title: Doctors as the governing body of the Kurdish health system: exploring upward and downward accountability among physicians and its influence on the adoption of coping behaviours.
abstract: BACKGROUND
  The health system of Iraqi Kurdistan is severely understudied, particularly with regard to patient-physician interactions and their effects. We examine patterns of behaviour among physicians in Kurdistan, the justifications given and possible enabling factors, with a view to understanding accountability both from above and below.
  
  
  METHODS
  An ethnographic study was conducted in the Sulaimaniyah Teaching Hospital in the Kurdistan Region of Iraq. Data was collected through negotiated interactive observation, and interviews were conducted with 10 participants, 5 physicians and 5 patients. Data collected was analysed using thematic analysis.
  
  
  RESULTS
  Common patterns of practice among physicians in Kurdistan include displays of discontent, reluctance to negotiate decisions with patients and unfavourable behaviours including dual practice and predatory behaviours towards patients. These behaviours are justified as a mechanism of dealing with negative aspects of their work, including overcrowding, low salaries and social pressure to live up to socially conceived ideas of a physician's identity.
  
  
  CONCLUSIONS
  Michael Lipsky's theory of street-level bureaucrats and their coping behaviours is a useful way to analyse the Kurdish health system. Physician behaviours are enabled by a number of factors that work to enhance physician discretion through lowering of upward and downward accountability. Physicians are under very little pressure to change their behaviour, and as a result, they effectively become the street-level governing body of the Kurdish health system.
authors.affiliation: Department of Family and Community Medicine, University of Sulaimaniyah, Sulaimaniyah, Kurdistan Region, Iraq. gkaradaghi@hotmail.co.uk.
authors.forename: Goshan
authors.initials: G
authors.lastname: Karadaghi
authors.affiliation: Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK. c.willott@ucl.ac.uk.
authors.forename: Chris
authors.initials: C
authors.lastname: Willott
mesh_terms: D000223:Adaptation, Psychological; D003695:Delivery of Health Care; D005006:Ethnicity; D006801:Humans; D007493:Iraq; D007588:Job Satisfaction; D007857:Leadership; D010817:Physician-Patient Relations; D010820:Physicians; D012941:Social Responsibility