Health Care Diplomacy in Iraq: A Multiagency Effort

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Health Care Diplomacy in Iraq A Multiagency
Effort

• CDR Bruno Himmler, MD, USPHS
• Dr. Terry Cline, DHHS
• Health Attachés, US Embassy Baghdad

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Health Care Delivery System Prior to 2003

• Iraq was the regional leader of health care in
  the late 70s and early 80s.
• Historically has served as the birthplace of many
  significant advances in medicine theory and
  practice.
• Treatise of Medical Diagnosis and Prognosis 7th
  Century BC
• First defined duty of physicians, fee schedule,
  malpractice
• Development of pharmaceuticals
• Caliphate Al-Razi Comprehensive Book of Medicine
  9th Century
• Defined Small Pox, Measles, Plaster of Paris, Cat
  gut
• Ibn Al Nafis described circulation of blood
  through lungs

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Pre 2003

• 1979 Dictatorship of Saddam Hussein took over.
  Establish very centralized eastern block
  mentality for health care system
• Much of economy diverted to the military and
  funding multiple wars. No investment in health
  care infrastructure or training of staff.
• Practice of use and throw away without
  maintenance mentality

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• Insert slide/photo on onset of OIF

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Pre 2003

• Many physicians worked for the government in the
  morning for meager salary and then operated
  private practice in afternoon. Pay 3 per month
  through govt. Earn 300 in private clinic.
• Patients seen in public clinics often had to buy
  medicine on the street. Often brought supplies
  for their treatment.
• Private sector healthcare valued greater by
  society though same physician working at both.

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Health Care Rebuilding 2003-07

• 2003-2007 Brain Drain
• Backlash against Baathist Party members
• Required membership during Saddam Era
• Still an issue with DeBatathification laws
• Violence against academics and medical personnel
• 2003-2007, 2000 physicians kidnapped, 200
  murdered
• Initial large investment by multiple
  organizations
• Increasing violence? less investment exodus of
  NGOs

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Health Care Rebuilding 2003-07

• Decreased nursing staff
• Stigma against female nurses
• Restrictions on male nurses caring for women
• Decreased pharmacy staff
• Used for administrative and other roles

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Health Care Rebuilding 2003-07

• Poor security hampered progress
• 800 deaths/day in August 2007
• Buildings destroyed before they were completed
• looting as well as battle damage
• Refugees

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Health Care Rebuilding 2003-07

• Against this backdrop, there were multiple
  efforts to rebuild healthcare hampered by
• Lack of security
• NGOs unwilling to invest
• Inability to gain traction with reconstruction
• Unsynchronized investment
• Equipment without training or OM piece
• Ambulances without EMTs
• Bloodmobiles without trained lab personnel
• Lack of coordination between agencies
• Challenges with leadership

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Health Care Rebuilding 2003-07

• Focus on infrastructure (hospitals and clinics)
• Delays due to poor performance by contractors and
  increased violence.
• PRT and MND efforts one time impact with lack
  of coordinated effort for long term
  sustainability.
• MoH fraught with corruption which diluted the
  impact of US funded projects.

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Rebuilding Efforts under new Minister, Dr Salih
December 2007- Present

• Priorities developed for MoH in 2008. No longer
  dependent on USG lead.
• Decentralization of health care system
• Splitting of public and private systems
• Focus on primary care and public health
• Modernization of medical infrastructure
• Repatriation of doctors that left MoH

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2008 USG Priorities

• HHS Training efforts for Iraqi Doctors in USA.
  Visa support is key.
• CDC increased capacity for disease surveillance
  and detection. Also help with epidemiology
  training.
• Development of training programs in country, in
  partnership with NGOs (IMC, USAID)
• Continued support of modernization of physical
  infrastructure in Iraq.

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Health Attaché Office Priorities

• Linkage of PRT, MND activities from Provincial
  level to central government.
• Project oversight of NGO health activities for US
  and foreign governments (Italy, Australia,
  Japan).
• Let MoH take the lead in health care reform with
  USG tactical support when needed.
• Timely completion and turnover of health projects
  to Ministry of Health.

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Iraqi Food Pyramid
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DoD Challenges

• Need for accurate data
• No recent good studies
• Lack of reporting mechanism
• Lack of information exchange
• Central to provincial and vice versa
• Among NGOs and government entities
• Culturally, few decision-makers lack of
  delegation
• Frequent rotation of DoS and DoD personnel
• MoH focus expectation of telemedicine and EMR
• Iraqi lack of experience with OM programs

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Diplomatic Challenges

• USG changing role
• Leader Partner Advisor
• DoD disengagement from Iraqi health care
• USG hospital for support?

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1- Reduction of Maternal, Neonatal, under
5 death rate
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Success up to 2008

• 2. Maintaining poliomyelitis free status since
  the year 2000.
• 3. Controlling of local increase in number of
  cases of measles with running into elimination of
  that disease.
• 4. Controlling of tuberculosis through
  application of DOTS program with treatment
  success rate exceeding 85.
• 5. Controlling of water-borne, food-borne
  diseases, including cholera .

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Success up to 2008

• 6. Strengthening all PHC centers through
  initiating the application of family medicine and
  referral system.
• 7. Supporting primary mental health care and
  psychosocial support at PHC centers.
• 8. Strengthening surveillance for communicable
  diseases and early detection of hypertension and
  diabetes mellitus within the catchments areas of
  PHC centers.
• 9. Supporting all activities of food safety and
  nutrition, concentrating on wheat flour
  fortification, iodization of salt, vit. A
  supplementations.

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Iraq MOH focus for 2009

• Increasing the coverage rate of vaccination by
  RED approach with reduction of drop-out rate.
• Preparation of Campaigns for polio vaccine Spring
  autumn, 2009.
• Concentration on Epidemiological surveillance
  activities of Measles elimination.
• Studies Research for new vaccines (HiB and Rota
  Virus)
• Activation organization of the referral system
  between the PHC centers hospitals .
• Training medical paramedical personnel on the
  activities of Family Medicine (FM) .
• Preparation of guidelines for FM application in
  health centers.

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Iraq MOH focus for 2009

• Health care of diabetic children in the primary
  and secondary schools.
• Expansion of early detection of hypertension and
  Diabetes through involvement of more PHCs in each
  governorate.
• Improved availability of antihypertensive drugs
  and antidiabetic drugs in PHCs.
• Incorporating Mental health services within PHC
  activities.
• Upgrading dental health activities in PHCs
  (preventive and curative ).
• Strengthening of epidemiological surveillance.
• Continued upgrading of MCH activities.

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Lessons learned

• Baseline requirement for security
• Engagement
• Between DoD and DoS
• Among NGOs (coordinated through a single agency)
• With the host government
• Know how they think
• Manage expectations

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Lessons learned

• Military medicine as a tool
• During conflict
• Healthcare delivery (LLE)
• Political tool
• Post conflict
• Education
• Political tool
• Mission creep
• Undermine local medical system

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