CHILDREN AND FAMILIES The RAND Corporation is a nonprofit institution that helps improve policy and EDUCATION AND THE ARTS decisionmaking through research and analysis. ENERGY AND ENVIRONMENT HEALTH AND HEALTH CARE This electronic document was made available from www.rand.org as a public service INFRASTRUCTURE AND of the RAND Corporation. TRANSPORTATION INTERNATIONAL AFFAIRS LAW AND BUSINESS Skip all front matter: Jump to Page 16 NATIONAL SECURITY POPULATION AND AGING PUBLIC SAFETY Support RAND SCIENCE AND TECHNOLOGY Purchase this document TERRORISM AND Browse Reports & Bookstore HOMELAND SECURITY Make a charitable contribution For More Information Visit RAND at www.rand.org Explore RAND Health View document details Limited Electronic Distribution Rights This document and trademark(s) contained herein are protected by law as indicated in a notice appearing later in this work. This electronic representation of RAND intellectual property is provided for non- commercial use only. Unauthorized posting of RAND electronic documents to a non-RAND website is prohibited. RAND electronic documents are protected under copyright law. Permission is required from RAND to reproduce, or reuse in another form, any of our research documents for commercial use. For information on reprint and linking permissions, please see RAND Permissions. This product is part of the RAND Corporation monograph series. RAND mono- graphs present major research findings that address the challenges facing the public and private sectors. All RAND monographs undergo rigorous peer review to ensure high standards for research quality and objectivity. Kurdistan Regional Government Ministry of Planning • Ministry of Health The Future of Health Care in the Kurdistan Region—Iraq Toward an Effective, High-Quality System with an Emphasis on Primary Care Melinda Moore C. Ross Anthony Yee-Wei Lim Spencer S. Jones Adrian Overton Joanne K. Yoong HEALTH Kurdistan Regional Government Ministry of Planning • Ministry of Health The Future of Health Care in the Kurdistan Region—Iraq Toward an Effective, High-Quality System with an Emphasis on Primary Care Sponsored by the Kurdistan Regional Government Melinda Moore C. Ross Anthony Yee-Wei Lim Spencer S. Jones Adrian Overton Joanne K. Yoong HEALTH The research described in this report was sponsored by the Kurdistan Regional Government and was conducted in RAND Health, a division of the RAND Corporation. Library of Congress Cataloging-in-Publication Data is available for this publication. ISBN: 978-0-8330-8578-8 The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND’s publications do not necessarily reflect the opinions of its research clients and sponsors. R® is a registered trademark Cover photograph courtesy Superstock © Copyright 2014 Kurdistan Regional Government Permission is given to duplicate this document for personal use only, as long as it is unaltered and complete. Copies may not be duplicated for commercial purposes. Unauthorized posting of RAND documents to a non-RAND website is prohibited. RAND documents are protected under copyright law. For information on reprint and linking permissions, please visit the RAND permissions page (http://www.rand.org/publications/ permissions.html). Published 2014 by the RAND Corporation 1776 Main Street, P.O. Box 2138, Santa Monica, CA 90407-2138 1200 South Hayes Street, Arlington, VA 22202-5050 4570 Fifth Avenue, Suite 600, Pittsburgh, PA 15213-2665 RAND URL: http://www.rand.org To order RAND documents or to obtain additional information, contact Distribution Services: Telephone: (310) 451-7002; Fax: (310) 451-6915; Email: [email protected] Preface In 2010, the Kurdistan Regional Government (KRG), under the auspices of His Excellency Dr. Ali Sindi, Minister of Planning, asked the RAND Corporation to undertake four stud- ies aimed at improving the economic and social development of the Kurdistan Region—Iraq. RAND’s work was intended to help the KRG expand access to high-quality education and health care, increase private-sector development and employment for the expanding labor force, and design a data-collection system to support high-priority policies. The studies were carried out over the year beginning in February 2010. The RAND teams worked closely with the Ministries of Planning, Education, and Health to develop targeted solutions to the critical issues faced by the KRG. This study provides an analysis of the health care system, with an emphasis on primary care, in the Kurdistan Region and what strategies can be pursued to move toward a more effec- tive and higher-quality health care system. This report is based on a variety of methods and analyses. These include a review of the existing literature; analyses of available data; an analysis of Kurdistan Regional and Iraqi National documents and laws; modeling of future health care demand; and a qualitative assessment of numerous conversations with government officials, health care providers, health care policymakers, and private sector health care leaders. This study was undertaken by the RAND Corporation at the request of the Kurdistan Regional Government under the auspices of the Ministry of Planning and in collaboration with the Ministry of Health. The research was conducted from February 2010 through March 2011. The findings should be of interest to those interested in health care and health care–related policies in the Kurdistan Region—Iraq specifically and in health care policy more generally. This research was prepared within RAND Health’s Global Health Initiative. RAND Health has built an international reputation for conducting objective, high-quality, empirical research to support and improve policies and organizations around the world. Its work focuses on a wide array of domestic and international policy areas, including quality of care, health promotion, financing, organization, public health preparedness, domestic and international health care reform, and military health policy. For further information, contact C. Ross Anthony, Ph.D., the principal investigator. Dr. Anthony can be reached by email at [email protected]; by phone at 310-393-0411; or by mail at the RAND Corporation, 1200 South Hayes Street, Arlington, VA 22202. For more information on RAND Health, contact RAND Health, RAND Corporation, 1776 Main Street, P.O. Box 2138, Santa Monica, CA 90407-2138. iii Contents Preface ........................................................................................................... iii Contents .......................................................................................................... v Figures ........................................................................................................... ix Tables ............................................................................................................ xi Executive Summary .......................................................................................... xiii Acknowledgments ........................................................................................... xxix Abbreviations ................................................................................................ xxxi Chapter OnE Introduction ..................................................................................................... 1 Methods ........................................................................................................... 2 Organization of This Report .................................................................................... 2 Chapter TwO Current health Care System in the Kurdistan region—Iraq and Vision for the Future ......... 5 Current Status .................................................................................................... 5 Mortality ........................................................................................................ 5 Morbidity ....................................................................................................... 8 Risk Factors .................................................................................................... 11 Strengths of the Current Primary Care System in the Kurdistan Region—Iraq ..................... 12 Current Challenges to Primary Care ....................................................................... 14 Key Aspects of a Well-Integrated Model of Care ............................................................ 18 Objective 1—Offer Services at the Appropriate Level of Care .......................................... 19 Objective 2—Create Incentives for Patients to Seek Care in Community Settings, When Appropriate ...................................................................................... 20 Objective 3—Integrate Health Information Across Levels of Care .................................... 21 Primary Care in the Twenty-First Century .................................................................. 21 Illustrative Examples of Good Health Practices, Appropriate Levels of Service, and Indicators and Benchmarks ....................................................................... 25 Chapter Three Projecting Future health Care Utilization ............................................................... 29 Introduction ..................................................................................................... 29 Constructing the Base Model ................................................................................. 31 Baseline Health