Investing in Education: The Pathway to Public Health
The following article is taken from a speech by Dr. Majeed Jawad al-Khatteeb, delivered at the Higher Education Conference for the Development of Iraq, which was organised by the Iraqi Embassy in London on the 14th September 2018. Majeed Jawad al-Khatteeb is a Consultant Paediatrician at the NHS Trust and serves as the Strategic Lead for Training on the Middle East & North Africa at the Royal College of Paediatrics.
Without attempting to address all of Iraq’s challenges or identify possible solutions, I will focus on two portfolios worth highlighting and argue that without a concerted effort in these areas no economic development nor any reform could be envisaged for Iraq. These are: Education and Healthcare.
Moreover, I will be reflecting on my personal experience from over 50 visits to Iraq since the regime change of 2003, during which time I delivered various trainings and helped establish medical centers while administering and advising on institutional reform and policy formation as a volunteer and in my professional capacity as member of the Royal College.
The level of education and healthcare are the two most important components in any state. They define whether a society is regressive or progressive. If a society has progressive values, it will invest in these two capacities, it will be a society that cares for the vulnerable citizens and elderly, and pave the way for future generations. It will be a society where public servants work to serve the citizens, and not the other way around.
To sum up this concept of supporting the wellbeing of the people, a well-known phrase was from the Roman philosopher Marcus Tullius Cicero was "Let the good (or safety) of the people be the supreme (or highest) law.”
For the education sector, investment from the state points to a government that thinks in the longest possible terms, the strongest possible investment in the future. Education has the power to completely transform societies, something the world witnessed in South Korea, where their government invested heavily in education. This was regarded by many development experts as being vital to the economic success of that East Asian country.
Iraq now needs to fix these two ideas, which are broken in our country. Firstly, that the health of the people is the highest law, and secondly that there can be no future without investing heavily in education.
One of the big challenges that faced Iraq since the regime change of 2003 and the subsequent unrest in the country has been the uncontrollable mismanagement, corruption and incompetence of staff, who have been in many cases appointed without proper consideration of their qualifications. Secondly, despite a massive reconstruction effort post 2003, there has been a lack of sufficient funds to sustain education, Research & Development and Healthcare. I will discuss the healthcare issue in a minute.
Iraq and partners have devoted massive attention to other vital sectors, including Iraqi security, physical reconstruction and the provision of vital services. But let me ask you: how will Iraq’s next strategic plans be formed? Iraq must successfully overcome the infrastructure challenges in the coming years, not limited to:
The provision of clean water in major cities such as Basra.
Solving the housing crisis.
Rebuilding the damaged cities of Mosul, Ramadi, Fallujah and Tikrit
Providing enough electricity to these cities, in addition to many other small towns.
Finally, properly housing the thousands of Iraqis who live in informal settlements,
So here is the big question:
How will this infrastructure be maintained and sustained? Without better education, to build the next generation of skilled, responsible Iraqi citizens, all of the billions of dollars being spent to rebuild Iraq will be wasted. The new infrastructure will rust and crumble.
Iraq must urgently address the lack of internationally ranked universities, teaching hospitals, and approved curriculums according to international standards. At the current time, Iraq’s universities simply are not producing enough relevant and good quality research material to be ranked by most international systems.
The lack of quality higher education will have a knock on effect on other sectors. It has already resulted in a lack of understanding of public policies, regulations, laws and bylaws to conduct institutional reform. There exists an overall lack of strategy within the Iraqi government.
Consider this underinvestment in the context of demand for better education in Iraq, Iraq arguably suffers one of the most concerning demographic youth bulges in the world. Even as education and health declined during the sanctions years of the 1990s and after 2003, with thousands of educated professionals leaving the country, Iraq’s population was growing, from 27 million in 2003 to 37m now, averaging around 3% per year. (References :WHO, WB).
In this situation, it is vital that the Iraqi government continues to restrain expenditure on salaries. For example, budgetary allocations for the health sector for 2018 have been worryingly low, at just 2% for Health and less than 4% for education. A lot must be done before 2030 when the population exceeds 50 million. These numbers are trivial when comparing Iraq’s financial allocations to those spending in the GCC or Europe.
The United Nations recommends governments allocate 20 percent of their national budgets to education. According to UNICEF, Iraq’s education budget for 2015-2016 was just 5.7 percent of government spending, a 15 percent drop from 2013-2014. We must ask why, as oil revenues rise, education spending still the lowest in the region at less than 4% when Iraq is expecting a budget surplus this year, of potentially more than $12 billion.
For example, the UAE, although small, spends 20% of its budget on education. Saudi Arabia, which typically spends 5% of GDP on education, allocated $50 billion for the sector this year. With this level of determined investment, these countries will remain the number one destinations for foreign investment in the Middle East in the coming years. Much of the Saudi funding in its education sector has gone to higher education. The GCC countries now have the best universities in the Middle East and the quality of these institutions will attract more global talent.
This is something Iraq can hopefully aspire to with the creation of an internationally focused university supported by twinning programs. But in order for Iraq to build world leading educational institutions, there must be an urgent focus on schools. In this area, we know Iraq can make progress, but in recent years schools in Iraq have been in a state of collapse.
As an example of progress, the total enrolment in primary education almost doubled to six million children in 2012 from 3.6 million in 2000. But now Iraq is seeing more and more children out of school and the quality of school resources is extremely low.
This unfortunate situation has occurred despite Iraq’s National Education Strategy, launched in 2012. Key educational targets in the strategy included increasing Iraq's pre-school enrolment rate from 7 per cent, to 22 per cent by 2020, as well as the primary school enrolment rate from 93 per cent to 98 per cent by the end of 2015.
The rise of Daesh means that Iraq has missed these targets. The war, and the rise in spending on defense so that Iraq could liberate its communities, meant that infrastructure spending has remained nearly non-existent. At the height of the war with Daesh, one out of every two public schools needed major repairs or did not meet national school construction standards. Furthermore, the massive disruption of the war means that up to 30 percent of Iraqi girls in rural areas do not attend primary school
Now there is a new challenge, and thankfully Iraq is getting strong support from international agencies in this area. Children make up almost half of the 3 million Iraqis displaced by the conflict and at least 70% of displaced children have missed a whole year of school.
Iraq may therefore struggle to raise expenditure on the education sector as a whole, while also trying to rebuild damaged areas and ensure that all cities have an equal level of service provision. For this reason, greater international support will be needed. Higher education of course also suffered during the war with Daesh, not only in the worst cases, such as the destruction of the universities at Mosul, Ramadi and Tikrit, but also with Iraqi programs to fund students in Europe.
In 2017, austerity measures forced the Iraqi government to withdraw its scholarships for students to study for graduate degrees in Western countries. Without financial support, students then found life extremely difficult in Europe with different countries imposing various financial demands on the students as foreign citizens residing there.
But in parts of Iraq that have not been directly affected by the war, there is a serious lack of regulation in the private education sector, which according to some accounts, has raised the level of corruption in education. For example, there have been many reports of new and careless institutions taking bribes to accept students who cannot achieve in the state education system. This does even more damage to the sector.
Since 2014 however, there have been some attempts to regulate these private institutions, which need to form the basis of a massive nationwide anti-corruption campaign.
Of course, another challenge in higher education goes back to rebuilding schools. This means reforming education and the curriculum to make Iraq’s schools leading in the region and internationally competitive. Too many Iraqi teachers are working long hours with oversized classes. The stress of these men and women increases the risk that some will fall victim to corruption. This is in addition to the significant number of adults and children who were affected by the traumatic effect of war and Daesh leading to post traumatic stress disorder and other mental health issues. This also rendering the teaching less meaningful and leaving Iraqi children ill equipped to progress and achieve in the future.
Iraq must do a lot more than simply increase the numbers, there needs to be a strong focus on quality. Saudi Arabia and the UAE are currently investing heavily in professional development for teachers and Iraq should do the same. There are now higher education facilities in the Gulf that Iraq should aspire to in terms of quality: for example King Abdulaziz University in Saudi Arabia , Khalifa University in Abu Dhabi, Qatar and others enhanced their status and position in the international ranking because of their adherence to the international standards and by producing good research.
These universities, as mentioned, will boost foreign participation in these country’s economies by bringing in foreign talent. Qatar University for example, has students from 52 countries while the United Arab Emirates University has students from 59 countries. Iraq needs to develop institutions like this of its own, but it is equally important that Iraq considers the skills and infrastructure that will make it a regionally competitive country.
Iraq must avoid the mistake some developing countries make, which is to focus on research and development that is irrelevant to its economic needs.
I now turn to the health sector. Iraq needs the best and brightest graduates to care for its most vulnerable citizens and to restore faith in government. But there have been many losses of talented people and we need to rebuild this human capacity.
A 2012 Johns Hopkins University survey on the health sector in Iraq assessed that hundreds of doctors were emigrating annually. By January 2012, Iraq had an estimated 7.8 physicians per 10,000 people – a rate three times lower than in neighboring countries like Jordan, Lebanon, Syria, and the Palestinian Territories. One third of these doctors were unable to complete higher education.
But just as Iraq’s universities in Tikrit and Mosul are in the process of being rapidly rebuilt, Iraq can restore its 21 medical colleges to the former glory that they once had. It is important to note here, that when some people discuss the health achievements of the former regime of Saddam Hussein, much of this progress was slowly destroyed during the eight-year war with Iran.
In addition to this fact, much of the success in Iraqi healthcare was created long before Saddam. For example, Baghdad’s Royal College of Medicine which opened in 1920, and trained Iraq’s first generation of doctors and nurses, allowing for specialisation in key areas and later, in the 1950s, when oil revenues were invested in the Iraqi people for the first time, allowed for an expansion of rural healthcare provision across many parts of Iraq for the first time.
Similar institutions need to be created. At the current time, the lack of academics in Iraq has led medical colleges bringing in working doctors and even professors from other faculties in Iraq. Iraq’s 21 medical schools lack professors, laboratory equipment and other basics supplies for teaching. At the University of Baghdad Medical College, there has also been a lack of teaching staff, made worse by the years of the oil price collapse and war with Daesh.
As a result of these problems, a recent study found that of the medical students questioned, only 2% rated their medical training as excellent and only 43% said it was good. Just over half, or 54% of students said they didn’t think that their institutions dedication to teaching was very high. Many of the training doctors, over 40% said that their institutions did not have enough access to recent medical literature.
Major savings could be achieved that would enable Baghdad to seriously invest in the human capital needed to rebuild healthcare. What Iraq needs now is a focus on preventative healthcare and healthcare education - millions of people fall ill due to preventable causes, through a lack of awareness regarding the spread of disease or a disregard for dietary health, indulging in smoking or having a high sugar intake. Iraq still relies on substandard secondary health care (hospitals) and a very much underdeveloped primary health care system. By contrast, the majority of health services in the developed countries are provided via well structured, primary health care .
There must be a greater effort to ensure that teaching hospitals are twinned with well-established universities and international health centers, to improve procedures and curriculums and to build well equipped Primary health centres.
The way forward
Going forward, Iraq urgently needs to focus on a number of areas that could, if properly pursued, have a transformative affect on both sectors:
Developing a special program to attract Iraqi expats, doctors and academics to participate in the capacity building of Iraq. We have over 4 million Iraqis living in the diaspora, while hundreds of thousands of them are very qualified across sectors, especially in medicine and academia.
Iraq must simplify the process of accommodating professional Iraqi expats to have their qualifications recognized by the Iraqi system – the current processes adopted are legacy practices and must be abolished. New processes should be in place and must not be time consuming e.g not more than a week with sensible requirements in place.
There must be a decoupling (separation) of regulator and regulated bodies by having ministries acting as regulators not operators. This requires complete review of legacy laws and public policies. (ministries act as operating companies)
Education and Higher Education should be merged in one portfolio, while universities (private and state run) should enjoy full independence but regulated by the ministry.
The same should apply to the Ministry of Health, it should be merged with the ministry of environment, and act as a regulator of the various operating entities such as hospitals (private and state owned) and environmental agencies. This would lead to efficiency gains.
The education budget should be increased to 15% of total federal budget, the same as healthcare budget (15%). However, this will require a review of the tax system to secure further funding in addition to petrodollar allocations, while having the government adhere to the social contract.
A rigorous review of all in-country qualifications must be conducted, and routine exams and test methods should be employed to assess nurses, doctors and practitioners to maintain a high level of performance and KPIs across all institutions.
Last but not least: financial allocations are not enough without proper leadership programs to develop the various level of management across Iraq’s public institutions, to have them benchmarked against well-established institutions in developed countries.
Ladies and gentlemen: This is a journey that will take around 10 years of a progressive development plan and a sustainable process to pave the ground for a prosperous Iraq in 2030 and beyond. - Thank you for your attention.