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


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The deterioration in Health services and standards

In its report of 17 August, 2007, IRIN quoted Dr. Ibrahim Khalil, a gynaecologist at al-Karada Maternity Hospital who said that in emergency deliveries at the hospital one out of every six mothers or newborns will die. The doctor went onto say that “Mothers are usually anaemic and children are born underweight as a result of poor nutrition and lack of pre-natal care”. He added that, while there are no official statistics, “we can see that the number [of such cases] has doubled since Saddam Hussein’s time”.

In the absence of district health centres and district health staff, women, especially women in rural areas, faced with insecurity and violence on the roads, curfews and road blocks, will only attempt to go to hospital as a very last resort64.

According to UNFPA’s “Iraq Reproductive Health Assessment” (2003), each Iraqi woman bears on average five children. Consequently, the economic sanctions of the 1990s had a devastating effect on the health of the approximate 2,000 women who give birth on a daily basis in Iraq65. The maternal mortality rate doubled between 1989 and 2004 and stood at 292 deaths per 100,000 in 200466.

Although statistics a year later in 2005 indicate that the maternal mortality rate fell to 250 deaths per 100,000, this number remains exceedingly high, especially in comparison with most developed countries67. In addition, between 1990 and 2005, skilled attendance at delivery dropped while infant mortality increased from 61 deaths per 1,000 live births to 88 per 1,000 live births.

The rate at which women access prenatal care is estimated to be less than 60%68 and less than 50% of PHCCs are able to provide basic maternal and child health services due to lack of equipment and qualified staff69.

The lack of trained professionals attending childbirths is a central issue to women’s maternal health70. As of 2003, it was estimated that only 70% of deliveries were attended by a trained health worker71. The use of midwives is on the rise, particularly in poor and rural areas, but they may not be properly equipped to deal with complications, with resulting fatalities. The MoH estimates that 30% of women in urban areas and 40% in rural areas deliver without assistance from qualified personnel. Many PHCCs lack basic supplies and equipment needed for antenatal services. Half of district-level institutions to which high risk pregnancies are referred lack essential resources and trained staff72.

Other maternal health problems identified include chronic iron-deficiency, estimated by the UNFPA to be as high as 50–70% of all pregnant women in Iraq73. Other concerns include the lack of pre-natal vitamin supplements, high rates of infection, high blood pressure and diabetes. Miscarriages, infertility and congenital defects have reportedly been abnormally high since the onset of the Iran-Iraq war and subsequent conflicts where the use of chemical weapons and depleted uranium were common74.

According to UNFPA’s 2003 Iraq Reproductive Health Assessment, Iraq has had an official policy of providing family planning and contraception for the last 14 years. However, it is unclear to what extent women are able to access family planning services. Amnesty International reported in 2005 that almost one-third of family planning institutions were destroyed during 200375. Advances in family planning methods are unavailable and neither healthcare providers nor Iraqi women are aware of newer family planning options76. In addition, due to looting, lack of basic supplies and inadequate training, over half of PHCCs no longer provide family planning services77. According to UNFPA (2004), prostitution, now much more common as a result of increasing poverty and social breakdown is associated with increased levels of STIs, including HIV78.

Breast cancer currently ranks as the most common type of cancer in Iraq79. Gynaecological care is difficult to access for most of the population80 and the State no longer has the funding, equipment or expertise to carry out routine examinations and diagnosis. In addition, there is little awareness regarding the importance of self-examination for cancers81. As of 2005, radiotherapy facilities existed in Baghdad and Mosul only, and drugs for cancer treatment were not usually available82. There are reports that the MoH does keep statistics on the prevalence of the disease through a population-based cancer registry established in 1976. However, the quality of the data and its usages remain unknown83.

Another area of concern relates to health services for adolescent girls and boys. Women’s health concerns are, more generally, defined as maternal health concerns and ignore those important years between puberty and pregnancy and the period after reproductive years, including menopause. Adolescent girls and boys may not be encouraged to seek medical assistance in an environment that does not consider their specific medical needs. This is an area of life cycle health care approach that must be considered.





  1. Economic and Geographic Barriers to accessing quality health services

A fee-for-service based system of healthcare was first introduced in 1997. Currently, there is a charge at public hospitals and public health clinics. All public health services, such as immunisation, prenatal care and health education are provided free-of-charge at PHCCs. If available at all, many public and private services, while subsidised, are often below acceptable standards.

Healthcare consultancy, treatments and medicines represent a significant cost in a country where the average annual income was $800 in 2004. According to Lynn Amowitz and colleagues writing in the American Medical Association in March 2004, an estimated 50% of the population uses the private sector as a first choice despite the considerably higher cost by Iraqi economic standards84.

Longer waiting times for free medical services force many Iraqi women to forego medical care for themselves and their families. Anecdotal reports suggest a disorganised healthcare system in which appointments are not available. In addition, the shortage of supplies, equipment and medical personnel, together with the large numbers of injured patients, often force patients to wait all day to receive state-funded care. Substantial waiting times are particularly problematic for Iraq’s ever increasing number of widows and single/female-headed households, who lack anyone with whom to share their childcare responsibilities85. Long waiting times can also be prohibitive for those Iraqi women who must work to support their families. Even those who are able to wait for care find themselves rushed through a health system unresponsive to their needs. In their June 2005 report, ‘Iraq Health Systems Profile’, WHO reports that doctors see between 30 and 100 patients during each three-hour shift, making consultation times between two and six minutes per patient, the brevity of which creates an increased risk of misdiagnosis and mistreatment of patients.

Transportation costs to reach services, especially for those in rural areas, add further to the cost of healthcare. With the increasing number of widow/female-headed households, the burden of healthcare for themselves, their children and other dependents has become ever more difficult for women.

Contraception is not considered essential and, therefore, is not fully covered by the State. Yet, as reported above under health statistics, according to MICS III (2006), a total of 10.8% of married women nationwide aged 15 – 49 years have an unmet need for contraception, with significant geographical variation - highest unmet need (17.7%) is in Dohuk; lowest (5.9%) is in Basra.

The greater level of security in the Iraqi Kurdistan Region has led to relative benefits for its residents in terms of the availability of resources and services in the health sector. According to the MoH in the KRG, in 2006, at least 53 medical doctors from other regions of Iraq have been employed in Kurdistan. This figure does not include doctors who have relocated to the region and are working as private practitioners. Iraqi Kurdistan-based respondents in the American Bar Association/Iraq Legal Development Project surveys in 2006 reported that many of the health sector problems they witnessed following the 2003 invasion improved significantly since 2005. Respondents referred to the arrival of new equipment, the increase from one to three in number of intensive care units, and the availability of internal heart surgery as evidence of general improvements in the quality of medical services.

In terms of women’s health, Iraqi Kurdistan-based respondents in the 2006 ABA/ILDP survey also reported that health centres specialising in maternal and post-natal care are free and available “all over Kurdistan”. The greater level of security and mobility enjoyed by Kurdish women also means that health care is more accessible to them than it is to women in other regions of the country. However, despite these relative advantages, respondents to the ABA/ILDP survey acknowledged that the standard of care still fails to meet their expectation.


  1. Displacement

In an article entitled ‘Iraq’s Internally Displaced Persons: Scale, Plight, and Prospects’ , Dana Graber Ladek states that “[t]he majority of Iraqi IDPs (66% of those assessed by IOM) are unemployed and without the means to cover basic needs such as rent, household goods, health care, rising fuel costs, and even food. Some who are less fortunate must find shelter in abandoned buildings or build makeshift housing on public land, facing the constant threat of eviction. These “homes” tend to be overcrowded and lack basic services such as running water, electricity, or sanitation facilities”86.

In terms of food and nutrition, Graber Ladek, writing in the same article, reports that only 29% of IDPs report regular access to the Public Distribution System (PDS) food rations and only 41% report receiving food assistance from another source. In view of the fact that females usually outnumber males in IDP (and refugee) situations, it is reasonable to extrapolate that women’s and girls’ nutritional levels are relatively more detrimentally affected.

In IDP environments, the lack of access to quality healthcare increases the spread of disease and deterioration of chronic health conditions. In this regard, Graber Ladek goes on to state in the report that 14% of IDPs who were interviewed reported that they have no access to healthcare services and 30% reported that they cannot access the medicines they require. While specialised health assistance, such as gynaecology and reproductive health services, is difficult for all Iraqis to acquire, it becomes even more elusive for IDPs.

Water shortages and the lack of access to potable water also affect IDPs’ health and living conditions negatively. Of the IDPs interviewed, 20% do not have regular access to water, a number that is likely to increase with the periods of drought affecting Iraq this year, especially in the north.

In the same publication87, writing in an article called ‘Brain Drain and Return’, Sasson states that “[Iraqi professional] women also may be reluctant to return, as they tend to focus on access to health care and education for their families and are often deterred by religious dogma and the associated erosion of women’s rights”.

Extrapolating from reports from the education sector that some Arabic-speaking IDP children are being excluded from accessing education in Iraqi Kurdistan where Kurdish is the language of instruction, it may be reasonable to assume that some Arabic-speaking IDPs in Iraqi Kurdistan may have problems in making themselves understood where the health service is also functioning in the Kurdish language.


5. Cultural Factors

Some cultural and social barriers also impede women’s health and wellbeing. Early marriage is on the increase, particularly in rural areas, jeopardising the reproductive and mental health of young girls who may not be physically, mentally or emotionally prepared to give birth. Social and religious beliefs sometimes prohibit the use of family planning and restrict women’s ability to choose the spacing and number of children in their families. Moreover, the preference for larger families compounds risks for women when comprehensive maternal health services are not available.

Several respondents in the ABA/ILDP survey (2006) also noted that some women may receive lower food quantities than the male members of their households, fuelling malnutrition rates among women88. As of 2004, over 40% of adult males in Iraq are overweight, while chronic malnutrition and anaemia was reported to be common in children, adolescents and pregnant women89.

Traditional notions of women’s roles and preferential treatment of male members of the family may also act as a barrier to women’s and girls’ health. A 2003 American Medical Association survey of Iraqi women found that only 18% of Iraqi women surveyed reported that they were unable to obtain healthcare without the approval of a male relative90.

There are reports that female genital cutting (FGC) has resurfaced in the northern part of Iraq. Although the practice has serious consequences for women’s long-term health, there appear to be no specific law against the practice. Amnesty International has reported that midwives in Northern Iraq regularly see women who have been cut and that doctors have carried out female genital cutting on married women at their husband’s request91.

The social stigma attached to crimes of sexual violence discourages many women from attempting to access medical treatment for injuries, wounds and STIs. Reporting assaults and rapes can also lead to other serious social and cultural consequences such as rejection or violence for having caused shame to the family – ‘honour’ crimes and killings (see ‘GBV in Iraq: The Effects of Violence – Real and Perceived – on the Lives of Iraqi Women, Men, Girls and Boys’ Report and database).



unct’s response to health services – a review of the gender perspective

The Health & Nutrition SOT has emphasised equitable access to health services, the engagement of women’s representatives in policies, strategies and guidelines and promoting equity, rights-based social justice and gender mainstreaming in the health sector within the UN Assistance Strategy 2008 – 2010 and, to a lesser extent, the CAP 2008. However, gender equality and women’s empowerment perspectives must be explicitly incorporated in all planned outputs, as set out in the recommendations on page 11 of this paper.




HEALTH AND NUTRITION

Outcome 1

By 2010, health- and nutrition-related programmes enhanced to ensure 20% increase in access to quality health care services with special focus on vulnerable groups

Output 1.1

Policies, strategies and guidelines related to health and nutrition developed if required; review based on standard human rights and principles.

Output 1.2

Institutional and personnel capacity of health/nutrition and related programmes strengthened for improved quality service delivery.

Output 1.3

Enhanced functional capacity of health and health related facilities and institutions (services) in low coverage areas (rehabilitation and procurement).

Output 1.4

Empowered and engaged local communities and private sector to enhance equitable access to health and nutrition services with special focus on missed opportunities in access to health.

Output 1.5

Enhanced monitoring and evaluation mechanisms in place to track progress and identify gaps in the provision of health and nutrition services with special emphasis on the un-reached.

Output 1.6

Emergency preparedness and response. Access to basic health services to the most vulnerable people affected by the ongoing humanitarian crisis assured.

General observations on the strength of the gender perspective in the CAP 2008 and the UN Assistance Strategy (2008 – 2011) health section:



  • While reference is made in the analysis narrative (CAP 2008, pgs 21-22) to the effect of conflict on the mental health and emotional stress of “victims and their communities, especially women and children”, there is no analysis or explanation as to the need for a special focus on women and children in this regard.

  • There is no attempt within the analysis to consider the different health care needs of women, men, girls and boys.

  • Despite the fact that the “provision of reproductive health and emergency obstetric care services” is listed among the six activity areas, there is no corresponding baseline or indicator included to measure progress in this regard.

  • The health sector is an important entry point for addressing issues of GBV. However, despite the inclusion of UNFPA’s project on ‘saving women’s life and dignity: increase access and utilisation of basic and comprehensive emergency obstetric care/reproductive health services, and counselling for GBV victims at 30 PHCCs and ten district hospitals’, WHO/IMC/UNIFEM’s project on ‘Emergency Assistance for victims of injuries and violence – mental health and psychosocial services in CAP 2008, there is no analysis, objectives, activities or indicators included on GBV in the UN Assistance Strategy 2008 – 2011 and minimal references in the CAP 2008.

  • There is an absence of sex-disaggregation in most of the project sheets, both in terms of the analysis of need and in the proposed activities, expected outcomes and indicators;

  • While there are references to the collection in health facilities of data related to GBV, there is no mention of the development and use of protocols for the ethical research, documenting and monitoring of GBV or of Standard Operating Procedures for the care of survivors of GBV.

  • The Health and Nutrition Sector’s Assistance Strategy will “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 there is a small but significant amendment that needs to be made to this comment, which should in fact 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”. In addition, while recognising the space limitations of the actual UN Assistance Strategy document, the issue of vulnerability, marginalisation and exclusion needs 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.

1 ‘Access’ – non-discrimination, physical accessibility, economic accessibility and information accessibility - is defined on page

2 The term ‘life cycle’ is adapted from UNFPA’s ‘life cycle approach’ model, which recognizes that “reproductive health is a lifetime concern for both women and men, from infancy to old age” and that we must supports health and nutrition programming tailored to the different challenges faced at different times in life. “In many cultures, the discrimination against girls and women that begins in infancy can determine the trajectory of their lives. The important issues of education and appropriate health care arise in childhood and adolescence. These continue to be issues in the reproductive years, along with family planning, sexually transmitted diseases and reproductive tract infections, adequate nutrition and care in pregnancy, and the social status of women and concerns about cervical and breast cancer. Male attitudes towards gender and sexual relations arise in boyhood, when they are often set for life. Men need early socialisation in concepts of sexual responsibility and ongoing education and support in order to experience full partnership in satisfying sexual relationships and family life”.



3 Santa Barbara, J. and MacQueen, G. (2004) Peace Through Health: Key Concepts, The Lancet, 24 July, cited in MEDACT (2004) Enduring Effects of War: Health in Iraq, pg. 3

4 MEDACT (2004) Enduring Effects of War: Health in Iraq, pg. 3

5 MEDACT, Enduring Effects of War: Health in Iraq, 2004

6 Adapted from the UN Assistance Strategy 2008 - 2011 Situation Analysis for the Health & Nutrition Sector Outcomes Team, pgs 16 - 17

7 Ibid.

8 Ibid.

9 Footnotes 8 – 28 are cited in The Women’s Commission for Refugee Women and Children, ‘Women, Children and Youth in the Iraq Crisis: A Fact Sheet’, January 2008

10UNFPA. State of the World’s Population 2002

11 Iraqi Red Crescent Society. The internally displaced people in Iraq – update 27. October 24, 2007.

12 Hassan, Nihal. '50,000 Iraqi refugees' forced into prostitution. The Independent. June 24, 2007. 11 Lyon, Alistair. Iraqi refugees turn to sex trade in Syria. Reuters. December 31, 2007.

13 IOM. Tension in the North Poses Additional Burden on Internally Displaced. November 2, 2007.

14 Lyon, Alistair. Iraqi refugees turn to sex trade in Syria. Reuters. December 31, 200

15 WHO. Iraq Annual Report. 2006.

16 Cluster D. Multiple Indicator Cluster Survey – MICS3. 2006.

17 Ibid.

18 IFHS 2006, compared to 192/100,000 reported in the UNDP Iraq Living Conditions Survey – ILCS. 2004.

19 Report of the Secretary General to the UN Security Council. October 15, 2007.

20 Harper, Andrew. Iraq: growing needs amid continuing displacement. Forced Migration Review. November 2007.

21 WFP and Government of Iraq: Food Security and Vulnerability Analysis in Iraq. May 2006.

22 World Vision. Trapped! The Disappearing Hopes of Iraqi Refugee Children. April 2007.

23 Ibid.

24 Ibid.

25 IRIN. Iraq: Male gynaecologists attacked by extremists. November 13, 2007.

26 UNFPA, UNHCR, UNICEF, WFP and WHO. Health sector appeal – Meeting the health needs of Iraqis displaced in neighbouring countries. September 18, 2007.

27 UNHCR. Surveys give valuable data on plight of Iraqi refugees. December 14, 2007.

28 Women’s Commission for Refugee Women and Children. Iraqi Refugee Women and Youth in Jordan: Reproductive Health Findings. September 2007.

29 Ibid.

30 Women for Women International,
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