Access1 To Quality Health Care In Iraq A Gender

Access1 To Quality Health Care In Iraq A Gender

DESCARGAR PDF

Access1 to Quality Health Care in Iraq:
A Gender and Life-Cycle Perspective

Alongside Iraq’s constitutional provisions that aim to promote the
health of all Iraqi citizens through provision of public health
services, Iraqi law provides broad measures aimed at supporting
maternal health, family planning, and children’s health. The law does
not, however, appear to provide detailed regulations for the provision
of women’s health care facilities and makes no provision for the
prevention and treatment of illnesses specific to women, apart from
those associated with pre-natal and post-natal health care.
ABA/ILDP, The Status of Women in Iraq: Update to the Assessment of
Iraq’s De Jure and De Facto Compliance with International Legal
Standards, December 2006
Siobhán Foran
GenCap Gender Advisor**
OCHA Iraq/UNAMI (Information Analysis Unit)*
July/August 2008
*Information Analysis Unit (IAU)
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.
IAU Participating UN Agencies and NGOs
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.
Purpose of the report
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.
A special word of thanks to Chen Reis, Technical Officer - Gender and
Gender-Based Violence Emergency Response and Operations, Health Action
in Crises, World Health Organization, Geneva for reviewing and
providing valuable comments on an earlier draft of this paper.
Introduction
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;
* The deterioration in the security situation and the deterioration in
healthcare services cannot be taken to be general across the whole of
Iraq; security and services conditions are frequently relative to
specific ethnic/religious groups, to specific geographical locations
and to areas and populations that were neglected under the previous
regime; indeed, in some instances, improvements have been noted.
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.
Executive summary
*
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.
It is in this complex context that this report attempts to examine the
gendered and life cycle perspective on access to quality health
services, how particular obstacles to access affect women, men, girls
and boys in different ways and to different degrees and to conclude
with some recommendations to assist the Health & Nutrition SOT.
Consistent reliable data, disaggregated by sex and age must be
available to allow for analysis of health trends and access to health
care
*
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.
Health Statistics
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.
In the 1990s, there were approximately 34,000 doctors registered with
the Iraqi Medical Association but, by 2005, this number was down to
18,126, with half of these in Baghdad, Basra and Ninewa governorates6.
*
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.
By 2001, this number had fallen to 929, of which one third were
considered to require rehabilitation.
*
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).
By 2008, this percentage has fallen even further to 2.5% of GDP and is
among the lowest in the region.
*
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).
Violence-related injuries were conservatively estimated at an average
of 400 per day over the period 2003-2006 (IFHS, 2007).
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%).
Four Dimensions of Accessibility
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:
Non-discrimination: health facilities, goods and services must be
accessible to all, especially the most vulnerable or marginalised
sections of the population, in law and in fact, without discrimination
on any of the prohibited grounds. (7)
Physical accessibility: health facilities, goods and services must be
within safe physical reach for all sections of the population,
especially vulnerable or marginalised groups, such as ethnic
minorities and indigenous populations, women, children, adolescents,
older persons, persons with disabilities and persons with HIV/AIDS.
Accessibility also implies that medical services and underlying
determinants of health, such as safe and potable water and adequate
sanitation facilities, are within safe physical reach, including in
rural areas. Accessibility further includes adequate access to
buildings for persons with disabilities.
Economic accessibility (affordability): health facilities, goods and
services must be affordable for all. Payment for health-care services,
as well as services related to the underlying determinants of health,
has to be based on the principle of equity, ensuring that these
services, whether privately or publicly provided, are affordable for
all, including socially disadvantaged groups. Equity demands that
poorer households should not be disproportionately burdened with
health expenses as compared to richer households.
Information accessibility: accessibility includes the right to seek,
receive and impart information and ideas (8) concerning health issues.
However, accessibility of information should not impair the right to
have personal health data treated with confidentiality.
Recommendations
*
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):
HEALTH AND NUTRITION
Outcome 1
By 2010, health- and nutrition-related programmes enhanced to ensure
20% increase in equitable access to quality health care services with
special focus on vulnerable groups and on women’s reproductive health
and family planning services.
Output 1.1
Policies, strategies and guidelines related to health and nutrition
developed if required; or reviewed within a gender sensitive approach
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,
including gender equality programming.
Output 1.3
Enhanced functional capacity of health and health related facilities
and institutions (services) in low coverage areas (rehabilitation and
procurement). This must include a comprehensive package of
reproductive health services as standard. The H&N SOT is encouraged to
consider the development of protocols in this regard for discussion
with the governments.
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. This will include
training and awareness-raising on age, gender and diversity
mainstreaming. In addition, there must be a focus on national social
safety nets that ensure access to health and nutrition services for
those with limited economic access.
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. Recognising the
specific obstacles to girls’ and women’s access to health care
services, and the lack of consistent sex- and age-disaggregated data
on the provision of health and nutrition services, it is imperative
that all monitoring and evaluation exercises include gender-specific
indicators and a gender analysis.
Output 1.6
Emergency preparedness and response. Access to basic health services
to the most vulnerable people affected by the ongoing humanitarian
crisis assured. Such emergency preparedness and response planning must
include a strong gender perspective.
*
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.
2.
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.
2.
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.
2.
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, Windows of Opportunity: The Pursuit
of Gender Equality in Post-War Iraq, January 2005, re-released in
March 2005.
31 From http://www.unhchr.ch/tbs/doc.nsf/(symbol)/E.C.12.2000.4.En)
32 Interview with Dr. Georges Georgi, UNFPA Representative, Iraq
Programme, Amman, 12 August 2008.
33 Adapted from Iraq Watching Briefs: Health and Nutrition, WHO and
UNICEF, July 2003
34 Ibid.
35 Ibid.
36 UNDP Programme on Governance in the Arab Region (POGAR) at
http://www.undp-pogar.org/countries/iraq/gender-pw.html
37 Garfield, Richard, Health and Wellbeing in Iraq: Sanctions and the
Impact of the Oil for Food Programme, 2002, cited in ABA/ILDP December
2006
38 UNICEF/Iraq, Situation Analysis of Children and Women in Iraq,
1998, cited in ABA/ILDP December 2006
39 Ibid.
40 WHO/UNICEF, Iraq Watching Briefs: Health and Nutrition, July 2003
41 Garfield, Richard, Jean Lennock and Sarah Zaidi, Medical Care in
Iraq After Six Years of Sanctions, 1997, cited in ABA/ILDP
42 UN/World Bank Joint Iraq Needs Assessment – Health, Working Paper,
October 2003, cited in ABA/ILDP, December 2006
43 Baram, Amatzia, The Effect of Iraqi Sanctions: Statistical Pitfalls
and Responsibility, The Middle East Journal, Vol. 54, No. 2, Spring
2000, cited in ABA/ILDP, December 2006
44 Article 30 of the 2005 Constitution reads – “First: The State
guarantees to the individual and the family - especially children and
women - social and health security and the basic requirements for
leading a free and dignified life. The state also ensures the above a
suitable income and appropriate housing. Second: The State guarantees
social and health security to Iraqis in cases of old age, sickness,
employment disability, homelessness, orphanage or unemployment, and
shall work to protect them from ignorance, fear and poverty. The State
shall provide them housing and special programmes of care and
rehabilitation. This will be organised by law.”
45 ABA/ILDP, The Status of Women in Iraq: Update to the Assessment of
Iraq’s De Jure and De Facto Compliance with International Legal
Standards, December 2006
46 IRIN, Iraq Focus on Water and Sanitation, 28 September 2004
47 UNDP/Ministry of Planning and Development Coordination, Iraq Living
Conditions Survey 2004, 2005
48 Ibid.
49 Alwan, Dr. Ala’din, Health in Iraq: the Current Situation, Our
Vision for the Future and Areas of Work, MoH, 2nd Edition, December
2004
50 UNICEF/WHO, Iraq Social Sector Watching Briefs: Health and
Nutrition, Juan Diaz and Richard Garfield
51 The Brookings Institute, Iraq Index: Tracking Variables of
Reconstruction and Security in Post-Saddam Iraq, 5 October 2006
52 UNAMI Human Rights Office, Human Rights Report, 1 May to 30 June
2006
53 ABA/ILDP, The Status of Women in Iraq: Update to the Assessment of
Iraq’s De Jure and De Facto Compliance with International Legal
Standards, December 2006
54 UNICEF/WHO, Iraq Social Sector Watching Briefs: Health and
Nutrition, Juan Diaz and Richard Garfield
55 Ibid.
56 UNICEF/WHO, Iraq Social Sector Watching Briefs: Health and
Nutrition, Juan Diaz and Richard Garfield
57 ABA/ILDP, The Status of Women in Iraq: Update to the Assessment of
Iraq’s De Jure and De Facto Compliance with International Legal
Standards, December 2006
58 GenCap Gender Advisor / UNAMI Information Analysis Unit, GBV in
Iraq: The Effects of Violence – Real and Perceived – on Women, Men,
Girls and Boys, June 2008
59 Human Rights Watch, Climate of Fear: Sexual Violence and Abduction
of Women and Girls in Baghdad, July 2003
60 Ibid.
61 Ibid.
62 Ministry of Health (2004) Mental Health Programme in Iraq: Summary
of Situation Appraisal, Recommendations and Implementation Plans,
cited in MEDACT (2004), Enduring Effects of War: Health in Iraq, pg. 4
63 WHO (2002) World Report on Violence and Health cited in MEDCAT
(2004) Enduring Effects of War: Health in Iraq, pg. 4
64 IRIN, 17 August 2007
65 McKenna, Megan, Preparing for War in Iraq: Making Reproductive
Health Care a Priority, Women’s Commission for Refugee Women and
Children. 2003, cited in ABA/ILDP, The Status of Women in Iraq: Update
to the Assessment of Iraq’s De Jure and De Facto Compliance with
International Legal Standards, December 2006
66 Physicians for Human Rights, One Year Later: Iraq Reconstruction
Efforts Show Gaps in Women’s Health and Trauma Recovery; Comprehensive
Process for Justice and Accountability for Past Abuses Lagging, March,
2004, cited in ABA/ILDP, The Status of Women in Iraq: Update to the
Assessment of Iraq’s De Jure and De Facto Compliance with
International Legal Standards, December 2006
67 According to figures available at
http://www.unicef.org/specialsession/about/sgreport-pdf/09_Maternal-Mortality_D7341Insert_English.pdf,
the maternal mortality rate in the developed world generally was less
than 100 per 100,000 live births in 2001. The MENA rate in 2001 was
over 300 per 100,000 live births, but this was likely skewed by very
high numbers in Yemen. Information cited in ABA/ILDP, The Status of
Women in Iraq: Update to the Assessment of Iraq’s De Jure and De Facto
Compliance with International Legal Standards, December 2006
68 According to the Iraqi MoH, cited in WHO, Briefing Note on the
Potential Impact of Conflict on Health in Iraq, March 2003.
69 UNFPA, Iraq Reproductive Health Assessment, 2003.
70 ABA/ILDP, The Status of Women in Iraq: Update to the Assessment of
Iraq’s De Jure and De Facto Compliance with International Legal
Standards, December 2006
71 United Nations/World Bank, Joint Iraq Needs Assessment – Health
Working Paper, October 2003.
72 Ministry of Health (2004) Health in Iraq: A Brief Review of the
Current Health Situation and the Challenges Facing Health Development
in Iraq, cited in MEDACT (2004) Enduring Effects of War: Health in
Iraq
73 UNFPA, Iraq Reproductive Health Assessment, 2003
74 ABA/ILDP, The Status of Women in Iraq: Update to the Assessment of
Iraq’s De Jure and De Facto Compliance with International Standards,
December 2006, pg. 45
75 Amnesty International, Iraq: Decades of Suffering – Now Women
Deserve Better, 2005
76 UNFPA, Iraq Reproductive Health Assessment, 2003
77 Ibid.
78 UNFPA (2004) Gender Profile: Iraq cited in MEDACT (2004) Enduring
Effects of War: Health in Iraq, pg. 4
79 Alwan, Ala’din, Health in Iraq: The Current Situation – Our Vision
for the Future and Areas of Work, MoE, Second Edition, December 2004,
cited in ABA/ILDP, December 2006
80 UNFPA, Iraq Reproductive Health Assessment, 2003
81 Alwan, Ala’din, Health in Iraq: The Current Situation – Our Vision
for the Future and Areas of Work, MoE, Second Edition, December 2004,
cited in ABA/ILDP, December 2006
82 UNFPA, Iraq Reproductive Health Assessment, 2003
83 ABA/ILDP, The Status of Women in Iraq: Update to the Assessment of
Iraq’s De Jure and De Facto Compliance with International Standards,
December 2006
84 Amowitz, Lynn, Human Rights Abuses and Concerns about Women’s
Health and Human Rights in Southern Iraq, American Medical
Association, March 2004.
85 ABA/ILDP, The Status of Women in Iraq: Update to the Assessment of
Iraq’s De Jure and De Facto Compliance with International Legal
Standards, December 2006, pg. 43
86 Iraq’s Refugee and IDP Crisis: Human Toll and Implications, The
Middle East Institute, Washington, DC,
http://www.mideasti.org/publications/iraqs-refugee-idp-crisis
87 Ibid.
88 ABA/ILDP, The Status of Women in Iraq: Update to the Assessment of
Iraq’s De Jure and De Facto Compliance with International Standards,
December 2006
89 Alwan, Ala’din, Health in Iraq: The Current Situation – Our Vision
for the Future and Areas of Work, MoE, Second Edition, December 2004,
cited in ABA/ILDP, December 2006
90 Amowitz, Lynn, Human Rights Abuses and Concerns about Women’s
Health and Human Rights in Southern Iraq, American Medical
Association, March 2004.
91 Amnesty International, Iraq: Decades of Suffering – Now Women
Deserve Better,2005
28