The newly installed administration under Mohammed Shia al-Sudani is attempting to convince the public and allies of its pro-reform intentions, but will the new government be able to respond to growing citizen anger about the lack of progress on healthcare? COVID-19 highlighted the vulnerabilities of healthcare systems the world over, but few countries struggled to handle the pressures of the pandemic as much as Iraq. A chaotic public health response culminated with two deadly fires in COVID-19 isolation wards, killing 174 citizens, the bulk of whom were patients hooked into ventilators and their devoted caregivers who refused to leave them. The tragedy set off a political crisis in Iraq, as citizens and government officials alike pointed to corruption and neglect in the state healthcare system as the cause. As the pandemic wanes in the collective conscious in Iraq and the broader Middle East region, it is important to look back and draw lessons from the public health response or lack thereof.

Breakdown in Trust between Medicine and Society

Globally governments struggled to convince populations that COVID-19 quarantine restrictions and testing regimes were necessary to reduce transmission, but in Iraq the breakdown in trust between state and society revealed more fundamental and enduring tensions. A pervasive skepticism of the state and the medical system generated popular apathy and resistance to pandemic measures on several levels. Citizens doubted pronouncements from the Ministry of Health and other officials about the seriousness of the illness; they feared going to public centers to get tested out of a concern that they were more likely to contract the disease than receive an accurate diagnosis; and they especially did not want to entrust their ailing loved ones to public hospitals and quarantine facilities. Distrustful of hospitals, home-based care became the only viable option for most citizens. They purchased medications and oxygen tanks in the market and set up make-shift intensive care units within the confines of their own homes.

This distrust in the state and the medical system is not the product of educational backwardness or religious ideology as some media publications inaccurately suggested. This collective distrust is a war-related phenomenon, resulting from the disastrous breakdown of the medical system over the course of three decades of conflict. Prior to the Gulf War of 1990-1991, Iraq boasted the strongest medical systems in the Middle East and patients travelled to Baghdad from across the region for care. This is not to romanticize the strength of the healthcare system; there were certainly still inequalities in access depending on geography, but overall Iraqis regarded the public medical system as reliable and comprehensive between the 1950s through the 1980s. But the UN sanctions of the 1990s followed by the violence and political chaos of the post-2003 period brought the technological capacity of the medical system to its knees and led to an exodus of highly skilled doctors. Many Iraqis voted with their feet, seeking care in neighboring countries. The sectarian war (2006-2008) and the ISIS conflict (2014-2017) were especially destructive periods for the healthcare system.

Even as the intensity of fighting has waned in recent years, reconstruction of the health care systems has proceeded slowly due to the pervasiveness of graft and corruption. During the protests that rocked Baghdad between 2019 and 2020, cancer patients descended into Tahrir Square with signs that read “Corruption Stole my Treatment.” Iraqis are not skeptical of medicine in an absolute sense; they are skeptical of a medical system that has yet to recover from decades of conflict and the channels of corruption that emerged in its wake.

Medical Infrastructure as Health Hazard

Indeed, Iraqi COVID-19 patients generally did everything they could to avoid hospitals. But many patients and their families had no choice: In severe cases, COVID-19 creates acute respiratory problems that outstrip the capacities of even the most well-stocked home care setup. Deteriorating Iraqi patients would abruptly abandon home-based care and rush into public medical facilities – often when they were gasping for air and desperately needed a ventilator. It was here that the vulnerabilities in the medical system became most dangerous. While fires in COVID-19 wards were a global phenomenon, the two hospital fires in Iraq were mass fatality events that produced deaths and injuries far in excess of any comparable case. The technical reason for these fires was the fact that having so many patients on ventilators allows for oxygen to accumulate and render nearly every object flammable. Fires in oxygen rich environments burn faster and hotter than normal fires. Such blazes are high-risk in wards with heavy ventilator usage unless proper risk mitigation procedures and systems are in place.

Modernized hospitals tightly manage the oxygen supply and ensure proper ventilation, and they install and vigorously maintain updated electrical systems and electrical devices. In older or under-resourced hospital facilities where the oxygen supply and electrical infrastructure are poorly maintained, fire risks can quickly accumulate. Both the Baghdad and Nasriyah hospitals were woefully lacking in oxygen management, ventilation, and electrical maintenance. A leak in the Nasiriya hospital’s oxygen supply and other structural vulnerabilities were identified in a routine engineering report months before the incident, but no action was taken.

The Pervasiveness of Corruption and Graft in Medicine

Why was no action taken? Iraqis saw the fires as further proof that the Ministry of Health’s system of medical procurements was structured around profit and corruption rather than care. To be sure, corruption in the healthcare sector is not unique to the post-2003 era. Corruption first became rampant during the harsh UN Sanctions of the 1990s, when widespread deprivation spawned elaborate black markets that preyed upon valuable public medical equipment. But the corruption of the 1990s was arguably a limited phenomenon compared to what emerged after 2003. In the years following the US-led invasion, political parties and their armed wings took full control of the Ministry of Health and the other agencies involved in medical procurements (e.g., KIMADIA General Company for the Marketing of Medicines and Medical Supplies, Ministry of Trade, Ministry of Interior, etc.). Political factions and armed groups proceeded to use medicine as a source of steady cash flow, profiting from the public procurement process for medical devices and especially pharmaceuticals.

Within this system of graft, parties and their affiliates maximize profits by evading the kinds of quality controls and safety standards that prevent fires. Maintenance is typically regarded as a cost driver rather than a profit center. This does not mean that maintenance contracts are never issued; but they are rarely executed in a manner that definitively resolves the core problem because doing so would be too costly and reduce profits. Profits are maximized either by overvaluing the contract, under-delivering the service/product, or both. This explains why the leak in the Nasiriya hospital’s oxygen supply did not receive the attention required. It also explains gaps in equipment required for fighting fires. After the second hospital blaze, one report linked the lack of fire hazard safety equipment in the Nasiriya hospital to the fact that “political parties routinely siphon vast sums from the country’s health budget through corrupt contracts that either deliver cut-rate services or do not deliver [services] at all.” A system organized around graft requires cutting corners to pocket cash. In this case, the results were deadly.

Broader Context: Iraq’s Political Economy of Healthcare

The political economy of health in Iraq is a function of the broader features of the post 2003 political order. After the US-led invasion, ministries were divided among the dominant political parties, many of which were and remain armed with para-military branches. (This process of allocating ministerial assets — known as muhasasa in Arabic — has been studied by political scientists in other government domains, but not extensively in healthcare). These actors gradually took control over Iraq's network of public hospitals in addition to the supply chains and contracting channels that furnished those facilities. They also wielded outsized influence over the emerging private market of hospitals, pharmaceuticals, and specialized medical services.

But the key interests of the political parties was the medical supply chain — both public and private. The dominant parties shaped which pharmaceuticals and medical devices were being brought into the country, and they influenced the quality control process. In other words, both the decisions around imports and the mechanisms that are designed to police those imports were under the control of the same set of political actors. The results of this chokehold on the supply chain was that particular kinds of medications and devices (sourced by specific companies) were granted a politically protected status that had little or nothing to do with the actual medical need for these items. Consequently, the medical supply chain became distorted and oriented around profit protection for this politically-backed pharmaceutical cartel, which resulted in a situation where by 2018 only 11% of the basic essential medications required in hospitals were actually available.

COVID-19 revealed the acute dangers of this medical supply chain graft, as the demand for new technologies and supplies (PPE, testing kits, oxygen therapy) came up against the entrenched interests of the parties in maintaining well-worn and politically protected procurements. The capacity to conduct supply chain triage — i.e., moving resources from one budgetary area to another — was extremely limited. This politically-induced rigidity tragically reduced the capacity of the MoH to respond to the unique risks and hazards associated with COVID-19 isolation wards, where the intensification of oxygen therapy in confined spaces generated the dual risks of oxygen accumulation and electrical overloads. Hospital fires in Iraq’s COVID-19 wards became a repeated occurrence because risk monitoring at the hospital level (of electrical shorts, oxygen supply defects) were rarely if ever paired with the necessary procurements of replacement parts. Risk management was effectively left to Iraqi patients and families, who had no choice but to enter COVID-19 hospitals assuming that the worst could happen at any moment and prepare accordingly.

Is there a way forward?

Importantly, the new administration should not be persuaded by those voices who argue that privatization and the emergence of healthcare startups can meaningfully cover gaps in the healthcare system. Private medicine is already a pervasive reality in Iraq, but it has not developed into an independent and advanced sphere of medical practice. Private medical services, markets and products are under the influence of the very same political actors that dominate the public sector. In everyday practice, the private/public medical sectors are already blurred. When Iraqis go to public hospitals, they often find that the doctor requests purchases of medications in private pharmacies or make referrals to private hospitals in Iraq or abroad – at great personal cost for the patient. The net result is that the post-2003 era has shifted the bulk of the burden of healthcare cost from the state to the population, and Iraqis suffer from some of the highest per capita medical costs out of pocket in the world. In sum, holding up “privatization” as an easy solution will only deepen distrust between state and society.

The notion that the Sudani administration can introduce broad reforms into state health agencies captured by political parties borders on the fantastical. But this does not mean that there is nothing that can be done. Despite the dominance of powerful political parties over the Ministry and the supply chain, one cannot assume that the policymaking and implementation process is entirely beyond the pale. Beyond anecdotal accounts, there is no reliable or systematic data on the degree to which a combination of evidence and targeted political pressure may create space for small but meaningful shifts in policy. During the brief tenure of the independently minded Alaa Alwan as Minister of Health, he managed to convince Parliament and the Ministry of Finance that the status quo in pharmaceuticals – with only 11% of the essential medications available in 2018 – was grotesque and unsustainable. Through great personal effort and advocacy, he succeeded in obtaining a budgetary increase towards essential drugs. This financial allocation alone was not sufficient to push the percentage of pharmaceutical coverage up considerably, however. Alwan paired the injection of funds with more efficient financial management in pharmaceutical procurements, resulting in in a marked increase in the supply of essential medications from 11% in 2018 to 50% in 2019. As these financial management practices threatened the vested interests in the pharmaceutical supply chain, however, he was eventually compelled to resign.

This short-lived policy victory shows that the system of allocating government resources and positions to political parties (muhasasa) can leave brief openings for independent officials. The political ownership of the Minister of Health may change hands from one party to the next -- and may even be granted to an independent figure -- but the director generals (DGs) who control procurements remain stable and generally do not change. A reform-minded Minister of Health certainly has the formal authority to reject the decision of the DGs (as Alwan attempted to do), but a Minister of Health and even a Prime Minister can only go so far in threatening the interests the party-affiliated officials protect.

If Sudani wants to show that he is serious about healthcare, he could champion Alwan’s bold approach of tackling the issue of pharmaceutical imports and the broader medical supply chain head on. As argued above, the distorted incentives in the medical supply chain are at the root of the lack of attention to maintenance and the proliferation of fire risks. Even if moderately successful, such an effort could improve the lives of everyday Iraqis who struggle with medication shortages, broken equipment, and poorly maintained facilities on a daily basis – the victims of the politically sanctioned corruption consuming the healthcare sector. 

A more cautious strategy would be for the new administration to address issues that do not threaten the core interests of the parties, such as the development of medical human resources. Many Iraqi doctors and nurses remain very committed to public medicine, and they work very hard to maintain and improve standards of care amidst all the challenges. During the pandemic, networks of doctors and nurses activated informal training platforms to ensure better levels of preparedness even though the Ministry of Health was broadly negligent in doing so. Medical professionals in the post-ISIS territories have labored diligently to return services to areas with destroyed or damaged facilities. The endurance of medical professionals is not infinite, however. More and more Iraqi doctors will continue leaving the country if they are not supported. Directing relatively modest amounts of funding towards the educational and research opportunities of young doctors – including scholarships to receive specialization training in regional countries – is the kind of policy that can bolster capacity even in the face of ongoing shortages and problems in the medical supply chain.

This commentary (published December 2022) was written by Mac Skelton as part of the project Restoring Trust: Creating a Roadmap for Health Policy in Iraq after COVID-19. The project was supported by the Konrad Adenauer Stiftung.