JMHSR/1998/10 - Note on the proceedings

The Joint Meeting on Terms of Employment and Working Conditions in Health Sector Reforms was held at the International Labour Office in Geneva from 21 to 25 September 1998.

The Office issued a report⁽¹⁾ to serve as a basis for the Meeting's deliberations. It addressed the following topics: challenges facing health care systems; health reforms as policy responses; the impact of reforms on health care staff; employment trends, structures and levels; reforms and their impact on human resource development, labour relations, working conditions and occupational health protection; reforms and trends in remuneration; and ILO policy and activities in relation to health sector reforms.

The Governing Body had designated Mr. D. Willers, representative of the Government of Germany in the Governing Body, to represent it and to chair the Meeting. The two Vice-Chairpersons elected by the Meeting were: Mr. L. Serfaty (Employer member) from the Government/Employers' group and Ms. A. Khoo Kim See from the Workers' group.

The Meeting was attended by Government representatives from Austria, Belgium, Canada, China, Colombia, Czech Republic, Kuwait, Mexico, Poland, Russian Federation, Slovakia, Sweden, Switzerland, Turkey; five Employer representatives from the private sector and 24 Worker representatives.

Representatives from the North American Free Trade Agreement and the World Health Organization were present at the Meeting as observers. Representatives from the following non-governmental international organizations also attended as observers: European Committee for Private Hospitals; International Confederation of Free Trade Unions; International Co-operative Alliance; International Council of Nurses; International Federation of Commercial, Clerical, Professional and Technical Employees; International Federation of Employees in Public Services; International Federation of University Women; International Organization of Employers; Public Services International; and World Confederation of Labour.

The two groups elected their Officers as follows:

Government/Employers' group

Chairperson:
Vice-Chairperson:
Secretary:

Mr. J. Servotte (Belgium)
Mr. N. Surani (Employer member)
Mr. J. Dejardin (International Organization of Employers) (IOE)

Workers' group

Chairperson:
Vice-Chairpersons:

Secretary:

Mr. W. Lucy
Mr. C. Kamondi
Mr. C. West Ocampo
Mr. J. Schlanger
Mr. A. Leather (Public Services International) (PSI)

The Secretary-General of the Meeting was Mr. V. Morozov, Director of the Sectoral Activities Department. The Deputy Secretary-General was Mr. V. Klotz, Chief of the Salaried Employees and Professional Workers Branch; the Executive Secretary was Ms. G. Ullrich and the Experts were Mr. W. Ratteree, Ms. L. Wirth and Mr. J. Sendanyoye of the same Branch. The Clerk of the Meeting was Ms. T. Bezat-Powell of the Sectoral Activities Department.

In his opening address, the Chairperson pointed to the discrepancy between the increasing need for health services and the diminishing possibilities to finance them. Referring to the situation in his country, Germany, and the attention given by the press to the consequences of reforming financial systems of health care for the sector's labour market, he urged the participants not to make the question of different financial systems the central concern of the discussions in the Meeting, but to focus instead on the impact of reforms on the situation of workers, on their employment perspectives, working conditions, health protection and pay, and on labour relations. He underlined the importance of discussing the potential as well as the limitations of privatization in the health sectors, which might differ from one region to another. Privatization could not be considered as a panacea to the problems of efficiency and finance in the public service. Finally, the participation of those concerned by reform processes should be discussed, as their exclusion could endanger the success of reforms.

Mr. K. Tapiola, Deputy Director-General of the ILO, stressed the vital role of the health sector for the development and well-being of societies everywhere and the role of its workers in the delivery of health care services. He highlighted the distinct challenges which warranted health sector reforms, such as demographic changes, unequal access to health services, their increasing costs, the structure and management of health systems as well as technological advances. Access to health care services was increasingly seen as a basic human right; against today's background of structural adjustment and economic constraints, however, many countries were obliged to rethink the financing and scope of services provided by national health systems. This had resulted in a growing debate on reform policies aiming to improve the efficiency and quality of health services while lowering or containing costs. The response of health reforms to these issues varied and included an examination of policies on cost reduction, quality improvement, equality of access, systems of management, employment levels and conditions of work. The ILO dealt with some of these issues directly and was concerned about their impact on working conditions in health services, on the health and social protection of the global workforce and on social security schemes. A natural partner of the ILO in this respect was the World Health Organization (WHO) whose "Health for All" strategy was endorsed by the ILO. Recalling that the basic international labour standards on freedom of association and collective bargaining were also applicable to the health sector, Mr. Tapiola indicated that these standards were restricted in some cases by national legislation particularly in the public health care sector. Moreover, it was often considered that certain health care services, such as hospital services, belonged to "essential services" in the strict sense of the term, the interruption of which could endanger the health, safety and life of individuals or parts of the population. In some countries, the right to strike was therefore restricted or denied. Health service personnel who were denied the right to strike should be compensated through other benefits such as improved pay and working conditions as well as impartial and speedy machinery to resolve disputes collectively. He drew attention to specific international labour standards which dealt with the employment and working conditions of nursing personnel: the Nursing Personnel Convention, 1977 (No. 149), and Recommendation, 1977 (No. 157). Recent developments in the health care services had demonstrated repeatedly how important international labour standards were in initiating and guiding social dialogue. The delayed or non-payment of salaries to health service workers in several developing and transitional countries, the increased occupational safety and health risks, unpaid overtime, stress and violence in the health sector were alarming signs for the need of consultation among all social partners in times of scarce financial resources. The participants would address in the course of the Meeting a wide range of fundamental issues in the health sector such as finance and employment, privatization and restructuring, management of work organization, contract arrangements, remuneration, training and ethical problems as well as questions of assisting developing and transitional countries to deliver efficient services of improved quality. In concluding, the Deputy Director-General recalled the vital role played by health workers in the delivery of health services. The ILO was convinced that negotiations and social dialogue could help in reform processes to create employment and working conditions which were conducive to the delivery of such services and that the active participation of the health service personnel in the reform process would enhance the quality and efficiency of the services provided.

1. ILO, Joint Meeting on Terms of Employment and Working Conditions in Health Sector Reforms, Geneva, 1998: Terms of employment and working conditions in health sector reforms, 92 pp.

Part 1

Consideration of the agenda item

Report of the discussion⁽¹⁾

Introduction

1. The Meeting met to examine the item on its agenda. In accordance with the provisions of article 7 of the Standing Orders for sectoral meetings, the Officers presided in turn over the discussion.

2. The spokesperson for the Government/Employers' group was Mr. J. Servotte (Belgium) and the spokesperson for the Workers' group was Mr. W. Lucy.

3. The Meeting held five sittings devoted to the discussion of its agenda item.

Composition of the Working Party

4. At its fifth plenary sitting, in accordance with the provisions of article 13, paragraph 2, of the Standing Orders, the Meeting set up a Working Party to draw up draft conclusions reflecting the views expressed in the course of the Meeting's discussion of the report. The Working Party, presided over by the Government/Employer Vice-Chairperson (Mr. L. Serfaty), was composed of the following members:

Government/Employer members

Mr. J.M. Dominguez (Employer member)
Ms. U. Fronaschütz (adviser, Austria)
Mr. L. Serfaty (Employer member)
Mr. J. Servotte (Belgium)
Mr. N. Surani (Employer member)

Worker members

Ms. J. Darcy
Mr. M. Kuzmenko
Mr. W. Lucy
Mr. Ma Wei Cheng
Mr. S. Shezi

Presentation of the report and general discussion

5. Introducing the report prepared by the International Labour Office, the Executive Secretary thanked all those who had contributed to its preparation by providing information, in particular those who replied to the Office's questionnaire. Chapter 1 dealt with the challenges to which health care systems were exposed, involving cost explosion, fiscal constraints as a consequence of economic transition, structural adjustment and globalization, problems inherent in the system and deficient management, technological progress, inadequate and unequal access to health care, demographic change and long-term unemployment. Chapter 2 concerned the patterns of health reforms as policy responses, including different types of structural, managerial, financial and workforce reforms, concepts of privatization, the introduction of market elements into the health systems, the public and private mix and governments' role, and reforms in relation to the principles emerging from recent international conferences. Chapter 3 explored the impact of reforms on health care staff, an impact especially hard for staff in Central and Eastern European countries. Furthermore, it noted the likelihood that employment opportunities would increase while more precarious forms of employment would emerge. These developments would affect women more than men. Moreover, the linkage with public service reform was underlined. Chapter 4 analysed the trends, levels and structures of employment, notably the definition of the sector's workforce, long-term growth in most countries, the composition of the workforce (mainly skilled and semi-skilled staff), shortages in certain professional groups, disparities among and within countries, restructuring and decentralization of employment and migration. Human resource development, working conditions, occupational health protection and labour relations were treated in Chapter 5 which focused on issues such as the changing legal status, lifelong learning, gender, working time, workforce adaptation to technological and structural change, physical hazards, stress and violence at work, and unionization, bargaining and workers' participation in reforms. Chapter 6 examined reforms and trends in remuneration, including differences between occupations and between men and women. Chapter 7 concerned the ILO and activities in relation to health sector reforms, while Chapter 8 provided the suggested points for discussion to guide the Meeting.

6. The spokesperson for the Government/Employers' group congratulated and thanked the ILO for providing the opportunity to look at the overall problems of the health care sector. The report was dense and wide-ranging, perhaps a bit too philosophical and not specific enough. He wondered why the ILO did not use the WHO definition of physical, mental and social well-being to define the concept of health. The Government/Employers' group had divergent views given its composition and the different economic and working conditions of countries represented. Governments intervened more and more and at greater length in different fields, including health. In all countries, irrespective of the amounts dedicated to health coverage, the demands in health care systems were on the increase while health costs were perceived to be too high, and savings were required. The definition of quality health care was ill-defined, inhibiting agreement on the notion. One school of thought held that expenditure should be drastically limited, whereas another advocated controlling cost evolution as a function of real demand. The Government/Employers' group felt that particular attention should be given to continual training of staff and not merely maintaining but actually increasing levels of employment. All the proposed points for discussion merited consideration.

7. An observer, the Director of the Division of Human Resources Development and Capacity Building of the World Health Organization (WHO), stated that the WHO shared the well-documented concerns in the ILO report. Health sector reform aimed to improve equity, quality, sustainability and efficiency of systems, but the reality in many poor countries was grim. Macroeconomic and political developments had led to reduced public health spending, privatization and user fees negatively affected equity and access, and health workers in many countries had not been paid for months on end. In addition to remuneration, housing, safe water and sanitation, transport and adequate supplies were basic conditions affecting health professionals. Other factors needing attention included autonomy commensurate with responsibility, particularly with regard to nursing staff, career structures and supportive supervision. In all six regions of the WHO, well-qualified health workers of all levels were migrating from the public to private sectors, from health to the commercial sector, and from poor to rich countries. The impact of the new WTO trade agreements on the health sector and its personnel was under careful study. Collaboration with the ILO on civil service reforms, payment schemes and their effect upon the health workforce continued, along with work on the migration of health professionals in cooperation with the International Council of Nurses and the World Medical Association. WHO welcomed close collaboration with the ILO and other sister agencies, as well as the NGOs and other players as part of its commitment to Health for All in the 21st Century.

8. The spokesperson for the Workers' group joined the Government/Employers' group in thanking the ILO for the report, which broadly reflected global conditions in the health care system. He noted that the economic importance of health care transcended the substantial amounts spent or the high number of people employed, since economic development and productivity were themselves dependent on efficient and effective protection of public health. The interests of health care workers had to be respected during the various reform initiatives to control costs while meeting increased needs for health care. The reforms might include decentralization, cuts in benefits, introduction of new financing mechanisms, privatization or a mix of public/private services. As the ILO report recognized, unfettered free-market forces adequately addressed neither the health care workers' terms of employment nor the health care needs of citizens. Reforms such as workforce cutbacks, the shifting of patient care duties to less trained staff or the increased use of part-time workers and individual contract arrangements had not only failed to achieve the goals of universal and equal access to health care, but had resulted in severely reduced earnings and working conditions of health care workers and an erosion of the quality of care. Among the negative consequences were increases in job insecurity, serious occupational safety and health hazards and job-related stress. Interventions combining identification of such hazards, training, and regulations were necessary to prevent injuries and illnesses and to establish proper infection controls. Given the predominance of women workers at the lower levels of the sector and consequent gender-related employment problems, it was regrettable that there had been slow progress in applying relevant ILO Conventions. Obstacles to gender equality included lack of child care, flexible work schedules, training and continuing education, career planning and equal employment opportunity. Collective bargaining was the best avenue for improving the terms and conditions of health care workers, including women, and both private and public sector health workers needed the right to organize and bargain collectively as provided by ILO Conventions Nos. 87 and 89, in accordance with the conclusions of the First Session (1992) of the Standing Technical Committee for Health and Medical Services. The Workers considered that a number of conditions were necessary for the successful implementation of health care reforms: their participation in the planning and execution of any initiatives; an understanding that adequate remuneration and satisfactory working conditions and training for health workers were conducive rather than detrimental to quality patient care; and close government oversight to reflect the fact that public health and medical care were essential for national well-being and development and not mere commodities best left to the private sector.

9. An observer, the Secretary General of Public Services International, welcomed the opportunity to discuss, once again after six years, the terms of employment and working conditions in the health sector. He regretted that the Standing Technical Committee no longer existed, and doubted that health care activities were of primary concern to the ILO in the light of its staffing levels and the budget of the Sectoral Activities Department which hardly supported that assertion. He was more inclined to think that there were those who wanted to get rid of ILO sectoral activities through starvation. Many of his organization's members had become cynical about all the solemn declarations made by governments in recent years and wondered whether the Governing Body and governments really had the political will to implement decisions taken at earlier meetings. He noted little progress in implementing the decisions of international meetings, including those of the 1995 UN World Summit for Social Development in Copenhagen, where health had been given a priority. The ILO had been given a prominent role in the Summit to ensure adherence to basic international labour standards in all sectors and cooperation among all UN agencies, including the World Bank and the International Monetary Fund. Similarly, the Ljubljana Charter on Reforming Health Care, launched by the WHO in 1996, articulated a set of principles requiring health care systems to be targeted on health rather than cost, on people's voices and choice, on quality, and on sound funding. He regretted that the World Bank, the main operator in health reforms, was absent although invited and could not provide the Meeting with a response as to why the reforms implemented by the Bank did not take into consideration recommendations from other institutions such as the ILO and the WHO. In line with the Declaration on Fundamental Principles and Rights at Work adopted by this year's International Labour Conference, the Governing Body needed to do more to ensure real ILO involvement in health reforms carried out by the World Bank, as agreed by the Social Summit, and to defend its position as the constitutionally mandated and competent international organization to set and deal with international labour standards. He hoped that at the forthcoming Governing Body session (November 1998) the Chairperson would be a strong defender of the role of the ILO on this matter.

10. Another observer, representing the International Federation of Employees in Public Service, congratulated the ILO for holding the Meeting and expressed her deeply felt thanks for the invitation extended to her organization to attend. When talking about reforms in the health sector, it was vital to remember its importance given that it employed 35 million people around the world and that it represented a significant component of the global economy, with a serious capacity for employment generation. She noted, however, that less than half the world population in countries at various stages of development currently enjoyed basic health care. The globalization of the world economy and the generalized reduction in public budgets were inducing reforms in most countries' health systems. Reforms were taking different forms, such as privatization, the use of private sector management techniques in public health services or a mix of public and private sector operation of health care systems. However, the key objective of any reforms should be to guarantee equity of access, solidarity between wealthy and poor countries to ensure full coverage in the provision of health care, and efficiency. Reforms also needed to take account of a variety of factors such as new technologies, demographic trends including population growth and ageing, changes in health patterns, and the impact of unemployment increases on labour market conditions. Given that staff costs tended to represent the greatest proportion of health systems' fixed costs, issues related to human resources -- including the balance between doctors and nursing staff, workers' contractual status, current and future training requirements, and equitable gender treatment -- had to be a central consideration if reforms were to be implemented successfully. As reforms in the health sector seemed to go hand in hand with increases in workload, job insecurity and higher work-related risks, it was important to assess the extent to which they impacted on workers' protection. In countries facing economic recession and thus reduced financial resources for health care, reforms had been problematic and had unforeseen consequences. The relative strength of private interests with respect to the public sector had impacted the capacity of governments to implement health reforms successfully in some other countries because of the introduction of ideological factors which ignored technical considerations. The International Federation of Employees in Public Service was a firm advocate of reforms in the health sector to extend coverage of quality services to the whole population on an equitable basis with flexible and effective management. Any such reforms should be subject to the workers' involvement in their planning and implementation to ensure there were no negative effects on working conditions, occupational safety and health and the quality of service and terms of employment of health workers.

11. An observer, representing the International Council of Nurses, welcomed the opportunity to discuss the impact of health reform on health care workers. She commended the ILO secretariat for actively consulting non-governmental organizations during the planning of the Meeting and development of background documentation. She congratulated the staff on the comprehensive nature of the report, and hoped the Meeting's conclusions would refer to and reflect the concrete examples of current trends described in the report. It was of concern that health sector reforms had often promoted cost containment as opposed to cost effectiveness, which tended to interfere with ethical professional accountability, prevented viable career opportunities and blocked the introduction of just reward systems. Recent reforms had furthermore deteriorated the working environment and weakened representation and negotiation mechanisms. She trusted the Meeting would support the basic principle that guaranteeing sound negotiation of health sector issues among the social partners was a fundamental safeguard if services were to be provided so as to meet consumer demand. Sound human resources management, including attractive career structures, and commitment to lifelong learning, were essential to a cost-effective health delivery system. Her organization was committed to support improvement of working conditions and organizational procedures within the health sector.

12. An observer, representing the International Federation of University Women as well as the NGO Geneva Working Group on Women's Employment and Economic Development, congratulated the ILO for its excellent report and welcomed the fact that one of the points for discussion was the impact of health care reform on gender issues in the workplace. Among the fundamental questions to be considered when examining health reforms from a gender perspective were the predominance of women in unpaid work as well as the increasing numbers of older women called upon to provide voluntary health and nursing and child services for the family and all their dependants where economic contribution and health care savings were neither recognized nor compensated. The double burden on work and family impacted on women's hours of work, their access to decision-making positions, career development, and participation in trade union activities. She noted that the UN Development Report had since 1995 identified women as the poorest of the poor because of poor pay and working conditions resulting from an absence of legislative rights to property, land, inheritance, reproductive rights, and an enabling environment. She recalled that, according to the WHO Constitution, education was a prerequisite of health and called for a reform programme to introduce institutional changes to promote an enabling environment for women, with a lifespan perspective. She felt that the ILO should continue its analysis of issues from a gender perspective and systematically disaggregate data by sex and age to highlight inequalities due to gender.

13. Employer members commented on the views expressed by Worker representatives and on the particular situation in one country. An Employer member clarified that nobody in the Government/Employers' group considered health care to be a consumer good. While there were divergencies within the group, particularly as it concerned some governments, whether such a public interest mission should be reserved for the public sector alone, the majority opinion recognized there was a role for the private sector in this public interest mission. Another Employer member reported that there was a tripartite mechanism in his country, Venezuela, where reforms such as those under discussion were decided with the full participation of representatives of all workers, employers and government. A new health service system, to be implemented soon, had just been agreed which balanced adequate workers' compensation and patient care. The system, which was intended to be comprehensive and cover health supervision, housing, pensions and recreation/leisure, aimed at guaranteeing service to the entire Venezuelan population, through a combination of public, semi-private and private sector delivery services. Workers would have the choice of which of the delivery systems to adhere to, depending on his/her health needs, but primary health care and disease prevention would have priority. Gender concerns had been taken into account in developing the system, given the preponderance of women in the health sector.

14. In the course of the discussions, the Worker member and the representative of the Government of the Russian Federation expressed their desire to see the results of the Meeting produced in Russian so as to facilitate access to its contents for all those in countries where Russian was spoken. The Chairperson explained that for financial reasons, the Governing Body of the ILO had decided to produce reports for sectoral meetings in the three official languages of the Organization, English, French and Spanish. Abstracts were available in Arabic, Chinese, German and Russian where there were participants from countries speaking these languages in the meetings. Given the fixed budgets for such meetings, expanding the number of languages for complete versions of the reports would probably mean a reduction in the number of meetings of this kind, a decision that only the Governing Body could take.

Conditions for quality care and successful reforms

15. Worker members addressed the conditions for high quality health care and successful health care reform by defining the concept of good health as a comprehensive state of physical, mental and social health. A more equal distribution of wealth was necessary to underpin these notions, within countries, even the richer ones, and between countries of different socio-economic standing. The Workers believed that reforms were indispensable to improve health care but many had gone in the wrong direction, away from the emphasis placed on primary health care for example by the Alma Ata Conference. Decentralization of health care had led to a loss of managerial control in some countries. Cost-driven reforms, almost ideological in nature and a major theme of the World Bank, reductions in public investments for health care, the obligations of debt repayments and increased privatization had combined to shift more costs to users but did not necessarily reduce overall costs, while creating a two-tiered system which permitted high quality care and wide choice in care providers for those who could afford to pay, and low quality care with reduced provider choice for those who could not. The results included increased mortality rates in some countries, particularly those of children, a general deterioration in the healthiness of populations, and a loss of confidence in the health care system. Moreover, cost reduction reforms were frequently uneven across different components of the system; for example in one country reforms had led to reduced hospital costs but encouraged increased spending on drugs, whereas in another country, drugs were so high now that people could not afford them. Cost-driven reforms also tended to put pressure on the salaries and job security of health care providers, the majority of whom were women. A major dilemma was created by the lack of consultation with health care workers, whose views on the reforms which were necessary or desirable were not taken into account in their design and implementation. Along with education, health occupied a primordial role in social policies for sustainable development. ILO principles should come to the fore in international discussions on desirable reforms, whereas the United Nations had to play a more active role in defining proper health care reforms if it did not wish to become obsolete like the former League of Nations.

16. Worker members felt that health care reform should take into account some key guiding principles, among which:

the need to examine the social determinants of health, not ignoring issues such as the impact of poverty and malnutrition on people's health;
the need for more preventive health care and education on health to address fundamental causes of ill health;
the need to take into account all health care providers' views on reforms -- from doctors to hospital caretakers -- as well as their conditions of service;
the importance of taking agreed principles at national level to international forums for negotiations on the proper nature of reforms, especially social clauses to protect health and workers' rights;
viewing health care as a human right, not as a source of profit.

17. The spokesperson for the Workers' group felt that there were a number of points of agreement with the Government/Employers' group, namely that the definition of health should include the social well-being of the society as a whole, that quality health care should be guaranteed by the appropriate authorities and that it was a right of citizenship. Policy-makers should adopt a set of principles that reflected dignity and equity in the creation, delivery and access to proper health care. If the views of the Worker members appeared to reflect an impatience with reforms, it was because of the reality that they faced in their countries, including the results of market-based processes imposed by the IMF and the World Bank.

18. The spokesperson for the Government/Employers' group prefaced his remarks by noting the enormous progress in medicine coupled with the profound demographic changes in most countries, provoking fundamental modifications in health care. Health care was not a consumer good or commodity, but a right or entitlement. No one in his group was in favour of rationing health care, but rationalization of the services offered was necessary in most countries, notably by favouring preventive medicine even if it led to increases in some expenditures. Overconsumption of health care resulting from pointless expenditures was of no interest to anyone. The Government representatives and Employer members furthermore condemned as unacceptable and immoral the concept of "economic euthanasia" whereby people reaching a certain age were refused care for reasons of cost. The definition of proper health care had to include its physical and mental aspects, as well as take account of the overall reform environment and time span. The Workers were dissatisfied with many current reforms because they saw only the negative aspects emerging from the initial phases of reforms, whereas the benefits would become clear only when the reforms were completed. Measuring the quality of health care required the establishment of reference standards at national level based on which an evaluation of the quality of service could be made by health care peers in each category, not by external sources. In making determinations with regard to quality care and reforms to improve it, patients and their families were not associated enough, nor were health care workers, as distinct from workers in general who should be considered as the users of the systems. To succeed, reforms should not be imposed, associating all those concerned with health care -- users and providers -- with their conceptualization and implementation. However, effective consultations should be based on the notion that governments would participate with users and providers in trying to achieve an agreement in the interests of everyone, not just to hold discussions for their own sake. Moreover, a distinction should be made between public sector health care coverage for those without the means to pay as part of the "solidarity" concept, broad-based insurance coverage such as invalidity and other social security schemes and private insurance schemes providing coverage for the insured. Access to quality health care had to be provided under all these systems; there was no question of introducing a two-tiered system. While health care was a public mission in that it served the public, it did not necessarily have to be delivered by the public service. Though part of the Government/Employers' group supported this concept, the majority believed that competition led to quality and that without competition, quality would plummet. Distinctions should be made between health care providers and health care financers, a role played predominantly by governments, which also had to establish the standards and conditions for the service, but this did not mean that governments had to supply all health care.

19. Government representatives noted different variables affecting health care conditions in their countries. The representative of the Government of the Russian Federation noted that the unprecedented scale of economic transformation in his country had significantly affected access to goods and services, general employment conditions and health care staff salaries. In countries undergoing a transformation from a centralized, planned economy to a market economy, restructuring had proven to be a difficult process involving changes of a profound nature. A course of reforms was being coordinated with the ILO, the World Bank, the IMF and other international organizations, although the social aspects of the problems were considered a lower priority for the international financial institutions. Such problems could not be resolved without a thorough analysis of the present situation in the Russian Federation. A key aspect of achieving solutions to the many-faceted problems would be cooperation among the social partners, based on a better information system or network for the sharing of information within Central and Eastern European countries which could underpin planning and policy development as was requested in the conclusions of the ILO/PSI workshop on health care reforms held in Prague in 1997. The representative of the Government of China agreed that the human-oriented target was an important consideration in guaranteeing quality and accessible health care; the most important practical consideration, however, was that health care should be affordable and sustainable. In his country, emphasis was on affordable access to basic health care for all of the population. China was now committed to setting up a basic social health insurance system covering all employees in urban areas; under this system, three concepts and values in health care had been added to the values and targets defined by the ILO and WHO, namely: basic health care was defined as the best affordable health care; the efficiency of the system rested on the allocation of limited health resources to those who had urgent health care needs; and the principle of equity aimed at allowing the greatest number to enjoy the benefits of health care. Over the past decade, the annual growth rate of health care costs was 20 per cent, or twice the growth rate of GDP. The situation of health care workers was good; their salary, social security coverage and reputation were at levels equivalent to those of other valued categories of public servants such as government personnel, teachers and police officers.

Privatization and the public/private mix of health care

20. The spokesperson for the Government/Employers' group reiterated four key points. First, there should not be confusion between primary health care and that provided in hospitals. The group favoured preventive medicine and access by all to primary health care. Second, the group was opposed to ready-made and supposedly comprehensive, "a to z" plans imposed from outside. Third, evaluation and monitoring of programmes supported by international resources should not be done by international financial institutions, but by professionals in the sector concerned as part of a peer review process at each level (doctors, nurses, etc.), and training should be constructed to facilitate this. Fourth, effective consultation was necessary with those who were directly involved in the health care system with the objective of reaching a voluntary agreement based on a unified understanding.

21. The representative of the Government of Canada noted the diversity in the concept of reform. In his country this was not a common process. There were various degrees of consultation; at the same time the consultative process had been widely used to discuss its implementation in the provinces of his country. Despite the existence of some private aspects outside the nationally insured programmes, there was strong support for publicly administered programmes through organizations such as autonomously run regional health boards. In fact, one of the principles of the Canada Health Act was that insured health programmes be publicly operated and administered. Having them operated and administered by non-profit regional health boards satisfied that criterion. The services did not have to be operated directly by governments.

22. The spokesperson for the Workers' group agreed on the need for an inclusive process of consultation involving all those concerned with health care, but distinguishing nevertheless between the implementation of reform programmes dependent on the individual voice of workers and the regulation of terms and conditions of service to be negotiated with workers' organizations. The Workers' group agreed on the need for evaluation and monitoring as part of the reform process, including treatment of ethical and protection questions faced by workers; they also supported the preventive approach in health care.

23. Worker members spoke about the impact of reforms and their underlying causes in their countries, and the means to ensure greater participation of workers in deciding on them. In some of the poorer countries, reforms imposed by international financial institutions in the framework of non-democratic decision-making processes had gone a long way towards destroying the public health system. A major contribution could be made by donor countries insisting on the full involvement of health care workers in reform implementation. In higher income countries, demographic factors and privatization had encouraged governments to try to make more effective use of the health care budget. Eighty per cent of health care in Japan for example was provided by the private sector, resulting in the highest ratio of hospital beds per capita in the world, and a large surplus of health care providers. This in turn led to the reduction in the number of health care institutions. Privatization had been accompanied by a reduction in the State's responsibility to those services which were politically important, standards were being lowered and maintenance of financially non-viable and community-based health care services was threatened. Tensions emerged between management objectives and user needs in such scenarios, leading to cost reductions and employment changes which lowered health care workers' motivation and service quality. In middle-income countries such as Argentina, private insurance companies had skimmed off the high-income, low-risk workers, shattering the solidarity concept which underpinned universal coverage. As a result, a large proportion of workers had no access to health care systems. The public/private mix in countries such as South Africa, where 61 per cent of the total expenditure in health benefited 20 per cent of the population, had reduced access to health services and staffing levels. Moreover, the workers had not been involved in policy formulation and implementation. The Worker members felt that the responsibility of governments should be restored at the appropriate level by use of councils or other consultative forums which would include all stakeholders in policy decisions, especially users and providers, thereby establishing the limits and the direction of reforms. Workers organized through trade unions should also take a more direct role on hospital boards and district health care authorities.

Access to health care

24. The spokesperson for the Government/Employers' group noted that equal access to health care was still a reasonable objective for some countries and yet utopic for others, although there existed inequalities with respect to access to health services in almost all countries. A major issue was whether state financing of health care and social insurance should be on an equal basis, irrespective of whether or not a patient could pay for his care, or whether there should be differential treatment with those who were better off paying more for treatment. There seemed to be little consensus on these questions, although it was known that patients who were unable to pay for health care were more likely to seek treatment in the emergency room. Provision of basic primary health care for the population as a whole was the main concern of developing countries and countries in transition. A national solution was not possible; therefore projects and partnerships with donors and international agencies were needed to develop adequate health care systems. Projects should be comprehensive and include training. They should also be monitored and evaluated not only by those providing the finance, but by the health care professionals concerned at all levels.

25. The spokesperson for the Workers' group considered that there should be more consultation and cooperation between international agencies such as the ILO, WHO, IMF and the World Bank, not just on reforms but on health care programmes in general. Normally the process between the World Bank and governments did not involve workers or consumers. The ILO should definitely have a role in the process of structural adjustment, especially as reductions in domestic expenditure practically always occurred as a result. Often health care reforms were experimental and so should involve more participation of the consumers and workers. Another issue to be addressed was the migration of health care professionals to industrialized countries and the subsequent depletion of resources available to developing countries and countries in transition.

26. An Employer member noted the encouraging results in Morocco in the provision of primary health care, especially prevention programmes and vaccination campaigns. This had mainly been achieved through health care centres staffed by physicians and dispensaries run by nursing staff. However, the benefits of technological developments in health care were concentrated in private hands in cities and so created a disparity of access to care. In improving health care access in developing countries, he considered that taxes played an important role. For example, value added tax on medical treatment should be lifted as it increased the cost of health care. Also, investment incentives should be applied to the health sector as in other economic sectors. Social and tripartite dialogue was very important in extending health care coverage in developing countries, as long as the parties were genuinely ready to find and implement solutions. International organizations had an important role in encouraging investment in the health sector, not only in the public sector, but also in the development of the private sector.

27. The representative of the Government of Slovakia noted that health reforms in countries in transition were taking place in a context of radical change in the political systems, including the financing, organization and structuring of health services. This meant that the health care system was perhaps changing far more quickly and having a more serious impact on the population than in other countries. Since 1991 there had been a positive development of the social dialogue process in confronting common problems and collective bargaining had led to written agreements. International meetings such as this were helpful for the countries in transition.

28. A Worker member expressed strong reservations about proposed health reforms in Bulgaria in a situation where 80 per cent of the population was already living below the poverty line. Under the reforms only emergency and psychiatric care services would operate according to the principle of public responsibility and the population would face a shortage of services in other areas such as the early diagnosis of diseases and long-term care. She indicated that this would be a violation of the Ljubljana Charter.

Employment perspectives and qualifications

29. A Worker member, speaking on behalf of his group, stated that the employment perspectives were less than satisfactory given recent trends marked by declining levels of employment, expanded subcontracting, outsourcing and flexitime, forced migration of health care staff to better prospects in other countries, stagnant salaries, increased working hours, and a diminution of the rights of workers. The health sector was particularly sensitive to changes in social policy, and it was important therefore to ensure stable employment in order to retain experienced professionals and as a basis for their professional development. Accordingly, international standards applicable to health personnel, including staffing ratios proportionate to the country's capacity and establishment of qualification levels, should be respected by public authorities, and the State should play an important regulatory role in the private sector, especially in terms of conditions of service and dispute settlement. Workers' organizations had to be intimately associated with the adoption of reform programmes.

30. The spokesperson for the Workers' group further stated their belief that a framework for discussing proper staff ratios and conditions was embodied in the Nursing Personnel Convention, 1977 (No. 149), along with the conclusions of the First Session of the Standing Technical Committee for Health and Medical Services (Geneva, 1992). The personnel of health service systems formed a team, and the uniqueness of such systems suggested that there could not be an effective private/public mix in delivery. For instance, dietary, cleaning, maintenance and laundry staff were an integral part of the delivery system; they should enjoy the same rights as other personnel, although employers often viewed them differently. The market forces at work exploited professionals within the system, as did competition among nations for trained personnel and organized immigration programmes which imported skilled personnel from abroad. The ILO should pay attention to these phenomena through the adoption of standards or agreed upon policies. Cross-training had become prevalent in the health care system, whereby training was broadened for some classifications, although not always appropriate, while pay and benefits commensurate to the new status did not measure up. Such practices were detrimental to the individuals concerned, and downgraded the status of others whose functions were shifted to the upgraded staff. The Workers were concerned about the trend towards part-time, temporary and contingent workers in the health field, as well as individual worker contracts. The transformation of full-time jobs into part-time and casual jobs with reduced benefits for cost rather than quality of care reasons, be it in the public sector or in private health care services, inevitably had an impact on the patient care system. It also impacted on workers' rights and benefits in those countries where collective bargaining agreements conferred certain benefits on full-time workers. Part-time, temporary and contingent workers should have the same protection as full-time workers in the service; just because their work was defined on an hourly basis should not lessen their rights. Moreover, part-time work should not be imposed on workers. The protections were best achieved through a collective bargaining relationship with the employers. Unfortunately, many cases could be cited where health sector workers did not benefit from international labour standards. His remarks were reinforced by a Worker member who contended that the integrated teamwork concept was an essential element of the preventive and holistic approach to health care delivery. Examples abounded of the adverse consequences when profit supplanted standards as subcontractors cut corners, for instance in the declining levels of cleanliness in many hospitals where it was said that people went to get sick, not well. The drop in conditions of service and salaries of health care workers caused by subcontracting worked against the required teamwork.

31. The spokesperson for the Government/Employers' group felt on the contrary that employment perspectives were not all that negative as far as the numbers were concerned, but subcontracting obviously conferred a new context. Managerial responsibility for health care delivery and technological progress created the need for subcontracting, but a distinction had to be made between direct health care activities and logistical support. The first had to be carried out by the responsible health care providers, individual or institutional, according to the standards and contracts defined by public authorities, although again, these could be public or private. The logistical activities which in the view of his group did not form part of the basic skills and trades exercised in a public health institution -- laundry, catering, cleaning, etc. -- could be subcontracted, but here also in the context of standards and contracts defined by the public authority. This distinction did not imply any discrimination in rights for staff in a particular job or occupation which was subcontracted. His group agreed that the right to consultation and participation in management by all those who were responsible for health care in an establishment should be respected, and in that regard felt that health care workers were sufficiently covered by international standards. There was not necessarily unanimity in the group on the question of collective bargaining. Another matter which should obviously not be ignored was the "brain drain" of skilled personnel from some countries. Part-time work, and indeed precarious work in the health sector, however vague this term might be, was a fact of life, yet their circumstances differed significantly. Short-term contracts should be accompanied by full social protection benefits, irrespective of the public or private nature of the employer, including for those workers holding jobs which were being shifted from civil or public service to private status. Part-time workers should enjoy benefits on a proportional basis to those enjoyed by full-time staff. It was important to preserve voluntary part-time options because they were in demand by certain staff, not the least in the public service, since they allowed workers to reconcile work and study obligations for example.

Gender issues

32. The spokesperson for the Government/Employers' group did not deny that the health sector workforce was predominantly female, nor that for a number of women, their careers were cut short or altered by marriage, childbirth and family responsibilities. In addition, women were often relegated to less well-paid posts. For some members of his group the reforms increased the negative impact on women but for the majority of the group the conclusions of the First Session of the Standing Technical Committee for Health and Medical Services on this question were still relevant.

33. A Worker member, speaking on behalf of his group, recalled the basic principle that discrimination on the basis of gender should be opposed because it was unfair and counterproductive. Unfortunately, retrenchments in many countries following health sector reform, including subcontracting, disproportionately affected women. Qualifications, relevant experience and meritocracy should be the defining criteria for decisions on employment, although given the subjective nature of the concept, pay and promotion based on merit should be defined within the context of a collective bargaining agreement which defined the criteria for merit. Women also suffered from violence at work, particularly in psychiatric hospitals and during night and weekend duties in many institutions when staffing levels were at their lowest, a direct consequence of reforms which had reduced staff ratios. In some countries women employees had been raped. Sexual harassment at work was another problem. Since the health sector employed more women than other sectors, special arrangements should be made to help resolve the difficulties previously mentioned, as well as the burdens of family responsibilities. Such arrangements could include redesign of jobs, working hours and shift patterns, provision of childcare facilities and leave arrangements such as the childcare sick leave, unpaid leave in the formative years of child development with guaranteed job retention, and voluntary part-time work options based on collective bargaining agreements. The Governing Body of the ILO should strongly urge member States to adopt measures which would effectively apply equal rights and opportunities for men and women health care workers.

34. Worker members furthermore pointed out the specific consequences of some reforms in developing countries. Health care commercialization through for example, user charges, had negatively impacted on female workers and patients in many African countries. Such charges should be excluded in maternal and child health services. Nurses in particular needed special workplace protection because of their close and constant contact with patients, particularly in high-risk situations of viral and bacterial contagion. In China, where women were the mainstay of the health care sector, representing two-thirds of those employed, changes in the socialist market economy had increased competition which in turn impacted on women's employment. Trade unions should take a more active role in the reform process to mitigate the negative impact on women through such measures as those adopted in China, namely: collective bargaining agreements regulating employment conditions, rights and duties of workers; active participation in the health care delivery and extension through employee meetings; and the promotion of non-discriminatory legislation, such as the applicable legislation governing the nursing profession and the soon-to-be applied law concerning physicians.

Salaries and working conditions

35. A number of Worker members highlighted the negative effects of restructuring and reforms on health care and social services sectors in various countries. In Finland, reforms had commendably aimed at developing less expensive non-institutional health care to support home-based care in part as a response to the rise in demand related to an increase in incidences of HIV/AIDS infection. However, restructuring had compelled personnel transfers, and necessitated partial retraining and staff cutbacks, which had been aggravated by severe economic recession experienced at the beginning of the 1990s. The rate of unemployment in the sector had oscillated between 7 and 12 per cent during the period and currently stood at 7 per cent. Another consequence of the reforms during a period of economic slump had been a rise in the proportion of part-time, short-term and fixed-term employment, as a result of which health workers on short or fixed-term contracts were now estimated to represent 30 per cent of the total workforce in the sector. Constant short-term contracts had eroded job security, incomes, job satisfaction and a rise in labour emigration.

36. In the Russian Federation, reforms in the health care sector had even graver results with respect to workers' safety and health, their incomes and general working conditions, and impacted negatively on patients' welfare. Over the previous year, incomes of health care workers from auxiliary staff to doctors had declined three times their previous levels, or to an average of about US$30-40 per month. Worse still, over the previous three years even those meagre salaries remained unpaid for as long as from six to nine months. Unable to support themselves and their families, health care workers had increasingly resorted to strikes, hunger strikes and even suicide. The Health Workers' Union of the Russian Federation had submitted a complaint citing the Government's violation of the Protection of Wages Convention, 1949 (No. 95), and hoped the ILO would apply appropriate pressure to induce the Government to respect its obligations under international labour standards.

37. Similar problems existed in Argentina and other Latin American countries resulting from market-oriented conditionalities imposed by the World Bank and the International Monetary Fund as a prerequisite for support to health sector reforms. Parallel labour market reforms, also dictated by the same institutions as a condition for financial assistance and unsuccessfully resisted by workers, essentially eliminated collective bargaining arrangements which were replaced with precarious contracts without social security, on which approximately 95 per cent of employment was now based, including in the public sector. The increase in precarious employment in the health sector had seriously affected quality of services. The interplay among the reforms, the effect of wage deflation, and geographical income inequalities all had a negative impact on the sector.

38. A Worker member observed that, contrary to what appeared in the ILO report, health sector reforms had severe consequences in Niger, especially with the return of a military Government in 1996, and restrictions on personnel recruitment to an expected 260 posts per year. Working hours had dramatically increased while wage cuts of about 40 per cent had been imposed unilaterally by the Government. For example, despite the extremely low average salaries of about 330 French francs per month for a certain category of nursing personnel, many went for months without being paid. Following a series of strikes, the Government had agreed to give compensation for risks incurred with effect from 1 January 1998. It had since reneged in the agreement citing World Bank and IMF pressure as an excuse. Further strikes were planned to compel the Government to respect international labour standards, and especially to acquire the right for health care workers to work a similar number of hours as other public sector personnel. In view of the serious likelihood that such action might result in perilous consequences, including imprisonment of striking workers, it was hoped the ILO could assist by writing to the Government to induce it to respect its constitutional obligations.

39. The spokesperson for the Workers' group re-emphasized and amplified on a number of points made by previous speakers. The Workers' main concerns related to radical changes in the process by which health care was delivered in both the public and private sectors: there had been a trend to longer shifts; higher growth in accumulated overtime; poor quality of service delivered; and increased worker morbidity, temporary disabilities and job-related fatigue. He considered many of these problems to be a result of poorly planned delivery systems as, in some cases, the number of overtime hours could have been converted into thousands of full-time positions. It would be desirable for the ILO to review the question of rational shift schedules most appropriate for effective health care delivery, and the extent to which the issue of pay and benefits were a factor in how shifts were scheduled and staff ratios were set. As a final point, he urged the ILO to take up the issue of non-payment of wages in the countries which had been cited as this was a clear violation of existing international labour standards.

40. The Executive Secretary of the Meeting responded to a number of remarks and suggestions made by previous speakers with regard to the report prepared by the ILO or possible future action. The situation as reported in Niger reflected what had appeared in a questionnaire completed and returned by the Government. The Workers' comments which contradicted these as to the real situation had been duly noted. Concerning the request for ILO action to induce the Government to respect the provisions of international labour standards, a sectoral meeting was not the appropriate channel to address such problems. However, a well-defined mechanism and procedures for submission of complaints in such situations existed, and the Office would willingly provide the necessary information.

41. The spokesperson for the Government/Employers' group reiterated their view that reforms presupposed consultations among all those involved in the health sector, including on the establishment of programmes with specific objectives. There should be no question of comprehensive reforms being imposed even at the behest of international bodies like the IMF or the World Bank. It was important, however, when assessing the effect of reforms on the health sector to separate these from situations where the general economic conditions of a country were catastrophic, as it would be surprising if the health care sector was at the same time flourishing. Reiterating previous comments on part-time work, nobody could oppose the right of part-time workers to benefits proportional to those of full-time workers. In response to suggestions to ban part-time work, he recalled that it existed not only for economic but also for social reasons. Part-time work, if introduced, should be only on a voluntary basis. In his country (Belgium), the trade union movement had initially refused to discuss terms and conditions of employment of part-time workers for a number of years. Eventually, however, the practice had become so widespread that a standard on their status had to be negotiated that could be applied to a series of sectors.

42. An Employer member observed that, while employment practices in a given country might act as a guide to other countries, these should not be taken as a standard. In Venezuela, for instance, reforms were working satisfactorily to the benefit of both workers and those who made use of the health care sector, and the country was working harmoniously with the international financial institutions on those reforms.

Stress and violence in the workplace

43. Worker members addressed the issue of stress and violence in the workplace, their influence on performance and motivation as well as possible ways to reduce them. In Finland, for example, rapid budgetary cuts had resulted in recourse to atypical working time arrangements as well as short-term contracts and, together with a constantly changing workforce, had contributed to work-related stress. There was also heightened anxiety at the workplace stemming from an escalation of psychological violence and bullying. In Niger and to a certain extent in Tunisia, on the other hand, stress and violence arose from other factors, even though they were also related to a lack of resources. The freeze on recruitment in the health sector in a country with a fast-growing population had resulted in a tremendous increase in workloads for existing staff. Unduly long working hours for meagre pay combined with ill-trained and incompetent supervision had exacerbated work-related stress. Following reforms, health care, which used to be extended free of charge was now paid for and patients and their relatives were more demanding and less appreciative of the services received. In such cases, frontline health care workers tended to bear the brunt of dissatisfied patients and their families, sometimes to the point of violence. In addition, there had been occasions where disgruntled patients created serious problems for health workers through their connections with senior government officials and other influential people. It was noted also that stress could be the result of unpunished violence exercised by a superior in relation to a subordinate through various forms which could be physical, psychological, verbal or through sexual harassment. All these phenomena, which were frequent and inevitable consequences of reforms in the health sector, had increased work-related stress and detrimentally affected workers' family life. Worker members considered it imperative for the ILO to address these problems by getting governments to face up to these issues.

44. The representative of the Government of Canada agreed that, while stress was pervasive today in all aspects of society, reforms had added a certain amount of stress on people at all levels in the health system. Where, or to the extent that excessive stress impacted on performance and therefore the quality of service provided, he believed it was necessary to come up with some mechanisms to help workers to cope. There was similarly a responsibility to promote a workplace of equal opportunity and dignity at work, be it through educational mechanisms or other measures, where violence or harassment of any sort would have no place.

45. An Employer member felt that the problems of stress and violence were distinct and should be discussed separately. Stress was intrinsic to the job and affected everybody throughout the organizational structure, regardless of the sector. Employers considered stress to be inversely proportional to the professional experience of the person concerned, which might best be addressed through basic training courses on stress management. From his own experience with urban transport drivers in his country, violence tended to be external to the institution rather than among fellow staff. However, as violence was basically a societal problem it was difficult to come up with a solution specific to the health care sector.

46. The spokesperson for the Workers' group welcomed the remarks made by the representative of the Government of Canada admitting the need to deal with stress and violence to the extent it existed. The problems were not a public sector phenomenon, but rather a health sector phenomenon which the ILO report adequately documented. He noted that injuries and violent incidents in the sector were the third highest after construction and mining. For example, handling of needle sticks was not an automatic stress-producing variable in the workplace, but the stress associated with the possibility of contracting HIV as a result of under- staffing and dealing with an infected patient on a one-to-one basis was a real by-product of the workplace and workforce design. There was a responsibility to develop procedures and processes to at least give the highest measure of protection and comfort to the worker and the patient and not dismiss the problem as a societal issue. External acts of violence could be dealt with as a security matter, but internal factors, such as proper patient/staff and shift/staff ratio ought to be addressed as well. The ILO had a responsibility to examine violence and determine whether it could be addressed so as to establish clearly the respective responsibilities of all parties.

47. Another Worker member considered that racism was a form of violence. He noted that stress, physical and mental violence, and racism all increased during reform processes which resulted in reduced staff levels. The negative impact on performance, as retention of staff became more difficult and levels of illness increased among personnel, was detrimental for patients and costly to health services. It was up to employers and governments in particular to ensure that the management process and ethos left no room for doubt that racism was unacceptable at the workplace. Further, if the management process did not challenge apparent racism, it was in effect supporting it. He pointed out that black British nurses took far longer to be promoted than those who were white, and suggested that the ILO could share good practices which addressed the problem of racism.

48. The spokesperson for the Government/Employers' group agreed on the necessity to fight racism. However, it was not just up to the employer, but also the government and trade unions as employers maintained that the problem of violence was a societal one not specific to the health sector.

Training and retraining

49. The spokesperson for the Workers' group stressed the importance of training as a means of providing better patient care. It was also essential to be able to forecast employment needs and for cooperation among the various entities to avoid massive shortages in the future. In the promotion of training, the emphasis needed to be placed on continuous training and education which should be developed jointly by workers and employers to ensure that it was appropriate. It was imperative that workers' organizations were involved in planning and implementation of training processes.

50. The spokesperson for the Government/Employers' group stated that training had to include training for change and had to be on a continuous basis. In fact this really had to be an absolute obligation in a sector such as health care. Measures needed to be developed to address the problem of the brain drain from developing countries and countries in transition. He considered that retraining was part of lifelong continuous training. Workers had to realize that this was indispensable throughout their careers. To ensure quality care, training had to be organized, supervised and evaluated by peers in the health care sector. Special attention had to be given to training with respect to career interruptions which particularly affected women re-entering the labour market. He agreed that consultation was essential in the development and implementation of training plans.

51. Several Worker members pointed to problems in their countries. In Bulgaria, under the pressure of the IMF and the World Bank, doctors and nurses were being required to shift from care requiring a high level of qualifications to general care. This amounted to career regression and not career progression. In Niger, under World Bank and IMF conditions for health care reforms, a five-year embargo had been placed on training for health care staff on the grounds that there were insufficient schools in the region and subregion. How then could health care services be effective without training of personnel? The ILO should intervene with the World Bank, WHO and IMF to impress upon them the need to preserve training programmes. In Sri Lanka there was a lack of professional and higher education facilities for health care staff and an inadequate supply and poor distribution of resources. Selection needed to be better organized with properly formulated recruitment criteria and political interference eliminated. Initial training, in-service training, scholarships and study tours were important training components to ensure efficient health care services. Career development schemes needed to be adapted to motivate and develop staff.

Managerial professionalism

52. The spokesperson for the Government/Employers' group stated that times had changed: the former approach based on set budgets and administering health care had been replaced by one where managing and investing in health care services and human resource development required modern management tools and an interdisciplinary and multidisciplinary approach. It was not just a question of financial or logistical management but of human resources management and health care delivery. To achieve this, all those concerned had to be involved. Training and career development had to be such as to equip people with the necessary skills to manage and deliver health care services in the future.

53. Worker members emphasized how crucial it was to strengthen the training of health care managers and to recognize that professionalism in management was basic to modernization and reform, particularly in health care. In Italy, experience had shown the importance of management training for the successful implementation of adopted plans and guidelines. Management training was not just an issue in the private sector; the public sector in Italy had adopted private sector methods but remained public. In Chile, the delivery of efficient and effective health care services was linked to improved public health management and strategic planning. It was important, however, that management training be participatory, involving directors and users of health care services, be they public or private.

Labour relations

54. The spokesperson for the Government/Employers' group stated that reforms would be successful only if people received information continually, were regularly listened to and questions were answered. All concerned had to be fully involved. He was opposed to imposed reforms, not only from outside but also from within an establishment. It had already been said that public services did not necessarily have to be delivered by the public sector itself, and in fact as regards industrial relations, sometimes collective bargaining was not possible in the public sector. On the other hand, in certain countries, particularly those which had ratified the Right to Organise and Collective Bargaining Convention, 1949 (No. 98), the private sector had elaborate systems for bargaining and industrial dispute settlement. Once an agreement was signed it had to be implemented, while in the public sector consultations could be held but afterwards the employer was free to approve or not any joint recommendations. Therefore, the private sector in many ways resulted in greater guarantees for the workers and their representatives. Also, in resolving conflicts, systems of conciliation existed in the private sector which allowed for a third party, if necessary, to assist in finding solutions, which was often not the case in the public sector. That being said, it was important that constructive dialogue occurred on the question of health care sector reforms in order to obtain the workers' support and that of their representatives. He stressed that the Government/Employers' group supported the principle of consultations and agreement.

55. The spokesperson for the Workers' group underlined the problem that in reality in many countries, including his own, the United States, the private sector was not well organized and employers did as they pleased. In the public sector there was a hodge-podge of laws, regulations and ordinances. Enormous changes had been taking place in the health care sector with virtually no input from the workers and their representatives. The expectation of the workers was to have a voice in the processes that directly affected the reforms and delivery systems in the health sector. Yet the daily reality of workers and their organizations was that many governments did not accept the notion of the right of employee organizations to have a voice anywhere in the process of reform. There were in fact few examples of constructive dialogue and negotiation.

56. Several Worker members echoed these remarks, stressing the importance of organizing broad dialogue between the government, political groups, workers' and employers' organizations, and health care professionals as a basis for formulating health care policies and implementation. This was lacking in many countries. A particular problem for the Central and Eastern European countries was replacing the former communist ideology with today's liberal ideology. Many of these countries had not ratified ILO Conventions. Often employers' organizations were not representative or were dependent on the State, and had difficulty to play their role in an industrial relations framework. Throughout the world the health care environment was constantly changing and so reforms were ongoing due to political, demographic or technological change. The best reforms were those which were "home grown" and developed through social dialogue, and not imposed by outside bodies such as the World Bank or imported from other countries. Implementation of reforms was best done through partnerships between workers and employers and the government had to be prepared to listen to their experiences and adapt its views accordingly. It was also important for trade unions to recognize the difficult economic situations countries were facing, and that they work towards being seen as part of the solution, rather than part of the problem. Negotiated agreements with trade unions respecting their rights and working conditions constituted the best way to prevent conflict. The ILO should assist by encouraging governments to recognize trade unions and develop mechanisms for resolving disputes. It could also disseminate information on positive models of cooperation; in Canada, for example, major restructuring in one province involved a negotiated agreement between all health care unions, the provincial government and the health employers' group. It was agreed to reduce a fixed number of positions in hospitals and to expand community care instead. There was to be no overall decrease in funding of health care, and no expansion of contracting out or shift from public to private sector in the guise of reform, while a reduction in working hours with no loss in pay formed part of the agreement. Very importantly, workers who would lose their jobs in one area of health care would be redeployed to another area with retraining provided. A labour adjustment agency was also established involving employers, the government and trade unions to oversee the restructuring process. This example in Canada reflected the recognition that health care workers were the most valuable resource in health care and their needs and rights had to be protected.

Ethics and accountability

57. Several Worker members addressed the relationship between professional ethics, accountability and the employment relationship by emphasizing the necessity of sharing the responsibility between employee and employer in terms of professional, legal and financial issues, as well as safe and efficient patient care. Among other prerequisites, authority relationships in health care provision would have to be transformed. Governments, and at the international level the ILO, had a responsibility respectively to adopt or advocate policies which ensured quality patient care acceptable to consumers. Consumers of health care should have guaranteed protection against malpractices which constituted medical hazards or negligence, preferably through a body responsible for public protection composed of an equal number of representatives of health care professionals, government authorities, workers' organizations and consumer representatives or civil society. Charges of malpractice by patients, assisted as needed by the body charged with public protection, should be directed at the company or institution concerned, with the employing authority ultimately responsible to respond on the negligence charges. Institutions should be responsible for ensuring the necessary facilities and care to avoid workers being made the scapegoats for omissions or commissions by employers, which was too often the case. Health care providers in developing countries faced other dilemmas: whether to pay for the care of indigent patients out of their own salaries as required by institutional regulations or refuse care, putting them into conflict with their professional ethics; whether to ration drugs which were in short supply or pay for them; and what to do about victims of civil or foreign conflicts when treating them would put the providers in conflict with their own authorities. The ILO and WHO should urge States to meet their international treaty obligations and, together with health care providers, ensure good care. A Worker member felt that a major contribution to confronting the black market in countries in transition to a market economy would be the creation of an international database which could underpin expenditure indicators for health care; a minimum of 5-6 per cent of GDP and not less than US$400-600 per capita was suggested as a target.

58. A Workers' adviser pointed out the experience in her country, the United Kingdom, where reforms which created markets and competition between health providers had been removed because they had failed dramatically. In this respect the ILO report was inaccurate by suggesting that elimination of reforms had led to enhanced competition, whereas their elimination encouraged provider units to work together, not against each other. The counsel to be patient in the reform process demonstrated a failure to listen to the ethical and professional dilemmas that health care professionals faced at human level on a daily basis. As standards of care deteriorated, providers were turning away patients and discharging them from institutions earlier than advisable. Market reforms had been used by employers to institute gagging clauses to force health professionals to remain silent about these conditions, placing them in a double-jeopardy situation between their professional responsibility to voice their concerns and the threat of discipline, including dismissal by their employer if they did so, and discipline by the regulatory body for violation of standards governing their profession if they remained silent. The ILO could offer technical advice and assistance to ensure that employers and governments include codes of professional conduct in the policies and procedures of all employing authorities. The statutory regulatory bodies governing the profession should be able to give rapid advice to professionals in such situations, and their legal remits should be altered to permit comments on employers, specifically the faults within the health care system that created the dilemma for practitioners, rather than making judgements and placing blame on the health care worker.

59. The spokesperson for the Workers' group stated that such dilemmas underscored the need for both a health workers' protection policy, those who were "whistle-blowers" of violations, and for a patients' bill of rights. His group did not condone the actions of incompetent workers, nor that contractual obligations should be used as a hedge against sound professional standards. Rather the systems were increasingly placing workers in an unprotected position, and he cited as an example the conflicts between directions on care issued by clerks and accountants in managed care systems, and the professional standards of care providers which were in direct contradiction, leading the latter to counsel patients to forego their litigation rights in some cases. Based on the conclusion that both health care professionals and patients had rights in the changing health care environment, legislation was in the works in his country, the United States, to deal specifically with patients' rights.

60. The spokesperson for the Government/Employers' group clarified that members of his group were not advocating that one wait forever to see the outcomes of reforms; if patients were not being treated properly it would not take millions of deaths to provoke governmental or employer action. He disagreed with the idea put forward by a Worker member to make employers responsible for decisions about negligence by a care provider. Such decisions were very complicated in any sector so great care should be taken before adopting a policy like this. Ethics ultimately involved both civil and criminal law. His group agreed that health providers should benefit from measures protecting their independence, and which gave them freedom of conscience. In situations of conflict over complaints or requests concerning proper care which involved patients, care providers and employers, the care provider should make a decision based on the best interests of the patient. Governments had the responsibility to ensure care to those who needed it by the most appropriate measures, but the providers should have the necessary latitude to meet their obligations. In a conflict between ethics and rules, ethics should prevail.

61. An Employer member agreed that workers needed protection but that such protection assumed that the worker was performing as a professional. He noted that in some countries such as his own, Venezuela, workers made use of collective agreements to avoid their responsibilities, and reforms to correct this problem would be fully in place by 1 January 2000.

ILO assistance in the reform process

62. Worker members, speaking on behalf of the Workers' group, said that it was essential for the ILO to play a basic role in pointing out the dangers of reform and where these might violate workers' rights to avoid situations such as in Chile, where a World Bank-assisted reform begun under the military Government had been a complete failure. This technical assistance role of the ILO, and that of the WHO, would be a valuable counterpoint to that played by the IMF and World Bank, whose acknowledged financial development role should not spill over into technical aspects of reform, especially when it did not respect the individual characteristics of countries. An ILO priority should be emphasizing to governments and to international financial institutions the need to involve workers' organizations in all aspects of planning, management and implementation of reform, to the point of making this a donor conditionality for funding. In line with this work, the ILO could also help to strengthen workers' organizations through capacity building, and apply pressure on employers to recognize workers' organizations.

63. The spokesperson for the Government/Employers' group stated that the ILO should assist countries to improve health care quality, and especially in transitional and developing countries, to develop primary health care, as well as to update social and labour legislation related to the health sector in these countries. The ILO should set up technical cooperation programmes in areas such as human resource development, and pursue regional follow-up action in the form of workshops. Cooperation with other international organizations should be strengthened. Another joint meeting should be held in a time span shorter than six years, in order to examine in greater detail one or two specific issues. A study by the ILO on the problems posed by the huge range and diversity of skill and qualification requirements in the health sector would be extremely beneficial.

International labour standards and health sector reforms

64. The spokesperson for the Government/Employers' group declared that there was no need for new standards. Standards already existed, they simply should be applied. With the application of standards such as Conventions Nos. 87, 98, 149 and 151 there would be fewer problems. A useful contribution in the current reform process would be a review of the application in member States of specific aspects of Convention No. 149, as was done in the form of observations by the Committee of Experts on the Application of Conventions and Recommendations in 1990 and 1994.

65. The spokesperson for the Workers' group noted the common ground with the Government/Employers' group on the positive benefits in this period of transition if key Conventions were applied. He referred to Conventions Nos. 87, 98, 149, 151, 157 and 159 and to the new Convention proposed on the worst forms of child labour, extremely important in relation to the surgical instruments manufacturing industry in Pakistan as these were used in hospitals all over the world. As mentioned by another Worker member, the ILO should take actions that would encourage governments to respect their obligations under ratified Conventions. The work on standards and technical assistance should benefit from a coordinated approach among a number of ILO departments, regional offices and multidisciplinary teams, and from an investment of resources in follow-up activities equal to that applied to the convening of this Meeting; it should not be subject to an uncertain budgetary process within this institution. Another meeting on health care should be held because of its global importance, focusing on the development role of the social partners in the health services. In that context the Meeting could look at the following sets of issues: ethics, professional conduct and professional standards such as staff/patient ratios which had a direct impact on working conditions; the development of managerial capacity, and the effectiveness of a social dialogue in different situations and with different procedures; and continuing education and training in relation to change and improved relationships with public and private employers.

Consideration and adoption of the draft report
and the draft conclusions by the Meeting

66. The Working Party on Conclusions submitted its draft conclusions to the Meeting at the latter's sixth sitting.

67. At its sixth plenary sitting, the Meeting adopted the present report and the draft conclusions. The representative of the Government of Switzerland expressed his reservation about the use of the word "immoral" to characterize rationalization of health services, at the end of the third sentence in the first paragraph of the conclusions; it was appropriate to state facts but not to make judgements in a text such as this one. The representative of the Government of Sweden opposed the reference in the last sentence of paragraph 12 of the conclusions to health care as a "basic human right"; in his view, the appropriate wording was "basic civil right" and he therefore expressed his delegation's reservation with regard to the term used.

Geneva, 25 September 1998.

(Signed) Mr. L. Serfaty,
Government/Employer Vice-Chairperson
of the Meeting.

1. Adopted unanimously.

Conclusions on terms of employment
and working conditions in
health sector reforms⁽¹⁾

The Joint Meeting on Terms of Employment and Working Conditions in Health Sector Reforms,

Having met in Geneva from 21 to 25 September 1998,

Adopts this twenty-fifth day of September 1998 the following conclusions:

1. Medical and technological progress as well as demographical change are leading inevitably to higher costs of health care. Many reform initiatives in health care have the objective of cost containment and may lead to rationalization. However, rationalization of health services, which leads to the exclusion of certain population groups from health care or from certain health care services because of cost-benefit analysis, is immoral. Health care reform efforts should foster primary care and preventive medicine for all, improve quality of care and create better work conditions in this area.

2. The provision of health care for all must be in the public interest. This does not necessarily mean that health care must be organized and implemented by public services but that it can also be provided on a private basis. Health care is not a commodity and thus not a tradable good.

3. Health care reforms cannot be imposed from above or from outside. They are most likely to be successful if they are implemented in effective and efficient concertation with the representatives of workers. In the course of this concertation, all parties should endeavour to achieve the largest possible consensus. Where collective bargaining arrangements exist, these should be respected.

4. 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. In industrialized countries there is a need for better distribution of health care services. This includes public responsibility to guarantee solidarity for all. In developing countries the main objective is the provision of health care services for all. There are large differences between industrialized and developing countries in the possibilities to finance health care. Self-reliant solutions in developing countries have not yet been found. Thus there is a need to develop partnerships in order to ensure the provision of quality health care. International organizations should assist developing countries in specific projects including training of health care staff, subject to peer evaluation and monitoring.

5. The health care sector is highly feminized, with women predominantly concentrated in low-paid jobs, which makes them more vulnerable. Major obstacles result from the fact that careers are often short and frequently interrupted. These facts influence the ability of women to compete for access to higher quality and better remunerated jobs. The Meeting endorsed the conclusions on equality of opportunities of the ILO Health and Medical Services Meeting of 1992.

6. Part-time work must always be protected and have proportional entitlements. Employees with fixed-term contracts should also enjoy social protection. Working conditions in health services have deteriorated in a number of countries in the course of reform processes. Health care workers in certain developing countries and countries in transition earn very low wages and the delay of payment of wages can amount to several months. This entails negative social consequences and has in general serious effects on the economy and the quality of services. Wages should be paid regularly to all workers, including health workers in accordance with the ILO Protection of Wages Convention, 1949 (No. 95).

7. Health care workers are particularly exposed to certain forms of stress and violence since they often have contact with people in distress and the large share of female health workers intensifies the problem of sexual harassment at the workplace. Health care reforms may aggravate this situation. There is a responsibility of governments and employers to create safe workplaces. Workers, including health care workers, may also be subject to racism at the workplace. This is unacceptable. Employers, workers and governments have the responsibility of fighting against racism at the workplace.

8. Basic training, lifelong learning and continuous training are essential for the maintaining of the quality of the services provided and for career development. Further training must be particularly provided for health care workers re-entering the service after a break. Training should be an obligation for both employers and workers. Workers' organizations should participate in the design and implementation of the training process. An evaluation of training, including by peers, and its contents is necessary. International migration by health care service personnel such as doctors and nurses 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.

9. All parties, especially workers and employers, should be involved in human resource management development. Management training in the health sector is essential.

10. In the health care reform process, policies should be developed for social dialogue since the best reforms are developed through such a dialogue. In accordance with ILO Conventions Nos. 87, 98 and 151, health workers have the same right to organize and to bargain collectively as workers in other sectors. Pay determination and working conditions should be subject to bargaining procedures between health workers and employers. Especially in times when the contents of work, the financial environment and job security are subject to rapid changes, collective bargaining mechanisms are an appropriate way to improve the situation of the workers and their families.

11. Contracts of employment of health care personnel and/or collective agreements should contain safety provisions for the employee, such as a conscience clause. While this clause protects the worker concerned from sanctions on behalf of the employer, a code of professional ethics does not absolve an individual from the duty to comply with civil and criminal law. The ILO should assist governments and the social partners in the development of a patients' charter.

12. 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 considers health care as a basic human right and an essential requirement for improving working and living conditions.

13. During reform processes in health care systems, the ILO can provide assistance with the aim of ensuring that changes which occur lead to positive outcomes both in the health services provided to all and employment conditions of health workers. Within this general objective, the ILO could undertake the following specific tasks:

develop internationally comparable statistics which are an acknowledged and reliable source of information for trend analysis and policy formulation;
facilitate the exchange of experiences among countries through regional meetings and network arrangements of representatives of employers and workers and governments;
facilitate research activities on trends and developments in areas identified by the Meeting as being important issues in reform processes in health sectors such as:

the impact of reform processes on the workforce;
gender issues;
changes in qualification requirements for health care staff;
workers' participation in reform processes;
trends and developments in pay systems, labour conditions and workers' participation;

increase the cooperation with other international organizations, its technical assistance and advisory services to governments, employers' and workers' organizations, particularly in developing countries, especially on the integration of relevant labour standards and planning and implementation of health sector reforms.

14. Relevant ILO Conventions and Recommendations provide basic standards which should be adhered to during any reform process. This counts especially for ILO Conventions Nos. 87 and 98 which cover workers' rights. In addition, special consideration should be given to the Nursing Personnel Convention, No. 149, and Recommendation, No. 157, and the Medical Care Recommendation, No. 69, which addresses the medical care service in general. It is also important to mention the work being undertaken on a new Convention that aims to tackle the worst forms of child labour.

15. The next sectoral meeting for the health sector should focus on the development role of the social partners in health services. It should include discussions on:

professional issues in the health services including professional standards, which have an impact on working conditions;
development of managerial capacity and the effectiveness of social dialogue, institutions and process;
education and training in health professions; and
changes in the health sector labour market.

1. Adopted by consensus, with reservations expressed by the Governments of Sweden and Switzerland.

Part 2

Resolutions

Consideration and adoption by the
Meeting of the draft resolution

At its third plenary sitting, the Meeting set up a Working Party on Resolutions, in accordance with article 13, paragraph 1, of the Standing Orders.

The Working Party, presided over by the Chairperson of the Meeting, consisted of the Officers of the Meeting and three representatives from each of the groups. The members of the Working Party were:

Officers of the Meeting

Mr. D. Willers (Chairperson)
Mr. L. Serfaty (Government/Employer Vice-Chairperson)
Ms. Kim See Khoo (Worker Vice-Chairperson)

Government/Employer members

Mr. M.E. Garzon Chapa (Mexico)
Mr. J.N. van Charante (Employer)
Mr. G. White (Canada)

Worker members

Mr. B. Abberley
Ms. B. Cruz
Ms. J. Pesola

At the Meeting's sixth plenary sitting, the Chairperson, in his capacity as Chairperson of the Working Party on Resolutions and in accordance with article 14, paragraph 8, of the Standing Orders, submitted the recommendations of the Working Party on Resolutions regarding the draft resolution before the Meeting. As required by the same provisions of the Standing Orders, the two Vice-Chairpersons of the Meeting had been consulted on the contents of his oral report.

The Working Party had before it one draft resolution submitted by the Workers' group, which was declared receivable. The Working Party amended the text within the time-limit set by the Officers of the Meeting, with the exception of two clauses on which general agreement could not be reached and which appeared between brackets in the text before them.

Resolution concerning future ILO activities
in the health sector and cooperation
with international institutions

In accordance with the provisions of article 14, paragraph 9, of the Standing Orders, the Worker members proposed amendments to the draft resolution duly submitted in plenary, among which a proposal concerning the texts in brackets. The amendments proposed, some of which were drafting changes, were agreed to by the Meeting.

The representative of the Government of Sweden, referring to operative paragraph (5) of the resolution, expressed a reservation concerning the concept of health care as a "fundamental human right"; his delegation was of the view that the words "basic civil right" should have been used instead.

The representative of the Government of Switzerland expressed reservations on three points. With regard to operative paragraph (1), his Government opposed the idea of referring to "relevant ILO labour standards" rather than to "fundamental labour standards". They stated a second reservation with regard to operative paragraph (5) which referred to the promotion of a human right as a concept, a notion which they did not grasp. Finally, the request addressed to the ILO to "promote the universal coverage of health care" in operative paragraph (9) was inappropriate since this task did not fall within the ILO's competence but rather that of the World Health Organization.

The Meeting adopted the amended resolution by consensus.

Text of the resolution adopted
by the Meeting

Resolution concerning future ILO activities
in the health sector and cooperation
with international institutions⁽¹⁾

The Joint Meeting on Terms of Employment and Working Conditions in Health Sector Reforms,

Having met in Geneva from 21 to 25 September 1998,

Recalling that the governments present at the UN World Summit for Social Development in Copenhagen (the "Social Summit") have committed themselves to give a high priority to health, especially for women and children and in rural areas,

Recalling also that the Social Summit called for universal application of fundamental ILO labour standards,

Recalling further the adoption in June this year of the ILO Declaration on fundamental principles and rights at work and its follow-up,

Recalling also that the Social Summit recommended a reinforcement of cooperation between all competent international institutions, including the UN and its specialized agencies as well as the World Bank and the International Monetary Fund,

Recalling the conclusions of the last Joint Meeting on Health and Medical Services in 1992,

Recognizing that health systems in some countries continue to remain in crisis -- or even to be deteriorating from what were parlous circumstances,

Recalling that an effort must be made to improve the training, the access conditions to the profession and working conditions of people employed in the health sector, so as to guarantee the best quality of care;

Adopts this twenty-fifth day of September 1998 the following resolution:

The Joint Meeting on Terms of Employment and Working Conditions in Health Sector Reforms calls on the Governing Body and the Director-General of the International Labour Office to:

promote the principles and full implementation of relevant ILO labour standards as part of the reform of the health care sector;
work closely with the WHO and encourage it to promote and implement its Charter on Health Care Reforms worldwide;
intensify its cooperation with the World Bank, the IMF and with the WHO in reform of the health services. This work should include the need to promote and respect ILO values and principles in the reform process;
fully carry out the role of the ILO in the SAPRI (Structural Adjustment Policy Review Initiative) exercise, together with other appropriate bodies;
promote the concept of health care as a fundamental human right as is noted in the Alma-Ata Health for All Declaration and the Universal Declaration of Human Rights;
hold as quickly as possible a new joint meeting on health sector matters;
convene as soon as possible ILO regional meetings and seminars on reforms in health care services;
promote a study of specific activities relating to the provision of health care. These activities imply a close cooperation between a large variety of professions for whom training, qualifications and skills are extremely varied. This cooperation is indispensable in guaranteeing the best possible care to patients;
promote the universal coverage of health care for vulnerable populations such as women, children, and the elderly.

Part 3

Other proceedings

Panel discussions

Why are ILO values relevant for the health sector?

Chairperson:

Panellists:

Mr. C. West Ocampo, Vice-Chairperson of the Workers' group

Ms. Y. Noguchi, International Labour Standards Department, ILO, Geneva
Mr. D. Dror, Social Security Department, ILO, Geneva
Mr. G. Coppée, Working Conditions and Environment Department, ILO, Geneva

Ms. Noguchi provided an overview of international labour standards as they related to the health sector and of tripartism and social justice. She highlighted the ILO's mandate as laid down in its Constitution (1919), the Declaration of Philadelphia (1944) and the ILO Declaration on Fundamental Principles and Rights at Work adopted by the International Labour Conference in June 1998. The principles of the fundamental rights enshrined in the core Conventions⁽²⁾ had to be respected and promoted by all member States. Ms. Noguchi stated that those Conventions were as relevant to the health sector as to any other and emphasized the relevance for the health sector of standards of general application such as the Termination of Employment Convention, 1982 (No. 158); standards on occupational health protection and on social security; and standards specific to the health sector such as the Nursing Personnel Convention, 1977 (No. 149), and the Labour Relations (Public Service) Convention, 1978 (No. 151). International labour standards had two major features. The first feature was the standard-setting procedure which had developed a total of 181 Conventions -- with more than 6,000 ratifications -- and 189 Recommendations adopted by the International Labour Conference. The obligations arising from international labour standards included regular reports by governments on ratified Conventions regarding the implementation in law and practice of these Conventions' provisions; reports could be also requested on unratified Conventions on subjects selected by the Governing Body. The second feature was the supervisory machinery which included three key procedures: the regular procedure through the Committee of Experts on the Application of Conventions and Recommendations, composed of 20 independent experts for the technical and legal analyses of the reports submitted by the governments, and the Conference Committee on the Application of Standards which constituted a forum for international tripartite dialogue; the ad hoc procedure under articles 24 and 26 of the Constitution; and the special procedure on freedom of association which applied also in the absence of ratification of Conventions.

Mr. Dror pointed out that the two major thrusts of health sector reforms were the separation of the different components of the health sector and the review of operations of public health systems. As regards the components of the health sector, he made a distinction between the development of public policy; finance (public and private); service delivery (public and private); and regulation of quality of services and equity of allocation (public). Health sector reforms had tried to remedy bureaucratic, inefficient operations of public systems, mainly by changing the public/private mix of providers and changing the public/private mix in the insurance systems. Mr. Dror emphasized the importance of distinguishing between the objectives of private and social health insurance. While private insurance aimed at commercial risk management, the objective of social health insurance was cross-subsidization between income groups. In private insurance, the demand arose from individual risk-averse behaviour whereas in social insurance the demand was driven both by individual and public priorities. The differences between the two insurance systems were reviewed in regard to the obligation to offer coverage, the legal liability, the responsibility of the individuals, the income side of insurance as well as the meaning of equity and risk pooling under both systems. Three principles of social health insurance were highlighted: universal access to a package of benefits, freedom of choice for services above the package and public responsibility of maintaining public health. The profit orientation of private insurance fostered a selection of the insured and tended to weaken solidarity among different groups in society. Social health insurance faced mainly the question of whether it should be compulsory or voluntary, or compulsory for some and voluntary for others, and whether it should be compulsory for a basic package and voluntary for services beyond this package. The question remained, however, whether the coverage would be provided through private or social insurance and how both schemes related to provider regulation. While private health insurers allowed the client freedom to choose the provider and allowed the provider to decide on the treatment plan, the social insurance scheme left less freedom of choice and emphasized containing costs with a view to reaching larger population groups. Mr. Dror stressed that universal access to health care was incompatible with risk differentiation. Enhancing consensus on equity was as important as pure efficiency, and the profit motive of private insurance could affect coverage or working conditions. He recalled, however, that in most countries the principles of private and public health insurance were not applied coherently and most people simply had no access to insurance. Finally, he pointed out that privatization of the health sector differed from other privatization processes and indicated that reasons might lie in the envisaged "product" -- health care or health? -- in the nature of the sector which was people-oriented and highly labour-intensive, as well in the simultaneous requirement of equity and efficiency.

Mr. Coppée stressed that occupational accidents and diseases were still too frequent and their cost to society, workers and their families continued to be unacceptable. The ILO estimated that occupational accidents around the world amounted to more than 250 million cases of which 330,000 were fatal, and that there were 160 million cases of occupational diseases. The economic losses incurred were equivalent to 4 per cent of the world's gross national product. The objective of occupational health had been defined by the ILO/WHO Joint Committee on Occupational Health; a safe and healthy working environment (healthy workplace) and workers' health (healthy workers) were objectives common to both the ILO and WHO. Occupational health practice was closely linked to social and health policies as well as to quality management, productivity and economic factors. He described occupational health care as the care of the health of workers, which included preventive health care, health promotion, curative health care, first-aid, rehabilitation and compensation, where appropriate, as well as strategies for prompt recovery and return to work. Occupational health practice encompassed the activities of all those who contributed to the protection and promotion of workers' health and to the improvement of working conditions and environment. These terms should not be understood as merely the practice of occupational health professionals. Occupational health practice, which was intrinsically multidisciplinary and inter-sectoral, involved other specialists both in the enterprise and outside in addition to occupational safety and health professionals, as well as the appropriate public authorities, employers, workers and their representatives. Occupational health professionals were defined as those who had been accredited through appropriate procedures to practice a profession related to occupational health or who provided occupational health services according to the provisions of relevant regulations; they included all those who by profession carried out occupational safety and health activities, provided occupational health services or were involved in occupational health practice, even if occasionally. Many others, in addition to occupational safety and health professionals, were involved in the protection and promotion of health workers, e.g. management and workers' representatives. He stressed that occupational health practice should take place in an organized framework and that occupational health services could be provided through a large variety of patterns. In this regard, one model which benefited from large support at the international level was proposed by the ILO Occupational Health Services Convention, 1985 (No. 161), and Recommendation, 1985 (No. 171): it provided for a comprehensive approach to occupational health including primary, secondary and tertiary prevention, and was consistent with the general principle of primary health care. Mr. Coppée mentioned the significance of ILO standards, training and meetings and underlined the dissemination of information as a means of improving occupational health. Care for occupational health was a holistic concept with strong interaction with other aspects of physical, mental and social well-being and called for an alliance of all those who cared for workers' health. In this perspective, occupational health also contributed to sustainable and equitable development. He emphasized the need to relate occupational safety and health to environmental health and the importance of occupational health care at micro and macro levels. One of them was supported by a large consensus at the international level: the model proposed by the ILO. Mr. Coppée briefly described the ILO's International Occupational Safety and Health Information Centre (CIS) and its crucial role as a valuable source of information collection and dissemination in this area. In concluding, Mr. Coppée recalled that public health and health policies were encompassed in WHO's mandate but that the ILO's approach complemented that of WHO, namely by directing its attention to those on whom health policies impacted and by assisting them in obtaining equitable access, for example, to occupational health services.

Discussion

An observer raised the question of how women's organizations or other NGOs could file complaints on violations of international labour standards. Ms. Noguchi replied that employers' and workers' organizations were represented on the various ILO bodies and that these organizations could act in collaboration with other NGOs. For example, an NGO report with ample information about forced labour raised by NGOs in one country was submitted to the ILO by a trade union: issues could be voiced by NGOs through workers' or employers' organizations.

A Worker representative wondered whether private health insurances had the capacity to solve the problem posed by the growing polarization of access to care due to the application of the "ability to pay" principle. Mr. Dror replied that the driving forces behind private health insurances did not have this intention and he cited the case of Chile as an example: it had undergone 17 years of privatization, with a growing need for public systems to provide services to all those who were rejected by private insurers. As a result, public expenditure remained at 2.6 per cent of GDP as before, although more personnel were working in the private sector and with better working conditions than in the public sector. Even in Chile, the private sector was only able to cover a small part of the population, and hence did not solve the problem of the market gulf. In reply to the question of whether the services should be client-oriented, he said that although this would be desirable, capacity was however often insufficient. As to the query whether the ILO also supported the World Bank's approach of a "basic health care basket" for all, the speaker recalled that since the adoption of the Alma Ata Declaration in 1977, there has been broad consensus on primary health care for all. If this had not yet happened, it was largely because many people could not pay for the minimum amount required by insurance systems. Therefore, the ILO would like to assist in launching initiatives to develop new mechanisms for those who had no access to the social insurance system. One such alternative might be through community solidarity, as in the case of mutual community-based funds.

On the question of cost containment in the health sector, Mr. Coppée stressed the importance of prevention and the promotion of health and well-being. On the other hand, he warned that health systems were being blamed for costs incurred by a person's lifestyle (e.g. the consumption of tobacco and alcohol) and which affected public and occupational health. Surprisingly, costs of the health system, while criticized in national debates, were accounted for as income in the calculations of GDPs.

Finance and employment in health sector reforms

Chairperson:

Panellists:

Ms. A. Khoo Kim See, Worker Vice-Chairperson of the Meeting

Mr. A. Weber, Specialist, Health Care Systems, Germany
Mr. O. Adams, Division of Human Resources Development and Capacity Building, World Health Organization (WHO), Geneva

Mr. Weber described the wide variety in levels of health care available to populations in different parts of the world, implying different challenges for health sector reform. In industrialized countries reform was driven mainly by the need to contain costs with emphasis on ambulatory care and insurance for long-term care. For countries in transition, a sweeping reorientation was occurring with emphasis being put on primary care. In middle-income countries, the accent was placed on extending existing services to the informal sector while poor countries focused on reducing mortality and increasing immunization with tight budgetary constraints. In some countries efforts were under way to set up a health insurance scheme and to decentralize budgets to regions. The existence of parallel private schemes had the effect of limiting public health capacity. The effects of privatization on labour also varied: a greater increase of jobs in the private sector had taken place together with growing rates of precarious work and self-employment. Concomitantly, there was a shortage of certain categories of health care staff such as nurses. In countries in transition and in middle-income countries, productivity had risen but workers were subject to increasing pressures especially in the transition countries where salaries were low and in arrears. Developing countries had serious difficulties to resolve in order to provide basic care in rural areas, owing to the high concentration and specialization of health care services in urban areas and the emigration of health care professionals to industrialized countries.

Mr. Adams, health care economist, presented information on WHO's programme on human resources development and recent research findings. The WHO aimed not only to improve and increase health care provision but increasingly to analyse policies and their impact on health care services in order to improve delivery and quality care. Issues relating to working conditions and relations between employers, workers and consumers in health care systems were important aspects of this approach. Research carried out in a range of developing countries showed that there were conflicts between objectives and the capacity to implement them, and between privatization of health care and policies to promote primary rural health care. With the growth of parallel systems, the quality of public sector health care had decreased in some countries due to an inadequate resource base. The private sector was growing but few standards existed to ensure quality care. In some cases the public/private sector balance worked well and improved access to health care. However, the quality of public sector care diminished when private care was set up without proper guidelines and in direct competition with the public sector. To define separate and complementary roles for public and private care required intensified dialogue between the social partners. Reducing hospital beds and downsizing sometimes allowed the development of new standards and approaches, with recruitment and promotion becoming based on competence rather than systems-based on seniority and without continuous skills upgrading of staff. In some instances, reform involved a certain amount of decentralization but problems occurred when this was limited to administrative responsibilities whereas funding and decision-making remained centralized, resulting in a deterioration of relations between employers and workers. During reform processes, a special short-term training budget was needed to ensure quality and access to health care, but this was rarely provided. In sum, the entire reform process had to benefit from better planning. Mr. Adams hoped that the WHO and ILO could work more closely on the question of human resource management of health sector reforms.

Discussion

The discussion focused mainly on problems related to diverting funding sources from the public sector which had to provide for a larger, poorer and unhealthier segment of the population, to private sector care which catered for fewer, wealthier and healthier categories. This was a consequence of parallel health systems which were not based on universal contributions. A representative of the Commission for Labor Cooperation of NAFTA pointed out that parallel schemes led to a splitting of the risk pool into a public and multiple private risk pools, raising thereby overall societal health risks. She considered that public financing of health was more efficient and equitable and was the most effective way in practice of controlling the costs of maintaining a universal service. Workers also argued that centralizing all funding receipts by the government was the most effective way of containing costs and maintaining universal service for all. To guarantee universal access to health care, there had to be a universal system of contributions and those who could afford it could subscribe to an additional private insurance. The question was raised as to whether studies measuring the impact of health care reform and privatization on health care indicators had been undertaken. The WHO was looking into the matter, but it was clear that policy reform was driven by financial considerations rather than improving health indicators. Another issue discussed was the problem of the concentration of health personnel in urban areas and the lack of health services in rural areas. Countries had tried different schemes to encourage or oblige health personnel to serve in rural areas in exchange for training or other benefits. Regardless of the strategies adopted, the basic issue was how to reconcile the rights of individuals with the rights of citizens to have access to medical care.

Closing speeches

The Deputy Secretary-General noted that the debates in plenary sitting, the working parties on resolutions and conclusions, and the panel discussions had made a marked contribution towards clarifying the challenges faced by the health sector in the reform processes taking place worldwide and, more importantly, had given insight on how these challenges could be met jointly by all groups concerned. The Meeting had adopted a set of conclusions and one resolution which would provide useful guidance to government policy- and decision-makers, private employers, trade union leaders and other interested parties as they sought ways to address the complex issues of health sector reform, reinforce social dialogue and promote the most valuable resources of health systems, their workforce. The texts adopted by the Meeting would also assist the Governing Body and the Office, especially the Sectoral Activities Department, in setting up and implementing the ILO's programme of work for the health sector. The resolution would contribute to strengthening the promising cooperation in the health sector, which had been initiated between the ILO, WHO and the World Bank.

Mr. Serfaty (Government/Employer Vice-Chairperson of the Meeting) stressed that the health sector was undergoing unprecedented changes relating mainly to increased life expectancy and the need to meet the health care needs of all population groups without limitations. These changes were painful and would succeed only with the participation of all concerned. The discussions in the course of the Meeting had also demonstrated that even though it had at times been difficult, reaching agreement between the two groups on a wide range of issues was a necessity. He urged the participants to pursue the work of the Meeting by implementing its results.

Mr. Abberley, speaking on behalf of the Workers' group, expressed satisfaction that after critical days of controversial discussions an agreement on the results of the Meeting had nonetheless been reached, in view of the millions of people who relied on the work of health care services and the workers who provided those services. The discussion process had at times been arduous and he urged the ILO to ensure that all participants attending sectoral meetings were familiar with the procedures governing the work of these meetings.

The Chairperson of the Meeting thanked the participants for having concluded, after lengthy discussions and conflicting opinions, that persons working in the health sector would not be assisted by the mere stating of controversial positions. He was pleased to note willingness on both sides to place common issues and interests above individual points of divergence. He commended the participants for the conclusions which emphasized the common interests of governments, employers and workers in positive reforms designed to improve the quality of health care without adversely affecting the working conditions of those employed in the sector. He further noted that the resolution gave the ILO valuable guidance for its future work in this field. The Chairperson declared the Joint Meeting on Terms of Employment and Working Conditions in Health Sector Reforms closed.

Evaluation questionnaire

A questionnaire seeking participants' views on various aspects of the Meeting was distributed before the end of the Meeting; the response rate was 15.5 per cent of participants. The Meeting itself, rated as regards six different criteria, obtained the highest scores for the choice of the agenda item and the points for discussion. Of the two panel discussions, the one concerning the relevance of ILO values for the health sector obtained the higher score. The report submitted to the Meeting was rated highest as regards the quality of analysis and the amount and relevance of information. The consolidated results are reproduced hereafter.

1. How do you rate the Meeting as regards the following?

Scoring

5

4

3

2

1

Excellent

Good

Satisfac-
tory

Poor

Unsatis-
tory

Average
score

The choice of agenda item (subject of meeting)

5

5

3

0

0

4.2

The points for discussion

3

4

2

0

0

4.1

The quality of the discussion

2

4

4

2

1

3.3

The Meeting's benefits to the sector

2

3

7

1

0

3.5

The conclusions

2

1

4

2

0

3.3

The resolution

2

2

4

2

0

3.4

Panel discussion: Why are ILO values relevant for the health sector?

3

5

2

0

0

4.1

Panel discussion on finance and employment in health sector reforms

2

6

1

1

0

3.9

Opportunity for networking

4

3

4

0

0

4.0

2. How do you rate the quality of the report in terms of the following?

Excellent

Good

Satis-
factory

Poor

Unsatis-
factory

Average
score

Quality of analysis

3

7

3

0

0

4.0

Objectivity

2

6

4

1

0

3.7

Comprehensiveness of coverage

2

7

2

1

0

3.8

Presentation and readability

2

8

1

1

0

3.9

Amount and relevance of information

4

5

4

0

0

4.0

3. How do you consider the time allotted for discussion?

Too much

Enough

Too little

Discussion of the report

0

9

3

Panel discussions

1

8

2

Groups

1

7

2

Working Party on Resolutions

3

5

3

Working Party on Conclusions

2

4

4

4. How do you rate the practical and administrative arrangements (secretariat, document services, translation, interpretation)?

Excellent

Good

Satis-
factory

Poor

Unsatis-
factory

Average score

6

4

1

0

0

4.5

5. Respondents to questionnaire

Government

Employer

Worker

Observer

Total

3

2

8

0

13

(% of participants: 15.5)

6. Participants at Meeting

23

5

35

21

84

1. Adopted by consensus, with reservations expressed by the Governments of Sweden and Switzerland.

2. The Freedom of Association and the Right to Organise Convention, 1948 (No. 87), and the Right to Organise and Collective Bargaining Convention, 1949 (No. 98); the Forced Labour Convention, 1930 (No. 29), and the Forced Labour Convention, 1957 (No. 105); the Minimum Age Convention, 1973 (No. 138); the Equal Remuneration Convention, 1951 (No. 100), and the Discrimination (Employment and Occupation) Convention, 1958 (No. 111).

For further information, please contact the Sectoral Activities Department (SECTOR) at Tel: +41.22.799.7513, Fax: +41.22.799.7296 or email: sector@ilo.org

This page was created by BR/CP. It was approved by GU/OdVR. It was last updated on 29 Feb 2000.

Government/Employers' group
Chairperson: Vice-Chairperson: Secretary:	Mr. J. Servotte (Belgium) Mr. N. Surani (Employer member) Mr. J. Dejardin (International Organization of Employers) (IOE)
Workers' group
Chairperson: Vice-Chairpersons: Secretary:	Mr. W. Lucy Mr. C. Kamondi Mr. C. West Ocampo Mr. J. Schlanger Mr. A. Leather (Public Services International) (PSI)

Scoring	5	4	3	2	1
	Excellent	Good	Satisfac- tory	Poor	Unsatis- tory	Average score
The choice of agenda item (subject of meeting)	5	5	3	0	0	4.2
The points for discussion	3	4	2	0	0	4.1
The quality of the discussion	2	4	4	2	1	3.3
The Meeting's benefits to the sector	2	3	7	1	0	3.5
The conclusions	2	1	4	2	0	3.3
The resolution	2	2	4	2	0	3.4
Panel discussion: Why are ILO values relevant for the health sector?	3	5	2	0	0	4.1
Panel discussion on finance and employment in health sector reforms	2	6	1	1	0	3.9
Opportunity for networking	4	3	4	0	0	4.0

	Excellent	Good	Satis- factory	Poor	Unsatis- factory	Average score
Quality of analysis	3	7	3	0	0	4.0
Objectivity	2	6	4	1	0	3.7
Comprehensiveness of coverage	2	7	2	1	0	3.8
Presentation and readability	2	8	1	1	0	3.9
Amount and relevance of information	4	5	4	0	0	4.0

	Too much	Enough	Too little
Discussion of the report	0	9	3
Panel discussions	1	8	2
Groups	1	7	2
Working Party on Resolutions	3	5	3
Working Party on Conclusions	2	4	4

Government	Employer	Worker	Observer	Total
3	2	8	0	13	(% of participants: 15.5)

INTERNATIONAL LABOUR ORGANIZATION

Sectoral Activities Programme

Note on the proceedings