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 Abstract
Objectives:
To know the defects and gaps in Iraqi
health care, according to health
providers' perspectives, as a baseline
for future renovation.
Methods:
Nationwide survey by questionnaire to 807 health providers pooled from a
national health conference, and 30
primary health care centers.
Results:
Response rate was 55% in a sample from all Iraqi regions, with equal
professional and paramedics, and female
to male ratio of 1:1.7.
Main defects in health care were lack of
essential drugs and supplies (43%), old
infrastructure (35%), and absence of
capacity building (26%). Other defects
include staff insufficiency (19%),
financial system failure (16%), poor
transport (14%), outdated health
information system (13%), ineffective
health education (13%), and inefficient
administration (13%). Less important
defects in providers' views were poor
emergency care (6%), no response for
providers' rights (4%), absent job
description (4%), and no referral system
(3%).
Conclusions:
Health providers have sound knowledge on
areas of weakness in health care that
can be helpful in any renovation
programs. Recent developments in health
care as evidence-based practice, and
quality assurance, were unknown by the
majority of providers.
Key words:
health care, health providers, health
system defects, Iraq.
Introduction
Iraq is suffering the effects of double burden disease,
the communicable and chronic (1). Health
system was damaged after 1991 as a
result of war, sanctions, and bad
governance, followed further by
widespread looting in April 2003 (2,3).
There is a promising trend towards
changing the health system (4). Health
systems tend to be rigid, resisting
changes, and often continue to operate
in the same way(5), that is why clear
focus should be applied to uncover areas
of defects and gaps in health care
activities.
As health providers - professional or paramedics - are
important pillars in health care due to
prolong direct contact, and thorough
understanding of health care dynamics,
their opinions and satisfaction is
assumed to reflect a sound picture of
health care.
Health personnel satisfaction in their care-providing work is
affected by several factors as health
resources, work autonomy, flow of work,
work status, pay, and relations with
other providers or clients (6).
In this national mini-survey, health workforce
detection insight is sought on areas of
defect in health care in Iraq. This
study is looking to the health care
system through providers' eyes, in order
to know why and where to renovate the
health system.
Methods
This is a cross-sectional health survey, in which a nationwide health provider sample was pooled from two sources: All the 155 participants in the Basra health conference " Better health for Iraq" in March 2004 (7), and all the available 652 health staff in 30 primary health centers sampled from all Iraqi regions through adjusted sampling: random, and non-random judgmental (17 from Baghdad, and 13 from another 7 governorates) during an academic research on primary health care for the period April - November 2004 (8).
All sampled personnel were given a questionnaire, with an open-ended question to state the main area(s) of defect in the current Iraqi health care system. In addition to inquires on name (optional), sex, governorate of residency, education degree, type of occupation, and current place of work.
The SPSS software package v.11.5 was utilized for data analysis.
Results
Of the 807 sampled health personnel, only 442 responded
with valid answers (55%). The
Respondents' residency included all
Iraqi regions (Table 1), with almost
equal medical and paramedics job
categories (44% and 46% respectively),
and a female to male ratio of 1:1.7
|
Table 1 : providers
residency |
|
Table 2 : providers
occupation by sex |
which doesn't significantly differ among
job categories indicating homogenous
sample (Table 2). Providers' sampled
included different education levels
(Figure1).
|
Fig. 1. providers education
degree
|
The majority of selected
health personnel were working in primary
health care centers.
Leading defects in
the health care system pointed out by
43% (95% Cl is 39-48) of health
providers are the unavailability of
essential drugs and medical supplies,
deteriorated infrastructure in terms of
buildings, furniture and medical
equipments (35%) (CI:31-40), and poor
capacity building of health workforce
(26%) (CI:22-30) (Figure 2).
|
Fig.2. Ranked health care
system defects according
to providers views
|
Next coming
defects are the insufficiency in health
staff (19%) (CI:15-22), failing health
finance system (16%) (CI:13-19), poor
health transport services (14%)
(CI:11-18), old-fashioned health
information system (13%) (CI:10-17),
lack of effective health education
activities (13%) (CI:10-16), and poor
health system administrative management
(13%) (CI:10-16) (Figure 2).
Discussion
The relatively low response rate
encountered isn't a surprise in view of
prevailing social, administrative,
political, and security disturbances.
Several reasons are acting: Lack of
trust for any research or project,
reflecting the unconscious fear of
Iraqis that no one is telling the truth!
In addition, hopelessness after
realizing that the promised paradise -
after the previous regime fall - is only
an intangible dream, resulting in
carelessness to participate for
improvement, or situation change.
Finally is the lack of courage to
criticize any governmental system,
precipitated by decades of threat.
According to health providers'
perspectives, the priority needs in the
coming few years for the health care
system in Iraq, are provision of
essential drugs and medical supplies,
rehabilitation of health organization
infrastructure, and health workforce
capacity building.
Drugs shortage has
resulted from sanction economy,
decreasing foreign exchange for drugs
imports, and deterioration of national
drug industry (9). Thus, there is a
necessity for an essential drug program,
with essential drugs list, and treatment
guidelines (2).
Most health organization
buildings are in dire need for
rehabilitation or expansion (9). After
the foreign invasion of Iraq, waves of
rehabilitation for health organizations
started. According to health providers'
opinions, they weren't indented to be
radical, concentrating mainly on general
look.
Discrepancies among providers' capacities are observed,
as many health workers begin to decline
after qualification(5). New
opportunities should be opened for
drawing on the skills and knowledge of
health-service personnel (10). Workforce
needed skills should be ensured via
licensure and lifelong learning (11).
For building of professional capacities,
the establishment of national schools of
public health is a necessity (9).
Staff insufficiency is also documented by MOH
reports of countrywide severe shortage
of pharmacists and nurses (particularly
females) with no reliable post
description (9).
Many researchers agree upon failure in MOH financing
policies. For example, the
auto-financing health system (1999-2003)
resulted in large burden on patients
through out-of-pocket payment (12). The
share of public spending on health has
decreased from 3.7% GDP in 1990 to 0.8%
GDP in 1997 (9). Financing systems
should become more efficient than they
currently are, in order to justify
allocation of new resources. This
requires cost-effectiveness analysis,
and evidence-based health policies,
identification of big consumers of
health care (13).
Health information system in Iraq is surely outdated
for decades if compared to the 21st
century health care with automation of
information, and electronic sharing
(10).
Highly centralized, bureaucratic management is another
drawback of health care delivery system
in Iraq (14). Decentralization requires
first, better-trained health managers at
district level, secondly a health team
approach, and thirdly planning support
from the central authority. Supportive
supervision is essential for good
management. It is often both infrequent
and poor, taking the form of an
"inspection" rather than a two-way
learning process (5).
Finally it should be noted that health providers
in Iraq are shortsighted regarding some
recent advances in health care
requirements as evidence-based medical
practice (15), and programs for quality
assurance.
References
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