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Access1 to Quality Health Care in Iraq: a gender and Life-Cycle Perspective


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  • Together with the Protection OT, prioritise the development and use of protocols for the ethical research, documenting and monitoring of GBV and of Standard Operating Procedures for the care of survivors of GBV specifically adapted to the Iraqi context;

  • Where training of medical staff is a component or focus of a project, attention must be given to training on medical confidentiality and psycho-medical management of GBV, including rape survivors, where appropriate;

  • Where appropriate and possible, the relevant personnel at medical centres must be trained and facilitated in the development of confidential referral mechanisms for health and psychosocial services for rape survivors;

  • In developing proposals based on the project sheets, refer to the recommendations within the IAU’s paper and database entitled ‘GBV in Iraq: the effects of violence – real and perceived – on the lives of women, men, girls and boys in Iraq’;

  • Ensure that there is a space available within the medical facility for private consultation with/examination of GBV survivors

  • Within the UN Assistance Strategy, the Health & Nutrition Sector undertakes to “provide support to improve the performance of the national health system and provide equal access to services, with special emphasis on vulnerable, marginalized and excluded individuals and families”. It is suggested that this commitment needs to be amended to read “provide support to improve the performance of the national health system to provide equal access to services, with special emphasis on vulnerable, marginalized and excluded individuals and families”. While recognising the space limitations of the actual UN Assistance Strategy document and the fact that the Health & Nutrition SOT may in fact have looked at the issue, the terms vulnerability, marginalisation and exclusion need further exploration and definition and must include a gender analysis.

  • In terms of advocacy, under the UN Assistance Strategy, the Health & Nutrition SOT undertakes to “assist in developing position papers on: governance, financing, human resources, health care delivery, drug policies, promoting equity, ‘rights-based’ social justice, gender mainstreaming and the allocation of resources in the health sector (emphasis added”. It is proposed that this paper and the recommendations herein is a ‘starting point’ on the development of a gender equality and gender mainstreaming position paper.

Background

Prior to the Iran-Iraq war (September 1980 – August 1988) and the subsequent decade of sanctions against Iraq, the country had a high standard of health care relative to the rest of the rest of the Arab region. Health care was free, centrally administered through the Ministry of Health (MoH) and well-equipped and –supplied, with modern hospitals and an adequate number of health service personnel.

The deterioration of services began in 1980 with the Iran-Iraq war and continued to decline throughout the subsequent conflicts and economic sanctions. However, according to UNDP’s Programme on Governance in the Arab Region, even as late as 1991, it is estimated that up to 97% of urban and 71% of rural populations had access to healthcare36.

In the 1990s, however, the health infrastructure, supplies of medical equipment and consumables and food availability became severely compromised by the economic sanctions. By August 1990, it was estimated that food and medicine imports had fallen by 85-90%37. Malnutrition became commonplace and, by 1996, had affected 30% of children under five years38.

The UN-supported Oil for Food Programme (OFFP) started in 1996 and supplied two-thirds of the nation’s food39, providing up to 2,215 calories per day per person receiving rations. Even after the programme’s inception, widespread protein deficiencies and malnutrition continued.

Within the OFFP, US$ 4,749 million was allocated to the health sector (73% of this for Central/Southern Iraq and 27% for Northern Iraq). Half of the funding was for medicines and half for medical equipment and other supplies. However, investment in medical supplies was not matched by internal investment in salaries, training and recurring expenses, making the system weak in terms of human resources and service quality40.

By 1996, over 30% of all hospital beds had been closed and public hospitals were struggling to provide essentials such as electricity, water and food to patients41. Basic medicines were often unavailable during this period. As a result of these deprivations, the distribution of health services and supplies in Iraq fell dramatically and infant mortality doubled42. It is estimated that more than 60 children died every day between August 1990 and March 1998 as a result of health and nutritional deficiencies caused by the sanctions43. James Owen Drife, writing in the British Medical Journal on 16 April 2005 states that, “[d]uring the 1990s maternal mortality in Iraq rose to medieval levels as a result of sanctions. Many women and babies died for the want of drugs and transfusions.”

During this period, trained health personnel fled the country for more stable and financially rewarding jobs in neighbouring countries, while those who remained were unable to gain access to new technologies and education.

In late 2003, WFP, together with COSIT and the MoH carried out a study on the public distribution system (PDS) that allocates food aid to most of the population. The survey found that 27% of under fives in Iraq had chronic malnutrition and that 6.5 million people (a quarter of the population) were highly dependent on food aid. The report found that “[a]cute malnutrition (wasting rates) for children under five within the sample is 4.4%, underweight 11.5%, and chronic malnutrition or stunting is 27.6%” and concludes that, without the PDS, the figures would be dramatically higher.

The 1970 Constitution guaranteed equal access to health care by way of the overarching equality clause (Art. 19). The 2005 Constitution goes further by specifically guaranteeing equal rights to health care, explicitly identifying women and children (Art. 3044).

Although free health care is not guaranteed by the 2005 Constitution, the Iraqi Public Health Law obliges the State to enforce the right of each citizen of Iraq to physical and mental health, as well as regulating maternity, children’s health and family health care, including nutrition.

In the late 1990s, during the UN sanctions imposed after the Gulf War, a Revolutionary Command Council decision (RCC Order No. 124, 1997) allowed some public hospitals to convert to a fee-based, private structure, thus limiting free services to those who could not afford it.

The Iraqi Public Health Law also obliges the MoH to educate women in maternal health and childcare and to provide periodic health tests for pregnant women. The law also supports family planning by advising “the family to keep a reasonable period of time between one pregnancy and another in accordance with the health needs of the mother, child and family” and provides for ongoing medical and nutritional care for children45.

Over the past five years of the current conflict, access to health care, food and water has deteriorated even further. Water treatment plants have been severely damaged by the war and only about half of the country’s sewage treatment plants are operational46. In some governorates, particularly those in the south, over 80% of those living in rural areas lack clean drinking water and only 3% of rural households are connected to a sewage system as compared to 47% in urban areas47.

Food insecurity remains a reality for many families and chronic malnutrition persists for almost a quarter of children between the ages of six months and five years48.

In addition, while there are approximately 1,700 functioning PHCCs in Iraq, only half of these are staffed by at least one medical doctor49. Assessments carried out by WHO indicate that approximately 12% of hospitals were damaged in the 2003 war50. However, the distribution of health services is often disproportionate. A 2004 report by the MoH revealed that at least four governorates (Basrah, Nasiriya, Wasit and Missan) have minimal or non-existent health services, while Baghdad is relatively better staffed. Even when healthcare is free, particular geographic areas are often isolated from healthcare facilities and have no access whatsoever. These problems have been exacerbated by curfews and continued insecurity. In addition, for safety reasons, many health facilities have reduced their hours significantly, opening only in the mornings and early afternoons.

Although estimates of the rate and causes of the loss of medical personnel – especially experienced doctors and specialists - vary, the negative trend is clear. An October 2006 study by the Brookings Institution concluded that 12,000 physicians have left Iraq since the beginning of the 2003 invasion, representing more than one-third of all registered physicians. An additional 2,000 have been killed51.

Often perceived as members of the elite, Iraqi doctors have increasingly been threatened, attacked and kidnapped for ransom. According to UNAMI’s HRO Report for the period 1 May – 30 June 2006, an estimated 250 Iraqi doctors were kidnapped between May 2003 and June 2006. In addition, the Iraqi MoH reports that, during the same period, 102 doctors, 164 nurses and 142 non-medical staff were killed. And finally, due to the proliferation of weapons, medical staff face insecurity inside the hospitals, including pressure by militias to sign certificates or to prioritise treatment52.

The flight of experienced medical personnel has resulted in many hospitals now being chronically understaffed and medical residents undertaking medical operations they are not yet qualified to perform. The departure of experienced physicians also leaves a void of trainers for the country’s up-and-coming health professionals, which threatens to prolong the human resources crisis in the country’s health sector. “The displacement of doctors and other health care professionals, coupled with lack of adequate facilities, equipment and shortages in medicine, have resulted in an overall decline in the quality of medical services”53.

By 1999, the Two-Year Assessment and Review Exercise of the Security Council Resolution 986 operation estimated that the reconstruction of the health care system in Iraq required investments of US$ 2 to 3 billion54.

Before the start of the war in 2003, the public medical system in Iraq included 282 hospitals; 1,570 PHCCs; 146 warehouses; 14 research centres and 10 drug production plants. Even then, few institutions had facilities and staff to provide triage, trauma and emergency medical care. The MoH maintained blood-bank facilities solely within central urban facilities55.

In addition to the more general problems that affect the entire population’s access to adequate health services – to some degree or the other – serious problems persist at a more specific level with the availability and quality of health services available to women, including pre- and post-natal care, reproductive health, cancers specific to women, etc.


Barriers to Health Care

  1. The deterioration of the security situation that limits access to health services

Attacks on Health Facilities and Health Personnel (HRO Human Rights Report)

11 December 2007 – the Director of al-Rashad Hospital for Mental Illnesses was gunned down in the Baladiyyat area of Baghdad.

Between 2003 and March 2007 - According to the Brookings Institution, 12,000 out of 34,000 doctors had left Iraq, 250 had been kidnapped and 2,000 killed.

25 September 2006, the Minister of Health and the Diyala Governor survived assassination attempts.

April 2007 edition of the British Medical Journal - In an article entitled, ‘Exodus of Medical Staff Strains Iraq’s Health Facilities’, it was reported that 14 staff members and volunteers from the Iraqi Red Crescent Society had been killed and 45 abducted (whereabouts of 12 remain unaccounted).

Between April 2003 and the end of May 2006 - MoH reported that 102 doctors and 164 nurses were killed and 77 wounded; 142 non-medical staff (drivers, guards, administration personnel) were killed and 117 wounded.

In May 2006 alone, eight doctors were killed and 42 wounded; eight nurses were killed and seven wounded and, among non-medical staff, six were killed and four wounded.

The Medical Association in Mosul informed UNAMI HRO that, since April 2003, at least 11 doctors had been killed while another 66 had left the city.

Mosul, 8 May 2006 - Unknown gunmen arrived in two private cars to the Al-Zayzafon pharmacy, opposite Al-Khansa hospital in Al-Sukar district. The men took the pharmacist and executed him in public before setting the pharmacy alight.

Mosul, 15 May 2006 - In Garage Al-Shemal area, unknown gunmen assassinated a doctor as he was leaving his private clinic. Two other doctors were said to have been killed the same week in Mosul.

According to the MoH in the KRG, between January 2006 and December 2007, at least 53 Arab medical doctors from other parts of Iraq were employed in the Region. The figure did not include other doctors who migrated to the Region to work as private practitioners or in other jobs.

9 April 2006, a group of armed men gunned down the Director of the Ear, Nose and Throat Centre at the University of Baghdad at the door of his clinic.

As a result of the violence, many health workers left the country or relocated to safer areas. In western regions of Iraq, where ongoing military operations have resulted in increased number of casualties, hospitals reported a lack of adequate supplies, military surveillance of medical facilities and intimidation and harassment of medical personnel. UNAMI’s HRO reports that health workers state that they failed to receive adequate protection during military operations and they were unable to carry out their work in safety.

Apart from threats to their personal safety, health care providers faced difficulties in carrying out their work because of the limited supply of electricity and the growing number of patients due to the increase in violence. Furthermore, because of the proliferation of weapons, doctors and nurses faced insecurity inside the hospitals, the kidnapping of patients, pressure by militias and other armed forces and groups to prioritise treatment. Corruption in hospitals was also noted as one of the obstacles for access to health by the population.

The attacks against health care providers, their displacement to safer areas of the country or to other countries, coupled with the lack of adequate facilities, equipment and shortages in medicine reportedly resulted in an overall decline in the quality of medical service.

The closure, deterioration and destruction of health care facilities and infrastructure during military operations, including the use of or direct attacks by military actors are all issues that limit the number of bed-spaces and the level of health-care available to Iraqis. There are specific articles in International Humanitarian Law on medical neutrality (see ICRC database on IHL for the specific provisions in 1949 Conventions and in the two 1977 Additional Protocols)

Between 1 July and 31 December 2007, UNAMI HRO recorded three separate attacks on civilian hospitals; a mortar attack on al-Sadr Hospital in Basra (24 July); an attack by unknown gunmen on a hospital in western Baghdad (22 September); and a hijacking by unknown actors of an ambulance carrying eight passengers in Ba’quba in Diyala governorate (16 September).

Security events that limited access to health facilities (UNAMI HRO Human Rights Reports)

November 2006, HRO submitted an official memorandum to MNF-I Chief of Staff, Maj. Gen. Thomas L. Moore, Jr., requesting information on a number of incidents involving MNF-I activities in Ramadi and Fallujah, including the use of hospitals as military bases. According to the Ramadi General Hospital, in the first week of November, MNF-I snipers were reported as having allegedly killed 13 civilians. For several months, patients refrained from using the hospital for fear of snipers allegedly placed on the hospital roof, in addition to the military occupation of the hospital garden.

Between September and October 2006, military operations by MNF-I and Iraqi Security Forces in Ramadi continued to affect the local population. The Iraqi forces occupied the garden of the local hospital and used it as a recruitment centre. Adjacent residents, fearing being caught in cross-fire, evacuated their homes. MNF-I snipers were reportedly placed over civilian houses, on high buildings and on the roof of the Ramadi Faculty of Medicine and General Hospital. As a result, most medical staff and local population were reluctant to access these facilities and some patients sought treatment in Tikrit General Hospital, Salaheddin Governorate, some 100 kilometres away.

5 July 2006, the MNF-I occupied Al-Ramadi Specialised Hospital because it allegedly harboured “terrorists.” Following negotiations with health officials in Al-Anbar, the MNF-I left the hospital on 13 July but maintained an outdoor patrol.

1 November – 31 December 2005 report – HRO received reports that Tel Afar Hospital was occupied by MNF-I and ISF forces for six months, limiting patients’ access to the facility and putting the lives of staff and drivers observed by insurgent forces entering the hospital premises at risk. Reports were also received alleging that access to Ramadi Teaching Hospital was restricted for several months by MNF-I roadblocks placed in the vicinity. The teaching hospital was reportedly searched on 8 November by the MNF-I claiming that they were looking for insurgents.

The HRO received numerous allegations that medical facilities were damaged and operations otherwise disrupted by MNF-I raids, involving in some cases the detention of medical personnel.

October 2005 - According to reports from WHO, during military operations in Al Anbar Governorate, medical doctors were detained and medical facilities occupied by armed forces. The UN raised this issue repeatedly with the MoH on the basis that such actions are contrary to international law governing armed conflict and in any event they constitute a denial of the protection of international human rights law.

4 October 2005 - According to a report released by Doctors for Iraq (www.doctorsforiraq.org) on 10 November 2005, in the course of an attack on the city of Haditha in western Iraq, US and Iraqi soldiers declared a curfew in the city and entered and occupied the hospital building; they occupied the building for seven days, arrested the hospital’s manager and another doctor. Medical personnel at the hospital reported that the military used violence against doctors in the course of interrogations, accusing them of being insurgents.

Doctors for Iraq Report (30 August 2005) - reports received from medical staff in Al Qaim Hospital in western Iraq that a field clinic in Al Karablaa village was bombed. Medical staff at Al Qaim Hospital also reported that the electricity at the hospital had been cut and that the Manager of the hospital had closed the hospital temporarily because of the “unsafe conditions in the area”.

As mentioned in ‘Background’ above, the Iraqi health system is based on a centralised, hospital-based approach. Therefore, in the absence of an outreach/PHCC system, combined with damages to hospitals and other centralised facilities, the population’s access to health services is immediately reduced.

Insecurity is a major barrier to Iraqis’ health. As of 2003, assessments estimated that security concerns impede healthcare access for up to 50% of the Iraqi population56. Neither more recent figures are not available nor sex-disaggregated data is available and, therefore, it is not possible to say with complete accuracy if and to what extent this issue affects women and men differently. For example, some reports emanating from Iraq suggest that men and boys, because of their gender roles and responsibilities have more freedom of movement, while other reports have suggested that, due to the fact that men and boys are more likely to be randomly rounded-up and detained, women have more freedom of movement. However, the ABA/ILDP Study (December 2006) contains the results of interviews with focal groups which suggest that Iraq’s deteriorating security situation discourages many more women from leaving their homes, thus restricting them and, in many cases, their children from accessing the few health services that are available57.

Insecurity – real and perceived – has also reduced the number of women and men working in the health sector. However, statistics are not available on the sex-disaggregation of medical personnel over the period of the last five years and, therefore again it is not possible to say conclusively whether the issue of insecurity, and other factors, has limited male and female medical personnel’s access to work to the same or to a greater or lesser degree.

Violence creates a steady flow of medical emergencies that diverts already over-stretched resources away from health problems that are not viewed as critical, such as ordinary maternal care and paediatrics. Once again, there is no concrete data on this but, if we look at the rising number of home births and the level of maternal deaths, then we can have some idea of its impact. However, sex-disaggregated figures for fatalities as a result of unattended injuries and sicknesses is also not available so, once again, we are left to conjecture on the nature and extent of the gendered difference, if any, in this regard.

There are a large number of credible reports that women have been victims of increased harassment and violence58. One effect of this is that women’s access to health care is constrained for both themselves and their children.

While it seems that the majority of women and girls who experience sexual violence do not seek medical care or pursue legal recourse due to the fear that this may provoke an ‘honour killing’ or social stigmatisation, where a woman does want to pursue a police investigation, which itself requires forensic examination, or medical assistance, they are often hampered from seeking assistance because “some hospital staff do not regard treating victims of sexual violence as their responsibility, or give such care low priority given their limited resources due to the war and its aftermath”59.

As Human Rights Watch (HRW) states in their July 2003 report ‘Climate of Fear’60, “insecurity affects women’s and girls’ access to health in complex ways”; they may have greater difficulties in accessing routine and preventative health care, including reproductive health care, when they are dependent on male family members to escort them to health facilities. In addition, women and girls who do make it to the health facility may find that female medical personnel are staying home due to insecurity “leaving them to choose between foregoing treatment or accepting treatment from a male doctor who may lack appropriate expertise or sensitivity”61.

The denial of or delay in medical treatment for victims of sexual violence may deprive a women or girl from access to medication to treat STIs that, untreated, can result in infertility.

In the course of their research for the 2003 report, HRW spoke to medical personnel in the Maternity Hospital in Baghdad who confirmed that they do treat victims of sexual violence. However, HRW also spoke to and documented several cases of women and girls who sought medical assistance but who were turned away from the Maternity Hospital, other hospitals in Baghdad and from the Institute for Forensic Medicine.

The Institute of Forensic Medicine is the only institute that conducts forensic examinations upon official referral. The Institute turns away victims who present without the required referral. The Institute does not provide any medical assistance; the victim must go to a hospital for medical treatment, enduring, it may be presumed, another possible round of questions and examinations. The need to obtain an official referral from the police places a significant burden on women and girls who do not want to report the incident but do want to obtain medical treatment.

In terms of psychological and social health support for Iraqis who are distressed by the security situation, in ‘Iraq Watching Briefs: Health & Nutrition’ (July 2003), WHO and UNICEF note that “[i]nformation on mental health status is limited to that which is available via the services provides by the two mental hospitals in Baghdad and wards in several other regional centres. This provides no information on the magnitude of need, coping mechanisms or adaptation methods for any population groups” (pg. 23).

In an IRIN report dated 24th May 2007, it was stated that mental health specialists in Iraq say that there has been an increase in domestic violence against children predominately as a result of the way that the violence that has gripped Iraq since the conflict began in 2003 has affected people’s behaviour. According to Ala’a al’Sahaddi, Vice-President of the Iraq Psychologists Association (IPA), the majority of the perpetrators of violence against children are the children’s own parents, with parental punishment becoming increasingly harsher. Ibrahim Abdullah, a psychiatrist and member of the National League for the Study of Health Disorders (NLSHD) reported that the majority of the children he sees are suffering from PTSD and exhibit “disturbed behaviour”. There are, reportedly, only 40 psychiatrists or psychologists in Iraq, as the majority of them have fled the country. The IRIN reports goes on to say that, in a privately-funded study, ‘The effects of war on psychological distress’ by the IPA with the support of the NLSHD in Baghdad, Anbar, Diyala and Babil governorates, of the 2,500 families interviewed, 87% had observed a family member with psychological distress; 91% of the children interviewed said they faced more aggression at home than before the onset of the conflict in 2003; and nearly 38% had serious haematomas after beatings.

In 2004, the MoH identified high rates of depression, anxiety and somatisation (the manifestation of mental illness in physical symptoms62. In addition to mental illness, related behavioural problems, such as domestic violence against spouses and children, and acts of public violence greatly increase in conflict and post-conflict situations63



In May 2008, UNICEF released a report based on the results of a rapid assessment by their partner IMC of parents, children and teachers in Sadr City Sectors 1, 2 and 6, involving formal interviews in schools and homes of 120 individuals. The report contains the results of the assessment and recommendations for providing assistance to those affected by the then recent violence in the city. While the report focuses on (non sex-disaggregated) children, there are some revealing findings which most certainly be equally applied to (again, non sex-disaggregated) adults;

  • Ongoing violence and insecurity has curtailed children’s mobility severely, preventing them from going outside their homes to play or interact with other children. A childhood lived in such conditions, deprived of basic needs and filled with restrictions, threats and violence impacts negatively on a child’s emotional and behavioural development. Filled with feelings of fear, anxiety and uncertainty, children and young adults struggle to cope with a range of psychosocial problems created by the breakdown in their living conditions and the social networks that normally protect them.

  • Parents acknowledged feelings of helplessness and inability to help children cope with the situation, both in terms of material and emotional needs.

  • Parents indicated that the greatest needs for children include:

    • Open and safe places for children to play;

    • Basic food items and vitamins to meet child-specific nutrition needs;

    • Good education;

    • Playgrounds and sports centres;

    • Extra-curricular education activities and cultural centres.

  • Teaching personnel also indicated that the most pressing problems facing their students include the lack of security and basic services, lack of healthy food and basic health issues. The children identified as most vulnerable are orphans and those coming from families with extremely low socioeconomic status.

  • Teachers requested training in mental health, which would provide them with the skills they need to identify and support children with traumatic stress disorders.

  • Children were asked how life was different for them during the increased insecurity and conflict. They consistently mentioned the shooting and military presence as well as the increased stresses they see among their adult family members.

  • Currently, IMC noticed that children’s main coping mechanisms come from their own families. Most children stated that when they are sad or angry they talk to a parent, an older sibling or another family member. Several children stated that they wished their parents and family members were happier or that they feel sad when their families are upset, indicating how dependent children are upon their immediate caregivers for support, particularly because the restricted lifestyle limits their social interactions with the rest of society.

  • The majority of children and youth in conflict-affected areas have unaddressed basic needs for shelter, clean water, proper nutrition and security. Previous research by IMC suggests that between 30-40% will have more significant psychological symptoms and disorders in response to the disruption of their lives. Such disorders include depression, anxiety, post-traumatic disorders as well as other emotional and behavioural problems such as increased aggression, fear, anxiety, sleep disturbances, recurrent nightmares and phobias, bedwetting, anger and emotional ability. Very young children report more generalised fears such as stranger or separation anxiety, avoidance of situations, sleep disturbances, feeding problems and repetitive trauma focused play. Breakdown of social and family support combined with lack of routine and recreation places children and adolescents at the risk of psychosocial problems and mental health disorders.

While the rapid psychosocial assessment carried out by IMC for UNICEF is generally to be welcomed, the report gives no sense of whether girls’ and boys’, women’s and men’s experiences of, coping mechanisms for and responses to stress are the same and, if not, where the differences may lie. This is an area that requires greater investigation in order to inform the most effective response.

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