"> Doctors and Nurses on Strike in Kurdistan: Politics or Policy?


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July 16, 2012

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Doctors and Nurses on Strike in Kurdistan: Politics or Policy?

Kurdishaspect.com - By Dr. Goran Abdulla

On July 12, 2012 doctors and nurses in Kurdistan abruptly ended their strike. While the reasons for ending it are not clear and might involve political pressure, examining the factors that contributed to causing the strike is more valuable. Those factors shed light on the interplay between important contextual and intrinsic elements that encourage instability within the health system. They particularly underscore the deleterious impacts of policy decisions that are not carefully planned and piloted. 

The strike by the doctors and nurses overlapped in timing and scope but bear important variations and differences. The strike by the ‘young’ doctors lasted for more than one month (on and off), while nurses, and although starting their strike threats much earlier, chose to end theirs after three days only. Junior and senior house officers and general practitioners mostly in the governorate of Sulemany and Germian district didn’t attend to their duties. Nurses on the other hand had a more widespread strike that included all of the governorates of the region. Combined, this civil disobedience by doctors and nurses in Kurdistan paralyzed the health system, a system that is already under pressure and criticism for its inability to deliver quality health services effectively and efficiently. 

As we will allude to below, the strike by doctors and nurses should not be analyzed in isolation of each other since there were interrelated in their causes and consequences. But first let’s review the main reasons of why we think that strike happened in the first place. To do that we categorize the causes into general ones related to important political and economic contextual factors, and those that are more specifically related to the health system and health policy in Kurdistan. 

The strike by doctors and nurses cannot be studied in isolation of the wider political and economic realities of the region. In fact, this feverish civic participation by doctors and nurses is linked and is a continuation of the impact of the Arab Spring on the Kurdish society. Inspired by toppling of dictatorships in the Middle East and North Africa last year, Kurdistan had its unsuccessful version of the spring. People took to the street for more than two months in Slemnay and other towns and cities in the region demanding an end to corruption, nepotism and injustice. Scores of civilians were killed and injured and the demonstrations died out following violent suppression from the authorities. The current strike by doctors and nurses is only one manifestation of the same root causes of wider civil disobedience and discontent. Limitations on the freedoms of speech and assembly, entrenched inequalities and injustice and lack of equal opportunities are the main reasons of the same phenomena within the health system or in the wider society. 

The demonstrations in Kurdistan pushed the authorities to announce ill-defined and poorly thought through plans of reform. The health system was identified as the most corrupt and ineffective sector of the society and economy. A report by the Presidency of Kurdistan region that outlined reform initiatives was quickly followed by sweeping changes in the leadership of the health system including a change in the minister of health and replacement of almost all of the managers of directorates of health and major hospitals. Since these changes failed to address the root causes of the problems plaguing the health system, they did not only fail to ameliorate public discontent but ignited a sense of inevitable need for change within the system itself. 

The limited scope of the politically motivated and centrally imposed changes in the leadership of the health system combined with unplanned and isolated changes within the system resulted in disastrous outcomes. One such decision, that in our view was crucial in introducing the current instability and chaos within the health system, was to entirely close more than 4000 private clinics run by nurses and paraprofessional medical staff. While those clinics were (and still are since the decision was never fully implemented) unregulated and are  risky to the population, they were providing necessary basic health services at low prices to those households who didn’t afford private health care or they were located in geographically disadvantaged places. The previous minister of health sought favor among specialist doctors (who consider those clinics as threats on their pool of private patients) and among the political elite (through showing active engagement in reform) and decided to close those 4000 clinics overnight. The use of security and police forces to implement the decision exacerbated the anger of nurses who owned those clinics. A newly elected nurse syndicate identified this as an opportunity to establish itself as a legitimate representative and called for a general strike. The demands were not limited to reversing the decision, but also included equal risk allowances with doctors. The latter demand might be interpreted as a retaliatory measure from the nurses against those doctors who were instrumental in pushing for the closure of the nurses’ private clinics. This is, in itself, a worrying indication of a deteriorating professional relationship between doctors and nurses in the region. Doctors started to complaint about the loss of professional boundaries and growing status of nurses compared to them. 

It is a naivety to disregard this rivalry as one of the main reasons behind the strike that young doctors undertook. But it is equally unrealistic to limit those reasons to professional rivalry alone. There are legitimate reasons that pushed doctors to resort to a rare act of civil disobedience for such a long time (something that never happened before in Kurdistan). Doctors pay, to take one example, is among the lowest in the world. Junior doctors are facing strong and sometimes violent reactions from an angry public. This is due to the fact that young doctors are the first line of contact with patients both at emergency and out-patient levels of the health system. Furthermore, doctors in Kurdistan are feeling the mismatch between their payroll and social status. While the first is deteriorating, they are under pressure from family and friends to perform competitive social function to other less educated but better paid individuals and groups. Demands for better pay is faced with lip service from a government that is introducing market mechanisms and encouraging private provision of services rather than an expansion of an inefficient and archaic public sector. 

The strike by doctors and nurses in Kurdistan provide an invaluable opportunity to study the interactions of contextual political and economic factors with health system related policy and decision making. In a transitional society like Kurdistan, health policy decision making should avoid political imperatives and focus more on careful planning and deliberate dialogue with various stakeholders. Political factors can be harnessed to achieve wider health system goals if the latter are clearly defined and prioritized. It is particularly important to pay attention to the dynamics that govern the health workforce’s behavior and reaction to health system reforms. Unless those steps and many others are respected, Strikes continue to be a nightmare for decision makers in Kurdistan. 


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