Tuesday, November 17, 2009

The Future of Rural Health in Southern Kurdistan

Justify Full

By Kate Dovel

Southern Kurdistan continues to make strides towards social stability and development. Yet, amid the success of this region, discouraging levels of inequality and poor health among vulnerable populations, specifically that of rural communities, continue to exist. The current health status throughout rural Southern Kurdistan represents the challenges to health and healthcare found throughout rural communities worldwide. Health in Southern Kurdistan has been historically poor, but significant improvements have been made in the recent years. [1] It is however, unfortunate that few of these efforts have resulted in improved health for rural populations. Consequently, there are large disparities between urban and rural health. The main factor influencing these disparities is lack of access to healthcare. While the Kurdistan Development Corporation claims that healthcare centers are distributed throughout urban and rural communities, [2] NGOs and testimonies from the local population show the inconsistencies in this claim. Rural communities have extremely limited access to health services. Recently, rural communities were promised approximately 30 new clinics by the government but only a handful have been completed due to lack of funds dedicated to the projects. The rest have been abandoned. Existing healthcare facilities are often unstaffed or ill-equipped to care for common health concerns and illnesses. The World Health Organization has found that, in all of Southern Kurdistan, 70% of primary healthcare centers are in need of renovation and have restricted access to water and electricity. Of staffed clinics, two-thirds were found to be staffed by medical assistants that have limited knowledge and resources and, therefore, can only treat basic health concerns. [3] These statistics are understood to be more severe in the rural areas. One villager reported that the nearest clinic was ten miles away from his village. He recalled that several times his family made the trip to the clinic, only to find it closed. The clinic was supposed to be open Monday through Thursday from one to three but often did not hold to the assigned hours. The villager himself had only successfully seen a doctor once in the last twenty years.

Poor health and access to healthcare in rural Southern Kurdistan is the result of historical and recent events, as well as beliefs held by policy makers and physicians. The violent and destructive acts of Saddam Hussein during the Anfal Campaign destroyed nearly all infrastructures within Southern Kurdistan. Poor roads, lack of electricity and means of communication, and lack of clean water dramatically hinder progress in rural healthcare. The thirteen-year embargo put in place by the United Nations (UN) impeded proper development of the region and created an information hiatus for doctors and other professionals. The UN relief coordinator for Iraq recognized the increasing burden the embargo placed on the people stating, “the imposition of sanctions does not impact the governance effectively but instead it damages the innocent people of the country”. [4]The current war, taking place in Iraq, also affects the state of health and healthcare within the rural Kurdish population. Nearly 20% of the Iraqi population, predominantly those from the central and southern region, are displaced with 2.7 million staying in Iraq. [5]Many internally displaced persons (IDS) have fled to Northern Iraq, within the Kurdish region. The influx of people has placed an increased burden on the Kurdish healthcare system, straining resources that could be allocated to the rural population. Many doctors and healthcare providers have fled the area, although there is a current increase due to Iraqi doctors from the south relocating to the Kurdish region.

Within Southern Kurdistan, healthcare strategies and individual beliefs limit access to healthcare among the rural population. Following the trend among most countries, the Kurdish Regional Government (KRG) has historically focused on urban health and secondary and tertiary care. One doctor in the region described the KRG as focusing on the urban environment. The rural areas are expected to follow the urban communities’ successes and therefore, little substantial attention has been given to rural communities.

With all of the barriers impeding improvement of health and healthcare among rural communities, is it really worth the extensive effort and resources needed to address the issue? One needs only to examine the examples of other countries to find the answer. First, rural populations should be a priority based on their contribution to society as a whole. Although often over looked, these populations are a key component to any society. Rural communities have been seen in many countries to be the vanguard of national prosperity and even social change. [6]They are central to agricultural production and are one of the main populations to maintain the culture and traditions of the society, an invaluable resource that is often lost in urban settings due to globalization. Within Southern Kurdistan, the deterioration of rural communities may result in the loss of important aspects of traditional culture that is such a rich resource and source of pride for the Kurdish community. Second, improved health has been shown to be intrinsically linked to improved economic status and overall community development. [7]Not only does improved health benefit the rural communities themselves, but also contributes to the overall well being of a society and decreases government expenditures on healthcare. [8]For example, without proper primary care, rural populations often do not see a doctor until the condition has progressed to a serious or critical stage. At this point, substantial expenditures and time must be dedicated to their recovery. Considerable time may also be taken off work and the illness may permanently compromise the individual’s ability to work. The impact of advanced illness negatively affects the individual themselves, their family, and their community. The impact on the community is especially felt within rural societies where families are often dependent on one anther for survival. On a larger scale, waiting to care for an illness until it is advanced, negatively affects the hospital or care center that provides care and the government who often pays for the expenses of care received.

Thankfully, the value of rural communities has begun to be recognized. Organizations within Southern Kurdistan are pursuing methods that may dramatically improve rural health. Both NGOs and the Ministry of Health have committed to devote greater resources towards primary care efforts, although it is unclear how much of these efforts will be allocated to rural settings. [9]The Health Minister was recently quoted saying “I am trying to shift spending, from secondary and tertiary care that benefit only five percent of the population to the primary health system that benefits 95 percent of the population. This is a slow and challenging transition that requires not only policy and fund allocation changes, but also an increase in primary care doctors and health prevention programs. It is hoped that during this needed transition the Ministry of Health and local NGOs will not forget the status of their rural citizens and the particular needs of rural settings. The transition to adequate primary healthcare is the first step towards improving rural health but it is just that, the first step. Extensive and innovative efforts are needed in order to increase adequate staffing and equipping of current rural health centers. Health centers that were previously promised but not delivered must also be completed to increase access. As well, a transition is needed in the way policy makers and doctors think about the rural population. Misinformed beliefs and assumptions about the rural population have led organizations to implement health programs that are based from urban settings and, therefore, are inappropriate and ineffective for rural communities. Doctors and other healthcare professionals often hold negative attitudes towards the rural population based on the perception that rural populations are uneducated and unable to understand details related to health and healthcare.

These attitudes and misunderstandings result in poor relations and, consequently, poor service to rural patients. Both NGOs and the ministry of health may increase their impact by addressing health professionals’ misinformed beliefs and attitudes towards rural populations and provide these professionals with the skills to properly communicate and treat rural communities within their social and cultural context. Creating, or adapting, programs that are specifically developed to target rural populations can also improve program effectiveness. These programs could be changed slightly to effectively meet the needs and social environment of rural Southern Kurdistan. Whatever steps are to be taken next, may it be realized that as resources for rural settings increase, success will be largely determined by the ability to recognize that rural communities are intrinsically different then urban communities both in health needs and cultural and societal norms.


Sindi, Ali. (2006). Yale World Fellow Speaks About Public Health in Iraq. Yale School of Public Health News.

KDC, Healthcare Sector Profile & Indicators for Erbil / Dohuk Governorate 2004.

World Health Organization. Iraq Briefing: Northern Governorates; Communicable Disease. November 2000.

World Report: Iraq. (1999). Human Rights Watch.

World Health Organization & Regional Health Systems Observatory. (2006). Health System Profile: Iraq.

De Ferranti, David. (2005). Beyond the city: the rural contribution to development. World Bank. Washington D.C.

Doeksen, Gerald A; Johnson, Tom; & Biard-Holmes, Diane. (2008) A Healthy Health Sector is Crucial for Community Economic Development. The Journal of Rural Health,

vol 14, is 1, pg 66 – 72.

Doeksen, G.A., Cordes, S., Shaffer, R. (1992). Health care's contribution to rural economic development. Unpublished manuscript. Rockville , MD : Office of Rural Health Policy.

KRG, Health minister: Top priority is improving primary healthcare, 20.10.06.