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

AuthorManuela Galetto
Published date01 May 2017
Date01 May 2017
Organised decentralisation, uneven
outcomes: employment relations in the
Italian public health sector
Manuela Galetto
This article looks at the difculties 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 dimensionto 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 governmentspublic expenditure
and greater responsibilities for these organisationshospitals and local health
Changes in the established systems of employment relations also took place in an
attempt to implement allegedly more efcient, 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;
Industrial Relations Journal 48:3, 196217
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 nancial 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 matterin
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 ndings; section 3 describes the
methodology, and the ndings are then presented in section 5, followed by discussion
and conclusions.
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.
Italys 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

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