War, prolonged sanctions, and the government’s inability to provide basic services consistently have resulted in the progressive deterioration of Iraq’s once well-performing health system. Hospitals that survived the fighting are often poorly maintained and chronically short of supplies, medication, equipment, and qualified medical staff. This adds to the challenges of providing emergency care and limits the ability to provide long-term treatment of chronic conditions, especially among underserved communities. “This is the worst situation we’ve faced in my memory,” explained Sadraddin Hariry, the manager of the government-run Helena Health Center for disabled and handicapped children in Erbil. “We weren’t really able to meet the needs before these crises and now we lack supplies and are overcapacity with patients displaced from other parts of Iraq, as well as refugees,” he said.
 
Iraq’s emergency support is organized by the Humanitarian Response Plan (HRP)—a comprehensive strategy for Iraq put together by the United Nations Office for the Coordination of Humanitarian Affairs, its humanitarian partners, and the Iraqi government—in clusters such as health, food security, and education. Within this framework, international and local health partners report to the World Health Organization to coordinate and provide medical services in Iraq. The humanitarian imperative to save lives means these actors focus on emergency response first, and other healthcare needs come second. “You don’t have that much time to establish full health systems and do capacity building in emergencies,” explained Fawad Khan, the WHO Health Cluster Iraq coordinator. “Health is for all, but no one has the capacity to go for all, so we target 60 to 70 percent of the needs,” still a massive undertaking given that the HRP estimates as many as 11 million of Iraq’s 36 million people are in need of some form of humanitarian assistance.

Under strain from protracted conflict, displacement, and a budgetary crisis, Iraq’s health system is struggling to care for the physically disabled.Physiotherapist Eman Tariq Khurshed holds an orthotic device at the ICRC Physical Rehabilitation Center in Iraq's Kurdistan Region. Photo by Angela Boskovitch, July 17, 2017.

Through the HRP, these humanitarian partners aim to reach 6.2 million highly vulnerable people by the end of 2017. Health partners provide not only emergency response, but also train medical staff, including in trauma care and triage, management of exposure to chemical agents, and outbreak management, according to Lise Grande, the United Nations Humanitarian Coordinator in Iraq. At the request of the Ministry of Health and depending on available funding, they also support local medical facilities struggling to cope under the strain of interconnected crises by providing medicine, medical equipment, and trained staff. WHO, as head of the Health Cluster, provided more than $18 million in medicines and medical equipment in 2016 to help fill the gaps, which are especially pronounced in the public sector. 

At 3 percent of GDP, the share of Iraq’s budget allocated to the health sector is low compared to other Middle East and North African countries, which average around 5 percent. Many Iraqis pay significant amounts out-of-pocket for medical services at private facilities they deem of better quality. But for families without the resources for costly private clinics, public hospitals and health centers remain one of the few options. Government-run facilities that provide services secondary to the emergency health response, particularly those treating long-term disabilities, struggle to provide cost-free treatments. Humanitarian organizations try to make up some of the shortfall. For example, the International Committee of the Red Cross (ICRC) Physical Rehabilitation Center in Erbil, where all services are also free of charge, is relieving some of the strain on clinics that serve the physically disabled, such as the Helena Center, which is part of the Erbil General Directorate of Health. 

Under strain from protracted conflict, displacement, and a budgetary crisis, Iraq’s health system is struggling to care for the physically disabled.Technicians at the ICRC Physical Rehabilitation Center in Erbil make prosthetic limbs designed to fit each patient. Photo by Angela Boskovitch, July 17, 2017.

Yet even the large organizations have their limits. For instance in the Kurdistan Region, facilities struggle to respond to the needs of the more than 1.4 million displaced Iraqis and refugees from nearby countries that are registered in the region as of December 2017, according to the Kurdistan Regional Government. Medical facilities in the Erbil Governorate not only serve families living in the Kurdistan Region, but those who have fled there. In addition, the conflict is driving a rise in war-related disabilities which require long term care and prostheses. Around 60 percent of the amputation cases received by the ICRC Center are war-related, and of those 36 percent are caused by mines, according to the center’s manager Srood Suad Nafie. “We’re trying to balance the needs of war-wounded and displaced Iraqis with those of the local community,” he explained. The ICRC Center now provides services to up to 50 people a day, and there is a waiting list of three months before those with disabilities can receive a cast for a prosthetic or an orthotic device.

More recently, such centers have also expanded their services to caring for long-term chronic conditions that have left adults and children disabled, and whom the public sector is struggling to serve. Statistics on disabilities in Iraq are hard to come by, but Ghassan Al-Alousi, the ICRC Center’s prosthetic and orthotic team leader, posits there are a high number of cerebral palsy cases, for example, in part because of the state of the country’s health system. Cerebral palsy—caused by damage to the fetal, infant or child’s brain from trauma or infections—may be exacerbated by wartime situations and a lack of experienced physicians. According to a 2011 study at Baghdad’s Central Hospital for Children, to which cerebral palsy cases from across Iraq are referred, doctors reported unprecedented numbers of children diagnosed with the disease annually. The study attributes this to the decline of obstetric and neonatal services over the past few decades.

Under strain from protracted conflict, displacement, and a budgetary crisis, Iraq’s health system is struggling to care for the physically disabled.The pharmacy at the public Helena Health Center. Photo by Angela Boskovitch, August 13, 2017.

A lack of materials and a shortage of specially trained staff contribute to the public health centers’ struggles to treat the high numbers of patients. The Helena Center, for example, was unable to make prosthetic limbs until receiving supplies from an international organization, as the Erbil Health Directorate had been unable to supply gypsum and plastics to manufacture such devices since 2014. Youssif Taher Sultan, the Helena Center’s longest-serving physiotherapist, recalled a time when medical staff made home visits to disabled children in hard-to-reach areas. “Now we don’t even have cars to send our therapists out.” As state employees, medical staff in Erbil’s public clinics have also had their salaries cut since 2015 by as much as fifty percent and working hours reduced on account of Iraq’s budgetary and political crises. In an intermingling of health systems, private practice physicians volunteer at short-staffed public clinics, bringing with them experience with newer medical technologies. As part of its longer-term outreach, the ICRC, one of the largest international organizations operating in health in Iraq, is urging the ministries of higher education and health to upgrade physical rehabilitation studies in the country to meet the growing need for skilled medical providers for people with disabilities.

Amid interconnected crises, Iraq’s already compromised public health system is struggling to provide adequate support to the growing numbers of people with disabilities and chronic diseases. Restructuring and developing the health system for the long term depends on a massive mobilization of resources in the post-conflict period. In the meantime, local and international organizations will continue to have to fill gaps in the existing system to provide a minimum standard of care to the most vulnerable. People with disabilities are doubly victimized by war, the top United Nations Humanitarian Coordinator for Iraq Lise Grande underscored. “They suffer the most during crises. First, because it is very difficult for them to physically flee and second, because when they reach safety, they often struggle to access the kind of specialized services they need.”
 
Angela Boskovitch is a researcher and project coordinator working in Egypt and Iraq. Follow her on Twitter @aboskovitch.‏