NARRATIVE

The actual health situation of the Iraqi population is poorly documented, particularly because health data are not systematically collected and are mostly on paper rather than collected electronically, with few non-aggregated data available or in a format suited for analysis or management ^{Reference Ross, Moore and Hilborne4} and with little health-related and epidemiological information. Data are not being routinely used for health planning, and the impact of the provided care is not efficiently monitored or evaluated. ^{Reference Webster5} In Iraq, as well as in KRI, there is no formal and institutionalized structure with the task of monitoring diseases and analyzing health care needs. ⁶ This results in inadequate knowledge on the population’s health and insufficient understanding of its needs, limited public health vision and organization, as well as lack in prevention activities and in preparedness response plans. ^{Reference Al Hilfi, Lafta and Burnham7} Wherever possible, data are deduced from sporadic surveys, ⁸ United Nations estimates, figures collected from neighboring countries, or from countries with similar health profiles. ^{Reference Mokdad, Forouzanfar and Daoud9} The absence of data collection systems is one of the reasons for the lack of “the capacity to deliver services that address the major health problems faced by the majority of the population in an equitable and sustainable manner.” ¹⁰ In order to start rebuilding a functioning public health system, there is the need to develop adequate epidemiological surveillance and health monitoring systems. ^{Reference Emberti Gialloreti, Moramarco and Palombi11} These are the foundations deemed necessary to create a health system capable of responding promptly to present and emerging needs, as well as to adequately inform the health policies of a country or region. ^{Reference Massoudi and Chester12}

To respond to this health priority, the University of Rome Tor Vergata (Italy) and the Ministry of Health of KRI have started a collaboration to implement an electronic system for epidemiological monitoring and health surveillance. The system has been designed to manage health care data by collecting, storing, managing, and transmitting patients’ electronic medical records, as diagnoses, vaccinations, births, and deaths.

The project began with a pilot in KRI in June 2015, as this Iraqi region had not been occupied by ISIS; however, the aim of the project is to set up the system in the whole country. By December 2017, 29 health centers and hospitals of KRI have been networked (about 5% of all health facilities in the region) and are routinely collecting diagnoses of all referred patients, using a data system put up on the District Health Information System 2 (DHIS 2) platform. ¹³ DHIS 2 is an online, open-source software for the reporting of routinely collected health data, which is in use by 67 low- and middle-income countries. Within DHIS 2, data elements are organized by a geographic unit, such as district or region, and can be pooled to develop indicators, which can be displayed by means of tables, figures, or maps. The platform is extremely flexible, and, as soon as the necessary legal permissions have been obtained, the platform can be adapted to interact with other already existing international databases and surveillance systems, such as, for example, the Global Health Observatory Data Repository. Interoperability with other systems is further enhanced by the fact that disease coding is based on the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10), the internationally recognized medical classification of the World Health Organization. In order to construe the diagnosis, even if the doctor did not use English and instead Arabic or Kurdish Sorani, an ad hoc software to automatically translate and code the diagnoses has been developed. Data can be easily entered through laptops, tablets, or smartphones.

In the framework of the project, a team of local collaborators has been established. Additionally, about 700 medical doctors, statisticians, and public health officials of the region have been trained on the use of health information and epidemiological surveillance systems, as well as the ICD-10.

After having considered and evaluated the positive results obtained by the pilot project, the implementation phase of the comprehensive program was started in 2018. Beyond the 29 already active centers, 30 new ones will start collecting data by the end of 2019 (Table 1). The health and administrative personnel of all of these centers have already been trained in data collection, analysis, and disease classification. By April 2019, more than 300,000 disease events have been recorded in the 4 Governorates of KRI – Dohuk, Erbil, Halabja, Sulaymaniyah – and stored in the system.

TABLE 1

Number of Centers Already Active and in the Process to be Activated in 2019, Distributed by Governorate

The aim of the full-fledged program is (1) to expand the health monitoring system already activated through the pilot project, so to network by 2021 the approximately 120 main health centers and hospitals of the region; (2) to train health and administrative staff in the management and analysis of health monitoring system data; (3) to train highly specialized personnel on public health and computer science, to guarantee the continuity and future sustainability of the health monitoring system by handing it over in 2021 to the local Ministry of Health; and (4) to include also in the health monitoring system the private facilities, especially hospitals, which still play a significant role in the Iraqi health system. A subsequent expansion of the health monitoring system to whole Iraq is foreseen in the following years.