Imagine what it would be like to create a new national healthcare system from the ground up-invent a financing mechanism, plan and build a delivery network, and educate managers and clinicians who come to the enterprise with a clean slate.
For some, this is not an imaginary exercise but a daily reality. Welcome to Iraq.
At one time considered a crown jewel of healthcare in the Middle East, Iraq's medical infrastructure all but crumbled under the regime of Saddam Hussein, who spent state money on palaces rather than hospitals and allocated nearly nothing to care for the people he ruled.
When Hussein realized that patients at a 400-bed hospital in Tikrit could see one of his sprawling compounds from their rooms, he ordered that the windows be boarded up with steel, said James Haveman, senior U.S. adviser to the Iraqi Ministry of Health and former director of Michigan's Department of Community Health.
Haveman's role in Iraq is to advise the minister of health, Khudair Abbas, and help him take steps toward building an accessible, affordable, quality healthcare system.
"Hospitals are empty, but people are not healthy," said Al Anaji Shakir, director general of the new Iraqi agency Specialized Health Services, in a telephone interview last week from his home in Baghdad. "We have a good tradition and heritage of medical care, but it was devastated during the last 50 years."
In 2002, the Iraqi government spent $16 million providing healthcare to 23 million people, roughly 70 cents per person, according to the U.S. Defense Department. Modern medical equipment is the exception rather than the rule, and salaries for healthcare workers are equally dismal-physicians earn an average of $50 per month and administrators $100, Haveman and others said.
"Once you go beyond stethoscopes and thermometers and blood pressure cuffs, (Iraq) needed everything else" after the U.S.-led invasion, said David Tornberg, deputy assistant secretary of defense for clinical and program policy, who assists in the supervision of Defense Department-led reconstruction efforts.
As the U.S. and international community begin to rebuild Iraq's war-torn infrastructure, hospitals and primary-care clinics are major priorities. While the tenuous security situation has prevented many U.S. civilians from traveling to Iraq to lend their assistance, hospital executives could soon participate in exchange programs to educate their Iraqi counterparts.
Some physicians and other healthcare professionals in the reserves, meanwhile, are leaving their U.S. jobs to serve in Iraq as hospital administrators at home grapple with the new vacancies.
Healthcare at home and abroad
Under the $87 billion appropriations bill President Bush recently signed into law, the U.S. will spend almost $800 million on healthcare in Iraq next year, a good portion of which is likely to benefit U.S. companies.
Some members of Congress believe at least some of that money should be reserved for spending at home-to reduce the number of uninsured, improve veterans' healthcare and address other domestic needs. Other lawmakers argue that improving the healthcare environment in Iraq is an inescapable obligation for the nation that conquered it.
"This money is spent to the benefit of Americans and to the benefit of a freer, more stable world," said Rep. John Kline (R-Minn.), one of several members of Congress to visit Iraq in recent months. "You can't have Third World medical care with high infant mortality and expect to have a successful outcome here."
Funding challenges represent only the beginning of the formidable tasks awaiting Iraq's healthcare leaders in the coming years. With an acute shortage of qualified hospital administrators, they will have to train people how to run effective and efficient healthcare organizations. And without any public or private financing mechanism, it is unclear how the services will ultimately be reimbursed.
"We're looking at a soup-to-nuts opportunity to evaluate what's there and what's not there," said Irwin Redlener, associate dean of the Columbia University Mailman School of Public Health and former president of Children's Hospital at Montefiore in New York.
Defense Department officials and members of Congress said the task of deciding how to develop a financing apparatus for healthcare in Iraq has barely begun. Acknowledging the complexity of that task, those same officials drew a blank when queried about how it might be done.
"One of the critical things I hope for is that the international community does not make that decision," said Rep. Mark Kirk (R-Ill.), who along with colleagues from the House and Senate visited a hospital in Baghdad last month.
Kirk and others said they believe that Iraqi government officials should be the ones to decide how to structure public programs. Few people interviewed for this article were enthusiastic about exporting the U.S. system.
"Even thinking about setting up a competitive situation for the healthcare industry would be completely inappropriate," Redlener said. "It's very difficult to use the American model as relevant to what has to happen in Iraq."
At least one Iraqi health official agrees.
"We're not copying anything from the Americans, or the British or anyone," Shakir said. Pointing to Iraq's one-time reputation as the leading healthcare provider of the Middle East, he added, "We can have more modernization and have our own way."
Iraq has no Medicare- or Medicaid-type program, and no managed-care plans to bill. After years of centrally controlled government operation, few people know what's involved in managing an independent organization.
Iraqi healthcare professionals have little if any experience building teams, delegating responsibility, establishing accounting controls, handling a budget, monitoring clinical quality or planning strategy, said the Americans helping them set up a new healthcare system.
"There's no management culture there, no management of care in the larger sense," said James Smith, executive director of the American International Health Alliance, which sets up training partnerships between American healthcare professionals and those in developing countries.
So far, because of security concerns, the alliance hasn't arranged any partnerships in Iraq, but "if security was fine, I'd have 50 hospitals interested in four weeks," Smith said. Interested parties, he said, would participate in education programs to help Iraqi officials become independent and informed managers.
Since 1992, Smith's organization has set up more than 100 partnerships between American hospitals and those in countries such as Romania, Slovakia and the former Soviet Union.
Such partnerships are a good idea that already is being tested, according to Shakir, who works closely with the U.S. Coalition Provisional Authority and currently is hosting two American doctors in his home. The security situation, Shakir said, is not as bad as news reports make it seem.
"Security is getting much better," he said. "I'll drive back to the main (provisional authority) compound at 10 p.m., which I think is very safe to do. It was not safe two or three months ago."
Officials guiding the reconstruction effort see a major challenge ahead but also cite significant progress. Since May 1, U.S. personnel have vaccinated some 4.2 million Iraqi children and delivered 12,000 tons of pharmaceuticals and medical supplies; the nation's 240 acute-care hospitals are all up and running, at least to some degree; and there have been no epidemics or other public health emergencies.
"It's better now and will be much better in the future," Shakir said.
Still, obstacles remain. Pentagon and Iraqi officials are seriously concerned about the dearth of managers with the skills required to run a hospital. And until the security situation in Iraq improves, Smith and others said, it will be difficult to recruit healthcare professionals from other countries to help.
Some industry officials said they would be willing to serve in Iraq, and that interest in doing so will grow if and when the country becomes a less dangerous place to work.
"You could find healthcare executives that would do short stints (in Iraq)," said Richard Salluzzo, chief executive officer and chief medical officer of Conemaugh Health System in Johnstown, Pa., one of many hospital CEOs who have had top-tier employees called to service in Iraq.
Earlier this month, a trauma surgeon serving 339-bed Conemaugh Memorial Medical Center was called to active duty in Iraq, leaving Salluzzo with just two trauma surgeons for an emergency room that fields 1,200 admissions per year.
The physician who left, Michael Najarian, also is director of Conemaugh's surgical residency program. Iraq will be Najarian's first combat deployment, he said, and he doesn't expect the emergency room to be adversely affected by his absence.
Medical reserve personnel serving in Iraq come from all 50 states and four U.S. territories, according to the Pentagon. In the Army alone, more than 2,300 medical reservists are deployed in Iraq and another 1,669 have been mobilized to replace active-duty soldiers who have left their U.S. military hospital posts.
One busy military hospital, 256-bed Walter Reed Army Medical Center in Washington, has treated a total of 1,900 patients from Operation Iraqi Freedom, 342 of whom were battle casualties, a hospital spokesman said.
Some members of Congress argue that the U.S. is spending money in Iraq that could be better applied to domestic priorities. The $87 billion appropriations bill Bush signed earlier this month, for instance, represents almost 25% of the amount Congress plans to spend on a Medicare prescription drug benefit.
"Our needs are every bit as much of an emergency in the U.S. today as they are in Iraq in terms of those who don't have insurance, hospitals that are closing, and Medicare and Medicaid not paying our health providers what they should," said Sen. Debbie Stabenow (D-Mich.), who introduced an amendment to the appropriations bill that would have earmarked $5 billion for healthcare needs at home.
Others in Congress disagree. Kline said the Medicare comparison is unfair because "the money we're putting into Iraq is in effect a one-time expense," while the drug benefit would amount to trillions in spending.
As that dispute continues, the money will begin flowing to help Iraq rebuild its medical infrastructure. Roughly $500 million will be used to reconstruct hospitals and clinics in 2004, and another $300 million will finance equipment purchases, according to the Pentagon.
Some reconstruction money already has benefited American companies, including Cambridge, Mass.-based Abt Associates, a for-profit research and consulting firm that recently won a $40 million contract to equip Iraqi healthcare facilities, train their workers and support quality improvement efforts.
Hussein's regime "used healthcare as a weapon and a way to control people and abuse people," Haveman said. The transformation from that medical world to a free, modern one, he said, "is all doable. It just takes time and patience and money."
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