The world health workforce and EMR
Strengthening the health workforce is a key priority for achieving universal health coverage (UHC) at the country level (Reid et al., 2020). Furthermore, a well-trained and salaried healthcare workforce at the primary health level is essential for continuity of care, which is, in turn, central to achieving UHC (Schwarz et al., 2019). The size of the global health workforce has increased. However, there are significant inequities in the size of this increase (World Health Organisation, 2014). Despite this increase, the world is still facing dangerous health worker shortages (The Lancet Global Health, 2023). The World Health Organisation (WHO) projected a shortage of 10 million health workers globally by 2023(Boniol et al., 2022). There are significant inequalities in such shortages. High-income countries (HICs) have 6.5 times more health workers per population than low- and middle-income countries (LMICs) (Boniol et al., 2022). Such inequalities are driven in part by the recruitment of health workers by the HICs despite the existence of the WHO’s Global Code of Practice on the International Recruitment of Health Personnel (World Health Organisation, 2010). These shortages were highlighted at high levels by the WHO and during the Fifth Global Forum on Human Resources of Health (Agyeman-Manu et al., 2023).
EMR is one of the regions severely affected by workforce shortages (Gedik et al., 2024). The region is estimated to face a shortage of 2.1 million health workers (World Health Organisation, 2021). This accounts for 20% of the global shortage of the healthcare workforce. Six countries in the EMR are included in the WHO’s Support and Safeguard list of countries with the most pressing health workforce challenges related to advancing UHC. The nurse shortage is particularly stark in the region, with the ratio of nurses to doctors declining. Such shortages are important factors in impeding the progress for achieving UHC-related visions and goals in the MENA region (El Rabat et al., 2022). As a result, EMR is not on track in achieving health-related SDGs, with no progress made in half of the 50 indicators with considerable inequalities and disadvantages related to social determinants of health exacerbated by COVID-19 (Doctor et al., 2021) (Marmot et al., 2021) (Al-Mandhari et al., 2021). The shortage of health workforce in is related to the lack of expansion in its size between 2013 and 2020 (Boniol et al., 2022). It is also driven by limited employment opportunities in both the public and private sectors with the latter becoming an increasingly significant employer (Zaidi et al., 2023).
While global health headlines focus on global shortages and inequalities in workforce distribution, a paradoxical oversupply of health workers exists in LMICs. Currently, many LMICs, including in EMR, are unable to offer formal employment to the ‘surpluses’ of health workers in their health economies in the form of unsalaried health workers (UHWs) (Asamani et al., 2019). The issue of UHWs has not been studied adequately worldwide and certainly in EMR. Recently, a scoping review of UHW in Sera Leone showed that the failure to employ UHWs undermines equitable access to healthcare (Pieterse & Saracini, 2023). Other systematic reviews have shown that unsalaried community health workers face exploitation, leading to inadequate provision of health services(Ballard et al., 2023). Another systematic review of lay health workers revealed that they often demand remuneration for their work, although some expressed concerns that payments might undermine their social status as selfless volunteers (Glenton et al., 2013). An anthropological study analysing archives exploring unsalaried female community health volunteers in Nepal revealed dissatisfaction with renumeration and failure of officials to prioritise this workforce (Tikkanen et al., 2024). However, we did not find any literature exploring the views and experiences of UHWs themselves regarding factors related to remuneration, exploitation and employment prospects.
Background of the Kurdistan Region of Iraq
The Kurdistan Region of Iraq (KRI) is in northern Iraq. The KRI is a federal entity within the country of Iraq. According to the Iraqi constitution of 2005, the KRI has executive powers exercised by the Kurdistan Regional Government (KRG) with a president and prime minister. It also has legislative authority with a Parliament and judicial powers. Health is largely devolved and exercised by the Ministry of Health of Kurdistan (MoH-K) in partnership with the Ministry of Health of Iraq (MoH-I). The public health system in the KRI consists of 74 hospitals and 847 health centres for a population of approximately 6 million people.
The KRI population is estimated at 5,122,747 individuals (compared to the Iraqi population at 36,004,552 individuals) (IOM et al., 2018). Thirty-five percent of the population is younger than 15 years, while 60% is younger than 25 years (Hayder Al-Shakeri, 2022). Roughly, the population is gender-balanced in terms of male to female distribution (IOM et al., 2018). The average household size is 5.1, with 90% being headed by men.
KRI is a classic example of what is called the ‘rentier economy’. (Deweaver, n.d.)Approximately 87% of households have a monthly income of less than 850 United States dollars. Approximately two-thirds of households are on government payrolls. The private sector employs less than 30% of the population (IOM et al., 2018). According to some surveys, 20% of young people have lost hope for finding a job. A particularly high percentage of women (30%) are unemployed. Women’s participation in the Iraqi economy has been declining (11% in 2023 compared to approximately 15% in 2016)(The Global Economy, 2023). Women’s employment is similarly low in the KRI, with an equivalent rate of 11% (2016 figures). This is low compared to even EMR standards (18%) (GHARAM, 2016) According for the same sources; only 1/100 of women work in the private sector in the KRI.
Prior to 2014, every graduate of medical colleges and healthcare institutions was formally employed by the Ministry of Health in a public facility (Rudaw, 2022). After 2014, only medical doctors were formally employed after graduation. Starting in 2015, the KRG implemented many aggressive austerity measures. These were justified by security instability due to ISIS-related conflict, low oil prices, disputes with the central Iraqi government over revenue sharing and other factors. As a result, the KRG cut public employees' salaries (Mahmood, 2016). The KRG framed such cuts in salaries as a policy to ‘withhold’ portions of those salaries to be paid later when financial circumstances were more favourable (The World Bank Group, 2016). It also promotes employment in the public sector (Baser & Fazil, 2022). These policies left approximately 25,000 new graduates from universities in KRI no option but to migrate or take to the streets, with some being killed in the process (Sardar et al., 2020). In short, what has happened in the KRI since 2015 can be described as ‘neoliberalism on crack’(Schwartz, 2007). These austerity measures further exacerbated the erosion of the equitable provision of health services caused by a fragile and fragmented health system from decades of conflict and political instability.
As a result of these austerity policies, there are an estimated 24,000 unsalaried health workers in the Kurdistan Region of Iraq (KRI) (Rudaw, 2023b). This represents approximately 30% of the entire workforce in the region. The surveyed UHWs included nurses, pharmacists, dentists and some doctors. The MoH does not have formal statistics about UHWs in the KRI. Hoping that they would be prioritised for permanent employment or contracts, new graduates would volunteer in mostly public facilities. This was justified not only by the needs of the health system but also by the need for new graduates to obtain practical experience in these mostly hospital placements. UHWs quickly became an indispensable part of the workforce, and boycotting work has resulted in disruptions in healthcare delivery in some hospitals (Rudaw, 2023a). On the other hand, the demand for volunteering by unsalaried health workers became so pressing that the Minister of Health of the Kurdistan Regional Government (KRG) issued an order prohibiting additional volunteers from being appointed in public facilities (Sharpress, 2020). The limited opportunities for formal employment have been eroded by political and regional nepotism triggering protests by UHWs (Awene, 2022).