Volume 362, Number 9392 18 October 2003



5 months after major combat ended in Iraq, the US-led Coalition Provisional Authority (CPA) has appointed Khudair Abbas as minister of health. Abbas faces daunting challenges. In most areas of Iraq it is not clear what has done the most damage to the health system: looting, lack of security, or corruption.

Access to health services was seriously compromised by the war.1 Around 7% of hospitals were damaged during combat, and about 12% were looted (figure). Security remains the country's main health issue: both as an underlying reason for seeking medical care and in limiting access to services. For example, more Coalition troops have died since major hostilities ended than during the 42-day war. Their deaths totalled more than 370 when this article went to press ( And while an estimated 4000 Iraqi soldiers and 8000 civilians died as a direct result of hostilities (http://www.iraqbodycount. net), indirect deaths, whether due to scores being settled, easy access to arms, or inability to access health services, cannot yet be reasonably calculated but must outnumber direct deaths. Since the war ended, about 500 excess deaths per month have been recorded at the Baghdad morgue alone. Most deaths are the result of gunshot wounds, and many bodies may not be reaching hospitals for death registration.

Visits to doctors and hospitals dropped by around half immediately after the war. The number of visits is now rising, but data systems are not yet able to monitor coverage and use of the health system. Increased security is one way to improve access to health institutions. Hundreds of guards have been trained solely to care for the ministry of health buildings, where gunshots from dissatisfied patients or discharged workers had become common in the initial post-war period.

To reduce financial barriers and improve access to care, user fees, introduced 3 years ago, were eliminated soon after the war. Far from the government-run, free health system the CPA assumed it would find, user fees were widely accepted as necessary to provide most of the budget for salaries and equipment in ambulatory care centres. Before 1990, the health budget was about US$80 per person; by 1996, it had fallen to $17.2 The UN-administered Oil for Food Program provided around $25 per person in medical imports during 1997-2003, but national support for other parts of the public health system amounted to only $2 per person, 85% of which was derived from fees.

Elimination of user fees greatly reduced physician incomes and access to local-purchase items such as oxygen. In some areas, war-damage to production facilities hindered oxygen supplies, but in others, health facilities ran out of funds to procure goods. User fees were quietly reintroduced in July, 2003, with the goal of covering 10% of current health spending. This about-face in policy showed the CPA that health reform was complex and should initially progress slowly.

Human capacity development, in particular in nursing, is only one of many huge challenges facing the health system. Primary health services need to be developed and the former hospital-based orientation changed. Reorganising health services will take time, stable funding, and leadership training. Reconnecting Iraqi health professionals to their international colleagues is also slow. No authority yet exists to issue new passports, and a visa to the USA involves two land-based trips across dangerous territory to apply in Jordan. However, proliferation of internet access should enable communication with relative ease.

Decentralisation of the formerly top-down hierarchical system and citizen participation in health are also on the CPA's agenda. UN and local and international non-governmental organisations are needed in this transition period to help develop these processes, but most external humanitarian workers were pulled out of the country after recent bombings.

The CPA has asked the US Congress for $850 million for 2004, but their spending proposal is mainly focused on hospitals. US Congress recognised this imbalance and early in October shifted $100 million in funds towards ambulatory care. Given the CPA's focus on hospital care, UN organisations have a vital part to play in supporting decentralised decision-making and primary care development. These issues will come to the fore when donor countries meet in Madrid, Spain, on Oct 24, 2003, to fund UN programmes for 2004. The failure of the USA and other countries to agree on power sharing for the UN and a transition timetable to Iraqi rule has limited the willingness of donors to support the UN appeal. The health system will improve only with innovation, cooperation, and improved municipal services. It is hoped that developing an effective and efficient health system with Iraqi capacity to lead it will play an important part in turning the ideal of self-governance into effective self-rule. But security remains the key. As one physician in Baghdad told me: "Before we had security, but no freedom. Now we have freedom, but no security. What we need is both."

Richard Garfield


Columbia University, New York, NY 10032, USA (

1 Valenciano M, Coulombier D, Cardozo BL, et al. Letter from Basrah: challenges for communicable disease surveillance and control in southern Iraq, April-May 2003. JAMA 2003; 290: 654-58. [PubMed]

2 Diaz J, Garfield R. Iraq health and nutrition watching brief. Geneva: WHO and UNICEF, July, 2003.