The study showed that the satisfaction of medical professionals was low with offered services and availability and quality of medications and equipments at the health institutions except for availability of sufficient number of health care professionals. Majority of respondents expressed a negative view on the overall health system with the main problems identified in the health system being the weak role of medical research, the weak role of professional associations, the weak role of health education and the low governmental fund allocation for health.
Social insurance of medical care for the poor was identified as the highest priority need for the health system improvement followed by enhancing the role of family medicine in the health system, adopting health insurance system, periodic scientific assessment of medical professionals and better involvement of the MoH and professional associations in controlling the private sector.
This study adds to the limited documented knowledge about the functionality of the regional health system in Iraqi Kurdistan and its priority needs for improvement. It provides an insight to this subject from medical professionals' view through defining the main themes related to its strengths, weaknesses and opportunities for improvement. Given the importance of having the views of medical professionals in any health system reform and the fact that these views are often not looked for, the relevance of this paper might go beyond the specific views of the Iraqi medical professionals that are primarily of local interest and it can serve as a case study which could be followed by others in other contexts.
The study, however, has a number of limitations. The survey targeted only the medical professionals working in Erbil governorate as the limited resources did not allow studying those working in the other two governorates in Kurdistan region; Sulaymaniya and Duhok. Professionals working in other governorates may face different problems and challenges and have different views on the issues included in this survey keeping in mind that the regional MoH is situated in Erbil governorate. Similarly, nurses and other health care workers were not included in this study. These may have different perception and concerns about the health system. Using close-ended questions might have assisted in increasing the response rate due to the simplicity of administration. However, close items do not allow study participants to openly and better express their viewpoints. This limitation was partially addressed through using an initial small scale survey with open-ended questions to develop the close items. Another limitation of the study includes the subjectivity of providers rating the health services while they are the one who deliver such services. The primary focus of the study was the public sector of the health system. Even though the role of private sector in delivering health services in Iraqi Kurdistan is increasingly growing, it was not included in this study. However, we think that this study has partially covered the view from private sector as most Iraqi medical professionals working in the public sector work also in the private sector in afternoon hours.
While the response rate to this survey was satisfactory, the reason why 16.4% failed to respond could be attributed to failure to see the respondents on the next day or follow up visits as many medical professionals have duties in more than one health facility. Medical professionals with stronger views on the need to reform might have more enthusiastically responded to the survey, while those with weaker views might have chosen not to respond.
A number of health system themes derived from the results of this study in relation to problems and priorities for improvement correspond well with those derived from other studies and reports from Iraq. The difficulties and challenges facing the public health facilities in providing quality health services have also been reported by another study . The main problem with human resources in Iraqi health system is not with the number of available staff, but it is related to their uneven distribution and shortage in some specific health professions. An example of this is the excess in specialist physicians and insufficient physicians focusing on the primary health care or family practice . While insufficiency in nurses and other health staff is well documented in the Iraqi health system, the Kurdistan region has the privilege of having better situation in this concern which might be related to having a more respective culture for nurses and thus the nursing job is increasing [11, 12]. The inadequate health education activities, which can be attributed to the nonexistence of programs for patient education and possibilities for strengthening self care, has also been identified by a WHO document . The low governmental fund allocation for health agrees with the fact that Iraq's fund allocation for health in 2008 was 4.1% of the gross national product, which accounts for US$87.7 per capita . This makes the country one of the low spending countries on health.
Interestingly a number of additional health system themes in relation to problems and priorities for improvement emerged from this study. The scarcity of medical research and its poor implications in health policy and evidence-based decision making are in fact well recognized problems in most developing countries including Iraq [3, 5, 17]. The need for social insurance of medical care for the poor is primarily related to the inability of the poor population to afford the cost of the private sector services where most of such services are provided . The need for enhancing the role of family medicine in the health system has emerged as family medicine practice has lately received much attention and has been recognized as a need in many countries, which is attributed to the successful experience in a number of countries particularly in the Middle East and the advocacy of WHO for its adoption . The need for adopting health insurance system is partly related to the increasing role of private sector in providing healthcare services and partly to the large number of marginalized and poor people who can not afford private sector costs . As the public facilities do not provide all health services and due to the load on public facilities many patients need the services of the private sector, which is a problem especially for the poor people due to the high costs of the private sector that need to be out of pocket payment. Since this problem is more related to the poor people, the need for adopting health insurance specifically to poor people was more strongly supported than adoption a general health insurance system.
Periodic scientific assessment of medical professionals is becoming an increasingly recognizable need for health system improvement especially with lack of procedures and guidelines for appraising the staff performance and knowledge in Iraq [5, 19]. The requirement for better involvement of the MoH and professional associations in controlling the private sector is again related to the uncontrolled rapid expansion of this sector and its increasing role in health care provision as reported by the WHO .
The different problems and priority needs identified in this study can guide and assist policy makers in their efforts to improve the current health system in Iraqi Kurdistan region and in Iraq as whole. The study can also guide researchers to expand on the individual issues recognized in this study and try to better elaborate and understand them.