqi population growth is now 50% higher than Jordan and Syria's and twice as high as Iran's. Basic education on family planning and contraception has withered among poorer families. “This obviously puts large numbers of women at risk. They are constantly facing malnutrition, complications, and stillbirths. In urban hospitals the numbers of emergency caesareans performed is huge. But in rural areas where primary care is primitive these are often not available.” “But by far the most serious problems we face are explosive population growth and far too few doctors”, Saudi warns. “Not many have come back. In fact, lots of young doctors continue to leave.” Iraq: putting people firstAs recently as the 1970s, Iraq enjoyed a strong health-care system and universal access to health care for its citizens—written into the country's constitution and the envy of many countries worldwide. Fast forward to today. Iraq, having suffered three shattering conflicts in the past 35 years—the war with Iran, the 1991 Gulf War, and the 2003 US-led military invasion—is a wounded nation. Full-Text PDF Civilian mortality after the 2003 invasion of IraqA historical view of the war in Iraq is essential to the understanding of the internecine controversies that arose about the validity of mortality studies, and the political pressures that influenced their interpretation to the world. The US Department of State (DoS) and US Agency for International Development (USAID), which were responsible for humanitarian assistance and recovery, were aware that, in prolonged warfare, preventable mortality and morbidity can exceed direct deaths from violence as public health infrastructure and social protections rapidly deteriorate. Full-Text PDF