 |
|
SECTOR
Home | What's New
| About SECTOR | Meetings
| Publications | Discussion
Forum | Contact Us
| Links | Site
Map
|
|
|
The increasing costs of health care services coupled with structural adjustment policies and cost containment measures have an impact on the employment situation and working conditions in the health sector. It is frequently argued that the health care workforce had to be restructured and downsized in order to create an effective and efficient health care system. Restructuring can be a means of improving the efficiency and availability of health services, however, the equal access to quality health services has to be ensured. There is the danger that a two-class health care system will evolve which would exclude the socially disadvantaged, especially in countries with inadequate insurance systems and social protection. Imagination and creativity are required in finding satisfactory solutions which should be developed in close cooperation between governments, employers' and workers' organizations.
Against this background the ILO Standing Technical Committee for Health and Medical Services requested the ILO in 1992 to carry out a study and to organize a workshop on the conditions of work and employment in health and medical services in economies in transition. The study was carried out in 1995/96 and published as ILO Sectoral Working Paper in 1997.3 The ILO together with Public Services International (PSI) organised the workshop on Employment and Labour Practices in Health Care in Central and Eastern Europe from 15 to 17 May 1997 in Prague/Czech Republic.
The objectives of the workshop 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. This has been achieved through the exchange of views about national experiences and the relevance of International Labour Standards, research being conducted for this sector by the ILO, PSI, the World Health Organization (WHO) and other institutions. The workshop was based on the results of discussions which took place in the region, ILO and PSI studies, relevant International Labour Standards for health personnel, particularly the Nursing Personnel Convention, 1977 (No. 149) and Recommendation, 1977 (No.157)4, as well as on the experiences of other organizations. Of particular relevance to the meeting was the Ljubljana Charter5 agreed upon by the European Conference of the World Health Organization (WHO) in 1996 which gave guidance to the processes of health care reforms in European countries.
The programme of the workshop referred to the following themes:
The Workshop was attended by Government and/or Workers' representatives from Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Moldova, Poland, Romania, Russian Federation, Slovak Republic, Slovenia and Ukraine; and private Employers' representatives from Croatia, Latvia, Poland and Romania. Observers and resource persons participated from the World Health Organization (WHO), the International Council of Nurses (ICN), the European Union, the International Cooperative Alliance, the London School for Hygiene and Tropical Medicine, the Nuffield Institute for Health (United Kingdom), the Public Service Privatisation Research Unit (London) and from workers' organisations in Finland and the United Kingdom.
The Workshop was opened by the organisers of the workshop, ILO and PSI, and by a Government and a Workers representative of the hosting country.
Mr. Richard Falbr, President of the Czech-Moravian Chamber of Trade Unions (Czech Republic) and Worker member of the Governing Body of the International Labour Office
Mr. Falbr welcomed all participants to Prague, and opened the Workshop on Employment and Labour Practices in Health Care in Central and Eastern Europe by paying tribute to the ILO and PSI for organising the event. He stressed the importance of the subject and drew attention to the composition of the workshop which included representatives of governments, employers and workers. He believed that the workshop represented a good model for social dialogue which would be facilitated and enhanced by the contributions of the consultant panellists.
Mr. Falbr said it was essential for all participants to have the opportunity to discuss their experiences and to contribute to the dialogue by sharing their considered views on the reforms that had taken place. He emphasised the need for participants to elaborate on the positive and negative consequences of such change, with specific reference to the effects on those who work in health care. In addition he recommended that the discussions should reflect on the effects on standards of care and the implications on equity of access for consumers of services.
Mr. Valentin Klotz, Chief, Salaried Employees and Professional Workers Branch, Sectoral Activities Department, International Labour Office
Mr. Klotz, representing the International Labour Organisation (ILO) welcomed delegates and began with an overview of the mandate of the ILO, which was established in 1919 to promote world-wide social justice.
Since 1946 the ILO has been a specialised agency of the United Nations (UN) with responsibility for social and labour affairs. Currently it has 174 member states, several of which come from central and eastern Europe and central Asia. The ILO is unique among UN organisations in that it is a tripartite organisation, which involves workers and employers alongside governments of member states with the decision-making process.
Mr. Klotz outlined three main functions of the ILO, the first being the establishment of international labour standards. The second function was the provision of technical assistance to member states, whereby ILO experts assist member states in the formulation of social policies, labour laws, the training of labour inspectors and the establishment of health and safety regulations. The third function noted by Mr. Klotz consisted in a great variety of research activities and in the publication of numerous ILO sectoral studies, reports and working papers on social and labour issues.
Mr. Klotz then turned to ILO sectoral activities programmes and to the ILO's views on structural adjustment in the public service sector. He recalled that the ILO held an international meeting in 1995 on this topic, with the conclusions laying down a set of guiding principles which public sector reforms should respect. These may serve as guidelines for those involved in the process of structural reform.
While respecting the importance of communal values and cultures, the conclusions from the meeting sought to expand the transparency and openness of government policies, and accountability to democratic political processes and institutions. The meeting called also for a consensus approach, advancing partnerships in decision-making and equity in access to public services. Finally, it called for the application of international labour standards for efficiency and performance in the public service. In addition, the meeting stressed the right of public sector workers to organise collectively, in accordance with international labour standards concerning collective bargaining, freedom of association and trade union rights.
In its conclusions the meeting emphasised that, while redundancies were often unavoidable, they ought to be a last resort, and negotiated career transition measures should be in place to minimise the impact. In relation to this, any changes arising from public sector reforms should be the subject of negotiation and consultation with public sector workers through their unions. Public sector reforms were likely to achieve their objectives only with full co-operation and participation of public sector workers in decision-making process. The meeting established several guiding principles to be taken into account when implementing structural adjustment in the public sector, in particular that governments should be a model for good employment practice.
Mr. Klotz stated that with a workforce of around 35 million people, the ILO attached importance to the needs of health personnel. He focused on the demands placed on health services, observing that personnel growth is unlikely to match the rise in demand. National constraints such as financial resources, availability of trained workers and rising health service costs had a negative effect on the working conditions and career prospects of health personnel. In particular, the restructuring of public health services in central and eastern Europe with their emphasis on cost-containment had made redundancies virtually unavoidable.
In 1992 the Standing Technical Committee for Health and Medical Services asked the ILO to undertake studies on the conditions of work and employment in health services in central and eastern Europe which were undergoing transition to market economies. As a result, the ILO published a study on health care personnel, the main conclusions of which were detailed by Mr Klotz. He noted that the transition to a market economy and economic decline had resulted in a fall in health sector expenditure in the countries of that region. He added that to keep health spending low, governments had often paid low wages to health service workers. This frequently meant that jobs had been maintained, and health services of central and eastern Europe remained labour-intensive rather than developing into the capital-intensive services of their western neighbours.
Ms. Zuzana Roithova, Director, Faculty Hospital, Czech Republic
Ms. Roithova, representing the Czech Government and the Association of Big Hospitals in the Czech Republic, began by highlighting the structural development of the Czech health care sector.
Following the Velvet Revolution in 1989, the restructuring of the Czech health care sector had been conducted in the context of the political and economic evolution of society.
Under the communist system of economic planning, health policy was centrally-regulated and funded entirely from state coffers. This method, explained Ms. Roithova, undermined the effective or efficient use of human and material resources. The focus was on simply expanding hospital capacities rather than concentrating resources on long-term patient care. In addition, she was critical of the limited social service provision and shortage of housing in towns and cities. Hence, she suggested that the health care services must be reformed in order to overcome this legacy.
According to Ms. Roithova, the solution was to strengthen follow-up of nursing care, removing the emphasis on service provision from the hospitals. She recognised, however, that these objectives were unlikely to be met without a intensifying of primary care, including home care and better quality specialised outpatient care. This led into changes in graduate and postgraduate education of health workers from all categories. She noted especially the role of nurses, who she believed, as a result of reform, would be able to provide specialised nursing care on their own.
Ms. Roithova observed that the reforms in the Czech health sector had been beneficial to the patient, who benefited from increased quality of comfort following competition, and also a reduced time in hospital. She added that most patients supported the principle of freedom of choosing a doctor and appreciated the quality of service provided. Another benefit brought by the reform was the improved levels of motivation of hospital management and more effective management of out-patient facility resources, such as operating theatres and equipment now being used in two shifts.
She sounded a note of caution, however, arguing that higher service provisions tended to lead to greater consumption of services, and this meant higher costs and a likely reduction in the general health insurance fund. She stated that the current cost of health care provision exceeded resources by almost 10%. In terms of health care personnel, this translated as low wages and a shortage of applications for positions as nurses and auxiliary staff. She believed that if the wages in the health service were brought up to a higher level, this would make the occupations more attractive. This could be done, she believed, initially by concentrating on the reduction of hospital capacities and developing the social services which were often provided in urgent care hospitals.
Ms. Roithova also advocated the pooling of health insurance and hospitals care insurance. She noted that society ought to begin to evaluate the effectiveness of health care not just from the costs to the health care fund, but also the follow-up costs from the hospital care insurance fund and even the pension fund. Patients, she believed, will retain control over their choice of physician and also from benefiting financially from what she called "the benefit of the curing process". Yet she added that, in the transition to a public/private health care mix, the most difficult problem of dealing with necessary care (covered by state funds) and care paid for by the patient had yet to be resolved.
Mr. Alan Leather, Deputy General Secretary, Public Services International
Mr. Leather, representing Public Services International (PSI), an international federation of public service trade unions with 490 affiliated organisations in 130 countries with a membership of 20 million, noted that health workers accounted for the largest single group, around one third of the total. In central and eastern Europe, PSI had affiliates in most countries, and had been working closely with several organisations in the region for the past six years. He stressed the dual role played by public services in society: in addition to a strong and efficient public service as a prerequisite to economic development, a properly resourced and regulated public service set the standards for the whole country in terms of ethics, emphasising the obligations to public service.
He called for health services to be given greater priority in decisions on spending and reform, echoing the consensus approach to progress offered by Mr. Klotz from the ILO. Mr. Leather identified this as a fundamental requirement of PSI and acknowledged that a similar sentiment was endorsed by a number of other international organisations such as the World Bank and OECD.
Mr. Leather also noted the importance of health care in economic planning of all countries. He asserted that for economic development to have a solid foundation it must be built on securing genuine improvements in living standards. He stated that it was important to see health care in this sense rather than a fiscal burden.
He advised against viewing health care in purely commercial terms. Arguing against performance-related pay he stated that health services were not a production line where productivity could be determined by the throughput of patients. Although he accepted the need for restructuring and reform, he warned against applying a universal model of reform, suggesting that it would be more effective to consider each health care system on its own merits.
Mr. Walter Baer, Public Health Unit,
DGV/F/1, European Commission
Mr. Baer, representing the Public Health Unit of the European Commission's Directorate General V (DGV), noted that the European Community had been involved with health for three decades, beginning with the 1957 Treaty of Rome. Since the 1993 Treaty of the European Union, the Community had been able to develop a pan-European health strategy, witnessed in the first public health programme, Europe against cancer. Mr. Baer moved on to outline the relevance of the Treaty on European Union to health issues, based around Article 129 of the Treaty, which emphasised the focus on health promotion and prevention of diseases and the implications of health issues upon other policy areas.
Following implementation of the treaty, the Commission published a communication setting out its strategy on health issues, placing it in the context in which it was to be developed. The communication considered the major causes of mortality and disease faced by member states such as the ageing population, new technology, environmental change, socio-economic developments and the rise in expectations about the remit of health provision. All were felt to have created challenges for health care systems.
The communication also outlined criteria for determining priority areas for public health.
Mr. Baer noted that these were broadly the socio-economic impact of a disease, how far prevention was practicable and how far community action could complement and add value to the efforts of member states. In the light of this, eight priority areas were identified, with programmes already implemented on the following issues: cancer, AIDS and other communicable diseases, health promotion and education and training.
Mr. Baer reported that progress has also been made on programmes for comparative information about health status, accidents and injuries, pollution-related diseases and rare diseases. In addition, a proposal for a network on surveillance and control of communicable diseases had been put forward, valuable in tackling the problem of CJD and BSE. Work had also been undertaken on the safety of blood and blood products.
He added that, since the communication, there had been several developments in the area of Community health policy. The legal basis is under examination and there are proposals to revise Article 129, with the current strategy finishing in 1998. A strategy will be developed for beyond 2000. In addition there were new health issues, such as the re-emergence of TB and outbreaks of communicable diseases such as Ebola.
Mr. Baer concluded by stating that all the Public Health Action Programmes of the EU were open to countries of central and eastern Europe. The Commission, through the PHARE programme, provided support to enable countries to improve their health services toward a level comparable with EU member states. A special meeting on the opening of these programmes to central and eastern European countries was to take place in Luxembourg on 12 and 13 June 1997. National governments involved in the meeting would include Czech Republic, Poland, Bulgaria and Hungary.
European Union Regulation, Funding and Social Dialogue
The representative for PSI inquired what the requirements for central and eastern European countries would be with respect to Article 129. Mr. Baer responded that there was no requirement to be met regarding health systems. The emphasis placed on subsidiary ensured sovereignty of each country. EU decisions taken on issues such as agriculture or the environment would take into account health requirements such as the giving of grants to tobacco farming and policy on advertising for tobacco products. However, there was a high level of focus on human health protection attaching a high priority to public health and setting targets for improving the health of the population within each country, in addition to demonstrating consideration of the implications for health policies in other sectors.
The spokesperson for the International Council for Nurses (ICN) sought clarification on how the 40 million ECU available for programmes were accessed. Mr. Baer advised that any organisation operating in the field of health may apply for funding by outlining the main principles of the programme. A management committee of each programme will consider and decide on the allocation. In June 1997, the EU will meet to decide how central and eastern European countries are to apply for funding. This will be the first step of the process.
The worker representative from Poland indicated that governments would be in attendance at the meeting in Luxembourg in June and sought clarification on what provision there was for member states to report to social partners. Furthermore, he wanted to know what provision existed for social partners to contribute. Mr. Baer stated that only governments were involved although dialogue was encouraged at a national level. Other activities undertaken involving dialogue included the ILO and its tripartite meetings on health and safety.
Ms. Majda Slajmer-Japelj,
World Health Organisation - European Region
Ms. Slajmer-Japelj presented the results of the WHO European Conference on Health Care Reforms held in Ljubljana in June 1996. It was an inter-governmental event which had three clear objectives:
1. to analyse health care reforms in Europe;
2. to agree policy principles and develop a consensus statement;
3. to make an action plan based on ideas and opinions from the countries involved.
Ms. Slajmer-Japelj said the Charter was a recommendation for reform. It was not binding but was endorsed by all the governments present (except the UK). The Charter stated a number of fundamental principles driven by the values of dignity, equity and professional ethics. Its aim was to address health care reform in Europe and was centred on the principle that health care should first and foremost lead to better health and quality of life. Health reforms should incorporate the citizen's voice and choice in care and in the way services are designed and managed. There should be a focus on quality and a clear strategy for continuous improvement. There should be sound financing, and to guarantee solidarity, governments must play a crucial role in regulating the financing of health care systems.
The Charter also set out key principles for managing change including the re-shaping health care delivery, reorientation of human resources, strengthened management and the promotion of information exchange based on experiences in reform. This should be supported by a well validated knowledge base which is understood and appropriately valued.
Ljubljana Charter endorsed by Worker Representative Organisations but not yet acted on by some Governments
The worker representative from the Czech Republic said the Ljubljana Charter was welcomed by the trade union and had been circulated to all health service members. What they found discouraging was that the Government had not signed up to the Charter. She emphasised that social partnership did not exist in her country and that decisions on health care were based on cost containment with no consultation and often were ad hoc short term arrangements.
The worker representative from Bulgaria said the Charter was an appreciated initiative. It was important to share experiences and challenges. The main problem in Bulgaria was that procedures fail to take account of the consensus, particularly from the well educated and experienced doctors and nurses. She emphasised the need for a data base to evaluate the transition period.
The Solvenian worker representative felt the Charter would be a positive force in the reforming process, particularly in relation to the management of change and stated that there were not enough standards governing reform activity especially concerning workforce standards for professionals. For example, the cut backs in staffing had led to a serious shortage of nurses.
Positive Outcome from the Ljubljana Charter
The worker representative from Croatia said that his union had problems with collective agreements. With assistance from Public Services International, they learned from the experiences of western countries and found a way to process their negotiations. Since the adoption of the Ljubljana Charter in Croatia, they were now experiencing co-operation and mutual relations. He believed the Ljubljana Charter was instrumental in the improvements and added that the Charter was also accepted by the private sector.
The employers' representative from Croatia briefly confirmed that a tripartite system was being implemented. This system would have an important role in developing their health care system particularly in relation to moving closer to European Union standards.
3 J. Healey/C. Humphries, Health Care Personnel in Central and Eastern Europe, ILO Sectoral Working Paper, Geneva, 1997 (published in English and Russian).
4 The text of the Nursing Personnel Convention, 1977 (No. 149) and Recommendation, 1977 (No. 157) is reprinted in the annex.
5 The text of the Ljubljana Charter is reprinted in the annex.
6 The detailed programme is annexed to this report.