There has been significant deterioration in infrastructure: more than 3 decades of humanitarian crises, mass population displacement, migration, unemployment and poverty, have exacted a high toll.

As health system components eroded a constellation of new arrangements emerged. The health system is now moving away from the old model and introducing greater decentralization. Accepting the inevitability of structural change is the first step towards steering changes in a positive direction.

Robust action at the federal and governorate levels is needed to tackle public health issues and adequate resources need to be allocated if clear structures are to be put in place to implement and monitor interventions.

A major objective of WHO support in 2018 was to provide technical and financial support for the development and implementation of evidence-based health policies capable of making substantial contributions to universal health coverage.

The priorities for health system development in Iraq are based on the Framework for action on advancing universal health coverage in the Eastern Mediterranean Region and the Iraq recovery and resilience programme.

Interventions centre on the following projects:

• the phased Iraq Public Sector Modernization Programme;
• universal health coverage, and the comprehensive health information systems needed to measure health needs and outcomes; and
• the Health in All Policies approach to help tackle problems such as road traffic accidents, gender-based violence and environmental risks and address the underlying social determinants of health.

The scope and direction of interventions is determined by:

• an adult literacy rate estimated at 43.7%, overall unemployment of 8.2%, and youth (15–24) unemployment of 18%;
• in 2017, 5.8 million Iraqis were under 5 years of age, 21.6% between 15 and 24 years and 1.2 million 65 years or older;
• Iraq was ranked 120 out of 189 countries and territories in the 2018 human development index;
• 18.9% of the population live at or below the poverty line (2016);
• an estimated 1.7 million people are currently in need of humanitarian assistance, including 250 000 Syrian refugees;
• the erosion of infrastructure and public services disproportionately affects the most vulnerable – women, children, older people, the injured, displaced and people with physical disabilities; life expectancy at birth is 71.1 years;
• of children aged under 5 years, 8% are moderately or severely underweight and 22.1% are stunted (UNDP 2018);
• 50 mothers die during childbirth per 100 000 live births;
• 76% of total deaths are due to noncommunicable diseases, 10% due to communicable diseases, maternal, perinatal and nutritional conditions and 14% are a result of injuries;
• mortality due to armed conflict has been estimated at 500 000 between 2003 and 2011 − 128 per 1000 people for females and 195 per 1000 for males (UNDP 2018);
• immunization coverage among 1-year-olds is 84%;
• 57% of mothers receive at least one antenatal visit from a health care worker;
• there are 8.4 physicians and 19.4 nurses per 10 000 population;
• general government expenditure on health is 4.8% of GDP; and
• there are 2765 primary health centres (7.2 per 100 000); 281 public hospitals (0.7 per 100 000) and 13.8 hospital beds per 10 000 population.

Areas prioritized for support include:

• technical and capacity building to formulate a clear roadmap towards universal health coverage;
• working alongside the Ministry of Health to develop stronger governance, institutional arrangements, managerial and leadership capacity and widen engagement with all stakeholders in inclusive policy dialogue and dynamic sector development;
• strengthening regulatory capacity; and
• strengthening national health information systems to better feed into evidence-based decision-making.

To ensure Iraq’s health information system provides reliable and timely data a comprehensive health information system (HIS) assessment was conducted to monitor the country’s health development agenda and enhance its reporting on the WHO Global reference list of 100 core health indicators (plus health-related Sustainable Development Goals), and the 75 core health indicators in the Regional Framework for health information systems.

The assessment allowed weaknesses and strengths in monitoring and evaluation to be identified. In line with assessment recommendations WHO is supporting the Ministry of Health as it installs the District Health Information System 2 (DHIS2) and trains 15 health service workers to customize Iraq’s data collection.

WHO supported the Ministry of Health standardize national data collection forms. In 2018 and 2019 WHO helped enhance the capacity of 207 health workers from the Iraqi Ministry of Health, the Kurdistan Regional Government Ministry of Health and directorates of health to ensure the generation, availability and accessibility of timely information on key health indicators which will facilitate the monitoring of Sustainable Development Goal health targets. To improve the health information management system 41 staff­, national and local, were trained in electronic data collection and analysis.

To strengthen the National Blood Transfusion service, WHO and the Iraqi Ministry of Health conducted a blood safety assessment, trained 30 hematologists and blood bank directors and developed an action plan to address gaps and weaknesses, including frequent interruptions in supplies, to better ensure the availability, accessibility and affordability of blood supplies.

WHO supported the Ministry as it reviewed medical supply procurement practices and ways to improve the availability of essential pharmaceuticals and other health products. An action plan has been developed to address the gaps identified in current medical supply procurement practices, and implementation has commenced. A follow-up evaluation will be conducted to assess progress and support is being provided to the Ministry and other stakeholders as they gauge capacity to conduct Iraq’s first market survey of substandard and falsified medicines, including the design of the survey protocol by the National Medical Regulatory Authority.

Thirty health workers, from the national core team, the Kurdistan Region Ministry of Health, and local governorates received training to facilitate the finalizing of the mapping phase of the 2018 Iraq Health Account.

To improve quality and accreditation in health care services WHO supported the Ministry’s assessment of care and patient safety in 4 primary health care facilities and 2 hospitals. As a result of the assessment a roadmap was developed to improve standards in hospitals and primary health care centres.