Thursday, July 30, 2009

Democracy in Kurdistan, Where Are We?

Now the elections in Kurdistan are over, it is time to sit down and think about what happened and identify the lessons learned. Understanding the political situation in Kurdistan has important health policy implications.
Kurdistan is now going through its second wave of democratization. The first wave started with freeing Kurdistan in the aftermath of first gulf war through the upraising of the Kurdish people in 1991. This stage of Kurdish politics has resulted over the last 18 years in an authoritarian democracy. The two main political parties that were crucial in creating and maintaining this first stage of Democratic development, the KDP and PDK, were neither internally democratic nor externally accountable. The failure to introduce a host of notions like accountability, transparecy and the rule of law has crippled the government with corruption, inefficiency and patronage. The unwillingness and fear of the KDP and PUK to test their popularity and a host of mutual narrow interest led to giving a fatal blow to the prospect of democratic development in Kurdistan by entering into a strategic agreement to assign the governmental positions between the two.
A host of political, social and economic factors had delayed the progress of Kurdish society from the authoritarian democracy of the first wave to a liberal democracy of the second wave. At the social levels, the people of Kurdistan are still far away from the individualism necessary to establish, support and sustain any liberal democracy. A quick look at the political campaigning period of the elections demonstrates the fact that most of the people that were talking on TV or Radio were refereeing to their tribes or families and talking on their behalf to express their support to this political party or that. It was a rare incidence to see a person talking on his own behalf.
In this first wave of democratization, tribes, families and other traditional social groups were and are still more important than individual members of those gatherings. However, the most prominent individual person in those groups and tribes is more important than the sum of the individuals in them.
This replacement of the importance and position of individuals with tribes have been transferred to the political arena. The political institutions, specifically the political parties, became more important than the individual members of those parties and political bodies, except for the prominent leaders of the party. The fact that Mr. Barzani won about 70% of the votes in the Presidential elections of Kurdistan while his list won about 10% less than the votes he won, is a proof that the most prominent person in a political institution is more important than the latter.
Without a respected individualism which is protected by political institutions, it is very hard for democracy in Kurdistan to progress from its authoritarian stage to a more liberal, accountable and transparent way of governance that respects the rule of law. Politically, the ascent of the change list to a competitive position in the parliament of Kurdistan can hopefully provide a push toward the second wave of democratization. But getting a little less than 40% of the seats of the Parliament by the apposition, can make the labor of a liberal democracy in Kurdistan a painful process. Lets cross our fingers and hope that the political calculus would not result in a stalemate and even more political stagnation.

Sunday, July 26, 2009

Kurdistan's Election: A Chance for a Better Health Care System

The people of Southern Kurdistan went to the polling stations yesterday July 25, 2009. Although the elections was tainted by some irregularities in terms of the easily removed secret ink and the disenfranchisement of thousands from their rights to vote including Kurds in diaspora, the election was the right step toward a more representative and liberal democracy in Kurdistan.
Representative democracies are crucial in themselves to the health of individuals and populations. Providing the opportunity for people to participate in the decision making process and to be advocates on their own behalf can have positive consequences on their mental and in consequence physical health. It was scientifically recognized that the greater social justice and representative democracy the better the health of people and individuals. Although the direct mechanisms of such a relationship need to be furthered explored, it is clear that there are a myriad of indirect mechanisms that mediate such a relationship.
first, it is not only the ability of the president and other political leaders of Kurdistan to get to world-class hospitals and clinics that is making them able to live longer. More importantly, it is their socioeconomic status and their ability to be heard are what make them able to live longer, achieve a better life expectancy and a higher moral. To overcome the inequality of such an outcomes like life expectancy it is necessary to achieve better equality in terms of self-actualization by providing more opportunities for participation in the decision making process and political representation.
Second, progress toward liberal democratic representation will hopefully have positive impacts on the political orientation toward a health related host of factors like health care system. A transparent and accountable governance will logically lead to a more responsive health care system that takes into account the will, needs and wants of people. The needs of people for primary health services for example will hinder any miscalculated or benefit driven health care policies as privatization of primary and secondary health care institutions and services.
The elections on July 25, was a turning point in the history of Kurds and Kurdistan. It was the beginning of the end of the authoritarian representation in Kurdish politics. The existence and engagement of an active opposition in Kurdistan Parliament will advance the prospect of a liberal and truly representative democracy. Beside the direct political influences of such a development, liberal democracy can have positive impact on the life expectancy of people and a genuinely responsive health care system. The next term of Kurdistan parliament will be not only interesting to watch but also extremely attractive for professionals and other stakeholders to engage in the decision making process. Lets roll our sleeves and go to work. Let a lot lying ahead of us.

Wednesday, July 22, 2009

Stop Privatization of Public Health in Kurdistan

Mr. Nechirvan Barzani, the Prime Minister of the Kurdistan Regional Government, opened yesterday July 20, 2009 Media Center for lab. investigation. The Prime Minister, described launching the center as a historic move and highly praised the role of the private sector in the progress of health care services in Kurdistan. Media is a world-class medical investigation center that is as the Prime Minster said is one of its kind in the whole Middle East.
This move is a disastrous step toward destroying the health care system of Kurdistan.
First, the financing and funding of this particular project raises a number of question marks about the use of public money for private aims and profits. The Prime Minister provided the land and an open budget for this project. There are un-confirmed accounts about the personal involvement of the Prime Minister in this project by being a partner. In the disastrous political situation of Kurdisan which is mired by corruption, fraud and a veil of misinformation behind which the financing of most projects are underwent, it should not be a surprise that this project too can be used for personal gains.
Second, The involvement of the private sector in such a crucial sector of the society as health and in particular secondary health care services is a prescription for disaster. While it is understandable that the private sector and open market mechanism can and should be used to promote competition and innovation for tertiary health care, the same move will produce disaster in primary and secondary health care arena. But the profit oriented mentality of the political leadership of Kurdistan is basing such a move on the premise that the most needed services would produce the largest profit.
While the people of Kurdisan are dying from Cholera and infants are dying from simple diarrhea, the profit minded political leadership is trying to improve its image through launching luxurious institutions and expensive clinics and investigation centers that are not accessible to the vast majority of people who the most in need for those services.
Privatization is not and will not be the panacea for all the problems that are crippling health care in Kurdistan. The use of open market mechanisms should be considered through careful planning and serious deliberation about the priorities of the system based on the needs of the ordinary people of Kurdistan.

Friday, July 17, 2009

The Revised Plan to Reform the Health Care System in Kurdistan

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 it’s 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. Furthermore, it is crucial to address the basic social and economic determinants of health like water, sanitation, welfare and electricity. 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.
iii. 1) The promotion of greater transparency in decision-making and governance (i.e. budgets of Ministry of Health, balance sheet of hospital / primary care / drug expenditures / HRH salaries; clarify the roles and competency of the parliamentary health committee, MoH and Directorates of Health). The presence of competent and accountable people can fix most of the financial problems facing the system.
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 hours’ lecture 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. Besides, 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 also 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 to undergo training in foreign medical institutions.
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 only 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 paper 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 in collecting, analyzing and using data in the implementation of health care programs in Kurdistan. The opportunity provided by the WHO to advance the performance of the surveillance system of developing countries to confront public health emergencies of international concerns can be used in this regard.
3) The promotion of free public health & primary care in urban and rural areas. This can be done by bringing together many GPs, nurses and pharmacists on board with this scheme by offering a decent salary, and incentives for research and further training, supported by organizations Good primary care will promote self-care, limit referrals and bad prescribing.
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.

Wednesday, July 15, 2009



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.