When democracies coerce their health professionals: institutional constraints and policy outcomes across four jurisdictions

Vollständiger Abstract

Worum geht es in dieser Arbeit?

Background Coercive health workforce policy—the use of legal mechanisms to compel professional compliance in ways that override established processes of negotiation, consent, or collective bargaining—has been deployed repeatedly by governments in high-income democracies through statutory wage controls, contract imposition, employment restructuring, and disciplinary orders backed by license sanctions. The conditions under which such policies achieve or fail to achieve their stated objectives remain poorly understood. Methods We conducted a comparative case study of four jurisdictions (South Korea, Ontario/Canada, England, and Hungary) over 2015–2025. Cases were selected from a defined universe of workforce conflicts in high-income democracies to maximize variation in coercive intensity—classified along a five-level escalation ladder derived inductively from the case material—and in institutional configuration, the latter assessed using third-party indices (World Justice Project, Reporters Without Borders, CIVICUS) from editions preceding each conflict’s onset where available. Outcomes were assessed in three layers: compliance with the instrument, persistence of the instrument, and attainment of each government’s stated objective against objective-specific indicators. Results In none of the four cases did coercive policy attain its stated workforce objective. South Korea’s return-to-work orders were abandoned amid mass non-compliance, and the quota expansion was reversed during an ensuing constitutional crisis. Ontario’s statutory wage cap was struck down as unconstitutional and repealed. England’s contract imposition produced procedural containment without resolution, followed by training attrition and renewed industrial action. Hungary’s employment restructuring achieved formal compliance amid weakened oversight, yet shortages and emigration persisted. Routine policy correction occurred only where substantive constitutional review of workforce legislation was available (Ontario); where it was absent (England) or eroded (Hungary), coercive policies persisted. Conclusion Across these four high-income democracies—including jurisdictions ranking among the top 20 worldwide on rule-of-law indices—coercive workforce policies did not produce the stable, motivated, and adequate health workforces their governments sought, and recourse to compulsion appeared across the democratic spectrum studied. These findings suggest the central policy question is not how to make coercion effective, but how to build the consultation and arbitration mechanisms that make it unnecessary.