Poor Accountability and Corruption and its Impact on Quality of Care in the Public Health Sector within the Kurdistan Region of Iraq

    Student thesis: Doctoral Thesis


    This thesis offers original insights into the dynamics between corruption and accountability measures in the health sector and evaluates their effects on the quality of care offered by healthcare providers. The health sector is frequently undermined by corruption, in particular political corruption, clientelism and nepotism and have a severe impact on the accessibility and quality of healthcare services. Corruption is a particularly notable challenge for healthcare providers in developing countries, where the lack of access to essential care has had a detrimental impact on people’s general level of health and wellbeing. This issue has been palpable in the context of the COVID-19 pandemic, with the uneven distribution of vaccines sparking renewed interest as to how best to curb corruption.
    Focusing on the case of corruption in the public health sector (PHS) in the Kurdistan Region of Iraq (KRI), this thesis explores public, healthcare providers, and policymaker perceptions of the PHS. In doing so, it addresses five broad issues in the literature on the PHS. First, the key challenges to quality in the PHS in the KRI. Second, the mechanisms and management of communications between patients and health professionals. Third, the major factors affecting the quality of care according to members of each group, including key similarities and differences in the priorities identified by them. Fourth, the type of change required so as to improve the quality of care and public satisfaction with the PHS. Finally, the broader structural changes and improvements required to implement health systems accountability (HSA) in the PHS.
    To explore these issues, the thesis draws on original evidence collected through a sequential, exploratory mixed methods research design using qualitative and quantitative approaches. Specifically, 39 semi-structured, face-to-face interviews and 551 surveys were conducted in different KRI locations, including urban, semi-urban areas and a town during August and September 2018. The triangulation of the evidence draws attention to a series of novel limitations at PHS facilities in the KRI, including the quality, accessibility, and availability of healthcare services. Political corruption was the main concern of respondents as well as the most common and key factor they identified as sustaining poor quality care in the PHS.
    Clientelism and nepotism were also noted as common across the PHS, from employment services to providing care for patients. The majority of respondents were aware and strongly concerned with this practice and observed it as a key source of inequality in the services offered by and received in the PHS. Taken together, these limitations revealed a broad dissatisfaction with the PHS by the majority of the public and healthcare providers that participated in the research. The findings also draw attention to the lack of public input in and accountability of PHS provisions.
    These findings strongly underline that to address current challenges posed by corruption in the PHS in the KRI and, more generally, in developing countries, accountability targets must reflect and be compatible with the local cultural and political environment. In developed countries where there is transparency, trust and adherence to the rule of law, corruption is less likely to grow and HSA is more successful. Hence, this thesis argues that effective HSA in developing countries requires a clear, cyclical process and the inclusion of all stakeholders, from the state to healthcare providers and individuals. Effective HSA also requires transparency, participation, and anti-corruption regulations. These measures would assist individual input and should be coupled with policies targeting clientelism, nepotism and improved equality in access to the PHS.
    Date of Award31 May 2023
    Original languageEnglish
    Awarding Institution
    • University of Portsmouth
    SupervisorMark Bradley Field (Supervisor), Nora Siklodi (Supervisor) & Paul Stephen Flenley (Supervisor)

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