Unpaid Clinical "Volunteer" Roles in Low- and Middle-Income Health Systems: A Narrative Review of Workforce Governance and Patient Safety.

Unpaid or unsalaried clinical "volunteer" roles are an underexamined workforce-governance issue in low- and middle-income countries (LMICs). This narrative review synthesized evidence on unpaid and unsalaried clinical work, labour-market transition, health-system governance, health-worker wellbeing, and patient safety. Targeted searches of PubMed, Google Scholar, World Health Organization (WHO), International Labour Organization (ILO), Cochrane, and grey-literature sources from 2000 to 2026 yielded 22 substantive sources: seven empirical or context-specific studies, six evidence reviews, and nine policy, technical, or country documents. Eight sources directly or closely described unpaid, unsalaried, volunteer, or transition-to-employment clinical roles. Evidence from Somalia, Sierra Leone, Nigeria, and Kenya confirms that such arrangements occur in several LMIC settings, although their prevalence and forms in private facilities remain poorly characterized. Across the wider evidence base, constrained employment absorption, weak supervision, poor working conditions, burnout, turnover, and limited reporting capacity are associated with workforce instability and patient-safety risk. The review develops a cautious framework linking enabling labour-market and governance conditions to workforce harms and plausible safety pathways, while distinguishing directly observed findings from contextual evidence. Clear role definitions, written documentation, supervision, worker protection, accountability, and setting-specific empirical research are priorities for healthcare leaders and regulators.