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This monograph is part of a series of research studies issued under the ILO's Action Programme on Privatization, Restructuring and Economic Democracy (1996-97). The objective of the Programme is to improve the capacity of ILO constituents, both to adopt a participatory approach to privatization and restructuring, and to better grasp and address the social and labour consequences of those processes. Its publications are primarily for use by governments, workers' and employers' organizations, development assistance agencies, but also consultants, scholars, and others involved in or studying them.
This work, which has been coordinated by the ILO's Salaried Employees' and Professional Workers' Branch of the Sectoral Activities Department, reviews the experience with privatization and restructuring of health care services in two different regions. Cases from the Americas (Canada, Chile and USA) by Sandra Polaski and from Europe (France, Germany, Sweden and the Unided Kingdom) by Stephen Bach are used to illustrate the broad variety of types of privatization and restructuring in different geographical, cultural, political and economic contexts. Against the background of specific health care systems, it assesses the extent, modalities and effects of stakeholders' participation in these reform processes. The impact of privatization and restructuring on employment levels and conditions of employment, working conditions and industrial relations is examined as well as the impact on the quality of the services. Lastly, it identifies conditions that can facilitate successful reforms of health care services. The studies are introduced by Gabriele Ullrich of the ILO Salaried Employees' and Professional Workers' Branch.
Due to the political sensitivity of public health and the special character of health care services which are classified as essential services and are services of general interest, privatization and deregulation in this sector face a number of limitations. This is also of relevance for the participation of different stakeholders in the reform processes. As the sector is highly labour intensive, the workforce is a vital factor for the quality and the efficiency of the services. Although changes in the health care system are not primarily aimed at the workforce, they are directly affected and condition, on the other hand, the quality of the services. Experience of the cases examined shows that the constructive involvement of workers and consumers in the design and implementation of the reform processes led to more sustainable results. However, the effects of privatizing parts of health care services did not necessarily correspond to the expectations and depended on different factors in a given situation. The reactions of the labour market appear to be very slow for professions which are subject to long-term education and training and to largely regulated practice. Therefore, conclusions on the impact of privatization and restructuring in health care also need long-term observation and may be premature at the present stage, since reform processes started often only in recent years.
The opinions expressed in the studies are those of the authors and not necessarily those of the ILO.
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Max Iacono
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Valentin Klotz
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International Labour Office - Geneva, December 1997
In the context of rethinking the role of the State, restructuring, adjusting and downsizing of public budgets, communities at local, national, regional and international level are looking for new models to finance and provide services of general interest.(1) In Europe, e.g., such services strive to serve the public while protecting the environment, enhancing economic and social cohesion, and the promotion of consumers' interests. Basic operating principles of such services are: continuity, equal access and universality.
There are various ways of organizing the delivery of these services, reflecting different geographical, and technical circumstances, political and administrative settings, cultural and social traditions. The services can be provided by both public and private operators, in either competitive or monopolistic situations. The European Commission lists among the providers private companies, public bodies, and joint public-private partnerships. These different organizational set-ups make it necessary to speak of services of general interest rather than of public services. The provision of these services is regulated by public authorities to various degrees, depending on the sector.(2)
While analysing the experience with restructuring and privatization of such services, social and labour issues are frequently ignored or left to the bargaining partners of a specific situation. The analysis of the impact on and the reaction of consumers of the services attracts more interest than the analysis of the situation of the workforce in this area. Hence, the absence of studies and literature in this area can be noted. Even though the impact on the consumer and society in general are linked, there is hardly any general evidence what impact restructuring and privatization have on the workforce of different sectors providing services of general interest and, vice versa, what impact the workforce can have on restructuring and privatization.
Therefore, the ILO launched in 1996/97, in the context of an interdepartmental action programme, a series of studies on restructuring and privatization of services of general interest which focused specifically on social and labour issues. The sectors selected were utilities (water, gas, electricity), telecommunication and health care. The results of these studies are complex and vary :
Additionaly, these factors mutually influence each other. The withdrawal of the State from the provision of services of general interest is often termed under the simplified and misleading heading "privatization". It refers to introducing private-type management and competition in the provision and finance of services of general interest, to contracting out of such services to the private sector, to selling the facilities, to licencing the provision of the services to the private sector, and to privatizing the finance of the services. The question of ownership is increasingly recognized as only one of a range of issues (e.g. the system of finance, degree of competition, etc.) which shape the impact of privatization initiatives. The studies show that the form of privatization is one of the determinents for its impact.
The results of restructuring and privatization vary according to the sector and have a very specific outlook in health care. More than the other sectors, as health services are strongly determined by the traditions of the countries and regions, these play a major role in the privatization in this sector. In the context of general interest services, the type of social dialogue is conditioned by their nature of being universal and essential services and the policy which regulates the sector.
Action to implement privatization is taken in industrialized and developing countries as well as in economies in transition. This publication refers only to the studies on restructuring and privatization of health services carried out by Sandra Polaski for selected cases in the Americas and by Stephen Bach for selected industrialized countries in Europe. Both studies are reproduced in their complete text after this introduction. The results of the two other sectors researched, utilities and telecommunication, are published separately.
Health is a major contributor to sustainable human development and at the same time, health is dependent on factors largely outside the health sector : economic and social development, poverty, environmental issues, agriculture and nutrition are major contributors to health. The ILO subscribes to the "Health For All" Strategy of the World Health Organization (WHO), which aims at achieving greater social equity, accessibility and affordability of health care through community-based provision of primary preventive and curative health care. As renewed global health policy for the 21st century, an intersectoral approach shall be pursued by this policy with health-related issues placed also on the agenda of non-health sectors. A similar approach is also being advocated by the European Union. In the framework of these factors outside the sector, health services are one of the basic sectors of society and the economy which concerns the whole population. Any changes in this sector face great political sensitivity and media coverage.
While health challenges differ from country to country, there is today near-universal recognition of substantial problems in allocating effectively human, material and financial resources for this sector. Therefore, many governments are rethinking the basic premises of the health care system, in which the consequences for employment practices are acknowledged, but rarely an integral part of the planned reforms. Over the past three decades, the health professions have been growing rapidly in most countries, often more rapidly than the population. Although countries are undergoing radical reforms based on new public management and market-based principles, the most rapid increase is to be noted in administration and senior management. Due to demographic and epidemiological conditions, the demands on health services will further increase, so could employment opportunities in this field. However, the impact on employment appears to be subject to national conditions, financial resources, and the availability of trained personnel. Increasing costs of health care services, structural adjustment policies and cost-containment measures seem to have a predominantly negative impact on the employment, working conditions and career prospects of health personnel.
Despite rapid technological developments, the sector of health care services still remains a very labour intensive sector. The share of personnel costs remains considerable, accounting normally for 50-75 % of the total costs. Doctor's pay alone is estimated to represent 25 % of the total costs of health care in OECD countries. Therefore, the efficiency and quality of the personnel is vital to the performance of the whole sector. Moreover, any shift in the demand for health services or in their finance impacts directly on the employment or rewards to employment in this sector. It is, however, not evident whether privatization reduces the overall employment, even when employment is being reduced in the public premises.
In industrialized countries, the trend towards decentralization of health services and the shift from curative to preventive care have led to a multiplicity of employers and working environments but also to new tasks and new professions, at times overlapping with social services. While medical doctors face a decline in average income and job security, in many countries, employment opportunities for nurses are increasing. Often there is a shortage of qualified personnel in specialized fields. In the transitional economies of Central and Eastern Europe, restructuring of public health services and reconsidering basically free service provision is seriously affecting the employment situation of health workers. Due to extensive cost-containment measures, redundancies appear or are made to appear to be unavoidable. In middle-income countries, overall health sector employment is increasing in response to the demands to extend basic health services to previously excluded groups and to upgrade the quality of care. Here, the problems are to train sufficient personnel, to provide them with jobs and to retain them in the national workforce. In low-income countries, where an overall accessible basic health infrastructure is still being built, the mostly public health services have to put up with a scarcity of trained health care workers. Many low-income countries are unable to improve the pay or employment conditions of their nursing and medical staff. In these countries public expenditure for health services is on average below 1 % of GNP.
Globalization has also had its impact on health care services. The labour market for health workers has become increasingly international. As many countries suffer from a shortage of staff, such workers tend to migrate to countries where the working and employment conditions are more favourable. Consequently, many developing countries face serious shortages of qualified personnel. Nevertheless, migration also takes place between industrialized countries (e.g. Finland and the United Kingdom). Such cross-border migration causes challenges to government regulation in view of credentialing and the execution of the profession. Such problems become particularly relevant in times of privatization in a widely regulated profession.
Health care has until now been largely in the public sector in many countries (except in the USA where only 47 % expenditure was public in 1996). Reforms in this sector often include privatization and increased use of market-type mechanisms. The solutions offered are mostly complex arrangements that combine both the State and the private sector. All governments recognize the need for public supervision and regulation of the health sector which often appears to be a more important role than getting directly involved in providing health care. Many countries want to arrive at a public/private mix of health services. Nevertheless, such hybrid forms are also drawn into question, as it is argued that private and public sectors in health care follow different, even contradicting patterns, such as competition and solidarity, or profit and cost coverage, or cost-efficiency and cost-effectiveness. Moreover, it is feared that pluralism leads to fragmentation in financing and providing health care.(3)
Restructuring and privatization can be a means of improving the efficiency and availability of health services; however, equal access to quality health services has to be ensured. There is a 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. The professions in this sector require long and intensive training which result in slow reactions of the labour market to changes in demand, and require government orientation and regulation.
There are certain features of the health services sector which need clarification before analysing restructuring and privatization on the workforce. In particular, a distinction needs to be made between financing, delivery and allocation mechanisms of the services.(4) As the studies on restructuring and privatization of health care services show, the impact on these three aspects of health care services is distinct and has to lead to different conclusions. Moreover, the shift from predominantly curative and hospital care to more primary and preventive care is changing the composition of the workforce and the required qualifications.
Beyond its general concern about health protection for workers and their social security and thus its involvement in health sector reform, the ILO attaches importance to the fact that the situation of health care and medical personnel is critical to the delivery of the services in this sector. Therefore, the ILO deals with this workforce (estimated employment : 35 million worldwide ; average share in total employment in OECD countries : 5.6 %) in specific labour standards and sectoral activities.
The basic labour standards on freedom of association and the right to organize and bargain collectively also apply in health care services. These rights are, however, restricted in some cases, particularly in the public health sector. The ILO Joint Meeting on Employment and Conditions of Work in Health and Medical Services of 1985 noted that these restrictions hinder full participation by workers in health and medical services and their representatives in the determination of their employment and working conditions through collective bargaining. The meeting recommended that measures should be taken, where necessary, to encourage and promote the full development of machinery for voluntary negotiations between employers and workers and their representatives, with a view to the regulation of terms and conditions of employment by means of collective bargaining as laid down in the Right to Organize and Collective Bargaining Convention, 1949 (No. 98), and reaffirmed in the Labour Relations (Public Service) Convention, 1978 (No. 151), and the Collective Bargaining Convention, 1981 (No. 154).(5)
As regards the right to strike, the health care services belong to the essential services in the strict sense of the term, i.e. services the interruption of which could endanger the life, the personal safety or health of the whole or part of the population. Although in several countries the right to strike is recognized in some health and medical services, in others these services, being considered essential, are subject to restrictions on the right to strike or this right is denied to all. If the staff in health and medical services are denied the right to strike they should be compensated through other benefits including reasonable pay and conditions of work and impartial and speedy machinery to resolve collective disputes. It has been considered by the ILO Committee on Freedom of Association that in case of work stoppages, a minimum service concerning specified categories of workers may be deemed justified since a total stoppage of work in these services may be such as to endanger the life, safety or health of persons in need of health care. Workers' representatives should be able, however, to participate effectively in defining such a minimum service.(6)
Specific international labour standards deal with employment and working conditions of nursing personnel : the Nursing Personnel Convention (No. 149) and Recommendation (No. 157). These standards refer to the establishment of a general policy concerning nursing services and the nursing personnel participation in the formulation of this policy ; education and training ; practice of the nursing profession ; career development ; remuneration; working time and rest periods ; occupational health protection and social security. The Convention was ratified by 36 countries at the end of 1997. The supervisory bodies have raised a number of problems of application. These concern, in general, the need for measures to adapt the legislation on safety and health at work to the risk of exposure of HIV and the negotiations on working conditions with the nursing personnel organizations. The Committee of Experts on the Application of Conventions and Recommendations has also raised various issues with individual governments regarding, e.g., conditions of employment in transition economies, and the question of overtime.
Earlier, in 1944, the ILO adopted the Medical Care Recommendation (No. 69) which deals with the forms, coverage and content of medical care and with working conditions of medical doctors and allied professions.
Within its Sectoral Activities Programme the ILO has held several meetings for the health sector. As health has to date been largely a public sector, these events were "joint" (i.e. bipartite) meetings involving governments and workers' representatives with some participation of private employers in this sector. The last meeting which dealt with health services, took place in 1992 in Geneva. It discussed the general trends of the sector including employment, labour relations and the determination of conditions of employment, occupational health and safety, training, remuneration, work organization and working time. As specific theme, the meeting discussed the equality of opportunity and treatment between men and women in health and medical services. Among the proposals for future ILO action for this sector was the promotion of dialogue on the impact of structural adjustment, transition to market economies and privatization of health services on the employment and working conditions of health workers.
Against this background, a number of reports and studies were published in this area as working papers, and particularly a study on health care personnel in Central and Eastern Europe. A subregional workshop on employment and labour practices in health care in Central and Eastern Europe took place in May 1997 in Prague. These activities revealed the challenge of restructuring and privatization of health care services in different parts of the world. In 1996/97, the studies published in this monograph were prepared with specific focus on the impact of restructuring and privatization on health service delivery and the work environment. A sectoral meeting on terms of employment and working conditions in health sector reforms will be held in 1998 which will also look into issues of privatization.
The ILO's efforts to analyse restructuring and privatization are, however, not limited to health and other services of general interest. Through the interdepartmental action programme, mentioned in paragraph 1 of this introduction, the ILO wants in general to enhance the capacity of constituents to adopt a participatory approach to restructuring and privatization which takes into account both social considerations and the need to be competitive. With various instruments, successful and less successful practices are being reviewed, and tools for practical implementation developed. A series of publications and training activities is the outcome of this action programme.
The studies which are published in this monograph, review experience of restructuring and privatization in the health sector to identify good practices and pitfalls. The ultimate goal was to provide guidance on how to enhance the prospects for a successful transition and a more equitable distribution of the benefits and possible costs among all actors concerned. Experiences of health care services were reviewed in selected regions and countries which represent a broad variety of types of restructuring and privatization endeavours.
This review was done either through an examination of the process at regional level, using specific case examples or through reviewing developments in a limited number of countries in a given region. The first approach was chosen for the Americas by Sandra Polaski who selected three cases to illustrate key issues in health sector reforms : the privatization of health care in the case of Chile, the restructuring of health care in the case of the Province of Alberta (Canada) and the restructuring and privatization of health service delivery in the case of Los Angeles County (USA). For industrialized countries in Europe, Stephen Bach chose the second approach to review country experience in regard to relevant issues in the processes of restructuring and privatization. The countries chosen for detailed study were: France, Germany, Sweden and the United Kingdom.
Areas covered were the typology of privatization processes in the health sector, changes in employment and in working conditions (including pay levels, components of pay, other benefits and working time), the participation in the restructuring process (including the role of social partners, labour relations, changes in collective bargaining and changes in unionization), service delivery (including universal access to health care and medical services, and cost efficiency), costs of health insurance systems and budgetary repercussions of privatization for governments.
National and international, governmental and non-governmental organizations were consulted and their documentation used. The thematic focus of the studies was the participatory approach in health care reforms, i.e. the involvement and initiatives of the parties concerned, including government departments, health funds, managements, employers' and workers' organizations concerned and independent providers of services. The question was, in particular, how their involvement (or lack of it) affects the outcome of the privatization process in view of issues of concern to the ILO and its constituents.
This introduction is not meant to summarize the results of the studies since the reader will find summaries in the beginning ofthe studies by Sandra Polaski and Stephen Bach. This introduction is meant rather to highlight some points of the studies which might be of particular relevance for analysis and practical work in other countries. It is, however, necessary to examine details of the respective issues inside the studies.
Due to the political sensitivity of public health which leads to essential limitations for the deregulation in this sector, and due to the relatively slow reactions of the labour market in this labour intensive sector, Polaski noted that it was difficult to identify the impact of restructuring and privatization on the workforce at this stage. Additionally, the impact of health reforms on labour practices did not attract much interest in the past, as they were not the primary target of the reforms and changes in this area were rather considered a side-effect. Consequently, an absence of studies in this area was noted.
As the health care system and its reform process have to be analysed before changes in labour practices can be assessed, Polaski and Bach put emphasis on the analytical description of the given health care system in relation to their cases.
For Europe, Bach noted that the reforms strengthened management, reorganized service delivery, decentralized to more autonomy at hospital and local government level and thereby put the traditional employment practices and working conditions under threat. However, despite attempts in the health sector to restructure with market-type elements and privatize parts of the service delivery, the traditional approach in Europe to consider health services as a public obligation remains strong.
Gender issues are included in the analysis ; however, there is no evidence that the disproportion between a high percentage of women in the total workforce of the health sector and their under- representation at higher and management levels is being changed through the reform processes. Furthermore, flexible work arrangements with their predominantly negative consequences for career advancement are still more frequent for the female workforce.
The employment variations in the health sector cannot be compared with the drastic drops in other general interest services such as in the utilities sector. However, the authors also observe increasing employment insecurity in the health sector.
For the cases in the Americas, Polaski describes various degrees of decline in employment. In Chile in the beginning of privatization under the military regime, a sharp decline in the employment of health workers occurred through drastic cuts in public health spending and the opening to private competition in the health sector. With re-democratization the situation improved slightly. In Alberta Province, lay-offs among hospital staff were observed when the provincial government as the single payer for health services decided to shift from hospital care to lower cost facilities. However, under pressure from the unions a part of these posts were re-established. In Los Angeles County, restructuring combined with privatization led to a loss of 10 % of jobs in this sector. The unions, however, reached an agreement by which the laid-off workers had a first right to newly created jobs in the private facilities.
Although flexibility in France is reduced by predominantly public service conditions for health workers, the unions are expecting considerable job losses in public hospitals in the future. In Germany, even though no lay-offs are noted, the efforts for cost control and reduced demand for medical and health personnel have already led to a situation which undermines the former strong position of medical staff in the labour market. Should the health care system develop further into managed competition, the impact on the employment situation would be even more far-reaching. In general, Bach observes a stagnation in labour markets after massive expansion in the past. Bach notes for the United Kingdom and also for other countries in Europe an increasing segmentation of the labour market with better employment and working conditions for well qualified nursing and medical staff and a more negative outlook for less qualified personnel. Ancillary staff employment fell by more than half in the UK between 1984 and 1994.
The majority of the cases investigated (with the exception of Chile and Sweden) leave the question open whether there is evidence of a surplus supply in the labour market of the health sector, whether workers laid off during restructuring and privatization are absorbed by other institutions of the sector or whether they remain in the sector as self-employed persons. Additionally, the absorption of migrant workers by the labour market is not evident. Social partners seem to have managed, however, to limit at present the reductions through their bargaining and industrial action.
As the sector is highly labour intensive and due to the direct relation between health workers and the consumers of the services, the working conditions have an immediate impact on the patients and their assessment of the effectiveness of the health services. This direct link, although often not consciously recognized, also contributes to the political sensitivity of the working conditions of health workers.
Polaski notes that in Chile a "double labour market" emerged, with higher pay and better working conditions in the private health sector as compared to the public health sector where the share of salaries in total public expenditure declined constantly. This led to a "migration" of parts of the best qualified workforce from the public to the private sector. In the case of Los Angeles County and Alberta Province, reduced incomes were being observed.
Bach concluded that in the United Kingdom the increase in salaries was paid for with reduced job security and worse working conditions. In France working conditions and pay in the health sector are regulated by the conditions for the public service. In Germany, the introduction of private for profit hospitals has made the pay structure more flexible as compared to the public and private, non-profit hospitals. The transfer of services to the private sector have resulted frequently in a worsening of working and employment conditions in both the public and the private sector. Particularly worth noting in all countries is the work intensification resulting from reduced staff and working hours. Bach notes that flexibility may be needed in work reorganization for multi-skilled staff. This may, however, result in more precarious contract situations and a loss of quality of the services.
Decentralization of public service has also affected health care and with it the centralized collective bargaining mechanisms of the past as becomes apparent in Sweden and the United Kingdom. The decentralization of pay determination has not, to date, produced the anticipated benefits. Nonetheless, efforts towards decentralization in its different forms will continue, because of the concern to contain wage costs and target wage increases in more specific ways. Bach analyses also the trend towards market-related and merit-based pay in Europe which devolves responsibilities to managers for improved efficiency. Such systems have gained limited experience and were mostly opposed by labour. His assessment of the effectiveness is, however, rather pessimistic. Objective criteria for differentiated pay are difficult to establish and the general effect is often demotivation rather than motivation.
Health professions require a long, specialized training and signals from the demand side of the labour market receive only slow response from the supply side. Polaski sees therefore a need for "market guidance" by government in this sector. In Alberta Province, she notes a change in the "skill mix" which is required due to the shift from hospital and curative care to primary and preventive care. In the short run this can be reorganized by assigning a different mix of tasks to the staff, like in the case of Alberta Province; in the long run training has to respond to these changed needs. Certainly this would also apply to the demand for "multi-skilled" staff (including management skills) which was noted by Bach. A specific problem for health services seem to lie in the indispensable requirement of regulation for training and practice of the health professions which might not keep pace with evolving new tasks due to technical change and work reorganization.
Polaski notes that restructuring and privatization in Chile was marked by the absence of participation of the workforce as the labour movement was a specific target of repression after 1973. Collective bargaining was first banned and then only allowed under restrictions which only changed with the re-democratization. In the case of Alberta Province, the restructuring was a big challenge to the unions, particularly caused by administrative reorganization which changed bargaining rights. The unions tried to coordinate bargaining power even though strikes were not allowed. In Los Angeles a process of "confrontation and cooperation" led to an alternative plan developed with the support of all stakeholders. It was achieved that the new private employers recognize as bargaining partners the unions which previously represented the affected workers.
In France in 1996, industrial action evolved also from labour movements outside mainstream labour unions and achieved changes in working conditions and pay. Other cases of industrial action took place in Germany in 1997, in Sweden and in the United Kingdom in 1995. Particularly in the last case, it resulted from changes in collective bargaining mechanisms caused by decentralization which targeted working conditions and terms of employment. Bach sees "winners" and "losers" of the market-style reforms which may result also in internal conflict in the labour movements. In most cases, the activities received sympathy from the public which was equally concerned by the changes.
In Chile, the public health care system spends only 60 % of the per capita expenditure of the private health plans. Therefore, 70 % of the population still covered by the public system are exposed to apparently worse treatment by health service delivery. In Alberta Province, the unions were able to gain the solidarity of the public since the restructuring led also to more finance by the users of health services who had more and more to cost-share. Jointly, they were able to reverse parts of the decisions of the provincial government having impact on the employment situation. In Los Angeles County, all stakeholders worked together to develop a future plan.
Due to the political sensitivity of the sector and its enhanced visibility, consumers of the health services are equally interested and concerned by the developments in health sector reforms. This concern is reinforced by the fact that cuts in public budgets are often compensated by direct or indirect transfer of health costs to the individual. The inclination to supportive solidarity with the health workers appears therefore to be higher than in other general interest services. Nevertheless, Polaski notes differences in the strategies and results in the three cases.
In Alberta Province and Los Angeles County the restructuring and privatization led to a short-term reduction of budgets or deficits. Since this experience is relatively recent, it remains to be revealed whether the effects can be maintained in the long run. On the contrary, the case of Chile shows very illustratively after 16 years that privatization does not necessarily mean in the long run a reduction of public funds involved. The private part of the health care system took over only the segment of the population which incurred relatively less costs. In the long run the State had to compensate for the loss of risk sharing and solidarity of the healthier part of the population with regard to the remaining public risk pool. This amount equals the original budgetary expenditure : public spending on health was 2.7 % of the GDP in 1974 and in 1993. Bach notes with a view to the UK that complex systems of managed competition have to face increased administration costs.
Due to the nature of health services and their impact on public health in general, regulations for the training, the practice of the profession, the labour market, and the management of the institutions of the sector are unavoidable. They may, however, be used to produce inefficiencies and unequal distribution of gains and burdens to the workforce and the consumers. Both studies note that progressing privatization may also require changes in regulations which may, however, not result in "deregulation". In France, restructuring in the health sector resulted in stronger regulation of the medical practice. In Germany, tendencies towards more commercial management of hospitals and therefore more managed competition evolve. In the Americas, some guidance may be also needed for the labour market.
Based on the evidence in the studies published hereafter and in other recent research work and discussions, the following paragraphs give some highlights of labour and social issues in implementing restructuring and privatization processes. They are by no means complete, detailed or specific for certain regions, they are rather meant as ideas for a checklist against which action from different parties concerned in those processes may be examined :
Notes
1. The terms for this type of services vary in political statements and research definitions. The European Commission gave some practical definitions which will be used for the purpose of this introduction : "Services of general interest cover market and non-market services which the public authorities class as being of general interest and subject to specific public service obligations". The term "universal services" wants to make sure that everyone has access to certain essential services of high quality and at prices that they can afford. The term public services is avoided in this context as it suggests that the provision of these services is made by public providers. Commission of European Communities, Communication of the Commission : "Services of general interest in Europe", COM (96)443, Brussels, 11 Sep. 1996, p. 2.
2. Commission of European Communities, op. cit. p. 3.
3. D. Hunter : "Public/private mix in health care restructuring : Challenges and problems", in : ILO : Terms of employment and working conditions in health care in Central and Eastern Europe, Workshop Report, ILO Sectoral Working Paper.
4. S. Polaski : "Restructuring and privatization of health care services -- Selected cases in the Americas" published in this monograph.
5. See paras. 18 and 19 of the conclusions on labour-management relations of the Joint Meeting on Employment and Conditions of Work in Health and Medical Services, Geneva, 1985.
6. ibid., para. 20.
