Building the Future

Short abstract

This article summarizes a study intended to help the Kurdistan Regional Government expand access to good health care.

Abstract

In 2010, the Kurdistan Regional Government (KRG) asked the RAND Corporation to undertake four studies aimed at improving the economic and social development of the Kurdistan Region of Iraq. RAND's work was intended to help the KRG expand access to high-quality education and health care, increase private-sector development and employment for the expanding labor force, and design a data-collection system to support high-priority policies. The studies were carried out over the year beginning February 2010. The RAND teams worked closely with the Ministries of Planning, Education, and Health to develop targeted solutions to the critical issues faced by the KRG. This article summarizes the health care study. It is intended to provide a high-level overview of the approaches, followed by the studies, key findings, and major recommendations.

The Kurdistan Regional Government (KRG) asked RAND to analyze the current health care system in the Kurdistan Region—Iraq (KRI); to make recommendations for better using resources to improve the quality, access, effectiveness, and efficiency of primary care; and to define the issues entailed in revising the existing health care financing system.

RAND staff reviewed available literature on the KRI and its health care system, as well as information relevant to primary care. We interviewed a wide array of policy leaders, health practitioners, patients, and government officials to gather information and understand their priorities, and we collected and studied all available data related to health resources, services, and conditions.

Using the available information, we described current service utilization, projected demand for services five and ten years into the future, and calculated the additional resources (e.g., beds, physicians, nurses) needed to meet future demand. We used these data, as well as information from those we interviewed, to develop an array of options for improving primary care organization and management, the health workforce, and information systems and to address issues in health financing. We developed an extensive list of policy options, discussed them with key policy leaders in the Kurdistan Region and among the research team to rate options by importance and feasibility, and then used the criteria to identify a subset of policy changes as potentially the highest priority for implementation over the next two years.

Summary Assessment of the Current Kurdistan Region—Iraq Health System

The health system in the KRI has many strengths:

• Access to care is excellent. The majority of people live within 30 minutes of some type of a primary health care center (PHC); in remote regions, hospital and emergency services are increasingly accessible.

• The total number of health facilities is adequate. All governorates have public general, emergency, and pediatric hospitals, and most PHCs provide most of the basic primary care services.

• Health care providers are knowledgeable and strongly committed to patient health.

• The commitment of health system leaders is strong, and they have set appropriate strategic goals and priorities for improvement.

However, the primary care health system also faces challenges:

• The overall distribution of PHCs and medical staff is not optimal. Slightly fewer than 30 percent of the 847 PHCs have at least one physician. Services offered at each type of facility and reporting requirements are not standardized. Facilities are not systematically networked; referrals are not well organized.

• The quality and availability of primary care vary. Quality is not systematically measured, and most personnel lack training in quality improvement methods.

• Physicians are overworked; nurses are underutilized and lack appropriate training. The number and distribution of medical staff are not optimal, especially in rural areas. Many general practitioners in PHCs are neither supervised nor mentored, and many physicians work only in the morning, devoting the rest of the day to private practice. Job descriptions and staff performance standards are lacking, and few health care managers are trained.

• Health information systems are not systematically used to support policymaking, regulation, or system management. Data collection and analysis are not standardized, and computer technologies are not fully utilized. Data systems are inefficient, and data are not readily available; available data are not routinely used at all relevant levels. Patient recordkeeping at ambulatory centers is virtually nonexistent.

• Health care is generally financed by government budgets with no incentives for efficiency. There is little private insurance.

A primary care–oriented health care system could help the KRG address many of these challenges. An ideal model is an integrated health care system that offers services at the appropriate level of care; creates incentives for patients to seek urgent and other care in the community, when appropriate; and integrates health information across levels of care. Such systems produce consistently higher-quality care and better clinical outcomes, with associated lower costs.

Projecting Future Health Care Supply and Utilization for the Kurdistan Region

To estimate future resource needs, we projected future demand and supply for health services in the KRI under a variety of assumptions. In the base case, we projected changes in utilization that would occur in the future as a result of current population growth, with all other parameters of care held constant. We then changed these assumptions in some scenarios to compare the gap between supply and needs under different scenarios.

Estimating Future Demand for Health Care: Base Case

We first projected health care supply and utilization for 2015 and 2020, assuming moderate population growth consistent with recent levels of population growth in the Kurdistan Region (3 percent annual growth between 2010 and 2020) and unchanged patterns of health service delivery and utilization. Table 1 shows additional workforce and hospital bed needs under these conditions.

Table 1.

Projected Workforce and Hospital Bed Needs, Base Case

Health Care Resources	2015	2020
Hospital beds	+1,343	+2,574
Physicians	+1,070	+2,097
Nurses	+1,681	+3,325
Dentists	+126	+246
Pharmacists	+82	+151

Estimating Demand for Health Care: Three Future Scenarios

We then estimated how the additional resources needed would change under different assumptions, focusing on three indicators of future health service utilization for each governorate: (1) total hospital admissions, (2) total emergency department visits, and (3) total outpatient visits (see Table 2).

Table 2.

Summary of Projected Changes in Resource Requirements in 2020 for Each Scenario, Compared with the Base Case (% difference)

Scenario	Hospitalizations	Emergency Department Visits	Outpatient Visits
Rapid population growth	28	75	8
Improved primary care (lower-bound estimate)	−1	−20	20
Growth in private-sector health care	2–10	0	5–20

Scenario 1 assumed rapid population growth due to expansion of the oil economy, with approximately a 2.4-percent yearly influx of foreign workers, primarily young male adults. The increase in net migration would result in an average annual population growth rate of 4.8 percent between 2010 and 2020 and a total projected population of about 8.75 million by 2020. These foreign workers will most likely be dominated by young males, who, in other countries, have higher rates of hospitalization and emergency department use and lower rates of outpatient care utilization. Under this scenario, hospitalizations could increase by as much as 28 percent over the base case by 2020, emergency department use by as much as 74 percent, and outpatient visits by as much as 8 percent.

Scenario 2 assumed enhanced primary care; fewer hospitalizations for care that could be provided in ambulatory facilities; increased outpatient utilization; and decreased emergency department utilization. These assumptions resulted in a 20-percent reduction in hospitalizations for chronic disease (a subset of overall hospitalizations), a 20-percent increase in outpatient visits, and a 20-percent decrease in emergency department utilization.

Scenario 3 assumed expansion of the private health care sector. These assumptions result in broad increases in utilization (2–10 percent in inpatient utilization, 5–20 percent in outpatient utilization, no change in use of emergency care).

Health Care Financing System

The KRG's Minister of Planning asked RAND to review the basic tenets of health care financing and to develop a road map to help guide KRG policy development in this area. We (1) provided an overview of health care financing and its basic tenets, (2) examined how other countries have dealt with financing issues, (3) developed a general profile of Kurdistan's present health care financing system, and (4) defined the questions the KRG will need to address as it considers its future financing system.

A country's health care financing system enables equitable collection of sufficient resources to offer efficient, quality care to all segments of society. The system defines the compensation that providers will receive and embodies incentives that help determine efficiency and quality of care. The system also reflects a country's basic cultural and economic values.

No two countries finance health care exactly the same way because each country has its own objectives, cultural context, and health status. But every health financing system must determine who is eligible for health care coverage, what services will be covered, where the funds will come from to pay for services, how the funds will be pooled, and how payment for services will be made.

Most financing systems fall into one of the five general types of health financing systems shown in Figure 1. The type of system a country has depends on a range of factors, including data systems, ability to collect taxes, the public workforce, number of physicians, education of the population, and the sophistication of the banking and insurance systems. Almost all countries have mixed systems.

Figure 1.

Common Health Care Financing Systems

Kurdistan's current health care financing system is primarily a public budget system. All Iraqis are covered under the system, and a wide range of primary, hospital, and other medical care is offered in the public facilities, where most health care is provided. Some services are provided by private hospitals and physicians in private practice.

Most services are paid for out of public budgets (KRG, governorates, or Baghdad); private physician and hospital services are paid for by individuals. In theory, the government regulates both the public and private health care sectors. Private insurance is almost nonexistent. Copayments for public services are very low. Costs are rising quickly, as are payments for care abroad. The system provides few incentives for efficiency, quality, or cost control.

The Kurdistan Region currently lacks the sophisticated data, information technology (IT) systems, and managerial skills required to successfully operate more management-intensive systems, such as social insurance or national health plans. These requirements must be in place before the KRG can successfully embark on reform. However, the KRI is rapidly developing and will likely be able to take the next step in establishing systems that are not primarily budget-driven. Careful planning and wise choices can help the Kurdistan Region achieve the health outcomes of much richer countries at a greatly reduced cost.

To examine other finance system options, the KRG will need to address multiple dimensions of the five key issues: eligibility, coverage, sources of funds, pooling of funds, and payment. The KRG also needs to begin a systematic review of all policy options and choices, including (1) what data are required to manage any system, (2) what actions can be taken now to improve efficiency and control costs, and (3) what incentives should be embedded in the system to ensure quality health care for all KRI residents. The KRG will also need a strategic health care financing plan and a research agenda to fulfill it.

Improving Primary Care

Primary care is key to the success of a modern health care system. Primary care serves as an anchor for the organization of health services by providing an ongoing patient-clinician connection for delivery of most care and a pathway to and from other sources of care. The Minister of Health and other KRG authorities identified improving primary care as a high priority. To address this priority, we examined the organization and management of primary care and associated needs related to the health workforce and health information systems.

Following our analysis of the current system, discussions with health care leaders and managers throughout the region, and guiding principles of primary care in the 21st century, we offered recommendations for improving Kurdistan's primary care system in three areas: (1) organization and management of primary care facilities and services, (2) the health care workforce, and (3) health information systems.

Organization and Management of Primary Care Facilities and Services

The KRI's primary health care system has important strengths on which to build, but it also faces challenges. We focus on three key goals for improving the organization and management of primary care facilities and services: (1) distribute facilities and services efficiently, (2) develop and implement a system for referrals and continuity of care, and (3) develop and implement a program for continuous quality improvement (CQI).

Distribute Facilities and Services Efficiently. The types, sizes, and locations of hospitals are relatively standardized across the three provinces. However, the primary health care centers (PHCs) are much less standardized, and the number of main PHCs (staffed by a physician) on a per capita basis falls short of international and Iraqi standards. Iraqi law defines different types of health centers and establishes criteria for population covered, physical infrastructure, and staffing at each type of facility, but these criteria have not been applied consistently across the region.

Functionally, the KRI primary care system has two types of centers:

• PHC main center (categories A, B, and C): Serving a population of 5,000 to 10,000, these are staffed with at least one physician, and they deliver all primary care services. Type B centers also serve as medical and paramedical training centers, and type C centers provide uncomplicated obstetric deliveries and simple medical and surgical emergency care.

• PHC subcenter or branch (category D): Serving a population up to 5,000, these are staffed by a male nurse, a female nurse, and a paramedical assistant. They provide simple maternal and child health services, immunizations, and simple curative services.

Health authorities suggest that PHCs are not necessarily distributed appropriately in the region, nor are they systematically standardized or monitored by such criteria as type, size of population served, staffing level, and services offered. Experts have also argued persuasively that chronic disease management should now be included in the package of primary care services because nearly three-fourths of avoidable mortality—including a significant proportion of deaths in the Kurdistan Region—can be attributed to behavioral and environmental factors, such as poor diet, lack of exercise, tobacco use, and alcohol consumption. Each of these can be significantly reduced through public education and other prevention-oriented interventions.

An important goal in the Kurdistan Region should be to make primary care services more comprehensive and more uniformly and universally accessible at appropriate levels of care. Absence of functional KRG standards for catchment areas, staffing, and services hampers efficiency and systematic improvement. The goals of universal access and high-quality care cannot be achieved without systematic application of such standards. Making the scope of services more uniform at each level of care is also a prerequisite to improving service quality, efficiency, and staff productivity.

We recommend that immediate attention be given to aligning services with appropriate levels of care, ensuring that facilities are properly equipped and staffed and can provide all appropriate services, and ensuring the quality of those services.

We suggest six specific strategies for achieving efficient distribution of facilities and services while maintaining sufficient flexibility to reflect different local conditions: (1) Define the appropriate scope of services to be provided at public-sector clinics, (2) organize the system of existing and new PHCs based on a core three-tiered networked system and specified access standards, (3) develop a plan to provide services based on standards appropriate for each type of facility, (4) extend the reach and quality of health services through telemedicine, (5) expand health education activities in clinics and schools, and (6) develop and implement public health education campaigns to promote safe and healthy behaviors of greatest relevance to the region.

The first two strategies seem the most important and feasible in the near term.

Develop and Implement a System for Referrals and Continuity of Care. If a primary care facility cannot provide specific services that are needed (e.g., specialized diagnostic or surgical care), continuity of care requires efficient referral from and back to a patient's first-level health facility. Ideally, there would be no gaps in care due to lost information or failed communication between providers. A patient should have a regular point of entry into the health system and an ongoing relationship with his or her primary care team. Continuity of care is also essential in chronic disease management, reproductive health, mental health, and healthy child development and requires that the system be as easy as possible for patients to use.

A system for referrals and continuity of care aims to ensure that patients receive services at the most appropriate time and in the most appropriate setting and that care is well coordinated across care levels and providers and entails no inappropriate delays or interruptions. The KRI does not currently have such a system.

We offer four specific interventions to improve referrals and continuity of care, of which the first appears to be the most important and at least moderately feasible to implement: (1) Develop and implement a patient referral system, (2) explore the feasibility of designating population catchment areas and a “home clinic” and primary care provider for all population members, (3) begin transitioning to electronic health records at all levels to facilitate referrals and continuity of care, and (4) promote local awareness of available services, appropriate use, and referrals within and beyond the local catchment area.

Develop and Implement a Program for Continuous Quality Improvement. The Kurdistan Region currently lacks a program to assess quality of care, draw lessons from any issues identified, or institute appropriate changes or incentives within the system to promote quality. These activities are the heart of CQI, an essential component of effective care. The goal of CQI is to help health systems and professionals consistently improve the quality of health care delivery and outcomes through access to effective knowledge and tools. An essential requirement for CQI is establishing clinical practice standards that are uniform and based on best evidence.

We suggest six specific interventions focused on CQI: (1) Develop and implement evidence-based clinical management protocols for common conditions seen at ambulatory and hospital facilities, (2) define and expand the safe scope of practice for nurses in ambulatory settings, (3) adopt standardized patient encounter forms (e.g., checklists) to facilitate use of clinical management protocols at PHC facilities at all levels, (4) identify and test efficiency measures to enhance patient flow, (5) develop and implement carefully focused surveys of client and staff satisfaction on a routine basis at PHC facilities, and (6) explore the feasibility of a regional and, ultimately, international accreditation process for ambulatory and hospital inpatient services.

In the near term, the first two interventions appear to be the most important and at least moderately feasible.

The Health Workforce

Many studies have demonstrated that the size and qualifications of a country's health workforce affect health outcomes. Preparing the workforce requires both careful planning and strategic investments in education, all designed to address the country's key health system priorities. Once trained, the workforce needs to be properly managed—clinical skills monitored, maintained, and updated.

Iraq has a long tradition of excellence in medical services and training. But areas for improvement remain with regard to the numbers and qualifications of its health workforce. For example, the Kurdistan Region has fewer physicians per capita than many other countries in the region. Physician shortages involve training and competencies, as well as numbers, distribution (shortages are especially pronounced in rural areas), and hours worked. Public-sector ambulatory care relies almost exclusively on obligatory one-year service of junior general practice physicians who have completed one or two years of postgraduate clinical (residency) training and who return afterward for a final year of residency training in which they can begin to specialize.

During the final residency year, these physicians receive no mentorship, supervision, or other professional development support, and they have limited access to professional resources, such as the Internet or professional journals. Virtually all of them provide clinic services in the morning and see private patients in the afternoon. All physicians who have completed their clinical training have guaranteed government jobs (and pensions), but they receive relatively meager government salaries for public-sector work and derive much more substantial income from seeing private patients.

According to KRG health authorities and consistent with our own observations, problems with the nursing profession are especially critical. The KRI has more nurses per capita than some countries in the region and fewer than others. However, the Minister of Health has indicated that the number of nurses in Kurdistan may not be as important as the distribution, qualifications, and competencies of nurses across all levels. The Minister of Health and most other health authorities are particularly concerned about poor quality of nursing care; lack of defined nursing competencies, responsibilities, and duties; and the resulting inefficient use of nurses in clinical care.

We focus on two goals for improving the health workforce in Kurdistan: (1) enhancing professional qualifications through education and training and (2) improving the distribution and performance of the health workforce through specific human resource management interventions.

Enhance Professional Qualifications Through Education and Training. The number and quality of health workers demonstrably affect all health outcomes, and the decisions they make determine whether resources are used efficiently and effectively. The U.S. Institute of Medicine recommends education that includes practical experiences so that clinicians master five specified core competencies: (1) patient-centered care, (2) ability to work in interdisciplinary teams, (3) utilization of evidence-based practice, (4) application of quality improvement, and (5) utilization of informatics (Institute of Medicine, 2005).

We offer 11 specific strategies to improve professional education and training: (1) Establish an executive committee to develop and oversee new professional education, training, licensing and recertification standards, recruitment of students across the medical professions, and management of the supply of medical personnel to meet forecasted demand; (2) preferentially recruit medical and nursing students from rural areas to attract professionals to more permanent rural service; (3) include primary care in medical and nursing school curricula; (4) provide preferential incentives and professional development opportunities to general-practice physicians during their year of obligatory medical service; (5) enhance the profile of family medicine; (6) include primary care in the clinical rotations of medical and nursing schools; (7) enhance training in practical clinical skills throughout all the phases of medical and nursing preparation; (8) revise and implement new nursing curricula and training at nursing schools; (9) develop and implement a mandatory continuing education system for medical, nursing, dental, and pharmacy professionals; (10) develop and implement a system for licensing and revalidation for medical professionals; and (11) enhance training and create a strong career track for preventive-medicine specialists.

The first four strategies might be the most appropriate near-term priorities because of their relative importance and feasibility.

Enhance the Distribution and Performance of the Health Workforce. Recruiting and retaining health care workers, especially in remote and rural areas, is not a problem unique to Kurdistan. It is seen worldwide and has been a focus of considerable research effort. The World Health Organization (WHO) has identified two types of factors that influence the choices of doctors, nurses, and midwives to work in rural areas. Factors that attract workers include better employment or career opportunities, better income and allowances, better living and working conditions, better supervision, and a more stimulating environment for worker and family. Factors that repel workers include job insecurity, poor working and living conditions, poor access to education for the workers' children, inadequate availability of employment for the workers' spouses, and work overload.

We offer six specific interventions to help improve health workforce management: (1) Develop, implement, and monitor qualifications and job descriptions for professional staff at all relevant levels; (2) develop a plan to distribute staff based on standards defined by law for each type of facility; (3) provide supportive supervision for physicians, nurses, and other health professionals serving in PHCs, especially in rural and remote areas; (4) institute appropriate incentives to attract medical, dental, and nursing staff to serve (and remain) in rural and remote areas; (5) increase the use of online human resource management forms, including applications for study, training, placement, licensure, continuing education, and related documentation; and (6) develop and implement strategies to reduce fraudulent private medical practice.

The first strategy appears to be both important and feasible in the near term.

Health Information Systems

A health care system depends on data to guide wise investments in policies and programs and to monitor their implementation. Management information systems make it possible to monitor health resources, services, and clinic utilization. Surveillance and response systems support the monitoring of mortality, morbidity, and health risk factors. Implementing such systems requires trained personnel and standardized data collection, processing, analysis, and presentation. Patient recordkeeping is key to managing primary care facilities and underpins efficient referrals and continuity of care.

KRG policymakers wish to have such data, but a “culture of data for action”—in which data collection, processing, analysis, presentation, and use are routine and relatively easy—remains elusive. We focus on strategies to achieve two main goals, corresponding to two broad types of health information system: (1) Develop and implement health management information systems and (2) enhance surveillance and response systems.

Both of these critical systems serve managers at the regional, governorate, and district levels; improvements are highly feasible in the near term because the important foundations are already in place. A third type of data system—patient clinical recordkeeping—serves primarily clinical providers and patients. It is also critically important to primary care, but the foundations are not yet in place for this. Efforts to lay such foundations should be a near-term priority.

Develop and Implement Health Management Information Systems. Health management information systems include data on health resources, services provided, and service utilization. Management information systems can help ensure service coverage, performance, and efficiency. For example, these systems can help managers and policymakers track the proportion of the population that has access to health services within specified standards and determine whether the distribution of health facilities and services is adequate; monitor the services delivered at specific health facilities and the number and qualifications of health workers providing the services; track equipment and supplies at health facilities, utilization of health services, the percentage of the target population covered by each type of service, and the efficient use of health facility staff; determine the proportion of the intended population that receives preventive services; and monitor patient referrals and continuity of care across different levels and providers of health services.

We offer two main recommendations for enhancing health system monitoring: (1) Develop a systematic mechanism to monitor clinic resources and services and (2) monitor clinic utilization.

The first recommendation appears to be most important and feasible in the near term. Monitoring clinic utilization also seems critical and only slightly more difficult. Both would significantly enhance management and, ultimately, the efficiency and effectiveness of primary health care services.

Enhance Surveillance and Response Systems. Public health surveillance is the ongoing, systematic collection and dissemination of health-related data to be used for public health action and ongoing management. These data include mortality, morbidity, and risk factors for communicable diseases, noncommunicable diseases, and injuries. Surveillance systems should have broad and representative coverage and provide high-quality and timely data. Such systems make it possible to monitor trends in health outcomes and risk factors, detect unusual health events, and respond appropriately to anomalous events or trends.

Taking responsible action based on surveillance requires information collection designed to be actionable, adequate workforce numbers and analytic capabilities (particularly in the areas of applied epidemiology and statistics), and established response mechanisms and procedures (especially for epidemiologic investigation of outbreaks, implementation of appropriate control measures, and design of further research).

We offer ten strategies to improve KRG surveillance and response systems: (1) Standardize the diseases and conditions to be included in routine surveillance, (2) standardize the data-collection forms, (3) hire and train personnel who are responsible for specific surveillance functions, (4) conduct a systematic assessment of current surveillance systems at all levels, (5) standardize the sources of surveillance information and reporting processes, (6) streamline data processing at governorate and regional levels, (7) develop and disseminate standardized analyses for surveillance information, (8) develop and implement a system for immediate alerts, (9) develop and implement standardized protocols for responding to events warranting timely investigation, and (10) monitor health risk factors.

These strategies largely represent a logical progression for improving surveillance and response. However, near-term priorities might focus on the first two strategies, which we judged to be both most important and most feasible.

Looking to the Future

The KRG has made significant progress in improving the region's health care services and the health of its people. However, more can be done, especially with respect to improving the health care system's quality, efficiency, organization, management, workforce, and data systems. Such initiatives will be increasingly important as Kurdistan continues on its trajectory of modernization and becomes more closely integrated with the rest of the world.