Interview with Health Minister Dr Ala'adin Alwan

Iraq's new minister for health, Ala'adin Alwan, is forward-thinking in his ideas about how to modernise health care in the country. Educated in the UK, Alwan previously served as the World Health Organization's (WHO) representative and head of mission in Jordan and Oman. He also served as head of WHO's office on chronic and non-contagious diseases in Geneva. In an interview with IRIN in the Iraqi capital, Baghdad, Alwan said his immediate priorities were to stop corruption and ensure there were enough medical supplies in the country, as well as providing a safe environment for medical staff to work in. QUESTION: There are reports that many doctors are leaving the country after receiving kidnapping and death threats. Can you comment on this? ANSWER: There is no doubt that the current situation has an adverse affect on the health workforce, but not to the extent that it threatens health care. The number of doctors who have left is very small. The vast majority of health sector staff are staying. We are coordinating with the Ministry of Interior on this issue, not just to offer protection, but to prevent the number of incidents from increasing. Q: IRIN has written in the past about the Health Ministry inspector-general's fight against corruption [an independent inspector general-now works in every ministry to investigate corruption] - mostly the illegal smuggling of medicine and equipment out of the country. How is that going now? A: We have a number of priorities in reconstruction, to improve management and to fight corruption. So, anti-corruption measures are very important to us. We're interacting with professional associations and the non-governmental organisations to fight corruption. Q: How, exactly, will you fight corruption, since it seems to be so ingrained in the system? A: We are fighting it with the other sectors, the security sector, the legal system and working closely with religious leaders. A week ago, we had a workshop on corruption, smuggling issues and the leakage of drugs onto the market, and religious leaders attended. The approach has to be multi-sectoral, it cannot just be an inspector-general who does all the work. Q: What about medical equipment the new inspector-general says is missing? Is it possible to get it back? A: You know what happened to Iraq in the last year - there was unprecedented looting and a huge amount of destruction in the health institutions. The borders were open. It's much more difficult to smuggle the equipment now, but it's still easy to smuggle drugs. The health sector has a system now, so regulations are applied to people who went back to work. They now have guidelines implemented. The checks are there. Even at the borders, things are improving now. We have guards at the hospitals that did not exist before. We have an active system of inspection. Awareness is increasing, and the salary of staff has increased. Q: What will happen to people who steal health equipment or medicine now? A: We're trying to be as tough as possible without violating people's human rights. When you say you are watching and following up, people who are misusing the system see what you're doing. When you investigate, when people are convicted, either administratively or by legal action, the possibility of future incidents decreases. We have to be serious about transparency. Besides open corruption, we also have to train our people in a number of issues, on bidding procedures, for example, and in procurement. We have to revisit our guidelines for procurement and bidding and strengthen them against corruption. We can see what other countries have done. Capacity building is important in the coming few months. Q: What is your relationship with aid agencies and United Nations agencies, since virtually all of them are outside of Iraq at the moment? A: We have a relatively good relationship with the United Nations agencies and other NGOs. Because of the lack of physical presence in Iraq, we want to see the United Nations come back as soon as possible. Our collaboration would be stronger if they came back. But we have close collaboration and coordination, either through their local staff or through infrequent meetings outside of Iraq. In addition, we are also increasingly doing telephone conferencing and video conferencing. We negotiated with the World Bank through a video conference. They're helping us with capacity building. We're doing projects with them like the projects I arranged at the Ministry of Education [where Alwan previously worked]. Q: We understand that some sort of health insurance system is being discussed for the first time in Iraq. A: What we are doing right now is an important step - we're making an analysis of the health sector in Iraq and a review of the current health situation of the current population and the current structure and performance of the health system itself. We are identifying the constraints and discussing our priorities. There will have to be a change in the current system, but we will not compromise the basic health needs of the general population. We will still provide preventive health care and emergency care and management of chronic conditions. In addition, the government will continue to upgrade primary health care services and do capacity building with the current human resources we have. We will not compromise the basic system. If there is to be universal health insurance, the government and other employers would be paying for it. We can't do it in a day or two, or a year or two - there will be a provision for access that makes it free to those who need it. Q: What will happen to the former state-run medicine company Kimadia? A: The state company for marketing and distribution of medicine has gone through a change in mandate in the last few months. Kimadia is now only in charge of storage and distribution. We're moving procurement to a separate office. The proposal is being reviewed right now. Q: What is the Health Ministry's new mental health strategy? A: We will continue to have mental health hospitals but the strategy is to handle mental health in the population. So the care of mentally ill and psychiatric patients is done in general hospitals, not in specialised institutions. The emphasis is to fold psychiatry into general health services rather than excluding and isolating the patients in a separate place. Q: What is your top goal for the Health Ministry in the next year? A: We have four priorities. The immediate priority is the gap we have in the availability of medicine. Many things are missing now because even though it might have been bought with Oil-for-Food money [former UN-administered programme that brought food and humanitarian aid paid for by Iraq's oil revenues], the ministry did not receive the correct amount of supplies or equipment. We're trying to establish a system to overcome the shortages. This is my biggest challenge. We have acute rehabilitation needs in some hospitals and health centres. We also need to do capacity building for physicians and nurses and other health professionals. We need to restructure the Health Ministry and develop a vision for a new health care system in Iraq in the short- and medium-term future. Workers need to do evidence-based planning and go through performance-based appraisals. We need to create a culture of monitoring and evaluation to fight corruption. These are enormous challenges. Q: Do you have the funding you need? A: Funding is a problem, but it's not the main problem. Time is a bigger problem. There are so many urgent needs and you have so little time to fulfil them. Capacity is extremely important. There are deficiencies in the number of doctors in training, for example. Our capacity to absorb quickly the amount of work that's needed isn't fast enough. For instance, out of the 1,300 health centres in the country, a good proportion need to be rehabilitated now. How many can you do per year? The PMO [Project Management Office, now called the Project and Contracting Office (PCO), a programme of the US Pentagon disbursing US $18.4 billion approved by the US Congress for Iraqi reconstruction] will be used to build 150 new health care centres and renovate several hospitals, including a paediatric hospital in Basra.