Background
Population | 5,472,436 (2015) [6] |
Iraqi IDPs | 958,344 (Aug 2016, figure not including IDPs in disputed territories) [54] |
Syrian refugees | 234,228 (Aug 2016) [54] |
Military casualties | > 1500 Peshmerga and Kurdish security forces (since 2014) [92] |
Annual budget transfer from Baghdad | 17% of oil revenues (~ $12 billion/year) [7] |
Actual budget received from Baghdad | ~ $2 billion (total since 2014) [7] |
Funds required to offset the impact of IDPs on KRI residents | $1.48 billion / year (2015) [7] |
KRI Debt | $17 billion [20] |
Budget deficit | $3.2 (2015); $2 billion (projected, 2016) [20] |
Austerity program fiscal consolidation | 37% of GRP (between 2014 and 2016) [20] |
Poverty rate | 3.5% (2012); 12% (2015, KRSO) [7] |
Corruption index | High (KRI received a score of mid-30s, where 0 is considered corrupt and 100 clean. Comparison: Iraq received a score of 10). (EIU 2014) [3] |
Theoretical annual public health sector budget (projected from pre-crisis levels) | $995.4 million (2015) [7] |
Actual public health sector budget | $179.9 million (2014) [7] |
Theoretical per-capita public health expenditure (projected from pre-crisis levels) | $159.91 (4) |
Actual per-capita public health expenditure | Total per-capita public health expenditure: $33.74 (2014); Primary health care per-capita expenditure: $5.80 [7] |
Physicians | 13 per 10,000 (2014) [6] |
Neonatal mortality | 9 per 1000 live births (2009); Comparison: Iraq 25 per 1000; WHO Eastern Mediterranean Region 35 per 1000 (2009) [22] |
Infant mortality | 28 per 1000 live births (2011); Comparison: Iraq 36 per 1000; WHO Eastern Mediterranean Region 57 per 1000 (2011) [22] |
Child (under 5 yrs) mortality | 32 per 1000 live births (2011); Comparison: Iraq 45 per 1000; WHO Eastern Mediterranean Region 78 per 1000 (2011) [22] |
Immunization coverage, children 12–23 months (Measles and DPT3 respectively) | 90% and 81% (2008); Comparison: Iraq 69% and 62%; WHO Eastern Mediterranean Region: 83% and 82% (2008) [22] |
Underweight, wasting and stunting (children under 5 yrs) | 7%, 5%, and 15%, respectively (2011); Comparison: Iraq 27.5% stunted (2011) [22] |
Cholera outbreaks (years) | 2007, 2008, 2012 and 2015 (contained) |
Diabetes (Type 2) | 6.2% (Sulaimani Governorate, 2011) [28] |
Cancer | 38/100,000 (2006); 61.7 /100,000 (2014) (Sulaimani Governorate) [29] |
Methods
Results
Policy context
Summary points
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➢ RAND Corporation has been commissioned by the KRG’s Ministry of Planning since 2010 to produce analyses of KRI’s health care system (with an emphasis on primary care), and provide evidence-based policy recommendations.
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➢ The World Bank has developed a structural economic reform program for KRI, drawing from the work of RAND Corporation.
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➢ UN’s Sustainable Development Goals and Universal Health Coverage (UHC) are being operationalized through programs such as the Iraq Public Sector Modernization (I-PSM) Program’s ‘Integrated District Health System Based on a Family Practice Approach’ (IDHS-FPA).
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➢ Millennium Development Goal (MDG) targets has been the focus of bilateral agencies such as the US Agency for International Development (USAID) in KRI, concentrating on primary care and reducing maternal and child mortality.
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➢ UN agencies and their partners are operationalizing the Humanitarian Response Plan (HRP) and Regional, Refugee and Resilience Plan (3RP) programs, which are being oriented around sustainable development.
Structural adjustment
Enabling universal health coverage (UHC)
Achieving millennium development goals (MDGs)
Development-oriented approaches to humanitarian crises
Health system structure and primary care governance
Summary points
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➢ The autonomous KRG MoH oversees six Directorates of Health, which in turn are comprised of Districts and Sub-Districts.
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➢ Little is published in relation to primary care governance structures, capacities and processes in either KRI or Iraq, or the nature of interactions between them.
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➢ The humanitarian crisis has led to an influx of a large number of international NGOs and donors, whose activities are mainly coordinated under the frameworks of the HRP and 3RP.
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➢ The KRG’s Joint Crisis Coordination Centre (JCCC) aims to strengthen institutional governance, data monitoring and coordination capacity in relation to the humanitarian crisis response.
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➢ The private health market is poorly governed and regulated. The structural adjustment program aims to enhance enhanced public oversight and regulation of KRI’s rapidly developing private health care sector.
Public health sector structure and primary care governance
Private health sector governance
Financing primary care
Summary points
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➢ The KRG is legally entitled to receive a proportion of Iraq’s overall public budget (a population-based resource allocation, set at 17%).
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➢ KRG public spending on health as a proportion of total government expenditure has been reported to be between 4.8–5.5%, similar to that of Iraq and regional countries. An estimated 20% of the public health care budget is allocated to primary care.
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➢ The WHO National Health Accounts (NHA) has not generated sufficiently accurate or updated figures for KRI, or Iraq in general.
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➢ Due to the ongoing crises, the KRG is running high annual deficits, with an estimated total debt of $17 billion as of January 2016. When factoring in the influx of refugees and IDPs, per capita health expenditure has been estimated to have decreased from $159.91 (pre-crisis) to $29 (2014). Actual per capita spend for public primary care decreased from $24.89 (2012) to $5.80 (2014).
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➢ The overwhelming majority of the budget is dedicated to salaries. Facility budgets and staff salaries are not linked to resource utilization, activity or performance.
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➢ Private health care facilities are financed largely by direct out-of-pocket payments (estimated at 39.7% of total health spend in 2014). These figures, however, are not accurate or appropriately disaggregated.
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➢ As of January 2016, funding the humanitarian response has been extremely limited (eg. only 35% of the 3RP’s health sector component has been funded).
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➢ A core component of the World Bank’s structural adjustment program relates to health system financing and funding reform. RAND has outlined a strategic vision and road map, moving initially towards a tax-based national health service, followed by the development of a social health insurance system.
Public sector financing
National Health Accounts (NHA)
Economic crisis
Public sector funding
Private sector financing
International NGO and donor funds for primary care
Financing reform
Health data and information systems
Summary points
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➢ There is a serious paucity of timely and accurate health-related statistics in KRI. Three main sources of data exist: surveys; a KRG Health Management Information System (HMIS); and data collected through humanitarian programs such as the 3RP and HRP.
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➢ Surveys conducted by national and international agencies are generally outdated and poorly disaggregated, and are therefore of limited present value.
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➢ RAND recommended interventions to develop and improve health information systems in KRI.
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➢ Both the HRP and 3RP programs conduct regular assessments in relation to the health needs of refugees, IDPs and host communities, along with health care supply and utilization.
Surveys
Health management information system (HMIS)
Humanitarian agency data collection
Human resources for health
Summary points
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➢ Accurate, disaggregated numbers relating to the total number and distribution of primary care physicians (by professional type, organizational setting, geography) are generally unavailable. The proportion of primary care physicians to specialists across KRI is unknown.
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➢ Primary care physicians are not equitably distributed in accordance to population health needs, with severe shortages in rural areas.
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➢ Physicians staffing public primary care centers are primarily recent medical graduates, with limited formal training.
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➢ Since August 2014 with the ISIS threat and the followed economic crises, many young physicians have left KRI seeking jobs in Europe, resulting in physician shortages.
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➢ Medical education is generally based on the standard Iraqi curriculum based on the six year traditional British curriculum. However, schools within KRI are increasingly integrating small group teaching and problem-based learning.
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➢ Since 2006, four-year family and community medicine specialties have been recognized and developed by the Kurdistan Board of Medical Specialties (KBMS).
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➢ The KRG’s Ministry of Higher Education has invested heavily in continuous medical education, training and professional development activities through its $100 million USD ‘Human Capacity Development Program’ (HCDP).
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➢ Accurate statistics of the number and distribution of nurses working in KRI’s primary care centers are unavailable. Key problems exist in relation to distribution, qualifications, competencies and experiences.
Primary care physicians
Numbers, types and distribution
Education and training
Postgraduate activities and continuous medical education (CME)
Nursing
Numbers and distribution
Education & training
Postgraduate and continuous medical education (CME)
Health technologies (drugs, devices and supplies)
Summary points
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➢ Governance capacities and processes relating to the domain of health technologies are weak.
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➢ The weak governance situation has manifested troublesome phenomena relating to the local manufacturing, importation and distribution of expired and counterfeit pharmaceuticals, which has been associated with significant morbidity, mortality and anxiety among the population.
Governance, regulation and quality control
Primary care service delivery
Summary points
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➢ De jure, all Iraqi citizens can access KRI’s public health care services. Primary care services are formally specified under the “Basic Health Services Package” (BHSP) and “Essential Drug List” (EDL). However, actual services are limited by resource and supply-chain management constraints, along with a lack of knowledge relating to the existence of the BHSP and EDL.
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➢ The BHSP specifies the content of four primary care models, outlining their required service components, essential medicines, equipment, staffing, and support and supervision requirements at district and national levels. The BHSP, however, has not been operationalized in a systematic, consistent or evidence-based manner across KRI.
Eligibility and scope of services
Basic health services package (BHSP)
Maternal and newborn health services | Antenatal, delivery, postnatal, family planning, newborn care |
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Child health and immunization services | Growth monitoring (<5 yrs), immunization (WHO EPI), Integrated Mgmt of Childhood Illness (IMCI, <5 yrs), Standard case mgmt. ARI <5 yrs., ear problems, fever, diarrhea (<5 yrs), diarrheal symptoms, measles, malnutrition and anemia, vitamin supplementation, case mgmt. For infants <2 months) |
Communicable disease control | Respiratory infections, gastrointestinal infections, amoebiasis, hemorrhagic fever, STIs, tuberculosis control (DOTS plus), HIV / AIDS, typhoid, hepatitis, leishmaniasis (CL + VL), schistosomiasis, meningitis |
Nutrition interventions | IEC (information, education, communication), nutrition promotion, malnutrition prevention / treatment |
Immunization | IEC, campaigns, disease surveillance and reporting |
Non-Communicable Disease Control | IEC, health promotion, cardiovascular (hypertension, heart, cerebrovascular), diabetes mellitus, arthritis, gastrointestinal (peptic ulcer, chronic ulcerative colitis, urinary tract infections, skin diseases, malignancies, breast cancer, cervical cancer, rheumatic fever, common eye diseases, conjunctivitis, cataract, glaucoma, corneal opacity, common ear diseases, hearing loss, other common ear infections |
Mental health | Education and awareness, psychosis (identification and biopsychosocial management), anxiety, depression, epilepsy, substance abuse, support, referral |
Emergency care | Case management (ie. respiratory/cardiac), diabetic emergencies, trauma, poisoning, bleeding, obstetrics, allergic reactions |
Food safety, environmental and school health | IEC, food safety, environmental health (ie. medical waste mgmt., water chlorination examination, student screening, vaccination |
Health education | Health education campaigns, materials, media, social mobilization for health programs |
Laboratory services | Hematology, serology, biochemistry, bacteriology (direct microscopy, staining smears, culture, rapid bacteriological test), parasitology, cytology |
Imaging | X-rays (chest, abdomen, skeletal), Ultrasound, ECG |
Essential medicines | Anesthetics (GA, oxygen, local anesthetics), Analgesics, antipyretics, NSAIDs, Anti-allergics and anaphylaxis medicines, anticonvulsants/anti-epileptics, anti-infective medicines (anti-heminthics, antibacterials, antituberculosis), antifungals, antiprotozoals, antileishmaniasis, urinary antiseptics, blood medicines (anti-anaemia, coagulation), blood products and plasma subs, cardiovascular drugs, dermatological, diuretics, gastrointestinal, hormones / endocrine, contraceptives, opthalmological preparations, oxytocics / antioxytocics, phychotherapeutics, respiratory, vitamins/minerals, vaccines |
Equipment | Imaging, laboratory, dental unit, EPI (immunization unit), labour and delivery unit and WMO clinic, procedure room, emergency/casualty room, observation room, consultation / exam room, |
PHC Main Center (Category A) Catchment area: 10,000–30,000 | Comprehensive PHC center, staffed by doctors, nurses, midwives and laboratory and pharmacy technicians. PHC main centres provide a wide range of preventive and curative services related to maternal & child health care, immunization, communicable diseases, non-communicable diseases, mental health, emergency care, general dentistry, laboratory services, and essential medicines. |
PHC Main Center (Category B) 10,000–30,000 | Same as Category A above, with the addition of a training facility. Staffed by doctors, nurses,midwives and laboratory and pharmacy technicians. |
PHC Main Center (Category C) 10,000–45,000 | Same as Category A, with the addition of uncomplicated emergency and obstetric care. Staffed by doctors, nurses, midwives and laboratory and pharmacy technicians. |
PHC Sub-Centers (Type D) 5000–10,000 | Not staffed by physicians; only trained health workers (nurses or paramedics, and a vaccinator). Services offered include preventive and basic curative services, simple diagnostic procedures and maternal & child health services. |
Community Health Houses (CHHs) | Staffed by community health workers offering simple public health functions, micronutrient supplementation, vaccination support and referrals. |
Standardizing the content of primary care
Primary care performance
Summary points
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➢ Access: the economic crisis has negatively affected access to public primary care. Short opening hours, coupled with increased reliance on the public sector and irrational utilization have been associated with severe overcrowding.
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➢ Attachment and continuity: there is no general system of rostering to ensure first contact (continuity of) care with a regular primary care provider or team.
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➢ Comprehensiveness: the content of primary care delivery in Kurdistan Region is not routinely or systematically measured or evaluated.
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➢ Coordination: public primary care centers are not systematically networked, and standardized referral systems to secondary care are not well developed
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➢ Patient experiences: KRI’s population has a general preference for consulting specialists rather than GPs, due to perceptions of better quality of care and patient-provider interactions.
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➢ Provider experiences: physicians have been reported to generally express discontent in primary care settings. Nursing has been associated with professional dissatisfaction, intellectual isolation, perceived low social status and emigration.