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Understanding Iraq’s BHSP: Examining the Domestic and External Politics of Post-Conflict Health Policy


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Presented by Goran Abdulla Sabir Zangana, Health Policy Research Organisation, Iraq.

Part of a session - 'Context, gender, and sustainability in introducing and scaling-up essential health care packages in fragile and crisis-affected countries' - at the Fifth Global Symposium for Health Systems Research in October 2018. The essential package of health services is a mechanism for expanding equitable coverage of primary health care and essential hospital services in countries recovering from conflict. The session explored the evidence-base on such healthcare packages in different contexts and prioritized areas for strengthening research.

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Understanding Iraq’s BHSP: Examining the Domestic and External Politics of Post-Conflict Health Policy

  2. 2. CONTEXT: GOOD TIMESIraq is a higher middle-income country with a GDP of $223.5 billion In the 1970s and 1980s, an extensive network of primary, secondary and tertiary health facilities was built. A national health services with no fee at the point of use. Had levels of health services that are similar to the BHSP (labelling of existing services by a new name) Iraq recorded some of the best health indicators in the Middle East
  3. 3. Many of the gains made in the 1970s and 1980s reversed because of: Conflict (both inter- and intra-state), Sanctions poor planning Introduction of user fees in the 1990s CONTEXT: NOT SO GOOD TIMES
  4. 4. CONTEXT: 2003...THE SILVER LINING Following the 2003 US led Iraq war: The country has retained an extensive healthcare infrastructure (only 27% of the equipment necessary to provide vaccination programmes were destroyed during or following the war) Had a ministry of health with considerable financial and administrative capacity.
  5. 5. BHSP: THE PUZZLE! Was BHSPs as a means of rapidly scaling-up services in health systems that are devastated by conflict, appropriate for a higher middle- income country such as Iraq? Why user fees have also been promoted as a way of raising revenue to enhance the financial sustainability of healthcare systems in such contexts.
  6. 6. THE AIMS OF THIS RESEARCH:  Explore the processes through which the BHSP was conceived and designed in Iraq.  Compare Iraq’s BHSP with similar policies in other post- conflict settings.  Examines the roles and preferences of domestic and external actors and models in the policy’s conception, design and financing.  Examine the extent of policy transfer in the formulation of Iraq’s BHSP.
  7. 7. METHODOLOGY: Two data sources: 20 Semi-structured key- informant interviews through Skype, phone, and face-to- face between January 2013 and August 2014. 47 official government publications, evaluations, reports, policy briefs and assessments.
  8. 8. LITERATURE REVIEW Three key gaps in existing evidence in fragile and conflict-affected settings (FCAS) in relation to Iraq;  Dearth of published work examining health policy in the conflict affected setting of Iraq.  Focus on impact of policy action, largely neglecting the processes through which those policies are introduced.  A focus on the roles of external actors, with limited attention to the role of domestic actors and politics.
  9. 9. RESULTS: SIMILARITIES WITH OTHER COUNTRIES Iraq’s BHSP shares commonalities with the other selected countries (Uganda, Afghanistan, and Liberia) in its:  primary aims, influential actors, interventions included financing principles
  10. 10. RESULTS: DIFFERENCES FROM OTHER COUNTRIES Iraq’s BHSP also aims at broader, and longer-term, structural reform. The MoH in Iraq also appears to assume prominent role in this case relative to others. Also, Iraq’s BHSP includes a greater number of interventions compared to the other countries.
  11. 11. RESULTS: EXTERNAL VS. INTERNAL ACTORS External actors such as: WHO World Bank IMF USAID US government Were influential in advocating for the introduction of the BHSP on the agenda drawing on the recent experience of a similar initiative in what was in some ways the similar context of Afghanistan
  12. 12. RESULTS: EXTERNAL VS. INTERNAL ACTORS However, internal actors were not passive: The removal of former politicians and the emergence of internal actors with considerable technical and financial capacity allowed the domestic authorities to debate, dispute and challenge the recommendations of external actors. Some of the internationally distinctive features of the BHSP in Iraq, including user fees, are similar to those that exist elsewhere in the health system.
  13. 13. RESULTS  The BHSP seen as a mean to enhance efficiency and financial sustainability by targeting resources at population health need. The BHSP represented the categories of healthcare that the government should finance, while allowing the private sector to meet demand for other services.  Many domestic actors supported the introduction of user fees as part of the BHSP. Several external actors either distanced themselves from this decision or declared no position, claiming that this was properly a matter for the government of Iraq.
  14. 14. DISCUSSIONS While the BHSP’s ‘label’ is new in the context of Iraq, its substantive content is not:  The BHSP can be seen as the outcome of the combination of old (existing) technologies and instruments presented in new (and introduced) ways.  The existing health system offered ideas, techniques and processes that were maintained and reproduced even if these were packaged in new ways, to create a policy framework which is genuinely novel.  External experts highlighted the idea of the BHSP and provided models (such as Afghanistan) on which the policy could be based.  Internal decision-makers were active players in policy formulation, not passive recipients who did not question or modify the policy during the process of transfer. On the contrary, it seems that the latter exerted considerable influence. User fees represent one aspect of that continuity.
  15. 15. DISCUSSIONS: Ownership of policies by ministries of health in FCAS is often advocated. However, such involvement introduces the potential for replicating old structures and policies, and may result in a degree of policy incoherence.  Policy ideas are likely to change significantly where there is considerable local engagement in policy design and implementation.
  16. 16. THANKS! Note of appreciation: Professor Jeff Collin/ supervisor Dr Mark Hellowell / supervisor Dr Sarah Hill/ internal examiner Dr Egbert Sondorp/ external examiner