The following column was first published by “The Rural monitor” in its issue of summer, 2008.  Myers’ columns appear quarterly under the series title, “Look What’s Coming”.

Baghdad Crystal Ball

Wayne Myers, MD

 In June, I was one of several Americans invited to Baghdad as advisors to the Iraqi Ministry of Health.  The occasion was a national conference on health care restoration and reform convened by the Ministry.  I’d like to tell you some of what we saw and heard. 

First, Baghdad is a big city with about seven million people.  By way of comparison, Chicago has nearly three million people within its city limits, but over nine million within the three-state metropolitan area.  Baghdad has no mass transit system, so traffic is dense.  Cars are old and breakdowns frequent.  The city is battered but millions of people are getting on with their daily lives.  Rental property is in increasing demand, as Baghdad becomes a reasonable place to live and do business. Sidewalks are piled high with crates of new merchandise for sale, especially generators.  Outside the International (“Green”) Zone, all the police and military personnel I saw were Iraqi.

The current phase of health care reform is titled, “Primary Care Reform First” (PCRF).  The Minister of Health and his colleagues propose to first overhaul the national primary care system before dealing with hospitals and other elements.   The five-day series of PCRF meetings included three days of small group sessions reviewing specific proposals.   Meetings held on the last two days reviewed overall strategic proposals—these were large, formal sessions of several hundred people including members of the Iraqi Parliament, leaders of most of Iraq’s national health-related organizations, the Ministry of Health, the U.S. military and State Department, the World Health Organization and several non-governmental organizations.  In all the meetings the focus was national policy.  None considered rural problems separately. 

 Before the Coalition invasion of 2003, Iraq had 2,000 public clinics providing some care for an average of 14,000 patients each.  Most closed during and after the invasion but practically all are now operating.  Iraqi doctors have traditionally been required to work in the morning in these public free clinics for a few dollars per month.  Doctors earn their livings in private practice clinics in the afternoon.  This divided system is generally acknowledged to work poorly with patients being rushed through the public clinics, and occasionally seen in groups, by doctors hurrying to get to their private fee-for-service practices.  One of the priority reforms for the Ministry of Health is to separate public and private practice, paying reasonably for doctors making careers in public care.  Salaries for public clinic work are expected to increase from three dollars per month for work in the morning clinics to 3,000 dollars per month for full-time doctors in the public clinics.

The professionalization of public clinics may be particularly helpful in rural areas.  Rural and other hard-to-staff clinics are now heavily dependent on young doctors in mandatory national service between internship and specialty residency.  In 2004, during an earlier two-week trip to Northern, Kurdish Iraq, I encountered only one fully trained career rural physician.  All the others were short-term assignees straight out of internship.  Rural hospitals were battered and poorly supplied but clean with staff proud of their work.  My impression was that physician coverage was the weakest element in the rural system of care.  Rural Iraqis face hazards ranging from land mines to cholera with care by partially trained personnel.  U.S. rural health care has its problems but they are of a different order than those in Iraq.  

Iraq has no health insurance.   Serious illness often means family bankruptcy.  The Ministry of Health is determined to develop a system of health insurance in the course of primary care reform.  I could not determine whether a decision or consensus has been reached regarding the nature of the national insurance system: public or private, for-profit or not-for -profit.  The insurance program is seen as an important contribution the government can make to stabilize private fee-for-service care.

Nursing is a new profession in Iraq.  In the past nurses got their training in vocational high schools.   Quite recently the nursing high schools have been closed.  Several universities have established nursing programs using faculty trained in other countries.   The professionalization of nursing in Iraq is an enormous task and complex challenge. 

 Some basic management systems are lacking or not well understood.  Stories of corruption in the UN Oil for Food program, in contractors under the Coalition Provisional Authority and in the Iraqi Government have been widely reported.  At the moment, though, fear of corruption is also a serious problem.   Last year the Ministry of Health reportedly spent less than 70 percent of its budget.  Officials were often unwilling to release funds that might be diverted.  Establishment of basic management systems is an urgent need.

Other major challenges include the establishment of pharmaceutical and medical supplies manufacturing across Iraq, the modernization of clinical data systems and carving out a reasonable share of the national budget for health.  

Will the Iraqis succeed in reforming their national approach to health?   I think there is a good chance that they will accomplish several of their goals.  In the final plenary meetings there seemed to be general consensus on many points.   Iraq is writing on a blank slate.   They have some oil income to work with.  The clinic system is getting back on its feet as physicians return to the country and security improves.  There is a sense of urgency. 

There is a lot to be done.  A half-dozen Americans are being recruited to help the Iraqis draft policies, procedures and standing orders to implement all these changes.   If you are willing and able to consider doing high-level national policy work in Baghdad, drop me an email for more information at wwm@midcoast.com.