In the 1970s, Iraq was at the forefront of healthcare in the Middle East. The Iraqi Government developed a centralized, free healthcare system by using a hospital-based, capital-intensive model of curative care. The war in 2003 destroyed an estimated 12 percent of Iraqi hospitals and two main public health laboratories. In 2004, some improvements were made. However, Iraq's supply chain was left significantly crippled, impeding its ability to support and sustain a health-care system. Nearly 9 years after the toppling of Saddam Hussein's government, Iraq's medical supply, distribution, and biomedical maintenance programs are still facing many challenges.
The Aftermath of War
When hostilities ceased in 2003, the Iraqi Government was left with an antiquated warehouse infrastructure and a handicapped distribution system. This caused a partial loss of medical stocks and biomedical equipment. All central and government warehouses required extensive repair or replacement since most of them were aging and not regularly maintained. The intravenous (IV) fluids warehouse was affected the most.
The supply delivery system was interrupted between March 2003 and the beginning of June 2003. This increased some of the shortages, particularly at hospitals and health centers in remote areas. These shortages included commonly used antibiotics, drugs used in anesthesia, anticancer drugs, most laboratory reagents, and medical supplies, such as surgical gloves, sutures, surgical blades, IV cannulas, and blood bags. Distribution activities gradually resumed when some contracts previously submitted by the former government were awarded.
The Iraqi Government medication production base was almost nonexistent, which exacerbated the shortages. The IV fluid plant in Ninewah completely stopped operating as a result of looting and vandalism. However, the Arab Company for Antibiotics Industries (ACAI) and Samara Industries were not affected by the war. The ACAI factory resumed activities in August 2003, but the raw materials available were only sufficient to maintain production for 1 month.
In June 2004, the Multi-National Security Transition Command–Iraq (MNSTC–I) was established to assist the Iraqi Government in developing capable ministries and adequate Iraqi Security Forces (ISF) that adhere to the rule of law. The establishment of MNSTC–I was a direct response to the need to create a new Iraqi Army and to build a new police force using a civilian police assistance team and advisory missions to the Ministry of Defense (MoD) and the Ministry of Interior (MoI).
The U.S. Congress appropriated funding for MNSTC–I to meet its mission of building and supporting the ISF. To assist in distributing this funding, MNSTC–I used nine advisory teams that advised and generated requirements for the ISF. These requirements involved developing the ministerial capacity, arranging training for Iraqi Army and Iraqi National Police forces, and building sustainment efforts on behalf of the ISF to enhance its performance.
The health affairs advisory team was tasked with advising the Surgeon General of Iraqi Joint Forces (SGIJF) (who worked for MoD) and the director of health affairs (who worked for MoI) and their staffs on healthcare policy, preventive medicine, medical training, medical logistics, and facility planning. The health affairs medical logistics section played a crucial role in the initial distribution of class VIII (medical materiel), in the design, development, and equipping of medical infrastructure and logistics systems, and in enabling the ISF to become capable and ready as they move forward toward self-sufficiency.
The Big Picture
The ISF faces discouraging challenges in its efforts to rebuild the shattered Iraqi medical infrastructure. These challenges can be attributed to excessive bureaucracy, the lack of healthcare professionals, widespread illiteracy, and inaccessible pharmaceuticals and medical equipment.
The shortage of healthcare personnel in Iraq is the direct result of its three wars since 1980 and years of ethnic persecutions. After June 2003, there was a massive exodus of healthcare professionals to neighboring nations. This created a huge void in access to care. The Ministry of Health (MoH) adopted an aggressive employment strategy that included a safe work environment, higher salaries, and an excellent retirement package. The SGIJF was forced to match, and in most cases exceed, MoH benefits in an effort to recruit more clinicians into the ranks.
This prompted extraordinary SGIJF office outreach efforts, from recruiting campaigns over the radio to bonuses for highly trained personnel. This endeavor has benefitted both MoD and MoI in healthcare. Ultimately, these underlying practices are necessary to having trained ISF medical personnel. Trained and proficient human capital is the most important aspect of ensuring that the Iraqis are able to attain true self-sustainment.
A complex hierarchy and administrative processes bound by red tape put severe limitations on ISF's ability to direct, control, and achieve the objectives and requirements from its requesting units and support agencies. Bureaucracy seemed to be the rule for day-to-day operations. The MoD and MoI acknowledged their inability to spend their annual budgets. The budget expenditures for the SGIJF office did not reach 30 percent of its annual funds by the end of the second quarter. In fact, this is one reason MoD provided its Commander's Emergency Relief Program (CERP) funds to MNSTC–I so that MNSTC–I could spend its own money.
Kimadia, the state company managing the importation and distribution of drugs and medical equipment, is the main drug supplier of Iraq. This organization operates a distribution network of specialized central, governorate, and district warehouses. Kimadia also is the sole source authorized by law for management, planning, selection, quantification, procurement, storage, and distribution of medicines and medical equipment. This restricts the SGIJF and the MoI Health Affairs from selecting their own sources of supply at home and abroad.
Laying a Foundation
Most people in the developed world take for granted access to basic health services and the existence of a functioning health system. The situation is different in Iraq because of fundamental limitations in funding, staffing, training, and other elements of essential infrastructure. Several steps must be taken to improve the Iraqi health services system.
Create a partnership with Kimadia. Establishing a strategic alliance between the ISF and Kimadia will enable both organizations to gain competitive advantage through access to each partner's resources, including markets, technologies, capital, and human resources. This partnership will create a flexible support infrastructure that can rapidly meet ISF medical supply needs, provide a distribution mechanism that is well represented both geographically and strategically, reduce cost through a greater pool of suppliers, and standardize supply-chain synergies throughout the country.
Train the ISF medical logistics force. The SGIJF logistics chief has developed guidelines for building and maintaining a comprehensive awareness and training program as part of an organization's medical logistics program. This guidance is presented in a life-cycle approach, ranging from designing, developing, and implementing awareness and a training program to post-
implementation evaluation of the program. The program includes guidance on how medical logistics professionals can identify awareness and training needs, develop a training plan, and get organizational buy-in for the funding of awareness and training program efforts.
Establish a biomedical maintenance program. A planned and well-orchestrated preventive maintenance program is regular and repetitive work done to keep equipment in good working order and to optimize its efficiency and accuracy. The SGIJF medical logistics office will promote regular, routine cleaning, lubricating, testing, calibrating and adjusting, checking for wear and tear, and eventually replacing components to avoid breakdown. This program includes the proper selection of equipment to be included in planned preventive maintenance. The SGIJF envisions a joint venture with the MoH to train and develop young engineers.
Regular Preventive Maintenance Performance
An important aspect of planned preventive maintenance is the participation and commitment of the users. Preventive maintenance should start with users, and the bulk of the work should be their responsibility. The user must perform preventive maintenance tasks daily, and the user must conduct joint activities with a technical engineer at the end of each week. Highly technical repairs, which are the engineer's responsibility, may be scheduled every 6 months.
The SGIJF medical logistics office knows that all equipment that is in the care of the service workshop should be recorded on cards. All relevant information about the equipment must be entered, including its location, records of repair and maintenance, and manufacturer. A reference number is given and written on a printed paper label, which is attached to each item. This number is recorded in a ledger of equipment with full identifying details.
Before beginning training, those who are qualified and available to do preventive maintenance must be identified. A list must be drawn up of personnel who are readily available. Once the personnel have been listed, specific responsibilities should be assigned, perhaps in the form of a work order, giving clear instructions for the task. Each person should understand his responsibilities. Job assignments must correspond to the training, experience, and aptitude of the individual.
The intent is to have two biomedical technicians per distribution center to assist in day-to-day maintenance. However, the maintenance depot will have the reach-back capability to augment regions on a case-by-case basis. If the MoH hospital staff includes a large number of well-trained, experienced individuals who are familiar with medical equipment, in-service training can easily assist MoD in gaining that technical edge.
Improvements have been seen in the form of new policies and procedures that have been staffed and published to address operating processes for both the healthcare field and garrison operations. The policies set into their day-to-day operations include disposal of regulated medical waste and cold-chain management.
Other improvements accomplished within the warehouse management arena include properly staged oxygen containment, inventory tracking systems, medical unit requisition systems, the introduction of a truck fleet for the distribution of temperature-controlled medical supplies, and the implementation of wireless and satellite logistics enterprise systems.
The challenges facing the SGIJF medical logistics office are large and exceedingly difficult to address. These include a compromised system of expired supplies, poor inventory automation capability in regional warehouses, difficulty in keeping the SGIJF medical logistics office informed of regional shortages, and a limited range of vendors for resupply.
To tackle these problems, rebuilding the relationship with the different healthcare organizations and groups in the country is indispensible. The central challenge to this rebuilding does not lie in the repair of the physical and institutional devastation but in restoring confidence in any political arrangement put in place and in the mechanisms of conflict prevention in general.
The success or failure of Iraq will depend chiefly on whether domestic realities and dynamics are accurately understood and can be translated into a form of governance that sets priorities for healthcare provided by the Iraqi constituency.