Slovakia: Industrial Relations in the Health Care Sector
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Slovak healthcare underwent major reforms during the period 1998-2006, including deregulation and decentralization of healthcare providers. Reforms produced discrepancies in pay and working conditions across university hospitals, smaller public hospitals, public care homes and private healthcare providers, which remains the main challenge in the sector together with migration and labour shortages. Social partners address the above challenges in multi-employer and single-employer bargaining. Despite relevant collectively agreed wage increases in the past five years, trade unions and smaller healthcare providers continue in their efforts to decrease the pay gap and labour shortages of nurses and care personnel.
1. Key developments and trends in the health care sector
1.1 Please provide information on key trends in health care policy
While healthcare reforms between 1998-2006 aimed at liberalisation, competition, and strengthened legal framework for private healthcare provision, the majority of healthcare is still publicly provided. According to 2009 OECD Statistics, the public share of total expenditure on health reached 89.4% in 2000 and declined to 66.8% in 2007. The growing number of private providers specializes in selected health services, i.e., one-day surgery, medical services outside the hospital subsector, and care homes for elderly.
Liberalisation also increased the variation in organizational forms of public healthcare providers and their access to public finances. Large university hospitals have better access to finances in case of debt creation, while smaller hospitals and specialized public healthcare organizations have to avoid debt accumulation. Such differentiation in access to public finances has the following consequences:
- discrepancy in wages of healthcare personnel in university hospitals and smaller healthcare providers and care homes (see Table 1 and 2),
- migration of nurses and care personnel to better paying employers and abroad,
- shortages of healthcare personnel in providers with larger budgetary constraints.
Budgetary constraints of private providers derive from health insurance companies’ contractual limits concerning the number of treated patients/clients and charges per particular service/diagnosis. Private providers bargain about their contractual terms individually with insurance companies.
| Occupation | FN | VUC | NO | Shareholder | Limited | PN |
|---|---|---|---|---|---|---|
| Pharmaceutical workers | 1,342 | 1,086 | 1,225 | 1,347 | 1,337 | 1,136 |
| Nurses | 820 | 607 | 580 | 730 | 578 | 749 |
| Midwives | 844 | 615 | 589 | 651 | 613 | n/a |
| Laboratory workers | 798 | 631 | 584 | 690 | 636 | 874 |
| Assistants | 803 | 587 | 530 | 628 | 617 | 591 |
| Other qualified healthcare workers | 937 | 782 | 853 | 786 | 845 | 743 |
| Medical orderly | 544 | 413 | 398 | 466 | 400 | 500 |
Source: Author’s adaptation from internal documents of Slovak Trade Union Association of Healthcare and Social Services (SOZZaSS).
Notes:
FN – university hospitals
VUC – hospitals and providers subordinated to regional self-governments
NO – hospitals and providers operating as non-profit organizations in public interest
Shareholder – hospitals and providers operating as shareholder companies with a 100% state ownership
Limited – hospitals and providers operating as Ltd. companies
PN – specialized psychiatrical hospitals and care institutions
| Occupation | Average wage in 2009 (in Euro) |
|---|---|
| Healthcare workers (physicians excluded) | 651.66 |
| Assistant healthcare workers | 563 |
| Workers responsible for social agenda | 696.28 |
| Social care workers | 664.21 |
| Ergo therapists | 620.63 |
| Psychologists | 570.11 |
| Professional care persons | 475.14 |
Source: Author’s adaptation from internal documents of SOZZaSS.
1.2. Please provide information on the views of the major social partner organisations (trade unions and employer organisations) on trends and changes in the care sector.
Social partners criticize the discrepancies in wages and working conditions across different healthcare providers. Part of the concern is the decentralized remuneration system after 2005 when wages of healthcare personnel no longer follow tariff wage tables for the public sector defined in the Act No. 553/2003. Trade unions strive for equal base wages for equal work regardless of the organizational form of the employer. Employers prefer avoiding competition and shortages of care personnel – especially among smaller public healthcare providers with significant budget constraints. Act No. 553/2003 still applies to remuneration in public care homes.
2. Industrial relations structures in the sector
2.1 Does the health care sector include any specificities in relation to the freedom of association, the right to collective bargaining and the right to strike?
No, there are no specificities applied to the sector.
2.2 Please provide details on the structure of trade union representation in the health care sector. For each trade union provide:
Slovak Trade Union Association of Healthcare and Social Services (SOZZaSS) is the only sector-level trade union representing nurses, midwives and other care personnel. Its domain is limited to the healthcare sector. SOZZaSS associated 305 establishment-level trade union organisations in 2009. Unionization rate in the sector is about 46% (SK0802019Q) making healthcare one of the best organized sectors in the economy.
In September 2009, SOZZaSS reported 26,450 members. Most members work in hospitals (69%) and in the field of social care (20%). 79% of members are women, 10% are retired and 12.6% are people younger than 35.
Membership structure of SOZZaSS includes nurses (41%), manual workers in healthcare and social care (20%), other healthcare workers (11%), technical and administrative workers (7.4%), health assistants (7.3%), laboratory workers (4.6%), physicians (4.6%), midwives (1.5%) and pedagogical workers (2%).
SOZZaSS is involved in multi-employer collective bargaining separately with three sector-related employers’ associations. Simultaneously, SOZZaSS member unions engage in single-employer bargaining.
SOZZaSS engages in bipartite and tripartite sectoral social dialogue. It is represented in national tripartite social dialogue in the Economic and Social Council (HSR) through the Confederation of Trade Unions of the Slovak Republic (KOZ SR).
The interrelationship between the trade unions in the health care sector:
- Specify whether there are differences between public and private operators in terms of trade union representation
The majority of union representation applies to public healthcare and public care homes, leaving part of private healthcare sector non-unionized.
- Are there rivalries and competition between trade unions in the sector? What is the relationship between more traditional organisations and emerging professional associations of health care workers?
No rivalries apply because SOZZaSS is the only trade union in the sector in terms of the study. The small Labour Union of Physicians (LOZ) is not covered in this report.
Professional associations, including the Slovak Chamber of Nurses and Midwives (SKSAPA) play an important role in lifelong learning, ethical issues and education of nurses and midwives. However, no rivalries exist between the union and professional associations.
- Have there been major reorganisations/splits/mergers of trade unions in the sector within the past five years?
The structure remained stable.
2.3 Please provide information on the structure of employer organisations in the health care sector. For each employer organisation provide:
There are four sector-level employer organisations with clearly delineated fields of operation. This structure has been at place since 2006.
The Association of University Hospitals of the Slovak Republic (AFN SR) associated 15 healthcare provider organizations in 2008, including 12 University hospitals and three highly specialized healthcare providers operating as state-owned shareholder companies. The number of AFN SR members has grown to 19 in 2010. As of 30 June 2009, university hospitals affiliated to AFN SR had 21,151 employees (source: SOZZaSS trade union and the National Health Information Centre (NCZI). AFN SR itself reports about 28,500 employees in its member organizations in 2010.
The Association of Hospitals of Slovakia (ANS) associated 53 smaller public healthcare providers of different organizational forms in 2008. No information on the number of employees working in affiliated organisations available.
Private Physicians’ Association of the Slovak Republic (ASL SR) represents individual physicians operating as private entrepreneurs providing their services upon contracts individually negotiated with health insurance companies. ASL SR associated 2,900 members in 2005.
Association of Slovak Spas (ASK) organizes healthcare providers in balneology and health spas and engages in the regulation of healthcare provision in spas. ASK has 26 members, the majority of them being privatized health spas. No information on the number of employees working in affiliated organisations available.
In terms of collective bargaining, three employer organisations (AFN SR, ANS and ASL SR) are individually involved in multi-employer bargaining with the trade union SOZZaSS. Members of these employer organisations also engage in single-employer bargaining with trade unions affiliated to SOZZaSS.
ASK engages only in single-employer bargaining with establishment-level trade unions.
AFN SR, ANS and ASL SR are involved in sector-level bipartite and tripartite social dialogue. Through their membership in the Federation of Employer Associations (AZZZ SR), all four employers organisations in the health care sector (AFN SR, ANS, ASL SR and ASK) are represented in national-level tripartism.
The interrelationship between the employer organisations in the health care sector:
- Specify whether there are employer organisations specific for public and private operators in the health care sector
AFN SR and ANS organize members from public healthcare. ASL SR represents exclusively private employers, and ASK represents employers both in public and private healthcare.
- Are there rivalries and competition between employer organisations in the sector?
The structure of Slovak healthcare accounts for a clear delineation of employer organisations’ operational domains; therefore, no direct competition between them applies.
- Have there been any major reorganisations/splits/mergers of employer organisations in the sector within the past five years?
Healthcare reforms brought new roles for larger and better-equipped hospitals with a direct state ownership (providing also education for medical students, therefore university hospitals); and for smaller public hospitals. In consequence, the single association of hospitals split into two organizations – AFN SR and ANS in 2006.
2.4 Please provide information on the structure of collective bargaining in the health care sector (covering nurses and care workers). Please explain whether the structure is different for public and private providers.
At what level are collective agreements in the health care sector concluded (multi-employer / single employer bargaining)?
Collective agreements are concluded at multi-employer and single-employer levels. At the multi-employer level, SOZZaSS individually bargains with AFN, ANS SR and ASL SR. Establishment-level trade union organizations that are members of SOZZaSS bargain at single-employer level with respective employers.
Public care homes are covered by multi-employer (so called higher-level - KZVS) agreements for public sector employees concluded between the government, Association of Towns and Communities of Slovakia (ZMOS), self-governing regions, KOZ SR, Independent Christian Trade Unions of Slovakia (NKOS) and the General Free Trade Union Federation (VSOZ).
Estimate the coverage rate of collective bargaining in terms of a) companies and b) employees.
Collective agreements cover about 95% of employees in public healthcare. Coverage is lower in private healthcare due to a low unionization rate of workers.
Multi-employer agreements apply to all employees working in establishments associated to one of the sector-level employer organisations engaged in sector-level bargaining. Single-employer agreements apply to all employees at the respective employer.
Is there a practice of extending multi-employer agreements to employers who are not affiliated to the signatory employer associations?
Extensions are not common in the standard bargaining practice.
In case of sectoral collective bargaining, are there derogation practices and opt-out rules from collective agreements and to what extend have these been used?
No formal derogation practices and opt-out rules apply.
2.5 Is there a forum for social dialogue dealing with matters of the health care sector? (Bi-partite and/or tripartite social dialogue; national, regional or local level?)
Healthcare matters are discussed within sector-level bipartite and tripartite social dialogue.
Sectoral bipartite dialogue evolves between SOZZaSS and employer organisations.
Sectoral tripartite dialogue (small tripartism) involves SOZZaSS, sectoral employer organisations (AFN SR, ANS, ASL SR, ASK), the Ministry of Healhtcare (MZ SR), secondary medical schools and independent polyclinics.
Public healthcare policy, e.g., legal regulation of healthcare provision, state contributions to public healthcare, relevant reforms, is subject to national-level tripartite social dialogue in the HSR.
2.6 Elaborate on the incidence of industrial action in past five years within the health care sector. (The nature of industrial action, number of employees involved, number of working days lost, reasons for conflict, outcomes)
Last strikes took place in April 2006 (before parliamentary elections and targeting the incumbent government) when healthcare employees, led by LOZ, showed their discontent with working conditions and wages. Actual wage increases that took place in 2006 did not directly result from these strikes, but from single-employer and multi-employer bargaining. The direct outcomes of the 2006 strikes include: a greater attention of the MZ SR to urgent problems in the healthcare sector (i.e. the effects of reforms), and a discussion on healthcare workers’ right to strike in contrast to their duty to provide healthcare services.
Since 2007, several incidences of strike alert and protest actions deriving from SOZZaSS’s demands on wage increases occurred, including:
- the 2010 protest demanding higher transfers from health insurance companies to ANS members that should produce wage increases in public healthcare. This action produced renewed discussions with the MZ SR and insurance companies. The ANS itself appreciates the SOZZaSS’s effort in lobbying for higher transfers, claiming that without union action improvement would not have been possible. Exact outcomes in terms of transfers are negotiated individually between ANS members and insurance companies.
- the 2009-2010 strike alert announced in public hospitals in Levice and Topoľčany due to an ownership change causing delays in wage payments and changes in workers’ contracts. Negotiations with the new owner are still in progress.
| 2005 | 2006 | 2007 | 2008 | |
|---|---|---|---|---|
| Number of strikes and lockouts | 0 | 4 | 0 | 0 |
| Number of workers involved* | 0 | 1,333 | 0 | 0 |
| Number of working days lost** | 0 | 14 | 0 | 0 |
Source: ILO Laborsta (2010).
* The number of workers involved in strikes and lockouts usually includes those involved indirectly as well as those involved directly.
** The number of days not worked is usually measured in terms of the sum of the actual working days during which work would normally have been carried out by each worker.
3. Contribution of collective bargaining and social dialogue to addressing the challenges facing the health care sector
3.1 Please indicate whether multi-employer collective bargaining has contributed to address the challenges facing the health care sector since 2005. Has multi-employer collective bargaining introduced specific clauses or instruments to address these challenges? Please illustrate the most important of such clauses or instruments and include a brief assessment of their impact.
Multi-employer bargaining plays an equally important role as single-employer bargaining in addressing the recent challenges facing the healthcare sector (pay levels, shortages of qualified healthcare staff, and discrepancies between wages across various providers due to liberalization of healthcare). Multi-employer bargaining succeeded in addressing these challenges in the following ways:
- Improvement of pay, benefits and working conditions of nurses and care workers
Since 1991, nurses’ average wages oscillated between 91 and 100% of the national average. Wages in social care homes oscillated between 58% and 85% of the national average. The goal of SOZZaSS is to bring nurses’ wages to 150% of the average wage in the national economy. Sector-level bargaining between SOZZaSS and AFN SR in the past five years stipulated the following wage increases in university hospitals:
- 10% from May 2006
- 10% from December 2006
- 10% from June 2007
- 10% from February 2008
Due to the economic crisis, social partners did not agree on wage increases after February 2008. A mediator’s decision stipulated a wage increase of 2.5% from November 2009 and 2.5% from April 2010.
SOZZaSS and ANS signed the last collective agreement in 2006 and failed to conclude an agreement afterwards. In August 2009, a mediator’s decision stipulated two waves of wage increases (3-4% from September 2009 and 3-4% from March 2010), financial compensation for uneven working hours in case of shiftwork, overtime and shiftwork premiums beyond the law.
Stipulations in the multi-employer public sector collective agreement from January 2010 brought a 1% wage increase in tariff wages in public care homes. Employers´ contributions to additional pension schemes of care workers are at least 2% of gross wage.
- Improvement of gender equality for nurses and care workers in the health sector (including improvement of work-life balance arrangements)
Work-life balance arrangements at multi-employer level refer to working time adjustments in shift work (stipulated in collective agreements)
- Improvement of access to career development/lifelong learning in the sector.
A mediator’s decision following the failure of SOZZaSS and ANS to conclude a collective agreement stipulates a contribution of 30 Euro/month to lifelong learning for all healthcare personnel. A similar provision also applies to university hospitals affiliated to AFN SR.
- Addressing risk factors at work, including health risks, violence and harassment
The above is subject to regular collective bargaining at multi-employer level. The current sector-level stipulation between SOZZaSS and ANS obliges employers to pay a compensation of 30 Euro/month in case an employee is exposed to health risk factors at work, i.e. infection danger. Specific provisions are agreed in single-employer agreements according to particular workplace types.
- Other measures to improve the recruitment and retention of nurses and care workers in hospitals, residential and home care
Mostly through wage increases, partially also through negotiated employer contributions to pension funds beyond legal requirements, higher redundancy pay upon layoffs than legally stipulated.
- Measures dealing with migration and labour mobility amongst nurses and care workers (including any agreements on ethical recruitment to limit the drain of skilled staff from countries where they are also in significant demand; measures for the better integration of migrant workers, attracting back those who have left the health workforce etc.)
Migration and worker shortages are a major concern in the Slovak healthcare. This problem has intensified after Slovakia’ accession to the EU and after the decentralization of wage setting in the healthcare sector in 2005. SOZZaSS successfully used migration of nurses and care personnel as an argument in multi-employer bargaining, as employers experiencing labour shortages were more eager to agree with wage increases in order to avoid further migration. Despite significant wage increases negotiated at the multi-employer level since 2005, migration and labour shortages derived from low base wages of care workers, medical orderlies and nurses remain a major problem.
3.2 Please indicate whether single-employer collective bargaining and social dialogue practices at company level have contributed to addressing the challenges facing the health care sector since 2005. Has single-employer collective bargaining introduced specific clauses or instruments to address these challenges at company level? Please illustrate up to three cases and include your assessment of their impact.
Healthcare reforms taking place before 2006 brought a decentralization of healthcare providers and of wage setting (multi-employer collective agreements applicable to the public sector no longer apply to healthcare providers, only to public care homes). Decentralization has significantly increased the role of single-employer bargaining in addressing challenges in the healthcare sector. Single-employer bargaining is complementary to multi-employer bargaining despite lacking close coordination between the two levels. Wage increases are exclusively bargained at the single-employer level. At the same time, sectoral multi-employer bargaining sets the general percentage of wage increases, which individual providers (members of sectoral employers’ federations) have to follow. However, wage bargaining at single-employer and multi-employer level remains largely uncoordinated. Sectoral social partners, especially trade unions, desire the sector-level wage bargainig to follow trends in single-employer wage increases. However, there is a lack of information on particular wage increases across particular healthcare providers and information on how exactly single-employer bargaining tops up multi-employer arrangements on wage increases is therefore not available.
Single-employer bargaining succeeded in addressing the sector’s challenges in the following ways:
- Improvement of pay, benefits and working conditions of nurses and care workers
Pay improvements and working conditions are the most important aspect in single-employer bargaining. Some providers (private and those affiliated to AFN SR) have less budgetary constraints and therefore address the mentioned healthcare challenges at company level more effectively. In contrast, smaller public providers with budgetary contraints address healthcare challenges differently, i.e. by pay improvements of the existing personnell (or part of it), but no new hiring, which deepens labour shortages.
- Improvement of gender equality for nurses and care workers in the health sector (including improvement of work-life balance arrangements);
Some providers in the Western part of Slovakia agreed to flexible contracts in order to allow nurses and care workers to work abroad for part of the month (mostly as private care workers in Austria and Germany) while keeping their job in Slovakia. This practice is not widespread and applies only to the Western border regions. In other parts of the country (more than 100 km away from the Western border of Slovakia), employers are not willing to provide such kind of flexible contracts and also do not face such requests from nurses and care workers. If migration of nurses and care workers occurred, it was on a long-term or permanent basis. Recently the first graduates of new university programs for nurses have entered the labour market, therefore, the problem of labour shortage in the central and Eastern part of Slovakia is slightly relieved even in smaller hospitals with lower wages.
- Improvement of access to career development/lifelong learning in the sector.
Upon individual decision, some providers contribute small amounts to nurses’ additional education, conference attendance and other forms of lifelong learning. The standard however is that nurses and other personnel cover their expenses for lifelong learning themselves.
- Addressing risk factors at work, including health risks, violence and harassment;
Risk factors at work are individually agreed at the single-employer level given the specificities of the workplace.
- Other measures to improve the recruitment and retention of nurses and care workers in hospitals, residential and home care;
Above-mentioned wage increases, pension contributions and the possibility of flexible contracts and working hours upon request
- Measures dealing with migration and labour mobility amongst nurses and care workers (including any agreements on ethical recruitment to limit the drain of skilled staff from countries where they are also in significant demand; measures for the better integration of migrant workers, attracting back those who have left the health workforce etc.);
The focus is on attracting those who have left to work abroad to return to Slovakia. Measures to attract workers to return mainly include pay improvements (within budgetary constraints of particular providers). Some hospitals and care homes offer subsidized housing for qualified nurses, especially in larger cities.
3.3 Please indicate whether social dialogue (national, regional, local level – bipartite/tripartite) has contributed to addressing the challenges facing the health care sector since 2005. Has this dialogue introduced specific instruments to address these challenges? Please illustrate the most important of these instruments, specify at which level they have been concluded, who was involved and include your assessment of their impact.
Social dialogue at sectoral and national level attempted to address systemic and strategic challenges facing the healthcare sector and social consequences of legislative developments for healthcare employees. Social dialogue does not address issues of pay, working conditions, career development, gender equality or migration, which are exclusively addressed by single-employer and multi-employer collective bargaining.
4. Commentary
Despite reforms and wage increases, the Slovak healthcare sector’s reputation in terms of wages and working conditions did not significantly improve. Due to budgetary constraints, many employers cannot effectively cope with high demand for nurses and care workers. Social partners continue to address the main challenges in social dialogue and multi-employer and single-employer bargaining. In the past five years, collective agreements stipulated wage increases, contributions to lifelong learning, and addressed health risk factors. The remaining challenge is the diversity of healthcare providers’ organizational forms producing budgetary differences and leading to discrepancies in wages and working conditions across public and private providers, and larger and smaller public providers. Discrepancies are also reflected in collective bargaining, where the AFN SR has the largest room to offer an improvement in wages due to lowest budgetary constraints. The SOZZaSS continues to struggle for equal pay for equal work of nurses and care personnel regardless of employers’ organizational form. With the growing share of private healthcare, social partners also face the challenge of organizing members from private healthcare, especially on the workers’ side.
Marta Kahancova. Central European Labour Studies Institute (CELSI), Bratislava