WORLD HEALTH ORGANIZATION
Health Update Iraq
24 November 2000
bidding process for an international contractor
will commence early next year.
Similar hospitals were built by the Government
of Iraq in the other Northern cities in the 1980s.
Sulaimaniyah city (population approximately
700,000) has a number of hospitals, including
teaching, general, paediatric and maternity
hospitals, and almost 1000 beds. But these
facilities are fragmented and have suffered
substantial damage and neglect over the years
of conflict.
The hospital will be built and fully equipped
using SCR 986 funds and local authorities have
given assurances they can staff and fund the
new hospital adequately. WHO is currently
managing the renovation of the Sulaimaniyah
Teaching and Paediatric Hospitals and the
Ministry of Health buildings, as well a number of
smaller projects. It is also studying the feasibility
of building three new 100-bed hospitals using
‘Oil for Food’ funds under local tender in Aqrah,
Amediya and Soran in the Erbil-Dohuk
governorates.
Policy and planning
Technical review guides new direction
WHO is carrying out a comprehensive review of
its programme in Northern Iraq and the needs of
the health sector.
The assessment comes three and half years
after the Organization joined the UN
humanitarian programme for Iraq (SCR 986*)
with responsibility in the North for distributing
drugs and medical supplies, procuring medical
equipment and helping the local health
authorities rebuild hospital facilities and the skill
base of health sector staff.
Long term planning in the health sector has until
now been deterred by several factors including
the temporary nature of the humanitarian
programme – funds are allocated on a six
monthly basis – and the initial focus on
reinstating supply lines. But, with exponential
growth in the funds available as a result of high
oil prices and limits to the capacity of health staff
to absorb new technology and approaches,
WHO believes it is now imperative to shift the
focus towards creating a comprehensive health
policy and building local capacity to fulfil it.
The review will take about two months and
involve technical experts from WHO’s Eastern
Mediterranean
Regional
Office,
WHO
headquarters in Geneva and international
specialists. The aim is to analyse the health
situation and needs in the Northern
Governorates in detail in order to provide local
health authorities with a solid context for future
activities and to enable the Organization to tailor
its own programme to support this.
Drugs and medical supplies
Discussions on ‘hold’ continue
WHO and other UN agency staff met the United
Nations Security Council in October to explain
the need to extend the list of pre-approved
medical supplies and release more healthrelated 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 for potential “dual use” and
withholds approval for items it considers could
be used in chemical or conventional weapons
manufacture.
In May, a similar meeting resulted in the release
of 50% of the health-related items on hold and
the development of a pre-approved list of drugs
to speed the process. In October 2000, however
some US$200 million health-related goods were
still on hold, including some childhood vaccines,
laboratory supplies and equipment components.
Not all delays are due to the dual-use criteria.
The Committee members say the lack of
technical specifications from suppliers are the
other key reason for placing a contract on hold.
Tender for Sulaimaniyah Hospital
After long negotiations, plans to build a new
400-bed hospital in the Northern city of
Sulaimaniyah are almost complete. Permission
to proceed with the US$50m construction has
been given by the Office of the Iraq Programme
in New York, on the condition that the project
when complete will be self-sustaining financially
and in terms of
human resources and
infrastructure, and master plans have been
drawn up by architects. It is expected that the
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*SCR 986 is the United Nations Security Council resolution which authorizes the sale of Iraqi oil to fund humanitarian
supplies, commonly known as the ‘Oil for Food’ programme.
WORLD HEALTH ORGANIZATION
systems. Now WHO and the directorate of
health in Sulaimaniyah have developed a joint
project to systematise ordering and base it on
actual need.
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 gather information needed to relate
pathology to consumption in order to improve
rational prescribing.
The director of the governorate’s pharmacy and
laboratory department has joined WHO for three
months to do the work, as part of a rotation
scheme intended to build the capacity of
directorate of health staff. WHO Sulaimaniyah is
also running training courses in record keeping
and drug management for pharmacy technicians.
More drugs but shortages remain
Total quantities of drugs coming into Iraq have
increased in the past four months due arrival of
past orders, the introduction of the pre-approved
list and the release of some products from the
sanctions committee hold list. But shortages are
still occurring, particularly in high use/turnover
drugs such as broad spectrum antibiotics,
analgesics and anti-inflammatory drugs. As a
result many health centres are rationing drugs
and dispensing only half courses.
The persistent problems with high turnover items
are due to a combination of factors according to
WHO’s pharmacists who supervise the ordering,
warehousing or distribution of pharmaceuticals
and medical supplies in the Northern
Governorates.
One key factor is the lack of anticipated local
manufacture. Before the imposition of sanctions,
state-owned Samara Drug Industries made 60%
of essential drugs required in primary health
care, particularly antibiotics and analgesics.
Now, however, holds on chemical and
equipment imports are preventing Samara from
restarting all its activities, and initial orders for
externally-manufactured drugs did not anticipate
the resulting gap in supplies.
In addition, the Office of the Iraq Programme
reports that the Government of Iraq has been
very slow in contracting for medicines and
medical supplies. It has also been difficult to
anticipate stock levels, partly because of
unpredictable arrival of previous orders due to
the UN approval process (speeded since March
by the introduction of pre-approved lists) and
manufacturer delays, but also because there is
little health information on which to base
accurate assessment of need.
While WHO observers confirm that some
shortage reports of these drugs are real, they
believe rationing in health care centres has
much to do with lack of trust that regular
supplies will arrive, or lack of confidence or
knowledge to prescribe available alternatives.
Certainly money is no barrier: The north of Iraq
was allocated US$50million on drugs in phase 8
(June to Dec 2000) – a figure which amounts to
almost $30 per person a year. This sum
exceeds local authorities’ total demand for drugs
in the previous phase by almost a third and is
raising
concerns
of
wastage
through
overstocking.
Medical equipment
Overload danger
In total, US$90 million has been made available
for medical equipment since the beginning of
humanitarian programme in 1997, and goods to
the value of around a third of this have been
approved 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 of more
sophisticated equipment is still far from optimal.
WHO teams of international and local
biomedical engineers (or in some cases
manufacturers’ representatives), deliver, install
and attempt to instruct on equipment. But high
turnover among users, low motivation, lack of
tools, spare parts and experience among
maintenance staff, problems during delivery and,
perhaps most importantly, lack of consumables
means almost every hospital has newly installed
machines which are either idle, underused or
needing repair.
The potential for similarly high allocations in
coming phases have prompted calls for a
massive re-orientation of funds towards training
activities.
Rehabilitation
New homes for nursing schools
Student nurses are among those feeling the
benefit of the schedule of renovation and
construction being carried out under the SCR
986 programme. In Dohuk and Sulaimaniyah,
new buildings have been designed by the WHO
renovations team and built by local contractors
Reducing the guesswork
Correctly assessing the quantities of drugs
required in individual hospitals has so far been a
matter of educated guesswork in Northern Iraq
due to the breakdown of health information
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WORLD HEALTH ORGANIZATION
to re-house the nursing schools of the two
governorates. Both cater for girls and boys and
are equipped with laboratories and libraries,
though the latter sorely lack materials.
In Erbil, WHO’s renovation team has supervised
the complete renovation of the 60-plus pupil
Nursing School for Girls and supplied equipment
from thermometers, baby scales and patient
dummies to autoclaves and microscopes.
School furniture, a mini-bus for clinical visits and
some reference materials have also been
provided. More sophisticated machines including
ventilators and electrocardiographs have also
been supplied to the Technical Institute’s
nursing department.
The nursing schools are among 38 building
projects currently underway in the Northern
Governorates which are made possible by the
cash ‘component’ of the Oil for Food
programme. The works range from intensive
care wards, water and clinical laboratories and
extensions for new radiological equipment to
warehousing, staff housing and rehabilitation of
heating and cooling systems. Local authorities in
the region are, however, eager to start building
several
long-requested
district
hospitals,
especially since oil prices have dramatically
increased the funds available.
investigation, sampling, data analysis and public
health issues.
Staff use rented vehicles 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.
Communicable diseases
Cholera under control
Prevention activities by local health authorities
and UN agencies have helped avert a repeat of
last year’s cholera epidemic in the year 2000.
By the end of October, only seven cases of
cholera had been reported in Erbil governorate
and zero cases in Dohuk and Sulaimaniyah,
compared to over 2,000 cases in Sulaimaniyah
alone in 1999. Case load 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
new system of outbreak surveillance and
control, focused on diarrhoeal diseases.
The project is part of a $800,000 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 now been schooled 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 colleges
Water quality control
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 just outside WHO standards while
semi-urban and rural areas are well below
acceptable levels.
Bacterial contamination, September 2000
% of contaminated samples
Erbil
Sulaimaniyah
Dohuk
Urban
11%
10%
10.5%
Semi-urban
20%
16.4%
25%
Rural
41%
38.5%
47%
*WHO guidelines state percentages of contaminated
samples should be below 5% to define water as safe
The monitoring network covers both urban and
rural areas and works through three central
laboratories in the governorate headquarter
towns and 10 basic testing satellites which have
all been equipped since 1998. Dr Hamasha has
also led 15 workshops for local health authority
staff in the past year covering techniques of
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WORLD HEALTH ORGANIZATION
suggest up to 95% of he 3.6 million targeted
children will be reached. Timing for subsequent
rounds depend on further vaccine arrivals.
Mobile teams on the lookout
This 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.
Using vehicles rented with SCR 986 funds, the
two-person teams continue to 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 cases reports and investigate
outbreaks. They also carry out surveillance of
acute flaccid paralysis for the polio campaign.
Community Health
Problem solving starts at home
WHO’s “district team problem solving” project is
coming up to 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.
“We help them to collect data, analyse the
problem, identify actions they can take without
help from outside. They can’t say ‘we need a car
from the directorate of health or inputs from
WHO’ – they should be able to draw on their
own resources to solve their own problems,”
says WHO medical co-ordinator for the three
Northern Governorates, Dr Mahgoub Ebrahim.
Groups were primed with a training workshop in
collection and analysis of health data which
enabled them to quantify the most pressing
problem in each community and produce a
practical action plan. Problems identified include
diarrhoea and malnutrition in under 5s, malaria,
typhoid fever, anaemia 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,
advice
sessions
for
other
professionals and wooing 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.
Food monitoring begins
Food handlers are a critical source of disease
transmission. Local authorities have reintroduced 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.
In Erbil, nasal swabs are also taken for
staphyloccus, 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 rounds of national immunisation days in
the Northern Governorates planned for October
finally started on November 18 after the delayed
arrival of vaccines due to sanctions committee
investigations.
The campaigns are a combined effort between
WHO, UNICEF and local authorities who come
together to give staff intensive training
beforehand and full support on the day so that
as many children as possible can be reached.
The polio situation throughout Iraq has stabilised
after intensive 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.
To date in 2000, there have been no confirmed
cases of wild polio virus out of the 180 cases of
acute flaccid paralysis reported in the Centre
and South and 24 in the north.
Early indications in the first rounds of the house
to house vaccination in the Centre and Southern
governorates which started on 12 November
Reaching out to the community
To support the district team activities (above),
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, political and
local government, educational establishments,
the media, farming communities, veterinary
services, municipalities, water and sanitation
services, religious groups, Islamic councils,
cultural and community centres.
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WORLD HEALTH ORGANIZATION
Nursing education
defining exactly what nurses should be doing in
different parts of the health service.
Mr Hoshyar Amin, WHO national nurse in Erbil,
says draft job descriptions drawn up during this
workshop now need to be debated in multidisciplinary groups including hospital directors
and doctors so that the end result is not only
acceptable to all but also promoted and
encouraged by all.
Expertise for three governorates
With the arrival of Egyptian expert nurse
educationalist, Dr Sheherazade Ghazi, in Iraq
this month (November), WHO is scaling up its
technical assistance in improving nurse training
for new and existing staff.
A former dean of Alexandra Nursing College, Dr
Sherazade will lead a team of three national
WHO nursing officers based in the three
headquarter towns and support local nurse
educationalists to implement a new curriculum
being designed in Baghdad. The Government of
Iraq has also promised to provide a series of text
books on 30 key clinical areas.
The majority of nurses in the Northern
Governorates currently function at a very low
level, partly due to lack of human and material
resources for training, but also because there is
little respect or appreciation of what nursing
means for patient care.
Often, say nursing tutors, higher standard
students are prevented from using what they
have learned since there is no difference in the
job descriptions of nurses with intermediate or
preparatory who are less able and those with
institute or higher level training.
Among the most urgent activities, according to
WHO national nurses, is introducing a new
curriculum that acknowledges the modern role of
nursing and then, perhaps even harder, starting
to change attitudes.
Health information
Data skills needed
Almost all hospital registries now have
computers, 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 proving difficult. 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
negotiations are also underway to create a
network to link hospitals with the central
directorate of health using radio communications
if permission to import these commodities can be
acquired. Longer terms plans include extending
the network to primary health care centres in
collaboration with UNICEF, which has already
equipped six centres with PCs to test the
feasibility of the proposal.
What is a nurse?
A series of workshops for local counterparts
organised by WHO throughout the autumn have
begun to address the urgent issue of how to
develop a more professional standard of nursing.
In late October, WHO national nurses from the
three Northern Governorates, together with
facilitators from the nursing department of the
technical institute, ran a three day refresher
course in basic nursing skills for head nurses
with the aim of arming them with techniques to
boost the skills of their own staff.
The next two months will see similarly structured
courses in basic skills in surgical nursing and in
cardiac care, management of nursing services,
nursing care of patients with burns and of
children and an introduction to primary care
nursing.
The WHO team have also held two workshops
specifically for local authority and academic
nurse counterparts, focusing on new methods of
teaching and addressing the burning question of
WHO in Iraq
WHO Headquarters Baghdad
Ph: +1 212 963 3010 (via New York)
or +964 1717 0961 (local line)
Fx: +1 212 963 3009
Email: WHO-Baghdad@un.org
WHO representative: Dr Ghulam Popal
Erbil: Dr Khaled Mneimne
Dohuk: Dr Enyatullah Aman
Sulaimaniyah: Dr Baddredine Fehri
This update was researched and written by
Hilary Bower, information officer with the
Department of Emergency and Humanitarian
Action, WHO Geneva. The opinions expressed
do not necessarily reflect official WHO policy.
For further information, phone +41 22 791 2454,
mobile +41 79 249 3528, email bowerh@who.ch
or hbower26@hotmail.com.
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