Shabila et al. BMC International Health and Human Rights 2012, 12:21http://www.biomedcentral.com/1472-698X/12/21RESEARCH ARTICLEOpen AccessIraqi primary care system in Kurdistan region:providers perspectives on problems andopportunities for improvementNazar P Shabila1*, Namir G Al-Tawil1, Tariq S Al-Hadithi1, Egbert Sondorp2 and Kelsey Vaughan3AbstractBackground: As part of a comprehensive study on the primary health care system in Iraq, we sought to exploreprimary care providers perspectives about the main problems influencing the provision of primary care servicesand opportunities to improve the system.Methods: A qualitative study based on four focus groups involving 40 primary care providers from 12 primaryhealth care centres was conducted in Erbil governorate in the Iraqi Kurdistan region between July and October2010. A topic guide was used to lead discussions and covered questions on positive aspects of and currentproblems with the primary care system in addition to the priority needs for its improvement. The discussions werefully transcribed and the qualitative data was analyzed by content analysis, followed by a thematic analysis.Results: Problems facing the primary care system included inappropriate health service delivery (irrational use ofhealth services, irrational treatment, poor referral system, poor infrastructure and poor hygiene), health workforcechallenges (high number of specialists, uneven distribution of the health workforce, rapid turnover, lack of trainingand educational opportunities and discrepancies in the salary system), shortage in resources (shortage and lowquality of medical supplies and shortage in financing), poor information technology and poor leadership/governance. The greatest emphasis was placed on poor organization of health services delivery, particularly theirrational use of health services and the related overcrowding and overload on primary care providers and healthfacilities. Suggestions for improving the system included application of a family medicine approach and ensuringeffective planning and monitoring.Conclusions: This study has provided a comprehensive understanding of the factors that negatively affect theprimary care system in Iraqs Kurdistan region from the perspective of primary care providers. From their experience,primary care providers have a role in informing the community and policy makers about the main problemsaffecting this system, though improvements to the health care system must be taken up at the national level andinvolve other key stakeholders.Keywords: Primary care, Care providers, Focus group, Service delivery, Kurdistan regionBackgroundThe Iraqi health system significantly deteriorated duringthe last few decades as a result of wars and economicsanctions. The primary care system did not escape thisdevastation and continues to suffer from problems common to the health care system in general [1-3].* Correspondence: [email protected] of Community Medicine, College of Medicine, Hawler MedicalUniversity, Erbil, IraqFull list of author information is available at the end of the articleWhile the need for re-organizing and restructuring theprimary care system in Iraq as part of the overall healthsystem is desperately recognized [2,4], there is limiteddocumented knowledge about the challenges and needsof the primary care system in Iraq, particularly in theKurdistan region [5]. Availability of such knowledge canhelp policy makers to better direct appropriate action toimprove the primary care system. Given their importantrole and the power they have in the health care system,obtaining perspectives of primary care providers on the© 2012 Shabila et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Shabila et al. BMC International Health and Human Rights 2012, 12:21http://www.biomedcentral.com/1472-698X/12/21Page 2 of 9problems and priority needs of the system is a cornerstone for any improvement to the system [6,7]. The useof focus groups is an effective technique for gaining adeeper understanding about the problem and exploringhealth providers experience and concerns about healthservices [8,9]. As part of a comprehensive study on theprimary care system in Iraq that targets different actorsin the system including decision makers, service providers and service users using different research methods,this study sought to explore primary care providers perspectives about the main problems influencing theprovision of primary care services in Erbil governorateand opportunities to improve the system.without a prescription are poorly applied in Iraq. Thereis also poor regulation of the public-private practice inIraq and most health care providers work in the publicsector in the morning and in the private sector after official working hours [2,12].MethodsSubject and settingPrimary care services in Iraq are provided by a networkof public primary health care centers (PHCCs) that areof two types: the main PHCCs located in main urbanand semi-urban areas and the smaller PHCCs located inrural areas. The main PHCCs are staffed by doctors,dentists, pharmacists, nurses, medical assistants, laboratory technicians and a number of administrative andsupport staff, while the smaller PHCCs located in ruralareas are staffed by non-physician providers [10]. Eachcenter has a manager, usually a physician, and an administrative director, usually a nurse or medical assistant.Primary care providers receive regular fixed salaries fromthe government. The salary is not related to the numberof patients visiting the center or consultation feesgenerated.Doctors working in PHCCs are mainly general practitioners. General practitioners in Iraq usually have notreceived any additional formal training after graduationfrom medical school, apart from a two year clinical internship and one year working in a remote PHCC orhospital. With the increasing number of specialist doctors in Iraq in recent years and the limited number ofpositions in hospitals and consultancy centers, more andmore specialists are assigned to work in PHCCs [1,2].The private health care sector provides mainly curativeservices and consists of a number of relatively small surgical hospitals, a high number of physicians clinics andmany private pharmacies. The private sector has beengrowing steadily since the last decade. Although figureson public and private health care spending are not available, the growth of the private sector is evident from thedisproportionate increase in the number of private hospitals in Iraq in recent years (from 65 in 2004 to 92 in2010, i.e. 42%) compared to public hospitals (from 197in 2004 to 229 in 2010, i.e. 16%) [2,11]. There are alsomany private clinics run by nurses or medical assistantsthat directly prescribe and sell most kinds of medicines.In fact, regulations that prohibit selling medicinesSamplingA multi-stage stratified sampling technique was used forthis study. In the first stage, the main PHCCs in Erbilgovernorate were stratified according to geographicallocations. A random sample of PHCCs was selectedfrom each stratum; four each from Erbil city and the district and sub-district centres in Erbil city suburbs andtwo each from district and sub-district centres outsideErbil city. In the second stage, a physician, a nurse and/or a medical assistant and an administrator were randomly selected from the list of employees at each PHCC.A total of 40 participants were selected and invited toparticipate in the focus groups.Data collectionFour focus groups were conducted between July and October 2010, each lasting approximately ninety minutes.The first focus group included 12 participants from thefour PHCCs in Erbil city. The second included another12 participants from the four PHCCs in district and subdistrict centers in Erbil city suburbs. The third focusgroup included eight participants from the two PHCCsin district centers outside Erbil city. The fourth focusgroup included another eight participants from the twoPHCCs in sub-district centers outside Erbil city. Allfocus groups were held in a meeting room or doctorsoffice in PHCCs.Each focus group was facilitated by two researchers,one as moderator and the other as observer. The purpose of the study and the ground rules regarding taperecording of discussions and anonymity of all materialswere explained at the beginning of each focus group before obtaining the participants consent. The study wasreviewed and eventually approved by the Research EthicsCommittee of Hawler Medical University.A topic guide was used to lead discussions andincluded questions about main problems influencing theprovision of primary care services and priority needs forimproving the system (Table 1). Each session was concluded when the discussion sufficiently covered the topicand no new information was emerging. At the end ofeach focus group a debriefing discussion between themoderator and the observer was held.All discussions were conducted in Kurdish andrecorded in full. To assure translation accuracy, audiorecordings were transcribed and translated into English.The translation subsequently was verified by an additional native Kurdish speaker fluent in English.Shabila et al. BMC International Health and Human Rights 2012, 12:21http://www.biomedcentral.com/1472-698X/12/21Table 1 Topic guide for focus group discussions1. What are the main positive aspects of the current primary caresystem?Page 3 of 9Table 2 Demographic and professional characteristics ofparticipantsCharacteristic2. What are the main problems facing the current primary care system?MaleNo.3. What are the priorities for improving the primary care system?Physician(%)TotalNo.No.(%)8*(66.7)4**(33.3)12(30.0)8(80.0)2(20.0)10(25.0)Profession4. What can be the main barriers to the future improvement of theprimary care system?Female(%)5. Do you have any additional comments about the primary caresystem and its improvement?Medical assistantNurseAdministrator4(66.7)2(33.3)6(15.0)12(100.0)0(0.0)12(30.0)(71.4)4(28.6)14(35.0)Data analysisEducationThe translated transcripts were analyzed qualitativelyusing content analysis, followed by thematic analysisusing a framework adapted from the WHO conceptualframework of health system building blocks [13]. Twoauthors reviewed the transcripts independently, compared notes and reconciled the differences. The condensed meaning units were identified and condensedbefore abstracting them and labeling them with codes.Emerging coding was used to obtain categories. The categories were further discussed between the two codersfor identification and formulation of themes and subthemes. A greater emphasis was placed on themes andsub-themes repeated by more than one group, initiallyraised themes and sub-themes, strong feelings, orthemes and sub-themes of long discussions. We haveincluded discordant views to highlight differing experiences or perceptions of individuals and groups [8]. Giventhe manageable length of the four focus groups, no software was used to analyze the data.College10Technical institute17(89.5)2(10.5)19(47.5)Secondary school5(71.4)2(28.6)7(17.5)ResultsIn total 40 primary care providers participated in thefocus groups: 12 physicians, 6 nurses, 10 medical assistants and 12 administrators. The participants mean ±SD age was 34.4 ± 7.8 years and their median experiencein the health system was 7 years (range 1 to 30 years).Details of demographic and professional characteristicsof the participants are shown in Table 2. The four focusgroups provided a wide representation of views and sufficient saturation. Problems in the primary care systemas emerged from the focus groups can be classifiedunder five main themes: 1) inappropriate health servicesdelivery, 2) health workforce challenges, 3) shortage inresources, 4) poor information technology, and 5) poorleadership/governance.Inappropriate health services deliveryIssues related to health services delivery particularly interms of organization of these services were the mainfocus of all focus groups. These issues can be classifiedunder the following subthemes:* Six of these 8 physicians were also managers of the PHCC.** One of these 4 physicians was manager of the PHCC.Irrational use of health servicesFocus group participants thought that PHCCs sufferfrom overcrowding which prevents physicians from having adequate time to provide quality care to patients.[We see] patients from 9:00 to 11:00 a.m. I can [onlygive] two minutes for each [patient] because of crowdingand because patients are always in a hurry and impatient to wait (F(=female)7, physician). Participantsthought that overcrowding is partially the result ofpatients seeking unnecessary care.Participants thought the low consultation fees (250 IraqiDinars ($0.2)) charged by PHCCs encouraged irrationaland repeated visits to PHCCs. They suggested that increasing the fees to 1000 or 2000 Iraqi Dinars per consultmight help in reducing many unnecessary visits and lowerthe irrational use of services. One medical assistant suggested the [services can be improved] by increasing thefees with provision of better care and [sufficient] drugs(F8, medical assistant). However, some participants hadconcerns about introducing higher initial fees that mightmake some patients, particularly the poor and uneducated, hesitant to visit PHCCs. It was mentioned thatsome patients may not know the seriousness of their illness or they may even turn to inappropriate health seeking strategies like visiting the private nurse clinics.Therefore, they suggested keeping the initial consultationfees at the current rate and charging additional fees forprescription and further services like laboratory tests andx-rays. We cannot increase the user fees. Even at [this]very low [rate], many patients can not [afford] visitingPHCCs. It is better to obtain additional fees for extra services like investigations [to reduce] unnecessary requestsfor investigations (M(=male)27, administrator).Some participants, particularly physicians, expressedgreat concerns about unlicensed drug sellers includingsome private clinics. Many medical assistants andShabila et al. BMC International Health and Human Rights 2012, 12:21http://www.biomedcentral.com/1472-698X/12/21Page 4 of 9nurses have opened clinics where they prescribe all typesof medicines including those that can cause addiction orlead to serious side effects. With my respect to their longexperience, [I think] the medicines they prescribe shouldbe restricted (M7, physician). Another participantnoted that these clinics have taught people to take[many types] of drugs together to get [rapid] relief. During the [flu] epidemic of this year, different [combinations] of injections and several types of drugs wereprovided to patients at these clinics to [get] immediaterelief (M13, medical assistant).Many participants emphasized the need to adopt a family medicine approach in the primary care system. Undera family medicine model patients would visit only thePHCC in their catchment area and see their own familymedicine physician. Each family medicine physician wouldmaintain electronic records for all patients. Participantsthought this approach would help control irrational andrepeated visits by patients. If the system is changed to afamily medicine system, it will benefit both the providerand the patient as better and more organized services willbe provided to people and the providers can interact in agood way with patients (M1, physician). The positiveexperience of the only family medicine center in Erbil wasfrequently cited as a model that could be adopted in theprimary care system.Physicians usually resist providing these inappropriatereferrals, and participants agreed that provision of betterservices and increasing the health awareness of thepeople will help in reducing self-requested referrals. Ifproper health care services are provided at PHCCs andpeople become aware that most of the cases can be [dealtwith] at the PHCC, we can control these unnecessaryreferrals (M14, physician).Poor infrastructure and hygieneThe facilities of most PHCCs were described as old,small and lacking sufficient space to provide health services to the current population. [This] PHCC was builtin 1987 when [this residential] area was small [andhad] a small number of inhabitants. The area has[grown substantially] and [is now inhabited] by a verylarge number of people, but the PHCC [remained] thesame (M17, administrator). Some participants emphasized the poor sanitary situation in PHCCs particularlyin the PHCCs located in Erbil city and attributed thismainly to the lack of sufficient numbers of cleaningstaff. We have only three cleaning staff. If they workproperly they may [maintain the cleanliness] well, buttwo of them are [completely busy] with organizing visitors at entry to [the consultation room] and cannot doanything else (M11, administrator).Irrational treatmentThe type of treatment provided at the PHCCs wasdescribed by some participants as irrational and basedprimarily on symptomatic treatment. Frankly speaking,we provide treatment for symptoms without knowing theactual cause of these symptoms (M3, physician). Theyattributed this to time constraints related to the highnumber of patients and a shortage of medicines anddiagnostic facilities. We only have some antibiotics andsimple analgesics. So when [receiving] a patient, whatever he has, I nearly have written the prescription [when]he starts talking (M12, medical assistant). Furthermore,some respondents reported lacking motivation to takegood patient histories and conduct physical examinations. We have no motivation in this job and there aremany patients. So we write the prescription immediatelyand send the patient out of room (M14, physician).Poor referral systemParticipants indicated that many patients attend PHCCsonly to ask for a referral to a specific hospital or consultation department without having a real reason for the referral. Referral is [very common] with patients requestingreferral for even very simple illnesses. We tell the patient;please sit down and let [a] physician see you [as] youmay not require a referral. [But he insists that] he needsto go to [that] particular hospital (M19, administrator).Health workforce challengesHigh number of specialists in PHCCsParticipants thought that the PHCCs located in Erbilcity are becoming like consultancy units as there aremany specialists working in different fields. However,the available facilities and medicines at these PHCCs arevery limited. [This] PHCC has a surgeon, internist, ophthalmologist, otolaryngologist, radiologist, pediatricianand dentist. We just need to change the name to becomea consultancy center. But [the available] facilities andmedicines are still simple analgesics and some antibiotics (M5, administrator). Some participants indicatedthat PHCCs often gradually increase the number of specialists in different fields as the local hospitals are unable to accommodate the growing number of newlygraduating specialists. Whilst many participants, particularly administrative directors, medical assistants andnurses, emphasized the importance of having specialistsat PHCCs, physicians argued that there is no need tohave specialists at PHCCs as general practitioners candeal with most patients and can refer them to specialized centers if required. [Within] the Iraqi primarycare system [there is no need] to have specialists inPHCCs. There is a need for hospitals in district or subdistrict centers to provide specialist [referral] services(M18, physician).Shabila et al. BMC International Health and Human Rights 2012, 12:21http://www.biomedcentral.com/1472-698X/12/21Uneven distribution of the health workforceThe uneven distribution of the health workforce inPHCCs, particularly with regards to physicians, skillednurses and medical assistants, was emphasized by someparticipants. Specific examples of the shortage of skilledhealth care workers were in the fields of laboratory andradiology personnel. We have now a new x-ray unit butit is still not operating for not having x-ray [personnel].There may be three or four [in a PHCC] but we do nothave any [at this] PHCC (M1, physician).Rapid turnover of the health workforceA number of participants emphasized the rapid turnoverof the health workforce. They indicated that somepersonnel ask to be transferred to another PHCC shortlyafter receiving training in a specific job at their currentPHCC. They cite different reasons for requesting the transfer, such as moving home to another area. Sometimes,[after] we send two staff members to get training on a specific [program], they ask to be transferred to another PHCC.[Even if] we do not agree, they manage to get transferredthrough personal connections and [this will affect] that program in the PHCC (M2, administrator).Physicians indicated that there are no incentives to retain physicians at PHCCs. They also thought that they donot have access to specialty training or postgraduate educational opportunities or benefit from supervision frommore senior physicians while working in PHCCs. Furthermore, because of high patient numbers and the resultingshort consultation times, as well as a lack of essential facilities and medicines, PHCCs are a challenging working environment. This will eventually result in a rapid turnoverof physicians. Physicians usually leave PHCCs to pursuespecialty training or postgraduate study. If I stay at thePHCC I will remain [a simple employee] without changinganything in my life (M7, physician). Rapid turnover ofphysicians is a big concern particularly in PHCCs outsideErbil city as physicians usually stay for six months to oneyear before being replaced by other physicians as part ofthe physicians internship system. Some of these physicians also hold the position of director of the PHCC.Thus, this rapid turnover similarly affects the management of PHCCs. [The doctor and the administrative director] need six months to start understand each other andonce they understand each other the doctor will leave [thePHCC] (M21, administrator).Lack of training and educationFocus group participants mentioned a lack of opportunities for professional development and education for primary care providers. The available training courses donot always address the actual needs of the providers.There are some training courses but these are mainlytheoretical [and] cannot be applied practically. IPage 5 of 9personally have participated in many tuberculosis training programs, but we have not implemented [this program] so far (F4, medical assistant).Salary discrepanciesParticipants had concerns about the extreme discrepancies in the salary system. A newly appointed nurse mayreceive a significantly lower salary than another nursewho has been in the job longer but has the same responsibilities. A [newly appointed] nurse gets 150,000 or200,000 Iraqi Dinars. It is not reasonable that anothernurse with less education but longer [years in services] to[get] a salary of 1,350,000 Iraqi Dinars, while the youngone works like or even harder than the old one (M4, administrator). They agreed that there should be some difference in salaries but not at the extreme levels that arecurrently present.Shortage in resourcesParticipants agreed that medicines provided to patientsin PHCCs often do not cover a full course treatment.The supplied medicines may be sufficient for one or twodays only, even if the treatment is required for five orseven days. Prescribing insufficient quantities of medicines is mainly due to the shortage or unavailability ofmedicines. We see patients [at PHCC] for six hours[each day]. Medicines are available in the first twohours only. Then half of the patients will return [home]without treatment or [we are] obliged to prescribe medicines from outside the PHCC (M18, physician). Manytimes patients need to come back for another consultation where they may see a different doctor and receivea completely different treatment regimen depending onthat physicians opinion or availability of drugs. If a patient has chest infection, he will receive few capsules thatwill meet two days need. Since he is not going tocomplete a full treatment course, he will [ret…