Representativeness of the European social partner organisations: Hospitals – Italy
The aim of this representativeness study is to identify the respective national and supranational actors (i.e. trade unions and employer organisations) in the field of industrial relations in the hospital sector in Italy. In order to determine their relative importance in the sector’s industrial relations, this study will, in particular, focus on their representational quality as well as on their role in collective bargaining.
1. Sectoral properties
The hospital sector in Italy is composed of public and private structures. Public hospitals are part of the National Health Service (Servizio Sanitario Nazionale, SSN). The public system was set up according to Law 833 of 1978, which united all of the various private health assistance organisations in one unique service controlled by the state. The SSN guarantees medical assistance to all citizens regardless of gender, age, income and work.
The service is financed through national taxation, with direct revenue from contributions that citizens must pay in order to obtain medical services. It is managed by the Ministry of Labour, Health and Social Policies (Ministero del Lavoro, della Salute e delle Politiche Sociali) at national level and by the regions at local level.
Some public hospitals specialise in particular medical fields and many have an excellent reputation due to the quality of their specialist treatments. In addition, polyclinics are linked to universities, where the medical specialists are also university lecturers. Alongside the numerous public hospitals, there are also a number of private nursing homes (case di cura), many of which are controlled by religious organisations. The majority of these are linked to the Catholic Church. Several nursing homes have signed conventions with the SSN and make some beds and specialist services available to it.
The sector is characterised by a high presence of women.
| 1991 | 2001* | |
|---|---|---|
| Number of employers | 809 | 1,225 |
| Aggregate employment | 607,294 | 661,580 |
| Male employment | 236,678** | 257,835 |
| Female employment | 370,616** | 403,745 |
| Aggregate employees | 605,370 | 660,191 |
| Male employees | 235,631** | 256,970 |
| Female employees | 369,739** | 403,221 |
| Aggregate sectoral employment as % of total employment in economy | 2.6% | 2.8% |
| Aggregate sectoral employees as % of total number of employees in economy | 3.6% | 3.8% |
Notes: NACE = General industrial classification of economic activities within the European Communities (Nomenclature générale des activités économiques dans les Communautés européennes). * No data more recent than 2001 are available. The dates considered (1991 and 2001) refer to the most recent censuses conducted by the National Institute for Statistics (Istituto Nazionale di Statistica, ISTAT) in the industrial and services sectors. ** Approximate data.
Source: ISTAT, Seventh Census of industry and services, 1991 and Eighth Census of industry and services, 2001
2. The sector’s unions and employer associations
The trade unions and employer organisations of the sector supplied their data for the entire Italian health sector, which employs about 705,000 people in the public sphere and 110,000 in the private sphere. For the trade unions, it is impossible to divide this data to consider only the people working in hospital activities. This part of the sector, however, contains most members.
The same difficulty arises for data regarding medics. In fact, the numbers estimated by the trade unions and employer organisations – about 110,000 in the public sector and 30,000 in the private sector – are higher than the number of medics working in hospitals.
2a Data on the unions
The representativeness of the workers in hospitals depends on the organisations which include only medical staff and others which include other workers. The sectoral federations of the General Confederation of Italian Workers (Confederazione Generale Italiana del Lavoro, Cgil) and the Union of Italian Workers (Unione Italiana del Lavoro, Uil) have a department for the workers in the hospitals and a separate one for medical staff. However, the Italian Confederation of Workers’ Trade Unions (Confederazione Italiana Sindacati Lavoratori, Cisl) is the only trade union of the three large confederations to have a federation for medics which is completely autonomous and separate from the other hospital workers.
The trade union organisations in the sector are as follows:
- Public Service Union of Cgil (Funzione Pubblica Cgil, FP Cgil) representing employees, doctors and non-medical managers of hospitals;
- Public Service Union of Cisl (Funzione Pubblica Cisl, FP Cisl) for employees and non-medical managers of hospitals;
- Federation of Medics (Federazione Cisl Medici, Cisl Medici) for medical staff;
- Uil Federation of Local Institutions (Uil Federazione Poteri Locali, Uil FPL) for employees, medical staff and non-medical managers of hospitals.
For employees in hospitals, the following trade union organisations also exist:
- Italian Autonomous Federation of Health Workers (Federazione Italiana Autonoma Lavoratori Sanità, FIALS);
- Independent Trade Union Health Federation (Federazione Sindacati Indipendenti Sanità, FSI Sanità);
- General Union of Workers – Health Sector (Unione Generale del Lavoro Sanità, Ugl Sanità).
Apart from Cgil, Cisl and Uil, for the medical managers in public hospitals, there are also the following organisations:
- Italian Confederation of Veterinary Surgeons and Preventative Medics (Confederazione Italiana Veterinari e Medici della Prevenzione, CIVEMP);
- Trade Union Federation of Medical Managers (Federazione sindacale medici dirigenti, FESMED);
- Union of Medical Specialist Managers (Unione medici specialisti dirigenti, UMSPED);
- Italian Coordination of Hospital Medics – Trade Union Association of Medical Managers (Coordinamento Italiano dei Medici Ospedalieri – Associazione Sindacale dei Medici Dirigenti, CIMO-ASMD);
- Association of Medical Managers (Associazione medici Dirigenti, ANAAO ASSOMED);
- National Association of Head Physicians of Hospitals (Associazione Nazionale Primari Ospedalieri, ANPO).
For non-medical managers in the public hospital sector, the trade union organisations are the:
- Italian Trade Union of Health Service Managers (Sindacato Italiano Dirigenti Servizio Sanitario, S.I.Dir.S.S.);
- United Association of Italian Psychologists (Associazione Unitaria Psicologi Italiani, AUPI);
- National Trade Union of Chemist Managers of the SSN (Sindacato Nazionale Farmacisti Dirigenti del SSN, Si.Na.F.O.);
- National Trade Union of Health Managers of the SSN and the Regional Agencies for Environmental Prevention (ARPA)-National Trade Union of Italian Biologists, Chemists and Physicists (Sindacato Nazionale Dirigenti Sanitari del SSN e delle Agenzie Regionali per la Prevenzione Ambientale (ARPA)-Sindacato Nazionale Biologi, Chimici e Fisici Italiani, SDS SNABI);
- Confederation of Trade Unions of Directors, Managers and High Professionals in Public Service – Health (Confederazione dei sindacati dei funzionari direttivi, dirigenti e delle elevate professionalità della funzione pubblica – Sanità, Confedir Sanità).
Medical managers in private hospitals are represented by the Italian Confederation of Private Hospital Medics (Confederazione Italiana Medici Ospedalità Privata, CIMOP).
FP Cgil represents workers in the public and private sector in the following areas: state ministries; state-controlled bodies, such as the National Social Security Institute (Istituto Nazionale Previdenza Sociale, Inps) and the Italian Workers’ Compensation Authority (Istituto Nazionale per l’assicurazione contro gli infortuni sul lavoro, Inail); public and private health; local bodies; public companies; private social, health and educative assistance; public and private health and safety; firefighters. At national level, FP Cgil is part of Cgil. At European level, it is affiliated to EPSU and, at international level, it is part of Public Services International (PSI).
FP Cgil Medici represents hospital medics and non-hospital medics of the SSN, general practitioners, first aid medics, service medics, out-patient specialists and medical employees of the private health sector.
FP Cisl represents workers in the public and private sectors and members of cooperatives in the following divisions: government, fiscal agencies, ministries, non-economic public bodies, regional and autonomous bodies, health and private social, health and educative assistance. At national level, FP Cisl is part of Cisl. At European level, it is affiliated to EPSU.
Cisl Medici represents the medical and veterinary managers of the SSN and private establishments, medical employees of public hospitals and the regions, general practitioners and out-patient specialists. At national level, Cisl Medici is part of Cisl. At European level, it is affiliated through Cisl with the European Trade Union Confederation (ETUC). At international level, it is affiliated to the International Confederation of Free Trade Unions (ICTFU).
Uil FPL represents workers in the public and private sectors in the following divisions: local bodies; public and private health, and private social, health and educative assistance. At national level, it is part of Uil.
Uil FPL Medici represents medical and veterinary surgeons of the SSN and private structures, as well as freelance professionals and atypical workers.
FIALS represents workers of health establishments including medical managers, administrative management and those in services such as cleaning, laundry and catering. At national level, FIALS is affiliated to the General Trade Union Confederation of Autonomous Workers (Confederazione Generale Sindacati Autonomi Lavoratori, Confsal). At European level, FIALS, through Confsal, is affiliated to the European Confederation of Independent Trade Unions (Confédération Européenne des Syndicats Indépendants, CESI).
FSI Sanità represents employees in the health sector. At national level, it is affiliated to the Federation of Independent Trade Unions (Federazione Sindacati Indipendenti, FSI). At European level, it is affiliated through FSI to the Union of Autonomous European Trade Unions (Unione Sindacati Autonomi Europei, USAE).
Ugl Sanità represents employees in the health sector. At national level, Ugl Sanità is part of the General Union of Workers (Unione Generale del Lavoro, Ugl). At European level, Ugl Sanità is affiliated to the European Federation of Public Service Employees (Eurofedop).
CIVEMP comprises trade union associations that represent surgical and veterinary managers of the SSN. No data are available regarding this organisation because it refused to provide any information.
FESMED represents medical managers of the SSN. At national level, it is affiliated to FSI.
UMSPED is a coalition of three trade unions: the Italian Association of Hospital Anaesthetists and Intensive Care Operators (Associazione Anestesisti Rianimatori Ospedalieri Italiani, AAROI), the Italian Association of Clinical Pathologists (Associazione Italiana Patologi Clinici, AIPaC) and the National Union of Radiologists (Sindacato Nazionale Radiologi, SNR). UMSPED signs the national collective agreements as a single association, which represents the medical managers of the health structures.
CIMO-ASMD represents medical managers employed by the SSN. At national level, it is affiliated to the Trade Union Confederation of Directors, Managers and High Professionals in Public Service (Confederazione dei sindacati dei funzionari direttivi, dirigenti e delle elevate professionalità della funzione pubblica, Confedir). At European level, it is affiliated to the European Federation of Salaried Doctors (Fédération Européenne des Médecins Salariés, FEMS).
ANAAO ASSOMED represents medical managers of the SSN. At national level, it is affiliated to the Confederation of Italian Medics (Confederazione Medici Italiani, COSMED) while, at European level, it plans to affiliate with FEMS.
ANPO represents head physicians of hospitals, today called directors. At European level, it is affiliated to FEMS.
S.I.Dir.S.S. represents administrative managers, non-medical health managers, technical and professional managers of the SSN. At national level, it is affiliated to the Italian Confederation of Managers and High Professionals (Confederazione Italiana dei dirigenti e delle alte professionalità, CIDA).
AUPI represents psychologists. At national level, it is affiliated to Confedir.
Si.Na.F.O. represents chemists who operate in hospitals and in local units of the SSN. At national level, it is affiliated to Confedir.
SDS Snabi represents biologists, chemists and physicists operating in the SSN.
Confedir Sanità is the section of Confedir that represents non-medical managers in hospitals.
CIMOP represents medics who operate in private structures.
Workers are free to choose whether to become members of the above trade union organisations.
All the above trade union organisations sign national collective agreements and company (hospital) agreements.
| Organisation* | No. of members | Female union members as % of total union membership | Potential union membership | Density with regard to union domain | Members in the sector | Union density with regard to sector** |
|---|---|---|---|---|---|---|
| FP Cgil (non-medical employees) | 397,468 | n.a. | 2,224,504 | 17.8% | 104,535 | 12.4% |
| FP Cgil (medics) | 397,468 | n.a. | 2,224,504 | 17.8% | 7,000 | 6.4% |
| FP Cisl | 350,000 | n.a. | 2,800,000 | 12.5% | 140,000 | 16.6% |
| Cisl Medici | 7,800 | 20% | 110,000 | 7,0% | 7,800 | 7.0% |
| Uil FPL (non-medical employees) | 196,231 | 61.8% | 2,019,000 | 9.7% | 89,115 | 10.6% |
| Uil FPL (medics) | 196,231 | 61.8% | 2,019,000 | 9.7% | 12,000 | 10.9% |
| FIALS | 60,000 | 60% | n.a. | n.a. | 40,000 | 4.8% |
| FSI Sanità | n.a. | n.a. | n.a. | n.a. | n.a. | n.a. |
| Ugl Sanità | n.a. | n.a. | n.a. | n.a. | n.a. | n.a. |
| CIVEMP*** | n.a. | n.a. | n.a. | n.a. | n.a. | n.a. |
| FESMED | 7,000 | n.a. | 110,000 | 6.4% | 7,000 | 6.4% |
| UMSPED | n.a. | n.a. | n.a. | n.a. | n.a. | n.a. |
| CIMO-ASMD | 13,500 | 20% | 110,000 | 12.3% | 13,500 | 12.3% |
| ANAAO ASSOMED | 18,000 | 15% | 110,000 | 16.4% | 18,000 | 16.4% |
| ANPO*** | n.a. | n.a. | n.a. | n.a. | n.a. | n.a. |
| S.I.Dir.S.S. | n.a. | n.a. | n.a. | n.a. | n.a. | n.a. |
| AUPI | n.a. | n.a. | n.a. | n.a. | n.a. | n.a. |
| Si.Na.F.O. | n.a. | n.a. | n.a. | n.a. | n.a. | n.a. |
| SDS SNABI | n.a. | n.a. | n.a. | n.a. | n.a. | n.a. |
| Confedir Sanità | n.a. | n.a. | n.a. | n.a. | n.a. | n.a. |
| CIMOP | n.a. | n.a. | n.a. | n.a. | n.a. | n.a. |
Notes: * The data were supplied directly by the organisations. Representation percentages might be overestimated.
**These percentages are based on the following data. For the trade union organisations in the health sector (FP Cgil, FP Cisl, Uil FPL, FIALS, FSI Sanità, Ugl Sanità), the following numbers are considered: 705,000 people in the public sector, 110,000 in the private sector and 25,000 non-medical managers, amounting to a total of 840,000 workers. For the medical organisations in the public sector (FP Cgil Medici, Cisl Medici, Uil FPL Medici, CIVEMP, FESMED, UMSPED, CIMO-ASMD, ANAAO ASSOMED, ANPO), a total of 110,000 workers should be considered. This figure is based on the average value of the data supplied by the representative organisations.
*** These organisations refused to provide any of the data requested. The others which did not provide any data did not openly refuse to do so, but simply never replied to numerous requests.
2b Data on the employer associations
The employer organisations that represent the public service are distinctly different from both the associations in the private service and the associations of religious origin in the private sector.
As was the case for the trade unions, the employer organisations do not divide their data and therefore do not distinguish between hospitals and other health structures. Therefore, the situation explained above for the trade union organisations also applies here.
- The public structures are represented by the State Bargaining Relations Agency (Agenzia per la rappresentanza negoziale delle pubbliche amministrazioni, ARAN).
- Private non-religious structures are represented by the Italian Association of Private Hospitalisation (Associazione Italiana Ospedalità Privata, AIOP).
- Private religious structures are represented by the Association of Religious Sociomedical Institutions (Associazione Religiosa Istituti Sociosanitari, ARIS).
- In addition, the Don Carlo Gnocchi Foundation (Fondazione Don Carlo Gnocchi) bargains directly without assistance from any employer organisation.
ARAN represents the entire public sector in negotiations. More specifically, it represents the fiscal agencies, the autonomous institutions, the non-economic public bodies, the ministries, the government, research institutes, university bodies, regions and local institutions (regions, provinces, local municipalities and town clerks), bodies of the SSN, teaching institutions, bodies mentioned in Article 70 of Decree Law 165/01, as well as academies and institutes of higher training and artistic specialisation. The entities mentioned in the decree law are: the Civil Aviation Authority (Ente Nazionale per l’Aviazione Civile, Enac), the National Agency for New Technologies, Energy and the Environment (Ente per le Nuove tecnologie, l’Energia e l’Ambiente, Enea), the National Council for Economics and labour (Consiglio Nazionale dell’Economia e del Lavoro, Cnel), the Chambers of Commerce Union Unioncamere, the National Olympic Committee (Comitato Olimpico Nazionale Italiano, Coni), the bank Cassa Deposti e Prestiti and the Independent Authority for the World Exposition (Ente Autonomo Esposizione Universale).
ARAN is part of HOSPEEM, which is, in turn, a sectoral association of the European Centre of Enterprises with Public Participation and of Enterprises of General Economic Interest (Centre européen des entreprises à participation publique et des entreprises d’intérêt économique général, CEEP).
Every public structure must be represented by ARAN.
AIOP represents the hospitals and private institutions of hospitalisation and scientific care and nursing homes operating privately or for the SSN. Membership of AIOP is voluntary. At national level, it is affiliated to the General Confederation of Italian Industry (Confederazione Generale dell’Industria Italiana, Confindustria); at European level, it is affiliated to the European Union of Private Hospitals (Union Européenne Hospitalisation Privée, UEHP).
ARIS represents the Catholic and non-profit scientific hospitals, nursing homes, rehabilitation centres, hospitals, sociomedical accommodation and ex-psychiatric institutions. Membership is voluntary. ARIS does not appear to have any affiliations at national or European level.
The Don Carlo Gnocchi Foundation is a non-profit organisation and private institution of hospitalisation and scientific care accredited through the SSN. It represents itself in collective bargaining and draws up national collective agreements with FP Cgil, FP Cisl, Uil FPL and CIMOP. The foundation is not affiliated to any national or international organisations.
| Number of member companies | Number of employees working in member companies | Density of association in terms of companies with regard to their domain | Density of association in terms of companies with regard to the sector | Density in terms of employees represented with regard to their domain | Density in terms of employees represented with regard to the sector | |
|---|---|---|---|---|---|---|
| ARAN* | 9,792 | 2,589,944** | 100% | 100% | 100% | 100% |
| AIOP* | 542 | 65,704 | 86.6% | 86.6% | n.a. | n.a. |
| ARIS* | 264 | 54,131 | n.a. | n.a. | n.a. | n.a. |
| Don Carlo Gnocchi Foundation* | 28 | 3,800 | 100% | 100% | 100% | 100% |
Notes: *The data were supplied directly by the organisations. The percentages could be overestimated. ** This number includes 2,416,879 workers on open-ended employment contracts and 173,065 atypical workers (including those on fixed-term or temporary contracts, as well as apprentices and teleworkers). Data from 31 December 2005.
3. Inter-associational relationships
The employer organisations of private hospitals further the interests of their enterprises and lobby regions and the government.
Relations between the trade union organisations are not good. Cgil, Cisl and Uil collaborate with each other, but there is no working relationship between them and the other organisations in the sector. Relations are negatively influenced by competition in the elections of the Unitary Workplace Union Structures (Rappresentanze Sindacali Unitarie, RSU), which take place every three years – or every four years in the private sector. The results of these elections are, in fact, fundamental for the trade unions in order to be able to participate in bargaining in the public sector (see Question 6).
4. The system of collective bargaining
The bargaining of the sector takes place on two levels – national and company (hospital) – together with a third regional level of bargaining directly between the regional administration, which controls the SSN, and the trade union organisations which operate at regional level.
The hospital sector is part of the bargaining system for public and private health. Five national collective agreements are applied in the hospital sector, as outlined in Table 4.
| National collective agreement | Bargaining parties: Employer organisations | Bargaining parties: Trade unions | Employees covered* |
|---|---|---|---|
| Employees of the SSN | ARAN | FP Cgil, FP Cisl, Uil FPL, FSI, FIALS | 570,000 |
| Medical and veterinary managers of the SSN | ARAN | FP Cgil Medici, Cisl Medici, Uil FPL Medici, CIVEMP, FESMED, UMSPED, CIMO ASMD, ANAAO ASSOMED, ANPO | 110,000 |
| Non-medical managers | ARAN | FP Cgil, FP Cisl, Uil FPL, S.I.Dir.S.S., Si.Na.F.O., AUPI, Confedir Sanità, SDS SNABI | 25,000 |
| Medical employees of nursing homes, private institutions of hospitalisation and scientific care, and private rehabilitation centres and nursing homes | AIOP, ARIS, Don Carlo Gnocchi Foundation | CIMOP | 30,000 |
| Employees of the health structures associated with AIOP, ARIS and the Don Carlo Gnocchi Foundation** | AIOP, ARIS, Don Carlo Gnocchi Foundation | FP Cgil, FP Cisl, Uil FPL | 110,000 |
Notes: * These figures include workers of hospital activities together with the workers of other areas within the health sector. ** This agreement is signed separately by Ugl Sanità with AIOP and ARIS, excluding the Don Carlo Gnocchi Foundation.
In the hospital sector, there are two areas of autonomous negotiations: one concerning all employees and another for medics. The bargaining for hospital activities is part of the general health sector bargaining, which also includes non-hospital structures such as local out-patient clinics and surgeries of the SSN. The national collective agreements apply to all workers operating in structures belonging to the employer organisation that signed the agreements. All bargaining within the sector takes place between the employer and trade union organisations, with the exception of the Don Carlo Gnocchi Foundation, which bargains directly.
The public structures are obliged to apply the national collective agreements covering their particular activity, while the private structures apply the national collective agreements of the organisations of which they are part. If a structure is not affiliated to any representative organisation, it is still obliged to apply a national collective agreement of the sector.
5. Formulation and implementation of sector-specific public policies
All of the trade unions and employer organisations are consulted by the public bodies and government in matters regarding the hospital sector.
Through the national collective agreement, it is possible for the actors to set up bipartite or tripartite observatories, committees and commissions. However, these have yet to be activated.
Frequent information meetings take place, as well as concertation, between the medical organisations and the Ministry of Labour, Health and Social Policies, parliamentary commissions, the Ministry of Public Administration and Innovation, and the government.
6. Statutory regulations of representativeness
The regulation of representativeness in the hospital sector differs according to whether the areas are private or public.
In the private sector, in Italy, no law establishes the criteria to follow when determining trade union representativeness. The level of representativeness of each organisation depends on the election results of the RSU representatives in the workplace. More general rights of representation are regulated through an interconfederal agreement of 1992. Law 300/1970 on workers’ statute of rights establishes workers’ trade union rights and the rights and duties for trade union representatives. The law stipulates one condition in order to allow the trade union organisations that sign the national collective agreement to nominate a representative in the workplace: a minimum of 15 employees for industrial enterprises and five employees for agricultural enterprises. Additional measures regarding individual and collective trade union rights are agreed on and set out in the national collective agreements.
In the public sector, representativeness is regulated by law. Employers are represented by ARAN, which is an agency instituted by law. A trade union can participate in bargaining if it represents at least 5% of workers in the sector. The percentage must be an average between the number of members of the organisation and the percentage of representativeness in the RSU; elections take place every three years. Based on these criteria, every two years, ARAN defines a list of trade union organisations that can take part in bargaining. Naturally, this situation creates tension in the trade unions which are excluded. Currently, the following organisations can bargain in the public hospital sector:
- for employees – FP Cgil, FP Cisl, Uil FPL, FSI, FIALS;
- for non-medical managers – FP Cgil, FP Cisl, Uil FPL, S.I.Dir.S.S., Si.Na.F.O., AUPI, Confedir Sanità, SDS SNABI;
- for medics – FP Cgil Medici, Cisl Medici, Uil FPL Medici, CIVEMP, FESMED, UMSPED, CIMO ASMD, ANAAO ASSOMED, ANPO.
The last RSU elections took place in November 2007; however, the data regarding these elections were not yet available at the time of writing. Table 5 outlines the figures for the previous elections of 2004.
| Organisations | % |
|---|---|
| FP Cgil | 30.70 |
| FP Cisl | 27.31 |
| Uil FPL | 18.15 |
| Others | 23.84 |
7. Commentary
The representativeness of workers in the hospital sector is particularly fragmented. Apart from the fundamental division between medical and non-medical staff, other differences also arise.
For non-medical staff, a considerable number of autonomous trade unions are organised at local or regional level. For this reason, the representativeness of workers is weak. Furthermore, with the exception of organisations affiliated to Cgil, Cisl and Uil, this representativeness simply defends its own corporate interests. The same situation occurs for medics, where – with the exception of the federation affiliated to Cisl – the other organisations are structured on a professional basis and their actions also concentrate on their specific corporate interests.
This weakness in representativeness is evident in salaries and working conditions. In fact, in the hospital sector, salaries are among the lowest and working conditions are among the worst compared with those of other employees in the public sector.
The situation is even worse in the private health service, where the majority of the nursing and auxiliary services are outsourced. The contractors that take on this work often pay very low salaries and much of the work is undeclared.
Vilma Rinolfi and Domenico Paparella, Cesos