Health Workers' Election, An example of an authoritarian democracy

On January 10th, 2011, the campaign for electing the members of the long overdue congress of the Kurdistan Health Workers (excluding physicians) started. The electoral process of this otherwise purely service oriented organization is tainted by huge political interferences and characterizations.
The health workers first organized themselves in lists that belong to the main political parties in Kurdistan. The PUK and KDP, as they did in the parliament and other elections, created a single list with candidates evenly distributed among the two. The Gorran movement also participates with a list, as did the Islamic Union, Islamic Group, the Communists and others. Lists carry names that are indicative of political party affiliation and the names of the candidates are not known, or only partly known, because the electoral lists are so called "closed" ones; meaning that the party will choose among a pool of candidates according to the vote the list receives in the election.
Apart from those disturbingly undemocratic processes of holding an election, the polarization of the health workers based on political lines, greatly undermine the ability of the new syndicate in advocating on their behalf. It is striking that the slogans, plans and programs of the lists are so similar that someone with no knowledge about the politics of the region would not be to distinguish among them. All the lists ask for a better pension, a better wage, and an equal opportunity policy with regard to health workers in the health care system. They all want the government to provide health education opportunities and continuous professional development program for them. There are no distinctively different ideological divide among the lists in terms of their attitude toward philosophical and/ or economic organization of the health care system.
The election will be a litmus test for the popularity of the political parties in the health care system, and it will not add any benefits neither to the health workers nor to the health system. The only benefit that health workers got was the series of invitations, lunches, dinners and prize distribution that the main political parties arranged for their affiliates.
It is disturbing that the political parties that regard themselves as opposition to the political establishment in Kurdistan use the same old anti-democratic mechanisms in relation to syndicates and associations. They use the latter as tools to advertize their political agenda inside the sections of the community that those syndicate exist. Political parties here in Kurdistan spend a significant chuck of their budget (which usually comes from public funds) on election campaigns and ads. This is not allowing a breathing space for a slow and progressive development of groups, associations and syndicates that are truly representative of their members and, willing to strongly advocate their rights and put pressure on the government and the political parties to fulfill their demands.

Health Policy: The New Taboo in Kurdistan!

The Minister of Health in the Kurdistan Regional Government filed a lawsuit against me in the court of Erbil city. Dr. Tahir Hewramy, The Minster of Health, is asking for 200,000,000 Iraqi dinars which is equivalent to about $20,000.00 in compensation for the "damage" I incurred upon the Ministry of Health.
The source of all of this noise by the Ministry is that I had recently said in a magazine interview that the decision by the Ministry of Health to raise the fee doctors charge in their private clinics is "illegal, unscientific and unethical".
The Minister of health decided in an order that holds his own signature on 27th of April 2010, to raise the fee doctors charge in their private clinics. The order had resulted in a wide outcry and condemnation by civil society organization who managed or organize a campaign against the decision and were able in a matter of a week to collect 16 thousands signatures of angry people against the decision.
My fault was that I characterized the decision as "illegal, unscientific and unethical" and below is a description of why I said that.
The decision in itself is an illegal move by the Ministry of Health. According to the laws of the Kurdistan Parliament and specifically Bill number 15 of the year 2007; the Ministry of Health is not responsible for regulating the fees of the private market health activities. In another word, there are no specific provisions in that bill that award the Ministry the authority to intervene in the regulation of the fees that health professionals charge in return for the services they provide. Another Bill (number 6 of the year 2000) authorizes the Doctor's Syndicate to regulate the private activities of doctors including the fees they charge in their private clinics. Specifically, the constitution of the Syndicate indicates that only the general congress of the body can determine how much doctors can charge their clients in their clinics.
Besides, the Kurdistan Regional Government through its Prime Minister, Ministers and other officials, announced more than once that it is adopting an open market policy. The Minister's move to fix doctors fees in some areas and raise it in others are in direct conflict with the free market economy claims of the government and it may alienate foreign investors in the health care system of Kurdistan.
The decision by the Minister of Health is also unscientific. The World Health Organization identified a number of tasks for Ministries of Health around the world which include but are not limited to; helping to remove economic hurdles in access to health care, attending to the principle of equity in health care provision and trying to engage citizens in health policy decisions. The Ministry's decision is contradictory to all of those principles.
Furthermore, form the ethical point of view, the Ministry of Health should act for the best interests of the people. Everyone knows that the people of Kurdistan had suffered a lot from chemical attacks, torture, economic and social devastation. The people here are suffering from the physical and mental health and social consequences of decades if not centuries of violence and mistreatment and they are in need for a health care system that rises up to their expectations and needs. We need a health system that is putting the patient at the center of its interests. I don’t see any ethical bases for raising doctor fees in the private market by a governmental body given the socio-economic status of the majority of the population in the region.
I strongly demand that the Minister of Health withdraw his lawsuit and try to communicate his policies and actions in a more civil way. It would have been much better if the Minister could take the time to explain his policies to me and the people in a TV, newspaper, magazine or radio interview just like I did. That would have served him better and could have saved him the headache of all those phone calls from the media about my case.

Are Most Kurds Mentally Ill?

In a recent media statement, the Minister of Health of the Kurdistan Regional Government announced that most of his fellow citizens “have mental diseases” . The minister presented this diagnoses during a conference to review the bill for a mental health act in Kurdistan. It was obvious that the minister wanted to make a point about the necessity of such an act for Kurdistan given that “90% of the Kurdish people" went through terrible atrocities like the Anfal and the gas attack on Halabja in the 80s of the last century.
The good intention of the minister of health to provide strong argument for the passage of the bill in the parliament doesn’t legitimize the betrayal of his scientific backgrounds. The minister, better than anyone else, knows the meanings of most, several, few and none in scientific language. The fact that the minister says “most” without providing scientific evidence brings into questions his scientific qualifications.
The only study done in the field of mental health in Iraq and Kurdistan was the Iraqi Mental Health Survey implemented by the World Health Organization issued in 2006/2007 in partnership with the Ministries of Health in Iraq and Kurdistan. The survey was conducted among 9,345 Iraqi families. The Kurdish families included in the study represented 16% of the sample. The study found that the life time prevalence of any affective disorder in Kurdistan was 8.97%, and that of any anxiety disorder 15.85% . The basic question given these numbers is; are these figures qualifying the Kurdish people to be diagnosed as having mental illnesses or psychiatric diseases?
Furthermore, in most of the standard classifications of mental illnesses including the International Classification of Diseases, mental illnesses are not classified as diseases, rather they are called disorders. There may be only subtle differences between the two terms. But at the ground and at the personal levels of people affected by mental disorders, it means a lot in terms of discrimination and stigma. The problem with the minister’s statement doesn’t only lie in its scientific ignorance, but also in its ramification for discriminating against people with mental illnesses in Kurdistan.
The minister of health need to be more cautious about his statements and not to forget his scientific backgrounds in presenting figures and numbers about health issues in Kurdistan.

http://www.sbeiy.com/ku/newsdetail.aspx?id=29321&cat=1
www.emro.who.int/iraq/pdf/imhs_report_en.pdf

Stop Throwing Money at Our Health Problems

Today I was reading the local newspapers in Kurdistan and two different news attracted my attention. The first one was from the paper of one of the ruling parties in Kurdistan (Kurdistany Nwe), featuring the selling of an MRI machine costing one million, eight hundred thousands of dollars. The other news was from Rudaw newspaper, having a piece about the health consequences of using sewage water for growing vegetables in the governorates of Erbil.
When I was reading those pieces of news, I was developing an image of the poor man, lady or kid, who consumes contaminated vegetables waterd by the dirty water, and developing a pain in the back, lung, stomach or having a seizure because of a haydatid cyst in those locations.
Our government will go bankrupt if it continuous to ignore the basic human needs of the population of clean drinking water and sanitation. There is no point in throwing money at our simply solved problems that arise from inattention to basic health infrastructure.
This is if we ignore the huge amount of money spent on the scan. I googled prices of the machine and I found figures way less than what (kurdistany nwe) presented.

Who Benefits from Fixing Doctor Fees?

The recent decision of the Minister of Health to fix physician fees in private clinics is a baseless act of policy confusion.
First and foremost, no legal provision allows the Ministry of Health to touch the private market with regulations. Ideally, Doctors’ Syndicate is the one who is supposed to propose regulations to the Ministry of Health and the cabinet.
Even if the Minister of Health allows himself jurisdiction over the private health market, the common sense is to do so in the best interest of the people. Fixing doctor fees is having unequal consequences in different geographic areas of Kurdistan. An ill person in Sluaimaniah may be hurt because of it while a person in Halwer will benefit. This is a consequence of the unequal socio-economic status of the people of this culturally, economically and politically diverse region. Such a decision will undermine the ability of the health system to provide universal coverage to the majority will diminish financial risks and will hurt efficiency in the delivery of health care services to the people of Kurdistan.
Furthermore, the decision is in total disagreement with the open market policies of the cabinet in general. The basic principle is clear; the government needs to intervene to prevent or fix market failures. These may arise as a result of the dominance of market monopoly. Fixing doctor fees will distort the natural power of competition and will prevent it from lowering costs and improving quality.
The Minister of Health should remember that he is responsible for not only the physical, mental and social wellbeing of the people of Kurdistan, but also their financial health. We don’t want our people to be one doctor’s visit away from bankruptcy and poverty. He should immediately suspend such a decision, otherwise the impression that he may be doing this for his own interest could gain credibility. Being a surgeon with a clinic in the market supports the evidence that the Minister is abusing his public position for private gains.

2010 Health Budget of Kurdistan

Kurdistan Parliament is currently discussing the budget of 2010 for the Kurdistan Regional Government (KRG). The budget has been announced in a press conference by Dr. Berham Salih, the prime minister, before getting it to the representatives of the people. The budget was delayed for months before finalizing it and getting it to the parliament. Furthermore, the oil revenues of the region were not included in the budget and the opposition is furious about that.
The good news is, this is the first time in 19 years that the budget is openly discussed in the Parliament, some members of which, mainly from the opposition, had the courtesy of distributing it around and inviting professionals in particular and the public in general to provide comments, suggestions and input into the details of the budget openly. The government, through its administrative and judiciary branches, however, provided copies of the general provisions of the budget that was so vague that didn’t allow for any space for discussion.
The health budget that was included in the projects funded by the government and implemented by the Ministry of Health were devoid from any scientific analysis and calculations. The type of the projects and their geographic distribution seem to answer political worries rather than the real public health needs of the people.
This is clearly demonstrated in the amount of funds allocated to different geographical areas. In that regard, a disturbing inequality is evident in terms of the resources allocated to the governorates of Slemany, Erbil and Dohuk; (the three governorates officially under the jurisdiction of KRG). Hence, while Slemany governorate is the biggest in terms of population, the governorate comes in the third place after Erbil and Dohuk for the proportion of funds for Health projects in the governorate. The share of Slemany compared to the whole KRG region is 15.7% which is totally disproportionate to the population of the governorate.
This inequality in the resource allocation is not limited to the size of the governorates, but also applies to the rural-urban distribution. The 2010 health budget of KRG allocates a lion share to the urban areas of Kurdistan, while the rural areas are getting the minimum. The budget dedicates only 27% of the resources for health project to rural areas while urban areas are getting 73%. This is a outright miscalculation of the health priorities in the KRG. It is clearly evident that the rural areas that suffered from destruction, displacement and drainage of human, capital and infrastructure are in urgent need for greated attention in terms of resource allocation.
The 2010 budget of KRG ignore the systematic thinking of health policy development and implementation in general and resource allocation in particular. The natures of the projects that are funded in the budget are paying too much attention to building infrastructure while ignoring the other equally important components of the Health System in Kurdistan. In this regard, the budget is allocating more than 92% of the resources to building hospitals and health centers. The disturbing news is that about 22% of the whole budget allocated for projects in Erbil Governorate is dedicated to buildiing a new office for the Ministry of Health’s in Erbil City.
The budget contains no plans or provision to increase the numbers of the human resources serving in the health sector in Kurdistan. According to the human resources section of the budget, every 1000 citizen in Kurdistan will receive care from only 8 health care workers, who include physicians, nurses, paramedical staff, pharmacists, dentists, laboratory workers…etc. Furthermore, there are no plans to overcome the clear gender inequality in the health care workforce. The vast majority of Kurdistan healthcare workforce is consisting of males. Only 40% of the health care workers in Kurdistan according to the Budget are females.
The fragmented health care system of Kurdistan is in urgent need for Electronic Medical Records and some kind of health information technology in place. But the budget dedicated 0% of resources to this crucial component of the health care system which should take care of the production, analysis and usage of information in the system.
The budget doesn’t answer the question of how those health centers and hospitals that take 92% of the resource would be supplied with medical technology and other necessary supplies. The budget dedicates only 7.6% of the total resources to providing health supplies and medical technologies.
There are no provisions in the budget with regard to training and advancing the skills and capacities of health care leaders in Kurdistan. No clear planning are demonstrated through the resource allocation in the budget to how the whole system would be financed.
The health budget of KRG for 2010, confirms our previous diagnosis of the ways the health care system in Kurdistan is governed; politics rather than health policies are what running the system. And that is a prescription for disaster!

Health Public-Private Mix in Kurdistan

Kurdistan is no longer the region we had known. Its political, social and economic elements are changing on daily bases. Although change is always a good thing; but it can bring with it unexpected ramification and consequences.
The economic arena of Kurdistan had started to change in the 90s. But after the Iraqi Freedom process in 2003, globalization, open trade and market mechanisms has been one of the basic characteristics of Kurdistan's economy.
This had significant impact on the health care sector. Health care has been strictly controlled governmental business, ruled through the notion of centralized planning, financing and administration. Opening up to outside trade and the growth of an active private sector, has changed that too.
A simple overview of the data available at the Directorate of Health in Erbil Governorate, demonstrate alarming expansion of the private sector at the expense of the public one. For example in 2009 the percentages of the patient’s beds in privately funded hospitals in Erbil city was two times higher than the same percentage for 2008. The percentage for 2008 stands is 5% while that of 2009 is 11%.
What is more interesting to examine is the rate at which that increase in the number of the privately funded patient bed had happened. Since 2005 (the year where data is available) the number of the beds remained the same through 2008. From November 2008 to November 2009, the number of the beds in private hospital increased from 96 patient beds to 216. This puts the rate of increase of those private patient beds at 120%.
Comparing that number to the 44% increase in the number of the publically funded patient beds, demonstrate the fact that the private sector in Erbil city is expanding at an alarming rate compared to the publically funded health infrastructure.
It is obvious that the government alone cannot finance and administer health services. The private sector can act as a crucial partner of the government in providing health care services that are either too expensive for the government or so necessary that cannot wait the bureaucratic procedures of the government.
What is interesting, however, is two things;
First, all those private beds where for profit businesses and none were not-for-profit private enterprises. Second, it is painfully evident that the government and the Ministry of Health has no regulations to control the work of the private health sector in order for the latter to rise to the mission and vision of the government in terms of health and health care.
The Ministry of Health and the Health Committee in the Parliament of Kurdistan should take this matter seriously and start to take action to regulate the enormously growing private for-profit health care in Kurdistan.