Note: China Labour Bulletin recently published our healthcare workers' report: Unprotected yet Unyielding: The Decade-Long Protest of China’s Healthcare Workers (2013-2023).
In the various healthcare workers’ protests, there is one common problem: healthcare workers lack effective representation for their interests, so much so that they have no choice but to assert their demands publicly and seek assistance or pressure from public support. As China’s official trade union–the All-China Federation of Trade Unions (ACFTU)–is the only legal union in China and has not effectively represented healthcare workers, workers are left to fend for themselves against systemic issues giving rise to protests across the country.
China’s healthcare workers theoretically belong to the largest sectoral union of the ACFTU: the Labour Union of Education, Science, Culture, Health and Sports (ESCHS) (教科文卫体工会). In other words, healthcare workers are supposed to have their own division of the trade union designated to represent their interests. It should, however, be noted that the organization of the ACFTU is mainly similar to a government body, which is structured from provinces, cities, and counties to districts (see figure below). Enterprise unions are affiliated with the regional unions but are established and mostly controlled by enterprise management. Sectoral unions are also nested under the government system – within the Ministry of Education for teachers, within the Ministry of Housing and Urban-Rural Development for construction workers, or the Ministry of Transport for transport workers. China’s official sectoral unions are more disconnected from regional unions or enterprise unions, and they usually have even less influence[8] .
Following the implementation of the 2009 national healthcare reform policy, the ESCHS issued a document in 2010 on unions’ role in public hospital reform (中国教科文卫体工会关于在公立医院改 革中充分发挥工会组织作用的意见) (hereafter “the 2010 document”). This national-level document called on lower-level trade unions to represent workers’ interests during the reform process. For example, Article 3 of the document urges local unions to “listen extensively” to the opinions of healthcare workers on the reform implementation and unions in areas designated for pilot programs to participate in that process, identify problems in a timely way, study solutions to these problems, and “actively reflect” them to the local party and government and higher-level trade unions. The goal of these activities is so that workers “can feel the benefits” of the reform. This article clearly describes how unions should participate in policymaking from a worker's perspective and ensure workers’ rights are not violated during the reform process.
However, CLB’s data collected since the start of healthcare reform clearly show that the lower union levels have not effectively taken up this mandate, and the national level of the ESCHS has not effectively implemented this policy document. To find out where the union’s energy has instead been concentrated, CLB has studied the work of the ESCHS and unions whose jurisdictions saw some of the major worker actions described in this report.
Searching for healthcare-related activities on the ESCHS’ official website, the sectoral union
focuses on giving out material benefits and hosting award ceremonies.
On International Nurses’ Day on 12 May and China’s Doctor’s Day on 19 August every year, the union holds competitions, selecting the “Best Nurses” and “Best Doctors” for awards. On the 1 May International Labour Day each year, workers are awarded labour medals and the union holds skills competitions. These activities are more about the union's visibility and creating a patriotic atmosphere rather than being in service of workers and promoting and protecting their labour rights.
At the beginning of the COVID pandemic, the local healthcare unions carried out corresponding support activities to healthcare workers in Wuhan, such as distributing welfare products and allowances, offering free housekeeping services for rank-and-file workers, and providing individualised academic guidance and psychological counselling for workers’ children. When the healthcare workers finished their work in Wuhan, the union provided staff recuperation and rest activities. Although these activities and services are in some ways targeted toward the needs of healthcare workers in Wuhan during a crisis, they still do not relate to fundamental labour rights concerns that workers were raising at that time.
At the enterprise level, hospital unions' common activities include lounges for doctors and nurses, organising daily stress relief activities, and visiting. These activities should be of some help to the health of healthcare staff, but they do not touch on the core issues such as salary, benefits, and work safety, which are of greater concern to staff. The reason workers need such rest is because of the systemic issues they face daily, and the union should be doing more to address those root causes instead of performing merely cosmetic activities.
The Shanghai Municipal Healthcare Union (上海市医务工会) has a long history and conducts frequent activities. It was established in 1949, with a number of primary hospital unions under its umbrella. According to its latest bulletin (see below), its various activities over the past six years have all been about selecting model workers and providing leisure or other services. None of them have been related to supporting or defending workers’ rights.
Photo: Bulletin Board of Shanghai Medical Labour Union Image Source: Shanghai Medical Labour Union Website
In the sharing board of its website, a trade union chairperson in a public hospital made no secret of the fact that he became the chairperson because of the party committee work assignment:
The chair of the trade union of Shanghai First People's Hospital (上海市第一人民医院) recalled that he “came to the city hospital as deputy secretary of the party committee. Based on the party committee's work distribution, he naturally became the trade union chairman and stayed for 10 years.”
The union president who had worked for many years in the Shanghai Shuguang Hospital (上海 市曙光医院), on the other hand, said:
“The labour union chair is the spokesman for the staff, and there are certain requirements for his speech and behaviour. He cannot act haughty or bureaucratic, and should be close to the staff; but he cannot follow the masses blindly. Labour union chairs should play the role of a bridge, a link, so that the staff and hospital board could come together, united in heart and strength.”
However, the Shanghai healthcare union is absent when workers’ rights are compromised. As shown in Chapter 6 of this report, in April 2022, employees of Shanghai Putuo District Central Hospital went on strike on issues of work safety and lack of pandemic control. If the union had intervened in time to secure pandemic supplies and quarantine arrangements for staff, workers would not have needed to go on strike.
The Report on the Nurses’ Working Conditions in China also touches on the problems of the healthcare unions: the enterprise unions of medical institutions are subordinate to the leaders of the institutions. As a result, although these unions may hold staff meetings and discuss hospital policies occasionally, it is difficult for the unions to wholeheartedly represent the interests of workers, let alone negotiate with management for the interests of workers and demand certain benefits.
Regional trade unions that CLB interviewed in 2020 also revealed that they do not dare to negotiate with hospital management. Staff from the Hanbin District Federation of Trade Unions (汉滨区 总工会) in Ankang, Shaanxi province, said that even the regional trade unions could not put too much pressure on the hospital’s management:
“Because they [the hospital’s administration] are on the front line, as the [regional] labour union, we can only show our encouragement. We can’t put too much pressure on the [hospital] administration.”
While the support activities of the healthcare unions and the regional unions are better than nothing, the reality is that the union basically ignored the immense pressures on frontline workers, and even abdicated its mandate by sympathizing with the hospital administration. Over the years, hospital enterprise unions have failed to stand up and speak out wherever workers' lawful rights and interests are being violated, despite that many were urged to do just this at least since the 2009 hospital reform.
Where are the union representatives when healthcare workers go on strike?
As China’s sole official trade union with a duty to workers and political loyalty, the ACFTU also has a duty to the public to resolve workers’ disputes. When healthcare workers go on strike, healthcare services are interrupted, meaning there are public health consequences to labour rights issues in China’s healthcare facilities. For example, when public hospitals reduced performance pay for nurses to boost doctors’ incomes during healthcare reform (see Chapter 4), nurses did not have representation and went on strike. If enterprise and local unions had been active in raising the nurses’ demands earlier and dared to negotiate with management, then the situation would not have developed to the point of a labour strike. People’s lives will be at stake when nurses have no options but to go on strike, which is going to put doctors’ operations to a halt and interrupt the routine of nursing care.
Similarly, when informal nurses were protesting unequal treatment (see Chapter 3), unions did not side with the workers. As mentioned above, on 24 October 2018, temporary and contract workers at the People’s Hospital of Jianli County in Jingzhou, Hubei province, went on strike over the fact that their wages were decreased, that their income had long been substantially lower than that of regular workers and that they did not have insurance policies or pension. The hospital labour union tried to resolve the problem only after the strike, with an announcement (jointly issued by the union and the hospital’s human resources department) stating that the hospital would devise a new plan to solve the problem at the end of December.
Article 9 of the Social Insurance Law states that “trade unions shall safeguard the lawful rights and interests of employees in accordance with the law”. Work records and online information of the Jingzhou City Union (荆州市工会) from April 2018 to April 2019, the period around this incident, show that the union focused on forming enterprise unions in private hospitals, providing medical assistance to workers, and carrying out patriotic education and mental health activities in public hospitals. All of these efforts had their significance; however, little work was done to improve the working conditions of hospital workers.
If the enterprise union had acted as a collective representative of workers before management, the hospital would have been able to address worker grievances, such as those regarding social insurance, at an earlier stage. The union can also bridge hospital management and workers, consulting workers before the hospital releases a policy. If the hospital faces difficulties or the county government has new financial obligations, the union can also help develop a response that considers workers’ needs. After all, letting the informal staff, who were already receiving disproportionate treatment, bear the brunt of salary adjustments is not justifiable. This incident demonstrates that employees have long lacked an effective mechanism to voice their demands and that without viable alternatives, they can only express them through protests.
In the process of restructuring, the labour union plays a limited role, especially since the staff congress (in which the union participates) is unable to check the power of the management. In the case of Tanggangzi Hospital (see Chapter 5), the union held a staff congress in 2013, a year before the restructuring, and declared that “the hospital has practised complete openness of hospital affairs (...) The majority of the workers have experienced real ownership”. However, grievances turned into protests and strikes during hospital restructuring.
In the Putian Hanjiang Hospital case, the hospital held a staff congress, with most of the staff disagreeing with the decision. Still, the decision was carried through. The hospital turned private in 2022, with performance pay in arrears due to operational difficulties and continuous deficit.
Some doctors clearly mentioned that only 15 per cent of the staff agreed to the restructuring in the staff congress. However, the staff congress system did not stop the restructuring process, and Hanjiang Hospital was recognised as private in 2022, while it continued to default on staff performance pay. On 28 June 2023, hundreds of workers finally protested in front of the hospital building. Still, the Putian City Labour Union was praised by the Workers’ Daily for carrying out the “Best Nurse” activities for five consecutive years in August 2023, campaigns that neither touch on the core interests of healthcare nor stop the protracted labour violations by Hanjiang Hospital.
Workers also approach government departments and seek judicial means to solve problems. However, when unions are absent, it is hard for individual workers to make management solve the problems. In the wage and pension arrear case of Tianyou Medical Group in Shaanxi, we see that the problem continued for years even though local governments were involved and workers went through legal procedures (see Chapter 2).
Tianyou has also set up several unions in its branch hospitals (e.g., a labour union in Shanghai Tianyou Hospital and a labour union committee in a hospital in Liquan, Shaanxi province), but the unions failed to intervene before the conflict erupted. After the incident, they also failed to help workers defend their rights. Workers could only seek help from government departments or go through the timeconsuming legal channels to seek justice.
The union was also ineffective in protecting healthcare workers from daily occupational safety hazards and the lack of adequate protection during the time of COVID (see Chapter 6). The trade union has a responsibility to safeguard a safe working environment. Article 7 of the Work Safety Law states that the union shall “organize the workers to participate in the democratic management and supervision of the work safety”. Article 60 of the Law states that unions “shall have the right to demand rectification of any violation of the laws and regulations on work safety”. The union also has the right to “put forward proposals to solve problems when they find that production and management units have violated the rules and regulations on work safety.” In fact, ensuring work safety should be the most routine work of the unions. The fact that the personal safety of healthcare workers continues to be jeopardised is also a consequence of a lack of union actions.
Similarly, the union has not taken seriously the concerns of healthcare workers who are excluded from the status of workers and, therefore, not protected by labour law, such as medical students/residents. Trade unions should first organize these workers, just as they did in the past with the “migrant workers joining union” (农民工入会) and the “eight major groups” (八大群体).
Going back to the 2010 document published by the ACFTU’s Union of Education, Science, Culture, Health and Sports, the sectoral union requested local trade unions to participate in the formulation of reform policies and represent the interests of healthcare workers. It also explicitly stated that trade unions should “strengthen democratic management”, “conduct an in-depth analysis of the reform policies of healthcare workers, reflect voices promptly, and maintain the stability of the healthcare workforce and general society”.
More than ten years after the release of the 2010 document, the interests of healthcare staff continue to be infringed upon (including by the effects of the 2009 healthcare reform). Therefore, CLB asks, what should China’s official union do to best protect and represent the interests of healthcare workers?
China Labour Bulletin’s Recommendations for the ACFTU to Represent Healthcare Workers in China
Based on the research and findings in this report, CLB has the following suggestions for trade unions in China:
(1) Ensure that all healthcare workers have the right to join a labour union
Specialized healthcare unions should be set up for all kinds of staff to join. In addition to formal doctors and nurses, informal healthcare workers, as well as medical trainees and postgraduates should all be able to join the union. The national ACFTU can consider breaking off a section of the ESCHS and creating a sectoral union for healthcare workers. Healthcare unions in local hospitals should have a direct channel with the sectoral union to communicate the issues workers face in their jurisdictions
(2) Medical unions should actively represent their members in negotiations with hospitals
When enterprise unions in hospitals become broadly representative, they should negotiate on behalf of their members. Trade unions should ensure that hospitals fulfil their legal responsibilities and treat workers fairly, including paying salaries, allowances and social security contributions on time, giving staff equal pay for equal work, not withholding promised benefits, and ensuring work safety. At the same time, trade unions should sign annual collective contracts through negotiation to gradually improve the welfare benefits of staff.
(3) Medical unions should actively represent individuals to defend their rights
When individual healthcare workers encounter labour disputes or unfair treatment, they should be able to seek the immediate intervention of union representatives.
(4) When policies may affect the interests of healthcare workers, healthcare unions should put forward policy proposals as early as possible
Local healthcare labour unions need to pay extra attention to the impact of government policies on workers, identify problems early, and propose appropriate solutions.
Download the full report as a pdf here.
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[8] For a detailed introduction to the structure of China’s official unions, readers can refer to CLB’s report Reimagining Workers’ Rights in China (Part Three)