WHO Collaborating Centre Imperial College London Iraq Health System Current & Future Challenges Salman Rawaf MD PhD FRCP FFPH Professor of Public Health

WHO Collaborating Centre

Imperial College London

Iraq Health SystemCurrent & Future Challenges

Salman Rawaf MD PhD FRCP FFPH

Professor of Public Health

[email protected]

mailto:[email protected]

© WHO C Centre, Imperial College London

Professor S Rawaf

Contents:

1. Achievements since 20032. Current Challenges 3. Way forwards 4. Learning from Experience 5. The Future

3


Professor S Rawaf

Iraq: Economic Indicators

Some data are estimates

23% of the population still live below poverty line 16% of population do not have access to clean water 36% of pop only have access to sanitation 78% of pop are ‘functionally’ literate


Professor S Rawaf

Current & Future Challenges facing HS in Iraq

Health System Performance

1

Substantial Improvements since 2003 Improved Finance Improved Manpower

The Gap still wideIncreased Public expectations

? Quality


Professor S Rawaf

Under 5 Mortality Rate /1000 live birth

2010 41/1000 live birth2015 (Target) 17/1000 live birth


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Proportion of births attended by skilled health personnel

Excellent progress 50% in 1990 to >85% by 2010

8

Comparison of health outcomes in EMR countries

– 2010Countries Population

(000)Population growth rate (%)

TFR LE at birth

(years)

U5 MR MMR Per cap THE (in US$)

Jordan 6,113 2.2 3.8 73.0 28.0 19.1 357.4

Lebanon

4,189 1.8 1.9 81.5 18.3 23 651.0

Syria 20,619 2.5 3.5 73.1 21.4 58.0 96.6

Egypt 78,728 2.4 3.0 73.2 21.3 54.0 123.2

Iran 74,733 1.5 2.0 72.1 20.0 30.0 316.9

Iraq 32,326 3.4 4.3 71.0 39.0 84.0 246.8

Trend in Demographic Indicators

Indicator YEAR2005 2006 2007 200

82009

2010

Crude Birth Rate

37.4 32.9 34 37 38 40

Crude Death Rate

5.2 7.7 5 5 4 4

Pop Growth Rate

3.2 2.5 3 3 3.4 3.4


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National Constitutions1 Leadership and Governance

2

Strategic vision Projections based on population needs Command & Control Managing Performance Managing People

Untrained leaders at all level Politics and Leaders in Health


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Legislature, Regulators, Executive

National Local


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National Constitutions1 Socio-economic Development

2 Laws & Regulations3

Lack of Independent Professional Regulations Lack of Providers Regulations Blurred Public and Private Practice Dated Public Health Laws Unclear Rights to Health

Control professional behaviours

(Clinical Governance)Medical and Research EthicConstitutional Rights

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Professor S Rawaf



2 Health Systems3 Health System Organisation

4

Hospital-led, Disease-model Weak Primary Care Weak link between Health & Social Care Not person-centred Profit before health Little or no consumer protections


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50-60m Contacts with

the Health System

1/3PRIMARY CARE

2/3HOSPITAL CARE

FP

HOSPITAL

1 2 3

Cost: 10% + 11% 45% Acute, 20% MH +Contacts: 85% - 90% 10-15%

NHS Direct

100%Registration

10% 10%


Professor S Rawaf

40%Healthy

40%Healthy

With Risk Factor(s)

10% Acute Illness

10% Disability

Rawaf’s Model for Burden of Disease - 2001

In Any Given Population



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2 Health Systems3 Public Health Laws 4 Health System Finance 5

% of GDP allocated to health Public vs Private Financial Protection / OOP Payment To ensure or not to ensure


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Iraq: Government Budget 2006-2010

© WHO C Centre, Imperial College London Source: WHO, 2013 IPSM 2009

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Iraq National Health Account 2011

4.6% of GDP on Health (2010) Health Budget:

80.5% Public18.7% Private (25.6% in 2008) ???

0.8% Donors 36.8 of H Budget spent on Pharmaceuticals 22.3% on Administration

Budgetary (Resource Allocation) is historical and NOT LINKED to Health Needs

In 2010, per capita THE (weighted average) in:

EMR = US$183

In Group 3 countries < US$ 40In Group 2 countries ≈ US$220In Group 1 countries > US$ 850

Source: WHO EMRO

The share of out-of-pocket spending is high in many countries of the Region, 2010

PA

L

Source: WHO EMRO


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2 Health Systems3 Public Health Laws 4 Privatisation (Market capitalism)5 Human Resources for Health

6

number needed competencies Skill mix Training capacities / conflict (MoH/MoHER)


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57,600

24,800

2,240

>500

Medical Schools (22)

In migration

?150


7300

57K

200

2450

1000

CompetentHR Needed(Physicians)

2400 1400

CCST

1400

10001000

All specialties

Family Medicine

<850

<100

>2,450 ……………………………………………………………………………………..<950

3500Yearly

2,100

57K

1,400

850

950

100

Current Supply

CurrentSpecialists


Professor S Rawaf

57,600

24,800

2,240

?100-500

Medical Schools (22)

In migration

?150

Gap:32,800

At current rateof Supply we need (MBChB):13 Years

All Specialists:25 Years

Family Physicians:230 years


Professor S Rawaf

HRH (Dr) Shortages:

Medical School Graduate: Supply 2,450 (needed 3,500) = [-1,050]

Family Medicine: Supply 100 (needed 1,400) = [-1,300]

Iraq needs 23,000 Family Physicians At this rate of production:230 years!!!

12345

F1F2

123

2345

1

A-level University

University(Medical School)

FoundationSchool (Virtual)

Med/Surg/PH/Diag General Practice

PMET Board +R. Colleges(Standards)

GMC

CST Principle GP Consultant

© WHO Centre, Imperial College London

Professor S Rawaf

3 Education & Training

MBChBMBBS

They Need: Structured Training


Professor S Rawaf


Professor S Rawaf



2 Health Systems3 Public Health Laws 4 Privatisation (Market capitalism)5 Human Resources for Health

6

NCD Psychological Trauma War consequences System Adaptation

6 Burden of Disease

Burden of Noncommunicable DiseasesPer 1000 Population/2009 Data

Total Male Female

Hypertension 41.8 34.4 48.8

Diabetes 21 21.6 22.1

Joint Diseases 18.6 13.1 24.1

Heart Diseases 12.0 11.1 12.9

Gastro Intestinal Diseases

11.2 12.6 9.7

Asthma 8.3 8.8 7.7

Urinary Tract Diseases 7.4 7.2 7.5

Chronic Respiratory Diseases

5.2 6.3 4.0

Chronic Back Pain 4.9 4.3 5.5

Anaemia 3.7 1.9 5.5

Persistent Headaches 3.2 2.3 4.1

Chronic Skin Problems 2.9 3.6 2.2


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2 Health Systems3 Public Health Laws 4 Privatisation (Market capitalism)5 The Arab Spring67

Electronic records Digital Technology connecting system

8 The Arab SpringInformation / digital Technology


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Some Future Directions


Professor S Rawaf

Strengthen the Legislative and Executive Links: N/L

New modern Laws Public Health Law (regulations) Strengthen Parliamentary Monitoring Protect Patients and Public Institutional and Individual Accountability


Professor S Rawaf

Strengthen the Legislative and Executive Links: N/L Review MoH & Governorates Structures & Functions FfP

Current structure & functions do not FfP Move key players from politics

(Undersecretaries & below) Competent and well trained leadership


Professor S Rawaf

Strengthen the Legislative and Executive Links: N/L Review MoH & Governorate Structures & Functions FfP Strengthen Health System (PHC & PH)

Strong Health System

Primary Care Hospital Care

Public Health

© WHO Collaborating Centre, London

Professor S Rawaf

Developing Family Medicine

EquitableCommunity-basedInfrastructure

EquitableCommunity-basedInfrastructure

Strong Postgraduate Training

Strong Postgraduate Training

Solid UndergraduateLearning

Solid UndergraduateLearning


Professor S Rawaf

1

2

New Entrance:Introduce A structured Training ProgramFamily Medicine 3-5 Years .. I/A BoardsCurrent PHC DoctorsOne Year on-the-Job Training Program Postgraduate Diploma in Family Medicine


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HRH: Bridging The Gaps

Clear Strategic Directions International Recruitments Effective use of current HR Regulate Private Practice - Only fully accredited specialists - No more than 10% of public Contract


Professor S Rawaf



Strengthen Public Institutions (Regulations)

Independent Professional Regulators Providers Regulatory Body [Standards settings and Monitoring] Supporting Laws and Enforcements Governance (including Clinical Governance)


Professor S Rawaf



Strengthen Public Institutions (Regulations)

Leadership for Health

All policy & decision-makers must be trained in

LeadershipAll must be assessed for their competenciesAnnual Appraisals including CPD and PDP


Professor S Rawaf

Service Provision

Universal Coverage Free at time of Delivery (Pre-Payments?) Person-centred care Integrated of Health and Social Care Competent Practitioners Safe and Quality Service

The Future?

Iraq is resource rich country

Look forward (not backward)

Invest in human being and infrastructures

Strengthen Institutions

The future will be bright

Thank you

Documents

WHO Collaborating Centre Imperial College London Iraq Health System Current & Future Challenges Salman Rawaf MD PhD FRCP FFPH Professor of Public Health