A Consequence of the Failure of the National Healthcare System and the Lack of Human Rights

The high rates of suicide attempts and ideation among medical students in Iran are deeply concerning, yet the causes are often inadequately explained. While Iranian authorities and others generally agree that intense work pressure and low income levels are major stress factors for medical students (Pirnia 2024; RFE/RL’s Radio Farda 2024), deeper systemic explanations are frequently overlooked.

Poor working conditions are a major source of psychiatric disorders among medical students (Saeed et al. 2024). To understand the situation in Iran, it is important to note that all medical students (including undergraduates, residents, and fellowship students) are required to work in public hospitals and health centers under the supervision of the Ministry of Health, which forms the backbone of the national healthcare system. In these public facilities, nearly all primary care responsibilities fall to medical students. Additionally, medical graduates are mandated to work in underserved areas for a period of two to four years following graduation.

Legally, medical universities and health centers are permitted to use their human resources as they see fit, offering compensation far below what a private healthcare system would provide. Moreover, medical students are required to handle an overwhelming workload, resulting in excessively long and exhausting shifts. The national healthcare system in Iran sustains its functionality by overworking its medical students at every level, compromising their well-being in the process. This exploitation is possible because of the absence of adequate human rights protections in the country.

Below is a list of specific challenges faced by Iranian medical students and residents working in public hospitals:

1. Excessive Workload

Medical students at various levels are often required to see a significantly higher number of patients than the standard limit. In Iran, public healthcare institutions provide the most affordable access to medical care, which increases the workload of medical staff, including students. Medical students’ working hours typically range between 24 and 36 hours per shift, with some shifts lasting even longer.

The frequency of their shifts can be arbitrarily increased at the discretion of senior students, with no practical enforcement of regulations to protect students from excessive working hours. As one resident noted, “Residents are responsible for around 30 patients, with general surgery residents handling up to 50 patients in a strictly hierarchical system where speaking out is nearly impossible” (Devi 2024). Also, when there is a shortage of private physicians in a department, hospital administration often unilaterally assigns responsibilities to medical students without consulting them.

2. Interpersonal Conflicts

The excessive patient load often leads to conflicts between patients’ companions and medical staff, particularly in emergency departments. While similar issues with patient load exist in developed countries, physical and verbal assaults on physicians are not routine there. In Iran, however, such assaults can escalate to extreme levels, even resulting in the death of physicians. A recent example is the murder of a cardiologist by a patient’s companion (Iran Wire 2024).

In Iranian hospitals, the presence of a patient companion is crucial, as they are responsible for non-medical tasks like transferring patients between departments. Unfortunately, verbal abuse and physical violence against medical students by patient companions are frequent, yet the perpetrators face little to no consequences. This reflects a systemic neglect of the mental well-being of medical students, as no institution or authority prioritizes their dignity or protection.

3. Power Imbalances in Public Hospital

There are no practical regulations governing interpersonal relationships within healthcare teams, which often results in medical students facing disrespect from nurses, senior students, and faculty members. Senior students and faculty can arbitrarily extend students’ shift hours, while nurses and senior students frequently assign them tasks outside their designated responsibilities, such as transporting patients between departments or carrying test tubes—duties that fall outside a doctor’s role.

4. Exclusion from Labor Laws

Medical students in Iran are excluded from labor laws, as they are not considered workers but are instead classified as students. As a result, they are subjected to extended shifts without the legal protections that workers typically receive. Their compensation is either non-existent or fixed, regardless of the number of shifts or the workload involved. “Residents earn roughly US$200 for working roughly 300 h per month, in 36 h shifts” (Devi 2024).

5. Barriers to Leaving Medical School

Students seeking to leave medical school face significant financial and legal obstacles. While high-achieving students benefit from free education, withdrawing requires reimbursement to the university for the full cost, an amount comparable to a house. In cases of death or suicide, the financial burden shifts to the family, who must pay for the years of mandatory service left unfulfilled. Additionally, recent legal changes prevent students from receiving their degree even after completing mandatory service, effectively trapping them within the system and barring them from practicing medicine abroad.

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The issues described arise from two main problems. The first is the lack of human rights protections. The second is the structural failure of the national healthcare system, which cannot hire enough private doctors to distribute patient loads effectively due to financial constraints. Instead of investing in private doctors, the system exploits residents by forcing them to handle the workload at a fraction of the cost. This approach reflects the state’s attempt to implement a radical socialist policy—avoiding health-related taxes while suppressing the real free-market salaries of doctors and nurses. As a result, a resident’s paycheck is often less than that of an unskilled laborer.

Consequently, newly trained doctors are driven to leave the country; those whose degrees are held hostage by the government often resort to cosmetic work or non-medical jobs. The combination of insufficient human rights protections and a flawed socialist healthcare model has led to disastrous outcomes for Iran’s healthcare system, hidden beneath its seemingly functional surface. However, the system is on the brink of collapse. “Thousands of Iranian health professionals have left their homeland in recent years, mainly due to the country’s deepening economic crisis, difficult working conditions [etc.]” (RFE/RL’s Radio Farda 2024). The national healthcare framework operates on a shoestring budget, sustained by exploiting the labor of medical students, residents, and other healthcare workers.

Two foundational changes are essential to address these systemic issues.

1. Recognition and Protection of Human Rights:

Medical students and healthcare workers must be granted basic rights, including regulated working hours, protection from abuse, and fair treatment within their workplace. Without these guarantees, other reforms will be superficial and ineffective.

2. Compensation Based on Market Rates:

The government’s practice of setting artificially low wages for doctors and medical residents must come to an end. Healthcare professionals should be compensated according to market rates. State-imposed wage controls result in underpaid healthcare workers, leading to mass emigration and exacerbating staff shortages. The excessive workload in public hospitals, driven by the inability to hire sufficient non-resident doctors due to financial barriers is a direct consequence of radical socialist policies.

Iran’s healthcare system exemplifies how a socialist healthcare model, implemented without the safeguard of human rights, can create severe dysfunction. While the system technically delivers services, it does so by overburdening its workforce to unsustainable levels. A viable healthcare system must balance the rights of its workforce with the needs of its population. Without fundamental reforms current model will continue to exploit medical students and healthcare workers, putting at risk both the quality of care and the system’s long-term survival.

Bibliography

Devi, Sharmila. 2024. “Iranian Medic Suicides Spark Criticism of Working Conditions.” The Lancet 403 (10431): 1010.

Iran Wire. 2024. “Cardiologist Killed in Revenge Attack Over Alleged Medical Negligence.” IRANWIRE. November 12, 2024.

Pirnia, Bijan. 2024. “Suicide among Medical Residents in Iran.” The Lancet Psychiatry 11 (6): 411. https://doi.org/10.1016/S2215-0366(24)00111-1.

RFE/RL’s Radio Farda. 2024. “Rise In Suicides Among Medical Students In Iran Highlights Growing Crisis

In Sector.” Radio Farda. February 19, 2024. https://www.rferl.org/a/rise-in-suicides-among-medical-students-in-iran-highlights-growing-crisis-in-sector/32826286.html.

Saeed, Fahimeh, Elaheh Ghalehnovi, Mahdieh Saeidi, Neda Ali beigi, Mohsen Vahedi, Mohammadreza Shalbafan, Leila Kamalzadeh, Ali Nazeri Astaneh, Amir Hossein Jalali Nadoushan, and Sheikh Shoib. 2024.

“Factors Associated with Suicidal Ideation among Medical Residents in Tehran during the COVID-19 Pandemic: A Multicentric Cross-Sectional Survey.” PLOS ONE 19 (3): e0300394-. https://doi.org/10.1371/journal.pone.0300394.