Iraq Report

On the
road to recovery


After years of devastating war, Iraq’s healthcare infrastructure was broken. Current health indicators, when compared to the relatively advanced state of healthcare the country enjoyed in the 1980s, are shocking and point to the dire state of healthcare in the country. However, with the war over and a modicum of stability and security returning to the country, along with vast financial resources from its oil wealth, the Iraqi Government in cooperation with a number of international consortiums, has embarked on a massive healthcare infrastructure reconstruction programme. Mathias Marx reports.

In the 1970s and 80s Iraq boasted one of the most advanced medical sectors in the entire Middle East, including free healthcare for every citizen. Few countries in the region could match Iraq’s 172 modern state hospitals and 1,200 primary healthcare centres in operation by the late 1980s. It was common for Iraqi specialist doctors to receive training in the UK, Germany and elsewhere in the West. Vaccination rates reached 90%. Infant and maternal mortality rates were the lowest in the region. But then came the Iraq War which began in 2003 and it took a heavy toll. Iraq’s healthcare infrastructure collapsed; thousands of medical staff were killed or forced to flee the country; hospitals were left in a state of virtual inoperation, with equipment and other facilities falling into disrepair. Add to this a chronic shortage of medicines and it fell heavily on the Iraqi patients who had to bear the brunt of this tragic situation – many dying who would otherwise have lived in a more stable environment But the tide has turned.

At present the country now has one of the lowest physician-per-person rates in the world. In the 1990s, Iraq counted 34,000 registered physicians. By 2008, that number had dropped to 16,000. The trend has not been reversed despite a recent appeal and incentives by the government for medical professionals to return. In many countries the standard nurse to doctor ratio is three to one. Alarmingly, now in Iraq there are roughly as many nurses as doctors.

Similarly, hospital bed density is very poor. The country needs 80,000 beds, but there are only about 30,000 to 40,000. Lack of primary healthcare facilities especially in rural areas is compounded by constant power cuts, a patchy water supply, unreliable sewage, faulty air-conditioning systems as well as inadequate solid waste disposal. Equipment is dated and poorly maintained.

As a result, infant mortality rates have soared. This is partly due to the fact that 45% of all babies are born at home without proper medical care, according to the World Health Organisation (WHO). Until recently one in eight children didn’t make it past their seventh birthday. Disease continues to plague the population: up to 70% of all infant deaths are the result of diarrhoea and respiratory ailments. The Ministry of Health estimates that 10% of all children are chronically ill.

Cancer is a major problem. Since the 1991 Gulf War the incidence of cancer has increased considerably, particularly in the South. According to the WHO, cancer among Iraqi children is 10 times higher than in the developed world. Root causes are disputed, but the exorbitantly high rate could in part be the effect of depleted uranium shells, which were widely used by US forces in the war of 1991. This and environmental pollution has also provoked unusually high numbers of miscarriages among Iraqi women.

In short, after 20 years of devastation, destruction and despair, healthcare services lack everything from equipment to personnel to proper hygiene. The Red Cross stated in March 2008 that Iraq’s humanitarian situation remained among the most critical in the world.

However, from about 2008 on the security situation began to improve and the government could finally start to try to turn things around. Serious efforts are now being made to reconstruct the country’s devastated healthcare infrastructure in both urban and rural areas.

Key challenges

However, there are many challenges in trying to rebuild this infrastructure. The problems troubling the sector are complex, but by no means incurable.

“A key problem is the unparalleled brain drain. The embargo and the continuing climate of violence has driven thousands of health professionals abroad to Europe or the Gulf,” explains Mahmoud Gaber, an Egyptian-born entrepreneur and adviser to the Iraqi MoH. “There is a shortage of personnel across the board, from nurses to general practitioners to hospital consultants.”

Gaber has been active in Iraq since 2003 with his Arab-German company Germany Medical Services (GMS). He complains it is a difficult place to do business as too much time is wasted with dealing with an inept bureaucracy: “Tenders are sometimes repeated. Each time it is under a different civil servant who is in charge in the Ministry of Health. And every time the previous decision is reversed.” He says government officials often tend to lack the necessary know-how and many are afraid to make decisions for fear of being reprimanded by their superiors.

Corruption is another pressing problem and can only be met by introducing a culture of transparency according to insiders. This view is corroborated by Gaber: “If one is honest in one’s dealings, everything will be fine,” he said. “My company for example does not hesitate to alert our Iraqi partners to corruption attempts. Everyone knows that we will not give in to bribery by dodgy officials.”

Security remains a serious concern. Whereas the situation in Kurdistan, in the north of the country, has been stable for years and the situation in the south is improving, Baghdad and swathes of the Sunni Triangle in central Iraq remain volatile.

Nonetheless, thanks to growing oil revenue there is funding for the reconstruction effort. In 2011 Iraq’s Ministry of Health had US$4.5 billion at its disposal, a 12.5% increase compared to the previous year’s budget. This spend on healthcare amounted to 5.5% of the government’s total budget for the year. In 2011, $1.5 billion was earmarked for the purchase of medicines and medical equipment alone.

According to government sources, healthcare spending in 2012 is set to rise to $6 billion and the main focus will now be on modernising the ailing infrastructure and expanding healthcare facilities. Iraq’s Minister of Health, Majeed H. Amin, has repeatedly stressed that this must be where resources are concentrated.

State-of-the-art hospitals

Healthcare facilities are now being built. Core projects include the speedy construction of numerous state-of-the-art hospitals in both urban and rural areas – the most visible indicators of better days ahead. In this respect the Iraqi Government is pulling out all the stops. A recent initiative was the commissioning of a number of international consortiums to construct eleven projects of varying capacity, ranging from 100 to 500 beds.

So far, German and Turkish firms have received a large share of these commissions; German companies have won these commissions on the back of the country’s fine reputation for high quality products ‘made in Germany’; Turkey – because of their highly competitive prices.

In October last year the Iraqi MoH signed contracts with Turkey’s Universal Hospitals Group and German Medical Services (GMS) to build six new 100-bed hospitals in Samarra, Al-Dur, Tuz Khurmatu and Dujail. In addition, work on two major hospital clinics in Wasit and Muthanna provinces will commence soon.

GMS, specialists in turnkey hospital projects, are currently constructing two 500-bed hospitals in Iraq: The Al-Najaf Hospital and Cancer Therapy Centre as well as the Al-Ninevah Teaching Hospital in Mosul. Both have an investment value of $150 million each. Services include everything from design, architecture, medical planning, to IT management systems, as well as the supply, installation, operation and maintenance of medical equipment. The company also assists in training staff both in Europe and on location in Iraq.

The MoH’s long-term strategy towards medical excellence explicitly includes even the remotest regions: “We are determined to intensify efforts to raise the profile of health services in all Iraqi governorates,” explained Amin in a recent interview. One such example is the above mentioned Muthanna project in Samawah, implemented by GMS. The new 492-bed general hospital includes an oncology department and looks set to dramatically improve healthcare in the hitherto neglected border region with Saudi Arabia. Moreover, the government has decided to establish mobile clinics. Some are already operational in Karbala Province.

One of the biggest reconstruction initiatives involves a strategic partnership with USAID. The turnkey project will see the construction of 360 primary healthcare centres across Iraq. These are regarded as cornerstones of a fully functioning health service.

There is also good news for oncology patients. Late last year, Iraq’s first specialised cancer unit opened in Baghdad’s al-Kathimiya Hospital.

International cooperation

By working together with a number of foreign health institutions and companies to train Iraqi health professionals, Iraq is hoping to have its healthcare system back on its feet quickly. The country continues to receive considerable help from a number of NGOs. For example, the International Committee of the Red Cross (ICRC) provides support to hospitals for emergency care and assists primary healthcare units. Hundreds of staff have been trained in trauma management and infection control. ICRC engineers repair water supply systems and upgrade existing installations. On the patient side, physical rehabilitation and limb-fitting services are offered, by a number of NGOs. Médicins Sans Frontières (MSF) has been very active in al-Najaf to improve the quality of obstetric and perinatal care, for example.

The Iraqi Government is in talks with the governments of France, the UK, Germany and other countries to intensify health cooperation. Talks are under way to involve Czech companies in the fields of medical supplies, alternative medicine, eye surgery and kidney transplants. Korean company Hyundai has been invited to bid for medical infrastructure projects. In a related development, the Ministry of Electricity in November last year awarded Hyundai Engineering deals worth $396 million to build two power plants. Also, South Korea’s International Cooperation Agency is to provide a mobile hospital for Basra province.

The Iraqi Government has made training and recruitment one of its priorities to counter the loss of thousands of doctors, nurses and engineers. At present there is a significant shortage of nurses and anaesthetists. Baghdad is hoping to fill this void by contracting Indian staff.

As for general staff, advanced training courses are being held in Lebanon, Jordan, Saudi Arabia and in Europe.

In 2011 Memos of Understanding were signed with Turkish universities to train Iraqi doctors and also treat Iraqi patients in Turkey. Acibadem Turkish Hospitals Group is offering radiation therapy to cancer patients sent from Iraq. Medicana and Florence Nightingale Turkish Hospital Group are also offering treatment. These hospitals envisage opening treatment centres on Iraqi soil in the future. Iraqi patients are also being sent to Lebanon and India for treatment at the Government’s expense.

Positive trends

One of the trickiest legacies left over from the Saddam regime is the cumbersome and inflated bureaucracy. However, progress is being made on this front. For example, the MoH is introducing software that delivers detailed information about the number of patients in A&E care, their condition and the number of occupied beds.

Further positive trends are beginning to emerge. The number of pharmacies is increasing as the government encourages private enterprise. This development is fuelled by a heightened health awareness of the general population – a consequence of new access to international satellite television and the internet.

A winning formula

How can international companies successfully contribute to Iraq’s healthcare reconstruction effort? Gaber seems to have devised a winning formula. “Our strategy has worked all the way along. We offer our Iraqi counterparts maximum services and total transparency. Their feedback has been extremely positive,” he said: “They realise that they can trust us. Why? Because we are not only there for the money, but to help the country get back on its feet.”

 Date of upload: 21st Jan 2012


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