Understanding the leadership and cultural dimensions of strategic healthcare policy-making in Iraq.
Article Type: Report
Subject: Medical policy (Interpretation and construction)
Leadership (Influence)
Health care industry (Laws, regulations and rules)
Health care industry (Social aspects)
Author: Bundt, Thomas S.
Pub Date: 10/01/2010
Publication: Name: U.S. Army Medical Department Journal Publisher: U.S. Army Medical Department Center & School Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 U.S. Army Medical Department Center & School ISSN: 1524-0436
Issue: Date: Oct-Dec, 2010
Topic: Event Code: 970 Government domestic functions; 290 Public affairs; 930 Government regulation; 940 Government regulation (cont); 980 Legal issues & crime Advertising Code: 94 Legal/Government Regulation Computer Subject: Health care industry; Government regulation
Geographic: Geographic Scope: Iraq Geographic Name: Iraq; Iraq Geographic Code: 7IRAQ Iraq
Accession Number: 253536857
Full Text: We can't solve problems by using the same kind of thinking we used when we created them.

Albert Einstein

To formulate policy that achieves our strategic ends in Iraq, we require an approach that embraces a more thorough understanding of the Middle East. More specifically, this includes an understanding of the differences in history, culture, leadership as core constructs that affect successful policy-making in this environment. (1) Speaking primarily through a medical lens, this paper includes commentary and discussion regarding strategic healthcare policy formulation and application in the Iraqi context. The end state of achieving an improved understanding of Middle Eastern systems and viable policy formulation then equates to a more effective transition in Iraq.

One key stabilization phase tenet in a theater of operations is reestablishment of essential services to support basic social structure needs (ie, specifically health care in this case). (2) This can ease the suffering caused by disruption to healthcare services from conflict and likewise help to strengthen the legitimacy of the presiding government (democratic or otherwise). (3(pp4,10,36,56)) The follow-on transition to local authorities via a functional health policy assists in the sustainment of this perception. However, effective transition requires a synchronized approach between the United States Government (USG) and the Government of Iraq (GOI) leadership. Establishment of a functional health policy through leadership and cultural appreciation can lead to a more synchronized transition and promote the operation of the Iraqi healthcare system--by the Iraqis. (4)

The following discussion relays some examples and suggestions on how to achieve a more coordinated, and synchronous strategic healthcare policy. The discussion involves a review of certain healthcare system history as well as the leadership attributes and cultural awareness variables involved. Additionally, recommendations are provided for negotiating healthcare design through leadership and cultural appreciation mechanisms in future contexts. These elements enhance USG effectiveness in addressing policy operations in stabilization and transitional phase contexts currently and in the future. (3(ppv,viii))

History. The first requirement in a review of the strengths and weaknesses of previous attempts at functional policy formulation is a thorough examination of history. Several examples can be gleaned in the case of Iraq through their pre-invasion management systems. The Ministry of Health (MOH) for example, operated under a severely restricted budget that did not allow for many types of care common to Western nations. Although there is a temptation to change this paradigm on the part of medical planners, one should ask whether or not a change is relevant and/or sustainable. If USG planners and policy-makers do not consider historical systems in this case, then we make the error of providing a service or infrastructure that they cannot, or will not, fully sustain. (5) If they cannot sustain it, the population could well look at this as a failure of the present regime, thereby damaging credibility and legitimacy. (6)

One current historical element under review is the interpretation of women's health in Middle Eastern culture. Attitudes toward female centric medical requirements are religious, political and health related issues. Often without a thorough understanding of all these elements in this context, policy-makers and operators on the ground (healthcare administrators and physicians primarily) can make erroneous assumptions resulting in embarrassment to authorities and wasted efforts. While working in the Health Attaches Office in Baghdad, I encountered one such example which evolved through a request of a representative in the

USG who asked for the status of abortion clinics to be constructed in Iraq. This is not an acceptable consideration of Middle Eastern cultures. By the nature of the office (US Department of State) however, we were asked to include this in discussions with the local medical authorities.7 For effective policy making in this context, the role of the Department of State is not to dictate the types of issues and topics that Iraqi medical leadership should address, but to see what the Iraqis want through their own involvement and recommendations. Had the leadership on the ground not argued against this incorporation, the results of this inclusion would have degraded the success of the health policy mission and, indirectly, our national policy objectives. To avoid these shortfalls, it is critical to develop training in policy development and leadership on the ground, prior to any deployment.

Leadership Training. As one might expect, disadvantages from lack of training, experience, and political acumen from USG elements hampered initial efforts to synch overall strategic healthcare policy operations.8 One example of lack of leadership training from the health policy perspective was during the initial introduction of provincial reconstruction teams (PRTs). The teams were at the operational, and, in some cases, strategic effects level of policy daily and have the potential to strengthen relationships and more seamlessly transition responsibility to local authority. However, due to their lack of initial orientation and health training, they did not understand the MOH strategic plan, the cultural sensitivity for specific medical concerns, and the makeup of the overall Iraqi healthcare system. Many of the healthcare representatives on the teams were not administrators and had little knowledge of health policy formulation or negotiations. Therefore, training of these USG key positions was initiated in-country in order to use those positions as a more effective catalyst to the overall government approach in policy formulation. (9) Improvements continued to develop over time which allowed leadership involved in negotiations to understand the plurality of paths available in healthcare policy in international contexts.

However the lack of initial training led to early ineffective policy development as USG agencies and MOH officials left negotiations with different understandings of each other's positions, and thereby executed different agendas. One example was a meeting which occurred in Baghdad in Spring 2007 between the Ministry of Defense (MOD), MOH, Multi-National Security Transition Command-Iraq, and the Health Attache elements regarding the modeling, standardization, and implementation of a training program for Iraqi clinical staff at our military facilities in country. Although initially agreed upon in full to begin immediately, participation was nonexistent in the first attempt. Findings revealed that the Iraqis assumed we were to meet several more times and agree several more times until the implementation occurred. Different cultural norms came into play in this scenario, and agencies created to provide "seamless" coordination lost the initiative in early policy negotiations. We need to note this for future contexts and work to incorporate the lessons into our leadership training programs.

As an added challenge, the MOH leadership does not maintain positive relationships with several other ministries, and are often at odds with the separate religious affiliations. These subtleties are relevant if we expect them to sustain any training and resources provided as the challenges inherent in this leadership culture impede forward progression.10 Part of the rejuvenation of essential services in a country which has suffered from deteriorating infrastructure and conflict requires a concerted effort toward the analysis of healthcare systems and needs for capacity development. If they fail in this endeavor, they could miss opportunities for deliberate funding from outside agencies, including the USG, to achieve true sustainment and legitimacy. The rationale for this from the historical perspective is this element of secularism and politics. When forming policy with institutions of this type--the secular nature of the government and the underlying religious dichotomy between religious sects (ie, a multilateral dynasty between Shiite, Sunni, and Kurd)--leadership needs to consider these factors in promoting certain ministerial and governmental systems.

As an example of this secular and political impact, when the budget was laid out for MOH as late as 2007, the minister's cabinet did not include 3 provinces of the 18 provinces throughout Iraq.11(p424) The 3 provinces happened to be in Kurdish dominated territory (what the Iraqis commonly referred to as Kurdistan). The Shiite dominated MOH felt that the Kurds were already adequately funded by other systems (means) outside of their purview and did not require this funding stream. (12(p224)) Additionally, the other Arab sects also saw the Kurds as more interested in pursuing their own sovereignty and therefore did not wish to include them in "Iraq's" foreign aid budget. USG planners were frustrated by this and tried to rectify the situation. Unfortunately, the USG leadership did not understand the Shiite and Sunni impression of the Kurds and failed to take that factor into account in their original negotiations with MOH on the equitable distribution of foreign aid funds. The MOH contended that they should alone manage the foreign aid fund distribution without any external interference. Any interjection into this process by the USG was then viewed as paternalistic and delegitimizing to their own systems of governance. (11) (p426) In this case, ministerial capacity development for leadership and administrative elements was introduced but still reduced to one essential element of culture that is best characterized by Gray: "Iraq can be transformed only within its own complex cultural parameters, not in defiance of them, and then only by Iraqis." (13)

Culture. The leadership element also correlates directly to these religious and cultural considerations. Reducing barriers to success by gaining a better understanding of the cultural differences in strategic healthcare planning is paramount. In this context, the Iraqis define healthcare (and democracy) differently than Western counterparts. (14) As such, some aspects of Western-based systems had to be excluded in planning for Iraqi health policy. For example, certain managed care imperatives, insurance systems, and geriatric long-term care facilities, though all tenets of Western systems, are either vastly different or altogether nonexistent in Iraq. Even the conduct of negotiations with the Iraqis and the relevant parties should be exercised in tandem with their norms. (11(p424)) As Gray states, "such is the enduring significance of culture." (13) To appropriately educate our medical practitioners and policy-makers through orientations, we must remove our Western lens and evaluate their system through Iraqi lenses. (15) Lastly, not only must we take local leadership and culture into consideration in synchronizing health policy planning, we also should review our own organizational culture to promote a singular strategic medical vision within the USG. (15)

Recommendation. Understanding the Iraqi health care environment requires particular attention to the leadership and cultural dimensions of their society. Many who deploy to Iraq, including me, had preconceived notions of healthcare delivery and other biases predicated on Western culture. Particular to healthcare, perhaps the simplest instructions should read, "please check your Western views at the door."16 The essential element here is an appreciation of the subtle differences in healthcare on the international stage. USG leadership should accept Iraq's definition and structure of a healthcare system. (17) This includes an understanding of a hybrid socialized healthcare system (public in the day and private in the afternoon), no taxation system to pay for access to care, and funding through oil revenues, just to name a few. (12(pp221-273)) As such, we should enjoin host nation medical authorities into discussions on the intricacies of their system first, and then determine how best to address their shortfalls and thereby enable their successful approaches.

Other themes emerge in the form of leadership and cultural strategies to enable future synchronization of healthcare policy. One element is an assessment of our current leadership competency in the healthcare context. (18) This will ensure the most capable and culturally versed leadership is selected for healthcare policy-making positions in these environments. Another component is forming a strategic health policy in international contexts through Middle Eastern models, to include our own leadership training and cultural adaptation.

Preparing now facilitates discussion and further introspection into these significant components of international health policy making.19 The future synchronization of health policies will then more effectively address the shortfalls of a disrupted healthcare system and could likely lead to a smoother transition to the Iraqis, as well as promote greater long-term sustainability. (20) A primary course of action for a predeployment phase course would be the execution of this training and open-forum discussions with previous policy-makers and other Foreign Service assets in the leadership and cultural needs of these key postings. (21) Agencies in Iraq, as well as those providing support from stateside and other international contributions, can then accomplish their mission with a more refined roadmap via improved leadership training and cultural appreciation within our own ranks. (22)

Although this article addresses only a few select segments of the training considerations for leadership and cultural awareness, there are dozens of subcomponent categories that can only improve upon this intent. Future courses could easily incorporate the differing subjects into a readymade template to provide to participants for use in other theaters of current operations. While we continue similar missions in Afghanistan, we should take heed of these recommendations so as to avoid any parallel pitfalls or shortcomings for future operations. In his article on counterinsurgency, General Petraeus aptly quotes Lawrence:


(1.) Tyrrell MD. What To Know Before You Go: 10 Questions to Ask Before, and During, a Mission. In: Kaufmann G, ed. Stability Operations and State-Building: Continuities and Contingencies. Carlisle Barracks, PA: Strategic Studies Institute, US Army War College; October 2008:129-130. Available at: http://www.strategicstudiesinstitute.army.mil/ pdffiles/pub879.pdf. Accessed September 13, 2010.

(2.) Field Manual 3-07: Stability Operations. Washington, DC: US Dept of the Army; October 6, 2008:chap 3.

(3.) Metz S. Learning from Iraq: Counterinsurgency in American Strategy. Carlisle Barracks, PA: Strategic Studies Institute, US Army War College; January 2007:4,10,36,56. Available at: http://www. strategicstudiesinstitute.army.mil/pdffiles/ pub752.pdf. Accessed September 13, 2010.

(4.) Force Health Protection and Readiness, Symposium Conveys Hope for Future of Health Services in Iraq. Available at: http://deploymentlink.osd.mil/new.jsp? newsID=37. Accessed Oct 13, 2008.

(5.) Health Capabilities in Stability Operations White Paper. Norfolk, VA: US Joint Forces Command; June 2006:3.

(6.) Diamond L. Building democracy after conflict: lesson from Iraq. J Democr. 2005;16(1):9-23.

(7.) Fallows J. Blind into Baghdad. Atl Mon. January/ February 2004:56.

(8.) Shadid A. This is Baghdad: what could be worse?. Washington Post. October 29, 2006:B1.

(9.) Major DW. Regional Initiatives: Eliminating the Causes of Terrorism [strategy research project]. Carlisle Barracks, PA: US Army War College; March 15, 2008:4. Available at: http://www.dtic.mil/cgi-bin/ gettrdoc?AD = ADA4 80162&Location=U2 &doc=GetTRDoc.pdf. Accessed September 14, 2010.

(10.) Hawail MJ. Guideline for Concise outlook for Health Approaches in Iraq: In Response to the Sixtieth Word [sic] Health Assembly Meeting. Paper presented at the 60th World Health Assembly; May 2007; Baghdad, Iraq.

(11.) Lewis RD. When Cultures Collide: Leading Across Cultures. 3rd ed. Boston, MA: Nicholas Brealey International; 2006:424.

(12.) Jones SG, Hilborne LH, Anthony CR, et al. Securing Health: Lessons from Nation-Building Missions. Santa Monica, CA: The RAND Corporation Center for Domestic and International Health Security; 2006. Available at: http://www.rand.org/pubs/ monographs/2006/RAND_MG321 .pdf. Accessed September 14, 2010.

(13.) Gray CS. After Iraq: The Search for a Sustainable National Security Strategy. Carlisle Barracks, PA: Strategic Studies Institute, US Army War College; January 2009:4. Available at: http:// www.strategicstudiesinstitute.army.mil/pdffiles/ PUB902.pdf. Accessed September 14, 2010.

(14.) Bundt TS. Healthcare Policy Operations--A Formulary for Effective Transition in Iraq, Policy Paper for Health Attache Operations. June 2007:4-5.

(15.) Wagner M. The challenges of Iraq: putting US Army stability operations doctrine to the test. Small Wars and Insurgencies. 2008;19(4):484-509.

(16.) Gerras SJ. Thinking Critically About Critical Thinking: A Fundamental Guide for Strategic Leaders. Carlisle Barracks, PA: US Army War College; June 2006. Available at: http://www.au. af.mil/au/awc/awcgate/army-usawc/crit_thkg_gerras.pdf. Accessed September 14, 2010.

(17.) Coffey R. Revisiting CORDS: the need for unity of effort to secure victory in Iraq. Mil Rev. 2006;86 (2):24-34. Available at: http://usacac.army.mil/ CAC2/MilitaryReview/Archives/English/ MilitaryReview_2006CR1031_art014.pdf. Accessed September 14, 2010.

(18.) Field Manual 6-22: Army Leadership: Confident, Competent, and Agile. Washington, DC: US Dept of the Army; October 12, 2006:27.

(19.) Flavin W. Planning for conflict termination and post-conflict success. Parameters. 2003;33(3):95-112. Available at: http://www.carlisle.army.mil/usawc/ parameters/Articles/03autumn/flavin.pdf. Accessed September 14, 2010.

(20.) Natsios AS. The Nine Principles of Reconstruction and Development, Parameters 2005;35(3):4-20.

(21.) Mori L, Meddings D, Bettcher D. Health, human security and the peace-building process. In: Conflict and Human Security: A Search for New Approaches of Peace-Building. Hiroshima, Japan: Institute for Peace Science Hiroshima University; 2004:176-196. English Research Report Series, No. 19. Available at: http://home.hiroshima-u.ac.jp/heiwa/Pub/E19/ Chap8.pdf.

(22.) Metz S. Rethinking insurgency, (Carlisle, PA: U.S. Army War College, Strategic Studies Institute, June 2007), 57. Carlisle Barracks, PA: Strategic Studies Institute, US Army War College; January 2007. Available at: http://www.strategicstudiesinstitute.ar myarmy.mil/pdffiles/pub790.pdf. Accessed September 14, 2010.

(23.) Lawrence TE. Twenty-seven Articles. Arab Bulletin. August 20, 1917. Cited by: Petraeus DH. Learning counterinsurgency: observations from soldiering in Iraq, Mil Rev. 2006;86(1):2-12. Available at: http:// usacac.army.mil/CAC2/MilitaryReview/Archives/ EnglishMilitaryReview_2006CR1031_art010.pdf. Accessed September 14, 2010.

LTC Thomas S. Bundt, MS, USA

LTC Bundt is Commander, 187th Medical Battalion, 32nd Medical Brigade, Army Medical Department Center and School, Fort Sam Houston, Texas.
... try not to do too much with your own hands.... Better
   that the Arabs do it tolerably than that you do it
   perfectly. (23)
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