Organised decentralisation, uneven outcomes: employment relations in the Italian public health sector

• Author: Manuela Galetto
• DOI: http://doi.org/10.1111/irj.12175
• Published date: 01 May 2017
• Date: 01 May 2017

Organised decentralisation, uneven

outcomes: employment relations in the

Italian public health sector

Manuela Galetto

ABSTRACT

This article looks at the difficulties of adapting a very centralised employment relations

system in a country characterised by a deep regional economic divide. In particular, by

looking at the Italian public health sector, it is contended that organised

decentralisation of employment relations implemented against wide regional

differences led to uneven outcomes in second-level (organisation) collective bargaining.

The debates on changes in the organisation of healthcare in the past 40 years and their

effects on employment relations in all countries have focused almost exclusively on

the national level. This article aims to add a ‘regional dimension’to the analysis that

can be crucial in the assessment of processes and outcomes. The Italian public

healthcare sector is chosen as case study as it is one of the European countries with

the deepest economic divides, but also characterised by a highly centralised system

of public sector employment relations.

Throughout the 1980s and 1990s, a common feature of the transformation of

traditional public administrations in most countries across the world has been that

of a new public management-inspired trend of reforms. For public health systems

this has meant, amongst other things, restructurings, mergers, closures or

privatisation of hospitals, cost saving redesigning of treatments and care, especially

for non-acute patients, and experimentations of mix of public and private providers

(Bach et al., 1999; Bach and Kessler, 2011). Such changes were aimed primarily, at

least in the discourse, at more effective control of governments’public expenditure

and greater responsibilities for these organisations—hospitals and local health

providers.

Changes in the established systems of employment relations also took place in an

attempt to implement allegedly more efficient, private sector-like practices. Degrees

of decentralisation of collective bargaining (CB) to organisation level, increases in

managerial discretion, introduction of job enlargement and other internal labour

and occupational experimentations took place in several countries. Despite the

expectations, however, studies highlighted both limited success, for instance, of early

attempts of performance-related pay mechanisms for health staff at the organisation

❒Manuela Galetto, Industrial Relations Research Unit, Warwick Business School, University of

Warwick, Coventry CV4 7AL, UK. Correspondence should be addressed to Manuela Galetto, Industrial

Relations Research Unit, Warwick Business School, University of Warwick, Coventry, CV4 7AL, UK;

email: manuela.galetto@wbs.ac.uk

Industrial Relations Journal 48:3, 196–217

ISSN 0019-8692

© 2017 Brian Towers (BRITOW) and John Wiley & Sons Ltd

level, as well as a continuing distinctiveness of public sector employment relations

that are strictly linked to the role of political choices and of central government

interventions (Hood, 1995; Grimshaw et al., 2007; Bordogna, 2008; Mehaut et al.,

2010; Bach and Kessler, 2011). The industrial relations literature showed, in

particular, that straightforward implementation of a private sector-like model of

employment relations had to take into account the capacity of organised social actors,

such as unions and employers, to frustrate or promote change (Galetto et al., 2014;

Greer et al., 2013; Schulten et al., 2008).

Health systems have also become systematically and increasingly territorially

decentralised. Budget pressures led countries as diverse in size and approach to their

national health systems as Italy, Germany, Spain, Belgium, Sweden, Denmark and

partly France to engage in devolution of financial as well as organisational

responsibility of the healthcare provisions to subnational administrative units

(regions, Länder,comunidades autónomas, federal states, etc.). Similarly, territorial

decentralisation took place in North and South America, India and Central Asia

(Pavolini and Vicarelli, 2012).

Given their increased involvement in healthcare planning and organisation, this

article explores what role and effects, if any, regional governments have in the

relevant industrial relations. While it has been established that ‘regions matter’in

the reform of public sector (Neri, 2006; Sarto et al., 2015, Greer et al., 2013), we know

less about whether and how they matter in the regulation of the labour relations

involved in those changes. Is the role of the regional governments as commissioning

and planning authorities to be matched by a role as employers too? And if so, what

is the resulting relationship with the extant levels of regulation of employment

relations? This is theoretically relevant for the study of industrial relations. National

systems are the default unit of reference when comparing developments in labour

relations across countries. Here, within-country variations are taken into

consideration in the interpretation of changes and trends in industrial relations.

Regional differences are shown to affect the access and quality to public services,

but are rarely analysed according to their implications on the terms and conditions

of work of healthcare staff and, in particular, on the institutions and the governing

mechanisms that determine those working conditions.

The following section introduces the case study; section 2, then, drawing from the

available, though sporadic, theoretical contributions on the role of the regions in

employment relations, outlines four possible scenarios of an intermediate, regional

level of regulation to guide the interpretation of our findings; section 3 describes the

methodology, and the findings are then presented in section 5, followed by discussion

and conclusions.

1 THE CASE OF ITALY: TENSION BETWEEN NATIONAL EMPLOYMENT

RELATIONS AND REGIONAL HEALTH SYSTEMS

Across different countries, hospitals are possibly amongst the most decentralised

public services and will be the focus of this article. Italy is then chosen as a textbook

example of historically wide economic regional divide contrasting with a very

centralised system of CB.

Italy’s overall national health expenditure has remained generally under the OECD

countries average, moving from 8 per cent in 1990 to just under 9 per cent of GDP in

2015 (OECD, 2015) but with a forecast of a decrease to 6.5 per cent by 2019,

197Organised decentralisation, uneven outcomes

© 2017 Brian Towers (BRITOW) and John Wiley & Sons Ltd