1. WHO Collaborating Centre Imperial College London Iraq Health System Current & Future Challenges Salman Rawaf MD PhD FRCP FFPH Professor of Public Health s.rawaf@imperial.ac.uk

2. © WHO C Centre, Imperial College London Professor S Rawaf Contents: 1. Achievements since 2003 2. Current Challenges 3. Way forwards 4. Learning from Experience 5. The Future

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4. © WHO C Centre, Imperial College London 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

5. © WHO C Centre, Imperial College London 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 wide Increased Public expectations ? Quality

6. © WHO C Centre, Imperial College London Professor S Rawaf Under 5 Mortality Rate /1000 live birth 2010 41/1000 live birth 2015 (Target) 17/1000 live birth

7. © WHO C Centre, Imperial College London Professor S Rawaf Proportion of births attended by skilled health personnel Excellent progress 50% in 1990 to >85% by 2010

8. 8 Comparison of health outcomes in EMR countries – 2010 CountriesPopulation (000) Populatio n growth rate (%) TFRLE at birth (years) U5 MRMMRPer cap THE (in US$) Jordan6,1132.23.873.028.019.1357.4 Lebanon 4,1891.81.981.518.323651.0 Syria20,6192.53.573.121.458.096.6 Egypt78,7282.43.073.221.354.0123.2 Iran74,7331.52.072.120.030.0316.9 Iraq32,3263.44.371.039.084.0246.8

9. Trend in Demographic Indicators IndicatorYEAR 200520062007200820092010 Crude Birth Rate 37.432.934373840 Crude Death Rate 5.27.75544 Pop Growth Rate 3.22.5333.4

10. © WHO C Centre, Imperial College London Professor S Rawaf Current & Future Challenges facing HS in Iraq National Constitutions 1 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

11. © WHO C Centre, Imperial College London Professor S Rawaf Legislature, Regulators, Executive National Local

12. © WHO C Centre, Imperial College London Professor S Rawaf Current & Future Challenges facing HS in Iraq National Constitutions 1 Socio-economic Development 2 Laws & Regulations 3  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 Ethic Constitutional Rights

13. Professor S Rawaf

14. © WHO C Centre, Imperial College London Professor S Rawaf Current & Future Challenges facing HS in Iraq National Constitutions 1 Socio-economic Development 2 Health Systems 3 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

15. © WHO C Centre, Imperial College London Professor S Rawaf 50-60m Contacts with the Health System 1/3 PRIMARY CARE 2/3 HOSPITAL CARE

16. FPFP HOSPITALHOSPITAL 1 2 3 Cost: 10% + 11% 45% Acute, 20% MH + Contacts: 85% - 90% 10-15% NHS Direct 100% Registration 10% © WHO C Centre, Imperial College London Professor S Rawaf

17. 40% Healthy 40% Healthy 40% Healthy With Risk Factor(s) 40% Healthy With Risk Factor(s) 10% Acute Illness 10% Disability Rawaf’s Model for Burden of Disease - 2001 In Any Given Population © WHO C Centre, Imperial College London

18. Professor S Rawaf Current & Future Challenges facing HS in Iraq National Constitutions 1 Socio-economic Development 2 Health Systems 3 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

19. © WHO C Centre, Imperial College London Professor S Rawaf Iraq: Government Budget 2006-2010

20. © WHO C Centre, Imperial College London Source: WHO, 2013 IPSM 2009 Professor S Rawaf Iraq National Health Account 2011  4.6% of GDP on Health (2010)  Health Budget: 80.5% Public 18.7% 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

21. In 2010, per capita THE (weighted average) in: EMR = US$183 In Group 3 countries < US$ 40 In Group 2 countries ≈ US$220 In Group 1 countries > US$ 850 Source: WHO EMRO

22. The share of out-of-pocket spending is high in many countries of the Region, 2010 PAL Source: WHO EMRO

23. © WHO C Centre, Imperial College London Professor S Rawaf Current & Future Challenges facing HS in Iraq National Constitutions 1 Socio-economic Development 2 Health Systems 3 Public Health Laws 4 Privatisation (Market capitalism) 5 Human Resources for Health 6  number needed  competencies  Skill mix  Training capacities / conflict (MoH/MoHER)

24. © WHO C Centre, Imperial College London Professor S Rawaf 57,600 24,800 2,240 >500 Medical Schools (22) In migration ?150

25. © WHO C Centre, Imperial College London 7300 57K 200 2450 1000 Competent HR Needed (Physicians) 2400 1400 CCSTCCST 100 0 All specialties Family Medicine <850 <100 >2,450 ……………………………………………………………………………………..<950 3500 Yearly 2,100 57K 1,400 850 95 0 100 Current Supply Current Specialists

26. © WHO C Centre, Imperial College London Professor S Rawaf 57,600 24,800 2,240 ?100-500 Medical Schools (22) In migration ?150 Gap: 32,800 At current rate of Supply we need (MBChB): 13 Years All Specialists: 25 Years Family Physicians: 230 years

27. © WHO C Centre, Imperial College London 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!!!

28. 1 2 3 4 5 F1 F2 1 2 3 2 3 4 5 1 A-level University University (Medical School) Foundation School (Virtual) Med/Surg/PH/Diag General Practice PMET Board + R. Colleges (Standards) GM C CST Principle GP Consultant © WHO Centre, Imperial College London Professor S Rawaf 3 Education & Training

29. MBChB MBBS They Need: Structured Training © WHO Centre, Imperial College London Professor S Rawaf

30. © WHO C Centre, Imperial College London Professor S Rawaf Current & Future Challenges facing HS in Iraq National Constitutions 1 Socio-economic Development 2 Health Systems 3 Public Health Laws 4 Privatisation (Market capitalism) 5 Human Resources for Health 6  NCD  Psychological Trauma  War consequences  System Adaptation 6 Burden of Disease

31. Burden of Noncommunicable Diseases Per 1000 Population/2009 Data TotalMaleFemale Hypertension41.834.448.8 Diabetes2121.622.1 Joint Diseases18.613.124.1 Heart Diseases12.011.112.9 Gastro Intestinal Diseases11.212.69.7 Asthma8.38.87.7 Urinary Tract Diseases7.47.27.5 Chronic Respiratory Diseases 5.26.34.0 Chronic Back Pain4.94.35.5 Anaemia3.71.95.5 Persistent Headaches3.22.34.1 Chronic Skin Problems2.93.62.2

32. © WHO C Centre, Imperial College London Professor S Rawaf Current & Future Challenges facing HS in Iraq National Constitutions 1 Socio-economic Development 2 Health Systems 3 Public Health Laws 4 Privatisation (Market capitalism) 5 The Arab Spring 6 7  Electronic records  Digital Technology connecting system 8 The Arab Spring Information / digital Technology

33. © WHO C Centre, Imperial College London Professor S Rawaf Some Future Directions

34. © WHO C Centre, Imperial College London 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

35. © WHO C Centre, Imperial College London 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

36. © WHO C Centre, Imperial College London Professor S Rawaf Strengthen the Legislative and Executive Links: N/L Review MoH & Governorate Structures & Functions FfP Strengthen Health System (PHC & PH)

37. Strong Health System Primary Care Hospital Care Public Health © WHO Collaborating Centre, London Professor S Rawaf

38. Developing Family Medicine Equitable Community-based Infrastructure Equitable Community-based Infrastructure Strong Postgraduate Training Strong Postgraduate Training Solid Undergraduate Learning Solid Undergraduate Learning © WHO Centre, Imperial College London Professor S Rawaf

39. 1 2 New Entrance: Introduce A structured Training Program Family Medicine 3-5 Years.. I/A Boards Current PHC Doctors One Year on-the-Job Training Program Postgraduate Diploma in Family Medicine

40. © WHO C Centre, Imperial College London Professor S Rawaf Strengthen the Legislative and Executive Links: N/L Review MoH & Governorate Structures & Functions FfP Strengthen Health System (PHC & PH) 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

41. © WHO C Centre, Imperial College London Professor S Rawaf Strengthen the Legislative and Executive Links: N/L Review MoH & Governorate Structures & Functions FfP Strengthen Health System (PHC & PH) HRH: Bridging The Gaps Strengthen Public Institutions (Regulations)  Independent Professional Regulators  Providers Regulatory Body [Standards settings and Monitoring]  Supporting Laws and Enforcements  Governance (including Clinical Governance)

42. © WHO C Centre, Imperial College London Professor S Rawaf Strengthen the Legislative and Executive Links: N/L Review MoH & Governorate Structures & Functions FfP Strengthen Health System (PHC & PH) HRH: Bridging The Gaps Strengthen Public Institutions (Regulations) Leadership for Health  All policy & decision-makers must be trained in Leadership  All must be assessed for their competencies  Annual Appraisals including CPD and PDP

43. © WHO C Centre, Imperial College London 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

44. The Future?  Iraq is resource rich country  Look forward (not backward)  Invest in human being and infrastructures  Strengthen Institutions The future will be bright

45. Thank you