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Forward by Dr Naeema Al-Gasseer, WHO Representative for Iraq Dear Colleagues, 2004 has been a testing and challenging time for all of us engaged in humanitarian relief operations for Iraq. Even more it has been a very difficult time for the people of Iraq as the security situation has deteriorated and needs there have oscillated between emergency and development. This difficult and constantly changing situation has meant that WHO and the UN have had to work together in a more coordinated way. Our responses have been at the coalface of implementing the resolve of the Secretary General to make the UN more efficient, effective and more responsive to the needs of both the recipients of humanitarian aid and the donors who have so generously funded our operations and who have such legitimate high expectations for our implementation. In fulfilling these expectations we have had to deal with the situation where, for security reasons, our international staff has not been able to work inside Iraq and we have been obliged to operate by virtual management and with ever increasing reliance on modern communications such as videoconferencing, internet and mobile phones. This has enabled us to link directly with our national staff in Iraq who have remained steadfast in their efforts to implement our programmes and for whom I have the highest respect and praise for their achievements and resolve. It has also enabled us to link directly with our colleagues in the Ministry of Health (MoH) and other Ministries in Iraq and to receive their input and keep informed on our progress in implementation. Together we have been able to identify the needs of the MoH and to design and run over 25 workshops and many more meetings to train MoH staff to meet the emerging challenges of designing and implement health programmes in Iraq. We have also begun to repair the infrastructure necessary for the functioning of a modern health system. We have rehabilitated Public Health Laboratories in Najaf, Mosul and Baghdad and the Blood Bank in Baghdad, delivered much needed supplies and equipment and urgently needed drugs. Yet so much more needs to be done and we are very conscious of the urgent needs of the people of Iraq and of the pressure from donors to implement. Internally within WHO we have challenged the status quo and implemented new procedures with support from our top management in our Regional Office and at Headquarters. I know with their continuing support, the support of our staff in Amman and in Iraq and with the excellent rapport we have developed with the MoH we will continue to push the boundaries of our mandate and implementation to help bring efficient and effective health systems and health care to the people of Iraq. Naeema Al-Gasseer WHO Representative to Iraq. June 2005
I Foreword Table of contents WHO Activities in Iraq Legend Nursing School Mental Units 0-1 2-3 Environment Lab Drug Lab II III Introduction a) Background b) Health situation in Iraq c) UN Health Cluster d) Ministry of Health Iraq WHO Programmes a) Access to quality health services b) Prevention and control of diseases c) Environmental health d) Mother and child health and reproductive health Ninewa Dahuk Erbil Sulaymaniyah Tameem Salah al-din Diyala Baghdad Communicable Disease C entre Community-based Initiative 1 2 Blood Bank Training Centre 1-2 Radiation Lab Polio Lab Public Health Lab Primary Health Care C entres 6-10 11-15 16-22 23-33 The placement of the icons does not represent specific Locations of activities within a particular governorate Anbar IV Resources Kerbala Babylon Wassit V Overall challenges and lessons learned Najaf Qadissiya Thi-Qar Missan VI Next steps 1:3,662,612 Kilometers 0 40 80 120 160 200 Muthanna Basrah VII Annexes Acronyms and abbreviations The map was produced as a reference aid only. The boundaries and names shown and the designations used on this map do not imply official endorsement or acceptance by the United Nations Communicable diseases surveillance system: Nationwide Immunization campaigns : Nationwild
Introduction Introduction II: INTRODUCTION A: Background Iraq became a Member State of the World Health Organization (WHO) in 1947. Before the 2003 conflict WHO Iraq assisted the Ministry of Health (MoH) in areas such as prevention and control of communicable diseases; development of policy and health system programmes; non-communicable diseases, maternal, child health and reproductive health and environmental health. With the implementation of the Oil for Food Programme (OFFP) in 1996 WHO acted as an observer to verify the equitable distribution of medical supplies and equipment as required under the terms of Security Council Resolution 986. In three northern governorates of Iraq WHO was entrusted with the implementation of a large part of the health component related to the OFFP encompassing activities such as shipment of drugs, distribution of medical equipment and supplies and rehabilitation of health services. When the conflict broke out in March 2003, WHO, UNICEF, UNFPA, international aid, donor agencies and non-governmental organizations had already pre-positioned supplies for basic health that would cover some 750,000 people for three months. Along the lines of the UN common strategy, WHO was chosen to chair a Health Coordination Group that was in charge of ensuring a joint response to the health threats posed by the conflict. WHO enhanced its field presence, logistics and communications capacity, in order to support national and international health partners for rapid assessment and for specific disease control activities. B: Health Situation in Iraq UN Cluster Title Lead Agency 1 Education and Culture UNICEF 2 Health WHO 3 Water and Sanitation UNICEF 4 Infrastructure and Housing HABITAT 5 Agriculture, Water & Environment FAO 6 Food Security WFP 7 Mine Action UNOPS 8 Internally Displaced Persons UNHCR 9 Governance and Civil Society UNDP 10 Poverty Reduction and Human Development UNDP Figure 1: The UN Clusters for Iraq In 2004 WHO 1 received the mandate to spearhead the UN Health Cluster in collaboration with UNICEF, UNFPA, WFP, UNDP, IOM, UNIFEM, UNIDO, and UNEP. The Cluster works towards the Ministry of Health s vision to: Provide accessible, affordable and available, safe and comprehensive quality health services. It engages in activities such as policy development, community mobilization, emergency response and capacity building inside Iraq. D: Ministry of Health Iraq The vision of the Ministry of Health of Iraq describes a system that is people-centred and empowers citizens to be responsible for their own health. Seven core elements identified are population empowerment, individual responsibility, community involvement, integrated health services with emphasis on primary-health care, financial risk protection (equity), health provider management autonomy, quality improvement and human resources development. Years of political and economic sanctions have left their toll on the people of Iraq. The military conflict in March 2003, combined with the lack of law and order following the civil unrest, led to the disruption of primary health care centres, sanitation facilities, water supplies and power production plants. Among some of the health concerns facing Iraq today are; high rates of maternal, infant and child mortality; widespread malnutrition; diarrhoea and other water and food-borne diseases; malaria, cholera and leishmaniasis; vaccine-preventable diseases such as measles, pertussis and diphtheria ; high rates of tuberculosis ; and trauma related injuries. Although HIV/AIDS is not a major public health problem today, data shows a high incidence of sexually transmitted diseases. Since April 2003, health outcomes are among the poorest in the region. Iraq has gone through phases of crisis and emergency and now through transition and reconstruction. Human Resource Development Individual Responsibility Community Involvement Primary Care Providers Inpatient Providers PeopleChoice & Responsibility For ownhealth Financial Risk Protection C: UN Health Cluster Quality Improvement Health Provider Management In line with the mandate given to the United Nations Development Group (UNDG) in 1997 to improve the effectiveness of UN development at country level, UN organizations have developed policies and procedures to analyse and work together on problems faced by Iraq. The UN Cluster System allows agencies that are best situated in terms of resources and expertise to lead the cluster. In collaboration with other relevant UN agencies the cluster implements projects and programmes in the different areas of work. Figure 2: Population Centered Integrated Health System The emphasis for the year 2004 was to focus on sustainability and consistency, standardization of equipment, coordination and management of donors contribution, and to encourage more interaction with the Iraqi Ministry of Planning and Development Cooperation (MoPDC). To implement this vision, WHO worked closely with the MoH by providing technical, logistical and financial support directly and through the UN Health Cluster. 6 7
WHO Iraq Programmes WHO Iraq Programmes III: WHO Programmes Throughout 2004 WHO focused on four main areas of work in Iraq; Access to quality health services, Prevention and control of communicable and non-communicable diseases, Environmental health and Mother and child and reproductive health. In order to provide for a complete and comprehensive review the report has been structured along crosscutting activities within the different areas of work: Access to quality health services Prevention and control of diseases Environme ntal health Mother and child health andre productive health During the last decades, the Iraqi health infrastructure suffered many set backs due to war, looting, and lack of resources. Dilapidated structures and absence of maintenance have required urgent response. WHO has provided financial, logistical and technical investment, by means of infrastructural and biomedical engineering, in order to supply the Iraqi people with primary, secondary and tertiary health care supplies. Provision of supplies and Rehabilitation has played a major role in WHO activities in Iraq throughout 2004. WHO s role is to assist countries in order to achieve the highest possible level of health. During the 1990s most medical schools and health faculties in Iraq were isolated from international developments in their fields. In its efforts of establishing an effective health care-delivery system, the Ministry of Health (MoH) identified the need for training and capacity building of health professionals and management staff as a top priority. WHO has worked heavily on Human resource development as well as Policy development in order to achieve long-term sustainable advances in the health care sector. Suveillance Emergency preparedness Provision of supplies and equipment Rehabilitation Policy development Human resource revelopment Surveillance and Emergency preparedness activities are presented first as WHO works on a consistent approach to collect and analyse data in order to intervene to the best of its capacity. Quality health information is essential for planning and implementing interventions. Country-level data is often sparse and when data is available, it is not always complete or comparable. Through its surveillance and emergency preparedness WHO s goal is to reduce avoidable loss of life, burden of disease and disability in emergencies and postcrisis transitions. This is achieved by ensuring presence and operational capacity in the field to strengthen coordinated management, collective learning and health sector accountability. 8 9
Access To Quality Health Services Access To Quality Health Services ACCESS TO QUALITY HEALTH SERVICES Vulnerability to ill-health can be reduced by taking steps to respect, protect and fulfill human rights e.g. freedom from discrimination on account of race, sex and gender roles, rights to health, food and nutrition, education, housing A: Access to Quality Health Services Background The major provider of health in Iraq is the Ministry of Health. The health sector is composed of small private hospitals and an unorganized network of clinics. Health planning and decision-making is centralised leaving the health directorates, at the governorate level, with little or no authority to act promptly on urgent matters. With regard to Primary Health Care (PHC) Centres some statistics for 2004 include: Existence of 1,285 PHC centres in Iraq Provision of one PHC centre per 35,000 people/120 patients per day Staffing of one medical doctor in about 55% of PHC centres Shortages of physicians in 6 of 18 governorates and overstaffing in 4 of 182 Reported distance of 14 to 30 km from rural villages to PHC centres Functional patient record system in about 15% of PHC centres. While the overall health care system currently in place in Iraq is hospital-oriented, WHO emphasizes a sustainable and cost-effective public health approach. During 2004, WHO took the lead of the UN Cluster to assist the MoH in Establishing a robust Primary Health Care system centred on strengthening general practice in the shortterm and in developing a family physician, nurse practitioner model in the long-term. It is expected that this tailored yet internationally acknowledged approach will substantially increase efficiency, thus making it more responsive to the needs of the people. The 18-month programme, developed in coordination with MoH is currently being implemented and is targeting completion by January 2006. Activities Surveillance Emergency preparendess Over the past 15 years some 4,750 families from Ninawa, Tikrit, Dohuk, Najaf and Tameem have been displaced. These Internally Displace Persons (IDPs) have been moving continuously and have settled in former prisons, military barracks, public buildings, damaged houses etc. Today, only few of IDPs have access to satisfactory basic health care services. In an effort to adequately integrate the IDPs into the MoH PHC program, WHO assisted the MoH in conducting a survey assessing the health situation and needs of the IDPs. The survey resulted in a plan of action in order to respond to their needs. In response to emergency situations in Falluja, Najaf and Kerbella, WHO acted as coordinator for the humanitarian health sector support. A Framework for Country Contingency Plan of the Ministry of Health-Iraq was developed in April 2004 which contains contingency health supplies list for Iraq. It was noted that in order to streamline coordination of emergency supplies a coordinating body within the MoH must exist to link the field to donor/technical agencies. nurse training on computer in basra training center Activity Obligated $ 21 Essential Medicines 2,000,000 Anti TB Drugs 500,000 Rabies Vaccine 157,858 Hospital supplies (external fixators, IV canulas..) 349,126 Laboratory kits ( HIV, HCV, HBsAg, IV fluids) 52,353 LC Delivery of water hygiene kits 10,000 TOTAL 3,069,337 Figure 3: Equipment and supplies procured during emergencies Iraq 10 11
Access To Quality Health Services Access To Quality Health Services Provision of Supplies & Equipment In order to ensure the provision of and enhance the access to quality basic health services, WHO initiated the procurement of 135 PHC packages, including instruments such as stethoscopes, sphygmomanometers, portable kits for food safety control, computers and software. In addition laboratory equipment and supplies (worth over US$ 2 million) were supplied to the National Blood Transfusion Centre. Activity Obligated $ Un-Liquidated $ 19 Ambulances, Four Wheel Drive 838,732 722,653 38 Toyota Hilux 4 WD 734,692 47,096 300 Motorcycles 286,350 0 Logistic support 57,960 33,532 Communication and data processing equipment 150,646 10,361 Hospital supplies 75,937 32,599 Printing calendars, folders, subscriptions etc 58,559 13 TOTAL 2,202,876 846,254 Figure 4: Equipment and supplies procured in support of the PHC program in 2004 Since July 2004 three Iraqi staff and two WHO staff have been sponsored by WHO to work in the International Department of the MoH and support interaction between the Health Cluster, the Government, NGOs and Donors. 3500000 3000000 2500000 2000000 1500000 1000000 500000 0 Funds Allocated in 2004 ($) Goods received in Jordan ($) Goods shipped to Public health lab 1,937,273 1,711,379 1,711,379 Food safety lab 2,092,662 1,001,980 38,506 National drug quality control 2,800,702 0 0 Primary health care 2,386,122 0 0 Mental Health & NCD 3,100,000 0 0 Water quality control 1,600,000 0 0 Iraq ($) Blood bank 2,100,000 2,000,000 2,000,000 Figure 5: Fund allocation and expenditure for biomedical engineering products per program and shipping status. Rehabilitation Policy Development In order to respond to the demands from the MoH, WHO provided full support through physical rehabilitation and provision of supplies and equipment to the following institutions: Public Health Laboratory, Najaf Public Health Laboratory, Baghdad Public Health Laboratory, Mosul National Drug Quality Control Laboratory (NDQCL) Blood Bank, Baghdad In early 2004, based on an extensive assessment (of health needs, physical condition, manpower needs, services and equipment available) the full rehabilitation of 19 Primary Health Care facilities was initiated. WHO also provided the MoH with technical support in establishing an effective referral system that minimizes duplication of services and inefficient use of resources. Towards the end of 2005 the project will be fully evaluated in order to expand to other districts. WHO provided technical support to the MoH in order to develop a National Medicine Policy and set up a robust and sustainable Drug Registration System. Key aspects include medical supply management system, registration process, registration legislation and information on requirements for a regulatory authority. The MoH in collaboration with WHO implemented a pilot project to monitor availability of specific drugs in selected health centres. A proposal was approved by the MoH to establish a Health Information System that will support communication, as of 2005, between the districts, governorate and central level. This project includes satellite linkage and web-based applications between the PHC centers throughout Iraq. WHO is technically and logistically supporting Community-Based Initiatives (CBI) and their integration into PHC in Iraq. The CBI project aims to empower communities to take charge of their own health, by enhancing their participation in the planning, decision-making and implementation processes. This is believed to ensure sustainability of health programs and initiatives overall and reduce the cost of health on the long-term. As part of the CBI, WHO and the MoH committed to : Integrating CBI Programme into the National Health Development Strategy Enhancing community engagement in the rehabilitation of PHC services Improving environmental services Focusing on the development of life-skills among women and youth Initiating income generation activities. In July 2004, health stakeholders supported a series of MoH Policy Seminars that resulted in a strategic document for Iraq. WHO and the MoH participated in seminars aimed at the development of national health policies. Advances were made in the following areas: Plan of action for Nursing and Midwifery in Iraq Maternal and Child Health and Reproductive Health Strategy Iraq National Medicine Policy (INMP) National Drug Quality Strategy Strategy on Food Safety in Iraq. 12 13
Access To Quality Health Services Access To Quality Health Services Human Resource Development In November a Seminar was held in Amman on Financing Options For Iraq s Health Sector. Current macroeconomic and fiscal situation of Iraq was discussed and future projections for economic growth. Preliminary views on health financing options were presented with focus on international and regional experiences such as relying on general taxation, social and private insurance and different forms of managing health funds. Strategies for reconstruction of the health sector in Iraq for 2004 to 2007 were outlined. WHO assisted with the development of human capacity among health professionals including nurses, health care managers, general practitioners, specialists, and ancillary staff through support of continuing education as well as fellowships. Some activities spearheaded by WHO in collaboration with the MOH included: March; workshop on the medical supply situation in the country and ways forward. May; workshop on establishment and implementation of a National Health Account (NHA). NHA is a standard set of tables showing the flow of funds through health systems. The NHA is a tool for policy formulation, monitoring, and evaluation. June; workshop on Improving Health Communication Strategies for the Prevention and Control of Micronutrient Malnutrition. Participants included Health Education and Nutrition Officers, representing 13 governorates. August; Training of Trainer s workshop on Vaccine Management. The workshop provided hands-on experience in vaccine management and new techniques. Participants conducted trainings of their colleagues in Iraq in order to share the knowledge and experience gained. Future directions Actions were taken to ensure the full functioning of the Continuing Education Development Centres (CED). This included the rehabilitation, re-equipping, hiring and training of communication facilitators, procurement of hardware and software equipment and development of teaching tools. In congruence with the MoH objective to update and strengthen the national health information system, WHO renewed the subscription of medical databases for several Iraqi Institutions such as the Faculties of Medicine in Baghdad and Basra, the MoH Libraries, the Environmental Health Division in MoH, National Cancer Registry and the Al Nahrain Medical College. Provide equipment, medical furniture and basic supplies for the 19 PHC facilies. Use the Primary Health Care project as a pilot project throughout Iraq. Develop the Iraqi national capacity through the creation of regional teams charged with the training, monitoring and evaluation within the PHC centers. Follow the assessment and rehabilitation of Public Health Labs and Blood Banks. Begin rehabilitation at governorate level. Provide MoH with technical and logistical support to respond to emergencies. Support the development and enhancement of the Iraq National Medicine Policy. Support capacity building in areas of pharmacy including rehabilitation of the National Drug Control Laboratorty. September and October; series of two training courses on Health Internet work Access to Research Initiative (HINARI). The course provided 21 health workers with the skills needed to access high quality health information via the Internet. September; workshop on the Orientation of Nursing & Midwifery Legislation and Regulation. 28 participants attended the workshop from the MoH and Ministry of Higher Education (MoHE), hospitals, technical institutes and training centres. October; WHO technically and logistically supported a National Workshop on Nursing and Midwifery Curricula Review. Attended by 32 participants, the workshop included deans and teachers from Iraqi universities and representatives from the MoH and the MoHE. 14 15
Prevention & Control Of Diseases Prevention & Control Of Diseases Prevention and control of diseases To ensure successful prevention and control of diseases, in poor remote rural areas and overcrowded cities by providing basic package of preventive and curative services B: Prevention and Control of Diseases Background As in many countries around the world, Iraq suffers from a double burden; communicable and non-communicable diseases. Diarrhoeal diseases, acute respiratory infections, measles, mumps, typhoid fever and Leishmaniasis have substantially increased since 1990 and are still the leading conditions reported from health facilities. On the other hand, diseases including malaria, cholera and diphtheria have been declining. Iraq has in addition managed to maintain a polio free status since January 2000. Iraq is still among the low prevalence countries for HIV/AIDS, in 2003 there were 275 cumulative HIV/AIDS cases reported mainly due to infected blood products. There are currently 67 cases receiving care. As a result of changes in risk factors, namely the opening of borders, the influx of large numbers of military and foreigners and increased possibilities for drug abuse, the magnitude of the problem and the current epidemiological patterns regarding communicable and non-communicable diseases (including HIV/AIDS) need to be carefully assessed. Activities Surveillance In March 2004, WHO organized a meeting in Amman with Representatives from the MoH, CPA, UNICEF, Voxiva, Center for Disease Control (CDC) and the United States Department of Health and Human Services (USHSS) to develop a Strategic Plan for a Communicable Disease Surveillance System (CDSS) that coordinates efforts of all stakeholders according to the goals of the MoH. A surveillance database was set up to provide health professionals with the information necessary for prioritization, planning and implementation of activities. The database is updated weekly with information provided by WHO and Public Health Directorates at the governorate level. The information is then disseminated to WHO and MoH to prompt decisions and action. WHO developed a tool for tracking emerging public health problems in Iraq. The Public Health Problem Identification and Verification List (IVL) is based on the model developed by WHO for outbreak verification. It assists health professionals in the decision making and planning by identifying and monitoring emerging public health problems. Acute Flaccid Paralysis (AFP) surveillance is a major strategy for Polio Eradication. A steady progress in the AFP surveillance performance indicators had been achieved since 1997. This progress was interrupted following the war in April 2003 when performance indicators marked a soaring regression. In order to reverse this regression, special attention was given by WHO and the MoH. The number of silent districts (not reporting AFP cases) was 19 in 2004 compared to 16 in 2001. The objective for 2005 is to bring back the number of silent districts to pre-war levels. 16 17
Prevention & Control Of Diseases Prevention & Control Of Diseases Provision of Supplies & Equipment Visceral and Cutaneous Leishmaniasis are seasonal diseases; their transmission period is between May and October, after the hatching of the sand-fly eggs. Although the diseases are normally confined to certain endemic areas in Iraq, cases were reported in non-endemic areas due to population migration brought by political unrest and insecurity. Between April and November, WHO assisted in the implementation of: National spraying and fogging campaigns for prevention of Leishmaniasis and Malaria Giving out of bed-nets Distribution of health education materials Provision of 40 entomological kits to evaluate density of sand flies and mosquitoes Supporting the rodent Control activities Supporting the Entomological surveillance activities Localized outbreaks and sporadic cases of Hepatitis E were reported and confirmed in different parts of Baghdad during the summer of 2004. WHO and CDC Baghdad successfully controlled the outbreak by implementing the following activities: Provision of 80 Hepatitis E diagnostic kits for the Public Health Central Lab in Baghdad Dissemination of health education pamphlets Development of Hepatitis Booklet CDC Baghdad on symptoms, treatment, and prevention Provision of supplies and equipments as requested by the MoH. During 2004, WHO continued providing support to reduce the incidence of Cholera in Basra, where it has been endemic for years. Some of the activities conducted were: Distribution of chlorine tablets and water collection cans amongst affected communities Provision of IV fluids and ORS Production and dissemination of education material on cholera prevention and management. In January and February of 2004, a Measles outbreak took place in the southern governorates of Iraq, which subsequently spilled over into nearby governorates, and affected more than 1,000 school children. WHO collaborated with the MoH to address this outbreak through: A nationwide catch-up vaccination campaign targeting 5.2 million children aged 6-12 A follow-up campaign touching 860,000 children aged 6-7 An immunization campaign targeting 38,000 children aged 9 month to 7 years. Figure 7: Incidence of some communicable diseases during 2004. Since WHO s adoption in 1988 targeting the eradication of Poliomyelitis, significant progress has been achieved in Iraq. The last confirmed poliomyelitis case was reported in January 2000, since then the country has been free of poliovirus transmission. During 2004, WHO provided the support needed for the implementation of successful National Immunization Days (NID) to maintain the country s polio free status and the excellent surveillance indicators. Figure 6: Cholera Cases and Carriers in Basra from April - December 2004. Figure 8: Number of Children Vaccinated in each NIDs Round, 2003 & 2004, Iraq 18 19
Prevention & Control Of Diseases Prevention & Control Of Diseases Rehabilitation In addition contingency supplies were provided to the Ministry of Health including: 600 packs of Tuberculin 2TU/ 0.1ml, 10 vials 1.5 ml for the diagnosis of Tuberculosis. 3000 doses of Rabies vaccine and 600 doses of Rabies Immunoglobulin 1000 doses of Anti- diphtheria sera. Equipment for the re-functioning of the Hemorrhagic Fever (HF) Laboratory Baghdad Rehabilitation initiatives in the area of preventing diseases included: Replacement vaccine cold chain equipments at all levels Refurbishment of the information system Renovation of the National Polio Laboratory (NPL) WHO collaborated with UNICEF on the Expanded Program of Immunization for Iraq aimed at strategies related to measles elimination and routine immunization coverage using the RED (Reaching Every District) approach. Future directions Identify priorities and responses with the MoH to prevent and control diseases. Support the development of standards and guidelines for communicable disease programs. Continue monitoring incidence of diseases and outbreaks by analysis and evaluations. Strengthen human resources in communicable diseases at all levels of the health services. Disseminate health education on communicable diseases. Promote research on communicable diseases and immunization programs. Assist in the development of national information and surveillance system. Strength laboratory activities. Cooperate with CDC Baghdad for the implementation of their work plan. Strengthen the prevention and control of HIV/AIDS. Support immunizations programs and assist national plan for the elimination of Measles. In addition, the Ministry of Health gave approval and endorsement for a joint Plan of Action for Substance Abuse. Human Resource Development Throughout 2004 WHO supported and participated in a series of capacity building workshops: Training of Trainer workshops on Control and surveillance of communicable diseases Vaccine management workshop on effective management of vaccines. 3-day workshop on treatment, control and prevention of Hepatitis A, B, C, D, E Non-Communicable Disease and Mental Health training courses in London and Lebanon Refresher Course for Psychiatrists for some 30 Iraqi health professionals Week-long Training of Trainers workshop on substance abuse prevention and mental health promotion. WHO also initiated fellowships to senior staff at CDC Baghdad and governorates throughout Iraq to improve their capacity in diseases surveillance and outbreak response. 20 21
Environmental Health Environmental Health ENVIRONMENTAL HEALTH C : Environmental Health To ensure further reinforcement of water-quality monitoring program with the overall purpose of supporting the provision of safe water to consumers according to Iraqi Standards and WHO guidelines for potable drinking water. Background In collaboration with the MoH, the main environmental health issues being tackled today are food safety, water safety and health care waste. Decades of wars in Iraq, coupled with the sanctions and the most recent conflict, have left the food safety infrastructure that existed before in a state of despair. Some of this infrastructure, including the food control laboratory network, was used to ensure that food items included in the monthly food basket ration are fit for human consumption. At present, most of these laboratories are not operational and require rehabilitation. Waterborne diseases, such as diarrhoeal diseases, hepatitis, typhoid fever, and other parasitic diseases, which once had been under control, have regained their foothold in recent years. WHO aims to improve health and reduction of mortality and morbidity due to communicable disease through the implementation of activities that protect and promote the safety and security water supplies. Improper handling of Health Care Waste (HCW) is a substantial cause of morbidity and mortality among hospitalized patients. About 20% of medical waste is treated as ordinary trash thus posing a great threat to the health of communities in the vicinity of the facilities. Despite the lack of information on the status of HCW management, it has been widely noted that hazardous practices are widely spread in today s Iraq, which constitutes a great public health threat that must be urgently addressed. By raising awareness among the various ministries and the public towards environmental contamination, environmental issues are gaining importance in their priorities. Activities Surveillance Through regular joint visits by WHO with the Ministry of Environment (MoEnv) and MoH to hospitals, health centres, water plants and local popular areas, the Organization obtained accurate information about the health and environmental status in the country. WHO, in partnership with UNICEF, received $6.2 million from the European Commission for a project entitled Waterquality Control and Surveillance in Iraq. The project is being implemented by the MoEn and the Ministry of Public Waters (MoMPW). To date some WHO activities include: Rehabilitation of Central Water-Quality Laboratory in Baghdad Provision of vehicles for field work Delivery of training courses Publications on environmental health School awareness campaign Community mobilization campaigns. 22 23
Environmental Health Environmental Health Provision of Supplies & Equipment Rehabilitation Supplies provided for the field of environmental health included: Support to waste management in Mosul and Kirkuk hospitals It is estimated that almost 5.5.tons/week of solid waste were collected and disposed correctly Laboratory reagents for the Water-Quality Control Laboratory Laboratory equipment and glassware worth of about 240,000 US$ Computers and printers at the MoEnv and the Department of Environment in Basra Educational material on environmental health issues for the MoEnv library. WHO financially and logistically assisted the MoEnv in the renovation of Radiation Protection Centre in Baghdad (RPC). Future directions With partners including the Iraqi government, UNICEF and UNEP, WHO will: Support the rehabilitation of the Nutrition Research Institute Strengthen the capacity of the food control laboratories Assist the MoH in implementing the Plan of Action on food safety Support consultations of countries neighbouring Iraq to enhance the regional cooperation Train 400 technicians at ministry level on water quality monitoring and control techniques. Enhance environmental awareness through health education campaigns Ensure supply of laboratory equipments and reagents to sustain functionality Encourage Iraqi NGOs to play a greater role to hygiene education and environmental health awareness. Policy Development In addition WHO provided laboratory equipment and supplies for the Food control laboratory at the newly rehabilitated Nutrition Research Institute. A Plan of Action on Food Safety was developed with detailed short and long term actions as a result of a national workshop on food safety organized by the MoH and WHO in July 20o4. Human Resource Development WHO activities in human resource development included assistance to the MoMPW in enhancing skills of some 600 lab technicians and health inspectors through 20 trainings and national dissemination of reference material on water-quality standards. In addition, WHO sponsored nation-wide activities, conferences, documentaries and printed materials, for the Arab Environmental Day on October 14 th. 24 25
Maternal Health Maternal Health MATERNAL HEALTH By year 2005, the under 5 and infant mortality will be reduced by 50% of their levels of 1999, and maternal mortality by 15% D: Mother and Child and Reproductive Health Background In September 2000 the United Nations launched the Millennium development Goals (MDGs) which identified maternal health as being a crucial health priority for both humanitarian and social reasons. Mothers provide social cohesion in the family and community, the children of a mother who is sick or who dies in childbirth are more vulnerable to sickness and death. In Primary Health Care Centres, maternal and child health (MCH) and reproductive health (RH) services include: Antenatal care: achieve at least 5 visits during pregnancy Post natal care: visit the PHC centre at least once during the 6 weeks after delivery Growth monitoring of under fives: routine visits are used to monitor growth Management of Acute Respiratory Infections and cases of Diarrhoea through Rehydration Counselling mothers on successful breast feeding and proper feeding recommendations Immunization for mothers and children Curative services to mothers and children WHO Iraq advocates for the implementation of the safe motherhood initiative, which aims to improve health and reduce maternal, as well as child morbidity and mortality. The main priorities for Iraq are the early implementation of the MCH and RH Strategy in Iraq for 2005-2008 utilizing. The Millennium Development Goals will be used as guidelines and framework to provide strategic directions for policy makers and health care providers. Activities Surveillance WHO organized a 6-days working session, from September 25 th to the 30 th, for the in-depth analysis of data available from the 1999 Infant, Child and Maternal Mortality Survey (ICMMS). A national team from the MoH and the Central Statistics Organization (CSO) met in Amman with national and international WHO research and statistics experts in order to determine a national figure for maternal and child mortality rate/ratio. Policy Development In October, WHO collaborated with MoH on a 4-day in a meeting to discuss the data merging of two surveys conducted in 1999 for the South, Centre and North governorates of Iraq. In June WHO organized a 6- day workshop in Amman for the development of the Maternal & Child Health and Reproductive Health Strategy in collaboration with the MoH, UNICEF and UNFPA. 95 Iraqi health planners, health care providers and decision makers participated in the development of the document which is based on the needs of the Iraqi people and is in accordance with the international and national directions in the area of Maternal and Child regulations, guidelines and current practices. 26 27
Maternal Health Resources Human Resource Development In September WHO supported a follow-up workshop on the Maternal & Child Health and Reproductive Health Strategy, in the governorate of Sulaimanyah, to gain the consensus of a larger local audience and to discuss the first draft of the action plan that resulted from the MCH/ RH Strategy. WHO supported various training courses on the safe motherhood initiative and essential obstetric care at central and peripheral level. As support to the Integrated Management of Childhood Illnesses trainings, WHO printed and disseminated the 7 training modules, a chart booklet and a photo booklet. Future directions In close collaboration with the MoH and in accordance with the Millenieum Development Goals WHO will continue to: Improve the quality of services for newborn babies and infants Improve access to family planning services and emergency obstetric care at district level Improve health service delivery for mothers and children under 5 Raise awareness on children and mother nutrition Establish an effective health information and surveillance system Monitor to ensure implementation Increase community awareness about women s and mother s health NEEDS. 28
Resources Resources IV: Resources Due to the emergency situation in Iraq throughout 2004, fundraising played a crucial role for WHO Iraq. In 2004, under the regular budget, WHO had almost 1,500,000$ allotted for the implementation of projects in Iraq. In addition, as illustrated below countries were generous in responding to Iraq s crisis situation bringing the extra-budgetary resources to 121,309,644$. Considering security reasons, irregular biennium funding procedures, and procurements initiated throughout 2004, some of the allotted funds were not spent but will be spent throughout 2005. Sources of WHO-Iraq Programmatic Funding - 2004 2% In 2003, WHO initiated the jumps-start program which provided rapid and direct support in 13 target areas. In 2004 the International Reconstruction Fund Facility for Iraq (IRFFI) was established which functions as an entity that receives and manages contributions from donor countries. The IRFFI encompasses two trust funds, the UN Development Group Trust Fund (UNDG ITF) and the World Bank Iraq Trust Fund. The UNDG ITF supports the UN Cluster approach under the Strategic Plan of Assistance to Iraq. The Facility helps donors channel their resources to the Iraq reconstruction effort. To date, 25 donors have committed about $1 billion to the Facility. With regard to the health sector, in 2004 the UNDG ITF invested approximately 60,602,700$ in implementing projects such as Supporting Primary Health Care System, Re-establishing the National Drug Quality Control Laboratory, Non-Communicable Diseases and Mental Health Water Quality Control and Surveillance. In addition, countries such as Australia, Italy, Greece, Korea, Spain, Sweden, the United Kingdom, the United States and the European Commission provided funding in accordance with the Iraqi WHO and MoH agenda and plan of action. Regular Budget Extra Budgetary Funding 98% Area of Work Amount Allotted$ Blood Safety and Clinical Technology 20,000 Child and Adolescent Health 20,000 Communicable Diseases Surveillance 190,100 Emergency Preparedness and Response 41,900 Evidence for Health Policy 60,000 HIV/AIDS 30,000 Health Promotion 110,000 Health Information Management and Dissemination 93,000 Disability / Injury Prevention and Rehabilitation 20,000 Immunisation and Vaccines Development 50,000 Mental Health and Substance Abuse 10,000 Making Pregnancy Safer 50,000 Surveillance, Prevention and Management of Non-communicable Diseases 50,000 Nutrition 48,000 Organisation of Health Services 190,000 Organisation of Health Services 265,000 Organisation of Health Services 210,000 Research policy and Cooperation 30,000 Total 1,488,000 Table to show breakdown of planned expenditure of Regular Budget Donor Source of Extra-Budgetary Funding in 2004 Sweden UNF Spain AUSAID DFID USAID ECHO EC UNDG ITF 30 31
Overall Challenges and Lessons Learned Next steps V: OVERALL CHALLENGES AND LESSONS LEARNED Challenges VI: Next steps Lessons Learnt The unpredicted security situation has led to limiting the numbers as well as movement of WHO staff. Following the Baghdad bombing on 19 th August 2003, WHO international staff was pressed to move to Amman, Jordan. Security remains one of the major challenges to program implementation in Iraq namely the localized security incidents and random bomb attacks. The office always worked with several scenarios when planning a workshop in Amman or in the Region. Flexible agendas and precautionary measures with bookings and travel were actions undertaken. The poor communication in Iraq has resulted in missed opportunities in capacity building where correct information could not be secured. WHO Iraq is currently utilizing the WHO sub offices in different regions as well as the focal points in certain governorates to follow up on the nomination of participants from governorates. WHO is using virtual communication methods, such as tele-videoconferencing and videoconferences on daily basis between the WHO Iraq office in Amman, its sub-offices and the MoH in Baghdad. Humanitarian and development activities are going on at the same time. WHO is providing support to humanitarian activities while providing technical advice for the development of health strategies and policies. Contingency planning and adequate emergency response to severe shortages in pharmaceuticals and other basic supplies in the context of violence and insecurity will continue to be a major challenge. The current level of unemployment and low wages in the public sector coupled with insufficient means to enforce legislation will continue to have a negative impact on the availability of essential and life saving medicines. Iraqis face great difficulties when applying for visas to certain countries. MoH participants, being Iraqis, bear with this difficulty when attending training courses in the referred countries. Due to security situation in Iraq, many countries do not have visa facilitation in Iraq which leads the WHO-Iraq office in Amman to work on obtaining visas for them from Jordan. The process is very slow and demands a lot of documentation and communication between Iraq, Amman and the country of training. Promotion of information management through appropriate technologies (internet, mobile phone, teleconference and video conference) and dissemination of publications both in English and Arabic enhances the implementation of various activities Partnership, communication and coordination between all stakeholders is essential for successful implementation at all levels. Establishing a clearing house for information in the MoH to verify information ensures clear and reliable reporting. Engagement of Iraqi counterparts at every stage of planning and implementation is essential to ensure ownership and congruence with their future vision. Building capacity at different hierarchical levels also ensures efficient and effective implementation of the programs. Regular visits to the local areas, are vital for correct situation assessments. Flexibility is required for implementation mechanisms as well as deadlines for project reporting to donors require when taking account the constantly changing situation in Iraq. More technical support from the UN is required than initially predicted, particularly in the areas of technical specifications of equipments to order. Years of isolation and lack of exposure to modern technology is a factor that is affecting the timely response and quality of inputs expected from some line ministries during the implementation. Under the current situation in Iraq, Jordan will continue to play an important role for coordination, consultation with Iraqi counterparts. While every effort is being made by the UN system to increase its presence in the country, there is still a need to continue reinforcing the capacity of the country offices temporally based in Amman. 32 33
Annexes Annexes VII: Annexes Conclusion LIST OF ABBREVIATIONS ARIs Acute Respiratory Infections CDs Communicable Diseases CDC Communicable Disease Control CPA Coalition Provisional Authority DDs Diarrhoeal Diseases EMRO Eastern Mediterranean Regional Office EPI Expanded Program for Immunization EHTP Essential Health Technologies and Pharmaceuticals FP Family Planning HCWM Health Care Waste Management IDP Internally Displaced People IEC Information, Education and Communication IHSS Iraq Health System Strengthening IMCI Integrated Management of Childhood Illnesses IMF International Monetary Fund IRFFI International Reconstruction Fund Facility for Iraq ITNs Insecticide Treated Nets MDGs Millennium Development Goals MoE Ministry of Education MoEnv. Ministry of Environment MoH Ministry of Health MoI Ministry of Information MoIA Ministry of Islamic Affairs MoMPW Ministry of Municipalities and Public Works MoPDC Ministry of Planning and Development Cooperation MoSA Ministry of Social Affairs MoWA Ministry of Women s Affairs NCDs Non-communicable Diseases NGO Non Governmental Organization NRIs National Research Institutions PDC Prevention and Disease Control PHC Primary Health Care RH Reproductive Health SM Social Marketing SCR Security Council Resolution UNDG United Nations Development Group SSI Surgery Site Infections WB World Bank WHO World Health Organization The past year has been a challenging and productive one. Although the security situation has acted as a significant hurdle, close collaboration with the Ministry of health and other line ministries has allowed WHO to provide reliable and steady support to the health system in Iraq. In 2005, WHO will shift from planning to the implementation activities in areas such as surveillance, emergency response, rehabilitation, human resource development and policy development. More than 100 staff will be functioning on the ground in Iraq and over 30 staff will continue operating from Jordan. Bearing in mind the changes in government that will be occurring, WHO will maintain close collaboration with the Ministry of Health to keep up existing activities and raise funds for new long-term, sustainable activities. WHO believes that building on national capacity is an essential path towards development in Iraq. In developing the countries potential and building new partnerships, WHO hopes to provide the Iraqi people with a healthier Iraq. 34 35