Health Workforce Shortages and Surpluses: The Case of Unsalaried Workers in Kurdistan Region of Iraq

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This study examines the paradoxical surplus of unsalaried health workers (UHWs) in the Kurdistan Region of Iraq (KRI) amidst global health worker shortages. Method: We conducted an online survey of 585 UHWs in KRI. Results: the research highlights the disproportionate impact on women, who constitute 77% of respondents, and the socio-economic implications of high unemployment rates among female health workers. The study underscores the challenges posed by austerity measures post-2014, leading to a reliance on volunteer work and exacerbating interprofessional tensions. Key findings reveal that the majority of UHWs prefer public sector employment due to perceived job security and societal norms. Conclusion: The study calls for prioritising formal employment, addressing gender inequities, and implementing broader economic reforms to enhance the health workforce's resilience. The findings stress the need for collaborative efforts between regional and central governments to create equitable and sustainable employment opportunities, thereby supporting the overall health system's capacity to achieve UHC. Unsalaried Health workers Kurdistan Region of Iraq Health Equity Background 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). Methodology We conducted an online survey among UWTPs in the KRI. A copy of the survey was distrusted first among a small number of UHWs. We sought feedback in relation to the questions and their clarity. The survey was then distributed on online platforms, including social media sites. The latter included the UHWs’ WhatsApp and Facebook groups. We used Google Forms for the questionnaire. A copy of the questionnaire is presented in appendix 1. In addition to the general demographic information, the survey questions also provided rich qualitative responses that we analysed thematically. Results General Demographics: A total of 585 UHWs responded to the survey. A total of 77% of the respondents were female, and 23% were male. In terms of marital status, the women were roughly equally distributed, with 56% single and 44% married. On the other hand, more male UHWs were married (60%) than 40% were unmarried. Fifty-four percent of the respondents were married. The youngest UHW was 20, and the oldest was 54 (Chart 1 ). [We did not include only 54-year-old respondents], and most of the respondents were between 22 and 34 years old. Chart 1 shows that most of the respondents were younger than 35 years old. A total of 63.4% of the respondents said they worked only in the public sector, 15.2% in the private sector, and 10% said they worked in both sectors. A total of 11.3% of the respondents said they did not work in the medical sector at all. Of those working in the public sector, 90.5% said they did not receive any renumerations. Of those surveyed, 69% said they were not satisfied that they were unsalaried health workers, and 45% stated that they actively considered leaving the country as a result. When asked about their expectations for volunteer work, the vast majority of the UHWs expressed interest in employment in the public sector (Chart 3 ). Eighty-three percent of the respondents said that they wanted employment in this sector. Only 3.4% said that they wanted employment in the private sector only. Four percent indicated that they would be interested in employment both in the private and/or the public sector. More than 8% stated that they do not have any expectations for employment as an outcome of their voluntary work. The respondents were clear in terms of who they thought was to be accountable to the issue of UHWs. We asked participants about who they thought was responsible for the fact that there were UHWs in the KRI. More than 73% said that the government is to blame for lack of employment (Chart 4 ). A nonsignificant number of respondents identified UHWs themselves as the cause of a lack of employment opportunities. From the limited elaborations we obtained from those responses, it appears that participants suggested that if UHWs did not continue working for free, the government would be obliged to employ them. Proposed solutions: The respondents were asked about their suggested solutions for the issue of UHWs. Below is a description of the major themes that emerged from their responses: Many of the respondents thought that formal employment in the public sector should be prioritised by the authorities. However, there were two views on this topic. One group, which appears to be the dominant group, states that UHWs should be employed permanently as salaried health workers. Others considered the possibility of employment through contracts as a viable option. Some called for banning the concept of ‘volunteering’ or unsalaried work and demanded a return for automatic employment. The respondents presented several specific mechanisms for achieving employment for UHWs. Many have suggested that UHWs are such an indispensable force in the health system that they should boycott work to put pressure on the authorities to respond to their demands. This group of respondents seemed to think that such activism would cripple the health system. Others suggested that the ‘old’ generation of the health workforce should be allowed (or even forced) to retire so that they are replaced by younger UHWs. Some highlighted the issue of ‘ghost’ workers and the need for those to be cleared from payrolls so that they could be replaced with UHWs. Similarly, it was highlighted that many health workers are engaging in dual practices in the public and private sectors. Banning such dual practices was proposed as a way for more UHP to be employed in the public sector than in the private sector. Expanding the health infrastructure, particularly in primary health care and rural areas, was also suggested as a tool to offer employment opportunities for UHWs. The respondents of the survey differed in their views on who should take responsibility for solving the issue of the UHW. Some have suggested that this problem should be solved at that level of the KRI and its regional MoH. Others disagreed and suggested that the central Government of Iraq and its Federal MoH intervene. Discussion Global health discourse focuses almost exclusively on shortages of healthcare workers and ethical codes of international recruitment. However, it appears, as this study shows, that a paradoxical surplus of healthcare workforce is at play at least in some LMICs in EMR. In the case of KRI, the issue of UHWs is linked to austerity measures related to cuts in public employment. It is also associated with the privatisation of education, resulting in high numbers of graduates. These policies, in the case of Iraq and the KRI, were promoted following the 2003 Iraq War and more aggressively following the 2008 global financial crisis. More recently, they were promoted more enthusiastically after the ISIS-related 2014 security and economic crisis in Iraq. At one level, austerity might produce savings but contradicts the fact that for every $ 1 invested in decent employment opportunities for health workers, the return on investment can be approximately $ 9(Jamison et al., 2013 ). Nevertheless, only a small fraction of domestic and development (7%) assistance to health is dedicated to supporting the health workforce ((Micah et al., 2022 ). The finding that women constitute 77% of the UHW participants in our survey is not dissimilar to the gender distribution of the workforce in general, with women making up approximately 70% 19039_Gender equity in the health workforce_Working paper For Web.pdf (who.int). Additionally, as in the wider health system, women are not featured in the leadership, and the representation of UHWs is an organised pressure group. Our review of the grey literature and informal interactions with UHWs clearly revealed that men are leading advocates for the majority of female UHWs. Similar gender inequities can be observed in the wider health system where the majority workforce is led by men. All ministers of health and directors of health in the KRI have been men. The gender distribution of UHWs also has wider societal economic implications. The high proportion of women among UHWs is likely to contribute to the high unemployment rates of women in the KRI. It has been documented elsewhere that austerity measures disproportionately impact women (Emejulu & Bassel, 2018 ; Towers & Walby, n.d.) The lack of employment opportunities for women is likely also to perpetuate gender-related inequities in KRI society. Furthermore, it will undermine women’s independence and agency. As a result, it is expected that women UHWs will be exposed to gender-based and domestic violence and abuse. We argue that the gender distribution of UHWs (with women being the majority) has implications for the preferences expressed by the former for employment prospects. In the Kurdish economy, women and their families generally prefer the public sector (GHARAM, 2016). This is due to the perceived (and real) better availability of protection mechanisms in the public sector. Furthermore, women who work in the private sector are being stigmatised in Kurdish society. The latter is still largely traditional regarding gender roles. Interestingly, an insignificant proportion (19%) of the UHWs did not blame themselves for a lack of employment opportunities. The respondents suggested that the willingness of UHWs to continue working voluntarily allows the authorities to continue using their services with no appropriate renumerations. Furthermore, it appears that the government has used UHWs to fill gaps in service caused by strikes from salaried health workers who were unsatisfied with payments or working conditions. As a result, there appears to be interprofessional animosity between the salaried and UHWs in the health system. Similar tensions appear to have been created between UHWs on the one hand and ‘older’ health workers, ghost workers, and those with dual practices in the public and private sectors. The authorities seem to be using this tension for their advantage through continuing the status quo. This survey sheds some light on the issue of UHWs in LMICs in EMRs. However, this study has several limitations related to the use of online surveys (Andrade, 2020 ). We received a nonsignificant response to our survey; however, the number of participants still represents a minority of the suggested total number of UHWs in the KRI. This introduces biases in terms of what proportion of the sample size (the entire UHR population in the KRI) has responded. Therefore, more research using other methods is needed to explore the themes identified in this survey. Conclusion The findings of this study underscore the complex and multifaceted challenges faced by the health workforce in EMR. Despite the global emphasis on healthcare worker shortages, this research highlights a paradoxical surplus of UHWs in LMICs, particularly within EMR. The austerity measures implemented post-2014 in KRI, combined with the privatisation of education, have led to a significant number of healthcare graduates unable to secure formal employment. The study reveals that women constitute a majority of UHWs, mirroring gender disparities seen globally in the healthcare sector. This gender imbalance contributes to broader societal and economic inequities, including high unemployment rates among women and increased vulnerability to gender-based violence. The preference for public sector employment among female UHWs is linked to societal norms and perceived job security. The lack of formal employment for UHWs has led to interprofessional tensions and a reliance on volunteer work to fill gaps in the healthcare system. This situation is exacerbated by political and regional nepotism, further complicating the employment landscape. The study suggests that sustainable solutions require prioritising formal employment for UHWs, addressing gender inequities, and implementing broader economic reforms to support the health workforce. In conclusion, while the survey provides valuable insights into the issue of UHWs in the KRI, it also highlights the need for more comprehensive research and policy interventions to address these challenges effectively. The findings call for a collaborative effort between regional and central governments to create equitable and sustainable employment opportunities for the healthcare workforce, thereby enhancing the overall health system's resilience and capacity to achieve universal health coverage. Declarations Ethics approval and consent to participate This study was approved by the ethics committee of the HUMAN Network for Health and Humanitarian Affairs “in accordance with the Declaration of Helsink Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on request. 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World Health Organization. (2010). WHO Global Code of Practice on the International Recruitment of Health Personnel . Zaidi, S., Das, J. K., Jamal, W., Ali, A., Siddiqui, F., Thabet, A., Salah, H., & Mataria, A. (2023). Government purchasing initiatives involving private providers in the Eastern Mediterranean Region: a systematic review of impact on health service utilisation. BMJ Open , 13 (2). https://doi.org/10.1136/bmjopen-2022-063327 Charts Charts 1-4 are available in the Supplementary Files section. Appendix Appendix 1 is not available with this version Additional Declarations No competing interests reported. Supplementary Files Charts.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 07 Aug, 2024 Reviews received at journal 20 Jul, 2024 Reviewers agreed at journal 11 Jul, 2024 Reviewers invited by journal 09 Jul, 2024 Editor assigned by journal 09 Jul, 2024 Submission checks completed at journal 08 Jul, 2024 First submitted to journal 03 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4682754","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":329446317,"identity":"80533ef0-57e7-4014-bd02-075cee6e8ba1","order_by":0,"name":"Goran Zangana","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAklEQVRIiWNgGAWjYCgAORBx4AEpWozBWhJI0ZLYACLxaZF37334uYDBjkG+/ezhFz932KXPDzv8EGiLnZxuA3YthmeOG0vPYEhmYOzJS7PsPZOcu/F2mgFQS7Kx2QEcWmakMUjzMDADYY6ZAW8bc+7G2QkgLQcSt+HWwvybh6GegY3/jZnh37b6dMPZ6R/wapGXSGMD2nKYgUcix/gxb9vhBHnpHPy2GPAcY7PmMTjOIyHxxoxZtu244QbpnIIDCQa4/SLf3sZ8m6eiWk6+P8f449u2ann52embP3yosJPDpcUALG7AwAMk2SSQRXAC+QYEm/kDusgoGAWjYBSMAhAAAA5cV4ldZR9lAAAAAElFTkSuQmCC","orcid":"","institution":"NHS Lothian","correspondingAuthor":true,"prefix":"","firstName":"Goran","middleName":"","lastName":"Zangana","suffix":""},{"id":329446318,"identity":"1dea4682-e4f8-40e1-a5b2-dfbdde451275","order_by":1,"name":"Ary Kareem Muhammad","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Ary","middleName":"Kareem","lastName":"Muhammad","suffix":""}],"badges":[],"createdAt":"2024-07-03 21:53:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4682754/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4682754/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":61096212,"identity":"f9703934-5a42-4daa-9b14-b26813a9208a","added_by":"auto","created_at":"2024-07-25 14:05:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":292500,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4682754/v1/1d0305d6-9a30-4200-95af-82ac416633f0.pdf"},{"id":61096200,"identity":"62fc7cb7-8e4c-4cc7-ad2a-b81ba17b912d","added_by":"auto","created_at":"2024-07-25 14:05:21","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":246422,"visible":true,"origin":"","legend":"","description":"","filename":"Charts.docx","url":"https://assets-eu.researchsquare.com/files/rs-4682754/v1/8b0c80ed457b7c1de7e56b01.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Health Workforce Shortages and Surpluses: The Case of Unsalaried Workers in Kurdistan Region of Iraq","fulltext":[{"header":"Background","content":"\u003ch2\u003eThe world health workforce and EMR\u003c/h2\u003e\n\u003cp\u003eStrengthening 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).\u003c/p\u003e\n\u003cp\u003eEMR 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).\u003c/p\u003e\n\u003cp\u003eWhile 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 \u0026amp; 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.\u003c/p\u003e\n\u003ch2\u003eBackground of the Kurdistan Region of Iraq\u003c/h2\u003e\n\u003cp\u003eThe 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.\u003c/p\u003e\n\u003cp\u003eThe 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.\u003c/p\u003e\n\u003cp\u003eKRI 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.\u003c/p\u003e\n\u003cp\u003ePrior 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 \u0026amp; 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.\u003c/p\u003e\n\u003cp\u003eAs 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).\u003c/p\u003e\n\n"},{"header":"Methodology","content":"\u003cp\u003eWe conducted an online survey among UWTPs in the KRI. A copy of the survey was distrusted first among a small number of UHWs. We sought feedback in relation to the questions and their clarity. The survey was then distributed on online platforms, including social media sites. The latter included the UHWs’ WhatsApp and Facebook groups. We used Google Forms for the questionnaire. A copy of the questionnaire is presented in appendix 1. In addition to the general demographic information, the survey questions also provided rich qualitative responses that we analysed thematically.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eGeneral Demographics:\u003c/p\u003e \u003cp\u003eA total of 585 UHWs responded to the survey. A total of 77% of the respondents were female, and 23% were male. In terms of marital status, the women were roughly equally distributed, with 56% single and 44% married. On the other hand, more male UHWs were married (60%) than 40% were unmarried. Fifty-four percent of the respondents were married. The youngest UHW was 20, and the oldest was 54 (Chart \u003cspan refid=\"Str1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). [We did not include only 54-year-old respondents], and most of the respondents were between 22 and 34 years old. Chart \u003cspan refid=\"Str1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows that most of the respondents were younger than 35 years old.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA total of 63.4% of the respondents said they worked only in the public sector, 15.2% in the private sector, and 10% said they worked in both sectors. A total of 11.3% of the respondents said they did not work in the medical sector at all. Of those working in the public sector, 90.5% said they did not receive any renumerations. Of those surveyed, 69% said they were not satisfied that they were unsalaried health workers, and 45% stated that they actively considered leaving the country as a result.\u003c/p\u003e \u003cp\u003eWhen asked about their expectations for volunteer work, the vast majority of the UHWs expressed interest in employment in the public sector (Chart \u003cspan refid=\"Str3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Eighty-three percent of the respondents said that they wanted employment in this sector. Only 3.4% said that they wanted employment in the private sector only. Four percent indicated that they would be interested in employment both in the private and/or the public sector. More than 8% stated that they do not have any expectations for employment as an outcome of their voluntary work.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe respondents were clear in terms of who they thought was to be accountable to the issue of UHWs. We asked participants about who they thought was responsible for the fact that there were UHWs in the KRI. More than 73% said that the government is to blame for lack of employment (Chart \u003cspan refid=\"Str4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). A nonsignificant number of respondents identified UHWs themselves as the cause of a lack of employment opportunities. From the limited elaborations we obtained from those responses, it appears that participants suggested that if UHWs did not continue working for free, the government would be obliged to employ them.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eProposed solutions:\u003c/p\u003e \u003cp\u003eThe respondents were asked about their suggested solutions for the issue of UHWs. Below is a description of the major themes that emerged from their responses:\u003c/p\u003e \u003cp\u003eMany of the respondents thought that formal employment in the public sector should be prioritised by the authorities. However, there were two views on this topic. One group, which appears to be the dominant group, states that UHWs should be employed permanently as salaried health workers. Others considered the possibility of employment through contracts as a viable option. Some called for banning the concept of \u0026lsquo;volunteering\u0026rsquo; or unsalaried work and demanded a return for automatic employment.\u003c/p\u003e \u003cp\u003eThe respondents presented several specific mechanisms for achieving employment for UHWs. Many have suggested that UHWs are such an indispensable force in the health system that they should boycott work to put pressure on the authorities to respond to their demands. This group of respondents seemed to think that such activism would cripple the health system. Others suggested that the \u0026lsquo;old\u0026rsquo; generation of the health workforce should be allowed (or even forced) to retire so that they are replaced by younger UHWs. Some highlighted the issue of \u0026lsquo;ghost\u0026rsquo; workers and the need for those to be cleared from payrolls so that they could be replaced with UHWs. Similarly, it was highlighted that many health workers are engaging in dual practices in the public and private sectors. Banning such dual practices was proposed as a way for more UHP to be employed in the public sector than in the private sector. Expanding the health infrastructure, particularly in primary health care and rural areas, was also suggested as a tool to offer employment opportunities for UHWs.\u003c/p\u003e \u003cp\u003eThe respondents of the survey differed in their views on who should take responsibility for solving the issue of the UHW. Some have suggested that this problem should be solved at that level of the KRI and its regional MoH. Others disagreed and suggested that the central Government of Iraq and its Federal MoH intervene.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eGlobal health discourse focuses almost exclusively on shortages of healthcare workers and ethical codes of international recruitment. However, it appears, as this study shows, that a paradoxical surplus of healthcare workforce is at play at least in some LMICs in EMR. In the case of KRI, the issue of UHWs is linked to austerity measures related to cuts in public employment. It is also associated with the privatisation of education, resulting in high numbers of graduates. These policies, in the case of Iraq and the KRI, were promoted following the 2003 Iraq War and more aggressively following the 2008 global financial crisis. More recently, they were promoted more enthusiastically after the ISIS-related 2014 security and economic crisis in Iraq. At one level, austerity might produce savings but contradicts the fact that for every \u003cspan\u003e$\u003c/span\u003e1 invested in decent employment opportunities for health workers, the return on investment can be approximately \u003cspan\u003e$\u003c/span\u003e9(Jamison et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Nevertheless, only a small fraction of domestic and development (7%) assistance to health is dedicated to supporting the health workforce ((Micah et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe finding that women constitute 77% of the UHW participants in our survey is not dissimilar to the gender distribution of the workforce in general, with women making up approximately 70% 19039_Gender equity in the health workforce_Working paper For Web.pdf (who.int). Additionally, as in the wider health system, women are not featured in the leadership, and the representation of UHWs is an organised pressure group. Our review of the grey literature and informal interactions with UHWs clearly revealed that men are leading advocates for the majority of female UHWs. Similar gender inequities can be observed in the wider health system where the majority workforce is led by men. All ministers of health and directors of health in the KRI have been men.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe gender distribution of UHWs also has wider societal economic implications. The high proportion of women among UHWs is likely to contribute to the high unemployment rates of women in the KRI. It has been documented elsewhere that austerity measures disproportionately impact women (Emejulu \u0026amp; Bassel, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Towers \u0026amp; Walby, n.d.) The lack of employment opportunities for women is likely also to perpetuate gender-related inequities in KRI society. Furthermore, it will undermine women\u0026rsquo;s independence and agency. As a result, it is expected that women UHWs will be exposed to gender-based and domestic violence and abuse.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWe argue that the gender distribution of UHWs (with women being the majority) has implications for the preferences expressed by the former for employment prospects. In the Kurdish economy, women and their families generally prefer the public sector (GHARAM, 2016). This is due to the perceived (and real) better availability of protection mechanisms in the public sector. Furthermore, women who work in the private sector are being stigmatised in Kurdish society. The latter is still largely traditional regarding gender roles.\u003c/p\u003e \u003cp\u003eInterestingly, an insignificant proportion (19%) of the UHWs did not blame themselves for a lack of employment opportunities. The respondents suggested that the willingness of UHWs to continue working voluntarily allows the authorities to continue using their services with no appropriate renumerations. Furthermore, it appears that the government has used UHWs to fill gaps in service caused by strikes from salaried health workers who were unsatisfied with payments or working conditions. As a result, there appears to be interprofessional animosity between the salaried and UHWs in the health system. Similar tensions appear to have been created between UHWs on the one hand and \u0026lsquo;older\u0026rsquo; health workers, ghost workers, and those with dual practices in the public and private sectors. The authorities seem to be using this tension for their advantage through continuing the status quo.\u003c/p\u003e \u003cp\u003eThis survey sheds some light on the issue of UHWs in LMICs in EMRs. However, this study has several limitations related to the use of online surveys (Andrade, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). We received a nonsignificant response to our survey; however, the number of participants still represents a minority of the suggested total number of UHWs in the KRI. This introduces biases in terms of what proportion of the sample size (the entire UHR population in the KRI) has responded. Therefore, more research using other methods is needed to explore the themes identified in this survey.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings of this study underscore the complex and multifaceted challenges faced by the health workforce in EMR. Despite the global emphasis on healthcare worker shortages, this research highlights a paradoxical surplus of UHWs in LMICs, particularly within EMR. The austerity measures implemented post-2014 in KRI, combined with the privatisation of education, have led to a significant number of healthcare graduates unable to secure formal employment.\u003c/p\u003e \u003cp\u003eThe study reveals that women constitute a majority of UHWs, mirroring gender disparities seen globally in the healthcare sector. This gender imbalance contributes to broader societal and economic inequities, including high unemployment rates among women and increased vulnerability to gender-based violence. The preference for public sector employment among female UHWs is linked to societal norms and perceived job security.\u003c/p\u003e \u003cp\u003eThe lack of formal employment for UHWs has led to interprofessional tensions and a reliance on volunteer work to fill gaps in the healthcare system. This situation is exacerbated by political and regional nepotism, further complicating the employment landscape. The study suggests that sustainable solutions require prioritising formal employment for UHWs, addressing gender inequities, and implementing broader economic reforms to support the health workforce.\u003c/p\u003e \u003cp\u003eIn conclusion, while the survey provides valuable insights into the issue of UHWs in the KRI, it also highlights the need for more comprehensive research and policy interventions to address these challenges effectively. The findings call for a collaborative effort between regional and central governments to create equitable and sustainable employment opportunities for the healthcare workforce, thereby enhancing the overall health system's resilience and capacity to achieve universal health coverage.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThis study was approved by the ethics committee of the HUMAN Network for Health and Humanitarian Affairs \u0026ldquo;in accordance with the Declaration of Helsink\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eWe declare no competing interest\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eNo funding\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eAKM conducted the online survey. GZ analysed the data and wrote the manuscript. AKM reviewed manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAl-Mandhari, A., Marmot, M., Ghaffar, A., Hajjeh, R., Allen, J., Khan, W., \u0026amp; El-Adawy, M. (2021). COVID-19 pandemic: A unique opportunity to \u0026lsquo;build back fairer\u0026rsquo; and reduce health inequities in the Eastern Mediterranean region. In \u003cem\u003eEastern Mediterranean Health Journal\u003c/em\u003e (Vol. 27, Issue 3, pp. 217\u0026ndash;219). World Health Organization. https://doi.org/10.26719/2021.27.3.217\u003c/li\u003e\n\u003cli\u003eAndrade, C. (2020). The Limitations of Online Surveys. \u003cem\u003eIndian Journal of Psychological Medicine\u003c/em\u003e, \u003cem\u003e42\u003c/em\u003e(6), 575\u0026ndash;576. https://doi.org/10.1177/0253717620957496\u003c/li\u003e\n\u003cli\u003eAsamani, J. A., Akogun, O. B., Nyoni, J., Ahmat, A., Nabyonga-Orem, J., \u0026amp; Tumusiime, P. (2019). 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S., Closser, S., Prince, J., Chand, P., \u0026amp; Justice, J. (2024). An anthropological history of Nepal\u0026rsquo;s Female Community Health Volunteer program: gender, policy, and social change. \u003cem\u003eInternational Journal for Equity in Health\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(1). https://doi.org/10.1186/s12939-024-02177-5\u003c/li\u003e\n\u003cli\u003eTowers, J., \u0026amp; Walby, S. (n.d.). \u003cem\u003eMeasuring the impact of cuts in public expenditure on the provision of services to prevent violence against women and girls\u003c/em\u003e.\u003c/li\u003e\n\u003cli\u003eWorld Health Organisation. (2014). \u003cem\u003eHealth inequities in the Eastern Mediterranean Region Selected country case studies\u003c/em\u003e.\u003c/li\u003e\n\u003cli\u003eWorld Health Organisation. 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Government purchasing initiatives involving private providers in the Eastern Mediterranean Region: a systematic review of impact on health service utilisation. \u003cem\u003eBMJ Open\u003c/em\u003e, \u003cem\u003e13\u003c/em\u003e(2). https://doi.org/10.1136/bmjopen-2022-063327\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Charts","content":"\u003cp\u003eCharts 1-4 are available in the Supplementary Files section.\u003c/p\u003e"},{"header":"Appendix","content":"\u003cp\u003eAppendix 1 is not available with this version\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Unsalaried Health workers, Kurdistan Region of Iraq, Health Equity","lastPublishedDoi":"10.21203/rs.3.rs-4682754/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4682754/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThe health workforce is crucial for achieving universal health coverage (UHC), yet significant inequities persist globally, particularly in the Eastern Mediterranean Region (EMR). This study examines the paradoxical surplus of unsalaried health workers (UHWs) in the Kurdistan Region of Iraq (KRI) amidst global health worker shortages.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod: \u003c/strong\u003eWe conducted an\u003cstrong\u003e \u003c/strong\u003eonline survey of 585 UHWs in KRI.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003ethe research highlights the disproportionate impact on women, who constitute 77% of respondents, and the socio-economic implications of high unemployment rates among female health workers. The study underscores the challenges posed by austerity measures post-2014, leading to a reliance on volunteer work and exacerbating interprofessional tensions. Key findings reveal that the majority of UHWs prefer public sector employment due to perceived job security and societal norms.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe study calls for prioritising formal employment, addressing gender inequities, and implementing broader economic reforms to enhance the health workforce's resilience. The findings stress the need for collaborative efforts between regional and central governments to create equitable and sustainable employment opportunities, thereby supporting the overall health system's capacity to achieve UHC.\u003c/p\u003e","manuscriptTitle":"Health Workforce Shortages and Surpluses: The Case of Unsalaried Workers in Kurdistan Region of Iraq","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-25 14:05:16","doi":"10.21203/rs.3.rs-4682754/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-07T09:24:38+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-20T08:55:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"58395822586892304379857584650076991184","date":"2024-07-11T16:00:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-09T15:56:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-09T15:52:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-09T03:49:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal for Equity in Health","date":"2024-07-03T21:50:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8b1a5f5f-12d4-4593-bbfd-046f49ce5d32","owner":[],"postedDate":"July 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-08-27T09:26:50+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-25 14:05:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4682754","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4682754","identity":"rs-4682754","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}