Injured and in shock, a man is rushed to the emergency room. A bleary-eyed doctor approaches. When asked, she concedes having been on duty for two days without sleep.
The story may be fictional, but it represents a growing reality in the health services. And the problem is global; everyone relies on health care when infirmity or accident strikes - from traditional healers to the most modern hospital facilities - and the health services are estimated to employ well over 35 million people worldwide.
Yet most people, like the patient in the emergency room, feel there is something wrong with medical systems which, at best, turn a blind eye to, or at worst, condone, long shifts for skeleton staffs, and working conditions which put both patients and health workers at risk.
Worldwide, there is universal recognition that the allocation of human, material and financial resources to health services is deficient. Many low-income countries spend less than 1 per cent of GNP, on average, on health services, and governments struggle to improve the pay or employment conditions of their health care personnel.
Reforms, but are they enough?
Recent reforms in health care have often involved privatization and increased resort to market forces, producing a mixed "public private" health sector. Some observers fear this is creating a two-tier health care system which may exclude those who are socially disadvantaged or without adequate insurance or social protection. Referring to the US, where public/private expenditure is split almost 50-50, US Senator Hillary Rodham Clinton recently wrote, "Twenty-first century problems, like genetic mapping, an aging population and globalization, are combining with old problems, like skyrocketing costs and skyrocketing numbers of uninsured, to overwhelm the twentieth century system we have inherited." ( Note 1)
Employment and career prospects of health workers suffer too. Overall remuneration in public sector health services has deteriorated over the past decade in most industrialized countries. Representing 80 per cent of the health sector workforce, women are at the bottom of the hierarchy in terms of authority, remuneration, and qualifications. Almost one quarter of all violent incidents at work are concentrated in this sector. In 1996 alone, over 30,000 nurses left the profession in the United Kingdom - increasing the strain on those who remained.
A common understanding
The ILO considers that health care is a basic right for all ( Note 2). It also stresses that for this right to be realized, working conditions for health care workers must be improved. How? Social dialogue presents a clear opportunity for governments, employers and workers to reach a common understanding, and identify and implement solutions on specific issues. To that end, the ILO recently released a publication, " Social dialogue in the health services: A tool for practical guidance".
The document emerged from a joint meeting on health services in Geneva, where representatives of governments, employers and workers avidly thrashed out a series of conclusions on social dialogue. ILO constituents subsequently asked for these conclusions to be made available as a "tool" for practical guidance, in order to establish and strengthen social dialogue in the health services. It sets out the context of social dialogue in the sector, and guides negotiators and facilitators step-by-step through the social dialogue process, from preparatory analysis and action to implementation and evaluation.
The tool is designed to be used in the context of labour relations systems in the health services sector, which in many countries only evolved in the 1980s. Laws regarding the right to strike vary greatly. In countries with no legal restrictions, employers and workers reach mostly voluntary agreements on minimum services during labour disputes. Other countries make such agreements a legal requirement. Some countries prohibit all strike action in the health sector, either on the grounds that the health sector performs essential services, or as part of the ban on industrial action applying to the public sector. In some countries there is a trend to replace central bargaining mechanisms by local or hospital-based arrangements.
In all these cases, the tool can provide practical guidance on both the context and process of social dialogue in health services. It also provides checklists at the end of each section to facilitate basic examination and practical implementation by the users, to be adapted for each country and situation. Cases of social dialogue are given throughout the document for reference and replication, from the development of health councils in Brazil to the launch of a tripartite activity plan in Ghana.
The Hippocratic Oath is one of the oldest professional compacts in history and its main premise, "Primum non nocere", or "Above all, do no harm", is sacrosanct for all in the medical profession. At the heart of social dialogue in the health services too, is the basic concern that governments, employers and workers not only want to do no harm, but want to provide the public with quality health care. Caring for workers in the health services and ensuring that they operate in decent conditions of work will ultimately reinforce the service given to the end-users of social dialogue - the patients.
Note 1 - Clinton, Hillary Rodham, "Now Can We Talk About Health Care?", The New York Times, April 18, 2004.
Note 2 - Resolution concerning health care as a basic human right, adopted by the Joint Meeting on Social Dialogue in Health Services, Geneva, 21-25 October 2002.