GENEVA (ILO Online) - More than a decade after the fall of the Berlin Wall, healthcare in many former East bloc states has been corroded to the point of near collapse, threatening an increasingly vulnerable population.But according to a new publication just out from the International Labour Organization (ILO) and Public Services International (PSI) *, not only patients are at risk. Public health systems on the brink of collapse are seeing healthcare workers struggling with high stress, poor working conditions and sub-par salaries B if and when they are paid.

"The physical environment of many workplaces is deplorable, often dangerous for both patients and health workers, with minimum sanitation lacking," says Guy Standing, Director of the ILO Socio-Economic Security Programme."Put simply, these countries are facing a severe 'crisis in care.'"

Among the causes are cuts in public funding which leave many local authorities without the resources or administrative capacity to meet new obligations.According to the study, total spending on health in Central and Eastern European countries ranges between 2.6 per cent in Romania and 7.2 per cent of GDP in the Czech Republic. The Central and Eastern European average is 5.3 per cent compared to the European Union average of 8.5 per cent.

"All of this has surely contributed to the catastrophic fall in life expectancy rates in Russia, Ukraine and some other countries in the region," says Mr. Standing, adding that the crisis has been worsened by rapidly increasing rates of sexually-transmitted diseases, HIV/AIDS, tuberculosis and numerous other chronic illnesses.

While the scale of job cuts and the ensuing unemployment has been markedly lower in health than in some other sectors, labour market security has been severely compromised during transition. Hospitals, polyclinics, dentist, diagnostic and general practices have begun to hire and fire staff directly, concentrating considerable power in the hands of a few senior managers.

Trade union membership rates in the healthcare sector have declined in much of the region. For example, in Lithuania health sector union membership has fallen from 100 per cent in 1990 to 20 per cent in 2001. In Poland, membership has halved, to about 20 per cent, with similar trends reported in most of the region.

Although some countries - Belarus and the Republic of Moldova - still have only one trade union covering the entire health sector workforce, more and more new unions and associations are being founded to represent and protect specific occupations. This has already occurred in Croatia, Lithuania and Poland and there is a risk that the strongest professions (the doctors) will win out at the expense of the weaker majority.

Meanwhile, doctors' pay has tended to rise relative to other groups working in healthcare, notably in countries such as Belarus, Croatia and the Czech Republic. In many countries, income from secondary sources account for more than a third of total income, while in Poland the figure is more than 50 per cent.

Other factors degrading public health include such practices as extensive "administrative leave", in which large proportions of the healthcare workers in such countries as Kyrgyzstan, Armenia and Moldova are told to not come to work because hospitals and clinics lack funds to pay them. And many workers suffer from 'presenteeism' whereby they are obliged to come to work when they are ill, as even one day lost pay can be a question of survival for some. Some workers have been put on contracts of limited duration with no guarantees for the future and temporary contracts have played a particularly increased role in Poland, Latvia and Kyrgyzstan.

* Corrosive Reform: Failing Health Systems in Eastern Europe, by Carl Warren Afford, ILO Socio-Economic Security Programme, ILO, Geneva, 2003.