Developing Iraq's Mental Health Policy

Societies torn by natural disaster and war face higher levels of emotional distress ( 1 ), and yet they are most in need of productive, healthy citizens. Preventing or reducing the impact of mental disability and substance abuse and promoting resilience in otherwise physically healthy individuals is critical to help rebuild those societies.

According to the World Health Organization (WHO), the fourth leading cause of morbidity among Iraqis older than five years is mental illness, which ranked higher than infectious disease ( 2 ). Iraq, like most low- and lower-middle-income countries ( 3 ), has struggled to establish a national mental health policy. Iraq has dedicated less than 1% of the total health care budget to mental health, has failed to establish community mental health centers, has not been able to secure essential pharmaceuticals, and has not developed a viable mental health care monitoring system. Iraq serves as a prime example of how global forces, political culture, and national history shape and constrain mental health programming. Drawing on Kingdon's ( 4 ) "three streams" model of policy development, which includes political analysis, problem defining, and proposal drafting, this brief report will explore the current state of Iraq's mental health policy and provide suggestions for future direction and development.

History

Although Iraq's political circumstances are currently unstable, several stable global forces, such as transnational corporations, the World Bank, and WHO, drive Iraq's national health policy. In order to understand potential determinants for policy development in Iraq, it is essential to understand the historical context of Iraq's health care system.

Psychiatric hospital care in Iraq began as early as the late eighth century with Islamic hospitals, which incorporated Galenic medicine, spirituality, mysticism, and music therapies in treating persons with mental illness ( 5 ). Medical care, including mental health care, in Iraq during the premodern era was highly advanced for its time and was financed both by the state and by private endowments. However, with the decline of the Ottoman Empire in the 18th and 19th centuries, health care, especially mental health care, became neglected.

In the 20th century, although British colonial rule was short lived (1919–1927), it had a profound impact on medical education and health care delivery style ( 6 ). Iraq's current system for medical education is based on the British medical education system, which includes very rigorous training and certifying examinations for all physicians.

Throughout the middle and late 20th century, Iraq's health system had been highly centralized and regulated by the Iraqi Ministry of Health. During the 1970s large sums of oil revenue allowed the government to function without a need to rely on tax revenue or interest groups ( 7 ). Annual oil revenue soared from U.S. $600 million in 1970 to U.S. $26 billion by 1980. This revenue was invested in government programming, such as the Iraqi military, social welfare, education, and health institutions. Approximately 21% of the Iraqi workforce and 40% of Iraqi households depended directly on government salaries. As recently as 2003, 92% of Iraqi physicians had government salaries and also worked in private clinics, and only 5% of physicians exclusively worked as private practitioners. Almost all medical staff were employed by the Iraqi government; medications were produced, stored, and distributed predominantly by the two state-owned pharmaceutical companies (KIMADIA and Samara Drug Industries). The management and administration of health care delivery was under the auspices of the Ministry of Health. The Iraqi government paid for primary care and hospital services, and specialized consultations were paid on a fee-for-services basis ( 8 ).

After the Iran-Iraq war (1980–1988), Iraq's invasion of Kuwait (1990), the U.S.-led economic sanctions (1990–2000), and the U.S. invasion of Iraq (2003), the Iraqi government could no longer afford to bear the costs of health care ( 9 ). In addition, during the past decade Iraqi professionals across disciplines, including mental health fields, fled Iraq to relocate in economically and politically more stable countries, leading to a massive "brain drain."

Political analysis

The impact of the United Nations economic embargo enforced from August 1991 to March 2003 (when the United States invaded Iraq) reflects the profound impact of the global economy on Iraqi health. During the 1990s funding for health care by the Iraqi Ministry of Health dropped by 90%, and the nation's health expenditure was reduced from 3.72% of the gross domestic product in 1990 to .81% in 1997 ( 8 ). During the 1990s there was a sharp increase in infant and child mortality rates (from 60 deaths per 1,000 live births in 1988 to 120 in 1999). In addition, maternal mortality more than doubled during this period, from 117 maternal deaths per 100,000 live births in 1989 to 294 in 2004. Malnutrition rates also increased, as measured by percentage of low birth-weight babies, from 4.5% in 1990 to 23.8% in 1998 ( 2 ).

The international community took notice of the devastating impact wars and sanctions had on Iraqi health. During the reconstruction phase of Iraq, there has been a new global interest in Iraqi health care reform ( 10 ). However, out of the approximately $4 billion originally allocated for reconstruction funding, only 4.8% went to the health sector, and 2% of that was allocated to systems improvement and training; over 97% of the health sector funding was spent on construction and equipment ( 11 ). International nongovernmental organizations provided mental health services and governmental agencies provided funding for mental health programming during the beginning of the reconstruction effort. New attention to mental health by various international health-related organizations provided an opportunity for Iraqi mental health professionals to reconsider the value of the development of a stronger Iraqi mental health policy.

Problem defining

Since 2003 the Substance Abuse and Mental Health Services Administration (SAMHSA) and WHO have been the primary facilitators in defining the mental health problem in Iraq. SAMHSA, in conjunction with experts from the U.K. National Health Service, the U.S. National Institutes of Health, and Iraq's Ministry of Health, has coordinated Iraqi mental health planning committees and hosted two major planning conferences in Amman, Jordan, and in Cairo, Egypt. The main themes that emerged across the work groups included lack of human and financial resources, stigma associated with mental illness, and the lack of allied professionals, such as professionals who are trained in primary care, social work, psychology, and nursing. WHO's influence in defining Iraq's mental health problem was facilitated by the production of the Iraqi WHO Assessment Instrument for Mental Health Systems (WHO-AIMS) ( 12 ).

The WHO-AIMS report for Iraq includes six domains: policy and legislative framework, mental health services, mental health in primary care, human resources, public education and links to other sectors, and monitoring and research. This report has been designed by WHO experts to create a periodic reporting mechanism so that problems related to the mental health of a developing country can be brought to the attention of policy makers within the country. Such monitoring is important, because as Kingdon ( 4 ) purports, national resources are not likely to be allocated to problems that cannot be defined and tracked over time.

In both the SAMHSA's and WHO's efforts, academic experts mostly from the United States and the United Kingdom worked to positively influence the development of an Iraqi mental health policy by providing the framework for assessing mental health systems. The framing of a problem in another country has cultural considerations, and the themes that emerge virtually unavoidably reflect the mental health reform experience of the United States and the United Kingdom. For instance, the shutting down of Iraq's only long-term inpatient psychiatric hospital ( 13 ) reflects the renewed emphasis on primary care and community mental health delivery. The deinstitutionalization movement, however, has particular ideological, social, financial, and political significance in the United States and the United Kingdom ( 14 , 15 ), which may not be applicable to Iraq's current circumstances. For example, in contrast to the United States and the United Kingdom, Iraq has essentially no community health centers, vocational or rehabilitative services, homeless shelters, or residential mental health programs, and it has fewer than 100 psychiatrists to serve 25 million Iraqis.

Proposal drafting

The mental health policy proposal generated by the planning conference includes 43 recommendations that may be categorized by four general themes: developing standards for clinical care, delivery of services, research, and education; training experts in administrative, public health and policy, and mental health subspecialties; integrating services across disciplines, including primary care; and addressing stigma associated with mental illness by the public and by other medical professionals and government agencies ( 16 ). The planning conference resulted in the drafting of a comprehensive Iraqi mental health plan that describes problems as well as a framework for resolutions ( 16 ). Iraqi mental health policy makers may draw from this newly developed plan. With tangible objectives and specific recommendations for policy intervention, once the political circumstances are favorable, or a "policy window" is opened, progress in mental health care reform is possible.

One of the major limitations of this particular process is the lack of specification in the areas that Robert and colleagues ( 17 ) have referred to as the "control knobs" of health reform, including financing, payment, organization, regulation, and behavior. Currently, Iraq essentially has no functioning national or social insurance system. Iraq's undervalued currency and economic recession result in a poor tax base, and the high rate of unemployment and weak labor force are poor sources for financing a health care system. Once financed by oil and other governmental revenue, the health care sector is now primarily dependent on foreign aid. The current security situation makes it nearly impossible for the Iraqi government to regulate the health care industry, and as demonstrated by the looting of government institutions, including health care institutions, and by ongoing publicized insurgent activity, many Iraqis have little faith in the state or a sense of civil responsibility ( 18 ). Again it is critical to remember that Iraq historically was highly industrialized, had high rates of literacy, and had a skilled workforce. As the security situation improves, there is hope that Iraqis will reestablish their culture of compassion and high-quality health care delivery.

Conclusions

It is not clear how the situation in Iraq will ultimately resolve. However, it is apparent that recent work has provided a basis for the development of effective mental health services policy in Iraq. We have outlined examples from the current situation in Iraq for each of the three traditional streams that converge to move policy development. These are political analysis, problem defining, and proposal drafting.

As the United Nations and the World Bank continue to develop assessment and strategic planning reports on health care needs ( 19 ), Iraqi mental health policy makers will need to propose a mechanism for the financing and regulatory aspects of health services. International partners, such as WHO, the World Bank, the International Monetary Fund, and SAMHSA, have served and could continue to serve useful roles in assisting Iraqi mental health policy developers in terms of problem defining, proposal drafting, and even political analysis. Furthermore, internal entities, such as government ministries and other health care specialty groups, will naturally vie for diminishing reconstruction funding as well as other national funding sources as funding sources emerge. Policy makers will need to continue to strengthen their partnerships with primary care services and other health care specialists when setting the health care reform agenda so that mental health remains in the forefront. Existing mental health care services, such as long-term inpatient care, should not be terminated before the establishment of alternative community health and mental health services. Consideration might be given to support the strong national regulation of foreign industries that wish to do business in Iraq so that profits would remain in Iraq where possible. Conversely, indigenous Iraqi health industries should be provided financial incentives to promote growth.

Iraqi mental health will continue to be marginalized if mental health policy makers do not participate in the broader aspects of health reform, such as financing, regulation, and organization of the health care system. Although global forces, such as war and international economic policy, are seemingly not within the influence of mental health policy makers, global and domestic players in health reform must be engaged. If the Iraqi mental health proposal takes into account the political factors and other "control knobs," it will be better prepared to be tested when the next "policy window" is opened.

Acknowledgments and disclosures

The authors thank Victor Rodwin, Ph.D., M.P.H., for his feedback.

The authors report no competing interests.