Rebuilding Iraq’s healthcare system was not as much of a
priority to U.S. officials as some other parts of the country, but it faced
more problems than any other. First, a political appointee by the White House
was sent to the Health Ministry who wanted to change the entire medical system
whether the Iraqis wanted it or not. That led to a huge waste of time, and
shortages in Iraq’s hospitals. Second, the Americans failed to manage and
coordinate the work. Finally, contractors couldn’t build all the new facilities
the appointee wanted. The result was that Iraqis ended up lacking the medical
care that they so desperately needed just when violence was picking up.
The first major problem that emerged was the post-invasion
chaos. The Health Ministry’s offices in Baghdad were looted after the fall of Saddam Hussein just like the rest of the government offices. It was
estimated that six tons of paper was destroyed or taken out of the Ministry
during this time. Even after the Americans came in and tried to put the
Ministry back together, it was set on fire two to three times, causing more
damage. The U.S. therefore had to start from scratch with the Ministry. It had
to find and bring back all the workers. It also had to replace almost
everything in the offices themselves, and this happened several times, because
of the arson.
When the real work of rebuilding Iraq’s health system got
under way, the United States Agency for International Development (USAID) was
originally put in charge. The Coalition Provisional Authority (CPA) gave it a goal
of basic health services for all Iraqis. Out of the $18.4 billion that the U.S.
first allotted for Iraqi reconstruction, $786 million was set aside for health.
The CPA appropriated $439 million for 150 new primary healthcare centers and to
fix 17 hospitals, $297 million for medical equipment, a mobile blood collection
program, rebuilding the Academy of Health Science, training staff, and
technical aid to the Health Ministry, and $50 million for new pediatric
hospitals in Basra. While minor in comparison to the funds put aside for
electricity and water, this was still a large infusion of cash to Iraq’s
healthcare system. The problem was that what the U.S. wanted for Iraq was not
what the Iraqis wanted.
This started with a political decision by the Bush White
House. The USAID initially appointed Frederick Burkle Jr., a deputy assistant
manager at the Agency, to advise the Health Ministry. He had a master’s
degree in public health, was a teacher at Johns Hopkins School of Public Health
with expertise in disaster relief, and had worked in Kosovo, Somalia, and
Kurdistan after the Gulf War. He was sent to Baghdad immediately after the fall
of the regime. Within weeks of arriving however, he was told that he was going
to be replaced by a political appointee from the White House. The new Health
Ministry adviser was James Haveman Jr. He was formerly the community health
director for a Republican governor of Michigan, John Engler, and had some
foreign experience working for International Aid, a Christian relief group.
Engler recommended Haveman to Deputy Secretary of Defense Paul Wolfowitz, who
had him hired. Burkle was obviously far more qualified than Haveman. Not only
that, but Burkle had worked in Iraq before in 1991 in Kurdistan, giving him
some on the ground experience in the country. Since health was not a major
priority, the Bush administration probably felt like it was okay to hand the
task over to someone with political connections rather than a USAID official.
Haveman then went about causing a major conflict with the
Iraqis. He wanted to completely change the country’s reliance upon hospitals,
and build a series of small clinics that would concentrate upon preventive
care. Haveman believed this would provide greater care to Iraqis. He also
didn’t like the fact that healthcare was free in Iraq, and wanted people to pay
for their services. Finally, Haveman pushed to privatize the importation and
distribution of drugs in the country. This led to a series of bureaucratic
battles with the Health Ministry. In the end, Haveman went ahead with his plans
even though he never convinced the Iraqis of his point of view. This came at a
bad time, because demand for emergency care was taking off in Iraq’s hospitals
as violence started. People were regularly being brought in from bombings and
shootings, while hospitals were not getting that much money, because Haveman
wanted new clinics built instead.
Trying to reform how Iraq procured and handed out its
medicine became a huge fiasco. Haveman was in charge of changing drug
distribution when he worked in Michigan. He wanted to cut costs in the state,
and decided to achieve that by limiting the number of drugs that doctors could
prescribe to patients. He wanted to do the same in Iraq. There, roughly 4,500
medications were used, which Haveman wanted to slash. Furthermore, he wanted to
stop Iraq from buying its medicines from Syria, Iran, and Russia, and have it
purchase them from the United States instead. Haveman asked Washington for help
with the task, and got a three-man team from the Pentagon. They were to draw up
a new list of drugs to be used in Iraq in two weeks, and then go home. The head
of the team quickly found out that this was a ridiculous task. He thought the
existing list that the Iraqis used wasn’t bad, that what Haveman actually
wanted was a complete institutional change in how healthcare was to be
provided, something a three man team was not capable of accomplishing, and that
Haveman didn’t know what he was doing. Some of Haveman’s staff shared these
criticisms as well. These issues were never worked out. By the time Haveman
left the country it was facing a severe drug shortage. The Health Ministry said
that 40% of the medicines that were on its essentials list were out of stock in
the country’s hospitals, because of Haveman’s attempts at reform.
The companies that the U.S. contracted to build medical
facilities also ran into problems. In March 2004, the Pentagon gave a $243
million contract to Parsons to renovate 17 hospitals, fix three Health Ministry
buildings, and build 150 new healthcare centers. Later, the Special Inspector
General for Iraq Reconstruction (SIGIR) found that the firm was not meeting its
goals. It said that high staff turnover, poor management, and weak quality
control were the reasons. From May 2004 to the end of 2005 for instance, eight
contract officers, six program managers, and five sector leads had come and
gone. By September 2005, the U.S. told Parsons it had lost confidence in the
company, and reduced its workload as a result. Eventually, its contract was
cancelled. By then, it had only built 6 of the 150 clinics at a cost of $186
million, 76% of the original deal’s funds. The Americans then turned to Iraqi
contractors to finish the job, and they built over 100 clinics. SIGIR found
that much of this was shoddy work. In Tamim province, the Inspector General
found five clinics that were so badly built that they were a threat to the
safety of the staff and patients. The basis of Haveman’s vision for a new Iraqi
health system was the creation of a series of small clinics across the country.
Neither Parsons nor the Iraqi companies were up to completing this task.
Parsons had another contract to equip Iraq’s clinics and
hospitals. That was for $70 million. Supplies started arriving in Baghdad in
the spring of 2006 before any of the new clinics had opened. The U.S. was not
ready for this huge influx, and had the U.S. Army build a storage facility in
Abu Ghraib, just outside of the capital, to hold everything until the clinics
were operational. This was badly managed as well, as officials didn’t know what
equipment Parsons was ordering. They ended up losing some of it in the red tape
after it arrived in country as a result.
America’s attempt to rebuild Iraq’s healthcare system was
problematic from the start. The Health Ministry itself was gutted after the
U.S. invasion, the White House decided who should run the effort, and he came
in wanting to change how the entire system operated, which led to a series of
disasters. Americans often go into other countries thinking about their own
experiences rather than what the locals want or need. Iraq became a perfect
example of this. The result was a series of hospitals that were overloaded with
the dead and wounded from the insurgency and civil war, that didn’t have the
supplies that were needed. At the same time, a series of new clinics were
opened, some of which could not be used, because of poor construction, and which
were not created to deal with shootings and bombings in the first place. The
U.S. came into Iraq with good intentions, hoping to leave the country a better
place, but its work on healthcare showed how bad things could get.
SOURCES
Chandrasekaran, Rajiv, “Ties to GOP Trumped Know-How Among
Staff Sent to Rebuild Iraq,” Washington Post, 9/17/06
Special Inspector General for Iraq Reconstruction, “Hard
Lessons,” 1/22/09
2 comments:
Have you seen any occupation force rebuild an occupied land? In fact the Americans destroyed out health system during the sanctions. We used to have the most developed and advanced health care system in the ME. We had the best hospitals and free healthcare. Now all this has gone for ever. After having the best physicians, now we are contracting 1000+ doctors and nurses from India.
I would say Germany and Japan came out pretty good after WWII. The problem was the complete failure at planning done by the Bush administration for the post-war situation in Iraq, then a series of bad decisions after the invasion, followed by the insurgency and civil war is what sunk the reconstruction of Iraq. And Iraq's healthcare was pretty good by the 1970s, but then the Iran-Iraq War, and the invasion of Kuwait/sanctions sunk the system.
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