JMHSR/1998 - Terms of employment and working conditions in health sector reforms

Report for discussion at the Joint Meeting on Terms of Employment and Working Conditions in Health Sector Reforms

This report has been prepared by the International Labour Office as the basis for discussions at the Joint Meeting on Terms of Employment and Working Conditions in Health Sector Reforms. It reviews the impact of health sector reforms on health workers and the implications of changes in employment and pay, labour relations, working conditions and terms of employment on the general performance of health systems in the light of the links between health policy, human health and the economy.

The meeting is part of the ILO's Sectoral Activities Programme, the purpose of which is to facilitate the exchange of information between constituents on labour and social developments relevant to particular economic sectors, complemented by practically oriented research on topical sectoral issues. This objective has traditionally been pursued by holding international tripartite sectoral meetings for the exchange of ideas and experiences with a view to: fostering a broader understanding of sector-specific issues and problems; promoting an international tripartite consensus on sectoral concerns and providing guidance for national and international policies and measures to deal with related issues and problems; promoting the harmonization of all ILO activities of a sectoral character and acting as focal point between the Office and its constituents; and providing technical advice, practical assistance and support for the latter to facilitate the application of international labour standards in various economic sectors.

At its 262nd Session (March-April 1995), the Governing Body of the ILO decided that a meeting on the terms of employment and working conditions in health sector reforms would be included in the programme of sectoral activities meetings for 1996-97. At its 268th Session (March 1997) the Governing Body decided that this meeting should be included in the programme of sectoral meetings for 1998-99 and that it should be bipartite with some representation of the private sector. It was decided to invite the following 18 countries: Austria, Belgium, Bulgaria, Canada, China, Colombia, Czech Republic, Kuwait, Lebanon, Mexico, Niger, Poland, Russian Federation, Slovakia, Sweden, Switzerland, Uganda and Zambia. A number of countries were included in the reserve list from which further invitees would be drawn in the event that a government in the first list declined the invitation. Furthermore, seven private employers' and 25 workers' representatives were invited. The Governing Body decided that the purpose of the meeting would be to facilitate an exchange of views on the impact on employment and working conditions of changes in the delivery of health services associated with the reform of the health sector in countries undergoing structural adjustment and transition to a market economy, and to adopt conclusions, including guidelines and proposals for further action, and a report on the discussions. The meeting may also adopt resolutions.

Against the background of increased competition in a globalized economy and declining public budgets, health care systems, like other public services, are increasingly subject to reforms. In many countries the performance of health care systems is severely deteriorating, at times to critical levels, and demands deep restructuring and improvements in efficiency. Owing to demographic developments (the growth and ageing of populations), the demand for health services is increasing. Restructuring and redesigning systems of financing health care (for example, by introducing user fees and other private contributions), appears to lead in the long run to a further increase in health sector employment, even though the structures of employment change.

In many countries, the increasing demand in parts of the sector often aggravates shortages of qualified personnel, whereas in others there is an oversupply. Pay, working conditions and terms of employment are often unable to attract new entrants or retain the existing workforce. Migration is the consequence of inter- and intra-country imbalances. Work reorganization, restructuring and privatization are frequent responses to the alarming situation of some health care systems. Shifts in health policies in order to make basic and primary services accessible to all population groups are also meant to improve the general situation. Health workers are torn between their professional responsibilities and economic pressures, as well as having to cope with their traditionally difficult duties.

In seven chapters, the present report outlines the changes brought about through health sector reforms and highlights the relevance of the ILO's activities to the management of change in partnership with the workforce. Chapter 1 describes the various challenges to which health care systems are exposed at present and Chapter 2 briefly outlines different patterns of health care reform as policy responses. Chapter 3 introduces the general trends with regard to the impact of reforms on health care staff. Chapter 4 analyses trends, levels and structures of employment in relation to health sector reforms. The various sections of Chapter 5 describe in some detail the impact of health sector reforms on human resource development, working conditions, work organization, occupational safety and health and labour relations. As the elements of health systems analysed in these chapters are interlinked, cross references have been made to other sections as far as possible. Chapter 6 summarizes some trends in remuneration in the health sector and the final chapter gives a brief overview of ILO policy and activities in relation to health sector reforms and improvements in working conditions. This last chapter refers to international labour standards of specific relevance to health care workers; however, preceding chapters also refer to international labour standards of general application whenever they are relevant to the subject of the section. The report concludes with a list of suggested points for discussion.

The information on which the report is based is derived from a variety of sources, although it should be noted that it was sometimes difficult to obtain comparable data on public and private health care. Extensive use was made of various publications as well as articles from the press. A number of governments which showed specific interest in the subject of the Joint Meeting, as well as affiliates of Public Services International and of the International Council of Nurses, replied to a questionnaire on issues dealt with here and the information provided was used at various places in the report; however, owing to the limited scope of this report, by no means all the information could be absorbed. The report also draws extensively on materials and data published by the World Health Organization and the World Bank. The World Health Organization provided comments on the first draft of the report. Use was also made of studies on restructuring and privatization of health care services prepared for the ILO by Stephen Bach and Sandra Polaski and of a study prepared for the ILO by Judith Healy on health care personnel in Central and Eastern Europe.

The report was prepared by the Salaried Employees and Professional Workers Branch and is published under the authority of the International Labour Office. Contributions to the report were provided by external collaborators (Mr. Axel Weber, senior specialist in health systems, Ms. Gabriele Mussnig and Mr. Derek Robinson).

The quality and quantity of health care depends largely on the availability of adequate numbers of properly trained health workers, who constitute the health sector's most important resource. This conclusion, adopted by the Joint Meeting on Employment and Conditions of Work in Health and Medical Services in 1985, is as valid today as it was 13 years ago.

The role and responsibility of the health sector are vital in underpinning the growth and development of society as a whole. Public sector reforms, especially in the health sector, should respect basic guiding principles: continuity of values, transparency and openness of policies, equity in access to services, provision of better services to citizens, the importance of good working conditions and the application of international labour standards to improve morale and performance.

Health reform may be defined as the attempt to improve the efficiency, equity and effectiveness of the health sector -- a definition which touches on a wide range of economic problems, as well as purely medical and social issues.

Indeed, the link between health policy, human health (defined as a state of physical and mental well-being) and economics is profound. The health sector is of crucial importance, not only for the health of the population, but also for the productive potential of the economy as a whole. Neglecting the health of a section of the population will have damaging effects on long-term productivity. The interplay of economic forces, and the way those forces are directed by governments, have the potential to improve or harm human health, and inevitably have an effect on present and future human welfare. The concept of welfare itself encompasses a broader vision than is implied by the more narrowly scientific medical terms.

The contours of the world economy have changed very considerably over the past few years as a whole series of countries have embarked upon radical programmes of reform. The optimism of the late 1970s, with the revolution in primary health care, has increasingly given way to concern over problems, such as the drastic reduction in health budgets caused by economic crises. This has frequently led to the adoption of structural adjustment programmes, and free market systems, increased inequity in access to health services, the appearance of new diseases such as AIDS and Ebola and the resurgence of diseases of poverty, such as cholera in Latin America and Africa and tuberculosis in Eastern Europe.

The current spectrum of ill health can be depicted as follows: populations in transition, as they become more "developed", gradually move from a situation in which ill health and premature mortality are caused primarily by infections and malnutrition to a situation characterized by a predominance of chronic, non-communicable diseases with high morbidity, particularly among the elderly. However, in many developing countries today both stages commonly exist at the same time, and this diversity complicates the setting of priorities for financing health services as well as health care provision itself.⁽¹⁾

These combined factors, together with the lack of sustainable finance and/or cost escalation, have led to the need for health care reforms throughout the world.

It is worth noting that in many countries, there has until recently been little interest in employment practices in the health sector, a fact which is reflected by the absence of published studies in this field. It was in this context that a request for information was addressed to governments, trade unions, nursing and other professional associations of health care providers, in order to fill this gap. The information gap concerns in particular recent upheavals within health systems, their direction and outcome. Comparative analysis is further complicated by the fact that, even between relatively homogeneous groups such as doctors and nurses, definitions of occupational groups and the tasks that they undertake vary considerably between countries.⁽²⁾ Hence, the relevance of the present Joint Meeting under the auspices of the ILO.

Beyond its general concern about health protection for workers and their social protection in general, the ILO attaches great importance to the fact that the improvement of employment and working conditions of health and medical staff is vital to the satisfactory delivery of services in this sector. In view of the critical importance of the health sector, in terms of its workforce and sheer size in terms of percentage of global GDP, the ILO has adopted a sectoral perspective, in accordance with its mandate, to deal with terms of employment and working conditions of health care delivery staff affected by recent health care reform initiatives. Such sector reforms are most likely to achieve their objectives of ensuring efficient, effective and high-quality services when they are planned and implemented with the full participation of health workers and their unions and of consumers of health services at all stages of the decision-making process. It goes without saying that the commitment of health care personnel to reform is crucial to its success. Effective communication, consultation and negotiation with a view to reaching consensus with workers and their unions, is essential during the restructuring process.

1. WHO: Towards an equity-oriented policy of decentralization in health systems under conditions of turbulence: The case of Zambia, by Katele Kalumba (Geneva, doc. WHO/ARA/97.2, Mar. 1997), p. 2.

2. Stephen Bach: "Restructuring and privatization of health care services: Selected cases in Western Europe", in Gabriele Ullrich (ed.): Labour and social dimensions of privatization and restructuring: Health care services (Geneva, ILO, 1998), p. 54.

Health systems, like other public services, are increasingly subject to reforms. Many societies and the world as a whole are facing a number of challenges which result from structural, social and economic changes and make reform initiatives necessary.

This also applies to health care systems, where a number of trends, often also seen in other sectors, make it necessary to search for new solutions. Failure to do so will mean that the systems will be unable to fulfil their tasks and/or costs will rise faster than the incomes of the people who finance them. Many health systems around the world are already facing situations where their performance is severely deteriorating. The countries of Central and Eastern Europe in particular are undergoing deep restructuring processes which have a considerable effect on the health sector.

There are a number of distinct challenges that need to be met. Some are found in certain country groups only, others occur in almost every country throughout the world. In any case, these challenges are the underlying reason for many reform initiatives in the countries concerned.

A growing number of countries face the challenge of rapidly rising health expenditure in both the public and private sectors. Some countries have increased health expenditure from 3-5 per cent of GDP to 8-10 per cent in only a few years. Since the 1960s, the share of GDP spent on health care in developed countries overall has been on the increase. The same trend is also seen in other countries. Argentina now spends more on health care in terms of the share of GDP than Canada, which for years took second place only to the United States.⁽¹⁾

With regard to countries with developed market economies, such growth has been accompanied in many cases by even larger growth in health expenditure by public agencies. As a result of this evolution and economic slow-downs, growing public concerns over controlling health care expenditures have become predominant.

In many countries, health care expenditure is growing faster than GDP. This leads to serious cost and distribution problems, especially in industrialized nations. The notion of a "cost explosion" in the health sector has become common place and represents a major problem for governments. Contribution rates to health insurance schemes are rising, public debt is growing. But public health expenditure is not the sole indicator of rising costs. Patients complain about having to pay a larger share of the costs every year, in addition to their insurance contributions and taxes. Health expenditure affects wage costs and corporate taxes. Rising costs affect the competitiveness of a country in world markets.

There are many reasons for the rising costs. Most of these are covered by the points set out below. Whatever the reasons for them, rising costs in the health care sector are a political issue of great importance. However, it should also be borne in mind that patterns of health care spending vary greatly around the world.

In 1994, global spending on health care was about US$2,330 billion (9 per cent of global GDP), making it one of the largest sectors in the world economy. Although low- and middle-income countries account for only 18 per cent of world income and 11 per cent of global health spending (US$250 billion or 4 per cent of global GDP), they contain 84 per cent of the world's population and account for 93 per cent of the world's disease burden.

However, health systems in all parts of the world are coming under strain as they attempt to meet the growing demands placed on them while also striving to contain costs. Few countries, if any, can expect to reduce spending on health care. Most are making concerted efforts to slow the growth in expenditure and maximize income. There is near universal recognition that substantial inefficiencies exist in the allocation of resources, whether human, material or financial, and many governments are re-thinking the basic assumptions of their health care systems.

The sheer size of the sector, and the fact that growth in health expenditure exceeds income growth, mean that it will continue to be a critical area of policy.

We face today an increasing interdependency of world markets. Trade is increasing worldwide. International economic networks are growing. The world is on its way to becoming a single market.

This globalization of markets brings with it a need to reduce costs of social systems in order to improve competitiveness. Wages and wage-related costs such as social security contributions and taxes have a major impact on world market prices and competitors are therefore interested in keeping these costs as low as possible. This effect may be observed in most countries, where initiatives to reduce the cost of social benefits lead to reforms. This generally means reductions in benefits, increases in co-payments, a weakening of solidarity. It may also mean improved efficiency of health care services without cuts in services, or the setting of new priorities in health care services.

A special case is that of countries in transition. They are in the process of changing their entire economic and legal systems to create market economies. With these changes comes the need to restructure the health sector. In many of these countries, a sharp decline in GDP at the beginning of the 1990s imposed severe budget constraints. This also had an impact on the health sector. These countries thus faced a double challenge: they had not only to manage rapid changes in policy and structures but also had to maintain their health care services in spite of shortages due to budget problems. In some countries, such as Poland, health care reforms have not yet been implemented owing to budgetary cuts and controversy over the design of the reform.⁽²⁾

Another development is that of structural change which may be observed in almost all countries and occurs in various patterns and in different sectors of the economy. In some sectors, especially the industrial sector, jobs are being lost, while in the service sector jobs are being created. This structural change is accompanied by growing unemployment and creates challenges for the workforce. Workers have to adapt to changing work environments and be more flexible and prepared for lifelong learning. These structural changes go hand in hand with changes in public tasks and public spending. Public services are privatized and public expenditure reduced. This creates budget constraints for health care systems as well as the other sectors.

System-inherent challenges emerge from the specific design of a system. There may be many elements of health care systems which lead to deficiencies including:

These deficiencies can lead to a general situation where reform of a health care system is unavoidable.

The development of new technologies and the growth of the information society will lead to a need to restructure economies, employment and production. In some sectors, employment will increase, while in others it will decline. All the sectors associated with services will become increasingly important. Health care is one of these sectors. But in line with the structural changes, forms of employment will change, and this will lead to new challenges in the area of social protection and working conditions.

In medicine, too -- as in many other economic sectors -- reform is under way as a result of this kind of change. Medical technology has advanced significantly in recent decades. Advances in electronics and biotechnology will bring about radical changes in the treatment of many diseases and the role of doctors and nurses will change accordingly. Diagnosis and surgery will change in a way which will further reduce hospital stays. Information and communication technology are likely to improve the quality of health care while cutting costs and waiting lists.⁽³⁾

Telematics in medicine, new procedures and machines, gene technology, etc., will lead to changes in the nature and organization of work, new requirements in terms of qualifications, new jobs and new occupations. This also requires flexibility on the part of workers and employers and poses problems for all concerned. This is why workers' participation in questions relating to the implementation of new technologies and subsequent changes in occupations and working conditions is of great importance. In general, experience suggests that workers are open to technological innovations.

The result of both trends is still not clear. In the short term, the new technologies require major investments in equipment, training and restructuring. The present climate of cost-containment might not be very conducive to such investment.⁽⁴⁾

In any case, the question of equal access to health care will also be posed by technological advances. Even today, the question arises as to which of the new technologies are available to everybody and which are available only to those who can pay for them.

Access to health care is still often inadequate and inequalities persist between countries and within countries. It remains a challenge throughout the world, especially in the developing countries, to ensure universal access at least to primary health care and family planning.

Health problems and reform issues are particularly difficult in most of the low-income countries, although there are variations within that group. With populations living "on the edge", health providers and governments in the world's least-developed countries must make a far greater effort to build a basic health infrastructure which can help ensure a decent quality of life for their citizens. At the end of the last decade, basic health care was available to less than half the world's population. Rural inhabitants, who make up the vast majority of the world's population, were particularly disadvantaged.

Table 1.1. Health indicators -- World averages


Country group	Life expectancy at birth	Under-5 mortality rate	Fertility rate	Health expenditure as percentage of GDP

East Asia and Pacific	68	53	2.2	3.5
Europe and Central Asia	68	35	2.0	5.5
Latin America and the Caribbean	69	47	2.8	7.2
Middle East and North Africa	66	72	4.2	4.4
South Asia	61	106	3.5	4.1
Sub-Saharan Africa	51	157	5.7	5.6
Low and middle income	65	60	3.1	5.6
High income	77	7	1.7	9.9
World	67	81	2.3	9.1
Source: World Bank.

In many developing countries, existing health care schemes cover only the small formal sector of the economy and the majority of the population lives entirely without or with very limited health care services.

It is well known that improvements in health care result in a more productive labour force, increasing life expectancy and better quality of life. On the other hand, this requires investments in health care which in many cases cannot be made by the respective countries alone, but depend on help from donors. Greater solidarity between poor and industrialized nations is necessary if the world's poorest countries are to advance in their struggle to provide basic health care for their people. The international community as a whole must seek ways to provide more favourable conditions of trade, debt relief and generous and carefully targeted assistance to enable these nations to build and maintain the basic infrastructure needed for health and well-being and to achieve economic growth which enables them to improve living conditions.

However, international assistance in most of the least-developed countries still covers on average less than 2 per cent of total health expenditure. An exception is sub-Saharan Africa, where aid flows represent more than 10 per cent of total health expenditure.


		Percentage

	Sub-Saharan Africa	10.40
	India	1.60
	China	0.60
	Other Asia	1.40
	Latin America	1.30
	Middle East	1.20
Source: World Bank.

The major challenge in developing countries is thus the extension and improvement of existing health care schemes.

But not only developing countries face the problem of insufficient access to health care. In transition countries and in some industrialized nations, where per capita income is much higher than in developing countries, some social groups, such as the urban poor and migrant workers, are in some cases excluded from adequate health care services.

The world population is ageing (see table below), although there are imbalances in this process between regions. In certain regions such as Africa and India, the problem of ageing is not as serious as in the industrialized nations or in China.

Table 1.3. Age structure of the world population, 1950-2030 (percentage)


	1950	1980	1990	2000	2030

0 to 4	13.5	12.1	12.0	11.0	8.4
5 to 14	21.0	23.0	20.4	20.5	16.7
15 to 59	57.5	56.4	58.3	57.8	59.7
Over 60	8.0	8.4	9.3	10.6	15.2
Source: World Bank.

The ageing of the population in most countries will lead to increasing health expenditure because older populations will need more and different kinds of health care. This effect will lead to a discussion about a new definition of solidarity and access to health care. Many countries are discussing new priorities in health care and new systems of social protection. Health schemes compete with pension schemes for scarce resources.

At the same time, the ageing of the population will result in fewer active and more economically inactive people in society. This will increase the burden on the active population and will lead to attempts to decrease this burden.

Even now it is evident that a major share of health spending goes on care for older people. For example, health spending in 1993 for people aged 65 and over as a share of total health care spending amounted to 42.9 per cent in Japan, 32.3 per cent in Germany, 41.1 per cent in France, 42 per cent in the United Kingdom and 37.2 per cent in the United States.

In Germany in 1970, 26 per cent of all members of health insurance funds were pensioners. In 1990, the figure was 29 per cent.

These percentages tend to increase as the population ages. Although according to some studies only 8 per cent of the elderly are seriously impaired or dependent on extensive supportive care and 4-6 per cent of them live in institutional settings, older people suffer more from chronic disease such as those related to vision and teeth. For example, a study of urban people aged 60 and over in nine provinces of China found that 59 per cent of them suffer from at least one kind of chronic disease -- mainly hypertension, chronic bronchitis, coronary heart disease and rheumatic arthritis.

Some experts even argue that it is precisely the demographic ageing in the developing countries of Asia and other parts of the world that is directly responsible for the emergent crisis in health care. They point out that the ageing phenomenon causes significant shifts in predominant disease patterns and also creates new demands on health systems that are typically overburdened even before such new needs arise. They maintain that in some developing regions, for example, the prevalence of chronic illness will soon surpass that of acute, largely infectious disease. Thus, the demographic transition is primarily responsible for the crisis in health care that is emerging in the developing world.⁽⁵⁾

This development will require the enhancement of medical services provided to the population in the regions of the world especially affected by ageing if the quality and quantity of medical services to the population is even to be maintained, let alone improved. As a result, employment in the health sector may increase especially in those occupations which deal with medical problems associated with ageing, in specialized institutions, clinics or the home.

Unemployment has become one of the most important political and economic problems of recent decades. In most industrial nations, long-term unemployment is a special challenge which is of increasing political and social importance, and one which has an impact on the health sector. Long-term unemployment leads to increasing rates of mental illness, suicide and violence. A special group among the long-term unemployed are young people who are lacking a perspective for their working life.

The health sector itself does not have the means needed to combat long-term unemployment. However, it can, in cooperation with the social sector as a whole, deal with its effects through self-help groups, medical assistance, social workers, etc.

In many developing countries, a growing population means that, in spite of a growing economy, GDP per capita is actually falling. This is an indicator of the scarce resources available for health care and family planning purposes. Most of these countries thus find themselves in a vicious circle: per capita income falls because GDP growth fails to keep pace with population growth and the population grows because there is no money for effective family planning and health care.

Table 1.4. Population and GDP per capita in selected African countries, 1960-90


	1960	1970	1980	1990

Ghana	6 774 177.6	8 612 251.9	10 736 412.3	15 020 381.0
Niger	3 028 147.9	4 165 153.1	5 586 447.4	7 731 319.6
Nigeria	42 305 99	56 581 214	78 430 1 130	108 542 296
Zambia	3 141 199.4	4 189 415.8	5 738 626.4	8 138 416.1
Zaire	15 333 215.1	20 270 232.9	27 009 520.5	37 391 191.9

Population in thousands, GDP per capita in US$ (second figure). Source: Eurostat.

Thus, per capita income is falling while the needs for public efforts in health care constantly increase as population grows. The margin for more public spending in most cases is very limited.

Population growth in many developing countries also leads to increasing urbanization. Because people have no means of subsistence in the countryside, they migrate to find work in the cities. There, they form the population of the growing slums with their well-known problems of disease, exclusion and poverty. Urbanization in most developing countries is a growing problem and the urban slums are a challenge to any health programme.

If we look at the different challenges facing the health sector from a regional point of view, four basic patterns can be observed, each of which represents a different mix of challenges for reform policy.

The first pattern is typical of industrialized nations and a few developing countries that have achieved high levels of health care.

In such countries, infant and maternal mortality rates are low, fertility tends to be low, life expectancy at birth is relatively high and the proportion of elderly people is growing.

The health problems these countries face are typically those associated with an ageing society, good life expectancy, personal lifestyles and environmental factors. Cardiovascular disease and cancer predominate, but care is often required for mental and neurological disorders, degenerative diseases, chronic diseases and conditions affected by behaviour.

A particular feature found in these countries is the tendency for health services to become increasingly a large market where people pay for additional services to promote or improve their own health in addition to publicly financed health care.

The major challenges facing these countries are: to extend quality health services to previously excluded socio-economic groups; to provide sophisticated treatment for the increasingly complex medical conditions they face; to provide long-term care for the growing proportion of the population that is entering old age and extreme old age; and to bear the financial burdens that such care implies. In addition technological advances in medicine are bringing about major reforms in treatment patterns. Finally, these economies are also under pressure to contain costs due to increasing world competition.

These countries have made considerable progress in building a health infrastructure based on primary care.

Their past efforts have been rewarded by declining infant mortality rates, increasing life expectancy at birth and diminishing fertility rates.

The traditional causes of mortality -- infectious and parasitic diseases -- remain the major killers, but new health problems such as the chronic non-communicable diseases associated with ageing and modern lifestyles are also appearing.

Given the rapid demographic changes that are now occurring and the shifting demands and expectations of the various population groups, these countries face both traditional and new health problems with limited resources. They will need to extend their infrastructures to provide essential health services to the rural groups and urban poor who are at present excluded, while at the same time developing more sophisticated treatment for an ever-growing portion of their population.

The third pattern occurs most frequently in the world's least-developed countries, particularly in Africa and South Asia.

The health outlook there is particularly distressing, since these nations face critically difficult situations and have limited financial and human resources with which to develop their health sectors. Their rapidly growing populations live in extreme poverty and often in deplorable conditions of health and hygiene. The most urgent health needs such as hygiene and nutrition, have to be met by economic development and distribution measures and cannot be met by the respective health care systems alone. Public health expenditure is insufficient to ensure clean water supplies, sanitation facilities and access to basic health care for large sections of the population.

Infectious and parasitic diseases, acute respiratory tract illnesses and malnutrition contribute to high morbidity and mortality.

Those responsible for providing health services in these countries face two main challenges: the first is to optimize the impact of existing health resources; the second is to greatly increase those resources, both domestically and through international assistance.

The fourth pattern is found in the transition countries of Central and Eastern Europe.

For many decades these countries have pursued a health care strategy quite different from the one in Western industrialized countries. For several decades, they had far higher physician and hospital bed ratios than those in the rest of Europe.

Despite this large medical sector, the epidemiological situation in the countries of Central and Eastern Europe compares unfavourably with that in the rest of Europe. Indeed, life expectancy in those countries is roughly five to seven years shorter and is actually declining in some countries.

Environmental factors, such as contaminated water supplies, air pollution, unsanitary waste disposal and inadequate food safety, have contributed to the relatively low health status of the population, as have poor personal health habits such as high rates of smoking, excessive alcohol consumption, frequent abortions and unhealthy diet.

Many of these countries are undergoing major reforms which reorient the health care system towards an insurance scheme with an emphasis on preventive and primary care. Private health care provision is increasing while public services are being cut back.

1. World Bank: Health nutrition and population (Washington, DC, Sep. 1997), p. 4.

2. Christopher Bobinski: "Polish health reform may be stalled", in Financial Times (London), 19 Mar. 1998.

3. Vanessa Houlder: "Anatomy of advancement", in Financial Times (London), 3 Feb. 1998, p. 9.

5. G.C. Mayers and S. Maggi: "World population aging: Implications for health research", in Aging and clinical and experimental research, 5(29), 1994, pp. 77-79.

Reform is a word with a generally positive meaning. Reform implies evolution towards a status that has been planned and, at least in the eyes of some social groups, means something better than the existing situation. In many countries, especially during the past decade, we have learned that reform may mean not only planned processes of improvement. It may also mean in many cases adjustment to deteriorating conditions. As an example of this one could cite the budget adjustments made in response to deteriorating world market conditions in many developing countries.

Many reform programmes are initiated in response to such challenges. Reform programmes may comprise different elements of differing relative importance, depending on the challenges to be met. These elements include the following:

Health care reforms may take place at one go or as part of an ongoing, continual process. Reforms at one go may lead to major changes in the system. The groups affected by the reforms will have to get accustomed to a lot of new regulations and will have little time to manage changes. This confirms the importance of consultation and workers' participation in health sector reform processes.

Ongoing reform processes, on the other hand, may result in a system failing for decades to get past the reform process. All areas may be subject to constant change. The workers in the health system may be confronted with ever-changing regulations and conditions. Their involvement in the reform process is of vital importance for its success.

In this context another effect should be mentioned. Reform normally means reform by political decision-making, by legislation, by administrative implementation (see the definition of reform in the introduction). But there is another kind of reform which also places a burden of change on all the partners in any economic sector. This type of reform is the result of the challenge of "technological progress" which brings about changes in skills and technologies and thus initiates a gradual reform of its own. In Denmark, for example, technological advances have brought about changes in patterns of treatment (see also section 5.8 of this report).

Some of the effects are long-term, others are medium- and short-term effects. In general there are opposing trends towards both increases and reductions in health care expenditure. The direction and relative importance of these opposing trends may vary between industrialized, transitional and developing countries. Ultimately, the observed trends will create the constant need to reform health care systems. These reforms will involve restructuring benefits, setting new priorities in the provision of health care services and finding new ways of financing health care.

The different challenges have different impacts on reform initiatives and health care policy. The following table gives an overview of the different challenges facing health care schemes and different types of reforms as responses to those challenges.

Table 2.1. Trends in health care, their effects and possible policies or strategies


Challenge	General effects	Policy

Rising health costs	Rising contribution rates, rising wage costs, rising public expenditure.	Improving efficiency, privatization, improving performance of labour force and management.
System-inherent deficiencies	Rising health costs, deteriorating quality of care.	Improving management. Improving provider payment schemes.
Technical advances in medicine	New treatments (in the short term), rising costs (in the long term), possibly reduce costs as a result of rationalization.	Setting new priorities, reshaping benefit schemes, increasing individual responsibilities.
Globalization of markets	Growing competition.	Reducing benefits, increasing co-payments and user fees.
Development of new technologies and evolution towards the information society	Changing labour world. New forms of labour. Restructuring of economy and production.	Reshaping and redefining social security benefits and finance including health insurance.
Ageing society	Higher health costs, smaller number of contribution payers.	Efforts to reduce the burden on the active population.
Increasing long-term unemployment	Increase in mental illness, suicides and violence.	Preventive care approaches, social services.
Better access to basic health care, especially in developing countries	Increasing life expectancy, increasing productivity, higher health costs.	Developing and improving health care services to reinforce economic growth.

Privatization is one of the key elements in the process of transition from a communist regime to a democratic political system and market economy. It has been broadly supported in the countries of the former Soviet Union and the countries of Central and Eastern Europe.

But other governments around the world have also been experimenting with privatization for a variety of reasons. Privatization initiatives in the health sector were developed in both advanced and developing economies mainly in an effort to contain costs. Before entering the controversial debate surrounding the privatization of health care, a major concern is the question: who decides the appropriate level of services provided? This concern is currently reflected in health reform debates about priority setting and rationing in a number of countries. Is it a matter for the public planner, epidemiologist or health economist to decide? Or should the core market mechanism centre on patient choice and consumer sovereignty? In this context, the Ljubljana Charter,⁽¹⁾ which will be discussed in detail in section 2.5, stipulates that "the exercise of choice and of other patients' rights, requires extensive, accurate and timely information and education. This entails access to publicly verified information on health services' performance". Countries in different categories (e.g. OECD or low- and middle-income) have adopted different positions in their national health policy debates.

The alleged limitations of government and the financial responsibilities of individual citizens are the principal foundations of this approach. Internationally, these positions are embodied in the approach to growth and development of the major lending institutions, the International Monetary Fund and the World Bank. In relation to health care, their clearest manifestation in official policy statements is perhaps found in the 1987 World Bank publication on "Financing health services in developing countries: An agenda for reform".⁽²⁾ This publication marked a major departure in the sense that the World Bank, which had previously restricted itself to other sectoral or general development issues, now began to devote large-scale finance and technical expertise to health. Since then, the debate regarding modalities of financing appropriate to the health sector has to a large extent been influenced by the World Bank, which has advocated greater reliance on user charges, insurance mechanisms, the private sector and administrative decentralization as the main pivots of policy change.

The influence of these agencies and their approaches to development policy is substantial, and they have been effective in supporting the increasing importance of the role of economists in determining the direction of health policy. The same applies to other sectors of the economy, particularly in low- and middle-income countries. The theoretical position of these major finance institutions has subsequently been refined in the light of practical experience, and as a result those agencies have tended to adopt "mixed approaches", as outlined below.

Box 2.3
Forms of privatization

Several forms of privatization may be distinguished and all have differing impacts on users of health care services and employees in the sector. They include:

privatization of ownership, which means that the ownership of facilities and service units is shifted from the public to the private sector. This may happen by sales of shares, voucher privatization (as in the Central and Eastern European countries), transfer to management or employees, direct sale, etc.;
privatization of responsibility, by formal transfer of responsibility for the service to a private organization, transfer to users via abolition or reduction of service, liquidation of state-owned enterprises, liberalization and reduction of planning of the sector;
privatization of provision through contracting out, leasing, operating concessions, management contracting, purchasing of private goods and services;
privatization of finance through higher co-payments and user charges, or by shifting to private health insurance funds, private capital for public infrastructure investment, joint ventures with private enterprises;
privatization through the introduction of markets (for example, competitive tendering between in-house and external contractors), creation of markets by splitting purchasers and providers or introducing greater choice for patients. ¹

¹ Public Services International (PSI): Public services and private interests (Ferney-Voltaire, France, 1997), p. 8.

An effort will be made to describe the concept of privatization per se in relation to health care. Under the broad heading of "cost recovery" in low- and middle-income countries, several initiatives have been undertaken ostensibly to improve efficiency in the health sector. Statements to the effect that the introduction of user charges provides a major source of revenue to the health care sector in most countries, taking into account both governmental and non-governmental health care providers, have been matched by statements advocating fees as a way of helping consumers (patients) to understand the true cost of health care provided free (or subsidized) at the point of delivery. In some cases, a concern to promote cost recovery in the health sector, in keeping with a general policy of economic restructuring and reviewing government functions in the broader context, has resulted in a narrow focus on raising revenue as an end in itself.

In this shift, the concept of "need" as a criterion of allocational efficiency is replaced by the concept of expressed demand (i.e. ability and willingness to pay). However, since health and education are different from other goods, it is accepted that, in order to measure the performance of health care systems, some operational assessment of need is necessary. The choice between need and demand as allocational devices is therefore a fundamental one: either financing and consumption patterns for health care are left to market forces, or overall health status is pursued as the policy objective.

Consequently, the whole controversy surrounding the privatization of health services tends to centre on the question whether (and through the application of which mechanisms) it might be feasible to redirect, restructure and reorganize health care to achieve both economic efficiency and social justice. The effectiveness of health care delivery should be measured in terms of health outcomes and long-term benefits to individuals and society as a whole. While such considerations have prompted modifications to target the level of user charges and provide exemptions for the poor, detractors of this approach have maintained that the obligation to provide care for the poorest (or in developed countries, for those affected by exclusion) -- a priority on grounds of social justice -- and privatization are quite simply mutually exclusive, however "refined", and "well adapted" the specific mechanisms may be (e.g. by being adapted to local conditions or socially stratified to allow exemptions).

In a fundamental shift away from the public sector (although not strictly speaking "privatization"), several developing countries have begun introducing simple social health insurance or prepayment schemes. Many recent insurance schemes centre on the principle of starting with compulsory insurance for workers in the formal sector and later on expanding this to include voluntary insurance for other population groups, such as:

Inclusion of these groups can be realized in stages, but basic respect of the principle that all risks must be pooled in order to achieve true health insurance is essential. If, for some reason, the pooling, or spreading, of risks between the healthy and sick -- the fundamental principle of health insurance -- is not guaranteed, this adverse selection (of persons at above average risk of illness) will invariably increase the average health cost of the insured, thus driving up insurance premiums and deterring the poorest from becoming members. In response to some of these inherent difficulties, some governments have adopted the concept of differential health insurance premiums, i.e. premiums that depend on the economic status of the insured, with the objective of attracting as many people as possible from the lower-income categories. This is equivalent to subsidization of health insurance premiums.⁽³⁾

There has been only limited empirical work in developing countries to illustrate the impact of expanding health insurance on the distribution of skilled health care personnel. Generally speaking, however, the growth of social health insurance combined with increased competition is likely to result in a movement of skilled personnel away from the public to the semi-public or private sector. The Chilean experience of privatization seems to support this view. By 1992, private health plans in Chile employed 38 per cent of practising physicians and more than half the employed nurses, although private plans cover only about 25 per cent of the population.⁽⁴⁾

"Privatization" in low- and middle-income countries has frequently been advocated, or used as a new label, for services that were otherwise run on a largely public basis, on the grounds that such a measure, when widely applied across sectors, sends a signal to domestic and foreign investors that the economic climate has improved. To that extent, the term has ideological connotations and has been employed, perhaps intentionally, irrespective of lines between sectors, by international finance institutions assuming extensive responsibilities for improving the domestic and international fiscal deficits of poor countries.

Conversely, investor-owned hospitals have presented a "vision of the future" (a future that already exists in some highly competitive environments generally in the OECD) and, under the broad heading "multi-hospital system management", have pioneered the use of multi-hospital system management models. They have demonstrated that system benefits, including standardized management applications, common accounting systems, distributed data processing capabilities, joint purchasing arrangements, and other mechanisms for achieving economies of scale and reduced redundancies, may be "the hospitals' best line of defence in the new market-driven environment".⁽⁵⁾ Such concepts are prevalent mainly in the United States, but are also increasingly being discussed in Europe. As far as changes in the professional structure are concerned, this evolution has created a "new breed of health care executives".⁽⁶⁾

As early as the 1980s, the Conservative Government in the United Kingdom introduced policy measures to enhance efficiency and to develop a more commercial ethos. These measures included the introduction of labour force targets to reduce staffing levels and obligations on health authorities to raise additional income and improve service to patients by, for example, opening shopping malls in hospitals. Most important was the introduction of mandatory competitive tendering for cleaning, catering and laundry services which allowed senior managers to alter employment practices and undermine terms and conditions of employment.⁽⁷⁾

If we briefly review the debate, the controversy of which is fuelled not only by ideological divergences about what constitutes "social justice", but also by extreme polarization along geographical lines (OECD versus low- and middle-income countries), we see that a degree of caution is warranted. Although privatization initiatives have occasionally brought a "notion of efficiency" into the health sector, the application of monetary, fiscal and pricing policy solutions to health care, as they are applied to other sectors, has in some cases been detrimental to health care objectives.

For the same reasons, ethical values have to a certain extent been undermined as commercial interests have entered the health sector through privatization and marketing initiatives. Although privatization and (social) marketing may be effective instruments for improving equity and access to health care and providing good health, these processes may have unpredictable consequences when managers respond to market signals in a way that is implicitly and explicitly inimical to the purposes of social health care provision. Beyond economic efficiency, a wide range of other criteria (epidemiological, technological, social) needs to be taken into account in assessing whether a particular configuration of health resources is socially efficient or not.

In recent years, various attempts have been made to introduce private sector management methods and elements of competition into public health services in developed and developing countries. There is now considerable experience in the health sector in northern Europe that demonstrates in a convincing manner that private ownership is not a prerequisite of competitive incentives. Public ownership of institutions -- as in the health sector in Sweden and the United Kingdom -- is perfectly compatible with the concept of vigorous competition.

An alternative term for this is "planned markets", meaning that all such systems attempt to use market mechanisms within structures that are still entirely (or in the case of mixed markets, predominantly) publicly planned.⁽⁸⁾

It is widely recognized that expenditure on health (and a similar argument can be made for education) represents a form of investment in human capital that confers substantial benefits both on the individual and on society as a whole. The definition of health care implies a social good, i.e. that all members of society benefit when a single individual receives care. That is to say, there are large positive "externalities" associated with health which the free market does not take into account. Hence there are good reasons, on grounds of allocational efficiency, for governments to retain regulatory control over health sector finance and to take an active if not dominant part in the financing of the health sector. By the same reasoning, there is a case for collective provision in the area of (disease) prevention and eradication. If left to market forces alone, these services will be underprovided. The implication of this argument is that, in the context of economic recession and structural adjustment most typically accompanied by a fall in government expenditure, the proportion of government expenditure devoted to health should actually rise, rather than fall.

This all appears to make a strong case for planned markets rather than privatization. It also takes up the argument that privatization can be implemented as a "feature", rather than a wholesale concept. "Planned markets" imply the conversion of civil servants in the health system or health delivery personnel to commercially minded professionals, or recruiting new personnel with such professional characteristics. Since planned markets are somewhere halfway between private and public systems, they should, if properly implemented, be cost-effective. As already pointed out, there is no necessary connection between competitive mechanisms and private ownership.

As referred to above, there is now widespread use of market mechanisms in what were once wholly publicly capitalized and publicly operated health systems in northern European countries. When assessing allocation -- and production -- side competition,⁽⁹⁾ we note that, by contrast with the paucity of reform activity on the finance side in industrialized countries, there is an extraordinary amount of reform activity on the allocation and production sides of the same health care systems.

An important competitive mechanism is reliance upon patient choice. This means asking patients to make the logistical choice about which hospital and which physician they prefer within the publicly operated health system, while hospitals, and sometimes physicians, are paid -- from public funds -- in some proportional relation to the number of patients they attract. This patient-led form of competitive incentive reflects the role of consumer sovereignty in market economics. However, within this conceptual framework (i.e. planned markets) it applies only in publicly operated facilities, where patients bring with them a fixed fee set by public planning officials.⁽¹⁰⁾

The system allows for setting fees in a manner that keeps total expenditure within predetermined limits. This arrangement thus clearly goes beyond a standard fee-for-service system. In this patient-based system, providers typically compete for patients on the quality of their services. Indeed this type of patient-driven framework can be described as a quality-based rather than price-based competitive mechanism. In Sweden, patient choice can be regarded as the predominant competitive mechanism. The introduction of such mechanisms has been valuable and regarded as such in northern Europe, precisely when applied in publicly regulated, publicly accountable health systems. Far from blindly giving way to privatization initiatives, publicly operated health systems are in the process of redesigning and strengthening their ability to achieve public sector health objectives through publicly owned and operated institutions.⁽¹¹⁾

With regard to a common pattern of problems encountered in transition countries, it should be noted that a market-oriented health policy may well require almost as much state activity -- although different in focus and purpose -- as any approach based on central planning. In order to prevent decentralization from deteriorating into fragmentation, the same analytic orientation needs to be applied to employment-related issues, in order to control cost-cutting and provide all possible assistance in redeployment.

Closely connected with the previous subsection on competition and planned markets, many recent reform efforts⁽¹²⁾ concentrate on correcting imbalances between the public and private mechanisms applied in the area of health care. Those imbalances and dysfunctions occur when the balance between government and private sector roles shifts excessively in one direction or the other. It should be noted in this context that the balance of public and private involvement varies considerably between countries, being rooted in social and economic history and conditions. It also varies between the various elements of the health sector, such as finance, information and service delivery, and is not fixed and unchanging.

In countries where reform efforts have been successful, governments have generally focused on increasing their role in providing information and laying down regulations and mandates. Those are unquestionably areas which lend themselves to enhanced public sector involvement and where the State has a pivotal role to play. Governments in these countries also assume sectoral oversight responsibility for medical education, research and development, and for quality control.

At the same time, successful reform has also meant fostering more balanced participation by NGOs, local communities and the private sector, notably in service delivery systems. Overall, governments have shifted their attention and scarce resources to securing access by the whole population to services with large externalities such as preventive public health services. In developing countries, strong emphasis has been given to the provision of basic health, nutrition and birth control services, especially for the poor. Judging by the experience of other sectors that have gone through this process and the health sector in the OECD countries, greater non-governmental participation does not necessarily imply the sale of public assets. On the contrary, initiatives can be favoured that allow and actively provide for private sector participation, such as private co-financing, management contracts, out-contracting, and trusts. The concept of the public/private mix and divestiture of social assets requires an enhanced, rather than diminished, regulatory role to be exercised by governments in setting and enforcing standards and quality control, ensuring fair competition, and controlling and preventing abuses. This regulatory role further involves defining the appropriate package of services and/or benefits, and determining access criteria. State responsibility also extends to the monitoring of professional conduct and performance of providers and, where applicable, insurers. Furthermore, the State is also responsible to some extent for awarding professional qualifications, so that patients choose among professionals who meet certain minimum clinical and educational criteria.

Future health reform initiatives may be largely based on these concepts. In areas where large externalities are involved, by definition, not everything can be private. Emphasis will therefore be placed on optimizing the regulatory role of the State and letting private initiatives take the lead in the areas referred to above where they can contribute most.

Moreover, some recent health care reforms in developed countries are not entirely competition-oriented; there has also been an increase in the use of regulatory mechanisms, e.g. of state-based intervention. One example of the enhanced use of regulatory concepts is Germany, which in 1993 introduced reference pricing for pharmaceuticals (and/or "negative lists" of drugs that cannot be purchased with health insurance funds). In other industrialized countries, too, recent coordinated measures to constrain pharmaceutical expenditures have turned to regulation, rather than competition, as the primary mechanism of reform. This demonstrates the whole spectrum of public/private mix as part of recent reform moves in the direction of cost-containment.⁽¹³⁾

With regard to the issue of public versus private roles, the central aim of national health policy will be to ensure the enforcement of quality standards in both the public and the private sectors.

Overall, the aim of mixing of public and private elements is to harness the respective strengths of both concepts and thus achieve the optimal solution. But there are dissenting voices; some would say that this is not possible, that introducing market elements into the health system is a risky business and lets the genie out of the bottle.⁽¹⁴⁾ According to this view, once market elements are introduced they tend to require more space and it is not possible to reduce them again.

On the other hand, current developments in the United Kingdom, where the Labour Government is on its way to revising managed competition in the health care system, show that these market elements may be kept under control using the same means by which they have been introduced: by legislation. The example referred to previously of the German pharmaceuticals market also proves that it is possible to introduce regulation in traditional market areas.

Strategies and objectives of health sector reforms have been influenced by a number of international policy statements or major international initiatives bringing health, nutrition and population issues into the spotlight of public interest. This section will highlight the results of major international initiatives of relevance to health sector reforms which have taken place outside the ILO. Chapter 7 will provide some insight into standard setting and supervision and other ILO activities which have a bearing on health sector reforms.

The International Conference on Population and Development (ICPD) which took place in Cairo in 1995 established a decisively new emphasis by focusing particularly on the importance of empowering women, and this has also had an impact on the health sector.

At the World Summit for Social Development (WSSD) in Copenhagen in 1995,⁽¹⁵⁾ important commitments were made by governments for the first time to eradicate poverty, not merely to alleviate it: "We commit ourselves to the goal of eradicating poverty in the world, through decisive national actions and international cooperation, as an ethical, social, political and economic imperative of humankind." Governments in addition promised to ensure economic and social protection during illness. The Summit also committed itself to promoting universal and equitable access to "... the highest attainable standard of physical and mental health and the access of all to primary health care ...". Particular attention was paid to the provision of education and health programmes, including preventive health programmes, for women and children. Attended by representatives of the entire United Nations system, the Summit also gave new impetus to various ILO activities.

The emphasis on poverty alleviation and the endorsement by the Social Summit and by the 1996 International Labour Conference of the objective of full employment has been particularly heartening in view of the growing scepticism in academic and policy-making circles regarding the feasibility of attaining that objective.

At the same time, a critical examination of the empirical basis of that scepticism in the ILO World Employment Report 1996-97 found it to be seriously flawed. The report argued that, with sufficient political will and the sustained implementation of a comprehensive set of policies, full employment remains an attainable objective. Economic efficiency is not conceptually opposed to social justice. In this context, it is important to develop tripartite forms of social dialogue between workers' and employers' organizations in support of employment generation as a priority item on the national policy agenda and to promote cooperation between labour and management which contributes to productivity enhancement and job creation.⁽¹⁶⁾

Similarly, the Fourth World Conference on Women (FWCW) in Beijing in 1995, and the Second World Conference on Human Settlements (Habitat II) in Istanbul in 1996 provided international impetus which, adopting an intersectoral approach, touched upon matters of relevance to the subject of health care. All the initiatives mentioned inevitably raised the fundamental question of how to accommodate the choices invariably imposed by the setting of priorities with limited resources. Hence the convergence between the most important concerns of health sector reform.

The WHO Health for All strategy emphasizes the importance of the environment to human health and well-being. This strategy encourages the provision of health care for everybody. In this respect, governments and the public sector play a prominent and decisive role in providing the necessities needed by all people to achieve the goal of health for all. The strategy places particular emphasis on the provision of primary care -- a strategy which has influenced many reform initiatives in the transition countries of Central and Eastern Europe, and also in industrialized and developing countries.

The Ljubljana Charter on Reforming Health Care (under the auspices of the World Health Organization's Regional Office for Europe in Copenhagen) which sets out objectives for European health care reforms (the full text is appended as Annex 1 to this report), is currently perhaps the only explicit programmatic document on health care reforms. Although focusing on Europe, some of its principles, for example the appeal for intersectorality and the emphasis on "citizens' voice and choice", would lend themselves to universal application. According to the Preamble of the Charter, dated 19 June 1996:

The extent to which the experience of industrialized nations is relevant in the political, economic, social and institutional conditions prevailing in the developing world or in transition countries is a matter for debate, since it is thought that major health system components will not interact in structurally different contexts in the same manner as in the conditions of developed countries.

1. WHO: The Ljubljana Charter on Reforming Health Care (Copenhagen, WHO, Regional Office for Europe), 19 June 1996, p. 3.

2. World Bank: Financing health services in developing countries: An agenda for reform (Washington, DC, 1987).

3. WHO: Health economics: Poverty and health, an overview of the basic linkages and public policy measures, by Guy Carrin and Claudio Politi (Geneva, WHO Task Force on Home Economics, Jan. 1997), pp. 28ff.

5. See Jack D. McCue (ed.): The medical cost-containment crisis. Fears, opinions and facts (Ann Arbor, Michigan, Health Administration Press Perspectives, 1989), p. 155.

8. WHO: Applying planned market logic to developing countries' health systems: An initial exploration, by Richard Saltmann (Geneva, doc. WHO/SHS/NHP/95.7, Sep. 1998), p. 6.

12. This subsection draws mainly on conclusions given in the most recent study by the World Bank: Health, nutrition, and population sector strategy (Washington, DC, 1997), pp. 7-8.

14. ILO/PSI: Workshop on employment and labour practices in health care in Central and Eastern Europe, Prague, 15-17 May 1997 (Geneva, ILO, 1998), pp. 63ff.

15. UNDP: Human Development Report 1997 (New York, Oxford, Oxford University Press, 1997), p. 106.

16. United Nations Economic and Social Council: Follow-up to the World Summit for Social Development (New York, doc. E/CN.5/1997/3, 23 Jan. 1997), pp. 7ff.

The health sector is an important employer worldwide with an estimated workforce of 35 million people. Employment opportunities will most probably increase in this sector in the future as a result of epidemiological and demographic factors and growing demands on health services. Unemployment in the health sector is still low compared with other sectors. Where it exists, it affects mainly young people who have just graduated and have no work experience. Health sector unemployment is also often due to structural changes in the sector. In fact, within the overall context of cost-containment, many countries have witnessed far-reaching changes in the composition of the workforce and in changed work practices.

There have been significant increases in the numbers of people employed under more precarious forms of employment contract, such as fixed-term and temporary contracts. The reasons for the increasing reliance on such contracts vary from one country to another. Another form of flexibility arises from challenges to existing working practices and the breaking down of boundaries between occupational groups of health care providers.

The impacts of reforms on workers in the health sector have varied between countries and country groups. In this context, it should be noted that the impact of reforms has been especially hard in some Central and Eastern European countries. Many workers have lost their jobs and it has not been possible to maintain the previous job security and high levels of employment in the health and social sectors. In a number of transition and developing countries, salaries have not been paid for varying periods, as a result of budget constraints.

Generally speaking, the reduction of jobs through structural adjustment has affected women more than men, especially women with a lower level of training than men. These findings have been confirmed in the countries of the Central and Eastern European region. It is anticipated that women in occupations that are financed from the central budget, such as social services (including health care) and public administration, will be at particular risk from the stabilization programme. The concentration of women in community and social services, especially health and education, has made them particularly vulnerable to the spending cuts imposed on these sectors, often in the overall context of structural adjustment programmes. In order to further substantiate these facts on a country-by-country basis, one needs only to note the scale of these cuts, which provides an indication of personnel cuts in sectors which are important employers of women.⁽¹⁾

The factors providing an impetus to the introduction of more flexible employment practices seen overall are considerable. Managers are in general seeking to convert high fixed labour costs into variable costs. For example, the Conservative Government in the United Kingdom implemented a system of managed competition earlier than other Western European countries. The system is, however, being reviewed at present by the Labour Government. Attempts by employers in that country to develop more flexible employment practices to cope with contract uncertainty and budgetary constraints are perhaps more marked and advanced than elsewhere. In hiring temporary staff, managers seek to link the length of the employment contract to the period of guaranteed funding by the purchaser. This situation is not new for certain groups of staff. It already existed for groups such as ancillary staff, who were subject to a process of compulsory competitive tendering (for cleaning, catering and laundry, for example). For some time, these staff have faced the risk that their jobs could be contracted out, and such services have indeed witnessed drastic reductions in staffing levels as a result of austerity measures. The novelty of managed competition is that such "contracting out" arrangements potentially extend more precarious forms of employment to professional staff as well. As a result, physicians are faced with situations where they fear that their professional autonomy is being undermined as budgetary logic overrides the particular demands of patient care.⁽²⁾ "It is probably no exaggeration to claim that flexibility in the use of labour, and in payment systems, is one of the most sought after effects of the entire health reform process."⁽³⁾

All these tendencies in combination have resulted in a situation where traditionally high levels of job security in the health sector have changed. In a labour-intensive sector in which the bulk of health care expenditure is accounted for by wages and salaries, privatization initiatives -- implying increasing flexibility in the use of human resources -- have "challenged existing patterns of industrial relations".⁽⁴⁾

However, it would be too simplistic to consider health workers as no more than an important cost factor. Health sector workers are also a major resource to the community and their knowledge and skills are vital to reform. Competitive and satisfactory working conditions are essential to ensure efficient and high-quality services.

The choice and sequencing of policies can have an immense impact on the welfare of workers involved in health care reforms. The key policy concern in managing reform is how to facilitate the change of workers from positions that have become redundant to new ones as smoothly as possible without raising the short-term costs of adjustment.

Important considerations that might provide direction and have a significant bearing on the shaping of health sector reform derive from an analysis of general public sector reform, particularly in transition countries and developing countries. A number of publications⁽⁵⁾ stress the importance of improving the performance of the civil service and thereby reducing the constraints within which the health sector functions.

"Wholesale" public sector reform -- reform that is substantial in content, widespread across sectors and concentrated in time -- is a rare experience outside situations of profound political change, war or revolution.⁽⁶⁾ When the notion of "public sector reform" came up in the 1980s, the initial emphasis in aid donor circles was on wholesale reform shaped by three key objectives, namely:

While public sector reform in developed countries has been based on the idea of competition and material incentives (in accordance with the "New Public Management" model), the standard public sector reform package for most developing countries is associated above all with the "traditional bureaucracy" model, the intention being to restore some elements of hierarchy, authority and accountability within the public sector. It is because these basic conditions are often not met in low-income countries that recreating them has been the main immediate objective of many externally assisted public sector reform programmes.

With due regard to these unquestionable typological differences and some serious drawbacks, we note that there has been an increasing emphasis on adjusting public sector reform programmes to particular circumstances, and programmes that are currently being advocated and introduced in developing countries take account of this trend. An important element in the argument here is that there is no single desirable direction or strategy for public sector reform.

Public service⁽⁷⁾ has the unique responsibility for redesigning and implementing a range of adjustment measures throughout the economy while being itself the subject of restructuring. The challenge facing governments and intergovernmental agencies -- planners and politicians -- is to ensure that the reform and restructuring of the public service will enhance its ability to plan and implement adjustment measures which promote economic growth and social and human development. To this end, the working conditions of public servants, the efficiency of their performance and the quality of the service they deliver all have a crucial role to play.⁽⁸⁾

There may be disagreement over which services the State should provide, and on what terms, and over the relationship between politics and the public service: one approach emphasizes the political nature of the civil service as the instrument of government policy, and the other its neutral advisory and managerial capacity.

However, the importance of the public service as an employer remains undisputed, hence the interest in examining its operational principles, and the scope for improving its efficiency and accountability. The fact that the State is the largest single employer in every country implies that it has an enormous impact on the labour market and one which is carried over into the private and even the informal sectors.

Another important concern is the role of the public service in shaping social and economic development through its policies, expenditure decisions and management. While it is pertinent to ask how far the State can adopt market-based concepts and involve private contractors, the answer obviously cannot be the same for all countries and at all times. Therefore, an important and continuing debate will concern the essential differences between state responsibility and the market with its own operating principles, the possibilities for interplay, i.e. which areas could be out-contracted or taken over by the private sector, and the identification of the State's basic responsibilities.

The phrase "public sector reform" is sometimes employed purely as a neutral descriptive term to indicate (substantial) changes, intended to improve performance, in the way in which the public sector is organized and managed. On the other hand, as outlined above, the relatively standard package of "downsizing" and salary "decompression" (i.e. increasing differentials) has become associated with public sector reform as supported by the World Bank in particular.⁽⁹⁾

It is obvious that each of these three arguments has its own particular relevance to health sector reform.

With regard to those basic structuring characteristics, what is termed here "conventional public sector reform for developing countries" was shaped by the perception that in many countries belonging in this group the public service was inefficient in that:

The conventional reform model was a logical response to this perception of facts. It comprised three main objectives, that were to some extent viewed as sequential, namely:

Since in many instances there existed no centralized control over pay and personnel (e.g. in matters of recruitment, promotion, retirement, termination) or even any centralized information about the composition of the public sector workforce and salary structure, the first major step towards reforming the public service has conventionally been an employment census as a prelude to the establishment of a central personnel information system.

However, experience of this public sector reform model has been mixed, particularly since it has encountered determined resistance from the public service itself. Although this resistance has often been only passive, it has nevertheless often had the effect of delaying reform indefinitely. This resistance must be seen within the following perspective. As outlined above, retrenchment measures are a basic constituent of the standard public sector reform package, and therefore pose a direct challenge to the livelihoods of most public sector employees. The implication is that besides a loss of formal remuneration, employees will experience a loss of opportunities of earning "informal income" concurrently with public employment. "Salary decompression" will benefit only small numbers of senior staff and, given the prevalent fiscal constraints, the intention of increasing formal remuneration after staff reductions is unlikely to appeal to staff who are anxious about the possibility of being directly affected by public sector retrenchment measures or even to those who may not themselves be affected.⁽¹¹⁾

In conclusion, beyond these divergences a priority concern of governments should be to see how the capabilities of its civil servants can be retained, strengthened and sustained over time, and, with regard to the issues discussed above, broader public sector reforms need to address this issue. The reader is also referred to the discussion in section 5.3.

It is not possible here to deal exhaustively with public sector reform. The ILO has dealt with this issue on a number of occasions, particularly at the sectoral meetings for the public service in 1994 and 1995 (see Chapter 7) and will specifically take up the issue of human resource development in the public service in a sectoral meeting in December 1998. In view of the complexity of the subject, the objective was to highlight the linkage between this package of measures and those implemented specifically within the framework of health sector reform.

What needs to be retained from this is that health sector reforms in the past were frequently implemented against the background of structural adjustment programmes (health sector reform as part of donor conditionality).

1. ILO: Impact of structural adjustment in the public services (efficiency, quality improvement and working conditions), Joint Meeting on the Impact of Structural Adjustment in the Public Services (Geneva, 1995), pp. 39ff.

3. R. Saltmann and C. von Otter (eds.): Implementing planned markets in health care: Balancing social and economic responsibility (Buckingham, Open University Press, 1995), p. 13.

5. WHO: Health sector reform: Key issues in less developed countries. Forum on health sector reform, by A. Cassels (Geneva, doc. WHO/SHS/NHP/95.4, Apr. 1995), p. 1.

6. WHO: Public sector reform: Downsizing, restructuring, improving performance, by Mick Moore (Geneva, doc.WHO/ARA/96.2, Sep. 1996), p. 1.

7. ILO: Impact of structural adjustment in the public services ..., op. cit., pp. 1-3.

8. See also the World Bank: The State in a changing world, World Development Report 1997 (New York, Oxford University Press, 1997), p. 92.

It is appropriate to define the health sector in a narrow and in a broader sense.

It should also be borne in mind that health care also includes much unpaid work especially by women caring for family members who are ill or working for voluntary organizations. This unpaid work has its own particular social and economic importance.

The health sector in a narrow sense covers the medical staff employed in health care provider units (hospitals, ambulances, pharmacies) and within these institutions mainly the medical staff (doctors, nurses, midwives).

Between these two extreme definitions there are a variety of approaches to the definition of health sector staff.

For example, other sources⁽¹⁾ distinguish five categories of health care personnel on the basis of their qualifications and their actual role in the provision of health and medical services (physicians, other graduate-level professionals, nurses and midwives, allied health personnel such as therapists, and other personnel such as cleaners and administrative staff).

There are also many workers employed in the health sector without having a medical background, such as health economists and information scientists. Thus, there are different notions of employment in the health sector and this makes it difficult to compare employment figures from different countries.

Health sector reforms do not only impact on the health sector in the narrow sense. For example, a restructuring of the benefit package, with reduced coverage for drugs and spas and greater coverage for long-term care, will lead to an increase in the number of people working in the field of long-term care and thus to an increase in employment in the health sector as defined in the narrow sense. But at the same time it will affect the health sector in a broader sense: the turnover of pharmacies and the pharmaceutical industry will be reduced and thus lead to less employment, although the net employment effect will be positive. Health services have a much lower labour productivity than the pharmaceutical industry.

Thus, the impacts of health care reform may be much broader if we consider all sectors that are linked to health care in the broader sense.

The general trend in employment in the health sector over recent decades has been positive. The number of people employed in the health care professions has continued to grow in most countries. As a result, the medical sector has become a major employer for a large proportion of workers in all countries and global health care spending reached 9.1 per cent of global GDP in 1996 (although poor countries spend much less than rich ones, both as a percentage of GDP and per capita).⁽²⁾ Despite major structural changes in health systems around the world, employment opportunities remain good. The proportion of people aged 60 and more is growing worldwide, while the proportion of people of working age is decreasing. The demand for medical personnel will therefore remain high.

However, the role of the health sector as an employer is subject to change. Many factors have some impacts on employment in health care. They include:

The health sector workforce is mostly skilled or semi-skilled. Of the estimated 35 million health care workers worldwide, some 18.5 million are doctors or nurses. Work in health care often requires qualifications which can only be obtained through specialized training up to university level. This applies both to medical staff and administrative staff. Work in the health sector requires the flexibility to adapt to changes which will inevitably take place in future. At the same time, the health sector is an area which offers job opportunities for skilled workers.

In terms of the density of medical and health personnel, there are huge disparities between developed and developing countries and the types of labour force imbalances vary accordingly. In established market economies, there are up to 20 times more doctors and nurses for a given population than in developing countries. In industrialized countries the market for labour in the health and medical services is thought to be generally saturated with the exception of nurses. The Canadian Nurses Association reported to the ILO that a study recently conducted for them predicts a severe shortage of nurses in the next decade. The predicted shortage of registered nurses is estimated at 59,000 and this is predicted to grow to 113,000 by the year 2011. In some industrialized countries and more particularly in transitional countries, there is concern about a predicted or actual surplus of doctors. In developing countries, on the other hand, there is ample evidence of shortages. But the concept of "shortage" is a relative one. It does not mean that posts remain unfilled in health care and medical services in the countries concerned, since the number of posts which can be created is limited by budgetary constraints. It means rather that one can safely assume the existence of latent shortages when considering the gap between the actual situation in various countries and the objectives set at national and international levels to monitor progress towards "Health for All" by the year 2000 -- a goal to which nearly all countries have subscribed.

Table 4.1. Health personnel and infrastructure, 1988-92


	Doctors per 1,000 population	Nurses/doctors ratio	Hospital beds per 1,000 population

Sub-Saharan Africa	0.12	5.1	1.4
India	0.41	1.1	0.7
China	1.37	0.5	2.6
Other Asian	0.31	3.0	1.8
Latin America	1.25	0.5	2.7
Middle East	1.04	1.5	2.9
Formerly socialist countries	4.07	2.2	11.4
Established market economies	2.52	2.1	8.3
Source: World Bank.

What applies to the relative employment situations in industrialized and developing countries also applies to urban and rural areas within developing countries. The situation in urban areas is normally much more favourable than in the countryside.

Another effect that should be taken into consideration relates to population growth or decline. As populations grow, the demand for health care personnel grows in proportion. In growing populations such as those of India, South America and many African countries, the latent shortage of medical personnel becomes increasingly acute if the ratio of health care personnel to population is to be kept constant.

In many industrialized countries, precisely the opposite development is observed: populations are decreasing or, at least, not growing. As a result of this, the health sector labour market is saturated and the market in some fields (e.g. pediatrics) may shrink. On the other hand, the populations in these societies are ageing as well as shrinking which ultimately leads to a growing demand for workers in the health and social services.

As a result of the budgetary constraints referred to previously, many developing countries experience not only staff shortages but also a drain of staff towards countries where there are employment opportunities and better working and living conditions. The result is that qualified workers move out of the country where there are no prospects of employment or where employment conditions are less attractive than abroad.

The health sector is a major employer of women. They are often employed on a part-time basis and concentrated at the bottom of the employment hierarchy, although in some countries they represent up to 80 per cent of health care staff. Low pay is the resulting problem.⁽³⁾

Globalization of the economy and increasing competition are creating budget constraints on public expenditure and social contributions. This raises the question from which funds the growing demand for health services will be financed. Individual payments and user fees are likely to be a growing source of funding for services.

Another trend is the trend towards temporary and part-time jobs with lower salaries. It is the responsibility of trade unions and employers to ensure that the quality of health care services remains high and does not deteriorate owing to deteriorating working conditions and major pay cuts.

Several countries with nationally organized health programmes are making efforts to decentralize control of medical services as a way of improving efficiency. Their present policy of developing more community-based care is forcing a redirection of resources and personnel away from central authorities toward local ones. In some cases this means transferring former national (federal) employees to regional (state), provincial or municipal jurisdiction. The notion of hospital-based care is also giving way to a far more decentralized mode of multiple small care centres and clinics. These range from health maintenance organizations and physician group practices to ambulatory surgery units, maternity clinics, hospices, drug abuse centres and long-term care facilities. As a result, hospitals are no longer seen as the main purveyors of treatment, although they remain the most important provider and the ones with the highest concentration of qualified staff.

In line with these changes, working conditions in the sector are also changing. The provision for acute care is becoming more and more fragmented. Whereas most health workers were once employed full time in hospitals, clinics and physicians' surgeries, more and more services are now being offered by part-time or independent care providers who are willing to travel to the patient's home. These include visiting nurses, midwives and physiotherapists. In response to the ageing of the population, countries are looking for solutions which are more home-based rather than concentrating patients, especially elderly people, in large institutions like hospitals and residential homes. An advantage of this solution is that it responds to patients' demands since most of them prefer to stay at home, and is also much cheaper than hospital care.

Thus, the trend towards decentralization is intended to improve the accessibility of health care services and to respond better to consumer demand. It normally means a restructuring of employment in health care and of patterns of working conditions. But there is no evidence that it means a sharp reduction in employment in the health sector. On the contrary, in most industrialized countries employment in health care is still growing. The only difference compared to previous years is that employment in many cases is developing outside the public and hospital sector and is decentralized.

Technological advances in medicine and the resulting escalation of patient costs have also been called into question. In many countries, in order to contain costs, the prescription of extensive and expensive laboratory tests, high-cost surgical procedures and specialized treatment is limited, often by the provisions of incentives to prescribing doctors to use less expensive methods.

But technological advances in medicine do not inevitably mean rising costs. Developments in genetic technology may lead to procedures for preventing and curing diseases in a more cost-effective way. "Advances in electronics and biotechnology could radically change the treatment of many diseases. It could also have a deep impact on the role of doctors and hospitals in the twenty-first century."⁽⁴⁾

In general, the trend is towards strengthening primary care facilities and reducing the concentration on secondary and tertiary care and this entails staff restructuring. Primary care facilities can deal with most diseases and can improve health promotion, health education and prevention. Moreover, a health system based on effective primary care units is less expensive than a system which relies mostly on large and specialized care units. In many Eastern European countries such a reorientation towards a health system oriented more towards primary care is under way. For health workers themselves, this often means retraining and changing occupation.

Health services are very labour-intensive, which means that the level of employment in the health sector may be seriously affected by reforms. Three types of reform should be distinguished in terms of their effects on employment in the health sector, namely:

In many countries, especially industrialized countries, the reform process is not aimed at reducing staffing levels, but rather at improving efficiency and reducing public spending, which does not necessarily mean reducing staff. It may also mean that patients are bearing a larger proportion of the costs themselves through higher co-payments or user charges. Another possibility is outsourcing and privatization of services, which is often accompanied by changes in the payment of staff and working conditions. Employment is not reduced but shifted from the public to the private sector.

Thus, in the industrialized countries reform processes have not had any major effect on employment in the health sector. In certain areas there has been a reduction of personnel and in other areas an increase, so that employment levels changed in certain individual sectors of health care.

The World Bank believes that established market economies have too many doctors rather than too few, and that the doctor/nurse ratio should be weighted more heavily towards nurses.⁽⁵⁾ Nurses are said to be leaving the health sector because wages are so low (see the section on wage differences in Chapter 6).


	1970	1980	1990	1992

United States	3.7	5.3	6.2
Japan	1.4		2.4	2.4
Germany	2.9	4.5		5.5
France			6.8
Italy	1.6	3.9	4.3	4.4
United Kingdom	3.1	4.7	4.6	4.8
Netherlands	6.4	6.4	6.4	6.6
Sweden	6.2	9.9	9.9	10.0
OECD	2.8	5.0	5.2	5.8
Source: OECD, 1995.

In the transitional countries of Central and Eastern Europe, there has traditionally been overstaffing in the health and social sectors, mainly with doctors. Previous regimes have left huge health enterprises with problems in labour relations, staffing and workers' morale. Hospitals are too big and suffer from an over-concentration of doctors, whilst trade unions and nursing associations report shortages of nurses. In general, countries which followed the Soviet model of health care have proportionally more doctors and the number continued to rise in the 1990s.

Productivity is said to be low in Central and Eastern European health systems, with doctors performing tasks that could be done by qualified nurses and performing administrative tasks better done by support staff. Nurses are performing tasks better done by nursing aides and are also called upon to provide other services such as radiology and occupational therapy. However, the former socialist economies have opted for labour-intensive, rather than capital-intensive, methods, and this should be borne in mind.⁽⁶⁾

A particular effect may be observed in these countries as the private sector develops. Qualified staff from public facilities are leaving in order to work for private insurers or private medical establishments. One country where such developments have been reported is Russia.

The transitional countries provide a stark illustration of the impact of the socio-economic situation on health status. The overall life expectancy at birth in these countries is currently the same as in Central America and the Caribbean, and the crude death rate is higher than in South Africa.

Developing countries generally suffer from a shortage of health personnel. The doctor or nurse/population ratio is an indicator of this. In Nepal, for example, there are 0.1 doctors per 1,000 people, whereas in Norway the ratio is 3.3. Thus the aim of reform processes should not normally be to reduce staffing levels but should rather aim to improve the staff situation. However, most developing countries suffer from budget constraints which do not allow them to expand health care financing. GDP per capita in many developing countries, especially in Africa, is falling.

A recent WHO study has examined the three factors that contribute to the growing crisis of health systems in developing countries, namely:

Indeed, many governments, particularly those in Latin America and sub-Saharan Africa, cite the economic crisis, the debt crisis and extended structural adjustment programmes as the main reasons for the decline of health care services and infrastructure. This, of course, also affects employment in health care systems. Many developing countries have not been able to keep pace with population growth in terms of expanding their health care facilities, training their staff and providing adequate medical supplies.

With regard to the effects on employment in particular sectors, one sector which has been affected by reforms in many countries is the hospital sector. Hospitals are the largest health care units and employ most health care personnel. They are also the units which provide the most specialized and expensive care. In many countries provision of hospital beds is said to be too generous. In Western market economies, and to an even greater extent in Central and Eastern European countries, hospitals were used not only for acute patients but also to provide "social beds". People stayed in hospital even when long-term community care, rather than acute care, would have been more appropriate. Most of these patients have nobody at home to care for them and closing beds may have serious consequences for them. In most countries, other ways of caring for these patients have been found, partly through outpatient services and partly by special home care.

Overall, there is a trend towards relieving hospitals of responsibility for social care. The result of this development is reflected in a continuous fall in the average length of stay and number of bed days, and an increase in the number of patients treated in outpatient wards. The fall in the average length of stay in hospital has in some countries resulted in a large reduction in the number of beds in somatic hospitals. In Denmark, for instance, in the 1980-94 period, the number of beds fell from 32,269 to 23,905. Similarly, in the psychiatric field there has been a development towards less and shorter hospitalization and more outpatient activity. In Denmark, this development has been made possible by the introduction of district psychiatric help close to the patient's home, and resulted in a fall in the number of beds in psychiatric hospitals from 9,352 to 4,259 in the period 1980-94. With patients being discharged earlier, care traditionally provided in the hospital must often be provided on an outpatient basis or at home. These changes have altered the role of nurses, family, other care providers and, most importantly, society's general perceptions and expectations of health care. The much-discussed shift to community care under the label of "decentralization" is largely rhetoric, as funding has not increased sufficiently to meet requirements, and there are many cases where the care and services still required by patients discharged from hospital and entering the community are not available. Many of these care requirements could be provided by community nurses, but funding and a commitment to change on the part of decision-makers are needed before this can be achieved.

The spa sector is a very important sector in countries like Germany, France and many Eastern European countries, where spa treatments were paid for by the health care financing institutions before the reform process began. Payment for spas was reduced and will probably be reduced even further during the next few years. This creates a problem for the spa institutions. Their main clients were patients whose treatment was paid for by health insurance funds or state health services. Most patients are tending to reduce or forgo entirely their spa stays. Most spas are located in remote areas with limited infrastructure and no industries or other major employers. Workers employed by the spas, some of which may be not be able to survive, are therefore obliged to look for employment in another area and possibly to undergo training. This is an example of the indirect effects of reforms on economic structures.

Another sector that has been affected by reform activities in some countries is the pharmaceutical industry. This sector is not very labour-intensive except for the distribution sector (e.g. pharmacies). The production sector does not employ large numbers of workers, as labour productivity is quite high. Moreover, outside the spa sector, price elasticity is not very high. Doctors prescribe drugs and patients buy drugs irrespective of who pays. Generic drugs are another factor. In the case of many drugs for which the patent protection has expired, generic products have come onto the market. Experience shows that the larger the co-payments required of patients for the purchase of drugs, the greater the market share of generics. In Germany, doctors have been obliged to use a comparative list of drug prices and prescribe generics where these are available. This has resulted in a 30 per cent reduction in the turnover of original products, with consequences not only for the producer firms but also for the distribution network (e.g. the pharmacies). However, the high labour productivity in this sector has kept job losses down.

Prevailing conditions in the health care sector require reform activities which often lead to a restructuring of employment. Thus, in many Central and Eastern European countries doctors are required to undertake tasks which in other countries are normally done by nurses. In some Western European countries such as Germany or Belgium, there is an oversupply of trained doctors. As a result of this, access to the public health service has been restricted which led to an oversupply and unemployment of doctors. On the other hand many industrialized countries are experiencing a shortage of nursing staff and, as already mentioned earlier, there is a shortage of all kinds of medical personnel in many developing countries. In most countries staff are concentrated in curative care institutions whereas there is a shortage of staff working in preventive care activities such as health education and family planning.

Traditionally too much emphasis was placed on secondary and tertiary care in large institutions like hospitals and specialized polyclinics, which has resulted in an oversupply of specialized doctors. On the other hand there is a shortage of qualified primary care personnel. This is true of most countries.

Health care reforms may thus not only have an impact on the level of employment in different areas but may also change the structure of employment. It may:

One example of the way reforms can lead to a requirement for new qualifications was the reform of the NHS in the United Kingdom under which general practitioners have become fund-holders. Thus, in addition to their work as physicians, they have to perform management tasks (although some of them employ staff to do this).

Another example is the development in Germany where an insurance scheme for long- term care was established some years ago. This insurance pays for services that formerly were not reimbursed. This has created a new field of activities and new teaching facilities have appeared. According to recent information provided by the Federal Ministry of Labour and Social Order, employment in this sector is currently booming and increased from 214,300 full-time employees in 1993 to 289,300 in 1996, an increase of 75,000 jobs.

The reform process in many Eastern European countries has led to cuts in doctors' posts although the demand for nurses remains. Moreover, primary care has been improved and specialists have been retrained to work as primary care physicians.

In the United Kingdom total employment in the health sector has remained stable, but there have been drastic cuts (52 per cent) among ancillary staff, reflecting the policy of compulsory tendering. At the same time, there has been a 25 per cent increase in the hiring of administrative and management staff as a result of the shift towards a more commercialized NHS and the establishment of a system of managed competition. Furthermore, greater uncertainty in funding for individual trust hospitals has prompted managers to increase the numbers of staff employed under more precarious forms of employment contract and to increase work intensity. Finally, although some occupational groups, particularly doctors and nurses, have experienced a marked growth in real earnings, this has to be offset against reduced job security and more intensive working practices associated with the system of managed competition. This has led to sporadic industrial action and created widespread stress and demoralization amongst NHS staff.⁽⁸⁾

Many countries report that an important structural effect on employment has been the trend towards replacing less qualified staff with qualified staff. In Lithuania, for example, less qualified staff are the first to lose their jobs. In Finland, on the other hand, qualified nurses have been replaced by less qualified staff. In France, where the health sector has been one of the fastest growing employers in the country (accounting for 7.4 per cent of the working population), hospital bed closures have led to redeployment of nurses into less qualified jobs.

Reform processes which involve cost-cutting measures often lead to cuts in the workforce. This is because the health care sector is very much service- and personnel-oriented. Any changes in structure and budget will be accompanied by cuts in staffing levels. Such reductions often involve a combination of several measures, such as compulsory redundancies, non-filling of vacancies, replacement of full-time jobs by part-time jobs, early retirement and voluntary redundancy schemes, recruitment freezes, retraining and other methods.

Such reductions can be made either globally throughout the entire health sector or in particular parts of it, even as other parts may be looking for personnel, for example in the hospital sector or the pharmaceutical industry, or among unskilled or less skilled workers. In other parts of the health sector, it may be that workers, especially workers with special skills, are in demand.

The kind of staffing cuts also depends on the size and the sector of the enterprise. In the private sector dismissal is normally easier than in the public sector. In larger enterprises flexible ways of retrenchment not involving dismissal are easier than in small enterprises. This is why small enterprises lay off workers more readily than large enterprises.

In Eastern European transition economies, redundancies have been the most frequent form of retrenchment. The number of women among those made redundant, has been disproportionately high. In Latvia, redundancies have mainly affected doctors of retirement age and those unable to speak the national language. At the same time, admissions of medical students have been restricted. In Slovakia most of the retrenchment during the major reform process has been achieved through attrition or migration to the private sector.

Staff reductions in the health sector have also occured in a number of developing countries such as Ghana where many health workers were made redundant four years ago. In Zambia there have also been cuts in support staff. In El Salvador, staff reductions have been achieved mainly through early retirement among unqualified staff. As already mentioned earlier, staff cuts have also taken place in a number of industrialized countries. In the United Kingdom, reductions of staff have occurred in the big municipal hospitals subject to restructuring. In Sweden, the number of health service employees has started to stabilize in recent years and among certain groups, such as nursing auxiliaries, numbers have declined.

International migration for labour is one of the most striking manifestations of globalization of the world economy. Transborder migrations for labour have long been a feature of health care occupations. Recent reforms of regional integration in various parts of the world (EU, NAFTA, etc.) as well as a general process of globalization tend only to give further impetus to migration. Within the framework of regional economic integration or on a bilateral basis, mutual recognition of medical qualifications has stimulated the migration of doctors, dentists, pharmacists, midwives and general nurses between the EU States, especially since the 1970s. The concept of free mobility of labour is one of the fundamental principles of the European Union. With the growing awareness of both employers and employees of the benefits offered by the single market from 1993 onwards, most observers expect labour mobility between member States to rise, although the evidence has been that international migration within the EU has declined in actual terms over a longer period, e.g. the past 20 years.

However, if migration of labour is to take place in an orderly manner, appropriate conditions must be created in the sending and receiving countries. Migration is motivated by the desire to find employment, or better paid work where the individual already has a job. For example, while staff nurses in the state-run Philippine General Hospital are paid US$146 per month, the going rate in the United States would be US$2,500 for work of equal value. The desire to emigrate may be strong, despite obstacles such as initial training requirements before nurses can be formally cleared for employment in the host country and various administrative formalities.

The recipient countries, mainly developed countries, gain from the arrival and employment of skilled workers and create conditions that encourage immigration by medical workers, as for example the United States immigration Act has done. In terms of numbers, the groups most affected by international migration have been the labour-intensive medical professions such as nurses. In all countries this profession is largely represented by women. For example, women comprise 88 per cent of nurses, midwives and health visitors in the United Kingdom. The recipient countries include a number of transitional economies -- for example some specialized medical establishments in Poland have recently attracted Russian eye surgeons whose skills in this field are internationally recognized.

Migration of health workers from developing countries to industrialized market economies has reached considerable dimensions. Some developed countries, such as the United States have relied on foreign nurses to fill gaps in the supply of labour. The United States continues to be a major recipient of foreign-trained nurses. A "severe widespread nursing shortage" was identified in the United States in 1992 and is predicted to increase dramatically in the future. The demand for nurses cannot be met by the national education and training system, and the shortfall cannot be remedied before the year 2000 at the earliest. Moreover, the demand for nursing personnel is predicted to rise further as a result of demographic trends and changes in health delivery systems.

While estimates vary, there were some 80,000 foreign nurses working in the United States, either on a temporary or permanent basis. Of that number, Asian nurses constitute the largest single group. The countries of origin include South Korea, India, China (Hong Kong), the Philippines and Thailand. On arrival, nurses are required to pass exams and only once they have done so are they permitted to work and maintain their visa status.⁽⁹⁾

Migration of health workers also plays an important role in the Gulf States, where many health workers are migrants, mainly from developing countries.

The numbers cited above show that migration for labour continues to play an important role in the employment of nurses, especially in certain developed countries. Employers are satisfied with the performance of foreign nurses and have even been focusing on possible strategies for keeping them. There is a strong and growing market for their services.

International migration by higher medical personnel such as doctors is sometimes referred to as the "brain drain", particularly when it means migration from developing and transitional countries to developed countries. The term "brain drain" implies a financial loss and is an unwelcome brake on national development. Thus, in the Sudan in 1978 alone lost 17 per cent of its doctors and dentists. Jamaica also lost large numbers of health personnel. Between 1978 and 1985, it lost 78 per cent of its output of trained doctors and 95 per cent of nurses. The potential effect of this "brain drain" on a country is clearly seen in Grenada, which has had to train 22 doctors for every one who stays in the country.

A survey of graduates of the All-India Institute of Medical Science in New Delhi (conducted in 1992) showed that 49 per cent of the respondents have settled abroad. In this group 86.9 per cent are located in the United States, 4.7 per cent in Australia, 3.15 per cent each in the United Kingdom and Canada, 1.6 per cent in the Gulf States and 0.6 per cent in Germany. The placement profile of respondents has revealed that 81.1 per cent are in clinical practice; furthermore, 35.9 per cent are medical teachers, 25.1 per cent are conducting research, 9 per cent are medical administrators, 5.1 per cent are involved in practical fields, 3.8 per cent are in medical journalism and 3.3 per cent are doing social work.

The brain drain reduces the scope of governments to carry out reforms in the health sector, since as it implies, among other things, substantial financial losses for the labour exporting countries. The extent of such losses depends on such factors as education and training costs which can be especially high in the case of medical workers, given the length of training required.

The brain drain may also be an indicator that reforms are needed. It is not necessarily only the higher salaries that attract qualified medical personnel abroad. Working conditions and other factors such as corruption may give an incentive to health workers to seek employment.

Reforms may also be a cause of the brain drain if they reduce employment opportunities for medical professions. Budget constraints may create a situation in which there are fewer jobs than graduates.

1. ILO: Report of the Joint Meeting on Employment and Conditions of Work in Health and Medical Services (Geneva, 1985).

3. ILO: Equality of opportunity and treatment between men and women in health and medical services, Report II, Standing Technical Committee for Health and Medical Services, First Session (Geneva, 1992).

5. World Bank: Investing in health, World Development Report 1993 (Washington, DC, Oxford University Press, 1993).

6. ILO: Health care personnel in Central and Eastern Europe, Sectoral Activities Programme, Working Paper (Geneva, 1997).

9. UN/UNDP: Foreign nursing professionals in the United States: Focus on Asian immigration (ILO-UNDP Project Report, doc. RAS/88/029, Sep. 1992), p. 119.

5. Reforms and their impact on
human resource development,
labour relations, working conditions
and occupational health protection

The legal status of health workers traditionally reflected the view that health services were "essential services", the interruption of which would endanger the life, personal safety, or health of the whole or part of the population (see also section 5.10.1). Consequently, employees in this sector frequently had the legal status of public servants. This was intended to protect health care personnel and consumers against any political, ethnic, religious, economic or other kinds of pressures that might interfere in the delivery of the services as labour legislation covering the private sector might not guarantee this independence. However, health workers found that they had to give account to both their employers and professional bodies. And unlike most other professions, employees in this sector were bound by very strict regulations and registration rules prevailing in all countries for health professions, and could lose their registration if their performance did not comply with their professional standards.

In the course of health sector reforms, it was often felt that this status was too rigid to allow adjustments to be made to the rapid changes described in Chapter 1. Privatization and the introduction of market elements into the health sector implied that management had to have more flexibility in determining pay and other terms of employment. As will be seen in the following sections of this report, the process of introducing more flexibility into the workforce was not only accompanied by changes in the perception of tasks and accountability but also frequently in the legal status of employees. As efficiency and rationalization became the focus of management and employers, occupations and tasks in the health services became increasingly perceived as "normal jobs", with less emphasis on providing services in the public interest. This trend may be observed in both public institutions and private organizations, irrespective of whether they are profit-making or non-profit-making.

In cases in which health sector jobs still have public status, market elements have been introduced. These take the form of new classifications, more individualized patterns of remuneration and market-related pay, amongst other things. When specific services have been contracted out or entire institutions privatized, work and contract arrangements have been renegotiated. If changes do not occur in the first instance, arrangements usually have to be renegotiated after the first transition agreement -- which is often reached by means of collective bargaining. In the case of private organizations, a distinction has to be made between profit and non-profit organizations. The latter mostly have an employment status which is similar to that of the public services and are not always covered by general labour legislation. As the legal status of employment changes, so does the pattern of staff representation. In some instances arrangements are drawn up on an individual basis.

In Canada and the United States privatization has, in some cases, led to renegotiated contracts or to the complete loss of representation. In their reply to the ILO questionnaire, the Canadian Nurses Association reported that there was a tendency in Canada to introduce competition and thus allow private for-profit agencies, especially in the area of home care services. It pointed out that these for-profit providers were usually composed of a non-unionized workforce and paid lower wages than non-profit agencies. Due to this wage differential it is expected that more service contracts will be awarded to for-profit companies. In Los Angeles County (United States) the staff of privatized hospitals had to renegotiate their terms of employment in 1997. The fact that they were able to be represented by the same trade unions was already considered to be an achievement.⁽¹⁾

The outlook for staff independence and impartiality differs when the legal status of staff changes. If personnel have public servant status, the possibilities of introducing efficiency-oriented criteria for benefits and staff bonuses remain limited and they are not exposed to considerations which go beyond professional and ethical issues. In the case of for-profit companies, pay differentials, flexible remuneration patterns and even contract arrangements may place greater emphasis on the economic objectives of the employer and thus reinforce the dilemma of the double accountability of staff towards their employer and their profession.

Two examples may be given of countries in which reforms have led to a change in the legal status of health sector workers. In Austria, health care reforms have resulted in a change of the status of health personnel who are now governed by general labour legislation. According to a Brazilian workers' organization replying to the ILO questionnaire, the country's constitutional reform expected in 1998 will lead to a change of the legal status of the entire public service. Indeed, the management of public institutions is already being increasingly outsourced to private for-profit organizations.

In all countries, human and institutional capabilities are critical to the success of policy reforms. Attempts will therefore be made to review and adjust recruitment processes as well as staff training and further training arrangements to reflect new policy directions. Emphasis will be placed on the development of a broad range of skills in such areas of health and nutrition. At the same time, due emphasis will be given to broader management issues, such as health care funding.

The performance of health systems may be improved by training adequate numbers of policy-making and management personnel, including public health specialists, policy analysts, hospital managers and drug management specialists. Over the past 30 years the role of managers, economists and planners -- sometimes even with the help of business advisory services -- has expanded in industrialized countries where hospitals are commonly run by non-physician hospital managers; in developing countries, hospitals tend to be managed by physicians.

It goes without saying that newly designed curricula for health care providers will have to take due account of the overall context in which health care reforms are implemented. For instance, more focused policy orientation would require the training of health care personnel on ways to implement cost-containment. Sound economic, demographic and epidemiological data are needed to guide investment decisions at various levels.

But training in the future will not only involve economic and administrative matters. As mentioned before, technical progress in medicine will imply that many health workers will have to keep up to date with new developments. Training will be even more necessary than before and this applies not only to doctors and nurses but also to ancillary staff.

"Lifelong learning"⁽²⁾ is also highly relevant to the health sector. In Ghana this concept was integrated into the Act of 1996 and a programme to restructure and overhaul training institutions was launched. In reply to the ILO questionnaire, Brazil, Canada, Colombia, El Salvador, Mexico, Austria, Finland, Latvia, Lithuania, Poland, Slovakia and Turkey pointed out that education and training systems were being adapted. A focus on the link between practical work, primary health care and lifelong learning seem to be the main features of these adjustments.

Coming back to the point of departure -- the implementation of reform -- there is a recognition of the fact that trained personnel are most effectively utilized and tend to be productive in an enabling and supportive institutional framework. And here it is necessary to draw a distinction between the capability to create and manage institutional mechanisms and arrangements and the capability of an individual to perform a specific task. When an institution employing health care staff has major shortcomings -- such as no clear idea of its role, inadequate structures, weak internal systems and practices or a lack of autonomy and incentives -- it is quite likely that the staff, even if well trained and capable, will not be productive or perform to the best of its ability. Although not all these deficiencies may be attributed to gaps in institutional capabilities, there is clearly a vast area that lends itself to systematic capacity building over time. One thing is clear: capacity building is not simply a new label for training but goes beyond it. In a given context, it is imperative to analyse and diagnose problems in terms of both human and institutional capabilities since the remedies will not be the same. While training for staff can be organized both locally and abroad, upgrading institutional capabilities may require a customized approach. Long-term capacity building for coping with constraints of human resources (technical, managerial and support staff) required to implement health reforms⁽³⁾ is particularly significant, especially when complex institutional capabilities are involved.

Capacity-building encompasses planning and implementation. By drawing attention to both these dimensions, emphasis is placed on the importance of strengthening capacity for action. On the one hand, planning capabilities focus on analytical skills, breadth and depth of sectoral understanding and interdisciplinary collaboration; on the other hand, implementation capabilities concentrate more on organizational action, incentives, teamwork and results. Those engaged in capacity building need to note the interdependence between both these elements. Of critical importance are capabilities to: assess and design organizational structures, systems and processes; create and enforce a suitable legal and financial framework; and motivate and provide guidance to people at different levels. It may be useful to examine different elements of health reform in the light of these considerations to identify the nature and mix of capacity dimensions required in a specific country context. Irrespective of the sector, capacity building seems to involve more than knowledge or skills transfer. It would be more appropriate, therefore, to conceive of it in terms of knowledge, processes -- referring to the institutional strengths and dimensions to be created -- and practice.

Autonomous centres and institutes for policy analysis and implementation may be set up as an independent entity, as part of a university or even as a private sector organization. Autonomous centres can build in greater flexibility, in terms of compensation and incentives, than government agencies, making it easier to attract and retain competent professionals. It is well known that lack of flexibility has always been a problem for governments. Moreover autonomous centres function as independent sources of policy advice and analysis, which is essential. The importance of establishing viable institutions with a critical mass of expertise in relevant subjects cannot be overemphasized. They are more likely to remain objective and independent than captive policy units within government. It was this consideration which prompted the World Bank, along with other donors, to launch the Africa Capacity Building Initiative (ACBI); this is a specially focused, long-term programme (as opposed to conventional short-term technical assistance projects) to provide support to such institutions. A major challenge is to provide for capacity building in health policy so that countries can share their institutional infrastructures -- which is particularly important given that small countries lack economies of scale and resources. One clear implication of this approach is that the institutions involved cannot be under any one government. Nevertheless this does not prevent ministries from having in-house units and from seeking policy advice from autonomous institutions.

There are, of course, marked differences between health care reforms which aim at a shift towards market orientation and health care reforms that are closely linked to public sector reforms; however, there are overlaps. A shift to market orientation, for instance, would call for enhanced expertise in contracting out or identifying areas for multi-hospital management -- although for many developing countries some of those aspects, especially the latter, may still be a vision of the future; their major concern is to obtain urgent medical or pharmaceutical supplies or ensure other preconditions to carry out emergency medicine.

But what can be considered common to all reform efforts is that managerial and implementation skills are vital to make these "systems" work. Moreover, efficient institutional arrangements are critical in addition to individual skills.

Particularly in sectors such as health, it is perfectly conceivable that those in authority are unfamiliar with or unconvinced about the nature of reform. Their professional backgrounds do not always equip them to initiate policy reform or carry out policy analysis. It is therefore not known for policy-makers or heads of ministries to be indifferent or even hostile to policy reform -- especially when they stand to gain from the status quo. In such cases, considering the vested interests, support for capacity-building is likely to remain weak. And this partly explains why major reforms tend to occur in times of severe financial crisis, in the form of donor conditionality for instance. Only in rare cases do exceptional leaders or new regimes, which are not concerned with maintaining the status quo, initiate such conceptual moves.

In some countries tasks traditionally performed by physicians have been successfully delegated to primary care providers as a way of improving the efficiency of health services.

The most remarkable observation is that in absolute figures sub-Saharan Africa has the fewest physicians and nurses of any region, which is an obstacle to the delivery of public health interventions and essential clinical services. This disadvantage is however partially offset by the relatively high ratio of nurses to physicians. No such accentuation and polarization in the nurse-to-physician ratio is observable in the other regions.

According to estimates, public health and minimum essential clinical interventions require about 0.1 physician per 1,000 population and between 2 and 4 graduate nurses per physician. The ratio of nurses to physicians is five to one in Africa but well under two to one in China, India, Latin America and the Middle East.⁽⁴⁾

The World Bank⁽⁵⁾ believes that addressing particular imbalances in human resources and education finance policies may result in curtailing education opportunities for physicians and specialists -- who are, with the exception of Africa and middle-income countries, in oversupply -- and expanding these opportunities for workers in primary health care, public health policy and management. During the 1960s and 1970s many governments encouraged, primarily through subsidies to education, a rapid expansion in the training of physicians to meet urgent needs.

However, by the early 1980s, the established market economies, Latin America and parts of Asia, were confronted with an excess of physicians in relation to nurses and of specialists in relation to general practitioners. Concomitantly, the quality of medical education also declined with the rapid expansion of medical faculties. Qualified medical personnel also tended to move away from rural or otherwise underprivileged areas in search of higher living standards. These policies have been costly. The way in which countries will try to address imbalances will essentially depend on the specific country context. Setting the right priorities, particularly in a context of resource constraint, is a fundamental aspect of health care reform.

Indeed, high numbers of medical specialists tend to result in unnecessary procedures which often involve uncalculated risk and increase health care costs. A United States study showed that a 10 per cent increase in surgeons would bring about a three to 3 to 4 per cent increase in surgical operations -- a phenomenon described as "supplier-induced demand". Practical guidelines and incentives might help to cut down on these operations; however, curtailing specialist training might also be a way of achieving this objective. In 1991, Latvia reduced the number of medical students from 2,500 to 350 and retrained many specialists as general practitioners (GPs), as reported by the workers' organization replying to the ILO questionnaire.

It is important that appropriate training be given to specialists when they become GPs in order to provide cost-efficient and good quality services. Many OECD countries drew the conclusion that it was preferable to limit the number of specialist training opportunities -- a policy which is increasingly relevant for middle-income countries interested in cost-containment. A number of countries have responded to oversupply by reducing working hours (Denmark); others have indirectly encouraged medical personnel to work abroad. The labour market for health care personnel has become increasingly international.

In addition to the nurse-to-physician ratio referred to above, the overall proportion of GPs to specialists is an important indicator for governments to monitor, but this information is at present not regularly collected and inventoried in many countries. A reasonable benchmark for the maximum proportion of specialists to GPs in developing countries might be 25 per cent, equivalent to the lowest proportion in the established market economies. In Belgium, France, Germany, and the Scandinavian countries, where regulatory bodies and expert committees determine the maximum number of physicians to be trained, the corresponding figure ranges between 25 and 50 per cent, while in the middle-income country Chile, the World Bank puts this figure at no less than 75 per cent.

Specification of those ratios and the role of private practitioners, for example, calls not only for good policy analysis, but also for organizational assessments and implementation analysis.⁽⁶⁾

Career development is most commonly defined as a process in which goals are set, specific talents, capabilities and interests are identified, (career) plans are implemented and counselling and guidance are available. Career development and in-service training are essential for further training, especially for staff in managerial positions.

Given the tendency in some countries to replace, due to a downward pressure on wages, skilled staff by unskilled cheaper labour, emphasis must be placed on satisfactory and continuous career planning which could lower costs by reducing the high labour turnover.

In the health sector attention should focus more on identifying professional profiles that will be part of the multi-professional teams of tomorrow's health care systems. There is a need to look beyond traditional models of health care and training. Quality of care, disease prevention and health promotion should be an integral part of this professional reorientation.⁽⁷⁾ Regional and -- to a more limited extent -- international training courses might afford prospects of career development.

In the wake of structural adjustment, particular emphasis has been placed on retaining staff in areas most suited to their tasks, whilst offering adequate opportunities for the further training and redeployment of health care personnel in similar professions. In reply to the questionnaire, Finland gave examples of further training programmes to reinforce community care and occupational health care. Severance and redeployment arrangements are an important aspect of retrenchment programmes. It should be noted that appropriate training does enhance the employability of health care personnel.

In addition to training, special schemes should be set up to facilitate redeployment and re-employment in the sense that retrenched workers are given priority when vacancies arise in the public service. Another crucial aspect is the development of an effective labour market information system.⁽⁸⁾

A number of countries with structural adjustment programmes are undertaking management support and training programmes under the auspices of the World Bank and UNDP. Examples of such programmes can be found in China⁽⁹⁾ and Ghana. Considerable resources are provided by the EU to enable various executing agencies, such as the SIGMA/OECD programme, to assist Eastern and Central European countries improve the management and organization of their respective public services which also impact on the health services.

It is increasingly recognized that macroeconomic policies and structural adjustment measures involving reallocation of resources and public expenditures are not gender-neutral. Similarly, the health care reforms implemented against the same background of structural adjustment programmes and as part of donor conditionality have also not been gender-neutral.

Gender does play a role in redeployment, since women generally have more limited labour market opportunities. They are moreover subject to a sociocultural bias limiting labour market participation and, although the health care professions which they chose are most likely to be exempted from this bias, they are at a disadvantage when redeployed to other professions. These trends affect the ability of women to compete in the labour market for access to higher quality and at least adequately, if not higher, remunerated jobs. The last ILO sectoral meeting on health and medical services in 1992 dealt extensively with the subject of equal opportunity and treatment between men and women in health and medical services and came to a number of conclusions.⁽¹⁰⁾

Funding cutbacks to the institutional sector, where the majority of registered nurses work, and the lack of funding for community-based services have contributed to nurses being more affected by health care reforms than any other health care professionals. Health care reforms are resulting in a decrease in employment and career development opportunities at a time when more nurses -- the majority of whom are women -- with higher levels of education are entering the workforce. Reactions to this situation vary. These developments have led to a growing interest by registered nurses to provide nursing services as self-employed entrepreneurs. According to the Canadian Nurses Association there is also an increasing trend for nursing personnel affected by this situation to move abroad to work. Nevertheless, the other replies to the questionnaire did not note any significant change regarding gender issues due to health sector reforms. Only UNISON in the United Kingdom pointed out that men continued to be overrepresented among senior grades and managers.

In this particular area the ILO has designed special education, training and capacity-building strategies aimed at eliminating structural gender inequalities and enhancing women's competitiveness in labour markets and their access to employment. Taking note of the special precarity of women's employment, the Governing Body of the International Labour Organization approved at its 265th Session a proposal for an international programme for "More and Better Jobs for Women" which will be the ILO's specific response to the successful implementation of the Platform of Action of the Fourth World Conference on Women and the gender dimensions of the Programme of Action of the World Summit for Social Development. It also represents a concerted effort to reinforce the ILO's longstanding priorities to promote full employment in conditions of equality.

As far as the specific situation in transition economies is concerned, the participation of women in the labour force was much higher in Central and Eastern Europe in the past than in the rest of Europe. Various changes brought about by the transition to a market economy, as well as privatization moves as part of health care reform, have eroded the formerly existing network of enterprise-level social benefits (e.g. child care) for women.⁽¹¹⁾ A larger proportion of women, who tend to be in lower-paid, lower-status branches of the health care system, have lost their jobs than men. Furthermore, outdated values are re-emerging, assigning all family responsibility to women and asserting that their place is in the home.

In other European countries the level of women's representation at higher educational and decision-making levels has increased in the last decade.⁽¹²⁾ However, compared to their share in the workforce of the health sector, women are still underrepresented at the decision-making level.

All this implies that multifaceted strategies are required to increase employment opportunities available to women, either in their capacity as health care providers or redeployed workers, and to improve the terms and conditions of their employment. It is likely that the extent of women's access to technological training will be a key factor in determining their future opportunities. These strategies must focus on mainstreaming women and women's issues into all areas of economic, social and political development.

Limitations on working hours and the provision of rest periods are of particular importance to health care workers because they impact directly on the quality of services -- which in turn affect the safety, health and well-being of the general public. Health sector reforms have had varying repercussions on the periods of work and rest in this sector. A distinction must be made between the working hours of salaried employees in larger health care establishments and of those working in smaller institutions and groups or independently. The various professional groups in the health sector must also be taken into account. The following paragraphs will give some indications of whether and how health sector reforms have changed normal working hours, overtime and shift work as well as periods of rest and annual leave. The impact of these changes on occupational safety and health will be dealt with in section 5.9.

From its earliest days, the ILO has taken a particular interest in the regulation of hours of work for all occupations as this is of critical importance to workers' health and their productivity. In the health services, the issue is particularly important because the activities of many health service professions have a bearing on public safety and health. It is for this reason that health services are categorized as essential services which have to be provided without interruption. At the same time, hours of work of the individual persons involved have to allow for the provision of these services in a responsible and accountable way towards the public. Confronted with the challenge of health sector reforms and cost-containment, the working time of health care workers has become a burning issue. The obligation of providing essential services around the clock requires a very complex work organization, including shifts, overtime and rest periods. The situation is additionally complicated by the fact that an increasing number of health care personnel are working under part-time and other flexible arrangements.

In regard to international labour standards, normal hours of work and overtime are regulated by the Hours of Work (Industry) Convention, 1919 (No. 1), and by the Hours of Work (Commerce and Offices) Convention, 1930 (No. 30). Both Conventions provide for an eight-hour day and a 48-hour week allowing for a maximum of nine and ten hours of work per day respectively. However, neither of the Conventions appear to have a direct bearing on the health sector. The definition of the "industrial undertaking" under Article 1 of Convention No. 1 does not include activities relevant to the health sector. Article 1 and 2 of Convention No. 30 explicitly excludes from the application of the Convention any "establishment for the treatment or the care of the sick, infirm, destitute, or mentally unfit".

The Forty-Hour Week Convention, 1935 (No. 47), and the Reduction of Hours of Work Recommendation, 1962 (No. 116), which have general application, are instead relevant in this respect. The Recommendation sets forth the principle of a 40-hour week to be achieved by the progressive reduction of normal hours of work as appropriate, without any reduction in the wages of the worker concerned. The Recommendation also sets a priority objective: where the duration of the normal working week exceeds 48 hours, immediate steps should be taken to bring it down to the level of 40 hours and it states that each Member should formulate and pursue a national policy designed to promote the principle of the progressive reduction of normal hours of work. According to the Recommendation a number of factors have to be taken into account in progressively reducing working hours. These seem of particular relevance in the context of countries undergoing structural adjustment and a transition to the market economy. Such factors include: (a) the country's capacity, given its level of development, to bring about a reduction of working hours without adversely affecting productivity, industrial development or competitiveness in international trade and without creating inflationary pressures which would ultimately reduce the real income of workers; (b) the extent to which productivity can be improved through the use of new technology and management techniques; (c) the need for improving standards of living in developing countries; and (d) the preferences of employers' and workers' organizations as to the manner in which the reduction in working hours might be brought about.

In the area of working time, two additional ILO instruments are also relevant: the Hours of Work and Rest Periods (Road Transport), 1979 (No. 153), and the Nursing Personnel Convention, 1977 (No. 149). Convention No. 153 establishes a total driving time, including overtime, of nine hours per day and 48 hours per week. It also establishes that the total driving time may be calculated as an average of a number of days or weeks to be determined by the competent authority in each country. It also provides for a break after a continuous period of five hours of work and for a daily rest period of at least ten consecutive hours during any 24-hour period. Convention No. 153 is, in principle, also relevant to ambulance drivers, although, according to Article 2, the competent authority in each country may exclude from its application "transport of sick and injured persons, transport for rescue or salvage work ...".

Convention No. 149, in particular Article 6 of the Convention, provides that "nursing personnel shall enjoy conditions at least equivalent to those of other workers in the country concerned in the following fields: hours of work, including regulation and compensation of overtime, inconvenient hours and shift work; weekly rest; paid annual holiday; educational leave; maternity leave; sick leave; and social security".

A number of ILO instruments deal with weekly rest periods: the Weekly Rest (Industry) Convention, 1921 (No. 14); the Weekly Rest (Commerce and Offices) Convention, 1957 (No. 106); and the Weekly Rest (Commerce and Offices) Recommendation, 1957 (No. 103). In particular, Convention No. 106, which establishes the entitlement to an uninterrupted weekly rest period of not less than 24 hours, provides in Article 3 that any Member ratifying the Convention may specify in a declaration accompanying its ratification that the Convention also applies to persons in "establishments, institutions and administrative services providing personal services". Recommendation No. 103 recommends that as far as possible, the entitlement to weekly rest be increased to not less than 36 hours.

The Holidays with Pay Convention (Revised) 1970, (No. 132), provides that the length of the annual paid holiday should be specified by each Member at the moment of ratification but that it should be a minimum of three working weeks for one year of service. In the case of a service of less than 12 months, a holiday with pay proportionate to the length of service should be granted. A minimum period of service, which should not exceed six months, may be required. This Convention applies to all employed persons, thus including employees in the health sector.

The Night Work Convention, 1990 (No. 171), and its accompanying Recommendation (No. 178) are applicable to the health sector. The Convention calls for specific measures to be taken for night workers to protect their health, assist them to meet their family and social responsibilities, provide opportunities for occupational advancement, and compensate them appropriately. Such measures include the establishment of the right for night workers to undergo a health assessment without charge and to receive advice on how to reduce or avoid health problems associated with their work. It provides that suitable first-aid facilities should be made available for workers performing night work, including arrangements whereby such workers, where necessary, can be taken quickly to a place where appropriate treatment can be provided. Night workers certified, for reasons of health, as unfit for night work should be transferred, whenever practicable, to a similar job for which they are fit. Before or after childbirth, a woman night worker should not be dismissed or given notice of dismissal, except for justifiable reasons not connected with pregnancy or childbirth; the income of the woman should be maintained at a level sufficient for the upkeep of herself and her child in accordance with a suitable standard of living; she should not lose the benefits regarding status, seniority and access to promotion which may be attached to her regular night work position. Compensation for night workers in the form of working time, pay or similar benefits should recognize the nature of night work. Social services should be provided for night workers and, where necessary, for workers performing night work. Finally, the employer, before introducing work schedules requiring the services of night workers, should consult the workers' representatives concerned on the details of such schedules and the form of organization of night work that are best adapted to the establishment and its personnel as well as on the occupational health measures and social services which are required. In establishments employing night workers this consultation shall take place regularly.

Part-time work is regulated by the Part-Time Work Convention, 1994 (No. 175), and its accompanying Recommendation, 1994 (No. 182). Protection is granted to part-time workers having regard to the level of protection granted to "comparable" full-time workers. Comparable full-time worker refers to a full-time worker who: has the same type of employment relationship; is engaged in the same or a similar type of work or occupation; and is employed in the same establishment or, when there is no comparable full-time worker in that establishment, in the same enterprise or, when there is no comparable full-time worker in that enterprise, in the same branch of activity, as the part-time worker concerned. In the case of fundamental rights, part-time workers receive the same protection as comparable full-time workers. These include the right to organize, to bargain collectively and the right to act as workers' representatives. The same level of protection is also granted in regard to occupational safety and health and discrimination in employment and occupation. A proportional treatment should be granted as far as basic wages are concerned. The treatment should be equivalent for statutory social security schemes, maternity protection, termination of employment, paid annual leave and sick leave. Finally, the Convention stipulates that measures should be taken to facilitate access to productive and freely chosen part-time work which meets the needs of both employers and workers, provided that the protection mentioned above is ensured.

These international labour standards should be borne in mind when looking at the impact of health sector reforms (regarding other international labour standards, see also section 5.10.1 of this report).

Regulations and agreements issued for limiting working hours are normally expressed in daily and weekly working hours. In the United Kingdom, there are also some pilot tests with "annualized hours" schemes. Normal working hours are indicated for different categories of occupations. Statistics increasingly use as an indicator working hours per year in order to calculate the average hours actually worked. The Nursing Personnel Recommendation, 1977 (No. 157), encourages the rapid reduction of weekly working hours to 40, and possibly less, and stipulates that the working day, including overtime, should not exceed 12 hours.

Much information on normal working hours and overtime is contained in the reports submitted to the Sectoral Health Meetings in 1985 and 1992⁽¹³⁾ and the ILO October Inquiry results (1995 and 1996).⁽¹⁴⁾

The greatest diversity in, and some of the highest normal working hours for, medical occupations are found in Nigeria. In 1995, normal hours for male physicians were 48 and for female physicians 56. In the category of professional nurses, men had to work 54 hours and women 46 hours. In the case of auxiliary nurses, men had to work 42 hours and women 47 hours; male X-ray technicians worked 54 hours and male ambulance drivers 53 hours. High hours for normal working are also found in China, Egypt and India, which all report 48-hour weeks.

A number of countries impose a maximum number of hours that can be worked by health service staff. In the Canton of Geneva in Switzerland an average of 50 hours a week are worked, calculated over a year, subject to an upper limit of 55 hours in any one week.

In some countries, normal working hours differ according to whether the employee is on shifts. In Spain normal working hours for night shifts are 35 but 40 for day shifts. In Guatemala they are 36 for night shifts and 44 for day shifts.

Normal weekly working hours do not seem to have increased as a result of health care reforms in all regions. They have more or less remained the same, particularly in the case of health workers who belong to the public service.

Amongst the countries and national organizations which replied to the ILO questionnaire, Canada, Colombia, El Salvador, Finland, Latvia, Niger, Poland, United Kingdom and Zambia all reported that there had been no change in their normal working hours. Lithuania and France reported that weekly working hours had been reduced, as they were now subject to the regulations of new labour legislation which included limitations on working hours in accordance with EU standards; South Africa also noted a reduction in working hours. The Russian Federation reported that the Labour Code of 1992 had fixed normal working hours at 40, and reduced working hours for work which carried a certain occupational risk. However, no specific mention was made of the health sector, although it was envisaged to reduce working time. In most countries, weekly working hours were below 40 -- the standard being somewhere between 35 to 39 weekly hours.⁽¹⁵⁾ The table below gives an overview of normal working hours in some selected European countries.


	Country	Hours

	Norway (communes)	35.5
	Denmark	37.0
	Cyprus	37.5
	Norway (state)	37.5
	Finland	38.3
	Germany	38.5
	Albania	40.0
	Croatia	40.0
	Lithuania	40.0
	Czech Republic	42.5
	Turkey	45.0
Source: PSPRU.¹ ¹Public Services Privatization Research Unit (PSPRU), on behalf of the European Federation of Public Service Unions (EPSU): Privatization of health care services across Europe (London, Sep. 1997), table 25.

Overtime is increasing due to shortage of staff or to cost-containment measures; both are phenomena which can be related to health care reforms. Already in 1992, the German Union of Salaried Employees (DAG) estimated that the overtime worked by health care providers was equivalent to 20,000 extra full-time staff posts.⁽¹⁶⁾ The German physicians' association "Marburger Bund" reiterated in 1998 that 33,000 new posts could be created for doctors if unpaid overtime were to be limited. The concern of workers' organizations in Canada and the United Kingdom today was that overtime was being used to substitute recruitment and that there was an increase in unpaid overtime. An independent survey commissioned in 1997 by the British workers' organization, UNISON Health Care, revealed that over four in ten respondents did more than two hours unpaid overtime.⁽¹⁷⁾ The 1997 annual membership survey of the Royal College of Nursing (United Kingdom) confirmed that nurses were overworked and short in supply; 65 per cent of the nurses reported that they had worked overtime in the last working week, compared to 57 per cent in 1996.⁽¹⁸⁾

Long hours of work and heavy overtime also seem to be a problem for physicians. A study conducted in 1996 by the Permanent Working Group, European Junior Hospital Doctors (PWG) indicated that 70 per cent of doctors in the study were contractually obliged to work between 37 and 45 work per week while 23 per cent were obliged to work from 46 to 72 hours per week. In addition, 67 per cent of the doctors had a weekly overtime of more than five hours and 25 per cent had an average of more than 21 hours of overtime per week; 49 per cent of doctors considered "sufficient leisure time" a major problem, while 46 per cent considered the major problem to be "feeling of exhaustion".

Nurses in Japan have long complained about difficult hours of work and the heavy workload. The number of nurses for 100 hospital beds was reported as being less than 20 -- compared with more than 40 in United Kingdom, almost 60 in the United States and more than 60 in Sweden and France.⁽¹⁹⁾ However, a recent survey by the Japanese Nursing Association (1997) showed an improvement in this area, with average working hours for nurses having decreased from 41.12 in 1991 to 39.32 in 1995, and with 57.5 per cent of the nurses enjoying two-day weekends.

Overtime seems to be part and parcel of certain health care occupations. In Austria, for instance, physicians have reported working an average of 55 hours over a number of years, and auxiliary nurses 46 hours, while both occupations are supposed to have a 40-hour week. In Romania, male physicians actually work one hour more than normal working hours and professional nurses work three hours more than they usually should.

In Brazil, the workers' organization reported that normal working hours are 35 in the public service and 40 in the private sector. However, it was very common for average working hours in the health services to be in the region of 70-80 hours a week.

Practices vary from country to country. In some, the same normal hours of work apply to all employees throughout the economy. In others, there is uniformity within the public service, sometimes with the exception of teachers who may have lower normal hours of work. In some countries, normal hours are the same for the medical occupations but these differ from other parts of the public service and from the private sector. In other countries working time varies for different medical occupations. Physicians and dentists may have shorter working weeks and ambulance drivers may work longer.

While long hours of work and overtime can constitute a problem, an even greater problem can be represented by the recurrent use of unsociable working hours. In the search for increased flexibility, the enterprise providing health services may make increasing recourse to a variety of working time arrangements. This trend can be accentuated in countries undergoing processes of structural adjustment or in transition to market economies by the need to reduce extreme centralization, excessive bureaucracy and low labour productivity. The shift from secondary to primary health care also demands that additional flexibility be added in the organization of health services.⁽²⁰⁾

A study undertaken in 1994 by the European Foundation for the Improvement of Living and Working Conditions on the working conditions in hospitals in the European Union showed that while the length of work was considered a main risk factor for occupational health in three countries, unsociable working hours were considered as a main risk factor in eight countries.⁽²¹⁾

Along the same lines, an OECD study on health care in the Netherlands indicated that while atypical working time arrangements concerned 10 per cent of the work force in the building and construction industry, 22 per cent in banking, finance, insurance and business services, 33 per cent in manufacturing and 42 per cent in the wholesale trade, they amounted to a staggering 86 per cent in the health care sector.⁽²²⁾

It is also extremely important to consider the combined effects of atypical working hours with an intense pace of work. Countries including France, Germany, Sweden and the United Kingdom have reported that normal working time -- or even actual hours worked -- do not reflect the increased intensity of the work.⁽²³⁾ Due to early discharges in hospitals, additional tasks, less standby staff and the supervision of less experienced and less qualified colleagues, in-patient services require more energy and staff care -- and the term "increased workload" gives no indication of what is really implied. In the Canadian Province of Alberta, layoffs have resulted in a heavier workload for the remaining staff, and "the quality is reported to have reached crisis level".⁽²⁴⁾

In general, reform processes accompanied by cost-containment have resulted in an increase in overtime and atypical working time arrangements, while normal working hours have remained more or less the same. And data on working time broken down according to occupation groups and types of institutions are scarce.

The very nature of health care services implies that they must be provided on a continuous basis. Consequently a wide variety of shift patterns is used. This is particularly relevant for in-patient establishments, where not only the health care and medical professions but also administrative and auxiliary personnel are affected.

The above-mentioned survey on working conditions in the hospitals of the European Union describes the extent to which the workforce is involved in shift work. In Belgium, for instance, about 83 per cent of the nursing staff are exposed to shift work -- either two, three or four shifts. About one-third of hospital workers in France and 48 per cent in Germany are concerned by shiftwork (mostly three shifts); 75 per cent of nurses in the United Kingdom work on shifts. Apart from people who work in rotating shift patterns, there are others who work a constant night shift (4 per cent of hospital workers in Denmark, 10 per cent in France, 38 per cent in Germany and 13 per cent in the United Kingdom). In France, it has been noted that people often opt for "unsociable" working hours, especially night work, for reasons linked with family and social life, for instance child care. This tendency has been reinforced by the reduction of working time to 35 hours a week in night work.⁽²⁵⁾

A survey carried out by the Institute for Employment Studies in the United Kingdom revealed that the three-shift system was the most common. This system was present in 99 per cent of the acute trusts and 86 per cent of non-acute trusts. Within the latter, however, there were marked variations by type of unit. A three-shift system was most common in mental health (90 per cent) and learning difficulties (71 per cent) but was much rarer in community-primary trusts (17 per cent). A two-shift system was less commonly reported. Two-fifths (40 per cent) of all trust respondents used a two-shift system, but this proportion rose to 57 per cent in the acute trusts. There was a noticeable move towards two-shift systems (i.e. 12-hour shifts) with two-thirds of responding trusts reporting that these had increased in the past two years. A possible, though as yet barely discernible, trend was the reduction in the three-shift system.

In reply to the ILO questionnaire, the French Nurses Association reported that there were plans to reduce working hours to 35 per week which would also imply changes in shift work; and the Canadian Nurses Association reported that health sector reforms have resulted in additional overtime and shifts. In developing countries the situation is not well documented. Niger reported to the ILO that the reforms had not changed regular working hours in the public service. In the private sector, two shifts of 12 hours had been introduced on account of staff reductions.

In Austria, according to the ILO October Inquiry (1995 and 1996) nurses may be required to work 12-hour shifts. In Belarus shifts may only exceed 12 hours with the agreement of the worker. In Belgium, although general labour legislation provides for a five-day 40-hour week, a Royal Order (14 April 1988) allows health care institutions to have work schedules with shifts of up to 12 hours a day and 50 hours a week providing that the total hours worked in a four-week period do not exceed 152 hours -- the sum of four weeks of 38 normal hours a week as set out in the collective agreement. In Comoros, shifts may last for 24 hours while in Colombia eight- hour shifts are the standard -- as they are in El Salvador where there is a shift maximum of 12 hours.

In a number of countries, such as the United Kingdom and Germany, fixed shift patterns of day and night duty have changed to internal rotation, requiring nursing staff to work day and night shifts on a rotating basis. Such shift patterns are frequently unpopular with the staff and apparently cause health and domestic problems.

Regarding rest periods and leave, no major changes have been reported to the ILO, with the exception of El Salvador, Latvia and Slovakia, where leave has been extended. However, the Canadian Nurses Association noted that additional shifts and overtime make the scheduling of rest and leave periods often problematic.

The following table gives an overview of some leave arrangements by grades in selected European countries.

Table 5.2. Days of annual leave in selected countries


Country	Nurses				Doctors or managers

	Lowest grade		Highest grade		Junior grades		Senior grades

	Min.	Max.	Min.	Max.	Min.	Max.	Min.	Max.

Czech Rep.	15	25	15	25	15	25	15	25
Cyprus		19		29		19		29
Finland	24	36	30	36	24	36
Germany	26	30	26	30	26	30	26	30
Norway	21	27	21	26	21	26	21	26
Turkey		30		30		30		30
Source: PSPRU.¹ PSPRU, op .cit.

Health sector reforms have brought about changes in the pattern of shift work, night work and rest periods; these are mostly targeted at higher efficiency, e.g. two shifts with 12 hours. If these arrangements are applied in accordance with agreements, they might also reduce the incidence of unsociable hours. However, staff shortages might prevent this. Although it is very difficult to provide guidelines on shift systems, it is generally recommended that shifts should be: (a) rotated rapidly; (b) in a forward fashion; and (c) that the longest period of rest should follow the night shift. A number of research workers have stressed the importance of social support to "buffer" (i.e. moderate) work stress -- and a recent study indicated that this is particularly relevant in the case of shiftworkers.⁽²⁶⁾

Contract flexibility may be in the interest of the enterprise, the employees or both. In the case of the employees, it allows them to adapt their working schedules to family responsibilities and other personal concerns. These arrangements may or may not, however, coincide with the enterprises's interests.

Alongside time-based flexibility, contract flexibility allows enterprises to increase their productivity and competitiveness in the market. This is particularly important when enterprises have to undergo structural adjustment and transition to the market economy. Traditional full-time contracts may still be the rule in the health sector -- but the trend is definitely towards more flexible contracts.

The above-mentioned study by the British Institute of Employment Studies indicated that more than one-third (35 per cent) of trusts using agency nurses had increased flexible contracts whereas 28 per cent had reduced them; more than two-thirds (69 per cent) of trusts reported an increased usage of bank nursing staff, with only 11 per cent signalling a decrease. Over half the respondents (54 per cent) identified a rise in the use of fixed-term contracts, whilst nearly two-fifths (38 per cent) reported a growth in the use of permanent part-time contracts. Finally, more than one-quarter (27 per cent) stated that the use of permanent full-time contracts had declined, while 25 per cent reported an increase.

Judging from these trends -- in the United Kingdom at least -- it would seem that the tendency is for a reduced use of permanent full-time staff and an increased use of permanent part-time staff. Most of the organizations interviewed in a 1994 study indicated that they expected to maintain or increase the use of fixed-term contract staff.⁽²⁷⁾ These forecasts are likely to change due to the commitment of the Labour Government in 1997 to reduce the levels of flexible short-term contracts. In the hospital sector of the European Union, the percentage of part-time contracts varies between less than 1 per cent (in Greece) to 52 per cent (in the Netherlands).⁽²⁸⁾

In 1997, the European Court of Justice, ruling on the case of two Northern Irish nurses, determined that part-time workers should have the same pension entitlements as full-time workers.⁽²⁹⁾

Although part-time work seems definitely to be on the increase this trend seems to have levelled out in some countries because there has been a general stabilization of female part-time work. The Canadian Nurses Association reported that part-time employment of nursing personnel grew from 29.3 per cent in 1970 to 38.8 per cent in 1995. In Canada, the percentage of part-time nurses, which is mainly a female-dominated profession, is significantly higher than the percentage of part-time women workers in the workforce as a whole (28.4 per cent). New entrants often work on several part-time jobs and the Canadian Nurses Association is concerned that this state of affairs will encourage nurses to emigrate. Finland reported a relatively low level of part-time work but noted that the trend was growing; it increased from 4.6 to 6.3 per cent from 1992 to 1994. In Germany, part-time work accounted for 24 per cent of total work in 1995.⁽³⁰⁾ It may be observed that flexible work arrangements are becoming more widespread in the area of long-term care and mobile services. These increasingly include "minor work arrangements" for cleaning and catering which do not require compulsory insurance.

In African countries, part-time work is virtually unknown in the health services sector as the staff are employed in the public service, where full-time jobs are still the rule. For instance, Ghana, Niger and Zambia reported that employees in the public health sector were still employed full-time and that no flexible working arrangements were envisage for the near future. Published documentation rarely gives any indications on the working time and work organization for health workers. In most cases, mention is only made of the lack of qualified personnel. Other developing countries such as Colombia and El Salvador also reported that there were no part-time or flexible work arrangements in the health sector. Similarly, countries in transition, like Latvia and Slovakia, noted that the incidence of part-time work was insignificant.

Part-time work has also started to become a feature in the work of doctors who are usually associated with full-time work. A study carried out in the United Kingdom⁽³¹⁾ on part-time work in general practice found that 53 per cent of men doctors and approximately one third of women doctors worked full-time in one job. A number of GPs combined several part-time jobs. The outlook was different among specialists: 87 per cent of the men and over half of the women had full-time jobs. The question of whether part-time or less than full-time working has an adverse effect on the careers of doctors is particularly relevant. (See also section 4.2 of this report). The survey indicated that over 40 per cent of women interviewed thought that their careers had suffered on account of their part-time work as they had less status in their practice. Over one third of the women in the survey felt that their careers had been affected by this aspect. Women often mentioned that they were treated less well than their full-time counterparts.⁽³²⁾

The adverse effects of on-call duty are also reported in the above-mentioned studies. A questionnaire sent out to young doctors in the United Kingdom in 1996 revealed that 22 per cent of young doctors who replied found the amount of work they had to do when on-call duty was a major problem; a further 39 per cent considered the amount of work very heavy.

Other flexible work arrangements may take the form of temporary contracts, seasonal contracts, standby contracts and flexible working times. Table 5.3 gives an overview of the situation in selected countries in 1997.

Reform processes, which aim at greater efficiency and lower costs, may warrant the flexible work arrangements which are being introduced. In industrialized countries, these arrangements are already fast gaining fround in the private sector. In the transition and developing countries, where most of the health staff are still employed in the public service, conditions have only started slowly to change.

Work reorganization in the health care services may be observed worldwide and is due to several developments which have a mutual impact on each other. Such trends may be attributed to changes in: medical technology; financing of health services; managerial methods; and the focus of health policy.


Country\type	Part-time/ temporary	Seasonal	24-hours	Flexi-time	Accumulated leave

Albania	X (priv. sect.)	X	X	X
Croatia	X
Czech Rep.	X		X
Cyprus	X	X	X
Denmark	X	X
Finland	X			X
Lithuania	X	X		X
Norway			X	X	X
Romania
Sweden	X	X		X	X
Turkey			X		X
Source: PSPRU.

Technological progress, as described under section 1.5 of this report, requires major short-term investments in equipment, training and restructuring. The restructuring of the work organization and tasks often seems to be the first issue addressed in health sector reforms.

New forms of work organization have emerged as a result of technological changes in medical treatment. Specialization in a number of services has increased and activities previously distributed amongst several services have been centralized. The advent of new technologies not only involves redefining activities themselves but also the role of each staff member within a given organization. Skills previously acquired become obsolete and new skills are necessary -- often requiring extensive training, adaptation and, at times, new credentialing and re-registration. The Union of Brazil reported that work in complex services previously carried out by a team of several professionals, was now being done by one multi-skilled person. However, in basic services, auxiliary personnel had replaced professionals. El Salvador also reported that new regulations for distributing tasks in health care services had been introduced. And in Lithuania and Slovakia the reforms have been accompanied by work reorganization and job reclassification.

The search for efficiency and flexibility is a leading issue in modern organizations -- and this obviously include organizations providing health services. Cost-containment measures and managed care are the main instruments used to change the way in which health care is financed. They affect or introduce quality management in the health sector⁽³³⁾ and have become a major concern of hospital management as well as of independent individual and group practice. Increased efficiency and flexibility may be achieved in different ways. However, it should be borne in mind that improvements in efficiency do not necessarily result in a higher quality of service and may have complex consequences for the workforce.

It goes without saying that the distribution of roles and tasks in health care services are largely conditioned by national traditions and culture. Cost-containment measures have a major impact on this distribution. The management of health care services is challenging the boundaries between occupational groups by reorganizing and reallocating tasks. In a number of countries new grades or profiles have been created such as the "community agent" in Brazil and the "health care assistant" in the United Kingdom. Although this might cut costs by diluting skills employees are obliged to reassess their roles. Industrial action in France, Sweden and the United Kingdom suggests that nursing staff are disenchanted with their low status and pay.⁽³⁴⁾ Indeed, in many countries there is a move to revalue the profession and reallocate tasks formerly allocated to higher paid doctors. In this respect, there is a possibility that physicians might lose a certain amount of influence in the reform processes of many countries.⁽³⁵⁾

A tendency to replace registered nursing personnel by less skilled workers may also be observed in a number of countries. Although this undoubtedly reduces expenditure, it might have a devastating effect on the level of patient care and the quality of services -- not to mention the overall image of the health organization. In the longer run, it might have also a negative impact on the financial situation of the care providers, as has been revealed in numerous cases in the United States which involved injuries and deaths of patients. As a result of these, additional training of staff had to be introduced -- thus consuming a part of the savings made. However, the information on the quality of care is not systematically monitored by independent bodies.⁽³⁶⁾ This has prompted initiatives to provide more protection to staff who give information on the quality of services, often termed as "whistle-blowing". In the United Kingdom, the groups "Freedom of Care" -- and subsequently "Freedom to Nurse" -- were formed to give nurses the chance to express concerns about the quality of care without being labelled "troublemakers". Protection for "whistle-blowers", who often act against specific contract clauses, is being claimed by the group and trade unions.⁽³⁷⁾ Such initiatives have contributed in the United Kingdom, as previously in the United States, towards the adoption of a law protecting workers against exclusion on the basis of public interest disclosure.

Changes in management have been introduced to help implement health care reforms. These include the use of modern management and information technologies, outsourcing and alternative management methods such as workers' participation and self-management.

New information technologies have allowed the computerization of personnel administration, patients' admittance, discharge and billing. They have also facilitated the reporting of data on sicknesses and their processing by the public health authorities. The information systems on public health have been further rationalized by linking various data processing systems in and between hospitals and individual practices. In the past, these tasks were carried out by administrative staff and middle management. With the introduction of these new technologies a substantial number of such posts have been abolished.

Major rationalization has also taken place in auxiliary services like catering, cleaning, laundry and transport; French hospitals are a case in point. In a number of countries, auxiliary services have been outsourced and privatized -- as in the United Kingdom, United States and Austria. This has reduced a number of administrative and management posts in public health services.

Despite this trend, the demand for management skills has increased at all levels. Countries in transition and developing countries have undertaken major efforts to upgrade management. One example is China where programmes for management improvement are being implemented with the WHO.⁽³⁸⁾ Partnerships between Chinese hospitals and universities and private health providers in the United States have also been established.⁽³⁹⁾

In the United States, the introduction of managed care has made individual practitioners or groups and networks of physicians focus their skills on management or at least cooperate with providers of such know-how. Some physicians, such as surgeons and ophthalmologists, feel restricted in an environment of managed care and have moved into other medical services, e.g. plastic surgeons provide cosmetic surgery or ophthalmologists eye surgery which is not covered by managed care. They not only find that they have an increased income but work less hours.

In the United Kingdom, pharmacists might be attributed a wider health role as "gate-keepers" to the National Health Service.⁽⁴⁰⁾ Doctors are likely to oppose such a move as they would feel that pharmacists were moving on to their territory. However, this could save the NHS a considerable amount of money.

A growing number of nurses are becoming self-employed, particularly in industrialized countries such as Canada.⁽⁴¹⁾ This might be due in part to staff cuts and the shift towards outpatient care. Other reasons might lie in the attempt to introduce alternative managerial methods. The nurses' associations have helped interested persons establish their own health care business. However, the advantages of more job autonomy, personal satisfaction and flexible management of working time must be weighed against the risk of isolation, lack of job security and possible disruptions in home life. In British Columbia, 260 nurses are self-employed. This obviously raises the major issue of how to keep up care standards and know-how, as well as managerial skills. Another problem is the usually very high indemnity insurances for which the income of independent midwives and nurse practitioners may not be sufficient -- as appears to be the case in the United Kingdom.

Other health care providers are increasingly joining together in groups, joint ventures, associations, cooperatives and networks. Examples of very large groupings are the federation UNIMED in Brazil (which counted 73,000 doctors -- over 30 per cent of all doctors in the country -- among its members in 1995), and the national network LAVINIA in Spain with over 15,000 doctors.⁽⁴²⁾ In August 1996, the United States Federal Trade Commission and the Antitrust Division of the Justice Department issued guidelines to help doctors form their own health care networks in order to compete with insurance companies and health maintenance organizations (HMO). By creating their own networks, doctors say they can regain control of medical decision-making and keep more of the income they generate.⁽⁴³⁾ The guidelines provide that such networks are legal if doctors cooperate to improve quality or share financial risks -- e.g. by accepting per capita payments. Price agreements may be accepted if doctors can prove that they benefit the consumers. The American Medical Groups Association (representing 350 group practices) believes that physicians can better respond to demands for high-quality health care with such networks.

In Germany, there are a number of pilot activities to promote cooperation between the compulsory health funds and practitioners to develop and monitor cost-saving methods in medical treatment. In the State (Land) of Hessen about 1,000 out of 8,000 doctors with their own practice have participated in such quality circles during the past five years. They now have a 40 per cent share in the savings made as a result of this scheme. The pharmacists, however, are opposed to such methods.⁽⁴⁴⁾

Joint ventures, partnerships and networks may also develop internationally. An example in Asia is the joint venture between the Stanford University School of Medicine in California and Pontiac Land and Health Corporation of Singapore. The University will take over the training of staff in Singapore and also the more advanced treatment of Asian patients in California.⁽⁴⁵⁾ International action often takes place through networks which exchange information on education, research and capacity building.⁽⁴⁶⁾ The linkages take place at different levels and include intergovernmental and non-governmental organizations. As such international education activities increase, credentialing will have to be guaranteed through partnerships and common standards.

As described in Chapter 1, health care reforms in many countries subscribe to the Health For All policy and specifically advocate a shift from tertiary care to primary health care and preventive care. The shift in policy focus has already had a bearing on work organization and the distribution of tasks and roles. The clearest move in this area may be seen in transition countries where health sector reforms are being introduced. Latvia has reported that the emphasis on primary health care, outpatient services and home care has started to affect the division of labour in the health sector.

Reorganization also results in the blurring of borderlines between health and social services. A number of functions are being externalized from in-patient care to home care and from health care to social care -- a tendency which may be attributed to the ageing of the population. The Finnish Government and the workers' organization, Tehy, reported that the reform processes are setting out to combine social welfare and health care. The closing down of 30 per cent of hospital beds by the year 2000 would have extended consequences for the reorganization of the whole health care system. In the light of this development, personnel will be retrained under a joint programme involving both the Government and workers' organizations. Those unable to be absorbed by the secondary and tertiary sector will be transferred to non-institutional health care which is cooperating intensively with social care and housing operations.

It is widely recognized that health care personnel are exposed to a great variety of occupational health hazards. Yet, for some reason, they are rarely seen as workers in need of occupational health protection The wide range of hazards to which workers are exposed was described in detail in the ILO report to the Joint Meeting on Employment and Conditions of Work in Health and Medical Services in 1985 -- which pointed out that regulations were designed more to protect patients than workers. Moreover, civil servants and self-employed persons were in some countries excluded from occupational health protection regulations.

Three aspects of occupational health protection warrant further analysis in view of the changes brought about by health sector reforms: physical hazards; stress-related risk factors; work-related violence.

All three aspects are interrelated and may reinforce each other. Physical hazards originate mostly from the nature of the work. However, the organizational setting also conditions whether and to what extent risk factors may be reduced. It is up to the institution to identify technical solutions for preventing occupational hazards; yet it is of major importance that the general work organization, working climate, training and communications facilitate the implementation of technical solutions. Stress may therefore prevent or reduce the ability to cope with hazardous work. In very extreme cases, which are unfortunately on the increase, stress results in violence, thus causing physical risk factors.

Last but not least, the creation of a healthy working environment requires not only the reduction of occupational health hazards but also the promotion of health and well-being at the workplace. Traditional and new hazards need to be analysed more carefully in situations in which resources have been reduced but demands for efficiency and a quality of services have increased.

The relative importance of risk factors may differ according to geographical regions and institutional settings. Figure 5.1 and table 5.4 analyse the nature of the risk factors in the work environment of the hospital sector in ten European countries.

Table 5.4. Main risk factors and related health problems in the hospital sector in ten countries


Main risk factors		Related health problems

Musculoskeletal loads: strenuous working postures strenuous manual handling		Musculoskeletal diseases Premature ageing Repetitive strain injuries Occupational accidents
Biological agents: micro-organisms viruses contaminated blood		Infectious diseases Occupational accidents
Chemical substances: harmful to the skin harmful to the respiratory system		Skin diseases Allergic respiratory diseases
Deviant working hours: shift patterns night work		Sleeping problems Gastrointestinal diseases Tiredness Back pain Stress-related problems Disruption of the biological rhythms of the exposed
Relations with clients and the public: confrontation with pain and with dying people violence at work		Stress Emotional disturbances Burnout
Division of work and job content: lack of autonomy and control monotonous work (some categories)		Stress Burnout
Relations with colleagues: lack of teamwork work in isolation lack of support and feedback		No data but likely: stress burnout
Source: R. Verschuren et al., op. cit., p. xii.

Statistically, health care professions have to be classified among the most dangerous professions. (For the specific risk of HIV exposure see also section 7.1 of this report.) In the United States, nursing is ranked with the third highest injury and illness rate, even before mining and construction. Over 200,000 persons or about 20 per cent of nursing homeworkers suffer injuries per year -- of which 42 per cent are estimated to be back injuries. The average back injury costs about US$8,400 in compensation alone; i.e., in the United States compensation of US$722.4 million is paid every year to nursing homeworkers. Recently, the Federal Occupational Safety and Health Administration (OSHA) has taken more interest in this industry because of its high number of injuries. In 1996, the OSHA started a joint nursing home safety campaign with the Service Employees International Union, a joint nursing home safety campaign. The employers, the American Association of Homes and Services for the Aging, is also participating in the campaign. It is generally felt that risk factors could be reduced by appropriate technologies which are not necessarily very expensive. But also training is considered to be very effective, particularly when it is organized with the participation of the unions.⁽⁴⁷⁾

In reply to the ILO questionnaires, Slovakia reported health care workers to be the third largest group affected by occupational hazards -- but without specifying the type of hazard. The Brazilian and Finnish workers' organizations noted increasing exhaustion of workers which has led to cardiovascular diseases and increased absenteeism. The workers' organization of Lithuania reported an increase in chronic diseases among health workers. Finland pointed out that although physical risks had not changed, the relatively high average age of the workforce was an additional factor of exhaustion. The national average age of health workers was 43 years in 1997. In 1995 Finland implemented a new occupational health programme which pays particular attention to ageing workers. On the request of the workers' organization, the Ministry of Social Affairs and Health is envisaging more detailed research on these issues.

The workers' organization of Latvia attributed physical hazards to outdated equipment which has not been renewed for the last five years. However, no government surveys were available on this issue. Conversely, in the United Kingdom, the workers' organization, UNISON (Health Care), thought that new technologies might be responsible for added risks.This was particularly relevant in the case of new complicated technologies which required substantial training and advanced skills. Cost-saving measures also appeared to result in an increase in cross-infection and problems with hazardous substances.

In Canada, fewer injuries have been reported in recent years. From 1993 to 1995 a decline of 9 per cent was noted. The Canadian Nurses Association pointed out that this might not actually imply there were few injuries; there might be less reporting and less acceptance for compensation. Austria noted less sick leave without specifying the reasons.

Health sector reforms have not changed the variety and type of physical risk factors for health care workers as borne out by the Russian Federation and Slovakia. Some respondent countries, like El Salvador, Ghana and Niger, reported that they had introduced occupational health programmes but no changes were noted for health workers. It would therefore seem that the ILO reports of 1985 and 1992 are still valid regarding the nature of physical risks factors. What has changed, however, under the increasing pressure for quality services and more competitiveness, has been the intensity and frequency of risks in industrialized countries. Pressure has also become more intense because of budget cuts in all countries, including developing, transition and industrialized countries. Cost-containment has also affected information and training on occupational safety and health. This, in turn, has reduced workers' ability to cope with traditional and new risk factors because properly trained and motivated workers are less likely to skip security precautions on the job due to haste or indifference. In general, it has to be noted that the reporting on changes in many countries is not always carried out systematically, as has been confirmed by the replies from Latvia, Poland and the Russian Federation.

As described in previous chapters, health-sector reforms have frequently implied an intensification of the workload, an extension of tasks, job insecurity and increased dangers at the workplace. The staff are subject to growing stress on account of the quality of their working conditions and their emotional involvement; they also feel that their professional value is underrated and that the quality of health services is declining.

The complexity and magnitude of all these changes add to the traditional risks of a physical or biological nature, which have always confronted the staff in health care organizations. Furthermore, they are faced with new responsibilities and the uncertainties of changing situations.

Taking nursing personnel as a particular example, several major sources of stress have been identified -- each of which has a direct organizational relevance: job design and workload, including job ambiguity, work overload and lack of supervision; interpersonal relationships at work, including conflict with other staff, conflict with medical staff and conflict with other nurses; relationships with patients and their families, particularly under situations in which they are inadequately prepared to deal with their emotional needs; work organization and the management of work including difficulties with management and supervisors, lack of resources and staff shortages; and technical aspects of nursing, particularly the concern of nursing staff about their technical knowledge and skills.

All these factors may have major effects on the quality of work and health of nursing personnel. There is a general consensus that work-related stress generally detracts from the quality of nurses' working lives and increases minor psychiatric morbidity; it may also contribute to some forms of physical illness. Even though these developments have not always been studied systematically, as reported by Poland, Slovakia and South Africa, such conclusions are borne out by governmental statistics in a number of countries.

In 1993, for example, the United Kingdom Health and Safety Executive published a document entitled "Self-reported work-related illness". This provided an interesting addendum to the national statistics: a representative national sample of 75,000 adults were asked about the nature of their illnesses and their views on what caused them. Since the survey did not include workers in communal establishments, the extent to which nurses suffered from these problems was thought to be underestimated by up to 7 per cent. Musculoskeletal disorders were the most common cause of ill-health among all respondents (42 per cent of cases), followed by stress and depression (8.1 per cent). Nurses were among those groups who reported significantly increased rates of stress and depression. In particular, the workers' organizations from Canada, Colombia, France, Lithuania and the United Kingdom reported evidence of increasing work-related stress. The Government of Finland also confirmed this trend.

As already mentioned in the previous section, one of the major causes of stress lies in the specific working time and work organization of health occupations. The impact of these time patterns, however, has been reinforced by the effects of health sector reforms. Shift work disrupts the biological rhythm of the workers and unsociable work schedules may result in health problems, such as sleeping problems, gastrointestinal diseases, tiredness and back pain. It also disturbs workers' social and family life. A Danish survey carried out among workers in the health care sector revealed that 22 per cent had experienced feelings of irritability and nervousness without reason during the past three months and that 27 per cent had had difficulty in concentration and experienced amnesia.

A French study established that the absenteeism rate was higher for the night shift. The influence of night work upon obesity is mentioned in several French studies. A Netherlands study on a group of 500 qualified female nurses working in 16 different nursing homes showed that 88 per cent of shiftworkers, as compared with 67 per cent of day workers, suffered from gastrointestinal disorders; this was considered a significant difference.⁽⁴⁸⁾

As the causes of stress are often of an organizational nature, an organizational response may prove decisive. In practice, however, organizations may react by: ignoring the problem; trying to use stress as a means to force people to work more; intervening when stress has already manifested its negative effects, thus operating on the consequences rather than on the causes; developing preventive responses which attack stress at its origin.

Only the last response may lead to more permanent and long-term positive results -- and this has to be built into managerial, economic and social strategies of the enterprise. The costs may be contained and become an integral part of the development of a sound organization, if accompanied by appropriate training, communication and worker participation. When a proper cost benefit analysis is carried out, it shows that stress prevention can eventually pay for itself.

Prevention has to ensure that attention is paid to measures to eliminate or reduce stress by improving work organization. These measures may include: improved job design and job content; the setting of realistic goals, performance standards, targets and deadlines; better organization of working time; and better interfaces between workers and machines or new technologies.

Since the manager often plays an essential role in connection with occupational stress, the responses should also concentrate on improving systems of work planning, control and evaluation and introducing supportive management styles and training for both management and workers to deal with stress.

Improvement can best be achieved by a control cycle for risk assessment and risk management in the workplace which should include the following steps: identification of hazards; assessment of associated risks; implementation of appropriate control strategies; monitoring of effectiveness of control strategies; reassessment of risks and review of information needs and training needs of workers exposed to hazards.⁽⁴⁹⁾

Violence is so common among workers who have direct contact with people in distress, that it is often considered an inevitable part of the job. Frustration and anger arising out of illness and pain, old-age problems, psychiatric disorders, alcohol and substance abuse can affect behaviour and make people verbally or physically violent. Contributing factors to an increase in work related violence are: poverty and marginalization in the community in which the aggressor lives; inadequacies in the environment where care activities are performed, or in the way these are organized; insufficient training and interpersonal skills of staff providing services to this population; and a general climate of stress and insecurity at the workplace.

Fifty-six per cent of staff working in the emergency care unit of a major hospital in Barcelona (Spain) reported being exposed to verbal aggression by patients or their relatives.

Although the majority of patients in psychiatric hospitals are not usually violent and violent episodes are in most cases non-traumatic, some episodes of violence can be extremely severe. In Sweden, psychiatric nurses are five times more likely to experience violence and three times more likely to experience sexual harassment by patients, compared to nurses in other disciplines.

A study carried out in eight old-age nursing wards in Sweden in 1993 showed that 75 per cent of the medical staff reported having been exposed to threats, 93 per cent to minor physical violence and 53 per cent to severe physical violence during the previous 12 months. A survey in 1992 conducted in seven old-age care facilities in the city of Adelaide in South Australia found that 91 per cent of all staff and 96 per cent of all personal care attendants in these nursing homes or hostels stated that they had experienced aggressive behaviour from a resident.

In one of such centres in Manila (the Philippines) violence and provocation occurred so often that they were described as "part of the way of life of the centre".

Staff in this group are reported to be the most exposed as they are often the first, together with the police, to arrive in situations of criminal violence, alcohol and drug abuse. This is the case in the United Kingdom, for example.

This category of staff mostly work on their own and are often attacked on their way to or from visiting home care patients.

A specific form of violence at the workplace is sexual harassment. As health care workers are predominantly female (and sexual harassment is mainly directed against women) this type of violence needs specific attention in the health care sector, as it has strong psychological effects on the person involved. Due to atypical working hours, the workers -- mainly women -- are exposed to a higher risk on their way to or from work. Not only do these incidents affect the individual but they also undermine the efficiency of the health care organization because they have adverse repercussions on work performance.

Increasing attention is also being paid to other forms of harassment such as "bullying at work", which may be defined as offensive and intimidating behaviour to undermine individual or groups of employees. These forms of harassment may result in stress and serious physical conditions -- and occur particularly in times of change, and the issue is being taken up more and more -- particularly in the European Union. Workers' organizations, such as UNISON (Health Care) in the United Kingdom have started programmes to provide information on the matter and assist in developing solutions. Particular attention is also being given to racial harassment, which is especially relevant in view of migrant workers. Racial discrimination at work, including racial abuse by patients and relatives, are being increasingly examined. Guidelines to address such incidences have been developed. Sweden has even established specific legislation against victimization at work.

Preventive strategies and early intervention are becoming recognized as the most effective way to contain and diffuse violence at work and they are being progressively incorporated. However, despite the lessons to be learned from forward-looking legislation, innovative guidelines and successful anti-violence programmes, their application is far from universal. Reactive responses, based on the use of fear and counter aggression, still prevail. These approaches concentrate on the effects of violence, rather than on its causes -- with a subsequent waste in terms of the cost-effectiveness of the action undertaken. In too many cases violence is a forgotten issue and little or no action is taken to deal with it. Lessons on prevention still need to be transformed into practice.

Violence may also occur because the general public has higher expectations of the health services. They are aware of the new technologies and the promises made by health care reformers to improve health services. The public increasingly consider themselves as customers of such services. The staff, on the other hand, faces the limitations of given resources and may not be able to satisfy the demands of patients. This can lead to violence, especially in emergency departments.

There is no evidence to what extent stress and violence at work have a bearing on the behaviour of health care workers towards patients. In cases where violence against patients has been reported, the question has seldom been raised of whether this might be due to the fact that the health care workers were victims of stress and violence themselves. However, research work has revealed that "... employees treat customers similar to the way in which they perceive themselves to be treated by their organization".⁽⁵¹⁾ Interaction of stress and violence may be prevented when an organizational culture is created which is able to communicate a clear vision, mission, value system and strategies for quality health care services.

Health care workers and managers are also increasingly exposed to a dilemma between medical and health care ethics on the one hand and business and policy perceptions on the other. Health workers have a professional responsibility and accountability towards the patients and the public which may bring them into conflict with their employer-employee relationship.⁽⁵²⁾ This may also apply to "gagging clauses" and "whistle blowing" as described in section 5.8.3 of this report. This type of dilemma adds to other sources of stress. Whereas, in the past, ethical issues mainly arose in relation to the performance of specific services, they now arise in connection with the general conduct of managers and workers. The impact on health workers might be even more critical as their registration based on professional patterns of conduct could be at stake. Already the ILO sectoral meeting in 1992 discussed the matter of integrating codes of ethics and practice for health workers and managers into collective agreements.⁽⁵³⁾

The most extreme form of professional dilemma may arise when health workers are exposed to political pressures in a situation of human rights violations. In 1996, Amnesty International launched a campaign defending the ethics of medical and health personnel by establishing minimum standards for health professionals.⁽⁵⁴⁾

ILO Conventions of particular relevance to health care workers are the Freedom of Association and Protection of the Right to Organise Convention, 1948 (No. 87), and the Right to Organise and Collective Bargaining Convention, 1949 (No. 98). Freedom of association and the right to organize appear to be widely granted to workers in the health sector,⁽⁵⁵⁾ although restrictions on these rights may apply to the public service and non-profit organizations of the private sector in some countries.

In a large number of countries these rights are enshrined in the Constitution and therefore cover all employees in the health sector. Other countries only provide for such rights under general labour legislation so that usually only those employed in the private sector come under its scope. Non-profit organizations are not always covered by such laws and problems may occur with regard to trade union rights. Some countries make no difference between the public and private sector as regards freedom of association. Other countries restrict the right to organize for public servants, which may include large parts of the health care services, certain categories of public servants or specific types of unions. A few countries deny completely the right to organize to the public service. An examination of the legislation of different countries shows that the terms used to refer to public servants vary a great deal.⁽⁵⁶⁾ The ILO Committee of Experts on the Application of Conventions and Recommendations (referred to as "the Committee" hereinafter) considers, however, that all workers in this category are covered by Convention No. 87 -- whatever the terms used.

The right to strike must be examined specifically in the case of the health services. In some cases, they may fall under the restrictions for the public service; in others, they may be classified as "essential services".⁽⁵⁷⁾

As regards restrictions relating to for the public service, national legislations vary widely; they may recognize the right to strike, prohibit it or simply not mention it. The definition of the concept of the public service is often decisive for the scope of the restrictions. An over-broad definition is likely to result in very wide restrictions or even in a prohibition of the right to strike for these workers. The Committee endeavours to establish fairly uniform criteria in order to examine the compatibility of legislation with the provisions of Convention No. 87. It considers that the prohibition of the right to strike should be limited to public servants exercising authority in the name of the State. In borderline cases, a solution might be not to impose a total prohibition of strikes, but rather to provide for maintaining negotiated and defined minimum services, when a total and prolonged stoppage might result in serious consequences for the public.

This solution is also recommended in the case of "essential services" which include the hospital sector.⁽⁵⁸⁾ The Committee considers that essential services are only those the interruption of which would endanger the life, personal safety or health of the whole or part of the population. The right to strike may be limited or even prohibited for such services. In the event of a strike, the authorities could establish a minimum service, limited to the operations strictly necessary to meet the basic needs of the population or the minimum requirements of the service, while maintaining the effectiveness of the pressure brought to bear. Workers' organizations should be able to participate in the definition of such minimum services along with employers and public authorities.

As regards Convention No. 98, bargaining in the public service has special characteristics which are found in various degrees in most countries. In the extreme case, according to certain legal and even sociocultural traditions, the status of public service may be incompatible with the concept of collective bargaining.⁽⁵⁹⁾ The situation of the public service is specifically dealt with in the Labour Relations (Public Service) Convention, 1978 (No. 151), and its accompanying Recommendation (No. 159), in terms similar to those of Convention No. 98. However, it allows some flexibility in the choice of methods of determining conditions of employment in the public service since it envisages: "such other methods as will allow representatives of public employees to participate in the determination of these matters." Although Convention No. 98 allows public servants engaged in the administration of the State to be excluded from its scope, other categories should enjoy the guarantees of the Convention and therefore be able to negotiate collectively their conditions of employment, including wages. The Committee has adopted a restrictive approach concerning the definition of those who may be exempted from the right to collective bargaining.⁽⁶⁰⁾ Regarding other relevant international labour standards, refer also to sections 5.7.1 and 5.7.2 of this report.

Privatization of public health services normally also imply changes in collective bargaining and pay determination. In the private service sector, the negotiation of working conditions, remuneration and other areas of collective bargaining are more a matter for bilateral negotiations between employer and employee.

Moreover, privatization often brings about a change in work contracts. A larger proportion of part-time work and more fragmented working environments result in lower unionization rates. Trade unions no longer represent the majority of workers as they do in public sectors of many countries.⁽⁶¹⁾

In addition, privatization often means that self-employed workers take the place of former public sector employees. But they are not represented by unions -- although many of them are in a situation similar to employees without their protection.

If employees in the private sector health services are represented by unions, these are often different from those representing public sector employees. A change of employer therefore implies a change in trade union. And the lower level of organization in the private sector means that these unions are less powerful than public sector unions in many countries -- making it more difficult to organize strikes or to put forward employees' claims.

If pay determination is left to bilateral negotiations between employer and employee, there are often no pay scales and tariff schemes. The process of pay determination in these cases is open and contingent upon the labour market situation. If unemployment is high and many former public employees are in search of employment, the chances of them finding a well-paid job and possible supplementary social benefits are not good.

The structural and social changes under way often result in new collective bargaining techniques or new subjects for negotiation, such as wages previously fixed by public authorities.

In general, there is a threefold shift of bargaining levels in many countries: from the plant level to even more decentralized bargaining at the unit level; from trade union collective bargaining to individual negotiation, often reduced to the starting wage in the case of new small enterprises; and from the trade union initiative to that of employers on matters such as flexible management, the individualization of wages, early retirement or the annualization of working time.

During health sector reforms, many countries have witnessed substantial changes in their methods of pay determination. These have often been implemented in a piecemeal manner⁽⁶²⁾ and have mainly taken the form of: decentralization and more flexibilty in work arrangements; privatization and restructuring processes, including outsourcing; and merit- and market-related pay and other bonuses in the pay package.

A frequent approach to reforms in pay determination has been to introduce decentralized bargaining mechanisms at regional or enterprise level. Sweden and the United Kingdom have experienced a marked trend towards such pay bargaining. In the United Kingdom, this tendency started to undermine the role of centralized bodies; however, decentralization has not gone as far as has been frequently reported. For one thing, the expertise of bargaining at local level is often lacking. Nevertheless, in those NHS trusts in the United Kingdom where local bargaining is practised, consultations and negotiations are more often concerned with working conditions and non-financial terms of employment than with pay. The trade unions and occupational associations, however, oppose these attempted reforms at pay determination and give highest priority to retaining national salary and grading structures.⁽⁶³⁾

The implications of decentralized bargaining are very complex as can be seen in the example of the United Kingdom. Governments are faced with a dilemma between having to devolve responsibilities to the local level in order to facilitate more flexible employment practices and having to control public health expenditure centrally. In the United Kingdom many trade unionists and trust managers believe that decentralized bargaining has resulted in a substantial increase in expenditure for establishing a local bargaining machinery. A more basic issue in assessing decentralized bargaining is, however, the potential jeopardy of solidarity and equity in the health sector, which are considered to be principles in any reform initiative.

In reply to the ILO questionnaire, the Danish Nurses Organization reported that a new system of remuneration had been introduced in Denmark in 1997 for public employees at county and municipal level -- involving the majority of Danish nurses. The new system makes it possible to negotiate larger shares of the salary at local level and gives more flexibility to employers to reward personal qualifications, staff carrying out specific tasks and the achievements of agreed-upon targets. These changes are considered the most significant in the last 30 years. In future, bargaining will take place at central and local levels. The Danish Nurses Organization is involved in negotiating all components of the salary: at central level the issues will be mainly the basic salary and automatic bonuses, bargaining on other matters being handled by the local branches of the organization. The organization feels that bargaining at local level has been successful; however, there is a concern about forthcoming differentials in pay and common strategies for the bargaining process. In Sweden, decentralized bargaining was introduced as early as 1985 and only a few issues are still negotiated at central level.

During the health care reforms in the Canadian Province of Alberta, unions were forced to face new representation elections in bargaining units which combined workers from two or more existing units.⁽⁶⁴⁾ In one case workers lost their representation without an election. The unions had to agree to a 5 per cent cut in pay.

In Central and Eastern Europe, responsibilities and decisions on pay and other terms of employment have often been devolved to local levels. In the case of some countries such as Latvia, trade unions reported that workers had not participated to any great extent in these processes -- and had not even been informed. Slovakia stated that pay determination continued to be the decision of the authorities. In Latvia, Lithuania and Poland it is expected that changes in pay determination will take place in 1998. In Poland the bargaining takes place at national, regional, local and enterprise level. However, hardly any "supraenterprise" agreements have been reached up to date. What is more, the national agreement faces many obstacles due to discrepancies in interpretating the Labour Code. A reform of health care finance is currently under way.

Mexico also reported that since decentralization, pay has been determined by the public authorities.

Box 5.1
Performance-based pay of GPs in the United Kingdom

Probably the most developed performance-based system is that applied to GPs in the United Kingdom. It is designed to provide an Intended Average Net Remuneration (IANR) of Ł46,450 to GPs (it was introduced in April 1997) and has various components. A basic practice allowance varies according to the number of patients on the GP's list -- with flat additions for those practising in two types of designated areas and three seniority payments. There is an additional allowance for the employment of a full-time assistant. To encourage doctors to practise in deprived areas there are additional payments for each patient at three different levels according to the extent of the deprivation in the area.

In addition, there are a series of payments based on the individual behaviour or circumstances of the GP. A capitation fee is paid for each patient with higher payments for patients aged 65 to 74 years and a higher level for those aged 75 years or more, which is just over two-and-a-half times as much as the standard capitation fee. This recognizes that the elderly are likely to need more medical treatment than the young and to remove any disincentive to GPs to retain old people on their lists if they have received only the standard fee. There is a flat-rate fee for making night visits to patients and a fee for each night visit.

There are also flat-rate fees for items of service carried out for reasons of public health policy such as vaccination and immunization and for provision of contraceptive services. Annual payments are made for carrying out health promotion programmes and for chronic disease management programmes for diabetes and asthma.

There are fees for providing treatment to a patient not on the GP's list -- for instance someone visiting the area. Allowances are paid for participating in postgraduate training and practitioner training.

Payment-by-results schemes exist also when GPs receive flat-rate payments for meeting a higher (90 per cent) or lower (70 per cent) target for childhood immunization and pre-school immunization boosters.

The restructuring of health services in the United Kingdom, which has led to decentralization of pay determination and conditions, has not been accompanied by the widespread use of performance pay. Only four out of 98 hospital trusts on one survey operated performance-pay schemes for grades other than management. In the main, the performance element consists of progression through a salary scale being based on assessment of an individual's contribution to the success of the section or department or in relation to job specifications. Most trusts have performance pay schemes for managers based on individual appraisal.

One example from the United States is worthy of note; during the reorganization of health services in Los Angeles County,⁽⁶⁵⁾ the union succeeded in making sure that new employers in privatized facilities recognized it as a negotiating partner. However, the terms of employment for former public employees had to be renegotiated.

Other changes in pay determination have occurred through the introduction of merit- and market-related pay.⁽⁶⁶⁾ Merit-related pay is connected to the whole process of devolving responsibilities to local managers. Special bonuses and supplements in the pay package have been used in such countries as Sweden to obtain small wage differentials and thus to overcome rigidities in public sector pay which can result in staff shortages. Bonuses have also been used in the public hospital system in France to boost the salary levels of specific occupations in the health sector without running the risk that other occupations might have to be classified at this level. Some of these bonuses do not appear in official statistics.

The lack of a link between wage setting and performance is frequently criticized. In the attempt to make the delivery of services more efficient, it is frequently argued that introducing merit elements would create incentives for better performance. Merit-related pay might also, it has been argued, allow managers to be more flexible by introducing decentralization and market elements into the public service. In the United Kingdom, the Conservative Government introduced such pay patterns for senior and middle managers in the 1980s. Other countries, such as Sweden and Germany have shown an interest in systems of merit pay; however, its use has not been very widespread because of the difficulties involved in establishing objective criteria of measurement and hesitations about introducing such an instrument into the health sector. Moreover, the results of the experience in the United Kingdom are widely questioned. Above all, there is little evidence that merit pay creates motivation in public services. On the contrary, due to a lack of objective performance appraisal and measurable indicators for the output, merit pay can act as a demotivator. It is even said to reinforce existing gender bias.⁽⁶⁷⁾ Particularly criticized in the United Kingdom is the inability of such pay systems to reward team performance and corporate success. In Denmark, however, such bonuses may be awarded to individuals or to a team. In the case of achievement-related bonuses, the team reward appears to be more likely.

Box 5.2
The German example

Non-hospital doctors are the occupations to which performance-related pay has been applied the most. In Germany, doctors providing ambulatory care are paid on a fee-for-service basis, which is a form of payment by results. Control is exercised through a budgetary limit on total expenditure. Each service to patients is given a points value and a value for each point is agreed upon between associations of doctors and the sickness fund managers who are responsible for disbursing the accumulated contributions to the medical insurance schemes. The gross income of a doctor therefore depends on the number of services provided, the average number of points per service, and the monetary value of a point. The value of each point depends on the size of the allocated budget and the total number of points claimed by all doctors in a region. This provides both control over total expenditure and in-built pressures to increase the amount of treatment given to patients and possibly the type of treatment given according to its cost to the doctor and its points value-for-payment purposes. The more that doctors seek to increase their number of points from providing treatment the lower will be the value of each point -- unless the total budget increases at a faster rate than the total number of points claimed.¹

¹S. Bach, op. cit., p. 67.

According to replies to the ILO questionnaire, result or merit-related pay may also be found in developing countries; a case in point is El Salvador.

In a number of countries increasing attention is paid to non-financial benefits which refer to terms of employment, working conditions and employment security. The Canadian Nurses Association underlined that nurses attached high value to "non-financial payment" for services such as vacation time, free legal advice, child and elderly care. Employment security was now of higher concern than remuneration.

Box 5.3
The French example

Overtreatment and overprescribing appears to occur in France where patients pay for treatment received according to a fees scale controlled by the insurance fund managers and receive a refund of about 75 per cent from the compulsory insurance funds. There is no control over the treatment provided so that doctors can increase their income by providing more services. There is no clearly established total expenditure in any one year so the costs to the insurance funds can continue to rise. This creates tensions between doctors and fund managers especially when there is growing unemployment because the funds obtain their income from payroll taxes whose levels are determined by government. The Government responded in 1996 by legislating that Parliament could control expenditure by penalizing doctors who exceeded the insurance funds with penalties if these are exceeded. It is also intended to control the freedom of patients to consult a number of doctors for the same complaint.¹

¹ ibid., pp. 63-66.

In some transition countries in Central and Eastern Europe and in developing countries, a problem of increasing concern is the delayed payment or non-payment of wages (for up to six months) in the health sector. This entails negative social consequences for the workers and their families and, in general, has negative repercussions on the economy and the quality of services as a whole. The regional ILO/PSI workshop on health services in Prague (1997) acknowledged this problem and concluded that "in accordance with the ILO Protection of Wages Convention, 1949 (No. 95), ratified by a number of countries of this region, wages should be paid regularly (as stipulated in Article 12) to all other workers which includes health workers".⁽⁶⁸⁾

There are other countries, such as Finland and Slovakia, where no changes in pay determination have taken place despite general health sector reforms and privatization.

Private service sectors in many countries are characterized by a lower degree of unionization this is valid for most European countries, the United States and Japan.⁽⁶⁹⁾ As major parts of the health sector are public and privatization has primarily affected only certain parts of the sector and only in some specific countries, the impact of reforms on the level of unionization may not yet be very visible.The levels of unionization in the health sector vary considerably from country to country -- and this is not necessarily related to the levels of organization in other sectors of the same economy. An overview on the European situation in 1997 is shown in the table below.

Table 5.5. Health workers: Trade union membership, gender breakdown
and percentage in private sector


	Employees total	Members %		Male	Female	Private	Mix

Albania	28 475	25.3				2.3
Czech	190 000	32.6				21.1
Republic of Croatia	71 500	69.9
Germany	2 000 000	(16.6)	*			30.0	25.0
Greece	84 000	89.3		40.0	60.0
France	1 072 517	15				28.7
Finland	123 868	90				14.3
Latvia	32 216	75.3
Lithuania	99 605	18.8		15.5	84.5
Norway	180 000	80.6		15.6	84.4	11.1
Romania	300 000	55.0		39.5	60.5	4.7	2.0
Sweden	220 000	96.8		5.5	94.5	10.0
Turkey	38 626	43.6				20.6
*Information provided by the Public Services, Transport and Communications Union (ÖTV, Germany). The percentage refers only to ÖTV membership. Health workers are also organized in other unions. Source: PSPRU. ¹1 PSPRU, op. cit., table 19, p. 27.

Health sector reforms have certainly had an impact on unionization rates; however, it is not clearly identifiable whether changes are due to general trends in unionization or to health sector reforms. The ILO World Labour Report 1997-98⁽⁷⁰⁾ stated that membership levels of trade unions had declined overall between 1985 and 1995 in 72 countries. The decline was most apparent in the former communist countries where membership was no longer compulsory. In Central and Eastern Europe this decline was particularly marked, ranging from 50.6 per cent in the Czech Republic to 22.8 per cent in Belarus. A radical drop in trade union membership had also occurred in Israel (75.7 per cent). However, in 20 countries union membership had risen. Table 5.6 shows the trade union density in selected countries and the change since 1985.

Health workers are represented by a range of trade unions. In many countries, they are included in the membership of public sector unions, which have special units for health workers; examples are the Public Services, Transport and Communications Union (ÖTV) in Germany and UNISON in the United Kingdom. As a result of privatization, membership in the public sector unions is declining. Recently, there have been discussions about mergers with other unions (for instance, ÖTV in Germany).

Declining levels of organization in the health sector were also reported by nurses' associations in Canada and France. The Canadian Association of Nurses attributed this decline to the fact that there were more part-time nurses who, for various reasons, would not seek membership -- as well as to the increasing entrepreneurship among nurses.

In other countries, such as Ghana and Slovakia, unionization rates had not changed.

It also has to be noted that changes take place with regard to the structure of workers' organizations. In the United States, doctors are showing considerable interest in organizing to meet the challenge of managed care and bargain collectively with insurers. Physicians are concerned with the issues of working time and pay, but are worried above all by interference with their professional decisions.⁽⁷¹⁾ The Brazilian workers' organization replying to the ILO questionnaire reported a trend towards one comprehensive workers' organization for the country's health sector. Workers are also attempting to create alliances with consumers of services. On the other hand, spontaneous workers' initiatives have emerged outside the unions in strained situations of labour disputes. This occurred in 1988 and 1989 in France, where nurses took initiatives outside mainstream organizations to coordinate strike action. A British workers' organization has reported attempts to bypass unions.


		1995 %	% change since 1985

	Sweden	91.1	+8.7
	Italy	44.1	7.4
	South Africa	40.9	+130.8
	Australia	35.2	29.6
	United Kingdom	32.9	27.7
	Germany	28.9	17.6
	New Zealand	24.3	55.1
	Japan	24.0	16.7
	United States	14.2	21.1
	Republic of Korea	12.7	+2.4
	France	9.1	37.2
Source: ILO World Labour Report 1997-98.¹1 ibid.; and Robert Taylor: "ILO foresees revival of trade union strength", in Financial Times (London), 4 Nov. 1997.

In Central and Eastern Europe, the social dialogue appears to be in its infancy. A number of countries face problems in identifying the employers with whom bargaining processes should be initiated. In many cases, employers, be they public or private, are not yet organized in a comprehensive way to allow collective bargaining. In Latvia, according to the workers' organization replying to the questionnaire, only ten hospitals have jointly formed an employers' organization, while the central authorities have ceased to be the employers. Similar problems may arise in developing countries. A workers' organization in Zambia reported in its reply to the ILO questionnaire that only individual hospitals could be a partner in negotiations. However, the Brazilian workers' organization in its reply reported a move to strengthen the municipal employers' organization. In Lithuania, too, the employers stressed more often the need for social dialogue.

Workers' participation in the reform process and their commitment to reform are essential for its successful implementation, since health workers are those who in the end have to manage the reform and put it into place. Participation of health care workers and their unions in health reforms has varied from one country to another. In some countries, health workers and their unions are involved in the preparation and implementation of health reforms. In general, however, they have had only a limited role in planning and implementing health reforms and have sometimes even been viewed as impediments to reform.

In some Canadian (provincial) jurisdictions, health care workers are eligible to serve on regional health authorities and there are in fact an increasing number of registered nurses serving as members of regional health authorities. In Ghana, Niger and South Africa, health care personnel particpate in the design and implementation of the reforms. Moreover, in Ghana the unions will be represented on the Health Service Council at various levels. In Mexico, the governments of the federal states and the health sector unions have signed a national agreement on the decentralization of the services. In Finland, health workers enjoy high prestige and were consulted during the decision-making process which led to the reforms and participated in their implementation. In Colombia, workers through their organizations are also involved in discussions on the form of the national health authority. Workers' organizations and professional associations have also participated in the reforms. In Austria, health care staff have been involved in the planning and implementation of reforms. This has also been the case in a number of Central and Eastern European countries, including Poland, Slovakia, the Russian Federation, Latvia and Lithuania. In the United Kingdom, according to information received from the unions, staff were once expected to implement reforms but were not involved in planning. A change has been promised here by the new Government. In other countries, health care workers are regarded mainly as a cost factor and do not participate in the reform process. This is the case in Zambia and in Brazil, where health workers are also not consulted; this may be one of the reasons why they resist reforms.

In many countries, health sector reforms have not provoked conflict. Workers' organizations have often supported the reform process, even when they were not directly involved, as was reported by the workers' organizations of Ghana and Niger replying to the ILO questionnaire. In El Salvador, the process of health sector reform has given rise to reflection on the need for more workers' participation. In Austria, the workers' organizations were initially quite supportive but are becoming increasingly sceptical, according to the Government.

On the other hand, labour disputes did arise in a number of countries during health sector reforms and were triggered by different factors, such as local pay determination, changes in the representation of staff and employers, health service restructuring, contracting out, income reductions through managed care, financing of health care, pay increases lagging behind inflation or non-payment of wages. Some examples of such labour conflicts in recent years are described below.

In the United Kingdom, the workers' organization replying to the questionnaire resisted the reform as a whole. The resistance culminated in a national dispute in 1995. This dispute over local pay determination was further complicated by a multiplicity of forms of staff representation. Unions and professional associations were divided over bargaining objectives and strategies.⁽⁷²⁾ In Sweden, bargaining at county level has led in recent years to lengthy periods of industrial action by medical and nursing staff.⁽⁷³⁾ Following nearly two months of industrial action during 1995, the nurses accepted a new agreement which will remain in force until the year 2000.

The restructuring of the health services in the Canadian Province of Alberta was a major challenge to workers and their unions and the bargaining was confrontational rather than cooperative.⁽⁷⁴⁾ This was caused in particular by the political decision to impose major budget cuts and administrative reorganization which altered bargaining rights. The unions tried to coordinate their bargaining power, although strikes were not allowed. Nevertheless, when large numbers of health workers were laid off -- including nurses who are generally in short supply -- the hospital laundry workers declared a wildcat strike over the plan to contract out their jobs to the private sector. The laundry workers had the broad support of other health workers and the general public in view of increasing individual costs and lengthening waiting lists. As a result, the laundry workers were given a one-year extension of their employment and the provincial government began to put funds back into the system.

In France, industrial action, including strikes and demonstrations, began at the end of 1995, following the announcement of a number of proposals to reform the public sector and to alter the governance of the health system. They reflected "the anger amongst the French health workers that these reforms were challenging fundamental principles of liberalism and solidarity which are deeply embedded in the French health system".⁽⁷⁵⁾ The public hospital sector in France is characterized by the civil service status of the staff. The agreements reached between the unions and the State are normally also the basis for bargaining with the private employers. The highly centralized system of collective bargaining appears not always to have satisfied the needs of all occupations in the country's health sector. In particular, the representation of the mainly female workforce in the nursing profession had become increasingly fragmented. Initiatives outside the mainstream unions to coordinate strikes in 1988 and 1989 brought about changes in working conditions and pay. In spring 1997, France again witnessed prolonged industrial action among junior doctors who were concerned about their future income through independent practice and about the introduction of elements of managed care and personalized medical cards.

Demonstrations and industrial action in response to health sector reforms also took place in Germany from the end of 1996⁽⁷⁶⁾ onwards, when doctors and nurses became increasingly concerned about the efforts to curb health expenditures. A dispute with doctors arose over government plans to make them financially accountable to the health insurance funds for their prescription budgets. Nursing organizations were particularly concerned about government plans to lift a 1993 law which tightened the regulation of workloads to ensure quality of care. They also resisted the introduction of new, less well-qualified and lower-paid nursing occupations.

In South Africa, nurses took a leading role in strikes in 1995.⁽⁷⁷⁾ They focused on their working conditions, but also brought up their concerns about the representation of their interests in umbrella organizations. Responding to the ILO questionnaire, the Government of South Africa stressed the responsible behaviour of organized labour during the strikes, when a minimum service was established, with a few exceptions. In Zambia, labour disputes in the health sector have been brought before the courts, according to the workers' organization replying to the ILO questionnaire.

In Israel,⁽⁷⁸⁾ nurses went on strike over a dispute between the Health Ministry and the local authorities regarding the sharing of costs to run the 500 family health stations throughout the country. The municipalities claimed that the national health insurance scheme was under a newly passed law, responsible for financing the services to their members. When the municipalities announced the closure of a number of family health stations, the nurses claimed that they had become "hostages" in this dispute between central and local authorities.

In Russia, strikes have increased dramatically since 1995.⁽⁷⁹⁾ Most of the strikes have been local, but some have developed into regional protests and in November 1996 and March 1997 they turned into nationwide action. In the health sector, 229 units were on strike in 1996 and 198 in 1997, involving about 25,000 and 22,000 workers respectively. The main reasons given for the protests were broken promises and non-payment of wages. In the Czech Republic, disputes over poor management were brought to court, according to the workers' organization replying to the ILO questionnaire, and in Romania, up to 150,000 health workers went on strike and demonstrated in early 1998 to request an increase in their wages in a situation of hyperinflation. They ultimately obtained a 30 per cent pay increase, a figure which, however, is far below the rate of inflation.

2. Fadwa Affara: "Why lifelong learning?", in International Nursing Review (Geneva), 44 (1997), pp. 177-180.

3. The outline on capacity building is notably based on the study by the WHO: Capacity building for health sector reform, by Samuel Paul (Geneva, doc. WHO/SHS/NHP/95.8, 1995), pp. 3-16.

8. ILO: Impact of structural adjustment in the public services, op. cit., pp. 36-38.

9. Wu Zhigang: "Hospital management improvement in China", in Public Administration and Development, Vol. 17, 1997, pp. 267-275.

10. ILO: Equality of opportunity and treatment between men and women in health and medical services, op. cit.

11. ILO: Health care personnel in Central and Eastern Europe, op. cit., p. 41.

12. European Commission: Gender, power and change in health institutions of the European Union, by Paola Viray (Luxembourg, 1997), pp. 7-13.

13. ILO: Employment and conditions of work in health and medical services (Geneva, 1985), pp. 53-70; ILO: General Report, Standing Technical Committee for Health and Medical Services, First Session, Geneva, 1992, pp. 30-39.

14. ILO: Statistics on occupational wages and hours of work and on food prices, October Inquiry results, 1995 and 1996, Special Supplement to the Bulletin of Labour Statistics (Geneva, 1997).

17. UNISON Health Care: Condition critical. The crisis in nursing pay (UNISON's evidence to the Nurses, Midwives and Health Visitors Pay Review Body, London, 1998).

18. I. Seccombe and G. Smith: Taking part: Registered nurses and labour market in 1997 (Institute of Employment Studies for the Royal College of Nursing, Brighton, United Kingdom, 1997).

21. R. Verschuren, B. de Groot, S. Nossent: Working conditions in hospitals in the European Union (European Foundation for the Improvement of Living and Working Conditions, Dublin, 1995).

22. W.A.M. Lange and D.M.C. van Maanan: "The Netherlands: The case of health care", in Flexible working time, collective bargaining and government intervention (Paris, OECD, 1992).

26. Robert A. Schmieder and Carla S. Smith: "Moderating effects of social support in shiftworking and non-shiftworking nurses", in Work and Stress (London, Taylor and Francis), Vol. 10, No. 2, Apr.-June 1996.

27. J. Buchan: Further flexing? NHS trusts and changing working patterns in BHS nursing (London, Royal College of Nursing, 1994), p. 15.

31. Isobel Allen: Part-time working in general practice (London, Policy Studies Institute, 1992).

33. D.G. Harber, N.M. Ashkanasy and V. Callan: "Implementing quality service in a public hospital setting", in Public Productivity & Management Review (Thousand Oaks, CA, Sage Publications), Vol. 21, No. 1, Sep. 1997, pp. 13-29.

35. P. Hassenteufel: Les médecins face ŕ l'Etat. Une comparaison européene (Presses de Sciences Po, Paris, 1997).

36. Steve Twedt: "A question of skill", in Pittsburgh Post-Gazette, 11-14 Feb. 1996.

37. "How to speak out and keep your job", in Nursing Standard (Harrow-on-the-Hill, United Kingdom), Vol. 11, No. 51, Sep. 1997; "Tougher stance on gagging clauses demanded of UKCC", in Nursing Times (London), Vol. 92, No. 9, Feb. 1996; Geoffrey Hunt: "Whistle Blowing", in Encyclopedia of Applied Ethics (London, Academic Press), Vol. 4, 1998, pp. 525-535. M. Miceli and J. Near: "Whistle-blowing as antisocial behaviour", in R. Giacolone and J. Greenberg (ed.): Antisocial behaviour in organizations (London, 1997), pp. 130-149.

39. B. Einhorn, K.H. Hammonds, J. Moore and M. Shari: "Health care in Asia -- The next business boom", in Business Week (London), 30 June 1997, pp. 32-35.

40. G. Parker and P. Hollinger: "Pharmacists may get a wider health role", in Financial Times (London), 4 Aug. 1997.

41. Laura Brown: "Self-employed nursing", in Nursing BC (Vancouver), Jan.-Feb. 1993, pp. 11-13.

42. United Nations: Cooperative enterprise in health and social care sectors -- A global survey (New York, 1997), p. 75. Such cooperatives of various sizes can be found worldwide in industrialized, developing and transition countries. They also exist as joint provider-user or user-owned cooperatives. The study estimates that there are over 52 million users of such organizations.

43. R. Pear: "US issues guidelines to help doctors form health networks", in The New York Times, 29 Aug. 1996; and S. Auerbach: "Doctors gain more freedom to form health networks", in Washington Post, 29 Aug. 1996.

44. S. Walker: "Arzte erhalten Geld für Sparbemühungen", in Oberhessische Presse (Germany), 27 Oct. 1997.

47. Press Associates, Inc. (PAI): Service employees, OSHA start nursing home safety campaign (Washington, PAI, Sep. 1996); S. King: "Nursing homes draw attention as worker safety focus shifts", in The New York Times (New York), 7 Aug. 1996.

49. Tom Cox and A. Griffiths: Work-related stress in nursing: Controlling the risk to health (Geneva, ILO working paper, CONDI/T/WP.4/1996, 1996).

50. D. Chappell and V. Di Martino: Violence at work (ILO, Geneva, 1998; forthcoming).

51. D. Harber, N. Ashkanasy and Callan: "Implementing quality service in a public hospital setting", in Public Productivity and Management Review (Thousand Oaks, CA 91320), Vol. 21, No. 1, Sep. 1997, pp. 13-29.

52. See, e.g., Association of Salaried Medical Specialists (ASMS): Making explicit dual accountability of medical senior staff (ASMS News Letter, Australia), July 1997; Mireille Kingma: "Marketing and nursing in a competitive environment", in International Nursing Review (Geneva, Mar.-Apr. 1998), p. 7.

53. ILO: Note on the Proceedings, Standing Technical Committee for Health and Medical Services, First Session, Geneva, 23 Sep.-1 Oct. 1992.

54. F. Giovanelli: "Amnesty lance un cri d'alarme: professionels de la santé en danger!", in Tribune de Genčve (Geneva, 23 May 1996).

55. ILO: Report of the Joint Meeting on Employment and Conditions of Work in Health and Medical Services, Geneva, 8-15 October 1985, pp. 27-28.

56. ILO: General Survey on Freedom of Association and Collective Bargaining, Report III (Part 4B), International Labour Conference, 81st Session, Geneva, 1994, para. 49.

58. For the list of what may be considered essential services see ILO Freedom of Association, Digest of decisions and principles of the Freedom of Association Committee, fourth (revised) edition (Geneva, 1996), paras. 540-545.

61. ILO: "Industrial relations, democracy and social stability, in World Labour Report 1997-98 (Geneva, 1997).

68. ILO/PSI: Workshop on employment and labour practices in health care in Central and Eastern Europe, op. cit., p. 27.

69. ILO: Industrial relations, democracy and social stability, op. cit., pp. 44-45.

71. Wall Street Journal (New York), 25 Feb. 1997; Michael P. Connair: The Boston Globe (Boston), 14 Nov. 1997; David R. Sands: "Union labels on white coats -- Organizing is hard pill for doctors to swallow", in The Washington Times (Washington), 21 Apr. 1996.

77. Tembeka Gwagwa and June Webber: "Striking nurses -- Trapped in frustration", in South African Labour Bulletin (Johannesburg), Vol. 19, No. 6, Dec. 1995, pp. 79-82; Gwede Mantasbe: "Organising nurses", idem, pp. 83-85.

78. J. Siegel: "Nurses to strike tomorrow", in Jerusalem Post, 19 May 1997, p. 12.

79. Frank Hoffer: Traditional trade unions during transition and economic reform in the Russian Federation, working paper of the Enterprise and Cooperative Development Department (Geneva, ILO, 1998), pp. 33-36.

The main source of information on pay in the medical occupations in different countries is the ILO October Inquiry (OI) for 1995 and 1996 which reproduces the results of national pay surveys submitted to the ILO by member countries. The survey covers eight health service occupations, namely: general physician; dentist; professional nurse (general); auxiliary nurse; physiotherapist; X-ray technician; ambulance driver; and occupational health nurse in the iron and steel industries.

A second source referred to here is the OECD studies of public service pay which include general nurses and nursing auxiliaries.⁽¹⁾

Remuneration can be measured in terms of one of the following: pay scales or job rates; average wage or salary rates; average earnings.

Box 6.1
Types of remuneration

Pay scales or job rates. This approach measures the pay level or salary scale for jobs or posts and positions, rather than the amount actually received by individuals. It shows the amount of pay that males and females in a given job or post are entitled to receive. In many types of employment, particularly in the public sector or in non-manual occupations, individual workers are classified in a job grade to which a particular pay scale is assigned. The scale frequently consists of a minimum and maximum rate of pay or basic pay which can be supplemented by various types of allowances or additional payments based on specified factors, such as location, type of work, changes in cost of living, qualifications, number of dependent children, and age or years of service. Countries differ considerably in the extent to which medical occupations in the public service have such allowances and in the number of years required to progress from the salary scale minimum to the maximum.

Average wage or salary rates. The ILO OI defines average wage or salary rates as "the rates paid for normal time of work, comprising: basic wages and salaries, cost-of-living allowances and other guaranteed and regularly paid allowances. The following should be excluded: overtime payments, bonuses and gratuities, family allowances other social security payments made by the employer directly to employees, and ex gratia payments in kind supplementary to normal wage and salary rates".

Average earnings. The third approach is that of average earnings. The ILO OI defines earnings as "the remuneration in cash and kind paid to employees, as a rule at regular intervals, for time worked or work done, together with remuneration for time not worked, such as for annual vacation, other paid leave or holidays, and including those elements of earnings which are usually received regularly, before any deductions are made by the employer in respect of taxes, contributions of employees to social security and pension schemes, life insurance premiums, union dues and any other obligations of employees". Excluded are employers' contributions to social security and pension schemes and any benefits received by employees from these schemes. Also excluded are "severance and termination pay, irregular bonuses such as year-end and other one-time bonuses which accrue over a period longer than a pay period". Both overtime payments and shift premiums should be included. Differences in average earnings for males and females on the same salary scale can arise from differences in average hours worked and possibly from differences in average overtime premium per hour worked.

Different methods of measuring pay will give different results. Some countries provide details of both wages and average earnings but may differ in the way in which wages are defined. Some provide only details of the minimum wage or salary for an occupation, others indicate the salary scale minimum and maximum. Some countries give average wages and some give prevailing wages. A few give details of median pay. Some give details of men and women separately while others group them together. Straightforward comparisons are therefore somewhat difficult, as countries provide information in different forms, not all countries provide information at all and those that do may not provide it for all occupations. Nevertheless the ILO OI is the best publicly available source of data on the health service occupations.

Some health service occupations such as nurses are in most cases staffed mainly by women, while others such as ambulance drivers are predominantly male occupations. In most countries, however, both men and women are represented in these occupations, and it is now rare or unknown for different salary scales to be applied to men and women in the same grade or job.

Nevertheless, there may still be differences in average pay for men and women. There can be several reasons for such differences, for example:

Location: where there are different levels of pay in different localities arising from different local labour market conditions affecting supply and demand and where there are different proportions of men and women employed in a given occupation in different localities, the overall average pay for men and women will be different, even if in any given establishment men and women are paid the same wage.

Occupational classification: jobs may be classified differently. Occupational titles can be broad and what are actually different jobs may be grouped together under the same title, so that if women are in the lower-paid job the overall average pay for women will be lower than for men.

Seniority distribution: if there are no discriminatory conditions, differences in average female and male pay based on single salary scale in which increments are based only on seniority within the grade will be determined by seniority distributional differences between men and women. Women often have career breaks which affect their seniority.

If, however, the salary scale or job rate is not based entirely on the rather rigid conditions specified in the illustration above, but contains discretionary elements such as merit payments or performance awards, or elements which may themselves be gender-based or gender-influenced (such as rent or housing allowances under rules which are different for men and women), then differences in average payments received under the same scale could indicate gender-based discrimination.

Women physicians are usually paid less than their male counterparts. The unweighted average difference for those countries providing information in the 1997 edition of the October Inquiry results is about 10 per cent but there are wide variations. No details of hours worked are given, so it is not possible to say whether the relatively higher average male earnings reflect more hours of overtime or the inclusion of some allowances that are not paid to women.

The largest positive differential for female versus male physicians in terms of average monthly earnings is found in Costa Rica, where women physicians earn 70 per cent more than men (although the differential is only 28.5 per cent in terms of average hourly earnings, much of the difference in monthly earnings being due to their working 59.6 hours compared to 45 hours for men). Of the 21 countries which have provided data on male and female pay in some of the occupations in question, only four pay women physicians more on average than their male counterparts.

Overall, women tend to have lower pay than men even in what are usually thought of as "women's occupations". In extreme cases, such as that of physicians in Nigeria, women and men cannot be on the same salary scale, since differences in average wages are too great. On the other hand, in the nursing profession, the differences are very slight and sometimes even favourable to women.

We have seen from OECD sources that in some countries, members of health service occupations receive allowances or other payments in addition to their basic salary. The ILO OI data also provide some evidence of this. For some countries, details are given of normal hours of work, hours actually worked, monthly wages and salaries and monthly earnings. Average hourly pay and earnings can thus be calculated.

Estimates of the overtime premium can be made if details are given of wages, average earnings, normal hours and hours actually worked, but are based on the assumption that the overtime premium is based on the average normal hourly wage.

In Mauritius, all four medical occupations covered in the 1996 OI had actual hourly earnings exactly equal to hourly wages and worked no overtime.

There are various relationships between average wages and earnings, not all of which are explained by overtime working or payments. Indeed in some countries, overtime work appears to be paid at lower hourly rates than normal hours of work for some medical occupations, particularly general physicians.

Comparisons of internal differentials among medical occupations can be based on comparisons between the salary scales plus allowances of different occupations or on comparisons between average wages or earnings. Unfortunately there is little information available on salary scales and allowances. A few comments can be made.

Any comparison between the salary scales and allowances of two occupations is complicated by the fact that salary scales are often of different lengths and contain different incremental increases from minimum to maximum. There may also be promotion opportunities for some occupations which take them to higher salaries.

In some countries, salary scales of different occupations overlap. In Madagascar, for example, the minimum salary for dentists is fr.262,894 whilst the maximum for professional nurses is fr.295,543, for auxiliary nurses fr.280,074, for physiotherapists fr.396,000 and for X-ray technicians fr.295,543.

In Belize, the minimum salary for both physicians and dentists is $24,444 and the maximum for professional nurses $26,028, for physiotherapists $24,528, and $33,516 for X-ray technicians. In Saint Vincent and the Grenadines the top of the salary scale for professional nurses, physiotherapists and X-ray technicians is only 76 per cent of the minimum salary paid to physicians and dentists.

There are very considerable variations in pay differentials between the seven medical occupations in the countries considered. Where details of pay are given for men and women separately, the pay for female professional general nurses is taken as the reference level 100 and the pay of other occupations calculated for men and women separately in terms of the reference level.

Physicians usually have higher salaries than dentists if the same gender comparison is applied, but there are some countries such as Belarus where male dentists have higher monthly and hourly pay than physicians, or Slovakia, where both male and female dentists have higher monthly salaries than physicians. In Cyprus, women dentists receive higher hourly pay than women physicians. This is also the case (by a narrow margin) in Finland.

Physicians usually have higher overall average salaries and earnings than nursing-related occupations. There are some exceptions. In Belarus, male physiotherapists have had higher average hourly and monthly earnings than female physicians, female physiotherapists are paid only 0.3 per cent less than female physicians in terms of average hourly earnings and actually receive more in terms of average monthly earnings. This is due to the fact that they worked considerably longer standard and average hours.

In most countries, dentists also have higher pay than professional nurses, but this is not the case in Bolivia, where both men and women dentists have lower monthly pay and men also have lower hourly pay, as they do in Tajikistan. The average hourly pay of male dentists is almost half as much again as that of female professional nurses, and hourly pay for female dentists is on average somewhat over 40 per cent more than for professional nurses. In terms of monthly pay the differentials are close to ten percentage points.

Table 6.1. Salary indices for members of medical occupations in certain countries
(100= salary of a professional nurse)


	Sex	Number of countries	Salary index (minimum)	Salary index (maximum)	Average salary index	Number of countries where salary index is < 100

General physician	M F	15 14	138.4 128.4	421.9 285.3	211.8 180.6	0 0
Dentist	M F	10 8	63.6 79.7	190.4 192.5	146.3 141.2	1 2
Professional nurse	M F	12 15	85.7 100.0	115.9 100.0	100.7 100.0	5 -
Auxiliary nurse	M F	10 14	48.2 47.4	93.7 94.2	69.6 66.0	10 14
Physiotherapist	M F	9 13	69.1 62.5	180.9 185.7	117.3 110.2	3 6
X-ray technician	M F	13 8	62.1 54.3	123.9 129.1	86.9 100.6	9 3
Ambulance driver	M	13	43.8	140.8	83.8	9
Reporting countries: Anguilla, Belarus, Bolivia, China, Cyprus, Finland, Ghana, Honduras, Malawi, Moldavia, Nigeria, Romania, Singapore, Slovakia, Tajikistan, United Kingdom. Source: 1997 ILO October Inquiry.

In Slovakia both male and female dentists have average pay that is almost twice as high as that of female professional nurses, but the differential for earnings is much less. In the case of women dentists, average hourly earnings are only 25 per cent more than those professional nurses and the differential with regard to average monthly earnings is only 16.4 per cent more.

If the figures for men and women are combined, dentists always have higher average pay and earnings than professional nurses. They also usually have higher average pay than the other nursing-related occupations, although there are exceptions. In China, female physiotherapists' average monthly pay in 1994 was 29.2 per cent higher than average monthly pay for male dentists. In Moldova both male and female physiotherapists had higher average hourly and monthly pay than male or female dentists.

Dentists tend to have lower differentials for earnings than for salaries. The overall unweighted average of male physiotherapists for average hourly earnings is higher than that for female dentists.

If figures for men and women are combined, dentists have higher average salaries and earnings than nursing-related occupations except in Kyrgyzstan, where dentists have low relative earnings and both physiotherapists and X-ray technicians have higher average monthly earnings and physiotherapists in the Russian Federation have both higher hourly and monthly earnings.

With the exception of a few countries where dentists have higher pay according to certain criteria (usually hourly pay), physicians always earn more than the other occupations. Dentists almost always earn more than the other occupations except physicians. Auxiliary nurses always have lower pay than professional nurses, physiotherapist and X-ray technicians. The latter have no clear pay relationships in different countries; the direction of the differential can change, so that a given occupation has relatively higher pay in one country and lower pay in another.

There are no marked similarities in the size of differentials between pairs of occupations even where the direction of the differential is always the same. Thus, even though the physicians' differential over professional nurses or one of the other related occupations is always positive, there are wide variations in the size of the differential.

There is no such thing as a "normal" or usual wage or earnings differential for any of the pairs of occupations shown. This is due in part to differences in relative skill levels and education and training requirements for different occupations in different countries. It is also partly due to differences in institutional arrangements for determining pay and to labour market conditions, including the opportunities available to members of an occupation to migrate in search of higher pay.

The range of pay varies considerably from one country to another. Pay of male physicians as a percentage of the pay of female auxiliary nurses provides a rough indication of the range in pay between medical occupations, and this can vary. In Yemen, for example, physicians receive only a quarter as much again in terms of hourly pay as auxiliary nurses; in Nicaragua, their hourly pay is nearly three times higher. If males and females are considered separately, male physicians in Tajikistan have hourly pay that is two-thirds higher than that of female auxiliary nurses, and in Nigeria their hourly pay is nearly seven times higher.

The relative pay of different occupations, especially in the public sector, is often an indication of the value society places on the occupation and the services it provides. The OECD has published details of total remuneration of individuals with one year of service in different public service occupations.⁽²⁾ General nurses have higher total remuneration than public service secretaries in every country except Australia, where secretaries have an advantage of 4.8 per cent, and Denmark, where the differential is 7.8 per cent. Auxiliary nurses are paid more than secretaries in Austria, Canada, Finland, Germany, Ireland and Italy. In the United States, they are paid the same as secretaries.

The ILO OI covers some public administration occupations. In most cases, what is shown is average wages or earnings for a given occupation, not the amount received after a specified time period. There can therefore be differences between these figures and the OECD figures, and differentials for occupations may also vary according to the type of data used. According to the ILO data, stenographer-typists (male or female) in Austria receive little more than half the salary and less than half the total earnings of professional nurses (male or female). Card-punch machine operators' average wages are about 70 per cent of those of professional nurses and their earnings between 78 and 87 per cent, while the figure for office clerks is about 60 per cent. All the related nursing occupations, including auxiliary nurses, receive wages that are at least equal to those of card-punch machine operators, but physiotherapists receive lower average earnings.

According to OECD data, general nurses receive less than primary school teachers in all countries except Austria, Canada, Iceland and Italy, and are paid the same in the United States. They are paid less than secondary school teachers in all countries except Austria and Iceland, and the same in the United States. Auxiliary nurses are paid less than primary or secondary school teachers in all countries except Italy.

These comparisons are based on total remuneration after one year of service. The data from the ILO OI indicates the different measures of pay for third-level, second-level, first-level and kindergarten teachers. Male third-level teachers in Cyprus have higher average hourly pay than female physicians, but female teachers do not; teachers' average monthly salaries are lower, but teachers work shorter hours. Male physicians, however, have higher average pay than male teachers. All types of teachers in Cyprus, including kindergarten teachers, have higher monthly and hourly pay than professional nurses, physiotherapists and X-ray technicians.

In some countries teachers have higher pay than physicians (particularly hourly pay, as teachers often work shorter hours). Teachers are more likely to earn more than professional nurses and related occupations, but this is not always the case.

Table 6.2. Indices of total remuneration in public service employment after one year of service
(100 = general nurse's salary)


	Nursing auxiliary	General nurse	Secretary	Primary school teacher	Secondary school teacher

Australia	85.2	100	104.8	107.0	107.0
Austria	82.3	100	72.5	93.6	93.6
Canada	91.3	100	52.8	92.5	104.4
Denmark	90.6	100	107.8	103.9	115.2
Finland	93.4	100	78.2	106.3	137.2
Germany	92.9	100	88.2	146.5	169.5
Iceland	71.7	100	85.4	87.6	92.9
Ireland	70.2	100	59.1	100.1	101.8
Italy	90.8	100	85.0	76.5	83.1
Luxembourg	83.1	100	95.9	102.5	132.2
Netherlands	90.1	100	95.5	145.9	181.1
Spain	63.4	100	95.0	123.9	134.3
United Kingdom	64.8	100	84.8	115.3
United States	89.4	100	89.4	100.0	100.0
Source: OECD: Trends in public sector pay, op. cit.

Health service occupations in different countries have had different experiences of changes in their relative pay in the 1990s. There are two important questions:

While reductions in pay have sometimes followed contracting out or privatization of services, it is not usual for pay to be reduced without a change of employer, although this does occasionally occur. The minimum monthly salary for physicians and dentists in Italy in 1993 was 4,855,829 lire. This fell to 4,608,563 lire in 1994. Other medical occupations received small increases of about 1.5 per cent in their minimum monthly pay. In 1995, physicians' and dentists' minimum pay remained unchanged and the other occupations were awarded increases of around 2.3 per cent. The minimum rate may not be a good indicator of what actually happened to average wages in Italy, as basic salary accounts for only about 40 per cent of nurses' total remuneration.

While details of changes in the consumer price index are not available for all the relatively few countries for which a time series of wage data can be compiled. It is possible in the case of some countries to examine changes in real pay.

In Austria the rise in average real pay for the medical occupations between 1990 and 1996 was a modest 1.4 per cent, the same as for the civil service occupations. The exception was average hourly earnings of ambulance drivers, whose hours worked fell drastically, causing average real hourly earnings to rise by 70 per cent. Female kindergarten teachers suffered a fall of 11 per cent in average real salaries and computer programmers in the insurance industry lost 25 per cent in average real pay, a figure that was offset by an increase of 7.6 per cent in average real hourly earnings.

In Finland, average real salaries of male physicians fell by 2 per cent over the period 1990-95 and those of professional nurses fell by 10 per cent.

In the United Kingdom, average real weekly earnings of male physicians increased by 16 per cent and those of female physicians increased by 30 per cent between 1990 and 1996, while professional nurses' earnings rose by 13-16 per cent.

Apart from male physicians, who gained 17.4 per cent in terms of real median weekly earnings, the medical occupations in the United States all experienced reductions in real earnings between 1990 and 1996. Median earnings fell by 16.7 per cent (in the case of female professional nurses by almost 5 per cent, female auxiliary nurses by 4 per cent and the others by around 1 per cent).

1. OECD: Trends in public sector pay in OECD countries (Paris, 1995) and idem (1997); Trends in public sector pay: A study of nine OECD countries 1985-1990, Public Management Occasional Papers (Paris, 1994), Series No. 1.

Under the terms of its mandate, the ILO engages in the promotion of basic human rights, the improvement of working and living conditions and the enhancement of employment opportunities. This is done through various means, including the formulation of development policies and programmes, the setting of international labour standards and the monitoring of their implementation as well as through technical cooperation and human resource development. The ILO's interest in health sector reforms relates to all these aspects and means. The ILO endorses WHO's "Health for All" strategy, since it considers health a basic human right and an essential requirement for improving working and living conditions. Employment opportunities have a direct impact on the accessibility and affordability of health care. As access to health care is often linked to secure employment, rising rates of unemployment may exclude significant sections of the population from health care. Health sector reforms may reinforce this trend by putting more emphasis on private contributions to financing health care. The ILO deals with these aspects in its programme on the organization and financing of health systems. The "Health for All" strategy aims at improving access to health care and other health services by emphasizing primary health care at the community level. This strategy is reflected in the majority of health care reforms and the ILO pays particular attention to the implementation of the reforms and their impact on the working and living conditions of workers.

Beyond this concern for improving the health situation of workers in general, the ILO also attaches importance to the fact that the situation of health care and medical personnel is crucially important to the delivery of health care services. Moreover, the number of workers employed in health services and related activities is substantial (at present an estimated 35 million) and is expected to grow. Therefore, the ILO addresses the needs of these workers in its sectoral activities and specific labour standards. Health sector reforms have a direct impact on health care workers as the sector is highly labour-intensive, with 50-75 per cent of health budgets spent on labour and related costs.

Important aspects of the ILO's activities related to health sector reforms and working conditions will be dealt with in subsequent paragraphs below. The activities employ various means and centre on the following major ILO programmes:

Sector: Health services

Occupational safety and health

The instruments available which are used, include setting and monitoring international labour standards, sectoral meetings, other ILO meetings at international, regional and national level, advisory services and research.

In addition to international labour standards of general application, to which reference has been made in the opening part of this report (see also section 5.7.2 and 5.10.1), the ILO adopted standards dealing specifically with health care workers in 1944 and 1977.

The Nursing Personnel Convention, 1977 (No. 149), applies to all categories of persons providing nursing care and nursing services wherever they work, with a limited possibility of establishing, after consultation with the employers' and workers' organizations concerned, special rules concerning nursing personnel who give nursing care and services on a voluntary basis (Article 1). Ratifying States undertake to adopt and apply, in a manner appropriate to national conditions, a policy concerning nursing services and nursing personnel designed, within the framework of a general health programme, where such a programme exists, and within the resources available for health care as a whole, to provide the quantity and quality of nursing care necessary for attaining the highest possible level of health for the population (Article 2, paragraph 1). This policy should be formulated and coordinated, in consultation with the employers' and workers' organizations concerned, with policies relating to other aspects of health care and to other workers in the field of health (Article 2, paragraphs 3 and 4). In particular, necessary measures should be taken to provide nursing personnel with education and training appropriate to the exercise of their functions and employment and working conditions, including career prospects and remuneration, which are likely to attract persons to the profession and retain them in it (Article 2, paragraph 2(a) and (b)).

Furthermore, measures should be taken to promote the participation of nursing personnel in the planning of nursing services and consultation with such personnel on decisions concerning them, in a manner appropriate to national conditions (Article 5, paragraph 1). The determination of conditions of employment and work should preferably be made by negotiation between employers' and workers' organizations concerned (Article 5, paragraph 2). The settlement of disputes arising in connection with the determination of terms and conditions of employment shall be sought through negotiations between the parties or, in such a manner as to ensure the confidence of the parties involved, through independent and impartial machinery such as mediation, conciliation and voluntary arbitration (Article 5, paragraph 3).

Besides the consultation, participation and negotiation process, the most substantial requirement of the Convention is that nursing personnel should enjoy conditions at least equivalent to those of other workers in the country concerned in the fields of hours of work (including regulation and compensation of overtime, inconvenient hours and shift work), weekly rest, paid annual holidays, educational leave, maternity leave, sick leave and social security (Articles 6(a) to (9)). Where necessary, endeavours should be made to improve existing laws and regulations on occupational health and safety by adapting them to the special nature of nursing work and of the environment in which it is carried out (Article 7).

These provisions are supplemented by the Nursing Personnel Recommendation, 1977 (No. 157), which suggests general and specific measures to be taken in the fields referred to in Convention No. 149. This Recommendation contains more detailed provisions with respect to policy concerning nursing services and nursing personnel, education and training, practice of the nursing profession, participation, career development, remuneration, working time and rest periods, occupational health protection, social security, special employment arrangements, nursing students and international cooperation. An annex to the Recommendation contains suggestions concerning practical application.

As regards remuneration, the Recommendation provides that the remuneration of nursing personnel should be fixed at levels which are commensurate with their socio-economic needs, qualifications, responsibilities, duties and experience, which take account of the constraints and hazards inherent in the profession, and which are likely to attract persons to the profession and retain them in it. Levels of remuneration should bear comparison with those of other professions requiring similar or equivalent qualifications and carrying similar or equivalent responsibilities. Levels of remuneration for nursing personnel having similar or equivalent duties and working in similar or equivalent conditions should be comparable, whatever the establishments, areas or sectors in which they work. The Recommendation also stipulates that remuneration should be adjusted from time to time to take into account variations in the cost of living and rises in the national standard of living and that it should preferably be fixed by collective agreement. Other provisions deal with scales of remuneration, which should take into account the classification of functions and responsibilities and the principles of career policy as recommended by the instrument; with work under particularly arduous or unpleasant conditions, which should be financially compensated; and with deductions from wages, which should be permitted only under conditions and to the extent prescribed by national laws or regulations or fixed by collective agreements or arbitration awards.

Finally, the Recommendation states that nursing personnel should be free to decide whether or not to use the services provided by the employer and that work clothing, medical kits, transport facilities and other supplies required by the employer or necessary for the performance of the work should be provided to them by the employer and maintained free of charge.

In addition to the international labour standards concerning nursing personnel, the ILO has adopted a broader instrument, the Medical Care Recommendation, 1944 (No. 69), which addresses the medical care service in general. This standard contains provisions on the following matters: (i) general principles of medical care service; (ii) the persons covered; (iii) the provision of medical care and its coordination with general health services; (iv) the quality of service, including provisions on the working conditions of doctors and members of allied professions (Paragraphs 56-65); (v) financing of medical care service; and (vi) supervision and administration of medical care service.

With particular regard to the working conditions of doctors and members of allied professions, the Recommendation provides that these conditions should be designed to relieve such persons of financial anxiety by providing adequate income during work, leave and illness and in retirement, and pensions to their survivors, without restricting their professional discretion otherwise than by professional supervision, and should not be such as to distract their attention from the maintenance and improvement of the health of the beneficiaries. The Recommendation further states that general practitioners, specialists and dentists, working for a medical care service covering the whole or a large majority of the population, may appropriately be employed full time for a salary, with adequate provision for leave, sickness, old age and death, if the medical profession is adequately represented on the body employing them. Among the members of allied professions participating in the service, those rendering personal care may appropriately be employed full time for salary, with adequate provision for leave, sickness, old age and death, while members furnishing supplies should be paid in accordance with adequate tariffs. Working conditions for members of the medical and allied professions participating in the service should be uniform throughout the country or for all sections covered by the service and agreed on with the representative bodies of the profession, subject only to such variations as may be necessitated by differences in the exigencies of the service.

Regarding supervision of the application of Convention No. 149, the Committee of Experts on the Application of Conventions and Recommendations made a general observation in 1990 and 1994 asking governments to indicate the measures taken or contemplated, in consultation with employers' and workers' organizations, to take into account the particular risk of accidental exposure to the human immunodeficiency virus (HIV) among nursing personnel and to indicate the measures taken or contemplated with respect to nursing personnel infected or considered to be infected by HIV (for example: adjustment of working conditions, confidentiality of test results, acknowledgement that the cause of the infection was occupational, etc.).

The Committee's other specific comments relate in particular to: (i) training, working conditions and occupational safety and health in the public and private sectors; (ii) participation of nursing personnel in the planning of nursing services; (iii) progress achieved in ensuring career prospects and remuneration that are likely to attract persons to the profession and retain them in it; (iv) compensation for overtime and inconvenient hours; (v) data on the number of persons leaving the profession and the number of persons working in the private sector; (vi) special measures that have been adopted respecting nursing personnel who give nursing care and services on a voluntary basis; and (vii) the existence and results of consultation and participation of representative organizations of nursing personnel in the determination and application of decisions concerning them.

In 1985, the ILO convened the first sectoral meeting to examine the work-related problems of medical and health personnel. It was organized in response to repeated requests of the Joint Committee on the Public Service. The report for this meeting in 1985 gave clear evidence of the importance of health services worldwide as major employers and the role played by the workers in this sector. The labour problems were many and serious. They were related to their participation in decision-making on working conditions and pay, as well as to occupational hazards and ethical problems. The report considered the health services to be at a critical stage of development as a result of the rising costs of health care. The objective of the meeting was to adopt conclusions (a) suggesting solutions to these problems which would serve at the same time as guidance of an international character, and (b) recommending further action. In view of the growing volume of health care provided by the private sector, the Governing Body of the ILO approved for the first time the inclusion of representatives of the private providers in a Joint Meeting.

The discussions and the conclusions of this meeting⁽¹⁾ can still be considered of great relevance to developments in the health sector and continue to be significant to assessing and improving the situation of health workers. The trends prevailing nowadays in health sector reforms were already evident in 1985. However, their intensity and outlook merit renewed consideration in the light of the ILO's mandate. The availability of adequate financial resources in times of budget reductions is still as crucial as the availability of qualified personnel. Health services remain services in the public interest, whether they are provided by the public or the private sector, and reforms in those services merit the very fullest consideration. The meeting's conclusions on employment, labour relations, remuneration, ethical problems, working time and occupational hazards are still largely relevant today and are referred to in various chapters of this report.

The resolutions of this Joint Meeting included the request to the Governing Body of the ILO to establish a standing committee for this sector. The committee was created by the Governing Body in 1989 under the title Standing Technical Committee for Health and Medical Services. Its first session took place 1992 in Geneva and considered the general situation of health workers, focusing on employment trends and working conditions. The technical item on the agenda was equality of opportunity and treatment between men and women in health and medical services. Reports on both agenda items as well as a record of the proceedings of the meeting were published by the ILO in 1992. With regard to employment trends, it was noted that the sector had substantial potential for expansion owing mainly to demographic trends, but that cost-containment and structural adjustment had a negative impact on this expectation. One trend that was observed was that of increasingly replacing skilled staff by less skilled personnel. It was noted that insufficient career planning and high staff turnover may have contributed to lower-quality services and, in the long term, to higher costs. Regarding working conditions and pay, the meeting focused on working time and rest periods, particularly part-time work, flexibility and atypical forms of employment. It was concluded that collective bargaining was the most appropriate means of pay determination in the health services which should take into account not only qualifications, experiences and standards of living, but also performance and market-related factors. Under the agenda item on equal opportunity and treatment, factors affecting employment and working conditions were examined. This was done in the context of women being the majority of the workforce in the sector and yet being underrepresented at decision-making levels. Given the need to attract and retain a sufficient number of qualified people to work in the sector, these issues were also crucial to the quality and effectiveness of health care in general. In view of the issues discussed, the meeting requested the ILO to conduct studies and follow-up workshops at regional level, particularly for countries undergoing structural adjustment and transition. The meeting asked the ILO to promote social dialogue on the impact of structural adjustment and privatization of health services and on the employment and working conditions of health workers, and to organize regional meetings on these issues.

As a result of the restructuring of the ILO's Sectoral Activities Programme, no further sessions of this Committee took place. The forthcoming Joint Meeting is the first sectoral meeting on health services under the new arrangements. Nevertheless, in 1994 and 1995 sectoral meetings took place for the public service which in most countries include major parts of the health services. Of particular relevance to the health sector were the technical agenda item on part-time and temporary work in the public service during the meeting in 1994⁽²⁾ and the general theme of the Joint Meeting in 1995 on the impact of structural adjustment in the public services (efficiency, quality improvement and working conditions). The conclusions of the latter meeting are important for public sector reforms in general. They underlined that public sector reforms achieve their objectives of delivering efficient, effective and high-quality services when they are planned and implemented with the full participation of public sector workers, their unions and the consumers of public services at all stages of the decision-making process. This also holds true for structural adjustment measures. A number of basic principles that should be respected in public sector reforms were established in the conclusions of the meeting and also have a bearing specifically on health sector reforms and their impact on employment and working conditions as dealt with in the present report. Those principles are:

The Occupational Health Services Convention (No. 161) and Recommendation (No. 171), 1985, provided for a progressive extension of occupational health services to cover all workers. This requires a gradual development of workers' health surveillance which is an essential element of preventive health care. In September 1997, the ILO convened a Meeting of Experts to examine the current practice and role of health surveillance and to prepare guidelines for workers' health surveillance. The guidelines are intended to assist governments, employers' and workers' organizations as well as occupational and public health professionals to design and establish workers' health surveillance schemes which would guide preventive action, protect and promote workers' health. The guidelines are of relevance to all health workers. This should be part of the objectives of health service reforms. The establishment of workers' health surveillance services has an impact on the employment outlook of the health sector in general. The Government of Finland and the Finnish trade union Tehy, in their reply to the ILO questionnaire, reported on such developments after introducing an occupational health care reform with the Occupational Health Care Act of 1991. The meeting concluded that the guidelines⁽³⁾ should be disseminated to ILO constituents and occupational health professionals and should provide the basis for training activities. They should also help in developing national codes of ethics for workers' health surveillance. Furthermore, the meeting advocated that adequate resources and means should be made available to meet occupational health needs. The ILO was requested to work in close cooperation with the WHO for the implementation of the conclusions of the meeting.

Occupational injuries and diseases form a particular and important element in the area of workers' health, including those in the health sector. Moreover, the health sector is involved in the notification as well as the treatment of such incidences. The relevance of occupational injuries statistics, which are covered by the provisions of the ILO Labour Statistics Convention (No. 160) and Recommendation (No. 170), for the health sector in general and its personnel in particular, show the far-reaching linkages of ILO activities with this economic sector.

A review of national data collection practices in the area of occupational injuries was undertaken in 1996 and led to a publication on "Sources and methods: Labour statistics" in the area of occupational injuries. It revealed great differences between countries in the coverage, concept and classifications used. The ILO Code of practice on the recording and notification of occupational injuries and diseases was adopted by a Meeting of Experts in 1994 as a basic standard for the collection of data in this field. The inadequacies of current international guidelines on statistics relate to two major aspects, namely, the methods used for measuring occupational injuries and the classification of occupational injuries themselves. The ILO Code of practice does not provide sufficient guidance on the first aspect and updating is needed on the second aspect. Therefore, the Governing Body of the ILO decided to hold from 30 March to 3 April 1998 a Meeting of Experts of Labour Statistics in order to deal with both aspects of occupational injuries and diseases. The ILO prepared a report to the meeting, which deals with occupational injuries only; however, it is hoped that in future other, increasingly important aspects of workers' health and well-being could be taken up, such as the effects of stress, overwork and the work environment. The meeting's conclusions will be considered by the Sixteenth International Conference of Labour Statisticians in October 1998.

Health care reforms in Central and Eastern Europe were discussed in the context of the ILO's Fifth European Regional Conference, held in Warsaw in 1995. The Director General's Report to the Conference examined a number of issues including health care programmes in the region⁽⁴⁾ and the status of health care reforms. Whereas the central and eastern parts of Europe were looking for appropriate ways of financing their delivery systems and adjusting them to the new financial mechanisms, Western Europe was trying to restructure allocation mechanisms in a way which makes health care provisions more efficient and effective. The Conference adopted the following conclusions regarding the item of health care programmes: "Publicly financed health care programmes throughout Europe provide generally high-quality health care, financed from taxes or social security contributions with universal access, at little or no cost to the patient at the point of delivery. The Conference reaffirms its commitment to the basic principles of these schemes, but notes that they are expensive, costs have grown rapidly, and there are concerns about their effectiveness and efficiency. Within this general framework, there is a need for substantial reforms and redevelopment."

The Standing Technical Committee for Health and Medical Services had requested the ILO in 1992 to carry out research work and convene a regional workshop on the conditions of work and employment in medical and health services in economies in transition. After the respective research work was carried out, the ILO together with Public Services International (PSI) organized a workshop in Prague on Employment and Labour Practices in Health Care in Central and Eastern Europe from 15 to 17 May 1997. The workshop was attended by government and worker representatives from 17 countries of the region. Its objectives were to create awareness of the need for social dialogue, to develop the means to implement it, and to establish the importance of working conditions in the context of improving the quality of health care delivery. Within the context of their respective national experiences, the participants discussed relevant international labour standards and research conducted by the ILO, WHO and PSI. The main themes were the social dimension of health care reforms, financing of health care, privatization and the public/private mix in restructuring health care.

The workshop came to the conclusion that reforms in the health sector in countries of Central and Eastern Europe were aiming to achieve better health care in the context of major economic, social and political changes. The scale and scope of economic changes in the region were unprecedented and led to increased complexity, risks and difficulties in achieving the goals of the reforms. Many of the problems in the health sector, such as the reduction of services, poorer access, and periods without pay for the staff, resulted in large part from economic decline and not directly from the structure and financing mechanisms. The pace and extent of health care reforms had been dramatic. But its very speed had been in some cases dysfunctional and risked causing a near collapse of health care services. Therefore, the question how a reform was introduced was at least as important as the nature of the reform.

The workshop stressed that the social dimension of health care reforms had to be understood in the broad sense which implied progress towards higher living standards, greater equality of opportunity and guarantees of basic human rights. Health care workers were a major resource to the community and their knowledge and skills were vital to reform. The workshop acknowledged the serious problem of non-payment or delayed payment of wages to health care staff in a number of countries in the region for periods up to six months. Dialogue on unemployment caused by structural adjustment needed to be given greater prominence in relation to the social consequence of reform, particularly when hospitals were closed or the number of beds reduced. The workshop underlined the importance of some specific aspects in the process of reforming health care systems. Lifelong learning for staff within the sector was a precondition for effective service delivery and should enable the staff to participate fully in the restructuring process. The way health care was funded was important in determining what care was available and how accessible it was to different groups of people. If the objective was to guarantee universal health care coverage, then as a fundamental principle funding should also be universal and compulsory. Where privatization occurred, an appropriate balance in each country and in each part of the economy had to be established through democratic discussion. The effectiveness of health care delivery had to be measured in terms of health results and long-term benefits to individuals and to society as a whole. The citizen's voice and choice had to play a significant role in shaping health care services. The exercise of choice and other citizens' rights required extensive, accurate and timely information and education. This entailed access to reliable information on the performance of health services. The impact of changes needed to be assessed independently before they were applied more widely.

The workshop recognized that there was inadequate information available on all aspects of reform which in turn made it difficult to assess whether the reform process was actually achieving its objectives. It was pointed out that information systems needed to be set up in Central and Eastern Europe with the assistance of the ILO and WHO and other agencies to support planning and policy formulation by tripartite agencies concerned with health issues. The workshop proposed that its conclusions be considered at the forthcoming ILO Joint Meeting on Terms of Employment and Working Conditions in Health Sector Reforms, in September 1998.

ILO advisory services of relevance to the workforce affected by health sector reforms are provided by various units at headquarters and by the multidisciplinary teams in the field. They focus mainly on the financing of health care systems, industrial relations and labour law in the public service, application of international labour standards, and occupational health protection and working conditions.

Research on the situation of the workforce in health sector reforms carried out as part of the Sectoral Activities Programme has focused on employment,⁽⁵⁾ labour market flexibility,⁽⁶⁾ remuneration,⁽⁷⁾ personnel in economies in transition countries⁽⁸⁾ and on privatization and restructuring in health services.⁽⁹⁾ Furthermore, the ILO Programme on Conditions of Work and Welfare Facilities issued a paper on work-related stress specifically in nursing.⁽¹⁰⁾ The research being carried out by the ILO in the areas of social protection and occupational health and safety are undoubtedly of great relevance to the policy and human resource development in health sector reforms.

1. ILO: Employment and conditions of work in health and medical services, op. cit.

2. ILO: Terms and conditions of employment of part-time and temporary workers in the public service, Joint Committee on the Public Service, Fifth Session, Report II, Geneva, 1994.

3. ILO: Technical and ethical guidelines for workers' health surveillance (Geneva, 1997).

4. ILO: Report of the Director-General, Fifth European Regional Conference, Warsaw, Sep. 1995, pp. 69-78.

5. C. Hancock, J. Buchan, P. Gray, C. Fontaine, S. Glouberman, T. Keighley: Trends and perspectives in the nursing profession (Geneva, ILO, sectoral working paper, 1995).

6. I. Powell: Labour market flexibility: The challenge facing senior medical officers in New Zealand (Geneva, ILO, sectoral working paper, 1991).

7. D. Marsden (ed.): The remuneration of nursing personnel: An international perspective (Geneva, ILO, 1994); A. Brihaye: Nurses pay: A vital factor in health care (Geneva, ILO, sectoral working paper, 1994).

8. J. Healy and C. Humphries: Health care personnel in Central and Eastern Europe, op. cit.

10. T. Cox, S. Cox: Work-related stress in nursing: Controlling risk to health (Geneva, ILO, Conditions of Work and Welfare Facilities Branch, working paper, 1996).

	INTERNATIONAL LABOUR ORGANIZATION
	Sectoral Activities Programme

INTERNATIONAL LABOUR ORGANIZATION

Sectoral Activities Programme