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The Workers’ group welcomes the decision of the ILO Governing body to organise this sectoral meeting.
We also appreciate the excellent work done by the International Labour Office in preparing for this meeting, including the robust background paper to guide our dialogue.
Opportunities and challenges
This meeting is very timely. Recent global policy initiatives, particularly the Sustainable Development Goals and the UN High-Level Commission on Health Employment and Economic Growth have drawn attention to the central importance of quantitative and qualitative adequacy of the health workforce for realizing the human right to health.
Achieving the aim of equal access to health for all and ensuring that we have the required trained workforce needed to deliver this faces huge challenges. This global concern is particularly exacerbated in low and middle-income countries, which would bear the larger burden of an envisaged shortage of 18 million health workers by 2030, if determined actions are not taken now.
Privatisation, commercialisation and cuts in the funding of public health; liberalisation of health services delivery, driven by free trade agreements; increased corruption; increasing labour market flexibilisation and deregulation, including outsourcing of non-clinical and clinical services; climate change, violent conflicts and humanitarian disasters and demographic transitions are all challenges for the health sector .
These have had alarming impact on employment creation and conditions, gender equality, skills development, and safe, healthy working conditions in the sector. While there is rising demand for health employment, cuts in funding result in limited employment creation, putting huge strains on the health workforce and affecting the quality of the health services. Austerity measures also include freezing in collective bargaining, caps on pay increases, which effectively amount to cuts in pay.
“Gender biases in the health sector are rife.” This situation is worsened with general attacks on income and job security which has been worsened during the economic crisis.
Investment in primary and preventive health care is crucial to decrease health costs. Primary and preventive health care are best carried out by community-based health care workers (CHWs). However, CHWs in several countries face underpayment, under-training and exploitation, and lack of sustainable funding.
All these problems coupled with broader social-economic inequalities adversely affect access to health services and provision of quality care and decent work. Work in the sector appears less attractive to prospective youth and several professionals make premature job exits. In many low-income countries, many choose to migrate looking for better conditions. Those who continue, under-payed and overworked, often suffer burn out. In already fragile health systems, crisis preparedness is undermined. The rising needs of Long-term care in upper and middle-income countries are not adequately met and increasing precarization of work numbs commitment.
Technology should be used to improve occupations and working conditions rather than to reduce the levels of the workforce.
Guidance, policies, strategies, programmes and tools required to ensure decent work
Health is universally considered a fundamental human right. This principle enshrined in several international and regional instruments is reflected in the constitutions of about 150 countries. We should appreciate this spirit to inform our strategies at the international, regional and national levels.
To such extent, we want to highlight some fundamental instruments:
The Five-Year Implementation Plan for Health Employment and Economic Growth presents an effective opportunity for concerted efforts at implementing the recommendations of the UN General Assembly. Achieving a Tripartite commitment to support the Implementation Plan would be needed to make the desired impact and it would help assisting all stakeholders in the implementation process.
International Labour Standards and Decent Work remain veritable means for promoting joint commitment of all social partners to decent work. The background report captures eleven key ILO Conventions and Recommendations relevant for the health sector, as well as guidance and training materials. Lack of ratification and implementation Conventions No 87 & 98, and limited number of countries which have ratified Convention 49 are some of the gaps limiting effectivity;
Non-Standard Forms of Employment and precarization have increased due to health and/or labour reforms. It is argued that this might be useful for meeting “changing demands, and replacement of temporary absent workers.” But it undermines job security compromises service delivery and care continuity. It should thus be discouraged;
Working time and shifts are very important issues considering the labour-intensive nature of the work in the sector. It is worrisome that the trend towards 12-hours shifts, from 8-hour shifts identified by the ILO in 1998 has become more prevalent. This violates decent work and has severe consequences for the quality of services delivery, the safety of both workers and patients. Guidelines for employment and working conditions in the sector should promote a reversal of this trend;
Safe and effective staffing for health is both critical for decent work in the sector and quality service delivery. The practice in Australia is a model for blending legislation and collective bargaining, where States legislate a basis reviewed periodically with the instrumentality of collective bargaining;
Migration of health workers remains an important global developmental issue of concern. Promoting respect for The WHO Global Code of Practice on the International Recruitment of Health Personnel (2010) is imperative in this regards, as well as taking a stand against workers having to pay recruitment fees in line with ILO Convention 181 and ILO Convention 97;
Violence at the work place reaches the highest levels in the health sector, along with the education sector. Special measures need to be considered to address the problem, particularly with regards to the third parties violence that has grown in recent years.
Standardization of guidelines is a contentious policy issue, particularly where Community Health Workers (CHWs) are concerned. In several countries, they are categorized as “volunteers” even though they work regular workhours. This is a major disincentive for quality provision of service. The ongoing CHWs guidelines development by the WHO should be supported;
Multinational health care and insurance companies are pushing the commercialisation of public health and social care services, included in international trade treaties, opening these services to competition. It is important that as a public good, health is not traded as a commodity, nor are patients. Decent work is key to ensure quality and safety, therefore standards harmonising employment and working conditions in public and private health care services are a grantee of financial and social stability, viability and quality of the health systems;
Trade Union Rights are pivotal to Tripartite intervention for decent work. We are seriously concerned that health workers’ rights to organise and collective bargaining remain constricted. Liberia is a particularly worrisome. We would want this meeting to reiterate the relevance of ILO Conventions 151, 87 and 98.
Enhancing social dialogue for promoting decent work
Enhancing social dialogue is important for taking the conclusions of this meeting forward. Regional Tripartite meetings to help generalise commitment would be valuable. Regarding social dialogue at the national and workplace levels, we must stress the need for trade union rights to be respected and for collective bargaining to be done in good faith by all social partners.
It is very disconcerting that in recent times more and more unions around the globe are calling for industrial actions demanding that governments and employers respect provisions of collective agreements or over non-payment of salaries when due.
We take due note of the examples of social dialogue contributing to decent work in the sector, presented in the background report. We will add the need for social dialogue as an instrument for curtailing workplace violence in the sector. Reviewing the 2002 Joint ILO, ICN, WHO and PSI Framework Guidelines for Addressing Workplace Violence in the Health Sector would be a place to start.
Recommendations for future action
Improving employment and working conditions in the health services is a means to achieving health for all. Towards this end, we recommend three actions.
We recommend the formulation of guidelines for the improvement of employment and working conditions in the health sector. Second, the request for a General Survey of the Nursing Personnel Convention C41, which thus far has been ratified by only 41 countries. Third, particular attention to health care workers in the revision of Recommendation 71, Employment and Decent work for peace and resilience.
We look forward to a fruitful discussion that will commit the ILO constituents to the achievement of health for all. A healthy world is a more equal and wealthier world, at the end a better world.
 HEEG Commission: Working for health and growth: Investing in the health workforce, Report of the High-Level Commission on Health Employment and Economic Growth (Geneva, WHO, 2016): 33
 International Labour Organisation: Improving Employment and Working Conditions in the Health Services (Geneva, ILO, 2017): 10
 Ibid: 21
 ILO, ICN, WHO and PSI: Framework Guidelines for Addressing Workplace Violence in the Health Sector (ILO, ICN, WHO and PSI, Geneva, 2002)