Labour strategies,cross-border solidarity and the mobility of health workers: Evidence from five New Member States

Abstract

Shortages of health workers in Western Europe have been addressed, in part, by recruitment from New Member States. In addition to concerns regarding social dumping and cohesion, the loss of human capital and subsequent deleterious impact on services poses a new challenge for trade unions. The aim of this article is to examine the strategies and interventions of health worker trade unions in five countries: Hungary, Latvia, Poland, Romania and Slovakia. Union capacity is analysed through the dimensions of structural power (ability to cause disruption through industrial action); institutional power (lobbying and negotiating with appropriate bodies); and coalitional power (mobilizing support across borders with labour and non-labour organizations). While structural power is generally weak, the deployment of institutional and coalitional power has been more varied across the five countries.

Keywords

Labour mobility migration New Member States solidarity trade unions

Introduction

A growing literature examines the response of Western trade unions to labour mobility from the new EU Member States (Dølvik and Eldring, 2006a, 2006b; Dundon et al., 2007; Fitzgerald and Hardy, 2010). Much of this work has focused on single industries such as construction (Anner et al., 2006; Woolfson and Sommers, 2006) and motor vehicles (Bernaciak, 2011), or on European Works Councils (Meardi, 2004). However, while the role of domestic actors and institutions in receiver countries has attracted increasing attention, that of labour organizations in sender countries has received less coverage.

In general, accounts of cross-border trade union linkages in the EU have focused on organized workers in production, in the context of footloose capital where workers in different countries are pitted against each other in terms of labour costs under the threat of relocation. Yet despite the increasing importance of the public sector as ‘the heartland of labour unionism’ (Gall, 2013: 668), little attention has been paid to cross-border solidarity between public sector trade unions. This is even more salient in the context of neoliberal globalization, which has extended exploitation into the sphere of social reproduction through the increasing marketization and commodification of areas such as health, social services and education (Bieler and Goudriaan, 2011).

With an increasingly ageing population, employment in the health sector is rising rapidly, accounting for some 10 percent of employment across OECD countries (OECD, 2011). This presents problems regarding the recruitment of workers: by 2020, there will be a shortage of between one and two million health sector workers across Europe, with a deficit of both nurses (600,000) and doctors (230,000) (EHFG, 2011). To varying degrees this shortfall has been addressed by ‘old’ member EU states through recruitment from both within and beyond Europe. Yet there has been little or no discussion regarding the implications of labour mobility in this sector for trade unions. In addition to established concerns about social dumping, where workers offer themselves (or are offered by agencies) at rates of pay or conditions that undercut those of indigenous workers (Kwist, 2004; Vaughan-Whitehead, 2003), a new set of issues is raised in sender countries regarding the loss of skilled workers (human capital) and the implications for those workers who remain and the quality of services that they provide.

This article focuses on the new EU Member States (NMSs) and discusses the range of strategies for health sector trade unions regarding labour mobility, their interventions in migration processes and their capacities to negotiate solidarity across national borders. In order to contextualize these strategies, we assume that migration is a constitutive and constructed process of capitalism, understood in an analytical framework of the dynamics of uneven development. Although migration is a structural phenomenon that lies in differential returns to labour, it is constructed in the sense that it is managed and mediated by national and supra-national states.

In this article we first explore labour mobility as a constituted and constructed process of capitalism to identify the potential points of intervention for labour and trade unions. We then outline our conceptual framework for examining the range of strategies that sender country labour can deploy, drawing on the notions of structural, institutional and coalitional power (Brookes, 2013). We go on to outline the methodology and data collection, before reporting the data through the lenses of structural, institutional and coalitional power. We end with some observations and conclusions.

Labour mobility as a constitutive and constructed process of capitalism

The global integration of health labour markets must be contextualized in the dynamics of capitalist production, social reproduction and state regulation (Sassen, 1988; Valiani, 2012; Yeates, 2009, 2012). The economic push and pull factors for labour mobility are determined by the intrinsically uneven nature of capitalism with divergent socioeconomic conditions, developmental capacities and institutional arrangements, variegated between and within supranational blocs (McKinnon, 2012; Smith, 2006). Economic and institutional unevenness in the EU has been exacerbated by enlargement in 2004 and 2007. The mobility of capital and labour need to be understood, therefore, as constitutive processes of capitalism (Stan and Erne, 2013). Some sections of capital, in both production and services, are outwardly mobile, and to varying degrees, can defend or enhance their competitive position by seeking lower production costs. Yet other sections of capital, such as those related to domestic infrastructure and social reproduction, are fixed.

The unevenness between old and new Member States (and among NMSs themselves) is reflected in differential wages which provide the incentives for outward migration. The disadvantaged starting point of NMSs is their position as economically less developed peripheries of the EU; they inhabit the bottom of the table in terms of expenditure on health per capita and total health expenditure as a percentage of GDP (Eurostat). Not only are average wages significantly lower than in the West, the salaries of health workers are lower in comparison to the national average. For example in 2011 the ratio of the salary of a general practitioner doctor to the national average was 1.4 in Hungary and 1.7 in Estonia, compared to 3.6 in the UK and 3.7 in Germany. There are similar disparities in the remuneration of nurses (Hardy et al., 2012).

The NMSs experienced the 2008 economic crisis in its most acute form, exacerbating inequalities, and the subsequent austerity measures have had a particularly deleterious effect on health budgets (Bach and Bordogna, 2013; Hardy, 2014). In some cases, IMF conditionality has meant that since 2008 public sector workers have faced particularly drastic reductions in the value of pay through extended wage freezes. In the most extreme case, in 2010 the Romanian government implemented a 25 percent cut in public sector wages, while prices over the same period rose by almost 17 percent. In real terms this meant that public sector workers lost at least a third of their pay (EPSU, 2012).

Power and strategy: Worker and trade union responses to mobility

Drawing on these broad conceptual assumptions, we outline the range of possible strategies and interventions that trade unions in sender countries can pursue: through structural power in terms of the potential for changing labour market incentives and rewards by winning concessions; institutional power in contesting or cooperating in the governance of migration; and the use of coalitional power with trade unions and non-labour organizations within and across borders.

Structural power

Structural power is defined here as the ability of workers to use their location within the system to influence the employer (Brookes, 2013). There will be sectoral specificities, and a distinction can be drawn between the strength and location of workers in the market, which will be influenced by labour shortages (or surpluses) and their ability and capacity for industrial action (Silver, 2003; Wright, 2000). The possible responses of labour in sender countries are twofold. The first is an abdication of collective power, as workers make an individual calculation on the basis of relative opportunities for remuneration and working conditions regarding their spatial and sectoral choice of work. The range of possibilities is more complex than a dichotomous ‘stay or go’ decision and includes moving out of health sector employment in the home country, moving employment within health care from the public to the private sector and moving across borders to take up work outside of the health sector. The aggregation of individual decisions to migrate (or remain) may be sufficiently significant to affect the market position of workers in the sector.

A second response is the use of collective structural power with the aim of improving wages, working conditions and opportunities in order to reduce differentials between conditions in the domestic economy and those elsewhere in the EU. Across Central and Eastern Europe (CEE), the possibility of outward migration, coupled with relatively high growth rates in the NMSs, led to tighter labour markets and the possibility of winning concessions in the workplace and strengthening trade unions (Meardi, 2007). Kaminska and Kahancová (2010: 9) suggest that migration after 2004, in the health sector in particular, produced labour shortages which offer unions a more powerful negotiating position. They argue ‘that this situation could offer grounds for unions in sender countries to enhance their position vis-à-vis governments and employers to regain societal legitimacy, and strengthen the existing bargaining institutions’.

Institutional power

The resources allocated to health care provision, regulations that pertain to working in the sector and its governance and the general mobility of workers within the EU have a strong institutional context: or as Brookes (2013: 191) defines it, ‘the constellation of laws, regulations, procedures, practices and other formal and informal rules that persist over time, structuring actors’ incentives, channelling their interests, and creating rational expectations of one another’s behaviour’.

The production and consumption of health care have been predominantly nationally constructed, and therefore the promotion of a single market in the EU for capital and labour in the sector requires institutional intervention. A series of directives and court rulings by EU institutions have furthered the drive to disembed national health care systems and re-embed them in a single European market (Morton, 2011). Efforts have been made to overcome obstacles to mobility through the Directive on the Recognition of Professional Qualifications established in 2005 and revised in 2011, which sets the rules for mutual recognition of professional qualifications between member states (EC, 2005, 2012). Therefore EU governance is a possible terrain for intervention. Workers can invoke existing formal regulations, directives, laws and codes of practice or lobby for the introduction of new ones.

Positing a ‘varieties of capitalism’ (VoC) framework, Hall and Soskice (2001) view the national institutional context as central to determining industrial relations, and by extension the capacity for cross-border labour alliances. However, they have been criticized for a functionalist and deterministic approach (Lillie and Greer, 2007), and VoC cannot easily be extended to capture the arrangements that have emerged in CEE from 1990 (Bohle and Greskovits, 2012). With regard to receiver countries, Krings (2009) argues that political, economic and institutional factors are decisive in shaping responses to NMS migration. Other accounts emphasize the importance of sectoral differences and the agency of individual unions in the formulation of strategies (Hardy et al., 2012).

Coalitional power

Brookes (2013: 192) draws on that strand of literature that can broadly be termed community unionism to define coalitional power as the ‘capacity of workers to expand the scope of conflict by involving non-labor actors’. These strategies are based on the idea that at the lower end of the labour market, where migrant workers are concentrated, new organizational forms draw on diverse actors to provide services and advocacy (Heckscher and Carre, 2006). These campaigns, it is argued, need to draw on a ‘wide diversity of actors with a multiplicity of interests’ (Wills, 2008: 320), which would include trade unions, community organizations and enlightened employers.

We understand the term more widely than union–community alliances, to include the capacity of trade unions to form relationships and draw on the resources of other unions and actors both within and outside the labour movement, and domestically and across borders. Therefore a further response to labour mobility is solidarity between unions in sender and receiver countries. While some have pointed to positive experiences of cross-border collaboration (Bronfenbrenner, 2007; Pulignano, 2007; Turnbull, 2007), others have suggested that these relationships are more likely to involve competition than cooperation (Lillie and Martínez Lucio, 2004). Other literature has noted that some weaker trade unions in ‘new’ Europe have colluded with employers in ‘old’ Europe to supply labour at wages below the ‘going rate’ (Woolfson, 2007; Woolfson and Sommers, 2006). This raises the question of how unions are cooperating and exchanging information across national boundaries to prevent the undercutting of wages and working conditions (Dølvik and Eldring, 2006a, 2006b), and in the context of the NMSs prevent a ‘brain drain’.

Organizational resources

The organizational capacities of trade unions – reflecting political legacies and orientations, their capacity for engaging members in democratic involvement (Hyman, 2011; Lindberg, 2011) and the quality of their leadership – are critical in determining their propensity to draw on structural, institutional and coalitional power. By 2000, assessments of the trade union movement in post-communist states suggested that its role was declining and peripheral (Cox and Mason, 2000), with little capacity for collective action (Gall, 2013). This pessimism was compounded by claims about the existence of widespread scepticism about organizational participation in political parties and trade unions (Martin and Cristescu-Martin, 2004). However, there are signs of a modest increase in trade union organization. By 2005, unions had responded to the challenges of an increasingly liberalized and marketized economy, by a step-change in attitudes towards recruitment, organization and industrial action, particularly in new sectors of the economy (Ostrowski, 2014).

Trade unionism in most NMSs was weakened because the main confederations and industrial federations were ideologically driven, adversarial and mutually hostile (Ost, 2002). In general, there was a division after 1989 between transformed versions of former ‘official’ unions and new ones, often vehemently anti-communist in their orientation. Unions have tended to be associated, tacitly or explicitly, with opposing political parties, supporting or resisting governments according to their political identity. This has obstructed inter-union cooperation.

Methodology and data

The article is based on case studies in five countries: Hungary, Latvia, Poland, Romania and Slovakia. This provides a variety in terms of date of accession (2004 or 2007), level of development, size of population and intensity of impact of the recession.

First, interviews were conducted at national level in each country. In Poland these were with the FZZPOZiPS (Federacja Związków Zawodowych Pracowników Ochrony Zdrowia i Pomocy Społecznej, Federation of Trade Unions of Health Care and Social Care Workers); the OZZPiP (Ogólnopolski Związek Zawodowy Pielęgniarek i Położnych, All-Poland Trade Union of Nurses and Midwives); and the OZZL (Ogólnopolski Związek Zawodowy Lekarzy, Doctors’ Trade Union). In Romania we interviewed the national president of the nurses’ professional body and the national president and vice-president of the Sanitas trade union. In the smaller economies of Latvia and Slovakia interviews took place with the one national trade union that represented all health workers (Latvijas Veselibas un Socialas Aprupes Darbinieku Arodbiedriba, LVSADA and Slovenský odborový zväz pracovníkov zdravotníctva a sociálnej starostlivosti, SOZ ZaSS respectively). In Hungary we could not gain access to the health workers’ trade union (Egészségügyi és Szociális Ágazatban Dolgozók Demokratikus Szakszervezete, EDSSz), but interviewed the leader of the doctors’ union (MOSz) and in addition two leading experts in Hungarian industrial relations. Table 1 gives an overview of health worker trade unionism in the five countries.

Table 1.

Health service trade unions.

Country	Union	Federation	Political affiliation	Representing	Membership
HU	EDDSz	LIGA (until 2009, SzEF)	FIDESz-MPSz (until 2009, MSzP)	Nurses, health assistants	30,723
	MOSz	LIGA	FIDESz-MPSz)	Doctors
LV	LVSADA	LBAS	None	Nurses, assistants, other professionals, doctors
PL	OZZPiP	FZZ	None	Nurses and midwives	77,000 nurses and 2000 midwives
	FZZPOZiPS	OPZZ	SLD	Nurses and ancillary workers	20,500, including 5000 nurses
	SOZ NSSZ Solidarność	NSZZ Solidarność	PO, PiS	All medical workers	45,000, including 9000–13,500 nurses and midwives
	OZZL	None	None	Doctors
RO	Federatia Sanitas	CNSLR Fratia	PSD	All medical workers	c. 100,000 (including 5000 doctors)
	Hipocrat	ALFA Cartel	None	All medical workers	c. 5000 (including c. 1500 doctors)
	Solidaritatea	ALFA Cartel	None	Medical and non-medical staff	At least 2000
	CNS SAN	ALFA Cartel	None	All medical workers	c. 15,000
SK	SOZ ZaSS		None	General healthcare workers	28,000

Second, in the ‘large’ economies (in terms of population), Poland and Romania, sub-national interviews were conducted in contrasting regions. In Poland these took place with presidents of OZZPiP in the less developed Lubelskie region (voivode) in the east, and the more developed regions of Lubuskie and Opole in the west. In Romania, interviews were conducted in the cities of Ploiesti near Bucharest and Braşov in the Central region.

Third, we conducted two key interviews with supra-country organizations. The European Federation of Public Service Unions (EPSU) provided an overview of labour issues regarding migration. Extensive information and knowledge from its affiliates made it well placed to comment on the strategies of affiliates. An interview with the President of the Visegrád doctors’ organization (Czech Republic, Hungary, Poland and Slovakia) enabled important insights into issues regarding migration from the perspective of highly skilled health care workers.

Fourth, secondary data in the form of academic articles, reports and statistics were used to supplement, elaborate and corroborate the data from interviewees. In particular, we have drawn on data from Eurofound to compile an inventory of disputes in nine countries.

Below we draw on the empirical data to provide an examination of the responses of health workers to mobility in terms of their deployment of structural, institutional and coalitional power.

Structural power

Interviewees consistently opposed restrictions on labour mobility: workers should be free to move to seek better opportunities and remuneration. Therefore greater priority should be given to fighting against the cessation of national agreements, the impact of cuts in health budgets and pay and deteriorating working conditions. The President of SOZ ZaSS in Slovakia argued that ‘the priority for the trade union is to gain better pay and conditions. We are against restrictions on labour mobility, but emphasize the importance of keeping skilled workers in Slovakia by improving pay and conditions.’

Similarly, the President of the Polish nurses suggested that ‘generally OZZPiP supports migration as a matter of free choice. However, it should not be an effect of poor working conditions and wages in Poland. People should choose migration in order to gain new experiences and not only better wages.’

Widespread discontent is manifest in regular disputes and protests in all parts of the sector and across the NMSs. This is evident in Table 2, which maps indicative disputes in seven countries.

Table 2.

Industrial action, selected countries, 2004 to 2012.

Country	Year	Union	Dispute
BG	2008	Nurses	100 nurses in children’s institutions resign against ‘humiliating wages’
	2007	Medical workers	Protest action for higher wages, improved working conditions and better quality equipment
	2006	Confederation of Labour (Podkrepa)	Protest action against reductions in wages caused by new financing system, demand for increase in health care budget and right to take strike action
CZ	2012	Trade unions and patients	Joint campaign against threatened hospital closure. Petition ‘Citizens, protect your hospital’
	2011–12	Medical Trio (Z3) of unions	Protest campaign over pay and funding: ‘We’re staying, keep your promises’
	2010–11	Hospital doctors	‘Thank you, we’re leaving!’ campaign: mass resignations over pay and funding
	2007	Doctors	Strike against insufficient payments by insurance company
HU	2012	Doctors (MRSz)	Mass resignations over low pay of trainee doctors
	2009	Municipality, trade unions and community groups	Protest action against privatization of Eger regional hospital
	2008	Doctors and nurses, opposition parties	Demonstrations and strikes against health insurance reform
	2007	Main opposition parties	Opposition to medical (and higher education) fees at demonstration commemorating 1956 revolution
LV	2012	LVSADA	Threat of protest action against reforms to sector which would restrict access to health care
	2012	LVSADA	Lobbying of European Council and EU Parliament against funding cuts
	2011	LVSADA	Demonstrations at three regional hospitals against cut in funds for emergency patients
	2009	LVSADA	One day strike and picket of parliament over wages
PL	2013	OZZPiP	Protests in all regional capitals against low pay, retirement age and understaffing
	2009	OZZL	Poster campaign and legal action against cuts in funding for particular medical procedures
	2008	Medical rescue personnel	National strike over pay and employment conditions
	2007	OZZL	National strike, hunger strikes and refusal of certain duties over mandatory minimum wage
	2007	OZZPiP	Demonstrations and eight-day ‘sit-in’ protest over pay
RO	2013	Doctors	Threat of strike and mass resignations over wages
	2012	Unions and workers	Mass country-wide demonstrations over cuts in public sector wages and austerity cuts in general
SK	2012	Nurses and midwives	Protest meetings against suspension of salary increases
	2011	Doctors	Mass resignations over transformation of hospitals into joint-stock companies, funding and salaries
	2011	Nurses and midwives	Delegation to submit petition over working conditions, retirement age, minimum wage
	2011	Doctors	One-hour stoppage over salaries
	2006	Healthcare workers	Strike in 21 hospitals over wages and working conditions

Source: Authors’ compilation from EIROnline.

Disputes focus on a number of interrelated issues. Protests centre around poor funding at national and regional level, and the resulting cutbacks in provision. They also target marketization of the sector and the impact on services, finance and salaries. However, these disputes cannot simply be taken as evidence of structural power; a deeper interrogation is needed into the nature of the disputes; the extent to which outward migration has provided leverage in negotiations with employers and the government and variations between countries and sub-groups of health workers.

First, they are mainly protests rather than industrial action. Full strikes were rare, and there are no examples of sustained industrial action. The forms of action span from one-day strikes and token one-hour warning strikes to mass protests at the level of individual hospitals, regions, nation and EU. Further, a number of tactics are evident that are not usual elements in the industrial relations repertoire in the west: hunger strikes, the threat or use of mass resignations and high-profile ‘stunts’.

Two interviews specifically pointed to the limitations of strike action. In Romania, the health sector is legally defined as an essential service and strike action is restricted: unions are required to ensure that at least a third of normal duties are performed. In addition, all strikes are forbidden during the duration of a national collective agreement. In Latvia the President of LVSADA commented that ‘there was a strike in 2008; we gave the appearance of being on strike, but it actually it had no impact. There is now only emergency care in oncology, paediatrics and psychiatry and our members wouldn’t let patients die.’

Second, the interviews revealed that migration was an element of a much wider crisis in the recruitment and retention of health workers and therefore part of more complex patterns of labour mobility. For example, a high proportion of health workers left the sector after training and before taking up employment. In Latvia and Poland, a low percentage of nurses who trained went on to work in the profession. In Latvia, only 50 percent of those who graduated as doctors in 2012 and 15–20 percent of those trained as nurses went on to work in the profession.

Interviewees, in Polish and Romanian regions particularly, described patterns of outward migration that were interwoven with other patterns of internal mobility: public to private sector, rural to urban areas and small towns to cities. Patterns also varied according to skills, with the highest outward migration among specialist doctors and nurses in anaesthetics, radiology, obstetrics, gynaecology, intensive care and psychiatry.

Objective assessments are further complicated by the lack of accurate data on the outward migration. A proxy for those interested in migrating is applications for the validation of qualifications from professional bodies. In Romania, the President of Sanitas cited Ministry of Health figures that between 2007 and 2013, 28,000 doctors and 16,000 nurses applied for such certificates, with approximately 80 percent approved. To put the impact into context, previously published figures (Galan et al., 2011; Vladescu and Olsavsky, 2009), official data and primary information suggest that 3 percent of doctors and 5 to 10 percent of nurses leave the country each year, although this may be an underestimate. A large increase in leavers was significantly enabled by EU accession in 2007, but also hastened by 2008–09 financial crisis and austerity measures.

With the exception of Romania, the outward migration of nurses was significantly more constrained than for doctors. This may reflect limited language skills and continued barriers to the mutual recognition of qualifications. In Poland, for example, the emigration of nurses and midwives turned out to be much lower than expected (Inoue, 2010). In addition, the President of the Slovakian health union (SZOSS) pointed to a wider trend whereby nurses migrate, but work either below their qualifications in the care sector or outside health care completely. Doctors were more mobile than other health workers, but the patterns varied between countries. In Poland, it is estimated that between 8 and 10 percent of registered doctors migrated by 2012. The Doctors’ Council estimates that anaesthetists were the first and most numerous group of specialist health workers that migrated (18%), followed by plastic surgeons (17%).

Third, the leverage of migration as an issue with governments and employers varies between countries. Employers in Slovakia were reportedly aware that their geographical location enabled the easy movement of workers to Austria and other surrounding countries. In Romania there does not appear to have been such a deliberate attempt to use migration as leverage at national level. However, interviews with managers and union officials in three Romanian hospitals in January 2012 referred to examples of collusion and informal agreement between unions and employers at local level, attempting to address migration issues by improving conditions, for example accelerating staff progression to pay scale maxima and finding ways of paying additional responsibility allowances.

In general, union leaders were not confident that migration had strengthened their bargaining position. The President of SOZ ZaSS in Slovakia insisted that ‘we do not think that migration has increased bargaining power’. This did not prevent unions from using the issue of migration as an argument in negotiations for higher pay and more resources. According to the President of LVSADA in Latvia, migration ‘is a “brain drain” of our potential, it is no good for patients or the health system – it is a kind of industrial action and telling the government that conditions and pay are not good. It is used as part of our negotiations’. In Bulgaria, the President of the main health sector union referred to a deliberate and partially successful attempt to collate figures on emigration by doctors and nurses and use these ‘as ammunition’ in negotiations. This led to the signing of a new national agreement which has raised minimum starting salaries, in some cases by 10 to 15 percent, although this agreement provides a framework to be implemented at branch level and it has not been implemented consistently.

Turning the argument on its head, there was one example where employers had facilitated emigration in order to deal with strained budgets and it. The leader of OZZPiP in Lubelskie region reported that:

after 2000 when the unemployment rate was very high and in many families nurses became single breadwinners, there were many cases of shuttle migration to Italy. They would take three months leave at work in Poland to work in Italy as carers. The hospitals were aware of this fact, they even established special work schedules to enable hospital employees to take unpaid leave in turn.

Fourth, leverage varied between different workers in the health sector. Doctors collectively and individually have been more prepared to capitalize on labour shortages: the President of the Visegrád doctors organization described the use of ‘exit’ as a credible collective threat in order to leverage higher pay. The tactic of mass resignations was first used in Poland in 2007, when 2000 doctors handed in letters giving notice, followed by the resignation of 3800 doctors in the Czech Republic in 2010 under the slogan ‘Thank you, we are leaving’. The same tactic was adopted in autumn 2011 when 2500 doctors (25%) resigned in Hungary and 2000 in Slovakia. This received high media coverage and led to some concessions by governments.

In Poland the situation started to change after 2006, when the EU imposed a maximum 56-hour week for junior doctors. Hospitals directors had three options: to contract out services, to introduce shifts or to introduce an opt-out clause. This strengthened the hand of doctors in making demands for significantly higher wages. According to the leader of OZZL in Poland, as a result of doctors protests wages improved further in 2007 and since then the material reason for migration was reduced. A similar trend was confirmed in Slovakia.

Institutional power

Institutional engagement through social dialogue at national level has varied across countries and over time, usually depending on the political complexion of the government. In Latvia, social dialogue with the government is well established and ongoing. However, in Hungary the relationship between the right-wing Fidesz government and the unions has more or less collapsed. In June 2013 the three main Polish trade union organizations, NSZZ Solidarność, OPZZ and FZZ, left the Tripartite Commission in protest against what the OPZZ interviewee described as ‘anti-social and anti-worker policies’. Therefore the sections of these organizations that represent health workers no longer participate in the health care committee of the Tripartite Commission.

In Romania, national social dialogue broke down during 2011–12; but in a changed political context with a new government and ‘more supportive health minister’, the health unions attempted to ‘bring social dialogue back’. Talks were re-opened and by early 2013 a new collective agreement for the health sector was signed. According to the President of Sanitas, this was with worse employment protection rights (increased ‘flexibility’ for employers) and without a pay increase that the unions had demanded, but ‘at least [they] had a national agreement back’.

After 2004, relationships were consolidated with other European trade unions, in particular through affiliation to EPSU. According to its representative, this enabled access to centralized resources, including information related to relevant legislation and policy frameworks, and in turn unions have been able to transmit their policy needs into lobbying processes. Their participation in social dialogue has led to the adoption of new discourses on issues such as ‘mobbing’ (bullying) and to campaigns against third-party violence and harassment of employees. Participation in EPSU has strengthened the structural power of NMS health worker unions and contributed to building cross-border and European solidarity.

The countries differed in levels of engagement and degrees of enthusiasm regarding participation in EPSU. The President of SOZ ZaSS in Slovakia described their relationship as:

very long-term and good quality. . . We have excellent communication and speak nearly every day. We campaign with EPSU on a regular basis, for example on the ‘right to water’ campaign where SOZ ZaSS pushed our own government. Also representatives go to various meetings and conferences and take part in mutual campaigns such as prevention of sharp injuries in the hospital sector.

The President of LSVADA in Latvia claimed that ‘through solidarity with Europe we have gained new experience’. An example was learning how to create much more lively campaigns, using t-shirts and flags to create higher visibility and a ‘buzz’ for those taking part. He underlined how knowledge was used to underpin campaigning. ‘If we know about the Lisbon Treaty, unions have the power to intervene and to prove how they construct their demands. . . . We can find out good practices and take a scientific evidence-based approach that governments cannot really dismiss.’

Hungarian and Polish health worker unions were much less engaged with EPSU. The Hungarian EDSzZ was completely inactive; Solidarność, OPZZ and FZZ have taken part in EPSU events, but are not active members. However, OZZPiP is debating joining EPSU and has sought observer status because, according to its President, ‘we see it as a network that can be supportive in terms of policy creation’.

Unions from some NMSs have initiated a debate in EPSU to address the issue of outward migration. One outcome was a Conference on Migration of the Healthcare Workforce in Bucharest in February 2013 with 20 delegates from four unions, two from Romania and two from Bulgaria. Discussions focused on cross-border cooperation, such as transferring union membership to other countries and the use of electronic membership cards, and an increased role for Public Services International and EPSU in facilitating bilateral agreements between trade unions. A second set of suggestions coalesced around better information and training, for example the development of a web page as a forum for discussions on migration, including legal counselling from the destination countries. Better education for trade union leaders on migration was urged, alongside the inclusion of migration on the agenda of the regular training activities for health professionals. The third strand of policies was to put pressure on the EU to speed up harmonizing professional qualifications. More broadly, Latvian health service trade unions (as part of a broad national coalition) used EPSU to mobilize pressure on the EU in the face of a deteriorating health service after the IMF imposed austerity measures in 2008. It is too soon to know how these initiatives are ‘playing out’ on the ground in terms of their effectiveness, but there are a number of concrete issues around which to organize, such as ethical recruitment and the transfer of trade union membership, which open a structured dialogue between the unions in sender and receiver countries.

Coalitional power

We examine coalitional power in relation to three themes: the propensity to work with other health sector unions; engaging with community groups and NGOs; and cross-border collaboration.

Establishing solidarity between different union organizations has been particularly difficult in Poland, initially because of extreme hostilities between OPZZ and NSZZ Solidarność, and more recently the challenge to both from the new confederation FZZ. The President of the nurses’ union OZZPiP, affiliated to FZZ, reported a history of cooperation with the rival confederations; but:

there were times when it was more difficult. In 2010 when nurses and midwives were guaranteed extra money and other trade unions perceived this decision as unconstitutional. In the end it turned out that the money guaranteed by ministry was very low or almost none, but the dispute seriously weakened the cooperation between the three trade unions.

However, interviewees from both OPZZ and OZZPiP explained how they joined efforts in 2011 to fight against the increased pension age for women. In September 2013 a joint demonstration was organized by the three confederations against the policies of the government; representatives from both OPZZ and OZZPiP described the action in front of the Ministry of Health protesting against the commercialization of hospitals and the increased the precariousness of health workers. Further, in May 2014 OZZPiP organized a conference and invited representatives of OPZZ and Solidarność, as well as the Nurses’ Chamber and Ministry of Health, to discuss the ‘contemporary situation’ of nurses and midwives.

In Latvia and Slovakia, health unions represented workers from all groups and no specific tensions were reported between doctors, nurses and health assistants; the President of the Slovakian SOZ ZaSS described a good relationship with the doctors’ union. However, in Poland and Hungary the relationship between doctors and other health workers was less than cordial. The leader of the doctors’ union (MOSz) in Hungary reported no contact or communication with EDSzZ that represents health workers; the relationship was hostile. The leader of Polish nurses’ union OZZPiP described their relations with the doctors’ union as ‘very distant’.

Given the dearth of civil society organizations in post-communist states, it is not surprising that working with NGOs and community groups is embryonic. However, LVSADA in Latvia has been very effective in mobilizing a national alliance to lobby the EU for better funding for the health sector. They elicited signatories from five organizations, including professional bodies (representing nurses, doctors and midwives), the body representing hospital managers and an umbrella organization lobbying for disabled people. In recognition of their campaigning and mobilizing (including collecting 54,000 signatures) in 2011 they were awarded the Silver Rose Award for Social Justice from Solidar (a European network of 52 NGOs). In Poland, similarly, the President of OZZPiP in Lubelskie described the formation of a regional coalition, which involved working with local government, hospital managers and patients to lobby for a national funding formula that was less disadvantageous to their deprived region.

There were growing initiatives in establishing or furthering cooperation with trade unions in other EU states, and in the case of Slovakia and Latvia with bordering countries. The President of SOZ ZaSS described how they had been involved in projects on migration; in particular, they participated in an initiative organized by ver.di from Germany, with NSSZ Solidarność from Poland and their Czech counterpart, which focused on wages and the working and living conditions of migrants in the four countries. This project not only gathered information in order to improve the working conditions for migrant health care workers generally, but also had a practical focus in providing Slovakian workers in Germany with advice and counselling in their native language. In a similar project, Zuwinbat (Zukunftsraum Wien-Niederösterreich-Bratislava-Trnava), SOZ ZaSS worked with the Austrian union vida to open offices in Austria and Slovakia to support migrant workers in each country, again providing counselling and advice.

LVSADA in Latvia has worked with the Lithuanian health workers’ union and Latvian and Lithuanian employers in a Social Partnership Project to promote dialogue at national level and continue to lobby the EU. According to its President, a key task with regard to mobility is to establish the WHO Global Code of Practice on International Recruitment and to implement the frameworks on recruitment and retention agreed between EPSU and HOSPEEM (the European Hospital and Healthcare Employers’ Association).

In Poland, OZZPiP formed a coalition with WZZ Sierpień 80 (a small radical union) and joined an international network of radical organizations opposing privatization of healthcare in Europe. However, a change of leadership in 2013 shifted its orientation to a more professional focus. In the beginning of 2014 OZZPiP decided to establish international contacts with other nurses’ unions in Europe, making contacts in Norway, Germany, the Czech Republic, Italy, the UK and France. Solidarność has linkages with the British TUC and bilateral relationships with some individual affiliates, but this did not extend to health sector trade unions. The OPZZ, however, seconded an organizer to Unison (which represents nurses, nursing assistants and care workers) to liaise with Polish workers in the sector, recruiting and promoting the union.

In addition to country-wide developments there has been a strengthening of sectional arrangements and organization across the region, particularly in respect of doctors and nurses. This is manifest, not only in the initiatives of OZZPiP, but also in the case of doctors in the Visegrád countries who have formed a cross-border organization to articulate demands and coordinate action. This is reflected in the Charter adopted in November 2011:

the doctors’ trade unions of the Visegrád countries wish to create a new way of professional advocacy. From now on they are making an effort to cooperate in their activities to protect rights and interests of the workers they are representing, in order to be able to make pressure on their governments more effectively.

Common goals include minimum salaries in relation to the national average; binding employment and patient standards in both public and private sectors; overtime regulated according to the EU Working Time Directive; and a defence of trade union rights based on ILO Conventions. To further these demands, as was discussed earlier, there was agreement to coordinate action around ‘quit and leave’ campaigns, organizing working to rule, joint activity and lobbying with regard to the possibility of strike action if necessary.

Conclusion

Despite the turbulence and discontent manifest in frequent protests in the health sector across the NMSs, there are no examples of disruptive industrial action and the structural power of trade unions is relatively weak. Assessments of the extent to which outward migration has changed labour markets are hampered by poor data. These factors do not support the conjecture proposed by Kaminska and Kahancová (2010) that the hand of labour organizations has been strengthened by outward migration. Beyond this, subjective assessments by union leaders of their structural power have been fairly pessimistic about their ability to mobilize members and win concessions. Doctors are the exception, particularly in the Visegrád countries: their labour market power and use of emigration as a threat has led to increased salaries and reduced differentials, thereby reducing the incentive to migrate.

More confidence has been shown by trade unions in wielding institutional power to intervene in labour mobility processes. LVSADA in Latvia is an exemplar of using the pan-European labour organization, EPSU, to lobby the EU against cuts in health budgets. Romanian and Bulgarian unions have participated actively in the EPSU agenda on migration, with the outcome establishing a series of campaign issues. However, there have been different degrees of engagement at European level, with EDSSz in Hungary and all Polish unions displaying a very low level of participation.

Coalitional power has also varied across countries. In Poland, anti-union legislation and the commercialization of hospitals has forced a break with the entrenched legacy of inter-union hostilities, bringing an alliance between health workers in the three main confederations that would have been unthinkable even five years previously. However, in Hungary the EDDSz has reverted to an autarchic position, with no cooperation with unions within or outside the country and no participation in European structures. Beneath EPSU, as a coordinator of cross-border solidarity, there is a web of bilateral initiatives between countries (particularly those in close proximity) and between different sectors within the health service; for example, the Visegrád doctors and new linkages being forged by the Polish nurses.

The research points to complex patterns of labour mobility within and between countries, and varied responses by unions that are subject to constant reappraisal and change. This does not fit well with explanations of strategies through the prism of VoC. Rather, locating an analysis within a framework of combined and uneven development enables a dynamic understanding of labour mobility and labour markets and the agency of workers as mutually constitutive. The idiosyncrasies and legacies of individual unions and qualities of their leaders are confirmed as key elements in explaining the varied strategies and capacity of engagement of labour organizations. Demographics, coupled with neoliberal policies of marketization of the health sector and budget cuts on one hand, and increasing moves towards a single market for health workers on the other, mean that the mobility and migration of health workers will assume even greater importance for trade unions.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/ or publication of this article: The data was gathered as part of contract research conducted for the European Federation of Public Service Unions (EPSU). The authors are grateful to be allowed to use the data for academic purposes.

Author biographies

Jane Hardy is Professor of Political Economy, and Moira Calveley and Steve Shelley are Principal Lecturers at the University of Hertfordshire, UK.

Julia Kubisa is an Assistant Professor at the University of Warsaw, Poland.

References

Anner

Greer

Hauptmeier

Lillie

Winchester

(2006) The industrial determinants of transnational solidarity: Global interunion politics in three sectors. European Journal of Industrial Relations 12(1): 7–27.

Bach

Bordogna

(2013) Reforming public service employment relations: The impact of the economic crisis and the new EU economic governance. European Journal of Industrial Relations 19(4): 279–294.

Bernaciak

(2011) East–West labour transnationalism(s) rivalry or joint mobilisations? In: Bieler

Lindberg

(eds) Global Restructuring, Labour and the Challenges for Transnational Solidarity. London: Routledge, pp. 33–47.

Bieler

Goudriaan

(2011) Trade union and social movement cooperation in defence of the European public sector. In: Bieler

Lindberg

(eds) Global Restructuring, Labour and the Challenges for Transnational Solidarity. London: Routledge, pp. 177–190.

Bohle

Greskovits

(2012) Capitalist Diversity on Europe’s Periphery. Ithaca, NY: Cornell University Press.

Bronfenbrenner

(ed.) (2007) Global Unions: Challenging Transnational Capital through Cross-Border Campaigns. Ithaca, NY: Cornell University Press.

Brookes

(2013) Varieties of power in transnational labor alliances: An analysis of workers’ structural, institutional and coalitional power in the global economy. Labor Studies Journal 38(3): 181–200.

Cox

Mason

(2000) Trends and developments in East Central European industrial relations. Industrial Relations Journal 31(2): 97–114.

Dølvik

Eldring

(2006a) Industrial relations responses to migration and posting of workers after EU enlargement: Nordic trends and differences. Transfer 12: 213–230.

10.

Dølvik

Eldring

(2006b) The Nordic labour market two years after the EU enlargement. TemaNord 2006:557. Nordic Council of Ministers, Copenhagen.

11.

Dundon

Gonzalez-Perez

McDonough

(2007) Bitten by the Celtic Tiger: Immigrant workers and industrial relations in the new ‘glocalised’ Ireland. Economic and Industrial Democracy 28(4): 501–522.

12.

EC (2005) Directive on the recognition of professional qualifications (2005/36/EC). Available at: http://ec.europa.eu/internal_market/qualifications/policy_developments/index_en.htm (accessed 22 September 2014).

13.

EC (2012) Modernising the professional qualifications directive. Green paper COM 365 Final, European Commission, Brussels.

14.

EHFG (European Health Forum Gastein) (2011) Health service staff shortfall by 2020 being filled by migrants. Available at: http://www.ehfg.org/846.html.

15.

EPSU (2012) The Wrong Target One Year On: Pay Cuts in the Public Sector in the European Union. Brussels: EPSU.

16.

Fitzgerald

Hardy

(2010) ‘Thinking outside the box?’ Trade union organizing strategies and Polish migrant workers in the UK. British Journal of Industrial Relations 48(1): 131–150.

17.

Galan

Olsavszsky

Vladescu

(2011) Emerging challenges after EU accession: Romania. Euro Observer: The Health Policy Bulletin of the European Observatory on Health Systems and Policies 13(2): 10–11.

18.

Gall

(2013) Quiescence continued? Recent strike activity in nine Western European economies. Economic and Industrial Democracy 34(4): 667–691.

19.

Hall

Soskice

(2001) Varieties of Capitalism: The Institutional Foundations of Comparative Advantage. Oxford: Oxford University Press.

20.

Hardy

(2014) Transformation and crisis in Central and Eastern Europe: A combined and uneven development perspective. Capital and Class 38(1): 143–155.

21.

Hardy

Calveley

Shelley

Zahn

(2012a) Opportunities and challenges related to cross border mobility and recruitment of the health sector workforce. Report for European Federation of Public Service Unions, available at: www.epsu.org/a/8920.

22.

Hardy

Eldring

Schulten

(2012b) Trade union responses to migrant workers from the ‘new Europe’: A three sector comparison in Norway, Germany and the UK. European Journal of Industrial Relations 18(4): 347–363.

23.

Heckscher

Carre

(2006) Strength in networks: Employment rights organizations and the problem of co-ordination. British Journal of Industrial Relations 44(4): 605–628.

24.

Hyman

(2011) Trade unions, global competition and options for solidarity. In: Bieler

Lindberg

(eds) Global Restructuring, Labour and the Challenges for Transnational Solidarity. London: Routledge, pp. 16–30.

25.

Inoue

(2010) Migration of nurses in the EU, the UK, and Japan: Regulatory bodies and push-pull factors in the international mobility of skilled practitioners. Discussion Paper, Series A No. 526.

26.

Kaminska

Kahancová

(2010) Emigration and labour shortages: An opportunity for trade union in new member states? Working Paper 10–87, AIAS, Amsterdam.

27.

Krings

(2009) A race to the bottom: Trade unions, EU enlargement and the free movement of labour. European Journal of Industrial Relations 15(1): 49–69.

28.

Kwist

(2004) Does EU enlargement start a race to the bottom? Strategic interaction among EU member states in social policy. Journal of European Social Policy 14(3): 301–318.

29.

Lillie

Greer

(2007) Industrial relations, migration and neoliberal politics: The case of the European construction sector. Politics and Society 35(4): 551–581.

30.

Lillie

Martínez Lucio

(2004) International trade union revitalization: The role of national union approaches. In: Frege

Kelly

(eds) Labour Movement Revitalization in Comparative Perspective. Oxford: Oxford University Press, pp. 159–180.

31.

Lindberg

(2011) Varieties of solidarity: An analysis of cases of worker action across borders. In: Bieler

Lindberg

(eds) Global Restructuring, Labour and the Challenges for Transnational Solidarity. London: Routledge, pp. 206–219.

32.

Martin

Cristescu-Martin

(2004) Consolidating segmentation: Post-socialist employment relations in Central and Eastern Europe. Industrial Relations Journal 35(6): 629–645.

33.

McKinnon

(2012) Reconstructing scale: Towards a new scalar politics. Progress in Human Geography 35(1): 21–36.

34.

Meardi

(2004) Short circuits in multinational plants: The extension of European Works Councils to Poland. European Journal of Industrial Relations 10(2): 161–178.

35.

Meardi

(2007) More voice after more exit? Unstable industrial relations in Central Eastern Europe. Industrial Relations Journal 38(6): 503–523.

36.

Morton

(2011) A single European market in healthcare: The impact of European Union policy on national healthcare provision. European Services Strategy Unit, Briefing 3. Available at: http://www.european-services-strategy.org.uk/news/2011/a-single-european-market-in-healthcare/

37.

OECD (2011) ALFS Summary Tables: Population. StatExtracts. Available at: http://stats.oecd.org/Index.aspx?queryid=254

38.

Ost

(2002) The weakness of strong social movements: Models of unionism in the East European context. European Journal of Industrial Relations 8(1): 33–51.

39.

Ostrowski

(2014) Searching for equilibrium in labour relations before the EU accession: Developing grassroots trade unions in private companies in Poland. Economic and Industrial Democracy 35(2): 205–223.

40.

Pulignano

(2007) Going national or European? Local trade union politics within transnational business contexts in Europe. In: Bronfenbrenner

(ed.) Global Unions: Challenging Transnational Capital through Cross-Border Campaigns. Ithaca, NY: Cornell University Press, pp. 137–154.

41.

Sassen

(1988) The Mobility of Capital and Labour. Cambridge: Cambridge University Press.

42.

Silver

(2003) Forces of Labor: Workers’ Movements and Globalization since 1870. New York: Cambridge University Press.

43.

Smith

(2006) The geography of uneven development. In: Dunn

Radice

(eds) 100 Years of Permanent Revolution: Results and Prospects. London: Pluto Press, pp. 180–195.

44.

Stan

Erne

(2013) Explaining East–West labour migration: From development gaps to development trajectories. A comparative assessment of the Romanian case across time. Labor History. DOI: 10.1080/0023656X.2013.843841.

45.

Turnbull

(2007) Dockers versus the directives: Battling port policy on the European waterfront. In: Bronfenbrenner

(ed.) Global Unions: Challenging Transnational Capital through Cross-Border Campaigns. Ithaca, NY: Cornell University Press, pp. 117–136.

46.

Valiani

(2012) Rethinking Unequal Exchange: The Global Integration of Nursing Labour Markets. Toronto: University of Toronto Press.

47.

Vaughan-Whitehead

(2003) EU Enlargement versus Social Europe: The Uncertain Future of the European Social Model. Cheltenham: Edward Elgar.

48.

Vladescu

Olsavsky

(2009) Migration of nurses: The case of Romania. Human Resources Management: Management in Health 4: 12–16.

49.

Wills

(2008) Making class politics possible: Organizing contract cleaners in London. International Journal of Urban and Regional Research 32(2): 305–323.

50.

Woolfson

(2007) Labour standards and migration in the New Europe: Post-communist legacies. European Journal of Industrial Relations 13(2): 199–218.

51.

Woolfson

Sommers

(2006) Labour mobility in construction: European implications of the Laval un Partneri dispute with Swedish Labour. European Journal of Industrial Relations 12(1): 49–68.

52.

Wright

(2000) Working class power, capitalist-class interests and class compromise. American Journal of Sociology 105(4): 957–1002.

53.

Yeates

(2009) Globalizing Care Economies and Migrant Workers. Basingstoke: Palgrave Macmillan.

54.

Yeates

(2012) Global care chains: A state-of-the-art review and future directions in care transnationalization research. Global Networks 12(2): 135–154.