Resilience of health systems in conflict affected governorates of Iraq, 2014-2018.
OBJECTIVES
The objective of this study was to assess the resilience of health systems in four governorates affected by conflict from 2014 to 2018, and to convey recommendations.


METHODS
Health managers from Al Anbar, Ninawa, Salah al-Din, and Kirkuk governorates discussed resilience factors of Primary Health Care services affected by the 2014-2017 ISIS insurgency in focus groups, and general discussions. Additional information was gathered from key informants and a UNICEF health facility survey. Three specific aspects were examined: (1) meeting health needs in the immediate crisis response, (2) adaptation of services, (3) restructuring and recovery measures. Data from a MoH/UNICEF national health facility survey in 2017 were analyzed for functionality.


RESULTS
There were many common themes across the four governorates, with local variations. (1) Absorption The shock to the public sector health services by the ISIS invasion caught health services in the four governorates unprepared, with limited abilities to continue to provide services. Private pharmacies and private clinics in some places withstood the initial shock better than the public sector. (2) Adaptation After the initial shock, many health facilities adapted by focusing on urgent needs for injury and communicable disease care. In most locations, maternal, neonatal, and child health (MNCH) preventive and promotive PHC services stopped. Ill persons would sometimes consult health workers in their houses at night for security reasons. (3) Restructuring or transformative activities In most areas, health services recovery was continuing in 2020. Some heavily damaged facilities are still functioning, but below pre-crisis level. Rebuilding lost community trust in the public sector is proving difficult.


CONCLUSION
Health services generally had little preparation for and limited resilience to the ISIS influx. Governorates are still restructuring services after the liberation from ISIS in 2017. Disaster planning was identified by all participants as a missing component, as everyone anticipated future similar emergencies.
['Ibrahim|Shaimaa|S|', 'Al-Dahir|Sara|S|', 'Al Mulla|Taha|T|', 'Lami|Faris|F|', 'Hossain|S M Moazzem|SMM|', 'Baqui|Abdullah|A|', 'Burnham|Gilbert|G|http://orcid.org/0000-0002-9991-4894']
Conflict Iraq Primary Health Care ISIS