Download 2. When the public system of care for patients with NCDs improves, it

HEALTH SECTOR
Non-Communicable Diseases
Country Context/Health Status:
The burden of cardiovascular disease (CVDs) and other non-communicable diseases
(NCDs) like cancer, chronic obstructive lung disease and diabetes is considerable.
Good data on these conditions do not exist. The latest information available on NCDs
if from 1999. These conditions were probably the first cause of morbidity and
mortality prior to 1990. With the decline in social conditions in the 1990s, infectious
conditions rose, with diarrhea and respiratory infections among young children
becoming the top causes of death. If these conditions decline rapidly in the next few
years, as is expected, then NCDs will again become the number one cause of death.
Control of NCDs suffered since 1990 through isolation from developments in the rest
of the world and impoverishment of the medical care system. Usual sources of
medicine supply and familiar doses disappeared, leading to an excessive focus on the
provision of drugs in place of a focus on health. Most importantly, those aspects of the
system that dealt with prevention and health promotion were most retarded during the
country’s period of wars and economic sanctions.
The number of cancer cases registered is between 8000-9000 per year. The most
frequently reported tumors are CA Breast (14%), Lung (10.6%), Bladder (7.5%)
followed by CA of the Lymphatic system. Childhood Cancers constitute about 8% of
total cancer in Iraq
The main determinants of NCDs are smoking, hypertension, diabetes, unhealthy diet
and lack of physical activity. Of these, smoking is probably the single most important
risk. The prevalence of smoking in males is 40% while in females 5%. A survey by
FAO in 2000 determined that 40% of the adults are overweight. There is no routine
surveillance system for NCDs risk factors.
Health Policy/ Management Structure:
Iraq was one of the first countries in the region initiate a population-based cancer
registry and a national cancer control plan. The Ministry of Health chairs the Iraqi
Cancer Board (ICB). Before the 2003 war it had14 provincial committees and
subcommittees for smoking control, cancer registration, prevention and early
detection, radiotherapy, chemotherapy and palliative cancer. Iraq was one of the first
countries in the region to establish a unit for NCD control in MOH about 17 years ago
. it is now part of the department of non-communicable disease and mental health.
MOH formulated a NCD prevention and control programme but implemented little of
it.
It organized several national workshops and training courses, produced health
education materials and disseminated several treatment guidelines. It launched a
national campaign for the early detection of breast cancer in 2001. It prohibited of all
forms of tobacco advertising and imposed tariffs on imported tobacco.
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Since the war the anti-smoking control program has been lost. The previous high
tariffs on imports of cigarettes disappeared.
To address this situation there should be:
 Re-activation of the Smoking Control Committee.
 Empowering this committee to enable anti-smoking regulations.
 Changes in the managerial structure of the NCDs program to better define
different levels of the health care system and emphasize decentralization.
Health Care Service Patterns:
PHC physicians are inadequately trained in the management and follow up of NCDs.
A semi-private nation-wide network of public clinics was established after the
embargo to ensure the availability of essential drugs to chronically ill patients. These
clinics (which are more or less dispensaries in reality) were managed by a DG of
public clinics and it offered better incentives to health workers, but operated only in
evenings.
Specialists in internal medicine working in private/public clinics now treat people
with NCDs. This form of health care delivery is loosely regulated and malpractice is
not uncommon.
Pharmaceuticals
A national NCD Drug policy but during sanctions there were frequent shortages and
interruptions of supply. Adherence to the formulated national drug policy was
inconsistent, case management impaired and control of complications nearly absent.
Most of the drugs for NCDs were subsidized.
Short Term Goals:
1. An effective National Surveillance System should be developed to monitor
NCD risk
factors strengthen mortality statistics and monitor the nutritional status of
the population. Better equipment, more modern patient management
approaches, improved referral systems, improvement in the referral and
counter-referal of patients from PHCs may notably reduce mortality.
2. Establishing a primary prevention program based on integrated prevention
of the major NCDs that share the same risk factors.
3. Developing a long term culturally specific health education strategy aimed
at raising public awareness on the prevention of risk factors and promoting
"self-care" and "self-monitoring".
4. Investments in interventions to change the KAP of the population should
be sustained over extended periods of time to achieve optimal changes in
risk factor levels and disease outcomes.
5. A national surveillance system for NCDs should be designed and built to
be an integral part of the overall disease surveillance.
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6. Create a special focus on housewives education that smoking inside
the house hurts the whole family, including the children
7. Approaching the people through intensive media campaign
designed to address the local community, for example interviewing
victims of smoking to tell their story and /or people who where
able to quit smoking specially the ones that are likely to influence
the beliefs and behavior of people
8. Actively involving high profile religious leaders in the campaign
against smoking would have an important impact on a society that
highly respects these leaders and is willing to follow their example.
9. Perhaps one of the most effective anti-smoking activities was the
global ban on smoking advertisement that was strictly enforced.
This ban should be reasserted now
Medium Range Goals:
1. The chronic disease cards system provides opportunities to deliver evidencebased practice and improve the skill levels of clinicians specializing in one
type of disease. Patient support groups and educational activities are also
relatively easy to organize with this population-based system of specialized
care. maintained because it offers every NCD patient with his or her monthly
“ration” of drugs. The opportunities offered by this system to maintain a
patient database and observe changes in treatment modalities is great.
2. When the public system of care for patients with NCDs improves, it will
become possible for the medical association and DOH to begin monitoring
quality of care in private practice. Malpractice reports can be followed up,
perhaps a legislative body can be established that looks into lawsuits filed by
victims of malpractice. Re-licensing of practice can be linked to attainment of
continuing medical training points (on the job training).
3. Training is an essential tool that is needed to improve medical care standards.
Continued medical training was used by MOH only occasionally. To correct
this situation, it is suggested that performance be linked to scholarship for
outside the country training and/or education opportunity.
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