Understanding Iraq’s basic health services package: examining the domestic and external politics of post-conflict health policy

Background: Iraq is a higher middle-income country with a GDP of $223.5 billion (as of 2014). In the 1970s and 1980s, an extensive network of primary, secondary and tertiary health facilities was built, and the country recorded some of the best health indicators in the Middle East. However, two decades of conflict (both inter- and intra-state), sanctions and poor planning have reversed many of the previous gains. In the aftermath of the 2003 war, the government of Iraq introduced a Basic Health Services Package (BHSP) with a user fee component. International actors often advocate BHSPs as a means of rapidly scaling-up services in health systems that are devastated by conflict. User fees have also been promoted as a way of raising revenue to enhance the financial sustainability of healthcare systems in such contexts. While Iraq is a conflict-affected state, it has retained an extensive healthcare infrastructure and has a ministry of health with considerable financial and administrative capacity. In such a context, the introduction of a BHSP is a notable and distinctive feature of health policy in this setting, and the process through which this occurred have not yet been examined. Aim: To explore the processes through which the BHSP was conceived and designed in Iraq. It compares Iraq’s BHSP with similar policies in other post-conflict settings. It examines the roles of domestic and external actors and models in the policy’s conception and design. It explores the preferences of internal and external actors about the financing of service delivery through user fees. The study also examines the extent of policy transfer in the formulation of Iraq’s BHSP. Methodology: The thesis utilises a qualitative case study approach, incorporating analysis of semi-structured elite interviews and documents. Twenty Skype, phone, and face-to- face interviews were conducted between January 2013 and August 2014. Interviewees included former ministers of health, directors of departments of health, academics and officials at donor agencies, bilateral and multi-lateral bodies and consultancies. Documents included 47 official government publications, evaluations, reports, policy briefs and assessments. Literature review: A search of the literature on health policy making in post-conflict and fragile settings identified three key gaps in existing evidence; first, there is a dearth of published work examining health policy in post-conflict Iraq. Second, the literature focuses mainly on the impact of policy action in post-conflict contexts, largely neglecting the processes through which those policies are introduced. Third, while the literature concentrates on the roles of external actors, it pays limited attention to the role of domestic actors and politics. Results: Iraq’s BHSP shares commonalities with the other selected countries (Uganda, Afghanistan, and Liberia) in its primary aims, influential actors, interventions included or excluded, and financing principles. However, Iraq’s BHSP also aims at broader, and longer-term, structural reform, while the BHSP in other countries is often motivated by short-term objectives. The MoH in Iraq also appears to assume a prominent role in this case relative to others. Also, Iraq’s BHSP includes a greater number of interventions compared to the other countries. The Iraq war of 2003 offered the opportunity for wide-ranging structural change in the healthcare system. External actors, especially the WHO, were influential in advocating for a BHSP drawing on the recent experience of a similar initiative in what was in some ways the similar context of Afghanistan. However, the removal of former politicians and the emergence of internal policy actors with considerable technical and financial capacity allowed the domestic authorities to debate, dispute and challenge the recommendations of external actors. Relatedly, some of the internationally distinctive features of the BHSP in Iraq, including user fees, are similar to those that exist elsewhere in the health system. Most interviewees agreed that the BHSP was a means of enhancing financial sustainability and that it would help to enhance efficiency by targeting resources at population health need. The BHSP, according to some, represented the categories of healthcare that the government should finance, while allowing the private sector to meet demand for other services. However, many domestic actors supported the introduction of user fees as part of the BHSP. Several external actors either distanced themselves from this decision or declared no position, claiming that this was properly a matter for the government of Iraq. Discussion: While the BHSP’s ‘label’ is new in the context of Iraq, its substantive content is not. The BHSP can be seen as the outcome of the combination of old (existing) technologies and instruments presented in new (and introduced) ways. The existing health system offered ideas, techniques and processes that were maintained and reproduced even if these were packaged in new ways, to create a policy framework which is genuinely novel. External experts highlighted the idea of the BHSP and provided models (such as Afghanistan) on which the policy could be based. Internal decision-makers, however, were active players in policy formulation, not passive recipients who did not question or modify the policy during the process of transfer. On the contrary, it seems that the latter exerted considerable influence. User fees represent one aspect of that continuity. Ownership of policies by ministries of health in post-conflict is often advocated. However, such involvement introduces the potential for replicating old structures and policies, and may result in a degree of policy incoherence. Policy ideas are likely to change significantly where there is considerable local engagement in policy design and implementation