When we assess how COVID-19 may affect fragile states, it’s important to remember the context of each country in question. Have serious disease outbreaks increased political unrest in the past?
If so, what might be different this time that might exacerbate the problem or reduce risk of instability? In Iraq, there are still many unknowns but now is a good time to take a look at Iraq’s ongoing health sector challenges.
First, the possible good news: The vast majority of Iraqis are under 45, while the number of most vulnerable Iraqis over 60 is in the low millions. Secondly, humid, hot temperatures are thought to slow transmission although there is a lack of certainty on this point and experts are cautioning on counting on the weather to slow the disease.
Even this may not be enough. Even having a small vulnerable population could present a tremendous challenge for hospitals when we consider there is already a high incidence of respiratory illness, cardiovascular conditions and cancer among younger adults in some parts of Iraq. Much will be revealed in the coming days as conditions in hospitals are reported and testing ramps up from 100 tests a day to 4500 per day, following WHO assistance.
The last crisis
Iraq’s most recent major public health crisis may provide evidence of what is to come. In late 2018, over 100,000 people were hospitalized in Basra, sickened by heavily polluted water. While this was part environmental catastrophe, due to prolonged drought, water salinity and upriver dam construction and part man made (infrastructure breakdown) the key point is that hospitals were rapidly overwhelmed. Many patients did not receive beds and found themselves on the floors of hospital corridors, a situation which exacerbated high levels of public anger.
It’s likely that the Basra water crisis emerged far more quickly than COVID-19, although some Basrawi doctors reported that cases may have begun to emerge over the summer. Even still, Al Sadr Hospital was overwhelmed by 300 cases of waterborne illness per day. Likewise in Brescia, Lombardy, with a far smaller population than Basra, far better equipped hospitals reported being overwhelmed by hundreds of COVID-19 cases per day.
This draws attention to two variables that will influence what happens next: available health resources and foreign aid (both available and potential). It is also worth looking at trends in Iraq’s health expenditure which reveal the extent of Iraq’s vulnerability to the crisis, as well as potential emergency expenditure.
Available health resources
How many intensive care unit beds does Iraq have and how many ventilators are available? A cursory glance at available information illustrates that Iraq’s health service could face its biggest challenge of the post 2003 era even in the best case scenario.
Even in Italy, which has 3.2 beds per 1000 people, high capacity health facilities such as the 900 bed Papa Giovanni XXIII Hospital have been overwhelmed. The largest hospital in Basra has almost 700 beds, but almost certainly has nothing like the Papa Giovanni XXIII’s Intensive Care Unit (ICU) capacity. Since ICU capacity is key for determining how quickly any facility can be overwhelmed it is alarming to think that countries such as the U.S., U.K and Italy are struggling to convert wards such as Pediatric units into ICU-like facilities for adults.
Regarding overall bed availability, the World Bank has reported 1.4 beds were available per 1000 citizens, but this is most likely a misleading figure because of informal settlement construction in many Iraqi cities and a lack of reliable demographic data. A recent report estimated availability at 1.2 per 1000 people, below the average MENA beds per capita of 1.9.
In 2010, the Japan International Cooperation Agency (JICA) estimated that Iraq had around 40,000 beds for a population of over 32 million, but would need to have an additional 107,070 beds by 2013 in order to cater for a population increase to 35 million (for 2013). In other words, health spending (discussed in more detail below) would need to rise very significantly to meet such targets.
War and displacement are also likely to cause massive regional variations. Two cities, Basra and Mosul, are particularly vulnerable. In 2019 Mosul only had 1,600 hospital beds for two million people, or a 0.8 beds to 1000 citizens ratio and according to Médecins Sans Frontieres (MSF), only three ventilators. Mosul and Basra may not be the only crisis centres; in Sadr City, Baghdad, only four hospitals serve over 3 million people.
Of course, ICU beds are a priority but even OECD countries have been forced to make as much room for the critically ill as possible, including setting up field hospitals. Of the latter, Iraq has established one such facility so far. In terms of ICUs, Iraq’s outlook is critical; in 2018 in Salahaddin for example, there was one five bed ICU for the province of over 1.5 million people; the same year, it was reported that the 158 bed Dohuk hospital in the Kurdish region had six beds in its ICU.
For the country, the official figure of ICUs is 799 ICU beds, but the actual total may be in the region of 350-400, according to information provided to Iraq country specialist Norman Ricklefs by Dr Waleed Al Ansari, who is Iraq’s leading ICU specialist at Shaheed Adnan Hospital in Baghdad.
In terms of equipment, figures to date have suggested anything from 200 medical ventilator units for the entire country, while unofficial sources suggest this figure may be as high as 500, with the latter figure being more likely (since it is closer to the ICU figure and ICUs typically have ventilators). One Baghdad ward recently reported having 10 ventilators, while according to MSF there were only three ventilators for all of Mosul in early 2019. It is not clear whether these figures include CPAP systems (non-invasive mask based systems).
Worryingly, there were reported shortages of oxygen to treat wounded protesters at some Baghdad hospitals over the winter. If the virus spreads over the summer, hospitals could come under unbearable strain: In last summer’s extreme heat, hospital ventilators failed due to lack of power. Stories like this help explain the massive lack of faith in healthcare which has likely held back COVID patients from reporting illness.
This brings attention to Iraq’s budgetary process which has not prioritised health and services. According to the WHO in 2015, Iraq already suffered a high incidence of respiratory diseases due to high levels of dust and pollution, in addition to previous Tuberculosis outbreaks, making it all the more surprising that resources are so limited.
As a result, Health Minister Jaafar Allawi has asked for $150m per month in emergency funding to equip hospitals and staff, while the Finance Ministry has called for donations from the public and private sector, including banks. In the latter case, the Trade Bank of Iraq has pledged $5 million.
Of course, vital equipment such as ventilators are only one part of the response to the crisis, which includes having staff trained to cater for patients in ICUs, a problem now experienced in the UK where there are not enough staff trained for critical care. In that sense, Iraq will also struggle to meet requirements, having struggled to combat extensive brain drain in the health sector. Indeed, some definitions of ICUs relate to staffing as much as equipment.
Considering this, Iraq will likely be dependent on foreign support in a worst case scenario, to include health workers as well as equipment. While ventilators will be a priority, Iraq will have to hope other countries which are controlling the pandemic will have excess capacity; Elon Musk recently purchased 1200 mechanical ventilators from China and shipped them to California, but global demand is thought to be approaching ten times available production capacity.
Iraq will therefore welcome Chinese support, which so far includes a testing lab in Baghdad with a 1,000 test per day capacity, 50,000 testing kits, a team of experts and several tons of aid including protective equipment. At the same time, the US announced $670,000 in support through WHO, amid a wider regional COVID-19 aid effort, while the Netherlands has pledged $2 million. Aid may also be forthcoming from a WHO fund, which aims to raise $650 million for fragile states. Iraq may also be hoping regional diplomatic efforts pay off and we may yet see a similar response for Iraq as with Gulf state COVID-19 aid to Iran. In the absence of enough equipment to contain the virus, parastatal groups may increasingly assist as part of their political efforts.
How did we get here?
The slow collapse of Iraq’s health system is a decades old story, beginning at the end of the Iran-Iraq war and worsening rapidly through the sanctions era, before being knocked hard during the chaos after 2003.
The last decade has seen Iraq witness a window of opportunity to address the chronic lack of capacity in the sector, but this has not translated into higher budgets for health. Iraq’s budgetary process has instead followed its own trajectory in favour of defence expenditure even when security incidents have fallen, particularly between 2010 and 2014. As the health crisis in Basra emerged through 2018, Kuwaiti funding was providing for new health facilities. At the same time, the Imam Ali Hospital in Baghdad which has a 20,000 patients per month capacity, had no triage system in place before the efforts of MSF.
Iraq’s budgets therefore show a curious lack of allocated funds for public health. Recent allocations peaked in 2013 at $5.8 billion, although budget execution has struggled, as with other ministries and as is typical, capital expenditure is often low due to high operational expenses.
A surge in construction of new facilities seems to have centralised waste along Iraq’s favoured primary healthcare model, although it is difficult to imagine a more decentralized system would have been more efficient, as evidenced by a number of high profile allegations against officials in the sector in both Ninewa and Basra in recent years.
By 2016, the Ministry’s budget was 5.044 trillion dinars (4.76% of a 105.8 trillion dinar or $88.2 billion budget), almost two billion short of the 2013 budget at $4.19 billion. At the time, the ministry had nearly 300,000 employees therefore, the combination of a high salary outlay and a low execution rate would have wiped out any progress in the sector even as health infrastructure was being destroyed in the war on ISIS. The situation barely improved by 2017 when spending fell to 3.8% of expenditure of $85.2 billion or $4.46 billion.
With the oil price crisis showing no sign of abating, Iraq will therefore have to take urgent action, finding savings in other sectors to ensure a minimum level of service survives the current emergency. Iraq may also be relatively “lucky” (due to the aforementioned demographic and climatic factors) but the Basra crisis shows how vulnerable Iraq is to any major health emergency.
If Iraq is lucky due to climatic factors, tough times lie ahead in any scenario, underlining the importance of a strong public health sector as a cornerstone of national resilience.
This is the second article in our coverage of the impacts of the global Coronavirus (COVID-19) outbreak on Iraq’s economy this year. If interested in contributing, please review our submission guidelines.