Impacts of industrial actions, protests, strikes and lockouts by health and care workers during COVID-19 and other pandemic contexts: a systematic review – Human Resources for Health

Healthcare workers (HCWs) strikes present an ethical tension between the obligation to care for current patients and the need to improve the healthcare system. This tension is further intensified when the strikes are driven by issues such as incompatible salaries with the cost of living, underfunding in the health sector, and degradation of public health services.

In some cases, authors like Smith et al. consider these protests to raise ethical concerns. On the other hand, from a utility-maximizing perspective, some strikes may be justified if they lead to long-term improvements in health facilities, particularly in developing countries due to the fragility of their health systems and medical care.

During the COVID-19 pandemic, the ethical dimensions of HCWs strikes were further emphasized. For instance, the 5-day strike in Hong Kong by approximately 8000 HCWs in early February 2020, while receiving considerable support from public opinion, was accused of violating professional ethics and neglecting responsibilities. However, evidence suggests that strikers showed care and concern for the community, the sustainability of the health care system, and the well-being of all people in Hong Kong.

The right of populations to receive healthcare is recognized, but HCWs should also be able to work safely and without fear of threats. Without adequate institutional protection, self-protection is justified and moral.

The literature review also highlights the main reasons for HCWs to undertake a strike during a pandemic, which include significant risk for HCWs, persistence of this risk, and inability to mitigate the risk due to inadequate personal protective equipment, staff shortages, and leadership and governance fragilities in health systems.

In low-income countries, the impact of HCWs’ strikes disproportionately affects the poor who can’t afford private sector alternatives, raising ethical concerns. The scarcity of population-based analysis to measure the impact of strikes on mortality and morbidity limits the value of these findings as serious morbidity may be transferred to the community rather than taking place in health facilities during strikes.

The limited literature suggests the need to invest in measures to prevent strikes, such as respect for direct care providers, shared governance, professional autonomy, and continuous quality improvement. Moreover, the lack of governance and leadership, particularly in low-income countries, is identified as one of the reasons for HCWs strikes.

This study has some limitations, including a limited number of studies from each region, which may limit the generalizability of the results, and a reduced amount of literature included in the review, which did not allow for answering all the initial questions, especially evidence related to the impact of strikes and interventions implemented to respond to the demands of HCWs in strikes.

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