The KRI is experiencing tremendous difficulties and challenges. Those difficulties are arising from a combination of exogenous and endogenous factors. At the exogenous level, the attacks by the Islamic State (IS) overwhelmed the health system. Millions of refugees and Internally Displaced Persons (IDPs) that arrived in the KRI introduced pressures on health services. On the other hand, political tensions with the Iraqi central government meant that KRI has not received its 17% share of the budget for several months. As a result, the health budget, which is already low on the KRI’s priorities, considerably declined. At the endogenous level, a political storm has been brewing that was triggered by disputes over the terms of the president in office. This is combined with long-term challenges resulting from poor governance and corruption in government institutions.
At the moment, the KRI has all of the features of a conflict-affected fragile setting. Applying definitions adopted by the UK’s Department for International Development, the KRI is clearly unable (or maybe unwilling) to provide essential and necessary social services to broad sectors of the population.
The damage introduced by the current crisis is exacerbated by already existing shortcomings. For example, health receives a meagre 5% of the KRI’s budget. This small budget is disproportionately allocated to tertiary (including medicines and advanced technologies) rather than essential primary health care services. Furthermore, there are considerable inefficiencies arising from unequal distribution, poor training and ineffective regulation of the health workforce. While the KRI has higher numbers of physicians (11.1/10,000) than the rest of Iraq (5/10,000) and the Middle East and North Africa Region (10/10,000), they are mostly concentrated in the large city centres.
In this difficult context, it is only inevitable that the health system will suffer. Since 2014, the KRI’s health sector lost more than $46 million mainly from the budget crisis with the central Iraqi government. A total of $317 million stabilisation cost is needed for the health sector, which far exceeds the KRI’s capacity and relief efforts by the international community. As a consequence, health services are undermined and unable to meet the basic needs of the host communities, refugees and IDPs simultaneously. The inability of the KRI to provide salaries to health workers resulted in a series of strikes by doctors, health workers and other health personnel. There are widespread and disconcerting shortages of essential medicines. Epidemics that were under control previously such as polio, measles and cholera, have started to emerge.
The way Forward
Decades of experience in attempting to meet the health needs of populations under stress can offer crucial lessons for policy makers in the KRI. One of the most widely recognised tools to rapidly scale up essential health services for affected populations is the provision of a Basic Health Services Package (BHSP). The BHSP is a list of core services that are cost-effective in meeting the most pressing health needs of populations. Those services include services targeting maternal and child health, communicable and non-communicable diseases, essential medicines, basic testing services and policies related to the structure and distribution of health facilities and the health workforce. Since the early 1990s, packages of basic and essential health services are becoming a best-practice in global health, particularly in countries and regions that are affected by conflict or natural disasters. One can argue that a BHSP is now crucial to save lives in the KRI with the difficult circumstances. Several reasons justify the introduction of a BHSP in the KRI at this juncture.
- Iraq introduced a BHSP in 2009. Although it has been piloted in four cities of the country (including Erbil), it has not been rolled-out. Iraq’s BHSP was introduced with the help of WHO and other international actors that are experienced in such policy. It has also been modified and adapted to the context of Iraq using Afghanistan as a model. Therefore, decision makers in the KRI do not need to start from scratch in introducing and formulating such policies. Iraq’s BHSP can be easily adapted to the context of the KRI. In fact, such adaptation might not even be necessary given the considerable similarities between Kurdistan and the wider Iraqi context. Furthermore, many of the components of the BHSP already exist in the health system in the KRI including the proposed level of health service delivery.
- The BHSP can function as a useful tool to harmonise and coordinate the efforts of various international and local actors. The conflict in the region and the relative stability of Kurdistan has attracted and enabled an influx of international humanitarian actors. Currently, there are at least 20 organisations that are providing various health services. While there are existing coordination mechanisms, such as the Health Cluster for Iraq, coordination in the health arena remains inadequate. Considerable overlap exists among the service providers while other areas of essential services are neglected. For example, currently no organisation provides services in the fields of disability or sexual and gender-based Agreement among various public and private actors to provide the list of the services in the BHSP (which include a comprehensive list of services) will offer the means necessary to decrease inefficiencies arising from duplications in the provision of services. Furthermore, various actors can be assigned to roles that they are comfortable with or best placed to provide. For example, UNICEF can provide the health services related to maternal and child health while other organisations can dedicate efforts to services that are within their remits of specialisation.
- The BHSP does not only provide urgently needed services to affected populations but will also contribute to long-term sustainability of healthcare services. One of the most widely acknowledged shortcomings of immediate relief and humanitarian activities is their short-termism and limited impact on long-term capacity and institution building. Introducing a BHSP in the KRI will contribute to longer-term goals such as good governance, transparency and accountability. Policy makers will be clear about the inputs that they need to provide in a cost-effective manner. Populations will also be aware of the expected services that they can access. As such the BHSP will function as a useful bridge between the relief and development phases of the current crisis.
- There is widespread agreement that defining a list of services through the BHSP can substantially contribute to meeting the priority needs of the population. Uncoordinated response to the health needs arising from the current conflict in Kurdistan can result in neglecting important priorities. Such shortcoming of the humanitarian and relief response can be adequately remedied through policies such as the BHSP.
The time is now for the KRI to start thinking strategically about solving the current challenges that it is facing in the health sector. The BHSP can be a good start towards the long-term development needed in the KRI, while at the same time addressing the more immediate humanitarian needs that the current circumstances have brought upon the KRI.
Article Citation: Zangana, G. (2016) Should Kurdistan Establish a Basic Health Services Package? MERI Policy Brief. vol. 3, no. 6.