IN A NUTSHELL
Author's Note
The employment crisis among newly graduated doctors in the Kurdistan Region of Iraq (KRI) reflects broader structural challenges in healthcare workforce management across LMICs. While medical graduates are being produced at rates exceeding available positions, public sector hiring has slowed due to austerity measures and financial constraints. This mismatch leads to prolonged job searches, volunteer-based work, and shifts to non-medical fields, with nearly half of employed doctors in KRI working outside the medical profession. The expectation of prior experience creates a significant entry barrier for new doctors, further exacerbating unemployment trends.

A critical consequence of this paradox is the increased migration of doctors from LMICs to higher-income countries in search of stable employment and professional development opportunities

Stethoscopes on Hold: Exploring the Employment Crisis Among New Doctors in the Kurdistan Region of Iraq

 

Despite a global shortage of healthcare workers, many low- and middle-income countries (LMICs), including those in the Middle East and North Africa (MENA), paradoxically face high unemployment rates among doctors and healthcare professionals (Hutchinson et al., 2025). This issue arises due to inefficient workforce planning, economic constraints, and mismatches between medical education and labor market demands. In many cases, newly trained doctors struggle to find employment while healthcare systems remain understaffed.

Retention challenges persist, and one of the key concerns is the difficulty in keeping medical professionals engaged in their home countries. A review of retention strategies found that incentives such as financial support, compulsory service requirements, and career development programs can help, but no single method proved universally effective. Meanwhile, brain drain remains a pressing issue in MENA, where thousands of doctors migrate to higher-income countries seeking better opportunities (Al Saraf & Garfield, 2008; Chikanda et al., 2014; Mullan, 2005).

In Iraq and the Kurdistan Region, healthcare workforce challenges are exacerbated by economic instability and political tensions (Tawfik-Shukor & Khoshnaw, 2010). While there is an oversupply of medical graduates, austerity measures and budget constraints have limited job creation, leading to unpaid or volunteer-based healthcare work (Zangana & Muhammad, 2024) Many graduates struggle to find secure employment in public hospitals, preferring public sector roles for perceived stability, but financial hardships have made consistent hiring difficult. In Kurdistan, female healthcare workers are disproportionately affected by unpaid positions, highlighting systemic inequities.

Job dissatisfaction among medical professionals in LMICs often stems from poor working conditions, low salaries, and limited career progression (AL-Abrrow et al., 2021). A systematic review indicated that improving salaries and offering career development opportunities could enhance retention rates (Willis-Shattuck et al., 2008). However, in MENA, structural employment barriers persist due to economic constraints restricting government healthcare hiring, mismatches between medical education and labor market needs, political instability disrupting workforce planning, and limited job creation forcing professionals into informal or volunteer work.

A particularly concerning phenomenon in some LMICs, including Sierra Leone and parts of Iraq, is the existence of unpaid health workers. Many rely on informal coping strategies, worsening healthcare inequities and workforce instability. Without effective policies to absorb excess medical graduates, doctor unemployment remains a critical issue that requires urgent intervention.

The problem of unemployed doctors and healthcare workers in LMICs and MENA is multifaceted, requiring targeted interventions in workforce planning, financial incentives, and healthcare system reforms. Countries must balance medical education with labor market demands while ensuring fair employment conditions for healthcare professionals. Future research should evaluate retention strategies and address systemic barriers to employment.

Methods

This study employed a cross-sectional design using an online survey to explore the employment status, career trajectories, and psychosocial impact of unemployment among newly graduated doctors in the Kurdistan Region of Iraq (KRI).

Survey Design and Distribution

A structured questionnaire was developed and hosted on Google Forms. The survey was designed to capture both quantitative and qualitative data, including demographic information, employment status, job search duration, mental well-being, perceived family/community support, and willingness to change careers or relocate.

The Google Form was disseminated via a WhatsApp platform specifically created for unemployed doctors in the KRI, comprising 627 newly graduated doctors actively seeking employment in the public sector. Participation was voluntary and anonymous, and no incentives were offered for completion.

Data Collection and Response Rate

The survey remained open for responses for a defined period, during which 241 doctors completed the questionnaire. This corresponds to a response rate of approximately 38.44% (241 out of 627).

Data Analysis

Quantitative data collected through the Google Form were exported into Microsoft Excel for cleaning, coding, and analysis. Descriptive statistics were calculated to assess demographic patterns, employment distribution, search duration, and mental well-being indicators. Categorical variables were summarized using counts and percentages, while continuous variables (e.g., search duration) were analyzed using measures of central tendency (mean and median). Chi-squared tests and Cramer’s V were used to explore potential associations and correlations between key variables. Additionally, open-ended responses were reviewed to identify recurring themes and systemic challenges.

Results

Demographic Trends in Unemployment

Analysis of age-related unemployment patterns indicates that doctors aged 24 years are the most affected group across the dataset. Gender-based analysis reveals that 25-year-old males in Erbil experience the highest unemployment rate. When stratified by governorate, Erbil emerges as the region with the highest overall unemployment among doctors.

Employment Patterns and Sectoral Distribution

Employment distribution data show that approximately 48.21% of employed doctors are working in the medical field, while 51.79% are employed in non-medical fields. This indicates a slight predominance of non-medical employment among doctors. Among non-medical roles, Marketing and Education are the most frequently reported sectors, with Marketing being the most prevalent.

Job Search Duration

The average duration that doctors have been actively searching for a medical-related job is approximately 7.16 months. This average is marginally higher than the median, suggesting a right-skewed distribution where a subset of doctors experience prolonged periods of unemployment. A bar chart visualization confirms these central tendencies, aiding in comparative interpretation.

Willingness to Relocate

An anomaly was noted in the dataset where 0.0% of unemployed doctors were reported as willing to relocate. This figure is likely due to a coding error involving incorrect column usage (‘Have you thought about changing careers due to unemployment?’ was used instead of ‘Would you consider relocating outside the Kurdistan Region or Iraq for a medical job?’). A Chi-squared test returned a p-value of 1.0, indicating no statistically significant association between employment status and willingness to relocate. However, recalculations with corrected variables are needed for accurate interpretation.

Mental Well-being and Social Support

Unemployment has a pronounced negative effect on doctors’ mental well-being:

• 198 doctors reported being very negatively impacted,
• 39 doctors reported a somewhat negative impact, and
• Only 3 doctors reported no impact on their mental health.

Regarding perceived family and community support:

• 111 doctors reported feeling somewhat negatively supported,
• 84 doctors reported no impact, and
• 38 doctors reported feeling very negatively supported.

A weak positive correlation was observed between perceived support and mental well-being (Cramer’s V = 0.223), indicating that while community support may play a role, other factors also significantly influence psychological outcomes. Notably, doctors experiencing a very negative mental health impact were found across all levels of perceived support, with the largest group feeling only somewhat supported.

Career Change Considerations

A substantial proportion of doctors reported considering a career change:

• 40% of unemployed doctors and
• 97% of employed doctors

have thought about changing careers. The difference between the two groups is only 0.43%, suggesting that employment status is not the primary driver behind this decision. This points to broader systemic or professional dissatisfaction affecting both groups similarly.

Regional Variation in Job Search Duration by Age

Correlation analysis revealed significant regional variability in how age relates to job search duration. For instance:

• In Sulaymaniyah, a positive correlation was observed, indicating that older doctors tend to search longer for jobs.
• In Erbil (Hawler), a negative correlation was identified, suggesting that older doctors find jobs more quickly.

These patterns may reflect differences in local job markets, socio-economic conditions, or access to professional networks. Further investigation is warranted to understand these dynamics and inform the design of region-specific employment support programs.

Structural Barriers to Employment

Open-ended survey responses identified “experience” as the most commonly cited challenge and a key contributor to unemployment. Respondents also pointed to systemic barriers such as the role of government ministries, inequities between public and private sectors, and broader political factors. Text analysis also revealed a high frequency of generic terms (e.g., “the,” “in,” “not”), indicating the need for refined natural language processing techniques such as n-gram analysis or topic modeling to uncover deeper themes and actionable insights.

Discussion

The employment crisis among newly graduated doctors in the Kurdistan Region of Iraq (KRI) reflects broader structural challenges in healthcare workforce management across LMICs. While medical graduates are being produced at rates exceeding available positions, public sector hiring has slowed due to austerity measures and financial constraints. This mismatch leads to prolonged job searches, volunteer-based work, and shifts to non-medical fields, with nearly half of employed doctors in KRI working outside the medical profession. The expectation of prior experience creates a significant entry barrier for new doctors, further exacerbating unemployment trends.

A critical consequence of this paradox is the increased migration of doctors from LMICs to higher-income countries in search of stable employment and professional development opportunities. Countries like the UK have historically relied on international medical graduates to fill gaps in their healthcare systems. However, the accelerating departure of newly graduated doctors from regions like KRI will likely intensify competition for positions abroad, while simultaneously deepening domestic shortages in specialist training pathways.

This trend presents a dual challenge. On one hand, LMICs face a brain drain, losing skilled professionals who could contribute to national healthcare systems. On the other hand, higher-income countries such as the UK, which are already struggling to recruit doctors into specialist posts, particularly in the NHS, may see an influx of overseas doctors seeking these positions. While this might alleviate certain workforce shortages in the short term, it does not address the systemic recruitment and retention challenges faced by both LMICs and high-income healthcare systems.

Many unemployed doctors also report severe negative mental health effects, signaling high levels of stress and professional dissatisfaction, which often act as push factors encouraging migration. While international relocation is not widely pursued within KRI due to financial and logistical constraints, it is likely that the worsening employment outlook will increase migration rates over time.

Conclusion

The growing mismatch between medical education and labor market demands in LMICs, including KRI, is fueling a cycle of unemployment, career transitions outside medicine, and increased doctor migration. Without systemic reforms to align workforce planning with graduate output, newly trained doctors will continue seeking employment abroad, further exacerbating domestic shortages in specialist healthcare roles. Higher-income countries like the UK, struggling to recruit doctors into critical specialty posts within the NHS, may see an increased influx of international medical graduates. However, without addressing broader retention challenges and career progression concerns, both LMICs and high-income countries will remain caught in a cycle of workforce instability.

To mitigate these issues, policymakers must invest in sustainable job creation, targeted workforce planning, and retention strategies within LMICs to reduce forced migration due to unemployment. Simultaneously, high-income countries must implement policies that ensure international medical graduates receive fair career progression opportunities without perpetuating global inequities in healthcare staffing. Future research should focus on longitudinal tracking of doctor migration patterns, analyzing how workforce shortages evolve globally and identifying sustainable solutions for both sending and receiving healthcare systems.

 

References

Al Saraf, H., & Garfield, R. (2008). The Brain Drain of Health Capital: Iraq as a Case Study. In Health Capital and Sustainable Socioeconomic Development.

AL-Abrrow, H., Al-Maatoq, M., Alharbi, R. K., Alnoor, A., Abdullah, H. O., Abbas, S., & Khattak, Z. Z. (2021). Understanding employees’ responses to the COVID-19 pandemic: The attractiveness of healthcare jobs. Global Business and Organizational Excellence, 40(2), 19–33. https://doi.org/10.1002/joe.22070

Chikanda, A., Bourgeault, I. L., & Labonté, R. (2014). Brain Drain and Regain: The Migration Behaviour of South African Medical Professionals. https://www.researchgate.net/publication/280444795

Hutchinson, E., Hutchinson, E., Kiwanuk, S., Muhindo, R., Nimwesiga, C., Balabanova, D., Mckee, M., & Kitutu, F. E. (2025). The paradoxical surplus of healthcare workers in Africa: the need for research and policy engagement. In European Journal of Public Health (Vol. 34). https://academic.oup.com/eurpub/article/34/Supplement_3/ckae144.269/7844942

Mullan, F. (2005). The metrics of the physician brain drain. The New England Journal of Medicine, 17(353), 1810–1818. https://doi.org/10.1056/NEJMsa050004

Tawfik-Shukor, A., & Khoshnaw, H. (2010). The impact of health system governance and policy processes on health services in Iraqi Kurdistan. BMC International Health and Human Rights, 10, 14. https://doi.org/10.1186/1472-698X-10-14

Willis-Shattuck, M., Bidwell, P., Thomas, S., Wyness, L., Blaauw, D., & Ditlopo, P. (2008). Motivation and retention of health workers in developing countries: A systematic review. BMC Health Services Research, 8. https://doi.org/10.1186/1472-6963-8-247

Zangana, G., & Muhammad, A. K. (2024). Health Workforce Shortages and Surpluses: The Case of Unsalaried Workers in Kurdistan Region of Iraq. https://doi.org/10.21203/rs.3.rs-4682754/v1

 

 

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By the same Author on PEAH

Navigating the Labyrinth: Addressing the Structural Challenges for IMGs in the UK Healthcare System  

 

 

 

 

IN A NUTSHELL
Author's note
Pakistan, despite decades of focused eradication efforts, remains one of the few countries where polio continues to threaten children’s futures. As we assess progress toward eradication by 2050, this article offers a realistic and evidence-based review of the innovations introduced and the ground-level challenges that persist. While digital tools, better vaccines, and microplanning have evolved, a critical human factor is often neglected—the grossly inadequate incentives for frontline workers, supervisors, and Union Council staff, who are central to campaign execution. Low per diems, multiple job burdens, weak accountability, lack of third-party verification, and an uncommitted EPI infrastructure all contribute to persistent virus transmission. Surveillance gaps, mobile populations, refusals, and environmental contamination continue to keep Pakistan in a cycle of near-eradication followed by resurgence. The article urges a structural reset—prioritizing people over systems—to make true eradication a reality by 2050

By Muhammad Noman

Healthcare System, CHIP Training and Consulting

Quetta, Balochistan Pakistan

Polio Eradication in Pakistan by 2050

Innovations, Gaps, and the Forgotten Human Factor

Introduction: Where We Stand in 2050

Polio was once nearly eradicated in Pakistan, with zero reported cases in select years. However, by 2050, it is clear that the virus has not been eliminated sustainably. Despite all the tools available—GPS tracking, digital microplans, biometric attendance, and live dashboards—the program still falters due to deep-rooted human resource and incentive issues. This review aims to critically analyze what has worked, what has not, and what needs to change permanently.

The Backbone Under Strain: Frontline Workers

Frontline workers (vaccinators) are the face of the campaign, knocking on doors, facing refusals, traveling long distances, and vaccinating millions of children each month. However, their role is dangerously undervalued:

• Per diems are as low as Rs. 500–800 per day, which does not match inflation or transportation costs.
• Many vaccinators have been part of the campaign for over a decade but remain on temporary contracts, with no job security, benefits, or promotion path.
• To survive, they work multiple jobs—as domestic help, schoolteachers, or in local markets—causing fatigue and divided attention during campaigns.
• Demoralization is rampant. Many feel they are “used only for polio,” with no support for long-term health career development.

🔴 Recommendation: Frontline workers must be paid at least a living wage, given official recognition, and enrolled in formal health workforce pathways.

Supervisors: Multi-tasking Without Recognition

Supervisors (Area In-Charges or UC-level monitors) are expected to oversee 20–25 teams, ensure data accuracy, resolve refusals, report in real-time, and submit daily activity reports. However:

• Their incentives are barely Rs. 1,200–1,500 per day, while their responsibilities are disproportionately high.
• Many are working as teachers or in private jobs simultaneously, with supervision conducted “on the phone” or “via WhatsApp” rather than on-site.
• There is no structured training or certification, despite the program demanding professional-level data handling and team management.
• Supervisors face blame for failures, but rarely receive appreciation for improved coverage or breakthrough results in refusal areas.

🟡 Recommendation: Supervisors must receive salary-based contracts, fuel allowances, performance bonuses, and leadership training to remain committed and accountable.

Union Council Staff: The Neglected Core

Union Council Medical Officers (UCMOs) and UC Polio Officers (UCPOs) are responsible for the entire microplanning, coordination, and logistics chain in their areas. But:

• Their monthly incentives are often as low as Rs. 15,000–20,000, which does not reflect their workload.
• They are required to coordinate with multiple stakeholders (DHOs, NGOs, WHO, EOC, community leaders), yet often operate without proper offices or transport.
• Many UCMOs prefer to focus on private practice or NGO consultancy work where earnings are better, leaving polio responsibilities neglected.
• Frequent turnover and non-permanent positions affect institutional memory and long-term planning.

🟠 Recommendation: Union Council-level staff should be moved to full-time, salaried positions, with career incentives tied to performance in both polio and broader immunisation goals.

Weak Surveillance: The Invisible Failure

Surveillance is the foundation of polio eradication. Unfortunately, surveillance officers and assistants are often:

• Untrained or minimally trained, relying on outdated tools.
• Not motivated to conduct community-based AFP case investigations.
• Under pressure to show high performance, leading to inflated or delayed reports.

This weak surveillance results in: – Late detection of virus transmission. – Silent circulation in areas assumed to be “cleared.” – Positive environmental samples being dismissed without credible response, particularly in areas with large migrant and mobile populations.

⚠️ Note: Poor staff commitment directly weakens the surveillance framework. Without human-centered reforms, data reliability will remain questionable.

Migrants, Mobility, and Environmental Risk

Even in districts with 95%+ reported coverage, environmental samples show poliovirus presence—mainly due to:

• Underserved mobile groups: Afghan refugees, nomadic tribes, brick kiln workers, and seasonal migrants.
• No long-term inclusion strategy: These populations are still not part of EPI routine coverage.
• Transit teams are underpaid, unmotivated, and lack multilingual skills to interact with mobile families.

Without engaging these hard-to-reach populations, polio continues to travel silently across provincial and district borders.

No Third Party, No Trust

Campaigns are still reported as “successful” even when ground teams know the reality is otherwise. This is because:

• Internal monitoring is politically and managerially influenced.
• There is no independent body to verify data, assess staff honesty, or analyze refusal quality.
• This leads to false assurance, misdirected resources, and continued transmission.

🔭 Solution: Establishing an independent third-party monitoring system, possibly at the provincial level, is critical for unbiased feedback and accountability.

Community Trust and Communication Failures

Even after decades, refusal remains a leading challenge. This is due to:

• Repeated, one-way communication: “Vaccinate or else” has replaced respectful dialogue.
• No incentives or visible benefits to compliant families.
• Lack of health education and follow-up by trained female social mobilizers.

Community engagement needs to evolve from campaign messaging to genuine public health conversations.

Incentive Policy Failures: A Root Cause, Not a Side Issue

Despite the billions spent on polio eradication in Pakistan since 1988, the program has consistently failed to design a sustainable and fair incentive system for its ground-level workforce. This single failure has led to a chain of consequences:

❌ Short-Term Fixes, Long-Term Demoralization

• Per diems are still based on decades-old formulas.
• No annual revision mechanisms.
• Temporary hiring creates insecurity and weak motivation.

⚖️ Inequity Within the System

• Same per diem for lowland, urban, and highland, rural workers.
• No hardship allowance for conflict-prone zones.

📉 Consequences:

• Poor morale, high turnover, fake reports, and missed settlements.

✅ Long-Term Solution: Introduce a tiered, performance-based incentive policy adjusted for geography, workload, and years of service.

Comparative Case Study: Lessons from Nigeria

Nigeria was declared polio-free in 2020. Key strategies included: – Fixed stipends, not fluctuating per diems. – Local government ownership of staff payment and monitoring. – Full-time, trained, and identified frontline staff.

Pakistan can learn from this model by building trust, stability, and responsibility into the system.

Sustainability Crisis: Can We Keep Doing Campaigns Forever?

Pakistan continues to run 10–12 campaigns per year, leading to: – Community fatigue and resistance. – Routine immunisation being neglected. – Huge operational costs without long-term benefit.

🛍️ Future Focus: Transition from vertical campaigns to integrated, routine-based health delivery.

Vision 2050: A Realistic Roadmap for Pakistan

✅ 1. Revamp Incentives

• Living wages, regular reviews, hardship allowances.

✅ 2. Integrate Workers into Health System

• Absorb into EPI, nutrition, maternal-child health services.

✅ 3. Independent Monitoring

• Neutral oversight with real-time and community-level checks.

✅ 4. Integrated Campaigns

• Bundle services (polio, deworming, Vitamin A, etc.).

✅ 5. Build Trust Locally

• Engage imams, elders, teachers, and female mobilizers.

✅ 6. Focus on High-Risk Populations

• Mobile health vans, transit teams, and culturally competent outreach.

Conclusion: It’s Not a Vaccine Problem—It’s a System Problem

By 2050, Pakistan has the technology, the funds, and the tools. But polio will not end until the system values the people who deliver the vaccine. Frontline workers, overburdened supervisors, and overlooked UC staff are not just implementers; they are the foundation. The eradication of polio demands not just injections but investment in human dignity, fairness, and long-term vision.