Although widespread public health and developmental progress has been made in recent decades, women, children and adolescents still face numerous health challenges and risks.

In the past 25 years, the population of Iraq has increased by more than 50% to about 40 million in 2018 according to most recent civil society organization data, with about 30% of the population living in rural settings¹.

The population is young, with 13.9% children less than 5-years of age and 22.3% adolescents aged 10–19 years old. Women of reproductive age (15-49) represent 24.7% of the total population¹.

Iraq is among 10 countries in the Eastern Mediterranean Region in terms of total fertility rate 3.6 and adolescent fertility rate 70/1000 15-19 girls.²

Decades of conflict, sanctions and political instability have slowed Iraq's progress in reducing child and maternal mortality but improving maternal and child health is a priority in the Ministry of Health’s strategic plans. Reproductive health services are improving after decline following the 2003 conflict but access to reliable data remain somewhat limited.

The UN Inter-Agency Group Estimate for Maternal Mortality Ratio shows a decline in the maternal mortality ratio (MMR) from 107 to 50 per 100 000 live births between 1990 and 2015, while according to the Iraq Poverty Map and Maternal Mortality Survey, the maternal mortality ratio was 35.7 per 100 000 live births in 2013.

Fig. 1. Trend of maternal mortality ratio, 1990–2015

Direct causes of maternal mortality according to Ministry of Health statistics for 2017 were:

haemorrhage (32.4%)

pre-eclampsia/eclampsia (14.5%)

thromboembolism (14.4%)

rupture uterus (4.7%)

sepsis (4.4%).

Early age of marriage and adolescent pregnancy negatively impact on the socioeconomic status of those women and their families; putting an under-served population in a more vulnerable context.

Fig. 2. Trend in under-5 mortality and neonatal mortality, 1990–2017

The Ministry of Health has adopted several policies and strategies in favour of maternal and child health with a vision that the health of women and children is the key to progress towards all development goals; investing more in their health will help building peaceful and productive societies and reduces poverty.

Following are some of the major policies and strategies introduced and currently being implemented:

National Health Policy (2014–2023)

Reproductive, Maternal, Newborn, Child and Adolescent Health Strategy (2016–2020)

Iraq Every Newborn Action Plan (2016–2020)

Iraq Nursing and Midwifery Strategy and Action Plan (2017–2027)

National Nutrition Strategy (2012–2021)

National Code of Marketing Breast Milk Substitutes, 2016.

National Strategic Plan of HIV/AIDS (2016–2020)

Maternal Death Surveillance and Response, 2012.

Adolescent health services for young people (10-24 years) are still neglected in the public sector. The lack of sustainable programme within the Ministry of Health and the overlap of the services among different programmes such as maternal and child health, noncommunicable diseases and school health represent one of the main obstacles. Trials to integrate the programme within school health since it is the section which cover most of the adolescent had been tried at 2013 which needed further restructuring and integration work within the Ministry of Health.

Fig. 3. Adolescent health profile

Maternal and perinatal death surveillance and response.

Child health and development.

Adolescent/youth health and development.

Adoption/update and implementation of WHO guidelines regarding reproductive, maternal, newborn child and adolescent health.

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¹ WHO 2015. Trends in maternal mortality: 1990 to 2015. Estimates by WHO, UNICEF, UNFPA, the World Bank and the United Nations Population Division. Geneva. 2015.

² Civil society organizations, UNFPA Iraq, 2013. Iraq Poverty Map and Maternal Mortality Survey, 2013.

³ Ministry of Health 2017. Annual Statistics Report 2017.

⁴ WHO Regional Office for the Eastern Mediterranean 2018. Framework for health information system and core indicators for monitoring health situation and health system performance, 2018.

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.

The World Health Organization (WHO) provides technical and logistical support to the Ministry to control many communicable diseases, including tuberculosis (TB), hepatitis, HIV/AIDS and neglected tropical diseases, and to tackle antimicrobial resistance, collect communicable disease surveillance data and help ensure adequate response to outbreaks.

Support focuses mainly on capacity-building, integrating responses at central and governorate levels, and developing technical guidance and guidelines. WHO also supports the Ministry’s analysis of data to evaluate the impact of interventions to control common communicable diseases and improve surveillance.

The Ministry of Health has developed an integrated vector management and control plan to strengthen prevention and control of neglected tropical diseases in the country, the most prevalent of which are leishmaniasis, soil-transmitted helminthiasis and rabies.

Public health surveillance provides national health authorities with accurate and timely data to facilitate the prevention and control of disease outbreaks and ensure an adequate response to any public health incident. To build the capacity of the communicable disease surveillance programme, WHO has trained 52 health workers from different health districts in the use of electronic surveillance software to generate reports and monitor trends.