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Hyunsoo Chung

L Karim, MM Sadat, D Larkin, E Yones, S Resool, CM Wiskin

College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom

Media reports have suggested that the Kurdistan region is the only state to have economically and politically benefited from the Iraq War. However, the literature regarding the impact of the war on medical care in the region is minimal. A descriptive, interview-based study was conducted with the aim of assessing whether the quality of medical care provided to patients in a local Kurdish hospital has improved since the fall of Saddam Hussein’s regime. With more studies such as these will improve the breadth of knowledge surrounding the changes to Kurdistan following the Iraq War.

Twenty patients from a local district general hospital were interviewed: 11 men between the ages of 35 to 70 and nine women between the ages of 33 to 60. The data were interpreted and coded into specific and fundamental themes. The derived themes included lack of punctuality (90% of patients described this), long waiting times (70%), lack of one-on-one patient-doctor consultations (95%), lack of female doctors in the hospital (50%), financial incentives by inappropriate private clinic referrals (100%), lack of vital investigations (100%), lack of anesthesiologists and cancellation of surgical operating lists (100%), lack of documentation (40%) and poor hygiene (100%).

There was general dissatisfaction with the quality of services provided at the local hospital, and all of the patients stated the quality of healthcare had remained the same or declined since the Iraq War. The authors attributed this to the lack of medical resources and funding, inconsistent disciplinary tribunals, poor internal auditing system and breakdown of communication locally and nationally that were consequences of the war.

Introduction

Media coverage suggests that there has been a general increase in the standard of living in the Kurdistan region since the invasion, but less is known about healthcare trends.1,2 This descriptive study aimed to interpret patients’ personal views to determine whether there has indeed been an improvement in the quality of health care provided at a local Kurdish hospital since the 2003 Iraq War. In more economically developed countries, effective health service is dependent on the feedback of the patients served and that their views should be at the heart of any policies made.3 Due to cultural and social differences, the feedback process is less consistent in Iraq, so this project provided a relatively novel opportunity to interact with patients in this way.

The Kurdistan region is a semi-autonomous state within the Republic of Iraq. Since the 1991 uprising, in which the Kurdish political parties regained control of major Kurdish cities from Saddam Hussein’s regime, the Iraqi Kurds have enjoyed the privilege of self-rule. They currently have their own regional government, national assembly and ministries that are democratically elected every four years.2,4

Since the liberation of the Kurdish cities by the Patriotic Union of Kurdistan (PUK) and Kurdistan Democratic Party (KDP) in 1991, the Kurdistan region was divided among two different political ideologies for an extended period of time. New borders were defined: the Duhok Province and the majority of the capital Irbil were under the control of the KDP, while the entire Sulaimany Province and the remaining portion of Irbil fell under the jurisdiction of the PUK.5,6

In 2003, a United States-led coalition invaded Iraq to end Saddam Hussein’s reign.7 Since then, a democratically-elected federal government was installed within Iraq, while simultaneously the Kurds were granted semi-autonomy in the North.4 The Kurdish leaders decided to end their localized tiers of government and unite to form the Kurdistan Regional Government. Interparty conflict was resolved to form a single government covering the entirety of the Kurdistan region.5

In this political context, we focused specifically on the Shahid Doctor Xalid Hospital which is located in the town of Koysinjak, situated within the Irbil province with a population of approximately 200,000. The Shahid Dr Xalid hospital was the only public health providing service in the area at the time of this study. A relatively small hospital, it consists primarily of an emergency department that serves 500 to 600 acutely unwell patients each day. There are also general surgical, general medical and pediatric departments within the hospital that work both acutely and electively in an independent manner. The closest alternatives to the Shahid Doctor Xalid Hospital are the various private- and state-owned hospitals in the cities of Irbil and Sulaimany, which are 70 minutes and 100 minutes away respectively. These are tertiary hospitals and therefore provide a wider range of services to treat a broad spectrum of diseases and ailments. Since 2003, the town has been a strong supporter of the PUK, and prior to the Iraqi invasion it was part of the Sulaimany Province.5 There is speculation that political divisions still exist within the Kurdistan regional government, with each party only serving the regions previously under its jurisdiction prior to the war. Koysinjak, although a supporter of PUK, is currently governed by the Irbil province, which is predominantly controlled by the KDP. As a result, support and provision of resources have been inconsistent and insufficient.4

During Saddam Hussein’s four-decade reign, medical education and healthcare in Kurdish regions were neglected: the hospitals lacked basic medicine and equipment to deliver standard care to their patients. Not much is known or understood about health trends in Kurdistan before the war due to the lack of health governance and health economics in the region since 1991.1

Since 2003, the Kurdistan Ministry of Health has invested a substantial amount of capital into its hospitals in hopes of increasing the overall quality of medical care.3,8 The Shahid Doctor Xalid Hospital is representative of a majority of hospitals in the Kurdistan region in terms of size, locality and medical resources available. The town’s political affiliations and complexities make it an ideal place to study trends. The literature currently available on the operations of Iraqi Kurdish hospitals before and after the 2003 war is minimal. This study will add to that literature and support increased health promotion in the region.

Method

This descriptive, interview-based study was conducted in May 2011. Any patient present at the hospital was considered eligible for participation, provided that supervising clinical staff deemed it safe for the patient to do so. Safety was assessed by determining whether partaking in the interview posed a threat to patient’s life or to the lives of immediate friends or family.

Patients were included in this study only if they had experienced both the previous and current healthcare systems, so that comparisons could be drawn from their responses. Patients suspected of being coerced by an external individual (family member or staff) were excluded from the study. This suspicion was evaluated by analyzing the patients’ communication and body language towards the researcher and others in the immediate vicinity. Patients under the
age of 16 and individuals who lacked capacity to answer questions (e.g. known learning difficulties) were also excluded. Prior to the interview, all patients were assessed for capacity. They were each asked a direct question, and if they were able to understand, retain the information, make a decision and communicate the answer coherently, then they were allowed to proceed with the interview. Patients who aired concerns that were not resolved effectively by the lead researcher at the beginning of the interview were also excluded. Ethical approval was granted by the directors of the Shahid Doctor Xalid Hospital.

Using convenience sampling (based on availability, wellness and access), patients were randomly recruited, asked for consent and interviewed about their personal experiences. Patients awaiting outpatient appointments were approached and asked whether they would like to participate in the interview. Patients were recruited daily over two weeks. Semi-structured interviews were conducted to obtain data verbally. Questions invited patients to reflect upon how medical care had changed since the invasion.

Interviews were conducted in Kurdish by Lawen Karim, a fourth-year medical student studying in the UK. He had familiarity with the cultural setting and spoke the native language fluently. He was not known to patients as one of their care providers, and his relationship with patients was developed only during the study period. Participants were made aware of the purpose of the study at the introduction of each interview, and any concerns highlighted were addressed promptly prior to starting.

If a patient was clearly uncomfortable or appeared unable to answer the question freely, the interview was terminated. With patient consent, voice recorders were used to record the interview, supported by hand-taken notes. The former was not used if the patient expressed any discomfort or concerns. All verbal data were transcribed and analyzed for themes using hand coding prior to their destruction. At the end of each interview, the researcher summarized key messages and themes back to the participant for comment, confirmation and/or correction.

Results

Eighty patients were approached, and 23 gave their consent to being interviewed. Twenty had attended the hospital prior to the Iraq War in 2003. The three patients who had not been present during Saddam Hussein’s regime were excluded. Participants included 11 males aged 35-70 and nine females aged 33-40.

The 20 patients interviewed all concurred that they were not satisfied with the quality of medical services provided in the hospital since the Iraq War. Fifteen patients stated that the quality of health care had not changed since Hussein’s era, and five mentioned that there had been a severe decline.

Nine themes emerged in the patients’ responses that were described as areas of serious concern, regarding conditions that had deteriorated since the Iraq War. These existing issues from Saddam’s era had been exacerbated due to political, social and economic turmoil. Each concern is presented below.

(1) Punctuality

Eighteen patients were concerned with the doctors’ punctuality in attending ward rounds and out-patient clinics. Doctors are expected to arrive every morning at the ward around 8AM. This arrival time is vital, as it allows doctors to assess new admissions and follow up on the care of current patients. A full history is taken, followed by the booking of relevant examination and appropriate investigations. The doctor is then expected to attend an outpatient clinic relevant to their specialty until midday. These were derived by the hospitals internal guidelines and the researchers’ observations. However, patients stated that doctors would take leave without alerting the administrative team.

“The doctors were taking two, maybe three days off without letting the hospital know.” Patient, male, aged 38.

Members of the administrative team are often unable to find replacement doctors at such short notice. However, even more common was the problem of clinicians not attending ward rounds and outpatient clinics at the times allocated to them.

“We would go days without seeing a doctor because they are always turning up late, and sometimes they just would not attend. This was happening in Saddam’s time as well. We thought it was going to stop. It hasn’t—it’s just getting worse.” Patient, female aged 55.

In the hospital there is no employment of a “disciplinary tribunal” (or the equivalent) to prevent and investigate uninformed absences and poor punctuality. Many patients believed that doctors were taking advantage of the lack of repercussions. Acutely ill patients with red flag symptoms were denied basic medical care necessary to ensure a good prognosis.

“I have been waiting here from 8:30AM to see the doctor (she points to clock), it is 11:04AM and the doctor is still not here.” Patient, female, aged 43.

(2) Long waiting times

Of the 20 patients, 14 complained about the long waiting times for a consultation with the doctor. For each specialty, there is a maximum of two clinicians available every day from 9:30AM-1:00PM. This means that patients are being seen at a slow rate. “There are too many patients for the doctors to deal with. There are many people who go days without being seen by a doctor.” Patient, female, aged 33.

Like many other hospitals in the Kurdistan region, there is no appointment system in place to allow patients to contact the administrative team in advance to set a time and date convenient for all parties involved. “The waiting times just seem endless, there appears to be no system in place like a queue or an appointment system like there is in Europe.” Patient, male, aged 69.

As well as the obvious frustrations for the sick and their families, these waiting times make it difficult for doctors to predict the number of patients that will be at the outpatient clinic. With limited number of clinics and clinicians, not all the patients can be seen by a physician; those who are lucky enough to receive a consultation are rushed by time constraints. On average, the doctors only have three to five minutes to spare with each patient. “The person who sees the doctor first is the person who is physically able to barge and push through the large crowds to get to the front. This has been an ongoing problem since I can remember. It was like this before the war, too.” Patient, male, aged 55.

(3) Lack of one-on-one patient-doctor consultations

Of the 20 patients, 19 stated that there is no access to one-on-one consultations with doctors, as there are always other patients present at the consultations.

As stated above, there is a noticeable shortage of physicians and no appointment booking system at the hospital. To combat the long waiting times, doctors allow more than one patient to wait in the consultation room at any given time, believing that it will reduce the clinic queues and hopefully decrease the number of patient complaints.

“Nothing has changed! In the consultation it isn’t just me and the doctor—it’s me, the doctor and three or more other patients. The doctors are letting patients in the room three at a time to combat the long queues outside. I find this very uncomfortable as there are certain things I want to tell the doctor without anyone else overhearing.” Patient, female, aged 45.

There is a serious ethical concern here: patients are being seen by doctors in the presence of other patients. Having to share personal information so publicly can be a very uncomfortable experience, especially in small towns such as Koysinjak where most people know each other. Many of the patients that were interviewed complained that they have held back vital information to the doctor to mitigate their embarrassment.

“Sometimes I don’t tell the doctor all of my symptoms. I hold back most of the personal stuff due to there being other people in the room.” Patient, female, aged 33.

In addition to obvious negative implications for diagnosis, this phenomenon also compromises an individual’s right to privacy.

(4) Lack of female Doctors

Of the 20 patients, ten patients (nine of whom were female) stated that there are not enough female doctors at the hospital. At the Shahid Doctor Xalid Hospital, there is currently only one female pediatrician. Some women with obstetric or gynecological problems felt embarrassed about consulting with a male doctor, stating that they would forego hospital visits and endure their symptoms for a longer period of time.

“I just feel embarrassed when I have to talk to male doctors about problems down there (referring to gynecological problems). If I know that a male doctor is heading the clinic then I just don’t attend. There were more female doctors during Saddam’s regime.” Patient, female, aged 40.

Addressing this problem would require a significant shift in staffing, which would not be without difficulty in such a male-dominated environment. Yet the consequences of withholding such a choice appear dire for female patients with serious conditions.

5) Doctors referring patients to their own private clinics

Of the 20 patients interviewed, all of them stated that doctors are not providing patients with the adequate quality of medical care at the hospital. Instead, patients are being referred to the doctors’ private clinics, which charge significantly higher fees.

Patients who visit the Shahid Doctor Xalid Hospital are expected to go to a reception area where they purchase a ticket for a set price. Without this ticket, the doctors are not allowed to see the patients in their clinic. The ticket contains the patient’s name, date of birth and investigations sheet, which is necessary for the physician to order any relevant tests. If any investigations are required, the patient takes the ticket to the Investigations Department.

Each investigational test also has its own set cost. The Kurdistan regional government has set these prices in all of the hospitals, which are under its constitutional jurisdiction, under the belief that they are affordable and fair. However, the majority of doctors at the Shahid Doctor Xalid Hospital run their own private clinics in the afternoon, where they charge for the consultations and investigations at higher rates.

“In Saddam’s time, doctors used to work for free. They used to care for the population. Oh, how things have changed. The hospital charges for consultations and investigations at a reasonable and cheap price. Some of the doctors are refusing to see us and they refer us to their private clinics with the promise that we will get a better service. This is not true at all—if anything, the service is worse. The only difference is that they charge us ten times mores [sic] than the hospital does.” Patient, male, aged 41.

According to patients, there have been cases of doctors refusing to see the patients at the hospital and referring them to their private clinics in order to increase private revenue. There are, again, obvious ethical and clinical issues inherent in this, and currently no governance system exists to protect patients from manipulation or financial risk. “I have had to pay 30,000 Iraqi dinars [30 USD] for a consultations and relevant investigations at one of these so called private clinics. This is too expensive, as the hospital only charges less than 1,000 Iraqi dinars [1 USD].” Patient, male, aged 70.

(6) Lack of vital tests and investigations available

Of the patients interviewed, all 20 claimed that the investigations facilities at the hospital are poor. There are certain investigations and tests that are not available.

“The only tests that the hospital seems to have are those for blood pressure and glucose testing. For the main hospital in Koysinjak, which is a relatively large town, this is unacceptable. The town has gone backwards since Saddam’s time. How is this possible?” Patient female, aged 59.

This means that the doctors have a more difficult time diagnosing patients, and that patients are referred to hospitals in neighboring towns and cities. The closest hospitals that offer a wider range of investigations are a distance away in Irbil and Sulaimany.

“I have problems with my liver. The hospital does not have the equipment and the facilities to check whether or not my liver is functioning well. They send me to neighboring cities like Erbil and Sulaimany for these tests. This is really inconvenient, as it means taking a day off work to travel an hour for a basic test, which should be readily available in Koysinjak.” Patient, male, aged 65.

Patients have to drive long distances for simple tests, such as those for thyroid and liver function. Based on these findings, access to healthcare may be burdensome and may be a barrier to receiving any help for some.

(7) Patient notes are not documented and stored

Of the 20 patients interviewed, eight were concerned that there was no system in which the doctor can review notes prior to a consultation and update them afterwards. The hospital currently has no effective system of documenting patient medical records. This lack of records affects patients with chronic illnesses who must attend consultations more often than those who have acute diseases. Because there is a lack of patient notes, doctors have to take down the same history every time the chronic patient attends.

“I have suffered from diabetes for ten years now. Every time I attend the consultation, the doctor doesn’t know who I am, what complications I have developed and how my diabetes has progressed because no notes have been documented. Every consultation becomes a clerking appointment, where the doctor takes a full history. I am not a doctor, but surely for something which is long-running like diabetes, would it not be better to take notes to monitor the disease more effectively?” Patient, male, aged 69.

As explained above, this record keeping is something the doctors simply do not have the time to do, due to long waiting times from the lack of physicians and clinics. As a result, patients with chronic conditions are not being provided with the essential follow-up needed to manage their disease effectively. The establishment of a basic patient record system would decrease waiting times and simultaneously increase consultation quality. 8

“The doctor will prescribe you medication at one consultation, and would tell you to return a week later to check if it is doing its job. When you return for the consultation, the doctor has forgotten who you are, what symptoms you presented with and what drugs he prescribed you. Unfortunately, this has always been the case in Iraq.” Patient, male, aged 35.

(8) Lack of Anesthesiologists

All 20 patients stated that all scheduled surgeries have been cancelled at the Shahid Doctor Xalid Hospital, due to the shortage of anesthesiologists in the Kurdistan region and the Republic of Iraq as a whole.8

As reported, this lack of anesthesiologists at the Shahid Doctor Xalid Hospital means that surgical theatre lists are regularly suspended. Transfer to hospitals in neighboring cities poses additional challenges to the seriously ill.

“All surgery has been cancelled at the hospital because there is shortage of anesthetic doctors. I needed emergency surgery for my stomach, so I was sent to Hawler (Irbil). Koysinjak is a large town; I think it is embarrassing that the government does not send us any anesthetic doctors. Surely, it’s just making the hospitals in the larger cities more busy [sic].” Patient, female, aged 35.

(9) Lack of hygiene and cleanliness in and around the hospital

Twenty patients complained about the general standard of hygiene in and around the hospital. From patient responses, it appeared that the hospital was not maintaining an adequate standard of hygiene to provide effective care. “It is absolutely disgusting here, I have seen toilets in restaurants cleaner than this.” Patient, female, aged 38.

At the time of the study, the hospital did not employ cleaners; the nursing staff was responsible for the task of cleaning. With staffing issues and constraints, this extra work for the nurses compromises the quality of care provided to patients as well as the basic hygiene levels. “There is blood everywhere. The staff just walk past oblivious to it. It seems to be cleaned only once a week.” Patient, male, aged 65.

Discussion

Most issues at the Shahid Doctor Xalid Hospital can be attributed to a breakdown of communication between the different healthcare professionals within the hospital and the Ministry of Health since the war. Corruption has been speculated to prevail within the Kurdistan regional government.9 Evidence suggests that the yearly budget the region receives from the central government is not divided fairly among the various ministries. Some politicians have been accused of stealing, leaving only a small amount to sustain a failing medical system. Corruption also existed during Saddam Hussein’s reign, but due to his dominance on media outlets and restriction on freedom of speech, this corruption was not as publicized as it is today.10,11

Regionally, there is a belief that a political divide still exists since the formation of a unified Kurdistan regional government.9,10 Koysinjak is renowned for its support of the PUK, and there is an argument that funding and deliverance of resources and new doctors to the area has decreased due to the ongoing rivalry between political parties. This theory has been denied by many politicians within the Ministry of Health.7

Since 1991, when the Kurdish political parties regained control of the Kurdistan region, lack of funding from the central government of Iraq increased neglect of health care in the Kurdistan region. The issues described above all stemmed from that era and conditions have continued to decline as a result of poor management by subsequent governments.7

The Kurdish Regional Government’s Ministry of Health has given many hospital directors the autonomy to oversee their own affairs. This independence was also the case during Saddam’s reign. This system can only be effective if the regional government is performing regular appraisals of the hospital and its ability to deliver the best quality of care to patients. Unfortunately, the appraisals for the Shahid Doctor Xalid Hospital are inadequate to allow this system to operate efficiently and effectively.

There is currently no audit system in place at the Shahid Doctor Xalid Hospital to identify potential high-risk concerns that prevent the optimal delivery of medical care. This information would be valuable to both the hospital and the Ministry of Health to identify common problems and set new guidelines to prevent them. Audits can also identify the need for certain resources, such as more investigative tests, new doctors, better cleaning facilities and more clinics.

Within the hospital, there is currently no tribunal to deal with disciplinary issues involving doctors, nurses and other healthcare professionals. Members of the staff seem to have the freedom to behave unethically without the fear of punishments and investigations. There are ethical issues with this lack of discipline that must be addressed promptly.

Conclusion

This study aimed to explore whether the quality of health care has improved in the Kurdistan Region since the Iraq War. All of the patients interviewed had stated that healthcare provision and deliverance has remained the same or declined. The following issues were derived from their responses: poor punctuality, long waiting times, lack of one on one patient-doctor consultations, lack of female doctors in the hospital, financial incentives by inappropriate private clinic referrals, lack of vital investigations, lack of anesthesiologists and cancellation of surgical operating lists, lack of documentation and poor hygiene.

“We thought things would improve after Saddam’s regime had collapsed. Yes, we are without a dictator now and are blessed with freedom of speech. However, our basic needs are not being met. We have poor health, education, water and electricity services.” Patient, female 38.

Access to healthcare is a basic human right. The Kurdistan regional government and its local hospital officials must execute changes to ensure that people’s needs are being met in a cost-effective way.

The hospital could introduce an appointment system that allows patients to contact the administrative team in advance to set a time suitable for all parties involved in the process. Measures must be taken to develop a disciplinary tribunal consisting of senior staff to prevent and investigate unethical practices by doctors. The hospital is in need of expansion to ensure that there is more than one clinic per specialty, that there are more than two doctors per specialty working every day and sufficient female doctors.

Doctors and nurses should be encouraged to increase efforts to ensure that patient notes are recorded and stored in a secure location. By employing a dedicated cleaning staff, hygiene levels would also improve while simultaneously allowing nursing staff to focus on patient care. Finally, regular audits could be performed by the hospital to identify problems, set new guidelines and account for resource deficits.

Limitations and Future Directions

The study identified patients who had experienced the health system at the hospital both before and after the end of Saddam Hussein’s regime so that comparisons could be made to determine the extent of change. When patients were invited to participate in the interview, the purpose of the study was explained to them in full. As a result, it was impossible to fully eliminate response bias, and the results could have been skewed by patients with ulterior motives or incentives. Response bias was reduced by using a clear language that patients could easily comprehend, offering options throughout the interview for the patient to speak freely and selecting questions n a specific sequence to prevent order and inherent biases.

The study analyzed the responses of 20 patients, and although this number fulfilled our inclusion criteria, the small sample size could have affected the statistical significance of the results by increasing the effects of random biases.

Interviews are an effective way to document a narrative history which can subsequently be explored.12 This documentation is dependent on the interviewer having integrity and developing a good rapport with the patient, i.e., a face-to-face interview. Face-to-face interviews are not anonymous, and are therefore open to influence. Mismanagement in this sensitive context could have led to misleading or “political” responses.12,13

The results of this study are specific to a particular hospital, and so may not reflect the conditions of other hospitals in the Kurdistan region. The findings, however, could inspire and encourage a larger-scale study involving more patients, more hospitals and even multiple cities in the Kurdistan region. The study could be extended by asking patients to identify which factors they believe would create an efficient health system, as well as the specific changes they want to see implemented. This direction would not only be a more robust method of involving patients, but would also allow them to exercise their democratic rights.

Due to the lack of available literature on the state of affairs prior to the Iraq War, it has been increasingly difficult to compare the management of hospitals during that era to the management since. Instead, patients found it easier to describe the current plight of the hospital and describe whether conditions had remained the same or declined since the war.

This study examined the effectiveness of the hospital from the patients’ perspective only, which may have introduced elements of information bias. It would be interesting to expand the study to involve the views and opinions of doctors and other health care professionals.

Acknowledgements: Dr. Shalaw Wahab, Dr. Shaho Wahab and the medical and surgical teams in the Shahid Dr Xalid hospital, without whose help and support this research would not have been possible.

Conflict of interest

None declared

References

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  13. Hawramy, F. (2012, May 10). Corruption scandals threaten to destabilise Iraqi Kurdistan. The Guardian. Retrieved from http://www.theguardian.com/commentisfree/2012/may/10/corruption-scandals-destabilise-iraqi-kurdistan

Appendix

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