A 5 years Plan to Reform the Health Care System in Kurdistan
2009-2015


The upcoming Parliament of Kurdistan has a historical responsibility to reform the Health care system in Kurdistan. The reform of the system is long overdue and can’t be further delayed. Despite the fact that there are no clear and solid data, it is well known that the expenditure on the health care system of Kurdistan is creating a huge burden on the budget of Kurdistan Regional Government. The high cost of health care didn’t succeed in offering an effective service. Kurdistan is trailing a lot of underdeveloped countries in a host of indicators like infant mortality, maternal mortality and expected survival. Furthermore, in spite of the existence of two colleges of Medicine and a Medical University and tens of Medical Institutions that graduate hundreds of doctors, nurses and medical staff, the people of Kurdistan are still suffering from a variety of communicate and non-communicable diseases like Heart Diseases, Cancers, and Cholera this beside the widespread existence of a host of medical and mental issues like suicide, addiction and female genital mutilation.
This report is an attempt to draw the broad lines for a plan of health care reforms in Kurdistan. Health care system not only in Kurdistan but also all over the world is characterized by great complexities and its hard to understand let alone trying to reform it and find solutions for its issues. Having said that, it is crucial for the political will in part of the authorities and the readiness of professionals to discuss, find and implement strategic plans for reforming the system. This is just a start to begin an open, genuine and independent thinking about the system and the main ways for reform.
To arrive at an appropriate solution for the main issues of the system the following points should be addressed:
1) Reform should be a holistic, multiphase process that addresses most of the areas of the health care system. Those areas that without addressing them even talking about reform would be a loss of efforts and time are:
I. The mechanisms of financing the health care system. This should be at the top of the priorities of the health care reform initiative. Its obvious that without reforms in the overall financial system in Kurdistan that is suffering from a myriad of issues like corruption, absence of transparency and planning, it is difficult, if not impossible, to reform the financing of the health care system. The eradication and mitigation of the untoward effects of corruption is of utmost importance for the health of not only the health of the health care system but also the overall effectiveness and efficacy of the overall administrative process in Kurdistan. This would be the starting point of creating an efficient system that achieves high quality outcomes without an ever rising cost. With regard to the health care system itself, it is crucial to start thinking about the following initiatives;
i. Separating the publically funded from the privately funded services from the administrative and human resources point of view. The fatal mixture of those two sectors had proved risky to the health care system and the financial security of the Kurdistan Regional Government. Furthermore it has untoward influence on the quality of the health care services. Currently, the physicians of Kurdistan, particularly those with high degrees, are able to see patients in their private clinics in the market and admit them in publically funded hospitals. The total expenditure on those privately seen patients is shouldered by the publically funded hospitals. On the top of this very expensive state, the government is reimbursing physicians through fixed wages and salaries. To overcome this very expensive state, it is essential that physicians be faced with two options; those who are willing to work in the publically funded hospitals, have to have their clinics located in those hospitals and see patients based on discounted rates that then will be reimbursed by the government. Those who prefer to work in the private sector, have to be taxed based on the expenditure of admitting and treating their patients in the publically funded hospitals. This can be done through not offering them wages or salaries that are now provided without considering their public vs. status.
ii. The introduction and implementation of health insurance system for the financing of the publically funded system. This would be a waste of time and efforts without bringing transparency, accountability and planning to the overall financing of Kurdistan.
II. The quality of the health care services: to level up the quality of the health care services, it is necessary to address both sides of the health care equation; i.e the patient and health care workers and work out the most crucial failures of providing a world-class health care service. The following are some of the steps that would be implemented to do that;
1) The patient should be at the center of the attention of every health care system. This is crucial condition for the success of the system. There is a fatal displacement of the attention of the system between the patient from one hand and the health care workers on the other hand. To overcome this, it is necessary to have a holistic plan; the following are some of the ideas that can be used;
i. The dedication of a special class in this regard to teach medical students and students in the health departments of different other educational institution about the up-to-date mechanisms of the doctor and medical staff-patient relationship. The class should be based on the human rights principles in general and patients in particular. Currently, this important issue is addressed through a couple of hours lectures that only addresses the moral and ethical faces of the patient-doctor relationship.
ii. The standardization and the respect for a define period of time that the doctor should spent with his patient. We suggest here a minimum of 15 minutes in outpatient clinics and 30 minutes in inpatients. Beside dealing with the clinical complaints of the patients, this time should be used to build a long term and friendly relationship with the patient in part of the doctor and the medical staff. To monitor the adherence to this basic need the patient- doctor relationship can be evaluated through the distribution of an evaluation form to patient to identify the abuse or neglect of patients and the failure to spend enough time with the patients.
iii. The patient-doctor relationship should not be limited to the brief encounter between the two and the medical staff at the start of the clinical interview. It is crucial, particularly with regard to those doctors that are working in publicly funded hospitals and clinics, to adhere to a previously agreed upon timetable to follow up with the patient even after s/he leaves the hospital or clinic. This will help in building a long term relationship between the two and increase the odds of complaint in part of the patient with managements described by the doctor.
iv. The reimbursement offered to the doctors, particularly those who are working in publically funded hospitals and clinic, could be based on those evaluation forms. For instance, those doctors who admit the same patient for the same reason many times, should not be treated in their salaries and wages the same way that others who successfully decrease the rate of admission and length of stay of their patients.
v. The encouragement and support for the establishment of organizations that are specialized in advocating in part of the patients and demanding their rights.
vi. The introduction of mechanisms and tools that would reimburse or punish health care workers based on their performance according to those evaluation forms and other tools.
2) To consolidate and advance the positioning of the patient at the center of the health care system, it is necessary to advance the quality of the services offered to the patients. The following points will guarantee the minimum increase in the level of the quality of the health care services offered;
i. Doctors and the health care staff should undergo a continuous process of training and education. For the health care providers to continue in their job, they have to renew their license. Mechanisms like CME could be implemented to replace an official test for licensure renewal. Health care providers can through this system collect a specified score over 5 years to replace tests. Otherwise a specific test should be designed and implemented for the licensure renewal.
ii. Encouraging the conduction of scientific research. The characteristic feature of the health care system and the medical education in Kurdistan is the near absence of research in the field. To start implementing this crucial necessity for a high quality of health care services, the medical schools and institutions can be used to conduct research. The medical education in these institutions is characterized by an old and classic style of teaching. It is necessary to involve medical student in research through requiring a thesis at the last year of their education and involving them with those which are conducted by their professors which is in turn very limited and need scaling up.
iii. The decrease and finally the elimination of the bad influence of politics on the medical education and practice. It is necessary to adhere to scientific methods in the selection of leaders of the health care institutions. This selection process should be based on their qualifications and experience. This also should be applied to the selection of doctors and medical staff travel abroad to do trainings in their fields.
iv. Giving more attention to the quality control measures in the regulations of the import, distribution and use of medicines and medical instruments. A crucial step in this regard would be ending the use of medicine as a product that everyone can use without the prescription by physicians.
v. The use of the advanced technological tools to provide health care services. This will not decrease the risk of mistakes in providing health care services but also decrease the administrative cost of the usage of classical methods like the use of papers in the keeping patients’ medical records. It is necessary to take advantage from the widespread availability of cell phones for example to create and maintain a long term relationship between the patients and health care providers.
vi. The status of the surveillance system in Kurdistan is very poor. This system had failed so far to collect, analyze and use data in the implementation of health care services in Kurdistan. The opportunity provided by the WHO to advance the performance of the surveillance system of the developing countries to confront public health emergencies of international concerns can be used in this regard.

2) Reform should be adherent to a number of specific measurable goals and objective that should be implemented over a desired period of time. In addition to designating those goals and objectives, it is also necessary to have a system of evaluation and monitoring in place that oversee the implementation of such programs. To achieve such a noble cause, it is necessary to have active members of the parliament. Most of the points indicated above can be implemented over the next 5 years.
3) Without a widespread discussion that will reach out to the largest number of doctors, medical staff and other stakeholders will guarantee the implementation of a successful reform project.