Transcript: Health Consultation
Iraq Sectoral Conferences - Third Series
September 25, 2003
MS. PETERSON: Good afternoon. I am Dana Peterson with the Asia Near East Bureau, here, at USAID, and it is my pleasure to welcome you this afternoon to our public sector consultation on the health sector in Iraq.
This session is actually part of a third series of public sector consultations USAID has conducted in the past five months.
This session is really intended to highlight efforts undertaken by the Coalition Provisional Authority and USAID and its partners to improve the health sector in Iraq, and it is also an opportunity for us to receive feedback from the public on our interventions.
USAID has been working with Iraqis and the Coalition Provisional Authority in support of a range of sectors for the past five months.
We are helping to restore economically critical infrastructure, improve the delivery of essential services, particularly health and education, expand economic opportunities and improve accountability and efficiency and governance focused at the local level
Despite security challenges there has been significant progress and tangible improvements in Iraqi lives.
Our interventions have the primary objective of supporting Iraqis in their own efforts. USAID is part of the Coalition Provisional Authority under Ambassador Paul Bremer.
We have been mobilized to provide reconstruction assistance since April and our mission director, Lew Lucke, formally established USAID's mission in country on July 27th.
USAID is presently implementing approximately $1.5 billion in reconstruction and humanitarian assistance. We work with a number of private sector NGO and United Nations partners to achieve our objectives.
In light of the highly fluid situation in country, our partners have had to demonstrate acceptable--excuse me--considerable flexibility and adaptability.
I would like to highlight that this session is focused on progress to date in the health sector in Iraq. We are not addressing Iraq reconstruction procurements in this session nor are we speaking to broader administration policies.
If you are a member of the press, if you could please hold any press questions until near the end of the session, we would appreciate it.
I would now like to introduce our presenters.
Jed Moline [?] is our team leader here at USAID for health programs in the Asia Near East Bureau.
We have Lisa Matt, who is the deputy for international health at Abt Associates, one of USAID's private sector partners, and Dr. Richard Alderslade who is senior external relations officer for health policy at the World Health Organization office at the United Nations in New York.
So I'd like to now turn the session over to Jed Moline. Thank you.
MR. MOLINE: Thank you, Dana.
I'm briefly going to set the stage, the context for the health system in Iraq, describe some of the conditions that were there prior to the conflict and on the ground as USAID activities began. Then I'm going to hand the presentation off to Lisa Matt who will describe some of the activities that Abt Associates, our primary private sector contractor have been undertaking in country on the health sector, and then we'll pass it off to Dr. Alderslade who will describe the activities the U.N. agencies, WHO and UNICEF are undertaking with AID funding in Iraq.
Briefly, at one point in the early '80s, Iraq was a star in the region in terms of health services. However, around the build-up to the Iran-Iraq War, the investment in health began to deteriorate and fade away, and as you can see, over time, the impact was felt by the people.
When you look at, for instance, in the graph, the infant mortality rate is one a the key indicators we look at and child morality rate is one of the key indicators we look at in terms of the success of any health system.
Some of the other indicators we look at are investments in health, for instance. At its lowest point, 72 cents per person was invested in the health system. This resulted in, just prior to the current conflict, 17 percent of children were suffering from severe or moderate malnutrition and the mortality rate was very high, at 369 per 100,000 live births.
This isn't to say the story is all bleak, because with the onset of the Oil For Food program, a portion of that program includes programming for health and medical supplies, including vaccines, and they did begin to have an impact on child health.
However, as I'll describe, the success of those impacts were limited by the debilitated system that was on the ground at the time.
When you look at the health system that exists in Iraq, it is very highly focused on tertiary care and the problems on the ground now, and have been for many years, in primary care. One a the indicators you can look at to see this is the number of physicians and the number of nurses on the ground.
At 53 per 100,000 people, there actually are a large number of physicians in Iraq; a great resource; however, many of these physicians are trained in the specialties, not in primary care or preventive health, which means that their skills and ability to meet these needs is not as great as it might seem with such a high number of doctors.
One of the bigger obstacles you see is in the number of nurses. Normally, the number of nurses would greatly outweigh the number of doctors but in fact it's less than the number of doctors in the country and this is the cadre of health worker that's primarily responsible for dealing with maternal and child health issues.
This results in one a the biggest obstacles to improving the health services. You can see this also in the facilities that have been invested in. There are approximately 280 hospitals in Iraq and a fraction of them were damaged or looted in the recent conflicts. The rest really have deteriorated over years, and so although there's been a large investment in a large number of facilities, they're not able to meet the needs at the moment.
There also are approximately 1500 primary health centers, the status of which hasn't been fully assessed but also are seriously degraded after the lack of investment over the last two decades and this is where the hope lies for making the biggest difference in the short term in improving maternal and child health outcomes.
Next slide, please.
As Dana pointed out, USAID's programming and planning in support of the Coalition Provisional Authority and the Ministry of health--well, actually, not with the Ministry of Health--began in fall of 2002, preparing for what might be and eventually turned out to be a military conflict.
It was in April, however, that AID finally got on the ground in Iraq and began providing technical assistance, in April 2003, and then we had a full-fledged mission open in July.
When you summarize our health programming for the first 12 months, it comes to approximately $149 million.
With both the human and infrastructure resources available on the ground, USAID has made a great deal of investment to raise health resources, and our investments are programmed around the following principles.
First and foremost, to try and ensure continuous access to care with this medicine, supplies, emergency facility repairs, transportation and other vital needs.
This is all done in conjunction with the Ministry of Health and the Coalition Provisional Authority, the current Ministry of Health, in order to build the capacities on the ground in Iraq to sustain the improvements. Also to build the capacity of the Iraqi people to provide these over the longer term and in collaboration with the United Nations, the NGOs, and our other donors, to be sure that the full gamut of both our technical expertise and our resources can be brought to bear.
So what is USAID doing? When you look at USAID investments in health, they really can be divided into two segments. One is humanitarian assistance, providing the immediate needs, and the other is reconstruction.
When you put these two together, this is just some of the expected results we hope to see by the end of the first 12 months, is a functioning and strengthened Iraqi Ministry of Health, much of which you can already see on the ground there.
Over 600 primary health care centers and clinics will be rehabilitated, equipped and will be properly functioning.
More than 170 hospitals will be refurbished, 21 referral centers will be reequipped and refurbished and we hope to essentially reestablish routine health care services.
If I may, I'm going to talk a little bit about the humanitarian assistance to date, and then I will hand it over to our other speakers.
USAID fielded a 60-person disaster assistance response team, or a DART team, to immediately get on the ground, examine the situation, assess the needs and begin planning for how our systems could be most effectively implemented.
The humanitarian activities included examining and providing services for food security, health and nutrition, emergency shelter, water and sanitation and logistics and commodity support.
This support went to, at first, primarily international organizations to develop the coordination structures as well as to work with the NGOs, international and local, that are on the ground.
Some of the investments include support to the World Food Program for logistics, support to the International Organization for Migration, to work with potential internally-displaced people, support to UNICEF for water, sanitation and immediate health needs, and support to a consortium of international NGOs for assessments and coordination.
A quick outline of some of our results of our humanitarian assistance include a 112 compact water treatment units and seven plants have been delivered and are completed to date, with nearly 200 more ongoing.
Forty-nine hospital and clinic rehabilitations have been completed with 131 more planned or ongoing, and more than 2,000 health care professionals have been trained, primarily to deal with malnutrition and to provide services to children and pregnant women.
That is a very brief summary of the humanitarian assistance activities.
Now to look at the reconstruction activities, first, I'm going to turn it to Lisa Matt from Abt Associates.
Abt Associates has received a contract for $43.9 million to improve health services in Iraq and I'll let her describe their successes and activities to date.
Lisa.
MS. MATT: Good afternoon. It's nice to be here today. Abt Associates, our team arrived in Baghdad in June, and we fairly quickly established three regional offices. One is in Urbil, one is in Basra, and another is in Al Hillah. We of course also have an office in Baghdad.
Our activities are focusing on four key areas. Of course all of our activities have meant that we really have to coordinate with all of the other players that are in the field with us.
So it's not just us doing it by ourselves. It's us working with the Iraqi organizations, the USAID, the CPA, and other NGOs in Iraq.
The four main activities that we're concentrating on is training the Iraqi medical personnel and reequipping primary health care facilities. Community education, so that the population can be involved in the building of a solid and stable Iraqi health system. Information for decision making. We are collecting information as we go along, so that we know whether we're going in the right direction or not, and, finally, quality improvement of health services.
What are our accomplishments to date? We're, right now, in the process of procuring 600 health kits for primary health care centers, and basically that will be done in 90 days. We'll have these 600 primary health care kits procured and in Iraq.
Some of the other major things that we have done is, I think, which--one thing that's going to be starting very soon is we put together a training program for improving quality primary health care clinics. We're using the model that we have used in Jordan, and we will be bringing some of our personnel from Jordan to do that and that will begin in October.
Another item that has been very helpful in guiding our program there is an assessment of what is the cost of providing primary health care in Iraq?
These are the areas where we are going to be concentrating, an area in the north around Urbil, and the central area around Baghdad, in the heartland and area around Al Hillah, and then in the south around Basra.
What you'll see here is we're concentrating on some densely-populated areas but it's also by selecting these areas in the ways that we have, we will be not only servicing urban areas but we'll be including a lot of rural areas as well.
One of the things that we have done is compiled a database for facilities inventory and you'll see here what the result of this has been. or these health centers, we will be--actually, it won't be us--it'll be USAID along with CPA, the Ministry of Health--will be selecting 600 of those health centers to be reequipped.
We'll also be working with 21 focus hospitals to help them improve their services.
And now we'll turn it over to the good doctor.
DR. ALDERSLADE: Good afternoon, ladies and gentlemen. My name is Richard Alderslade. I work, as you've heard, with the World Health Organization in New York and I have a background in humanitarian assistance work with WHO, mostly in Eastern Europe.
WHO, as you know, is a part of the United Nations system. It's a body with global public health expertise and activities and it works in emergency, post-emergency, transitional, and development situations.
I won't go through too much of the background in the 1990's, you've heard a little of that already, but just to emphasize that certainly by the year 2000, a very underprovided health system had been associated in the population with high levels of maternal and child mortality and with a very limited capacity for public health functions, and there had been a pretty systematic failure of planning and training for modern public health and health system management and training amongst critical health personnel.
Then immediately after the war with the looting and the sabotage and the failure of provision of essential services, the situation deteriorated further.
Our response was to do what we could with partners, to try to provide some emergency support, and at least get the infrastructure, public health and health system infrastructure back towards the level of prewar functioning. We started with a more humanitarian focus and WHO was active in several governments, which had the technical capacity, in Basra, in Urbil, in Kirkuk and Mosul, as well as in Baghdad.
There were serious difficulties, with which you will be familiar, in terms of insecurity and communications. However, we tried to display the range of interventions which we customarily try to provide in this situation, a credible operational presence, good public health surveillance and public health information, essential support to public health systems, for example public health laboratories, support to communicable disease control and working particularly with our partner, UNICEF, with immunization. Essential public health interventions relating, for example to women and children, and I'll say a little bit more about that later.
Essential programs for vulnerable people. The provision of drugs and supplies, essential drugs and supplies, and support to primary health care structures, looking right across the spectrum from communicable disease support to the support of elderly people with chronic disease conditions.
So our activities can be summarized in terms of support to public health functions, support to essential primary health care and hospital functions, and the provision of urgently required medicines.
Now in these activities, we were supported by a very generous grant from USAID, which has been deployed across the full range of activities that I have described, I think to good effect.
Moving to the reconstruction phase, as you know, there is a joint process which is being supported by The World Bank and by UNDG as well as by the CPA and the international community, for a series of needs assessments, and hope this will culminate in the reconstruction conference which will be held in Madrid on the 24th of October, and there was a priority-setting workshop which was facilitated by WHO, held in Baghdad between the 17th and 19th of August, as part of that process.
This slide, which is a rather crowded slide, but it illustrates the number of parties involved in that process, and we have tried to of course work constructively with the CPA, with Abt Associates, but also with a number of Iraqi partners in this process, and the needs assessment work is coming to a culmination at the moment.
A number of priorities were identified in the workshop and I've tried to summarize them on the next couple of slides.
These are the issues which need considerable attention in the immediate future in the context of the public health and health systems in Iraq.
Reliable information, universal access to affordable, good quality and equitable care. Getting down the relative high maternal and child mortality which two of the speakers, including myself, have so far emphasized. Some quick impact programs in the governance [?], to try to get results quickly. To sustain priority public health services, particularly public health laboratory services and communicable disease control services. To work always with the Ministry of Health to encourage capacity and stewardship.
To deal with some of the backlogs of health personnel training and move in more modern directions in terms of accreditation, and to include in that sustaining and supporting the capacities of people in the system for health system planning and management, and most particularly to make sure that after the Oil For Food program ends on November the 21st, that the flow of essential medicines continues, that there is no gap in the supply pipeline.
There needs to be a good health system assessment. There needs certainly to be better epidemiological data on a more comprehensive and reliable basis, whilst at the same time we need to respond to immediate needs.
We need to encourage the Iraqi institutions and personnel to take a rather different approach.
You've heard that the system previously was dominated by hospitals and tertiary intervention, although the considerable capacities of the individuals working in the system, a more modern health system will look towards public health, towards primary health care, towards the development of community-based options and evidence-based responses.
There will be, for now, limited financial availability, although the scenarios of course are open, but one would anticipate an increasing flow of funds into the system, and the system should be able to develop to a point where it is comparable with the system of neighboring countries.
There will need to be a substantial investment in human resources, and we continue to need to deal with the challenges of general insecurity, particularly for women and for women health system staff, and difficulties of reaching modern standards of management of finance and accountability.
To take this work forward, coming out of the conference in August, there were ten working groups established which WHO will continue to support. I'll just read through the list to give you some sense of the key priority issues right now in the reconstruction phase.
Public health, including public health laboratory capacity, and including the training, to a high level, of public health workers, possibly moving even towards a School of Public Health.
Modern health information systems and the information technology to support them. Modern health system legislation and regulation. The development of highly-capable human resources and I've illustrated that, and the education and training of health professionals and their accreditation and the credentials and licensing to support that.
Looking carefully at what are the absolutely core elements of a modern--and that means preventively focused and community based wherever possible, primary care dominated health care delivery system--the affordable and sustainable financing of health care and the provision of pharmaceuticals, medical supplies and equipment.
And taking forward the work of these working groups, we will continue to work with the CPA, with all our Iraqi counterparts and also with nongovernmental organizations, and right now we're working on some joint programming to support the public health priorities that I've emphasized and also the urgent quick-start actions in the governance [?]. But we intend to focus as well on the health professional training, education issues that I have focused on, and continue to provide support or essential medical supplies and equipment.
Just in conclusion, I need to say something about the current security situation as far as the United Nations is concerned, since the 19th of August.
The United Nations has conducted a thorough-going review of security and that will be ongoing.
At the moment, there is minimal staff, international staff working inside the country and that will inevitably, to some extent, affect our capacity to provide the sort of input and support that I have described.
There are, however, a substantial number of United Nations staff working in Amman. We have some 40 internationals working in Amman. Now, dependent upon the security review and a clarification of clear United Nations role, and the security environment to support it, of course we would hope that it would be possible to resume, at full vigor, the programs that I have described.
I would like to just speak, if I may, on behalf of my sister agency, UNICEF. Unfortunately, there was no one available to come to speak to you, so I will say a few words about UNICEF.
UNICEF is one of the United Nations most significant operational agencies, with a mandate specifically focused on children and women.
It has had, as we have had, a continuous presence in Iraq, right through the 1990's, and prior to the conflict, it did see increased immunization rates and substantially improved support or child health activities in the country.
Now since the conflict, four monthly vaccination days have been held and more than 1.4 million doses of vaccine have been administered to Iraqi children.
There was a significant deficiency in immunization uptake and that is always an absolute priority in this situation.
UNICEF has also contributed some 3 million oral rehydration packets designed to treat diarrhea in children and 325 metric tons of high-protein biscuits for malnourished children and breast-feeding mothers.
Looking forward, they have trained somewhat over 8,000 health workers in issues such as malnutrition, the monitoring of growth retardation, the rehabilitation and case management of acutely-malnourished children and breast feeding, and they have rehabilitated some 20 delivery rooms in hospitals and primary health care centers, particularly in Basra.
So I hope that's given some sense of UNICEF's activities, and also that you can see that that fits well into the overall strategic framework which WHO Is working to support.
Thank you very much, indeed.
MS. PETERSON: Thank you very much.
We'd now like to open this up to questions of comments from the audience.
Because this is actually being broadcast live on the Web, this session as well, we would ask that people approach the microphone and speak into the microphone, so that those who cannot be physically present can at least continue to hear the discussion as it unfolds, so does anyone have any questions? Or comments? Please.
Question and Answer Session
QUESTION: Hello. Yes, this is John Eli from the International Medical Corps. A couple of questions.
Ambassador Bremer, today, on the Hill, is talking about all 240 hospitals which are now operating in Iraq and I'm wondering what the difference is between the 240 and the 282 that are being mentioned here, whether that's an estimation on reducing the number of hospitals or maybe just different numbers, and I guess a question to WHO and to Abt: How many international staff do each of your organizations have on the ground now in Iraq?
MS. PETERSON: Okay. Technical office, if you want to clarify the number of hospitals, and then the respective organization speaking to the staff issues. Thank you.
MR. MOLINE: It's a little difficult for me to clarify exactly what the discrepancy in the numbers is of course. I can imagine one of the main sources is that, of course, in Iraq, there are many different types of hospitals. Some are sort of general hospitals, as we would know it, some are mental hospitals, some are cardiac hospitals. There are a significant number of medical specialty hospitals and so that may be the discrepancy, and the total number of actual hospital buildings on the ground versus those that may be a focus for rehabilitation for general hospital needs.
I'm afraid that's the best I can give you in terms of looking at the discrepancy in the numbers.
Lisa, do you want to describe the number of people on the ground.
MS. MATT: Right. In terms of staff, we have staff coming and going quite a bit, so I would, you know, I'd say that we've had about fifty of our own staff coming and going, you know, sort of at all times. We have probably a permanent staff of about twenty-five, right now, of, you know, sort of all nationalities, and we're in the process right now of substantially increasing our local staff and we expect to have approximately a 100 local staff hired by, in the next month.
DR. ALDERSLADE: Yes, at the moment, inside the country, as I emphasize, we have a minimum staff, international staff, dependent upon the security review which is ongoing.
The bombing of the Canal Hotel on August the 19th is familiar to all of you as will be the attacking on the United Nations complex just a couple a days ago. So there is, as I said, a substantial security review and for the moment, the secretary-general has decided that there will be a minimal staff, international staff inside the country until that review is completed.
In total, in the region, we have some 39 or 40 international staff, and in Amman and Kuwait at the moment.
It is clear, as I said, that whilst that is a significant international presence, it is not as ideal as having them working inside Iraq. So there will be some slowdown in the rate of what we can deliver from that situation. Thank you.
MS. PETERSON: Please.
QUESTION: Good afternoon. It's Nigel Mason from GE Medical Systems. Several mentions have been made today about the need for quick-impact programs. I wonder if one of the panel could comment and give, perhaps, examples of the types of programs they have in mind, with some idea of the time scale.
MS. PETERSON: Yes, absolutely. There are some that have already started, so if you wanted to elaborate on those.
MR. MOLINE: I mentioned some, and others have mentioned some of the quick-impact programs. The first place you focus of course is meeting the nutritional needs, the vaccination programs, breast-feeding programs. Those are the quick-impact programs that need to be in place right away, to first and foremost make an impact on the ground, and additionally, you go in and you make assessments so that your investments go in the right direction and many of those assessments are completed already, including the number of facilities, the types of facilities, the types of staff that are on the ground, the other situations in place.
When you look at other quick-impact programs, you really look to UNICEF who, they were the first ones on the ground, and the humanitarian assistance needs as I described. Water treatment plants, as I had mentioned. Some of the hospital and clinic rehabs that were most needed. Immediate training for health professionals to be sure that there are trained staff available in the facilities. These are the types of the quick-impact programs that are already underway and much of which has already been completed.
I think--I hope that answers your question in a certain degree. Thank you.
DR. ALDERSLADE: Yes; thank you. As I mentioned, our priority is always to get a quick impact in terms of good health information, good public health surveillance analyzed and disseminated, and then to support to basic public health functions--water, sanitation, food hygiene, and food control. These are all the absolute basics of public health support, but they do require support in terms of public health laboratory capacity, the refurbishment often of laboratories, and the training, appropriate training of staff as well as the supply of pharmaceutical and reagents.
Immunization is another quick-impact program. I've referred to UNICEF's substantial work in that field. It is always in this sort of environment an absolute priority, an absolute priority to get adequate levels of immunization amongst the childhood population.
Then we would focus on supporting primary health care structures, refurbishment, staffing and supplying of basic primary health care structures, and beyond that, we would look at some essential core elements of the hospital system, for example emergency rooms, particularly services for pregnant women and the adequate management of labor, including high-risk labor and basic diagnostic and therapeutic services.
So it's axiomatic that a public health organization would start from that perspective and that end of the telescope, starting with basic public health support and working up through primary, secondary care.
It's also I think important to look for some quick impact in terms of the training of the planners and managers within the system, I would highlight that group, and secondly, some of the health professionals that we will need in the future.
I would emphasize again, as I did when I spoke here two or three months ago, the vital importance of developing modern nursing training and capacity in the Iraqi situation. So not just focusing on buildings or supplies but also looking for quick impact in terms of staff capacity as well as managerial and planning capacity and focusing wherever possible of course on capacity amongst the Iraqi counterparts. Thank you.
QUESTION: Jim Regan, IBC. Lisa, could you talk about what the constituent elements are of the equipment packets or primary care equipment packets that you're procuring and how that process is being undertaken.
MS. MATT: The basic equipment--these are basic equipment and instrument kits to be provided for the primary health care centers, and these kits are really very, very basic. They include such things as diagnostic sets, Actascopes [ph], Sofathamascopes [ph], stethoscopes. You know, it's very, very basic equipment, and also some furniture which would include examination tables, scales, that sort of thing.
The process that we follow to do this is that we do, we have a subcontractor that does our procurement for us, and they will be--and they have put out an RFP for this and we will be procuring this and kitting it and getting it out to primary health care clients. I hope that answers the question.
MS. PETERSON: Thank you, Lisa. Any other questions? Comments?
QUESTION: If I may be allowed to come by with another question. Again, quite a lot of discussion today about the assessments of the health care in Iraq. I wonder how are the health initiatives being coordinated between the various NGOs to avoid further duplication of any assessment work and would there be a direction you could give us to a source of your best knowledge of the assessments that have been completed.
MS. PETERSON: The United Nations, working with the Coalition Provisional Authority, and the Ministry of Health, has played a particularly important role in coordination, so Jed would you like to start and then Dr. Alderslade, or--okay--just to give a context. Thank you.
MR. MOLINE: I think the health sector has been particularly successful, particularly lately, in terms of coordinating across the donors and the NGOS, and others, in terms of both assessments and activities on the ground.
Some of the assessments were already done prior. You know, we have data on the health sector, particularly from UNICEF and some of the other NGOs on the ground, on what occurred prior to the conflict, and then the assessments since the conflict are actually pretty well-coordinated cause they come under the domain of the CPA and the Ministry of Health, primarily.
I might direct you, and the last slide of the overheads was, to a couple of Web sites, and particularly the, I believe it's the WHO Web site has a pretty good assessment and a history of the last 20 years of the health sector and it's available on the Web site.
In terms of donor coordination, I'll let Dr. Alderslade talk a little bit about that because with our funding, with USAID's funding, WHO's been leading that process quite successfully.
I would say that as was mentioned, an overall assessment of needs in the grander scale is being developed for the donor conference in Madrid in October and it's not yet available but I'm sure it will be made available as soon as it's completed.
But perhaps Dr. Alderslade can talk about that a little more specifically.
DR. ALDERSLADE: Well, I think I would agree with everything that's been said so far. Here, a United Nations agency such as WHO, is working with the CPA and with the Ministry of Health, and I'd emphasize those points. However, we can and do play a role in these situations in terms of humanitarian and reconstruction coordination.
And one of the ways in which that can be facilitated is through good public health information, analysis and communication, and I've emphasized that point.
We have a fair amount of experience in the field of coordination and in the field of facilitating coordination by a public health analysis. So we would expect to play a role in terms of coordinating between the various actors, the NGO actors, the government actors and the donor actors, and in terms of reconstruction to including the international financial institutions such as The World Bank.
As part of the information base which we try and develop as part of the U.N.'s overall activities in humanitarian information, we would attempt to conduct or facilitate--I'm not suggesting that we do all of this work ourselves, very far from it--but to conduct, coordinate and facilitate an assessment of the basic needs for rehabilitation and reconstruction in the essential health care institutions.
In the reconstruction phase, and I mentioned this--WHO has been the task manager, a WHO staff manager has been the task manager in the health sector for the reconstruction.
This started with a series of working papers, some written outside but many written inside Iraq based upon the information already in hand.
One of the advantages that the U.N. agencies have is that they have been in the country for a number of years and these working papers were then discussed, to some extent, quality controlled, but form the basis for the reconstruction conference that I described, which will form the basis for, firstly, a needs assessment which will go to the Madrid conference on the 24th of October, and the underpinning of the ten working groups that I described to you.
So that is basically how we would aim to facilitate the coordination, both immediately in the humanitarian phase and lastly in the reconstruction phase, but I must emphasize that in doing so we are working here with the CPA, with the Ministry of Health, with our partners such as Abt Associates, and with the nongovernmental organizations. So the role is coordination, facilitation. We're certainly not doing all this work ourselves. Thank you.
MS. PETERSON: If I could just supplement, I understand another useful Web source is www.agoodplacetostart, all one word, dot.org, for assessments. I just thought, if one of my colleagues could elaborate a little bit on the IMAC system that's in place to help coordination and look at particularly with respect to donations and identifying needs. Are you able to elaborate on that at this point or any--
MR. : [inaudible].
MS. PETERSON: Okay. Would you like to elaborate from up there, or is it related to that or--okay. This gentleman back there also had a question. Is it following on this particular issue, sir, or--okay. I'll just finish off my acronym of IMAC, what that means, and then, sir.
I understand that there is an International Medical Assistance Committee, I think is what it stands for, that is helping to--it's a very coordinated effort that is helping to identify particular needs in the health sector and some forms have been prepared that help those who want to donate and target assistance into the most appropriate areas and I believe that information on that effort is located at www.cpa-iraq.org. So if you're, if anyone is having challenges locating that information, please let us know. We will have contact information available at the end of this session as well.
But if you search that Web site, that should hopefully lead to what's called the IMAC, I-M-A-C. Please, sir.
MR. : Keith Johnson with the Selen [ph] Group. Following up on Dr. Alderslade's comment about staffing, is there a need seen in the short term for health care professionals from outside Iraq, and if so, both nursing and doctors, and if so, is that part of Abt's contract?
MS. PETERSON: So it sounds like both WHO and Abt to help address that question. Thank you.
DR. ALDERSLADE: Yes. I can't obviously comment on the element of your question concerning Abt Associates' contract. The focus in these operations is always necessarily on the indigenous expertise. This is a well-developed health system in comparative terms, and it has within it many well-educated and smart people.
So our focus would always be on building on that, supporting them, facilitating education and development. They're well-educated but they have been somewhat outside the international practice for the last ten years and have not been easily able to keep up to date with modern developments.
So it's in that sort of area that we would make some effort. I've referred also to the idea of developing more modern systems of staff development and accreditation as part of the overall management and regulatory functions within the Iraqi health system.
There are, however, certain staffing deficiencies. One can think, I emphasized nursing a little while ago, and also when I was here before, and of course a community-based health system needs a wide range of therapy skills of various sorts to work in teams--doctors, nurses and therapists working in teams.
There may be some place for people coming in and assisting. Some nongovernmental organizations do help and facilitate in that way by bringing in staff skills as exemplars of what is needed for the future.
But I would see it in that way, rather than any sort of wholesale international recruitment. I don't think that would be appropriate and that's absolutely not normally the line that we take. Thank you.
MS. MATT: I certainly support what was just said. The Abt Associates contract does not specifically ask us to hire Iraqi medical personnel, to bring them back. However, you know, we are hiring a lot of specialists to come in and help, especially with training and so on, and there are quite a number of Iraqis that we are considering for these jobs, and so it is highly possible that we will hire some Iraqi medical personnel from, expatriate Iraqis from the U.S. or some place else.
MS. PETERSON: Sir, thank you for waiting.
QUESTION: Kaya Sadla [ph] from USIVR. Been in Iraq since June. I have my own assessment too. I have two three questions to both Abt representative and U.N. agency.
First of all, we have not heard about what kind of education you're doing in Iraq to educate people regarding health. I have not heard from anyone, from south to center to north, that we do have such kind of conferences to educate people, and even physician by themselves. You know, some physicians ask me and I have request from specialists who graduated from U.K. and other, they say since 1989 we have not received a single information regarding these diseases. Okay?
So I'd like to hear more about that. Second, about the supplies. The medical supplies are very poor in Iraq. As you know, that it comes from Jordan and Syria and other places, which is very, you know, I mean poor, and this being done since 1996 with Oil For Food. As I understand this need to be changed. I mean, many physician, they were talking about this, you know, we need good medical supplies, in a state of, I would call it "garbage."
And last question is about woman health. Seeing many cases. One of my relatives has been like--she had breast cancer and she went to Mosul to have chemotherapy treatment. They give her like six months, and she said that's all we can do about it. So what we can do about breast cancer for woman? Not only we talking about malnutrition, about kids, kids, kids, and some areas we see people in Iraq, we didn't have an emergency for food or this kind of--we do have other diseases, we need to take care of it, like breast cancer for woman. Can we hear some answers from both, please.
MS. PETERSON: Yes; thank you very much. Dr. Alderslade, would you like to start, please.
DR. ALDERSLADE: Yes. Thank you very much. I made the point that there's been a gap in modern training and information, but I also made the point that the specialist population in the country are well-educated. So there is an important task in helping people come back up to a good level of understanding of modern clinical practice and the changes that have taken place in the last ten years, and to build that into a program of staff development and ultimately quality control and accreditation, and I would agree with all that you have said there.
In terms of the public, because you mentioned the general public, there is an enormous task to bring the system up to a level of capability when it can provide modern health promotion and disease prevention services, and universal access to essential primary care.
That is the focus that we are adopting, as I've tried to emphasize, but I wouldn't want to underestimate the challenge in that respect.
Currently, the disease profile in Iraq contains both unnecessarily high levels of communicable disease but also contains high levels of preventable chronic disease as you have referred to, sir.
So the new Iraqi health system will need to develop a capacity to provide health promotion, disease prevention, therapy and rehabilitation, with a focus on community and primary health care as the fundamental building block, as all modern health systems do. That would be my answer to your first point.
Your second point, I understand the point that you made about the drugs and medical supplies that have come through the Oil For Food program.
Nevertheless, as I said, there has been a very significant amount of drugs, for example since earlier this year with the first of the resolutions. I think in around April, WHO alone has brought in around $150 million worth of drugs and supplies.
So this is a very significant pipeline. The Oil For Food program will come to an end on the 21st of November and it will be the responsibility of the CPA to continue the pipeline. We are working with them now on priority, continuing work on priority contracts and I hope that we will be able to bring more drugs and supplies in beyond the 150 million so far, before November the 21st.
But it is very important to make sure that the pipeline is not interrupted.
Now, over time, with the growth in the capacity and funding of the Iraqi health system, which we would all want to see, I think some of the issues that you raised about diversity and about quality can be addressed using normal commercial methods. But for the moment, I wouldn't want to underplay the importance of the Oil For Food program.
Your final point about women's health. You're absolutely right. It is very important to try to focus on, to include amongst the thinking about the vulnerable groups, adults with chronic conditions or adults with life-threatening conditions, and it is important to start to think what is needed in terms of modern diagnostic and therapeutic methodology as Iraq's health system comes back up to high, comparatively high international levels of performance.
That will be a challenge and it will depend upon resources; but it is essential to think about what is needed. You used a very good example, sir, the modern management of breast cancer. Breast cancer is, unfortunately, a mass population disease and it's extremely important the system develop the capacity to deal with it.
However, I have emphasized, I think necessarily, that an organization like WHO starts from the public health and the primary care perspective, but that doesn't mean that we would lose sight of the secondary level of provision, and in the needs assessment process that we have been facilitating, thinking about planning for developments and the sort of services that you mentioned have been very much a part of that. Thank you.
MR. MOLINE: I would agree with Dr. Alderslade's eloquent response and I would just like to add one or two points. When you asked about education there, there are two sides to that, and one is the education of the health professionals, which I think you mentioned, which is beginning and Abt Associates has given a small grant to--let me see if I can get the organization's name correct--the Nurses and Doctors Association, to begin to hold conferences to bring together the medical professionals in the field, to begin to discuss these updates, cause as Dr. Alderslade had mentioned, the professionals have been somewhat isolated from the medical world and the medical advances that have occurred over the last decade.
The other half of the education component which was perhaps more emphasized in the presentation was communication, behavior change communication to the general population in terms of trying to promote positive behaviors that prevent communicable diseases, including proper breast feeding, the use of oral rehydration solutions to treat diarrhea, and, frankly, that was some of more the emphasis of the presentation, though the need as you mentioned with the medical professionals as well has been identified and some work is beginning in that area as well.
MS. MATT: I don't have a whole lot to add. I certainly appreciate the comments that you've made. We will be working quite a bit on training, in helping to improve clinical skills, also to improve quality of care at primary health care clinics.
Once again, we are the same as WHO. We are concentrating on primary health care and that is, you know, that's what we're meant to be doing, and we wont be going beyond that in this, the period of this contract, and certainly we are concentrating on women and children health as well. I mean, it's an extremely, as you know, is an extremely challenging place to be working and there, I think after a period of time, we'll see significant results. I think right now, for us, having been on the ground since June, we're just about at the point, we're having a significant amount of activities taking place, and I would hope if you talk to me in another three months I can tell you a lot more about how many people we have trained, and so on.
MS. PETERSON: Please.
QUESTION: Thank you. My name is George Sharfenberger, I work for Voxciva [ph] and we're a partner, very proud to be partnered with Abt on the health systems strengthening project, specifically working on health information systems and in collaboration with WHO on disease surveillance. But my question is otherwise.
When I left Iraq in mid August, we spent some time talking to our colleagues with UNICEF and at that point there was considerable concern about environmental factors affecting health, particularly in Baghdad.
At that point there was absolutely no sewage treatment for the city, functioning sewage treatment for the city of Baghdad. 100 percent of the sewage was going untreated into the Tigris River, and I just wondered if there's been any update on that and whether that situation's been improved?
MS. PETERSON: Well, maybe I could first mention that we will be holding a public sector consultation focus specifically on water and sanitation issues at a later date, and the schedule for all of our consultations are up on the Web page, usa.gov Web page. I think it's probably in another three or four weeks, if I recall correctly.
But I can say we're actively involved in repairing water treatment facilities, sewage facilities, et cetera, to address that, and he didn't really focus on preventative health care through that. But I don't know if you wanted to add anything to that at this point.
Again I would encourage going to that consultation for more in-depth information on that sector. Any additional--please.
QUESTION: Craig Gordon. I'm a reporter with Newsday out of New York. Two questions related to drugs and supplies.
The Pentagon, recently they had a briefing, or I think it was Jim Haverman [ph], talked about something like 3,000 tons of pharmaceuticals coming through already, and I'm sort of curious, sort of where those are coming from, if that's still remaining from the Oil For Food program or who is paying for those, or if there have been any new contracts let and if any U.S. companies have gotten those.
And then the second part would be kind of looking forward, when Oil For Food ends in November, what do you envision as the process for, you know, obtaining drugs and supplies? Will there be more contracts let, RFPs, that sort of thing, or how is that going to work, exactly? Thanks.
MS. PETERSON: Thank you for your question. My colleagues can speak to some of those. In terms of broader questions on procurements, et cetera, the Coalition Provisional Authority is probably in the best position to answer those questions.
As Dr. Alderslade mentioned the transition of the Oil For Food is under intensive discussion and evaluation and preparation for follow-on, et cetera.
But if my colleagues want to address some of the immediate pharmaceutical issues. Thank you.
MR. MOLINE: Again, I can't speak to precisely what was included in that statement of 3,000 metric tons or tons of pharmaceuticals. I will say that there are ,you know, as we mentioned, there's a large number of vaccines coming in country, that the pharmaceuticals, the WHO brings into country.
It's important when you're looking at that, Haverman and Bremer look at the sector which is broader than just USAID, and even WHO and UN and our contractors, so their figures look broader still with everyone in play in the country.
Granted, we're in close coordination with the CPA and the Ministry of Health and Dr. Haverman, and of course under Paul Bremer. But that vision and those numbers probably look even broader than USAID's activities. So it's difficult for me to address the source of that figure cause I would imagine that it's broader than what we support and so I'm afraid that's the best answer I can give to you on that point, and I think the discussions on what will happen following the Oil For Food programs ending, I can just say the discussions are underway.
I can't say for sure that there's been a clear process laid out at this point.
DR. ALDERSLADE: Thank you. Just in parentheses, if I might, I would like to add a point on the question on the environment and simply to note that a new, the governing council has established a ministry for the environment.
The environmental issues are a cost-cutting issue within the needs assessment process. There are a number of sectors in the needs assessment process. I have simply emphasized the health sector cause that's the discussion that we're having here today.
But each of the sectors has been asked to look carefully at the environmental issues.
I agree of course with you in your comments about the importance of that, and also, there are active UN agencies such as UNET, who I know will be available to facilitate and support the work. I just wanted to add that point.
On the pharmaceuticals, I of course can't comment on any statements from the Pentagon, nor can I speak for the CPA.
What I've tried to do is emphasize, too, the importance of recognizing that the Oil For Food program will end on the 21st of November. It has brought in a very significant number of pharmaceuticals and medical equipment into the country since the mid 1990's. It has improved the functioning of the Iraqi health system and it has done something to improve the public health experience of the population, although it has not been able to address many investment items. It really has focused on keeping the system running.
So I just wanted to make those points about the Oil For Food program, but it will end and it will be the responsibility of the CPA to answer the question about what will happen after that.
However, there are, as has been mentioned, intensive discussions between officials of the UN and the Oil For Food program and discussions with the CPA, regular information briefings have been made available by senior officials of the Oil For Food program.
So it is a very important ongoing, discussion, just how this handover will take place. But in the end, whatever will happen between times, in the end one would look for the provision of pharmaceuticals to the Iraqi health system on some normal commercial basis. Thank you.
MS. PETERSON: Thank you.
Any additional questions or comments?
I apologize. This format is not as conducive to easy exchange, let's say, with having to approach the microphone, but--yes, please?
QUESTION: Sue Fleming from Reuters. I just wanted to ask about the Iraq health ministry and how that's operating at the moment. Is it completely functional and what are they doing?
MS. PETERSON: Yes, some of my colleagues--obviously there's been a minister of health named by the governing council and a number of staff residing in the Ministry of Health, if colleagues would like to elaborate on that.
Dr. Alderslade?
DR. ALDERSLADE: The ministry was in a poor state after the conclusion of the hostilities and a great deal of effort and attention has gone in to bring it back to a basis level of functioning and as I emphasized several times in my intervention, we've been trying to work with offices of the Ministry of Health and to assist in capacity building.
When you refer to the point of fully functional, of course fully functional in terms of the sort of developed health system that I have outlined involves some sustained attention in each of the ten areas, the ten priority areas that I identified and I indicted that working parties have been set up after the August conference to try to take issues forward.
Now in each of those cases these will be developmental issues between the CPA, WHO, and the Ministry of Health.
So I would say the answer is that a basic level of functioning has been restored but that there is a very long way to go before the ministry is planning and managing the sort of modern health system which we're committed to seeing in Iraq.
MR. MOLINE: The only thing I would add to that is that the functioning of the Ministry of Health is a key function of USAID support. Perhaps we have been focusing a little bit more on those quick life-saving activities that were put in place, that are perhaps more dramatic and a little bit spicier to talk about.
But putting in the bureaucratic and systematic, and the systems that are needed to make the Ministry of Health fully functioning is the key component certainly of the Abt contract and it's also a key component of our support to WHO and their work there as well.
So I would say that we realize the importance and are heavily investing in being sure that the Ministry of Health is growing and becoming strengthened as fast as possible, but I think Dr. Alderslade's assessment is probably the most accurate at the moment.
MS. PETERSON: If I can just elaborate and reference some of what was said earlier about preparing for the Madrid donors conference, a staffer actively looking at what are their critical needs, what are the resource requirements? what are the budgetary requirements for the Ministry of Health and the director-generals of, say, of the 18 governorettes and the communication flow and issues along those lines? So just to supplement what my colleagues have said, that appears to be what is consuming various people's time out there in the ministry at the moment.
Please.
QUESTION: Modiqi Haka [ph] from Academy for Education and Development. Regarding communicable disease, which communicable disease has higher risk or concern to the working group in Iraq? Did needs assessment identify some kind of priority among the communicable disease? Thank you.
MS. PETERSON: Thank you.
If someone could elaborate. The focus of the question is on communicable diseases. What are those diseases that are of greatest concern out there, and that also probably ties in with the immunization campaigns and efforts undertaken, and what has come out of assessments, needs assessments to date with respect to communicable diseases?
MR. MOLINE: I can begin by saying that the assessments have been focusing--I think the assessment and the outcome from the strategic planning has been focusing on reducing child mortality, so it's not really a disease specific, but more an outcome is what the focus has been on, and appropriately so I think on child mortality.
Now you can look at the diseases of child, that are leading to child mortality, including acute respiratory infections and diarrheal disease, among others, but it's difficult to say what communicable disease they're focusing on. It's more appropriate perhaps to say they're focusing on reducing child mortality and the various components that feed into that, including nutrition, disease, et cetera.
Would you like to add anything, Dr. Alderslade?
DR. ALDERSLADE: Yes. Thank you. I'll try to be specific. First of all, I emphasize the importance of vaccine-preventable diseases and the absolute priority of getting immunization rates up to acceptable and effective levels.
Yes, we have conducted, to the extent that it's possible with the information systems, as they currently exist, inevitably, as part of the needs assessment exercise, a review of the spectrum of disease, both communicable and noncommunicable, and as far as we can establish the determinants thereof.
So that is part of the needs assessment and I'll try, just from a document I have here, to try and answer your question directly.
The most important communicable diseases, upper respiratory infection and diarrheal diseases. The incidence of tuberculosis is higher, markedly higher than in neighboring countries.
Apart form the three northern governments, cholera is endemic and visceral leech moniysis [?] and malaria epidemics have occurred also in the north, and the incidence of the most important vaccine-preventable disease, measles, has declined since vaccine coverage improved in the late 1990s and I referred to that in my introductory remarks.
However, measles remains a common cause of death and therefore it's worth repeating yet again my emphasis on immunization and effective primary care management.
Currently HIV/AIDS does not seem to be a major public health problem but of course that situation could change in Iraq as we've seen it change in a number of other countries and I would just conclude by putting on to the agenda again the importance of thinking about communicable and noncommunicable disease and some of the issues that you raised. So I hope that is helpful and answers your question.
MS. PETERSON: Actually, we probably have time for just one more question or comment.
If not, I would like to thank you very much for coming this afternoon.
Just to highlight, we will be having a public sector consultation next Tuesday, planned for 11:00 o'clock on local governance. We had that scheduled last week but due to Hurricane Isabel, we had to postpone that. So next Tuesday is on local governance and a week from today is on our economic governance efforts in Iraq.
Thank you very much for coming.
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