The establishment of regular and professional healthcare is regarded by many as being the most pressing of all needs for post-war Iraq. The current healthcare system is currently in a state of ruin, suffering from a lack of equipment, depleted ranks of trained personnel - with many having fled the country - and an overall poor standard of care. The principal areas that require improvement are cardiovascular treatment capability, general hygiene products, dialysis and a lack of functional laboratories.

The healthcare system supported by Saddam Hussein was riddled with corruption, healthcare quality varying according to ethnic region. Southern regions of Iraq, mainly populated by Shiite Muslims, had higher infant mortality rates than Baghdad, while health standards in the city of Kirkuk were manipulated. Companies wishing to sell pharmaceutical products to the Iraqi Ministry of Health were required to offer a 'service charge' of 10 per cent.

There are approximately 240 hospitals operating in Iraq, with around 1,200 primary healthcare clinics also in the country. Since March 2003, 49 hospitals and clinics have been rehabilitated, with plans for a further 131 units to also be improved. Most of the equipment at the hospitals and clinics is either broken, outdated or inadequate, with the better services generally located around Baghdad and the country's northern regions.
Iraq's Ministry of Health has a professional staff of around 100,000, over 80 per cent of which are female. A large percentage of Iraq's healthcare professionals are specialised in their respective fields, with a severe lack of primary healthcare workers. Additionally, there is a distinct lack of first-tier pharmaceuticals available.

Following the conflict in Iraq and the overthrowing of the country's previous regime, it was only through quick action from the former Coalition Provisional Authority (CPA), the US Agency for International Development (USAID) and a number of other international relief agencies that a public health crisis was averted. These parties have since been able to restore the Iraqi healthcare system to its pre-war levels. Over $40 million has been spent on 128 generators for healthcare sites, with over 13,000 tons of pharmaceutical supplies delivered since May 2003. Existing medical equipment has been surveyed and repaired where possible.

A number of programs have been undertaken by the Ministry of Health to foster international assistance, including the recent 'Adopt a Hospital' program and the 'Monthly National Immunisation Day' program, under which three million children have been vaccinated. The United Nations Children's Fund (UNICEF) has been heavily involved in delivering vaccines, with 1.4 million doses of vaccinations delivered since July 2003. An additional 30 million doses have been procured with the aid of both UNICEF and USAID.
 
 
Malnutrition is also a major issue in Iraq, particularly in the southern and central regions, where almost a third of children are sufferers. Many women in these regions suffer from Anaemia. Child mortality rates are high, through a combination of low breast-feeding levels, low birth weights, diarrhoea and respiratory infections.

The Iraqi healthcare system under the previous regime was highly centralised, tending to concentrate on curing illnesses as opposed to looking to prevent them. Decentralisation of the management system has been deemed a priority. Other targets include the establishment of a body to oversee healthcare standards and to license healthcare professionals that will adhere to those standards; the incorporation of definitive legislation, updating whatever regulations are already in place. Satisfactory training and education programs also need to be put in place, along with the necessary infrastructure to enable healthcare management, planning and finance.

Iraq Health System

The health system in Iraq will aim to promote health and improve access to quality health care irrespective of ethnic, religious or geographic origin or socioeconomic status. It will also aim to improve management of the health sector. A clear vision is needed to translate the principle objective of the new health system into concrete policies and strategies. The MOH established, for this purpose, a process of ten working groups and a steering committee which operated from October 2003 to January 2004. The groups proposed a consolidated vision which describes the desired features of the future health system in Iraq. The suggested overall vision is included in a document drafted in April 2004 [1] . It describes a system which is people-centred, giving citizens choice and makes them responsible for their own health. Seven core elements are identified: population empowerment, community involvement, integrated health services with emphasis on primary health care, financial risk protection (equity), health provider management autonomy, quality improvement, and human resources development. While the proposed vision provides the basis for wider and more in-depth discussion on the future shape of the Iraqi health system and requires long-term planning, there is a pressing need for focusing on the current needs and for adopt concrete strategies to address the enormous challenges currently facing the health sector in the reconstruction phase. The following are our immediate needs and strategies. They are based on the analysis of the current health situation and a series of meetings and discussion sessions with health officials, members of the health profession, other related sectors, as well as international partners.
Short- and medium-term strategies (covering the period 2004 - 2007)
They include five areas for action:

• Meeting urgent needs and improving services
• Strengthening management
• Developing and implementing a 4 year plan for reconstruction
• Training and capacity building
• Mobilizing resources
• Meeting urgent needs
  

These needs represent urgent priorities requiring immediate action. In some of the areas mentioned below, action has already been initiated. In others, action should be taken as soon as possible in 2004. It is hoped that these urgent needs should be met by the end of 2005.

• Addressing shortages in medicines and urgent supplies
• Upgrading emergency services including obstetric care
• Increasing immunization coverage
• Upgrading blood transfusion services
• Establishing a more efficient information system
• Improving communications
• Improving food safety measures
• Re-organizing the pharmaceutical sector
• Conducting an in-depth review of primary care
• Strengthening disease surveillance system
• Intensifying communicable disease control activities
• Meeting most urgent rehabilitation needs
• Developing a plan for human resources development and attending to urgent organizational and coordination issues 2. Strengthening management
  

Reconstruction of the health system cannot be achieved without drastic changes in the management of the health sector. There is currently limited capacity in planning, budgeting, finance and management functions of the Ministry of Health. Management practices are often bureaucratic and generally outdated. Corruption and financial irregularities are widespread. Action should be initiated immediately. It will focus on:

• Restructuring to respond to strategies
• Institutionalizing values like transparency, openness, equality and participation
• Strengthening capacity in planning, management and procurement; modernizing budgeting and finance functions
• Building capacity in decentralization and leadership development
• Changing to evidence-based decision-making, performance appraisal, monitoring and evaluation
• Overcoming corruption
  

3.Developing and implementing a four year plan of reconstruction of the health sector
The Needs Assessment report of the United Nations and the World Bank, developed in collaboration with Iraqi Ministries, provides an outline of reconstruction needs and financial requirements. However, careful analysis of available data and experience gained over the last few months demonstrated the need for a more reliable assessment of needs. The process has already begun and is currently providing a more clear vision on the physical infrastructure of the health sector. A four year plan is being developed and action has already been initiated in some areas. The plan focuses on:

• Re-visiting reconstruction requirements and prioritizing
• Developing standards for rehabilitation and new construction
• Strengthening capacity in project management and implementation
• Strengthening coordination with partners
  

4. Training and capacity building
Training and capacity building of health professionals and management staff is a top priority. The four areas which require special emphasis are:

• Training and capacity building in management
• Strengthening capacity in public health and related branches like health planning, economics, financing, and other areas
• Training in clinical skills
• Upgrading health professional education (basic, post-graduate, continuing)
  

5. Mobilizing resources
The regular budget of the Ministry of Health can only meet the cost of salaries, operating expenditure, and the medicines bill. There are no reconstruction funds. Policy makers must recognize that investment in health is a strategic priority for Iraq. It is a prerequisite to sustainable development. The current expenditure on health, as a proportion of GDP, is considerably lower than neighboring countries like Jordan and Lebanon and must therefore increase. At the same time, much of our funding requirement for rehabilitating the physical infrastructure of the health sector will depend on donor funding. Thus, our strategy should focus on effective action to mobilize funds at the national, regional, and international levels.
The following represent basic areas of action:

• Raising commitment to the health sector
• Improving information on current status and needs
• Intensifying work with the media
• Strengthening donor partnerships and coordination
• Encouraging partnerships with non-governmental organizations and communities.