INTERNATIONAL JOURNAL OF BIOPHARMACEUTICAL SCIENCES (ISSN:2517-7338)

Due to 30 years of war and trade sanctions, critical gaps in the higher education system in Iraqi Kurdistan have developed. In recognition of the need for curricular change, the Kurdistan Ministry of Higher Education (KMoHE) worked with U.S. universities in 2008 to update various curricula including pharmacy. A pharmacy curriculum reform committee was formed and charged with identifying current and future needs of pharmacy practice and education, evaluating the current curriculum, recommending curricular change, and identifying needs to implement the new curriculum. The curricular changes recommended by the committee were accepted by the Minister of Higher Education and have been implemented in all three pharmacy programs in Iraqi Kurdistan. Faculty development to assist with delivery of the curriculum has been successful and continued support is provided.

Iraq; Kurdistan; Pharmacy Education; Doctor of Pharmacy; Curriculum

Kurdistan is an extensive area in the Middle East covering areas in Turkey, northern Iraq, northwestern Iran and parts of southern Syria. Small areas of Azerbaijan and Armenia are also considered to be a part of Kurdistan. The Iraqi government subjected ethnic Kurds to forced displacement and assimilation for decades, and from 1986 to 1989, genocide under the Baathist regime. Iraqi Kurdistan has gained official recognition as an autonomous federal entity established by Article 113 of the Iraqi constitution. The Kurdish Regional Government (KRG) includes three provinces, Duhok, Erbil and Sulimani has been under self-rule since 1992.

Concern has been expressed that no “system” is in place and that physician services are offered by many practitioners, some of who are unqualified, unlicensed, or both. Public hospitals and public primary care centers are available but often overused for minor illnesses and return visits due to lack of trust of healthcare professionals. The public primary care centers are often viewed as referral stops; patients present to the clinic only desiring referral to the hospital or a specialist. In some cases, the clinic physician may refer the patient to his private clinic. In addition to an unenforced referral system, prescribing often complies with a patient request.

Brand-name products are widely prescribed over generic products since Western brand-name products are perceived as more effective than generics. Further complicating prescribing and medication use, prescription medications can easily be obtained from private pharmacies or street vendors selling improperly stored or expired drugs. Due to overcrowded clinics, physicians are seeing patients at a rapid rate and addressing only the most immediate concerns. Additionally, lack of access to medications limits their ability to treat chronic health issues causing public health initiatives to suffer. Within the clinic, the roles, responsibilities, and functions of staff are unclear and may lead to internal power struggles [1] In general, inter- professional working conditions may be poor, and lack of regard or respect for the role of nurses has been reported [1-3]. Hospital record-keeping is minimal and thought to be nearly non-existent in outpatient clinics [2]. In addition, records of adverse events or complaints about medications are not maintained [1]. According to a 2012 interview with the Minister of Health, money has been budgeted to computerize the health-system; however, pen and paper are still being used [3].

In a survey of medical professionals (physicians, dentists and pharmacists), seven healthcare priorities were identified: adopting a health insurance system (76.1%), periodic scientific assessment of physicians and staff (69.8%); minimizing the gap between urban and rural health services (58.2%); social insurance for medical care of the poor (82%); public-private systems separation (50.5%); better role for regional Ministry of Health and professional associations in controlling the private sector (61.5%); and enhancing the role of family medicine in the health system (77.2%) [4].

The first medieval school of pharmacy founded in Baghdad; [5,6] and pharmacists in Iraq were among the forerunners in developing standards for preparing and storing medicines [5]. According to one source, Mercurial ointments, mortars and pestles, flasks and spatulas, as well as evidence based pharmacotherapeutics have their roots in Arabic pharmacy [6].

In 2005, an academic pharmacist in Iraq was interviewed. He reported a “complete breakdown” in the pharmaceutical distribution system. Access to essential drugs was limited, counterfeit medications had infiltrated the market resulting in 97% of medicines of unknown quality, and an increasing number of unlicensed street vendors were selling pharmaceuticals. Additionally, prescription medications were being used for grossly inappropriate indications such as piperacillin for toothaches and quinolones for minor fever. He reported that community pharmacies had been destroyed, looted and that pharmacists and academic staff had been attacked by terrorists, murdered or kidnapped. Exacerbating the shortage of community pharmacies caused by violence, new pharmacy graduates were taking clinically-oriented jobs in hospitals instead of pursuing community practice [6].

In a follow-up interview two years later, he reported that community pharmacies were open and functioning, but hours were limited due to curfews. He continued to report escalating violence and murder of pharmacists, he also stated that professional standards were lacking and that continuing education had stopped [7]. According to a companion article written by another Kurdish pharmacist, the state of pharmacy in Kurdistan was much improved and a “unified pharmaceutical society covering the whole of the Kurdistan region” was active and effective [8]. The author stated that the removal of sanctions had improved the drug supply making nearly all drugs available. He also noted that the KRG was building a quality control unit to address illegal drug sales by unqualified personnel and that a pharmaceutical production facility was being built next to a school of pharmacy. Specifically, it was stated that insulin from Novartis was available [8]. At the same time, insulin was in shortage in other areas of Iraq but seen in the market “baking in the sun” [7].

In Iraq as a whole and the Kurdistan region, availability of drugs from unlicensed street vendors is uncontrolled [7]. And undermines the role of the community pharmacist [5].Drugs dispensed to patients virtually free are often resold on the black market [1]. Further, drug shortages and lack of enforcement of drug regulation has made the country a “haven to counterfeit medicines and drugs of substandard quality” [5]. In a survey of medical professionals, the majority of respondents considered the “availability of required quality and quantity of medications” to be weak or very weak [4]. In 2012, the Kurdistan Minister of Health summarized the current efforts of the MoH to stop the use of counterfeit or poor quality medications in Kurdistan. In order to toughen border checks, pharmacists are inspecting medications at the border and can refuse entry of poor quality or unregulated medications. There may be as many as 4,000 illegal pharmacies in the Kurdistan region. Many are run illegally by unofficial nurses [3]. To address this issue, monitoring of private pharmacies was scheduled to start on August 1, 2012. The minister stated, …if poor quality or expired medicine is found it will be burned and the responsible party will be arrested and sentenced [3].

In general, critical gaps have occurred in the higher education system in Kurdistan and were caused by more than 30 years of wars and embargos. During that time, no significant change or update of school of pharmacy curricula has occurred for almost 30 years. The Bachelor of Science in pharmacy curriculum is offered by all pharmacy schools in Kurdistan and Iraq [9]. The curriculum is arranged in a 0/5 lockstep method [5,6]. After graduation, completion of a “preregistration” year is required prior to licensure [5]. According to a 2013 letter, there are 13 public and four private colleges of pharmacy in Iraq [9]. Three of these are located in the Kurdistan region. In Kurdistan, every school of pharmacy in the country teaches the same curriculum with the same syllabi at the same time and it is delivered by faculty with a Ph.D. degree. The Doctor of Pharmacy degree is not recognized as sufficient qualification to teach in higher education.

In a 2005 interview, the lack of pharmacy faculty in Iraq was reported. Causes of the shortage included assassination of 40 academics in an eight month period and the opening of five schools pharmacy in six years. Schools hired faculty who were not licensed pharmacists and concern was raised that teaching was not oriented to pharmacy practice which would contribute to the stagnation of the profession [5]. Classroom, laboratory, and library facilities are inadequate and instructional resources such as laboratory equipment, textbooks, and computer equipment remain in short supply [5,6]. In some cases, libraries could only obtain photocopies of references and texts; few or no original copies from the publisher were available [5].

The lack of academic staff in Iraq has been recognized as severe and supports the concept that fewer advanced degree pharmacist faculty has resulted in more non-pharmacists teaching courses. It has been reported that some schools have began to hire top graduates as “academic pharmacist” instructors [6]. Higher education in Iraq is free to students and they may receive extra support and incentives for their education [10]. An assessment of the demographic transition and development of Kurdistan was published in 2009. The authors stated that the education system was below international standards but noted advances in the system in the last few years. The need to strengthen policies already initiated for better and more effective education was identified as well as, on-the-job training, and health services [10].

The Kurdistan Ministry of Higher Education and Scientific Research (KMoHE) partnered with Appalachian State University and the U.S. Department of State to re-examine and revise their curricula so that students are provided with “market ready” skills to meet the present and future needs of the country. The 10 academic disciplines identified by KMoHE for curricular review are as follows: Biology, Chemistry, Civil Engineering, Computer Sciences, Dentistry, Education, English, Family Medicine, Pharmacy, and Sociology. Five public universities under the purview of the Kurdistan Regional Government’s Ministry of Higher Education and Scientific Research are involved in this project. In some cases, Appalachian State University could not provide faculty with expertise in a specific discipline. In these cases, Appalachian State University collaborated with member institutions of Tennessee Independent Colleges and Universities Association (TICUA), Belmont University, Meharry Medical University, and Tennessee Technical University, and East Tennessee State University. Table 1.

Implementation of the program activities commenced in January 2009 after the formalization of the agreement between Appalachian State University and the Kurdistan Ministry of Higher Education and Scientific Research (KMoHE). At the Ministry level, a specific department was established with responsibilities for coordinating curriculum development efforts. Additionally, each university established a university committee to oversee curriculum development efforts. These university-based committees have worked closely with the U.S. faculty from academic disciplines identified previously to address curricular revisions and enhancements.

The entire curricular design process was completed at the request of the Minister of Higher Education. The pharmacy curricular reform committee was under the direction of the Dean of the Hawler School of Pharmacy, Dr. Abdulqader Aziz Alnakshabandi.

Additional committee members were the chairs of the following departments of Hawler Medical School: Pharmacology and Toxicology, Chemical Pharmaceutics, Laboratory Analysis, and Pharmacognosy; the on- site U.S. facilitator (Dr. Webster); and a U.S. assistant (Dr. Ficzere). All faculties from Hawler Medical College of Pharmacy were pharmacists with a Ph.D. degree. The on-site team met daily for up to eight hours a day, six days a week for over two weeks and followed four steps in their approach to curricular reform:

• Identify current and future needs for pharmacy practice and education
• Evaluate the current curriculum
• Recommend changes to the current curriculum
• Identify resources needed to deliver the revised curriculum 

Students in the Bachelor of Science program take laboratory courses and practice rotations to support the requirements for community, industrial and clinical laboratory practice prior to graduating. Doctor of Pharmacy students take advanced clinical coursework in pharmacokinetics, therapeutics, epidemiology, drug information and nutrition. This is then followed by ten one-month clinical rotations in the sixth year prior to graduation. (Appendix A)

Additionally, student progression and program rigor were discussed. Different options were examined and a thorough review will be performed by the college committee. The proposal was modified and details for implementation were finalized during three meetings of the Kurdish council of deans. Finally, it was accepted at Hawler-Medical University and at all three pharmacy schools in Iraqi Kurdistan: Hawler Medical University, University of Duhok, and University of Sulaimaniyah. 

Agreeing on the move from annual course offerings to a semester approach provided us more flexibility in the curriculum design process. With this change, the committee was able to keep about 60% of the old curriculum, if in name only, to soften the perception of change. The course names that did not change are identified in Appendix A. With revision needed for the entire curriculum, retaining course names but updating content was more easily accepted than recreating all new courses. Obtaining benchmark syllabi was a useful component in order for the deans to accept change. The ability of the consultant to provide the committee information and suggestions and then step back and let the committee have time to discuss and modify the consultant’s input was essential. The Kurdish members of the committee had greater confidence in the process and greater ownership of the final product. Ultimately, the support and direction of the Minister of Higher Education and the passion, drive, and commitment of Dr.Alnakshabandi, Dean of the Hawler Medical School were crucial to the successful functioning of the committee and acceptance of the committee’s recommendations. With no change to the curriculum in 30 years, updating of all courses was a requirement.

Depth of content in basic sciences courses had to be reduced and in many cases laboratory requirements were completely removed from some courses. The curricular revision committee encountered significant resistance to change from faculty. In many cases, faculty had been teaching the same courses in the same manner for many years. While resistance was met, younger faculty was more ready to accept change. In order to deliver the new curriculum, the curricular revision committee recognized the need for faculty development. In a 2012 article, the teaching staff at the Medical College at Hawler Medical University identified the following priorities for medical education: improving quality of teaching including use of small group teaching strategies in all study years; improving infrastructure and facilities for teaching; providing continuous academic development programs for teaching staff [11]. While pharmacy education is not specifically addressed, this article does indicate interest in improving healthcare professional education.

The relationship between Belmont University College of Pharmacy and Hawler-Medical University that began in 2008 has continued. Because current faculty are now faced with teaching subjects or courses that they have not experienced or taught previously. Belmont and Hawler-Medical developed a training program for current faculty to gain experience in drug information and clinical pharmacy education. Faculty training includes drug information practice, institutional and clinical practice, and classroom clinical pharmacy instruction in topics such as therapeutics. The most difficult topics to teach are pharmacy administration and pharmacoeconomics. Common Western business practices and banking principles are often in conflict with Islamic law since charging interest is not allowed. For example, the purchasing of a drug information reference or textbook online becomes complicated since credit cards are not used. The faculty development program has been extended to the other Kurdish pharmacy schools and to date. Belmont has hosted 10 faculty members from the three schools in Kurdistan.

Since a PhD is required to teach in higher education, the Pharm.D. Degree is not sufficient for faculty appointment. Most current faculty in the Kurdish pharmacy schools was educated in Iraq, mostly at the University of Baghdad. The need for qualified faculty is so great that hiring of adjuncts has been required in order to fulfill the faculty needs in Kurdistan. Current faculty are partnering with Kurdish medical faculty to deliver the newly adopted curriculum.

In 2008, the curriculum reform committee envisioned that graduates of the new Doctor of Pharmacy program will become the leaders of change in pharmacy in Kurdistan and Iraq by creating the needed drug information centers, poison control centers and clinical pharmacy disease state management programs. The curricular revision process that began amidst the Iraq war, is now in its third year of implementation. Feedback indicates that the Kurdish faculty are using what they have learned and making the new curriculum their own.

It is hoped that the curricular revisions will prepare students to become pharmacists that are ready for the future of pharmacy practice in the region. As these pharmacists graduate with greater clinical skills, it is anticipated that they will improve patient care and become leaders in transforming the pharmacy practice model in Kurdistan. Changes and adoption of the curriculum have occurred albite slowly due to the regional political strife. This work serves as a beginning foundation of change for the practice of pharmacy in the Kurdish Region of Iraq.

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