London School of Hygiene & Tropical Medicine, London, UK.
BMC Int Health Hum Rights. 2010 Jun 8;10:14. doi: 10.1186/1472-698X-10-14.
Relative to the amount of global attention and media coverage since the first and second Gulf Wars, very little has been published in the health services research literature regarding the state of health services in Iraq, and particularly on the semi-autonomous region of Kurdistan. Building on findings from a field visit, this paper describes the state of health services in Kurdistan, analyzes their underlying governance structures and policy processes, and their overall impact on the quality, accessibility and cost of the health system, while stressing the importance of reinvesting in public health and community-based primary care.
Very little validated, research-based data exists relating to the state of population health and health services in Kurdistan. What little evidence exists, points to a region experiencing an epidemiological polarization, with different segments of the population experiencing rapidly-diverging rates of morbidity and mortality related to different etiological patterns of communicable, non-communicable, acute and chronic illness and disease. Simply put, the rural poor suffer from malnutrition and cholera, while the urban middle and upper classes deal with issues of obesity and Type 2 diabetes. The inequity is exacerbated by a poorly governed, fragmented, unregulated, specialized and heavily privatized system, that not only leads to poor quality of care and catastrophic health expenditures, but also threatens the economic and political stability of the region. There is an urgent need to revisit and clearly define the core values and goals of a future health system, and to develop an inclusive governance and policy framework for change, towards a more equitable and effective primary care-based health system, with attention to broader social determinants of health and salutogenesis.
This paper not only frames the situation in Kurdistan in terms of a human rights or special political issue of a minority population, but provides important generalizable lessons for other constituencies, highlighting the need for political action before effective public health policies can be implemented - as embodied by Rudolf Virchow, the father of European public health and pathology, in his famous quote "politics is nothing but medicine at a larger scale".
自第一次和第二次海湾战争以来，全球对该地区的关注和媒体报道相对较多，但在卫生服务研究文献中，有关伊拉克卫生服务状况的内容却很少，特别是在库尔德斯坦半自治区。本文基于实地考察的结果，描述了库尔德斯坦的卫生服务状况，分析了其背后的治理结构和政策流程，以及它们对卫生系统质量、可及性和成本的总体影响，同时强调了重新投资公共卫生和以社区为基础的初级保健的重要性。
关于库尔德斯坦的人口健康和卫生服务状况，几乎没有经过验证的基于研究的数据。现有的少量证据表明，该地区正经历着一种流行病学的两极化，不同人群的发病率和死亡率迅速分化，这与不同的传染病、非传染病、急性和慢性疾病的病因模式有关。简单地说，农村贫困人口患有营养不良和霍乱，而城市中、上层阶级则面临着肥胖和 2 型糖尿病等问题。这种不平等现象因治理不善、碎片化、不受监管、专业化和高度私有化的系统而加剧，这不仅导致医疗质量差和灾难性的医疗支出，还威胁到该地区的经济和政治稳定。现在迫切需要重新审视和明确未来卫生系统的核心价值观和目标，并制定一个包容性的治理和政策框架，以实现一个更加公平和有效的以初级保健为基础的卫生系统，并关注更广泛的健康决定因素和健康促进。
本文不仅从少数人群的人权或特殊政治问题的角度来描述库尔德斯坦的情况，而且为其他利益相关者提供了重要的可推广经验教训，强调了在实施有效的公共卫生政策之前需要采取政治行动——正如欧洲公共卫生和病理学之父鲁道夫·菲尔绍（Rudolf Virchow）在他著名的言论中所说的那样：“政治只不过是规模更大的医学”。
