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This Thesis Has Been Submitted in Fulfilment of the Requirements for a Postgraduate Degree (E.G This thesis has been submitted in fulfilment of the requirements for a postgraduate degree (e.g. PhD, MPhil, DClinPsychol) at the University of Edinburgh. Please note the following terms and conditions of use: This work is protected by copyright and other intellectual property rights, which are retained by the thesis author, unless otherwise stated. A copy can be downloaded for personal non-commercial research or study, without prior permission or charge. This thesis cannot be reproduced or quoted extensively from without first obtaining permission in writing from the author. The content must not be changed in any way or sold commercially in any format or medium without the formal permission of the author. When referring to this work, full bibliographic details including the author, title, awarding institution and date of the thesis must be given. i UNDERSTANDING IRAQ’S BASIC HEALTH SERVICES PACKAGE: EXAMINING THE DOMESTIC AND EXTERNAL POLITICS OF POST-CONFLICT HEALTH POLICY By Goran Abdulla Sabir Zangana This thesis is submitted in fulfilment of the degree of Doctor of Philosophy, University of Edinburgh Global Public Health Unit Social Policy School of Social and Political Science University of Edinburgh 2016 ii Declaration of originality I, Goran Abdulla Sabir Zangana, declare that the work presented in this Ph.D. thesis is my own and that it has not been submitted for any other degree or professional qualification. Signed: _________________________________________________________________ iii UNDERSTANDING IRAQ’S BASIC HEALTH SERVICES PACKAGE: EXAMINING THE DOMESTIC AND EXTERNAL POLITICS OF POST- CONFLICT HEALTH POLICY Abstract 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. iv 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. v 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. vi Acknowledgments It would not have been possible to conduct this research project without the help, support and encouragement of a number of individuals, institutions, and family members. Firstly, I would like to express my sincere gratitude and appreciation to both of my supervisors, Professor Jeff Collin, and Dr Mark Hellowell. It has been an extreme privilege and honour to work with them. I would like to thank them for their commitment to this research and providing stimulating critique and encouraging input. A number of people have also provided support, comments and encouragement throughout this journey. Significant thanks are due to Dr Andy Aitchison and Drc Johanna Hanefeld for providing invaluable input into earlier versions of the research project. I would like to acknowledge the participants of this research who dedicated time and efforts to provide comments as well as documents. I would like to thank the generous funding and financial support from the Ministry of Higher Education and Scientific Research of the Kurdistan Regional Government of Iraq. I am truly indebted to the beloved people of Kurdistan and can only hope that this research begins to contribute to their health and wellbeing. I would like to acknowledge the love, support and encouragement of my partner Aveen. This thesis is devoted to our daughter Larisse who was born as the project was coming to its final stages. Last but not least, warm thanks should go to my parents, brothers and sister. vii List of acronyms and abbreviations BHSP Basic Health Services Package BI Bamako Initiative BPEHS Basic Package of Essential Health Services BPHE Basic Package of Health Entitlements BPHNS Basic Package of Health and Nutrition Services BPHSW Basic Package of Health and Social Welfare services for Liberia CAQDAS Computer Assisted Qualitative Data Analysis Software CDC Centres for Disease Control and Prevention CHWs Community Health Workers CPA Coalition Provisional Authority DALYs Disability Adjusted Life Years DLYs Discounted Life Years DoH Directorates
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