Iraq and mental health policy: a post invasion analysis Intervention 2011,Volume 9, Number 3, Page 332 - 344 Iraq and mental health policy: a post invasion analysis Sonali Sharma & Jack Piachaud The Iraq war, and the subsequent involvement of are estimated to be in Iraq (UNHCR, 2011). various stakeholders in the post con£ict reconstruc- In addition, almost 50% of the total Iraqi tion of the health sector, presented an opportunity population is comprised of those below to learn about mental health policy development, 18years of age, posinga signi¢cant challenge challengesandobstacleswithin apost con£ict context for policy on mental health. Although the in 2003.This paper documents and explores mental overall impact is unknown, the increased health policy in post invasion Iraq, using qualitative mental health burden is high, and demands methodsand a healthpolicyframeworkthat analyses that mental health policymakers adequately context, content and process. Findings indicate that respond to the crisis. there are many challenges, both in repairing an In order to better understand the experi- already weakened health sector, and in maintaining ences faced in the Iraqi context, and to con- mental health as a health priority. In addition to tribute to the dialogue on best practice security issues, fragmentation of power, change of guidelines for other states in transition, this leadership and lack of funding pose signi¢cant pro- paper will examine mental health policy blems. Achievements are evident, though insu⁄cient development in post invasion Iraq. to address the overall mental health burden. The policy process is examined over a four-year period. Methodology Lessons learned are presented as best practice guide- Because the study was initially conducted in lines for post con£ict mental health reconstruction. the autumn of 2007, the period selected for review was 2003 to 2007. For this period, a Keywords: con£ict, Iraq, mental health retrospective qualitative case study method- and complex emergencies, mental health ology was utilised (an intensive analysis of policy, post con£ict reconstruction, war a process which took place in the past using qualitative methods to study it), supported by literature reviews and key informant Introduction interviews, in order to gather data. Over 40 More than 30 years of an oppressive regime, documents from scienti¢c and peer- and the ensuing war in 2003, have devas- reviewed journals, newspapers, various tated Iraqi society and imposed a large pub- institutions (including the World Health lic mental health crisis on the population. Organization (WHO), the U.S. Substance Forced migration of over four million Abuse and Mental Health Services Admin- people, pervasive human rights abuses, and istration (SAMHSA), key nongovernmental years of daily violence since the 2003 inva- organisations (NGOs) such as Medact, and sion, have taken a toll, both on the individual donors, mental health institutions, academic and on the society. Approximately 1.3 institutions and unpublished ‘grey’ policy million internally displaced persons (IDPs) documents were collected and analysed. A 332 Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Sharma & Piachaud select group of international and Iraqi Stockwell et al.,2005).The frameworkorgan- experts were surveyed, all with experience, isesthematic content into four areas: context, either directly in Iraq or indirectly with post actors, content of policy, and process, and con£ict health reconstruction in low and speci¢cally examines the interaction middle income countries. A snowballing between these four areas. This paper is technique identi¢ed potential interviewees. organised into two sections on context and Of 35 people contacted, 21 responded content/process. The authors utilised this (60%) and were interviewed over a six-week methodology as a means to better under- period in August^September 2007, either stand various in£uences and factors in men- by telephone, or in person where possible. tal health policy development, post invasion. Interviews were conducted in English, using Because this paper was submitted a few years a semi-structured interview tool with 20 after the key informant interviews took open-ended questions divided among the fol- place, an additional review of the literature lowing topics: drivers and in£uences of men- was conducted to analyse the period since tal health policy, planning of services, 2007, in order to have a more comprehensive achievements in mental health, obstacles to and updated view. However, due to budget mental health reform, e¡ect of the war on and time constraints, follow-up interviews the mental health burden, and the role of of respondents were not conducted, and NGOs and other stakeholders. Of the 21 therefore not incorporated into the policy respondents, the group consisted of ¢ve civil analysis. society leaders in mental health service delivery, seven senior experts in policymak- Ethical considerations ing for mental health service delivery, and A description of this project, and a request nine mental health professionals, both from for informed consent, were sent by email to within and outside of Iraq, across six all respondents. Those in insecure environ- countries. Only three of these respondents ments with no internet access were briefed were located (at the time of the study) in about the project by telephone. Personal Iraq, due to security issues. Consumers were information was not collected on partici- contacted, but all declined to participate pants, and all information obtained from due to personal security issues. Data interviews was anonymous, unless otherwise obtained from key informant interviews speci¢ed in the report. For participant pro- was cross-referenced, and substantiated by tection, no protocol approval was needed written literature to ensure accuracy. for this study. Methodology for data analysis consisted of thematic analysis on interview content, grey Limitations of our analyses policy documents, and literature reviewed Limitations of the analysis include lack of usingWalt’s analysis (Walt,1994) as a frame- consumers interviewed due to security issues work for mental health policy analysis.Walt’s and language barrier, under-representation analysis was chosen due to its framing of of Iraq-based respondents due to insecurity health policy within an economic and and poor access to communication, exclu- political perspective in low and middle sion of those who did not speak English; pre- income countries and its use across various dominance of senior leaders and sta¡ countries and areas of health, including rather than mid-level respondents; and mental health (De Vries & Klazinga, 2006; exclusion of those in insecure environments 333 Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Iraq and mental health policy: a post invasion analysis Intervention 2011,Volume 9, Number 3, Page 332 - 344 or with poor access to telecommunications. Further con£ict ensued with the Iran/Iraq In addition, observations by respondents war from 1980 to 1988, the invasion by Iraq are based on the period between 2003 and into Kuwait in1990 and1991,and subsequent 2007 and therefore this study does not UN sanctions due to the invasion of Kuwait. examine interviewee observations on Oil revenues, which had generously ¢nanced changes in policy after 2007. much of the social services in Iraq through the 1970s, ceased and health care costs were Background and context of no longer met. The UN Oil for Food Pro- mental health policy gramme began in1996 in response to the cri- development sis, and required that two thirds of oil Following a bloodless military coup in 1968, proceeds were earmarked for humanitarian the Ba’athists came to power in Iraq for needs (UN, 2010). almost four decades of totalitarian rule. By 20 March 2003, when the invasion began, Human rights abuses such as torture, assassi- both from a socio-political and economic nations, disappearances, detentions, forced point of view, the region had weakened. As conscription, and amputations were perva- the invasion proceeded, further destruction sive during this period (Amowitz et al., took place, and internal displacement wor- 2004). sened with 402,000 persons displaced from Although Iraq initially prospered under 2003 to 2005 (IOM, 2007), and another 1.6 Saddam’s rule, the economy and civil society million after a shrine bombing in Samarra weakened with increasing militarisation of (ReliefWeb, 2008) (Table 1). the country. Military expenditure rose from In the1960sand1970s, the health care system 19.4% of GDP in 1975, to 38.4% in 1985, £ourished and was a model for the region peaking at 70.1% in 1981 (Al-Khalil,1989). with mental health services well serving Table 1. General country information ^ Iraq Geographical area 440,000 square km Population 30.01million (2008) Population growth rate 2.2% (average over 2005^2010) Population aged 0 to 14 years 41.1% (2009) Main languages Arabic, Kurdish,Turkmens Number of governorates 18 Main religions Muslim 97% Christian, or other 3% Ethnic groups Arab 75^80% Kurdish 15^20% Turkmens, Assyrian, or other 5% Socio-economic: Lower middle income group (World Bank criteria) GDP USD $40.66 billion (2006) Life expectancy at birth 59.1years for males, 63.1years for females Literacy rates 54.9% men, 23.3% women Country Information on Iraq (CIA, 2010). Health care system prior to the 2003 invasion. 334 Copyright © War Trauma Foundation. Unauthorized