Voices from the Margins: Citizen-Led Health Accountability in Kurdistan
EXPLORING ACCOUNTABILITY FOR HEALTH RIGHTS, VIEWPOINT, Vol 27/2, 2025, pp. 17-20, PDF
Goran Zangana, Shokh Mohammad, Baxan Jamal, Azadeen M. Amin, Isis Elgibali, and Thomas von der Osten-Sacken
Introduction
In fragile and conflict-affected settings, traditional accountability structures are often weak or absent. The Kurdistan Region of Iraq (KRI) offers a stark illustration: electoral delays, parliamentary paralysis, and widespread corruption have eroded public trust and oversight. Within this vacuum, grassroots citizen committees have emerged as crucial actors in advancing the right to health and fostering people-centered accountability. Drawing on lived experience and field engagement, this viewpoint examines how these committees have created space for community dialogue, monitored service delivery, and leveraged local knowledge to promote transparency in health governance. We argue that despite political constraints and institutional fragility, citizen activism can form the basis of a resilient, human rights-based approach to health governance.
Accountability—understood as the mechanisms that require those in authority to explain and justify their actions and remedy failures—is a cornerstone of human rights.[1] However, in fragile and conflict-affected settings, the literature on citizen-led accountability remains limited. Much of the focus has been on external, donor-driven interventions, while endogenous, community-based forms have been overlooked due to their informality and slow evolution.[2] External support for accountability has largely prioritized technical advice to governments rather than the empowerment of citizens.[3]
The KRI’s history of political fragility underscores the need for such endogenous responses. Cycles of conflict—from early 20th-century Kurdish uprisings to the Iran-Iraq War, Anfal Campaign, and post-2003 political instability—have shaped its governance landscape.[4] Despite the KRI’s de facto autonomy after 1991, internal division between major parties and a contested independence referendum in 2017 have perpetuated political deadlock. Recent crises, including unpaid public salaries, energy shortages, and deadly protests, highlight widespread public frustration.[5] While over 6,000 nongovernmental organizations operate in the region, they remain largely constrained by party influence and corruption (hence our distinction between nongovernmental organizations and citizen committees as separate forms of civil society).[6] Press freedom is limited, and donor withdrawal—such as the termination of the US$75 million Primary Health Care Project run by the United States Agency for International Development (USAID)—has left a vacuum in community engagement.[7]
This viewpoint explores the emergence of citizen-led committees aimed at promoting health rights and accountability within this fragile governance context. The committees’ work aligns with article 12 of the International Covenant on Economic, Social and Cultural Rights and the United Nations’ AAAQ framework of availability, accessibility, acceptability, and quality.[8] Their activities demonstrate how informal citizen structures can uphold human rights-based principles even where formal accountability has collapsed.
Health governance in Kurdistan
Modern public health in Iraq was institutionalized under British colonial influence, embedding physicians as both healers and political actors within governance structures.[9] Subsequent decades, particularly under the Ba’ath regime, prioritized tertiary hospital expansion at the expense of primary care, creating an imbalanced system.[10] The 1991 Gulf War and sanctions exposed the fragility of this model, leading to widespread service collapse.[11]
Post-2003 reforms driven by liberalization and market-oriented policies deepened inequities.[12] Profit incentives within public facilities transformed health from a human right into a commodity. Political parties gained control over pharmaceutical procurement and health contracts, eroding regulatory oversight.[13] Conventional accountability mechanisms—such as parliamentary scrutiny, media oversight, and civil monitoring—failed to prevent corruption, while the public sector’s neglect of primary care entrenched inequality. Restoring trust therefore requires reimagining accountability through citizen-led participation rooted in transparency and ethics.
Citizen-led accountability initiatives
Since 2024, the Human Network for Health and Humanitarian Affairs (HUMAN), an independent nonprofit, has initiated a grassroots accountability project across the KRI in partnership with WADI. Supported with Dutch funding, the project promotes citizen participation and monitoring to rebuild trust in public health governance. While still informal, this effort represents an early step toward participatory accountability mechanisms.
Citizen committees under this initiative include medical professionals, civil society actors, and representatives of vulnerable groups. They collect community input, engage with local institutions, and formulate recommendations addressing service gaps, such as staff shortages and lack of mental health provision. Operating voluntarily, these committees act as advisory and advocacy bodies promoting transparency, inclusion, and accountability.
Their influence extends to educational and environmental initiatives. In refugee and displacement settings such as Yazidi camps in Duhok, the committees have preserved access to education and psychosocial support following government funding cuts. The “Playbus” and “No to Violence” campaigns introduced trauma-informed learning and environmental health practices, improving student well-being and civic participation. Between September and December 2024, HUMAN conducted 10 public health seminars addressing hygiene, early disease detection, drug prevention, and the right to health, each reaching up to 50 participants. Youth engagement was central, linking awareness with social responsibility.
Workshops also tackled structural inequities in health care delivery, highlighting discrimination and mistreatment, particularly of women in maternity services. Citizen dialogue reframed health care as a human rights-based, rather than transactional, domain. Environmental activism—such as campaigns against single-use plastics—linked health awareness to climate justice and mobilized collaboration between schools, municipalities, and nongovernmental organizations. These cross-sectoral actions reinforced civic engagement and helped position health as integral to sustainable development.
Mechanisms and impact
Citizen committees have adopted several mechanisms to promote accountability. They use community-based monitoring, shadow reporting, and public forums to document service failures. Social media has become an especially effective tool, enabling the anonymous reporting of malpractice and corruption to protect individuals from retaliation. Volunteer-run platforms expose violations and amplify citizens’ voices, generating pressure for official responses.
Although outcomes vary, these informal approaches have yielded tangible improvements—such as reinstated services and responsiveness to public complaints. By leveraging local networks and cultural legitimacy, committees translate abstract human rights into concrete community demands. Their participatory nature fosters collective ownership of public health, challenging entrenched hierarchies and promoting ethical governance in a politically restricted environment. They also contribute to evidence-informed policymaking in the form of local knowledge.
Challenges and power dynamics
Despite their promise, citizen committees face significant constraints. Members report surveillance, intimidation, and accusations of serving foreign agendas, particularly since the closure of initiatives backed by USAID. Such pressures deter participation and undermine trust. Sociocultural barriers, including patriarchal norms and tribal divisions, further fragment citizen engagement.
Resource scarcity and dependence on external funding leave committees vulnerable to changes in donor priorities. Without formal institutional channels or enforcement mechanisms, committees’ recommendations are often ignored. Geographic diversity, while a strength, complicates coordination and reduces policy influence. These dynamics reveal persistent power asymmetries between grassroots initiatives and state institutions.
Broader reflections
The emergence of citizen-led health accountability in Kurdistan represents an organic response to systemic governance failures. As external actors retreat and donor priorities shift toward short-term interventions, local citizens have stepped in to monitor, document, and identify breaches of the right to health. Their reliance on lived experience, trust, and digital connectivity offers lessons for other fragile and conflict-affected settings through, not least, evidence-informed health policymaking.
Enduring impact requires formal recognition, pathways for redress, and integration with institutional frameworks. The challenge lies in bridging informal citizen oversight with formal governance mechanisms while safeguarding civic autonomy.
Conclusion
Citizen-led health committees in the Kurdistan Region exemplify how grassroots initiatives carry the potential for sustaining accountability where formal structures fail. They operate under political fragility, limited resources, and surveillance, yet continue to champion transparency, participation, human dignity, and the right to health. Their emergence signals a shift toward localization and community-driven governance.
As international development agendas increasingly emphasize local ownership, community empowerment must go beyond rhetoric. Genuine accountability requires recognizing and protecting the spaces in which citizens can hold authorities to account. In fragile contexts such as the KRI, these committees can become foundational to rebuilding trust and reasserting health as a human right.
Goran Zangana, MD, MPH, PhD, GZ, is an advisor for the Human Network for Health and Humanitarian Affairs, Edinburgh, UK.
Shokh Mohammad is a project planning coordinator at WADI, Suleymaniah, Iraq.
Baxan Jamal is a project coordinator at WADI, Suleymaniah, Iraq.
Azadeen M. Amin is director of the Human Network for Health and Humanitarian Affairs, Suleymaniah, Iraq.
Isis Elgibali is a project support coordinator at WADI, Brussels, Belgium.
Thomas von der Osten-Sacken is a manager at WADI, Frankfurt, Germany.
Please address correspondence to Goran Zangana. Email: goran.a.zangana@gmail.com.
Competing interests: None declared.
Copyright © 2025 Zangana, Mohammad, Jamal, Amin, Elgibali, and von der Osten-Sacken. This is an open access article distributed under the terms of the Creative Commons Attribution-Noncommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited.
References
[1] A. Kapilashrami, N. Quinn, and A. Das, Advancing Health Rights and Tackling Inequalities: Interrogating Community Development and Participatory Praxis (Policy Press, 2025).
[2] D. Green, “Theories of Change for Promoting Empowerment and Accountability in Fragile and Conflict-Affected Settings,” Institute of Development Studies Working Paper (2017).
[3] A. Christie and R. Burge, “The Role of External Actors in Supporting Social and Political Action Towards Empowerment and Accountability with a Focus on Fragile, Conflict- and Violence-Affected Settings,” Institute of Development Studies Working Paper (2017).
[4] “Timeline: Iraqi Kurds,” BBC (April 19, 2011), http://news.bbc.co.uk/2/hi/middle_east/country_profiles/2893067.stm.
[5] TII Team, “Kurdistan Reels from Power Cuts, Water Shortage, and Unpaid Wages,” Insight International (July 16, 2025), https://theinsightinternational.com/kurdistan-reels-power-cuts-2025-07-16; “Beyond 50°C: How Decades of Conflict Are Heating Iraq,” Shafaq News (July 27, 2025), https://shafaq.com/en/Report/Beyond-50-C-How-decades-of-conflict-are-heating-Iraq; “One Killed as Iraqi Kurds Protest Power Cuts,” Arab News (July 14, 2025), https://www.arabnews.com/node/2608081/middle-east.
[6] J. M. Ameen Hussein and M. D. Moniruzzaman, “Civil Society Organisations in Iraqi Kurdistan: An Analysis of Challenges,” Asian Affairs 55/2 (2024).
[7] QED Group, Mid-Term Evaluation of USAID/Iraq Primary Health Care Project (2013).
[8] International Covenant on Economic, Social and Cultural Rights, G.A. Res. 2200A (XXI) (1966).
[9] A. S. Jawad, “Sir Harry C Sinderson Pasha (1891–1974): Physician, Medical Educator and Royal Confidant,” Journal of the Royal College of Physicians of Edinburgh 43/1 (2013).
[10] H. C. Sinderson, Ten Thousand and One Nights (Duckworth, 1973).
[11] Harvard Study Team, Public Health in Iraq After the Gulf War (Harvard University, 1991); E. Hoskins, “Public Health in Iraq After the Gulf War,” in B. S. Levy and V. W. Sidel (eds), War and Public Health (Open University Press, 1997).
[12] F. M. Burkle and E. K. Noji, “Health and Politics in the 2003 War with Iraq: Lessons Learned,” Lancet 364/9442 (2004).
[13] A. Tawfik-Shukor and H. Khoshnaw, “The Impact of Health System Governance and Policy Processes on Health Services in Iraqi Kurdistan,” BMC International Health and Human Rights 10 (2010), p. 14.