In Canada, understaffed ERs, crumbling hospitals, and a government playing Russian roulette with public health have become the norm. At this critical juncture, the need for worker-led strategies in the health sector has never been more pressing.

Public sector workers and supporters encourage motorists to honk during a strike outside a hospital in Montreal, Quebec, Canada, on December 8, 2023. (Allen McInnis / Bloomberg via Getty Images)

Canadian hospitals are on the brink of collapse. Decades of underfunding at both provincial and federal levels have enfeebled hospital and community-based health resources, producing chronic staffing shortages that have only grown worse since the pandemic began. In Ontario, where I live and work in the health sector, hospitals have been operating at over 100 percent capacity for years, resulting in unsafe wait times, “hallway health care,” and an increasingly worn-down and exploited workforce. In recent months, understaffed emergency departments have been forced to limit services, and even close permanently, endangering isolated rural communities.

In the lingering wake of COVID’s impact, Canada’s already imperfect public health care system — Medicare — now faces an existential crisis as the country’s provincial governments seek to further privatize health care services as a panacea to multiplying problems born of their own choices.

In Ontario, undeniable issues — like the province’s dangerously long backlog of surgeries — are used to fuel conservative premier Doug Ford’s slash-and-burn attack on public care. While numerous hospital operating rooms sit idle on evenings and weekends, Ford’s plan to reduce wait times by increasing surgeries in for-profit clinics overlooks the simple solution of adequately staffing existing resources.

Research has repeatedly shown that for-profit clinics only worsen health service delays by diverting staff away from the public system to for-profit clinics. As public funds are funneled into the pockets of corporate firms like Clearpoint, Northwest Healthcare, and MyHealth Centre, patients will also become more vulnerable to illegal and manipulative upselling.

A Critical Juncture

Nursing and health worker unions — long champions of public care — face a critical juncture. Health workers are leaving the profession at alarming rates, and the escalating reliance on costly temporary staffing agencies to address widening personnel shortages has produced a parallel workforce. This development has the potential to divide workers and erode the foundations of organized labor. The fight to improve working conditions in the health sector is not only pertinent to workers but also to health care users — essentially, everyone. As the distinguished Canadian health researcher Pat Armstrong puts it: “the conditions of work are the conditions of care.”

Business-as-usual strategies won’t help us break free from decades of austerity, anti-union efforts, and political neglect even from ostensibly progressive governments. Winning a truly universal and comprehensive public health care system will require historic levels of worker participation across the labor movement. This entails coordinating political activity and disruptive strategies when necessary. Health care providers are uniquely positioned to unite workers across sectors by foregrounding labor struggles as an effective lever for improving both public services and population health. When worker-led organizing is backed by public trust and action, ordinary people hold a tremendous amount of power to determine who our governments serve.

Recent developments in Ontario’s labor movement offer glimpses of how this could be accomplished. Last fall, public sector education workers demonstrated the strategic advantages of deep, worker-led organizing and how labor movement unity can be achieved. The Ontario Federation of Labour’s Enough Is Enough campaign drew public attention to the collective power unions have to improve the lives of workers and nonworkers alike.

This spring, Ontario’s largest nursing union worked around the legal constraints imposed on their bargaining process to win a strong contract through powerful public campaigning and active membership involvement. And just a few weeks ago, three of the largest unions representing health workers in Ontario formed a strategic “solidarity pact” with the explicit goal of embracing a more militant and worker-led approach. The success of worker efforts to mount a formidable threat to corporate interests and the accelerated privatization of our health system will hinge on the capacity to build it worker by worker.

Diagnosing the Problem

The health care staffing crisis is a direct result of diminished investment in public health care services, and the erosion of stable, well-paying public sector work. When compared to other provinces, per capita health care spending in Ontario has declined since Dalton McGuinty’s Liberal government was in power in 2005. Despite changes in political parties over the years, Ontario’s per capita health care spending has remained the lowest in the country.

As the province continues to skimp on hospital funding, fiscally conservative hospital boards — overwhelmingly stacked with representatives from finance and real estate development sectors — have tightened budgets by cutting programs and employee compensation (their largest expense by far). As a result, the quality of work in the hospital sector has deteriorated. According to recent Government of Canada Job Bank data, a greater share — 20 percent — of workers in Ontario’s health care and social assistance industry hold part-time or temporary roles compared to the overall economy. Half of the members in one of Ontario’s largest hospital unions — the Ontario Council of Hospital Unions — work part-time or casual positions.

The success of worker efforts to mount a formidable threat to corporate interests and the accelerated privatization of our health system will hinge on the capacity to build it worker by worker.

Confronted with demanding schedules and the suppression of public sector wages, an increasing number of nurses are leaving the field or seriously considering it. What began several years ago as an emergency response to labor shortages in hospitals and long-term care facilities (LTCs) has become a chronic dependency on parasitic and poorly regulated for-profit agencies to address staffing gaps. Public spending on nursing agencies has quadrupled since the pandemic began, and as these companies rake in record profits, hospitals and LTCs are veering ever-closer to bankruptcy.

More nurses are choosing to leave their benefits, pensions, and permanent unionized jobs behind to pursue agency work. The allure of flexible shifts and higher pay, in the context of rising living costs, is a significant factor in this decision. While notorious for being bad employers, agencies have the capacity to offer nurses pay rates two to three times higher than their regular earnings.

Privatization poses a direct threat to organized labor by undermining any meaningful ability workers have to influence their working conditions. The vulnerability of nonunionized workers to exploitation is heightened as many agencies misclassify workers as “independent contractors.” This exempts them from the minimum standards set out in the Employment Standards Act (like paid overtime and reasonable notice of termination) and the right to collective bargaining — a crucial tool for workers to assert their rights and democratize the workplace.

The rise of agency work has resulted in the development of a parallel workforce which, by simply existing, undermines the bargaining power of unionized workers by presenting employers with a reserve pool of labor. Meanwhile, agency workers are disadvantaged by having essentially two bosses: on paper it’s the agency — at great remove from their daily activities — but in practice, workers report to the clinical managers overseeing their assignments in hospitals or long-term care homes.

Reviving Public Care

The Ontario Health Coalition (OHC) represents the largest coordinated political campaign to defend public health care in recent years. The five-hundred-member-strong coalition — which includes patient organizations, nonprofit community agencies, unions, and more — has pushed for reinvestment in public services and a halt to privatization through political lobbying, public education, and large-scale protests.

Outside the health sector, instructive lessons can be drawn from the deep organizing that led fifty-five thousand public sector education workers to push Ontario’s labor movement into a general strike position last fall.

In order to build the kind of power that is needed to both defend and improve public care, a worker-led organizing strategy is also necessary. Outside the health sector, instructive lessons can be drawn from the deep organizing that led fifty-five thousand Canadian Union of Public Employees (CUPE) public sector education workers to push Ontario’s labor movement into a general strike position last fall.

In their fight to improve their conditions of work, the CUPE–Ontario School Board Council of Unions (CUPE-OSBCU) modeled an approach to worker organizing that extended beyond securing better contracts. The focus was on fostering the confidence of ordinary people to demand more from their governments and bosses. As former CUPE-OSBCU president Laura Walton explains: “We need to be talking to each other, and seeing each other, as workers who are equally deserving of better working conditions regardless of where we work.”

By building up the leadership capacities of all CUPE-OSBCU members, workers were able to engage the broader public in different settings — like faith groups, waiting rooms, neighborhoods, at social functions with friends and family — and incorporate the concerns of the public into their demands. The message was clear and well-understood: to get the best possible education for children, education workers need the best possible working conditions.

Public service unions — including those in education and health care — are in the best position to highlight the benefits of public services and to link struggles across sectors and along class lines. Wherever we happen to work, we don’t live separately from one another. And we have far more in common with one another than we do with our bosses.

It Takes a Village

Liberal democracies face competing fiscal pressures: on the one hand, to appease corporate interests by facilitating capital accumulation, and on the other, to uphold political legitimacy by delivering various goods and services to the public. The strength and universality of public programs largely mirror the capacity of ordinary people to counter corporate demands on governments. Organized labor offers the only effective means of transforming the collective interests of workers into political power and expression.

A robust body of scholarship has established a strong relationship between union density and greater income equality, particularly for low-income and racialized workers. In Canada — where most public services fall under provincial jurisdiction — research has found that provinces with greater union density and governing left or center-left parties (i.e. parties that are more likely to be influenced by labor pressures) have more generous welfare programs and lower rates of inequality.

In fact, organized labor played a much larger role in the history of Medicare than is generally acknowledged. Tommy Douglas — Canada’s most widely respected progressive politician, is often credited with bringing public health insurance to the masses through his personal vision and political acumen. But he did not act alone.

When he was swept into power on Saskatchewan’s Co-operative Commonwealth Federation (CCF) ticket in 1944, his win was owed to a broader working-class movement that had been building power for decades. Douglas’s political agenda was developed through this political coalition of unions, farmers, and socialists and their commitment to regulating production and distribution of goods and services like health care “according to the needs of people, not profit.”

The CCF’s remarkable ability to mobilize unions and the public for the implementation of a public health insurance plan is astonishing, especially considering the fierce opposition from physicians and corporate lobby groups. Their successes emboldened ordinary people and organizations across the country, from the Canadian Labour Congress to community associations and churches, to push for a public health insurance scheme binding on all provinces.

Writing to Prime Minister Louis St Laurent in 1955, conservative Ontario premier Leslie Frost complained that he was “under tremendous pressure from the unions” to advance a public health insurance scheme which, despite his own opposition, seemed inevitable. Defending public care today will require nothing less than the unity of purpose, public support, and supermajority worker action that won it in the first place.

Playing on an Uneven Field

The varying union density across health care settings is influenced partly by long-standing trends in privatization and the outsourcing of care. Over one-third of health sector workers are employed in hospitals where most, but not all, belong to a union (77 percent). This stands in stark contrast to home and community care, where the privatization of services in the 1990s led to a sharp decline in union density. Only 31 percent of the largely racialized and female workforce is now unionized.

Building worker power and coordinated action across the sector as a whole will require strategic cooperation across multiple unions and a commitment to engaging the growing number of nonunionized health workers.

If current trends in temp agency nursing and privatization continue, it will pose a direct threat to union membership across more areas of the sector. Without sectoral bargaining, building worker power and coordinated action across the health sector as a whole will require strategic cooperation across multiple unions and a commitment to engaging the growing number of nonunionized health workers.

The legislation around collective bargaining in health care varies by province, but Ontario falls on the most conservative end of the spectrum with its near-total ban on strikes in the health sector. In other provinces, health workers either have the right to regulated strikes (with the maintenance of essential services required), or an unregulated right to strike (where essential services are negotiated).

The bargaining rights of Ontario’s health workers are also contingent on their place of employment. Canada imposes stringent restrictions on the right to strike — notably differing from the United States, where nonunionized workers can legally strike. Unionized workers in Canada are also prohibited from striking, or threatening to strike, unless they are in the process of negotiating a collective agreement, and even then, only after certain procedures have been followed.

The most important piece of legislation governing labor relations in Ontario’s health sector is the Hospital Labour Disputes Arbitration Act (HLDAA). In the aftermath of a prolonged support staff strike at a small Ontario hospital in 1965, the conservative provincial government of the time revoked the right to strike from all hospital employees. The definition of a “hospital” under the HLDAA is broad and subject to interpretation, and generally hinges on the extent to which the institution in question provides “observation, care and treatment” fundamental to the health, safety, and well-being of its clients. As a result, long-term care homes and medically intensive residential programs also fall into this category, whereas mobile home care and public health units do not.

When the right to strike was revoked, it was replaced with interest arbitration — a mechanism for resolving bargaining issues, via “neutral” third-party arbitrators, that have reached an impasse. According to Ontario labor scholar Larry Savage, the interest arbitration process threatens union democracy and power for several reasons. For one, decisions are binding — they don’t have to go back to union membership for a vote. There’s no technical prohibition on sharing information during negotiation talks, but there’s nothing motivating unions to do so either. Because final contract decisions are in the hands of a third party, the perceived need for the union to engage its membership is diminished. What’s more, since arbitrators are tasked solely with resolving issues within the union/management relationship, they are not in a position to consider broader union demands, such as advocating for increased investments in public goods and services.

Expanding the Horizon of the Possible

During their most recent contract negotiations with the Ontario Hospital Association (OHA) last spring, the Ontario Nurses Association (ONA) secured significant wage and benefit gains for both full- and part-time nurses. This achievement was won through transparent communication, public-facing campaigns, and an actively engaged membership. Without the disruptive power of a strike, the union had to find creative ways of harnessing the most important source of its power: an organized and mobilized membership.

Still, without a credible strike threat, workers lose a fundamental tool to leverage power in an otherwise deeply asymmetrical relationship with their employers. Through decades of rulings, Ontario courts have repeatedly legitimized binding interest arbitration as a fair substitute for the right to strike, rendering any future legal challenges difficult.

When the Ontario Public Service Employees Union (OPSEU) challenged the HLDAA’s strike ban in 2003, the labor board ruled that the HLDAA’s restrictions on freedom of expression and freedom of association (two foundational rights in the Canadian Charter of Rights and Freedoms) were reasonable when weighed against “the public interest” for undisrupted access to essential services.

The OPSEU case is an outlier. With few exceptions, health care unions — particularly those representing low-wage workers in residential facilities and home care settings — are more likely to argue that their workplaces ought to be covered by HLDAA. In these settings, where staff turnover is high and organizing is more difficult, binding interest arbitration can seem like a simpler and easier route to wrangling wage increases from the employer. Still, giving up the right to strike is a high price to pay.

The limited right to strike for health workers in Ontario puts serious constraints on their political muscle and bargaining power. But it does not make well-organized, militant action impossible; in fact, it often makes greater militancy necessary.

Workers’ Struggles

The right to strike has been, and will always be, won through the struggles of workers. Laws are not immutable facts of nature; they can be challenged, amended, and circumvented. Studies examining legal prohibitions on the right to strike in the public sector have found that while such restrictions do dampen strike activity, they by no means eliminate it. In 2020, over eight hundred nursing staff, custodial and maintenance workers, and health care aides went on a wildcat strike in Alberta in response to the provincial government’s threat to outsource eleven thousand public sector jobs to the private sector. The striking workers received an outpouring of community support and drew widespread political attention to the damaging effects of privatization on worker power and public health care.

Between 1983 and 2007, the volume of strikes among health workers in Alberta — where such strikes were illegal until 2015 — was fifty times greater than the number of strikes among health workers in the province of Nova Scotia, where the right to strike has been protected. Even when controlling for population size, Alberta still experienced almost fifteen times more health sector workplace disruptions compared to Nova Scotia during this time.

Nurses in Ontario have also pushed the limits of the law and evaded punishment while doing so. In 2001, hospital nurses across Ontario coordinated a “day of protest” in response to mounting frustrations in their negotiations with the OHA. By working to rule and refusing overtime assignments and extra shifts, nurses were able to simulate the disruptive impact of a strike. Although such actions could have been interpreted as a “strike” under the HLDAA, the OHA declined to invoke the legal sanctions available to it in order to deescalate the situation.

Today, three of Ontario’s major hospital unions are also pushing the limits of what’s possible by forming a “solidarity pact.” Together, they aim to improve the working conditions of hospital workers, save public hospitals, and halt the privatization of our health system by “any means necessary including militant action and . . . mass mobilization.” The alliance’s underlying message emphasizes how the conservative government’s attack on public health care is also an attack on labor rights and on public health. Since each of these unions represents workers in a variety of settings — hospitals, public health, home care, long-term care, and ambulance services — the solidarity pact opens exciting possibilities for organizing an otherwise siloed sector.

The single-payer Medicare model in Canada today is an incomplete version of the more radical program of socialized health care envisioned by its earliest proponents. Our overall aim should not be limited to defending public health care as we’ve known it; it must extend to achieving its original aims and include the public funding and provision of pharmacare, dental care, psychotherapy, optometry, and various other services essential to a healthy society.

The process of decommodifying health care and other essential goods in capitalist welfare states can only be won through a united, working class struggle that begins in the workplace. Health workers, being strategically positioned, can forge connections between our material interests as workers and our diverse needs as individuals. We have the capacity to engage the fight for decent working conditions, improved public services, and a better quality of life for everyone. The decision to seize this potential is entirely in our hands.

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