Thursday, October 11, 2012

Rebuilding Iraq’s Healthcare System In A War Zone

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.


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


عشتار العراقية said...

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.

Joel Wing said...

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.