Introduction
Decades of violence, conflict, and humanitarian crises, combined with international sanctions and continuous neglect of the health sector, have seriously harmed Iraq’s healthcare system. As a result, many skilled physicians and other medical practitioners have left the country, causing a shortage of medical staff. Furthermore, Iraqis harbor a great degree of mistrust for the government and the public healthcare system, particularly following the outbreak of the COVID-19 pandemic, which exposed and aggravated the multitude of vulnerabilities in public healthcare infrastructure and delivery. Once a prosperous and advanced healthcare system, Iraq has been steadily bleeding out talent, with medical staff and other healthcare practitioners emigrating to find better working conditions abroad; in the same vein, a large number of Iraqis travel to regional neighbors for medical care, including to Lebanon, Iran, Jordan, and Türkiye.
Ideally, the state would provide social safety and healthcare as fundamental rights for everyone to guarantee fair access and complete coverage. Yet, Iraq’s healthcare system remains in a state of acute crisis and is characterized by disorganization and poor planning, shortages of staff and resources, fragmentation and insufficient coverage, and pervasive corruption, which instead erode the quality, affordability, and accessibility of basic as well as specialist healthcare services for a majority of Iraqis. The lack of long-term, sustainable health policies is widening inequality between Iraqis; large-scale private healthcare systems, acting as substitutes for the public health system, are spreading at a steady rate throughout the country, creating a “two-tier” healthcare system—in other words, one for those who can afford private healthcare services, and the other for those who cannot. Hence, the current landscape is enabling and widening the gap in health disparities for Iraqis.
This paper relies on documentation, reports, and studies, in addition to previous recent experience on the ground in terms of public finance management programs as well as regional finance and public policy. It will map the history of Iraq’s healthcare crisis and the impact of the sanctions on health coverage, as well as the strain imposed by the COVID-19 pandemic on service delivery. The paper will then build a case for a collaborative health insurance scheme as an intermediary response to leverage the strengths of Iraq’s public and private sectors, and most pertinently, to alleviate the immediate healthcare needs of the country’s population. Finally, the paper will articulate policy recommendations towards that end, and for the overall Iraqi healthcare system.
Part I: Background and Context: The Limitations of the Social Protection System in Iraq
Previously, social security in Iraq, including social insurance, childcare provisions, and pensions, was closely tied to employment in the public sector. The COVID-19 pandemic dramatically increased poverty rates, unemployment, and food insecurity. The main reason for resource poverty in Iraq is the lack of work opportunities for its growing population. Today, approximately 96% of Iraqis are without health insurance, and therefore most Iraqis rely on the central government-run public health care system, which suffers from poor funding and limited treatment options. Given the public sector’s limitation in providing universal healthcare to Iraqi citizens, a more collaborative approach between public and private entities has proven to be needed to help secure this basic human right. Iraq is an oil-rich country, which allowed it to obtain an upper-middle-income status, even though its institutions and socioeconomic outcomes do not meet the same standard. Consecutive World Bank Country Economic Memoranda (CEM) have called for reform in order to improve living conditions and standards, most notably: transitioning from (a) conflict to rehabilitation, (b) state dominance to market orientation, (c) oil dependence to diversification, and (d) isolation to global and regional integration. Following the economic deterioration of the COVID-19 pandemic, the government of Iraq adopted a White Paper on economic reform in October 2020 which singled out Iraq’s extreme dependency on oil, bloated state sector, and insufficient infrastructure as key structural obstacles that needed to be addressed to achieve a functional Iraqi economy. Cutting across all four pillars called for by the CEM, the new collaboration health insurance model recommended in this paper would see the government be responsible for the accessibility and quality of the healthcare system, but delegate management to the private sector.
The Public Programs for Social Protection in Iraq, their Challenges and Shortcomings
Social assistance in Iraq takes many forms, resulting in uncoordinated responsibilities across different bodies and authorities, and creating a fragmented social protection landscape. As a result of the lack of a unified national vision, various authorities are unable to collaborate, resulting in the duplication of some social protection benefits and the lack of others. Four main schemes exist within the social protection framework, namely the state-employee retirement system, social security for workers, the ration card system, and the social protection network. Each system operates independently from one another, creating an overlap and/or incomplete database.
The Social Protection Commission was created to oversee social assistance in Iraq by the Social Protection Law (Law 11), which went into force in 2014. The Iraq Social Protection Strategic Roadmap, launched in November of that year, aimed for a complete, integrated, and effective system of social protection for Iraq that included social safety nets, social insurance, and labor market programs. However, a sizeable section of the Iraqi population — including many of the most vulnerable — remains uninsured under either contributory or non-contributory programs. Prior to 2014, Iraq's basic social security program relied on pre-established categories based on age, disability, and other factors that could or could not be related to poverty and vulnerability. As a result, the majority of poor and vulnerable people did not benefit from this program. In 2012, 18.9% of Iraqis were classed as poor, a figure that rose to 22.5% as a result of internal conflict and the 2014 oil price collapse. The government began prioritizing social protection more after 2014 and passed laws focusing on the reform of essential social assistance programs and the establishment of the current Social Protection Network.
An important development occurred in February of 2023, throughout which the Iraqi Ministry of Labor and Social Affairs decided to evaluate the situation of 180,000 displaced Iraqis (IDPs) living in 24 camps in Iraqi Kurdistan, with special priority accorded to the cases of displaced persons and returnees in the Kurdistan Region to register in its poverty reduction program “Social Safety Network” (SSN). This was to be done irrespective of individuals’ registration status in the Ministry of Labor and Affairs’ online registration system, which otherwise is a requirement for any Iraqi citizen who claims to meet the social safety net criteria. Accordingly, IDPs who are found to meet the Ministry of Labor and Social Affairs’ vulnerability criteria will benefit from monthly cash payments to help them meet their immediate needs (an average of $85/125,000 Iraqi dinars per person monthly). Vulnerable individuals and families, including families supported by women and persons with disabilities, will receive additional cash assistance. Since the beginning of the registration campaign carried out by the Ministry of Labor and Social Affairs, as of 5 August 2023, a total of 5,490 families in Dohuk camps and 900 families in Erbil-managed camps have already registered with the Social Safety Network and many of them had begun receiving cash grants from the SSN since the beginning of July of 2023.
The Formal and Informal Social Protection System in Iraq
Formal Programs of Social Protection
Iraq's contributory social insurance system is made up of two funds: the state pension system (which includes civil servants and employees in state-owned enterprises), and the social insurance system established by the Unified Pension Law No. 9 of 2014, which provides pensions in the event of old age, disability, or death. Benefits for illness and maternity are provided directly by the administration to public sector employees in compliance with the Civil Servants Law. Under the Social Security Law No. 39 of 1971, workers in the private sector are protected by social insurance. Although the law provides for comprehensive social security benefits, including illness and maternity, only the pension system is currently available to private sector workers.
Moreover, there are two main tax-funded social assistance programs in Iraq, namely the Public Distribution System (PDS), which provides food rations to almost all households in the country, and the Social Safety Net, a poverty-targeted conditional cash transfer which covers some 1.2 million Iraqi households. Both programs face a series of challenges, with very little coordination between them, making the overall social assistance system a weak one. While the social protection schemes put a significant burden on the government’s budget, their impact is inadequate for the developmental objectives of protecting people during life and work transitions, promoting formalization and labor mobility, and fostering a shift to higher productivity, human capital-led inclusive growth model. The moment public finances are under pressure, the rest of the economy will be under pressure.
Informal Programs of Social Protection
The non-governmental (or informal) social protection system primarily targets people who are not covered by government-funded and supervised programs. This is close to a social and humanitarian aid system. In Iraq, there are numerous non-governmental groups, some of which are involved in social protection (for example, caring for the destitute, orphans, widows, divorcees, and the displaced). This system includes civil society organizations (CSOs) and faith-based organizations. CSOs’ activities vary, but a large percentage focuses on giving support and help to poor and vulnerable people through cash grants and in-kind services such as legal advice; however, their functions often duplicate those covered by the government, though, with fewer resources. Faith-based institutions have emerged in the name of religious actors and entities, which are active in the community. Various forms of Islamic charity, such as Zakat, Khums, and Alms, are also reflected in this scope of work. These institutions offered basic refuge for vulnerable individuals in Iraq during the years of economic sanctions and state neglect. Faith-based organizations also offered social services like healthcare and education. Furthermore, the United Nations High Commissioner for Refugees (UNHCR) has continued its work in strengthening existing public services in the Kurdistan region of Iraq, aiming to provide protection and support to Iraqis and refugees alike, and citing a transition from a humanitarian response to a development-focused approach.
The Social Security System in Iraq
The Iraqi social security system is composed of a component for public sector workers and another for the private sector. For the public sector, the dedicated fund manages to achieve a relatively high coverage of almost 50% of the labor force working in the sector; however, benefit levels are set very high and are widely considered financially unsustainable. The fund for private sector workers only covers between 13% and 16% of the private-sector workforce and provides a limited range of benefits with employers remaining liable for maternity, work injury and disability, and no unemployment benefit. At the national level, Iraq put in place the Poverty Reduction Strategy 2018-2022, which identifies the building of an effective social protection system as a strategic objective. The passage of the Social Protection Law No. 11 of 2014 was a significant milestone. In addition, the Iraq Social Protection Strategic Roadmap 2015-2019 was created to help with the implementation of the 2014 law. Its objective was for Iraq to have a comprehensive social protection system that had three primary pillars: social safety nets, social insurance, and labor market reforms.
Part II: Challenges and Shortcomings of the Iraqi Social Safety Net Programs: Impact on Health Coverage
The Iraqi social security system has experienced numerous and significant difficulties, especially with the sanctions (1990-2003) placed on Iraq and exhausting the allocated funds, and was especially strained following the outbreak of the COVID-19 pandemic.
Evolution of the Healthcare System in Iraq (1970–2024)
The current status quo of the Iraqi health system must be understood and contextualized by the country’s long history of conflict, which spans three decades. Internal and foreign policy decisions throughout Saddam Hussein’s administration and its aftermath gradually weakened governmental services, whilst socioeconomic conditions in Iraq became more precarious. The 1980s Iran-Iraq War, the 1990-1991 Gulf War, the subsequent decade of economic sanctions imposed by the UN Security Council, and the 2003 US invasion are all notable factors that defined the humanitarian crisis Iraq has been grappling with and that devastated the country’s social development, along with Iraq’s previously eminent public health system.
Prior to 1990, Iraqis once benefitted from some of the finest standards of life in the Middle East thanks to the country’s cutting-edge social infrastructure and first-rate selection of medical facilities; indeed, Iraq had been able to develop a sophisticated healthcare system with sizable and well-equipped hospitals using the oil funds that made up 60% of its GDP. Specifically, Iraq’s health system and medical education curriculum emulated those of the United Kingdom, with many upcoming physicians gaining their competencies and training abroad, especially in the UK and Germany. Furthermore, the Iraqi healthcare system that emerged in the 1970s and 1980s was characterized by its high level of centralization and hospital-based capital-intensive model of curative care, rather than a population-based care approach, the necessity of ongoing large-scale importation of pharmaceutical drugs and equipment, and an emphasis on offering specialized medical operations delivered by trained experts. Nonetheless, the health system was fully subsidized, and Iraqis all over the country could be provided free high-quality healthcare services in 172 hospitals and 1200 primary healthcare clinics, whereas the private health sector was relatively weak.
However, under Saddam Hussein’s regime, funds were diverted away from the healthcare sector; and the Iraqi healthcare system has endured a massive blow during the last decade of Saddam Hussein’s administration, during which public health funding was cut by 90%. The 1980-1988 war between Iran and Iraq that ensued further aggravated the accessibility of physicians and medical care by civilians. Prior to August 1990, it was estimated that 97% of Iraq’s urban population and 71% of its rural population had access to primary healthcare services. However, as a response to the Iraqi military’s invasion of Kuwait on 2 August 1990 - thereby kickstarting a chain of events that would evolve into the 1990–1991 Gulf War, the UN Security Council imposed widespread economic sanctions on Iraq that restricted the access to essential goods, including pharmaceuticals. Consequently, food and medicine imports fell by 85 to 90%. With the extensive damage done to Iraq’s infrastructure, rates of mortality among infants rose by 17%, whilst mortality rates for children under five years of age increased by 11% compared to their respective pre-war and sanction rates.
The Oil For Food Program (OFFP) was initiated in 1996 to alleviate the rapidly deteriorating living conditions of Iraqi citizens; overseen by the UN, Iraqi oil was sold to provide funds to procure essential goods and humanitarian aid and succeeded in raising over US$25 billion, $3.3 billion of which were allocated to the health sector, to this end. Nonetheless, despite the growing availability and accessibility of essential medicines, the health infrastructure continued to progressively decay; indeed, by 2003, Iraq’s healthcare was in deep crisis and mismanagement, and wholly unequipped to withstand the US Invasion that began that same year and that would destroy 12% of Iraq’s hospitals and public health laboratories. In 2002, Iraq could only allot $22 million of its national state budget to healthcare, compared to $450 million in 1990; furthermore, Iraq was becoming the victim of a brain drain of a variety of qualified healthcare personnel, with the World Health Organization (WHO) estimating that there were only 55 doctors per 100 000 people in 1998.
However, while government spending on healthcare managed to increase from 2.99% of GDP in 2003 to 3.77% in 2010, the quality and availability of healthcare services, facilities, personnel, and medication have yet to reflect these investments. Uneven distribution of health centers and hospitals prevents many Iraqis, especially those living in remote areas and those forcibly displaced, from having adequate access to medical care. Furthermore, Iraq continues to suffer from a shortage of medical staff, as many have emigrated to seek better working conditions. The public health sector is currently in bad shape. The numbers of health professionals and centers are very low and do not match the increase in population. There is a lack of medical supplies and mismanagement of human resources. The waiting list in public hospitals is very long. Patients who can afford it often resort to the private sector for care. There are no guidelines for treatment, proper sanitation or disposal of waste. The health sector in Iraq is currently largely focusing on responding to emergencies and ad hoc crises rather than using a systematic and proactive strategic planning approach for long-term development. Poor public services like electricity, water supply, waste disposal, and others have serious health implications.
The Iraqi Health Insurance Law, or Law No. 22 “IHIL”, was approved in October 2020; it mandates several structural modifications to the Ministry of Health, including the creation of a Health Commission to outsource healthcare operations from state hospitals to private healthcare providers, in effect representing a step towards healthcare privatization in Iraq. However, contracts between insurance firms and the Health Commission will be heavily controlled to curb potential abuses. Furthermore, insurance coverage will become mandatory for government employees and foreign expat workers, with insured individuals paying a percentage not exceeding 25% of medicine, laboratory, x-ray, and dental services costs as co-insurance. While a welcome step towards safeguarding the quality of services through competition and enabling greater access and coverage of healthcare services overall, it faces several challenges, most notably its failure to implement the law within the legal period (6 months after its approval) due to the crises Iraq witnessed throughout that period. The head of the Iraqi Doctors Syndicate, Jassem Al-Azzawi, has highlighted the difficulties that hinder the implementation of the law, namely, the need for widespread education and awareness of the law in the media, and the government’s commitment to sourcing the necessary funding; the implementation process will unfold over three stages, the first of which began in January 2023, and with all procedures anticipated to wrap up and be completed within 5 years, per Al-Azzawi.
Collaborative Health Insurance Scheme in Iraq
The public sector represents around 60% of those who are formally employed, with the government of Iraq providing 40% of those jobs. Until 2016, social protection was only available for public-sector employees, thus disincentivizing private-sector employment and growth. Iraq now has a social insurance system that covers people in the private sector, which includes social protection related to old age, illness, invalidity and disability, employment injury, and maternity leave; however, even if about 56% of people above statutory pensionable age receive a pension in Iraq, only three% of private sector employees qualify.
The current private sector social insurance system does not cover medical care, which has meant that exorbitant health expenditures remain a critical factor to vulnerability and poverty. Approximately, 96% of Iraqis are without health insurance, and therefore most Iraqis rely on the central government-run public health care system, which suffers from poor funding and poor diversity of treatment options. The existing social protection schemes fail to cover the unemployed, refugees, IDPs, and those without access to their civil documentation. Corruption and poor policy choices have held back investments in service delivery.
There are several reasons for implementing a collaborative health insurance system in Iraq, most notably: (a) the significant increase in the rate of population growth in Iraq and the need to ensure access to healthcare; (b) the vulnerabilities revealed in medical care delivery by the pandemic, and the need for pandemic preparedness in the future; (c) the need to maintain the quality of health services by providing a source of financing and reducing pressure on the services of public health institutions, and; (d) the need to reduce pressure on public utilities which are no longer able to persist amid the existing context of Iraq, and which are in dire need for reform.
This collaborative system needs to be also cognizant of the main challenges facing private health insurance, which include:
- A fragmented social protection landscape, which fails to adequately address the needs of the poor and vulnerable.
- A failure to apply the articles of the Health Insurance Law of 2005, especially Article 13 and Article 14 that are related to Iraqi companies’ subscriptions and their registration in the Iraqi Chamber of Commerce.
- An under-involved private sector and no investment in health insurance and health insurance companies in particular.
- A weak infrastructure for insurance companies, health insurance in particular, which limits their ability to provide adequate services to the insured and hinders coverage and protection.
- A fragile Iraqi business environment, especially for foreign investment, which would play a role in activating the Iraqi private sector and therefore in revitalizing the insurance sector.
Part III: Conclusion and Recommendations
Overall, the social security system in Iraq faces significant challenges and shortcomings, especially in the context of health coverage. The historical context, including periods of conflict and economic sanctions, has greatly impacted the development and infrastructure of the Iraqi healthcare system. Healthcare and social protection, as fundamental rights for all, are ideally provided by the state to ensure equitable access and comprehensive coverage. However, given Iraq's complex politico-economic landscape, the historical trajectory of its healthcare system, and the myriad institutional and financial challenges it faces, relying solely on the public sector is currently impractical. The optimal solution lies in investing heavily in the system while carving out a collaborative framework between the public and private sectors. This collaborative approach serves as a temporary but necessary measure to stabilize and improve healthcare provision until long-term radical reforms become feasible. By doing so, Iraq can build a solid infrastructure that will support and sustain future comprehensive healthcare reforms.
Although some positive steps have been taken in recent years to improve access to social protection, investing in additional measures, such as investing in a collaborative system, not only leverages the strengths of both the public and the private sector but also paves the way for the establishment of a more resilient and efficient healthcare infrastructure. This approach can address immediate healthcare needs, increase insurance coverage, and improve health outcomes while setting the groundwork for more profound and systemic changes. Efforts to strengthen the private health insurance sector, improve the business environment, and encourage investment will be vital in establishing a sustainable collaborative health insurance model that effectively addresses the healthcare needs of the population. This will ultimately contribute to the overall improvement of living conditions and standards in Iraq.
Recommendations for the overall health system
- Increase the number of medical professionals working in public facilities to meet the needs of the Iraqi people. The government should invest in medical staff training and education while meeting the immediate, temporary need through partnerships with other countries, international governmental organizations, and international non-governmental organizations. Cooperation agreements between Iraq and Lebanon on the exchange of medical health expertise for oil, similar to the agreement in 2021 is one example of a success story on this level.
- Establish educational faculties, certifications, and training programs for upcoming doctors, nurses, and hospital staff in line with international standards that would result in the graduation of highly skilled professionals.
- Cooperate with international institutions, such as the World Bank, to provide support for improved public service delivery, provided that positive conditionality is imposed to ensure that governance challenges are controlled.
- Develop a national strategy for the digitalization of healthcare that is tied to a concrete implementation plan with a dedicated budget and workforce. In Iraq, the health sector is currently mostly focused on responding to emergencies and ad-hoc crises rather than utilizing a systematic and proactive strategic planning approach for long-term development. Digitizing patient records and developing a health ID enables providers easy access to accurate, up-to-date information on patients, essential to accurate diagnoses and reduced medical mistakes.
- Implement a tracking system for medications to manage medicine consumption, as well as prevent smuggling and hoarding. Today, public health officials claim that over 40% of medicine in the market is smuggled from countries including Türkiye, Iran, Jordan, Lebanon, India, and China. Introducing a barcode system in hospitals and pharmacies to track legitimately imported drugs is one means to counter smuggling.
- Improve access to quality, safe, effective, and affordable medicines, and other health technologies, through building capacity for local production, technology transfer on voluntary and mutually agreed terms with other countries, supporting the development of voluntary patent pools and other voluntary initiatives, and promoting generic competition.
- Found telemedicine centers in rural areas across the country to provide easy access to healthcare for those most in need. Telemedicine includes teleconsultations, videoconferencing, and remote patient monitoring. Patients usually access telemedicine at a local hospital, clinic, pharmacy, or kiosk, where local healthcare workers consult with doctors or specialists on diagnosis and treatment options.
Recommendations specifically targeting the support for a Universal Collaborative Health Care Model
- Develop a new health insurance system in cooperation with the private sector to ensure universal healthcare for all members of society, whereby accessibility is guaranteed by the government, while management and operation are done by the private sector. This should be accomplished in several phases:
- First, efforts should be taken to consolidate and unify the fragmented social assistance programs, their data, and their implementation tactics into one program that tackles distinct categories. This will help reduce national spending since it will limit duplication, allow for a more strategic targeting approach to make sure the most vulnerable are being reached, and facilitate administrative tasks.
- Second, the government should invest in business climate reforms to mobilize private sector participation through direct and joint public-private investments, or public-private partnerships (PPP) structures across all priority sectors, namely the health sector. Iraq's cabinet passed a draft law on PPP in August 2019 to increase cooperation between government agencies and the business sector. The next step would be to have this law ratified by parliament as a first step towards creating an enabling business environment for private investment, as well as introduce a corporate social responsibility legal framework that allows holding the private sector accountable in light of these partnerships.
- Third, introduce cooperation agreements with international insurance companies to develop a strategic roadmap for the health insurance sector in Iraq, and exchange best practices.
- Promote and develop productive sectors with the aim of economic diversification and job growth.
- Implement the 2005 Health Insurance Law, requiring companies to register with the Office of Health Insurance, and prohibiting unregistered companies from operating in the Iraqi insurance market.
- Adopt a law mandating that all Iraqi citizens must hold insurance. Private insurance companies will provide different tiers and packages of health coverage. The idea is to have the basic statutory benefits package available to all Iraqi citizens at affordable prices. Companies should be mandated to buy insurance for their employees. For those who are unemployed or are from a relatively low-income background and cannot afford private insurance, their insurance should be funded by the Iraqi Ministry of Health. Collaborating with international donor institutions merely in the short term could help provide the needed funds for universal coverage. This is why it is crucial to consolidate all data into one database. The Ministry will fund their insurance, whilst the private companies provide it.
- Transition, in the medium-long run, this health insurance system towards becoming more public, financed by social contributions and progressive tax reforms, especially focusing on income and wealth taxation. Employers’ share of contributions to social insurance should also be increased with time.
- Hold public awareness campaigns in low-income areas to explain what buying insurance means and educate residents on the new insurance policy.
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The views represented in this paper are those of the author(s) and do not necessarily reflect the views of the Arab Reform Initiative, its staff, or its board.
