Why gender discrimination lies at the heart of the country’s chronic healthcare staffing crisis
Work burnout, unsanitary practices, poor social status and unsustainably low pay. These are just some of the grievances voiced by Iran’s mostly female nursing workforce. Though widely reported as a pressing labor issue, the subject warrants further examination as a gender rights issue. Tehran Bureau’s interviews with healthcare workers and review of publicly available data provide a gender-focused overview of the challenges faced by Iran’s healthcare workers. The results suggests that, in the healthcare sector, being female significantly raises workers’ chances of underpayment, job insecurity, occupational hazards and sexual harassment.
The exploitation of Iran’s nurses and other healthcare workers has long been a catalyst for labor protests, most recently on April 23, when about 40 nurses and operating room staff at north Tehran’s Tajrish Martyrs Hospital published a petition and resignation letter due to working conditions. It was also one of the focal points of the 2022 “Women, Life, Freedom” protests, during which demonstrators expressed support for healthcare workers based on their experiences of gender discrimination, namely the contrast between their high educational levels and everyday on-the-job realities.
Number of Female Nurses in Iran
Iran employs 226,000 nurses across 1,061 hospitals, with a significant portion (700 hospitals) affiliated with medical sciences universities. The workforce spans from undergraduate to doctoral levels, covering various specialties such as operating rooms, anesthesia, nursing aides, and midwifery, the Deputy Minister of Nursing of the Ministry of Health announced via various official news outlets in 2023.
Around 75% of these nurses are female, according to the Ministry of Health.
Interestingly, this gender disparity in nursing is a relatively recent phenomenon, according to a 2009 article published by the Ministry of Health. The article states that, in the final years of the Iran-Iraq war from 1985 to 1988, about 50% of the baccalaureate students admitted to the nursing program were men. After the war, however, this number decreased to approximately just above 20%.1
The low social status of nursing is currently one of the most influential factors preventing Iranian men from choosing the nursing profession, according to a 2021 article in the International Journal of Environmental Research and Public Health. “Portraying nurses as physician assistants” and the overall “poor image of nursing” are the main causes of the high turnover among male nurses in Iran, which has “exacerbated nursing shortages”.2
“Gender discrimination is more evident in management levels within hospitals, in the broader health sector management, and among executives, making inequality manifest as gender discrimination. Another significant issue is the stark difference in salaries between doctors and nurses, which is a current challenge and a cause for protest among nurses,” Davood M., a male nurse employed at one of Iran’s hospitals, told Tehran Bureau. “This wage disparity effectively leads to further degradation of nurses in their workplace.”
Number of Nurses Per Hospital Bed
The Health Ministry has long recognized the dire staffing shortage in the nursing sector. Currently, there are just under 0.8 nurses for each hospital bed in Iran, according to official figures, well below the standard of 1.8 nurses per bed in developed countries.
The Lancet medical journal, citing a source which refers to Iran Nursing Association numbers from 2014, puts the total number of nurses at 230,000 and the number of hospital beds at 16 to 17 hospital beds per 10,000 populations. This would make the nurse-to-bed ratio even less than 0.8.
Burnout, overwork, lack of recognition, and being asked to perform duties beyond their job description were the most frequent cases of job dissatisfaction among Iranian nurses, according to various studies.3
Wage Disparity Through a Gender Lens
The most striking evidence of gender discrimination among health sector employees is the disparity between the salaries of nurses, most of whom are female, and those of doctors, who are mostly male.
The minimum salary and wages for nurses in Iran in 1402 (2023-2024) was about 10 million Tomans ($163, at an exchange rate of 61,850 Tomans/$1), according to the Supreme Labor Council’s annual salary and wage report. This amount can vary depending on the level of expertise, the city of activity, work experience, and education level. It may also include a maximum 3,895,000 Tomans ($63.60) in add-on benefits, tax credits, overtime, and year-end bonuses.
This level of remuneration compares poorly to the standard in Organization for Economic Cooperation and Development (OECD) countries, where nurses receive about 20% more than the average wage. As a result, many nurses in Iran are compelled to emigrate, or to supplement their incomes with additional labor, such as driving a shared taxi.
“Those like me who have a personal vehicle can engage in such jobs, but nurses without their own cars are forced into accepting low-paid mandatory overtime and often wait several months to receive their overtime pay,” says Davood M.
Some of these most underpaid nurses then face further exploitation by being offered even lower compensation for their overtime work, much of which is mandated by their employers. Abolishing this mandatory overtime requirement is therefore a frequent demand of protesting nurses.
“There are nurses who accept overtime compensation of 20,000 Tomans per hour,” explains Davood M. “To put this into perspective, purchasing a can of tuna costs around 100,000 Tomans, meaning a nurse has to work for about 5 hours just to afford a can of tuna. Despite protests against this injustice by nurses in many cities and hospitals, this issue persists.”
The situation is significantly worse in private hospitals, he adds.
Physicians vs. Nurses
The alarmingly low level of financial compensation and social status of Iran’s mostly female nursing workforce contrasts with the disproportional growth in the salaries of Iran’s mostly male physicians. The office of Iran’s leader Ali Khamenei states that nearly 40% of Iran’s specialized physicians are women, implying that more than 60% are male. The Islamic Republic of Iran Medical Journal estimates the mean income of Iran’s specialist physicians to be 10.8 times higher than that of nurses. On average, physicians’ income is 2.4 times more than that of nurses in OECD countries. Studies have consistently shown that, despite recent reforms, the bulk of the Iranian healthcare sector’s expenditures in all settings is mainly dedicated to physicians.4
Male vs. Female Physicians
Despite the tendency of regime spokespeople to tout the growing number of female physicians, average salaries of Iran’s male physicians remain significantly higher than those of their female colleagues. In a 2019 study in which a total number of 666 Iranian GPs participated, female respondents said they received only 65% of the salaries of their male counterparts.
Rise of Temporary Contracts
Another frequent complaint of protesting healthcare workers is that a significant number of them are employed on insecure contracts, many of which contradict Iranian labor laws. Commonly known as 89-day contracts, this type of employment gained popularity after the Health Ministry eased restrictions to address a chronic staffing shortage during the COVID-19 pandemic. The contract increases the maximum hours of a part-time contract to 100 hours per month. It then reduces the contract period to 89 days with the possibility of extension if necessary. This effectively removes the obligation for an employer to officially hire a nurse, excluding them from social security or occupational insurance benefits.
While official estimates regarding the number of healthcare workers employed on these types of contracts are outside the public domain, a 2015 study in Medical Science performed on 136 nurses in Sanandaj city found that only 30.1% of them were full-time, while 69.9% were employed on some form of temporary contract.5
Gender-disaggregated data about these types of contracts was unavailable at the time this article was published. However, two facts suggest that here, too, female workers are at a disadvantage: First, these types of contracts predominantly affect nurses and other lower-paid workers, of which a high percentage (at least 75%) are women. Second, the proportion of male hospital employees tends to increase with management rank and salary level. The prevalence of male specialized physicians according to official statistics, as well as the responses of male and female nurses interviewed for this article, support this observation.
The number of female workers on 89-day contracts are likely to have grown following the pandemic. Our survey of 31 women working in the unofficial sector included three healthcare professionals (9.6% of the whole), all of whom said they were employed on short-term contracts. Their insecure employment status heightened their stress level, they said, and left them more exposed to financial and health risks.
The first respondent, a 33-year-old, married laboratory assistant and mother from Karaj, said she worked ten hours per day for 9 million Tomans ($146) a month:
“In our lab, we were dealing with non-sterile equipment and inadequate facilities. Two years ago, we faced the challenge of managing highly infectious and contagious waste.”
The second respondent, a 43-year-old divorced mother of two, stated she works 55 hours a week on average for a gross monthly wage of 4,500,000 Tomans ($72.76). Her employer regularly requires her to perform medical procedures beyond her qualification level, she added, making the risks to the employee and the patient she treats all the more imminent:
“I’m a secretary in a doctor’s office. I do typical work. I check in patients. I also answer calls. I also help clean up and assist the doctor with simple in-office operations.”
The third respondent, a nurse at an unnamed hospital, confirmed that in her work setting, income disparity correlated with the gender gap:
“In general, as you move up the management chain, the proportion of men tends to increase along with the salary….Men get paid better and receive better benefits….Often, they get extra hours and assignments, so they can earn more money.”
Gender-based violence and sexual harassment
In addition to high job stress, overwork and contract insecurity, many female healthcare workers are subjected to sexual harassment, research suggests. Though largely overlooked by lawmakers, sexual harassment is a worrying, though underreported trend in Iran, with as many as 89% of women reporting they experienced sexual harrassment at some point in their lifetime, according to a 2021 study by Cheragh Academy, an educational platform.
In Tehran Bureau’s own surveys, several respondents mentioned witnessing sexual harassment, including in work environments where most of their colleagues were also female.
“Our workplace mostly has women, so we don’t really deal with harassment or abuse about gender among ourselves,” said the 33-year-old laboratory assistant. “But, sadly, we’ve had a few times where patients have sexually harassed us, saying things or even getting physical.”
Violent behavior towards women working in healthcare is unfortunately not a rarity in Iran. In a 2020 Journal of Interpersonal Violence study among female clinical staff in Kerman, most participants (97.5%) said they experienced domestic violence at least once. The results showed that the most common types of violence against women were psychological/ verbal (58%), physical (29.25%), and sexual (10%).6
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- Maleki M, Mardani A, Vaismoradi M. Insecure employment contracts during the COVID-19 pandemic and the need for participation in policy making. Int J Environ Res Public Health 2021; 18: 12548.
- Barasteh S, Rassouli M, Karimirad MR, Ebadi A. Future Challenges of Nursing in Health System of Iran. Front Public Health. 2021 Jul 23;9:676160. doi: 10.3389/fpubh.2021.676160. PMID: 34368051; PMCID: PMC8345111.
- Maleki M, Mardani A, Vaismoradi M. Insecure employment contracts during the COVID-19 pandemic and the need for participation in policy making. Int J Environ Res Public Health 2021; 18: 12548.
- Naderi A, Ghaderi C, Hashemlu L, Aliramaei N. Factors affecting the implementation of evidence-based nursing care and related factors from the perspective of nurses. Med Sci 2018; 22: 319–27.
- Sheikhbardsiri, Hojat, Ahmadreza Raeisi, and Gholamreza Khademipour. “Domestic violence against women working in four educational hospitals in Iran.” Journal of interpersonal violence 35.21-22 (2020): 5107-5121.