Poland: Industrial Relations in the Health Care Sector

  • Observatory: EurWORK
  • Topic:
  • Social dialogue,
  • Collective bargaining,
  • Social partners,
  • Industrial relations,
  • Published on: 13 February 2011



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Low wages, the migration of doctors and nurses abroad and the increase of workload in hospitals and residential care centres constituted the key challenges of the health sector in Poland in the years 2005-2010. The main achievement of social partners was the negotiation of the law on transferring additional financial resources from the National Health Fund (Narodowy Fundusz Zdrowia, NFZ) to medical service providers to increase wages. However, the actual wage increase was largely the result of a wave of strikes in the sector. The main obstacles to collective bargaining included limited representativeness of social partners and unstable financing from NFZ which made it difficult to conclude any kind of collective agreements.

1. Key developments and trends in the health care sector

1.1 Please provide information on key trends in health care policy

In the years 2005-2010, the key policies affecting expenditures and operational framework in health care included:

  • the act on restructuring hospitals proposed by the liberal government led by the Civic Platform (Platforma Obywatelska, PO) in 2008. It assumed the compulsory transformation of public hospitals into joint-stock companies. In October 2008, the act was vetoed by President Lech Kaczyński (Law and Justice, Prawo i Sprawiedliwość, PiS). However, since February 2009 the government has pursued the so-called ‘Plan B’. Local authorities can apply for money to pay back the debts of public hospitals providing that they prepare restructuring plans, which in effect means the transformation of hospitals into joint-stock companies.
  • the law on guaranteed health care services ( ‘Basket Act’, Ustawa koszykowa), signed in July 2009, regulating the type of health care services that can be fully refunded by the National Health Fund (Narodowy Fundusz Zdrowia, NFZ);
  • the act on the rights of patients, enacted on 31 March 2009, which, among others, introduced individual contracts between patients and nurses for treatments that are not refunded by the National Health Fund.

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.

All nationally representative trade union confederations consequently expressed the opinion that health care reforms proposed by the Civic Platform government would pave the way to more widespread privatisation of health care services, threaten jobs in the sector and limit the availability of health services. They also emphasised that the transformation of hospitals into businesses should be voluntary, not compulsory (PL0808029I). By contrast, employer organisations generally support the far-reaching privatisation of health care services accompanied by the regulations, which would grant equal access of private and public service providers to contracts with the National Health Fund and the introduction of private health insurance.

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. The exception is the new act on the rights of patients, enacted on 31 March 2009, which specifies penalties of up to PLN 500,000 for organisers of strikes in the health care that had infringed on the law on solving collective disputes (articles 59 and 68 of the act). General rules of organising a strike specified by the Act on Solving Collective Disputes of 23 May 1991 apply. Before the strike is organised, trade unions should go through the process of collective negotiations mediation unless ‘a lawless action of employer made it impossible to organise negotiation and mediation’ (article 17 of the act on solving collective disputes). Strike should be supported by the majority of employees in a strike ballot, in which at least 50% of the employed in a given establishment should participate.

2.2 Please provide details on the structure of trade union representation in the health care sector. For each trade union provide:

Four main trade unions in the health sector organise nurses and care workers and take part in collective bargaining at the sector level and company level. All four are affiliated to one of the nationally representative trade union confederations:

  • the All-Poland Union of Nurses and Midwives (Ogólnopolski Związek Zawodowy Pielęgniarek i Położnych, OZZPiP), affiliated to the Trade Unions Forum (Forum Związków Zawodowych, FZZ), 79,000 members, including 77,000 nurses and around 2,000 midwives. Some 5,500 of the union members are home care nurses and 200 are residential care workers.
  • the Nationwide Trade Union of Operating Block, Anaeshesiology, and Intensive Therapy Employees (Ogólnopolski Związek Zawodowy Pracowników Bloku Operacyjnego Anestezjologii i Intensywnej Terapii, OZZPBOAiIT), affiliated to the Forum of Trade Unions (Forum Związków Zawodowych, FZZ), 1,680 members, including nurses in operating blocks (33%), nurses in anaesthesiology, and intensive care units (67%) in hospitals.
  • the Health Care Secretariat of the Independent and Self-Governing Trade Union ‘Solidarity’ (Sekretariat Ochrony Zdrowia Niezależny Samorządny Związek Zawodowy ‘Solidarność’, SOZ NSZZ Solidarność) , 45,000 members, all medical occupations.No separate statistics for nurses and care workers exist According to the estimations provided by the Secretariat's leader, some 20-30% of members are nurses and midwives (around 9,000-13,500 people), including 2% of home care nurses (around 900 people), and around 7% are residential care workers (around 3,100 people).
  • the Federation of Healthcare and Social Care Employee Unions (Federacja Związków Zawodowych Pracowników Ochrony Zdrowia i Pomocy Społecznej, FZZPOZiPS), affiliated to the All-Poland Alliance of Trade Unions (Ogólnopolskie Porozumienie Związków Zawodowych, OPZZ), 20,500 members, all medical occupations. Some 25% of members are nurses (i.e. around 5,000 people). There are 1,366 members in various types of social care centres both in health care services and in administrative professions.

The confederations, to which the above mentioned trade unions are affiliated, take part in the Tripartite Commission on Socio-Economic Affairs (Trójstronna Komisja ds. Społeczno_Gospodarczych), Voivodships Social Dialogue Commissions (Wojewódzkie Komisje Dialogu Społecznego) and the Tripartite Health Care Team (Trójstronny Zespół Branżowy ds. Ochrony Zdrowia).

In addition, there are autonomous trade unions not affiliated to nationally representative confederations, which number and coverage is difficult to estimate. There is also an autonomous nationwide trade union confederation, the Nationwide Trade Union Confederation of Health Care Employees (Ogólnopolska Konfederacja Związków Zawodowych Pracowników Ochrony Zdrowia, OKZZPOZ), which groups over 70 independent union organisations in hospitals and residential care centres, as well as health care employees in hospitals belonging to the Ministry of Internal Affairs and Administration (Ministerstwo Spraw Wewnętrznych I Administracji, MSWiA) and the Ministry of National Defence (Ministerstwo Obrony Narodowej, MON) (no reliable membership data is available). It does not take part in cross-sector bodies of social dialogue, but it is involved in collective bargaining at the company level and at the regional level.

The interrelationship between the trade unions in the health care sector:

Trade union representation exists almost only in the public health care operators. The relationships between trade unions in the sector are overall marked by cooperation. However, there is also rivalry between new professional associations of nurses, such as OZZPiP, and traditional, all-encompassing trade unions of health care workers, such as FZZPOZiPS and SOZ NSZZ Solidarność. The major reorganisation of trade unions in the sector within the past five years included the founding of OKZZPOZ by two break-away regional structures of FZZPOPiS (Wielkopolska region and Podlasie region) in 2006.

2.3 Please provide information on the structure of employer organisations in the health care sector. For each employer organisation provide:

The two most relevant, nationally representative employer organizations, which are active in the health care sector, include:

  • The Confederation of Polish Employers (Konfederacja Pracodawców Polskich, KPP), represents 7000 employers which employ 3 million workers in all sectors, including 113 employers active in the health sector (23,805 employees), mostly in the non-public service providers.
  • Business Centre Club (BCC), over 2,500 employers which employ 500,000 workers; 26 companies in the non-public entities in the health sector which in total employ 10,000 workers.

Both employer associations are involved in the bodies of social dialogue at the national and regional levels. Three employer federations active in the health sector, who are the members of the Confederation of Polish Employers, include:

  • the Nationwide Union of Private Healthcare Employers (Ogólnopolski Związek Pracodawców Prywatnej Służby Zdrowia, OZZPPSZ), 26 employers, no data on the number of employees, non-public entities in the health sector.
  • the Nationwide Association of Non-Public Hospitals (Ogólnopolskie Stowarzyszenie Szpitali Niepublicznych, OSSN), 18 employers which employ 4,441 employees, including 3,821 employees in the health sector (non-public entities).
  • the Nationwide Association of Non-Public Local Government Hospitals (Ogólnopolskie Stowarzyszenie Niepublicznych Szpitali Samorządowych, OSNSS), 53 employers, non-public hospitals belonging to local governments. No data on the number of employees.

Two other nationally representative employer organizations, the Polish Confederation of Private Employers ‘Leviathan’ (Polska Konfederacja Pracodawców Prywatnych Lewiatan, PKPP Lewiatan) and the Polish Crafts Union (Związek Rzemiosła Polskiego, ZRP), also participate in the national level social dialogue within the health sector. However, they do not affiliate employers that are active in this sector. In addition, there is an independent ‘Zielona Góra Agreement’ Federation of Health Care Employer Unions (Federacja Związków Pracodawców Ochrony Zdrowia Porozumienie Zielonogórskie, PZ), established in 2003 to represent the interests of general practictioners (GPs) in non-public health care entities (Pl0602103f). In 2006, it had 15,000 members (no recent data available). None of employer organizations participates directly in collective bargaining with trade unions at the company level as the majority of collective negotiations involve trade unions and individual employers and chiefs of health care entities.

The interrelationship between the employer organisations in the health care sector:

Employer organisations cover almost exclusively private health care providers. In case of public health care providers, they are directors of such entities and regional public authorities who are partners of trade unions in collective bargaining. The interrelationships between the employer organisations are marked by cooperation.

The most important organisational change was the founding of the Healthy Health Corporation (Korporacja Zdrowe Zdrowie) in 2006, which is an informal structure dealing with the issues of health within KPP. It is based on individual members active in the sector and three employer federations: the Nationwide Union of Private Healthcare Employers, the Nationwide Association of Non-Public Hospitals and the Nationwide Association of Non-Public Local Government Hospitals.

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 in the health care sector covering nurses and care workers are concluded at the company level and only in a limited number of the public healthcare providers.

Estimate the coverage rate of collective bargaining in terms of a) companies and b) employees.

No data exist on these issues. According to the estimations provided by union leaders, collective agreements might cover not more than 5% of nurses and care workers. Single employer collective agreements have been drawn up in no more than 20% of hospitals (Pl0802019q). Two separate collective agreements were concluded in the health care entities belonging to the Ministry of National Defence (covering over 10,000 employees) and the Ministry of Internal Affairs and Administration (covering over 6,000 employees). In the residential care, two local collective agreements exist for entities in the cities of Częstochowa and Piotrków Trybunalski.

Is there a practice of extending multi-employer agreements to employers who are not affiliated to the signatory employer associations?

Not applicable as there are no multi-employer collective agreements.

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?

Not applicable as there are no multi-employer collective agreements.

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?)

There is the Tripartite Healthcare Team (Zespół Trójstronny ds. Ochrony Zdrowia) which deals with matters of the health sector. It was founded in February 2005. It operates outside the Tripartite Commission on Socio-Economic Affairs, in affiliation with the Ministry of Health (Ministerstwo Zdrowia, MZ). It includes six representatives of government ministries of health, economy, labour and social policy, finance, state treasury, and education and science, two representatives of each nationally representative employer organisations (KPP, PKPP Lewiatan, ZRP and BCC) and two representatives of each nationally representative trade unions (FZZ, NSZZ Solidarność and OPZZ).The regional social dialogue bodies (WKDS) have often their own health care teams. However, their scope is very limited.

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)

The health care sector in Poland witnessed an increase of strike actions in the last five years, where the main actors were doctors and nurses in public health care entities (table 1).

Table 1. Strikes in the health care in Poland

Year

Number of strikes

Number of strikers

Number of working days lost

2005

1

12

8

2006

24

3,459

12,284

2007

113

8,040

137,643

2008

80

3,048

2,769

No data available for 2009-2010. Source: Statistical Yearbooks of Poland, the Central Statistical Office (GUS)

The bottom line of the tensions between health care employees and the National Health Fund was inadequate financial expenditure on the public healthcare system in general and insufficient pay levels in particular (PL0602103F). The escalation of conflicts in the health care was first observed in April 2006, when the nationwide protest was held (PL0604039I), including demands of an immediate 30% pay raise for healthcare employees and an increase in state healthcare expenditure from 4% to 6% of gross domestic product (GDP). An immediate outcome of these protests was the law on transferring additional financial resources for service providers dedicated to increase wages (so called Wedel Act concluded on 22 July 2006). However, actual pay increase had to be negotiated at the level of hospitals. Significant disparities between the increase in the wages of doctors and nurses, as well as the underprivileged situation of hospitals at the level of poviats (basic administrative units) as compared to specialised hospitals in larger cities fuelled successive wave of nurses’ strikes. In June 2007, OZZPiP held protest in front of the Prime Minister’s Chancellery in Warsaw, which gave rise to the so-called ‘White Village’ protest next to the occupied building, involving several hundred nurses and health care employees camping on site for almost four weeks (PL0707019i). In the next years, sit-in strikes, hunger strikes and marches were organised (mostly by OZZPiP) in hospitals across Poland in order to force the increase nurses’ wages. It should be noted, however, that nurses in home care and residential care centres were not covered by the ‘Wedel Act’. Nevertheless, as the unionisation of both categories is very limited, their collective protests are very rare.

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 collective bargaining is not present in the Polish health care sector. Except for sectoral collective agreement covering employees in Chief Sanitary Inspectorate (Państwowa Inspekcja Sanitarna, PIS) , which do not employ nurses and care workers, no multi-employer collective agreements exist in the sector.

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.

In the years 2005-2010, single-employer collective bargaining concerned mostly wages and, as already mentioned, very rarely resulted in concluding formal collective agreements. The pay raise of nurses was assumed by the ‘Wedel Act’ (Ustawa wedlowska), enacted on 22 July 2006. guaranteed that 30% of means gained through additional contracts with the National Health Fund (NFZ) with service providers had to be spent on wage increase for medical staff. Pay increase should have not been larger than 40%, but its actual level was left for negotiations between trade unions and chiefs of hospitals.

One of the examples, in which pay rise was successfully negotiated by trade unions, is the Centre for Tuberculosis and Lung Diseases (Centrum Gruźlicy i Chorób Płuc) in Warsaw. In October 2008, trade unions reached an agreement with the director which established that doctors’ wages would rise 40% (PLN 800 gross) and nurses’ wages 35% (between PLN 400 and 700).

Another example of a successful pay negotiation in Social Aid Centres (Domy Pomocy Społecznej, DPS) is the DPS in Brwilno (Płock Poviat). In August 2007, NSZZ Solidarność demanded 30% pay raise for nurses and care workers employed in this DPS. However, the starosta (head) of Płock Poviat proposed 5% pay raise and a one-of payment amounting to 8% of yearly wage. On 20 August 2007 employees went on hunger strike, which resulted in an agreement between the starosta and the regional structure of NSZZ Solidarność on 24 August 2007. It provided for a 12% pay raise and guarantees for trade unions to take part in determining the budget of the Poviat.

According to the data provided by the Department of Social Dialogue at the Ministry of Health, the average increase of wages resulting from the ‘Wedel Act’ from the mid 2006 till November of 2009 was 27%. According to average yearly figures from the Central Statistical Office (GUS), average pay increased by around 25% in the years 2006-2009. It would suggest that pay rise in the health sector only slightly exceeded average wage increases in the national economy. It should also be noted that the figures on the average increase of wages in the sector refer to the situation of both nurses and much better paid doctors. Pay increase was on average higher in specialised hospitals in large cities, while the situation of staff in health care entities in smaller towns improved to lesser extent. Hence, overall all progress in enhancing economic attractiveness of the sector was rather moderate.

3.2 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.

The main achievement of the Tripartite Healthcare Team was the cooperation of social partners on the law on transferring financial resources for service providers to increase wages (the abovementioned ‘Wedel Act’).

The issues of career development, the recruitment or retention of nurses and care workers, or gender equality do not constitute an important subject of social dialogue at any level. Social partners consider them to be specific occupational problems that should be addressed by self-governing occupational body of nurses, the Main Chamber of Nurses and Midwives (Naczelna Izba Pielęgniarek i Położnych, NIPiP). Since 2008, OZZPiP has tried to negotiate minimal wages of nurses and midwives at the national level. However, bilateral talks with the Ministry of Health did not bring any significant results and raised criticism of other social partners, who considered it an attempt to override sectoral structures of social dialogue.

As far as the situation of nurses in Social Aid Centres (DPS) is concerned, the intervention of trade unions secured the rights to 5 years earlier ‘bridge pensions’ for employees in residential care centres for long-term mentally ill in the law on ‘bridge pensions’ enacted on 19 December 2008.

4. Commentary

The involvement of the Tripartite Healthcare Team in the preparation of the ‘Wedel Act’ in 2006 was an important step to improve the economic attractiveness of jobs in the sector through collective bargaining. However, further progress of sectoral social dialogue faces serious obstacles. Since employer organisations represent mostly non-public health service providers and trade unions are predominantly present in the public health care entities, there is no common platform of interest that would encourage social partners to negotiate measures at the sectoral level. Furthermore, local governments, which manage a large part of health care entities and residential care centres in the sector, are unwilling to play the role of a collective bargaining party either. Finally, the contracts with the National Health Fund (NFZ) for particular services constantly change over the years which, in effect, makes it very difficult to conclude any collective agreements that would be sustainable in a long run. Remarkably, collective bargaining in the health sector in Poland is predominantly focused on pays. Non-economic aspects of the situation of nurses and care workers, including gender equality or access to continuing education and career development, are not tackled via the institutions of social dialogue and left to the professional self-government bodies of nurses.

Adam Mrozowicki, Institute of Public Affairs and University of Wroclaw

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