The public’s attitude towards strike action by healthcare workers and health services in South Africa

Ames Dhai, MB ChB, FCOG (SA), LLM, PG Dip Int Res Ethics

Harriet Rosanne Etheredge, BA, MScMed (Bioethics and Health Law)

Merryll Vorster, MB BCh, MMed (Psych), BA, PhD, FC (Psych), Dipl Research Ethics

Yosuf Veriava, MB BCh, FCP (SA), FRCP (Lond), PhD (Hon)

Steve Biko Centre for Bioethics, School of Clinical Medicine,
University of the Witwatersrand, Johannesburg

Corresponding author: A Dhai (amaboo.dhai@wits.ac.za)

Striking involves withdrawing services by employees (in any sector) in a democratic state to realise particular goals in the workplace. Striking is generally the last resort to solving a problem and occurs when the collective bargaining process makes insufficient inroads and the unions are not satisfied with management’s offer to correct the situation.1 Strikes are common worldwide. Since the 12th century BC, strikes were (and still often are) believed to be the only method by which employees could express discontent with their working environments and achieve desired outcomes.2
Healthcare worker strikes pose difficult questions, especially considering their ethical codes and professional tenets. The Hippocratic Oath states that doctors undertake to act in the best interests of the safety, welfare, health and well-being of all those entrusted to their care, and the community.3 The Florence Nightingale Pledge binds nurses to act in the best interests of their patients and their profession.4 The World Medical Association has published many declarations and codes of conduct which underscore the importance of the fiduciary relationship.5 , 6 In modern medicine, the fiduciary relationship between healthcare worker and patient must be honoured to achieve satisfaction.
International studies reveal that the foremost reason for strikes in the medical field is poor working conditions, followed by wage and other concerns.7

Healthcare worker strikes in South Africa

Healthcare worker strikes in South Africa have been motivated by the same concerns as internationally. In South Africa, wage disputes are the catalyst of almost all healthcare worker strikes and wage negotiations are pivotal when it comes to speedy resolution.8

In 2007, nurses’ strikes, sometimes violent, occurred countrywide. These were ‘largely about pay and conditions’, but also opposition to the government’s economic policy for healthcare.9 The cornerstone of this policy is the Occupation-Specific Dispensation (OSD) that allows for wage increases based on incremental linkage to experience, skill and good performance.10 Due to commence implementation in July 2007,11 the OSD was substantially delayed.10 A recent study concludes that nursing strikes lower the standard of patient care.12

In 2009, further healthcare sector striking occurred, influenced by poor salaries, deterioration of academic facilities, low numbers of doctors being produced, poor working conditions in the public sector and the unfortunate conditions facing patients at public health facilities. Implementation of the OSD was still contentious.13 Concerned doctors who did not participate in the protest action issued a statement that they considered the strike to be misguided, although concurring ‘with the legitimate grievance of (their) colleagues’.14 They maintained that the Hippocratic Oath has always been the basis of ethical and professional practice – patient interests are paramount and striking entailed consciously foregoing this commitment. The group also cited conditions and management capability in the public sector as the most contentious issues, rather than salaries.

In 2010 public sector healthcare workers threatened further strike action because of failure to implement the OSD in some sectors. However, this was cancelled as other avenues of negotiation had not been exhausted.15 As the 2010 FIFA World Cup approached, matters remained unresolved and frustrated healthcare professionals vowed to protest during the event, believing that striking during such a high-profile occasion would result in a quicker resolution of grievances.16

The right to strike and the rights of patients to healthcare

Regulations governing healthcare worker strikes in South Africa are drawn from the Constitution17 and the Labour Relations Act No. 66 of 1995.

While Section 23 of the Bill of Rights accords all workers the right to strike, it is conditionally limited by Section 36.17 Section 64 of the Labour Relations Act reiterates that every worker has the right to strike.18 Section 65 qualifies the general right to strike in that individuals who provide essential services may not participate in strike action. Public service healthcare workers may therefore not enter protected strike action in the absence of a minimum service level agreement.18 Should such an agreement be in place, only minimum services would be considered as essential.

Within the terms of the Act, trade unions embarking on strike action must arrange for the provision of minimum level service. However, there is no agreement about a minimum service level with the Public Health and Social Development Sectoral Bargaining Council. Public healthcare workers may therefore not embark on a strike,19 as this would be unlawful and unprotected and could lead to disciplinary measures.18

Section 27 of the Bill of Rights mandates the right to access healthcare services.17 The National Health Act and the Patients’ Rights Charter have been enacted to realise Section 27,20 stipulating the precise rights and responsibilities of patients.21 As healthcare workers currently have no right to strike, any such claim would violate the patient’s right to healthcare.

Rationale

Despite South Africa’s human-rights-based Constitution,17 it has experienced crippling public sector healthcare worker strikes. The media captured the fallout from healthcare worker strikes and suggested how the public might feel about them. No published research has studied the attitude of the South African public towards healthcare worker strikes. Similar studies undertaken overseas have proved useful for policy-making. We aimed to address this gap by exploring the attitudes of a representative population of South Africans towards strike actions by healthcare workers.

Methods

The study evaluated public opinion in South Africa concerning how the participants felt about strikes in the healthcare context; whether healthcare workers have a right to strike; whether they were satisfied with treatment received in public hospitals; and if they were aware of their rights regarding health care.

The study design was descriptive, cross-sectional and quantitative, using a self-administered questionnaire. The study was approved by the Human Research Ethics Committee (Medical) of the University of the Witwatersrand, Johannesburg (clearance number: M10M10).

The study was conducted at two shopping malls in Gauteng, mall A and mall B. Based on the premise that individuals tend to frequent malls close to where they live, mall A was based in a more affluent area and attracted wealthier individuals. Mall B was situated in a less-affluent area where poorer individuals reside and shop. Appropriate sample malls were determined on relative average housing prices in the areas concerned.

The study population was derived from members of the public who frequented either mall A or mall B. Three hundred individuals were approached at each mall and invited to participate. Once the participant information sheet had been explained, individuals willing to participate were given a questionnaire to fill in. Consent to participate was implied as the study instrument was self-administered. Individuals under the age of 18 and those unable to read and write English were excluded.

The main limitation of this study was that the population might not be truly representative of the South African public. Although initial analysis finds in favour of a representative sample, less-educated people might have been excluded by the reading and writing requirement of the study.

Outcome measures

The questionnaire data were captured, cleaned of bad values, tabulated and analysed with SAS software version 9.1.3 for Windows. After primary analysis, the answers were stratified by:

• Mall A/mall B, which was used as a proxy indicator of broader demographic and economic conditions; and

• Demographic and economic variables (race, age, gender, employment status, level of income).

Tests for significant relationships were carried out using Pearson’s χ2 test at the 0.05 confidence level. The strength of the associations was determined by Cramer’s V. Associations which were at least relatively strong (Cramer’s V >0.4) were noted in the results.

Logistic regression was carried out by stepwise regression using the demographic and economic variables and the mall indicator, at the 0.05 confidence level. No interaction between the variables was considered as this would lead to very low cell counts (i.e. the frequency of some combinations of the levels of the variables in question) in some cases. Questions 7 and 8a were analysed as yes/no options only (i.e. the ‘unsure’ category was allocated as missing data for the purpose of this analysis).

In all stratified analyses, the race category ‘other’ was excluded as this comprised only two respondents.

Results

Demographic data were stratified and analysed according to shopping mall (Table I).

Ninety per cent of respondents declared that they were aware of strike action by healthcare workers in South Africa over the last 5 years and that this awareness came about primarily from television, radio and newspapers.

Thirty per cent of respondents indicated that they supported strike action by healthcare workers, 51% did not and 18% were unsure (1% did not answer the question). There was no significant difference in the responses from the two malls.

The right to strike by healthcare workers was supported by 52% of respondents; 34% indicated that they did not support the right, and 13% were unsure (1% did not answer the question). There was no significant difference in the responses from the two malls. Participants felt that healthcare workers should strike for improved working conditions, better wages and improved conditions for patients.

Fifty per cent of respondents thought that healthcare workers should demonstrate during their lunch times, 24% thought that while healthcare workers could strike, they should still treat emergencies, and only 7% thought that healthcare workers should strike by completely discontinuing their services (there was no significant difference between the two malls).

More people in the mall A group (83%) than in the mall B group (74%) felt that South African clinics were understaffed (Table II).

More respondents at mall B (52%) than at mall A (33%) said they had been affected by a healthcare worker strike themselves and more respondents at mall B (73%) than at mall A (65%) said they knew someone who had been affected. Of the sample who indicated that they were not aware of the strikes, 3% now claimed that they knew an affected party or had been affected themselves.

Seventy-one per cent of respondents at mall B indicated that they used a public hospital, while only 43% at mall A indicated that they did so; 66% of those respondents who indicated that they did use public hospitals felt that they did not receive adequate care. Of those who use public hospitals, 54% felt they received adequate care from doctors while only 32% of respondents were satisfied with the care they received from nurses.

Of all respondents, 43% indicated that they were aware of the Patients’ Rights Charter, while 55% were not. There was no significant difference in responses between the malls. The veracity of these answers was not tested in the questionnaire, which may prove a limitation of this question.

Concerning individual rights, 40% of the mall B and 32% of the mall A respondents were aware of their own rights with regard to a healthcare worker strike.

Discussion

The results suggest that many South Africans feel strongly about healthcare worker strikes; 90% of the research population knew about the strikes and had an opinion regarding their methodology and outcome.

South African healthcare workers do not legally have the right to strike. However, 52% of the study population felt that healthcare workers did have the right to strike. Despite this sentiment, there was overall dissatisfaction about the form that previous strike actions have taken. Because South Africa is a rights-based society, and employs rights-based language, the public may tend to assume that rights are unlimited and people have the right to strike. It is interesting that in spite of the 52% who considered it a right, 70% did not support healthcare worker strikes and were therefore not in favour of healthcare workers exercising the right to strike.

Regarding the format of healthcare worker strikes, lunch-hour strikes were favoured, with complete cessation of treatment considered inappropriate. Therefore, while South Africans respect individual rights, in the healthcare context, there is little support for neglect and abandonment of critically ill patients. Analysing participants’ ‘other comments’ revealed strong feelings that, as providers of essential services, healthcare workers in South Africa were irresponsible and selfish to strike. These responses reflect the intentions of Section 65 of the Labour Relations Act, which, with the minimum service agreement, would effectively render healthcare worker strikes as ‘industrial action’ as opposed to full-blown striking. This suggests that there would be significant public support for a minimum service agreement, and the government would be advised to fast-track this in the interests of the public and healthcare professionals.

A large majority of the study sample stated that they use public hospitals, of whom two-thirds considered their care and treatment to be inadequate. Concerning services rendered by doctors, only half the sample felt that these services had been adequate. The responses regarding doctors contrast with those concerning nurses; only 32% indicated that they were satisfied with nursing treatment and care.

‘Any other comments’ at the end of the questionnaire revealed strong feelings about nurses who were perceived to be ‘incompetent’, ‘lazy’, ‘lacking in empathy’, and ‘rude to patients’. Responses were along the lines of: ‘They [nurses] must stop taking long lunches and tea breaks and they must work during their working hours. They must stop being rude to the patients and give the right medicines and the right treatment to the patient’ (Mall B) and ‘Nurses should learn to treat patients better. More attention should be placed towards providing better communication skills for nurses’ (Mall A).

The data indicate that people are dissatisfied with the overall experience at public hospitals. This was felt even by those who support striking and in some cases might have been the recipients of poor treatment. Furthermore, the results suggest that some healthcare professionals, especially nurses, do not practise according to their professions’ oaths. This result is not surprising, as the literature indicates that healthcare professionals are not satisfied financially or professionally, which in turn affects their quality of service. Poor treatment received by respondents in the public sector might have reinforced their support for strike action, as those who use public hospitals have first-hand experience of the poor conditions.

These observations can assist in answering another objective of this research – whether or not the public feels that they can trust healthcare workers. Although this question was not explicitly asked in the questionnaire, an air of distrust becomes apparent, especially when it comes to nurses. Patients do not consider nurses reliable or dependable, both of which indicate a level of distrust.

This study revealed that many South Africans are unaware of their healthcare-related rights, a perception consistently faced by policy makers.22 This has negative consequences for empowerment, as people who do not know their rights are vulnerable as a result of a diminished ability to negotiate better healthcare treatment. The responses to the rights-based questions confirm observations about rights awareness by patients. Many South Africans are not fully aware of their rights, and this situation requires urgent remedy.

Conclusion

We aimed to evaluate public attitudes towards healthcare worker strikes. Negative perceptions of service quality during strikes were voiced strongly by the study population. The majority stated that withholding services completely during a strike was unacceptable. The most appropriate form of strike action was considered to be an ‘industrial action’-orientated lunchtime picket. South Africans are dissatisfied with the manner in which healthcare workers conduct strikes. South Africans would be more inclined to support healthcare workers in their endeavours for improved wages and working conditions if strikes occurred in a manner that posed less risk to patients.

The study demonstrated a lack of knowledge concerning general human rights. Participants were not aware that healthcare workers are not legally permitted to strike and were unaware of their own personal healthcare rights. This finding suggests that many may be unable to actively assert their healthcare rights.

Few participants felt that they received adequate treatment in the public sector, with healthcare workers being criticised harshly in this regard.

References

1. Ashenfelter O, Johnson GE. Bargaining theory, trade unions and industrial strike activity. American Economic Review 1969;59(1):35-49. http://www.jstor.org/stable/1811091 (accessed 6th June 2011).

2. Ogunbanjo GA, Knapp van Bogaert D. Doctors and strike action: can this be morally justifiable? South African Family Practice 2009;51(4):306-308. www.safpj.co.za/index.php/safpj/article/viewFile/1424/1580 (accessed 7 June 2011).

3. Jonsen AR, Jameton AL. Social and political responsibilities of physicians. J Med Philos 1977;2(4):376-400. http://jmp.oxfordjournals.org/cgi/pdf_extract/2/4/376 (accessed 22 June 2010).

4. American Nurses Association. The Florence Nightingale Pledge (Online). 2011. http://www.nursingworld.org/FunctionalMenuCategories/AboutANA/WhereWeComeFrom/FlorenceNightingalePledge.aspx (accessed 6 June 2011).

5. World Medical Association. International Code of Medical Ethics (Online). 2006. www.wma.net/en/30publications/10policies/c8/index.html (accessed 16 April 2010).

6. World Medical Association. Declaration on the Rights of the Patient (Online). 2005. http://www.wma.net/en/30publications/10policies/l4/ (accessed 7 June 2011).

7. Keith, NS. Collective bargaining and strikes among physicians. J Natl Med Assoc 1984;76(11):1117-1121. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2609768/?tool=pmcentrez (accessed 7 June 2011).

8. Kale R. South Africa’s health: impressions of health in the new South Africa: a period of convalescence. BMJ 1995;310(6987):1119. http://www.bmj.com/content/310/6987/1119.full (accessed 6 June 2011).

9. Sidley P. Strike cripples health services in South Africa. BMJ 2007;334(7606):1240-1241. http://www.ncbi.nlm.nih.gov.innopac.wits.ac.za/pmc/articles/PMC1892462/?tool=pmcentrez (accessed 6 June 2011).

10. Casale D, Posel D. Unions and the gender wage gap in South Africa. Journal of African Economics 2010;20(1):27–59. http://jae.oxfordjournals.org/content/20/1/27.full.pdf+html (accessed 6 June 2011).

11. The South African Government. Occupation Specific Dispensation (OSD) in the public service (Online). June 2007. http://www.info.gov.za/speeches/2007/07061811451001.htm (accessed 6 June 2011).

12. Gruber J, Kleiner SA. NBER working paper series: Do strikes kill? Evidence from New York State (Online). National Bureau of Economic Research. http://www.nber.org/papers/w15855 (accessed 7 June 2011).

13. Bateman, C. OSD strikes: possible censure in 6 months. S Afr Med J 2009;99:(11)783-784. http://www.samj.org.za/index.php/samj/article/view/3816 (accessed 7 June 2011).

14. Christian Medical Fellowship. Statement from concerned doctors in public service: regarding strike actions by doctors (Online). 2009. www.givengain.com/cause_data/images/975/09_06_29_concerned_docs_re_strike.doc (accessed 14 April 2010).

15. Bateman C. Occupation Specific Dispensation – a hapless tale. S Afr Med J 2010;100(5):268-272. http://www.samj.org.za/index.php/samj/article/view/4185/2786 (accessed 6 June 2011).

16. Stuart K. Of professionalism and healthcare strikes. South African Journal of Bioethics and Law 2010;3(1):4-8. http://www.sajbl.org.za/index.php/sajbl/article/view/98 (accessed 6 June 2011).

17. The South African Government. Bill of Rights of the South African Constitution (Online). 1996. http://www.info.gov.za/documents/constitution/1996/96cons2.htm#23 (accessed 6 June 2011).

18. The South African Department of Labour. Labour Relations Act No. 66 of 1995 (Online). http://www.labour.gov.za/legislation/acts/labour-relations/labour-relations-act (accessed 7 June 2011).

19. Fashoyin T. Management of disputes in the public service in Southern Africa. Journal of Industrial Relations 2008;50(400):578-594. http://jir.sagepub.com/content/50/4/578.full.pdf+html (accessed 6 June 2011).

20. The South African Department of Health. National Health Act No. 61 of 2003. Government Gazette. http://www.info.gov.za/view/DownloadFileAction?id=68039 (accessed 29 June 2011).

21. The South African Department of Health. Patient’s Rights Charter (Online). www.doh.gov.za/docs/pamplets/patientsright/chartere.html (accessed 7 June 2011).

22. The South African Human Rights Commission. Human Rights Development Report (Online). 2008. http://www.sahrc.org.za/home/21/files/Reports/HR%20Development%20Report%202008.pdf (accessed 25 June 2011).