WHO-IRAQ Newsletter
A monthly newsletter on the various activities of the
World Health Organisation and the news of its staff in Iraq
Volume 1, No. 1
January, 2001
Message from
the Editorial Board
We have, for quite some time, been considering issuing a bulletin or a newsletter
that would highlight samples of the good work that is been accomplished by WHO in
Iraq. When discussing it among ourselves, we sometimes felt it might deal with only
scientific topics, or merely reflect glimpses of our work, or that it should specifically
deal with just the SCR986 Programme or that it should be a combination of all. This
always meant deferring the subject. However, there came the time when we did not
want to delay it any longer. Here is our first issue, which we intend to publish, as far
as possible, on a monthly basis, from now and onwards.
We will be pleased to receive comments about this issue and contributions for
the future ones so as the Newsletter becomes a useful tool of communication for us
all.
It is with these thoughts that we are immensely pleased to be able to present
this first issue of the WHO-Iraq Newsletter.
In this issue
Message from the Editorial Board
Page
Review of Health Programme
Sulaimaniyah 400-bed Hospital
Non-Communicable Diseases
Drug Supplies Community Health
WHO tries again
Status of Concluded & Onhold Contracts
Assessing quantities of drugs
Medical Equipment
Renovation & Construction
Water Quality
WHO Mission on Environmental Health
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Communicable Diseases
Mobile Teams
Food Monitoring
Polio Eradication Campaigns
Partnership with the Community
Renewal of Nursing
Health Information Profiles
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The Editorial Board
Dr. G. Popal – Chair
Dr. K. Mneimne – Member
Dr. Z. Hussein – Member
Dr. M. Ibrahim – Member
Dr. A. R. Wayyess – Member
A. Qaradaghi - Editor
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WHO Iraq Newsletter - January 2001
RECENT DEVELOPMENTS
WHO review of the health programme in northern Iraq
WHO will undertake an appraisal of its support to the health services in the three northern governorates of
Iraq under the terms of, inter alia, UN Security Council resolutions 661 and 986. This is being done as part of a
wide-ranging evaluation of all supported programmes in Iraq, covering the period from1997 to the present. The
purpose of the evaluation is to form the basis for a review and restructuring of OIP funded programmes in Iraq.
Ideally the review would be comprised of 2 elements: (1) health sector wide review and (2) the particular role and
performance of WHO (as having implemented part of the overall operations but also as leading agency in health).
The main emphasis will have to be put on the second objective as other agencies involved in the health sector are
conducting their own evaluations.
In order to carry out the evaluation, WHO has identified a team of experts with experience in public health
and proven expertise in the analysis of each specific health field included in the WHO programme in the three
northern governorates of Iraq. The mission will be fielded as soon as the travel arrangements are finalised.
The Terms of Reference for the evaluation team whose assignment will last six weeks, is to produce a
report which will consist of 3 parts:
- was what we were asked to do the most appropriate thing to do
- did we do what we were asked to do
- what should we be doing in future.
Construction of a 400-bed Hospital in Sulaimaniyah Governorate of Iraq
After long negotiations, plans to build a new 400-bed hospital in the northern city of Sulaimaniyah are now
complete. The topographical work of the site has been completed and its soil test is currently being carried out.
Legal approval for the construction is being obtained. The master plans have been drawn up and accepted, and it
is expected that the choice of an international contractor for the project will be finalised.
The Government of Iraq built similar hospitals in the other northern cities in the 1980s. Sulaimaniyah City
(population approximately 1.5 million) has a number of hospitals, including teaching, general, paediatric and
maternity hospitals, and almost 1000 beds. However, facilities are not only fragmented but have suffered
substantial damage and neglect. WHO has also completed the renovation of the Sulaimaniyah Teaching and
Paediatric Hospitals and is working on other health related buildings. It is also studying the feasibility of building
three new 100-bed hospitals using the ‘986 programme’ funds under local tender in Aqrah, Amadiya and Soran in
the Erbil-Dohuk governorates.
Non Communicable Diseases
Late last year, and as a result of a WHO mission of specialists, a non-communicable disease (NCD)
programme was initiated. The project is intended to assist in broadening the skill base of the health services
through periodical meetings of WHO and local health authority representatives to discuss matters relating to
generally applicable NCD issues such as oncology, training and development of health staff (including the use of
Internet and distance learning).
Another visit of the WHO experts took place in late January 2001 to follow up with the project. The mission
comprised of Prof. Jan Eric Eyvind, Prof. Jacob Anton Hjervell and Dr. Gojka Roglic. The newly introduced NCD
project will cover areas such as cancer, cardiovascular and diabetes control.
Drug supply improves but shortages remain
Total quantities of drugs coming into Iraq have increased in the past six months due to arrival of orders, the
introduction of the pre-approved list and the release of some holds. But shortages are still occurring particularly in
high use, fast moving essential drugs such as broad-spectrum antibiotics, analgesics and anti-inflammatory drugs.
As result many health centres are rationing these drugs for adults.
Supplies of the majority of the drugs and supply items delivered into the northern Governorates of Iraq
under the UN humanitarian programme have proved fairly stable say WHO’s observer teams who travel the region
checking on stock levels. But the persistent problems with high use items continue due to a combination of factors.
Not least is the complexity of the UN’s approval and contracting processes and the difficulty of making accurate
requests when the arrival of previous orders is unpredictable. There is also the third key factor of anticipated local
manufacture.
Before the imposition of sanctions, state-owned Samara Drug Industries (SDI) made about 60% of
essential drugs required in primary health care, particularly antibiotics and analgesics. Now, however, holds on
chemical and equipment imports are preventing the SDI from restarting all its activities, and initial orders for
externally manufactured drugs have not sometimes anticipated the resulting gap in supplies.
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WHO tries again to reduce holds
WHO and other UN agencies met the members of the 661 Committee of the United Nations Security
Council in October 2000 to try and convince members of the need to extend the list of pre-approved medical
supplies and release more health-related products under ‘hold’.
All imports for Iraq via the SCR 986 ‘Oil for Food” programme have to be approved by the Security
Council’s Sanction Committee which scrutinises each product. The ‘hold’ process has caused many difficulties, not
only in terms of barring certain supplies and equipment components, but also because of the time-consuming
nature of technical and logistic detail required. In May, WHO won the release of a good percentage of emergency
medical equipment on hold and a pre-approved list developed to speed the process of drugs was accepted. Since
then, however, the value of holds on health goods has again increased, with banned items including childhood
vaccines such as diphtheria and measles, laboratory supplies and equipment components.
Status of concluded and on-hold contracts
The following are details of all on-hold items from the beginning of the programme to the end of the year 2000
Phase
Number
Allocated
PHASE 1 210,000,000
PHASE 2 210,000,000
PHASE 3 200,000,000
PHASE 4 274,000,000
PHASE 5 210,000,000
PHASE 6 300,000,000
PHASE 7 300,000,000
PHASE 8 550,000,000
TOTAL 2,254,000,000
Concluded
Submitted
197,404,173
212,306,235
193,826,754
185,991,205
222,143,793
327,296,045
497,351,630
299,847,864
2,136,167,698
199,225,421
204,789,020
189,434,361
164,546,750
219,287,458
304,985,957
453,861,776
55,693,429
1,791,824,172
Medicines, and
Lab Reagents
0
87,319
129,559
1,687,087
343,825
2,247,790
Medical
Supplies
Equipment,
Spare parts,
SDI and
Insecticides
1,656,677
56,353
2,097,082
94,157
186,263
351,353
266,075
74,941,197
16006863 122,144,859
269,789
20,212,960 197,857,708
Total On-hold
0
0
1,713,030
2,191,239
624,935
75,336,831
139,838,809
613,614
220,318,458
Assessing Required Quantities of Drugs
Correctly assessing the quantities of drugs required in individual hospitals has not always been based on
methodical procedures in the three northern governorates due to the breakdown of health information systems.
Now WHO in consultation with the directorates of health are attempting to systematise ordering and base it on
actual needs.
The first part of the project involves tracking consumption over the past year, assessing the impact of gaps
in supply, and calculating averages for summer and winter. The second step will be to gather information needed to
relate pathology to consumption so as to improve rational prescribing.
For purposes of capacity building of health staff, WHO has been running many training courses, including
programmes on drug management and record keeping for pharmacists and pharmacy technicians.
Medical Equipment
Since the beginning of the humanitarian programme in 1997 to July 2000, all equipment requested up to
(Phase V) and partially of (Phase VI) has made it through the complex approvals required under the sanctions
procedures. In many cases, this equipment has revitalised hospitals, enabling them to return to some semblance of
normality, but use particularly of more sophisticated equipment is still far from optimal.
WHO teams of international and local biomedical engineers in each of the three governorates, or in some
cases, manufacturers, deliver, install and instruct on equipment. But high turnover among users, sometimes low
motivation, lack of tools and experience among maintenance staff, and problems in delivery of equipment and
spare parts means almost every hospital has machines which are either idle, underused or needing repair.
The total amounts allocated (contracts let), received and distributed throughout the three northern
governorates are as shown below:
Total allocated (contracts let) for all
the eight phases and projects from
1997 to 31.8.2000 in US$
58,229,708.00
Total received from 1997 to
December 2000 in US$
Total distributed from 1997 to
December 2000 in US$
48,656,296.00
45,858,507.00
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Renovation and Construction
The renovation activity to improve and enhance the storage capacity of drugs and rehabilitate existing
drugstores and warehouses that were in very bad condition started during Phase IV, in the middle of 1998. The
activity has also covered the preparation of sites for installing new medical equipment provided by the WHO. Since
1998 and until December 2000, 93 projects were completed, 41 projects are under implementation and 68 others
are under study. These projects consist of renovation, rehabilitation, extension and construction of warehouses,
nursing schools and hostels, physicians’ residences, medical and dentistry institutes, colleges, drugstores,
departments for out-patient, medical, surgical, x-ray and laboratories.
Moreover, in view of the very bad condition of some of the health facilities and upon the request of the
local health authorities, and the approval of the WR and HQ, work has begun on carrying out studies for two-three
100-bed district hospitals.
WATER QUALITY
Diagnosis good, treatment poor
Thirteen water quality laboratories in the Northern Governorates are now open and functioning thanks to
renovations carried out by WHO under the SCR 986 programme. But water quality remains poor. Recent
bacteriological tests show urban water sources fall within WHO guidelines, except for Erbil and the other two
governorates’ semi-urban and rural areas.
The monitoring system across both urban and rural areas works through five central laboratories in the
governorate headquarter towns and eight basic testing satellites which have all been equipped since 1998. In the
past year, WHO has also led 15 workshops for local health authority staff covering techniques of investigation,
sampling, data analysis and public health issues.
Rented vehicles allow staff to make daily random visits throughout the governorate to examine water
sources, storage tanks and water delivery networks, take samples for analysis and carry out chlorination. They also
work to raise community awareness of safe water practices and, together with WHO consultants, co-ordinate
emergency response to outbreaks of water-born epidemic diseases.
WHO Mission on Environmental Health
Two WHO experts on environmental health, from WHO Centre for Environmental Health Activities which is
based in Amman, visited Iraq, including trips to two of the three northern governorates. These were to Erbil and
Sulaimaniyah where the experts got acquainted with the environmental health status of the region. The mission
toured the modern water quality laboratories established by WHO and field visits revealed that the main problems
were: poor water supply quality, inefficient water supply systems, inadequate sanitation and lack of hygiene and
sanitation awareness.
COMMUNICABLE DISEASES
Cholera epidemic prevented
Prevention activities by local health authorities and UN agencies have helped avert a repeat of the year
1999’s cholera epidemic in 2000. By the end of December 2000, only five cholera carriers had been reported in
Erbil governorate and zero cases in Dohuk and Sulaimaniyah, compared to over 1980 cases in Sulaimaniyah alone
in 1999. Caseload in Erbil is thought to have been even higher in 1999, though no records are available to confirm
numbers.
Experience of last year’s epidemic prompted WHO to work with local authorities to set up a completely
new system of outbreak surveillance and control, focused on diarrhoeal diseases.
This is part of the SCR 986 project designed to mitigate the health effects of the now three-year old
drought, which together with poor water and sanitation infrastructures has greatly increased the incidence of
diarrhoeal diseases particularly in young children.
The project has involved creating a network of mobile surveillance and response teams (see below),
prepositioning emergency treatment supplies, instigating regular examination of food premises and handlers, and
running a series of training activities for health staff and the general public aimed at improving management of
diarrhoea and raising awareness of risks and protective activities.
Over 350 doctors, 400 medical and disease prevention assistants, and 21 laboratory technicians have so
far been trained in the investigation and management of communicable diseases by local clinicians and medical
school lecturers, who were trained as trainers by WHO.
The drought response package has also funded repairs or new purchase of air conditioners, air coolers
and refrigerators for hospitals, laboratories, medical and nursing institutions.
Mobile teams track infectious diseases.
Last year’s summer saw 25 new mobile teams trained and equipped to provide the three governorates with
advance warning of outbreaks of communicable disease and the ability to respond to them.
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Using vehicles rented with SCR 986 funds, the two-person teams form a crucial surveillance, investigation
and community education network in a region where communications are poor, primary health care services are
run down and public knowledge of preventative measures is low. Each team covers 12 health centres and visits
regularly to carry out public education, take stool samples, follow up case reports and investigate outbreaks.
Food Monitoring Begins
Local authorities have re-introduced regular investigation of licensed food handlers and premises as part of
a concerted effort to avert diarrhoeal diseases which studies suggest affect over a third of children at any one time.
Food handlers are a critical source of disease transmission. Under the new activities which have been
developed with WHO’s guidance, people working in licensed premises must give a stool sample every six months
which is investigated for diseases such as cholera and salmonella.
Regulations regarding infected staff have been put in place, but no positive cases have yet been found. In
Erbil, nasal swabs are also taken for staphylococcus, though other governorates follow the more accepted wisdom
that this knowledge has little impact on infection rates.
At presents tests cannot be done on food itself because of lack of instruments and knowledge.
Polio Campaigns Kick Off
The first round of national immunisation days (NIDs) planned for October finally took place in mid
November due to the delayed arrival of vaccines. The second round was conducted during the first week of
January 2001 instead of mid-November 2000 (again due to delays in the arrival of the Oral Polio Vaccine).
According to MOH reports, 95% of the 4.2 million targeted children were reached and vaccinated during
each of the two rounds. In order to verify the MoH figures, independent monitoring (co-ordinated, supervised and
supported by WHO/UNICEF, IFRC and medical schools) was conducted in the most risky areas of Baghdad,
Mosul, Basrah and Sulaimaniyah. The independent monitoring revealed an average coverage of 96% in the study
areas.
NIDs are a joint effort of WHO, UNICEF and MoH who come together to give their full support so that all
under 5 children are reached and vaccinated.
The polio situation in Iraq has stabilised after high quality and effective immunisation campaigns were
carried out last year to quell an outbreak in the Centre and South in which 88 cases of wild polio were confirmed.
Out of the 269 cases of Acute Flaccid Paralysis investigated during the year 2000, only four cases were
confirmed as poliomyelitis due to the wild virus. All of the four cases occurred during the month of January 2000.
Since then the country has no reports of fresh polio incidence.
COMMUNITY HEALTH
Acting Locally
WHO’s 'district team problem solving’ project has just had its one year anniversary. The project has
brought together small teams of doctors and nurses in each of 12 pilot towns with the aim of learning how to
correctly analyse the priority health problems of their area and, most importantly, take action to tackle the issue
without seeking any input from outside agencies
WHO helps them to collect data, analyse the problem, and identify actions they can take without help from
outside. Moreover, groups were primed with training workshops in collection and analysis of health data, which
enabled them to quantify the most pressing problem in each community and produce a workable action plan.
Problems identified include diarrhoea and malnutrition in under 5s, malaria, typhoid fever, anemia in pregnancy,
brucellosis and endemic goitre.
Given the need to use only resources freely available to them, most teams have focused on health
education, organising community meetings, and advice sessions for other professionals and encouraging the mass
media to help raise awareness. Evaluating the contribution of their efforts to the improved health of their community
will be the final step.
Partnership with Community
To support the above district team activities, WHO has also run a series of three-day workshops on
community public health in each of the pilot areas covering all aspects of common communicable diseases. Around
30 people attended each workshop representing youth, women and student groups, officials from the local
authorities, educational establishments, the media, farming communities, veterinary services, municipalities, water
and sanitation services, religious groups, Islamic councils, cultural and community centres.
RENEWAL OF NURSING
Service and Education
The accumulated effect of the past years has negatively influenced the development of the nursing
profession. Nurses need to be recognised and related to the other professions in order to contribute towards
improving the health care delivery. There seems to be a feeling that anyone can be a nurse and that nursing does
not need advanced training. The mal-distribution of graduates of various programmes has somehow resulted in
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weakening motivation. WHO has collected data to identify the nature of the problem in order to contribute towards
solving it. WHO’s international and national nurses have met with teachers to identify training needs and some
workshops have already been held, so as to develop the technical skills of the teachers and the nurses. Preliminary
action has also been undertaken by the DOHs to develop job descriptions for nurses.
Moreover, WHO has participated in a workshop run by the LHA in Erbil and Dohuk for improving the health
service, and as a result of which action is being undertaken to form a department for nursing affairs, which is to be
headed by a nurse. WHO, in consultation with the local health authorities, plan to run training programmes and
workshops on various aspects of the nursing profession, in order to raise the all round concept and standard of
nursing in the three northern Governorates.
Health Information Profiling: A tool for health management
Almost all hospital registries have by now received computers under the SCR 986 programme, but putting
them into action is proving more difficult. Some key staff from hospitals and the directorates of health have
participated in weeklong training courses on the data collection software and basic statistical analysis techniques,
but with most participants starting from scratch in both subjects, practical application of the courses is less easy.
Staff changes, equipment defects and the inevitable software crashes that occur when any new computer system
is installed have further deterred progress.
Nevertheless further training is planned and longer-term proposals include a network to link hospitals with
the central directorates of health, in collaboration with UNICEF, which has already equipped six primary health care
centres with PCs to test the feasibility of the facility.
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