Iraqi System of Primary Health Care: A communitarian system of family medicine under a dictatorship framework
Olivier Godichet
Comité d´Aide Médicale and European Commission, Humanitarian Office (ECHO), Ninehva Governate, Mosul, Iraq
Vivian Ghanem
Comité d´Aide Médicale and European Commission, Humanitarian Office (ECHO), Ninehva Governate, Mosul, Iraq
PP: 113
Article Text
Introduction
Primary Health Care Centers (PHCC) in Iraq provide preventive & primary health care with and without doctors. They are 2 kinds of PHCC: main, or small and structurally different, according to their location in urban and rural areas. Across Iraq there are they are 1453-1570 PHCCs. Corresponding to an increase in sanitary crises since end of the 1990s, about 10% of secondary health centers have been closed as a result of post war infrastructure beak down.
In rural areas small health centers operate mainly in the morning; however clinics treating chronic diseases also operate in the afternoon. The latter work with a system of cards for provision of drugs. The former also provide mainly essential acute, drugs. Much care is taken to separate systems, according to the pathologies presented; but emergencies are covered by both kinds of PHCC and also by hospitals.
In urban areas PHCC often occupy small houses, where various physicians often practice in the same room. Patient privacy, if required, is preserved with clothing (one advantage of large veils) and consulting room screens, or gender separation into different rooms, if available.
Iraqis have open access to PHCC with the payment of 500 Iraqi Dinars (0.35-0.50 US cts) and receive free of drugs under severe restrictions in quantities (2 or only 1 vials, 10 tablets or capsules regardless of the drug, 1' 100ml - 120ml bottle of syrup, 1 small tube of cream and so on).
Drugs have been provided without payment since the May 2003 War. Before that they all were paid but at a cost 2 to 10 times less than in private pharmacies. Private pharmacies also had their prices controlled and were provided by national factories (the State Samara Industry). National production of drugs is commonly seen as of good quality by Iraqis themselves. Provision of imported drugs increased notably after the start of Oil for Food Program implemented in Iraq in 1996-97 under United Nations authority for the relief of embargo.
In mid October 2003, consultations were made free for all children under 12 years of age; this measure has been implemented commonly in rural areas (where we work). Before the last war, gratuity in any health structure was existing for any pupil or student with a bill obtained near their school authority.
PHCCs are open from 08:00-13:00h. Since drug shortages start soon in opening (around 9:30h) patients late in the period can avoid paying consultation, by asking whether the drugs exist that he or she thinks they require, at the pharmacy. In fact these drugs are simply provided every 2 months to pharmacies under a system organized by the State specialized Agency: Kimadia. PHCCs then receive each day an almost fixed and exact assignment of the provided drugs by the pharmacy.
PHCCs play a direct and indirect role in preventive health care with social benefit: pregnancies and most clinically evident problems of public health such as malnutrition are followed up. Some preventive health care is channelled through procedures (rheumatic fever sequels with monthly injections of Benzatine Penicillin), other care (chronic disease care after detection and enrolment), public health programs (immunization, school health, infectious diseases, and a mix of different situation. For example, malnutrition or rehydration is covered by a program and nutrition rooms in main primary care centers. Immunizations have weekly special day care and programs or campaigns employing health promoters.
Source of information
Comité d'Aide Médicale, a French Non-Governmental Organization dedicated to rehabilitation of Primary Health Care Centers and provision of drugs in Nineveh Governorate since September 2003 and supported by European Emergency Humanitarian Commission (ECHO), has conducted an investigation about drug shortages since December 2003. Our main purpose is to explore better alternatives of provision of drugs in primary health care centers in the Nineveh Governorate. Our information has been based on patients and physicians in these PHCCs.
The first period of the study covered 4 rural primary health care centers (PHCC) in 2 different health sectors. PHCCs have different characteristics. Random choice has been avoided because of security reasons and constraints in areas of service. But 2 of the investigated PHCCs are not served by the organization (at present) and in the other 2, inputs have been strictly controlled.
Our basic registers were completed by 2 mini-questionnaires. One has been completed by patients, 10 people in all 4 PHCC (almost at random) on 4 different days (at random) during end of February and beginning of March 2004, at the worst period of drugs shortage.
The second mini-questionnaire was completed by 13 general practitioners present that day in the health center. Most of information comes from these mini-questionnaires.
Patients: who they are where they go
More than half the patients (or family) come from the same big village; villages immediately around it are disturbingly under represented compared to the availability of healthcare services in them. This may reflect the economic tightening of the system. Objectively people accessing the PHCC are poor. Patients coming from another village have to add the payment of transport, and may be unsure about the availability of drugs even if the 'payment for entry' is quite small.
Iraqi physicians clearly are not sectarians and the past laic system ensured that the provision of health was provided by the State and authoritarian direction not driven by religious support. As a result, care is given normally to all patients. Nevertheless, the effect is localized or communitarian. Noticeable contrasts exist between the villages we investigated. They have often mixed composition, sometimes in the same village, of faith and ethnic origin. Surrounding villages represent a little more than a third of patients. This is a significant decay compared to what to expect from an evenly distributed and selecting system of health care.
The distribution of visitors to PHCCs in Fig. 1 (upper left) shows the disequilibrium of the mini-questionnaire (to adults) as well as of the circumstances with no payment to entry for children less than 12 years. It is also affected by combined visits (parents and/or various children together paying a visit to the physician). The very low complement of people coming with a third person may be taken as an argument toward family medicine.
Attendance by age appears in Fig. 2 for all 4 PHCC s with large numbers of patients (many dozens over 4 days at random). Given the similarities across the 4 PHCCs, our investigation appears to be based on normal populations of PHCC attendants and communities, from this human geography. Women of fertile age and children under 1 year represent 21% and 5%, respectively; the other 3 groups have a representation close to a quarter.
Figure 3 presents a histogram of the frequency of visits at the PHCC in the last 6 months. Patients have no clear memory of the distribution of their visits over the past 6 months. A high repetition is presented for about a third of them (more than 20 times); a third in the medium range (from 10 to 20) and a third less than 10 times (from our investigation - not presented here). However, families are large and the questionnaire was often answered by the head of the family bringing the child to the PHCC (mother in most cases but quite often also the father) rather than the patient.
Visits increased when children under 12 years were admitted free, but also with but with a large increase of upper respiratory infections in winter when no more drugs were distributed. The 2003-2004 winter in Nineveh Governorate was exceptional (with the first snow storm since more than 10 years) in February 2004. Climate is highly versatile.
We shall examine other characteristics of the rural patients such as drug consumption and epidemiological profile, and we compare them with urban areas in further papers. Here we asked patients a small complementary question on how they remembered arriving at the hospital (Figure 4). For this, despite the limits of the method, we observe that small hospitals also play a role in primary level of access. Large hospitals provide specialist patient consultations but small hospitals provide some primary care. The provision of primary health by small hospitals differentiates the role of small and large hospitals in the health care system.
Of the 40 patients at the PHCC, 21 remembered that they arrived at the small hospital directly. This may be explained by differentiation in the kind of service they expect, according to their symptoms. For example, chronic disease emergencies are treated by the PHCC in the afternoon by a staff of chronic diseases clinicians; 12 of them where referred by the PHCC to the Hospital. In our place of investigation one had a small hospital in another part of the village (less than 50 beds). In this survey, 7 patients went to the hospital after what they felt as a failure of the treatment provided by the PHCC.
Health provision
The mini-questionnaire directed to physicians was very short on this aspect and more about adaptation to drugs shortages (we will examine that also in another article). It shows results from over 80% of health care staff investigated during our period of data collection. Dentists were not included, since our inquiry followed the shortage of drugs as a medical activity.
Critically, as a result of the past general dictatorship, physicians had been born, had practiced and had died in their local communities. Figure 5 shows the proximity and length of service of physicians in PHCCs. They made their studies in the faculty of medicine close to their town. A few who passed specialized examinations had more mobility; the best had to be in on good terms with the regime, for travel and study abroad. For those students the permanent State of war and military constraints were a strong incentive for succeeding in the studies abroad until family pressures intervened to make them return. Authority of State was absolute and anyone had to go where assigned at very low cost. For example, houses for urban primary health care centers were requisitioned and rented to owners for few dollars monthly.
Professionals had to go where required without any incentive. They were also controlled by the system of license and very tightly since it could allow emigration. Through corruption, this certification cost 300 USD. Physicians had to be in the party or in the army to achieve mobility. Salary scales were simple and transparent: 100-200-300-400 USD per annum. Products from private business were allowed only to a few important persons. The system functioned very economically and not without public health sense.
For common people, and despite the developing health crisis, it is possible that public health interventions developed as extra-social activities with special health days promoted to legitimize the appearance of an administration.
These mechanisms, as reported in conversations, may be reflected in these graphs. PHCC general medicine physicians have a long experience there - this is not fully shown in Figure 5 (left and upper panels). Physicians were locally experienced rather than probationary (at least, in the places we made our investigation). It is possible that afternoon clinics of chronic diseases are more open: in PHCC there are attended by physicians working in the public health care system, plus young physicians on probation from their days at the hospital. While at the local hospital, specialists and some young physicians co-exist in prolonged probation.
In Fig. 5, 2 physicians were recorded as 6 months into their duty at the PHCC and 8 physicians for more than 6 months (in fact often years). In the bottom right graph, most of them live less than 15 minutes from the PHCC, 5 nearby and only one at more than 30 minutes from the PHCC (living in fact in Mosul).
Considering the disparities between places, where only one is a special strong and almost closed community, we have few reasons to think that this rural organization could be very different in other places in the Governorate. However, specific places may have another profile, especially when lacking the local elite for attending their health system. This may have been disturbed by changes since the May 2003 War.
Discussion and conclusion
There is an impression that, despite a theoretical purpose for preventive health care, PHCCs in Iraq represented a substitute for family health care during an intensifying social crisis, as a way of social compensation for the regime. General family medicine physicians, caring for increasingly poor people, were finding an alternative to higher costs for provision of drugs. Although this system was subjected to war and embargo scarcity, it nevertheless provided some minimal drugs and health care advice. Under the present circumstances, the system is facing erratic experimental changes that may well create more social difficulties.
Abrupt changes have driven have people to find relief and safety from their family practitioner whom they knew in their town or earlier, when the community was more at ease. This applies especially in socially bordering places, where mechanisms of adaptation could be slower, particularly in disputed areas where ethnic and faith areas are not in conflict.
Primary health care physicians need to conduct dual activities to maintain some level of self subsistence. In the mornings they need to train themselves, experiencing community intervention across health sectors. In the afternoons the need to double their duties in clinics and maintain access for the poor population, to a system of care where they can receive some individual consideration and health care provided by few available drugs. This needs to be upheld to placate anger about a richer World constraining even more the poor's consumption of drugs while rehabilitating their buildings.
Some reorganization of the structure of salaries, which is more complicated but also transparent, has also started within the health care profession - but is still far from international health professional practice.
The previous system mixed a too efficient system of authority with a situation of scarcity; however, it was not irresponsible, professionally or socially. It could be unwise on ideological grounds for a new democratic order to apply an inappropriate social or cultural gauge to primary health care. While the need for organizational intervention is widely recognized, the creation of an artificially regulated market for the benefit of outside big firms would not contribute to national rent. When Iraqi people recover some purchasing power, perhaps deregulating or freeing processes could be instituted in a gradual, wiser way.
There is an obvious need to explore ways to adapt profiles of medical consumption in the primary health care centers of Iraq. There is also an urgent need to help communities find more peaceful ways to cooperate for solutions to their problems, without intervention and arbitration from the State.
Tables 1(a)-(g) indicate the broader picture of public health in Iraq to date and propose a hypothesis for a training pilot program to cope with problems of drugs prescription in Primary Health Care Centers in the future.
Footnote
This investigation is conducted in partnership with the Planning Service of the Directorate of Health of Nineveh Governorate and Iraqi professionals. It could have not been done without their help. Opinions expressed here do not necessarily reflect Iraqi professional opinion, our organization's opinion or our financiers opinion (European Commission Humanitarian Office).
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