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The crisis of capitalist healthcare: forced labour is threatened in European Slovakia!

 

 

At the end of 2024, there was no shortage of protests and conflicts related to the health sector in Europe (Germany, Spain, Slovakia...), which took various forms: street demonstrations, protests, mass quits as a coercive method…; were linked to staff shortages – i.e. the long-term overwork of these workers –, low wages and the privatisation of health facilities.

Germany: in October, thousands of health workers demonstrated in Berlin and other cities over worsening working conditions, staff shortages and for pay rises, with some hospitals having to limit operations to essential care. The protests ended after an agreement was reached with the centre-left government formed by a coalition of the Social Democratic Party of Germany (SPD), the Union 90/Greens and the Free Democratic Party (FDP) on a gradual 6% pay rise over the next two years and a promise to improve working conditions for health workers.

Spain: in November 2024, mass demonstrations by health workers took place in Madrid, the next phase in a series of protests linked to the problems in the Spanish health sector, particularly after the COVID-19 pandemic. More than 10 000 health workers took part, protesting for improved working conditions in the face of staff shortages, work overload and low pay; there were also temporary closures of some health facilities. Following an 8% pay rise approved by the government and a promise to hire more staff, the health workers' protests have been suspended for the time being, awaiting action by the government led by the coalition of the Spanish Socialist Party (PSOE) and the left-wing SUMAR party (successor to the left-wing Unidas Podemos alliance).

Slovakia: in October 2024, 2 700 hospital doctors, led by the medical union LOZ, filed mass quits in protest against the Robert Fico government's consolidation package, which reduced the percentage of salary increases for health workers; they also protested against the government's inaction on previously promised healthcare reforms and against the transformation of hospitals into joint stock companies. Once again, this is another critical issue in the chronically problematic Slovak healthcare system, which has long been burdened by a lack of staff, funding and outdated infrastructure. The government – Robert Fico's fourth government, made up of the left-populist social-democratic SMER-SD, HLAS-SD (defectors from SMER-SD) and the right-wing nationalist Slovak National Party (SNS) – has passed a law that partially cancels the planned reduction in salary increases for healthcare workers, but salaries will continue to rise at a slower pace. As a result, hundreds of doctors refused to perform night and weekend shifts in December, intensifying pressure on the government. The latter responded by passing a law that allows the government to declare a state of emergency in the case of critical unavailability of hospital care and forcing doctors in this situation to compulsorily continue working under threat of prosecution and possible imprisonment. Faced with the possible leave of more than 3 300 disgruntled doctors, i.e. the majority of hospital doctors, which experts say would paralyse the operation of Slovak hospitals at the beginning of 2025, the government backtracked and reached an agreement with the trade union (an agreement of a good 30 pages, including annexes) that guarantees some doctors the previously agreed salary increase; however, the agreement will not apply to those doctors who work in hospitals less than half of their normal daily working hours and who practice mainly outside hospitals; the agreement also includes a promise of changes in the financing of health care facilities, reform of medical education or an increase in the number of medical students and includes changes to existing laws.

These protests reflect a broader trend in Europe whereby health workers demand better working conditions and greater economic remuneration for their work; it also shows how most protests and conflicts are quelled by temporary concessions in the form of modest pay rises, one-off bonuses and a whole plethora of promises to address structural problems that are mostly not implemented. Under capitalism, workers in the health sector are exploited as in any other sector of the economy; but in addition, they are “broken” by moral scruples, whereby it is exploited that they care about the lives and health of patients and therefore cannot simply “switch off the machines”, turn off the lights and walk away. This is why the health service is considered a highly “critical” service, so that, for example, the possibility of a strike is often limited: first of all, the provision of essential health care (acute, urgent or emergency care) must be guaranteed and, in the event of a strike, many days' notice must be given, which reduces the effectiveness of the action.

From a Marxist point of view, the economic and social laws of capitalism subordinate not only production but also the reproduction of labour power (wage workers) to the needs of the market, which includes health care. Health, in this case health care, is “prioritized” only when it brings economic benefits: health care is thus considered a cost in capitalism that must be minimized because investment, even by the state, must bring profit, as much as possible. The bourgeois state, which is a political organ – imposing on the entire population, and especially on the proletarians, the obligation to pay taxes – if it invests the capital so accumulated, it invests it only with respect to capitalist profit, which, by coincidence, only the capitalists (who constitute the ruling bourgeois class) put in their pockets. The fact that the public health sector is systematically being cut from state investment in favour of private health care clearly shows that the interests of the capitalist bourgeoisie are at odds with the interests of the population, and especially with the interests of the workers; this reality cannot but provoke protests in this sector as well.

In Slovakia, the health sector – the majority of health care is provided through the public health system – has repeatedly faced protests since 2000, under eleven governments (five left-populist, three right-wing, two centre-right and one so-called technical government). In 2006: protests by doctors and nurses over low salaries and better working conditions – mitigated by partial pay rises (right-wing government); in 2007–2008: protests by nurses (left-populist Fico government); in 2011: more than 2 000 doctors handed in mass quits as pressure to increase salaries, improve working conditions and to protest against attempts to privatise hospitals – the (right-wing) government wanted to force doctors to stay on the job by declaring a state of emergency and received help from Czech military doctors; eventually the situation was mitigated by an agreement on gradual salary increases and better working conditions; in 2012, protests by nurses and midwives – the (left-populist Fico) government introduced a modest increase in nurses' salaries by law and promised a structural solution, which was not implemented; in 2015: doctors again threatened to quit en masse in protest against broken promises – the situation eased thanks to a revision of salary tariffs and a partial increase in hospital funding (second Fico government); in 2018: protests by nurses and other health workers, who tried to draw attention to the seriousness of the situation by symbolically wearing black T-shirts, for a pay rise and improved working conditions – de-escalated by the approval of one-off bonuses and smaller pay rises (the left-populist Pellegrini government); in 2021 (COVID-19 pandemic) protests and threats of mass quits of nurses and doctors due to low salaries and unsatisfactory working conditions – de-escalated by the government offering health care workers extra pay for working during the pandemic and promising gradual improvements in salaries and working conditions, agreement realized only in 2022, with salaries’ increases actually starting in 2023 (centrist Heger government); in 2022–2023: in 2022, mass resignations of more than 2 000 doctors in protest against unsatisfactory conditions – de-escalated by an agreement to increase salaries (in some cases by up to 20–30%), better financing of hospitals, legislative changes in favour of young doctors, while the government had to respond to the de facto departure of doctors abroad and the possible attraction of doctors back to Slovakia, as well as other protests and quits (Heger's centre government); in 2024: as noted above, conflicts were caused by the reduction of agreed salary increases and continued unsatisfactory working conditions.

All of these protests in this model example from Slovakia revolved around the same thing: these proletarians in the health sector have faced and are facing low wages, overwork and a large number of hours and extra services due to understaffing, and are facing the consequences of underfunding of the health sector, which affects not only them directly but also the quality of care they provide to patients.

This totally unsatisfactory situation of the health care system under the capitalist regime has forced many Slovak doctors and nurses to go abroad; the exact number is difficult to determine, but according to the Slovak census of 2021, about 18% of the doctors residing in Slovakia lived abroad, i.e. more than 4 000 doctors (Czech Republic: about 2 500; Germany: about 800; Austria: about 200, then the UK, Switzerland, Italy…); as for nurses, it is known that they often go to Austria and the Czech Republic.

Healthcare is an integral part of the reproduction of the labour force under the capitalist regime. However, the purpose of health care, i.e. the area of care for human health, is distorted under the capitalist regime: instead of prioritising human health, it serves only to keep the labour force in productive state, while both health care – the much-vaunted “care for the human being” – and all spheres of life, including the public sphere, become instruments for profit. The word “human being”, so dear to the bourgeoisie, cannot be understood in socio-political terms to mean anyone other than the wage-earning proletarian, whose “labour-power, or labour-capacity, the aggregate of those mental and physical capabilities existing in the physical form , the living personality, of a human being, capabilities which he sets in motion whenever he produces a use-value of any kind” (Marx, Capital). This proletarian, or rather his labour-power, is a commodity, its exploitation by the capitalist produces value, but it is itself a value to be reproduced: it “is determined, as in the case of every other commodity, by the labour-time necessary for the production, and consequently also the reproduction, of this specific article. (…) it represents no more than a definite quantity of the average social labour objectified in it”. The proletarian, man without reserves, this true producer, in whom labour power is embodied, plays the role of a mere means to the production of material wealth, which is an end in itself and is therefore sustained only to the extent that it can continue its productive function. And this sustaining of the productive function applies both to patients and to the health workers themselves, who are subjected to low wages, to excessive overwork, that is, to the maximum exploitation of their individual labour power, just like the workers in the classic example of the industrial factory, except that here a special commodity is 'produced': labour power.

As regards the underfunding of health care and the so-called limited redistribution of wealth, it is the class aspect that needs to be highlighted. As in the case of pensions, health insurance contributions are understood in Marxist analysis as part of the value that workers create but for which they do not get paid. This part of the wage is diverted into a common fund from which health care is to be provided. This “collectively deferred wage” may at first glance appear to be a collective form of solidarity, but in fact it is closely linked to the logic of capital. This part of the wage is not an altruistic mechanism, but is intended to reproduce the labour force, and as such is managed by capitalism according to market principles: it is not intended to ensure the quality of the population's health, but to keep the labour force in a productive state at minimum cost, that is to say, it favours cost-cutting at the expense of the quality and availability of health care. Greater funding of public health care is a serious problem for each state in terms of the overall impact on the average rate of capitalist profit, as nation-states fight for their respective bourgeoisies and their enterprises in an increasingly fierce competitive struggle internationally.

Another aspect is the commodification of health care, i.e. its perception as a commodity to be purchased rather than as an essential aspect of human existence. Capital has taken over all aspects of social life; the commodification and privatisation of health care is an elementary part of this process: health care institutions outsource their services to private companies, which draw on public funds for their profitable activities (in the context of reflecting on this form of “collectively deferred wages”, we could say that there is a further parasitism on an already extracted part of the value); the transformation of public hospitals into joint-stock companies leads to the prioritisation of their annual financial balance sheet, the so-called financial efficiency. The fact that the pharmaceutical companies themselves see health, care and health crises as an opportunity for profit is probably clear to all; let the COVID-19 period be an example.

The class aspect, then, is that health care depends on class struggle and the economic position of the individual in capitalist society, which is precisely a class-divided society. If the working class is weak, the ruling class can allow itself to fund public services less. The wealthy and members of the bourgeoisie naturally have easier access to health care; they can avoid long waits for treatment in the public health service by bribes, favouritisms or by directly using private health facilities, which are economically unaffordable for most proletarians; the problem of the wealthy classes in relation to health care is therefore a formal problem and one of habit of using public or private health care; for the wage workers it is an economic problem, a problem of existence.

The privatisation of health care is definitely an attack on the living conditions of the working class: it is another attack on that part of the wage which is diverted to the “common fund” which is supposed to provide health care; it is an instrument of further exploitation of the workers through private companies.

In the absence of the classist struggle of the proletariat, the struggle for the exclusive defence of the class interests of the proletariat, bourgeois power increases the oppression of the wage workers in all spheres of their daily life. The low wages, the increase in the pace of work, the increase in job insecurity and thus the increase in the number of accidents and deaths at work, the increase in unemployment and the increasing precarization of work, the increase in competition among the proletarians, the general deterioration of the working and living conditions of the wage-earning masses directly and negatively affect the care of health. To fight against this deterioration is, of course, natural for every proletarian. But to fight to defend public health care against private health care does not substantially challenge the capitalist system, which is entirely based on the valorisation of capital and profit. It would indeed be a distinctly political struggle, but within the politics of capitalist conservation, hence only the “executive” with which wages, working conditions, etc. would be dealt with would change, not the economic logic of capitalist profit.

Above all, the bourgeois state defends the interests of capital, even if it becomes an entrepreneur itself; and if it is forced by the proletarian class struggle, even if it is fierce and long-lasting, to make concessions in some aspect of its economic management, then it simultaneously heals up in all other economic and social aspects of public life, and through taxes, in transport, fuel, food, services, etc. it takes back from the proletariat what little it has been forced to grant in the face of fierce but partial and temporary struggle. The bourgeois state fights to defend capitalist interests 24/7, every month and every year, as long as its function of preserving capitalism is in operation. The proletarians come out of a situation where they are forced to work for the capitalists or else they will starve; and when they finally find the strength to take up the struggle, they cannot do so immediately or all together, united as one army. The bourgeoisie relies precisely on this objective weak point of the proletariat, on the individual need of each proletarian to survive day by day. In reality, every struggle of the workers on the terrain of the immediate defence of their working and living conditions is an unequal struggle because it is confronted by a universally organised force which is ready to intervene in every corner of the country by any means: economic, political, social, financial, military. Of course, the proletarians cannot not fight: sooner or later, when working and living conditions become unbearable, protest, anger, the desire to put their wages, their lives and the lives of their families at stake in order to win more bearable working and living conditions will inevitably erupt. With the struggle comes the need to organise and to face the blows that the “other side” – in reality the class enemy – does not spare. The proletarians know that they will have to fight again because their wages – even if they increase by a few percentage points – are not enough to get them through the end of the month, periodically repeatedly reduced by inflation, or even vanishing as a result of lay-offs.

 In the face of this general situation, which constantly arises again and again before the proletarian masses, the dominant bourgeoisie has one more weapon at its disposal to defend its class interests: the forces of political and trade union opportunism, whose task is to direct the protest, anger and struggle of the wage workers into the arena of reconciliation with bourgeois interests, into the arena of reform, of appealing to the bosses and the state for compassion on the conditions in which the proletarians are forced to live. Moreover, the forces of opportunism systematically seek to persuade the proletarians that the state, if pushed and forced to do so by the struggles of the workers, will ally itself with the proletariat against the interests of private capital and capitalism in general. The very history of capitalism shows that this objective of the workers' struggle has only served to defend the general interests of capitalism and to deceive, weaken and disorganize the workers' struggle. In the case of health care, as in the case of public transport and services in general, fighting for the state to seize for itself these economic sectors and their management does not turn the capitalist law of profit into a socio-economic order in which capitalist profit does not dictate the rules. Fascism has fully demonstrated this, as have, on the other hand, the large monopolistic groups in industry, commerce, information, services, agriculture.

The struggle of the proletariat in the field of the immediate defence of classist interests – that is, those which exclusively concern the proletariat and its working and living conditions can become the motor of  the decisive battle of the proletariat, provided it is elevated to class struggle, a struggle which has a larger and more general objective: to change the economic and social system completely, to overcome capitalism by destroying its economic laws. But in order to arrive at such an outcome – which is the revolutionary end that the proletariat as class is historically capable of realizing, and which we call communism – the proletariat must go through a series of steps on this long historical road, beginning with the decisive one, distinct break with the practice and politics of class collaboration, with class conciliation, adopting the classist means and methods of struggle, as the proletarian generations of the nineteenth and twentieth centuries did, and organizing independently of all the influences of the politics of class collaboration.

It is precisely such a struggle, on this classist terrain, that gives rise to class solidarity, which may involve proletarians from different economic sectors, of different ages and nationalities, uniting in the same anti-capitalist struggle.

The elimination of capitalism as an obstacle requires the mobilization of the working class as a unified force and as an international force; the reorganization of the immediate economic organs of the working masses so that they become real structures of defence and resistance of the working class as a whole, workers of the public and private sectors, of this or that sector, category, nationality, into a potentially unitary mass movement; the mobilisation of proletarian forces for exclusively proletarian aims, which means struggling with classist means and methods (protests and indefinite strikes in support of economic and immediate demands, negotiations under continuous active struggle, solidarity demonstrations, active participation in the struggles of proletarians of other enterprises, sectors, etc.).

This process is not possible spontaneously or somehow from above (by a mere change of “bureaucratic” leadership): it needs and will need constant and continuous work of the proletarians who are the most sensitive to the objectives of their class and those most conscious ones, who will have to take on the task of forming the backbone of a new independent proletarian organizational network, since such a perspective is not possible without the recognition of the incompatibility of the interests of the proletarians and those of the capitalists and their state, i.e. without nullifying the influence of the elements, structures, organizations promoting inter-class collaboration in order to achieve harmony between the interests of the “enterprise”, the “sector” and those of the workers.

Various political subjects have always intervened in the proletarian struggle, some of which may potentially partially express the real immediate interests of the workers' struggle; otherwise they would have been consigned to the rubbish heap of history long ago; but they do so from a perspective and according to a political line in which they accept to share with their “counterparts” the same economic management objectives of the enterprises, only that on the level of supposed equality or participation in the decision-making of the enterprises. This opportunist political response, which often only becomes apparent in the course of the struggle, instead of further strengthening the movement, actually dampens it; when they get to the head of it, they try to push through compromises that make them the real social firemen, appearing before the bourgeoisie as the only leaders capable of breaking the movement to save the regime, save the national economy.

For an effective struggle, which inevitably tends towards the struggle on the eminently political terrain, i.e. to the struggle for power, it is necessary to carry out the propaganda work of the means and methods of class struggle, which today's proletarians must re-adopt, struggling against the opportunist influences of the various schools, and constantly and uninterruptedly setting a classist line on the immediate terrain, which only intransigent communists are capable of giving, contributing in this way to the reconstitution of the classist workers' associationism and to the maximum possible organisation of the proletariat at all levels – the class party, the communist party, which represents the most complete consciousness of the class and its supreme organisation, which alone is capable of uniting and integrating all struggles surpassing the limits of space and time, with the objective that the proletarian struggle would lead to its real class emancipation, putting an end definitively to the age of the bourgeois mercantile system.

 

14 January 2025

 

 

International Communist Party

Il comunista - le prolétaire - el proletario - proletarian - programme communiste - el programa comunista - Communist Program

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