Information is edited extracts from the report, Representativeness of the European social partner organisations: Hospitals – Belgium, produced for EIRO by Guy Van Gyes, Higher Institute of Labour Studies (HIVA), Catholic University of Leuven (KUL), 28 April 2009

The full report is available at > EIRO Hospitals Belgium

Hospital sector

Hospitals are a key factor in the high-quality Belgian health system. Collective bargaining is organised differently, but is coordinated, for the private (mainly not-for-profit) hospitals and public hospitals. The bargaining takes place with well-established rules and actors. However – compared with other sectors – the employer side in particular has a fragmented organisational structure, albeit amounting to a coverage of 100%.

A common categorisation is to divide the hospitals in terms of their general and psychiatric care. The general category is itself divided into acute care hospitals (80%), geriatric hospitals (4%) and specialist hospitals (16%). Some general hospitals have psychiatric departments but these can treat psychiatric cases for short stays only. A specific category of general hospitals are the university hospitals, which are large establishments combining specialist treatment with research and education. However, care is not only provided in hospitals but also in rest homes, combined rest and nursing homes, and psychiatric care houses. The latter category is not taken into account for this study. Finally, Belgium also counts a number of military hospitals. Unlike the other hospitals, military hospitals do not come under the Hospital Law; instead, they are under the authority of the Ministry of Defence. These are also excluded from the study.

About 60% of all Belgian hospitals are non-profit private institutions and the remainder are public institutions. Most of the private hospitals are owned by non-profit organisations that originally had links with religious charitable orders, some 5% are owned by mutual funds and a small number are owned by specialist doctors. A public hospital, on the other hand, can be run by the Public Centres of Social Welfare (Openbare Centra voor Maatschappelijk Welzijn, OCMW), a public law association, an inter-municipal association, a province, a regional community or by the state. OCMW hospitals are the most common type of public law hospitals; however, OCMW hospitals are not necessarily of a public law nature. Most hospitals are non-profit institutions and there are only a limited number of for-profit hospitals: in 1999, there were two for-profit hospitals.

The system of collective bargaining

Private (not-for-profit) hospitals

The Belgian hospital law requires that private hospitals have a not-for-profit statute. Collective bargaining for these hospitals takes place in joint committee 330. This is a new sector committee, established since 2003, but only recently activated by the necessary Royal decrees. Joint committee 330 covers all of the Federal Health Services – not only the hospitals – and replaces the activities and agreements of joint committee 305, which has been split up. The social partners advised the Minister of Employment and Equal Opportunities in the summer of 2007 to set up a specific subcommittee 330.1, which will focus only on hospitals.

Public hospitals

The employment relationship in public hospitals is organised by legislation. Bargaining takes the form of negotiation or consultation. Negotiation can lead to agreements that are laid down in protocols. These protocols are morally or politically binding for the government, but are not legally binding and the government can act unilaterally. However, the trade union statute stipulates that negotiations and consultations – in other words, the actual processes – are a legal pre-condition for measures to be valid. The topics requiring prior negotiation or consultation are defined in the trade union statute.

The main feature of the collective bargaining system in the Belgian public sector is its tiered structure, from federal state down to the local level.

There are three negotiating levels: Committee A – representatives of the federal government, the communities and regional governments negotiate protocols with the three representative trade unions for all public sector workers in Belgium. The activity of Committee A is in this regard comparable with the intersectoral private sector bargaining in the National Labour Council (Conseil National du Travail/Nationale Arbeidsraad, CNT/NAR). Any matters that are addressed by Committee A can no longer be dealt with in the other committees; Committee B – the bargaining partners involved here are the Minister of Civil Service and Public Enterprises, the ministers for the departments concerned, the officials in charge of the public bodies concerned and the trade unions. At this level, the bargaining is done in 15 different bargaining committees, known as sectoral committees; Committee C – provincial and local administrations. From the bargaining perspective of the public hospital personnel, Committees A and C are very important. Most of the public hospitals are run by local OCMW.

Trade unions and public authorities conclude collective agreements or protocols at national level, which are complemented by additional agreements at regional and local level. Unions have been requesting a specific sector committee for the public care sector, but so far this has not been created.

Coordination in practice

Since 2000 and under trade union pressure, bargaining in the hospital sector has significantly altered. Agreements have been set for five years and are based on tripartite dialogue, between employer organisations, the government (partly as employer, partly as subsidising actor) and trade unions. The dialogue covers both the private and public sectors, and includes not only hospitals but also other care services. Twice so far (2000–2005; 2005–2010), these talks have resulted in a final agreement, which afterwards has had to be implemented in the different formal bargaining committees and to be finalised in legally binding texts of the private sector and the public sector. Such texts for the private sector comprise mutually binding collective agreements, which are extended, while protocols translated into governmental official decisions at different policy levels apply in the public sector. Key aspects of these agreements are: the involvement of the subsidising government, which could guarantee the necessary financial funds to implement the agreement; ‘solidarity’ bargaining – wage settlements that create a catch-up process in earnings for care workers in other sectors than hospitals (for example, nursing personnel in elder care facilities); specific measures to keep older care workers in the workplace.

Semi-collective bargaining doctors As noted earlier, doctors in Belgium are self-employed. As a liberal profession, they can have a private practice and/or be linked to a hospital. In any case, they keep their independent statute although they need an accreditation. The Belgian health system combines this type of independent medical practice with compulsory health insurance. Payment is mainly fee-for-service and patients have a large degree of freedom in their choice of provider.

Each year, representatives of the sickness funds and the healthcare providers – including doctors’ associations and the hospital federations – negotiate a detailed fee schedule for each type of service, the so-called nomenclature. In all of these negotiations, the sickness funds act as a cartel and are seen as a kind of representative for patients. As the government has a veto power over the fee levels, the whole process resembles a bilateral bargaining monopoly supervised by the central government. During the year, health expenditure is closely monitored and, if there is a danger of transgressing the budget, negotiations begin between the government, the providers and the sickness funds to find solutions, which may include a change in the fee schedule and the co-payments. If necessary, the government can impose measures unilaterally.

Rate of collective bargaining coverage

Private sector hospitals: 100%. Every hospital is a member of a signing employer organisation. Furthermore, agreements are normally always extended by royal decree and so they apply legally to all employers and their employees in the sectors concerned.

Public sector hospitals: 100%, when the protocols are transposed into legal texts, which can take some time.

Sectoral multi-employer wage agreements in the private sector are negotiated by joint committee 330 (previously 305.01). The main agreements include the collective agreement of 10 September 2007, which prolonged all of the still existing agreements of the former 305.1 joint committee; the wage agreement of April 2005; pay rise for specific categories and night/shift work; automatic indexation of wages; and the sectoral job and wage classification (agreement of 1982, amended several times).

In the public sector, the agreement on the federal health sectors – public sector 2005–2010 (protocol implemented afterwards) is negotiated by the government and public sector trade unions in coordination with private sector bargaining.

Trade unions

The trade unions participating in collective bargaining are sectoral federations of the three, traditional, representative trade union confederations in Belgium. Different sectoral federations are involved for the public sector – which accounts for about a quarter of the employee population – and for private sector hospitals. Within the Christian trade unions, these organisations are also split by a language divide (Flemish/Walloon).

In the public sector the ACV-CSC, ACOD-CGSP and VSOA-LRB/SLFP-ALR federations negotiate in committees A and C and sign protocols with the government. In the private sector the negotiating committee for health establishments and services is 330 and the union federations involved are LBC-NVK, CNE-GNC, BBTK-SETCa, AC-CG and ACLVB-CGSLB.

Besides these trade unions, professional associations for nurses are also active in the sector. However, they do not participate in the system of collective bargaining. Most of the time, these associations also cover self-employed nurses. The umbrella organisation of these nursing associations is the General Union of Nursing Personnel in Belgium (Algemene Unie Van Verpleegkundigen België/Union Générale des Infirmiers de Belgique, AUVB/UGIB). Recently, the nursing associations also created an umbrella organisation on the Flemish side, called the Flemish Nursing Union (Vlaamse verpleegunie). These professional associations are involved in some of the sectoral concertation bodies, mainly dealing with accreditation, planning and skills issues in the sector. Doctors in Belgium are self-employed. They also have their own interest groups and associations.

ACV-Public Services (ACV-Openbare diensten/CSC Services Publics) covers all public service workers; in the sector, public hospitals, all personnel, total membership 148,908, 46% women, 30% density in the sector of public hospitals. General Federation of Public Services (Algemene Centrale der Openbare Diensten/Centrale Générale des Services Publics, ACOD/CGSP) covers all public service workers; in the sector, public hospitals, all personnel, 284,576 members with 11,423 in sector, 25% density in the sector of public hospitals. Free Trade Union of the Public Service (Vrij Syndicaat voor het Openbaar Ambt – Groep Lokale en Regionale Besturen/Syndicat Libre de Fonction Publique – Groupe Administrations Locales et Régionales, VSOA-LRB/SLFP-ALR) covers all public service workers; in the sector, public hospitals, all personnel. National Employee Federation (Landelijke Bediende Centrale/Nationaal Verbond van het Kaderpersoneel, LBC/NVK) covers all white-collar workers including professional and managerial staff in Flanders and Brussels and working in the private sector; in the sector, private hospitals, all personnel (white-collar and blue-collar workers) in Flanders and Brussels, 297,449 members, 59% women. National Employee Federation (Centrale Nationale des Employés – Le Groupement National des Cadres, CNE-GNC) covers all white-collar workers including professional and managerial staff in Wallonia and Brussels and working in the private sector; in the sector, private hospitals, all personnel (white-collar and blue-collar workers) in Wallonia and Brussels, 145,415 members, 64% women Federation Employees, Technicians and Cadres (Bond Bedienden, Technici en Kaderleden/Syndicat des Employés, Techniciens et Cadres, BBTK/SETCa) covers all white-collar workers including professional and managerial staff working in the private sector; in the sector, private hospitals, all white-collar personnel, 356,912 members, 10,000 in sector, density of around 10% in sector General Federation (Algemene Centrale/Centrale Générale, AC/CG) covers blue-collar workers in a range of industry and services sectors; in the sector, private hospitals, only blue-collar workers – who are a minority in the hospital sector, 350,764 members ACLVB-Liberal trade union (ACLVB-Liberale Vakbond/CGSLB-Syndicat Liberal) covers all personnel in the private sector; in the sector, private hospitals, all personnel, 220,000 members with 2,089 in sector, 2%-3% density in private sector hospitals

Employer associations

From a collective bargaining point of view, which is mainly a concept relevant in the private sector, employers were traditionally organised according to the following criteria: statute – private for-profit, that is, run by doctors; private not-for-profit run by ‘pillar’ organisations (mainly Catholic, but also socialist and to a lesser extent liberal); public (ownership by communal or to a lesser extent provincial authorities); within the dominant not-for-profit segment of ‘pillar’ ownership – Catholic and socialist, and within the Catholic sector between the hospitals owned by religious charities (Caritas Catholica Belgica) and by the Christian health fund (mutualistic fund); region – for some of the segments mentioned, a further division in employer organisations exists by region: Flanders, Wallonia and/or Brussels; finally, the large university hospitals – which have a special statute in the Belgian hospital system – have created an additional interest group, although they are usually also members of another employer organisation.

Furthermore, many of the employer organisations not only cover hospitals but also other parts of the supply-side in the healthcare system, such as elder care, mental care or day care.

Moreover, several mergers have been happening in the Belgian hospital sector. This means that the formerly ‘clear’ statute of hospitals – for example, public owned by the local authorities, or private not-for profit owned by a Catholic organisation – is now more confused. Conglomerates now exist that can merge hospitals with a different background.

These situations lead, on the one hand, to the fact that probably a number of the hospitals are members of more than one employer organisation. On the other hand, it means that the employer organisations outlined in this report, and which are present in the bargaining joint committee 330 of the private hospital sector, together cover the whole hospital sector on the employer side with a coverage of 100%.

All of the employer organisations participate in a general council of dialogue between the employers, known as the National Confederation of Care Institutions (Nationaal Verbond van Verzorgingsinstellingen/Confederation Nationale des Établissements de Soins, NVVI/CNES). However, as this is only a concertation body to prepare common opinions and positions, it is not considered here as a real employer organisation.

It should be noted that these employer organisations count their representativeness based on how many hospital beds the member institutions represent. These beds are traditionally a crucial factor in the accreditation and financing of hospitals. Based on these bed figures, the Ministry of Social Affairs and Public Health distributes mandates in the key concertation bodies in the planning system of the sector – for example, the Council for Hospital Services. As a result, the organisations have difficulties in counting the number of employees in relation to their representativeness.

The nine employer organisations are: Federation of Caring Institutions (Vereniging van Verzorgingsinstellingen, VVI) Federation of Public Care Institutions (Vereniging van Openbare Verzorgingsinstellingen/Association des Établissements Publics de Soins, VOV/AEPS) Belgian Confederation of Private Healthcare Institutions (Belgische Confederatie voor Private Inrichtingen/Confédération Belge des Établissements Privés de Soins de Santé, BECOPRIVE/COBEPRIVE) National Federation of Medicosocial associations (Nationaal verbond van medisch-sociale verenigingen/Fédération nationale des associations médico-sociales, NVMSV/FNAMS) Belgian Association of Hospitals (Belgische Vereniging van Ziekenhuizen/Association belge des Hôpitaux, BVZ/ABH) Federation of Walloon Hospital Institutions (Fédération des Institutions Hospitalières de Wallonie, FIH-W) French-speaking Association of Healthcare Institutions (Association Francophone d’Institutions de Santé, AFIS) Brussels Confederation of Social and Healthcare Institutions (Confédération Bruxelloise des Institutions Sociales et de Santé/Coördinatie van Brusselse Instellingen voor welzijnswerk en gezondheidszorg, CBI) Socialist Federation of Flemish health services (Socialistische vereniging van Vlaamse gezondheidsvoorzieningen, SOVERVLAG)

Formulation and implementation of sector-specific public policies

All of the trade union and employer organisations are usually consulted by the authorities on sector-specific matters. The form and content of the consultation depend on the issue. Furthermore, other associations – representing nurses, doctors and patients – are involved in this type of consultation, again depending on the issue and advisory body. There are five main sector-specific bipartite concertation bodies: Social sector fund for private hospitals (Sociaal Fonds voor de privé-ziekenhuizen/Fonds Social pour les Hôpitaux Privés), Intersectoral fund for the health sector, Social Maribel Fund, Sectoral saving fund (pension fund) and Institute for Job Classification. There are two statutory, tripartite bodies: National Council of Nursing and Technical Commission on Nursing.

Statutory regulations of representativeness

Private sector hospitals

The Collective Agreements Act 1968 lays down the criteria to be fulfilled by representative organisations - inter-professional organisations of workers and employers established at national level and represented on the Central Economic Council (Conseil Central de l’Économie/Centrale raad voor het bedrijfsleven, CCE/CRB) and the National Labour Council; these worker organisations shall furthermore have at least 50,000 members; and professional organisations affiliated to, or forming part of, an inter-professional organisation. These criteria determine the external representativeness of trade unions. When a trade union meets these criteria, it can conclude collective agreements and apply for representation in a joint committee – in this case, 316. At present, three trade unions have the status of a representative worker organisation: FGTB/ABVV, CSC/ACV and CGSLB/ACLVB, and their member federations.

Public sector hospitals

Only representative trade unions can have seats in the negotiation and consultation committees. These unions subsequently have the freedom to choose and assign their own delegates, including at workplace level in the staff committees, which in the private sector are elected by the whole workforce.

Representative public service unions must be affiliated at national level to a trade union confederation represented in the National Labour Council. Further criteria are that their activities must be organised at national level and represent the interests of all categories of public service staff. These trade unions represent civil servants in the general committees (A, B and C).

Representativeness in a sector committee requires a trade union to have 10% membership of the total workforce of that sector. The representativeness is examined by an independent control commission. However, the trade unions presented in the general committees do not have to fulfil this 10% quorum. With this recent measure, the liberal union VSOA/SLFP obtained seats in all sector committees, besides the socialist and Christian trade union.

Some organisations are only registered. When they are registered, they are allowed, for example, to intervene with the authority covering the services for which they have obtained registration, as well as to assist employees and post opinions in workplaces; they also sometimes take part informally in negotiation and concertation exercises. However, they do not have legal rights to be involved in negotiation and consultation activities.

Besides the three representative trade unions, no registered public sector unions are active in the hospital sector.

In general, trade unions meeting the above criteria can be represented in consultative bodies. As such, the trade unions are involved in a range of bipartite and tripartite funds, commissions and working groups related to the industrial relations of the sector. Nevertheless, the professional associations that do not act as trade unions in collective bargaining participate in the bodies involved in the accreditation and occupational skills-related regulation of the nursing personnel in hospitals. For example, representatives of the National Federation of Catholic Flemish Nurses and Midwives (Nationaal Verbond van Katholieke Vlaamse verpleegkundigen en vrouwvrouwen, NKVV) have seats in the following councils and commissions, which play an advisory role to the Minister of Social Affairs and Public Health: National Council of Nursing (Nationale Raad voor de Verpleegkunde); National Council for Midwives (Nationale Raad voor de Vroedvrouwen); Technical Commission on Nursing (Technische Commissie Verpleegkunde); National Council for Hospital care (Nationale Raad voor Ziekenhuisvoorzieningen); and Commission Patient rights (Comissie Patientenrechten).

Elections for representation bodies

Private sector

A trade union recognised as a representative organisation in the external sense can apply for a mandate in a joint committee. In that case, the internal representativeness of the organisation for that sector in particular will be examined. In general, trade unions accord reciprocal recognition to their representativeness in a sector. If they do not, then the Minister of Employment and Equal Opportunities will base a decision on the results of the national elections for the works councils, held every four years. The division of mandates in the newly established joint committee 330 is based on an agreement between the trade unions.

Public sector

In the public sector, the principle works the other way round. The three nationally representative trade unions can use this status to claim seats in local employee representation – that is, the basic concertation committee (basisoverlegcomité/comité de concertation de base).