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Briefing on the Progress of Iraqi Health Care System Reconstruction

Presenters: William Winkenwerder, Jr., ASD (Health Affairs)
September 04, 2003 11:00 AM EDT

(Briefing on the progress of Iraqi healthcare system reconstruction.  Participating were Dr. William Winkenwerder, Jr., assistant secretary of defense for health affairs, and Jim Haveman, Coalition Provisional Authority senior advisor to the Iraqi Ministry of Health.)

 

     Staff:  Morning.  Today we have Assistant Secretary of Defense for Health Affairs Dr. William Winkenwerder, and Coalition Provisional Authority Senior Adviser to the Iraqi Ministry of Health Jim Haveman, to update you on how Iraqi health care system reconstruction is going.

 

     I'll believe you'll find Mr. Haveman's first-hand observations, after spending months in Iraq, very useful in reporting on this important subject.

 

     Dr. Winkenwerder?

 

     Winkenwerder:  Thank you.  Good morning.

 

     Following a trip I made to Iraq in mid-July, I provided a press briefing here describing the status of the Iraq health system, the health of the Iraqi people, and coalition efforts to work with Iraqis to rebuild their health system in a free and democratic society.  I reported at that time on a number of startling statistics, making clear just how degraded the health system had become under the Hussein regime, but also reported on a number of promising efforts that had just begun under the leadership of the interim Ministry of Health, and the senior adviser to the ministry, Jim Haveman, who works under CPA head, Ambassador Bremer.

 

     Jim, who had previously served as the head of the Department of Health for the State of Michigan, and who also has experience in international health, has been in Iraq leading a team, working with the Ministry of Health since the first of June -- so for the past three months.

 

     Jim has returned briefly to the United States, and is here today to give us an update on progress, and a valuable, very valuable, I believe, first-hand view from being on the ground, literally out and about visiting with dozens, if not hundreds, of Iraqi leaders and Iraqi professionals in the health system.  Jim and his team have been doing a remarkable job.  Although as he will describe, there are some significant challenges for the health system in Iraq, there are also promising indications of success, and there is tremendous progress that is being made for the Iraq health system and for the people of Iraq.

 

     With that, let me turn it over to Jim and have him come forward and share with you his observations.

 

     Jim?

 

     Haveman:  Thank you.  Good morning.  It's a pleasure to be here.  I have to be in the United States on emergency leave; my mother passed away recently.  And I'm now leaving for Iraq today, so I'll be leaving this afternoon.  But it gave me an opportunity to stop by and visit Health Affairs and also to get prepared to leave today for Amman, Jordan, and to Baghdad over the weekend.

 

     There's great potential in health care.  And what I would like to do is just talk a little bit about what's going on in Iraq.  And I've traveled to Basra, up to Tikrit, up to Kirkuk, and can kind of give you a sense of what the status is as we speak.

 

     What has impressed me is the potential of health care.  I had dinner not that long ago with some surgeons who in 1964 were doing kidney transplants, over a hundred a year in Baghdad.  And so some of the old physicians have a reference point to what it used to be, and they share that with young physicians, and the young physicians keep thinking about what it can be and how they can build on that and where it can be in the future.

 

     Saddam Hussein over the last 10 years took 90 percent of the health care dollars out of the health-care delivery system in Iraq. In 2002, the budget for 23 million in Iraq -- for 23 million people was $16 million.  That's a very small per capita, less than 40, 50 cents, compared to Jordan, that has a per capita of $80, and some of the other countries in the region of certainly higher than that. During that time, many palaces were built.  Out of the Al-Rashid, where I stay, I can see four or five palaces in and around Baghdad just from my window.  And minimal dollars of infrastructure were spent over the last 15 years.

 

     So we have 250 hospitals, but when you visit a hospital, you'll find them in very poor condition maintenance-wise.  I visited a hospital recently in Tikrit that overlooked the president compound, that has 116 buildings in it and has four to six different palaces, and it was a hospital of 400 beds, and the whole side of it was covered with steel so that the people in the hospital could not see into the compound, which was a mile and a half away.  And this was just typical of not only the attitude towards health care but also what it was doing to patients.  When the liberation took place, the first thing the hospital director did, and the military, is to take down those steel sheets that now sit in the parking lot, so at least the patients can have sunlight into their rooms right now.

 

     We found a country that -- the health care was geographically varied.  If you were a Shi'ite person in the south, health care and infant death rates were higher than they were in Baghdad, or if you were in Kurdistan or if you were in Kirkuk, health care standards were manipulated.  And many of the health care statistics, even prior to 2001, 2002, were suspect, because they were often made up to make it look good, and particularly, to blame the sanctions for what was going on in health care, which, I think, people are believing now and know that that is not true, because the funds were there to do everything that could have been done in health care.

 

     I found a system of purchasing drugs, equipment and supplies that was corrupt.  Any company that wanted to sell drugs to the Ministry of Health had to pay a 10 percent service charge, which went into an account in Amman, Jordan, which went into the Ba'athist treasury. There were also other service charges once equipment came into Baghdad from the intelligence, up to 15 percent.  So, we're beginning to believe that anywhere from 20 to 30 percent of drugs and equipment and supplies that came into Iraq were money -- the value certainly wasn't there as to what was purchased.  And what people did is they were just told to increase their price to pay the illegal prices, and that was funds that were being purchased through the oil-for-food program.

 

     Doctors were only being paid, in 2002, $20 a month.  Pharmacists who work for me were making $1 a month.  Generators were outdated in the hospitals, much as the equipment was.  Our estimates are when I toured our equipment warehouse the other day, the staff was telling me that upwards to 50 to 70 percent of the equipment in the hospitals, which had been purchased over the last 10 years, either wasn't working or was inadequate or was old equipment.  When I go to most of the hospitals, most of the regulators for IC units are all about 1980. You do not find defibrillators in hospitals.  I mean, none of that type of equipment was purchased.  Throughout this, though, the physicians community -- there's about 23,000 physicians, 39,000 nurses -- people provided basic services.

 

     The Ministry of Health building, 11 stories, was completely looted in Baghdad of all its furniture, of all of its computers.  We are now back into the Ministry of Health.  I go to the Ministry of Health every day for our meetings.  I don't have a separate management team for the Coalition Provisional Authority.  It's an integrated team with Iraqis.  As you know, yesterday, the new ministers were appointed, and Dr. Abbas, who was appointed as the new minister of Health, the interim minister, toured the Ministry of Health today with our staff.  And I'll be meeting with him next week.  And we'll certainly be installing phones and other communication at the Ministry of Health soon.

 

     What's important here is that the 240 hospitals of Iraq are operating; 1,200 primary health care clinics are operating.  Many of the clinics are scheduled, and are currently being remodeled through some of the Bechtel contracts, as well as through some of the other NGOs.

 

     The budget that I have from CPA, from July 1 until December 31 of this year, is $210 million, which is $20 per capita, which is significantly higher than what it was in the past.  We are currently putting $8 million out into basic infrastructure improvement of water, sewer.  We are installing over 128 generators.  I have $40 million in my budget to get stable generators into Baghdad, and we'll be going throughout all the country, in the hospitals, so that when the electricity might go off for two to four hours a day, the generators will be strong enough to carry the electricity through that day.  The previous ones did not.

 

     Since May 24, we have distributed 9,000 tons of drugs throughout all of Iraq.  This is up to Kurdistan, to Basra, different parts of the country.  Each truck holds anywhere from five to 10 tons, so you can about guess the number of convoys and trucks that we've put out into the country.  What has surprised me about the drugs is that there has been hardly any first-tier drugs available in Iraq because many of the companies would not sell and pay the service fee.  So many of the drugs were inadequate.  As you know, the oil-for-food program ends on November 21, and that's going to give us, as the Ministry of Health, and the Iraqis great opportunities to bring in the type of drugs that people have been wanting for some time.

 

     The equipment is old.  We have a Tiger Team, that I've called it, of volunteers of the various companies have given us over 100 engineers to go out and repair equipment, and that -- what cannot be repaired, we'll order the spare parts and get them fixed.

     We've trained over 500 security people, Iraqi security people.  I travel with Iraqi security people.  Iraqi security people are in the Ministry of Health.  We now have enough that we can begin placing them in the various hospitals in Baghdad.  And we are currently training people throughout Iraq as well to assume security within hospitals. This is extremely important to patients and for staff, especially in the evening, to get back to work.

 

     We are training EMS workers.  We just started a post-traumatic stress program for children and adults.

 

     And what's really important is that on August 17 and 18, we had a strategic planning meeting at the Ministry of Health.  I chaired it. David Nabarro from World Health Organization was a facilitator.  But in that room was the World Health Organization, the World Bank, UNICEF, the Red Crescent from Iraq, International Committee of the Red Cross; DFID, which is an organization similar to USAID, from the United Kingdom; USAID, the European Commission, CPA, representatives from my director generals who work with us at the Ministry of Health, as well as people from Basra and people from Kurdistan.  And we met for three days, setting the priorities for 2005 and 2006, because our 2004 budget has already been submitted.  And we came out of that committed to pool our efforts and support the Ministry of Health.  And here was a whole mosaic group of people working together for one purpose.

 

     And since that time, and during that time, we've had many countries step forward, from Japan and Egypt and Korea and Turkey, the United Arab Emirates, Spain, Italy, Saudi Arabia and others who come forward to want to help us remodel and rebuild, and also train staff.

 

     After the U.N. bombing -- and I was there about an hour and 15 minutes after it because right next to it we had a spinal injury hospital.  Seventy-six patients were in that hospital.  Most of them were paraplegic.  Most of them were quadriplegic.  They were children and adults.  It was virtually destroyed, and we had to move 76 people that night, which we were able to do.

 

     But we also put together an emergency response plan if something like this would happen again, and it did happen at the Imam Ali Mosque, as you know, in Najaf over the weekend.  And very quickly we were able to assemble a professional team from Baghdad.  We sent 15 ambulances, a refrigerator truck for the people who were killed, so that we could maintain them until they were identified.  We had 40 cylinders of oxygen.  We had 45 units of blood.  And we brought it down there.  And it was all Iraqi physicians, all Iraqi security. Visited several hospitals, not only brought 17 to 18 more severely injured people back to Baghdad for treatment, but, you know, showed that they could respond in an emergency.

 

     The challenges we face.  This is a country that was oppressed for 36 years.  I don't think people clearly understand the oppression and the isolation that the professional community of Iraq had for all these years.  I mean, the newest journal in some of the medical schools -- and there are 15 medical schools -- I picked up one the other day -- was a 1970 -- a 1997 journal of -- New England Journal of Medicine.  They're eager for new information.

 

     I don't think people were aware of the corruption that was going on.  Everything in Iraq was set up to make money for the former regime and to siphon money for palaces or to hide or to benefit the Ba'athist Party.

 

     Expectations when we came in was that this was going to be a quick fix.  It's not going to be a quick fix.  You don't repair hospitals that haven't been repaired in 16 years overnight, or the clinics.  You don't develop a health system overnight.

 

     One of the things we're doing with the priority-setting workshop is setting -- we set up -- I've set up 15 workgroups, about: What should the financing of the health system look like?  You know, where should the hospitals be located?  How do we do accreditation?  How do you work on human resources?  How do you develop a nursing profession? Those are the issues we're working on.

 

     And also the lack of communications.  Only about 3 percent of the people in Iraq had access to telephones.  And so communication is something.  And once the Internet gets up, not only would the type of training that can be done, but also to open the doors and windows of Iraq to the world.

 

     I went to Iraq as a senior adviser.  My role is to advise Ambassador Bremer on health care issues, but also to work with the Ministry of Health to make sure that it's strong.  And it's happening.  And I just want to certainly share that with you, that health care is being delivered.  There has been no major epidemics.  Their surveillance system of public health works.  I have about 37 people who are part of the CPA team.  And it's also an international -- I have people from the Netherlands, I have people from the United Kingdom, I have people from Italy, I have people from the United States.  And we work cooperatively to focus on what needs to be done to meet the objectives of a basic health care system that we can build on in the future in Iraq.

 

     So that's kind of my comments.  I'd be certainly happy to answer any questions.  Yes, sir?

 

     Q:  You mentioned that going in, you thought it was going to be a quick fix, and now you realize it's not.  What led to that preconceived notion that you had?

 

     Haveman:  It wasn't my preconceived notion.  I think it was many of the folks from the professionals -- Iraq thought that we could come in and very quickly the health care system would kind of be back to where it was, and now recognizing that to develop a health care system needs financing, and it needs training.  It needs to bring them up to date to modern techniques.  It's going to take the new purchase of the new drugs, and that's not going to happen overnight.  And also the remodeling of the hospitals, bringing in the new equipment -- that is something that can take place in a transition over the next few years.  And the Ministry of Health people are well aware of that, and the doctors are very accepting of that.

 

     Q:  Was this very surprising to you and your staff?

 

     Haveman:  Pardon me?

 

     Q:  Was this very surprising to you and your staff?

 

     Haveman:  No.  No.

 

     Q:  Or the folks at CPA?

 

     Haveman:  No.  No.  CPA people are very -- and I worked at the Republican Guard palace, and I also work at the Ministry of Health -- are very realistic about expectations, are very realistic about strategic planning, about what's our 30-day goals, what's our 60-day goals, and what are our six-month goals and what are our long-term   goals.  And in the 204 budget, which I submitted, we did set our priorities -- you know, to focus in on public health, to focus in on surveillance systems, to focus in on standing up some of the laboratories that were looted.

 

     We have already submitted our request for the donor conference, which would be held in Madrid, Spain, in October.  And we are focusing the budget of CPA on the operational issues for a health care system in Iraq and then saving the donor conference request and then some of the other countries that have come in for some of the major infrastructure issues of hospital refurbishing or refurbishing of primary health-care clinics.

 

     Yes, ma'am?

 

     Q:  What was the impact of the war on the health care infrastructure?

 

     Haveman:  The health care, prior to the war, was minimally offered.  And when the war happened, as you know, some of the hospitals were looted, some of the larger hospitals.  But even within that, physicians tried to come to work, nurses tried to come to work.

 

     Many of the drugs that had been diverted for other uses prior to the war were not being delivered, because the infrastructure wasn't there to do it.  After the war, the military and CPA was able to work with the Iraqis to develop that infrastructure.  So in May, the drugs began to flow again.  But I've got to tell you, they're flowing at a rate which significantly exceeds prior to the war of how drugs were being delivered.

 

     And many of the hospitals that were looted are scheduled to be repaired and fixed up.  And basic repairs have been done already.  And the war had a major effort -- impact on the Ministry of Health, as you know, in the looting of the building.  That wasn't -- much of the damage, as you know, in the infrastructure of health care was not done through the war efforts, it was done after the war efforts.

 

     Q:  You mentioned a budget of $210 million, but that's from when to when?  You said --

 

     Haveman:  From July 1, '03, to December 21 -- 31, '03.  So, it's the six months that we're currently in.

 

     Q:  And you have submitted a 2004 budget request?  I mean, how much more do you expect to need?

 

     Haveman:  Well, we hope to double what we currently have and then add some additional funds for pharmaceutical drugs that we know or want to purchase that are currently now being purchased by the Ministry of Health.  And we're currently in negotiations of that with Management and Budget.

 

     Q:  So, roughly double the 210 (million dollars) for, like, operating budget --

 

     Haveman:  It'll be a budget -- I daresay the budget for 2004 will be somewhere between $600 million and $800 million.

 

     Q:  And then, an additional amount for buying drugs?

 

     Haveman:  No.  That's within that amount.

 

     Q:  Oh, okay.

 

     And you mentioned drugs several times here.  I mean, talk about that a little bit.  Where were they getting drugs before, and where are you getting the drugs now?

 

     Haveman:  Well, we're currently within the oil-for-food- program, so there hasn't been any changes in the acquisition of drugs, because many of the contracts had already been let, even prior to the war, and they're being run by the United Nations under the resolutions and the World Health Organization.

 

     We are currently looking at what our acquisition priorities will be after November 21, when the oil-for-food program ends, and we'll be going to the market and buying those drugs in a transparent way, in a fair way, and looking at bids and looking at the priority of what drugs that we need -- and equipment that needs to come into the country.

 

     And actually, the Ministry of Health people have been so excited about putting together a formulary and putting together of their priority drugs.  I mean, they've heard about some of the new drugs for cancer treatment and cardiovascular treatment, and beta blockers they've heard about, some of the new psychiatric drugs, but they've just read about them.  But just to have access to them after November is something that they're really looking forward to.

 

     Q:  So basically, the drug contracts are all through the oil- for-food program, which ends, and that's when the contracts end, and that allows you to sort of start --

 

     Haveman:  Yeah.  Most of those contracts are with Jordan, with Syria, with India, with Russia, with China, with Sudan, things like that.

 

     Q:  Will that continue with those more local countries, or do you expect U.S. companies to get involved in that?

 

     Haveman:  Well, I think it's going to be more of a global purchase and it won't be focused into particular countries. And the biggest difference is that the corruption fee is gone, so we can now go to the open market and people can now bid and come to us with drugs of choice without having to pay the service charge.

 

     Q:  You talked about status of the infrastructure.  What about the status of the health of the people themselves?  If so little money was being spent on them, how healthy are they?  And what problems do they have?

 

     Haveman:  Well, infant mortality rates, 108 out of 1,000 children were dying, some of the highest --

 

     Q:  (Off mike.) -- U.S.?

 

     Haveman:  Pardon me?

 

     Q:  Compare that to the U.S.?

 

     Haveman:  Seven or eight.  The children under five was 131 out of 1,000, some of the highest in the world.  And it varied geographically around the country.  Our vision statement which we submitted to Ambassador Bremer basically talks about equality of health care -- accessible, available, affordable -- geographically, and there will be no religious discrimination in delivery of health care.  And our goal is to cut the infant mortality and the child mortality rate in half in 2005.  And that was a commitment that came out of our priority-setting workshop, that had UNICEF and WHO and the World Bank and everybody sitting around the table, including CARE, to make that happen.  And we believe it can.

 

     Now, we're also putting a lot of emphasis on vaccine rates. Vaccine rates -- UNICEF has been in Iraq for the last 10, 12 years and  have done a pretty good job getting basic vaccines there, and still do.  We have plenty of access to vaccine.  We have a "Vaccine Day" once a month that we widely publicize.  We put posters up around the country.  And vaccine rates in some areas are higher than other parts of the world.

 

     Q:  And the overall status of the adult population?

 

     Haveman:  Sixty to 70 percent of the childbearing women are anemic.  We're seeing some evidences of increased cancer rates, particularly in Kurdistan, where there were a thousand chemical attacks 10 years ago, and we're seeing evidence of that.  We're doing epidemiological studies on that.  General health care on a scale -- if you look at the World Health Organization different indicators of health care status, it's not good.  And it's improving every day.

 

     See, I believe very strongly -- and one of the reasons that I really welcome the opportunity to be a senior adviser there is that -- and I saw that in Michigan as well, and you see it elsewhere around the world -- that health care is key to any reconstruction.  It's -- it's key to any successful economic development.  I mean, there's no -- you know, the middle class -- I mean, all the money was with the Ba'athist group, and people were in a poverty situation. Well, for the country to really expand there's got to be a growing middle class.  We now pay our physicians between $160 and $260 a month.  And there's a new salary scale coming out that'll significantly increase that again.  So there's a growing purchasing power that the Iraqis are beginning to have, and that's the way this economy is going to turn around.

 

     Coupled with that, there has to be a strong health care system, because health care is key to recovery of any country.  So we're really excited about not only where we are in the current status, but also setting the platform for the future.  The challenges are still there, but they're all doable.  All the challenges are doable.

 

     Yes.

 

     Q:  What's the role of the U.S. military personnel in all this?

 

     Haveman:  I have physicians on my staff who are part of civil affairs and people who have been in Iraq.  Some of them have been there since the war in April.  We also work very closely with the various medical surgeons that are spread around the various parts of the country.  They do a great job in rural areas and in some basic health care.  They have liaisoned well with community groups.  Some --

 

     I mean, one of our objectives is -- because all health care was run by Baghdad.  And one of the results of isolationism has been -- is that people in the provinces -- and there are 21 provinces -- never had to make any decisions about health care.  I mean, there is no community boards at the hospitals.  There's no community participation historically in the primary health care clinics.  That's all changing now with neighborhoods being organized, and we're going to form boards for hospitals.  But the military has been a key to identify leadership and to also provide some basic services.  And it's been a good combined effort.  Yesterday, if I would have been there, I would have spoke to all the surgeons with the various groups around Iraq and to continue those liaison relationships.

 

     There are over 400 military physicians from different parts of the world in Iraq right now providing health care.  And we're also starting the lecture series -- I think it starts this week -- whereby we're inviting in various specialists in epidemiology and cancer and cardiovascular issues to present at the Baghdad convention center and inviting the Iraqi physicians in, and also inviting some greater dialogue between Iraqi physicians and the resources that are there. The Iraqi physicians are just eager to learn new techniques and the new procedures.

 

     Q:  Just to close the loop on something I asked you earlier, of the nine -- you mentioned 9,000 tons of drugs.  Is that something coming in under oil-for-food, or is that additional -- something that you --

 

     Haveman:  No, it's basically the drugs that we're bringing in through Jordan into Iraq, that we're distributing throughout the country and getting them out our warehouses.

 

     Q:  That's your program, not sort of the oil-for-food program?

 

     Haveman:  Yeah, it's the oil-for-food program, but we're accelerating it.  We're pushing it forward.

 

     Before, it was very interesting to watch, because -- and that's where the whole issue of equipment comes in.  The corruption was in buying the equipment.  When the companies then would want somebody to come to be trained how to do the equipment, the people that went to be trained were Ba'athist leadership who went on vacation.  So they never trained the technicians to fix the equipment.  So they just bought more equipment.

 

     So I mean, we --- when they buy a laptop computer, they would buy spare parts for that computer for five years, and that -- because that's where all the corruption was at the beginning, not at maintaining the equipment.

 

     Q:  Right.

 

     Haveman:  So it was in ordering it.

 

     So what we've done is an inventory in the warehouses to find out what we have and are identifying those and getting those lists out to the hospitals and clinics and saying, "Tell us what you need, and we'll go bring it to you."

 

     So before there was no concept of customer service; it was just -- there was 139 warehouses of stuff.  And there was no inventory that -- if equipment got old or if drugs got old and outdated, we could shift them around to make sure the drugs didn't expire.  So we're doing that as well, and we've really put in place an inventory control program.

 

     Q:  Thank you.

 

     Q:  Were those warehouses looted, though?

 

     Haveman:  Pardon me?

 

     Q:  Were the warehouses looted?

 

     Haveman:  Several of the warehouses in Baghdad were looted, and elsewhere around the country as well.  And we've got security at all the major warehouses now.  And where there was corruption and graft at the warehouses, and stuff was being sold illegally out the back doors, we've stopped that as well.  And quite honestly, the Iraqi people have really welcomed the stopping of that type of behavior.

 

     There's 100,000 people that work for the Ministry of Health, and there's very -- there's less than 30 multinational people who go into the Ministry of Health to work and be supportive.  The leadership of health care is the Iraqis and will continue to be so.

 

     Anything else?

 

     Q:  (Off mike.)

 

     Haveman:  Okay.  Thank you for your time.

 

     Q:  Thanks very much.

 

     Haveman:  Appreciate it.

 

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