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• Guide to Travel, Hospitality, Conference and Event Expenditures

More information

• Travel, Hospitality, Conference and Event Expenditures, Directive on

Terminology:

This guide replaces:

• Travel, Hospitality, Conference and Event Expenditures, Guideline on [2017-09-15]

1. Date of publication

This guide was published on September 15, 2017 and incorporates changes effective as of August 1, 2020 .

This guide replaces the Guideline on Travel, Hospitality, Conference and Event Expenditures dated January 6, 2014 .

2. Application, purpose and scope

This guide applies to the organizations listed in section 6 of the Treasury Board Directive on Travel, Hospitality, Conference and Event Expenditures (the Treasury Board Directive).

This guide outlines recommended best practices for implementing the Treasury Board Directive. Examples and tips are provided for illustrative purposes only and may not apply to all departments or situations.

Grants and contribution payments made in accordance with the Policy on Transfer Payments are not subject to the provisions of the Treasury Board Directive.

3. Guiding principles

When planning travel, hospitality, conference and event expenditures, individuals with delegated approval authority are to exercise professional judgment in determining whether the expenditures meet the objective of the Policy on Financial Management Footnote 1 .

According to section 4.2 of the Treasury Board Directive , individuals with delegated approval authorities are responsible for ensuring that the costs of travel, hospitality, conference and events are minimized and are necessary to support the departmental mandate, operational activities, objectives or priorities, while ensuring that the provisions of legislation, regulations, orders-in-council, National Joint Council directives, collective agreements or Treasury Board–approved instruments are respected.

Table 1 illustrates the principles that should guide the planning, approval, recording and reporting of travel, hospitality, conference and event expenditures. Individuals with delegated authority should consider the questions in column two to ensure that these principles are respected.

4. Overview of travel, hospitality, conference and event expenditures

Appendices A to D provide guidance for the planning, approval and reporting of travel, hospitality, conference and event expenditures. These appendices explain specific requirements in the Treasury Board Directive by providing best practices and examples. Appendix E describes how taxes (for example, the Goods and Services Tax / Harmonized Sales Tax) are to be planned for and recorded. Appendix F provides guidance on the transparency of these expenditures, and appendices G, H and I provide guidance on the annual reporting of travel, hospitality and conference expenditures.

The Treasury Board Directive supports the implementation of the National Joint Council Travel Directive and the Special Travel Authorities , which detail the requirements for individuals travelling on government business, including Governor in Council appointees. Contact your designated departmental travel coordinator for guidance on these requirements.

Table 2 summarizes the approval authorities and thresholds for each type of expenditure. More information is provided in appendices A to D.

5. References

Legislation.

• Access to Information Act
• Financial Administration Act (sections 7 and 9)
• Privacy Act

Related policy instruments

• Policy on Financial Management
• Directive on Delegation of Spending and Financial Authorities
• Directive on Travel, Hospitality, Conference and Event Expenditures
• Guide to Delegating and Applying Spending and Financial Authorities

Other relevant documents

• Global Affairs Canada policy on Official Hospitality Outside Canada
• Guide to the Proactive Publication of Travel and Hospitality Expenses
• Government-wide chart of accounts for Canada
• Heads of Post and Foreign Service Official Hospitality directives
• National Joint Council Foreign Service Directives
• National Joint Council Isolated Posts and Government Housing Directive
• National Joint Council Relocation Directive
• National Joint Council Travel Directive
• Policies for Ministers’ Offices
• Special Travel Authorities
• Values and Ethics Code for the Public Sector
• Information Bulletin: Conference attendance by members of the Research (RE) group

6. Enquiries

Members of the public may contact Treasury Board of Canada Secretariat Public Enquiries if they have questions about this guide.

Individuals from departments should contact their departmental financial policy group if they have questions about this guide.

Individuals from a departmental financial policy group may contact Financial Management Enquiries for interpretation of this guide.

Appendix A: Travel

A.1 introduction.

This appendix discusses best practices for developing travel plans, explains the travel approval authorities and illustrates the reporting of travel expenses.

The travel approval authorities described in this appendix are organized according to the answers to the following three questions, as illustrated in Figure 1:

• Who is travelling?
• Where are they travelling?
• How often do they travel?

This figure provides an overview of the content discussed in Appendix A. It presents the travel approval authorities according to the answers to the following three questions:

A.2 Travel planning

In accordance with the guiding principles in section 3 of this guide and subsection A.2.2.1 of the Treasury Board Directive on Travel, Hospitality, Conference and Event Expenditures (the Treasury Board Directive), the chief financial officer (CFO) is responsible for ensuring that travel is avoided where appropriate and that travel is cost-efficient, including:

• limiting the number of departmental travellers to the minimum necessary to deliver the business of the government
• selecting the most economical means of travel when booking transportation, accommodations and meeting facilities

Departments can use travel plans to support the following:

• the departmental travel approval process
• management oversight and resource planning to ensure cost-efficient travel decisions

The following questions and answers explain the key aspects of travel plans.

What is a travel plan?

A travel plan is a document that contains information about travel requirements for employees over a specific period.

When should a travel plan be used?

A travel plan can be useful in situations where departments can predict in detail who will need to travel, as well as when and where the travel will occur.

What should be included in a travel plan?

When the travel plan is used to obtain expenditure initiation approval, it should contain detailed estimates of travel costs and a rationale for why the travel is required, as described in subsection A.2.2.8 of the Treasury Board Directive .

If travel expenditures for companions are permitted under legislation, regulations, orders-in-council, National Joint Council directives or Treasury Board–approved instruments, or approved as per subsection A.2.2.12 of the Treasury Board Directive, the authority should be documented in the travel plan or in the travel request. Further information on companion travel can be found in subsection A.6.3 of this guide.

How often should a travel plan be prepared?

Travel plans can be prepared monthly, quarterly, semi-annually or annually, depending on a department’s operational needs.

What is the development and approval process for travel plans?

The CFO should:

• develop and coordinate the department’s travel plan process, including the format and content of travel plans
• establish procedures for approving travel plans and for approving trips not included in those plans
• present the consolidated departmental travel plan to the department’s executive management committees to support effective management oversight and resource planning

To maximize efficiencies in the approval process, approvals of travel plans and events can be coordinated (see section D.2 of this guide for more information on combining travel approval with event approval).

A.3 Delegation of travel approval authority

The senior departmental manager can be delegated the authority to approve travel expenditures. Departments may decide to delegate travel approval authority below the senior departmental manager level if at least one of the following three operational needs listed in subsection A.2.2.4 of the Treasury Board Directive is met:

• the program’s operations are regionally or globally dispersed, and there is no senior departmental manager present in certain offices
• the operational requirements for travel are frequent, may involve a significant number of travellers, and concentrating approvals with one position would create potential delays
• the potential for delay in obtaining approval could be injurious to the public interest or the timely delivery of departmental services or operations

When delegating below the senior departmental manager level, departments should consider, on the basis of operational needs, how many and which managers should exercise the delegations.

As part of their maintenance of delegated spending and financial authorities, CFOs should formally document delegated travel approval authorities and should review them at least once a year to ensure that they are still relevant.

For more information on documenting delegations, see the Directive on Delegation of Spending and Financial Authorities .

A.4 Blanket travel authority

According to the National Joint Council Travel Directive (the NJC Travel Directive), blanket travel authority (BTA) is an authorization for travel that is continuous or repetitive in nature, with no variation in the specific terms and conditions of trips, and where it is not practical or administratively efficient to obtain prior approval from the employer for each trip. Any exceptions to the BTA parameters shall require that each trip be specifically approved, prior to travel status, where possible. BTA does not apply to groups of employees. Employees may have more than one BTA simultaneously.

BTAs are to include reasonable estimates of costs and related elements from the checklist of trip authorization elements in subsection A.2.2.8 of the Treasury Board Directive (see subsection A.7.1 of this guide for additional information).

The approval authority level for a BTA is based on the estimated travel costs per travel activity, not the total amount of the BTA. The approval of BTAs depends on the departmental delegation chart of spending and financial authorities. Approval of BTAs can be to positions identified by title.

BTAs should be included as part of the departmental travel plan (see subsection A.2 of this guide).

CFOs should ensure that the approval of BTAs is formally documented and reviewed at least once a year.

If an individual has to travel to attend an event, the expenditure initiation approval for the event takes precedence over any BTA that is in place for that individual. Therefore, the travel costs otherwise approved under a BTA are to be included in the total departmental estimate of event costs.

The NJC Travel Directive provides guidance on creating and determining the content of BTAs. Contact your designated departmental travel coordinator or your departmental financial policy group for more information on BTAs.

A.5 Treatment of other travel approval authorities

A.5.1 local travel.

According to subsection A.2.2.6.1 of the Treasury Board Directive , travel approval authorities under the Treasury Board Directive do not apply to local travel within the normal office location and surrounding working area of a public servant.

Departments should define local travel to reflect their operational circumstances. The definition of “local travel” should include the limits under which local travel would be excluded from the travel approvals in the Treasury Board Directive . Departments should define and document the approval authorities for local travel, for example in their supporting notes to the delegation chart.

Departmental definitions of local travel apply to expenditure initiation authority for travel and are independent of the definitions relating to travel entitlements in the various modules of the NJC travel directive . Contact your designated departmental travel coordinator or your departmental financial policy group for more information.

A.5.2 Approval authority for travel by the deputy head

According to subsection A.2.2.9 of the Treasury Board Directive , the CFO must approve travel by the deputy head. Departments should establish written policies or procedures for approval and payment of the deputy head’s travel expenses.

A.6 Travel of non-public servants

A.6.1 travel of non-public servants.

For the purpose of the Treasury Board Directive , non-public servants include the following:

• Canadians who are travelling to receive departmental services and programs
• individuals who are participating in departmental consultations and negotiations
• contractors who are doing the work specified in their contract
• individuals who are being interviewed for employment in the department

When a contract sets out travel requirements and states that the contractor will be reimbursed for travel costs, any travel by the contractor must be explicitly approved. If it is determined that the contractor will need to travel after the contract is signed, a subsequent travel approval is required.

The department should determine where in the contracting process it is most efficient and effective to obtain the necessary travel approval authority.

A.6.2 Travel of ministers and their exempt staff

According to subsection A.2.2.3 of the Treasury Board Directive , travel undertaken in support of departmental business by appropriate ministers and their exempt staff is not subject to travel expenditure initiation under the Treasury Board Directive. This travel falls under the Policies for Ministers’ Offices and the Special Travel Authorities .

The CFO should advise the minister’s chief of staff on the development of relevant procedures.

A.6.3 Companion travel

A minister can approve companion travel in accordance with subsection A.2.2.12 of the Treasury Board Directive . The minister may choose to approve on a case-by-case basis or for types of situations. Examples could include attending key award and recognition ceremonies or activities requiring participation of companions for reason of protocol or diplomacy. This authority can only be delegated to the deputy head.

Companion travel authorized under legislation, regulations, orders-in-council, National Joint Council directives or Treasury Board–approved instruments are not subject to the restrictions of the Treasury Board Directive .

In situations where there are existing authorities to allow for companion travel, the authority should be documented in the travel plan or in the travel request as described in subsection A.2 of this guide.

A.7 Reporting travel expenses

A.7.1 recording trip authorization elements.

Departments need to ensure that the trip authorization elements are included in the travel authorization for expenditure initiation purposes when the department pays travel costs for a public servant or a non-public servant.

The trip authorization elements are to be captured and recorded for each trip or in a travel plan.

The trip authorization elements, as described in subsection A.2.2.8 of the Treasury Board Directive , are as follows:

• Category (see subsection A.7.2 of this guide for more information)
• Traveller as public servant or non-public servant
• Virtual presence or other remote meeting solutions
• Number of travellers
• Mode of transportation (including the six modes of transportation)
• Accommodations
• Incidentals and other costs

As described in subsection A.2.2.13 of the Treasury Board Directive , the following trip authorization elements must be recorded in either the departmental financial management system, a related system (such as the Shared Travel Services travel authorization module or a departmental online system) or a departmental process that uses travel authorization forms:

• B. Category
• F. Mode of transportation (including the six modes of transportation)
• G. Accommodations
• I. Incidentals and other costs

It is expected that the departmental financial management system will directly capture the trip authorization elements through the use of general ledger codes aligned with the 10 detailed object codes in the government-wide chart of accounts for Canada (see section A.7.3 of this guide) if the department chooses not to use a related system.

A.7.2 Categories of travel

According to subsection A.2.2.7 of the Treasury Board Directive , one of the following five travel categories must be recorded as element B in the trip authorization elements (described in subsection A.7.1 of this guide):

• Operational activities: travel required to support the department’s operational activities (other than the following categories), legislative or legal requirements
• Key stakeholders: travel necessary to engage key stakeholders in relation to such matters as policy, program or regulatory development or renewal
• Internal governance: travel necessary to support sound internal departmental governance
• Training: travel to enable the training of public servants
• Other travel

The “operational activities” category should be selected for activities that meet the definition of operational activities and for travel that does not fit with the definition of “key stakeholders,” “internal governance” or “training.”

The “key stakeholders” or “internal governance” categories should be selected when they represent the main purpose of the travel, even if the trip includes some aspects of “operational activities.”

The following examples illustrate the selection of the appropriate travel category in different situations:

• record the costs for departmental employees to travel to engage with stakeholders on the design of a new departmental program as “key stakeholders” even if the program is considered one of the department’s “operational activities”
• record the travel costs of Departmental Audit Committee members as “internal governance”
• record the costs for a food inspector to travel to a meat-processing plant to perform a food safety inspection as “operational activities”

A.7.3 Economic object codes for the travel of public servants and non-public servants

Travel costs are to be recorded using the economic object code for the appropriate category of public servant and non-public servant travel listed in the government-wide chart of accounts for Canada, as illustrated in Table 3.

Appendix B: Hospitality

B.1 introduction.

According to the Treasury Board Directive on Travel, Hospitality, Conference and Event Expenditures (the Treasury Board Directive), hospitality consists of the provision of meals, beverages or refreshments that are necessary for the effective conduct of government business and for reasons of courtesy, diplomacy or protocol.

The hospitality approval authorities described in this appendix are organized according to the answers to the following three questions, as illustrated in Figure 2:

• What is the cost of hospitality?
• What type of hospitality is being provided?
• Who is receiving the hospitality?

This figure provides an overview of the content discussed in Appendix B. It presents the hospitality approval authorities according to the answers to the following three questions:

B.2 Hospitality planning

Departments must try to avoid or minimize their use of hospitality and maintain rigorous management oversight over their hospitality expenditures. Departments need to carefully consider the decision to offer hospitality and must ensure that the hospitality is required for reasons of courtesy, diplomacy or protocol, or to facilitate the achievement of the business of the government, as set out in subsection B.2.2.1 of the Treasury Board Directive .

Departments may find it useful to establish a hospitality plan to streamline the approval process when multiple hospitality activities require approval by the same delegated authority.

To maximize efficiencies in the approval process, departments should coordinate hospitality approvals with event approvals.

B.3 Hospitality approval authority

Subsection B.2.2 of the Treasury Board Directive sets out the approval authority for hospitality expenditures.

Approval authority thresholds are summarized in Table 4. To determine the approval authority based on threshold, the total cost for the hospitality needs to be calculated. These costs include, as applicable, meals and beverage costs, elements listed under subsection B.2.2.5 of the Treasury Board Directive and exceptional hospitality under subsection B.5.5 of this guide.

Notwithstanding the above hospitality approval thresholds, when a hospitality activity includes components under subsection B.2.2.6 of the Treasury Board Directive , ministerial approval is required unless delegated to the deputy head as per subsection B.2.2.6 of the Treasury Board Directive .

If food and beverages are provided as part of hospitality, the cost should not normally exceed the standard cost per person. Unless approval authority is delegated to the deputy head, the appropriate minister is the approval authority for exceptional circumstances where it is anticipated that the standard cost per person in subsection B.2.2.2.1 of the Treasury Board Directive will be exceeded.

When calculating the cost per person of food and beverage, departments should include all related costs, such as the service delivery charges, gratuities and applicable taxes.

An amended approval at the appropriate delegated authority level is required if there are significant changes to the originally approved nature or extent of hospitality before an activity. It is up to individual departments to define “significant” in the context of their organization. Departments are expected to monitor actual expenses against planned costs and to minimize variances.

Hospitality expenditures are to be coded under hospitality for reporting purposes (see subsection B.7 of this guide for more information).

B.4 Delegation of hospitality approval authority

Subsection B.2.2.6 of the Treasury Board Directive sets out the hospitality components where ministerial approval is required. Appropriate ministers may choose to delegate to the deputy head some or all the hospitality components listed in that subsection. The deputy head cannot sub-delegate the approval of these hospitality components.

B.5 Blanket hospitality authority

According to the Treasury Board Directive , blanket hospitality authority (BHA) is authorization for hospitality which is continuous or repetitive in nature and where it is not practical or administratively efficient to obtain prior approval for each individual hospitality occurrence.

BHAs cannot include any of the hospitality components that require ministerial approval in accordance with subsection B.2.2.6 of the Treasury Board Directive .

Subsection B.2.2.11 of the Treasury Board Directive provides the authority for the use of BHAs. Approval of BHAs depends on the components included in the BHA. Chief financial officers (CFOs) should ensure that the approval of BHAs is formally documented and reviewed at least once a year. A BHA cannot be carried over to the next fiscal year.

When obtaining approval for a BHA, the following information should be provided:

• the nature of hospitality that can be offered, ensuring that it excludes those hospitality components and any related limitations, listed in subsection B.2.2.6 of the Treasury Board Directive
• the estimated number of hospitality events during the fiscal year
• the estimated cost and the maximum cost of each hospitality event
• the types of possible participants (for example, public servants or non-public servants)
• the estimated number of participants for each hospitality event
• the period in the fiscal year when the BHA will apply

The approval authority level for a BHA is based on the estimated hospitality costs per hospitality activity, not the total amount of the BHA. The approval of BHAs depends on the departmental delegation chart of spending and financial authorities.

A new approval should be obtained if there are any substantive changes to the above information.

Costs covered under a BHA that are related to an event must be considered when calculating total event costs for event approval. To maximize efficiencies, hospitality and event approvals can be combined.

BHAs are considered a higher-risk business process, so departments must have proper controls and oversight in place. The controls over BHAs are part of the department’s system of internal controls over financial management.

B.6 Treatment of specific types of hospitality

B.6.1   private club membership.

Departments are not permitted to purchase memberships in private clubs, either in the name of the department or an individual. 

As per subsection B.2.2.13 of the Treasury Board Directive , a minister has the authority to approve on an exceptional basis the purchase of a membership in a private club. This authority can only be delegated to the deputy head.

Private club membership does not include membership in a professional body, for example, the Chartered Professional Accountants of Canada, the Canadian Medical Association or the Canadian Bar Association.

B.6.2 Situations where only public servants are present    

In situations where only public servants are present, hospitality should be provided only on an exceptional basis. Subsection B.2.2.3 of the Treasury Board Directive states that when only public servants are present, hospitality can only be provided in situations where participation is required in operational meetings, training or events that extend beyond normal working hours, including where there are no nearby or appropriate facilities to obtain refreshments or meals, or staff dispersal is not effective or efficient. “Beyond normal working hours” includes situations where public servants are required to work through normal break and meal periods.

B.6.3   Award and recognition ceremonies for public servants

Paragraph 12(1)(b) of the Financial Administration Act provides deputy heads with the authority to provide awards to employees. Hospitality provided as part of a related award and recognition ceremony to public servants should be provided only on an exceptional basis and should follow the hospitality approval process. Event approval is also required. The authority under paragraph 12(1)(b) of the Financial Administration Act does not provide authority for the reimbursement of expenses for companion travel (see subsection A.6.3 of this guide for information on approval of companion travel).

B.6.4   Situations where the department has no discretion in the provision of hospitality

Subsection B.2.2.4 of the Treasury Board Directive recognizes that in some circumstances, departments must provide meals to public servants. For example, when a collective agreement stipulates that meals must be provided to public servants in the course of their duties, no hospitality approval is required. In these circumstances, Appendix B of the Treasury Board Directive does not apply.

B.6.5   Exceptional hospitality

Approval from the appropriate minister is required for hospitality that is considered exceptional due to unusual circumstances and that is not covered under the ministerial approval authority in subsection B.2.2.6 of the Treasury Board Directive . Exceptional hospitality can be approved by the appropriate minister as long as it is deemed necessary for reasons of courtesy, diplomacy or protocol, or to facilitate the achievement of the business of the government in accordance with subsection B.2.2.1 of the Treasury Board Directive . Appropriate ministers may choose to delegate to the deputy head the approval of exceptional hospitality in accordance with subsection B.2.2.6 of the Treasury Board Directive . The deputy head cannot sub-delegate the approval of exceptional hospitality.

B.6.6   Situations where the individual who would normally approve hospitality also attends the event

Subsection B.2.2.9 of the Treasury Board Directive states that an appropriate alternative approval authority must be obtained when the individual who would normally approve the hospitality is also a participant at the hospitality event. Only ministers are exempted from this requirement. The alternative individual needs to have sufficient delegated approval authority.

Subsection B.2.2.10 of the Treasury Board Directive states that the CFO will be the approval authority for hospitality when the deputy head is in attendance at the event and where the deputy head would normally approve the hospitality. To avoid the perception that the deputy head is in conflict of interest, the CFO approves the hospitality up to the limits delegated to the deputy head, including when the CFO is also in attendance at the same hospitality event.

B.6.7 Coordination of approvals

To maximize efficiencies, if approval is required for an event and the event includes hospitality, then the event and hospitality should be approved together at the highest approval level.

For example, a department is organizing an event. The travel and other costs are low, but the food and beverage costs are above the standard cost per person in subsection B.2.2.2.1 of the Treasury Board Directive . Ministerial approval should therefore be sought for both hospitality and event expenditures, in accordance with subsection B.2.2.6.3 of the Treasury Board Directive .

Departments can determine how to coordinate event approvals. In cases where the CFO has approved hospitality because the deputy head is in attendance, the deputy head approves the event within the event approval authorities, as applicable.

B.7 Recording hospitality expenditures

Hospitality expenditures are recorded using economic object 0822 from the government-wide chart of accounts for Canada. Hospitality expenditures include elements listed under subsection B.2.2.5 of the Treasury Board Directive and exceptional hospitality under subsection B.5.5 of this guide.

In situations where public servants are required to attend an event organized by an external organization as official departmental representatives, any costs associated with such attendance (for example, tickets) should be recorded using economic object 0352 (public relations services) rather than economic object 0822 (hospitality). Attendance at such events must support departmental operational activities and be properly justified.

Appendix C: Conferences

C.1 conference definition.

According to the Treasury Board Directive on Travel, Hospitality, Conference and Event Expenditures (the Treasury Board Directive), conferences are events and refer to a congress, convention, seminar, symposium or other formal gathering, which are usually organized by a third party external to government, where participants debate or are informed of the status of a discipline (for example, sciences, economics, technology, management).

C.2 Conference planning

Departments should plan the necessary departmental staff attendance and identify any additional required event or travel approval for expected upcoming conferences.

C.3 Conference approval authority

According to subsection C.2.2.3 of the Treasury Board Directive , conference approval authority is at the senior departmental manager level. The elements of the guiding principles described in section 3 of this guide should be considered by the senior departmental manager before exercising approval authority.

C.4 Types of conferences

Figure 3 illustrates how the purpose for attending the conference determines the approval authority required.

This figure provides an overview of conference approval authority. It explains how the purpose for attending the conference determines the approval authority required.

If the purpose for attending the conference is to gain information on a product or service, conference approval and event approval are required.

If the purpose for attending the conference is to increase awareness of specific issues or to receive updates on a discipline unrelated to daily tasks, conference approval and event approval are required.

If the purpose for attending the conference is to promote a departmental service or program, attendance is considered an operational activity; therefore event approval is not required.

If the purpose for attending the conference is to engage with stakeholders, attendance is considered an operational activity; therefore event approval is not required.

If the purpose for attending the conference is to support learning and professional development, see subsection D.3.2.1.

C.4.1 Conference attendance to share information

Attendance at a conference to share recent developments on a product or service provided by a private organization or to increase awareness of a certain subject requires conference and event approval. For example, a conference that an employee attends to gather information on a product (such as a trade show) that the department is considering purchasing requires conference and event approval.

Attendance at a conference that is not necessary for the department to achieve its objectives requires conference and event approval. For example, a conference that an employee attends to increase his or her awareness of specific issues or to receive updates on a discipline unrelated to his or her daily tasks requires conference and event approval.

C.4.2 Conference attendance in support of departmental programs

There may be situations where attendance at a conference is required to help deliver the department’s programs or services, such as promoting a departmental program or service or engaging with stakeholders. In these situations, the attendance at the conference may be considered an operational activity; therefore, conference and event approval is not required. For example:

• a conference where an employee delivers a presentation or discusses with stakeholders the design of a departmental program could be considered an operational activity
• a student conference where human resources employees responsible for recruitment work at an information booth to promote careers in the Government of Canada could be considered an operational activity

C.4.3 Conference attendance in support of learning and professional development

Attendance at a large information-sharing or learning session for the purpose of learning or professional development (for example, fees for employees to participate in a large learning session to help them maintain or acquire skills or knowledge they need to perform their duties) may be considered training by the government-wide functional community leads. See subsection D.3.2.1 of this guide for more information.

C.5 Reporting of travel expenses related to conference attendance

Conference expenditures are to be recorded using object 0823 of the government-wide chart of accounts for Canada. See subsection G.3.3 of this guide for more information.

Travel costs for attendees of a conference should be recorded using the appropriate category of travel. The categories are listed in subsection A.7.3 of this guide.

Appendix D: Events

D.1 introduction.

According to the Treasury Board Directive on Travel, Hospitality, Conference and Event Expenditures (the Treasury Board Directive), events involve gatherings of individuals (both public and non-public servants) engaged in activities other than operational activities of the department. Examples of events include, but are not limited to:

• management and staff retreats
• participation in conferences
• award and recognition ceremonies
• departmental celebrations

D.2 Event planning

To maximize efficiencies, approvals for travel, hospitality, conferences and events should be coordinated and submitted to the most senior approval authority. For example, coordinating approval of an event and a conference requires approval at no lower than the senior departmental manager level, because conference attendance must be approved at this level.

D.3 Determining whether event approval is required

Event approval is not required for operational activities (see subsection D.3.1 of this guide) or training (see subsection D.3.2 of this guide). For guidance on whether an event or a class of events requires event approval, delegated managers should contact their departmental financial policy group.

D.3.1 Operational activities

Operational activities do not require event approval. The Treasury Board Directive defines operational activities as those activities undertaken to deliver departmental programs and services, including departmental internal services. For individuals, operational activities are those activities undertaken in the performance of their assigned tasks, as set out in position descriptions, terms of reference, statements of work, or other similar documents. Any gathering of individuals whose purpose is not to conduct operational activities is to be defined as an “event.”

The chief financial officer (CFO) should ensure that the department has a process in place to support individuals who have delegated approval authority in making the distinction between operational activities and events.

The CFO is encouraged to confirm with the deputy head the desired treatment of certain approvals, including where discretion may be applied. Factors such as public perception, nature, scale or significance of an event, and ministerial expectations may all affect the determination of whether an activity should be classified as an operational activity or an event.

Figure 4 provides examples to illustrate when an activity could be considered an operational activity or an event.

This figure provides examples of operational and non-operational activities and whether event approval is required.

D.3.2 Training

Training activities are not considered events. They should be approved according to the established departmental processes for training, such as the delegated spending and financial authorities or the delegation of human resources authorities. They should also form part of an individual’s annual training plan, as described in subsection D.2.2.2 of the Treasury Board Directive .

D.3.2.1 Conference versus training: large information-sharing or learning sessions

What are large information-sharing or learning sessions.

Large information-sharing or learning sessions are conferences that may support an individual’s learning and professional development or provide information on the status of a subject. These sessions have a large number of participants and may include participants from the public sector and private sector. These sessions do not include traditional forms of training, such as courses offered by the Canada School of Public Service, a university or other post-secondary institutions. Each large information-sharing or learning session is to be assessed on a case-by-case basis to determine whether it is to be considered as a conference or as training for approval purposes.

What is the role of government-wide functional community leads?

The government-wide functional community leads at the Treasury Board of Canada Secretariat (as described in Table 5) will objectively determine, on a case-by-case basis, whether large information-sharing or learning sessions are to be considered conferences or training.

For example, the Comptroller General of Canada will make decisions on the treatment of large information-sharing or learning sessions for the financial management function. The financial management function could include several occupational groups, for example, Financial Management (FI) and Administrative Services (AS) involved in the financial management function.

How do government-wide functional community leads communicate decisions about the designation of a large information-sharing or learning session?

When the government-wide functional community lead has made a decision about the designation of a large information-sharing or learning session, the information will be posted on the GCpedia page (accessible only on the Government of Canada network).

CFOs and departmental heads of human resources are responsible for regularly reviewing the GCpedia page (accessible only on the Government of Canada network) to ensure that the appropriate approvals for the large information-sharing or learning sessions are obtained for their departmental staff.

What if there is no government-wide functional community lead?

If there is no government-wide functional community lead, the deputy head will decide how large information-sharing or learning sessions will be treated for their staff. It is recommended that departments maintain a list of conferences for which an internal decision has been made and make it available within their department.

What approvals are required?

If the large information-sharing or learning session is designated as a conference , then conference approval and event approval are required.

If the large information-sharing or learning session is designated as training , then conference approval and event approval are not required.

• Training approval is to be obtained through the established departmental processes as described in subsection D.3.2 of this guide.
• Ideally before the conference, the CFO should provide the deputy head with a report for information purposes (not for approval) on the total departmental costs and number of participants when the total cost of the conference (including associated costs, such as travel) exceeds $50,000.

Figure 5 shows the process to determine which approval is required for a large information-sharing or learning session.

This figure provides an overview of the approval process for large information-sharing or learning sessions. It illustrates the difference in the process for decisions made by the government-wide functional community lead and the deputy head (when there is no government-wide functional community lead).

Approvals process when there is a government-wide functional community lead

If the government-wide functional community lead has designated a large information-sharing or learning session as training, training approval is required.

If the government-wide functional community lead has not yet designated a session as training or a conference, he or she is asked to make a decision. If the government-wide functional community lead decides that the large information-sharing or learning session is training, training approval is required. If the functional community lead decides that the session is a conference, conference approval and event approval are required.

Approvals process when there is no government-wide functional community lead

If there is no government-wide functional community lead, the departmental process should be followed; for example, consulting a list of sessions that the deputy head has designated as training or conferences. If the deputy head decides to designate a session as training, training approval is required. If the deputy head decides to designate a session as a conference, conference approval and event approval are required.

D.3.3 Recording of large information-sharing or learning session expenses

To ensure consistent government-wide coding, all travel expenses incurred to attend a large information-sharing or learning session should be coded to the appropriate economic object code, as described in Table 3 of Appendix A of this guide.

If a large information-sharing or learning session is designated as a conference , then the expenses should be recorded using economic object 0823.

If a large information-sharing or learning session is designated as training , then the expenses should be recorded using economic object 0447.

D.3.4 Summary of when event approval authority is required for training, conferences and events

Table 6 shows the distinction between training, conferences and events and outlines when event approval is required.

D.4 Determining and monitoring event expenditures

To determine the approval required in accordance with the event approval thresholds in Table 7, the total cost for the event needs to be calculated.

The calculation of the total departmental costs for a single event should include the following:

• conferences fees
• professional services charges
• hospitality
• accommodation
• transportation
• meals while travelling
• taxes, gratuities and service charges
• costs incurred by the appropriate minister or the appropriate minister’s staff for activities related to a department’s programs that are charged to the department’s budget
• other relevant costs directly attributable to the event

These costs exclude salary costs and other departmental fixed operating costs that are part of the department’s ongoing operations.

When upfront costs for a major event are being paid by a department but the reimbursement of some costs will be sought from other departments or external participants, the event approval authority will be determined in accordance with the total costs of the event before any reimbursement. The planned reimbursements should, however, be disclosed to the event approval authority.

According to subsection D.2.2.4 of the Treasury Board Directive , the CFO must ensure that the appropriate minister is provided with the total estimated federal cost for all participating departments, including the total estimated travel costs, for information purposes, when their approval is required for an event hosted by the department. Each department participating in the event must obtain its own travel and event approvals, as appropriate.

Departments are expected to monitor actual event costs against planned event costs to minimize cost increases. An updated approval should be obtained if there is a significant increase in costs for an upcoming event.

Appendix E: Approvals and planning for taxes

To determine the level of approval authority for travel, hospitality, conferences and events, the Goods and Services Tax / Harmonized Sales Tax (GST/HST) and the Quebec Sales Tax (QST) should be included in the total for planning and approval purposes. For the recording of the GST/HST and QST incurred for actual expenses, departments should charge these taxes to the GST/HST Refundable Advance Account or the QST Refundable Advance Account, respectively.

In general, provincial sales tax (PST), except for QST, is not payable on federal government purchases. However, if employees use personal funds or their individual designated travel card to pay for items such as meals, taxis, vehicle rentals and hotel accommodations, which will then be reimbursed to the employee, PST will be charged and, therefore, should be included in the total for planning and approval purposes. For the recording of the PST paid as part of reimbursements to employees, departments should charge these amounts to the departmental operating vote.

Appendix F: Transparency of travel, hospitality and conference expenditures

F.1 proactive publication of travel and hospitality expenses.

As per the Access to Information Act , heads of government institutions are responsible for the proactive publication of travel and hospitality expenses of senior officers or employees. Institutions can refer to the Guide to the Proactive Publication of Travel and Hospitality Expenses for guidance on the proactive publication of travel and hospitality expenses.

F.2 Disclosure of travel receipts

Receipts supporting travel claims of senior officers or employees may be disclosed, with appropriate redactions to protect personal information, when they are requested under the Access to Information Act .

F.3 Reporting annual travel, hospitality and conference expenditures

Departments must annually disclose their total travel, hospitality and conference expenditures, in accordance with subsection 4.1.2 of the Treasury Board Directive. Total travel expenditures must be reported by travel categories, in accordance with subsection A.2.2.14 of the Treasury Board Directive and explanations be provided for main variances from the previous year per travel categories. See appendices G to I of this guide for additional information.

Appendix G: Template and guidance for annual report on travel, hospitality and conference expenditures

G.1 introduction.

This template and guidance are issued to support chief financial officers (CFOs) in planning and preparing their department’s annual report on travel, hospitality and conference (THC) expenditures. This report does not include event expenditures. The following sections outline the expected content and format of the report. Compliance with this template and guidance will ensure consistency and minimize effort across government in reporting to the public on THC expenditures.

Subsection 4.1.2 of the Treasury Board Directive on Travel, Hospitality, Conference and Event Expenditures (the Treasury Board Directive) requires that departments disclose the total annual expenditures for each of travel, hospitality and conference fees. They must also indicate the main variances from the previous year’s actual expenditures. This disclosure is to coincide with the tabling of the Departmental Results Report.

Departments should post their annual report on THC expenditures on the Government of Canada website open.canada.ca for centralized access.

G.2 Content of the Annual Report on Travel, Hospitality and Conference Expenditures

The objective of the annual report on THC expenditures is to provide the following:

• the department’s total annual expenditures for each of travel, hospitality and conferences
• information on how the expenditures were incurred in respect of the department’s mandate and business objectives
• a brief explanation of significant variances in expenditures from the previous year, except in the case of the first annual report for new departments (see Appendix H of this guide)

In previous years, annual reports on THC expenditures reported on travel expenditures based on whether the travel was by public servants or by non-public servants. In accordance with subsection A.2.2.14 of the Treasury Board Directive , departments must provide the total expenditures for public servants and non-public servants for each travel category, starting for the 2017–18 fiscal year.

Comparative information must be provided for each travel category, and variance explanations must be provided for variances from the previous year’s total travel expenditures. Departments do not have to restate their travel expenditures for the year ended March 31, 2017, by travel category. See Appendices H and I of this guide for reporting templates.

Departments will also provide the total international travel expenditures for their minister and minister’s staff when those expenditures are charged to their departmental budget as part of a departmental program (where applicable).These expenditures are included in the expenditures for specific travel categories and are reported separately under international travel by minister and minister’s staff. See the Policy for Ministers’ Offices for guidance on travel expenditures for ministers and minister’s staff.

New departments will not provide data for the previous year. Comparison with the previous year and related variance explanations will commence only with a new department’s second annual report. Departments that have undergone major organizational changes should contact the Office of the Comptroller General for specific guidance on reporting.

Appendices H and I of this guide provide templates for the first annual report and for the second and subsequent annual reports on THC expenditures, respectively.

G.3 Categories of expenditures

G.3.1 travel.

Travel expenditures include the following expenses of public servants and non-public servants, including when a travel agency invoices a department for the following expenses:

• transportation of people by air, rail, sea, bus, taxi, air taxi and tolls
• meals, incidentals and accommodation services such as hotels, motels, corporate residences, apartments, private non-commercial accommodation, and government and institutional accommodation

Travel expenditures are to be recorded using the five categories of travel listed in Table 3 of Appendix A of this guide.

G.3.2 Hospitality expenditures

Hospitality expenditures refer to amounts paid for the provision of hospitality to individuals under the Treasury Board Directive and hospitality governed by other authorities such as Global Affairs Canada’s Official Hospitality Outside Canada policy and the Heads of Post and Foreign Service Official Hospitality directives. Hospitality expenditures are to be recorded using object 0822 of the government-wide chart of accounts for Canada .

G.3.3 Conference expenditures

Conference expenditures refer to fees paid to attend a conference, congress, convention, briefing seminar or other formal gathering in one location where participants debate or are informed of the status of a discipline (for example, science, economics, technology or management).

Conference expenditures do not include amounts paid for the following:

• attending an event for the primary purpose of acquiring training to maintain or acquire skills or knowledge (object 0447)
• travelling to attend a conference (objects 0251 to 0265)
• hosting a conference (for example, facility rental, hospitality, equipment rental)
• attending retreats and work-planning meetings

Conference expenditures are to be recorded using object 0823 of the government-wide chart of accounts for Canada.

Appendix H: Template for first annual report (new department)

Annual report on travel, hospitality and conference expenditures, [name of department].

[This template provides generic text that should be included in the report.]

As required by the Treasury Board Directive on Travel, Hospitality, Conference and Event Expenditures , this report provides information on travel, hospitality and conference expenditures for [name of department] for the fiscal year ended March 31, YYYY.

Travel, hospitality and conference expenditures incurred by a federal department or agency relate to activities that support the department or agency’s mandate and the government’s priorities.

[Name of department]’s travel, hospitality and conference expenditures support the delivery of the following core programs and services to Canadians:

• [describe, in a few sentences, the department’s mandate, major programs and linkages with core laws or regulations to help readers understand the travel, hospitality and conference expenditures incurred by the department and how they support the department’s mandate.]
• [to avoid duplication of information, include hyperlinks to sections of the department’s Departmental Plan, Departmental Results Report, or other sources of relevant public information]

Travel, Hospitality and Conference Expenditures

Year ended march 31, yyyy.

Note [if applicable]: This is a [new/reorganized] department; therefore, no comparison with the previous year is provided.

Appendix I: Template for second and subsequent annual reports

• [describe, in a few sentences, the department’s mandate, major programs and linkages with core laws or regulations to help readers understand the travel, hospitality and conference expenditures incurred by the department and how they support the department’s mandate]
• [to avoid duplication of information, include hyperlinks to sections of the department’s Departmental Plan, Departmental Results Report or other sources of relevant public information]
• [mention significant structural or program changes (for example, new programs or initiatives, increased program budgets, mergers with other departments, or sunsetting of programs) if there is a direct relationship to variances from the previous year’s expenditures]

Significant variances compared with previous fiscal year

[Where applicable, briefly explain significant variances from the previous year’s expenditures for each category.]

Travel: compared with fiscal year YYYY–YY, departmental travel expenditures for [specify the expenditure category] [increased/decreased] mainly due to [briefly explain the main reason(s) for the increase or decrease].

Hospitality: compared with fiscal year YYYY–YY, departmental hospitality expenditures [increased/decreased] mainly due to [briefly explain the main reason(s) for the increase or decrease].

Conference fees: compared with fiscal year YYYY–YY, departmental conference fee expenditures [increased/decreased] mainly due to [briefly explain the main reason(s) for the increase or decrease].

Minister and minister’s exempt staff: compared with fiscal year YYYY–YY, departmental expenditures for international travel by the Minister and the Minister’s exempt staff [increased/decreased] mainly due to [briefly explain the main reason(s) for the increase or decrease].

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Tuberculosis and Air Travel: Guidelines for Prevention and Control. 3rd edition. Geneva: World Health Organization; 2008.

Tuberculosis and Air Travel: Guidelines for Prevention and Control. 3rd edition.

10 recommendations.

While the following recommendations are provided for guidance and are not legally binding upon States, it is important to note that depending on the particular national context, the same subjects or issues may also be covered by national or international laws or regulations which are legally binding.

In addition, these recommendations should be distinguished from official “temporary recommendations” during a public health emergency of international concern or “standing recommendations” for routine application which may be issued under the International Health Regulations (2005) as noted in Annex 1 . Such IHR recommendations have particular legal consequences as indicated in the Regulations, and are adopted and issued according to specified procedures.

• For travellers

People with infectious or potentially infectious TB should postpone all travel by commercial air transportation 1 of any flight duration until they become non-infectious.

• For physicians

Physicians should inform all infectious and potentially infectious TB patients that they must not travel by air on any commercial flight of any duration until they are sputum smear-negative on at least two occasions (additional steps are required for MDR-TB and XDR-TB, see recommendation 3).

Physicians should inform all MDR-TB and XDR-TB patients that they must not travel by any commercial flight – under any circumstances or on a flight of any duration – until they are proven to be non-infectious (i.e. two consecutive negative sputum-culture results).

Physicians should immediately inform the relevant public health authority when they are aware that an infectious or potentially infectious TB patient intends to travel against medical advice.

Physicians should immediately inform the relevant public health authority when they are aware that an infectious or potentially infectious TB patient may have exceptional circumstances requiring commercial air travel.

Post-travel

Physicians should immediately inform the public health authority when an infectious or potentially infectious TB patient has a history of commercial air travel within the previous three months.

• For public health authorities (see also requirements under the IHR)

Public health authorities aware that a person with infectious or potentially infectious TB is planning to travel via a commercial air carrier should inform the concerned airline and request that boarding be denied.

If an infectious or potentially infectious TB patient has exceptional circumstances that may require commercial air travel, public health authorities should ensure that the airline(s) involved and the national public health authorities at departure, arrival and any transit points have approved the commercial air travel and the procedures for travel.

The public health authority (see section 6.1 ) should promptly contact the airline when an infectious or potentially infectious TB patient is known to have travelled on a commercial flight that may have been of 8 hours duration or longer within the preceding three months in order to obtain the information required for the initial risk assessment (i.e. confirm that the passenger was on the flight and the total flight duration).

The public health authority of the country of diagnosis should carry out a risk assessment based on the specific conditions of the case. If the index case is considered to be infectious or potentially infectious, the public health authorities of all countries involved should be informed (i.e. all countries where the flight(s) departed and landed).

If a contact investigation involves more than one country, national public health authorities of the involved countries should agree on their respective roles and responsibilities (including who will request the passenger manifests from airlines). International bodies such as WHO, the EC, ECDC or others may provide assistance if requested.

The national public health authority that obtained the passenger information from the airline should contact counterpart public health authorities in the appropriate countries and provide them with the relevant information on the source case and the available contact information of all travellers identified as potentially exposed (i.e. those passengers seated in the same row and in the two rows in front of and behind the index case) in their jurisdiction. (See chapter 7 on legal confidentiality and permitted dissemination of such information.)

Public health authorities may follow national policies and guidelines regarding TB contact investigation involving potentially exposed travellers in their jurisdiction (see also Annex 3 for a suggested approach), in accordance with requirements under the IHR.

Public health authorities should be in communication with their national IHR focal point concerning any event that may involve the IHR, including events for which international contact-tracing may be initiated, for assessment of any action that may be required under the IHR and support in facilitating communication.

National and international public health authorities are encouraged to collaborate on a TB and air travel research agenda.

• For airline companies

Airline companies should deny boarding to any person who is known to have infectious or potentially infectious TB as informed by the relevant public health authority.

Airline companies should, in the case of ground delays that last for 30 minutes or longer with passengers on board, ensure that the ventilation system is in operation.

Airline companies should ensure that all their aircraft which recirculate the cabin air are fitted with a filtration system. New aircraft should be fitted with 99.97% efficiency HEPA filters, or an alternative of at least this level of efficiency. The filtration system should be maintained in accordance with the recommendations of the filter manufacturer.

Airline companies should ensure that cabin crew receive adequate training on potential exposure to communicable diseases, in first aid, and in applying universal precautions when there may be exposure to body fluids.

Airline companies should ensure that there are adequate emergency medical supplies aboard all aircraft (including gloves, surgical masks, biohazard disposal bags and disinfectant).

Airline companies should cooperate with national public health authorities in providing as quickly as possible all available contact information requested for contact-tracing of travellers, in accordance with applicable legal requirements including the IHR (see Annex 1 ).

Excluding specially-designated aircraft – air ambulance.

All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: tni.ohw@sredrokoob ). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: tni.ohw@snoissimrep ).

• Cite this Page Tuberculosis and Air Travel: Guidelines for Prevention and Control. 3rd edition. Geneva: World Health Organization; 2008. 10, Recommendations.
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Tuberculosis (TB)

What is tuberculosis, who is at risk, what can travelers do to prevent tuberculosis, after travel, more information.

Tuberculosis (TB) is a disease caused by bacteria called Mycobacterium tuberculosis . People with TB can spread it in the air to others when they cough, speak, or sing. You can get sick when you breathe TB bacteria into your lungs. TB bacteria in the lungs can move through the blood to infect other parts of the body, such as the kidney, spine, and brain.

Symptoms of TB disease in the lungs include

• Cough that lasts 3 weeks or longer
• Pain in the chest
• Coughing up blood or mucus
• Weakness or fatigue
• Weight loss
• Loss of appetite
• Sweating at night

Symptoms of TB infection in other parts of the body depend on the area affected.

Not everyone infected with TB bacteria becomes sick or has symptoms. This is called latent TB infection . People with latent TB infection cannot spread TB to others. However, a person with latent TB infection can get sick years later if their immune system becomes weak. People with latent TB infection can take medicine to prevent developing TB Disease.

Where are you going?

TB occurs throughout the world but is much more common in some countries. Most TB occurs in sub-Saharan Africa, Eastern Europe, and Asia. Some TB bacteria are resistant to the drugs used to treat infection ( drug-resistant TB ). Fortunately, drug-resistant TB is rare.

Travelers planning to work in health care settings should consult infection control or occupational health experts in the country before seeing patients.

People with weak immune systems, especially those with HIV infection, are much more likely to develop TB disease compared to people with healthy immune systems.

A traveler’s chances of getting TB on a plane are very low.

Travelers can protect themselves by taking the following steps

• Avoid being close to or around a person who could have TB for long periods of time . This is especially important for travelers spending time in crowded environments, like clinics, hospitals, prisons, or homeless shelters.
• Avoid close contact with people who are coughing and who look sick .
• Take special precautions around people known to have TB. Travelers spending time working in health care settings should talk to an infection control or occupational health expert about what steps they can take to prevent TB infection, such as wearing an N95 respirator. They should also talk to a doctor about being tested for TB infection before leaving the United States. If the test reaction is negative, have a repeat TB test 8 to 10 weeks after returning to the United States

A TB vaccine exists, but CDC does not recommend it for travelers.

If you traveled and feel sick, particularly if you have a fever, talk to a healthcare provider and tell them about any areas you recently traveled to. 

If you need medical care abroad, see Getting Health Care During Travel .

• Tuberculosis Information for International Travelers
• Basic TB Facts
• CDC Yellow Book: Tuberculosis

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Special Travel Authorities

Table of contents, 1. ministers, 2. members of parliament, 3. exempt staff, 4. heads of departments and agencies, 5. deputy ministers and gics (gc 8-11 and gcq 8-11), 6.1 general, 6.3 incidentals, 6.4 taxis and parking, 6.6 calls home, 6.7 business class air, 7.1 identify travel costs in contract, 7.2 amounts payable, 7.3 no fees paid, 7.4 air fares, 7.5 private motor vehicles, 7.6 crown-owned vehicles, 7.7 insurance, 7.8 booking air and hotels, 7.9 reimbursement of costs, 7.10 travel advances, 7.11 business and pleasure, 7.12 treasury board approval, 8. students.

• Ministers are excluded from the requirement to follow the terms of the Travel Directive . In a letter from the President of the Treasury Board to his colleagues dated March 17, 1992 , ministers were reminded to use government travel services when booking air travel related to departmental business when pre-paid tickets are needed. Ministers may book directly with carriers, or travel agents, and claim reimbursement following a trip, as long as the department is not billed directly by travel suppliers.
• In the February 25, 1992 Budget, ministers as well as deputy heads and public servants, were directed to refrain from using first class air travel, other than in special circumstances, as highlighted in a letter from the President to his colleagues in May 1992.
• the period covered by the trip and the places visited;
• transportation expenses; and
• other expenses (such as, accommodation and meals).

This statement of expenses may be submitted on a monthly rather than a per-trip basis and must include the following certification, pursuant to Section 34 of the Financial Administration Act :

"I certify that the foregoing expenditures have been incurred by me on official government business." (Minister's signature.)

• The aforementioned 1963 letter also specifies that where requested advances are greater than the actual costs incurred, the difference should be remitted to the department in the form of cash or a personal cheque, made payable to the Receiver General for Canada.

When Members of Parliament other than Cabinet ministers travel on behalf of government departments, their travel expenses shall be governed by the Travel Directive . However, such travel is subject to trip approval by Governor-in-Council of an Order-in-Council submitted to the Privy Council Office in accordance with section 33.1(1)(c) of the Parliament of Canada Act .

When a minister requires exempt staff to travel on departmental business, their expenses are reimbursed in accordance with the Travel Directive. Travel expenditures are chargeable to the minister's operating budget. They should be authorized by the minister or the chief of staff and reviewed by a senior financial officer. The chief of staff's own travel should be authorized by the minister or the minister's senior delegate for financial matters. When exempt staff accompany the minister, the appropriate signature is necessary to upgrade travel to business class, in the event that the minister does not personally sign the travel authority.

Note: Exempt staff equivalent to EX-02 and above travelling on departmental business have the same travel entitlements as the Executive Group, EX-02 and above stipulated in the Special Travel Authorities.

Heads of departments and agencies have discretion over commercial accommodation selected, telephone calls, meals and incidentals in excess of the per diems, based on receipts. Meal expenses should not include alcohol. Costs associated with guests are governed by the TB Hospitality Policy and should be reported as such.

This discretion should be exercised with prudence and probity, mindful that all expenditures must further government objectives. Although specific circumstances may warrant exceptional expenses, the basic norm should be comfortable and convenient, but not excessive. A benchmark may be found in the provisions of the Treasury Board Travel Directive. Deputy ministers and heads of agencies are accountable and must be prepared to justify their expenses in keeping with the responsibility of public office holders to conduct themselves in a manner that can bear the closest public scrutiny.

By Order-In-Council (number P.C. 1997-1810), the government directed that organizations with their own travel authorities, and GICs appointed to such organizations, should also be guided by the above principles. Such organizations are accountable to justify their policies and their heads to justify their personal expenses.

Deputy ministers (1-4) and GC (8-11) and GCQs (8-11) may use business class travel at their discretion but must book through the government travel service. (First class travel was eliminated by Cabinet direction in 1992).

6. Executive Group

• GX, LA-2, Sub-level B; LA-3, Sub-levels A, B and C; MD-MOF-4 and 5 exclusions; MD-MSP-3; PM-MCO-4; DS-7A, 7B and 8 exclusions; and
• Governor-in-Council Appointees whose terms of travel are not otherwise specified on appointment.
• The above-mentioned groups are subject to the terms and conditions of the Travel Directive . In addition, during normal business trips away from the vicinity of the headquarters area (excluding weekends home, extended travel, relocations and expenses related to guests, which automatically fall under hospitality), the following flexibility apply.
• Claims may include the daily meal allowances or actual and reasonable meal expenses based on receipts. When actual expenses are claimed for a given meal (based on receipts), meal allowances are applicable to other meals purchased that day (and no receipts are required).
• Actual meal expenses shall not include alcohol, costs associated with guests or co-workers, or the additional cost of room service, which is to be identified by the claimant. Employees must submit the actual bill for their own meal, rather than claim a bill that covers a number of people, except under the Hospitality Policy .
• The incidental allowance covers such items as laundry, dry cleaning, gratuities, a daily newspaper, luggage depreciation over the duration of a trip, even though a particular expense may be higher on a given day.
• Whenever actual and reasonable expenses are claimed, the Travel Expense Claim must include a brief statement describing why the meal or incidental allowances were inadequate under the specific circumstances.
• The incidental allowance is cumulative. For example, with respect to laundry and dry cleaning costs, even though such expenses are unlikely to occur before day three, the allowance is provided on a daily basis so that when a dry cleaning expense is incurred, the employee has the necessary funds to cover the cost.
• Actual incidental costs may be claimed in unusual circumstances. However, if one decides to claim actual incidental costs instead of the pre-determined incidental allowance, then all incidental expenses reimbursements incurred on that trip will be on the basis of receipts.
• It is recommended that the claims of employees who qualify under the Executive Group be flagged for easy retrieval should the Treasury Board Secretariat request an internal audit.

On overnight business trips away from the vicinity of the headquarters area, actual expenses may be claimed for taxis and parking, based on the honour system (without receipts). Receipts may be submitted if preferred.

The Accommodation and Car Rental Directory no longer lists properties on white or green pages. Accommodations are now listed by the equivalent, as within the city rate limit or above the city rate limit. As a result of changes from the Budget of February 25, 1992 , accommodation above the city limit rate must be justified on the travel claim. Selection of such properties should be because it is cost-effective or because exceptional circumstances warrant.

• For travel in Canada and continental USA, home communication is included in the new revised incidental expense allowance.
• For international travel, the regular telephone provisions of the Travel Directive apply when inter-city authorization codes are not provided or cannot be used because cities are not linked to this network, as is often the case for overseas travel.
• When inter-city authorization codes are provided and may be used, executives should use them and not separately claim the cost of telephone calls home. Executives are asked to exercise discretion in their use of this facility as to the frequency and duration of calls home.
• The February 25, 1992 Budget specified that Deputy Heads will manage a reduction in the use of business class travel. The reduction refers to air travel outside the terms of article 3.4.11 of the Travel Directive which is covered by a collective agreement. It includes travel by the Executive Group, Governor-in-Council appointees, and other situations where business class could be individually authorized.
• The Treasury Board authorized the use of business class air travel for trips of 850 air kilometres or more one way by the following groups and levels, and above:
• outside the NCR: EX-1, LA-2A, PM-MCO 4, GC3 and CGQ3,;
• in the National Capital Region: by EX-2, GX, LA-2B, excluded MD-MOF-4, MD-MSP-3, DS-7A, GC4 and GCQ4 as well as to equivalent senior RCMP and military personnel.
• first class travel was eliminated by Cabinet direction on February 25, 1992 ;
• upgrades to business class do not apply for relocations and weekend travel home (when returning to the duty travel location immediately following the weekend);
• where business or executive class is unavailable, economy (or reduced) fares are to be used. This authority does not provide for the reimbursement of first class air travel;
• this authority does not entitle persons accompanying the above to upgrade their fare at the employer's cost.

7. Persons on contract

The authority to enter into a contract with persons outside the Public Service is contained in the Contracting Policy . The rates and allowances to be reimbursed for government business travel are stipulated in Appendices B, C and D of the Travel Directive . Travel expenses must be treated as an amount payable under the contract for services rendered. All travel expenses payable should be specified and the costs should be included as part of the overall cost of the contract. Only original receipts will be accepted from contractors; photocopies of hotel bills, air tickets, etc. are not claimable.

Where a contract specifies that "travel is in accordance with the Travel Directive ", it refers strictly to the negotiated meal, private vehicle and incidental allowances specified in Appendices B, C and D, and to those policy provisions referring to "travellers" rather than those referring to "employees". It is a department's responsibility to inform contractors (and those bidding on contracts) of the current government rates and allowances.

A contract may be entered into where the only consideration for services rendered is payment of all or part of the travelling expenses incurred, and there are no fees paid. This could include volunteers and private sector experts. Where the contract is a verbal agreement between the parties concerned, officers with payment authority should obtain a memorandum from the contracting authority outlining the agreed-upon terms of the engagement and the applicable travel provisions.

In an effort to contain costs, the department will reimburse consultants for fares up to full-fare economy only. Contractors are required to seek the lowest possible airfares, including charters and other discounts for each trip, and to book immediately upon contract approval, in order to take advantage of the lowest fares. The employing department retains the right to limit the reimbursement of the air portion when the lowest appropriate fare is not obtained. Upgrades to business or first class may be personally paid by the contractor or private sector company, where this is company policy.

Contractors who use a private motor vehicle are entirely responsible for the management and underwriting of risk pertaining to the operation of the vehicle. Insurance premiums are paid by the contractor and are not reimbursed other than through the payment of the kilometric allowance (Appendix B of the Travel Directive ). This mode of travel, once parking and time-billed are included, is only permitted when cost-effective in relation to commercial transportation.

Crown-owned vehicles should not be driven by contractors or other people travelling on government business. If they are authorized by a department, it is with the knowledge that the Crown self-insures for vehicles and that insurance protection is not provided for either the driver or vehicle.

Individuals other than public servants who travel as passengers in government-owned vehicles are not covered by the Crown for any type of insurance purposes. Certain insurance benefits are part of employees' compensation package, but it is the financial responsibility of contractors to cover the cost of insurance, such as, for cars/accidents/sickness/airline travel and immunizations.

Reservations for transportation and accommodation will, where determined to be practical by the department concerned, be arranged through the department in order to qualify for reduced rates. In cases, where they are not, hotel management is not obligated to provide government preferred rates to government contractors, although it may elect to do so. Contractors are expected to use moderately priced hotels, and they risk partial reimbursement of actual costs should claims be for unreasonably high-priced accommodation or transportation. Should a contractor stay with friends or relatives, the private non-commercial accommodation rate is reimbursed. When a department makes the travel arrangements, the transportation expenses must be booked through the government travel services.

Contractors, when so advised, are permitted to make their own travel arrangements. Arrangements may be made through private travel agents or directly with suppliers. In such cases the contractor is expected to pay for all travel and related living expenses personally and subsequently invoice the department for reimbursement. Departments shall not pay the suppliers of travel and related services (hotel, air, etc.) directly, but will reimburse the contractor for appropriate costs incurred. Such expenses as telephone calls home, child care and weekend travel home are not paid to contractors (persons other than employees).

Contractors are not supposed to be provided with a travel advance as this is one of their normal business expenses. Advances could imply an employer-employee relationship. Contractors are expected to fund their own travel expenses and bill the department following the trip, within the terms of the appropriate travel provisions and the level of travel funds authorized within the terms of the contract. The cost of self-funding travel is to be covered within the administrative overhead of the contract and/or per diem payment. Departments can approve a limited advance, only in highly exceptional circumstances where the contractor is in the unusual situation of being unable to finance the trip, for example, to a university professor. Departments are advised that it would be difficult to recover an advance from an individual or company in the event of financial difficulties.

When contractors combine government business travel with either personal or business travel for other clients, or other departments, the travel expenses must be appropriately apportioned. Additional travel costs pertaining to indirect routings and stopovers, or extensions at work location(s) will be paid by the contractor.

Treasury Board approval is not required for a given contract unless the total amount payable under the service contract is greater than the financial limitations established by the Contracting Policy .

The travel allowance for persons engaged under one of the student employment programs are published in the Terms and Conditions of Employment for Students .

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Tuberculosis and Air Travel: Guidelines for Prevention and Control, Second Edition

The revised guidelines address the concerns about transmission of TB during air travel and provide the following: (i) information on transmission of TB on aircraft; (ii) a summary of the practices adopted for the management of patients with infectious TB associated with air travel, and of commonly encountered diffi culties; (iii) suggestions on practical ways to reduce the risk of exposure to M. tuberculosis on board commercial aircraft, and (iv) guidance on procedures to follow and responsibilities when infectious TB is diagnosed in a patient who has a history of recent air travel, including contact tracing, notifying and screening for possible interventions. It also introduces the revised International Health Regulations, adopted by the World Health Assembly in May 2005, which will enter into force in June 2007, establishing basic rules for international coordination in the detection, investigation, and response to public health risks including the area of communication and information sharing. The guidelines are applicable to all domestic and international airlines worldwide.

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Country policy and information note: medical and healthcare issues, Iraq, August 2024 (accessible)

Updated 27 August 2024

© Crown copyright 2024

This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3 or write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: [email protected] .

Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned.

This publication is available at https://www.gov.uk/government/publications/iraq-country-policy-and-information-notes/country-policy-and-information-note-medical-and-healthcare-issues-iraq-august-2024-accessible

Version 3.0

Country information

About the country information.

This note has been compiled by the Country Policy and Information Team (CPIT), Home Office.

It provides country of origin information (COI) for Home Office decision makers handling cases where a person claims that removing them from the UK would be a breach of Articles 3 and/or 8 of the European Convention on Human Rights (ECHR) because of an ongoing health condition. It contains publicly available or disclosable COI which has been gathered, collated and analysed in line with the research methodology .

The note aims to be a comprehensive but not exhaustive survey of healthcare in Iraq.

The note’s structure and content follow the terms of reference .

For general guidance on considering claims based on a breach of Article 3 and/or 8 of the ECHR because of an ongoing health condition, see the instruction on Human rights claims on medical grounds .

This note makes use of information compiled by Project MedCOI (MedCOI), which was set up and operated by the Belgium and Netherlands immigration authorities until 31 December 2020. Thereafter MedCOI was run by the European Union Agency for Asylum (EUAA), formerly known as the European Asylum Support Office (EASO).

MedCOI’s information gathering and quality assurance processes remain unchanged since December 2020 when the UK Home Office’s access stopped.

The EUAA website explains how the project currently operates:

‘EUAA MedCOI relies on a worldwide network of medical experts that provides up-to-date medical information in countries of origin. Based on this information and combined with desk research, the EUAA produces responses to individual requests from EU+ countries and maintains a portal with a specific database where the information can be found. The portal also allows for the continuous exchange of information between countries, and between countries and the EUAA. The database is only accessible to trained personnel in EUAA and the EU+ countries’ relevant administrations…The high quality and medical accuracy of the information is guaranteed by specifically trained medical advisors and research experts who also provide guidance to the users of the portal.

‘EUAA MedCOI is continuously subject to internal and external quality assurance activities such as validations, audits, and peer reviews.’ [footnote 1]

The UK Home Office’s access to MedCOI ended on 31 December 2020. However, copies of all MedCOI documents referred to in this note have been retained and are available on request.

1. The healthcare system

1.1 organisation of the healthcare system.

1.1.1 The People’s Dispatch, an international news media outlet [footnote 2] , article, ‘Iraqi health system struggles to recover after three decades of setbacks’, dated 14 August 2023, stated:

‘During the 1970s and 1980s, Iraq’s primary care-based health system was recognized as one of the best in the region. Two decades after the US-led invasion, it is in ruins, scarred by decades of war and economic sanctions. Health services in Iraq remain unevenly distributed and burdened by a critical shortage of health workers, infrastructure, and supplies…

‘This situation is aggravated by long gaps in constructing new health infrastructure. According to a 2013 review of health services in the country, over 50% of the hospitals in Iraq were constructed during the 1970s and 1980s. A report published six years later by Riyadh Lafta and Maha Al-Nuaimi highlighted that no public hospital was built in Iraq between 1986 and 2019, the time when the article was published.

‘Muntather Hassan, the author of a report on the right to health in Iraq published in the Arab Watch Report 2023, offers a similar description of the situation. He explains that health facilities in Iraq are concentrated in areas built during the 1970s and 1980s. The neighborhoods and areas which were populated afterwards are confronted with a different reality…

‘Inequalities are not limited to the physical distribution of health facilities. “For example, in the smaller cities, the number of public and private hospitals is somewhere in correlation with the number of people. But the quality is something that needs to be discussed,” Hassan says.

‘Access to health care is particularly problematic in rural areas. Hassan highlights the absence of health services and the challenge this poses to people living in villages scattered across 10 to 15 kilometers, often sharing a single, ill-equipped health center. For them, accessing health care represents a feat.’ [footnote 3]

1.1.2 The same source also stated:

‘While primary healthcare remains weakened, the private sector has expanded significantly over the past decade, with notable growth in niche areas such as cosmetic medicine and laboratory diagnostics. Hassan sees laboratories marketing tests directly to individuals, a practice he compares to promoting a product, as something quite specific to Iraq. The tests provided through this strategy might be of extremely limited use to the people, but they have proven to be a good way to increase profits. In most cases, they cost less than other medical procedures, making them an easy path to earnings.’ [footnote 4]

1.1.3 The International Organisation for Migration Germany (IOMG) report, ‘Iraq Country Fact Sheet 2022’, stated:

‘The Iraqi health system consists of both private and public sector facilities. In general, the services provided by the private sector may be better in quality with fewer waiting times but could be more expensive. The public hospitals and clinics charge a minimal cost for medical check-ups and provide medication at a lower price compared to the private sector. However, not all health services are available in the public sector and there may be waiting times particularly in larger cities or for certain specializations. Most of the infrastructure has been rehabilitated, and the availability of services has been enhanced. However, in the recently liberated areas, the infrastructure might still be affected. The quality of care depends on whether the health infrastructure has been rehabilitated and restored, and doctors and nurses have returned.’ [footnote 5]

1.2 Provision of healthcare

1.2.1 The Australian government’s Department of Foreign Affairs and Trade (DFAT) 2023 Country Information Report on Iraq stated:

‘The overall quality and availability of healthcare in Iraq is low. There is a nationwide shortage of doctors and nurses, a situation made worse by prolonged conflict and a long-term brain-drain of medical professionals. The Ministry of Health (MoH) is the primary health care provider. Chronic underinvestment and corruption have undermined its capacity to deliver quality healthcare. Waiting lists are long and hospitals often lack essential supplies such as cancer drugs. Iraqis who can afford to use private hospitals and clinics prefer them but, because private health insurance is unavailable, this can be expensive. The quality and availability of healthcare is slightly better in the Kurdistan Region of Iraq (KRI).’ [footnote 6]

1.3 Health insurance

1.3.1 The Physicians for Human Rights article, ‘Challenges Faced by the Iraqi Health Sector in Responding to COVID-19’, dated 6 April 2021, stated:

‘For Iraqis, accessing public medical care is inexpensive. However, the quality of care is so substandard that many resort to private medical care if they have the financial means to do so. Because there is no private health insurance, the average Iraqi covers about 70 percent of their out-of-pocket health expenditures, making quality health care an expensive proposition for most people.’ [footnote 7]

1.3.2 The Expat Arrivals website stated: ‘There is no formal private healthcare insurance system in Iraq. In some instances, wealthier Iraqis may pay out of pocket to receive speedier treatment at a public facility, or opt to go to a neighbouring country for treatment.’ [footnote 8]

1.3.3 The IOMG report, ‘Iraq Country Fact Sheet 2022’, stated: ‘A public health insurance system is not available in the country. Certain companies and organizations may have private health insurance schemes that are provided to the employees and possibly their families. This type of health insurance is still not covering for all type of medical and health expenses…Medical costs and health services are not covered by health insurance. No expenses are covered by the health insurance.’ [footnote 9]

1.3.4 An article published by Al Tamimi and Co (law firm active in the Middle East and north Africa) [footnote 10] stated:

‘The Health Insurance Law specifies three transitional phases for its entry into force. The first phase will conclude after twelve months from publication of the Health Insurance Law in the official gazette. Specifically, a public insurance provider, the “Health Commission” should be established in the Ministry of Health by 23 December 2021. The Health Insurance Law then requires the Health Commission to create and maintain a database of potential beneficiaries in the following categories:

• members of the General Federation of Employees’ Union;
• members of the General Federation Farmers Union;
• members of the unions who are not public employees;
• beneficiaries of the political prisoners’ institute and the Mayor’s institute;
• employees registered in the Ministry of Labour social security department;
• all other Iraqis, presumably to be clarified by regulations to be issued by the Ministry of Health.

‘Despite the above database, insurance coverage is only mandatory for government employees and foreign expat workers. The Health Insurance Law requires all resident foreign expats, visitors and arrivals to apply and obtain approved health insurance coverage from insurance providers contracted with the Insurance Commission.

‘The Health Insurance Law does not specify a timetable for completing the database or completing the other steps required before the public insurance programme can be rolled out. However, the Health Insurance Law specifies one year after completion of the database and other preparatory steps to roll out the programme, register all covered beneficiaries, conclude with private and public healthcare providers, and issue health insurance cards.’ [footnote 11]

1.4 Number of healthcare facilities and personnel

1.4.1 The Arab NGO Network for Development (ANGOND) and the American University of Beirut Faculty of Health Sciences (AUBFHS) 2023 report, ‘Right to Health in Iraq – Fragile structures and growing challenges’, stated:

‘Iraq’s health policy and the Ministry of Health and Environment’s directives aim to provide comprehensive health coverage. Iraq has 295 governmental and 155 private hospitals, at a rate of 1.2 beds per thousand people, providing secondary and tertiary health services. As for primary health care, 2,805 centers…that provide regular care for children and pregnant women, including free vaccination, exist… Moreover, in 2019, a special budget was allocated for purchasing medicines, independent of the Health Ministry’s budget.’ [footnote 12]

1.4.2 The World Health Organisation (WHO) website stated that in 2021, there were 9.72 doctors per 10,000 of the population; 24.4 nursing and midwifery staff per 10,000 of the population; 4.32 dentists per 10,000 of the population, and 4.9 pharmacists per 10,000 population. [footnote 13]

1.5 Non-governmental organisations (NGOs) and other support

1.5.1 A number of national and international NGOs are active in Iraq, such as the Iraq Health Access Organisation [footnote 14] , which provides primary healthcare services, Heevie [footnote 15] , which provides healthcare services in the Kurdistan Region of Iraq (KRI), and Médecins Sans Frontières (MSF) [footnote 16] , which provides a range of basic and secondary health services.

1.6 Availability of and accessibility to medical treatment and drugs

1.6.1 A 2022 medical research study, entitled ‘General Oncology Care in Iraq’, written by Nada Al Alwan, published on the Springer Link (science, technology, medicine, humanities and social sciences publisher website [footnote 17] , stated: ‘Article 31 (1) of the Iraqi Constitution guarantees citizens the right to health care and commits the state to maintain public health freely through provision of prevention and treatment in hospitals and health institutions. Article 31 (2) guarantees individuals and entities the right to build hospitals, clinics, or private health care centers under state supervision.’ [footnote 18]

1.6.2 A Chatham House article, entitled ‘Moving medicine in Iraq: The political economy of the pharmaceutical trade’, dated 14 September 2022, stated:

‘Brand-name drugs – even tried, tested, and approved generics – can be too expensive in a country where wealth inequality is only growing. People on low incomes, or no income at all, are forced to use the cheapest alternative, despite knowing such medicines are also of inferior quality. Such social determinants of health become only more pronounced within this political economy of Iraq’s pharmaceutical trade, and the routes through which medicines pass across ostensibly sovereign Iraqi territory.’ [footnote 19]

1.6.3 The National (a United Arab Emirates media outlet [footnote 20] report, ‘Iraq’s fragmented healthcare system “at the heart of the struggle to overcome war”’, dated 2 December 2022, stated:

‘Iraq’s corrupt healthcare system lies at the centre of the country’s failure to overcome conflict, an expert has said.

‘Citizens of the fifth oil-richest nation in the world struggle to access basic medicine and treatment for conditions and injuries under a network blighted by inadequacy and upheaval.

‘Medicine destined for public use too often ends up being sold for private profit in under-the-table deals in which the Iraqi upper-class benefits at the expense of the poor. What is left for the public health system is often unusable because it has expired or is not genuine.

‘War, UN sanctions, sectarian battles and the rise of ISIS [Islamic State of Iraq and Syria] have made for a lethal concoction of problems that have led to a years-long crisis in Iraq’s healthcare system…

‘Over the past decade, as Iraq has tried to rebuild, the government pumped more money into the healthcare system. Between 2003 and 2010 spending on health jumped from 2.7 per cent of GDP to 8.4 per cent, the World Bank said.

‘But the system is failing millions of Iraqis in dire need of medical care and the country spends far less on health than other Middle Eastern nations…

‘Foreign companies looking to ship medicine to Iraq face a long, drawn-out process. It entails gaining approval from local health representatives on Iraq’s border, which sometimes involves favouritism and political bias.

‘If the firm manages to gain approval, the process of getting the equipment into Iraq is not easy. Many end up paying bribes to border officials to have cargo pass through sea, land and air borders at a faster pace.’ [footnote 21]

1.6.4 The IOMG report, ‘Iraq Country Fact Sheet 2022’, stated:

‘All Iraqi citizens can access the health care system…The Patient needs to visit a clinic or hospital first then based on the initial diagnosis, they will be asked to conduct some medical tests/analysis in order to see a specialized doctor that will be available in private clinics (very few are in public clinics which may take weeks to wait for an appointment). Then they can be referred to get more advance medical interventions, if needed, which also can be done through the private or public hospitals…

‘Costs of medical services are determined by numerous factors such as age, gender and residence. The costs of medication differ depending on the patient’s diagnosis. In government-run hospitals or clinics, there is a risk that medication is subject to shortages although should be available at a low cost.’ [footnote 22]

1.7 Emergency medical services

1.7.1 Faruk Medical City (FMC), built in 2014 in Sulaymaniyah (a city in the KRI), is ‘the first and only state of the art private hospital complex in Iraq’ and is ‘equipped with the most advanced technology and medical systems meeting global healthcare standards and facilities’ [footnote 23] . FMC can provide emergency medical services, as explained on its website:

‘Emergency Department (ED) is one of the vital departments of FMC due to its life saving services. The department of emergency is open 7 days a week including official holidays providing a wide range of high quality service provided by highly qualified and experienced physicians and nurses.

‘The ED is equipped with all necessary tools and equipment that enable health care providers to receive all types of accidents and injuries in addition to all urgent/emergent medical cases in all disciplines…

‘The emergency team include, emergency nurses, emergency reception staffs, patient services, porters, in addition to highly qualified emergency doctors with distinguished skill and competencies to provide the best medical services according to the best medical practice.

‘Emergency Services

• Triage room
• Resuscitation room
• Minor surgery room
• Medical observation room
• Pediatric room
• Gynecological examination room
• Ambulance service

‘Our ambulances are specialized vehicles that fully equipped with necessary equipment and the ambulance service is available 24 hours a day for emergency situation, such as critical cases, accidents and transferring patients from and to FMC. This services provide by highly qualified and experienced medical team in 24 hours around clock.’ [footnote 24]

1.7.2 CPIT was not able to find information about what emergency medical-care services are available throughout Iraq in the public healthcare sector, in the sources consulted (see Bibliography ).

2. Paediatric diseases and healthcare

2.1 paediatric hospital care services.

2.1.1 A United Nations Development Programme (UNDP) article, entitled ‘Doctors in the spotlight: Saving lives and reviving Iraq’s health system’, dated 18 October 2023, stated:

‘Dr. Muhannad Shaker Al Fahdawi started as a young resident doctor at Ramadi Teaching Hospital for Women and Children…

‘Today, Ramadi Teaching Hospital for Women and Children has upgraded operating theatres, labor wards, 260-bed patient wards, laboratories, teaching halls, and staff accommodation. It also has modern medical equipment for maternal and natal care, testing, complex surgeries, and screening.

‘“…With operating rooms and equipment for maternal and pediatric surgeries, we are able to perform life-saving surgeries and provide a wide range of services for women and children,” Dr. Muhannad says.’ [footnote 25]

2.1.2 The Children’s Village (American NGO that provides help and support to disadvantaged children) [footnote 26] website provided information about its paediatric care services in Iraq:

‘Our medical clinics developed in close partnership with the Iraqi Children’s Foundation (ICF) and the Iraq Health Access Organization (IHAO), specialize in providing healthcare to children and families with disabilities in Mosul, Fallujah, and Baghdad. Hundreds of Iraqis receive crucial medical care at these facilities each year. Their treatment ranges from limb amputations to medicine for chronic illnesses to support for intellectual or developmental disabilities. Many of our children are directly or indirectly related to patients living within a conflict zone.

‘In addition to ongoing medical care, these clinics provide physical therapy, access to wheelchairs and medical devices, psychosocial support groups for clients and their families, and hygiene kits designed to support an individual’s health outside of the center.’ [footnote 27]

2.1.3 The WHO report, ‘New paediatric unit opens its doors for newborns and children in Akre Paediatric and Maternity Hospital in Duhok Governorate’, dated 14 September 2022, stated:

‘The World Health Organization (WHO), in collaboration with the Directorate of Health in Duhok Governorate in the Kurdistan Region of Iraq, today [14 September 2022] inaugurated a new paediatric department in Akre Hospital.

‘With the opening of this department, the hospital becomes the only facility in the city to offer specialized services to children and newborns.

‘The new unit will provide the population of Akre with support to address the increasing need for neonatal and paediatric health care services in Akre and surrounding districts, including Bardarash, which is home to 3,500 Syrian refugees.

‘The new department comprises 28 beds equipped with emergency care supplies and medical equipment, enabling the hospital to provide intensive care treatment to newborns and children. To further improve the quality of care in the department, advanced training sessions to enhance the technical capacity of the health staff working in it are being carried out as a collaboration between WHO, the Directorate of Health in Duhok Governorate and the Italian Association for Solidarity Among People (AISPO).’ [footnote 28]

2.2 Paediatric cardiology and heart surgery

2.2.1 In July 2023, the International Journal of Surgery published a medical study entitled ‘The evolution of congenital heart disease surgeries in Iraq’, which stated:

‘On November 9, 2011, the cardiovascular surgery division was launched at the Azadi Heart Center in Duhok, Kurdistan Region of Iraq…This well-equipped Cardiac Care Unit with a trained team provided the Center with the capabilities to handle complex cardiac cases…The team has successfully operated on several complicated patients, including a low-weight child with an aortopulmonary window who had pulmonary blood pressure close to systemic pressure.

‘A new era begins after 2020 when the local team at Azadi Heart Center in Duhok (cardiothoracic surgeons, pediatric cardiologists, anesthesiologists, intensive care unit staff, and nurses, etc.) were proficient enough to handle the majority of congenital cardiac cases. The operations were either corrective surgery or palliative surgery for both cyanotic and acyanotic congenital heart disorders…

‘The following complex operations were done recently in the center; Cone Repair of tricuspid valve, Ebstein’s anomaly for a lady in her second decade, Rose procedure for severe aortic stenosis in an infant, and Senning procedure to treat transposition of the great arteries in a 1-year-old male baby.’ [footnote 29]

2.3 Paediatric cancer treatment

2.3.1 The Nada Al Awan medical research study paper stated:

‘In 2010, the first “Children Cancer Hospital” in Iraq was opened in Basra as the largest state of the art referral specialty care facility. It includes 101 beds, imaging department with MRI, automated laboratories and oncology departments provided with linear accelerators. Within the MCTC [Medical City Teaching Complex] in Baghdad, the 240 bed “Children’s Welfare Hospital” offers public services by a competent specialized multi-disciplinary team for diagnosis and treatment of childhood neoplasms. The oncology unit receives an average of 300 new malignant cases per year. Improvement in childhood cancer services was achieved over the past two decades through better availability of WHO essential chemotherapy drugs, introduction of advanced diagnostic/screening tools and bone marrow transplant services, provision  of satellite telemedicine e-learning training program…, in collaboration with Sapienza University in Rome, fostering consultation and quality control, using Tele-Pathology, introduction of ATRA [all-trans retinoic acid], adapted APL [acute promyelocytic leukaemia] protocols, [and] strengthening research in coordination with Japanese institutes…’ [footnote 30]

2.3.2 The Basra Children’s Hospital has facilities to treat children with cancer:

‘Inaugurated in 2010, the Basrah Children’s Hospital, the first hospital to be built in Iraq since the 1980s, provides Basra and the southern governorates of Iraq with a wide range of healthcare services dedicated to the care of acute paediatric patients with a particular focus on oncology.

‘The hospital occupies a central area of 16,000 sqm which is easily accessible from the different districts of Basra and accommodates a total of 101 beds.’ [footnote 31]

2.4 Paediatric nephrology (kidney disease)

2.4.1 CPIT was not able to find information about the availability of treatment for paediatric kidney diseases in the sources consulted (see Bibliography ).

3.1 General

3.1.1 The Nada Al Alwan medical research study on cancer stated:

‘The Iraqi Cancer Board of the Ministry of Health is responsible for implementing the National Cancer Control Plan (NCCP). The latest Iraqi Cancer Registry revealed that the top recorded malignancies among the population are the breast, bronchus, and lungs followed by colorectal cancers, whereas the most common causes of malignant related deaths are cancers of the bronchus and lungs, breast, and leukemia. Overall, there are over 40 public cancer care facilities distributed among the governorates.’ [footnote 32]

3.1.2 The same source also stated:

‘Excluding the private sector, the whole spectrum of cancer care services (including diagnostic imaging and laboratory tests, chemotherapy, radiotherapy, other relevant drugs, and medical appliances) is being provided by [the] MOH [Ministry of Health] freely without any charges in specialized oncology hospitals and cancer centers…Currently, MOH is collaborating with the private sector to cover the requested cancer care specifically in the field of treatment.’ [footnote 33]

3.2 MRI and CT scanning machines

3.2.1 The Nada Al Alwan medical research study on cancer stated:

‘It has been registered in 2019 that there are 152 Computed Tomography (CT) scans and 90 Magnetic Resonance Imagining (MRI) machines, constituting 3.9 and 2.3/100,000 population, respectively. Positron Emission Tomography/Computed Tomography (PET/CT) is available in the Medical City Teaching Hospital and in private oncology centers in Baghdad, Najaf, and Erbil. There are five Gamma Cameras in Baghdad and Gamma knife procedures are readily practiced in Erbil. Excluding Baghdad and Erbil, there is very limited access to nuclear medicine diagnostic and treatment facilities.’ [footnote 34]

3.3  Radiation therapy

3.3.1 The Nada Al Alwan medical research study on cancer stated:

‘Oncology care is provided through specialized oncology and radiotherapy hospitals. Clinical oncologists are licensed by the Ministry of Health to perform chemotherapy and radiotherapy. It has been recorded that out of 11,585 specialized physicians in Iraq, there were 128 medical or radiation oncologists. Excluding KRG [the Kurdistan Region], 72 medical oncologists and 58 radiation oncologists have been officially registered at the present time in the Iraqi MOH, whereas 75 postgraduate medical students are completing their board-certified studies in oncology and radiotherapy. In addition, there are 42 oncology physicians currently running the cancer care facilities in KRG. Nevertheless, the total number in most governorates is still lower than that requested to reach a coverage rate of 80% and is obviously far less than the international recommendations on oncology consultant staffing. This shortage emphasized the urgent need for the MOH and MOHESR [Ministry of Higher Education and Scientific Research] in Iraq to invest in qualifying human resources in all aspects of cancer care.’ [footnote 35]

3.2.2 The same source also stated:

‘Progress in radiation oncology has been proceeding in Iraq through continuous establishment of specialized centers and rehabilitation of the staff. Within the past 5 years, national societies for radiation/clinical oncology and medical physics have been established. Currently, there are 21 Mega Voltage Machines in Iraq, six in Baghdad. A high dose rate Brachytherapy has been functioning in Zhianawa Cancer Center. The directory of Radiotherapy Centers has revealed the registered public oncology facilities within the corresponding governorates:

‘Baghdad: Al-Amal National Oncology Hospital, Kadhimiya Teaching Hospital, and Medical City Radiotherapy and Nuclear Medicine Center

‘Babylon: Babylon Oncology Center, Marjan Hospital, and Al Imam Jaafar al-Sadeq Hospital

‘Basra: Children Specialist Hospital, Educational Oncology Centre, and Basra Hospital

‘Erbil: Rizgary Teaching Hospital—Oncology Center

‘Karbala: Holy Karbala Hospital

‘Maysan: Al Maysan Hospital and Maysan Oncology Center

‘Mosul: Hazim Al-Hatiz Radiotherapy and Nuclear Medicine Hospital

‘Holy Najaf: Al Najaf Hospital, Oncology Specialists Centre, and Middle Euphrates Cancer Centre

‘Dhi Qar: Al Naseriya Hospital

‘Al-Anbar: AlRamadi Hospital and Ramady General Hospital

‘Sulaimaniya: Zhianawa Cancer Center and Hiwa Cancer Hospital.’ [footnote 36]

3.4 Availability of anti-cancer drugs

The Nada Al Alwan medical research study on cancer stated:

‘The MOH imports cancer drugs and medical equipment through the “State Company for Marketing Drugs and Medical Appliance” (KIMADIA) and distributes throughout all governorates, where chemotherapy is administered at specialized public tertiary hospitals and cancer centers free of charge. As the provision of affordable access to cytotoxic medicine is a major challenge in the cancer care of patients in middle- and low-resource settings, WHO developed its “Model Lists of Essential Medicines,” to support countries in prioritizing their reimbursable medicine. Within the past decades, many of the essential cancer drugs were in short supply in Iraq. The situation improved recently when the government increased the allocated budget to the MOH. The UICC [Union for International Cancer Control] declared that Iraq has made progress towards achieving the world cancer control targets through improving the free access to accurate diagnosis and multimodal treatment of cancer, adding that almost 80% of the treatment protocols are covered and the waiting lists for radiotherapy in the cancer centers have been significantly shortened.’ [footnote 37]

3.5 Surgery

3.5.1 The Nada Al Alwan medical research study on cancer stated: ‘Cancer patients receive surgical treatment by specialized surgeons, following international guidelines, in tertiary public hospitals and private centers. Robotic surgery has not been commonly practiced in Iraq yet. Postgraduate studies in the fields of surgical oncology have been initiated within the past few years by the Arab and Iraqi Boards for Health and Medical Specializations.’ [footnote 38]

3.6 Lung cancer

3.5.2 CPIT was not able to find information about the availability of treatment for lung cancer, from the sources consulted (see Bibliography ).

3.7 Breast cancer

3.7.1 CPIT was not able to find information about the availability of treatment for breast cancer, from the sources consulted (see Bibliography ).

3.8 Brain cancer

3.8.1 CPIT was not able to find information about the availability of treatment for brain cancer, from the sources consulted (see Bibliography ).

3.9 Liver cancer

3.9 CPIT was not able to find information about the availability of treatment for liver cancer, from the sources consulted (see Bibliography ).

3.10 Cervical cancer

3.10 The World Health Organisation (WHO) 2021 Cervical cancer country profile stated that Iraq did not have a national cervical cancer screening programme in 2021. Cancer diagnosis and treatment services for women with cervical cancer were generally available in 2021, including pathology services, cancer surgery, radiotherapy and chemotherapy [footnote 39] .

3.1 1 Cancer of the head and neck

3.11 CPIT was not able to find information about the availability of treatment for cancer of the head and neck, from the sources consulted (see Bibliography ).

3.12 Thoracic surgery

3.12 CPIT was not able to find information about the availability of thoracic surgery, from the sources consulted (see Bibliography ).

3.13 Gastroenterological cancers

3.13 CPIT was not able to find information about the availability of treatment for gastroenterological cancer, from the sources consulted (see Bibliography ).

3.14 Bone and skin cancers

3.14 CPIT was not able to find information about the availability of treatment for bone and skin cancer, from the sources consulted (see Bibliography ).

3.15 Colorectal cancers

3.15 CPIT was not able to find information about the availability of treatment for colorectal cancer, from the sources consulted (see Bibliography ).

3.16 Blood cancers

3.16 CPIT was not able to find information about the availability of treatment for blood cancer, from the sources consulted (see Bibliography ).

3.17 Urological cancers

3.17 The Cancer Care Specialties (MENA) website stated:

‘Urological oncology, a specialized field within medicine, focuses on the diagnosis, treatment, and management of cancers affecting the urinary tract and male reproductive system. In Iraq, urological oncology has witnessed significant advancements, with renowned medical centers and skilled specialists offering comprehensive care for patients battling these malignancies.

‘Iraq boasts specialized urological oncology centers equipped with advanced diagnostic and treatment facilities. These centers provide a comprehensive approach to cancer care, encompassing diagnosis, treatment, and ongoing support services…

‘Treatment for urological cancers depends on the type, stage, and extent of the cancer. Common treatment modalities include surgery, radiation therapy, chemotherapy, and targeted therapies. Advancements in surgical techniques, such as minimally invasive procedures, have reduced surgical trauma and improved recovery times…

‘The fight against urological cancers in Iraq is gaining momentum with the establishment of specialized centers, the expertise of multidisciplinary teams, and advancements in treatment modalities. Early detection, comprehensive care, and psychosocial support are crucial elements in improving outcomes and empowering patients to navigate their cancer journey with strength and resilience.’ [footnote 40]

3.17.2 CPIT was unable to find information regarding where the urological oncology centres are located in Iraq, in the sources consulted (see Bibliography ).

4. Cardiovascular diseases

4.1 cardiology.

4.1.1 A European Union Agency for Asylum (EUAA) MedCOI 2020 response to an information request stated there were cardiologists and facilities in Iraq to treat people who needed cardiac catheterisation, implantable cardioverter defibrillators (ICDs), heart valve surgery, left ventricular assist devices, for example at the Ibn Al-Bittar Specialist Hospital in Baghdad. [footnote 41]

4.1.2 The Faruk Medical City facility, a private hospital in Sulaymaniyah, has the facilities to treat people with heart conditions, and can provide the following tests and treatment, as stated on its website:

‘Electrocardiography (ECG)

Echocardiography

Transesophageal Echocardiography (TEE)

Treadmill Test

Rhythm Holter Monitoring

Blood Pressure Holter Monitoring

Coronary Angiography

Coronary angioplasy and stenting

Complex coronary interventions

TAVI (Transcatheter Aortic Valve Implantation)

Temporary pacemaker

Permanent pacemaker

ICD (Implantable Cardioverter Defibrillator)

CRT-D (Biventricular Pacemaker Placement)

Electrophysiological Study

RF ablation

Mitral balloon valvuloplasty

Septal ablation

Atrial Septal Defect/Ventricular Septal Defect/Patent Foramen Ovale closure

Coronary arteriovenous fistula closure

Angioplasty for fistula stenosis of haemodialysis patients

Peripheral vascular interventions

Carotid stenting

Subclavian stenting

Renal vascular stenting

Venous stenting

Mesenteric artery stenting

Endovascular repair of aortic aneurism (EVAR)

Lower extremity pecutaneous transluminal angioplasy, atherectomy, stenting.’ [footnote 42]

4.1.3 The PAR Hospital in Erbil is a private hospital whose website states that it is ‘one of the finest medical institutions in Kurdistan’ [footnote 43] which ‘utilizes the most advanced medical technology in its state-of-the-art medical and surgical care facilities’. [footnote 44] The Cardio Thoracic Centre at hospital can provide cardiological medical care, as stated on its website:

‘The Cardio Thoracic Center at the PAR Hospital Erbil is a regional center of excellence for cardiac and thoracic care, providing standards of care to patient in Iraq and the region. The center is capable of treating all type of cardiac conditions including interventional cardiology and surgery.

‘The center is one of select group of medical centers worldwide, and among the few private healthcare institution in the region, capable of undertaking advanced interventional and surgical procedures, such as minimally invasive cardiac surgery, thoracic surgery and VAT (video-assisted thoracoscopy). State of the art heart valve repair and advanced aortic arch procedures are further high lights to be provided by the cardio thoracic center.’ [footnote 45]

4.2 Drugs used to treat heart-rhythm disorders

4.2.1 A EUAA MedCOI 2020 response to  an information request stated that the following drugs (used to treat heart rhythm disorders) were available, for example at the Fawzi Pharmacy in Baghdad:

• Sotalol [footnote 46]

4.3 Drugs used to high blood pressure and cholesterol levels

4.3.1 A EUAA MedCOI 2020 response to an information request stated that eplerenone (used to treat high blood pressure) was available, for example at the pharmacy of the Baghdad Teaching Hospital [footnote 47] . EUAA MedCOI 2020 responses to information requests stated that the following drugs (used to treat high blood pressure) were available, for example at the Dawa Pharmacy in Baghdad:

• Perindopril [footnote 48]
• Lisinopril [footnote 49]
• Carvedilol [footnote 50]
• Bisoprolol [footnote 51]
• Propranolol [footnote 52]
• Bumetanide [footnote 53]
• Spironolactone [footnote 54]
• Atenolol [footnote 55]
• Metoprolol [footnote 56]
• Nebivolol [footnote 57]

4.3.2 A EUAA MedCOI 2020 response to an information request stated that the following drugs (use to lower cholesterol levels) were available, for example at the Dawa Pharmacy in Baghdad:

• Pravastatin
• Simvastatin [footnote 58]

4.4 Drugs used to treat blood clots

4.4.1 A EUAA MedCOI 2020 response to an information request stated that acenocoumarol (anti-clotting drug) was available, for example at the Dawa Pharmacy in Baghdad [footnote 59] . Another EUAA MedCOI 2020 response to an information request stated that the following anti-clotting drugs were available:

• Aspirin (Ibn Rushid Hospital, Baghdad)
• Ticagrelor (Ibn Rushid Hospital, Baghdad)
• Clopidogrel (Dawa Pharmacy, Baghdad)
• Prasugrel (Dawa Pharmacy, Baghdad)
• Ticlopidine (Dawa Pharmacy, Baghdad) [footnote 60]

4.5 Heart surgery

4.5.1 A United Nations Development Programme (UNDP) report on Iraq, entitled ‘New Cardiac Surgery Centre at Al Salam Hospital gives hope to thousands’, dated 18 August 2021, stated:

‘Supporting the health care system build back, UNDP is rehabilitating eight major health care institutions in Mosul. As a part of these larger efforts, the Cardiac Surgery Centre at Al Salam Hospital was recently established to provide much-needed medical treatment with cardiology diseases such as heart failure, coronary artery diseases and strokes…

‘Today, the center performs complex open and close heart surgeries. UNDP supported the establishment of two inpatient wards with eight beds each, an administration office, two fully equipped operation theaters, a recovery room, and an intensive care unit. The center has a dedicated team of six doctors, four surgeons, two anesthesiologists and more than 50 administrative staff, serving 30,000 Iraqis in Ninewa.’ [footnote 61]

4.5.2 Another UNDP report, entitled ‘Doctors in the spotlight: Saving lives and reviving Iraq’s health system’ dated 18 October 2023, also commented on Al Salam Hospital in Mosul:

‘With 25 years of experience in the field of cardiac surgery, Dr. Ammar Abdel Salam Hamed has witnessed the triumphs and trials of Iraq’s healthcare system. A man with a mission, Dr. Ammar remains committed to providing the best medical care possible to the people of Mosul. 

‘Dr. Ammar has been overseeing Al Salam Hospital’s Department of Cardiac Surgery since its establishment in 2020. Although relatively new, the facility has become a vital hub for cardiac care in the region.   

‘“The cardiac centre provides much-needed care to those with heart conditions in a city where such facilities are scarce. There is no other hospital in the health directorate that is equipped to handle the complex procedures we do. This centre fills that void and gives hope to those in need,” Dr. Ammar says. 

‘Dr. Ammar and his team perform an average of 20-22 surgeries per month. With more families returning home and the prevalence of heart disease increasing, there is a growing demand for these cardiac services. To meet this growing need, Dr. Ammar envisions the establishment of more cardiac centres like Al Salam’s, ensuring that every Iraqi has access to this specialized service…

‘The Cardiac Centre at Al Salam Hospital was established with generous support from the European Union, Netherlands, and Norway. It serves over 30,000 people in Ninewa.’ [footnote 62]

5. Dental treatment and conditions

5.1.1 The University of Kerbala Dental Clinic has facilities to treat people with a wide range of dental and oral conditions, as explained on its website:

‘The dental clinic at the University of Kerbala is recognized as one of the prominent medical facilities in the city. It offers comprehensive treatment for various oral diseases and dental issues…

‘The clinic is managed by a team of highly experienced dentists and dental technicians who strive to provide exceptional care to patients. Working collaboratively, they diagnose and treat a wide range of oral health problems, from routine procedures like dental cleaning and filling to more complex ones such as teeth implants and jaw surgeries.

‘Equipped with state-of-the-art technologies and tools, the dental clinic at the University of Kerbala ensures accurate diagnosis and effective treatment of oral conditions. The staff strictly adheres to hygiene and safety standards, creating an optimal environment for patients.

‘Moreover, the clinic actively participates in raising awareness about oral hygiene by offering tips and advice to patients for proper oral care. The staff also engages in community campaigns to promote public awareness about oral hygiene and care…

‘To sum up, the Dental Clinic at the University of Kerbala represents a leading center for oral healthcare in the region. It provides high-quality services and promotes health awareness among patients and the local community. With its specialized team and advanced equipment, the clinic meets patients’ needs and strives to maintain oral health, improve dental care, and enhance the quality of life for the community.’ [footnote 63]

5.1.2 The Denta Dental Clinic in Erbil states on its website that it can provide the following treatment:

• Laminated veneers
• Tooth-coloured fillings
• Crowns and bridges
• Inlays and onlays
• Teeth whitening
• Dental implants
• Dentures and maxillofacial prosthesis
• Laser surgery [footnote 64]

5.1.3 The Dentistry Clinic of the University of Alkafeel (located in Najaf [footnote 65] ) provides a wide range of dental treatment, as explained on its website:

‘A number of professors, experienced dentists, supervisors, teaching assistants, employees and workers responsible for certain services work in the clinics, in addition to service and security workers…

‘The work in the clinic is divided into several clinics:

• Surgery clinic (extractions and various surgical procedures)
• Healing and treatment clinic (fillings and root fillings)
• Pediatric clinic (treatment of children and primary teeth and preventive procedures)
• Orthodontic clinic (diagnostics and treatment with orthodontic appliances)
• Industrial Clinic (Full and Partial Denture Fabrication)
• Oral medicine clinic (diagnosing various conditions and prescribing appropriate medications)
• Periodontal clinic (various periodontal treatments).’ [footnote 66]

6. Diabetes

6.1.1 Mohammed Abusaib, Mazyar Ahmed, Hussein Ali Nwayyir, et al, wrote a 2020 study entitled ‘Iraqi Experts Consensus on the Management of Type 2 Diabetes/Prediabetes in Adults’, published on PubMed Central (free full-text archive of biomedical and life sciences journal literature [footnote 67] ). The study stated that metformin, glibenclamide and insulin (drugs used to control blood sugar levels) were available in Iraq. [footnote 68]

6.1.2 A EUAA MedCOI 2020 response to an information request stated that HbA1C tests (used to test blood sugar levels) could be carried out at the Al Diwaneya Teaching Hospital in Diwaneya, Al-Qadisiyyah governorate. Laboratory research of kidney function could also be carried out at the Al Diwaneya Teaching Hospital. [footnote 69]

6.1.3 A EUAA MedCOI 2020 response to an information request stated that dapagliflozin, gliclazide, glibenclamide, and glimepiride (used to lower blood sugar levels) were available at the Al Namothajya Pharmacy in Diwaneya. [footnote 70]

7. Ear, nose and throat conditions (ENT)

7.1.1 The Faruk Medical City facility, a private hospital in Sulaymaniyah, has facilities to treat people with a wide range of ENT conditions, as explained on its website:

‘The ENT and skull base surgery specialist works with a neurosurgeon and a surgical technician as a team to perform all skull base surgeries, whether it is anterior skull base or lateral skull base surgery…through the nose (rhinoscopy) to the anterior skull base, in addition to microscopic surgeries. Lateral skull base surgeries include, but are not limited to:

  ‘Acoustic neuroma (vestibular schwannoma), meningioma and petrous apex lesion

  ‘MVD [microvascular decompression]… jugular [sic] and tympanic paragangliomas, temporal bone resection in tumor cases, facial nerve injury repair

  ‘Endoscopic anterior skull base surgeries…

  ‘Functional endoscopic sinus surgery, turbinoplasty, and endoscopic septoplasty

  ‘Middle ear surgeries, including Stapedotomy and ossiculoplasty, myringoplasty, mastoid surgeries and atresia surgeries.

‘Cochlear implantation and rehabilitation

‘Endoscopic evaluation of nasal and sinus disorders

‘Reconstructive and Aesthetic Rhinoplasty and Septoplasty

‘Tonsillectomy and nasal adenoidectomy with the use of latest devices

‘Evaluation and treatment of snoring and sleep apnea

‘Coblator surgeries

‘Salivary Gland Surgery

‘Surgery of Tongue and Oral Cavity

‘Laryngeal carcinoma management, neck dissection, pharyngeal disease management, management of neck mass and vocal cord lesion management

‘Balance Disorders Assessment: including Vestibular Nystagmography (VNG), Spontaneous Nystagmus, Gaze, Smooth Pursuit, Saccade, Dix-Hallpike, Positional and Optokinetic Tests

‘Hearing Assessment: including Pure Tone Audiometry (PTA), Tympanometry with Reflexes, Otoacoustic Emissions (OAE), Auditory Brain Stem Response (ABR) and Auditory Steady State Response (ASSR).’ [footnote 71]

7.1.2 The Erbil International Hospital is a private hospital which describes itself as a ‘leading medical institution in Erbil’ with ‘state-of-the-art facilities’ [footnote 72] . The hospital has an ENT clinic that can deal with a wide range of ENT conditions, such as:

• Ear, nose and throat specialist surgery
• Otitis media balance problems
• Tonsillectomy and adenoidectomy
• Septoplasty, rhinoplasty, alarplasty
• Extra-corporal septoarhinoplasty, and blepharoplasty
• Otoplasty, reduction of ear lobule, removal of concha bullosa, removal of vocal cord nodule and small tumours [footnote 73]

8. Epilepsy and other neurological conditions

8.1.1 The Faruk Medical City, a private hospital in Sulaymaniyah has facilities to treat people with a wide range of neurological conditions, as explained on its website:

‘The Neurology Department at FMC; consists of:

‘Neurology Clinic; In which we provide a comprehensive individual evaluation and care of the full range of neurological conditions affecting the brain, spinal cord, nerves and muscles, as well as Inpatient and Intensive care Departmeent [sic]; We can provide excellent care to patients with neurological conditions, including patients in critical conditions where we have a critical care unit with exemplary facilities to care for critically ill patients.

‘We also provide:

‘Radiology tests that are necessary for cases of the nervous system such as: magnetic resonance imaging, magnetic imaging of the veins, computed tomography of blood vessels, Doppler of the carotid artery and digital imaging of blood vessels

‘Neurophysiological examinations, which include (NCV, EEG and VEP)

‘Physiotherapy and rehabilitation.’ [footnote 74]

8.1.2 A EUAA MedCOI 2020 response to an information request stated that baclofen and tizanidine (used to treat dystonia) were available, for example at the Dawa Pharmacy in Baghdad. [footnote 75]

9. Eye conditions and diseases

9.1.1 The English Medical Centre, a private eye hospital in Erbil [footnote 76] , has facilities to provide the following eye-care treatment, as explained on its website:

‘Laser vision correction

Cataract surgery

Small incision, no stitch - no patch cataract surgery

Pediatric Ophthalmology and Adult Strabismus

Diabetic exams and laser treatment

Complete eye exams

Contact lens fitting

Glaucoma management with computerized testing

Complete optical shop on premises

Vetro-Retinal treatment and surgery

Oculoplastic surgery…

Keratoconus treatment and cross linking

Keratpplasty and corneal graft

ICL [implantable contact lenses].’ [footnote 77]

9.1.2 The Faruk Medical City, a private hospital in Sulaymaniyah, has an Ophthalmology Department which can provide the following eye-care treatment:

• Diagnostics
• Refraction check up
• Ocular Tension Measurement
• Retinal examination by direct and indirect ophthalmoscope
• Refractive Surgeries
• Special room for Refractive Check up
• Corneal Mapping Topography…
• LASIK [Laser-Assisted In Situ Keratomileusis] and PRK [Photorefractive keratectomy]
• Cross-Linking
• Intracorneal rings and intacs
• Implantable Contact Lens procedure ICL
• Contact Lens Fitting…
• Cataract – Phacoemulsification with monofocal, toric or trifocal intraocular lens implant
• Glaucoma – trabeculectomy, Ahmad valve implant, I stent implant
• Corneal transplant
• Parsplana vitrectomy
• Oculoplastic surgery
• Strabismus surgery
• Dacryocystorhinostomy…’ [footnote 78]

9.1.3 The Ibn Al Haytham Eye Teaching Hospital in Baghdad has facilities to provide ophthalmic plastic surgery, treatment for strabismus, treatment for refractive errors, treatment for glaucoma, and retinal and vitreous fluid resections. [footnote 79]

10. Gastroenterology

The Faruk Medical City, a private hospital in Sulaymaniyah, has facilities to treat people with gastroenterological conditions, as explained on its website:

‘The Endoscopy Unit at Faruk Medical City provides services to patients of various age groups in both inpatient and outpatient settings. Services provided are a wide range of gastrointestinal and hepatology examinations and procedures.

‘Our department works as a referral center for specialized gastrointestinal endoscopic procedures such as endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound.

‘Diagnostic Services

• Diagnostic EGD [Esophagogastroduodenoscopy} and Biopsy
• Diagnostic Colonoscopy and Sigmoidoscopy and Biopsy
• Single Balloon Enteroscopy
• Capsule Endoscopy
• Radial and Linear Endoscopic Ultrasound
• Fine Needle Aspiration FNA
• Endoscopic Retrograde Cholangiopancreatography
• Esophageal Function Test and Esophageal Manometry
• 24 hours pH/Impedance.
• Fibroscan for assessment of fibrosis of the liver.

‘Therapeutic Services

• EGD with Polypectomy
• Colonoscopy with Polypectomy
• Endoscopic Mucosal Resection (EMR)
• Esophageal Band Ligation
• Hemostatic Interventions
• Basket Retrieval of Biliary Stones, Pancreatic Stent Placement and Removal
• Esophageal, Duodenal Stenting
• Intragastric Balloon Placement and Removal
• PEG [Percutaneous endoscopic gastrostomy] Tube Placement and Removal
• Treatment of Esophageal, Colonic and Duodenal Dilatation.’ [footnote 80]

10.1.2 A EUAA MedCOI 2020 response to an information request stated that lactulose and macrogol (used to treat constipation) were available, for example at the Dawa Pharmacy in Baghdad. [footnote 81]

10.1.3 The Gastroenterology and Hepatology Teaching Hospital in Baghdad has:

• 4 operating theatres
• 4 therapeutic endoscopy/radiology theatres
• 4 endoscopy rooms for upper/lower gastrointestinal endoscopy
• Facilities for disinfections, video recording and digital links
• Specialized clinics for liver diseases, colon and small bowel diseases, hepato-biliary and pancreatic diseases
• X-ray and ultrasound department with interventional activities [footnote 82]

11. Gynaecology, maternity care and obstetrics

11.1.1 The Faruk Medical City, a private hospital in Sulaymaniyah, has a gynaecological and obstetrics department which can provide women with a wide range of gynaecological and obstetric care, as explained on its website:

‘Obstetric Care

• Prenatal Check-up
• NIFTY [Non-invasive Fetal Trisomy] Test
• Fetal Non-Stress Test
• Post-Partum care
• High-risk Pregnancy Monitoring
• Recurrent Miscarriage Management

‘Gynecological Services

• Annual check-up
• Pap Smear test
• Contraception and Birth Control
• Menopause Management
• Polycystic Ovarian Syndrome (PCOS) Management
• Diagnostic Colposcopy
• Simple cyst aspiration
• Cryo-cautery of cervix procedure.’ [footnote 83]

11.1.2 The UNDP report, ‘Improving Access to Maternal Care in Ramadi’, dated 9 September 2021, stated:

‘In early 2020, UNDP completed the large-scale rehabilitation of Ramadi Teaching Hospital for Women and Children. The work included rehabilitating operating theatres, labor wards, water, electrical systems, and doctor’s accommodation. The 260-bed modern medical facility serves over 400,000 women in Anbar with specialized maternity services…

‘The rehabilitation included significant parts of the hospital, such as the operating theatres, water piping, electrical systems, patient wards, and staff accommodation. UNDP also supplied medical equipment for natal care, testing, complex surgeries, and screening. Currently, the hospital serves over 6000 women every month. Of which, over 1,200 are complex cases and more than 600 are surgeries requiring intensive post-operative care…

‘As the only such facility in Anbar, the hospital serves women from areas such as Heet, Haditha, Anah, Rawa, and Al Qaim. They have over 1450 qualified medical and administrative staff to provide quality maternal care to patients.’ [footnote 84]

12. HIV/AIDS

12.1.1 A New Region (Iraqi news media outlet) [footnote 85] report, entitled ‘Iraq’s AIDS infections surpass 2000; actual numbers likely higher’, dated 9 April 2024, stated:

‘Following diagnosis, AIDS patients in Iraq receive antiretroviral drugs and specialized treatments, alongside essential guidance to help them adjust to their new reality and manage the illness. They undergo regular monitoring, essential tests, and receive ongoing treatment to ensure their well-being…

‘Ali Abu al-Tahain, a member of the media support team for the Ministry of Health, allays fears regarding the potential surge in HIV/AIDS cases, refuting claims of an increase in Iraq’s recorded cases.

‘He underscored that “HIV/AIDS infections in Iraq remain under control, unlike the concerning trends observed in regions such as Africa, Central and South America, and Southeast Asia.”…

‘Despite government assurances regarding the limited number of recorded cases in the country, statistics from the Ministry of Health for 2021 revealed 392 reported cases and 21 fatalities. The figures for 2022 saw an increase, with 446 cases reported nationwide, excluding the Kurdistan region, where 33 deaths were recorded, including 9 females.’ [footnote 86]

12.1.2 A Shafaq News (Iraqi Kurdish news media outlet) report, entitled ‘AIDS Struggle: insights across Iraqi governorates’, dated 30 April 2024, stated:

‘In Iraq, including the Kurdistan Region, periodic reports of AIDS cases continue to surface, underscoring ongoing concerns about the virus’s prevalence…

‘According to patients’ statements, Luay Abdul Amir, the Babil [governorate in central Iraq] health department’s media director, highlighted that many of these cases are associated with travel and visits to cosmetic and dental centers in Lebanon and other locations or the possibility of transmission through sexual contact.

‘Abdul Amir emphasized to Shafaq News agency that the situation does not indicate an epidemic, and there are no severe or escalating cases reported, reassuring the public that “treatment options are available at Al-Imam Al-Sadiq Teaching Hospital, and the health system is equipped to handle such cases effectively.”

‘Furthermore, Maher Al-Abboudi, the media official of Najaf Health Department, told our agency that AIDS is not absent from any governorate. However, he refrained from providing official statistics until the number of registered cases with Najaf health departments was confirmed…

‘Highlighting recent developments in Najaf, Al-Abboudi mentioned the inauguration of an immunodeficiency treatment center at Al-Amal Hospital approximately six months ago.

‘“This facility boasts a specialized doctor, a private laboratory, and a dental clinic dedicated to treating AIDS patients.”…

‘Moreover, the Ministry of Health in Iraqi Kurdistan announced in December 2023 that 72 new cases of AIDS were registered in the Kurdistan Region during 2023, with a primary concentration among foreigners.

‘In a statement released on World AIDS Day, the ministry highlighted the extensive efforts undertaken as part of the control program for 2023.

‘“These efforts included conducting 598,000 tests for HIV across various segments of the population. Specifically, testing was prioritized for foreigners before granting residency, before blood donation, marriage, and among employees in tourist areas. Additionally, tests were carried out for detainees, prisoners, thalassemia patients, and individuals with hepatitis.” The ministry said.’ [footnote 87]

13. Liver diseases

13.1 liver disease.

13.1.1 CPIT was not able to find information about the availability of treatment for liver disease in the sources consulted (see Bibliography ).

13.2 Liver transplants

13.2.1 CPIT was not able to find information about the availability of liver transplants in the sources consulted (see Bibliography ).

14. Haematological conditions

14.1.1 A EUAA MedCOI 2020 response to an information request stated that haematologists were available, for example at the Baghdad Medical City Hospital in Baghdad. [footnote 88]

15. Kidney diseases

15.1 dialysis.

15.1.1 The Farouk Medical City (FMC), a private hospital in Sulaymaniyah, has facilities to provide kidney dialysis, as explained on its website:

‘The FMC  Hemodialysis unit was established in 2015 and had provided service to more than thousands of patients since then. The unit comprises of three beds and three operational Fresenius 4008s Next Generation machines.

‘The unit regularly operates from eight in the morning to nine in the evening from Wednesday to Saturday but accommodates emergency cases beyond the operating hours and days. It offers comfortable and pleasant environment with air conditioning room; access to entertainment such as television; and access to food and drinks.

‘FMC Hemodialysis gears toward providing excellent services that promotes longevity of life and optimal care for patients with acute and chronic renal disease. We also strive to establish a trusting relationship with our patients together with their families and to empower them to take an active role on choosing their treatment. We make sure that our patient’s health and safety our top priority. To ensure these aims are being delivered, well-experienced registered nurses and nephrology residents are always present within the unit.’ [footnote 89]

15.1.2 A June 2021 article by Ala Ali, entitled, ‘Renal Transplantation in Iraq’, published by Transplantation (medical news journal) [footnote 90] , obtained from the Lippincott website (publisher of medical and nursing research) [footnote 91] , stated: ‘There are 35 hemodialysis centers with approximately 6000 patients on dialysis.’ [footnote 92]

15.1.3 The Erbil International Hospital, a private hospital in Erbil, can provide the following treatment services for people with kidney disease:

‘Erbil International Hospital’s Dialysis Centre provides specialised peritoneal and haemodialysis facilities for both inpatients and outpatients with chronic or acute chronic renal failure requiring treatment. This brand new state-of-the-art unit comprises of stations for regular dialysis treatments.

‘The focus of the centre is to provide quality clinical care and enhance the quality of life for our patients with Chronic Kidney Disease (CKD). Our competent and caring team of nephrologists, dialysis nurses and dietitians offer patients a warm, friendly and safe environment.’ [footnote 93]

15.2 Kidney transplants

15.2.1 The June 2021 article by Ala Ali, entitled, ‘Renal Transplantation in Iraq’, stated:

‘Currently, 8 renal transplant units are active in Iraq…The largest governmental center is the Nephrology and Renal Transplantation Centre, Medical City in Baghdad. Renal transplants are also performed at another unit in Baghdad, 1 in Basra, and 3 in Kurdistan. An additional renal transplant center in the Holy City of Najaf has been active until 2009. Two units have recently been established in the city of Karbala, in hospitals supported by religious authorities helping with management, donor support, and financial assistance for patients in need.

‘Until December 31, 2019, approximately 5400 renal transplants have been performed in Iraq. Annual numbers have been increasing, and approximately 650 transplants have been performed in 2019.’ [footnote 94]

16. Thyroid and other endocrinological diseases

16.1.1 The Farouk Medical City (FMC), has facilities to provide treatment for people with thyroid and other endocrinological diseases, as explained on its website:

‘FMC Endocrine and Diabetes Clinic diagnoses and treats patients with the following Endocrine Systemic Diseases and Disorders:

• Thyroid diseases
• Metabolic disorders
• Pituitary conditions
• Sex and fertility disorders
• Parathyroid, calcium and bone conditions
• Condition of the adrenal gland
• Cholesterol (lipid) disorders
• Abnormal growth disorders (short and tall stature)
• Neuro-endocrine conditions…’ [footnote 95]

16.1.2 The Best Thyroid Centre in Baghdad has facilities to provide treatment for people with thyroid diseases, as explained on its website:

‘The Best Thyroid Center Baghdad is a comprehensive medical facility dedicated to providing exceptional care for patients with thyroid disorders. It is a beacon of hope for those seeking expert diagnosis, treatment, and management of thyroid conditions, ensuring optimal health and well-being…

‘The Best Thyroid Center Baghdad adopts a holistic approach to thyroid care, encompassing a range of services:

a) Comprehensive Diagnosis: The center utilizes advanced diagnostic technologies, including ultrasound, thyroid scans, and fine-needle aspiration biopsy, to accurately diagnose thyroid conditions.

b) Personalized Treatment Plans: A team of experienced endocrinologists and surgeons collaborate to develop personalized treatment plans tailored to each patient’s unique needs.

c) Expertise in Thyroid Surgery: The center boasts skilled endocrine surgeons specializing in thyroidectomy, the surgical removal of all or part of the thyroid gland.

d) Ongoing Management and Support: The center provides continuous monitoring and management of thyroid conditions, ensuring long-term health and well-being.’ [footnote 96]

17. Palliative care

17.1.1 A 2020 medical research study, written by Samaher Fadhil and Hasanein Ghali, entitled ‘The Current Situation of Palliative Care Services in Iraq’, published on the Springer Link website, stated: ‘At the time of writing this document, national palliative care programs have yet to be established in Iraq, and there is only limited data available on this subject aside from that of healthcare providers working in the field of oncology, and primarily in pediatric oncology.’ [footnote 97]

17.1.2 A December 2023 Bahrain Medical Bulletin (Vol 5, No 4) article, entitled ‘Effectiveness of Instructional Program on Nurses’ Knowledge Concerning Palliative and Supportive Care for old Adults with Heart Failure’, stated:

‘Palliative care improves the quality of life of patients and that of their families who are facing challenges associated with life-threatening illness, whether physical, psychological, social or spiritual. The quality of life of caregivers improves as well. The concept of palliative care among Iraqi people and patients is primitive; the majority of them have no idea what palliative care is about. As long as there is no national palliative care program most of the medical health care providers themselves are also not familiar with palliative care it is not more than a terminology they had read about during under and postgraduate course if this ever happened.’ [footnote 98]

18. Tuberculosis (TB) and other lung diseases

18.1.1 A EUAA MedCOI 2020 response to an information request stated that inpatient treatment by pulmonologists (lung disease specialists) was available, for example at the Baghdad Teaching Hospital in Baghdad. Diagnostic testing of lung function was also available at private health facilities in Baghdad. [footnote 99]

18.1.2 A EUAA MedCOI 2020 response to an information request stated that the following drugs, used to treat chronic obstructive pulmonary disease, were available, for example at the Baghdad Teaching Hospital:

• Ipratropium
• Aclidinium Bromide
• Tiotropium [footnote 100]

18.1.3 A 2021 letter, written by various healthcare professionals to the editor of the International Journal of Tuberculosis and Lung Diseases, published on the Médicins Sans Frontiers (MSF) Science Portal stated:

‘In 2020, the Iraqi National Tuberculosis Programme (NTP), with the support of Medecins Sans Frontieres (MSF), introduced an all-oral, long DR-TB [drug-resistant TB] treatment regimen based on the new TB drug, bedaquiline (BDQ). This made Iraq one of the first Middle Eastern countries to provide access to better and safer DR-TB  treatment. Until recently, DR-TB treatment guidelines in Iraq recommended the older 18- 24-month long regimen comprising 6 - 8 months of injections. Loss to follow-up was at 20%, and irreversible hearing loss due to injectables and challenges in adverse events monitoring were common. In addition, DR-TB regimen design and treatment initiation were centralised in the capital, Baghdad…, contributing to delayed treatment initiation, and increased morbidity and transmission. This was exacerbated by common security issues, and the lockdown due to the current COVID-19 pandemic.

‘In Baghdad, MSF has collaborated with the NTP since 2018 to provide care to DR-TB patients and help improve overall DR-TB programmatic management through 1) laboratory support to increase access to diagnostics methods such as Xpert MTB/RIF [Mycobacterium tuberculosis/ Rifampin]… and line-probe assays; 2) technical support to healthcare workers for DR-TB regimen design, management and monitoring; 3) patient and community support by raising awareness, fighting stigma and patient empowerment; and 4) introduction/provision of new drugs, and other repurposed oral regimens, previously unavailable in the country.

‘In 2020, the Iraqi NTP was able to implement a paradigm shift in changing the DR-TB treatment with the introduction of BDQ [Bedaquiline] as part of an all-oral, long regimen for newly and previously diagnosed and treated patients with complex resistance profiles…Furthermore, the NTP expanded this access to highly vulnerable groups, including children, pregnant women and patients with comorbidities.’ [footnote 101]

18.1.4 The Faruk Medical City, a private hospital in Sulaymaniyah, has facilities to provide people who have lung diseases with diagnostic and therapeutic services, as explained on its website:

‘Our consultants provide diagnostic, and therapeutic services for the full spectrum of pulmonary diseases, disorders of breathing, and critical care illnesses. These services include:

• Physiologic assessment of the respiratory system
• Pulmonary functions at rest and during exercise
• Polysomnography
• Diagnostic and therapeutic fiberoptic bronchoscopy
• Diagnostic and therapeutic thoracentesis, pleural biopsy, and transthoracic needle aspirate
• Respiratory care for the patient on chronic ventilation therapy.’ [footnote 102]

18.1.5 The UNDP Iraq report, ‘New Intensive Care Unit for Respiratory Tract Infection Hospital supported by Canada opens in Sulaymaniyah’, dated 3 May 2023, stated:

‘A new Intensive Care Unit for Respiratory Tract Infection Hospital in Sulaymaniyah was inaugurated today, strengthening health infrastructure in the region and providing access to life-saving and specialized respiratory care services for over 730,000 residents.

‘…UNDP’s Funding Facility for Stabilization and the Government of Canada built the Intensive Care Unit for Respiratory Tract Infection Hospital and equipped it with advanced medical tools. The unit has 20 isolation rooms, each with a ventilator and humidifier, patient monitor, mechanical bed, and necessary medical devices and accessories. The hospital was also provided with a defibrillator, a video laryngoscope, an ECMO [extracorporeal membrane oxygenation] device, and generators.’ [footnote 103]

18.1.6 A WHO Eastern Mediterranean Region report, entitled ‘Yes! We can end TB!’, dated 24 March 2024, stated:

‘Iraq has made significant steps in the fight against TB through its partnerships with the National TB Program (NTP), WHO, International Organization for Migration, Iraqi Anti-TB Association and others…

‘One fundamental advance has been the shift in the treatment approach for drug-resistant TB since 2020, from a series of injections to an all-oral regimen. This move has improved treatment outcomes and lessened the burden on patients, marking a significant milestone in Iraq’s TB control efforts.

‘Another breakthrough has been the adoption of BPaL/M, a second-line treatment regimen which lasts only 6 months rather than 2 years. This innovative approach has been progressively implemented in both community and detention areas, offering renewed hope for more effective and accessible TB treatment in Iraq.

‘Central to Iraq’s success has been the implementation of a real-time, web-based and case-based platform on DHIS2. This serves as a tool for surveillance, electronic patient file archiving, and programme performance monitoring. This technology has revolutionized TB service delivery and monitoring, ensuring that patients receive timely and appropriate care.’ [footnote 104]

19. Musculoskeletal conditions

19.1.1 A EUAA MedCOI 2020 response to an information request stated that orthopaedic surgery could be carried out, for example at the Al Jadriya Hospital in Baghdad. Outpatient orthopaedic treatment was also available, for example at the Al-Wasity Specialist General Hospital in Baghdad. [footnote 105]

20. Mental healthcare

20.1 availability of facilities and treatment.

20.1.1 The 2023 DFAT report stated:

‘Mental health services are inadequate. There are two dedicated psychiatric hospitals in the country, Al-Rashad Psychiatric Hospital and Ibn Rushd Hospital, both located in Baghdad. There are psychiatric wards in some general hospitals, as well as some out-patient clinics, often run by international non-government organisations (NGOs) such as Medicins sans Frontieres. The absence of community-based mental health care means that often the only care available is family-based or in psychiatric institutions, which have been linked to inhumane treatment and degrading conditions.’ [footnote 106]

20.1.2 A letter written by Abdul Rahman Saied, Sirwan Ahmed, Asmaa Metwally and Hani Aiash (medical professionals), entitled ‘Iraq’s mental health crisis: a way forward?’ and published in the 7 October 2023 edition of the medical journal, The Lancet, stated:

‘For the past 20 years, mental health in Iraq has been a difficult issue to address as the country has faced wars, conflicts, and political instability… Over 20% of Iraqis have mental illnesses, and that percentage is steadily rising…

‘The mental health system in Iraq is not well developed. Iraq passed legislation governing mental health in 2005, but it has not been used to its full potential yet. There are only six specialised psychiatric hospitals in Iraq (two in Baghdad and four in the Kurdistan region), which do not even meet the bare minimum of the demand. Iraq has approximately 0.34 psychiatrists per 100,000 population. Iraq urgently needs mental health services as there is a severe lack of skilled personnel and poor infrastructure, which severely restricts access to care. Several difficulties confronting mental health workers include inadequate training, restricted access to resources, and social stigma against working in mental health. Because there is no public health insurance system to cover the entire population, the Iraqi people rely on the central government-run public health-care system…

‘There has been a gradual reduction in the stigma associated with mental health issues, leading more people to seek treatment.

‘However, the situation is far from ideal. There is a severe scarcity of mental health experts, and the Iraqi health-care system is still trying to keep up with population needs. Furthermore, many people in Iraq still do not have access to mental health services because of a scarcity of funding for such programmes.’ [footnote 107]

20.2 Availability of medication

20.2.1 A EUAA MedCOI 2020 response to an information request stated that the following drugs were available at the Al Namothajya Pharmacy in Diwaneya [a city in Al-Qadisiyyah governorate]:

• Mirtazapine (anti-depressant)
• Escitalopram (anti-depressant)
• Citalopram (anti-depressant)
• Sertraline (anti-depressant)
• Chlorpromazine (anti-psychotic)
• Alprazolam (anti-psychotic)
• Bromazepam (anti-psychotic)
• Diazepam (anti-anxiety) [footnote 108] .

20.2.2 A EUAA MedCOI 2020 response to an information request stated that amitriptyline, venlafaxine, imipramine, and paroxetine (anti-depressants) were available, for example at the Dawa Pharmacy in Baghdad. [footnote 109]

Research methodology

The country of origin information (COI) in this note has been carefully selected in accordance with the general principles of COI research as set out in the Common EU [European Union] Guidelines for Processing Country of Origin Information (COI) , April 2008, and the Austrian Centre for Country of Origin and Asylum Research and Documentation’s (ACCORD), Researching Country of Origin Information – Training Manual, 2013. Namely, taking into account the COI’s relevance, reliability, accuracy, balance, currency, transparency and traceability.

Sources and the information they provide are carefully considered before inclusion. Factors relevant to the assessment of the reliability of sources and information include:

• the motivation, purpose, knowledge and experience of the source
• how the information was obtained, including specific methodologies used
• the currency and detail of information
• whether the COI is consistent with and/or corroborated by other sources

Wherever possible, multiple sourcing is used and the COI compared and contrasted to ensure that it is accurate and balanced, and provides a comprehensive and up-to-date picture of the issues relevant to this note at the time of publication.

The inclusion of a source is not an endorsement of it or any view(s) expressed.

Each piece of information is referenced in a footnote.

Full details of all sources cited and consulted in compiling the note are listed alphabetically in the Bibliography .

Terms of reference

A ‘Terms of Reference’ (ToR) is a broad outline of the issues relevant to the scope of this note and forms the basis for the country information .

For this medical information note, the following topics were identified prior to drafting as relevant and on which research was undertaken:

• public - free or subsidised at point of entry
• private - pay at point of entry
• health insurance system - private, public and community based insurance systems, cost and contributions
• non-government organisation (NGO) provision and assistance
• costs to: consult a general practitioner, consult a specialist and receive treatment, contribute to an insurance scheme
• number, location and type of medical facility (and specialism) - primary, secondary and tertiary
• number and location in absolute and per head of population of nurses and doctors, including specialists
• provide links to medical, dental and other healthcare practitioners, and hospitals
• availability of therapeutic drugs
• accessibility of therapeutic drugs, cost and other factors affecting access
• number and location of pharmacies
• national programme for control and treatment
• availability of treatment: facilities, personnel and location
• accessibility: cost of treatment and other factors affecting access, such as location of particular treatment centres
• support in obtaining treatment from state, private or civil society sectors
• blood and immune system conditions, including sickle cell disease
• cardiovascular conditions
• Diabetes and other endocrinal, nutritional and metabolic conditions
• digestive tract conditions
• eye conditions
• gynaecological conditions
• kidney conditions
• liver conditions, including hepatitis
• mental health, behavioural and neurodevelopmental conditions
• musculoskeletal conditions
• oral and dental conditions
• neurological conditions
• palliative care
• paediatric conditions
• respiratory conditions, including tuberculosis
• skin conditions
• urological conditions

Bibliography

Sources cited.

Abusaib, Mohammed; Ahmed Mazyar; Nwayyir, Hussein; Alidris, Haider; Al-Abbood Majid; Al-Bayati, Ali; Al-Ibrahim, Salim; Al-Kharasan, Abbas; Al-Rubaye, Haidar; Mahwi, Taha; Ashor, Ammar; Howlett, Harry; Shakir, Mahmood; Al-Naqshbandi Murad; Mansour, Abbas, ‘ Iraqi Experts Consensus on the Management of Type 2 Diabetes/Prediabetes in Adults ’, 19 August 2020, PubMed Central. Last accessed: 17 June 2024

Al Alwan, Nada, ‘ The Current Situation of Palliative Care Services in Iraq’ , 30 October 2020, published by Springer Link. Last accessed: 7 August 2024

Al Tamimi and Co

‘ An overview of the new Iraqi Health Insurance Law’ , no date. Last accessed: 21 August 2024

‘Our Services’ , no date. Last accessed: 21 August 2024

Arab NGO Network for Development/American University of Beirut Faculty of Health Sciences, ‘ Right to Health in Iraq – Fragile structures and growing challenges’ , 2023. Last accessed: 6 June 2024

Bahrain Medical Bulletin, ‘ Effectiveness of Instructional Program on Nurses’ Knowledge Concerning Palliative and Supportive Care for old Adults with Heart Failure’ , December 2023. Last accessed: 17 June 2024

Cancer Care Specialties (MENA), ‘ Best Urological Oncology in Iraq’ , no date. Last accessed: 11 June 2024

Chatham House, ‘ Moving medicine in Iraq: The political economy of the pharmaceutical trade’ , 14 September 2022. Last accessed: 7 June 2024

Children’s Village

‘ The Children’s Village Impact in Iraq’ , no date. Last accessed: 26 July 2024

‘ History ’, no date. Last accessed: 16 August 2024

Denta Dental Clinic, ‘ Our Services’ , no date. Last accessed: 26 June 2024

Department of Foreign Affairs and Trade (Australian government), ‘Country Information Report – Iraq ’, 16 January 2023. Last accessed: 6 June 2024

English Medical Centre, ‘ Home’ , no date. Last accessed: 12 June 2024

Erbil International Hospital

‘ ENT Clinic’ , no date. Last accessed: 31 July 2024

‘ Dialysis Unit’ , no date. Last accessed: 31 July 2024

European Union Agency for Asylum (EUAA), ‘ MedCOI’ , no date. Last accessed: 30 December 2020

Expat Arrivals, ‘ Healthcare in Iraq’ , no date. Last accessed: 21 August 2024

Fadhil, Samaher; Ghali, Hasaneini , ‘The Current Situation of Palliative Care Services in Iraq’ , 30 October 2020, Springer Link. Last accessed: 11 June 2024

Faruk Medical City

‘ Cardiology Department’ , no date. Last accessed: 11 June 2024

‘ Chest and Respiratory Diseases Department’ , no date. Last accessed: 14 June 2024

‘Dialysis Center’ , no date. Last accessed: 13 June 2024

‘ ENT (Ear, Nose & Throat) and Skull Base Surgery Department’ , no date. Last accessed: 12 June 2024

‘ Neurology Department’ , no date. Last accessed: 12 June 2024

‘ Endocrinology and Diabetes Clinic’ , no date. Last accessed: 17 June 2024

‘ Gastroenterology’ , no date. Last accessed: 17 June 2024

‘ Emergency Services’ , no date. Last accessed: 19 June 2024

‘ Obstetrics and Gynecology (OB/GYN) Department’ , no date. Last accessed: 20 June 2024

‘ Ophthalmology Department’ , no date. Last accessed: 26 June 2024

Gastroenterology and Hepatology Teaching Hospital, ‘ About the Hospital’ , 2024. Last accessed: 31 July 2024

Heevie, ‘ Kurdish NGO provides free treatment to patients with rare diseases’ , 3 March 2023. Last accessed: 24 June 2024

Ibn Al Haytham, ‘ Ibn Al Haytham Eye Teaching Hospital’ , no date. Last accessed: 31 July 2024

In AR Consulting, ‘ Children’s Hospital, Basra’ , no date. Last accessed: 22 July 2024

International Journal of Surgery ‘The evolution of congenital heart disease surgeries in Iraq’ , July 2023. Last accessed: 12 June 2024

International Organisation for Migration Germany, ‘ Iraq Country Fact Sheet 2022’ , December 2022. Last accessed: 1 August 2024

Iraq Health Access Organisation, ‘What we do’ , no date. Last accessed: 24 June 2024

‘English Medical Center – About us ’, no date. Last accessed: 6 August 2024

‘ Erbil International Hospital – About us ’, no date. Last accessed: 6 August 2024

‘ About Us’ , no date. Last accessed: 13 June 2024

Transplantation, ‘ Renal Transplantation in Iraq’

‘Iraq Briefing’ , no date. Last accessed: 24 June 2024

‘ About us ’, no date. Last accessed: 26 July 2024

‘Iraq’s fragmented healthcare system “at the heart of the struggle to overcome war” ’, 2 December 2022. Last accessed: 26 July 2024

‘ About Us’ , no date. Last accessed: 16 August 2024

‘ Iraq’s AIDS infections surpass 2000; actual numbers likely higher’ , 9 April 2024. Last accessed: 13 June 2024

PAR Hospital

‘ About PAR Hospital ’, no date. Last accessed: 6 August 2024

‘ Cardiothoracic Center’ , no date. Last accessed: 26 July 2024

‘ PAR Hospital ’, no date. Last accessed: 6 August 2024

People’s Dispatch

‘ About ’, no date. Last accessed: 15 July 2024

‘ Iraqi health system struggles to recover after three decades of setbacks’ , 14 August 2023. Last accessed: 6 June 2024

Physicians for Human Rights, ‘Challenges Faced by the Iraqi Health Sector in Responding to COVID-19’ , 6 April 2021. Last accessed: 21 August 2024

PubMed Central, ‘Home’ , no date. Last accessed: 12 June 2024

Saied, Rahman; Ahmed, Sirwan; Metwally Asmaa; Aiash, Hani, ‘Iraq’s mental health crisis: a way forward?’ , published in the 7 October 2023 edition of The Lancet. Last accessed: 26 June 2024

Shafaq News, ‘ AIDS Struggle: insights across Iraqi governorates’ , 30 April 2024. Last accessed: 13 June 2024

Springer Link

‘ homepage ’, no date. Last accessed: 7 August 2024

‘ General Oncology Care in Iraq’ , 16 March 2022. Last accessed: 11 June 2024

Tesfahun H M, Moussally K, Al-Ani N A, Al-Salhi L G, Kyi H A, Simons S, Isaakidis P, Ferlazzo G, Pangtey H, Mankhi A A, letter entitled ‘Introduction of new drugs for drug-resistant TB in Iraq’, 2021, International Journal of Tuberculosis and Lung Diseases, ‘ MSF Science Portal ’, (to access the document, use the Google search-term ‘Introduction of new drugs for drug-resistant TB in Iraq’). Last accessed: 14 June 2024

Thyroid Surgery UAE, ‘ Best Thyroid Centre Baghdad’ , no date. Last accessed: 1 August 2024

Times Higher Education, ‘ University of Alkafeel’ , no date. Last accessed: 7 August 2024

United Nations Development Programme,

‘ New Intensive Care Unit for Respiratory Tract Infection Hospital supported by Canada opens in Sulaymaniyah’ , 3 May 2023. Last accessed: 1 August 2024

‘ New Cardiac Surgery Centre at Al Salam Hospital gives hope to thousands’ , 18 August 2021. Last accessed: 12 June 2024

‘ Improving Access to Maternal Care in Ramadi’ , 9 September 2021. Last accessed: 31 July 2024

‘ Doctors in the spotlight: Saving lives and reviving Iraq’s health system’ , 18 October 2023. Last accessed: 12 June 2024

University of Alkafeel, ‘ Dentistry Clinic’ , no date. Last accessed: 31 July 2024

University of Kerbala, ‘ University of Kerbala Dental Clinic’ , no date. Last accessed: 12 June 2024

World Health Organisation

‘ Data on Iraq’ , 2024. Last accessed: 14 June 2024

‘ 2021 Cervical cancer country profile’ , 17 November 2021. Last accessed: 6 June 2024

Eastern Mediterranean Region, ‘ New paediatric unit opens its doors for newborns and children in Akre Paediatric and Maternity Hospital in Duhok Governorate’ , 14 September 2022. Last accessed: 26 July 2024

Eastern Mediterranean Region, ‘Yes! We can end TB! ’, 24 March 2024. Last accessed: 14 June 2024

Sources consulted but not cited

Foreign, Commonwealth, and Development Office, ‘ Foreign travel advice – Iraq’ , 12 June 2024. Last accessed: 26 June 2024 

World Health Organisation, ‘Iraq’ , no date. Last accessed: 26 June 2024

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EUAA, ‘ Country of Origin Information’ (Medical country of origin information (MedCOI)), no date  ↩

People’s Dispatch, ‘ About ’, no date  ↩

People’s Dispatch, ‘ Iraqi health system struggles to recover after three decades…’ , 14 August 2023  ↩

IOMG, ‘ Iraq Country Fact Sheet 2022’ , December 2022  ↩

DFAT, ‘ Country Information Report – Iraq’ (page 8), 16 January 2023  ↩

Physicians for Human Rights, ‘ Challenges Faced by the Iraqi Health Sector…’ , 6 April 2021  ↩

Expat Arrivals, ‘ Healthcare in Iraq’ , no date  ↩

Al Tamimi and Co, ‘ Our Services’, no date  ↩

Al Tamimi and Co, ‘ An overview of the new Iraqi Health Insurance Law’ , no date  ↩

ANGOND/AUBFHS, ‘ Right to Health in Iraq – Fragile structures and growing challenges’ , 2023  ↩

WHO, ‘ Data on Iraq’ , 2024  ↩

Iraq Health Access Organisation, ‘What we do’ , no date  ↩

Heevie, ‘ Kurdish NGO provides free treatment to patients with rare diseases’ , 3 March 2023  ↩

MSF, ‘ Iraq briefing’ , no date  ↩

Springer Link, ‘ homepage ’, no date  ↩

Nada Al Alwan, Springer Link, ‘ General Oncology Care in Iraq’ , 16 March 2022  ↩

Chatham House, ‘ Moving medicine in Iraq: The political economy of the…’ , 14 September 2022  ↩

The National, ‘ About us ’, no date  ↩

The National, ‘ Iraq’s fragmented healthcare system “at the heart of the…’ , 2 December 2022  ↩

Zarya Construction Co., ‘ Faruk Medical City ’, no date  ↩

Faruk Medical City, ‘ Emergency Services’ , no date  ↩

UNDP, ‘ Doctors in the spotlight: Saving lives and reviving Iraq’s health system’ , 18 October 2023  ↩

Children’s Village, ‘ History ’, no date  ↩

Children’s Village, ‘ The Children’s Village Impact in Iraq’ , no date  ↩

WHO, ‘ New paediatric unit opens its doors for newborns and children…’ , 14 September 2022  ↩

International Journal of Surgery , ’The evolution of congenital heart disease surgeries…’ , July 2023  ↩

In AR Consulting, ‘ Children’s Hospital, Basra’ , no date  ↩

WHO, ‘ 2021 Cervical cancer country profile’ , 17 November 2021  ↩

Cancer Care Specialties (MENA), ‘ Best Urological Oncology in Iraq’ , no date  ↩

EUAA, MedCOI, BMA-13207, 18 January 2020  ↩

Faruk Medical City, ‘ Cardiology Department’ , no date  ↩

PAR Hospital, ‘ PAR Hospital ’, no date  ↩

PAR Hospital, ‘ About PAR Hospital ’, no date  ↩

PAR Hospital, ‘ Cardiothoracic Center’ , no date  ↩

EUAA, MedCOI, BMA-14239, 24 November 2020  ↩

EUAA, MedCOI, BMA-13207, 20 January 2020  ↩

EUAA, MedCOI, BMA-13726, 20 June 2020  ↩

EUAA, MedCOI, BMA-13958, 2 September 2020  ↩

UNDP, ‘ New Cardiac Surgery Centre at Al Salam Hospital gives hope…’ , 18 August 2021  ↩

University of Kerbala, ‘ University of Kerbala Dental Clinic’ , no date  ↩

Denta Dental Clinic, ‘ Our Services’ , no date  ↩

Times Higher Education, ‘ University of Alkafeel’ , no date  ↩

University of Alkafeel, ‘ Dentistry Clinic’ , no date  ↩

PubMed Central, ‘Home’ , no date  ↩

M Abusaib, M Ahmed, H Ali Nwayyir, et al, PMC, ‘Iraqi Experts Consensus… ;, 19 August 2020  ↩

EUAA, MedCOI, BMA-14281, 9 December 2020  ↩

Faruk Medical City, ‘ ENT (Ear, Nose & Throat) and Skull Base Surgery Department’ , no date  ↩

LinkedIn, ‘ Erbil International Hospital – About us ’, no date  ↩

Erbil International Hospital, ‘ ENT Clinic’ , no date  ↩

Faruk Medical City, ‘ Neurology Department’ , no date  ↩

EUAA, MedCOI, BMA-14133, 28 October 2020  ↩

LinkedIn, ‘English Medical Center – About us ’, no date  ↩

English Medical Centre, ‘ Home’ , no date  ↩

Faruk Medical City, ‘ Ophthalmology Department’ , no date  ↩

Ibn Al Haytham, ‘ Ibn Al Haytham Eye Teaching Hospital’ , no date  ↩

Faruk Medical City, ‘ Gastroenterology’ , no date  ↩

Gastroenterology and Hepatology Teaching Hospital, ‘ About the Hospital’ , 2024  ↩

Faruk Medical City, ‘ Obstetrics and Gynecology (OB/GYN) Department’ , no date  ↩

UNDP, ‘ Improving Access to Maternal Care in Ramadi’ , 9 September 2021  ↩

The New Region, ‘ About Us’ , no date  ↩

The New Region, ‘ Iraq’s AIDS infections surpass 2000; actual numbers likely higher’ , 9 April 2024  ↩

Shafaq News, ‘ AIDS Struggle: insights across Iraqi governorates’ , 30 April 2024  ↩

EUAA, MedCOI, BMA-13344, 23 February 2020  ↩

Faruk Medical City, ‘Dialysis Center’ , no date  ↩

Transplantation, ‘ About the Journal’ , no date  ↩

Lippincott, ‘ About Us’ , no date  ↩

Lippincott, Transplantation, ‘ Renal Transplantation in Iraq’ , June 2021  ↩

Erbil International Hospital, ‘ Dialysis Unit’ , no date  ↩

Faruk Medical City, ‘ Endocrinology and Diabetes Clinic’ , no date  ↩

Thyroid Surgery UAE, ‘ Best Thyroid Centre Baghdad’ , no date  ↩

S Fadhil and H Ghali, Springer Link, ‘ The Current Situation of Palliative Care…’ , 30 October 2020  ↩

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Tuberculosis

At a glance.

The domestic medical screening guidance is for state public health departments and healthcare providers in the United States who conduct the initial medical screening for refugees. These screenings usually occur 30-90 days after the refugees arrive in the United States. This guidance aims to promote and improve refugee health, prevent disease, and familiarize refugees with the U.S. healthcare system.

This guidance briefly describes the required overseas tuberculosis (TB) medical screening process for refugees resettling in the United States and outlines the recommended evaluation of newly arrived refugees for TB during the domestic medical screening examination. This document supplements CDC guidelines for the general U.S. population and highlights specific needs among refugees to be used in conjunction with guidance from state TB control programs.

• All refugee applicants must undergo evaluation overseas for TB and are assigned one or more TB classifications prior to departure. Overseas TB screening results, treatment, and classifications are documented on the US Department of State (DS) forms.
• As part of the domestic screening, all overseas medical records should be reviewed, a thorough medical history obtained, and a physical examination completed.

The United States has one of the lowest TB rates in the world and most U.S. residents are at minimal risk for TB 1 . However, the epidemiology of TB reflects persistent disparities by origin (country) of birth and race and ethnicity in the United States 1 . Origin of birth is a prominent risk factor for TB in the United States because of the substantially greater risk of exposure to TB outside the United States 2 . In 2023, 76% of cases in the United States occurred among non-U.S.-born persons 1 .

Studies have indicated that reactivation of latent tuberculosis infection (LTBI), rather than recent transmission, is the primary driver of TB disease in the United States, accounting for approximately 85% of all TB cases 1 2 . Therefore, it is important that clinicians identify and offer treatment for LTBI soon after arrival to prevent development of TB disease in refugees, and evaluation has shown that the domestic medical screening examination can be a highly effective method to identify LTBI 3 . The risk for development of TB disease appears to remain high for many years after resettlement, so clinicians who serve refugees, immigrants, and other newcomers should maintain a high index of suspicion for TB diseases even long after arrival 4 . Living conditions and other factors may place refugees at continued risk of exposure to TB. The prevalence of drug-resistant TB and extrapulmonary TB are also higher among non-U.S.-born persons 2 . Clinicians should consider these conditions when caring for new arrivals.

Overview of Overseas Tuberculosis Screening for Refugees

Before departure for the United States, all refugees must undergo an overseas medical examination that focuses on inadmissible conditions, including infectious TB disease. By law, refugees diagnosed with an inadmissible condition are not permitted to depart for the United States until the condition has been treated, unless they obtain a waiver from U.S. Citizenship and Immigration Services within the Department of Homeland Security. CDC stipulates the content of the overseas medical examination through Technical Instructions (TIs) issued to panel physicians and organizations that perform the medical screening examinations. Figure 1 outlines the required TB screening components for refugees being resettled to the United States from countries with a low or high burden of TB. For the purposes of screening, low burden is defined as any country with World Health Organization (WHO)-estimated TB disease incidence rate of < 20 cases per 100,000 population and high burden as any country with a WHO-estimated TB disease incidence rate of ≥ 20 cases per 100,000 population.

Figure 1. Overseas tuberculosis (TB) screening for applicants in low and high TB burden countries

• "Medical history"
• "Physical examination"
• "IGRA (or TST for applicants <2 years of age)"
• "Chest x-ray"
• "Three sputum specimens for smears and culture plus molecular testing of the first specimen"
• "Drug susceptibility testing"

*Countries with a World Health Organization-estimated tuberculosis disease incidence- rate <20 cases per 100,000 population.

IGRA = Interferon-gamma release assay

TST = Tuberculin skin test

• "IGRA or TST"
• "All applicants ≥15 years of age regardless of IGRA result"
• "Those <15 years of age with a positive IGRA, or signs or symptoms of tuberculosis, or known HIV infection"
• Three sputum specimens for smears and culture plus molecular testing of the first specimen

*Countries with a World Health Organization-estimated tuberculosis disease incidence rate ≥20 cases per 100,000 population.

Source: CDC Division of Global Migration Health, Tuberculosis Technical Instructions for Panel Physicians

Classifications and Travel Clearance

All refugee applicants must be assigned one or more TB classifications. TB classification is determined by screening results, and treatment, if required (see TB TI for panel physicians for the TB classifications and travel clearance for all refugee applicants).

Documentation of Overseas TB Evaluation

Panel physicians must document TB screening and treatment results on the DS 2054 ( Medical Examination ), DS 3030 ( TB Worksheet ), and DS 3026 ( Medical History and Physical Examination Worksheet ) forms. All medical documentation must be included with the required DS forms. Refugees receive copies of these documents and should provide them to the evaluating provider in the United States. In addition, the information is available through CDC's Electronic Disease Notification (EDN) system to state or local health departments at refugees' U.S. destinations. Evaluating providers in the United States who are not receiving this information should contact the state refugee coordinator or state refugee health program. Overseas medical documents include information pertinent to the TB evaluation, such as:

• Medical history and physical examination
• The interferon-gamma release assay (IGRA) laboratory report or TB skin test (TST) documentation (including name of product, expiration date, amount administered), if either of these tests was conducted
• Radiology report of digital chest X-ray (CXR) findings for all applicants aged ≥15 years, and for younger applicants when conducted
• DICOM chest X-ray image, if CXR conducted
• Sputum acid-fast bacilli (AFB) smear, molecular testing, and culture results for TB, if such testing was conducted
• Drug susceptibility test results for Mycobacterium tuberculosis complex isolate
• Direct observed therapy regimen received, including does of all medications, start and completion dates, and periods of interruption
• Radiology reports of CXR findings before, during and at the end of treatment
• Sputum AFB smear reports obtained before, during, and at the end of treatment
• Reports of culture findings obtained before, during, and at the end of treatment, including reports of contamination
• Reports on clinical course, such as clinical improvement or lack of improvement, during and after treatment

Treatment for LTBI is not required as part of the overseas medical examination but may be offered by the panel physician on a voluntary basis if the panel physician is able to do so. CDC encourages applicants diagnosed with LTBI overseas to seek treatment. Panel physicians are instructed that they may offer voluntary LTBI therapy to contacts of tuberculosis cases, who are diagnosed with LTBI, if the panel physician is able to do so. In addition, directly observed preventive therapy is recommended overseas for applicants <4 years old or with impaired immunity (e.g., HIV infection) who are contacts of a person with known infectious TB disease and who have a negative evaluation for TB disease, regardless of IGRA results. If overseas treatment is provided, it should be documented on the DS forms and available in EDN. For more information, see the Technical Instructions .

Domestic Refugee Screening for Tuberculosis

All refugees should receive a comprehensive domestic medical screening within 90 days of arrival. The goal of the domestic screening for TB is to find persons with LTBI, and to find persons who may have developed TB disease since the overseas medical examination, to facilitate prompt treatment and prevent transmission.

Medical History and Physical Examination of Refugees for Tuberculosis during the Domestic Medical Screening Evaluation

TB disease should be encountered infrequently during the domestic medical screening examination because all new refugee arrivals have been screened for TB disease prior to departure. Clinicians should be aware that the overseas medical exam is aimed at diagnosing infectious TB disease and may fail to detect all forms of extrapulmonary disease. Therefore, it is important for clinicians to perform a thorough history and physical examination aimed at identifying any refugee who may have pulmonary or extrapulmonary TB disease. Some persons with TB disease have minimal symptoms, and a high index of suspicion should be maintained for those with any concerning history, such as household exposure to TB, or signs of active disease.

All predeparture medical records for the refugee should be closely reviewed. A thorough medical history should be obtained post arrival. In addition to current signs or symptoms of TB disease (e.g., weight loss, night sweats, fever, cough), specific information may be helpful in recognizing persons who might have TB disease or LTBI:

• Previous history of TB
• Prior treatment suggestive of TB treatment
• Prior diagnostic evaluation suggestive of TB
• Family or household contact with a person who has or had TB disease, treatment, or diagnostic evaluation suggestive of TB

In addition, in children, a history of recurrent pneumonias, paroxysmal wheezing, failure to thrive, or recurrent or persistent fevers should increase the index of suspicion.

Signs and symptoms of pulmonary TB are often indolent and nonspecific, and include malaise, weight loss, night sweats, cough, chest pain, fever, and hemoptysis. Symptoms of extrapulmonary TB disease generally reflect the organ involved (e.g., abdominal pain with gastrointestinal TB). Although extrapulmonary TB can be found in nearly any organ of the body, lymph nodes, including those in the thorax, are the most common extrapulmonary sites.

For general guidance on the physical examination, see History and Physical Examination Screening Guidance . The examination for TB should include inspection and palpation of all major palpable lymph node beds and a careful skin examination, as it may reveal cutaneous disease, erythema nodosum, scars from scrofula, or hints of prior chest surgery.

Testing Newly Arrived Refugees for TB Infection and Disease

Domestic TB testing recommendations are based on signs and symptoms of TB and the results of screenings refugees received overseas.

• Any new arrival with signs or symptoms of TB, regardless of country of origin, should undergo clinical evaluation for TB disease.
• If no IGRA (or TST) was completed overseas (or result was indeterminate*), and there are no signs or symptoms of TB disease upon physical examination, conduct TST. Skin testing and interpretation should be completed in accordance with the ATS/CDC/IDSA Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and Children .
• If IGRA (or TST) was negative overseas (within the last 6 months), and there are no signs or symptoms of TB disease upon physical examination, no further domestic evaluation is needed.
• If the overseas IGRA (or TST) was negative but performed ≥6 months prior to the domestic examination, and there are no signs or symptoms of TB, conduct TST.
• Treatment for LTBI should be offered after TB disease is ruled out for those with positive IGRA (or TST) results (if there are no contraindications).
• If no IGRA (or TST) was completed overseas (or the IGRA result was indeterminate*), and there are no signs or symptoms of TB disease upon physical examination, conduct IGRA.
• If the overseas IGRA (or TST) was negative but performed ≥6 months prior to the domestic examination, repeat IGRA (or TST).

*The U.S. Food and Drug Administration (FDA) has approved two TB blood tests that are commercially available in the United States: QuantiFERON®-TB Gold Plus (QFT-Plus) and T-SPOT®.TB test (T-Spot). While QFT-Plus can provide a positive, negative, or indeterminate result, the T-spot test can provide a positive, negative, invalid, or borderline result. For this guidance, invalid or borderline results may be interpreted as indeterminate.

Additional Testing Considerations

• If overseas evaluation occurred <8 weeks after contact ended and the IGRA (or TST) was negative or indeterminate, refugees assigned Class B3 TB should be evaluated domestically with IGRA (or TST) at least 8 - 10 weeks after contact ended.
• Living conditions and other factors may place refugees at continued risk of exposure to TB after the overseas examination while still overseas or after arrival in the U.S. During the history and physical exam, clinicans should consider inquiring about risk factors for continued exposure and repeating LTBI screening if negative or indeterminate overseas, if necessary.

Testing for Infection

Tb blood tests (interferon gamma release assay [igra]).

An IGRA is a blood test used to determine if a person is infected with M. tuberculosis . IGRAs measure a component of cell-mediated immunity reactivity to M. tuberculosis in fresh whole blood. Food and Drug administration-approved IGRA tests are recommended for TB testing in the United States. It is important to note that IGRA should not be performed on a person who has written documentation of either a previous positive TB test result (IGRA or TST) or treatment for TB disease. For additional information on TB blood tests, refer to the C linical Testing Guidance for Tuberculosis: Interferon Gamma Release Assay .

Mantoux Tuberculin Skin Test (TST)

The TST is performed by injecting a small amount of a standardized fluid (called tuberculin PPD solution) under the skin, usually on the volar surface of the forearm. A person given the tuberculin skin test must return within 48 to 72 hours to have a trained health care provider look for a reaction on the arm. In otherwise healthy refugees from areas of the world where TB is common, ≥10 mm of induration is considered a positive result. A cutoff of ≥5 mm of induration is considered a positive result in persons with HIV infection, those with recent close contact with a known case of infectious TB, persons with fibrotic changes on CXR consistent with prior TB, persons with organ transplants, and other immunosuppressed persons (see CDC’s Clinical Testing Guidance for Tuberculosis: Tuberculin Skin Test ). Many refugees from TB-endemic areas have been vaccinated against TB with BCG vaccine. IGRA is preferred for testing persons who have been vaccinated with BCG. Although previous BCG vaccination may influence TST results, especially in infants, a history of vaccination with BCG should not influence interpretation of TST results in adults. Some refugees may believe their test is positive due to past BCG vaccination, but clinicians should be prepared to thoroughly explain the reasons for not considering BCG vaccination in the interpretation of TST or IGRA results (for more information, see CDC’s Tuberculosis Vaccine webpage ). For additional information about performing a TST, visit the CDC Mantoux Tuberculin Skin Test Toolkit .

A summary of recommended uses, benefits, and limitations for IGRA and TST can be found in the ATS/CDC/IDSA Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and Children . It should be noted that a negative IGRA or TST result does not exclude TB disease from the differential diagnosis in a person with signs or symptoms of TB disease. Additionally, a positive test result, from either IGRA or TST, should be accompanied by an evaluation for TB disease with a thorough history and examination for signs and symptoms and a CXR.

Diagnostic Evaluation

Chest radiography (cxr).

Any patient with signs or symptoms of TB disease should have a CXR. If CXRs from the overseas medical exam are available and there has been no change in clinical status (no new signs or symptoms of pulmonary or extrapulmonary TB disease or new positive TB infection test), there is no need to repeat the CXR. However, clinical judgment should be used in each case. If documentation is not available at the initial screening visit, providers should contact their State Refugee Coordinator, or the CDC ( [email protected] ) to obtain overseas testing results. If overseas CXR results cannot be obtained, or the test was done >6 months prior and the result was negative, repeat CXR should be considered.

Confirmed LTBI

Some states require LTBI reporting. Asymptomatic refugees with positive IGRA or TST results and normal findings on CXR should be offered LTBI treatment in accordance with CDC guidelines 5 . Information on how to choose the most effective treatment regimen for each patient, adverse drug effects, monitoring, and assessing adherence is available on the CDC’s Treatment Regimens for LTBI webpage .

Suspected or Confirmed TB Disease

Screening results indicating TB disease may include a combination of positive results from IGRA or TST, abnormal findings on CXR, pathology findings consistent with TB disease (e.g., caseating granuloma), signs or symptoms consistent with TB disease, sputum or tissue smear positive for AFB, a positive nucleic acid amplification test, or a culture positive for M. tuberculosis complex. Prompt treatment should be initiated for presumptive or confirmed clinical TB disease. All presumptive or confirmed cases (pulmonary or extrapulmonary) should be reported to the local health authorities within 24 hours of determination so that appropriate public health measures can be implemented and management with an infectious disease or TB expert can be implemented. Culture confirmation is not needed before starting therapy for cases with a high index of suspicion. When pulmonary or laryngeal TB is suspected, the person should be isolated in an appropriate setting to prevent spread of infection until the patient is no longer considered infectious.

Tuberculosis Treatment

A complete discussion of treatment for TB disease and LTBI is beyond this scope of this guidance document; however, more information on treatment can be found at: Treatment for TB disease webpage and Treatment Regimens for Latent TB Infection webpage . The CDC recommends use of directly observed therapy (DOT) during TB treatment, and video DOT (vDOT) is recommended as an equivalent alternative to in-person DOT for patients on treatment for TB (see CDC Video Directly Observed Therapy During Tuberculosis Treatment ).

Domestic Tuberculosis Screening for New Arrivals Other than Refugees

The introduction of alternative pathways to enter the United States has allowed parolees, asylees, and some migrants eligibility for financial assistance to cover the cost of the domestic medical exam. However, providers should be aware that the overseas medical screening provided to individuals in these groups may differ from the screening provided to refugees. Providers should review the past medical history for these individuals to fully understand the TB screening and treatment that was provided overseas. While this domestic TB guidance was written primarily to address the evaluation of refugees, it can also be used as a reference tool for completing the physical examination and TB screening for other new arrivals.

Additional Information

Additional information regarding tuberculosis can be found on the CDC’s Clinical Overview of Tuberculosis webpage.

• Williams P.M., et. al., Tuberculosis – United States, 2023. MMWR Morb Mortal Wkly Rep 2024;73:265-270.
• Centers for Disease Control and Prevention (CDC). Reported tuberculosis in the United States, 2021. Atlanta, GA: US Department of Health and Human Services, CDC; 2022.
• Nuzzo, J.B., et. al., Postarrival Tuberculosis Screening of High-Risk Immigrants at a Local Health Department, American Journal of Public Health 105, no. 7 (July 1, 2015): pp. 1432-1438.
• Tsang, C.A., et al., Tuberculosis Among Foreign-Born Persons Diagnosed >/=10 Years After Arrival in the United States, 2010-2015. MMWR Morb Mortal Wkly Rep, 2017. 66(11): p. 295-298.
• Sterling, T.R., et al., Guidelines for the Treatment of Latent Tuberculosis Infection: Recommendations from the National Tuberculosis Controllers Association and CDC, 2020. MMWR Recomm Rep, 2020. 69(1): p. 1-11.

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