This report summarizes analysis of three distinct but intertwined health policy issue areas for the Kurdistan Regional Government: health financing, primary care, and quality and patient safety. The researchers assessed policy options, developed plans to overcome barriers and achieve policy objectives, and developed and helped implement a new management information system.

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Health Sector Reform in the Kurdistan Region — Iraq

Financing Reform, Primary Care, and Patient Safety

by C. Ross Anthony, Melinda Moore, Lee H. Hilborne, Andrew W. Mulcahy

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Research Questions

  1. What is Kurdistan's current health care financing system, and how can the Kurdistan Regional Government guide reform efforts?
  2. What should be Kurdistan's targets for primary care?
  3. What is the current quality of health care available in the Kurdistan Region of Iraq, and how safe are patients in the health care system?
  4. How can the Kurdistan Regional Government implement health policy recommendations?

In 2010, the Kurdistan Regional Government asked the RAND Corporation to help guide reform of the health care system in the Kurdistan Region of Iraq. The overarching goal of reform was to help establish a health system that would provide high-quality services efficiently to everyone to prevent, treat, and manage physical and mental illnesses and injuries. This report summarizes the second phase of RAND's work, when researchers analyzed three distinct but intertwined health policy issue areas: development of financing policy, implementation of early primary care recommendations, and evaluation of quality and patient safety. For health financing, the researchers reviewed the relevant literature, explored the issue in discussions with key stakeholders, developed and assessed various policy options, and developed plans or approaches to overcome barriers and achieve stated policy objectives. In the area of primary care, they developed and helped to implement a new management information system. In the area of quality and patient safety, they reviewed relevant literature, discussed issues and options with health leaders, and recommended an approach toward incremental implementation.

Key Findings

  • The way in which services are purchased ideally provides incentives to purchase the right amount of the right kind of services; however, presently in the region, such incentives are lacking. The Ministry of Finance pays physicians' salaries, and facilities receive a budget. There is no relationship between pay and performance; the system does not reward facilities that do a good job or physicians who work longer hours and provide more care in the public sector.
  • Physicians are paid salaries in the public sector but spend significant amounts of time working in private-sector clinics, where pay is higher. This phenomenon is often referred to as dual practice.
  • Kurdistan lacks a consistent, organized plan for improving quality and safety across all health care facilities.

Recommendations

  • The Kurdistan Regional Government should reform health care financing in two phases: In the next five to seven years, it should move from its current budget-based system to an accountable national health service; in phase II, the government would consider whether to move to a functioning social health insurance (SHI) system along with an organizational structure to manage the system. Supplemental private insurance would be allowed and encouraged in both phases to supplement payment for uncovered or partially covered services in the public sector and to help individuals spread their risk should they decide to use the private sector.
  • The government should begin to address the dual-practice issue immediately by requiring physicians to work for three to five years in the public health sector before working in the private sector, linking wages to the number of hours worked, and reforming physician pensions to link payouts to years of service. When better data systems are operational and hospital reform is complete, quality of care or procedures performed could be incorporated as measures so that a comprehensive pay-for-performance policy could be established.
  • The government should use the new management information system to help guide management decisions aimed at improving care currently being provided to achieve standards of service established for primary care.
  • To improve quality of care and patient safety, the government should pursue international accreditation for health care facilities; examine accredited hospitals to learn how they achieved success; attend a Joint Commission International practicum program; and establish a regional leadership team.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    Health Financing Literature

  • Chapter Three

    Health Financing Reform in the Kurdistan Region — Iraq: A Way Forward

  • Chapter Four

    Dual Practice: Options for Dealing with Combined Public and Private Practice Among Physicians

  • Chapter Five

    Primary Care

  • Chapter Six

    Quality and Patient Safety

  • Chapter Seven

    Summary and Conclusions

The research described in this report was sponsored by the Kurdistan Regional Government and was conducted in RAND Health, a unit of the RAND Corporation.

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