Public healthcare systems have become increasingly commodified in the past fifteen years, with the drivers for this commodification coming from several directions. National governments in high-income countries with aging populations are concerned about the increasing demand for healthcare services, particularly for high-technology treatments. Low taxation policies preclude the raising of more revenue for improved public healthcare services, and these have been reinforced by policies such as the European Union's Maastricht Treaty entry criteria, which set limits for public-sector spending.
National public healthcare systems have developed according to their own specific histories, and these often influence the effects of commodification and the nature of resistance to these changes. In low-income countries, the international financial institutions have imposed funding conditions that have forced government to introduce reforms of the public healthcare sector (Verheul & Rowson, 2001; Lister, 2006). Trade treaties have contributed to this process by encouraging policies of liberalisation, which have opened up public services to global multinational service companies (Lipson, 2002).
The private sector has entered public healthcare systems through several mechanisms. As a way of preparing the public healthcare sector for competition and marketisation, one of the initial stages of reform is for public hospitals to become 'corporatised'--a process by which they have to operate according to business principles. This contributes to the commodification of healthcare, even if full privatisation does not take place (Sen, 2005; Leys, 2001). Services may be gradually contracted out to the private sector, often starting with catering, cleaning and facilities management before moving on to clinical services; and the development of public-private partnerships to build and manage new hospitals has presented many governments with an apparent solution to short-term funding, though in the long term, governments will be paying the private sector for inflexible long-term contracts (Pollock, 2004).
Thus there is a growing presence of private-sector companies operating in public healthcare systems, as well as significant changes taking place in the role of government in public healthcare systems (Lethbridge, 2005). The impact of these changes on healthcare workers and on healthcare users has been felt in a variety of ways. For healthcare workers, their socioeconomic security has been undermined by either the introduction of corporatisation to public-sector hospitals, or the contracting out of services to the private sector. Changes in wage levels and terms and conditions are the immediate results of the commodification of public healthcare, leading to increasingly precarious employment (Afford, 2003). The lack of investment in public healthcare combined with deteriorating working conditions has resulted in depleted public health services (Laurell, 2001), and it has also led to the migration of skilled health workers from many low-income countries to higher-income countries. For healthcare users, the effect has often been to limit access and worsen the quality of the services delivered (Gilson, 1995; Bloom & Lucas, 1999; Bloom & Standing, 2001; Hilary, 2001). It also creates a feeling of insecurity about the future of healthcare provision. The introduction of user fees has often had a devastating effect, restricting access to healthcare even when there are exemptions for disadvantaged groups (Gilson, 1995; Nyonator & Kutsin, 1999; Jeppsson, 2001).
The nature of healthcare has an important influence on the kinds of resistance to changes that can be seen in public healthcare services. Access to healthcare which is free at the point of access is an important factor in preventing loss of income due to illness, which contributes to the reduction of income inequalities. People use healthcare services throughout their lives, and though the nature of their relationship with healthcare is different to the relationships people have with other public utilities because other factors influence health besides access to treatment, people often have close ties with local healthcare facilities. When these facilities are threatened, people respond with strong campaigns. The relationships between healthcare users and healthcare workers may be strengthened by their campaigning together (Lethbridge, 2004).
Much research into trade union resistance to globalisation has concentrated on the manufacturing sector, and although there has been some specific research into campaigns against the privatisation of public services, models of resistance are dominated by the manufacturing perspective. Healthcare trade unions have been active in campaigns to protect public healthcare services throughout the world, and this article aims to contribute a specific sectoral analysis to resistance to neoliberalism, as seen in the experience of public healthcare services.
This study will explore four examples of resistance to healthcare commodification by trade unions alongside community organisations and social movements. A case study approach was chosen as a way of analysing the patterns of resistance. The four dimensions of commodification considered here are hospital privatisation, hospital corporatisation, a post-privatisation campaign against low pay, and a campaign for access to HIV/AIDS treatment.
The four case studies were chosen in pursuit of a global reach, with examples from El Salvador, Spain, the UK and South Africa. They also showed trade unions taking different roles within partnerships and alliances, and with different levels of involvement with community organisations, social movements and international campaigns.
* The Salvadorean case study features a trade-union-led campaign against the privatisation of hospitals in El Salvador in 2002, which built on other campaigns against the privatisation of other public services.
* The Spanish case study examines the campaign of the Federacion para la Defensa de Salud Publica (FADSP) against the corporatisation of hospitals in Galicia, a region of Spain. This was chosen as an example of a campaign against one aspect of commodification, led by a broad-based campaign consisting of trade union members and other players.
* The UK case study examines an example of a trade-union--community campaign for improved wages for health workers in services that have already been contracted out. In this case, the campaign takes place in the post-privatisation period and illustrates what actions can be effective after privatisation has taken place.
* The South African case study is an examination of the alliance between the Confederation of South African Trade Unions (COSATU) and the Treatment Action Campaign (TAC), which campaigns for improved access to HIV/AIDS treatment. The TAC is the lead organisation.
Material was gathered through a review of public documents, local and national press coverage and the publications of organisations involved in the campaigns. The conceptual section develops a framework of analysis for the four case studies, and this follows below.
New models of trade unionism
Over the last two decades, trade unions have had to deal with falling membership, the rapid movement of capital, and increasingly precarious employment accompanied by a hostile environment for organised labour. The search for new strategies that will strengthen trade unions has focused on the development of community alliances and an increased international perspective. These have informed new forms of trade union organisation and activity. This paper examines some of the themes emerging from studies of the changing relationships between trade unions and civil society organisations. The discussion will start by looking at social-movement unionism, new labour internationalisation and health activism.
Social-movement unionism is characterised by unions taking action on issues by effectively combining collective bargaining activities and collective action (Hyman, 1997; Moody, 1997). This may involve campaigns for housing, social services, health, education and other basic public services. Union democracy is an important feature of social-movement unionism. Social-movement unionism is also different from political unionism in that rather than its being linked to a political party, it is involved in broad-based social movements. Unions fight for power and organisation in the workplace as well as reaching out to other unions (locally, nationally and globally), community organisations and other social movements (Hyman, 1997; Moody, 1997), and the issue of political party involvement is one of the more contentious elements of social-movement unionism.
The South African experience has exerted a strong influence on the conceptual development of social-movement unionism. In the 1980s, labour-movement and civil-society organisations worked together to promote the cause of democracy, bringing workplace and community struggles together. COSATU worked with the African National Congress (ANC) to mobilise for elections in the early 1990s (Hirschsohn, 2007).
Some of the problems facing trade-union--community collaboration in South Africa and elsewhere can be seen in the relationship between the Western Cape Anti-Eviction Campaign (AEU) and the South African Municipal Workers Union (SAMWU). Different membership systems and decision-making structures pose a barrier to collaborative working between AEU and SAMWU, so that although SAMWU has a commitment to working with social movements, and SAMWU members live in the same districts, Xali (2006) found that few SAMWU members were active members of the AEU.
Different attitudes to the ANC government and to the promotion of municipal authorities and services led to SAMWU's questioning the campaigning activities of AEU, which were seen as anti-government and damaging to public...