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

Siobhán Foran

GenCap Gender Advisor**

OCHA Iraq/UNAMI (Information Analysis Unit)*

The IAU is an interagency unit within the RC/HC’s Office in UNAMI. It was created in January 2008 to improve the impact of the humanitarian and development response in Iraq through the strategic use of information.

UNAMI, OCHA, UNDP, UNICEF, UNFPA, WFP, FAO, WHO, UNHCR, IOM

Mercy Corps, International Medical Corps, and IMMAP

Index

Page

• 
  Purpose of the Report 3
  
• 
  Introduction 4
  

• 
  Executive Summary 5
  

• 
  Health Statistics 7
  
• 
  Four Dimensions of ‘Accessibility’ 10
  

• 
  Recommendations 11
  
• 
  Background 14
  
• 
  Barriers to Accessing Health Facilities and Services 17
  

1. 
   Deterioration in the Security Situation, including Psychological and Social 17 Impacts
   
2. 
   Deterioration in Health Services and Standards 21
   
3. 
   Economic and Geographical Barriers 24
   
4. 
   Displacement 25
   
5. 
   Cultural Issues 26
   
• 
  UNCT Response to Health Services – a review of the gender perspective 27
  

** The author of this report is a GenCap Gender Advisor deployed to the UNCT Iraq from February to August 2008. GenCap is a standby roster of gender experts managed by the IASC Sub-Working Group on Gender in Humanitarian Action and NRC. GenCap Advisors (UN P4/P5 equivalent) are deployed to humanitarian situations for six to twelve months to sit in the HC/RC’s office and provide support to information collection and analysis, programme planning, capacity building, coordination and advocacy on gender equality programming.

The Inter-agency Information and Analysis Unit (IAU) is a group composed of analysts from different participating UN agencies and NGOs in Iraq. The IAU was formed in early 2008 to improve the effectiveness of programming, advocacy, policy and coordination of the international response in Iraq and, therefore, the impact of the humanitarian and development response through the strategic use of information. A GenCap Gender Advisor (** see page 2) is deployed to the IAU to ensure a gender perspective and analysis is included in all of the Unit’s work.

The IAU identified that, while many of the obstacles, gaps and needs in the health sector are well documented, there is a dearth of data and information on the gender and life cycle perspective – relating to different vulnerabilities, needs, impacts, access for women, men, girls and boys - of these obstacles, gaps and needs. This gap in knowledge meant that the Unit is not in a position to analyse the challenges, threats and opportunities that would guide the UNCT and the UN’s partners on the optimal intervention to promote gender and age equality in the health sector. Accordingly, the purpose of this report is to explore the gendered nature of the factors contributing to obstructing women and men, girls and boys’ (including adolescents’) equal access to quality healthcare facilities and services in Iraq and to make recommendations to the UNCT and its operational partners for moving forward on the issue.

While it is encouraging to see the emphasis that the Health & Nutrition SOT (H&N SOT) has put on 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 (UN Assistance Strategy 2008 – 2011 and, to some degree, within the CAP 2008), it is envisaged that the recommendations within this report will assist the H&N SOT to enhance and to operationalise these commitments and to strengthen the gender and life cycle perspective within the CAP 2009 and other strategic and policy documents.

The focus of this briefing paper is on the gender-equality perspective of access to healthcare in Iraq. Presently, the most significant obstacles to health include the following;

1. 
   The deterioration* in the security situation, including the psychological and social Impacts;
   
2. 
   The deterioration* in healthcare services and out-dated standards;
   
3. 
   Economic and geographical barriers;
   
4. 
   Displacement;
   
5. 
   Cultural factors;
   

Each of these factors impact on women, men, girls and boys’ access to quality healthcare in different ways and to different degrees. It is the nature and extent of these differences that shapes the gendered nature of access to healthcare, which is the subject of this report.

The observations and recommendations below must be viewed in the context of an overall analysis of the health system in Iraq with regard to the establishment of a national framework for healthcare across primary, secondary and tertiary healthcare, including reproductive health, mental health and which is reflected in health professional teaching/training (medicine, nursing, midwifery). While this national framework has been the subject of a number of studies and reports and addresses broader issues, including the strategic re-orientation of the health care system from a hospital-based approach to a primary health care centre (PHCC) approach with a parallel enhancement of and an operational referral system to secondary and tertiary facilities, the focus of this report is more specific, addressing a gender and life cycle² perspective of the barriers to accessing quality healthcare.

In addition, while the observations and recommendations below focus on the need to improve the situation of girls and women in particular, it is important that girls and women are not seen as a homogeneous group; Iraq has a very diverse population and access to healthcare will as much depend on a person’s social status, ethnicity, geographical location (especially in terms of whether they are urban- or rural-based), culture/religion, etc. as on their gender and age. In view of the time-scale involved in developing this report and the breadth of study required to examine an age, gender and diversity matrix of analysis, it was not possible to explore the intersections between gender and these other characteristics in the context of this report. However, in reading the observations and the recommendations, this issue must be borne in mind.

• 
  The most significant threat to Iraqis’ health comes from the overall deterioration in health facilities and services resulting from the cumulative effect of many years of economic sanctions, neglect and war. Access to quality health care for all Iraqi people is severely undermined.
  
• 
  Thousands of Iraq’s medical doctors, among them the most experienced and specialised, have fled Iraq due to the increasing threats and violence directly against them thus affecting the overall capacity to deliver health services in Iraq.
  
• 
  The cumulative affect of years of neglect of the health service and the ongoing security situation affect the people of Iraq – to varying degrees - regardless of their sex, age, ethnicity, religion or [urban or rural] location.
  
• 
  “The immediate impact of conflict on physical and mental health accounts for a relatively small proportion of the suffering³. In the longer term too, health is harmed by conflict-related damage to essential health-sustaining infrastructure and to the health system, as well as the corrosive effects of conflict-related factors such as poverty, unemployment, disrupted education and low morale. It is difficult if not impossible to disentangle the indirect effects of conflict on health in Iraq from other under-lying health trends, especially in the absence of reliable, valid, current data. Because the impacts are interactive and cumulative, it is also extremely difficult to make causal connections with each successive war or period of conflict”⁴.
  

• 
  Prior to the Iran-Iraq war of September 1980 – August 1988 and the subsequent years of conflict and decade of sanctions, Iraq had a high standard of health care relative to the rest of the Arab region. Health care was free, centrally-administered through the Ministry of Health (MoH) and was well-equipped and well-supplied, with modern hospitals and an adequate number of well-trained medical personnel. In addition, the 1970 Constitution, through the equality clause (Article 19) guaranteed equal access to health care.
  
• 
  The deterioration of the health care service, together with an increase in food insecurity and the deterioration in the supply and quality of water began in 1980 with the Iran-Iraq war and continued to decline throughout the subsequent years of war and economic sanctions.
  
• 
  While Iraqi law provides for a right to health care and specifies that children and women should be afforded health security, the legal framework is inadequate to ensure women’s equal access to health care. It also fails to address the full range of women’s, especially adolescent girls and women’s reproductive health issues and concerns, including GBV, instead focusing primarily on prenatal and maternal health.
  
• 
  The law does not regulate the provision of health services in such a way as to ensure that quality health care is accessible and affordable to women, especially widowed women or women heading up households. The privatisation of some health care facilities and the resulting fee structure has further limited women’s access to health care. The problem is particularly acute in rural areas, where health care facilities are often non-existent due to the emphasis on the provision of hospital-based care, which are located in bigger urban areas.
  
• 
  Early marriage and pregnancy, preferential treatment within the household for men in access to food and traditional practice whereby women must obtain permission from a male relative before seeking medical care are significant cultural barriers to good health for women and girls.
  
• 
  Men may suffer other health disadvantages related to their gender role socialisation. For example, men’s roles as protectors and providers may place a greater responsibility on them to take risks during ongoing insecurities, therefore, exposing them to random or discriminatory violence, meaning that they limited health services are stretched to address their medical care needs if injured.
  
• 
  The current emphasis in the health sector appears to be on women’s reproductive health; neglecting issues specific to women, girls and adolescents throughout their life cycle and the creation of an environment that is conducive to such extended care.
  
• 
  Our understanding of the trends in the health service in general and gender trends in particular during this period up to the present day is curtailed severely by the dearth of consistent, reliable data, the absence of sex-disaggregated data and the fact that it is not possible to disentangle a myriad of other social, political and economic dynamics that were occurring at the same time, including the deterioration in the education system and the subsequent increase in illiteracy levels especially among girls and women; increasingly weak stewardship of the health sector and consequent “creeping privatisation and commercialisation of health care”⁵ which may have excluded an increasing number of widows and female-headed households, as well as exposing a degree of preferential treatment for men in accessing health outside of maternal health care; and chronic under-funding as financial and human resources were diverted to the ongoing military operations.
  

Set out below is some of the information and data that are available:

• 
  In 2006 there were 94,815 health workers, giving a ratio of 3.5 health workers to every 1,000 people. This compares to the East Mediterranean average of 4.2:1,000.
  

• 
  According to the Iraq Living Conditions Survey (ILCS), 2004, between 1991 (beginning of the first Gulf war) and 2001 Iraq had approximately 1,800 PHCCs.
  

• 
  Also according to the ILCS 2004, in 2001, as a result of the diversion of finance to fund three consecutive wars, the era of sanctions and re-prioritisation away from the health sector, the total expenditure on health was 3.2% of GDP (compared to 9.55% in Jordan).
  

• 
  The Iraq Family Health Survey (IFHS) 2006 indicates a high proportion of out-of-pocket spending on health (13% of monthly household expenses).
  
• 
  Environmental health, more specifically related to the availability of potable water and adequate sanitation, has also deteriorated. Poor sewage and waste management systems have affected the health status of many urban-based people. Two thirds of childhood mortality is due to diarrhoea and respiratory infections⁷.
  
• 
  Multiple sources indicate that, with increased food insecurity, the nutritional status of the population deteriorated considerably as demonstrated by worsening indicators (with wide range between different sub-groups): Low birth weight 15%, stunting 21%, underweight 8% and wasting 5% (MoH/UNICEF MICS III, 2006)⁸.
  
• 
  Chronic non-communicable diseases afflict many adults: hypertension 40%, diabetes 10%, overweight 34% and obesity 33% (MoH and WHO, 2006). The situation is further exacerbated by shortages of health services and drug supplies (10 out of 32 essential medicines are not regularly available).
  

Mental health status estimates showed that 4% of the population have severe mental health disturbances and 20% have common disturbances (WHO, 2006) while 35.5% of people claimed emotional stress (IFHS, 2007). There are very few adequate, well-developed curative services or prevention/rehabilitation programmes available.

• 
  Of those women who deliver in public or private health institutions, many received inadequate care because of the lack of essential drugs, transport to referral institutions is not possible or is not timely, or medical personnel lack training in emergency obstetric care. It is mainly referral institutions at a district level that have the capacity to attend complicated births and many of these lack some key resources to provide appropriate care. Women are at increased risk of poor birth outcomes with high rates of anaemia, short birth intervals and early marriage/pregnancy and need advanced medical support.
  
• 
  Appropriate family planning is essential to the health of women and children. According to MICS III (2006), a total of 10.8% of currently married women nationwide (due to the sensitivity of the subject matter, only married women were asked questions about contraceptive use during the survey) aged 15 – 49 years have an unmet need for contraception; there is significant geographical variation, with the highest unmet need (17.7%) in Dohuk and the lowest (5.9%) in Basra.
  
• 
  ⁹On average, between 75 and 80% of the displaced in any crisis are women and children¹⁰. The Iraqi Red Crescent Society estimates that more than 83% of those displaced inside Iraq are women and children, and the majority of the children are under 12 years of age¹¹.
  
• 
  There have been numerous reports of women and girls forced into prostitution and children sent out to the work to help support their impoverished families both in Iraq and in neighbouring countries of refuge¹²,¹³,¹⁴.
  
• 
  Iraq remains on the list of the 60 countries in the world with the highest infant, under-five and maternal mortality rates, according to available data¹⁵.
  
  • 
    Infant mortality rate: Estimated at 35 per 1000 live births¹⁶.
    
  • 
    Under-five mortality rate: Estimated at 41 per 1000 live births¹⁷. Diarrhoea and acute respiratory infections account for about two out of three under-five deaths, with malnutrition a major contributing factor.
    
  • 
    Maternal mortality rate: 84 per 100,000 live births (2004)¹⁸.
    
• 
  According to UNICEF, in 2007 only one in three children under five years of age in Iraq has access to safe drinking water¹⁹.
  
• 
  23% of children in southern Iraq are chronically malnourished²⁰.
  
• 
  25.9% of children under five in Iraq suffer from stunted growth²¹.
  
• 
  An April 2007 report found that 43% of the Iraqi refugee children it surveyed in Amman had witnessed violence in Iraq; 39% said they lost someone close through violence²² and over 30% of the refugee children surveyed said they had no hope for the future²³.
  
• 
  Male gynaecologists are being targeted for violence and intimidation by Islamic extremists, accused of invading the privacy of women²⁴. In addition, according to the Iraqi Medical Association, at least 75% of doctors, pharmacists and nurses in Iraq have left their jobs at universities, clinics and hospitals. Of these, at least 55% have fled abroad²⁵.
  
• 
  As of August 2007, 19% of refugees registered with the UNHCR in Syria reported having significant medical conditions and 14% of those registered in Jordan were identified as having special needs²⁶. Ten percent of Iraqis in Lebanon suffer from chronic disease²⁷.
  
• 
  The two main clinics that service Iraqi refugees in Amman do not have medicine to prevent pregnancy or HIV transmission for rape survivors²⁸. Mental health care is also generally not available for Iraqis in Jordan who survived or witnessed violence²⁹.
  

• 
  In a 2004 survey³⁰ of 1,000 women from different educational, economic, ethnic and religious backgrounds in seven cities in three governorates carried out by Women for Women International, 57.1% said that their families lacked adequate medical care. However, the greatest needs declared were for electricity (95%), work opportunities (87.3%) and access to clean water (63.5%).
  

There are a number of dimensions to accessibility to health services that must be considered³¹.

Iraq is a State Party to the ICESCR, wherein it specifies that accessibility to health care services means that health facilities, goods and services (6) must be accessible to everyone without discrimination, within the jurisdiction of the State party.

Accessibility has four overlapping dimensions:

• 
  Despite the legal guarantees, maternal and child health services are inadequate resulting in poor access to prenatal care and family planning services and high maternal mortality rate. Greater emphasis must be given to providing services and information, or enhancing the governments’ capacity to provide services and information on reproductive health, family planning and modern contraceptives. According to UNFPA³², several local studies show that there has been an increase in the incidence of abortion. The existing family planning policy and strategy should be reviewed and publicised and trained professionals should provide reproductive health services that are easily accessible for women both in urban and rural areas.
  
• 
  The Health & Nutrition SOT must lobby the governments to address harmful social practices, such early marriage and early pregnancy; preferential treatment for men in access to food; the traditional practice whereby women must obtain permission from a male relative before seeking medical care; and female genital cutting in Iraqi Kurdistan, through focused efforts to enhance awareness of the risks to women’s health and the importance of equal treatment for all members of the family.
  
• 
  As part of the decentralisation programme, focus on the recruitment, training and employment of female health workers and related health disciplines, as well as the promotion of the social status of the nursing profession in the overall context of the development of a strong community health-nursing programme.
  
• 
  In collaboration with colleagues in the Education SOT, the H&N SOT, through its ongoing work in the development of community-based health services, must encourage the development of health education for behavioural change through schools, newspapers, religious institutions and leaders, television and radio. Popular education and promotion should be developed in areas of personal hygiene, life skills for adolescents, immunisation, breast-feeding, oral health, avoidance of early marriage and short birth intervals, pre- and post-natal care and nutrition³³.
  

• 
  Emergency obstetric care should be upgraded with equipment, drugs, training and referral capacity. Addressing the primary health care needs of pregnant women, and the secondary care needs of women with complicated deliveries, will greatly improve birth outcomes and reduce maternal mortality³⁴.
  
• 
  Almost all of the limited information available on health status is focused on young children or pregnant women. Population groups with little known needs including adolescents, elderly, IDPs, widows, female-headed households, street children and orphans, those with mental health needs and those with disabilities must be studied³⁵.
  
• 
  While it is encouraging to see the emphasis that the Health & Nutrition SOT has put on 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 (UN Assistance Strategy 2008 – 2010), it is also important that gender equality and women’s empowerment dimensions are explicitly incorporated in all planned outputs, as follows (comments added in bold type):